Surgical management of pelvic organ prolapse in women

Christopher Maher; Benjamin Feiner; Kaven Baessler; Corina Schmid

doi:10.1002/14651858.CD004014.pub5

Surgical management of pelvic organ prolapse in women

Authors' declarations of interest

Version published: 30 April 2013 Version history

https://doi.org/10.1002/14651858.CD004014.pub5

Collapse all Expand all

Abstract

available in

Background

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.

Objectives

To determine the effects of the many different surgeries used in the management of pelvic organ prolapse.

Search methods

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In Process and handsearching of journals and conference proceedings, healthcare‐related bibliographic databases, handsearched conference proceedings (searched 20 August 2012), and reference lists of relevant articles. We also contacted researchers in the field.

Selection criteria

Randomised or quasi‐randomised controlled trials that included surgical operations for pelvic organ prolapse.

Data collection and analysis

Trials were assessed and data extracted independently by two review authors. Six investigators were contacted for additional information with five responding.

Main results

Fifty‐six randomised controlled trials were identified evaluating 5954 women. For upper vaginal prolapse (uterine or vault) abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse on examination and painful intercourse than with vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. In single studies the sacral colpopexy had a higher success rate on examination and lower reoperation rate than high vaginal uterosacral suspension and transvaginal polypropylene mesh.

Twenty‐one trials compared a variety of surgical procedures for anterior compartment prolapse (cystocele). Ten compared native tissue repair with graft (absorbable and permanent mesh, biological grafts) repair for anterior compartment prolapse. Native tissue anterior repair was associated with more recurrent anterior compartment prolapse than when supplemented with a polyglactin (absorbable) mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.08, 95% CI 1.08 to 4.01), however there was no difference in post‐operative awareness of prolapse after absorbable mesh (RR 0.96, 95% CI 0.33 to 2.81) or a biological graft (RR 1.21, 95% CI 0.64 to 2.30). Data on morbidity and other clinical outcomes were lacking. Standard anterior repair was associated with more anterior compartment prolapse on examination than for any polypropylene (permanent) mesh repair (RR 3.15, 95% CI 2.50 to 3.96). Awareness of prolapse was also higher after the anterior repair as compared to polypropylene mesh repair (28% versus 18%, RR 1.57, 95% CI 1.18 to 2.07). However, the reoperation rate for prolapse was similar at 14/459 (3%) after the native tissue repair compared to 6/470 (1.3%) (RR 2.18, 95% CI 0.93 to 5.10) after the anterior polypropylene mesh repair and no differences in quality of life data or de novo dyspareunia were identified. Blood loss (MD 64 ml, 95% CI 48 to 81), operating time (MD 19 min, 95% CI 16 to 21), recurrences in apical or posterior compartment (RR 1.9, 95% CI 1.0 to 3.4) and de novo stress urinary incontinence (RR 1.8, 95% CI 1.0 to 3.1) were significantly higher with transobturator meshes than for native tissue anterior repair. Mesh erosions were reported in 11.4% (64/563), with surgical interventions being performed in 6.8% (32/470).

Data from three trials compared native tissue repairs with a variety of total, anterior, or posterior polypropylene kit meshes for vaginal prolapse in multiple compartments. While no difference in awareness of prolapse was able to be identified between the groups (RR 1.3, 95% CI 0.6 to 1.7) the recurrence rate on examination was higher in the native tissue repair group compared to the transvaginal polypropylene mesh group (RR 2.0, 95% CI 1.3 to 3.1). The mesh erosion rate was 35/194 (18%), and 18/194 (9%) underwent surgical correction for mesh erosion. The reoperation rate after transvaginal polypropylene mesh repair of 22/194 (11%) was higher than after the native tissue repair (7/189, 3.7%) (RR 3.1, 95% CI 1.3 to 7.3).

Data from three trials compared posterior vaginal repair and transanal repair for the treatment of posterior compartment prolapse (rectocele). The posterior vaginal repair had fewer recurrent prolapse symptoms (RR 0.4, 95% CI 0.2 to 1.0) and lower recurrence on examination (RR 0.2, 95% CI 0.1 to 0.6) and on defecography (MD ‐1.2 cm, 95% CI ‐2.0 to ‐0.3).

Sixteen trials included significant data on bladder outcomes following a variety of prolapse surgeries. Women undergoing prolapse surgery may have benefited from having continence surgery performed concomitantly, especially if they had stress urinary incontinence (RR 7.4, 95% CI 4.0 to 14) or if they were continent and had occult stress urinary incontinence demonstrated pre‐operatively (RR 3.5, 95% CI 1.9 to 6.6). Following prolapse surgery, 12% of women developed de novo symptoms of bladder overactivity and 9% de novo voiding dysfunction.

Authors' conclusions

Sacral colpopexy has superior outcomes to a variety of vaginal procedures including sacrospinous colpopexy, uterosacral colpopexy and transvaginal mesh. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living, and increased cost of the abdominal approach.

The use of mesh or graft inlays at the time of anterior vaginal wall repair reduces the risk of recurrent anterior wall prolapse on examination. Anterior vaginal polypropylene mesh also reduces awareness of prolapse, however these benefits must be weighted against increased operating time, blood loss, rate of apical or posterior compartment prolapse, de novo stress urinary incontinence, and reoperation rate for mesh exposures associated with the use of polypropylene mesh.

Posterior vaginal wall repair may be better than transanal repair in the management of rectocele in terms of recurrence of prolapse. The evidence is not supportive of any grafts at the time of posterior vaginal repair. Adequately powered randomised, controlled clinical trials with blinding of assessors are urgently needed on a wide variety of issues, and they particularly need to include women's perceptions of prolapse symptoms. Following the withdrawal of some commercial transvaginal mesh kits from the market, the generalisability of the findings, especially relating to anterior compartment transvaginal mesh, should be interpreted with caution.

PICOs

Population

Intervention

Comparison

Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

available in

Surgical management of pelvic organ prolapse in women

Pelvic organs, such as the uterus, bladder or bowel, may protrude into the vagina due to weakness in the tissues that normally support them. The commonest symptom experienced by women with prolapse is the sensation or feeling, or seeing, a vaginal bulge. Commonly these women have abnormalities in bladder, bowel and sexual function that may or may not be related to the prolapse. The surgical repair performed depends on the type of prolapse seen on examination and on the associated symptoms. Women should be aware that the principle aim of surgery is to relieve the vaginal bulge. Women who have stress urinary incontinence in addition to their prolapse commonly have that corrected at the same surgery. Pelvic organ prolapse surgery is usually effective in controlling the principle symptoms of prolapse (awareness of vaginal bulge). The impact of pelvic organ prolapse surgery on specific bowel, bladder and sexual functions can be predicted however individual women should be aware that occasionally the intervention may make symptoms worse or result in new symptoms, such as leakage of urine or problems with sexual intercourse.

The review found 56 trials including 5954 women with a variety of types of prolapse. The trials showed that abdominal sacral colpopexy, 'abdominal route surgery', may be better than vaginal sacrospinous colpopexy or 'vaginal route surgery' for prolapse of the uterus or vaginal apex after hysterectomy. Limited evidence suggests that vaginal surgery may be better than surgery performed through the anus for posterior vaginal prolapse (rectocele). The use of grafts (biological or synthetic) reduces the risk of prolapse symptoms and recurrent anterior vaginal prolapse on examination when compared to native tissue repairs (colporrhaphy). However, the advantages of a permanent polypropylene mesh must be weighed against disadvantages including longer operating time, greater blood loss, prolapse in other areas of the vagina, new onset urinary stress incontinence, and the mesh becoming exposed in the vagina in 11% of women. In general, there is a lack of evidence to support transvaginal mesh operations used in apical or posterior compartment surgery.

Continence surgery performed at the time of prolapse surgery is effective in reducing the risk of urinary stress incontinence after the prolapse surgery. Overall, however, there was not enough evidence on most types of common prolapse surgery nor about the use of mesh or grafts in vaginal prolapse surgery.

Authors' conclusions

Implications for practice

The data from randomised trials are currently insufficient to guide practice.

The following conclusions from the review relate to the four areas of surgical management of pelvic organ prolapse where at least two randomised controlled trials have been completed.

Abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse and less dyspareunia than vaginal sacrospinous colpopexy. The abdominal sacral colpopexy had a longer operating time, longer recovery time and higher cost than the vaginal surgery. Data on the subjective success rate, patient satisfaction and impact of the surgery on quality of life were too few for reliable conclusions. In single studies the sacral colpopexy had a higher objective success rate and lower reoperation rate as compared to vaginal uterosacral ligament suspension and transvaginal polypropylene mesh. Small studies compared laparoscopic sacral colpopexy to open and robotic techniques without decisive outcomes.
The evidence suggested that the use of absorbable polyglactin mesh overlay, absorbable porcine dermis or polypropylene mesh at the time of anterior vaginal wall repair reduces the risk of recurrent cystocele on examination, however improved outcomes including patient satisfaction, quality of life and reduced operations for recurrences have not yet been demonstrated. Furthermore, anterior polypropylene mesh alone demonstrated an improved subjective outcome as compared to native tissue anterior repair without any difference between the groups in the rate of dyspareunia. The operating time, blood loss, rate of apical or posterior compartment prolapse and de novo stress urinary incontinence were greater in the polypropylene mesh group, which was associated with a 11.4% rate of mesh erosion and 6.8% requiring surgical reintervention.
The limited evidence suggested that posterior vaginal wall repair may have a better anatomical success rate than transanal repair in the management of posterior vaginal wall prolapse but the clinical effects are uncertain. There was no evidence to support the use of graft materials in the posterior compartment.
The evidence at this stage does not support the use of transvaginal combined total, anterior or posterior mesh kits for multi‐compartment prolapse. While three studies demonstrated an improved anatomical outcome after the transvaginal permanent mesh as compared to native tissue repair, no difference was found in symptoms or quality of life outcomes. The mesh exposure rate was 18%, with one half of these (9%) requiring surgical intervention. The total reoperation rate was significantly higher after the transvaginal permanent mesh at 11% compared to 3.7% following native tissue repair.
Performing continence surgery at the time of prolapse surgery in women with stress urinary incontinence is likely to be beneficial. This benefit is also considerable in continent women undergoing prolapse who have demonstrated occult stress incontinence pre‐operatively.

There was generally a lack of information on the cost of surgery.

Implications for research

None of the objectives pre‐stated in the protocol for this review have been completely addressed, and all would benefit from testing in further good quality randomised controlled trials.

More broadly, further evidence on the surgical management of pelvic organ prolapse should include, but not be limited to, the following.

Upper vaginal prolapse: vaginal surgery (e.g. vaginal hysterectomy, cervical amputation, uterosacral ligament plication, or sacrospinous colpopexy); abdominal surgery (e.g. open, laparoscopic or robotic sacral colpopexy, abdominal hysterectomy); laparoscopic pelvic floor repair; and the use of mesh or grafts.
Anterior vaginal wall prolapse: vaginal surgery (e.g. anterior vaginal wall repair, vaginal paravaginal repair); open or laparoscopic abdominal surgery (e.g. paravaginal repair); and the use of mesh or grafts.
Posterior vaginal wall prolapse: vaginal surgery (e.g. midline posterior vaginal wall repair, fascial repairs); the abdominal or laparoscopic approach to rectocele; and the use of mesh or grafts.
The place for concomitant continence surgery alongside prolapse surgery.
Evaluation of different types of sutures, mesh and grafts.

Other trials relating to pelvic organ prolapse should include comparisons with conservative treatment including, but not limited to, pelvic floor exercises, lifestyle changes and mechanical devices (pessaries).

The challenge in prolapse surgery is that while the prolapse itself may cause difficulties with bladder, bowel and sexual function, surgical correction may also affect these functions in unpredictable ways. Therefore, all trials need to include patient‐reported and clinician‐observed outcomes; and direct interaction with bladder, bowel and sexual function must be measured. The impact of interventions should also be assessed by utilising validated pelvic floor and quality of life questionnaires, morbidity and cost analyses. Ideally long‐term outcomes should be reported, at least at two and five years after surgery.

Background

Pelvic organ prolapse is common and is seen on examination in 40% to 60% of parous women (Handa 2004; Hendrix 2002). The annual aggregated rate of associated surgery in the USA is in the range of 10 to 30 per 10,000 women (Brubaker 2002).

Description of the condition

Pelvic organ prolapse is the descent of one or more of the pelvic organs (uterus, vagina, bladder or bowel). The different types of prolapse include:

upper vaginal prolapse i.e. uterus, vaginal vault (after hysterectomy when the top of the vagina drops down);
anterior vaginal wall prolapse i.e. cystocele (bladder descends), urethrocele (urethra descends), paravaginal defect (pelvic fascia defect);
posterior vaginal wall prolapse i.e. enterocele (small bowel descends), rectocele (rectum descends), perineal deficiency.

A woman can present with prolapse of one or more of these sites.

The aetiology of pelvic organ prolapse (POP) is complex and multi‐factorial. Possible risk factors include pregnancy, childbirth, congenital or acquired connective tissue abnormalities, denervation or weakness of the pelvic floor, ageing, hysterectomy, menopause and factors associated with chronically raised intra‐abdominal pressure (Bump 1998; Gill 1998; MacLennan 2000).

Women with prolapse commonly have a variety of pelvic floor symptoms only some of which are directly related to the prolapse. Generalised symptoms of prolapse include pelvic heaviness; bulge, lump or protrusion coming down from the vagina; a dragging sensation in the vagina; or backache. Symptoms of bladder, bowel or sexual dysfunction are frequently present. For example, women may need to reduce the prolapse by using their fingers to push the prolapse up to aid urinary voiding or defaecation. These symptoms may be directly related to the prolapsed organ, for example poor urinary stream when a cystocele is present or obstructed defaecation when a rectocele is present. They may also be independent of the prolapse, for example symptoms of overactive bladder when a cystocele is present.

Many women with POP report concomitant stress urinary incontinence (SUI); in women with stage II POP, about 55% also have stress urinary incontinence. However, this prevalence decreases with increasing prolapse, and possibly obstruction of the urethra due to the prolapse, to 33% in women with stage IV POP (Slieker‐ten Hove 2009). As it is unclear how to approach cases with POP and concomitant SUI, this review includes studies with appropriate data.

Although in many women SUI decreases with increasing prolapse, stress incontinence may be demonstrated when the prolapse is reduced digitally or with the help of a pessary, sponge holder or speculum in up to 80% of women (Visco 2008; Wei 2011). This type of incontinence is termed occult stress incontinence to describe SUI which is demonstrable only when the prolapse is reduced in otherwise continent women. No standardisation or best technique to test for occult incontinence has been established (Visco 2008).

The term de novo SUI is used to describe stress incontinence that develops following surgical correction of the prolapse amongst women who were symptomatically continent prior to surgery. De novo or new SUI after prolapse surgery is clearly disappointing to women and was one of the outcome measures considered in this review.

