Key messages
- Compared with using a woman's own body tissue in surgery for anterior compartment prolapse, using permanent vaginal mesh placed through the vagina probably results in fewer women having prolapse symptoms (i.e. feeling a lump or bulge from the vagina), needing another operation for prolapse or experiencing prolapse again.
- New pain during sex is probably more likely with vaginal permanent mesh surgery than with abdominal mesh surgery.
- Future studies should test new meshes or other long-lasting biological materials, and they should report on quality of life.
What is pelvic organ prolapse and how is it treated?
Pelvic organ prolapse is common, especially amongst women who have previously given birth and are now past menopause. It involves the organs of the pelvis dropping down within and outside the vaginal opening. 'Anterior compartment prolapse' specifically involves dropping of the bladder into the front wall of the vagina. This often leads to an uncomfortable feeling of a bulge, a dragging feeling, incontinence (urine leaking) and difficulties with sex. These problems can have a serious impact on quality of life.
Pelvic organ prolapse can be treated with surgery. The surgeon can use different materials: a woman's own body tissue and ligaments (native tissue repair); natural material (biological graft) or artificial material (synthetic mesh) that disintegrates and is absorbed into the body; or permanent artificial material (permanent mesh). Surgery can be done through the vagina (transvaginal), or a long cut in the tummy (abdominal), or a tiny hole (keyhole) in the tummy (laparoscopic). Keyhole surgery is sometimes done with the help of a robot.
What did we want to find out?
We wanted to find out the most effective surgical method with the lowest risk of unwanted effects. We were interested in the effects of different methods on prolapse symptoms, prolapse coming back (recurrence), repeat prolapse surgery, surgery for urine leaks, repeat surgery for mesh exposure (when mesh sticks through the surgical cut and into the vagina), and new or continuing pain during sex.
What did we do?
We searched for studies that compared different surgical ways to repair anterior compartment prolapse.
What did we find?
We found 41 studies evaluating 4531 women with anterior compartment prolapse. Most studies reported results one to two years after surgery.
Native tissue repair versus repair with biological graft (1 to 2 years after surgery)
Recurrence is probably more likely with native tissue repair than a biological graft (8 studies, 707 women). For example, if 21% of women had a prolapse come back after a biological graft, 24% to 40% would have it come back after native tissue repair.
Results with both methods are probably similar for prolapse awareness (5 studies, 515 women) and pain during sex (2 studies, 151 women), and may be similar for repeat prolapse surgery (6 studies, 524 women).
Surgery for urine leaks and new-onset pain with sex were not assessed.
Native tissue repair versus permanent mesh inserted through the vagina (1 to 2 years after surgery)
Native tissue repair probably results in more prolapse awareness than permanent mesh repair (10 studies, 1203 women); for example, if 13% of women were aware of prolapse after mesh repair, 17% to 29% would be aware after native tissue repair.
Native tissue repair may lead to slightly more recurrence (20 studies, 2483 women). For example, if 13% of women had recurrent prolapse after mesh repair, 29% to 58% would have recurrence after native tissue repair.
Repeat prolapse surgery is probably more likely after native tissue repair (14 studies, 1799 women).
There is probably little or no difference between the methods in surgery for urine leaks (6 studies, 967 women), pain during sex (8 studies, 1096 women) and new-onset pain during sex (11 studies, 797 women).
Permanent mesh inserted through the vagina versus through the abdomen (1 year after surgery)
New-onset pain during sex is probably more likely with permanent vaginal mesh than with abdominal mesh (in which mesh is attached from the top of the vagina to the base of the spine) (2 studies, 248 women).
There is probably little or no difference between permanent vaginal and abdominal mesh in recurrence (4 studies, 306 women), and may be little to no difference between them in prolapse awareness (3 studies, 441 women), repeat prolapse surgery (3 studies, 455 women), surgery for mesh complications (2 studies, 373 women) and surgery for urine leaks (2 studies, 299 women).
Pain during sex was not assessed.
What are the limitations of the evidence?
Our confidence in the evidence varied from 'very low' to 'moderate'. The studies did not report all of their methods, and some studies were very small. Many of the mesh products tested in the studies have been voluntarily taken off the market. There are newer, lighter mesh products, but these have not yet been tested in the most reliable type of study.
How up to date is this evidence?
The evidence is current to 29 April 2024.
Read the full abstract
Anterior compartment prolapse is the most common pelvic organ prolapse. Clinicians have utilised various surgical techniques to minimise the rate of recurrent pelvic organ prolapse (POP).
Objectives
To determine the benefits and harms of surgery for anterior compartment prolapse.
Search strategy
We searched the Cochrane Incontinence Specialised Register on 29 April 2024. This includes records indexed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ClinicalTrials.gov and WHO ICTRP. We also handsearched journals, conference proceedings and the reference lists of included studies.
Selection criteria
We included randomised controlled trials (RCTs) that compared surgical operations in women with anterior compartment prolapse.
Data collection and analysis
Two review authors independently selected trials, assessed their risk of bias and extracted their data.
Main results
We included 41 RCTs evaluating 4531 women. The certainty of evidence ranged from very low to moderate due to risk of bias and imprecision.
