A 3-year follow-up after anterior colporrhaphy compared with collagen-coated transvaginal mesh for anterior vaginal wall prolapse: a randomised controlled trial

Comparison of Morbidity and Retreatment After Urethral Bulking or Midurethral Sling at the Time of Pelvic Organ Prolapse Repair

OBJECTIVE

To compare postprocedure retreatment rates for stress incontinence in patients who underwent either midurethral sling or urethral bulking at the time of concomitant repair of pelvic organ prolapse (POP).

METHODS

This was a retrospective cohort study using data from the Premier Healthcare Database. Using Current Procedural Terminology codes, we identified patients who were undergoing POP repair and concomitant urethral bulking or midurethral sling between the years 2001 and 2018. Patients who underwent concomitant nongynecologic surgery, Burch urethropexy, or oncologic surgery, and those who did not undergo concomitant POP and anti-incontinence surgery, were excluded. Additional data collected included patient demographics, hospital characteristics, surgeon volume, and comorbidities. The primary outcome was a repeat anti-incontinence procedure at 2 years, and the secondary outcome was the composite complication rate.

RESULTS

Over the study period, 540 (0.59%) patients underwent urethral bulking, and 91,005 (99.41%) patients underwent midurethral sling. The rate of a second procedure within 2 years was higher for urethral bulking, compared with midurethral sling (9.07% vs 1.11%, P <.001); in the urethral bulking group, 4.81% underwent repeat urethral bulking and 4.81% underwent midurethral sling. In the midurethral sling group, 0.77% underwent repeat midurethral sling and 0.36% underwent urethral bulking. After adjusting for confounders, midurethral sling was associated with a decreased odds of a repeat anti-incontinence procedure at 2 years (adjusted odds ratio 0.11, 95% CI 0.08-0.16). The probability of any complication at 2 years was higher with urethral bulking (23.0% vs 15.0%, P <.001).

CONCLUSION

Urethral bulking at the time of POP repair is associated with a higher rate of repeat procedure and postoperative morbidity up to 2 years after surgery.

Modified Vaginal Mesh Procedure with DynaMesh®-PR4 for the Treatment of Anterior/Apical Vaginal Prolapse

(1) Background: Treating female pelvic organ prolapse (POP) is challenging. Surgical meshes have been used in transvaginal surgeries since the 1990s, but complications such as mesh exposure and infection have been reported. Polyvinylidene fluoride (PVDF) mesh, known for its stability and non-reactive properties, has shown promise in urogynecological surgeries. (2) Methods: A retrospective analysis was conducted on 27 patients who underwent a modified PVDF vaginal mesh repair procedure using DynaMesh®-PR4 and combined trans-obturator and sacrospinous fixation techniques. Additional surgeries were performed as needed. (3) Results: The mean operation time was 56.7 min, and the mean blood loss was 66.7 mL. The average hospitalization period was 4.2 days with Foley catheter removal after 2 days. Patients experienced lower pain scores from the day of the operation to the following day. Postoperative follow-up revealed that 85.2% of patients achieved anatomic success, with 14.8% experiencing recurrent stage II cystocele. No recurrence of apical prolapse was observed. Complications were rare, with one case (3.7%) of asymptomatic mesh protrusion. (4) Conclusions: The modified vaginal mesh procedure using DynaMesh®-PR4 showed favorable outcomes with a short operation time, low recurrence rate, rare complications, and improved functional outcomes. This surgical option could be considered for anterior and apical pelvic organ prolapse in women.

Polypropylene Pelvic Mesh: What Went Wrong and What Will Be of the Future?

Background: Polypropylene (PP) pelvic mesh is a synthetic mesh made of PP polymer used to treat pelvic organ prolapse (POP). Its use has become highly controversial due to reports of serious complications. This research critically reviews the current management options for POP and PP mesh as a viable clinical application for the treatment of POP. The safety and suitability of PP material were rigorously studied and critically evaluated, with consideration to the mechanical and chemical properties of PP. We proposed the ideal properties of the ‘perfect’ synthetic pelvic mesh with emerging advanced materials. Methods: We performed a literature review using PubMed/Medline, Embase, Cochrane Library (Wiley) databases, and ClinicalTrials.gov databases, including the relevant keywords: pelvic organ prolapse (POP), polypropylene mesh, synthetic mesh, and mesh complications. Results: The results of this review found that although PP is nontoxic, its physical properties demonstrate a significant mismatch between its viscoelastic properties compared to the surrounding tissue, which is a likely cause of complications. In addition, a lack of integration of PP mesh into surrounding tissue over longer periods of follow up is another risk factor for irreversible complications. Conclusions: PP mesh has caused a rise in reports of complications involving chronic pain and mesh exposure. This is due to the mechanical and physicochemical properties of PP mesh. As a result, PP mesh for the treatment of POP has been banned in multiple countries, currently with no alternative available. We propose the development of a pelvic mesh using advanced materials including emerging graphene-based nanocomposite materials.

A novel bilateral anterior sacrospinous hysteropexy technique for apical pelvic organ prolapse repair via the vaginal route: a cohort study

Background

Uterine-preserving techniques are becoming increasingly popular in the last decade. This investigation evaluates a novel hysteropexy technique using a mesh in sling-alike configuration [Splentis (Promedon, Argentina)] which is attached anteriorly to the cervix and suspended to the sacrospinous ligaments bilaterally via the vaginal route in women undergoing surgery for uterine prolapse.

Methods

This was a single-center cohort study, evaluating women who underwent transvaginal hysteropexy with Splentis for primary uterine descent. Data have been collected prospectively as part of the quality assurance system. Primary endpoint was treatment success, defined as a combined endpoint including the absence of a vaginal bulge symptom and no retreatment of apical prolapse. A validated questionnaire to evaluate quality-of-life and prolapse symptoms was utilized. Descriptive analysis was applied. Wilcoxon signed-rank test was performed to compare paired samples. The significance level was set at 5%.

