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Meta-Analysis
. 2016 Nov 30;11(11):CD004014.
doi: 10.1002/14651858.CD004014.pub6.

Surgery for women with anterior compartment prolapse

Christopher Maher  1 , Benjamin Feiner, Kaven Baessler, Corina Christmann-Schmid, Nir Haya, Julie Brown
Affiliations
Meta-Analysis

Surgery for women with anterior compartment prolapse

Christopher Maher et al. Cochrane Database Syst Rev. .

Abstract

Background: To minimise the rate of recurrent prolapse after traditional native tissue repair (anterior colporrhaphy), clinicians have utilised a variety of surgical techniques.

Objectives: To determine the safety and effectiveness of surgery for anterior compartment prolapse.

Search methods: We searched the Cochrane Incontinence Group Specialised Register, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In Process (23 August 2016), handsearched journals and conference proceedings (15 February 2016) and searched trial registers (1 August 2016).

Selection criteria: Randomised controlled trials (RCTs) that examined surgical operations for anterior compartment prolapse.

Data collection and analysis: Two review authors independently selected trials, assessed risk of bias and extracted data. Primary outcomes were awareness of prolapse, repeat surgery and recurrent prolapse on examination.

Main results: We included 33 trials (3332 women). The quality of evidence ranged from very low to moderate. Limitations were risk of bias and imprecision. We have summarised results for the main comparisons. Native tissue versus biological graft Awareness of prolapse: Evidence suggested few or no differences between groups (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.52 to 1.82; five RCTs; 552 women; I2 = 39%; low-quality evidence), indicating that if 12% of women were aware of prolapse after biological graft, 7% to 23% would be aware after native tissue repair. Repeat surgery for prolapse: Results showed no probable differences between groups (RR 1.02, 95% CI 0.53 to 1.97; seven RCTs; 650 women; I2 = 0%; moderate-quality evidence), indicating that if 4% of women required repeat surgery after biological graft, 2% to 9% would do so after native tissue repair. Recurrent anterior compartment prolapse: Native tissue repair probably increased the risk of recurrence (RR 1.32, 95% CI 1.06 to 1.65; eight RCTs; 701 women; I2 = 26%; moderate-quality evidence), indicating that if 26% of women had recurrent prolapse after biological graft, 27% to 42% would have recurrence after native tissue repair. Stress urinary incontinence (SUI): Results showed no probable differences between groups (RR 1.44, 95% CI 0.79 to 2.64; two RCTs; 218 women; I2 = 0%; moderate-quality evidence). Dyspareunia: Evidence suggested few or no differences between groups (RR 0.87, 95% CI 0.39 to 1.93; two RCTs; 151 women; I2 = 0%; low-quality evidence). Native tissue versus polypropylene mesh Awareness of prolapse: This was probably more likely after native tissue repair (RR 1.77, 95% CI 1.37 to 2.28; nine RCTs; 1133 women; I2 = 0%; moderate-quality evidence), suggesting that if 13% of women were aware of prolapse after mesh repair, 18% to 30% would be aware of prolapse after native tissue repair. Repeat surgery for prolapse: This was probably more likely after native tissue repair (RR 2.03, 95% CI 1.15 to 3.58; 12 RCTs; 1629 women; I2 = 39%; moderate-quality evidence), suggesting that if 2% of women needed repeat surgery after mesh repair, 2% to 7% would do so after native tissue repair. Recurrent anterior compartment prolapse: This was probably more likely after native tissue repair (RR 3.01, 95% CI 2.52 to 3.60; 16 RCTs; 1976 women; I2 = 39%; moderate-quality evidence), suggesting that if recurrent prolapse occurred in 13% of women after mesh repair, 32% to 45% would have recurrence after native tissue repair. Repeat surgery for prolapse, stress urinary incontinence or mesh exposure (composite outcome): This was probably less likely after native tissue repair (RR 0.59, 95% CI 0.41 to 0.83; 12 RCTs; 1527 women; I2 = 45%; moderate-quality evidence), suggesting that if 10% of women require repeat surgery after polypropylene mesh repair, 4% to 8% would do so after native tissue repair. De novo SUI: Evidence suggested few or no differences between groups (RR 0.67, 95% CI 0.44 to 1.01; six RCTs; 957 women; I2 = 26%; low-quality evidence). No evidence suggested a difference in rates of repeat surgery for SUI. Dyspareunia (de novo): Evidence suggested few or no differences between groups (RR 0.54, 95% CI 0.27 to 1.06; eight RCTs; n = 583; I2 = 0%; low-quality evidence). Native tissue versus absorbable mesh Awareness of prolapse: It is unclear whether results showed any differences between groups (RR 0.95, 95% CI 0.70 to 1.31; one RCT; n = 54; very low-quality evidence), Repeat surgery for prolapse: It is unclear whether results showed any differences between groups (RR 2.13, 95% CI 0.42 to 10.82; one RCT; n = 66; very low-quality evidence). Recurrent anterior compartment prolapse: This is probably more likely after native tissue repair (RR 1.50, 95% CI 1.09 to 2.06; three RCTs; n = 268; I2 = 0%; moderate-quality evidence), suggesting that if 27% have recurrent prolapse after mesh repair, 29% to 55% would have recurrent prolapse after native tissue repair. SUI: It is unclear whether results showed any differences between groups (RR 0.72, 95% CI 0.50 to 1.05; one RCT; n = 49; very low-quality evidence). Dyspareunia: No data were reported.

