Surgery for women with anterior compartment prolapse

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).

To determine the benefits and harms of surgery for anterior compartment prolapse.

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.

We included randomised controlled trials (RCTs) that compared surgical operations in women with anterior compartment prolapse.

Two review authors independently selected trials, assessed their risk of bias and extracted their data.

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.

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.