Surgery for women with apical vaginal prolapse

196 Pages·2017·1.38 MB·English

CochraneDatabaseofSystematicReviews
Surgery for women with apical vaginal prolapse (Review)
MaherC,FeinerB,BaesslerK,Christmann-SchmidC,HayaN,BrownJ
MaherC,FeinerB,BaesslerK,Christmann-SchmidC,HayaN,BrownJ.
Surgeryforwomenwithapicalvaginalprolapse.
CochraneDatabaseofSystematicReviews2016,Issue10.Art.No.:CD012376.
DOI:10.1002/14651858.CD012376.
www.cochranelibrary.com
Surgeryforwomenwithapicalvaginalprolapse(Review)
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
SUMMARYOFFINDINGSFORTHEMAINCOMPARISON . . . . . . . . . . . . . . . . . . . 4
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Figure3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Figure6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Figure7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Figure8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
ADDITIONALSUMMARYOFFINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . 35
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Analysis1.1.Comparison1Vaginalprocedureversussacralcolpopexy,Outcome1Awarenessofprolapse(2years). . 96
Analysis1.2.Comparison1Vaginalprocedureversussacralcolpopexy,Outcome2Repeatsurgery(2-4years). . . . 97
Analysis1.3.Comparison1Vaginalprocedureversussacralcolpopexy,Outcome3Anyrecurrentprolapse(1-2years). 98
Analysis1.4.Comparison1Vaginalprocedureversussacralcolpopexy,Outcome4Meshexposure(1-4years). . . . 99
Analysis1.5.Comparison1Vaginalprocedureversussacralcolpopexy,Outcome5Injuries. . . . . . . . . . 100
Analysis1.6.Comparison1Vaginalprocedureversussacralcolpopexy,Outcome6Repeatsurgeryformeshexposure(2-4
years). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Analysis1.7.Comparison1Vaginalprocedureversussacralcolpopexy,Outcome7Objectivefailure(2-4years). . . 102
Analysis1.8.Comparison1Vaginalprocedureversussacralcolpopexy,Outcome8POPQassessment(2years). . . 103
Analysis1.9.Comparison1Vaginalprocedureversussacralcolpopexy,Outcome9Stressurinaryincontinence(2years). 104
Analysis1.10.Comparison1Vaginalprocedureversussacralcolpopexy,Outcome10Urgeincontinence(denovo(2
years). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Analysis1.11.Comparison1Vaginalprocedureversussacralcolpopexy,Outcome11UrinaryVoidingdysfunction(de
novo). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Analysis1.12.Comparison1Vaginalprocedureversussacralcolpopexy,Outcome12Dyspareunia. . . . . . . 106
Analysis1.13.Comparison1Vaginalprocedureversussacralcolpopexy,Outcome13Sexualfunction. . . . . . 107
Analysis1.14.Comparison1Vaginalprocedureversussacralcolpopexy,Outcome14Qualityoflifeandsatisfaction(4
years). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Analysis1.15.Comparison1Vaginalprocedureversussacralcolpopexy,Outcome15Operatingtime(minutes). . . 109
Analysis1.16.Comparison1Vaginalprocedureversussacralcolpopexy,Outcome16Lengthofhospitalstay. . . . 110
Analysis1.17.Comparison1Vaginalprocedureversussacralcolpopexy,Outcome17Bloodtransfusion. . . . . . 111
Analysis2.1.Comparison2Vaginalsurgerywithmeshversuswithoutmesh,Outcome1Awarenessofprolapse(3years). 112
Analysis2.2.Comparison2Vaginalsurgerywithmeshversuswithoutmesh,Outcome2Repeatsurgery(1-3years). 113
Analysis2.3.Comparison2Vaginalsurgerywithmeshversuswithoutmesh,Outcome3Recurrentprolapseonexamination
(1-3years). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Analysis2.4.Comparison2Vaginalsurgerywithmeshversuswithoutmesh,Outcome4Injuries. . . . . . . . 115
Analysis2.5.Comparison2Vaginalsurgerywithmeshversuswithoutmesh,Outcome5Objectivefailure. . . . . 116
Analysis2.6.Comparison2Vaginalsurgerywithmeshversuswithoutmesh,Outcome6POPQassessment(1year). 117
Surgeryforwomenwithapicalvaginalprolapse(Review) i
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Analysis2.7.Comparison2Vaginalsurgerywithmeshversuswithoutmesh,Outcome7Stressurinaryincontinence(1-3
years)). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Analysis2.8.Comparison2Vaginalsurgerywithmeshversuswithoutmesh,Outcome8Urgeincontinence. . . . 119
Analysis2.9.Comparison2Vaginalsurgerywithmeshversuswithoutmesh,Outcome9Voidingdysfunction. . . 120
Analysis2.10.Comparison2Vaginalsurgerywithmeshversuswithoutmesh,Outcome10Dyspareunia(1-3years). 121
