Surgical management of pelvic organ prolapse in women

Review question

Which surgical interventions for apical vaginal prolapse have the best outcomes?

Background

Apical vaginal prolapse is a descent of the uterus or the top of the vagina (vault) after hysterectomy. Various surgical treatments are available and there are no guidelines to recommend which is the best.

Study characteristics

Fifty-nine randomised controlled trials (RCTs) evaluated 6705 who underwent surgery for apical vaginal prolapse. The most common comparisons were between vaginal surgery and sacral colpopexy (an abdominal procedure suspending the upper vagina to the sacrum with a graft) (seven RCTs), vaginal surgery with mesh versus without (seven RCTs), vaginal hysterectomy versus abdominal suspensions (six RCTs), and different types or routes of sacral colpopexy (six RCTs). The evidence is current to March 2022.

Key results

In those with recurrent prolapse after a hysterectomy, sacral colpopexy (abdominal procedure) was associated with lower rates of awareness of prolapse, repeat surgery for prolapse, prolapse on examination, and urinary stress incontinence (SUI) compared to vaginal procedures. If 8% of women are aware of prolapse after sacral colpopexy, 18% (16% to 32%) are likely to be aware after vaginal procedures. If 6% of women require repeat prolapse surgery after sacral colpopexy, 14% (8% to 18%) would require it after vaginal procedures. If 17% of women have SUI after sacral colpopexy 31% (19% to 49%) would have it after vaginal apical surgery.

Sacral colpopexy can be utilised in those with uterine prolapse in the following ways: with uterine preservation (sacral hysteropexy), with subtotal hysterectomy (body of the uterus removed, and the cervix retained) or after total hysterectomy. However, the limited data are inconclusive of any benefit when compared to alternative vaginal interventions.

The limited evidence does not support the use of transvaginal mesh compared to native tissue repairs without mesh (vaginal repairs utilising sutures). The evidence was imprecise, but suggests that if 18% of women are aware of prolapse after surgery without mesh, between 6% and 59% will be aware after surgery with mesh. If 10% of women require repeat surgery for prolapse after surgery without mesh, 3% to 11% are likely to do so after surgery with mesh. We found no clear evidence that surgery with mesh decreases recurrent prolapse. Mesh was associated with a 17.5% rate of mesh exposure (mesh eroding into the vagina).

The evidence was inconclusive in comparisons of uterine preserving surgery versus vaginal hysterectomy, and different access routes for performing sacral colpopexy.

Certainty of the evidence

Evidence quality certainty ranged from very low to moderate. Limitations included imprecision, poor reporting of study methods and inconsistency.

Authors' conclusions: 

Sacral colpopexy is associated with lower risk of awareness of prolapse, recurrent prolapse on examination, repeat surgery for prolapse, and postoperative SUI than a variety of vaginal interventions.

The limited evidence does not support the use of transvaginal mesh compared to native tissue repair for apical vaginal prolapse.

There were no differences in primary outcomes for different routes of sacral colpopexy. However, the laparoscopic approach is associated with a shorter operating time than robotic approach, and shorter admission than open approach.

There were no significant differences between vaginal hysteropexy and vaginal hysterectomy for uterine prolapse nor between vaginal hysteropexy and abdominal hysteropexy/cervicopexy.

There were no differences detected between absorbable and non absorbable sutures however, the certainty of evidence for mesh exposure and dyspareunia was low.

Read the full abstract...
Background: 

Apical vaginal prolapse is the descent of the uterus or vaginal vault (post-hysterectomy). Various surgical treatments are available, but there are no guidelines to recommend which is the best.

Objectives: 

To evaluate the safety and efficacy of any surgical intervention compared to another intervention for the management of apical vaginal prolapse.

Search strategy: 

We searched the Cochrane Incontinence Group's Specialised Register of controlled trials, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings and ClinicalTrials.gov (searched 14 March 2022).

Selection criteria: 

We included randomised controlled trials (RCTs).

Data collection and analysis: 

We used Cochrane methods. Our primary outcomes were awareness of prolapse, repeat surgery and recurrent prolapse (any site).

Main results: 

We included 59 RCTs (6705 women) comparing surgical procedures for apical vaginal prolapse. Evidence certainty ranged from very low to moderate. Limitations included imprecision, poor methodology, and inconsistency.

Vaginal procedures compared to sacral colpopexy for vault prolapse (seven RCTs, n=613; six months to f four-year review)

Awareness of prolapse was more common after vaginal procedures (risk ratio (RR) 2.31, 95% confidence interval (CI) 1.27 to 4.21, 4 RCTs, n = 346, I2 = 0%, moderate-certainty evidence). If 8% of women are aware of prolapse after sacral colpopexy, 18% (10% to 32%) are likely to be aware after vaginal procedures.

