Complications of pelvic organ prolapse surgery and methods of prevention

Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with the prolapse.

To summarize published data about abdominal sacrocolpopexy and to highlight areas about which data are lacking. We conducted a literature search on MEDLINE using Ovid and PubMed, from January,1966 to January, 2004, using search terms "sacropexy," "sacrocolpopexy," "sacral colpopexy," "colpopexy," "sacropexy," "colposacropexy," "abdominal sacrocolpopexy" "pelvic organ prolapse and surgery," and "vaginal vault prolapse or surgery" and included articles with English-language abstracts. We examined reference lists of published articles to identify other articles not found on the electronic search. We examined all studies identified in our search that provided any outcome data on sacrocolpopexy. Because of the substantial heterogeneity of outcome measures and follow-up intervals in case studies, we did not apply meta-analytic techniques to the data. Follow-up duration for most studies ranged from 6 months to 3 years. The success rate, when defined as lack of apical prolapse postoperatively, ranged from 78-100% and when defined as no postoperative prolapse, from 58-100%. The median reoperation rates for pelvic organ prolapse and for stress urinary incontinence in the studies that reported these outcomes were 4.4% (range 0-18.2%) and 4.9% (range 1.2% to 30.9%), respectively. The overall rate of mesh erosion was 3.4% (70 of 2,178). Some reports found more mesh erosions when concomitant total hysterectomy was done, whereas other reports did not. There were no data to either support or refute the contentions that concomitant culdoplasty or paravaginal repair decreased the risk of failure. Most authors recommended burying the graft under the peritoneum to attempt to decrease the risk of bowel obstruction; despite this, the median rate (when reported) of small bowel obstruction requiring surgery was 1.1% (range 0.6% to 8.6%). Few studies rigorously assessed pelvic symptoms, bowel function, or sexual function. Sacrocolpopexy is a reliable procedure that effectively and consistently resolves vaginal vault prolapse. Patients should be counseled about the low, but present risk, of reoperation for prolapse, stress incontinence, and complications. Prospective trials are needed to understand the effect of sacrocolpopexy on functional outcomes.

The use of standardized mesh kits for repair of pelvic-organ prolapse has spread rapidly in recent years, but it is unclear whether this approach results in better outcomes than traditional colporrhaphy. In this multicenter, parallel-group, randomized, controlled trial, we compared the use of a trocar-guided, transvaginal polypropylene-mesh repair kit with traditional colporrhaphy in women with prolapse of the anterior vaginal wall (cystocele). The primary outcome was a composite of the objective anatomical designation of stage 0 (no prolapse) or 1 (position of the anterior vaginal wall more than 1 cm above the hymen), according to the Pelvic Organ Prolapse Quantification system, and the subjective absence of symptoms of vaginal bulging 12 months after the surgery. Of 389 women who were randomly assigned to a study treatment, 200 underwent prolapse repair with the transvaginal mesh kit and 189 underwent traditional colporrhaphy. At 1 year, the primary outcome was significantly more common in the women treated with transvaginal mesh repair (60.8%) than in those who underwent colporrhaphy (34.5%) (absolute difference, 26.3 percentage points; 95% confidence interval, 15.6 to 37.0). The surgery lasted longer and the rates of intraoperative hemorrhage were higher in the mesh-repair group than in the colporrhaphy group (P<0.001 for both comparisons). Rates of bladder perforation were 3.5% in the mesh-repair group and 0.5% in the colporrhaphy group (P=0.07), and the respective rates of new stress urinary incontinence after surgery were 12.3% and 6.3% (P=0.05). Surgical reintervention to correct mesh exposure during follow-up occurred in 3.2% of 186 patients in the mesh-repair group. As compared with anterior colporrhaphy, use of a standardized, trocar-guided mesh kit for cystocele repair resulted in higher short-term rates of successful treatment but also in higher rates of surgical complications and postoperative adverse events. (Funded by the Karolinska Institutet and Ethicon; ClinicalTrials.gov number, NCT00566917.).