Results

A total of 103 women with a median age of 68.0 [IQR 11.5] years with a median apical POP-Q stage of 3 were included. The median surgery time was 22 [IQR 12] minutes and no intraoperative complication occurred. After a median follow-up time of 17 months, treatment success was achieved in 91 (89.2%) patients and quality of life and patient report outcomes improved significantly (p < 0.001). Mesh exposure occurred in 3 (2.9%) patients. Of these, two patients required surgical revision, and one patient was treated conservatively. One patient required partial mesh removal due to dyspareunia.

Conclusion

Bilateral sacrospinous hysteropexy with Splentis offers an efficacious and safe alternative for apical compartment repair, incorporating the advantages of pelvic floor reconstruction via the vaginal route.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00404-022-06486-4.

Sexual function after pelvic organ prolapse surgery: a systematic review comparing different approaches to pelvic floor repair

OBJECTIVE

Women consider preservation of sexual activity and improvement of sexual function as important goals after pelvic organ prolapse surgery. This systematic review aimed to compare sexual activity and function before and after prolapse surgery among specific approaches to pelvic organ prolapse surgery including native tissue repairs, transvaginal synthetic mesh, biologic grafts, and sacrocolpopexy.

DATA SOURCES

MEDLINE, Embase, and ClinicalTrials.gov databases were searched from inception to March 2021.

STUDY ELIGIBILITY CRITERIA

Prospective comparative cohort and randomized studies of pelvic organ prolapse surgeries were included that reported the following specific sexual function outcomes: baseline and postoperative sexual activity, dyspareunia, and validated sexual function questionnaire scores. Notably, the following 4 comparisons were made: transvaginal synthetic mesh vs native tissue repairs, sacrocolpopexy vs native tissue repairs, transvaginal synthetic mesh vs sacrocolpopexy, and biologic graft vs native tissue repairs.

METHODS

Studies were double screened for inclusion and extracted for population characteristics, sexual function outcomes, and methodological quality. Evidence profiles were generated for each surgery comparison by grading quality of evidence for each outcome across studies using a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

RESULTS

Screening of 3651 abstracts was performed and identified 77 original studies. The overall quality of evidence was moderate to high. There were 26 studies comparing transvaginal synthetic mesh with native tissue repairs, 5 comparing sacrocolpopexy with native tissue repairs, 5 comparing transvaginal synthetic mesh with sacrocolpopexy, and 7 comparing biologic graft with native tissue repairs. For transvaginal synthetic mesh vs native tissue repairs, no statistical differences were found in baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, persistent dyspareunia, and de novo dyspareunia. Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form change scores were not different between transvaginal synthetic mesh and native tissue repairs (net difference, -0.3; 95% confidence interval, -1.4 to 0.8). For sacrocolpopexy vs native tissue repairs, baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, de novo dyspareunia, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form score differences were not different. For biologic graft vs native tissue repairs, baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form changes were also not different. For transvaginal synthetic mesh vs sacrocolpopexy, there was no difference in sexual activity and sexual function score change. Based on 2 studies, postoperative total dyspareunia was more common in transvaginal synthetic mesh than sacrocolpopexy (27.5% vs 12.2%; odds ratio, 2.72; 95% confidence interval, 1.33-5.58). The prevalence of postoperative dyspareunia was lower than preoperative dyspareunia after all surgery types.

CONCLUSION

Sexual function comparisons are most robust between transvaginal synthetic mesh and native tissue repairs and show similar prevalence of sexual activity, de novo dyspareunia, and sexual function scores. Total dyspareunia is higher after transvaginal synthetic mesh than sacrocolpopexy. Although sexual function data are sparse in the other comparisons, no other differences in sexual activity, dyspareunia, and sexual function score change were found.

The role of hydrodissection in native tissue repair of anterior vaginal wall defects

AIMS

A variety of surgical techniques are available for vaginal prolapse repair, indicating a lack of consensus. A debate regarding the utility of hydrodissection for splitting the surgical plane of the vaginal wall exists. The aim of this study is to evaluate the impact of hydrodissection in anterior colporrhaphy (AC).

MATERIALS

Patients undergoing primary AC were randomly assigned to an approach with (study group) versus without (control group) hydrodissection. Five surgeons performed both techniques, and the trimmed vaginal tissue was retrieved for histological analysis. Two pathologists, blinded to the surgical approach, evaluated the presence of a loose connective tissue at the surgical dissection plane (controversially deemed 'fascia', as explained in this article). In addition, we compared the operative time, pain score and haemoglobin levels. After statistical analysis, data were presented using percentile, and statistical significance was tested using the χ² and Fisher's exact tests.

RESULTS

Forty-six patients underwent primary elective AC, with 23 patients in each, the study and control groups. The groups were comparable regarding age (study group 60.33 ± 11.95 years and control group 59.86 ± 12.04, P = 0.90), menopausal status (study group 17 (73.9%) and control group 15 (68.2%), P = 0.67) and other characteristics. We found no difference in sample characteristics between the two groups. Connective tissue was found in only 13.6% (n = 3) of patients after hydrodissection and in 27.3% (n = 6) of patients without hydrodissection (P = 0.46). The hydrodissection group had significantly less bleeding than the control group (ΔHB 0.66 ± 0.66 vs 1.21 ± 0.84, P = 0.05).

CONCLUSIONS

After hydrodissection, less bleeding was noted without compromise the surgical planes.

Update in Transvaginal Grafts: The Role of Lightweight Meshes, Biologics, and Hybrid Grafts in Pelvic Organ Prolapse Surgery

Transvaginal mesh/grafts have been popularized over the past 20 years in an attempt to improve the longevity of traditional vaginal pelvic organ prolapse (POP) surgery. Several national bodies have concluded that the proposed benefits of mesh/graft implantation are outweighed by the significant increase in surgery complications related to these products. As a consequence mesh products for vaginal POP surgery have been withdrawn from use in many countries. This article is a narrative review of newer mesh and graft products including lightweight polypropylene mesh products, biological grafts, hybrid grafts, and tissue engineered grafts.

