Is levator ani avulsion a risk factor for prolapse recurrence? A systematic review and meta-analysis

Abstract

Introduction and hypothesis: Levator ani muscle avulsion as a risk factor for prolapse recurrence is not well established. This systematic review was aimed at evaluating the correlation between levator ani avulsion and postoperative prolapse recurrence with meta-analysis, specifically, the risk of subjective or objective prolapse recurrence and reoperation.

Methods: The protocol was registered in the International Prospective Register of Systematic Reviews (registration number CRD42021256675). A systematic literature search was conducted using PubMed, EMBASE and Cochrane Database of Systematic Reviews to identify all peer-reviewed studies that described levator avulsion in women and investigated operative and postoperative outcomes. All peer-reviewed, English-language cohort studies in those with and without levator avulsion with a minimum of 3 months' follow-up were included. Pooled unadjusted and adjusted odds ratios were calculated for subjective recurrence, objective recurrence and rates of re-operation. The Cochrane Collaboration Risk of Bias In Non-Randomized Studies (RoBINS) and The Grading of Recommendations Assessment, Development and Evaluation (GRADE) tools were used to assess the quality of the studies included.

Results: Twelve studies with a total of 2,637 subjects and a follow-up period 0.3-6.4 years were identified. There were insufficient data to report a pooled adjusted risk for subjective recurrence and reoperation. On low to moderate quality-adjusted data, the pooled odds of objective recurrence was not significantly associated with levator ani avulsion (aOR 1.68; 95% CI 0.78-3.66).

Conclusion: Levator ani avulsion has not been confirmed as a risk factor for objective prolapse recurrence. Further evidence is needed to investigate the correlation between levator ani avulsion and the risk of subjective recurrence and reoperation.

Keywords: Levator ani muscle avulsion; Pelvic organ prolapse; Recurrence; Risk factors; Surgery.

Fig. 1

Systematic review of the literature evaluating levator ani avulsion as a potential risk factor for prolapse recurrence. Flow chart summarising study selection and exclusion process

Fig. 2

Forest plot comparing unadjusted odds ratios (ORs) for subjective prolapse recurrence in patients with levator ani muscle avulsion. Summary of unadjusted odds ratios of papers reporting subjective prolapse recurrence. One asterisk indicates the native tissue group, two asterisks indicate the mesh group (vaginal and abdominal)

Fig. 3

Forest plot comparing unadjusted (a) and adjusted (b) odds ratios (ORs) for objective any-compartment prolapse recurrence in patients with levator ani muscle avulsion. Summary of odds ratios (unadjusted and adjusted) of papers reporting objective any-compartment prolapse recurrence. One asterisk indicates the native tissue group, two asterisks indicate the mesh group (vaginal and abdominal)

Fig. 4

Forest plot comparing unadjusted (a) and adjusted (b) odds ratios (ORs) for objective anterior compartment prolapse recurrence after native tissue or vaginal mesh surgery in patients with levator ani muscle avulsion. Summary of odds ratios (unadjusted and adjusted) of papers in subgroup analysis reporting objective anterior compartment-only prolapse recurrence

Fig. 5

Risk of bias summary. Visual representation using the robvis visualisation tool of risk of bias for all studies included in the meta-analysis

Fig. 6

Funnel plot and Egger regression test for a subjective recurrence (unadjusted), b objective any-compartment recurrence (unadjusted), c objective any-compartment recurrence (adjusted) and d adjusted objective anterior compartment-only recurrence. Summary of publication bias presented as funnel plots and Egger regression for subjective recurrence, objective any-compartment recurrence (unadjusted and adjusted) and objective anterior compartment-only recurrence

Fig. 7

Summary of findings