Surgical management of pelvic organ prolapse in women

Christopher Maher*, Benjamin Feiner, Kaven Baessler, Cathryn M. A. Glazener

*Corresponding author for this work

Research output: Contribution to journalArticle

364 Citations (Scopus)

Abstract

Background

Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with the prolapse.Save

Objectives

To determine the effects of the many different surgeries used in the management of pelvic organ prolapse.

Search strategy

We searched the Cochrane Incontinence Group Specialised Register (9 February 2009) and reference lists of relevant articles. We also contacted researchers in the field.

Selection criteria

Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse.

Data collection and analysis

Trials were assessed and data extracted independently by two review authors. Six investigators were contacted for additional information with five responding.

Main results

Forty randomised controlled trials were identified evaluating 3773 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86). However there was no statistically significant difference in re-operation rates for prolapse (RR 0.46, 95% CI 0.19 to 1.11). The vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The three trials contributing to this analysis were clinically heterogeneous.

For anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented with a polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14); but data on morbidity and other clinical outcomes were lacking. Standard anterior repair was associated with more anterior compartment failures on examination than for polypropylene mesh repair as an overlay (RR 2.14, 95% CI 1.23 to 3.74) or armed transobturator mesh (RR 3.55, 95% CI 2.29 to 5.51). Data relating to polypropylene mesh overlay were extracted from conference abstracts without any peer reviewed manuscripts available and should be interpreted with caution. No differences in subjective outcomes, quality of life data, de novo dyspareunia, stress incontinence, re-operation rates for prolapse or incontinence were identified. Blood loss with transobturator meshes was significantly higher than for native tissue anterior repair. Mesh erosions were reported in 10% (30/293) of anterior repairs with polypropylene mesh.

For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele or enterocele, or both, than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64); although there was a higher blood loss and post-operative narcotic use. No data exist on efficacy or otherwise of polypropylene mesh in the posterior vaginal compartment.

Meta-analysis on the impact of continence surgery at the time of prolapse surgery was performed with data from seven studies. Continence surgery at the time of prolapse surgery in continent women did not significantly reduce the rate of post-operative stress urinary incontinence (RR 1.39, 95% CI 0.53 to 3.70; random-effects model).

Authors' conclusions

Abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse and dyspareunia than with vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair reduces the risk of recurrent anterior wall prolapse, on examination. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The value of the addition of a continence procedure to a prolapse repair operation in women who are dry before operation remains to be assessed. Adequately powered randomised controlled clinical trials are urgently needed on a wide variety of issues and particularly need to include women's perceptions of prolapse symptoms.

Original languageEnglish
Article numberCD004014
Number of pages99
JournalCochrane Database of Systematic Reviews
Issue number4
DOIs
Publication statusPublished - 12 May 2010

Keywords

  • rectal prolapse [surgery]
  • randomized controlled trials as topic
  • endopelvic fascia plication
  • humans
  • reduction efforts care
  • skin collagen implants
  • urinary bladder diseases [surgery]
  • prolapse
  • urinary incontinence [surgery]
  • gynecologic surgical procedures [methods]
  • Burch colposuspension
  • anterior colporrhaphy
  • randomized controlled-trial
  • polypropylene mesh
  • abdominal sacral colpopexy
  • uterine prolapse [surgery]
  • suture techniques
  • surgical mesh
  • female
  • stress urinary-incontinence
  • vaginal wall prolapse

Cite this

Surgical management of pelvic organ prolapse in women. / Maher, Christopher; Feiner, Benjamin; Baessler, Kaven; Glazener, Cathryn M. A.

In: Cochrane Database of Systematic Reviews, No. 4, CD004014, 12.05.2010.