Analysis2.11.Comparison2Vaginalsurgerywithmeshversuswithoutmesh,Outcome11Pelvicorganprolapse/urinary
incontinencesexualquestionnaire(PISQ)(1year). . . . . . . . . . . . . . . . . . . . . . 122
Analysis2.12.Comparison2Vaginalsurgerywithmeshversuswithoutmesh,Outcome12PatientGlobalImpressionof
Improvement(PGI-I)(muchorverymuchbetter3years). . . . . . . . . . . . . . . . . . . 123
Analysis2.13.Comparison2Vaginalsurgerywithmeshversuswithoutmesh,Outcome13QualityoflifePROLAPSE. 123
Analysis2.14.Comparison2Vaginalsurgerywithmeshversuswithoutmesh,Outcome14Operatingtime(mins). . 124
Analysis2.15.Comparison2Vaginalsurgerywithmeshversuswithoutmesh,Outcome15Bloodtransfusion. . . 125
Analysis3.1.Comparison3Vaginalsurgery:comparisonofonenativetissuerepairversusanother,Outcome1Awareness
ofprolapse(2years). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Analysis3.2.Comparison3Vaginalsurgery:comparisonofonenativetissuerepairversusanother,Outcome2Repeat
surgery(2years). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Analysis3.3.Comparison3Vaginalsurgery:comparisonofonenativetissuerepairversusanother,Outcome3Injuries. 127
Analysis3.4.Comparison3Vaginalsurgery:comparisonofonenativetissuerepairversusanother,Outcome4Objective
failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Analysis3.5.Comparison3Vaginalsurgery:comparisonofonenativetissuerepairversusanother,Outcome5POPQ
assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Analysis3.6.Comparison3Vaginalsurgery:comparisonofonenativetissuerepairversusanother,Outcome6Stress
urinaryincontinencedenovo(1year). . . . . . . . . . . . . . . . . . . . . . . . . . 130
Analysis3.7.Comparison3Vaginalsurgery:comparisonofonenativetissuerepairversusanother,Outcome7Urge
incontinence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Analysis3.8.Comparison3Vaginalsurgery:comparisonofonenativetissuerepairversusanother,Outcome8Dyspareunia
(1year). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Analysis3.9.Comparison3Vaginalsurgery:comparisonofonenativetissuerepairversusanother,Outcome9Blood
transfusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Analysis4.1.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome1Awarenessofprolapse. 134
Analysis4.2. Comparison 4Vaginal hysterectomyvsalternativesforuterineprolapse,Outcome2Repeatprolapse
surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Analysis4.3.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome3Objectivefailureanysite
(POP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Analysis4.4.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome4Bladderinjuries. . 137
Analysis4.5.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome5Bowelinjuries(1year
review). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Analysis4.6.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome6Meshexposure. . 139
Analysis4.8.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome8Repeatsurgeryfor
incontinence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Analysis4.9.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome9Anteriorcompartment
prolapse(1yearreview). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Analysis4.10.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome10Apicalcompartment
prolapse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Analysis4.11.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome11Posteriorcompartment
prolapse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Analysis4.12.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome12POPQassessment
PointBa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Analysis4.13.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome13POPQassessment:
PointBp. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Analysis4.14.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome14POPQassessment:
PointC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Surgeryforwomenwithapicalvaginalprolapse(Review) ii
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Analysis4.15.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome15POPQassessment:
