Surgery for women with anterior compartment prolapse

Maher C, Feiner B, Baessler K, et al. Syst Rev. 2016 Nov 30;11:CD004014.

The aim of this meta-analysis was to clarify the level 1 evidence surrounding anterior vaginal wall repair. The analysis included 33 trials with 3,332 women and the quality of evidence ranged from very low to moderate.

Compared with repair involving a biological transvaginal mesh, native tissue repair was associated with significantly more recurrent anterior compartment prolapses (RR 1.32, 95% CI 1.06 to 1.65), but there were no differences in awareness of prolapse, repeat surgery for prolapse, stress incontinence or dyspareunia rates. Compared with repair involving polypropylene transvaginal mesh, native tissue repair was associated with significantly higher rates of awareness of prolapse (RR 1.77, 95% CI 1.37 to 2.28), of repeat surgery for prolapse (RR 2.03, 95% CI 1.15 to 3.58) and of recurrent anterior compartment prolapse (RR 3.01, 95% CI 2.52 to 3.60). The composite outcome of repeat surgery for prolapse, stress incontinence and mesh complications was significantly less likely after native tissue repair (RR 0.59, 95% CI 0.41 to 0.83). The rate of mesh exposure was 11.3%. The operating time, and the rates of transfusion, cystotomy and prolapse in the apical and/or posterior compartments were all significantly higher after polypropylene mesh repair than after native tissue repair. There were no differences between the rates of stress incontinence and dyspareunia.

The authors conclude that the evidence does not support the use of mesh in the anterior compartment due to the increased morbidity to set against only modest gains. The authors also point out that all the meshes involved in theses randomized controlled trials have been voluntarily removed form the market and that there are no comparative data available for the two transvaginal meshes currently available in Australia.