Mesh Sacrocolpopexy Compared With Native Tissue Vaginal Repair

Abstract

Objective To systematically review outcomes after mesh sacrocolpopexy compared with native tissue vaginal repairs in women with apical prolapse. Data Sources We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov through June 4, 2012. Methods of Study Selection For anatomic and functional analyses, we included studies comparing mesh sacrocolpopexy compared with native tissue vaginal repairs with at least 6 months follow-up. The primary outcome was anatomic “success” after surgery. Secondary outcomes were reoperation and symptom outcomes. We included large case series and comparative studies with shorter follow-up to increase power for adverse event analyses. Tabulation, Integration, and Results Evidence quality was assessed with the Grades for Recommendation, Assessment, Development and Evaluation system. Meta-analyses were performed when at least three studies reported the same outcome. We included 13 comparative studies for anatomic success, reoperation, and symptom outcomes. Moderate-quality evidence supports improved anatomic outcomes after mesh sacrocolpopexy; very low–quality evidence shows no differences in reoperation between sacrocolpopexy and native tissue vaginal repairs. Evidence was insufficient regarding which procedures result in improved bladder or bowel symptoms. Low-quality evidence showed no differences in postoperative sexual function. Adverse event data were compiled and meta-analyzed from 79 studies. When including larger noncomparative studies, ileus or small bowel obstruction (2.7% vs. 0.2%, p < 0.01), mesh or suture complications (4.2% vs. 0.4%, p < 0.01), and thromboembolic phenomena (0.6% vs. 0.1%, p = 0.03) were more common after mesh sacrocolpopexy compared to native tissue vaginal repairs. Conclusion When anatomic durability is a priority, we suggest that mesh sacrocolpopexy may be the preferred surgical option. When minimizing adverse events or reoperation is the priority, there is no strong evidence supporting one approach over the other.

Readmission and Prolapse Recurrence After Abdominal and Vaginal Apical Suspensions in Older Women

“…In contrast to previous Cochrane review 1 , our study suggests that women ≥65 years have similar prolapse recurrence after abdominal sacrocolpopexies and vaginal apical suspensions during 12-month follow-up. The increased risks of gastrointestinal complications after abdominal sacrocolpopexy in older women are comparable to reported increased risks of gastrointestinal complications in a systematic review (OR 9.5, 95% CI 3.4–26.4) 6 .…”

“…Randomized controlled trials (RCTs) and systematic reviews have investigated optimal surgical approaches for pelvic organ prolapse, but the safest and most durable apical suspension is yet to be definitely identified 1–6 . Estimates of prolapse recurrence vary widely due to differences in study design and length of follow-up ranging from 2.3% 5,7 to 29.2% 8 .…”

“…Moreover, differential findings from three RCTs resulted in discordant conclusions with respect to the best apical surgery 2–4 . Systematic reviews suggest that abdominal sacrocolpopexy with synthetic mesh provides more durable repair than vaginal apical suspensions but is associated with higher rates of gastrointestinal, mesh/suture, and thromboembolism complications 1,6 . Recent research indicates that older women experience greater morbidity and higher mortality after surgical prolapse treatment 9,10 .…”

An Update on the Use of Mesh in Pelvic Reconstructive Surgery

“…With regard to the use of mesh for sling surgery and sacrocolpopexy, AUGS is in line with the FDA's stance: the risks associated with these procedures are not as prevalent as those associated with transvaginal mesh placement and robust clinical trials exist confirming the safety and efficacy of these types of mesh [31]; therefore, use of mesh products for incontinence surgery and abdominal placement for treatment of prolapse remains permissible and appropriate. In August 2012, AUGS announced the release of their guidelines for providing privileges and credentials to physicians performing transvaginal mesh procedures for the treatment of pelvic organ prolapse; and, in 2013, the society did the same for physicians performing sacrocolpopexy procedures [32].…”

Native Tissue Surgery for Prolapse versus Graft/Mesh Use: Current Trends in Reconstructive Surgery

“…Abdominal sacrocolpopexy has high success rates that range from 78 to 100 %, with a reoperation rate 4.4 % [39]. Compared to any type of native tissue repairs, the evidence supports abdominal sacrocolpopexy to decrease prolapse recurrence, [40,41], but the trade-offs of these surgeries include longer operating times, longer recoveries, and greater expense [28•, 38]. Studies suggest rates of mesh exposure can range from 4.2 % to as high as 10.5 % with long-term follow-up [40,42], approaching rates of mesh exposure with transvaginal mesh repairs.…”