Podcast: Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse

Many women who have had children will suffer from pelvic organ prolapsed and a series of six Cochrane Reviews are being prepared relating to the surgical management. The first of these has been published in February 2016 and we asked lead author, Chris Maher from the Royal Brisbane Women’s Hospital in Australia, to tell us about the findings.

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John: Many women who have had children will suffer from pelvic organ prolapse and a series of six Cochrane Reviews are being prepared relating to the surgical management. The first of these has been published in January 2016 and we asked lead author, Chris Maher from the Royal Brisbane Women’s Hospital in Australia, to tell us about the findings.

Chris: As John said, pelvic organ prolapse is common and, in fact, it can affect as many as 50% of women who have had children. It’s the descent of one or more of the pelvic organs: the womb, vagina, bladder or bowel; and our focus in this review is on vaginal prolapse. The traditional method of repairing this uses a woman’s own tissue (called native tissue), but is associated with high rates of recurrence. As an alternative, it’s thought that transvaginal grafts made of absorbable or permanent mesh or biological material may improve the outcomes of prolapse surgery. Our review has confirmed that there is moderate quality evidence in favour of using transvaginal permanent mesh compared to native tissue repair. These include lower rates of subjective awareness of prolapse, reoperation for prolapse and recurrent prolapse on examination. However, there are also some problems associated with the treatment, which I will mention in a moment.
For the review, we evaluated a total of 37 randomised trials with more than 4000 women, which had compared transvaginal grafts with traditional native tissue repair for repairing vaginal prolapse. The evidence suggests that if about 20 women in a hundred are aware of prolapse after native tissue repair, this will fall to 10 to 15 after permanent mesh repair. Similarly, if the rate of recurrent prolapse on examination after a native tissue repair is about 38%, the risk would be between 11% and 20% after a repair with transvaginal permanent mesh.
Alongside these benefits, though, there are also problems associated with permanent transvaginal mesh. For example, if 5% of women need a second operation for prolapse, urinary incontinence or mesh exposure after native tissue repair, this rises to between 7% and 18% after permanent mesh repair. Eight percent of women who have permanent transvaginal mesh require repeat surgery for mesh exposure.
There is low quality evidence that absorbable mesh may reduce the risk of recurrent prolapse on examination compared to native tissue repair, but there is insufficient evidence comparing these interventions to draw any conclusions for other outcomes.
The low quality evidence that we found from trials that had compared biological grafts versus native tissue repair could not show differences in awareness of prolapse or reoperation for prolapse. And, with only very low quality evidence on prolapse on examination for this comparison, we cannot be certain of the impact of the interventions on this outcome.

John: To learn more about the trials and the comparisons in this review, and to watch out for the other Cochrane Reviews in the series, visit Cochrane Library dot com. You can find this review easily with a search for 'transvaginal mesh and prolapse'.

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