Anterior native tissue repair versus biological graft at 1 to 2 years
There is likely little to no difference between these two methods in terms of awareness of prolapse (RR 1.20, 95% CI 0.80 to 1.81; 5 RCTs, 515 women; moderate certainty).
Native tissue repair likely increases the risk of recurrent anterior compartment prolapse (RR 1.53, 95% CI 1.19 to 1.97; 8 RCTs, 707 women; moderate certainty); the result suggests that if 21% of women had recurrent prolapse after biological graft, 24% to 40% would have recurrence after native tissue repair.
There may be little to no difference between native tissue repair and biological graft repair groups for repeat surgery for prolapse (RR 0.99, 95% CI 0.45 to 2.17; 6 RCTs, 524 women; low certainty).
Surgery for stress urinary incontinence was not reported.
There is likely little to no difference between groups in dyspareunia (RR 0.87, 95% CI 0.39 to 1.93; 2 RCTs, 151 women; moderate certainty).
De novo dyspareunia was not reported.
Anterior native tissue repair versus transvaginal anterior permanent mesh at 1 to 2 years
Native anterior tissue repair likely results in more awareness of prolapse than anterior mesh repair (RR 1.77, 95% CI 1.37 to 2.27; 10 RCTs, 1203 women; moderate certainty); the result suggests that if 13% of women were aware of prolapse after mesh repair, 17% to 29% would be aware after native tissue repair.
Native tissue repair may result in slightly increased recurrent anterior compartment prolapse (RR 3.21, 95% CI 2.27 to 4.55; 20 RCTs, 2483 women; low certainty). There was moderate heterogeneity (I2 = 73%). The result suggests that if 13% of women had recurrent prolapse after mesh repair, 29% to 58% would have recurrence after native tissue repair.
Repeat surgery for prolapse is probably more likely after native tissue repair (RR 2.17, 95% CI 1.31 to 3.58; 14 RCTs, 1799 women; moderate certainty); the result suggests that if 2% of women required repeat surgery after mesh repair, 3% to 8% would do so after native tissue repair.
There is likely little or no difference between groups in surgery for stress urinary incontinence (RR 1.32, 95% CI 0.73 to 2.40; 6 RCTs, 967 women; moderate certainty).
There is likely little or no difference between groups for dyspareunia (RR 1.06, 0.59 to 1.90; 8 RCTs, 1096 women; moderate certainty).
There is likely little or no difference between groups for de novo dyspareunia (RR 0.64, 95% CI 0.36 to 1.12; 11 RCTs, 797 women; moderate certainty); the result suggests that if 7% of women reported dyspareunia after mesh repair, 2% to 8% would do so after native tissue repair.
Permanent anterior vaginal mesh versus abdominal sacrocolpopexy at 1 year
There may be little to no difference between permanent anterior vaginal mesh and abdominal sacrocolpopexy groups in awareness of prolapse (RR 0.93, 95% CI 0.45 to 1.94; 3 RCTs, 441 women; low certainty). There was some heterogeneity (I2 = 37%).
There is likely little or no difference between groups in recurrent anterior compartment prolapse (RR 0.95, 95% CI 0.46 to 1.97; 4 RCTs, 306 women; moderate certainty). There was some heterogeneity (I2 = 69%). The result suggests that if recurrent prolapse occurred in 26% of women after sacrocolpopexy, 12% to 51% would have recurrence after transvaginal mesh repair.
There may be little or no difference between groups in repeat surgery for prolapse (RR 1.68, 95% CI 0.56 to 5.04; 3 RCTs, 455 women; low certainty).
There may be little or no difference between groups in repeat surgery for mesh complications (RR 2.61, 95% CI 0.62 to 10.99; 2 RCTs, 373 women; low certainty); the result suggests that if 1% of women needed repeat surgery for mesh exposure after sacrocolpopexy, 0.5% to 12% would do so after transvaginal mesh repair.
There may be little or no difference between groups in surgery for stress urinary incontinence (RR 0.78, 95% CI 0.20 to 3.12; 2 RCTs, 299 women; low certainty). There was some heterogeneity (I2 = 60%).
Dyspareunia was not reported.
De novo dyspareunia is probably more likely to be reported with permanent anterior vaginal mesh than after abdominal sacrocolpopexy (RR 2.15, 95% CI 1.17 to 3.98; 2 RCTs, 248 women; moderate certainty); the result suggests that if 10% of women reported dyspareunia after abdominal sacrocolpopexy, 12% to 40% would do so with permanent anterior vaginal mesh.
Authors' conclusions
Recurrence is probably more likely after native tissue repair than with biological graft or absorbable synthetic mesh at one to two years. We found no data for surgery for stress urinary incontinence.
Anterior native tissue repair likely increases awareness of prolapse, recurrence and surgery for prolapse compared with transvaginal anterior permanent mesh repair.
It is likely that fewer women report dyspareunia after abdominal sacrocolpopexy than with permanent mesh repair.
For other outcomes, there was little or no difference between the groups being compared.
Many of the transvaginal permanent meshes evaluated have been removed from the market because of reported complications. Five studies tested mesh kits that are currently available. We suggest that clinicians and women use caution when utilising these products as their long-term safety and efficacy have not yet been established.
