Summary: 2021 International Consultation on Incontinence Evidence-Based Surgical Pathway for Pelvic Organ Prolapse
Abstract
:1. Introduction
2. POP Outcomes’ Assessment
- The anatomical outcomes reported should include all POP-Q points and staging utilizing a traditional definition of success. Assessments should be prospective, and assessors should be blinded to the surgical intervention performed wherever possible and should not possess any conflict of interest related to the assessment undertaken (GoR C).
- Prolapse surgery should be defined as primary surgery and repeat surgery sub-classified as primary surgery of a different site for repeat surgeries, complications related to surgery, and surgery for non-prolapse-related conditions (GoR C).
- Functional outcomes are best reported using valid, reliable, and responsive symptom questionnaires and condition-specific HRQOL instruments (GoR C).
- Sexual function is best reported utilizing validated condition-specific HRQOL instruments that assess sexual function or validated sexual function questionnaires such as the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire (PISQ) or the Female Sexual Function Index (FSFI). The sexual activity status of all the study participants should be reported pre-and post-operatively under the following categories: sexually active without pain, sexually active with pain, or not sexually active (GoR C).
3. Anterior Compartment Surgery
- Polypropylene mesh has a superior anatomical outcome compared to a biological graft (Pelvicol) in the anterior compartment (Feldner, Menefee). However, the mesh exposure rate was significantly higher in the polypropylene mesh group (GoR A).
- Polypropylene mesh demonstrates improved anatomical and subjective outcomes compared to AC with no difference in the functional outcomes using validated questionnaires or a lower reoperation rate for prolapse. The mesh group was also associated with longer operating times, greater blood loss, and a non-significant tendency towards higher cystotomy, de novo dyspareunia, and de novo stress urinary incontinence rates compared to AC. Apical or posterior compartment prolapse was significantly more common following polypropylene mesh and the mesh exposure rate was 10.4% with 6.3% undergoing surgical correction (GoR B).
- The data for recurrent anterior vaginal wall prolapses show conflicting information regarding the advantages for polypropylene mesh compared to AC, with relatively high rates of mesh complication reported in the long-term (GoR C).
4. Surgical Treatment of Uterovaginal Prolapse
- Hysteropexy is reasonable in women undergoing surgery for uterovaginal prolapse without contraindications to uterine preservation. However, long-term data are limited and the need for subsequent hysterectomy is unknown (GoR C).
- When considering relative contra-indications to uterine preservation, an opportunistic salpingectomy, which cannot be performed during vaginal hysteropexy, should be included in the shared decision-making process (GoR C).
- Large database studies demonstrated lower reoperation rates for recurrent prolapses and slightly higher complication rates in the hysterectomy group compared to hysteropexy (GoR C).
- Consistent level one and two evidence reveal no differences in outcomes comparing sacrospinous hysteropexy to vaginal hysterectomy with native tissue prolapse repair, with the exception of a single smaller RCT showing a higher risk of apical recurrence for patients with advanced prolapse undergoing hysteropexy (GoR B).
- A partial Colpocleisis is preferred over a vaginal hysterectomy and total colpocleisis when there is no specific indication for hysterectomy and no interest in preserving coital function (GoR C).
- The role of the Manchester procedure for the treatment of a mild uterovaginal prolapse with or without cervical elongation has yet to be determined based on limited, poor level two and three evidence (GoR D).
- The data are not supportive of transvaginal meshes and hysterectomy for uterine prolapse. Consistent Level two evidence shows no difference in anatomic success when comparing a sacrospinous hysteropexy with a mesh graft to a hysterectomy with a graft; additionally, the mesh exposure rate was significantly higher after a hysterectomy than hysteropexy (11% vs. 5%) (GoR C).
- Sacrohysteropexy (SHP) has a similar success rate and reoperation for prolapse when compared to a vaginal hysterectomy and USLS; however, it has lower success rates than sacrocolpopexy with total or supracervical hysterectomy (GoR C).
