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Meta-Analysis
. 2018 Mar 5;3(3):CD012975.
doi: 10.1002/14651858.CD012975.

Surgery for women with posterior compartment prolapse

Alex Mowat  1 , Declan Maher, Kaven Baessler, Corina Christmann-Schmid, Nir Haya, Christopher Maher
Affiliations
Meta-Analysis

Surgery for women with posterior compartment prolapse

Alex Mowat et al. Cochrane Database Syst Rev. .

Abstract

Background: Posterior vaginal wall prolapse (also known as 'posterior compartment prolapse') can cause a sensation of bulge in the vagina along with symptoms of obstructed defecation and sexual dysfunction. Interventions for prevention and conservative management include lifestyle measures, pelvic floor muscle training, and pessary use. We conducted this review to assess the surgical management of posterior vaginal wall prolapse.

Objectives: To evaluate the safety and effectiveness of any surgical intervention compared with another surgical intervention for management of posterior vaginal wall prolapse.

Search methods: We searched the Cochrane Incontinence Group Specialised Register of controlled trials, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (searched April 2017). We also searched the reference lists of relevant articles, and we contacted researchers in the field.

Selection criteria: We included randomised controlled trials (RCTs) comparing different types of surgery for posterior vaginal wall prolapse.

Data collection and analysis: We used Cochrane methods. Our primary outcomes were subjective awareness of prolapse, repeat surgery for any prolapse, and objectively determined recurrent posterior wall prolapse.

Main results: We identified 10 RCTs evaluating 1099 women. Evidence quality ranged from very low to moderate. The main limitations of evidence quality were risk of bias (associated mainly with performance, detection, and attrition biases) and imprecision (associated with small overall sample sizes and low event rates).Transanal repair versus transvaginal repair (four RCTs; n = 191; six months' to four years' follow-up)Awareness of prolapse is probably more common after the transanal approach (risk ratio (RR) 2.78, 95% confidence interval (CI) 1.00 to 7.70; 2 RCTs; n = 87; I2 = 0%; low-quality evidence). If 10% of women are aware of prolapse after transvaginal repair, between 10% and 79% are likely to be aware after transanal repair.Repeat surgery for any prolapse: Evidence is insufficient to show whether there were any differences between groups (RR 2.42, 95% CI 0.75 to 7.88; 1 RCT; n = 57; low-quality evidence).Recurrent posterior vaginal wall prolapse is probably more likely after transanal repair (RR 4.12, 95% CI 1.56 to 10.88; 2 RCTs; n = 87; I2 = 35%; moderate-quality evidence). If 10% of women have recurrent prolapse on examination after transvaginal repair, between 16% and 100% are likely to have recurrent prolapse after transanal repair.Postoperative obstructed defecation is probably more likely with transanal repair (RR 1.67, 95% CI 1.00 to 2.79; 3 RCTs; n = 113; I2 = 10%; low-quality evidence).Postoperative dyspareunia: Evidence is insufficient to show whether there were any differences between groups (RR 0.32, 95% CI 0.09 to 1.15; 2 RCTs; n = 80; I2 = 5%; moderate-quality evidence).Postoperative complications: Trials have provided no conclusive evidence of any differences between groups (RR 3.57, 95% CI 0.94 to 13.54; 3 RCTs; n = 135; I2 = 37%; low-quality evidence). If 2% of women have complications after transvaginal repair, then between 2% and 21% are likely to have complications after transanal repair.Evidence shows no clear differences between groups in operating time (in minutes) (mean difference (MD) 1.49, 95% CI -11.83 to 8.84; 3 RCTs; n = 137; I2 = 90%; very low-quality evidence).Biological graft versus native tissue repairEvidence is insufficient to show whether there were any differences between groups in rates of awareness of prolapse (RR 1.09, 95% CI 0.45 to 2.62; 2 RCTs; n = 181; I2 = 13%; moderate-quality evidence) or repeat surgery for any prolapse (RR 0.60, 95% CI 0.18 to 1.97; 2 RCTs; n = 271; I2 = 0%; moderate-quality evidence). Trials have provided no conclusive evidence of a difference in rates of recurrent posterior vaginal wall prolapse (RR 0.55, 95% CI 0.30 to 1.01; 3 RCTs; n = 377; I2 = 6%; moderate-quality evidence); if 13% of women have recurrent prolapse on examination after native tissue repair, between 4% and 13% are likely to have recurrent prolapse after biological graft. Evidence is insufficient to show whether there were any differences between groups in rates of postoperative obstructed defecation (RR 0.96, 95% CI 0.50 to 1.86; 2 RCTs; n = 172; I2 = 42%; moderate-quality evidence) or postoperative dyspareunia (RR 1.27, 95% CI 0.26 to 6.25; 2 RCTs; n = 152; I2 = 74%; low-quality evidence). Postoperative complications were more common with biological repair (RR 1.82, 95% CI 1.22 to 2.72; 3 RCTs; n = 448; I2 = 0%; low-quality evidence).Other comparisonsSingle RCTs compared site-specific vaginal repair versus midline fascial plication (n = 74), absorbable graft versus native tissue repair (n = 132), synthetic graft versus native tissue repair (n = 191), and levator ani plication versus midline fascial plication (n = 52). Data were scanty, and evidence was insufficient to show any conclusions about the relative effectiveness or safety of any of these interventions. The mesh exposure rate in the synthetic group compared with the native tissue group was 7%.