Description of the intervention

Treatment of prolapse depends on the severity of the prolapse, its symptoms, the woman's general health, and surgeon preference and capabilities. Options available for treatment are conservative, mechanical or surgical interventions.

Generally, conservative or mechanical treatments are considered for women with a mild degree of prolapse, those who wish to have more children, the frail or those women unwilling to undergo surgery. Conservative and mechanical interventions have been considered in separate Cochrane reviews (Adams 2004; Hagen 2011). There was no good evidence to guide management in either of these reviews.

The current review considers all surgical procedures for women with pelvic organ prolapse. The aims of surgery include:

the restoration of normal vaginal anatomy;
the restoration or maintenance of normal bladder function;
the restoration or maintenance of normal bowel function;
the restoration or maintenance of normal sexual function.

A wide variety of abdominal and vaginal surgical techniques are available for the treatment of prolapse (see Appendix 1). The most common procedures are anterior repair (colporrhaphy) for anterior vaginal wall prolapse and posterior repair (colporrhaphy) for posterior vaginal wall prolapse. Together, anterior and posterior compartment surgery account for over 90% of all prolapse operations (Olsen 1997). Two main approaches can be used.

Vaginal approaches include vaginal hysterectomy, anterior or posterior vaginal wall repair (colporrhaphy), McCall culdoplasty, Manchester repair (amputation of the cervix with uterus suspension to the cardinal ligaments), prespinous and sacrospinous colpopexy, enterocele ligation, paravaginal repair, Le Fortes procedure and perineal reconstruction.
Abdominal approaches include hysterectomy, sacral colpopexy, paravaginal repair, vault suspending and uterosacral ligament plication, enterocele ligation and posterior vaginal wall repair. Abdominal surgery can be performed through an open incision or keyhole incisions via the laparoscope or robot.

A combination of some of these procedures may be employed in the surgical correction of prolapse as frequently more than one type of prolapse may occur.

In addition to the variety of prolapse operations, the surgeon must choose whether to use absorbable sutures such as polyglycolic acid based materials (for example polyglactin), delayed‐absorption sutures such as polydioxanone, or non‐absorbable sutures such as polypropylene. Furthermore, some techniques require the routine use of grafts or mesh, for example sacral colpopexy uses different materials to bridge the gap between the vaginal cuff and the hollow of the sacrum, whereas for other techniques grafts are optional. Graft material can be synthetic (for example permanent polypropylene or absorbable polyglactin mesh) or biological. Biological grafts can be further divided into autologous (using a person's own tissue, such as fascial sheath), alloplastic (from animals, for example porcine dermis) or homologous (for example cadaveric fascia lata).

The choice of operation depends on a number of factors, which include the nature, site and severity of the prolapse; whether there are additional symptoms affecting urinary, bowel or sexual function; the general health of the woman; and surgeon preference and capability. Concomitant procedures to treat or prevent urinary incontinence are often performed at the same time.

To aid the assessment of the success of surgery, clear pre and post‐operative site‐specific vaginal grading and details of the operative intervention should be recorded in the reports.

Why it is important to do this review

The wide variety of surgical treatments available for prolapse indicates the lack of consensus as to the optimal treatment. Guidelines have been published using the available literature but are based on studies of mixed type and quality (Carey 2001). Provided that sufficient numbers of trials of adequate quality have been conducted, the most reliable evidence is likely to come from the consideration of randomised controlled trials, and this is the basis for the review. The aim is to help identify optimal practice and to highlight where there is a need for further research.

Objectives

To determine the impact of pelvic organ prolapse surgery including patient symptoms, examination findings, complications, cost, and bladder, bowel and sexual function.

The following comparisons were made.

1. One type of upper vaginal prolapse (uterine and vaginal vault) repair versus another

Including open or laparoscopic abdominal sacral colpopexy, vaginal sacrospinous colpopexy, vaginal or abdominal hysterectomy, high levator myorrhaphy, uterosacral ligament vault suspension, vaginal Mayo McCall repair.

2. One type of anterior vaginal wall prolapse repair versus another

Including anterior vaginal wall repair (anterior colporrhaphy) with or without graft reinforcement, abdominal paravaginal repair.

3. One type of posterior vaginal wall prolapse repair versus another

Including posterior vaginal wall repair (posterior colporrhaphy) with or without graft reinforcement, transanal repair, abdominal posterior repair.

4. Any type of surgical prolapse repair versus conservative treatment

5. Any type of surgical prolapse repair versus mechanical devices

6. No graft versus use of graft (synthetic mesh or biological graft)

7. One type of graft (synthetic mesh or biological graft) versus another type of graft

8. One type of suture versus another type of suture

9. Prolapse surgery and bladder function

A. One type of POP surgery alone versus another type of POP surgery alone

B. POP surgery alone versus POP surgery with an additional continence procedure

Methods

Criteria for considering studies for this review

Types of studies

Randomised controlled trials (RCTs) or quasi‐randomised controlled clinical trials (CCTs) in which at least one arm was a surgical intervention for pelvic organ prolapse.

Types of participants

Adult women seeking treatment for symptomatic pelvic organ prolapse. Both primary and recurrent prolapse were considered.

Pelvic organ prolapse includes:

upper vaginal prolapse (uterine or vaginal vault);
anterior vaginal wall prolapse (cystocele, urethrocele, paravaginal defect);
posterior vaginal wall prolapse (enterocele, rectocele, perineal deficiency).

Types of interventions

Trials including any type of abdominal or vaginal surgery for pelvic organ prolapse in at least one trial group. Comparison interventions included no treatment, conservative management, a mechanical device, or an alternative approach to surgery. Concomitant operations to treat or prevent urinary incontinence were also evaluated.

Types of outcome measures

Primary outcomes

Women's observations related to prolapse

Perceived cure or improvement in prolapse symptoms
Acceptability of procedure or satisfaction with outcome (e.g. Patient Global Impression of Improvement (PGI‐I))
Prolapse‐specific quality of life questionnaires (e.g. Prolapse ‐ Quality of Life (P‐QOL), Sheffield Prolapse Symptoms Questionnaire)

Clinicians' observations related to prolapse

Site‐specific grading of prolapse, reported as rate of recurrence, for example:

International Continence Society Pelvic Organ Prolapse Quantification System (POP‐Q) classification (Bump 1996a);
Baden‐Walker half‐way system (Baden 1972).

Secondary outcomes

Quality of life

Other condition‐specific quality of life questionnaires: related to urinary incontinence (e.g. Bristol Female Lower Urinary Tract Symptoms Questionnaire (BFLUTS), Incontinence Impact Questionnaire (IIQ), International Consultation on Continence Questionnaire ‐ Short Form (ICI‐SF); sexual function (e.g. Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ), ICIQ‐FLUTSsex); bowel function (e.g. Faecal Incontinence Quality of Life Scale, Wexner score)
Generic quality of life or health status measures (e.g. Short Form‐36) (Ware 1992)
Psychological outcome measures (e.g. Hospital Anxiety and Depression Scale (HADS)) (Zigmond 1983)

Measures of associated symptoms (objective or subjective)

Bladder symptoms, including symptomatic and occult incontinence
Bowel symptoms
Sexual problems

Surgical outcome measures

Operating time, blood loss, inpatient days
Further pelvic organ prolapse surgery
Further continence surgery

Complications

Need for transfusion
Infection including mesh or graft infection
Adverse effects (e.g. return to theatre, damage to surrounding viscera, mesh or graft exposure, graft rejection)
Other adverse effects

Economic measures

For example catheter days, inpatient days, days to return to activities of daily living

Use of resources
Costs of interventions or resources
Resource implications of effects of treatment
Formal economic evaluations

Search methods for identification of studies

We did not impose any language or other limits on any of the searches which are detailed below.

Electronic searches

This review has drawn on the search strategy developed for the Cochrane Incontinence Review Group. Relevant trials were identified from the Group's Specialised Register of controlled trials which is described, along with the Review Group search strategy, under the Group's module in The Cochrane Library. The Register contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL and handsearching of journals and conference proceedings. The Incontinence Group Specialised Register was searched using the Group's own keyword system (all searches were of the keyword field of Reference Manager 12, Thomson Reuters). The search terms used were:

({design.cct*} OR {design.rct*})
AND
({topic.prolapse*})
AND
({intvent.surg*})

The trials in the Incontinence Group Specialised Register are also contained in CENTRAL.

The review authors also undertook searches of healthcare‐related bibliographic databases (most recent 20 August 2012).

Searching other resources

We handsearched conference proceedings, searched the reference lists of relevant articles, and contacted researchers in the field.

Data collection and analysis

Selection of studies

Titles and, if available, abstracts of all possibly eligible studies were assessed by two review authors for their methodological quality (method of randomisation and adequacy of concealment of the randomisation process; intention to treat analysis; and completeness of follow‐up). In this update blinding status of patients and assessors and sources of funding of the updated trials were recorded, and relevance to the review objectives. Full reports of each study likely to be eligible were then independently assessed by at least two review authors using the Cochrane Incontinence Group's assessment criteria. Authors agreed on whether or not to include the study according to the inclusion criteria for the review.

Studies were excluded if they were not randomised or quasi‐randomised trials of surgery for women with pelvic organ prolapse or if the sample size was less than 20 in each group and the review time was less than six months. Excluded studies are listed with the reasons for their exclusion in the table Characteristics of excluded studies.

Data extraction and management

Data extraction was undertaken independently by at least two review authors and comparisons made to ensure accuracy. Discrepancies were resolved by discussion or by referral to a third party. Where trial data were not reported adequately, attempts were made to acquire the necessary information from the trialist.

Data synthesis

Included trial data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). Meta‐analyses were undertaken to synthesise trial data, when appropriate. The method of meta‐analysis depended on the nature of the outcomes. For categorical outcomes we related the numbers reporting an outcome to the numbers at risk in each group in order to derive a risk ratio (RR). For continuous variables we used means and standard deviations to derive a mean difference (MD). As a general rule, a fixed‐effect model was used for calculations of summary estimates and their 95% confidence intervals (CI).

Subgroup analysis and investigation of heterogeneity

Trials were only combined if the interventions were similar enough based on clinical criteria. When important heterogeneity was suspected from visual inspection of the results, the Chi² test for heterogeneity (at 10%) or the I² statistic (Higgins 2003) was determined looking for further differences between the trials. When concern about heterogeneity persisted, a random‐effects model was to be used.

Trials were separately identified and combined if they addressed other secondary objectives of the review related to the prevention or treatment of complications or evaluation of urinary, bowel or sexual function.

Results

Description of studies

Results of the search

Full reports of 94 potentially eligible studies were assessed. For this update, 20 new eligible studies were assessed and 16 were included (Altman 2011; Farid 2010; Feldner 2010; Halaska 2012; Iglesia 2010; Maher 2011; Menefee 2011; Minassian 2010 abstract; Paraiso 2011; Rondini 2011 abstract; Sung 2012; Thijs 2010 abstract; Vijaya 2011 abstract; Vollebregt 2011; Wei 2011; Withagen 2011). Ten previously included studies were updated (Al‐Nazer 2007; Borstad 2010; Carey 2009; Costantini 2008; Culligan 2005; Dietz 2010; Guerette 2009; Natale 2010; Nieminen 2008; Pantazis 2011) and Sokol is a one year update of Iglesia 2010 which was included for the first time. There are two studies (Ek 2010; Ek 2011) which are ancillary reports to Altman 2011.

The flow of literature through the assessment process is shown in the PRISMA flowchart (Figure 1).

Figure 1

PRISMA study flow diagram.

Studies randomising catheter issues (Dixon 2010; Huang 2011; Kamilya 2010; Kokabi 2010; Kringel 2010; Van Der Steen 2011; Weemhoff 2011) only at the time of POP surgery will be reviewed in a separate analysis within the Cochrane Incontinence Group.

In total, 56 randomised controlled trials on the surgical management of pelvic organ prolapse were evaluated in this review. These trials were conducted in 12 countries (Italy, USA, Australia, UK, the Netherlands, Taiwan, Finland, Belgium, Chile, Czech Republic, Egypt, France, Singapore and Sweden). The trials involved a total of 5954 women of which 1873 were new in this update and all of whom received a surgical intervention.

Seven trials (Ali 2006 abstract; Borstad 2010; Farid 2010; Jeng 2005; Pantazis 2011; Schierlitz 2007; Vijaya 2011 abstract) reported median follow up of less than one year and only four trials reported outcomes at greater than five years (Colombo 1997; Colombo 2000; Roovers 2004; Culligan 2005).

Given the diverse nature of pelvic organ prolapse, to allow a meaningful and structured analysis of the data the review was divided into three sections related to the site of the prolapse.

1. Upper vagina including cervix, uterus or vault (post‐hysterectomy).

2. Anterior vaginal wall.

3. Posterior vaginal wall

Two further sections related to:

4. prolapse surgery and impact on bladder function;

5. prolapse surgery with and without grafts.

Full details of the description of the studies under the nine objectives of the review are available as Appendix 2.

Full details of the included trials are given in the 'Characteristics of included studies' table.

Excluded studies

Overall 38 studies were excluded from the review, four during this update (Lopes 2010; Lundarelli 2009; Svabik 2010; Tincello 2009). Full details are given in the 'Characteristics of excluded studies' table.

Risk of bias in included studies

Allocation

Including the 26 new or updated trials, sufficient detail was provided in 31 of 56 RCTs, which adequately described the randomisation process and confirmed that secure concealment of the randomisation process was used, for example allocation by a remote person or sealed envelopes (Ali 2006 abstract; Allahdin 2008; Al‐Nazer 2007; Altman 2011; Benson 1996; Borstad 2010; Brubaker 2008; Bump 1996; Costantini 2008; Culligan 2005; Dietz 2010; Feldner 2010; Gandhi 2005; Guerette 2009; Hviid 2010; Iglesia 2010; Maher 2004; Maher 2011; Meschia 2004; Meschia 2004a; Meschia 2007; Minassian 2010 abstract; Natale 2009; Nguyen 2008; Nieminen 2008; Paraiso 2006; Roovers 2004; Sivaslioglu 2008; Sung 2012; Weber 2001). However, in one of these trials four women received the opposite treatment to their randomised allocation (mesh instead of fascia) and were subsequently analysed in the mesh group thus compromising the randomisation process; an intention‐to‐treat analysis was not used (Culligan 2005).

Of the remainder, 23 trials stated that they used computer generated number lists but it was unclear whether the allocation was concealed before assignment (Braun 2007 abstract; Carey 2009; Colombo 1996; Colombo 1997; De Ridder 2004 abstract; de Tayrac 2008; Costantini 2007; Halaska 2012; Menefee 2011; Kahn 1999; Lo 1998; Natale 2010; Nieminen 2004; Pantazis 2011; Paraiso 2011; Rondini 2011 abstract; Sand 2001; Schierlitz 2007; Thijs 2010 abstract; Vijaya 2011 abstract; Vollebregt 2011; Withagen 2011; Wei 2011); another gave no details of the randomisation process (Jeng 2005). The last trial stated that a computer generated but open number list was used and it was, therefore, classified as a quasi‐randomised trial (Colombo 2000).

