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      The treatment of post-hysterectomy vaginal vault prolapse: a systematic review and meta-analysis

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          Abstract

          Introduction and hypothesis

          The treatment of post-hysterectomy vaginal vault prolapse (VVP) has been investigated in several randomized clinical trials (RCTs), but a systematic review of the topic is still lacking. The aim of this study is to compare the effectiveness of treatments for VVP.

          Methods

          We performed a systematic review and meta-analysis of the literature on the treatment of VVP found in PubMed and Embase. Reference lists of identified relevant articles were checked for additional articles. A network plot was constructed to illustrate the geometry of the network of the treatments included. Only RCTs reporting on the treatment of VVP were eligible, conditional on a minimum of 30 participants with VVP and a follow-up of at least 6 months.

          Results

          Nine RCTs reporting 846 women (ranging from 95 to 168 women) met the inclusion criteria. All surgical techniques were associated with good subjective results, and without differences between the compared technique, with the exception of the comparison of vaginal mesh (VM) vs laparoscopic sacrocolpopexy (LSC). LSC is associated with a higher satisfaction rate. The anatomical results of the sacrocolpopexy (laparoscopic, robotic [RSC]. and abdominal [ASC]) are the best (62–91%), followed by the VM. However, the ranges of the anatomical outcome of VM were wide (43–97%). The poorest results are described for the sacrospinal fixation (SSF; 35–81%), which also correlates with the higher reoperation rate for pelvic organ prolapse (POP; 5–9%). The highest percentage of complications were reported after ASC (2–19%), VM (6–29%), and RSC (54%). Mesh exposure was seen most often after VM (8–21%). The rate of reoperations carried out because of complications, recurrence prolapse, and incontinence of VM was 13–22%. Overall, sacrocolpopexy reported the best results at follow-up, with an outlier of one trial reporting the highest reoperation rate for POP (11%). The results of the RSC are too small to make any conclusion, but LSC seems to be preferable to ASC.

          Conclusions

          A comparison of techniques was difficult because of heterogeneity; therefore, a network meta-analysis was not possible. All techniques have proved to be effective. The reported differences between the techniques were negligible. Therefore, a standard treatment for VVP could not be given according to this review.

          Electronic supplementary material

          The online version of this article (10.1007/s00192-017-3493-2) contains supplementary material, which is available to authorized users

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          Most cited references27

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          The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction.

          This article presents a standard system of terminology recently approved by the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons for the description of female pelvic organ prolapse and pelvic floor dysfunction. An objective site-specific system for describing, quantitating, and staging pelvic support in women is included. It has been developed to enhance both clinical and academic communication regarding individual patients and populations of patients. Clinicians and researchers caring for women with pelvic organ prolapse and pelvic floor dysfunction are encouraged to learn and use the system.
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            Anatomic aspects of vaginal eversion after hysterectomy.

            Our aim was to understand how vaginal eversion after hysterectomy differs from other forms of prolapse. The role of individual structures involved in vaginal support was studied by pelvic dissection of 61 cadavers. Serial cross sections from 13 additional cadavers were examined. The upper third of the vagina (level I) is suspended from the pelvic walls by vertical fibers of the paracolpium, which is a continuation of the cardinal ligament. In the middle third of the vagina (level II) the paracolpium attaches the vagina laterally to the arcus tendineus and fascia of the levator ani muscles. The vagina's lower third fuses with the perineal membrane, levator ani muscles, and perineal body (level III). Dissection reveals that the paracolpium's vertical fibers in level I prevented prolapse of the vaginal apex and vaginal eversion. The paracolpium in level I forms the critical factor that differentiates vaginal eversion from posthysterectomy cystocele-rectocele or enterocele in which the vaginal apex remains well suspended.
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              Defining success after surgery for pelvic organ prolapse.

              To describe pelvic organ prolapse surgical success rates using a variety of definitions with differing requirements for anatomic, symptomatic, or re-treatment outcomes. Eighteen different surgical success definitions were evaluated in participants who underwent abdominal sacrocolpopexy within the Colpopexy and Urinary Reduction Efforts trial. The participants' assessments of overall improvement and rating of treatment success were compared between surgical success and failure for each of the definitions studied. The Wilcoxon rank sum test was used to identify significant differences in outcomes between success and failure. Treatment success varied widely depending on definition used (19.2-97.2%). Approximately 71% of the participants considered their surgery "very successful," and 85.2% considered themselves "much better" than before surgery. Definitions of success requiring all anatomic support to be proximal to the hymen had the lowest treatment success (19.2-57.6%). Approximately 94% achieved surgical success when it was defined as the absence of prolapse beyond the hymen. Subjective cure (absence of bulge symptoms) occurred in 92.1% while absence of re-treatment occurred in 97.2% of participants. Subjective cure was associated with significant improvements in the patient's assessment of both treatment success and overall improvement, more so than any other definition considered (P<.001 and <.001, respectively). Similarly, the greatest difference in symptom burden and health-related quality of life as measured by the Pelvic Organ Prolapse Distress Inventory and Pelvic Organ Prolapse Impact Questionnaire scores between treatment successes and failures was noted when success was defined as subjective cure (P<.001). The definition of success substantially affects treatment success rates after pelvic organ prolapse surgery. The absence of vaginal bulge symptoms postoperatively has a significant relationship with a patient's assessment of overall improvement, while anatomic success alone does not. II.
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                Author and article information

                Contributors
                +31-40-8888384 , anne_lotte_coolen@hotmail.com
                Journal
                Int Urogynecol J
                Int Urogynecol J
                International Urogynecology Journal
                Springer London (London )
                0937-3462
                1433-3023
                16 October 2017
                16 October 2017
                2017
                : 28
                : 12
                : 1767-1783
                Affiliations
                [1 ]ISNI 0000 0004 0477 4812, GRID grid.414711.6, Department of Obstetrics and Gynecology, , Máxima Medical Centre, ; De Run 4600, 5500 MB Veldhoven, The Netherlands
                [2 ]ISNI 0000 0004 0398 8384, GRID grid.413532.2, Department of Obstetrics and Gynecology, , Catharina Hospital, ; Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
                [3 ]ISNI 0000 0004 1936 7304, GRID grid.1010.0, Robinson Research Institute, Adelaide Medical School, , University of Adelaide, ; Adelaide, SA Australia
                [4 ]ISNI 0000 0001 0481 6099, GRID grid.5012.6, Department of Obstetrics and Gynaecology, , Maastricht University, Grow School for Oncology and Developmental Biology, ; Minderbroedersberg 4, 6211 LK Maastricht, The Netherlands
                [5 ]ISNI 0000000404654431, GRID grid.5650.6, Department of Gynecology and Obstetrics, , Academic Medical Centre Amsterdam, ; Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
                Author information
                http://orcid.org/0000-0002-0056-0804
                Article
                3493
                10.1007/s00192-017-3493-2
                5705749
                29038834
                605261ae-c330-47ce-94b7-c3850e30c9ea
                © The Author(s) 2017

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                : 13 May 2017
                : 13 September 2017
                Funding
                Funded by: Maastricht University
                Categories
                Review Article
                Custom metadata
                © The International Urogynecological Association 2017

                Obstetrics & Gynecology
                vaginal vault prolapse,pelvic organ prolapse,treatment,surgical treatment,sacrocolpopexy,trans vaginal mesh,sacrospinous fixation

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