Across studies, erosion rates generally ranged from 1.4–19%, with most of these treated in the office. Operative mesh revision rates ranged from 3–8% across studies. When reported, there were rarely significant differences between groups for overall reoperation rates.
In summary, there is high-quality evidence that the use of synthetic nonabsorbable mesh improves anatomic outcomes compared with native tissue anterior colporrhaphy. Data from meta-analyses confirm that mesh repairs also provided superior relief of subjective bulge symptoms. However, there is also high-quality evidence to suggest no difference for subjective outcomes including quality of life and urinary and sexual function.
Eleven comparative studies assessed anatomic efficacy between different graft or mesh materials in the anterior compartment (Appendix 3, http://links.lww.com/AOG/A809).21,26,52–60 These included seven cohort studies (one moderate-quality, six low-quality) and four RCTs (two high-, one moderate-, one low-quality).
In studies comparing biologic graft with synthetic nonabsorbable mesh, mesh was consistently found to have superior anatomic outcomes.21,26,53 All three studies used self-tailored polypropylene mesh. Porcine dermis, which is no longer available in the United States, was the biologic graft used in all three studies, including two RCTs and one retrospective cohort. When subjective outcomes were reported, there were no between-group differences, except one moderate-quality study53 that showed graft material resulted in better sexual function scores compared with mesh. That same study found a higher rate of erosion in the mesh group with no erosions in the biologic group, although all erosions were treated in the office.53
In the only study comparing biologic graft with absorbable synthetic mesh, the graft group had a higher rate of failure and there were no reported differences in subjective outcomes.52The only study comparing two different biologic grafts showed that porcine dermis resulted in superior anatomic outcomes compared with cadaveric dermis.54 There were no significant differences in functional status, rates of urinary incontinence, new-onset urinary urgency, or dyspareunia between groups. No graft-related complications were seen.
The remaining six studies compared different kits, insertion techniques, or both for polypropylene mesh. When different trocar-based kits were compared,57 Anterior Prolift and Perigee did not show a difference for anatomic or subjective outcomes, mesh erosion, or dyspareunia rates. Perigee was found to have superior anatomic outcomes to the Anterior Elevate in a retrospective cohort study.60 Satisfaction and subjective cure rates similarly favored Perigee. Although Perigee had a higher erosion rate, the difference was not statistically significant.
In summary, the heterogeneous evidence comparing use of various grafts and mesh with each other in repair of anterior vaginal wall prolapse limits our ability to draw conclusions. Like in other comparisons, synthetic nonabsorbable mesh tends to provide superior outcomes compared with other surgical repairs.
Three studies (one moderate-quality RCT, two low-quality cohort studies) looked at repair exclusively of the vaginal apex, two comparing synthetic nonabsorbable mesh with native tissue repair and one comparing two different synthetic nonabsorbable meshes with each other (Appendix 4, http://links.lww.com/AOG/A809).62–64 Two studies used the IVS Tunneller, which has been recalled from the market as a result of a high complication rate. No study showed any significant difference in anatomic outcomes at 17–58 months of follow-up, but the ability to draw conclusions from the few and lower quality studies in this group is limited.
Sixteen trials evaluated concomitant repair of multiple vaginal compartments (Appendix 5, http://links.lww.com/AOG/A809).65–83 This included five high-quality and four moderate-quality RCTs and four moderate-quality and three low-quality cohort studies. With the exception of one study,67 all were published since the 2008 review.
One low-quality cohort and one moderate-quality RCT evaluated multiple-compartment repair.65,66 Overall, there was no difference between groups for anatomic outcomes or sexual functioning (Appendix 5, http://links.lww.com/AOG/A809).
There are 10 studies, including seven RCTs (five high, two moderate-quality) and three moderate-quality cohort studies reporting anatomic and functional outcomes with use of synthetic nonabsorbable mesh in multiple compartments compared with native tissue repair (Appendix 5, http://links.lww.com/AOG/A809).68–80 The 2008 review included only one cohort study and no RCTs. Every study in this comparison utilized lightweight, macroporous polypropylene mesh for that study arm. Eight studies studied a trocar-based kit and two incorporated self-tailored placement; five studies utilized some form of the Prolift system as the trocar-based kit, which is no longer available commercially (Appendix 5, http://links.lww.com/AOG/A809). In these studies, native tissue procedures included anteroposterior colporrhaphy and sacrospinous or uterosacral ligament suspensions.
Prolapse anatomic outcomes favor mesh placement in most studies when the outcome of interest is overall POP-Q staging. When analyzed separately by vaginal compartment, results at the posterior and apical vaginal compartments showed no significant difference between arms, but the anterior vaginal compartment outcomes always favor mesh use for a better anatomic result.
