Surgical management of symptomatic apical pelvic organ prolapse: A systematic review

Abstract

<h3>Objectives</h3> To systematically review success and complication rates of apical suspension procedures for symptomatic uterine/vaginal vault prolapse. <h3>Methods</h3> MEDLINE, CENTRAL and Embase were searched October 2002–October 2019. Search included apical prolapse surgery-related terms. We included randomized controlled trials and comparative studies. We excluded prolapse repairs using transvaginal mesh, and procedures without apical suspension. Outcomes of interest were selected a priori. <h3>Results</h3> Search yielded 2,665 records; 64 articles were used for qualitative synthesis and 50 were included in the meta-analysis. In short to medium-term follow-up: 1.Vaginal procedures showed higher risk of overall and apical anatomic recurrence vs. sacrocolpopexy (RR 1.82, 95% CI 1.22–2.74 and RR 2.70, 95% CI 1.33–5.50 respectively), with similar risk of subjective recurrence and reoperation for recurrence. 2. Minimally invasive sacrocolpopexy showed less overall and posterior anatomic recurrence vs. open sacrocolpopexy (RR 0.59, 95% CI 0.47–0.75 and RR 0.59, 95% CI 0.44–0.80 respectively), with similar subjective recurrence and reoperation for recurrence. 3.Vaginal uterosacral suspension and sacrospinous fixation showed similar anatomic and subjective outcomes, but uterosacral suspension had higher risk of ureteric injury (RR 2.46, 95% CI 1.41–4.31). 4. Hysterectomy and suspension vs. hysteropexy showed lower risk of overall anatomic recurrence (RR 0.76, 95% CI 0.62–0.94), but similar subjective outcomes and reoperation rates. Described surgical procedures were heterogeneous in materials and techniques. Postoperative pain, dyspareunia, and sexual function were infrequently reported. <h3>Conclusions</h3> Apical suspension procedures have variable anatomic success and similar subjective success and risk of reoperation in the short to medium-term. More research is needed on long-term, pain and sexual function outcomes.