Outcomes of a fixed skeletonised mini mesh implant for pelvic organ prolapse repair with uterine preservation

Mesh repair of pelvic organ prolapse (POP) is complicated, causing erosions, postoperative pain and surgical failure. We hypothesised that reducing the mesh size and fixating it would result in significant cure rates and reduce complication rates. Here, we present the effectiveness of mini mesh implants in POP reconstruction. Sixty women who underwent repair of stage III and IV apical prolapse with cystocele or rectocele using skeletonised mesh implant Seratom PA MR MN® were evaluated. Anatomical outcomes were assessed using modified POP-quantification (POP-Q) staging and functional outcomes were self-reported by patients - one and three months post-operatively. Apical support with anterior and/or posterior colporrhaphy was performed, resulting in 96.6% success rate. Follow-up conducted one and three months post-operatively revealed significant improvement on the modified POP-Q (p < .001) and no complaints of dyspareunia. Para-vesicular fixation using a skeletonised mini mesh implant is feasible and effective in POP repair and has low surgical complication risk.Impact StatementWhat is already known on this subject? Mesh repair for pelvic organ prolapse (POP) is currently under scrutiny as it may result in erosions, postoperative pain, and surgical failure.What do the results of this study add? The use of an apical support with mini-mesh implants resulted in a 96.6% (58/60) success rate and excellent outcomes at 1- and 3-month follow-up.What are the implications of these findings for clinical practice and/or further research? Reconstruction using skeletonised and fixated mini-mesh implants may be safe and effective for POP treatment.

Transperineal pelvic floor ultrasound for analyzing the outcomes of pelvic floor surgery for the treatment of anterior compartment prolapse: A comparative study of transvaginal mesh and native-tissue repair

OBJECTIVE

To compare the outcomes of transvaginal mesh (TVM) and native-tissue repair (NTR) for the repair of anterior compartment prolapse.

METHODS

This retrospective study involved 90 patients with anterior compartment prolapse who underwent pelvic organ prolapse surgery between January 2018 and October 2020. A TVM was used to treat 53 patients and 37 underwent NTR. All patients underwent a standardized interview, clinical examination, and four-dimensional pelvic floor ultrasound (PFUS) before and after the surgery. The primary outcome was anatomic recurrence evaluated by ultrasonic parameters. The secondary outcomes were subjective recurrence and complications.

RESULTS

Subjective recurrence was 9.43% (5/53) for TVM and 16.22% (6/37) for NTR (P = .522). Significant recurrence of prolapse on ultrasound occurred in five patients (9.43%) after TVM and 12 (32.43%) after NTR; there was a significant difference between the TVM and NTR groups (P = .006). In the TVM group, the mesh was visible on ultrasound in each patient. The mesh exposure rate was 1.89% (1/53). The postoperative hiatal area reduction in the TVM group, compared with the NTR group, was statistically significant (5.55 ± 4.71 cm² vs 3.09 ± 5.61 cm² , P = .027). The incidence of de novo stress urinary incontinence was higher in the TVM group (20.75% vs 2.70%, P = .03). After surgery, there were significant differences between the two groups based on bladder descent (12.02 ± 8.64 mm vs 22.41 ± 13.95 mm, P = .000) and urethral rotation angle (25.26 ± 13.92° vs 40.27 ± 23.72°, P = .001).

CONCLUSION

PFUS is effective for evaluating postoperative outcomes. TVM facilitates a better anatomic cure than NTR for anterior compartment prolapse.

Mesh-augmented transvaginal repair of recurrent or complex anterior pelvic organ prolapse in accordance with the SCENIHR opinion

INTRODUCTION AND HYPOTHESIS

To evaluate the performance of mesh-augmented repair of anterior pelvic organ prolapse (POP) with or without apical vaginal wall involvement in women with recurrent or complex prolapse.

METHODS

This multicenter cohort study included women undergoing surgery with Calistar S (Promedon, Argentina) for anterior POP between 2016 and 2018. The SCENIHR opinion was considered for patient selection, surgeon's experience and choice of implant. Patients were prospectively invited to assess effectiveness and safety by anamnesis, validated questionnaires and pelvic examination. A composite endpoint defined by POP-Q ≤ 1, absence of a vaginal bulge symptom and repeated surgery for POP was used to define treatment success. Descriptive statistics were applied. McNemar or Wilcoxon signed rank tests were used as paired samples tests. The significance level was set at 5%.

RESULTS

A total of 107 non-fertile women with a mean age of 70.6 years were enrolled. Ninety-three (86.9%) women presented with recurrent prolapse. The mean follow-up time was 18.5 months. Treatment success was achieved in 76% of cases according the composite endpoint, with 98% reaching POP-Q ≤ 1 and a significant improvement in quality of life (p < 0.001). Mesh exposure occurred in six (5.6%) patients, although none required further surgery. Four (3.7%) patients reported dyspareunia, and a single (0.9%) patient displayed a prominence due to mesh folding.

CONCLUSIONS

Mesh-augmented repair of anterior POP is effective and safe in women with recurrent or complex prolapse. Hence, in a select patient population, the benefits of mesh-augmented POP repair still outweigh the risks.

Does the choice of pelvic organ prolapse treatment influence subjective pelvic-floor related quality of life?

OBJECTIVES

The relationship between pelvic organ prolapse (POP) treatment and subjective pelvic-floor related quality of life (QoL) was examined.

STUDY DESIGN

130 postmenopausal women with symptomatic POP were included: 45 % (59/130) were treated conservatively with pessary and 55 % (71/130) underwent pelvic floor surgery. All participants answered the validated German pelvic floor questionnaire at the time of baseline examination, as well as three months later.

RESULTS

Our results demonstrated a significant improvement regarding mean score in the domains "prolapse" (p = 0.001) and "sexual function" (p = 0.001) three months after prolapse surgery, whereas in the pessary group only the score in the "prolapse" domain improved (p < 0.001). When comparing the two treatment arms after three months, patients reported a significant advancement regarding their "sexual function" domain in the surgery group (p < 0.0001). Furthermore, univariate analysis revealed a significant positive correlation between "prolapse" domain score (correlation coefficient = 0.0001) as well as "bladder" domain score (correlation coefficient <0.001) and POP-Q stage. Additionally, a significant negative correlation between "sexual function" domain score and POP-Q stage was found (correlation coefficient = 0.0001).