Research output: Contribution to journalArticle

Maher, Christopher ; Feiner, Benjamin ; Baessler, Kaven ; Glazener, Cathryn M. A. / Surgical management of pelvic organ prolapse in women. In: Cochrane Database of Systematic Reviews. 2010 ; No. 4.
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title = "Surgical management of pelvic organ prolapse in women",
abstract = "BackgroundPelvic organ prolapse may occur in up to 50{\%} of parous women. A variety of urinary, bowel and sexual symptoms may be associated with the prolapse.SaveObjectivesTo determine the effects of the many different surgeries used in the management of pelvic organ prolapse.Search strategyWe searched the Cochrane Incontinence Group Specialised Register (9 February 2009) and reference lists of relevant articles. We also contacted researchers in the field.Selection criteriaRandomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse.Data collection and analysisTrials were assessed and data extracted independently by two review authors. Six investigators were contacted for additional information with five responding.Main resultsForty randomised controlled trials were identified evaluating 3773 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95{\%} CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95{\%} CI 0.18 to 0.86). However there was no statistically significant difference in re-operation rates for prolapse (RR 0.46, 95{\%} CI 0.19 to 1.11). The vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The three trials contributing to this analysis were clinically heterogeneous.For anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented with a polyglactin mesh inlay (RR 1.39, 95{\%} CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95{\%} CI 1.20 to 6.14); but data on morbidity and other clinical outcomes were lacking. Standard anterior repair was associated with more anterior compartment failures on examination than for polypropylene mesh repair as an overlay (RR 2.14, 95{\%} CI 1.23 to 3.74) or armed transobturator mesh (RR 3.55, 95{\%} CI 2.29 to 5.51). Data relating to polypropylene mesh overlay were extracted from conference abstracts without any peer reviewed manuscripts available and should be interpreted with caution. No differences in subjective outcomes, quality of life data, de novo dyspareunia, stress incontinence, re-operation rates for prolapse or incontinence were identified. Blood loss with transobturator meshes was significantly higher than for native tissue anterior repair. Mesh erosions were reported in 10{\%} (30/293) of anterior repairs with polypropylene mesh.For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele or enterocele, or both, than the transanal approach (RR 0.24, 95{\%} CI 0.09 to 0.64); although there was a higher blood loss and post-operative narcotic use. No data exist on efficacy or otherwise of polypropylene mesh in the posterior vaginal compartment.Meta-analysis on the impact of continence surgery at the time of prolapse surgery was performed with data from seven studies. Continence surgery at the time of prolapse surgery in continent women did not significantly reduce the rate of post-operative stress urinary incontinence (RR 1.39, 95{\%} CI 0.53 to 3.70; random-effects model).Authors' conclusionsAbdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse and dyspareunia than with vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair reduces the risk of recurrent anterior wall prolapse, on examination. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The value of the addition of a continence procedure to a prolapse repair operation in women who are dry before operation remains to be assessed. Adequately powered randomised controlled clinical trials are urgently needed on a wide variety of issues and particularly need to include women's perceptions of prolapse symptoms.",
keywords = "rectal prolapse [surgery], randomized controlled trials as topic, endopelvic fascia plication, humans, reduction efforts care, skin collagen implants, urinary bladder diseases [surgery], prolapse, urinary incontinence [surgery], gynecologic surgical procedures [methods], Burch colposuspension, anterior colporrhaphy, randomized controlled-trial, polypropylene mesh, abdominal sacral colpopexy, uterine prolapse [surgery], suture techniques, surgical mesh, female, stress urinary-incontinence, vaginal wall prolapse",
author = "Christopher Maher and Benjamin Feiner and Kaven Baessler and Glazener, {Cathryn M. A.}",
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TY - JOUR

T1 - Surgical management of pelvic organ prolapse in women

AU - Maher, Christopher

AU - Feiner, Benjamin

AU - Baessler, Kaven

AU - Glazener, Cathryn M. A.

PY - 2010/5/12

Y1 - 2010/5/12

N2 - BackgroundPelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with the prolapse.SaveObjectivesTo determine the effects of the many different surgeries used in the management of pelvic organ prolapse.Search strategyWe searched the Cochrane Incontinence Group Specialised Register (9 February 2009) and reference lists of relevant articles. We also contacted researchers in the field.Selection criteriaRandomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse.Data collection and analysisTrials were assessed and data extracted independently by two review authors. Six investigators were contacted for additional information with five responding.Main resultsForty randomised controlled trials were identified evaluating 3773 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86). However there was no statistically significant difference in re-operation rates for prolapse (RR 0.46, 95% CI 0.19 to 1.11). The vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The three trials contributing to this analysis were clinically heterogeneous.For anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented with a polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14); but data on morbidity and other clinical outcomes were lacking. Standard anterior repair was associated with more anterior compartment failures on examination than for polypropylene mesh repair as an overlay (RR 2.14, 95% CI 1.23 to 3.74) or armed transobturator mesh (RR 3.55, 95% CI 2.29 to 5.51). Data relating to polypropylene mesh overlay were extracted from conference abstracts without any peer reviewed manuscripts available and should be interpreted with caution. No differences in subjective outcomes, quality of life data, de novo dyspareunia, stress incontinence, re-operation rates for prolapse or incontinence were identified. Blood loss with transobturator meshes was significantly higher than for native tissue anterior repair. Mesh erosions were reported in 10% (30/293) of anterior repairs with polypropylene mesh.For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele or enterocele, or both, than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64); although there was a higher blood loss and post-operative narcotic use. No data exist on efficacy or otherwise of polypropylene mesh in the posterior vaginal compartment.Meta-analysis on the impact of continence surgery at the time of prolapse surgery was performed with data from seven studies. Continence surgery at the time of prolapse surgery in continent women did not significantly reduce the rate of post-operative stress urinary incontinence (RR 1.39, 95% CI 0.53 to 3.70; random-effects model).Authors' conclusionsAbdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse and dyspareunia than with vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair reduces the risk of recurrent anterior wall prolapse, on examination. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The value of the addition of a continence procedure to a prolapse repair operation in women who are dry before operation remains to be assessed. Adequately powered randomised controlled clinical trials are urgently needed on a wide variety of issues and particularly need to include women's perceptions of prolapse symptoms.