- A sacrocolpopexy with a total hysterectomy is not recommended due to a three- to five-fold higher mesh exposure rate (GoR C).
- A single small study sacrocolpopexy with a supracervical hysterectomy had a lower anatomic success rate than a sacrocolpopexy with a total hysterectomy (GoR D)
- Level three evidence reveals low rates of unanticipated pathology (1.5%) and endometrial cancer (0.3%) with no cases of sarcoma identified during hysterectomies in women with a low risk of malignancy and dysplasia undergoing prolapse surgery (GoR C).
5. Apical Prolapse Surgery
- A single large RCT suggests that USLS and SSLF have similar anatomical, functional, and adverse event outcomes (GoR B).
- Level one evidence demonstrates transvaginal mesh procedures offer no significant advantage over vaginal native tissue apical repairs and are associated with mesh exposures (GoR A).
- Level one evidence suggests that overall sacrocolpopexy is associated with a lower risk of awareness of prolapse, a recurrent prolapse on examination, repeat surgery for prolapse, and post-operative SUI and dyspareunia when compared broadly with vaginal prolapse repairs with and without mesh augmentation (GoR A).
- Level one evidence suggests that ASCP has a higher success rate as compared to SSLS with fewer occurrences of SUI and post-operative dyspareunia. ASC had a greater morbidity including regarding operating time, inpatient stay, a slower return to activities of daily living, and a higher cost (GoR A).
- In a single RCT, ASCP was associated with greater anatomical success, fewer reoperations, and greater post-operative complications than USLS but no difference in the improvement in symptoms or quality of life was reported (GoR B).
- LSCP is associated with lower levels of blood loss, longer operating times, and shorter hospital stays than ASCP, with no difference in the objective or subjective cure rates (GoR B).
- Compared to LSCP, RSCP is associated with longer operating times, greater post-operative pain, and a higher cost with similar rates of anatomic success and complications (GoR B).
- ASCP performed with polypropylene mesh has superior outcomes to fascia lata (GoR B).
- In a single RCT, LSCP had superior objective and subjective success rates and lower reoperation rates compared to polypropylene transvaginal mesh for vault prolapses (GoR B).
- Level three evidence suggests McCall culdoplasty, Iliococcygeus fixation, and colpocleisis are relatively safe and effective interventions (GoR C).
6. Surgery for Posterior Vaginal Wall Prolapse
- Level one and two evidence suggest that a midline plication posterior repair without a levatorplasty has superior objective outcomes as compared to a site-specific posterior repair (GoR B).
- A higher dyspareunia rate is reported when a levatorplasty is performed (GoR C).
- The transvaginal approach is superior to the transanal approach for the repair of a posterior wall prolapse (GoR A).
- To date, no study has shown any benefit to a graft or mesh overlay or to the augmentation of a suture repair for a posterior vaginal wall prolapse (GoR B).
- While modified abdominal sacrocolpopexy results have been reported, the data on how these results would compare to the traditional transvaginal repair of a posterior vaginal wall prolapse are lacking.
- The data comparing Delorme’s procedure and ventral mesh rectopexy (VMR) for an external rectal prolapse are conflicting, with a single RCT demonstrating no statistical difference, while the level 3 data are supportive of VMR performed laparoscopically or robotically, with low rates of recurrent rectal prolapses and improved rates of fecal incontinence and constipation (GoR D).
- VMR appears superior to other abdominal rectopexies (posterior mesh rectopexy, Ripstein, and Orr–Loygue) with different rectal mobilizations to treat ERP in terms of functional outcome (GoE C).
- LoE 3 supports a ventral rectopexy for an Oxford grade 3–4 internal rectal prolapse. The data are not conclusive regarding the graft material or route of surgery (GoR C).
- No data demonstrate that a ventral rectopexy with or without a graft attachment to the posterior vaginal wall is effective for the management of rectocele (GoR D).