CONCLUSION

Our results revealed that three months after prolapse surgery, pelvic-floor related QoL showed significant improvement in the domain "sexual function" compared to three months pessary treatment. Besides, advanced prolapse stage correlated with higher symptom burden and worse sexual function.

Transvaginal Paravaginal Native Tissue Anterior Repair Technique: Initial Outcomes

OBJECTIVE

To present the surgical technique and initial outcomes for a novel lattice-work technique, developed to increase the durability of the native tissue repair.

METHODS/ MATERIALS

All patients undergoing transvaginal anterior prolapse repair with a single surgeon with at least 30 days of follow-up were prospectively enrolled starting in 2017. All patients received the same repair (Fig. 1). 2.0 polydioxanone (PDS) sutures are placed at the level of the obturator fascia/arcus tendineus distally and proximally on each side. The midline anterior colporrhaphy is performed with 4 2.0 PDS sutures which are then intertwined with the obturator sutures and tied to form a lattice of sutures to reinforce the cystocele repair and elevate the central defect repair laterally. Clinic notes, objective physical exam, and standardized subjective patient questionnaires (Pelvic Floor Disorders Inventory) were evaluated for patient outcomes. Recurrence was defined anatomically (Pelvic organ prolapse-Q Ba ≥-1) and subjectively (bothersome vaginal bulge).

RESULTS

There were 109 patients enrolled with a mean follow-up time was 12 months. Over the follow-up period, there were 12 anatomic recurrences (11%). This was not associated with concomitant apical or posterior repair. Mean time to recurrence was 13.9 months. There were no intraoperative complications. Transient urinary retention was the most notable complication (19%, managed conservatively). Rate of de novo stress urinary incontinence was low at 4%.

CONCLUSION

This novel lattice-work technique is simple to perform and has excellent short term anatomic outcomes. Transient postoperative retention was observed; however, all cases self-resolved. Further follow-up is ongoing to characterize the long-term durability of this repair.

Long-term follow-up of native tissue anterior vaginal wall repair: does the POP-Q stage really reflect patients' satisfaction rate?

INTRODUCTION

Anterior colporrhaphy (AC) is one of the most commonly performed surgical procedures for pelvic organ prolapse treatment; however, there are only few data in the literature regarding its long-term outcomes. Our aim was to assess the long-term efficacy and satisfaction rate after AC.

METHODS

Patients who underwent AC at our institution from 2011 to 2014 were invited to this follow-up study, which took place in January-February 2019. Medical history and gynaecological examination with POP-Q assessment were performed. Patients filled out validated questionnaires UIQ-7, CRAIQ-7, POPIQ-7, PFIQ-7, POPDI-6, CRADI-8, and UDI-6 and evaluated their satisfaction with the procedure. Objective success was defined as anterior wall prolapse stage 0 or 1 assessed by the POP-Q system. Subjective success was defined as the absence of bulging sensation or a sense of falling out that can be felt or seen in the vaginal area. Data were analysed using descriptive statistics and non-parametric tests.

RESULTS

Seventy out of 137 (51.1%) patients attended the follow-up. Mean follow-up period up was 74.1 ± 12.6 months. Two patients were excluded from the analysis because they had another surgical procedure due to central compartment prolapse. Of the remaining patients, 50 had AC and 18 had AC and posterior colporrhaphy (PC). Objective success rate was 13.2% and subjective success rate was 68.7%. Almost all patients (98.5%) were satisfied with the procedure. In the group of patients with objective recurrence, 66.1% had no prolapse symptoms.

CONCLUSION

Despite having a low objective success rate, patients' satisfaction with AC is very high.

Current surgical management of pelvic organ prolapse: Strategies for the improvement of surgical outcomes

There are a variety of surgical management strategies to help surgeons repair pelvic organ prolapse (POP). Surgical treatment for POP includes native tissue repair, augmentation with mesh, and minimally invasive surgeries. Currently, laparoscopic or robotic techniques for POP repair are increasing in popularity and continuing to evolve. The aim of this review is to present an up-to-date review of surgical techniques used for POP repair and to discuss ways to optimize surgical outcomes.

Primary surgical management of anterior pelvic organ prolapse: a systematic review, network meta-analysis and cost-effectiveness analysis

BACKGROUND

Anterior compartment prolapse is the most common pelvic organ prolapse (POP) with a range of surgical treatment options available.

OBJECTIVES

To compare the clinical effectiveness and cost-effectiveness of surgical treatments for the repair of anterior POP.

METHODS

We conducted a systematic review of randomised controlled trials comparing surgical treatments for women with POP. Network meta-analysis was possible for anterior POP, same-site recurrence outcome. A Markov model was used to compare the cost-utility of surgical treatments for the primary repair of anterior POP from a UK National Health Service perspective.

MAIN RESULTS

We identified 27 eligible trials for the network meta-analysis involving eight surgical treatments tested on 3194 women. Synthetic mesh was the most effective in preventing recurrence at the same site. There was no evidence to suggest a difference between synthetic non-absorbable mesh, synthetic partially absorbable mesh, and biological mesh. The cost-utility analysis, which incorporated effectiveness, complications and cost data, found non-mesh repair to have the highest probability of being cost-effective. The conclusions were robust to model inputs including effectiveness, costs and utility values.

CONCLUSIONS

Anterior colporrhaphy augmented with mesh appeared to be cost-ineffective in women requiring primary repair of anterior POP. There is a need for further research on long-term effectiveness and the safety of mesh products to establish their relative cost-effectiveness with a greater certainty.

TWEETABLE ABSTRACT

New study finds mesh cost-ineffective in women with anterior pelvic organ prolapse.

Changes in Female Sexual Function After Vaginal Mesh Repair Versus Native Tissue Repair for Pelvic Organ Prolapse: A Meta-Analysis of Randomized Controlled Trials

AIM

To evaluate changes in female sexual function after transvaginal mesh (TVM) repair versus native tissue repair for pelvic organ prolapse.

METHODS

Eligible studies, published through November 2017, were retrieved through searches of ClinicalTrials.gov, MEDLINE, Embase, and Cochrane Review databases and associated bibliographies. We included randomized control trials of transvaginal prolapse surgery with either mesh repair or native tissue repair regarding the outcomes of sexual function, de novo and postoperative dyspareunia with a minimum of 3 months of follow-up.