Blinding

Women and surgeons could not be blinded to the procedure when different surgical routes were compared (Benson 1996; Braun 2007 abstract; Colombo 2000; Maher 2004; Maher 2011; Roovers 2004). Blinding of patients and the post‐operative reviewer were performed in nine trials (Allahdin 2008; Brubaker 2008; Culligan 2005; Iglesia 2010; Menefee 2011; Nguyen 2008; Paraiso 2006; Paraiso 2011;Sung 2012). Outcome assessments were conducted by non‐surgeons in 16 trials (Allahdin 2008; Al‐Nazer 2007; Benson 1996; Costantini 2008; Culligan 2005; Feldner 2010; Iglesia 2010; Maher 2004; Maher 2011; Meschia 2007; Natale 2009; Paraiso 2006; Paraiso 2011; Roovers 2004; Sung 2012; Weber 2001). These findings are summarised in Figure 2.

Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Incomplete outcome data

Loss to follow up was a variable problem, ranging from zero (Allahdin 2008; Colombo 1997; Jeng 2005; Kahn 1999; Meschia 2004; Meschia 2004a) to 53% (49 out of 93) in Guerette 2009. Weber also reported a statistically significant higher loss to follow up in one arm of the trial (ultra‐lateral anterior vaginal wall repair) (Weber 2001).

Other potential sources of bias

CONSORT statements were reported by 13 trials (Altman 2011; Brubaker 2008; Costantini 2008; Dietz 2010; Halaska 2012; Iglesia 2010; Nguyen 2008; Nieminen 2008; Maher 2011; Paraiso 2006; Paraiso 2011; Roovers 2004; Sivaslioglu 2008). In 13 trials, data were analysed on an intention‐to‐treat basis (Allahdin 2008; Altman 2011; Brubaker 2008; Iglesia 2010; Jeng 2005; Maher 2004; Maher 2011; Meschia 2007; Nguyen 2008; Paraiso 2006; Paraiso 2011; Roovers 2004; Sung 2012, Weber 2001). These findings are summarised in Figure 3.

Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Baseline descriptive characteristics were reported in all trials and were equally distributed except in four trials: Sand 2001 reported that previous hysterectomy was more common in the mesh overlay group; Kahn 1999 reported a difference in menopausal status and previous hysterectomies between the groups; women in the vaginal sacrospinous colpopexy arm in Meschia's trial were significantly older (Meschia 2004a); and women in the native tissue group had greater degree prolapse at point A posterior (Ap), point B posterior (Bp) and genital hiatus (GH) as compared to the mesh group, and prior sacral colpopexy was three times more frequent in the mesh group than in the native tissue group in Withagen 2011. Pre‐operative prolapse status was reported in all trials but one (De Ridder 2004 abstract), but equal distribution and severity of prolapse between groups was not specifically reported in seven trials (Ali 2006 abstract; Benson 1996; Bump 1996; Meschia 2004; Pantazis 2011; Sand 2001; Schierlitz 2007). One trial included 7% of women with Stage 1 anterior vaginal wall prolapse pre‐operatively (at time of inclusion), which would also have been classified as a post‐operative success (Weber 2001).

Length of follow up was less than one year in nine trials (Ali 2006 abstract; Borstad 2010; Farid 2010;Jeng 2005; Pantazis 2011; Paraiso 2011; Schierlitz 2007; Vijaya 2011 abstract) and greater than five years in another four trials (Colombo 1997; Colombo 2000; Culligan 2005; Roovers 2004) with all other trialists reporting results at between one and five years.

Effects of interventions

1. One type of upper vaginal prolapse (uterine and vaginal vault) repair versus another (Comparison 1)

Nineteen studies evaluated surgeries for upper vaginal prolapse (uterine or vault) (Benson 1996; Braun 2007 abstract; Brubaker 2008; Costantini 2007; Costantini 2008; Culligan 2005; de Tayrac 2008; Dietz 2010; Halaska 2012; Jeng 2005; Lo 1998; Maher 2004; Maher 2011; Meschia 2004a; Natale 2010; Pantazis 2011; Paraiso 2011;Rondini 2011 abstract; Roovers 2004).

Four of these were new included trials (Halaska 2012; Maher 2011; Paraiso 2011; Rondini 2011 abstract) and four were updates of previously included trials (Culligan 2005; Dietz 2010; Natale 2010; Pantazis 2011 from abstract). All trials provided data regarding the outcome of prolapse surgery except Jeng 2005. All the trials with mesh used non‐absorbable, permanent mesh except one trial in which an absorbable mesh was compared with a non‐absorbable mesh (Culligan 2005 UPDATE).

Abdominal sacral colpopexy versus vaginal sacrospinous colpopexy

Three trials were considered to be similar enough to address the comparison of abdominal sacral colpopexy and vaginal sacrospinous colpopexy (Benson 1996; Lo 1998; Maher 2004).

There was no statistically significant difference between the abdominal and vaginal approach in the number of women reporting prolapse symptoms, although there were more reports of subjective failure in the vaginal group (subjective failure after abdominal surgery 9/84 versus 18/85 after vaginal surgery; RR 0.53, 95% CI 0.25 to 1.09; Analysis 1.1.1) (Benson 1996; Maher 2004). The limited evidence was not sufficient to detect a statistically significant difference between the abdominal and vaginal approach for patient satisfaction (RR 0.82, 95% CI 0.32 to 2.06; Analysis 1.2.1) (Maher 2004).

Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of:

the number of women failing to improve to Stage 2 or better (3 out of 52 versus 13 out of 66; RR 0.29, 95% CI 0.09 to 0.97; Analysis 1.5.2) (Lo 1998);
a lower rate of recurrent vault prolapse (3 out of 84 versus 13 out of 85; RR 0.23, 95% CI 0.07 to 0.77; Analysis 1.6.1) (Benson 1996; Maher 2004);
less post‐operative SUI (14 out of 47 versus 28 out of 81; RR 0.55, 95% CI 0.32 to 0.95; Analysis 1.15.1) (Benson 1996; Maher 2004);
less post‐operative dyspareunia (7 out of 45 versus 22 out of 61; RR 0.39, 95% CI 0.18 to 0.86; Analysis 1.27) (Benson 1996; Lo 1998; Maher 2004).

However, caution should be exercised when evaluating these data due to significant variation in the methodology of the three trials as detailed in the 'Description of studies, appendix 2'.

There were no statistically significant differences in objective failure at any site (any pelvic organ prolapse RR 0.77, 95% CI 0.39 to 1.53; Analysis 1.5.1) (Maher 2004) or reoperation rates for SUI (RR 0.6, 95% CI 0.21 to 1.73; Analysis 1.40) (Benson 1996; Lo 1998; Maher 2004).

Although data were available for bowel outcomes (Analysis 1.24; Analysis 1.23; Analysis 1.26) and adverse events (Analysis 1.32), they were too few to provide sufficiently precise estimates to identify or rule out clinically important differences.

The lower reoperation rate for prolapse after abdominal surgery as compared to vaginal surgery did not reach statistical significance (6 out of 84 versus 14 out of 85; RR 1.46, 95% CI 0.19 to 1.11; Analysis 1.39.1) (Benson 1996; Maher 2004).

The results for intra‐operative blood loss were inconsistent in two studies, with a mean difference of 298 ml less blood loss in the abdominal group in Lo's study (Lo 1998) and 33 ml more blood loss in Maher's trial (Maher 2004) (Analysis 1.30.1). Benson did not report blood loss but the post‐operative change in haemoglobin was not statistically different (Benson 1996).

Women treated abdominally took significantly longer to present with recurrent prolapse (months to recurrence MD ‐10.90, 95% CI ‐17.12 to ‐4.68; Analysis 1.38.1) in one trial (Benson 1996). On the other hand, abdominal sacral colpopexy was associated with a longer operating time (MD 21 min, 95% CI 12 to 30; Analysis 1.33.1) (Benson 1996; Lo 1998; Maher 2004), a longer time to recover (MD 8.3 days, 95% CI 3.9 to 12.7; Analysis 1.35.1) (Maher 2004) and was more expensive (weighted mean difference (WMD) USD 1334, 95% CI 1027 to 1641; Analysis 1.37.1) (Benson 1996; Maher 2004) than the vaginal approach.

Sacral colpopexy and abdominal hysterectomy versus vaginal Mayo McCall culdoplasty and vaginal hysterectomy

One small trial (Braun 2007 abstract) compared 47 women who underwent total abdominal hysterectomy (TAH) and sacral colpopexy using synthetic combined absorbable and non‐absorbable (Vypro) mesh with 47 women who underwent vaginal hysterectomy (VH) plus anterior and posterior colporrhaphy plus the Mayo McCall procedure using delayed absorbable polydioxanone (PDS) sutures. Anatomical failure rates at 33 months mean follow up were none in the sacral colpopexy group and 2/24 in the Mayo‐McCall group (one with vault prolapse and one with anterior prolapse which required further intervention), although a quantitative definition for success or failure was not provided (Analysis 1.5.3). The mean operating time, length of hospitalisation and rates of complications were higher in the sacral colpopexy group but, in the absence of statistical analysis to support these results, one cannot comment on their significance.

Abdominal sacral colpopexy versus high vaginal uterosacral colpopexy (HUSLS)

In a single study, Rondini 2011 abstract compared sacral colpopexy (n = 54) and high uterosacral vault suspension (n = 56) in women with point C greater than 1 cm beyond the introitus. At one year the objective success rate at point C less than ‐1 cm was 100% (54/54) as compared to 46/56 in the uterosacral suspension group. Recurrence in the anterior or posterior compartment (point Ba or point Bp) was significantly less after the sacral colpopexy 5.5% (3/54) as compared to 33.9% (19/56) in the HUSLS. The reoperation rate for prolapse was significantly lower after sacral colpopexy: 5% (3/54) as compared to 17.8% (10/56) in the HUSLS. Both intra‐operative complications (3.7% versus 0%, P = 0.15) and post‐operative complications (20.4% versus 7.3%, P = 0.047) were higher following the sacral colpopexy as compared to HUSLS. The operating time in minutes (102 versus 80) and hospital stay in days (3.7 versus 2.1) were significantly less (P < 0.01) after the sacral colpopexy as compared to HUSLS.

Uterine suspension (preservation) versus vaginal hysterectomy

Three trials addressed this comparison (Dietz 2010; Jeng 2005; Roovers 2004). These trials could not be combined as the non‐hysterectomy groups were too different (clinical heterogeneity) and Jeng did not supply any anatomical outcomes.

Abdominal uterine preservation versus vaginal hysterectomy and repair

One trial (Roovers 2004) compared abdominal sacral hysteropexy with uterine preservation versus vaginal hysterectomy and repair with vault fixation to the uterosacral‐cardinal ligament complex. Although more women had subjective prolapse symptoms at one year after abdominal surgery (RR 3.2, 95% CI 1.29 to 7.92; Analysis 1.1.2), there was no statistically significant difference in the prolapse domain of the urinary distress inventory (UDI) (mean difference 4.1, 95% CI ‐5.4 to 13.6) nor the score for urinary incontinence (mean difference (MD) 6, 95% CI ‐2 to 14). However, at one year after surgery the vaginal group reported significantly better (lower) scores on the discomfort/pain domain (7.1, 95% CI 1.1 to 13.2), overactive bladder domain (8.7, 95% CI 0.5 to 16.9) and the obstructive micturition domain (10.3, 95% CI 0.6 to 20.1) as compared to the abdominal group.

More women in the abdominal group required repeat prolapse repair (RR 9.00, 95% CI 1.19 to 67.85; Analysis 1.39.2). In the first year after surgery five women (12%) in the abdominal group had or were due to undergo a reoperation for recurrent cystocele and four women (10%) for recurrent uterine prolapse, whereas in the vaginal group only one patient required surgery for vaginal vault prolapse. The operating time was less for the abdominal group (MD ‐10 min, 95% CI ‐12 to ‐8; Analysis 1.33.2) possibly reflecting the less invasive nature of the abdominal procedure in this trial (the uterus was preserved in the abdominal group as opposed to removed in the vaginal group).

Long‐term follow up

At the eight year follow up in one trial (Roovers 2004), the higher number of women reporting prolapse symptoms at one year was not reproduced: 87% in the vaginal group versus 68% in the abdominal group reported that prolapse symptoms had improved compared to before primary surgery (RR 2.60, 95% CI 1.02 to 6.65; Analysis 1.1.3). There was also no statistically significant difference in the prolapse reoperation rate: 11/42 (26%) patients in the abdominal group and 6/42 (14%) in the vaginal group required further prolapse or incontinence surgery (RR 1.83, 95% CI 0.75 to 4.50; Analysis 1.41.2). IIQ scores and POP‐Q scores were similar for both groups. Defecation symptoms had more adverse effects on quality of life in the abdominal group than in the vaginal group. The difference in the constipation obstruction domain of the Defecation Distress Inventory (DDI) was statistically significant. Eight (19%) of the 42 patients in the vaginal group and 18 (43%) of the patients in the abdominal group (P = 0.03) visited a physician after primary surgery because of pelvic floor symptoms (Analysis 1.3) (Roovers 2004).

Vaginal sacrospinous uterine suspension versus vaginal hysterectomy

In another trial (Jeng 2005), vaginal sacrospinous uterine hysteropexy (suspension) with uterine preservation was compared with vaginal hysterectomy. There were few reports of dyspareunia in either group (Analysis 1.27.3) but there were more adverse symptoms in the sacrospinous suspension arm, mostly due to buttock pain (RR 4.23, 97% 1.25 to 14.25; Analysis 1.32.6) (Jeng 2005).

In a third, small trial, Dietz 2010 reported on vaginal sacrospinous uterine hysteropexy as compared to vaginal hysterectomy. At one year, the higher rate of apical compartment recurrence in the hysteropexy group of 7/34 (21%) was not statistically different from that in the hysterectomy group with 1/33 (3%) (RR 0.16, 95% CI 0.02 to1.20; Analysis 1.6.4). The rates of cystocele and rectocele recurrence were not significantly different between the groups. Four women (12%) underwent further prolapse surgery in the hysteropexy group as compared to two (6%) in the hysterectomy group (Analysis 1.39). Women undergoing the sacrospinous hysteropexy had a median hospital stay that was one day shorter than in the hysterectomy group (3 versus 4, P = 0.03), and the mean number of days to return to work was 23 days earlier (95% CI 9 to 37; Analysis 1.36.1) than in the hysterectomy group. No differences were reported in domain scores for quality of life and urogenital symptoms between the two procedures one year after the surgery.

Hysterectomy with high levator myorrhaphy (HLM) versus hysterectomy with uterosacral vaginal vault suspension (UVVS)

One trial (Natale 2010) compared two vaginal vault procedures, HLM (n = 116) and UVVS (n = 113), in patients with Stage 2 or more uterine prolapse. All women underwent vaginal hysterectomy and anterior repair with concomitant mono‐filament polypropylene mesh in over 90% of women.