Authors' conclusions: Biological graft repair or absorbable mesh provides minimal advantage compared with native tissue repair.Native tissue repair was associated with increased awareness of prolapse and increased risk of repeat surgery for prolapse and recurrence of anterior compartment prolapse compared with polypropylene mesh repair. However, native tissue repair was associated with reduced risk of de novo SUI, reduced bladder injury, and reduced rates of repeat surgery for prolapse, stress urinary incontinence and mesh exposure (composite outcome).Current evidence does not support the use of mesh repair compared with native tissue repair for anterior compartment prolapse owing to increased morbidity.Many transvaginal polypropylene meshes have been voluntarily removed from the market, and newer light-weight transvaginal meshes that are available have not been assessed by RCTs. Clinicans and women should be cautious when utilising these products, as their safety and efficacy have not been established.

PubMed Disclaimer

Conflict of interest statement

Nil.

Figures

1
1
PRISMA study flow diagram for 2016 review.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Forest plot of comparison: 1 Native tissue versus biological graft, outcome: 1.1 Awareness of prolapse.
5
5
Forest plot of comparison: 2 Native tissue versus polypropylene mesh, outcome: 2.1 Awareness of prolapse.
6
6
Forest plot of comparison: 2 Native tissue versus polypropylene mesh, outcome: 2.3 Recurrent anterior compartment prolapse.
7
7
Funnel plot of comparison: 2 Native tissue versus polypropylene mesh, outcome: 2.3 Recurrent anterior compartment prolapse.
1.1
1.1. Analysis
Comparison 1 Native tissue versus biological graft, Outcome 1 Awareness of prolapse.
1.2
1.2. Analysis
Comparison 1 Native tissue versus biological graft, Outcome 2 Repeat surgery.
1.3
1.3. Analysis
Comparison 1 Native tissue versus biological graft, Outcome 3 Recurrent anterior compartment prolapse.
1.4
1.4. Analysis
Comparison 1 Native tissue versus biological graft, Outcome 4 Stress urinary incontinence.
1.5
1.5. Analysis
Comparison 1 Native tissue versus biological graft, Outcome 5 POPQ assessment.
1.6
1.6. Analysis
Comparison 1 Native tissue versus biological graft, Outcome 6 Urge incontinence.
1.7
1.7. Analysis
Comparison 1 Native tissue versus biological graft, Outcome 7 Voiding dysfunction.
1.8
1.8. Analysis
Comparison 1 Native tissue versus biological graft, Outcome 8 Dyspareunia.
1.9
1.9. Analysis
Comparison 1 Native tissue versus biological graft, Outcome 9 Quality of life PROLAPSE.
1.10
1.10. Analysis
Comparison 1 Native tissue versus biological graft, Outcome 10 Operating time (minutes).
1.11
1.11. Analysis
Comparison 1 Native tissue versus biological graft, Outcome 11 Hospital stay.
2.1
2.1. Analysis
Comparison 2 Native tissue versus polypropylene mesh, Outcome 1 Awareness of prolapse.
2.2
2.2. Analysis
Comparison 2 Native tissue versus polypropylene mesh, Outcome 2 Repeat surgery.
2.3
2.3. Analysis
Comparison 2 Native tissue versus polypropylene mesh, Outcome 3 Recurrent anterior compartment prolapse.
2.4
2.4. Analysis
Comparison 2 Native tissue versus polypropylene mesh, Outcome 4 Bladder injury.
2.5
2.5. Analysis
Comparison 2 Native tissue versus polypropylene mesh, Outcome 5 Apical or posterior compartment prolapse.
2.6
2.6. Analysis
Comparison 2 Native tissue versus polypropylene mesh, Outcome 6 POPQ assessment.
2.7
2.7. Analysis
Comparison 2 Native tissue versus polypropylene mesh, Outcome 7 Stress urinary incontinence (de novo).
2.8
2.8. Analysis
Comparison 2 Native tissue versus polypropylene mesh, Outcome 8 De novo dyspareunia.
2.9
2.9. Analysis
Comparison 2 Native tissue versus polypropylene mesh, Outcome 9 Voiding dysfunction.
2.10
2.10. Analysis
Comparison 2 Native tissue versus polypropylene mesh, Outcome 10 Urge incontinence.
2.11
2.11. Analysis
Comparison 2 Native tissue versus polypropylene mesh, Outcome 11 Dyspareunia.
2.12
2.12. Analysis
Comparison 2 Native tissue versus polypropylene mesh, Outcome 12 Quality of life PROLAPSE.
2.13
2.13. Analysis
Comparison 2 Native tissue versus polypropylene mesh, Outcome 13 Hospital stay (days).