RESULTS

Seventeen trials including 2,976 patients (1,488 with TVM repair and 1,488 with native tissue repair) were identified. There was no significant difference in postoperative dyspareunia after TVM repair versus native tissue repair (risk ratio [RR] = 1.07; 95% confidence interval [CI] = 0.76-1.50). Likewise, there was no significant difference in de novo dyspareunia after TVM repair versus native tissue repair (RR = 0.91; 95% CI = 0.52-1.61). There was also no significant difference in the short form Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire score after TVM mesh repair versus native tissue repair (mean difference = 0.26; 95% CI = -1.34 to 1.85).

CONCLUSION

Sexual function and de novo and postoperative dyspareunia were similar between the patients who underwent TVM repair and those who underwent native tissue repair. Liao S-C, Huang W-C, Su T-H, et al. Changes in Female Sexual Function After Vaginal Mesh Repair Versus Native Tissue Repair for Pelvic Organ Prolapse: A Meta-Analysis of Randomized Controlled Trials. J Sex Med 2019;16:633-639.

A systematic review of outcome and outcome-measure reporting in randomised trials evaluating surgical interventions for anterior-compartment vaginal prolapse: a call to action to develop a core outcome set

Introduction

We assessed outcome and outcome-measure reporting in randomised controlled trials evaluating surgical interventions for anterior-compartment vaginal prolapse and explored the relationships between outcome reporting quality with journal impact factor, year of publication, and methodological quality.

Methods

We searched the bibliographical databases from inception to October 2017. Two researchers independently selected studies and assessed study characteristics, methodological quality (Jadad criteria; range 1–5), and outcome reporting quality Management of Otitis Media with Effusion in Cleft Palate (MOMENT) criteria; range 1–6], and extracted relevant data. We used a multivariate linear regression to assess associations between outcome reporting quality and other variables.

Results

Eighty publications reporting data from 10,924 participants were included. Seventeen different surgical interventions were evaluated. One hundred different outcomes and 112 outcome measures were reported. Outcomes were inconsistently reported across trials; for example, 43 trials reported anatomical treatment success rates (12 outcome measures), 25 trials reported quality of life (15 outcome measures) and eight trials reported postoperative pain (seven outcome measures). Multivariate linear regression demonstrated a relationship between outcome reporting quality with methodological quality (β = 0.412; P = 0.018). No relationship was demonstrated between outcome reporting quality with impact factor (β = 0.078; P = 0.306), year of publication (β = 0.149; P = 0.295), study size (β = 0.008; P = 0.961) and commercial funding (β = −0.013; P = 0.918).

Conclusions

Anterior-compartment vaginal prolapse trials report many different outcomes and outcome measures and often neglect to report important safety outcomes. Developing, disseminating and implementing a core outcome set will help address these issues.

Effectiveness, quality of life and sexual functions in women with anterior compartment prolapse treated by native tissue repair

Anterior compartment defect is the most common pelvic organ prolapse. It is defined as the descent of the bladder into the anterior vaginal wall. The etiology is multifactorial and the main risk factors are vaginal delivery and conditions associated with increased abdominal strain. Aging is significantly associated with the prevalence and severity of pelvic organ prolapse. Treatment may be conservative or surgical according to symptoms, prolapse degree and not forgetting both patient and doctor preferences. The aim of this work is to identify the most efficient surgical treatment of cystocele and its recurrences. There are two different surgical approaches for the treatment of cystocele: traditional repair and mesh repair. Prosthetic treatment gives higher anatomical success rate but traditional anterior repair has less complication demonstrating a lower risk of reoperation. Surgical treatment in general improves both the quality of life (QoL) and the sexual function. We carried out a research on the impact of the anterior defect before and after native tissue surgery on QoL and sexual function. The efficacy and complications of the treatment were also assessed.

Surgery for women with pelvic organ prolapse with or without stress urinary incontinence

BACKGROUND

Pelvic organ prolapse (POP) is common in women and is frequently associated with stress urinary incontinence (SUI). In many cases however, SUI is present only with the prolapse reduced (occult SUI) or may develop after surgical treatment for prolapse (de novo SUI).

OBJECTIVES

To determine the impact on postoperative bladder function of surgery for symptomatic pelvic organ prolapse with or without concomitant or delayed two-stage continence procedures to treat or prevent stress urinary incontinence.

SEARCH METHODS

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 journals and conference proceedings (searched 11 November 2017) and reference lists of relevant articles. We also contacted researchers in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) including surgical operations for POP with or without continence procedures in continent or incontinent women. Our primary outcome was subjective postoperative SUI. Secondary outcomes included recurrent POP on examination, overactive bladder (OAB) symptoms, and voiding dysfunction.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane.