There were no data on the subjective reporting of prolapse symptoms by the women.

At follow up, apical (Analysis 1.6.5), anterior (Analysis 1.9) and posterior (Analysis 1.12) compartment recurrence rates were similar in both groups. The mean total vaginal length was significantly shorter (7.9 cm after HLM versus 8.91 cm after UVVS, P = 0.04).

Urinary symptoms (Analysis 1.15; Analysis 1.17; Analysis 1.18; Analysis 1.20; Analysis 1.16; Analysis 1.21), bowel symptoms (Analysis 1.25), sexual function (Analysis 1.27; Analysis 1.28) and urodynamic parameters did not differ between groups post‐operatively. Post‐operative unilateral ureteric angulation leading to hydronephrosis was identified in 10/113 patients in the UVVS group; and was identified intra‐operatively and corrected with replacement of uterosacral sutures (Analysis 1.32.8). Mesh erosion rates were comparable between the two groups.

Open abdominal sacral colpopexy versus laparoscopic sacral colpopexy (LSC)

A single multi‐centre equivalence trial (Pantazis 2011) compared open and LSC in the treatment of POP‐Q Stage 2 vault prolapse. The median Patient Global Impression of Improvement (PGI‐I) (one to seven score, one being best improvement and seven being worst deterioration) was one in both groups. At one year the elevation of the vaginal vault above the hymen (point C) was similar in the two groups (open 6.6 cm, laparoscopic 6.7 cm, P = 0.71; MD 0.00, 95% CI ‐0.74 to 0.74; Analysis 1.7.4) and there was no difference in the number of patients who were 'very satisfied' using the PGI‐I (D 0.88, 95% CI 0.26 to 2.99; Analysis 1.4.1). The mean blood loss was significantly greater in the open arm (MD 184 ml, 95% CI 96 to 272; Analysis 1.30.6) and the number of inpatient days was less in the laparoscopic group (MD.0.9 days, 95% CI 0.1 to 1.7) (Al‐Nazer 2007). There was no difference in operating time (Analysis 1.33.6), serious adverse events (Analysis 1.32.9) or in the Prolapse quality of life outcome (Analysis 1.44.1).

Laparoscopic sacral colpopexy (LSC) versus total vaginal polypropylene mesh kit (TVM)

A single centre randomised controlled trial compared LSC (n = 53) and a total vaginal polypropylene mesh kit (Prolift) (n = 55) in women with grade 2 post‐hysterectomy vaginal vault prolapse at mean two year review (Maher 2011). The LSC took significantly longer to perform with a MD of 52 min (95% CI 41.2 to 62.6), had reduced blood loss (MD 32 ml, 95% CI 5 to 59), reduced inpatient days with a MD of 0.5 days (95% CI 0.1 to 0.9), and resulted in quicker return to activities of daily living with a MD of 5.3 days (95% CI 2.3 to 8.4) as compared to TVM.

The objective recurrence rate (Stage 2 POP at any vaginal site) was significantly lower in the laparoscopic group (12/53) compared to the TVM group (32/55) (RR 0.39, (95% CI 0.23 to 0.67; Analysis 1.5.8). Following LSC point C (vaginal vault) was significantly higher with a MD of 1.39 cm (95% CI 0.39 to 2.39; Analysis 1.7.2), point Ba (middle anterior vaginal wall) was significantly higher with a MD of 0.7 cm (95% CI 0.36 to 1.04; Analysis 1.11.2), point Bp (mid‐point posterior vaginal wall) was significantly higher with a MD of 0.7 cm (95% CI 0.37 to 1.03; Analysis 1.14.2) and total vaginal length was significantly longer with a MD of 1.0 cm (95% CI 0.6 to 1.4; Analysis 1.8.4) as compared to TVM.

Mesh exposure risk was not significantly different after the LSC (1/53) as compared to TVM (7/55) (RR 0.13 95% CI 0.02 to 1.11; Analysis 1.42.1), however the reoperation rate related to primary intervention was significantly less likely after the LSC (3/53) as compared to TVM (12/55) (RR 0.26, 95% CI 0.08 to 0.87; Analysis 1.41.3). Mean patient satisfaction on a visual analogue scale of 0 to 100 ( with 100 being the highest) was significantly higher following LSC as compared to TVM, with a MD of 8.1 (95% CI 0.2 to 16.0). Two validated pelvic floor questionnaires were utilised, the Australian Pelvic Floor Questionnaire (APFQ) and the Prolapse Quality of Life Questionnaire (P‐QOL), and both demonstrated a significant improvement following the interventions as compared to before surgery. There was not enough evidence to detect a difference in outcomes between the groups after the intervention.

Total vaginal polypropylene mesh (TVM) versus sacrospinous colpopexy

A single multi‐centre randomised trial compared sacrospinous colpopexy (n = 83) and native tissue repairs with the total vaginal mesh Prolift (n = 85) for grade 2 or greater post‐hysterectomy prolapse (Halaska 2012). The allocation concealment and blinding status of patients and reviewer were not recorded. No concomitant surgery was performed. All surgeons had completed at least 20 cases of each procedure prior to commencing the study. The primary outcome was any grade 2 or greater prolapse on examination at one year and demonstrated that the sacrospinous colpopexy group had a higher objective recurrence rate: 28/72 (39%) compared to 13/79 (17%) in the TVM group. Mesh exposure was identified in 16 of 79 (20%) with 10 of 79 (13%) undergoing surgical correction. Reoperation for prolapse was performed in 3 of 72 in the sacrospinous colpopexy group and 1 of 79 in the vaginal mesh group. No differences were identified between the groups in terms of de novo SUI, bladder overactivity, dyspareunia, pelvic pain or in functional outcomes measured with the Prolapse Incontinence Sexual Questionnaire ‐ 12 (PISQ‐12), the Urinary Impact Questionnaire (UIQ), the Colo‐Recto‐Anal Impact Questionnaire (CRAIQ) or the Pelvic Organ Prolapse Impact Questionnaire (POPIQ).

Laparoscopic versus robotic sacral colpopexy

Paraiso 2011 demonstrated that LSC (n = 33) had a shorter operating time of 199 ± 46 minutes as compared to 265 ± 50 minutes to the robotic group, and less use of NSAIDS (11 days versus 20 days). The laparoscopic approach was significantly cheaper than the robotic approach (MD ‐$1936, 95% CI 417 to 3454). At one year both groups reported significant and similar improvements in objective assessment and functional outcomes.

Vaginal sacrospinous colpopexy versus posterior intravaginal slingplasty (PIVS) also termed infracoccygeal sacropexy

Two trials (de Tayrac 2008; Meschia 2004a) compared vaginal sacrospinous colpopexy with PIVS using multi‐filament polypropylene tape in women having uterine or vault suspension. They were considered similar enough to combine in a meta‐analysis. The combined trials had too few data to identify differences in most of the outcomes reported, including:

satisfaction (Analysis 1.2.2);
objective recurrences at the upper vagina following PIVS and sacrospinous colpopexy (Analysis 1.6.2);
anterior compartment prolapse (Analysis 1.10.1);
posterior compartment prolapse (Analysis 1.13.1);
the rate of post‐operative SUI (Analysis 1.15.2);
urge incontinence ( Analysis 1.17.2);
constipation (Analysis 1.24.2);
adverse events (Analysis 1.32.3);
hospital stay (Analysis 1.34.3).

On the other hand, with the PIVS operation the mean operating time was shorter (MD 8 min, 95% CI 4 to 11; Analysis 1.33.3) and blood loss less (MD 70 ml, 95% CI 56 to 84; Analysis 1.30.3) (Meschia 2004a).

Apical prolapse repair without continence surgery versus prolapse repair with any continence surgery (also Comparison 9)

Two trials (Brubaker 2008; Costantini 2008) evaluated the efficacy of adding continence surgery to sacral colpopexy. As the primary focus of these papers was continence outcomes they were also evaluated in prolapse surgery and bladder function (Comparison 9). However, regarding their prolapse and other outcomes:

women were more satisfied after surgery with additional colposuspension, in one trial (Analysis 1.4) (Costantini 2008);
the vault was higher (better) and the vaginal length longer after additional colposuspension (Analysis 1.7; Analysis 1.8);
the anterior wall of the vagina was higher (better) in women who had the additional colposuspension (Analysis 1.11) but the results were conflicting with regard to the position of the posterior wall (Analysis 1.14): in one trial (Brubaker 2008) the posterior wall was higher (better) in the sacral colpopexy alone arm while in the other (Costantini 2008) the posterior wall was higher in the group who had the additional colposuspension;
there were too few women having repeat prolapse surgery to draw conclusions (Analysis 1.39.6).

One type of graft versus another type of graft in sacral colpopexy (also Comparison 7)

One trial (Culligan 2005) compared abdominal sacral colpopexy using either absorbable cadaveric fascia lata graft (Tutuplast) or non‐absorbable (permanent) mono‐filament polypropylene mesh (Trelex). There were no recurrences of vaginal vault prolapse in either group, but the objective failure rate for recurrence at any other vaginal site was significantly worse (14/44 (32%) in the fascial graft group versus 4/45 (9%) in the mesh group (RR 3.58, 95% CI 1.28 to 10.03; Analysis 1.5.4). There were no vaginal erosions in the 46 women in the fascial graft group but two out of 54 women had mesh erosion in the non‐absorbable mesh group. No data on bladder, bowel or sexual function were provided.

Additional five year data have been published and on examination recurrence (any POP‐Q point ≥ ‐1) was higher if cadaveric fascia was utilised (9/29) as compared to mono‐filament polypropylene mesh (2/29; P = 0.02) (TATE 2011). No difference was detected between the groups at five years for the individual points Ba (Analysis 1.11.3), Bp (Analysis 1.14.3), C (Analysis 1.7.3) and TVL (Analysis 1.8.3).

2. One type of anterior vaginal wall prolapse repair versus another (Comparison 2)

Twenty‐one trials included various surgical procedures for treating anterior vaginal wall prolapse with or without SUI (Allahdin 2008; Ali 2006 abstract; Al‐Nazer 2007; Altman 2011; Carey 2009; Colombo 2000; De Ridder 2004 abstract; Feldner 2010; Gandhi 2005; Guerette 2009; Hviid 2010; Menefee 2011; Meschia 2007; Natale 2009; Nguyen 2008; Nieminen 2008; Sand 2001; Sivaslioglu 2008; Thijs 2010 abstract; Vollebregt 2011; Weber 2001).

Combination of data was possible for the following sets of trials:

two were comparable in terms of type of population (women with prolapse only) and types of operation (anterior repair with and without absorbable mesh) (Sand 2001; Weber 2001);

three were comparable in terms of types of interventions (anterior colporrhaphy versus porcine dermis graft (Pelvicol)) (Hviid 2010; Meschia 2007; Menefee 2011);

one trial compared anterior colporrhaphy with small intestine submucosa graft (Feldner 2010);
10 trials assessed anterior colporrhaphy versus polypropylene mesh (Ali 2006 abstract; Al‐Nazer 2007; Altman 2011; Carey 2009; Nguyen 2008; Nieminen 2008; Menefee 2011; Sivaslioglu 2008; Thijs 2010 abstract; Vollebregt 2011).

The last 10 trials were further divided in order to assess (a) anterior colporrhaphy alone versus inlay or armed mesh, and (b) anterior colporrhaphy alone versus mesh with anterior colporrhaphy.

Three trials assessed anterior colporrhaphy alone versus polypropylene Gynemesh inlays (Ali 2006 abstract; Al‐Nazer 2007; Carey 2009).
Six assessed anterior colporrhaphy alone versus armed transobturator polypropylene meshes (Altman 2011; Nguyen 2008; Nieminen 2008); Sivaslioglu 2008; Thijs 2010 abstract; Vollebregt 2011).
Two assessed anterior colporrhaphy alone versus polypropylene mesh alone (Menefee 2011; Sivaslioglu 2008).
Four trials assessed anterior colporrhaphy alone versus anterior colporrhaphy plus polypropylene mesh (Ali 2006 abstract; Nguyen 2008; Nieminen 2008; Carey 2009).
Two trials compared anterior colporrhaphy and self‐styled armed transobturator polypropylene mesh (Nieminen 2008; Sivaslioglu 2008).
Four trials compared anterior colporrhaphy and commercial transobturator polypropylene mesh kits (Altman 2011; Nguyen 2008; Thijs 2010 abstract; Vollebregt 2011).

Anterior vaginal wall repair versus abdominal paravaginal repair

No trials were identified.

Anterior vaginal wall repair alone versus anterior vaginal wall repair with graft or mesh reinforcement (see also Comparison 7 below)

These results have been divided into two to reflect the different qualities of types of biological grafts and synthetic meshes.

Anterior vaginal wall repair versus anterior vaginal wall repair with biological graft reinforcement (for midline cystocele defects)

One trial (Meschia 2007) compared anterior colporrhaphy (vicryl plication) without and with porcine dermis overlay (Pelvicol). The trial demonstrated that at one year follow up the objective failure rate of the anterior compartment was higher (20/103, 19%) in the anterior colporrhaphy alone group as compared to the porcine dermis group (7/98, 7%) (Meschia 2007). There were no differences between groups in blood loss, inpatient days, changes in haemoglobin, post‐operative voiding dysfunction and dyspareunia; but all had wide CIs. There was one porcine dermis graft rejection requiring surgical removal (Table 1). The two year update of this trial (from an abstract) confirmed that women had a better anatomical outcome at point Ba (failure rate 11/98, 11%) with Pelvicol augmentation versus without (24/103, 23%) (RR 2.08, 95% CI 1.08 to 4.01; Analysis 2.6.9) (Meschia 2007).

Open in table viewer

Table 1. Graft erosion

	Number with erosion	Total number of women
Polyglactin (Vicryl, absorbable synthetic)
Allahdin 2008	2	32
Sand 2001	0	73
Biological (porcine, Pelvicol)
Meschia 2007	1	98
Non‐absorable synthetic polypropylene
Ali 2006 abstract	3	46
Carey 2009	4	62
Menefee 2011	5	28
Nguyen 2008	2	37
Nieminen 2008	18	104
Sivaslioglu 2008	3	43

Hviid 2010 also compared Vicryl plication anterior colporrhaphy and a Pelvicol porcine dermis (4 x 7 cm) graft at one year and the objective failure rate (defined as point Ba ≥ ‐1) was 2/28 in the Pelvicol group as compared to 4/26 in the anterior colporrhaphy, which was not significant. When evaluated in a meta‐analysis with Meschia 2007, the failure rate on examination with anterior repair was significantly greater as compared to a Pelvicol repair (RR 2.09, 95% CI 1.14 to 3.84; Analysis 2.6.9). The difference in operating time was significantly less in the no graft repair group (MD 9 min, 95% CI 4.4 to 13.6; Analysis 2.24.3) with no difference in blood loss between the groups (Analysis 2.19.1) (Hviid 2010). No significant difference was seen in the P‐QOL questionnaire scores between the groups at one year although full data were not available. Due to variations in the methodology, including Meschia 2007 allowing concomitant continence and prolapse surgery and Hviid 2010 not, no other meta‐analysis was performed.