- Limited level three evidence suggest that patients with combined rectal and vaginal prolapses benefit from colorectal surgeons and urogynecologist collaborating closely (GoR C).
7. Surgery for Pelvic Organ Prolapse and Bladder Function
- Continent women who test negative for occult SUI do not require a concurrent prophylactic continence procedure (GoR B).
- In continent women who test negative for occult SUI undergoing sacrocolpopexy, an additional Burch colposuspension may reduce the occurrence of postoperative SUI (GoR C).
- Anterior mesh repair increases the risk for SUI as compared to anterior repair without mesh in continent women (GoR B).
- Continent women with occult SUI benefit from POP surgery with concomitant continence procedures as compared to POP surgery without continence intervention (GoR B).
- In women with POP and SUI, a concomitant continence procedure increases postoperative SUI cure rates (GoR A).
- A preoperative OAB (40%) resolves in approximately 50% of post-prolapse surgeries, although the impact of a concomitant non- surgical treatment remains unclear (GoR C).
- The rate of de novo OAB varies widely (2–32%) (GoR C).
- The rates of urinary retention following POP surgery varies from 0–34% and are nearly always temporary (GoR C).
- Pre-operative urinary retention resolves in as many as 90% of post-prolapse surgeries (GoR C).
8. Pelvic Organ Prolapse Surgery and Sexual Function
- While synthetic transvaginal mesh and non-mesh vaginal repairs have similar rates of de novo and total dyspareunia, the transvaginal mesh repair has a poorer sexual function as measured by the PISQ when compared to non-mesh repairs (GoR B).
- Synthetic transvaginal meshes have a higher rate of total dyspareunia when compared to sacrocolpopexy (GoR B).
- When comparing vaginal biologic grafts to vaginal native tissue repairs, there are similar decreases in postoperative dyspareunia and similar changes in sexual function (GoR B).
- Postoperative sexual activity in patients undergoing POP reconstructive surgery ranges from 42–65%, while postoperative sexual activity ranges from 32–62% (GoR C).
- The de novo dyspareunia rates for native tissue vaginal repair and sacrocolpopexy range from 2–8% (GoR C).
- Total dyspareunia rates generally decrease following native tissue repairs and sacrocolpopexy from 15–30% preoperatively to 8–20% postoperatively (GoR C).
- It is preferable to use validated questionnaires measuring sexual function in women before and after prolapse surgery. We also recommend reporting sexual activity and dyspareunia rates de novo, pre-, and post-intervention in all patients (GoR C).
9. Discussion
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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de Tayrac, R.; Antosh, D.D.; Baessler, K.; Cheon, C.; Deffieux, X.; Gutman, R.; Lee, J.; Nager, C.; Schizas, A.; Sung, V.; et al. Summary: 2021 International Consultation on Incontinence Evidence-Based Surgical Pathway for Pelvic Organ Prolapse. J. Clin. Med. 2022, 11, 6106. https://doi.org/10.3390/jcm11206106
de Tayrac R, Antosh DD, Baessler K, Cheon C, Deffieux X, Gutman R, Lee J, Nager C, Schizas A, Sung V, et al. Summary: 2021 International Consultation on Incontinence Evidence-Based Surgical Pathway for Pelvic Organ Prolapse. Journal of Clinical Medicine. 2022; 11(20):6106. https://doi.org/10.3390/jcm11206106
Chicago/Turabian Stylede Tayrac, Renaud, Danielle D. Antosh, Kaven Baessler, Cecilia Cheon, Xavier Deffieux, Robert Gutman, Joseph Lee, Charles Nager, Alexis Schizas, Vivian Sung, and et al. 2022. "Summary: 2021 International Consultation on Incontinence Evidence-Based Surgical Pathway for Pelvic Organ Prolapse" Journal of Clinical Medicine 11, no. 20: 6106. https://doi.org/10.3390/jcm11206106