Totalvaginallength. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Analysis4.16.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome16Dyspareunia. . 148
Analysis4.17.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome17Qualityoflife:Pelvic
organprolapse/urinaryincontinencesexualquestionnaire. . . . . . . . . . . . . . . . . . . 148
Analysis4.18.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome18Operatingtime
(minutes). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Analysis4.19.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome19Hospitalstay. . 150
Analysis4.20.Comparison4Vaginalhysterectomyvsalternativesforuterineprolapse,Outcome20Bloodtransfusion. 151
Analysis5.1.Comparison5Sacralcolpopexymeshversusbiological,Outcome1Awarenessofprolapse(1-5years). . 151
Analysis5.2.Comparison5Sacralcolpopexymeshversusbiological,Outcome2Prolapsesurgery(1-5year). . . . 152
Analysis5.3.Comparison5Sacralcolpopexymeshversusbiological,Outcome3Surgerystressurinaryincontinence5
years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Analysis5.4. Comparison 5Sacral colpopexy meshversusbiological, Outcome 4Recurrentprolapse(any site on
examination(1-5year)). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Analysis5.5.Comparison5Sacralcolpopexymeshversusbiological,Outcome5Meshexposure(1-5year). . . . 155
Analysis5.6.Comparison5Sacralcolpopexymeshversusbiological,Outcome6Bladderinjury. . . . . . . . 156
Analysis5.7.Comparison5Sacralcolpopexymeshversusbiological,Outcome7Bowelinjury. . . . . . . . . 157
Analysis5.8.Comparison5Sacralcolpopexymeshversusbiological,Outcome8Surgerymeshexposure1-5years. . 158
Analysis5.9.Comparison5Sacralcolpopexymeshversusbiological,Outcome9apicalprolapse. . . . . . . . 159
Analysis5.10.Comparison5Sacralcolpopexymeshversusbiological,Outcome10POPQassessment. . . . . . 160
Analysis5.11.Comparison5Sacralcolpopexymeshversusbiological,Outcome11Dyspareunia(denovo1year)). . 161
Analysis5.12.Comparison5Sacralcolpopexymeshversusbiological,Outcome12Sexualfunction. . . . . . . 162
Analysis5.13.Comparison5Sacralcolpopexymeshversusbiological,Outcome13QualityoflifePROLAPSE(iyear). 163
Analysis5.14.Comparison5Sacralcolpopexymeshversusbiological,Outcome14Operatingtime(mins). . . . 164
Analysis5.15.Comparison5Sacralcolpopexymeshversusbiological,Outcome15Hospitalstay. . . . . . . . 164
Analysis5.16.Comparison5Sacralcolpopexymeshversusbiological,Outcome16Bloodtransfusion. . . . . . 165
Analysis5.17.Comparison5Sacralcolpopexymeshversusbiological,Outcome17painatnormalacivities(weekone). 166
Analysis5.18.Comparison5Sacralcolpopexymeshversusbiological,Outcome18Surgeryorpessaryforprolapse. . 166
Analysis6.1.Comparison6Sacralcolpopexy:Laparoscopicversusother,Outcome1RepeatProlapseSurgery. . . . 167
Analysis6.2.Comparison6Sacralcolpopexy:Laparoscopicversusother,Outcome2Recurrentprolapse(anysiteon
examination). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Analysis6.3.Comparison6Sacralcolpopexy:Laparoscopicversusother,Outcome3Meshexposure. . . . . . . 169
Analysis6.4.Comparison6Sacralcolpopexy:Laparoscopicversusother,Outcome4Bladderinjury. . . . . . . 170
Analysis6.5.Comparison6Sacralcolpopexy:Laparoscopicversusother,Outcome5Bowelinjury. . . . . . . . 171
Analysis6.6.Comparison6Sacralcolpopexy:Laparoscopicversusother,Outcome6PointBa. . . . . . . . . 172
Analysis6.7.Comparison6Sacralcolpopexy:Laparoscopicversusother,Outcome7PointBp. . . . . . . . . 173
Analysis6.8.Comparison6Sacralcolpopexy:Laparoscopicversusother,Outcome8PointC. . . . . . . . . 174
Analysis6.9.Comparison6Sacralcolpopexy:Laparoscopicversusother,Outcome9Stressurinaryincontinence(denovo
andpersistent). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Analysis6.10.Comparison6Sacralcolpopexy:Laparoscopicversusother,Outcome10QualityoflifePROLAPSE. . 175
Analysis6.11.Comparison6Sacralcolpopexy:Laparoscopicversusother,Outcome11Operatingtime(mins). . . 176
Analysis6.12.Comparison6Sacralcolpopexy:Laparoscopicversusother,Outcome12Hospitalstay. . . . . . . 177
Analysis6.13.Comparison6Sacralcolpopexy:Laparoscopicversusother,Outcome13Bloodtransfusion. . . . . 178
Analysis6.14.Comparison6Sacralcolpopexy:Laparoscopicversusother,Outcome14continencesurgery. . . . . 179
Analysis7.1.Comparison7Sacralcolpopexywithcontinencesurgeryvswithout,Outcome1Awarenessofprolapse(7
years). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Analysis7.2.Comparison7Sacralcolpopexywithcontinencesurgeryvswithout,Outcome2Repeatprolapsesurgeryor
pessary(2-7years)). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Analysis7.3. Comparison 7Sacralcolpopexy with continence surgery vswithout, Outcome 3Repeatsurgery for
incontinence(7years)). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Analysis7.4.Comparison7Sacralcolpopexywithcontinencesurgeryvswithout,Outcome4Objectivefailureanysite
(POP7years). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Surgeryforwomenwithapicalvaginalprolapse(Review) iii
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Analysis7.5.Comparison7Sacralcolpopexywithcontinencesurgeryvswithout,Outcome5POPQassessmentPoint
Ba. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Analysis7.6.Comparison7Sacralcolpopexywithcontinencesurgeryvswithout,Outcome6POPQassessment:Point
Bp. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Analysis7.7.Comparison7Sacralcolpopexywithcontinencesurgeryvswithout,Outcome7POPQassessment:Point
C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Analysis7.8.Comparison7Sacralcolpopexywithcontinencesurgeryvswithout,Outcome8Stressurinaryincontinence
(4-7years). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Analysis7.9.Comparison7Sacralcolpopexywithcontinencesurgeryvswithout,Outcome9Operatingtime(minutes). 185
Analysis7.10.Comparison7Sacralcolpopexywithcontinencesurgeryvswithout,Outcome10Bloodtransfusion. . 185
ADDITIONALTABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
WHAT’SNEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
DIFFERENCESBETWEENPROTOCOLANDREVIEW . . . . . . . . . . . . . . . . . . . . . 190
INDEXTERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Surgeryforwomenwithapicalvaginalprolapse(Review) iv
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[InterventionReview]
Surgery for women with apical vaginal prolapse
ChristopherMaher1,BenjaminFeiner2,KavenBaessler3,CorinaChristmann-Schmid4,NirHaya5,JulieBrown6
1RoyalBrisbaneWomen’sHospital,Brisbane,Australia.2HeadofUrogynecology&ReconstructivePelvicSurgery,HillelYaffeMedical
Center, Technion University, Hadera, Israel. 3Urogynaecology Department, Pelvic Floor Centre Charite, Berlin, Germany. 4New
Women’sClinic,LucerneCantonalHospital,Lucerne,Switzerland.5DepartmentofObstetricsandGynaecology,LadyDavisCarmel
MedicalCenter,andtheRuthandBruceRappaportSchoolofMedicine,Technion-IsraelInstituteofTechnology,Haifa,Israel.6Liggins
Institute,TheUniversityofAuckland,Auckland,NewZealand
Contact address: Christopher Maher, Royal Brisbane Women’s Hospital, University Queensland, Brisbane, Queensland, Australia.
[email protected].
Editorialgroup:CochraneGynaecologyandFertilityGroup.
Publicationstatusanddate:New,publishedinIssue10,2016.
Reviewcontentassessedasup-to-date: 6July2015.
Citation: MaherC,FeinerB,BaesslerK,Christmann-SchmidC,HayaN,BrownJ.Surgeryforwomenwithapicalvaginalprolapse.
CochraneDatabaseofSystematicReviews2016,Issue10.Art.No.:CD012376.DOI:10.1002/14651858.CD012376.
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
ABSTRACT
Background
Apicalvaginalprolapseisadescentoftheuterusorvaginal vault(post-hysterectomy).Various surgicaltreatmentsareavailableand
therearenoguidelinestorecommendwhichisthebest.
Objectives
Toevaluatethesafetyandefficacyofanysurgicalinterventioncomparedtoanotherinterventionforthemanagementofapicalvaginal
prolapse.
Searchmethods
We searchedthe Cochrane Incontinence Group’s Specialised Register of controlledtrials, which contains trials identified from the
Cochrane CentralRegisterof ControlledTrials(CENTRAL), MEDLINE, ClinicalTrials.gov, WHOICTRP andhandsearchingof
journalsandconferenceproceedings(searchedJuly2015)andClinicalTrials.gov(searchedJanuary2016).
Selectioncriteria
Weincludedrandomisedcontrolledtrials(RCTs).
Datacollectionandanalysis
WeusedCochranemethods.Ourprimaryoutcomeswereawarenessofprolapse,repeatsurgeryandrecurrentprolapse(anysite).
Mainresults
Weincluded30RCTs(3414women)comparingsurgicalproceduresforapicalvaginalprolapse.Evidencequalityrangedfromlowto
moderate.Limitationsincludedimprecision,poormethodologicalreportingandinconsistency.