Another trial (Gandhi 2005) compared anterior colporrhaphy without or with Tutoplast (solvent dehydrated cadaveric fascia lata). At 13 months the objective and subjective failure rates of the anterior compartment were not statistically significantly different: 23/78 and 16/76 (RR 1.4, 95% CI 0.8 to 2.44; Analysis 2.6.10) and 6/57 and 6/55 (RR 0.96, 95% CI 0.33 to 2.81; Analysis 2.1.1), respectively (Gandhi 2005). Apart from urinary voiding function there were no other bladder, bowel or sexual function outcomes reported.

Guerette 2009 compared the anterior colporrhaphy group (n = 47) and anterior colporrhaphy with bovine pericardium collagen matrix graft reinforcement (n = 46). This trial reported no difference in recurrence rate on examination (Ba failure Ba ≥ ‐1) with anterior colporrhaphy 10/27 (37%) versus 4/17 for bovine pericardium (24%) (RR 1.6, 95% CI 0.6 to 4.2; Analysis 2.6.19) or reoperation rate for prolapse (37% versus 24%, RR 1.6, 95% CI 0.6 to 4.2; Analysis 2.26.8), similar in both groups at two year review. Quality of life data from the Urogenital Distress inventory‐6 (UDI‐6) and PISQ‐12 reported no difference in outcomes between groups, however only median results without measures of variation were reported so the data was not able to be included for meta‐analysis. Unfortunately less than 50% of patients completed examination at the two year review with no measures in the methodology to account for this loss.

Feldner 2010 compared anterior colporrhaphy (AC) with a 7 x 10 cm small intestine submucosa (SIS) graft and demonstrated reduced operating time in the AC group (30 min versus 46 in the SIS group, P = 0.02). The objective failure rate was 9/27 (33%) versus 4/29 (13.8%) in the SIS group (RR 2.42, 96% CI 0.84 to 6.94; Analysis 2.6.20). The dyspareunia rate was similar in both groups (AC 4/27 versus 5/20 SIS) and no reoperations were reported. The P‐QOL improved post‐operatively in both groups with no significant difference between the groups (WMD ‐0.10, 95% CI ‐0.63 to 0.42; Analysis 2.4.3).

Finally, Menefee 2011 compared three operations, AC (midline plication delayed absorbable suture), vaginal paravaginal repair using porcine dermis graft (Pelvicol) and vaginal paravaginal with self‐styled polypropylene mesh. They reported a 10/19 (53%), 12/23 (52%), and 25/29 (86%) objective success rate, respectively. The subjective failure rate was similar in all three groups (3/19, 16%; 3/23, 13%; and 1/29, 3.4%, respectively). The graft erosion rate was 1/23 (4.3%) in the Pelvicol group and 4/29 (13.8%) in the mesh group. There were significant differences in the methodology of this study in comparison to the other graft studies and Menefee 2011 could not be included in any meta‐analysis due to significant differences in surgical techniques.

When AC was compared to any biological graft the objective failure rate in the anterior compartment was significantly higher in the AC group: 70/246 (28%) as compared to biological graft group 43/244 (18%) (RR 1.64, 95% CI 1.18 to 2.27; Analysis 2.6.23). Results from two trials (Gandhi 2005; Meschia 2007) demonstrated no difference in awareness of prolapse when native tissue repair was compared to biological graft repair (RR 1.2, 95% CI 0.6 to 2.3; Analysis 2.1.14). When AC was compared to a porcine dermis graft (Hviid 2010; Menefee 2011; Meschia 2007) the objective failure rate in the anterior compartment was significantly higher in the AC group 42/153 (27%) as compared to the porcine dermis group (25/152, 16%) (RR 1.7, 95% CI 1.1 to 2.6; Analysis 2.6.9). Differences in the methodology and the nature of the different biological grafts utilised in the remaining trials (Feldner 2010; Guerette 2009) were considered to be too dissimilar to combine with any other results in a meta‐analysis.

Anterior vaginal wall repair alone versus anterior vaginal wall repair with synthetic mesh reinforcement (for cystocele or anterior compartment prolapse)

Absorbable synthetic mesh

Three trials evaluated the effects of using absorbable polyglactin (Vicryl) mesh inlay to augment prolapse repairs (Allahdin 2008; Sand 2001; Weber 2001). The data from two trials were aggregated in a meta‐analysis as they included follow up of at least 12 months (Sand 2001; Weber 2001) and the non‐mesh arms from one trial (traditional anterior vaginal wall repair and ultra‐lateral anterior vaginal wall repair) were also aggregated for comparison with the mesh arm in one of the trials (Weber 2001). Standard colporrhaphy was associated with a significantly higher recurrence rate of cystocele compared with augmentation with polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90; Analysis 6.4.1) (Sand 2001; Weber 2001). One vaginal polyglactin mesh erosion was reported from two trials (Sand 2001; Weber 2001) and two women needed removal of some mesh in the other (Allahdin 2008). Rectocele recurrence appeared to be equally common with and without polyglactin mesh augmentation in another trial but the CIs were wide (RR 1.13, 95% CI 0.40 to 3.19; Analysis 6.6.1) (Sand 2001). Other outcomes were inconclusive due to small numbers.

Non‐absorbable synthetic mesh

Objective and subjective prolapse outcomes

Data from eight of 10 trials on transvaginal polypropylene mesh (Ali 2006 abstract; Al‐Nazer 2007; Altman 2011; Menefee 2011 Nguyen 2008; Nieminen 2008; Sivaslioglu 2008; Vollebregt 2011) demonstrated a higher recurrence rate on examination following anterior colporrhaphy (220/478, 46%) as compared to any transvaginal polypropylene mesh (69/498, 14%) (RR 3.3, 95% CI 2.6 to 4.2; Analysis 2.6.14) in the management of anterior compartment prolapse.

Data from three trials (Ali 2006 abstract; Al‐Nazer 2007; Menefee 2011) demonstrated a higher recurrence rate on examination after the native tissue anterior colporrhaphy (25/87, 29%) as compared to the polypropylene mesh inlay (9/94, 10%) (RR 3.08, 95% CI 1.56 to 6.11; Analysis 2.6.1).

Transobturator armed polypropylene meshes (Altman 2011; Nguyen 2008; Nieminen 2008; Sivaslioglu 2008; Vollebregt 2011) had a lower rate of anterior compartment prolapse on examination (59/424, 14%) as compared to anterior colporrhaphy alone (200/410, 49%) (RR 3.50, 95% CI 2.71 to 4.52; Analysis 2.6.17). Both self‐styled (Nieminen 2008; Sivaslioglu 2008) (RR 3.41, 95% CI 2.04 to 5.67; Analysis 2.6.16) and commercial transobturator polypropylene mesh kits (Altman 2011; Nguyen 2008; Vollebregt 2011) (RR 3.53, 95% CI 2.62 to 4.74; Analysis 2.6.15) had a lower rate of anterior compartment prolapse as compared to anterior colporrhaphy alone.

Data from four trials (Altman 2011; Al‐Nazer 2007; Sivaslioglu 2008; Vollebregt 2011) demonstrated that polypropylene mesh repair without a concomitant anterior colporrhaphy was superior to anterior colporrhaphy alone in reducing anterior compartment prolapse (RR 3.49, 95% CI 2.59 to 4.7; Analysis 2.6.22).

Polypropylene mesh repair with a concomitant anterior colporrhaphy was also better than anterior colporrhaphy alone (RR 3.38, 95% CI 2.15 to 5.33; Analysis 2.6.18) (Ali 2006 abstract; Nguyen 2008; Nieminen 2008).

Four trials demonstrated that women receiving anterior colporrhaphy (98/349, 28%) had a higher awareness of prolapse (subjective failure) than with the anterior transvaginal mesh repair (62/363, 17%) (RR 1.6, 95% CI 1.2 to 2.2; Analysis 2.1.9) (Al‐Nazer 2007; Altman 2011; Carey 2009; Nieminen 2008). Further prolapse surgery was not significantly more common after anterior colporrhaphy (14/459, 3%) as compared to after transobturator polypropylene mesh (6/470, 1.3%) (RR 2.18, 95% CI 0.93 to 5.10; Analysis 2.26.2) (Altman 2011; Menefee 2011; Nguyen 2008; Nieminen 2008; Thijs 2010 abstract; Vollebregt 2011).

Two trials reported on the impact of anterior compartment surgery on other vaginal compartments (Nieminen 2008; Vollebregt 2011). They demonstrated that those women undergoing polypropylene mesh kits repair were more likely to develop apical or posterior compartment prolapse than those undergoing anterior colporrhaphy (27/153, 18% versus 14/147, 10%) (RR 1.8, 95% CI 1.0 to 3.4; Analysis 2.2).

Quality of life outcomes

Three of the available 10 studies reported no validated pelvic floor questionnaires (Ali 2006 abstract; Al‐Nazer 2007; Vollebregt 2011). Altman 2011 reported the Urinary Distress Inventory (UDI) and Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire (PISQ‐12), Menefee 2011 reported changes in the short form of Pelvic Floor Distress Inventory (PFDI) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ‐12), and Nyugen 2008 reported P‐QOL, PFIQ, Pelvic Floor Distress Inventory (PFDI‐20) and PISQ, Nieminen 2008 reported unvalidated questions, and Thijs 2010 abstract reported the UDI.

Nguyen 2008 did not demonstrate a difference in quality of life between the two groups (PFIQ‐7 MD 9, 95% CI ‐4 to 22; Analysis 2.16 and PFDI‐20 MD 11, 95% CI ‐3 to 25; Analysis 2.8). Altman 2011 detected no difference between the groups utilising the UDI (MD 0.00, 95%CI ‐1.57 to 1.57; Analysis 2.31.1), and Thijs 2010 abstract was unable to demonstrate a significant difference in outcomes between the two groups utilising an alternative UDI. Sivaslioglu 2008 was also unable to demonstrate a difference in quality of life outcomes using the P‐QOL (MD 0.22, 95% CI ‐0.21 to 0.65; Analysis 2.4.1). Menefee 2011 reported no significant change between the groups pre and post‐intervention in the short form of the PFDI and PISQ‐12

There was no difference in sexual function in trials evaluating anterior colporrhaphy and polypropylene mesh as measured by the PISQ‐12 (MD 0.08, 95% CI ‐0.18 to 0.35; Analysis 2.35) (Altman 2011; Nguyen 2008).

Perioperative outcomes

In four trials which compared transobturator meshes with anterior colporrhaphy blood loss was significantly less in the anterior colporrhaphy group as compared to the transobturator mesh group, measured as blood loss (MD ‐56 ml, 95% CI ‐72 to ‐42; Analysis 2.19) (Al‐Nazer 2007; Altman 2011; Nieminen 2008) or change in haemoglobin (Analysis 2.20.2) (Nguyen 2008).

The operating time was significantly reduced in the anterior colporrhaphy group as compared to polypropylene mesh repair (WMD ‐16 min, 95% CI ‐18 to ‐13; Analysis 2.24.6) (Al‐Nazer 2007; Altman 2011; Nguyen 2008).

Complications

The intra‐operative cystotomy rate was 1/307 (0.3%) after anterior colporrhaphy as compared to 8/340 (2.4%) after a transobturator mesh (RR.0.19, 95% CI 0.0 to 1.1; Analysis 2.34) (Al‐Nazer 2007; Altman 2011; Menefee 2011; Nieminen 2008).

There were no significant differences in the rates of de novo dyspareunia after anterior colporrhaphy or anterior transvaginal mesh (4% versus 7%, RR 0.6, 95% CI 0.3 to 1.3; Analysis 2.28) (Al‐Nazer 2007; Altman 2011; Nguyen 2008; Sivaslioglu 2008; Vollebregt 2011) and sexual function was described in two trials using the PISQ and again no difference was identified between the groups (RR 0.08, 95% CI ‐0.18 to 0.35; Analysis 2.35) (Altman 2011; Nguyen 2008).

Mesh erosions were reported in 11.4% (64/563) of women who had an anterior compartment polypropylene mesh (Analysis 2.22.1), and surgical intervention to correct mesh erosion occurred in 6.8% (32/470) (Analysis 2.32.1). The risk of subsequent surgery (prolapse, stress incontinence, mesh exposure or pain) was significantly reduced after native tissue anterior repair (31/626, 5.0%) compared to anterior transvaginal permanent polypropylene mesh (65/647, 10%) (RR 0.5, 95% CI 0.4 to 0.8; Analysis 2.41) (Al‐Nazer 2007; Altman 2011; Carey 2009; Menefee 2011; Nieminen 2008; Sivaslioglu 2008; Thijs 2010 abstract; Vollebregt 2011). See Table 2.

Open in table viewer

Table 2. Polypropylene mesh erosion

Ali 2006	3	46
Carey 2009 NEW	4	62
Iglesia 2010 NEW	5	32
Menefee 2011	5	28
Nguyen 2008	2	37
Nieminen 2008	18	104
Sivaslioglu 2008	3	43
Thijs 2010 NEW	9	48
Vollebregt 2010 NEW	2	53
Withagen 2011 NEW	14	83
Subtotal (95% CI)		536
Total events	65

Continence issues (also Comparison 9)

Four trials evaluated de novo SUI in women undergoing anterior colporrhaphy as compared to transvaginal mesh for anterior compartment prolapse (Al‐Nazer 2007; Altman 2011; Nieminen 2008; Sivaslioglu 2008). There was a lower rate of de novo SUI after anterior repair as compared to transvaginal polypropylene mesh (26/324, 8% versus 41/320, 13%) (RR 0.6, 95% CI 0.4 to 0.9; Analysis 2.9.1).

Further continence surgery was performed in 15/368 women following anterior colporrhaphy and 12/380 after the polypropylene mesh procedure (RR 1.29, 95% CI 0.63 to 2.63; Analysis 2.27.1). These data need to be interpreted with caution as variations in concomitant surgeries existed.

Anterior colporrhaphy versus any permanent mesh or biological graft

Meta‐analysis of no mesh versus all types of grafts showed the following.