MAIN RESULTS

We included 19 RCTs (2717 women). The quality of the evidence ranged from low to moderate. The main limitations were risk of bias (especially blinding of outcome assessors), indirectness and imprecision associated with low event rates and small samples.POP surgery in women with SUIVaginal repair with vs without concomitant mid-urethral sling (MUS)A concomitant MUS probably improves postoperative rates of subjective SUI, as the evaluated clinical effect appears large (risk ratio (RR) 0.30, 95% confidence interval (CI) 0.19 to 0.48; 319 participants, two studies; I² = 28%; moderate-quality evidence), and probably decreases the need for further continence surgery (RR 0.04, 95% CI 0.00 to 0.74; 134 participants, one study; moderate-quality evidence). This suggests that if the risk of SUI with POP surgery alone is 39%, the risk with an MUS is between 8% and 19%.Rates of recurrent POP on examination, OAB, and voiding dysfunction were not reported.Vaginal repair with concomitant vs delayed MUSEvidence suggested little or no difference between groups in reporting postoperative SUI (RR 0.41, 95% CI 0.12 to 1.37; 140 participants, one study; moderate-quality evidence).Rates of recurrent POP on examination, OAB, and voiding dysfunction and the need for further surgery were not reported.Abdominal sacrocolpopexy with vs without Burch colposuspensionAn additional Burch colposuspension probably has little or no effect on postoperative SUI at one year (RR 1.38, 95% CI 0.74 to 2.60; 47 participants, one study; moderate-quality evidence), OAB symptoms (RR 0.85, 95% CI 0.61 to 1.18; 33 participants, one study; moderate-quality evidence), or voiding dysfunction (RR 0.96, 95% CI 0.06 to 14.43; 47 participants, one study; moderate-quality evidence). Rates of recurrent POP and the need for further surgery were not reported.POP surgery in women with occult SUIVaginal repair with vs without concomitant MUSMUS probably improves rates of subjective postoperative SUI (RR 0.38, 95% CI 0.26 to 0.55; 369 participants, five studies; I² = 44%; moderate-quality evidence). This suggests that if the risk with surgery alone is 34%, the risk with a concomitant MUS is between 10% and 22%. Evidence suggests little or no difference between groups in rates of recurrent POP (RR 0.86, 95% CI 0.34 to 2.19; 50 participants, one study; moderate-quality evidence), OAB symptoms (RR 0.75, 95% CI 0.52 to 1.07; 43 participants, one study; low-quality evidence), or voiding dysfunction (RR 1.00, 95% CI 0.15 to 6.55; 50 participants, one study; low-quality evidence). The need for further surgery was not reported.POP surgery in continent women Vaginal repair with vs without concomitant MUSResearchers provided no conclusive evidence of a difference between groups in rates of subjective postoperative SUI (RR 0.69, 95% CI 0.47 to 1.00; 220 participants, one study; moderate-quality evidence). This suggests that if the risk with surgery alone is 40%, the risk with a concomitant MUS is between 19% and 40%. Rates of recurrent POP, OAB, and voiding dysfunction and the need for further surgery were not reported.Abdominal sacrocolpopexy with vs without Burch colposuspensionWe are uncertain whether there is a difference between groups in rates of subjective postoperative SUI (RR 1.31, 95% CI 0.19 to 9.01; 379 participants, two studies; I² = 90%; low-quality evidence), as RCTs produced results in different directions with a very wide confidence interval. We are also uncertain whether there is a difference between groups in rates of voiding dysfunction (RR 8.49, 95% CI 0.48 to 151.59; 66 participants, one study; low-quality evidence) or recurrent POP (RR 0.98, 95% CI 0.74 to 1.30; 250 participants, one study; moderate-quality evidence. No study reported OAB symptoms and need for further surgery.Vaginal repair with armed anterior vaginal mesh repair vs anterior native tissue Anterior armed mesh repair may slightly increase postoperative de novo SUI (RR 1.58, 95% CI 1.05 to 2.37; 905 participants, seven studies; I² = 0%; low-quality evidence) but may decrease recurrent POP (RR 0.29, 95% CI 0.22 to 0.38; 848 participants, five studies; I² = 0%; low-quality evidence). There may be little or no difference in rates of voiding dysfunction (RR 1.65, 95% CI 0.22 to 12.10; 125 participants, two studies; I² = 0%; low-quality evidence). Rates of OAB and the need for further surgery were not reported.Adverse events were infrequently reported in all studies; cost was not studied in any trial.

AUTHORS' CONCLUSIONS

In women with POP and SUI (symptomatic or occult), a concurrent MUS probably reduces postoperative SUI and should be discussed in counselling. It might be feasible to postpone the MUS and perform a delayed (two-stage) continence procedure, if required.Although an abdominal continence procedure (Burch colposuspension) during abdominal POP surgery in continent women reduced de novo SUI rates in one underpowered trial, another RCT reported conflicting results. Adding an MUS during vaginal POP repair might reduce postoperative development of SUI.An anterior native tissue repair might be better than use of transobturator mesh for preventing postoperative SUI; however, prolapse recurrence is more common with native tissue repair.

No. 351-Transvaginal Mesh Procedures for Pelvic Organ Prolapse

OBJECTIVE

This guideline reviews the evidence related to the risks and benefits of using transvaginal mesh in pelvic organ prolapse repairs in order to update recommendations initially made in 2011.

INTENDED USERS

Gynaecologists, residents, urologists, urogynaecologists, and other health care providers who assess, counsel, and care for women with pelvic organ prolapse.

TARGET POPULATION

Adult women with symptomatic pelvic organ prolapse considering surgery and those who have previously undergone transvaginal mesh procedures for the treatment of pelvic organ prolapse.

OPTIONS

The discussion relates to transvaginal mesh procedures compared with other surgical options for pelvic organ prolapse (mainly about vaginal native tissue repairs and minimally about other alternatives such as biological and absorbable vaginal mesh and abdominally placed surgical mesh).

OUTCOMES

The outcomes of interest are objective and subjective success rates and intraoperative and postoperative complications, such as adjacent organ injury (urinary, gastrointestinal), infection, hematoma/bleeding, vaginal mesh exposure, persistent pain, dyspareunia, de novo stress urinary incontinence, and reoperation.

EVIDENCE

PubMed, Medline, the Cochrane Database, and EMBASE were searched using the key words pelvic organ prolapse/surgery*, prolapse/surgery*, surgical mesh, surgical mesh*/adverse effects, transvaginal mesh, and pelvic organ prolapse.

RESULTS

were restricted to English or French language and human research. Articles obtained through this search strategy were included until the end of June 2016. Pertinent new studies were added up to September 2016. Grey literature was not searched. Clinical practice guidelines and guidelines of specialty societies were reviewed. Systematic reviews were included when available. Randomized controlled trials and observational studies were included when evidence for the outcome of interest or in the target population was not available from systematic reviews. New studies not yet included in systematic reviews were also included. Only publications with study groups larger than 20 individuals were selected because this criterion was used in the largest meta-analysis referenced in this guideline. A total of 1470 studies were obtained; after selecting only applicable studies and excluding duplicates, 68 manuscripts were reviewed and included.

VALUES

The content and recommendations were drafted and agreed upon by the principal authors and members of the Urogynaecology Committee. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework. The Summary of Findings is available upon request.