Vaginalproceduresversussacralcolpopexy(sixRCTs,n=583;onetofour-yearreview).
Surgeryforwomenwithapicalvaginalprolapse(Review) 1
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Awarenessofprolapsewasmorecommonaftervaginalprocedures(riskratio(RR)2.11,95%confidenceinterval(CI)1.06to4.21,3
RCTs,n=277,I2=0%,moderate-qualityevidence).If7%ofwomenareawareofprolapseaftersacralcolpopexy,14%(7%to27%)
arelikelytobeawareaftervaginalprocedures.
Repeatsurgeryforprolapsewasmorecommonaftervaginalprocedures(RR2.28,95%CI1.20to4.32;4RCTs,n=383,I2 =0%,
moderate-qualityevidence).Theconfidenceintervalsuggeststhatif4%ofwomenrequirerepeatprolapsesurgeryaftersacralcolpopexy,
between5%and18%wouldrequireitaftervaginalprocedures.
Wefoundnoconclusive evidence thatvaginal proceduresincreaserepeatsurgeryforstressurinaryincontinence(SUI)(RR1.87, 95%
CI0.72to4.86;4RCTs,n=395;I2 =0%,moderate-qualityevidence).If3%ofwomenrequirerepeatsurgeryforSUIaftersacral
colpopexy,between2%and16%arelikelytodosoaftervaginalprocedures.
Recurrentprolapseisprobablymorecommonaftervaginalprocedures(RR1.89,95%CI1.33to2.70;4RCTs,n=390;I2 =41%,
moderate-qualityevidence).If23%ofwomenhaverecurrentprolapseaftersacralcolpopexy,about41%(31%to63%)arelikelyto
dosoaftervaginalprocedures.
Theeffectofvaginalproceduresonbladderinjurywasuncertain(RR0.57,95%CI0.14to2.36;5RCTs,n=511;I2=0%,moderate-
qualityevidence).
SUIwasmorecommonaftervaginalprocedures(RR1.86,95%CI1.17to2.94;3RCTs,n=263;I2=0%,moderate-qualityevidence).
Dyspareuniawasalsomorecommonaftervaginalprocedures(RR2.53,95%CI1.17to5.50;3RCTs,n=106,I2=43%,low-quality
evidence).
Vaginalsurgerywithmeshversuswithoutmesh(6RCTs,n=598,1-3yearreview).
Awarenessofprolapse-Theremaybelittleornodifferencebetweenthegroupsforthisoutcome(RR1.0895%CI0.35to3.301RCT
n=54,lowqualityevidence).Theconfidenceintervalwaswidesuggestingthatif18%ofwomenareawareofprolapseaftersurgery
withoutmesh,between6%and59%willbeawareofprolapseaftersurgerywithmesh.
Repeatsurgeryforprolapse-Theremaybelittleornodifferencebetweenthegroupsforthisoutcome(RR0.69,95%CI0.30to1.60;
5RCTs,n=497;I2=9%,low-qualityevidence).If4%ofwomenrequirerepeatsurgeryforprolapseaftersurgerywithoutmesh,1%
to7%arelikelytodosoaftersurgerywithmesh.
WefoundnoconclusiveevidencethatsurgerywithmeshincreasesrepeatsurgeryforSUI(RR4.91,95%CI0.86to27.94;2RCTs,
n=220;I2=0%,low-qualityevidence).Theconfidenceintervalwaswidesuggestingthatif2%ofwomenrequirerepeatsurgeryfor
SUIaftervaginalcolpopexywithoutmesh,2%to53%arelikelytodosoaftersurgerywithmesh.
Wefoundnoclearevidencethatsurgerywithmeshdecreasesrecurrentprolapse(RR0.36,95%CI0.09to1.40;3RCTsn=269;I2=
91%,low-qualityevidence).Theconfidenceintervalwasverywideandtherewasseriousinconsistencybetweenthestudies.
Otheroutcomes
ThereisprobablylittleornodifferencebetweenthegroupsinratesofSUI(denovo)(RR1.37,95%CI0.94to1.99;4RCTs,n=
295;I2=0%,moderate-qualityevidence)ordyspareunia(RR1.21,95%CI0.55to2.66;5RCTs,n=501;I2=0%moderate-quality
evidence).Weareuncertainwhetherthereisanydifferenceforbladderinjury(RR3.00,95%CI0.91to9.89;4RCTs,n=445;I2=
0%;verylow-qualityevidence).