Results from five trials (Allahdin 2008; Altman 2011; Gandhi 2005; Meschia 2007; Nieminen 2008) demonstrated that significantly more women had an awareness of prolapse (subjective failure) after the anterior colporrhaphy (118/430, 27.4% as compared to 86/436, 18.3%) after anterior compartment graft repair (RR 1.5, 95% CI 1.2 to 1.9; Analysis 2.1.13).
Results from three trials (Gandhi 2005; Guerette 2009; Meschia 2007) demonstrated no difference in prolapse symptoms when native tissue repair was compared to biological graft repair (RR 1.03, 95% CI 0.61 to 1.75; Analysis 6.1.8).
The results from 12 trials (Ali 2006 abstract; Al‐Nazer 2007; Altman 2011; Feldner 2010; Gandhi 2005; Hviid 2010; Menefee 2011; Meschia 2007; Nguyen 2008; Nieminen 2008; Sivaslioglu 2008; Vollebregt 2011) combined found more women had recurrence on examination (objective failure) with anterior colporrhaphy (281/719, 39.0%) compared to graft repair (99/736, 13.4%) (RR 2.91, 95% CI 2.38 to 3.56; Analysis 2.6.24).

Anterior colporrhaphy had a significantly reduced operating time (MD ‐16.36 min, 95% CI ‐18.50 to ‐14.22; Analysis 2.24.5) (Altman 2011; Feldner 2010; Hviid 2010; Meschia 2007; Nguyen 2008) and blood loss (MD ‐35 ml, 95% CI ‐47 to ‐23; Analysis 2.19.4) (Al‐Nazer 2007; Altman 2011; Hviid 2010; Meschia 2007; Nieminen 2008).

One type of graft (synthetic mesh or biological graft inlays) versus another type of graft (for midline cystocele defects) (see also Comparison 7 below)

Two trials evaluated different mesh inlays:

polyglactin versus Pelvicol (De Ridder 2004 abstract); and
armed polypropylene mesh versus Pelvicol (Natale 2009).

Due to the nature of the different types of mesh used in the trials and the different inclusion criteria in De Ridder 2004 abstract and Natale 2009, we considered the trials too dissimilar to combine them in a meta‐analysis.

De Ridder 2004 abstract compared two types of absorbable mesh, polyglactin (Vicryl) inlay versus porcine dermis (Pelvicol). The objective failure rate at 25 months follow up was significantly worse in the Vicryl group: 19/62 (31%) compared with 6/63 (9.5%) for Pelvicol (RR 3.22, 95% CI 1.38 to 7.52; Analysis 2.6.11) (De Ridder 2004 abstract). Further prolapse surgery had to be performed in 3/63 versus 9/62 women respectively (RR 3.05, 95% CI 0.87 to 10.73; Analysis 2.26.1) (De Ridder 2004 abstract).

In another trial, Natale 2009 compared polypropylene mesh (Gynemesh) with porcine dermis (Pelvicol). At two years, significantly fewer women had anterior vaginal wall recurrence: 28% (27/96) of the mesh group compared to 44% (41/94) of the porcine graft group (RR 0.64, 95% CI 0.43 to 0.96; Analysis 2.6.13). De novo SUI was seen in two women following the polypropylene mesh and in one after the porcine dermis graft (Analysis 2.9:2), and similar numbers of women reported dyspareunia (10 versus 12; Analysis 2.18.3). The difference in post‐operative urgency urinary incontinence (more in the Pelvicol group despite less urinary frequency) did not reach statistical significance (Analysis 2.10.7). Comparing post‐operative data in the two groups, the authors reported a better impact of surgery on sexuality with porcine dermis than with polypropylene mesh (P = 0.03) but data were not provided (Natale 2009).

Other comparisons for anterior vaginal wall prolapse

Five other trials were identified which compared different operations for anterior vaginal wall prolapse or different continence procedures for women with urinary incontinence or occult urinary incontinence as well as anterior vaginal wall prolapse (Bump 1996; Colombo 1996; Colombo 1997; Colombo 2000; Meschia 2004).

One small trial (Colombo 2000) comparing anterior repair with Burch colposuspension showed statistically significant lower rates of cystocele recurrence (RR 0.09, 95% CI 0.01 to 0.64; Analysis 2.6.5) but higher rates of persisting urinary incontinence (RR 3.39, 95% CI 1.40 to 8.22; Analysis 2.8.3). However, this was not reflected in differences in reoperation rates for either prolapse or incontinence (Analysis 2.26.3; Analysis 2.27.2) (Colombo 2000). Another small trial (Meschia 2004) reported that more women were incontinent after endopelvic fascia plication than after tension free vaginal tape (TVT) supplementing prolapse surgery (RR 9, 95% CI 1.23 to 65.85; Analysis 2.9.6) but the data were too few to comment on the effect on prolapse or other clinical outcomes. However, operating time was 19 minutes shorter for the operation without the TVT (MD ‐19 min, 95% CI ‐29 to ‐9; Analysis 2.24.2) (Meschia 2004).

3. One type of posterior vaginal wall prolapse repair versus another (Comparison 3)

Three small trials compared vaginal and transanal approaches to the management of rectocele (Farid 2010; Kahn 1999; Nieminen 2004) and two others examined posterior repair with and without mesh reinforcement (Paraiso 2006; Sand 2001). One of these trials compared three techniques to correct posterior vaginal compartment prolapse (Paraiso 2006). Two trials compared native tissue repair with tissue repair with a porcine small intestine submucosa graft (Paraiso 2006; Sung 2012).

Posterior vaginal wall repair versus a transanal repair

Seven trials included women with posterior vaginal wall prolapse (Farid 2010; Kahn 1999; Nieminen 2004; Paraiso 2006; Sand 2001; Sung 2012; Vijaya 2011 abstract).

Three trials (Farid 2010; Kahn 1999; Nieminen 2004) compared vaginal and transanal approaches for the management of rectocele. In addition, another trial provided data for women with rectocele undergoing posterior repair with and without absorbable mesh (Sand 2001). A fourth trial compared rectocele repair using traditional posterior colporrhaphy (n = 28), site‐specific repair (n = 27) and site‐specific repair augmented with a porcine small intestine submucosa graft inlay (Fortagen, Organogenesis) (n = 26) (Paraiso 2006). The Vijaya 2011 abstract compared fascial and levator ani muscle plication. Finally Sung 2012 evaluated native tissue posterior colporrhaphy with native tissue repair with porcine small intestine submucosa graft.

Several authors evaluated posterior wall native tissue repairs and polypropylene mesh repairs (Carey 2009; Iglesia 2010; Withagen 2011); however these trials included a wider range of operations. The inclusion criteria and outcome data were not specifically limited to the posterior compartment and will be fully evaluated in Comparison 6 (no graft versus use of graft (synthetic mesh or biological graft)).

Many of the important outcome parameters were not reported thus limiting the data available and the ability to perform meta‐analyses. The results for posterior vaginal wall repair were better than for transanal repair in terms of awareness of prolapse (subjective failure) (RR 0.36, 95% CI 0.13 to 1; Comparison 03.01.01) (Kahn 1999; Nieminen 2004) and recurrence on examination (objective failure) (RR 0.24, 95% CI 0.09 to 0.64; Analysis 3.2.3) (Kahn 1999; Nieminen 2004) failure rates (persistence of rectocele or enterocele, or both). Analysing women with rectocele alone showed that recurrent rectocele occurred in 2 out of 39 in the vaginal group and 7 out of 48 following the transanal repair, a difference that did not reach statistical significance (RR 0.32, 95% CI 0.07 to 1.34; Analysis 3.2.1) (Nieminen 2004). Post‐operative enterocele was, however, significantly less common following the vaginal surgery as compared to the transanal group (RR 0.23, 95% CI 0.07 to 0.83; Analysis 3.2.2) (Kahn 1999; Nieminen 2004).

Post‐operative hospital stay was longer after vaginal surgery than after transanal surgery in one trial (MD 1 day, 95% CI 0.47 to 1.53; Analysis 3.15.1) (Kahn 1999) despite a shorter operating time (MD ‐7 min, 95% CI ‐12 to ‐2) (Kahn 1999). The operating times in the other trial (Nieminen 2004) were the same for both groups (35 minutes). When data for operating times were combined (MD ‐3.6 min; Analysis 3.14.1), there was significant heterogeneity (P = 0.07, I² = 69%) and the difference was not significant if a random‐effects model was used (95% CI ‐10.4 to 3.3 min). The vaginal approach was associated with a significantly higher blood loss (79 ml, 95% CI 40 to 119; Analysis 3.8.1) (Kahn 1999; Nieminen 2004) and post‐operative narcotic use (Analysis 3.11.1) (Kahn 1999) compared to the transanal approach.

Nieminen reported that the mean depth of rectocele on post‐operative defecography was 4.13 cm in the transanal group and this was significantly larger than the 2.73 cm in the vaginal group (MD ‐1.43, 95% CI ‐2.86 to 0, P = 0.05; data not shown). Post‐operative difficulties in bowel evacuation were seen in 9 out of 31 in the vaginal group as compared to 14 out of 34 in the transanal group, a difference that was not significantly different (RR 0.73, 95% CI 0.37 to 1.42; Analysis 3.5.1) (Kahn 1999; Nieminen 2004). No significant differences were seen in the rate of incontinence to flatus or faeces post‐operatively between the groups, nor in rates of post‐operative dyspareunia, but the trials were too small for these data to be reliable. There were differences between the trials for the outcome post‐operative complications: in one trial four women had a haematoma and one needed a blood transfusion in the vaginal arm (Kahn 1999); whereas in the other arm one woman had a wound infection after transanal operation (Nieminen 2004) (Analysis 3.12.1).

Farid 2010 also reported on outcomes on three types of rectocele repairs comparing transperineal repair (3.0 Vicryl, n = 16), levatorpasty (0.0 Vicryl, n = 16), and transanal repairs (2.0 Vicryl, Delorme, n = 16) at six months. This trial was not able to be included in meta‐analysis due to widely different methodology and outcome assessment although the conclusions were similar to the above meta‐analysis. The size of rectocele of defecography was significantly lower after the transperineal repair (with or without levatorplasty) as compared to the transanal repair (MD ‐1.14 cm, 95% CI ‐1.96 to ‐0.32; Analysis 3.17). The functional outcome on a modified obstructed defecation syndrome patient questionnaire were also significantly lower (better outcome) after the transperineal repair as compared to transanal (MD ‐5.1, 96% CI ‐9.6 to ‐0.057; Analysis 3.18). There were no patients with de novo dyspareunia in either group and 3/32 (9%) reported wound infection in the transperineal group and all settled with conservative treatment.

Fascial plication posterior repair versus levator ani plication repair

In a single small trial Vijaya 2011 abstract reported at six months that superior support of the posterior vaginal wall was attained after the fascial plication as compared to levator ani repair (MD ‐0.68 cm, 95% CI ‐1.08 to ‐0.28; Analysis 3.19). The abstract states that quality of life assessment using a P‐QOL questionnaire was significantly improved in both groups without any difference between the groups. No data were available. There was also no difference in sexual function pre and post‐intervention between the groups.

Posterior vaginal wall repair versus an abdominal posterior repair

No trials were identified.

Posterior vaginal wall prolapse: a traditional posterior repair versus posterior repair with graft reinforcement

One trial compared posterior repair with and without mesh reinforcement (Sand 2001). Rectocele recurrence appeared equally with and without polyglactin (Vicryl) mesh augmentation (7 out of 67 versus 6 out of 65) but the CIs were wide (RR 1.13, 95% CI 0.40 to 3.19; Analysis 3.2.4) (Sand 2001). No trial reported mesh erosion.

Another trial compared posterior colporrhaphy, site‐specific repair and site‐specific repair augmented with porcine small intestine submucosa graft inlay for repairing rectocele (Paraiso 2006). There was no statistical difference in recurrence rate on examination (objective failure) between posterior colporrhaphy and site‐specific repair (RR 0.64, 95% CI 0.20 to 2.03; Analysis 3.2.5) (Paraiso 2006). There was a lower objective failure rate at one year following the posterior colporrhaphy as compared to porcine graft inlay (RR 0.31, 95% CI 0.11 to 0.84; Analysis 3.2.6) (Paraiso 2006). However, there were no differences in subjective report of prolapse symptoms (Analysis 3.1.2; Analysis 3.1.3). Rates of post‐operative dyspareunia were similar between posterior colporrhaphy and site‐specific repair (RR 1.65, 95% CI 0.71 to 3.81; Analysis 3.7.2) (Paraiso 2006) and between posterior colporrhaphy and porcine graft groups (RR 2.85, 95% CI 0.91 to 8.96; Analysis 3.7.3) (Paraiso 2006). There were no significant differences between the groups in operating time (Analysis 3.14), change in haematocrit, post‐operative complications (Analysis 3.12), duration of hospital stay, post‐operative bowel and sexual function or reoperation rate for prolapse recurrence (Analysis 3.16). The nature of the different grafts utilised in the Sand and Paraiso studies did not allow for meta‐analysis.

Sung 2012 compared native tissue repair (n = 70) (site‐specific or fascial repair) as compared to native tissue repair with porcine small intestine submocosa (SIS) overlay (n = 67). At one year there was no difference in objective and subjective failure rate between the groups. The graft group had a slightly longer operating time and greater blood loss than the native tissue repair group. The rate of intra‐operative complications reoperation and dyspareunia were low and similar between the groups. Meta‐analysis was able to be performed for two trials (Paraiso 2006; Sung 2012). Whilst the objective failure rate was significantly lower in the native tissue group (10% (10/98) as compared to 21% (20/93) in the SIS group) (RR 0.47, 95% CI 0.24 to 0.94; Analysis 3.2.6) the subjective failure rate was similar between the groups (RR 1.09, 95% CI 0.45 to 2.62; Analysis 3.1.3). There was no difference in the rate of post‐operative dyspareunia between the groups (RR 1.26, 95% CI 0.59 to 2.68; Analysis 3.7.3).

For posterior vaginal wall prolapse: one type of graft (synthetic mesh or biological graft inlays) versus another type of graft

No trials were identified.

4. Any type of surgical prolapse repair versus conservative treatment (Comparison 4)

No trials addressed this comparison.

5. Any type of surgical prolapse repair versus mechanical devices (Comparison 5)

No trials addressed this comparison.

6. No graft versus use of graft (synthetic mesh or biological graft) in any prolapse surgery (Comparison 6)

Twenty‐one trials compared standard (no graft or mesh) vaginal prolapse repairs with those which included mesh or graft material:

polyglactin mesh (absorbable synthetic, Vicryl) (Allahdin 2008; Sand 2001; Weber 2001);
porcine dermis graft (biological, Pelvicol) (Hviid 2010 (anterior compartment); Meschia 2007);
porcine small intestine submucosa graft inlay (SIS, Fortagen) (Feldner 2010 (anterior compartment); Paraiso 2006; Sung 2012 (posterior compartment));
cadaveric fascia lata graft (biological, Tutoplast) (Gandhi 2005 (anterior compartment));
bovine pericardium collagen matrix graft reinforcement (biological) (Guerette 2009 (anterior compartment));
non‐absorbable synthetic mono‐filament permanent polypropylene mesh (Ali 2006 abstract; Al‐Nazer 2007; Altman 2011; Carey 2009; Halaska 2012; Iglesia 2010; Nguyen 2008; Nieminen 2008; Sivaslioglu 2008;Thijs 2010 abstract; Vollebregt 2011; Withagen 2011).