Erosion rates in these studies ranged from 3–36%, which is higher than rates for isolated anterior compartment repair. The highest reported rate of reoperation for a mesh-related indication was 8%. Postoperative dyspareunia and urinary incontinence rates do not significantly differ between arms in any study, and only one study showed a significant difference in sexual functioning after surgery.78
In summary, there is high-quality evidence that the use of synthetic nonabsorbable mesh in multiple vaginal compartments improves anatomic outcomes compared with native tissue repair. However, there is also high-quality evidence to suggest no difference for subjective outcomes including quality of life and urinary and sexual function at 1 year of follow-up.
Three cohort studies (one moderate-, two low-quality) compare mesh products in different study arms (Appendix 5, http://links.lww.com/AOG/A809).81–83 All arms of all studies used a lightweight, macroporous polypropylene mesh, so these studies primarily compared surgical placement technique. Only one arm in one study82 utilized self-tailored mesh, whereas the other five arms in this comparison used trocar-based kit placement (Prolift, Apogee/Perigee, and Prolift-M). The small number of studies in this group limits the ability to draw generalizable conclusions.
No differences between arms were noted in any study for anatomic outcomes. Dyspareunia rates, which were as high as 25%, did not differ between arms in any study. Mesh erosion rates were as high as 17% but were not different except for Prolift-M, a hybrid mesh including some synthetic absorbable fibers. Prolift-M had a lower erosion rate (5%) than did Prolift (12%, P<.001).
Prolapse surgery continues to pose challenges as a result of high recurrence rates combined with the demand to perform minimally invasive vaginal surgery that also addresses quality-of-life outcomes. Based on this review, there is strong evidence to support the use of synthetic mesh at the anterior wall compared with native tissue repair for vaginal POP repair anatomically and for relief of bulge symptoms. Use of biologic grafts or synthetic mesh did not improve anatomic or subjective outcomes in any other vaginal compartment.
Since our initial review, the number and quality of comparative studies evaluating transvaginal graft and mesh use for POP repair have greatly increased. However, the majority of studies still focus on anatomic outcomes and are powered on that basis. There is improved consensus of the definition of anatomic failure as POP-Q stage 2 or greater since the last review. More studies now report subjective and functional outcomes, although they are not often adequately powered to detect differences for these outcomes.
Some caution is advisable in interpretation of the meta-analyses for subjective prolapse symptoms of the anterior vaginal wall after synthetic mesh or native tissue repair. Only 5 of 20 available studies reported subjective prolapse results specifically using the Pelvic Organ Prolapse-Distress Inventory, limiting inclusion in the meta-analysis. Our meta-analysis of “bulge symptoms” included any studies that asked about bulge symptoms postoperatively, but the verbiage was heterogeneous.
We question whether comparing native tissue anterior colporrhaphy and mesh-augmented repair is truly a similar comparison. Many mesh-based anterior compartment repairs attach the mesh to either the proximal arcus tendineus fascia pelvis or the sacrospinous ligament, whereas a traditional anterior colporrhaphy does not take advantage of this element of apical support. It remains unclear whether the mesh augmentation or the additional apical support differentiates later success. Although many of these RCTs strictly enrolled patients with anterior wall prolapse, it is an unresolved question whether stage 3 anterior wall prolapse is truly isolated from apical support defects.
The use of vaginal mesh has come under considerable federal, medicolegal, and public scrutiny in addition to improved scientific rigor. Many women continue to present with debilitating complications such as erosion, chronic pain, and dyspareunia.84 Surgical management may not completely resolve these symptoms,85 and all of these outcomes except mesh erosion can occur with any form of prolapse repair regardless of mesh or graft use. The studies in this review report relatively few serious complications with rates generally similar between groups. This may be the result of variability in reporting subjective outcomes such as pain and dyspareunia, loss to follow-up, and small study numbers. In the setting of the reported studies conducted by presumably experienced pelvic reconstructive surgeons, the rates of pain and dyspareunia show little difference between groups, but this may not be generalizable to all surgical settings. Clinical application of these results and guidelines should take this into account. There is no universal answer to what prolapse surgery to perform in a specific situation because no prolapse or patient is identical. The data reported here provide part of the picture, which also include surgeon experience, patient surgical history, desired sexual functioning, and related symptoms such as incontinence or bowel issues. We encourage surgeons to consider these factors when planning surgery as well as incorporating them into a thorough consent process.
Although the number of studies has increased since our last review, there are still few studies with long follow-up and relatively few enrolled patients, suggesting goals for future research. Most patients improve subjectively regardless of treatment option, so larger numbers of study participants need to be followed to adequately power for subjective outcomes.
The strengths of this review are its robust methodologic approach and insight from gynecologic surgeons who have prior experience at reviewing this topic. The quality of literature on this topic is growing, making the strength of practice guidelines stronger. We were able to draw data from comparative studies with at least 12 months of follow-up, including a growing number of RCTs.
Like with any systematic review, we are limited by the available literature, which in this case was heterogeneous. Currently, we are unable to comment on subpopulations of interest such as primary compared with repeat surgery, because they were not separately evaluated. Subjective outcome reporting is still heterogeneous as are data on retreatment and reoperation. Multicompartment concomitant surgery such as vaginal hysterectomy or midurethral sling placement may also confound our conclusions.
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