Vaginalhysterectomyversusalternativesforuterineprolapse(sixstudies,n=667)
Noclearconclusionscouldbereachedfromtheavailableevidence,thoughoneRCTfoundthatawarenessofprolapsewaslesslikely
afterhysterectomythanafterabdominalsacrohysteropexy(RR0.38,955CI0.15to0.98,n=84,moderate-qualityevidence).
Othercomparisons
Therewasnoevidenceofadifferenceforanyofourprimaryreviewoutcomesbetweendifferenttypesofvaginalnativetissuerepair(two
RCTs),comparisonsofgraftmaterialsforvaginalsupport(twoRCTs),differentroutesforsacralcolpopexy(fourRCTs),orbetween
sacralcolpopexywithandwithoutcontinencesurgery(fourRCTs).
Authors’conclusions
Sacralcolpopexyisassociatedwithlowerriskofawarenessofprolapse,recurrentprolapseonexamination,repeatsurgeryforprolapse,
postoperativeSUIanddyspareuniathanavarietyofvaginalinterventions.
Surgeryforwomenwithapicalvaginalprolapse(Review) 2
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Thelimitedevidencedoesnotsupportuseoftransvaginalmeshcomparedtonativetissuerepairforapicalvaginalprolapse.Mostof
theevaluatedtransvaginalmeshesarenolongeravailableandnewlightermeshescurrentlylackevidenceofsafety
Theevidencewasinconclusivewhencomparingaccessroutesforsacralcolpopexy.
Noclearconclusioncanbereachedfromtheavailabledatacomparinguterinepreservingsurgeryversusvaginalhysterectomyforuterine
prolapse.
PLAIN LANGUAGE SUMMARY
Surgicalmanagementofpelvicorganprolapseinwomen
Reviewquestion
Whichsurgicalinterventionsforapicalvaginalprolapsehavethebestoutcomes?
Background
Apical vaginal prolapse is a descent of the uterus or (after hysterectomy) the upper vagina (vault). Various surgical treatments are
availableandtherearenoguidelinestorecommendwhichisthebest.
Studycharacteristics
Thirtyrandomisedcontrolledtrialsevaluated3414womenwhounderwentsurgeryforapicalvaginal prolapse.Themostcommon
comparisonswerebetweenvaginalsurgeryandsacralcolpopexy(anabdominalproceduresuspendingtheuppervaginatothesacrum
withagraft)(sixRCTs),vaginalsurgerywithmeshversuswithout(sixRCTs),vaginalhysterectomyversusalternatives(sixRCTs),and
differenttypesorroutesofsacralcolpopexy(eightRCTs).TheevidenceiscurrenttoJuly2015.
Keyresults
Compared to various vaginal repairs, sacral colpopexy was associated with lower rates of awareness of prolapse, repeat surgery for
prolapse,prolapseonexamination,urinarystressincontinence(SUI)andpainfulintercourse.If7%ofwomenareawareofprolapse
aftersacralcolpopexy,14%(7%to27%)arelikelytobeawareaftervaginalprocedures.If4%ofwomenrequirerepeatprolapsesurgery
aftersacralcolpopexy,between5%and18%wouldrequireitaftervaginalprocedures.
WefoundnoconclusiveevidencethatvaginalproceduresincreasetheneedforrepeatsurgeryforSUI.If3%ofwomenrequirerepeat
surgeryforSUIaftersacralcolpopexy,between2%and16%arelikelytodosoaftervaginalprocedures.
Thelimitedevidencedoesnotsupporttheuseoftransvaginalmeshcomparedtonativetissuerepairs.Theevidencewasimprecise,but
suggeststhatif18%ofwomenareawareofprolapseaftersurgerywithoutmesh,between6%and59%willbeawareaftersurgerywith
mesh.If4%ofwomenrequirerepeatsurgeryforprolapseaftersurgerywithoutmesh,1%to7%arelikelytodosoaftersurgerywith
mesh.Wefoundnoclearevidencethatsurgerywithmeshdecreasesrecurrentprolapse.Mostoftheevaluatedtransvaginalmeshesare
nolongeravailableandnewlightermesheslackevidenceofsafety.
Theevidencewasinconclusiveincomparisonsofuterinepreservingsurgeryversusvaginalhysterectomy,anddifferentaccessroutesfor
sacralcolpopexy.
Qualityoftheevidence
Evidencequalityrangedfromverylowtomoderate.Limitationsincludedimprecision,poorreportingofstudymethodsandinconsis-
tency.
Surgeryforwomenwithapicalvaginalprolapse(Review) 3
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
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