BENEFITS, HARMS, AND/OR COSTS

It is expected that this guideline will benefit women with pelvic organ prolapse by ensuring that health care providers are aware of outcomes related to transvaginal mesh procedures and steps in the management of related complications. This should guide patient-informed consent before such procedures are undertaken. The benefits clearly outweigh the potential harms or costs of implementation of this guideline, although no direct harms or costs are identified.

GUIDELINE UPDATE

Evidence will be reviewed 5 years after publication to decide whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Long-term outcome after surgical repair of pelvic organ prolapse with Elevate Prolapse Repair System

Female pelvic organ prolapse (POP) is a common condition and the correction of prolapse remains a major challenge for the surgical community. A retrospective study of women with POP undergoing pelvic reconstructive surgery with the Elevate System followed-up for 48 months. A total of 138 women with POP were included in the study. We observed an objective cure rate of 94.9% for the anterior wall after 4 years' follow-up. The subjective cure rate was 97.1%. Improvement in the urinary symptoms was seen after the surgery: the number of asymptomatic patients increased from 14.5 to 77% after the 4 years of follow-up. We reported no cases of bleeding, haematoma, mesh infection and bowel injury, while we had four cases of bladder injury and one case of sepsis. The mesh extrusion rate was 7.3%, all cases interested the anterior compartment. Postoperative dyspareunia and pelvic pain were rare. In this cohort, the Elevate Prolapse Repair System was associated with excellent long-term results, for both anatomical corrections of prolapse, with a high objective and subjective cure rate and a functional urinary outcome. Impact statement What is already known on this subject? Female pelvic organ prolapse is a common condition and the correction of prolapse remains a major challenge for the surgical community. The optimal treatment of POP has still to be determined. What do the results of this study add? The findings from this study shows that the Elevate Prolapse Repair System had high anatomic results associated with a good durability, low morbidity and excellent subjective outcome. To the best of our knowledge, this is the first study that reports a follow-up up to 48 months. What are the implications of these findings for clinical practice and/or further research? The Elevate Prolapse Repair System was associated with excellent long terms results in terms of safety, durability and tolerability during the 4 years' follow-up. Despite the fact that the Elevate kit produced by AMS was withdrawn from the market and it is no longer available, we believe that it is helpful to have data about the outcomes of a transvaginal mesh implant.

Current trends and future perspectives in pelvic reconstructive surgery

Pelvic organ prolapse is a prevalent disorder with a high lifetime incidence of surgical repair. Pelvic organ prolapse surgery has greatly evolved over the past years, and pelvic floor reconstructive surgeons are faced with a vast array of treatment options for their patients. Our review article illustrates the current trends and future perspectives for the surgical treatment of pelvic organ prolapse.

Anterior colporrhaphy plus inside-out tension-free vaginal tape for associated stress urinary incontinence and cystocele: 10-year follow up results

AIMS

We report the success rate and complications rate of combined ultralateral anterior Colporrhaphy plus Tension-free Vaginal Tape (TVT-O) in a long-term (10 year) follow-up prospective survey.

METHODS

Patients previously treated for associated stress urinary incontinence (SUI) and cystocele were subjected to annual follow-up for 10 year with a complete urogynecologic evaluation. Furthermore, an urodynamic assessment and a quality of life questionnaire (ICIQ-UI SF) were recorded at the 5th and 10th year of follow up.

RESULTS

Fifty patients treated between June 2004 and May 2006 were included in the analysis. Five patients did not return to 5-yr follow-up: two patients developed a median tape erosion and three patients withdraw. At 10-yr follow-up two more patients withdraw for a total of seven patients lost to follow-up. After 10 years patients objectively cured from cystocele were 41 (95%) while patients objectively cured from SUI were 39 (91%). At 10th year follow-up 38 patients (89%) result cured from both SUI and cystocele, 3 (7%) patients result cured only from prolapse, 1 (2%) patient only from SUI, and 1 (2%) patient result objectively failed for both SUI and cystocele. The ICIQ-UI SF scores at 10th year follow-up was 6.2 ± 3.7. The late complication rate at 10th year follow-up was 32% (OAB symptoms 20%; Mixed incontinence 2%; Bladder outlet obstruction 0%; Dyspareunia 6%; Chronic pelvic pain 0%; Vaginal tape erosion 4%; Detrusor hyperactivity 0%).

CONCLUSIONS

The combined procedures shown proved to be an effective and safe procedure to treat concomitant SUI and cystocele.

Outcome of vaginal mesh reconstructive surgery in multiparous compared with grand multiparous women: Retrospective long-term follow-up

We aimed to compare the long-term surgical outcome and complications of multiparous and grand multiparous women undergoing reconstructive surgery with vaginal mesh implants for repair of pelvic organ prolapse. This retrospective, long-term follow-up (28.17±20.7 months) comprised 113 women who underwent surgical reconstructive surgery with vaginal polypropylene mesh in a high parity rate population medical center. The women were divided into 2 groups (multiparous and grand multiparous) and each group was evaluated for objective and subjective surgical outcome. Patient demographics and surgical data were retrieved from electronic medical records. Outcome measure included POP-Q exam as objective outcome and validated Pelvic Floor Distress Inventory questionnaire (PFDI) to assess subjective outcome. Average age of patients was 62±7.9 (range 42–83) years. Average parity was 5.6±3.1 (range 1–14). There were 54 (47.7%) multiparous women and 59 (52.3%) grand multiparous women. The grand multiparous women were younger than the multiparous women and had a significantly higher degree of prolapse. At the last follow-up, the only significant difference was related to symptoms of an overactive bladder. In conclusion, long-term follow-up demonstrates that vaginal mesh surgery in grand multiparous women offers anatomical and subjective cure rates comparable to multiparous women.