2.14
2.14. Analysis
Comparison 2 Native tissue versus polypropylene mesh, Outcome 14 Operating time (minutes).
2.15
2.15. Analysis
Comparison 2 Native tissue versus polypropylene mesh, Outcome 15 Transfusion.
3.1
3.1. Analysis
Comparison 3 Subgroup analysis: native tissue versus polypropylene mesh available for use, Outcome 1 Awareness of prolapse.
3.2
3.2. Analysis
Comparison 3 Subgroup analysis: native tissue versus polypropylene mesh available for use, Outcome 2 Repeat surgery.
3.3
3.3. Analysis
Comparison 3 Subgroup analysis: native tissue versus polypropylene mesh available for use, Outcome 3 Recurrent anterior compartment prolapse.
4.1
4.1. Analysis
Comparison 4 Native tissue versus absorbable mesh, Outcome 1 Awareness of prolapse (2‐year review).
4.2
4.2. Analysis
Comparison 4 Native tissue versus absorbable mesh, Outcome 2 Repeat surgery for prolapse (2 years).
4.3
4.3. Analysis
Comparison 4 Native tissue versus absorbable mesh, Outcome 3 Anterior compartment prolapse (3 months‐2 years).
4.4
4.4. Analysis
Comparison 4 Native tissue versus absorbable mesh, Outcome 4 Death.
4.5
4.5. Analysis
Comparison 4 Native tissue versus absorbable mesh, Outcome 5 Posterior compartment prolapse.
4.6
4.6. Analysis
Comparison 4 Native tissue versus absorbable mesh, Outcome 6 Stress urinary incontinence.
4.7
4.7. Analysis
Comparison 4 Native tissue versus absorbable mesh, Outcome 7 Quality of life.
5.1
5.1. Analysis
Comparison 5 Mesh versus biological graft, Outcome 1 Awareness of prolapse.
5.2
5.2. Analysis
Comparison 5 Mesh versus biological graft, Outcome 2 Repeat surgery.
5.3
5.3. Analysis
Comparison 5 Mesh versus biological graft, Outcome 3 Recurrent anterior wall compartment prolapse (stage 2 or greater).
5.4
5.4. Analysis
Comparison 5 Mesh versus biological graft, Outcome 4 Mesh exposure.
5.5
5.5. Analysis
Comparison 5 Mesh versus biological graft, Outcome 5 Stress urinary incontinence (de novo).
5.6
5.6. Analysis
Comparison 5 Mesh versus biological graft, Outcome 6 Urgency, detrusor overactivity or overactive bladder (de novo).
5.7
5.7. Analysis
Comparison 5 Mesh versus biological graft, Outcome 7 Dyspareunia (persistent).
6.1
6.1. Analysis
Comparison 6 Vaginal repair versus abdominal repair, Outcome 1 Recurrent anterior wall prolapse.
6.2
6.2. Analysis
Comparison 6 Vaginal repair versus abdominal repair, Outcome 2 Injury.
6.3
6.3. Analysis
Comparison 6 Vaginal repair versus abdominal repair, Outcome 3 Posterior compartment prolapse.
6.4
6.4. Analysis
Comparison 6 Vaginal repair versus abdominal repair, Outcome 4 POPQ assessment.
6.5
6.5. Analysis
Comparison 6 Vaginal repair versus abdominal repair, Outcome 5 Dyspareunia.
6.6
6.6. Analysis
Comparison 6 Vaginal repair versus abdominal repair, Outcome 6 Quality of life PROLAPSE.
6.7
6.7. Analysis
Comparison 6 Vaginal repair versus abdominal repair, Outcome 7 Operating time (minutes).
6.8
6.8. Analysis
Comparison 6 Vaginal repair versus abdominal repair, Outcome 8 Transfusion.
7.1
7.1. Analysis
Comparison 7 Native tissue repair versus graft repair for anterior and/or posterior prolapse, Outcome 1 Awareness of prolapse.
7.2
7.2. Analysis
Comparison 7 Native tissue repair versus graft repair for anterior and/or posterior prolapse, Outcome 2 Repeat surgery prolapse.
7.3
7.3. Analysis
Comparison 7 Native tissue repair versus graft repair for anterior and/or posterior prolapse, Outcome 3 Recurrent anterior wall prolapse (stage 2 or greater).
7.4
7.4. Analysis
Comparison 7 Native tissue repair versus graft repair for anterior and/or posterior prolapse, Outcome 4 Bladder injury.
7.5
7.5. Analysis
Comparison 7 Native tissue repair versus graft repair for anterior and/or posterior prolapse, Outcome 5 Stress urinary incontinence (de novo).
7.6
7.6. Analysis
Comparison 7 Native tissue repair versus graft repair for anterior and/or posterior prolapse, Outcome 6 Dyspareunia (de novo and persistent).
7.7
7.7. Analysis
Comparison 7 Native tissue repair versus graft repair for anterior and/or posterior prolapse, Outcome 7 Quality of life PROLAPSE.
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Update of