Surgery for recurrent prolapse was more common after vaginal procedures (RR 2.33, 95% CI 1.34 to 4.04; 6 RCTs, n = 497, I2 = 0%, moderate-certainty evidence). The confidence interval suggests that if 6% of women require repeat prolapse surgery after sacral colpopexy, 14% (8% to 25%) are likely to require it after vaginal procedures.

Prolapse on examination is probably more common after vaginal procedures (RR 1.87, 95% CI 1.32 to 2.65; 5 RCTs, n = 422; I2 = 24%, moderate-certainty evidence). If 18% of women have recurrent prolapse after sacral colpopexy, between 23% and 47% are likely to do so after vaginal procedures.

Other outcomes:

Stress urinary incontinence (SUI) was more common after vaginal procedures (RR 1.86, 95% CI 1.17 to 2.94; 3 RCTs, n = 263; I2 = 0%, moderate-certainty evidence).

The effect of vaginal procedures on dyspareunia was uncertain (RR 3.44, 95% CI 0.61 to 19.53; 3 RCTs, n = 106, I2 = 65%, low-certainty evidence).

Vaginal hysterectomy compared to sacral hysteropexy/cervicopexy (six RCTS, 554 women, one to seven year review)

Awareness of prolapse - There may be little or no difference between the groups for this outcome (RR 1.01 95% CI 0.10 to 9.98; 2 RCTs, n = 200, very low-certainty evidence).

Surgery for recurrent prolapse - There may be little or no difference between the groups for this outcome (RR 0.85, 95% CI 0.47 to 1.54; 5 RCTs, n = 403; I2 = 9%, low-certainty evidence).

Prolapse on examination- there was little or no difference between the groups for this outcome (RR 0.78, 95% CI 0.54 to 1.11; 2 RCTs n = 230; I2 = 9%, moderate-certainty evidence).

Vaginal hysteropexy compared to sacral hysteropexy/cervicopexy (two RCTs, n = 388, 1-four-year review)

Awareness of prolapse - No difference between the groups for this outcome (RR 0.55 95% CI 0.21 to 1.44; 1 RCT n = 257, low-certainty evidence).

Surgery for recurrent prolapse - No difference between the groups for this outcome (RR 1.34, 95% CI 0.52 to 3.44; 2 RCTs, n = 345; I2 = 0%, moderate-certainty evidence).

Prolapse on examination- There were little or no difference between the groups for this outcome (RR 0.99, 95% CI 0.83 to 1.19; 2 RCTs n =367; I2 =9%, moderate-certainty evidence).

Vaginal hysterectomy compared to vaginal hysteropexy (four RCTs, n = 620, 6 months to five-year review)

Awareness of prolapse - There may be little or no difference between the groups for this outcome (RR 1.0 95% CI 0.44 to 2.24; 2 RCTs, n = 365, I2 = 0% moderate-quality certainty evidence).

Surgery for recurrent prolapse - There may be little or no difference between the groups for this outcome (RR 1.32, 95% CI 0.67 to 2.60; 3 RCTs, n = 443; I2 = 0%, moderate-certainty evidence).

Prolapse on examination- There were little or no difference between the groups for this outcome (RR 1.44, 95% CI 0.79 to 2.61; 2 RCTs n =361; I2 =74%, low-certainty evidence).

Other outcomes:

Total vaginal length (TVL) was shorter after vaginal hysterectomy (mean difference (MD) 0.89cm 95% CI 0.49 to 1.28cm shorter; 3 RCTs, n=413, low-certainty evidence).

There is probably little or no difference between the groups in terms of operating time, dyspareunia and stress urinary incontinence.

Other analyses

There were no differences identified for any of our primary review outcomes between different types of vaginal native tissue repair (4 RCTs), comparisons of graft materials for vaginal support (3 RCTs), pectopexy versus other apical suspensions (5 RCTs), continuous versus interrupted sutures at sacral colpopexy (2 RCTs), absorbable versus permanent sutures at apical suspensions (5 RCTs) or different routes of sacral colpopexy. Laparoscopic sacral colpopexy is associated with shorter admission time than open approach (3 RCTs) and quicker operating time than robotic approach (3 RCTs). Transvaginal mesh does not confer any advantage over native tissue repair, however is associated with a 17.5% rate of mesh exposure (7 RCTs).