Mesh Sacrocolpopexy Compared With Native Tissue Vaginal Repair

Abstract

Published case series, prospective cohort studies, and large reviews have suggested that transvaginal mesh procedures are safe and effective for repair of apical prolapse. Such data led to widespread use of these devices to augment native tissue repairs. In recent years, however, several published reports have raised substantial concerns that these procedures are unsafe and may be associated with a number of significant adverse events. These concerns have led to a decreased use of transvaginal mesh procedures for repair of apical prolapse, and instead surgeons often favor native tissue vaginal repair or mesh sacrocolpopexy. Few well-designed studies have compared the safety and efficacy of mesh sacrocolpopexy with native tissue vaginal repair for repair of prolapse. This study performed a systemic literature review to compare anatomic and functional outcomes after mesh sacrocolpopexy with native tissue vaginal repairs in women with apical prolapse. A systematic search was conducted using the MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov (through June 4, 2012) to identify studies comparing use of native tissue vaginal apex repairs and mesh sacrocolpopexy for treatment of apical pelvic organ prolapse. Eligible studies had a follow-up of at least 6 months. The primary study outcome was anatomic “success” following surgery. Secondary outcomes evaluated were reoperation and effects on bladder, bowel, and sexual function; surgical time; hospital stay; and blood loss. Evidence quality of individual studies was assessed using the Grades for Recommendation, Assessment, Development, and Evaluation system. Meta-analyses were performed only when 3 or more studies were identified reporting the same outcome. The initial search identified 3119 citations, 34 of which met criteria for inclusion full-text review, including 13 that compared anatomic success, reoperation, and symptom outcomes. Moderate-quality evidence supported improved anatomic outcomes following mesh sacrocolpopexy; very-low-quality evidence showed no differences between the 2 groups in reoperation. There was insufficient evidence regarding which procedure resulted in better bladder or bowel symptoms. Low-quality evidence showed no differences between the procedures in postoperative sexual function. Meta-analysis was performed on adverse event data from 79 studies; findings from longer noncomparative studies were included. More adverse events were noted after mesh sacrocolpopexy compared with native tissue vaginal repairs: ileus or small bowel obstruction (4.2% vs 0.4%, P < 0.01) and thromboembolic phenomena (0.6% vs 0.1%, P = 0.03). These data suggest that mesh sacrocolpopexy may be the preferred surgical option for repair of vaginal apex prolapse when anatomic durability is a priority. There is no strong evidence supporting one method over the other when minimizing adverse events or reoperation is the priority.