References

References to studies included in this review

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Sivaslioglu 2008 {published data only}
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Vollebregt 2011 {published data only}
    1. Vollebregt A, Fischer K, Gietelink D, Vaart CH. Primary surgical repair of anterior vaginal prolapse: a randomised trial comparing anatomical and functional outcome between anterior colporrhaphy and trocar‐guided transobturator anterior mesh. BJOG 2011;118(12):1518‐27. [42606] - PubMed
    1. Vollebregt A, Gietelink D, Fischer K, Vaart H. One year results of colporrhaphy anterior versus a trocar guided transobturator synthetic mesh in primary cystocele repair: a randomized controlled trial (Abstract number 51). Neurourology and Urodynamics 2010;29(6):880‐2. [40124]
Weber 2001 {published data only}
    1. Weber AM, Walters MD, Piedmonte MR, Ballard LA. Anterior colporrhaphy: a randomized trial of three surgical techniques. American Journal of Obstetrics and Gynecology 2001;185(6 Pt 1):1299‐306. - PubMed
Withagen 2011 {published and unpublished data}
    1. Milani AL, Withagen MI, The HS, Nedelcu‐Van der Wijk I, Vierhout ME. Sexual function following trocar‐guided mesh or vaginal native tissue repair in recurrent prolapse: a randomized controlled trial. Journal of Sexual Medicine 2011;8(10):2944‐53. [42064] - PubMed
    1. Withagen MI, Milani AL, Boon Den J, Vervest HA, Vierhout ME. Tension free vaginal mesh compared to conventional vaginal prolapse surgery in recurrent prolapse: a randomized controlled trial (Abstract number 090). International Urogynecology Journal 2009;20 Suppl 2:S153‐4. [39885]
    1. Withagen MI, Milani AL, Boon J, Vervest HA, Vierhout ME. Trocar‐guided mesh compared with conventional vaginal repair in recurrent prolapse: a randomized controlled trial. Obstetrics and Gynecology 2011;117(2 Pt 1):242‐50. [40881] - PubMed

