Sacral Colpopexy Versus Transvaginal Mesh Colpopexy in Obese Patients

Sacrocolpopexy compared with transvaginal mesh surgery: a systematic review and meta-analysis

BACKGROUND

The use of mesh is controversial in the treatment of female pelvic organ prolapse.

OBJECTIVES

To systematically review the outcomes of sacrocolpopexy compared with transvaginal mesh surgery and to provide evidence-based suggestions.

SEARCH STRATEGY

The MEDLINE, EMBASE, Cochrane Library and clinicaltrials.gov databases were searched on 21 November 2018.

SELECTION CRITERIA

Randomised controlled trials and prospective and retrospective cohort studies were included.

DATA COLLECTION AND ANALYSIS

Data were extracted by one reviewer and examined by a second reviewer for accuracy. Odds ratios and 95% CI were calculated using random-effects models.

MAIN RESULTS

Twenty comparative studies were included. The meta-analysis was performed with subgroups. The summary odds ratios of the randomised controlled group were 1.84 (95% CI 0.79-4.29, I²  = 75%) for anatomical success, 1.41 (95% CI 0.47-4.24, I²  = 38%) for subjective success, 0.42 (95% CI 0.18-0.98, I²  = 0%) for mesh complications, 0.61 (95% CI 0.20-1.91, I²  = 0%) for prolapse reoperation and 0.44 (95% CI 0.23-0.88, I²  = 0%) for de novo dyspareunia. The mean differences were 0.77 (95% CI 0.31-1.23, I²  = 66%) for total vaginal length and -1.28 (95% CI -2.00 to -0.55, I²  = 66%) for point C after surgery.

CONCLUSIONS

Very-low-quality evidence indicated that the anatomical and subjective success rates of sacrocolpopexy were similar to those of transvaginal mesh surgery; sacrocolpopexy might be more beneficial than transvaginal mesh surgery in terms of mesh-related complication rates, prolapse recurrence and de novo dyspareunia. However, additional high-quality randomised trials with long-term follow-up durations are needed.

TWEETABLE ABSTRACT

Sacrocolpopexy is beneficial after surgical anatomical changes and has decreased rates of mesh-related complications and dyspareunia.

Obesity and pelvic organ prolapse

PURPOSE OF REVIEW

The purpose of this review is to review the data on the relationship of obesity and pelvic organ prolapse (POP). This review is timely and relevant as the prevalence of obesity is increasing worldwide, and it is an important risk factor to consider in counseling women on management of prolapse symptoms and outcomes for surgical treatment.

RECENT FINDINGS

The main findings in the literature include: Obesity is increasing worldwide and impacts health, social life, work and healthcare costs. Elevated BMI is an important lifestyle factor affecting pelvic prolapse. The most probable mechanism of POP development among obese women is the increase in intra-abdominal pressure that causes weakening of pelvic floor muscles and fascia. Obesity is associated with significant pelvic floor symptoms and impairment of quality of life (QOL). Weight loss is likely not associated with anatomic improvement, but may be associated with prolapse symptom improvement. Weight loss should be considered a primary option in obese women for its beneficial effects on multiple organ systems and reducing pelvic floor disorder (PFD) symptoms. Although the operation time in obese women is significantly longer than in healthy weight women, the complication rate of surgery has not been shown to be increased compared to nonobese patients, regardless of route of surgery. There are data to support the vaginal approach in obese women. Some studies have shown that women with high body weight are associated with an increase in the risk for both anatomical and functional recurrence, and other studies have shown no difference.

SUMMARY

Obesity is a prevalent modifiable condition that impacts PFDs including pelvic prolapse. Patients should be counseled using clinical judgment, knowledge of the literature and with the goal of improving QOL.

[Are there selection criteria between abdominal approach and vaginal route for genital prolapse surgical management?]

INTRODUCTION

The never ending debate over the surgical approach of genital prolapse repair (abdominal versus vaginal route) is as passionate as ever. The available literature may support a multidisciplinary analysis of our expert daily practice.

OBJECTIVE

Our purpose was to define selection criteria for surgical approach between abdominal and vaginal route in the management of genital prolapse by reviewing the literature.

MATERIAL AND METHODS

Systematically review of the literature concerning comparative anatomical and functionnal results of surgery of pelvic organ prolaps by vaginal or abdominal route.

RESULTS

We were confronted to the lack of data in the literature, with few prospective randomized comparative studies. Many limitations were identified such as small populations in the studies, no description of sub-population, multiplicity of surgical procedures. Moreover, vaginal route was compared to sacral colpopexy by open abdominal approach, whereas laparoscopic sacrocolpopexy is now recommended. Only one prospective randomized comparative trial assessed laparoscopic sacrocolpopexy and vaginal approach, in which was used a mesh withdrawn from the market.

CONCLUSION

The lack of available randomized trials makes it impossible to define HAS compliant guidelines on this topic. However, selection criteria for each surgical approach and technique were drawn from experts' advices. © 2016 Published by Elsevier Masson SAS.

Obesity and Pelvic Floor Disorders: A Review of the Literature

Overweight and obesity are becoming a worldwide health problem associated with numerous co-morbidities. National costs of obesity and pelvic flor disorders have been rising since the 1950s across the world. Obesity is thought to have a very strong effect on pelvic floor disorders, and, considering the high prevalence of both problems worldwide, it is of utmost importance to evaluate the association between these pathologies as well as the impact of obesity on treatment efficacy. This review is based on a selection of reports in the literature (PubMed search), including guidelines and Cochrane reviews.

Obesity seems to be a well-documented risk factor for lower urinary tract symptoms (LUTS) and is a predictor of exacerbation of stress urinary incontinence (SUI) and overactive bladder (OAB). Weight loss is also associated with improvement or resolution of SUI and OAB. In the case of pelvic organ prolapse (POP), weight loss is associated with improvement in quality of life. Although obesity is associated with POP in general, the exact role of obesity in symptomatic POP remains uncertain. While outcomes of anti-incontinence surgery among obese women are similar to those in non-obese women, postoperative urge incontinence is more likely to occur. It seems that obesity is not a risk factor for postoperative complications or short-term efficacy of POP surgical treatment. Long-term effects are still uncertain.

Obesity is a strong risk factor for LUTS, but in most cases it does not affect efficacy of operative treatment. It may be associated with some post-operative complications. Weight loss in many cases allows avoiding surgical intervention.