Reasons for and Against Use of Non-absorbable, Synthetic Mesh During Pelvic Organ Prolapse Repair, According to the Prolapsed Compartment

Awareness and reporting of mesh-related complications of pelvic organ prolapse repairs have increased in recent years. As a result, deciding whether to use a mesh or not has become a difficult task for urogynecologists. Our aim was to summarize reasons for and against the use of mesh in prolapse repair based on a review of relevant literature. Scopus and PubMed databases were searched for papers reporting on the efficacy and safety of native tissue versus non-absorbable, synthetic mesh prolapse repairs. Randomized controlled trials, systematic reviews, and meta-analyses were included. Evidence is presented for each vaginal compartment separately. In the anterior compartment, mesh repairs seem to offer clearly superior efficacy and durability of results compared to native tissue repairs, but with an equally clear increase in complication rates. In the isolated posterior compartment prolapse, high-quality evidence is sparse. As far as the apical compartment is concerned, sacrocolpopexy is the most efficacious, yet the most invasive procedure. Data on the comparison of transvaginal mesh versus native tissue repairs of the apical compartment are somewhat ambiguous. Given the inevitable coexistence of advantages and disadvantages of mesh use in each of the prolapsed vaginal compartments, an individualized treatment decision, based on weighing risks against benefits for each patient, seems to be the most rational approach.

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

BACKGROUND

A wide variety of grafts have been introduced with the aim of improving the outcomes of traditional native tissue repair (colporrhaphy) for vaginal prolapse.

OBJECTIVES

To determine the safety and effectiveness of transvaginal mesh or biological grafts compared to native tissue repair for vaginal prolapse.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ongoing trials registers, and handsearching of journals and conference proceedings (6 July 2015). We also contacted researchers in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing different types of vaginal repair (mesh, biological graft, or native tissue).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed risk of bias, and extracted data. The primary outcomes were awareness of prolapse, repeat surgery, and recurrent prolapse on examination.

MAIN RESULTS

We included 37 RCTs (4023 women). The quality of the evidence ranged from very low to moderate. The main limitations were poor reporting of study methods, inconsistency, and imprecision. Permanent mesh versus native tissue repairAwareness of prolapse at one to three years was less likely after mesh repair (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.54 to 0.81, 12 RCTs, n = 1614, I(2) = 3%, moderate-quality evidence). This suggests that if 19% of women are aware of prolapse after native tissue repair, between 10% and 15% will be aware of prolapse after permanent mesh repair.Rates of repeat surgery for prolapse were lower in the mesh group (RR 0.53, 95% CI 0.31 to 0.88, 12 RCTs, n = 1675, I(2) = 0%, moderate-quality evidence). There was no evidence of a difference between the groups in rates of repeat surgery for continence (RR 1.07, 95% CI 0.62 to 1.83, 9 RCTs, n = 1284, I(2) = 21%, low-quality evidence). More women in the mesh group required repeat surgery for the combined outcome of prolapse, stress incontinence, or mesh exposure (RR 2.40, 95% CI 1.51 to 3.81, 7 RCTs, n = 867, I(2) = 0%, moderate-quality evidence). This suggests that if 5% of women require repeat surgery after native tissue repair, between 7% and 18% in the permanent mesh group will do so. Eight per cent of women in the mesh group required repeat surgery for mesh exposure.Recurrent prolapse on examination was less likely after mesh repair (RR 0.40, 95% CI 0.30 to 0.53, 21 RCTs, n = 2494, I(2) = 73%, low-quality evidence). This suggests that if 38% of women have recurrent prolapse after native tissue repair, between 11% and 20% will do so after mesh repair.Permanent mesh was associated with higher rates of de novo stress incontinence (RR 1.39, 95% CI 1.06 to 1.82, 12 RCTs, 1512 women, I(2) = 0%, low-quality evidence) and bladder injury (RR 3.92, 95% CI 1.62 to 9.50, 11 RCTs, n = 1514, I(2) = 0%, moderate-quality evidence). There was no evidence of a difference between the groups in rates of de novo dyspareunia (RR 0.92, 95% CI 0.58 to 1.47, 11 RCTs, n = 764, I(2) = 21%, low-quality evidence). Effects on quality of life were uncertain due to the very low-quality evidence. Absorbable mesh versus native tissue repairThere was very low-quality evidence for the effectiveness of either form of repair at two years on the rate of awareness of prolapse (RR 1.05, 95% CI 0.77 to 1.44, 1 RCT, n = 54).There was very low-quality evidence for the effectiveness of either form of repair on the rate of repeat surgery for prolapse (RR 0.47, 95% CI 0.09 to 2.40, 1 RCT, n = 66).Recurrent prolapse on examination was less likely in the mesh group (RR 0.71, 95% CI 0.52 to 0.96, 3 RCTs, n = 292, I(2) = 21%, low-quality evidence)The effect of either form of repair was uncertain for urinary outcomes, dyspareunia, and quality of life. Biological graft versus native tissue repairThere was no evidence of a difference between the groups at one to three years for the outcome awareness of prolapse (RR 0.97, 95% CI 0.65 to 1.43, 7 RCTs, n = 777, low-quality evidence).There was no evidence of a difference between the groups for the outcome repeat surgery for prolapse (RR 1.22, 95% CI 0.61 to 2.44, 5 RCTs, n = 306, I(2) = 8%, low-quality evidence).The effect of either approach was very uncertain for recurrent prolapse (RR 0.94, 95% CI 0.60 to 1.47, 7 RCTs, n = 587, I(2) = 59%, very low-quality evidence).There was no evidence of a difference between the groups for dyspareunia or quality of life outcomes (very low-quality evidence).

AUTHORS' CONCLUSIONS

While transvaginal permanent mesh is associated with lower rates of awareness of prolapse, reoperation for prolapse, and prolapse on examination than native tissue repair, it is also associated with higher rates of reoperation for prolapse, stress urinary incontinence, or mesh exposure and higher rates of bladder injury at surgery and de novo stress urinary incontinence. The risk-benefit profile means that transvaginal mesh has limited utility in primary surgery. While it is possible that in women with higher risk of recurrence the benefits may outweigh the risks, there is currently no evidence to support this position.Limited evidence suggests that absorbable mesh may reduce rates of recurrent prolapse on examination compared to native tissue repair, but there was insufficient evidence on absorbable mesh for us to draw any conclusions for other outcomes. There was also insufficient evidence for us to draw any conclusions regarding biological grafts compared to native tissue repair.In 2011, many transvaginal permanent meshes were voluntarily withdrawn from the market, and the newer, lightweight transvaginal permanent meshes still available have not been evaluated within a RCT. In the meantime, these newer transvaginal meshes should be utilised under the discretion of the ethics committee.