References to studies excluded from this review

Heinonen 2011 {published data only}
    1. Heinonen PK, Nieminen K. Combined anterior vaginal wall mesh with sacrospinous ligament fixation or with posterior intravaginal slingplasty for uterovaginal or vaginal vault prolapse. European Journal of Obstetrics, Gynecology, and Reproductive Biology 2011;157(2):230‐3. - PubMed
Kringel 2010 {published data only}
    1. Kringel U, Reimer T, Tomczak S, Green S, Kundt G, Gerber B. Postoperative infections due to bladder catheters after anterior colporrhaphy: a prospective, randomized three‐arm study. International Urogynecology Journal 2010;21(12):1499‐504. - PubMed
Tincello 2009 {published data only}
    1. Tincello DG, Kenyon S, Slack M, Toozs‐Hobson P, Mayne C, Jones D, et al. Colposuspension or TVT with anterior repair for urinary incontinence and prolapse: results of and lessons from a pilot randomised patient‐preference study (CARPET 1). BJOG 2009;116(13):1809‐14. - PubMed
    1. Tincello DG, Mayne CJ, Toozs‐Hobson P, Slack M. Randomised controlled trial of colposuspension versus anterior repair plus TVT for urodynamic stress incontinence with anterior vaginal prolapse: proposal (Abstract). Proceedings of the International Continence Society, 11th Annual Scientific Meeting; 2004 Mar 18‐19; Bournemouth, United Kingdom. 2004:46. [17170]
Van Der Steen 2011 {published data only}
    1. Steen A, Detollenaere R, Boon J, Eijndhoven H. One‐day versus 3‐day suprapubic catheterization after vaginal prolapse surgery: a prospective randomized trial. International Urogynecology Journal 2011;22(5):563‐7. - PMC - PubMed
Weemhoff 2011 {published data only}
    1. Weemhoff M, Wassen MM, Korsten L, Serroyen J, Kampschöer PH, Roumen FJ. Postoperative catheterization after anterior colporrhaphy: 2 versus 5 days. A multicentre randomized controlled trial. International Urogynecology Journal 2011;22(4):477‐83. - PMC - PubMed

References to ongoing studies

ACTRN12616000159459 {unpublished data only}
    1. ACTRN12616000159459. Anterior Pelvic Organ Prolapse Surgery: A randomised controlled trial of Xenform anterior repair versus anterior colporrhaphy [Anterior Pelvic Organ Prolapse Surgery: A randomised controlled trial of Xenform anterior repair versus anterior colporrhaphy evaluating at one‐year: recurrence, quality of life and need for re‐operation on anterior pelvic organ prolapse]. http://www.anzctr.org.au/ACTRN12616000159459.aspx 13 November 2015.
Cortesse 2010 {published data only}
    1. Cortesse A. Evaluating the necessity of TOT implantation in women with pelvic organ prolapse and occult stress urinary incontinence (ATHENA). http://clinicaltrials.gov/ct2/show/NCT01095692 (accessed 19 April 2011) 2011. [41350]
Glazener 2009 {published data only}
    1. Glazener CMA. Clinical and cost‐effectiveness of surgical options for the management of anterior and/or posterior vaginal wall prolapse: two randomised controlled trials within a comprehensive cohort study (PROSPECT). www.controlled‐trials.com/ISRCTN60695184 (accessed 13 April 2010) 2009.
Lucot 2015 {published data only}
    1. Lucot JP, Cosson M, Debodinance P, Bader G, Youssef A, Akladios C, et al. PROSPERE randomized controlled trial: Laparoscopic sacropexy versus vaginal mesh for cystocele pop repair. International Urogynecology Journal and Pelvic Floor Dysfunction 2015;26(1 Suppl 1):Abstract number PP 03.
NCT00955448 {published data only}
    1. NCT00955448. Randomized Controlled Trial of SIS Mesh for Anterior Repair: A Pilot Study [Trial of Small Intestine Submucosa (SIS) Mesh for Anterior Repair: A Pilot Study (Anterior SIS)]. http://clinicaltrials.gov/show/NCT00955448 5 August 2009.
NCT01497171 {published data only}
    1. NCT01497171. The Elegant Trial: Elevate Transvaginal Mesh Versus Anterior Colporrhaphy [Safety and Efficacy of Transvaginal Mesh Colposuspension for Anterior Vaginal Prolapse: the Elevate vs. Anterior Colporrhaphy Trial]. http://clinicaltrials.gov/show/NCT01497171 20 December 2011.
Verleyen 2004 {published data only}
    1. Verleyen P, Filip C, Bart K, Frank VDA, Jan D, Dirk DR. A prospective randomised trial comparing Pelvicol (trademark) and Vicryl (trademark) for cystocoele repair in the Raz‐colposuspension (Abstract number 613). Proceedings of the International Continence Society (34th Annual Meeting) and the International Urogynecological Association; 2004 Aug 23‐27; Paris. 2004.

Additional references

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Ek 2011
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Fatton 2007
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Ford 2015
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Hendrix 2002
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Maher 2016
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References to other published versions of this review

Maher 2004
    1. Maher C, Baessler K, Glazener CMA, Adams EJ, Hagen S. Surgical management of pelvic organ prolapse in women. Cochrane Database of Systematic Reviews 2004, Issue 4. [DOI: 10.1002/14651858.CD004014.pub2] - DOI - PubMed

Publication types