We searched the Cochrane Incontinence Group trials register (8 June 2004) and reference lists of relevant articles. We also contacted researchers in the field.
SELECTION CRITERIA: Trials were assessed and data extracted independently by at least two reviewers. Four investigators were contacted for additional information with two responding.
MAIN RESULTS: Fourteen randomised controlled trials were identified evaluating 1004 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), but the trend towards a lower re-operation rate for
prolapse following abdominal sacrocolpopexy was not statistically significant (RR 0.46, 95% CI 0.19 to 1.11). However, the vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to
activities of daily living. The data were to evaluate other clinical outcomes and adverse events. For the anterior vaginal wall
prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented by
Vicryl mesh overlay (RR 1.39, 95% CI 1.02 to 1.90) but data on morbidity and other clinical outcomes were too few for reliable comparisons. For posterior vaginal wall
prolapse, the vaginal approach was associated with a lower rate of recurrent
rectocele and/or
enterocele than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64), although there was a higher blood loss and postoperative
narcotic use. However, data on the effect of surgery on bowel symptoms and the use of
polyglactin mesh overlay on the risk of recurrent
rectocele were insufficient for meta-analysis.Meta-analysis on the impact of
pelvic organ prolapse surgery on continence issues was limited and inconclusive, although about 10% of women developed new symptoms after surgery. However, more women with occult
stress urinary incontinence developed postoperative
stress urinary incontinence after endopelvic fascia plication alone than after endopelvic fascia plication and
tension-free vaginal tape (RR 5.5, 95% CI 1.36 to 22.32).
REVIEWERS' CONCLUSIONS: Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault
prolapse and
dyspareunia than the 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 a
polyglactin mesh overlay at the time of anterior vaginal wall repair may reduce the risk of recurrent
cystocele. Posterior vaginal wall repair may be better than transanal repair in the management of
rectoceles in terms of recurrence of
prolapse. Adequately powered randomised controlled clinical trials are urgently needed.