Authors' conclusions: Transvaginal repair may be more effective than transanal repair for posterior wall prolapse in preventing recurrence of prolapse, in the light of both objective and subjective measures. However, data on adverse effects were scanty. Evidence was insufficient to permit any conclusions about the relative effectiveness or safety of other types of surgery. Evidence does not support the utilisation of any mesh or graft materials at the time of posterior vaginal repair. Withdrawal of some commercial transvaginal mesh kits from the market may limit the generalisability of our findings.

PubMed Disclaimer

Conflict of interest statement

AM, DM, KB, CC, NH, and CM have no interests to declare.

Figures

1
1
PRISMA study flow diagram.
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 Transanal versus transvaginal, outcome: 1.1 Awareness of prolapse (subjective failure).
5
5
Forest plot of comparison: 1 Transanal versus transvaginal, outcome: 1.2 Repeat surgery for any prolapse.
6
6
Forest plot of comparison: 1 Transanal versus transvaginal, outcome: 1.3 Recurrent posterior vaginal wall prolapse (objective failure).
7
7
Forest plot of comparison: 4 Biological graft versus native tissue, outcome: 4.1 Awareness of prolapse (subjective failure).
8
8
Forest plot of comparison: 4 Biological graft versus native tissue, outcome: 4.2 Repeat surgery for any prolapse.
9
9
Forest plot of comparison: 4 Biological graft versus native tissue, outcome: 4.3 Objective failure (prolapse).
10
10
Forest plot of comparison: 5 Synthetic graft versus native tissue, outcome: 5.1 Repeat surgery for any prolapse.
11
11
Forest plot of comparison: 5 Synthetic graft versus native tissue, outcome: 5.2 Objective failure (prolapse).
1.1
1.1. Analysis
Comparison 1 Transanal versus transvaginal, Outcome 1 Awareness of prolapse (subjective failure).
1.2
1.2. Analysis
Comparison 1 Transanal versus transvaginal, Outcome 2 Repeat surgery for any prolapse.
1.3
1.3. Analysis
Comparison 1 Transanal versus transvaginal, Outcome 3 Recurrent posterior vaginal wall prolapse (objective failure).
1.4
1.4. Analysis
Comparison 1 Transanal versus transvaginal, Outcome 4 Bowel function.
1.5
1.5. Analysis
Comparison 1 Transanal versus transvaginal, Outcome 5 Sexual function.
1.6
1.6. Analysis
Comparison 1 Transanal versus transvaginal, Outcome 6 Prolapse outcomes.
1.7
1.7. Analysis
Comparison 1 Transanal versus transvaginal, Outcome 7 Adverse events.
1.8
1.8. Analysis
Comparison 1 Transanal versus transvaginal, Outcome 8 Perioperative outcomes ‐ dichotomous.
1.9
1.9. Analysis
Comparison 1 Transanal versus transvaginal, Outcome 9 Perioperative outcomes ‐ continuous.
1.10
1.10. Analysis
Comparison 1 Transanal versus transvaginal, Outcome 10 Investigations.
2.1
2.1. Analysis
Comparison 2 Site‐specific repair versus midline fascial plication, Outcome 1 Awareness of prolapse (subjective failure).
2.2
2.2. Analysis
