Perioperative interventions in pelvic organ prolapse surgery

A wide variety of interventions are undertaken at prolapse surgeries; however data are lacking and consensus has not been reached on the efficacy of these interventions. The most reliable evidence is likely to come from randomised controlled trials, and this is the basis for this review.

Review questions

• Which perioperative interventions reduce rates of intraoperative and postoperative complications?

• Which perioperative interventions improve outcomes of surgery performed for pelvic organ prolapse?

Background

Surgery for pelvic organ prolapse is commonly performed and a variety of perioperative interventions are undertaken to improve outcomes of surgery.

Study characteristics

Cochrane review authors evaluated randomised controlled trials (RCTs) that compared prolapse surgery with and without any perioperative (before, during, or after) interventions. The evidence is current to 30 November 2017. Reviewers included 15 trials that evaluated eight different interventions related to prolapse surgery. Although primary outcomes of the review were objective failure (recurrence of prolapse on examination) and awareness of prolapse, reviewers also measured adverse effects, focusing on intraoperative blood loss, intraoperative ureteral injury, postoperative urinary tract infection, and repeat surgery.

Key results

Reviewers found very little evidence on perioperative interventions in pelvic organ prolapse surgery. Few trials reported primary outcomes. A structured programme of pelvic floor muscle training before and after surgery did not consistently demonstrate any benefit for the intervention. With regard to other preoperative interventions, neither bowel preparation nor detailed preoperative mapping demonstrated significant benefit when compared to usual care.

Intraoperative interventions such as injection of a vasoconstrictor agent, ureteral stent placement during uterosacral ligament suspension, or placement of a vaginal pack did not demonstrate benefit for reduced blood loss or rate of urinary tract infection or injury to the ureter.

Vaginal packing postoperatively did not reduce the rate of haematoma (collection of blood) when compared to prolapse surgery without packing in a single trial. The rate of postoperative urinary tract infection was not reduced by use of a vaginal pack, prophylactic antibiotics, or vaginal dilators.

Quality of the evidence

The quality of the evidence ranged from very low to moderate. The main limitation was imprecision, associated with small sample sizes and low event rates.

Authors' conclusions: 

There was a paucity of data about perioperative interventions in pelvic organ prolapse surgery. A structured programme of pelvic floor muscle training before and after prolapse surgery did not consistently demonstrate any benefit for the intervention; however, this finding is based on the results of two small studies. With regard to other interventions (preoperative bowel preparation and injection of vasoconstrictor agent, ureteral stent placement during uterosacral ligament suspension, postoperative vaginal pack insertion, use of vaginal dilators, prophylactic antibiotics for postoperative catheter care), we found no evidence regarding rates of recurrent prolapse and no clear evidence that these interventions were associated with clinically meaningful reductions in adverse effects, such as intraoperative or postoperative blood transfusion, intraoperative ureteral injury, or postoperative urinary tract infection.

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Background: 

Pelvic organ prolapse (POP) affects as many as 50% of parous women, with 14% to 19% of women undergoing a surgical correction. Although surgery for the treatment of POP is common, limited supportive data can be found in the literature regarding the preoperative and postoperative interventions related to these procedures. The main goal of perioperative interventions is to reduce the rate of adverse events while improving women's outcomes following surgical intervention for prolapse. A broad spectrum of perioperative interventions are available, and although the benefits of interventions such as prophylactic antibiotics before abdominal surgery are well established, others are unique to women undergoing POP surgeries and as such need to be investigated separately.

Objectives: 

The aim of this review is to compare the safety and effectiveness of a range of perioperative interventions versus other interventions or no intervention (control group) at the time of surgery for pelvic organ prolapse.

Search strategy: 

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In Process, ClinicalTrials.gov, WHO ICTRP, handsearching of journals and conference proceedings (searched 30 November 2017), and reference lists of relevant articles. We also contacted researchers in the field.

Selection criteria: 

We included randomised controlled trials (RCTs) of women undergoing surgical treatment for symptomatic pelvic organ prolapse that compared a perioperative intervention related to pelvic organ prolapse surgery versus no treatment or another intervention.

Data collection and analysis: 

We used standard methodological procedures recommended by Cochrane. Our primary outcomes were objective failure at any site and subjective postoperative prolapse symptoms. We also measured adverse effects, focusing on intraoperative blood loss and blood transfusion, intraoperative ureteral injury, and postoperative urinary tract infection.

Main results: 

We included 15 RCTs that compared eight different interventions versus no treatment for 1992 women in five countries. Most interventions were assessed by only one RCT with evidence quality ranging from very low to moderate. The main limitation was imprecision, associated with small sample sizes and low event rates.

Pelvic floor muscle training (PFMT) compared with no treatment (three RCTs) - peri-operative intervention

The simplest of the PFMT programmes required women to attend six perioperative consultations in the three months surrounding prolapse surgery. Trial results provided no clear evidence of a difference between groups in objective failure at any site at 12 to 24 months (odds ratio (OR) 0.93, 95% confidence interval (CI) 0.56 to 1.54; two RCTs, 327 women; moderate-quality evidence). With respect to awareness of prolapse, findings were inconsistent. One RCT found no evidence of a difference between groups at 24 months (OR 1.07, 95% CI 0.61 to 1.87; one RCT, 305 women; low-quality evidence), and a second small RCT reported symptom reduction from the Pelvic Organ Prolapse Symptom Questionnaire completed by the intervention group at 12 months (mean difference (MD) -3.90, 95% CI -6.11 to -1.69; one RCT, 27 women; low-quality evidence). Researchers found no clear differences between groups at 24-month follow-up in rates of repeat surgery (or pessary) for prolapse (OR 1.92, 95% CI 0.74 to 5.02; one RCT, 316 women; low-quality evidence).

Other interventions

Single RCTs evaluated the following interventions: preoperative guided imagery (N = 44); injection of vasoconstrictor agent at commencement of vaginal prolapse surgery (N = 76); ureteral stent placement during uterosacral ligament suspension (N = 91); vaginal pack (N = 116); prophylactic antibiotics for women requiring postoperative urinary catheterisation (N = 159); and postoperative vaginal dilators (N = 60).

Two RCTs evaluated bowel preparation (N = 298), and four RCTs assessed the method and timing of postoperative catheterisation (N = 514) - all in different comparisons.

None of these studies reported our primary review outcomes. One study reported intraoperative blood loss and suggested that vaginal injection of vasoconstrictors at commencement of surgery may reduce blood loss by a mean of about 30 mL. Another study reported intraoperative ureteral injury and found no clear evidence that ureteral stent placement reduces ureteral injury. Three RCTs reported postoperative urinary tract infection and found no conclusive evidence that rates of urinary tract infection were influenced by use of a vaginal pack, prophylactic antibiotics, or vaginal dilators. Other studies did not report these outcomes.

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