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Surgery for posterior vaginal wall prolapse

  • POP Surgery Review
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Abstract

Introduction and hypothesis

The aim was to review the safety and efficacy of surgery for posterior vaginal wall prolapse.

Methods

Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or “majority evidence” from RCTs. Grade C recommendation usually depends on level 4 studies or “majority evidence‟ from level 2/3 studies or Delphi processed expert opinion. Grade D “no recommendation possible” would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi.

Results

Level 1 and 2 evidence suggest that midline plication posterior repair without levatorplasty might have superior objective outcomes compared with site-specific posterior reopair (grade B). Higher dyspareunia rates are reported when levatorplasty is employed (grade C). The transvaginal approach is superior to the transanal approach for repair of posterior wall prolapse (grade A). To date, no studies have shown any benefit of mesh overlay or augmentation of a suture repair for posterior vaginal wall prolapse (grade B). While modified abdominal sacrocolpopexy results have been reported, data on how these results would compare with traditional transvaginal repair of posterior vaginal wall prolapse are lacking.

Conclusion

Midline fascial plication without levatorplasty is the procedure of choice for posterior compartment prolapse. No evidence supports the use of polypropylene mesh or biological graft in posterior vaginal compartment prolapse surgery.

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Acknowledgements

This publication results from the work of the Committee on Pelvic Organ Prolapse Surgery, part of the 5th International Consultation on Incontinence, held in Paris in February 2012, under the auspices of the International Consultation on Urological Diseases, and enabled by the support of the European Association of Urology.

The authors wish to acknowledge the fine work of previous consultations led by Professor Linda Brubaker.

Conflicts of interest

M. Karram: speaker and consultant for AMS, Astellas, and Medtronic; C. Maher: none.

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Authors and Affiliations

  1. The Christ Hospital, Cincinnati, OH, USA

    Mickey Karram

  2. Royal Brisbane and Wesley Urogynaecology, Brisbane, Queensland, Australia

    Christopher Maher

  3. 30 Chaseley Street, Auchenflower, 4067, Brisbane, Australia

    Christopher Maher

Authors
  1. Mickey Karram
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  2. Christopher Maher
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Corresponding author

Correspondence to Christopher Maher.

Additional information

On behalf of Committee 15 “Surgical Management of Pelvic Organ Prolapse” from the 5th International Consultation on Incontinence held in Paris, February 2012

This work has been previously published as: Maher C, Baessler K, Barber M, Cheon C, Deitz V, DeTayrac R, Gutman R, Karram M, Sentilhes L (2013) Surgical management of pelvic organ prolapse. In: Abrams, Cardozo, Khoury, Wein (eds) 5th International Consultation on Incontinence. Health Publication Ltd, Paris, Chapter 15 and modified for publication in International Urogynaecology Journal.

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Karram, M., Maher, C. Surgery for posterior vaginal wall prolapse. Int Urogynecol J 24, 1835–1841 (2013). https://doi.org/10.1007/s00192-013-2174-z

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