Comparison 2 Site‐specific repair versus midline fascial plication, Outcome 2 Repeat surgery for any prolapse.
2.3
2.3. Analysis
Comparison 2 Site‐specific repair versus midline fascial plication, Outcome 3 Objective failure (prolapse).
2.4
2.4. Analysis
Comparison 2 Site‐specific repair versus midline fascial plication, Outcome 4 Bowel function.
2.5
2.5. Analysis
Comparison 2 Site‐specific repair versus midline fascial plication, Outcome 5 Sexual function.
2.6
2.6. Analysis
Comparison 2 Site‐specific repair versus midline fascial plication, Outcome 6 Quality of life and satisfaction.
2.7
2.7. Analysis
Comparison 2 Site‐specific repair versus midline fascial plication, Outcome 7 Adverse events.
2.8
2.8. Analysis
Comparison 2 Site‐specific repair versus midline fascial plication, Outcome 8 Perioperative outcomes ‐ dichotomous.
2.9
2.9. Analysis
Comparison 2 Site‐specific repair versus midline fascial plication, Outcome 9 Perioperative outcomes ‐ continuous.
3.1
3.1. Analysis
Comparison 3 Absorbable graft versus native tissue, Outcome 1 Objective failure (prolapse).
4.1
4.1. Analysis
Comparison 4 Biological graft versus native tissue, Outcome 1 Awareness of prolapse (subjective failure).
4.2
4.2. Analysis
Comparison 4 Biological graft versus native tissue, Outcome 2 Repeat surgery for any prolapse.
4.3
4.3. Analysis
Comparison 4 Biological graft versus native tissue, Outcome 3 Objective failure (prolapse).
4.4
4.4. Analysis
Comparison 4 Biological graft versus native tissue, Outcome 4 Bowel function.
4.5
4.5. Analysis
Comparison 4 Biological graft versus native tissue, Outcome 5 Sexual function.
4.6
4.6. Analysis
Comparison 4 Biological graft versus native tissue, Outcome 6 Prolapse outcomes.
4.7
4.7. Analysis
Comparison 4 Biological graft versus native tissue, Outcome 7 Quality of life and satisfaction.
4.8
4.8. Analysis
Comparison 4 Biological graft versus native tissue, Outcome 8 Adverse events.
4.9
4.9. Analysis
Comparison 4 Biological graft versus native tissue, Outcome 9 Perioperative outcomes ‐ dichotomous.
4.10
4.10. Analysis
Comparison 4 Biological graft versus native tissue, Outcome 10 Perioperative outcomes ‐ continuous.
5.1
5.1. Analysis
Comparison 5 Synthetic graft versus native tissue, Outcome 1 Repeat surgery for any prolapse.
5.2
5.2. Analysis
Comparison 5 Synthetic graft versus native tissue, Outcome 2 Objective failure (prolapse).
5.3
5.3. Analysis
Comparison 5 Synthetic graft versus native tissue, Outcome 3 Prolapse outcomes.
5.4
5.4. Analysis
Comparison 5 Synthetic graft versus native tissue, Outcome 4 Quality of life and satisfaction.
5.5
5.5. Analysis
Comparison 5 Synthetic graft versus native tissue, Outcome 5 Adverse events.
5.6
5.6. Analysis
Comparison 5 Synthetic graft versus native tissue, Outcome 6 Perioperative outcomes ‐ dichotomous.
See this image and copyright information in PMC

References

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Allahdin 2008 {published data only}
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