We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In Process and handsearching of journals and conference proceedings, healthcare-related bibliographic databases, handsearched conference proceedings (searched 20 August 2012), and reference lists of relevant articles. We also contacted researchers in the field.
SELECTION CRITERIA: Trials were assessed and data extracted independently by two review authors. Six investigators were contacted for additional information with five responding.
MAIN RESULTS: Fifty-six randomised controlled trials were identified evaluating 5954 women. For upper
vaginal prolapse (uterine or vault) abdominal sacral colpopexy was associated with a lower rate of recurrent vault
prolapse on examination and painful intercourse 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. In single studies the sacral colpopexy had a higher success rate on examination and lower reoperation rate than high vaginal uterosacral
suspension and transvaginal
polypropylene mesh.Twenty-one trials compared a variety of
surgical procedures for anterior compartment
prolapse (
cystocele). Ten compared native tissue repair with graft (absorbable and permanent mesh,
biological grafts) repair for anterior compartment
prolapse. Native tissue anterior repair was associated with more recurrent anterior compartment
prolapse than when supplemented with a
polyglactin (absorbable) mesh
inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh
inlay (RR 2.08, 95% CI 1.08 to 4.01), however there was no difference in post-operative awareness of
prolapse after absorbable mesh (RR 0.96, 95% CI 0.33 to 2.81) or a
biological graft (RR 1.21, 95% CI 0.64 to 2.30). Data on morbidity and other clinical outcomes were lacking. Standard anterior repair was associated with more anterior compartment
prolapse on examination than for any
polypropylene (permanent) mesh repair (RR 3.15, 95% CI 2.50 to 3.96). Awareness of
prolapse was also higher after the anterior repair as compared to
polypropylene mesh repair (28% versus 18%, RR 1.57, 95% CI 1.18 to 2.07). However, the reoperation rate for
prolapse was similar at 14/459 (3%) after the native tissue repair compared to 6/470 (1.3%) (RR 2.18, 95% CI 0.93 to 5.10) after the anterior
polypropylene mesh repair and no differences in quality of life data or de novo
dyspareunia were identified. Blood loss (MD 64 ml, 95% CI 48 to 81), operating time (MD 19 min, 95% CI 16 to 21), recurrences in apical or posterior compartment (RR 1.9, 95% CI 1.0 to 3.4) and de novo
stress urinary incontinence (RR 1.8, 95% CI 1.0 to 3.1) were significantly higher with transobturator meshes than for native tissue anterior repair. Mesh erosions were reported in 11.4% (64/563), with surgical interventions being performed in 6.8% (32/470).Data from three trials compared native tissue repairs with a variety of total, anterior, or posterior
polypropylene kit meshes for
vaginal prolapse in multiple compartments. While no difference in awareness of
prolapse was able to be identified between the groups (RR 1.3, 95% CI 0.6 to 1.7) the recurrence rate on examination was higher in the native tissue repair group compared to the transvaginal
polypropylene mesh group (RR 2.0, 95% CI 1.3 to 3.1). The mesh erosion rate was 35/194 (18%), and 18/194 (9%) underwent surgical correction for mesh erosion. The reoperation rate after transvaginal
polypropylene mesh repair of 22/194 (11%) was higher than after the native tissue repair (7/189, 3.7%) (RR 3.1, 95% CI 1.3 to 7.3).Data from three trials compared posterior vaginal repair and transanal repair for the treatment of posterior compartment
prolapse (
rectocele). The posterior vaginal repair had fewer recurrent
prolapse symptoms (RR 0.4, 95% CI 0.2 to 1.0) and lower recurrence on examination (RR 0.2, 95% CI 0.1 to 0.6) and on defecography (MD -1.2 cm, 95% CI -2.0 to -0.3).Sixteen trials included significant data on bladder outcomes following a variety of
prolapse surgeries. Women undergoing
prolapse surgery may have benefited from having continence surgery performed concomitantly, especially if they had
stress urinary incontinence (RR 7.4, 95% CI 4.0 to 14) or if they were continent and had occult
stress urinary incontinence demonstrated pre-operatively (RR 3.5, 95% CI 1.9 to 6.6). Following
prolapse surgery, 12% of women developed de novo symptoms of bladder overactivity and 9% de novo voiding dysfunction.
AUTHORS' CONCLUSIONS: Sacral colpopexy has superior outcomes to a variety of vaginal procedures including sacrospinous colpopexy, uterosacral colpopexy and transvaginal mesh. 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. Anterior vaginal
polypropylene mesh also reduces awareness of
prolapse, however these benefits must be weighted against increased operating time, blood loss, rate of apical or posterior compartment
prolapse, de novo
stress urinary incontinence, and reoperation rate for mesh exposures associated with the use of
polypropylene mesh.Posterior vaginal wall repair may be better than transanal repair in the management of
rectocele in terms of recurrence of
prolapse. The evidence is not supportive of any grafts at the time of posterior vaginal repair. Adequately powered randomised, controlled clinical trials with blinding of assessors are urgently needed on a wide variety of issues, and they particularly need to include women's perceptions of
prolapse symptoms. Following the withdrawal of some commercial transvaginal mesh kits from the market, the generalisability of the findings, especially relating to anterior compartment transvaginal mesh, should be interpreted with caution.