AB - BackgroundPelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with the prolapse.SaveObjectivesTo determine the effects of the many different surgeries used in the management of pelvic organ prolapse.Search strategyWe searched the Cochrane Incontinence Group Specialised Register (9 February 2009) and reference lists of relevant articles. We also contacted researchers in the field.Selection criteriaRandomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse.Data collection and analysisTrials were assessed and data extracted independently by two review authors. Six investigators were contacted for additional information with five responding.Main resultsForty randomised controlled trials were identified evaluating 3773 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86). However there was no statistically significant difference in re-operation rates for prolapse (RR 0.46, 95% CI 0.19 to 1.11). The vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The three trials contributing to this analysis were clinically heterogeneous.For anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented with a polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14); but data on morbidity and other clinical outcomes were lacking. Standard anterior repair was associated with more anterior compartment failures on examination than for polypropylene mesh repair as an overlay (RR 2.14, 95% CI 1.23 to 3.74) or armed transobturator mesh (RR 3.55, 95% CI 2.29 to 5.51). Data relating to polypropylene mesh overlay were extracted from conference abstracts without any peer reviewed manuscripts available and should be interpreted with caution. No differences in subjective outcomes, quality of life data, de novo dyspareunia, stress incontinence, re-operation rates for prolapse or incontinence were identified. Blood loss with transobturator meshes was significantly higher than for native tissue anterior repair. Mesh erosions were reported in 10% (30/293) of anterior repairs with polypropylene mesh.For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele or enterocele, or both, than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64); although there was a higher blood loss and post-operative narcotic use. No data exist on efficacy or otherwise of polypropylene mesh in the posterior vaginal compartment.Meta-analysis on the impact of continence surgery at the time of prolapse surgery was performed with data from seven studies. Continence surgery at the time of prolapse surgery in continent women did not significantly reduce the rate of post-operative stress urinary incontinence (RR 1.39, 95% CI 0.53 to 3.70; random-effects model).Authors' conclusionsAbdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse and dyspareunia than with vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair reduces the risk of recurrent anterior wall prolapse, on examination. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The value of the addition of a continence procedure to a prolapse repair operation in women who are dry before operation remains to be assessed. Adequately powered randomised controlled clinical trials are urgently needed on a wide variety of issues and particularly need to include women's perceptions of prolapse symptoms.

KW - rectal prolapse [surgery]

KW - randomized controlled trials as topic

KW - endopelvic fascia plication

KW - humans

KW - reduction efforts care

KW - skin collagen implants

KW - urinary bladder diseases [surgery]

KW - prolapse

KW - urinary incontinence [surgery]

KW - gynecologic surgical procedures [methods]

KW - Burch colposuspension

KW - anterior colporrhaphy

KW - randomized controlled-trial

KW - polypropylene mesh

KW - abdominal sacral colpopexy

KW - uterine prolapse [surgery]

KW - suture techniques

KW - surgical mesh

KW - female

KW - stress urinary-incontinence

KW - vaginal wall prolapse

U2 - 10.1002/14651858.CD004014.pub4

DO - 10.1002/14651858.CD004014.pub4

M3 - Article

JO - Cochrane Database of Systematic Reviews

JF - Cochrane Database of Systematic Reviews

SN - 1469-493X

IS - 4

M1 - CD004014

ER -