The non‐absorbable mesh category was further subdivided into:

mesh overlay (Ali 2006 abstract; Al‐Nazer 2007; Carey 2009);
self‐styled or armed transobturator mesh (Nieminen 2008; Sivaslioglu 2008);
transobturator mesh kits (Altman 2011 (anterior Prolift mesh kit); Halaska 2012 (total Prolift mesh kit); Iglesia 2010 (anterior or total Prolift); Nguyen 2008 (Perigee mesh kit); Thijs 2010 abstract (Perigee mesh kit); Vollebregt 2011 (Avulta mesh kit); Withagen 2011 (anterior, posterior, or total Prolift mesh kit).

In two trials outcome data were available for women who underwent a posterior vaginal wall repair (Paraiso 2006; Sand 2001).

The data from five trials included women with multiple compartment prolapse who were undergoing repair with polypropylene mesh (Carey 2009; Iglesia 2010; Withagen 2011) and polyglactin (Allahdin 2008; Sand 2001).

In the trials from Allahdin 2008, Carey 2009, Iglesia 2010 and Withagen 2011, outcomes were not differentiated for anterior and posterior pelvic organ prolapse.

No mesh versus biological graft

Seven trials used biological graft inlays for anterior or posterior repairs (Feldner 2010; Gandhi 2005; Guerette 2009; Hviid 2010; Menefee 2011; Meschia 2007; Paraiso 2006).

There were no statistically significant differences in prolapse symptoms in any of these trials, however the CIs were wide (Analysis 6.1).

Three of the trials compared anterior vaginal wall repair without and with porcine dermis graft (Pelvicol) (Hviid 2010; Menefee 2011; Meschia 2007) and one without and with cadaveric fascia lata (Tutoplast) (Gandhi 2005). Anterior colporrhaphy has a higher recurrence rate on examination as compared to Pelvicol inlay (RR 1.7, 95% CI 1.1 to 2.6; Analysis 2.6.9). While there were fewer women with objective recurrence of prolapse in the Tutoplast cadaveric fascia lata inlay this did not reach statistical significance (Analysis 6.4.3). There were too few data reported for the other outcomes to provide reliable estimates.

When native tissue repair was compared to SIS graft on the posterior vaginal wall the recurrence rate on examination was significantly less after native tissue repair (10/55 (18%) as compared to 12/26 (46%) in the SIS group) (RR 0.39, 95% CI 0.20 to 0.79) (Paraiso 2006). Interestingly in the anterior compartment the recurrence rate was significantly higher after anterior repair as compared to SIS graft (RR 2.95, 95% CI 1.07 to 8.17; Analysis 6.4.4) (Feldner 2010).

The objective failure rate was not significantly different after native tissue repair in anterior or posterior compartments (66/277, 24%) as compared to any biological graft (43/244, 18%) (RR 1.3, 95% CI 0.6 to 2.7; Analysis 6.7.2).

No mesh versus permanent synthetic mesh reinforcement

Absorbable synthetic mesh (polydioxanone (Vicryl) inlay

Three trials evaluated the effects of using absorbable polyglactin (Vicryl) mesh inlay to augment prolapse repairs (Allahdin 2008; Sand 2001; Weber 2001) and for full analysis readers should see Comparison 2 (anterior vaginal wall repair alone versus anterior vaginal wall repair with synthetic mesh reinforcement (for midline cystocele defects)).

Permanent mesh reinforcement (inlay, armed inlay or mesh kit)

A total of 13 studies evaluated native tissue repair at any site versus any transvaginal polypropylene mesh (Ali 2006 abstract; Al‐Nazer 2007; Altman 2011; Carey 2009; Halaska 2012; Iglesia 2010; Menefee 2011; Nguyen 2008; Nieminen 2008; Sivaslioglu 2008; Thijs 2010 abstract; Vollebregt 2011; Withagen 2011).

Ten trials compared anterior repair to a variety of permanent transvaginal mesh repair techniques and were considered similar enough to combine in various meta‐analyses (Ali 2006 abstract; Al‐Nazer 2007; Altman 2011; Carey 2009; Menefee 2011; Nguyen 2008; Nieminen 2008; Sivaslioglu 2008; Thijs 2010 abstract; Vollebregt 2011) and for full analysis of comparison of permanent mesh in the anterior compartment readers should see Comparison 2 (anterior vaginal wall repair alone versus anterior vaginal wall repair with synthetic mesh reinforcement (for midline cystocele defects).

The following three trials evaluated native repairs compared to transvaginal permanent mesh in the anterior, apical or posterior vaginal compartments and were similar enough to combine in various combinations using meta‐analysis (Halaska 2012; Iglesia 2010; Withagen 2011).

Native tissue versus combined total, anterior or posterior compartment polypropylene mesh

Data from three trials (Halaska 2012; Iglesia 2010; Withagen 2011) compared native tissue repairs with a variety of total, anterior or posterior polypropylene kit meshes. While no difference in awareness of prolapse was able to be identified between the groups (25/132, 19% versus 18/123, 15%) (RR 1.3, 95% CI 0.8 to 2.3; Analysis 6.1.9) in two trials (Iglesia 2010; Withagen 2011) the recurrence rate on examination was higher in the native tissue repair group as compared to the transvaginal polypropylene mesh (native tissue 103/18, 55% versus polypropylene mesh kits 74/194, 38%) (RR 1.40, 95% CI 1.0 to 2.0;Analysis 6.7.8). The mesh erosion rate was 35/194 (18%) (Analysis 6.19), and 18/194 (9%) (Analysis 6.20) underwent surgical correction for mesh erosion. The reoperation rate after native tissue repair was higher after the combined polypropylene mesh kits (22/194, 11%) compared with native tissue procedures (7/189, 3.7%) (RR 1.1, 95% CI 1.0 to 1.2; Analysis 6.25).

No mesh (native tissue) versus any graft (synthetic mesh or biological graft)

Meta‐analysis of no mesh versus all types of grafts showed:

the results from eight trials (Allahdin 2008; Altman 2011; Gandhi 2005; Carey 2009; Meschia 2007; Nieminen 2008; Paraiso 2006; Withagen 2011) comparing native tissue repair with any graft demonstrated that symptoms of awareness of prolapse are significantly greater after native tissue repair (162/682, 24%) as compared to graft repair (117/649, 18%) (RR 1.4, 95% CI 1.1 to 1.7; Analysis 6.1.7);
results from three trials (Gandhi 2005; Guerette 2009; Meschia 2007) demonstrated no difference in awareness of prolapse when native tissue repair was compared to biological graft repair (RR 1.03, 95% CI 0.61 to 1.75; Analysis 6.1.8);
the results from 17 trials (Ali 2006 abstract; Allahdin 2008; Al‐Nazer 2007; Carey 2009; Feldner 2010; Gandhi 2005; Hviid 2010; Iglesia 2010; Meschia 2007; Nguyen 2008; Nieminen 2008; Paraiso 2006; Sand 2001; Sivaslioglu 2008; Vollebregt 2011; Weber 2001; Withagen 2011) combined found more women had objective failure with no mesh (346/905, 38%) as compared to any graft (180/856, 22%) (RR 1.8, 95% CI 1.4 to 2.5; Analysis 6.7);
results from six trials (Feldner 2010; Gandhi 2005; Guerette 2009; Hviid 2010; Meschia 2007; Paraiso 2006) demonstrated no significant difference in prolapse recurrence on examination when comparing native tissue repair to biological graft repair (RR 1.3, 95% CI 0.7 to 2.5; Analysis 6.7.2). If the Paraiso 2006 trial, which was the only trial to evaluate posterior compartment prolapse, was excluded the benefits of utilising biological grafts as compared to native tissue anterior repair were significant on objective examination (RR 1.7, 95% CI 1.2 to 2.5; Analysis 6.7.2).

7. One type of graft (synthetic mesh or biological graft) versus another type of graft (Comparison 7)

Three small trials in women having anterior repair compared two types of overlay:

non‐absorbable polypropylene (Prolene Soft) mesh versus absorbable porcine dermis graft (Pelvicol) (Cervigni 2005);
non‐absorbable armed mono‐filament polypropylene (Gynemesh) versus absorbable porcine dermis graft (Pelvicol) (Natale 2009);
absorbable porcine dermis graft (Pelvicol) versus absorbable polyglactin mesh (Vicryl) (De Ridder 2004 abstract).

Only one trial measured prolapse symptoms reported by women (Cervigni 2005): there was no statistically significant difference between the groups, albeit with wide CIs.

In the De Ridder trial (De Ridder 2004 abstract) fewer women had objective recurrence of prolapse when porcine dermis was used rather than polyglactin to reinforce an anterior repair (RR 3.22, 95% CI 1.38 to 7.52; Analysis 7.2.1), although this trial was small. In the Natale trial (Natale 2009) armed polypropylene mesh proved better than armed Pelvicol inlay regarding objective success (RR 0.64, 95% CI 0.43 to 0.96; Analysis 7.2.2) but women had more daytime urinary frequency (RR 4.24, 95% CI 1.83 to 9.84; Analysis 7.5.1).

The trials were too small to demonstrate other statistically significant differences and the CIs were wide.

8. One type of suture versus another type of suture (Comparison 8)

One trial addressed this comparison (Allahdin 2008), comparing polyglactin sutures (Vicryl) with polydioxanone (PDS). The study was too small to draw reliable conclusions and only included objective assessment at three months.

9. Pelvic organ prolapse (POP) surgery and bladder function (Comparison 9)

In general, after prolapse surgery 434 of 2125 women (20.4%) reported new subjective SUI after prolapse surgery in 16 trials (Altman 2011; Brubaker 2008; Bump 1996; Colombo 1996; Colombo 1997; Costantini 2008; de Tayrac 2008; Halaska 2012; Iglesia 2010; Maher 2004; Meschia 2004a; Natale 2010; Nieminen 2008; Sivaslioglu 2008; Wei 2011; Withagen 2011). New overactive bladder symptoms were noted in 119 of 1005 (12%) undergoing prolapse surgery in 11 trials (Al‐Nazer 2007; Brubaker 2008; Bump 1996; Colombo 1996; Colombo 1997; Colombo 2000; de Tayrac 2008; Halaska 2012; Maher 2004; Natale 2009; Natale 2010). New voiding dysfunction was reported in 109 of 1209 (9%) women undergoing prolapse surgery in 12 trials (Al‐Nazer 2007; Bump 1996; Colombo 1996; Colombo 1997; de Tayrac 2008; Feldner 2010; Gandhi 2005; Maher 2004; Meschia 2004; Meschia 2007; Natale 2009; Natale 2010).

A. One type of pelvic organ prolapse (POP) surgery alone versus another type of POP surgery

Six trials comparing anterior native tissue repair with anterior transobturator mesh repair included only symptomatically continent women or provided separate data on pre‐operatively continent women (Altman 2011; Halaska 2012; Iglesia 2010; Nieminen 2008; Sivaslioglu 2008; Withagen 2011). The meta‐analysis evaluating de novo SUI demonstrated a reduced risk of developing SUI post‐operatively in the anterior native tissue groups (50/449, 11%) as compared to polypropylene mesh repair (74/449, 17%) (RR 0.7, 95% CI 0.5 to 0.9; Analysis 9.1.7).

In two trials, women with prolapse and stress urinary incontinence pre‐operatively who underwent prolapse surgery without concomitant continence surgery had significantly higher rates of persisting SUI than those that had continence surgery performed at the time of prolapse surgery (76/117, 65% versus 17/111, 15%) (RR 4.4, 95% CI 2.7 to 7.1; Analysis 9.25) (Borstad 2010; Costantini 2008).

B. Pelvic organ prolapse (POP) surgery alone versus POP surgery with an additional continence procedure

Additional continence procedures included Pereyra needle suspension, Burch colposuspension and suburethral tapes.

Needle suspension

One trial demonstrated no difference in objective rate of new SUI after pubo‐urethral ligament plication or Pereyra needle suspension (RR 1.2, 95% CI 0.8 to 1.9; Analysis 9.2.1) (Colombo 1997).

Two studies did not demonstrate a subjective reduction in post‐operative SUI in including a needle suspension as compared to bladder neck plication at vaginal prolapse surgery (RR 2.0, 95% CI 0.1 to 50.9; Analysis 9.1.3) (Bump 1996; Colombo 1997).

Colposuspension

Two trials evaluated the impact of adding a colposuspension to sacral colposuspension in women who had prolapse and were continent pre‐operatively and found conflicting results. While more women (who were continent at baseline) had become incontinent in the group who did not have Burch colposuspension in addition to abdominal sacral colpopexy in Brubakers trial, Costantini described the opposite. The random‐effects model meta‐analysis did not reveal significant results (RR 1.04, 95% CI 0.4 to 2.8; Analysis 9.1.4) (Brubaker 2008; Costantini 2007).
Sacral colpopexy alone resulted in lower blood loss (MD ‐73 g, 95% CI ‐115 to ‐31; Analysis 9.16.1) (Brubaker 2008) and a shorter operating time (MD ‐20 min, 95% CI ‐33 to ‐7; Analysis 1.33.5) (Brubaker 2008) as compared to sacral colpopexy and colposuspension. Surprisingly, at two years symptoms of SUI were not significantly different between the groups (sacral colpopexy without colposuspension 68/186, 37% versus sacral colpopexy with colposuspension 47/178, 26%) (RR 1.0, 95% CI 0.4 to 2.8; Analysis 9.1.4) (Brubaker 2008; Costantini 2007). A third article described in more detail the outcomes of stress continent women with a positive stress test after each undergoing two forms of prolapse reduction. To avoid doubling the cases and inappropriately increasing the sample size we halved the figures for de novo SUI and the number undergoing stress testing post‐intervention (Visco 2008).

Counter intuitively, Costantini 2008 demonstrated no benefit in adding colposuspension to sacral colpopexy in those with prolapse and SUI. Persisting SUI post‐operatively was similar whether without or with colposuspension (9/23, 39% versus 13/24, 54%) (RR 0.54, 95% CI 0.2 to 1.7; Analysis 9.25.4).

Suburethral tape

Three trials evaluated vaginal prolapse surgery with and without suburethral tape (TVT) in women with occult SUI (Meschia 2004; Schierlitz 2007; Wei 2011). There was no difference in rates on post‐operative assessment after prolapse repair without a tape as compared to prolapse repair with TVT in respect to both subjective SUI (43% versus 25%, RR 2.4, 95% CI 0.7 to 8.0; Analysis 9.1.5) (Meschia 2004; Wei 2011) and objective SUI (41% versus 22%, RR 3.7, 95% CI 0.9 to 15.2; Analysis 9.2.2) (Meschia 2004; Schierlitz 2007; Wei 2011). However, subsequent continence surgery was required more frequently in those that underwent prolapse surgery without TVT as compared to prolapse surgery with TVT (5.7% versus 0.5%, RR 6.8, 95% CI 1.5 to 30.5; Analysis 9.3.7) (Meschia 2004; Schierlitz 2007).

