, Volume 24, Issue 11, pp 1859-1872
Date: 19 Oct 2013

Complications of pelvic organ prolapse surgery and methods of prevention

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Introduction and hypothesis

The aim was to review complications associated with pelvic organ prolapse surgery.


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 and conclusions

Transvaginal mesh has a higher re-operation rate than native tissue vaginal repairs (grade A). If a synthetic mesh is placed via the vaginal route, it is recommended that a macroporous polypropylene monofilament mesh should be used. At sacral colpopexy mesh should not be introduced or sutured via the vaginal route and silicone-coated polyester, porcine dermis, fascia lata and polytetrafluoroethylene meshes are not recommended as grafts. Hysterectomy should also be avoided (grade B). There is no evidence to recommend routine local or systemic oestrogen therapy before or after prolapse surgery using mesh. The first cases should be undertaken with the guidance of an experienced surgeon in the relevant technique (grade C). Expert opinion suggests that by whatever the surgical route pre-operative urinary tract infections are treated, smoking is ceased and antibiotic prophylaxis is undertaken. It is recommended that a non-absorbable synthetic mesh should not be inserted into the rectovaginal septum when a rectal injury occurs. The placement of a non-absorbable synthetic mesh into the vesicovaginal septum may be considered after a bladder injury has been repaired, if the repair is considered to be satisfactory. It is possible to perform a hysterectomy in association with the introduction of a non-absorbable synthetic mesh inserted vaginally, but this is not recommended routinely.

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.
This work has been translated and adapted from the Guidelines of the French College of Obstetrician and Gynecologist previously published by Deffieux X et al.: [Prevention of the complications related to the use of prosthetic meshes in prolapse surgery: guidelines for clinical practice - literature review]. J Gynecol Obstet Biol Reprod (Paris) 2011;40(8):827-50.