One trial showed a higher rate of persisting SUI in women with prolapse and SUI undergoing prolapse surgery without suburethral tape (TVT) as compared to prolapse surgery with TVT (67/94, 71% versus 4/87, 5%) (RR 51, 96% CI 17 to 154; Analysis 9.25) (Borstad 2010). In this trial women were randomised to undergo a TVT concomitantly with prolapse repair or three months later. Success rates based on an 'on‐treatment' analysis were 83/87 (95%) versus 47/53 (89%) three months later (Borstad 2010). Twenty‐seven of 94 women (29%) were cured of SUI after prolapse surgery alone and declined to have a TVT inserted (Borstad 2010).

Five meta‐analyses were possible, as follows.

Eight trials described the rate of objective SUI in all women undergoing prolapse surgery with and without continence surgery (Brubaker 2008; Bump 1996; Colombo 1996; Colombo 1997; Costantini 2008; Meschia 2004; Schierlitz 2007; Wei 2011). Continence procedures employed included: pubo‐urethral ligament plication (Colombo 1996a); needle suspension (Bump 1996a; Colombo 1997); colposuspension (Brubaker 2008; Costantini 2008; Visco 2008); and suburethral tape (Meschia 2004; Schierlitz 2007a). The studies demonstrated that not performing continence surgery at the time of prolapse surgery significantly increased the risk of SUI post‐operatively (RR 1.6, 95% CI 1.3 to 2.1; Analysis 9.7.1).
Six trials described the rate of de novo SUI after prolapse surgery without continence surgery and prolapse surgery with continence surgery (Brubaker 2008; Bump 1996; Colombo 1996; Meschia 2004a; Schierlitz 2007; Wei 2011). The studies demonstrated an advantage of including continence surgery at the time of prolapse surgery in reducing the risk of de novo SUI (146/460, 32% versus 84/438, 19%) (RR 2.0, 95% CI 1.4 to 2.3; Analysis 9.1.6). In this group of 438 women, undergoing continence surgery at the time of prolapse prevented 62 (14%) women from developing de novo SUI post‐prolapse surgery.

Five trials described the rate of de novo SUI after prolapse surgery without continence surgery and prolapse surgery with continence surgery in a subgroup who had occult SUI pre‐operatively (Brubaker 2008; Bump 1996; Meschia 2004; Schierlitz 2007; Wei 2011). The meta‐analysis demonstrated a significantly higher rate of post‐operative SUI in women who did not receive continence surgery (53/124, 43% versus 23/118, 19% with a continence procedure) at the time of prolapse surgery (RR 2.0, 95% CI 1.4 to 2.8; Analysis 9.6.1). Performing continence surgery at the time of prolapse surgery in 118 women with occult stress incontinence prevented 30 (25%) women developing SUI post‐prolapse surgery.
Two trials described the benefit of adding continence surgery to prolapse surgery in women who pre‐operatively had no SUI and no occult stress incontinence (SUI with prolapse reduced) (Brubaker 2008 colposuspension at sacral colpopexy; Wei 2011 TVT at vaginal prolapse surgery). Women undergoing prolapse surgery who were without symptoms of SUI and had no SUI with the prolapse reduced and did not have continence surgery performed were more likely to develop post‐operative SUI than if continence surgery was performed (94/235, 40% versus 52/220, 25%) (RR 2.2, 95% CI 1.4 to 3.3).

Two trials demonstrated that in those with prolapse and SUI pre‐operatively who underwent prolapse surgery without continence surgery had non‐significantly higher rates of persisting SUI than those that had continence surgery performed at the time of prolapse surgery (76/117, 65% versus 17/111, 15%) (RR 4.36, 95% CI 2.68 to 7.10; Analysis 9.25) (Borstad 2010; Costantini 2008).

Discussion

This is one of three reviews of interventions for pelvic organ prolapse and it should be viewed in that context (Adams 2004; Hagen 2011). In the other two reviews, no randomised trials evaluating mechanical devices or pessaries (Adams 2004) and limited trials on conservative, physical or lifestyle interventions (Hagen 2011) were identified.

In total, 56 randomised controlled trials on the surgical management of pelvic organ prolapse were evaluated in this review. These were conducted in 12 countries (Italy, USA, Australia, the UK, the Netherlands, Taiwan, Finland, Belgium, Chile, Czech Republic, Egypt, France, Singapore and Sweden). The trials involved a total of 5649 women of which 1695 were new in this update and all of whom received a surgical intervention.

Amongst the 56 trials that addressed surgical management of pelvic organ prolapse, the quality of the trials was variable. All trials reported an objective evaluation of the specific pelvic floor defect that was repaired but full vaginal site‐specific outcomes were available for only 13 trials (Altman 2011; Brubaker 2008; Colombo 1996; Colombo 1997; Colombo 2000; Costantini 2008; Maher 2004; Maher 2011; Meschia 2004a; Natale 2009; Nguyen 2008; Sivaslioglu 2008; Weber 2001). All but six trials (Ali 2006 abstract; Allahdin 2008; Farid 2010; Jeng 2005; Pantazis 2011; Schierlitz 2007) reported a median follow up of greater than one year, and only four trials reported outcomes at greater than five years (Colombo 1997; Colombo 2000; Culligan 2005; Roovers 2004).

Generally, the reporting of the impact of surgery on associated pelvic floor symptoms including bladder, bowel and sexual function; quality of life; cost; and patient satisfaction is improving. Validated pelvic floor questionnaires were reported in 14 trials (Altman 2011; Brubaker 2008; Costantini 2008; de Tayrac 2008; Guerette 2009; Halaska 2012; Maher 2004; Maher 2011; Menefee 2011; Nguyen 2008; Paraiso 2011; Roovers 2004; Sivaslioglu 2008; Thijs 2010 abstract), cost issues by four trialists (Benson 1996; Maher 2004; Maher 2011; Paraiso 2011) and impact of surgery on quality of life and patient satisfaction in six trials (Brubaker 2008; Halaska 2012; Iglesia 2010; Maher 2004; Maher 2011; Withagen 2011). The variability in reporting largely reflects the difficulties associated with evaluating prolapse surgery. One of the principal aims of prolapse surgery is to correct the vaginal protrusion and any associated pelvic floor dysfunction, however the anatomical correction of the vaginal architecture does not ensure normal bladder, bowel and sexual function. Until recently, standardised history, validated pelvic organ prolapse (POP) and specific quality of life questionnaires or other outcome assessment tools were not available.

It was disappointing that few trials were found which evaluated conservative, physical, lifestyle or mechanical means of prolapse treatment (Adams 2004; Hagen 2011) and none which compared these interventions with surgery.

Summary of main results

Upper vaginal prolapse (Comparison 1)

The abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse (Benson 1996; Maher 2004), reduced grade of residual prolapse (Lo 1998), greater length of time taken to recurrence of prolapse (Benson 1996) and less dyspareunia (Benson 1996; Lo 1998; Maher 2004) as compared to vaginal sacrospinous colpopexy. However, the abdominal sacral colpopexy was associated with a longer operating time (Benson 1996; Lo 1998; Maher 2004), a longer time for recovery (Maher 2004), and it was more expensive (Benson 1996; Maher 2004) than the vaginal approach. The finding of less post‐operative stress urinary incontinence after the abdominal approach must be viewed with caution due to the different continence procedures performed in the two trials (as described in the Methodology section). Although there was a lower reoperation rate in the abdominal group, this did not reach statistical significance (Benson 1996; Maher 2004). The data were too few to reliably assess possible differences in satisfaction, bowel outcomes or adverse effects. Culligan 2005 reported that there were no recurrent vault prolapses using either abdominal sacral colpopexy with mono‐filament polypropylene mesh or sacral colpopexy using cadaveric fascia lata graft inlay (Tutoplast) at one year. At five years they reported the polypropylene mesh as a superior graft to cadaveric fascia lata using objective anatomic outcomes at time of sacral colpopexy.

In a single study at one year, Rondini 2011 abstract demonstrated that the sacral colpopexy was superior to vaginal uterosacral colpopexy with a higher objective success rate and lower reoperation rate. The operating time, admission days and post‐operative complication rate were all higher after sacral colpopexy as compared to vaginal uterosacral colpopexy. These findings mirror the outcomes of sacral colpopexy as compared to sacrospinous colpopexy.

In a small single study, Pantazis 2011 compared open and laparoscopic sacral colpopexy and the outcomes were similar except for reduced blood loss and analgesic requirements in the laparoscopic group. Again, in a single trial, Maher 2011 demonstrated that laparoscopic sacral colpopexy took longer to perform than total vaginal polypropylene mesh repair and had reduced blood loss, admission days and reoperation rate. The recurrent prolapse rate, both on examination and subjectively, was lower after the laparoscopic sacral colpopexy. Paraiso 2011 demonstrated that robotic sacral colpopexy had increased operating time, post‐operative non‐steroidal anti‐inflammatory drug (NSAID) use and costs compared to laparoscopic sacral colpopexy, with no difference in anatomical or functional outcomes.

Two trials evaluated uterine preservation in at least one arm. Roovers 2004 reported more women needed repeat prolapse surgery after abdominal sacral hysteropexy (without hysterectomy) and fewer women had pain, overactive bladder symptoms or obstructive micturition symptoms after vaginal surgery which included hysterectomy. At an eight year review, more women saw their primary physician for pelvic floor problems in the abdominal group as compared to the vaginal group. Non‐statistically significant higher rates of prolapse symptoms and reoperation were seen after the sacral hysteropexy as compared to the vaginal group (Roovers 2004). A further trial in which women in one arm had uterine preservation reported few relevant outcomes (Jeng 2005). However, the clinical relevance of these trials, which compared different approaches and uterine preservation in one arm and hysterectomy in the other, is debatable.

Two small studies (de Tayrac 2008; Meschia 2004a) were unable to demonstrate a difference in anatomical or functional outcomes between vaginal sacrospinous colpopexy and posterior intravaginal slingplasty. The posterior intravaginal sling was quicker to perform and showed reduced blood loss. It was associated with a 9% rate of mesh complications (Meschia 2004a). However, due to a high reported rate of adverse effects with the multi‐filament polypropylene mesh used (Baessler 2005), the posterior intravaginal sling kit has now been withdrawn from the market and recruitment in the second trial stopped prematurely.

Anterior vaginal wall prolapse (Comparison 2)

There is increasing information available on the repair of the anterior vaginal compartment. Most new studies investigated anterior compartment operations.

There was some evidence from two small trials that absorbable polyglactin mesh (Vicryl) might reduce objective prolapse recurrence compared with anterior repair alone (Sand 2001; Weber 2001). However, this type of mesh is not available in all countries any more. Two randomised controlled trials demonstrated that porcine dermis augmentation of the anterior vaginal wall might be beneficial in reducing recurrent anterior vaginal wall prolapse (Hviid 2010; Meschia 2007). Neither cadaveric fascia lata (Tutoplast), bovine pericardium collagen, nor small intestine submucosa (SIS) augmentation of anterior vaginal wall was beneficial in reducing recurrent anterior vaginal wall prolapse (Feldner 2010; Gandhi 2005; Guerette 2009). Overall the anterior repair had a significantly higher rate of recurrent anterior wall prolapse on examination when compared to any biological graft. No differences in subjective outcomes were identified.

Two further RCTs compared biological grafts with various mesh augmentations. In a single RCT (De Ridder 2004 abstract) it was demonstrated that porcine dermis reduces recurrent anterior vaginal wall prolapse compared to polyglactin augmentation. Armed porcine dermis overlays resulted in a non‐statistically significant higher failure rate compared with armed mono‐filament polypropylene mesh overlay in women with recurrent symptomatic cystocele (Natale 2009). In women with primary cystocele, simple porcine dermis and polypropylene overlays proved similar regarding success rates (Cervigni 2005). It is pertinent, however, that of these four types of mesh or grafts only polypropylene was non‐absorbable. These four studies evaluated five interventions, anterior colporrhaphy and four different grafts, and primary and secondary cystoceles, which resulted in considerable variation making a meta‐analysis inappropriate. Also, the heterogenicity of the grafts used made the comparison of complications impossible. There was a lack of information on functional (subjective) outcomes.

In one trial concerning women who had stress urinary incontinence as well as pelvic organ prolapse, Burch colposuspension was subjectively better at curing the incontinence and anterior repair was better for the prolapse (Colombo 2000). The trial was too small to judge whether this affected subsequent reoperation rates or the effect on other aspects of bladder, bowel or sexual function.

Ten studies demonstrated that the polypropylene mesh anterior repair was superior to native tissue anterior colporrhaphy on objective evaluation, in reducing the risk of anterior compartment prolapse irrespective of whether an anterior colporrhaphy was performed concomitantly or not, Data from three studies also demonstrated that polypropylene mesh repair had a higher subjective success rate than native tissue anterior repair. No differences between the groups was identified in quality of life outcomes, rate of dyspareunia, or reoperation rates for prolapse or incontinence. The operating time, blood loss, rate of de novo stress urinary incontinence and subsequent prolapse in the posterior or apical compartment were less with the native tissue repair. Where polypropylene mesh was utilised in the anterior compartment, mesh erosion occurred in 11.6% with 6.8% undergoing surgery to correct the mesh exposure. The total reoperation rate for prolapse, stress urinary incontinence, mesh exposure or pain were significantly higher after transvaginal permanent mesh (10%) as compared to after anterior colporrhaphy (5%). Furthermore, two trials described more prolapse in the untreated compartments.

Prior to mesh being considered for standard repair in the anterior compartment a number of factors in the risk benefit analysis should be further explored, and they may only become apparent in studies with longer review times. The improved reduction in prolapse symptoms and anterior compartment prolapse on examination has at this stage not translated into reduced reintervention for prolapse, and in fact the reintervention rate is higher following transvaginal permanent mesh than after the native tissue repairs. It is also anticipated that the management of women undergoing subsequent surgical intervention for prolapse after permanent mesh placement would be significantly challenging and this factor should be included in any risk benefit analysis. Finally, and interestingly, In this group no patient had mesh removed due to pain or dyspareunia, which is in contrast to the US Food and Drug Administration (FDA) report (FDA 2011) in which the leading cause of complaints was pain or dyspareunia (590/1503, 38.6%). If the complication of pain associated with the polypropylene mesh is further documented this would be an important factor in a risk benefit analysis regarding employment of transvaginal polypropylene mesh. Most recently some of the products evaluated in this section, including Bard Avaulta, Gynemesh overlay and Prolift Johnson & Johnson products, have been removed from the market leaving only the self‐styled mesh (Parietene light, Sofradim) (Nieminen 2008; Sivaslioglu 2008) and Perigee mesh kit (Nguyen 2008) available for use that have been evaluated under the auspices of randomised controlled trials.

Posterior vaginal wall prolapse (Comparison 3)

Posterior vaginal wall repair performed better than the transanal repair of rectocele in terms of a significantly lower recurrence rate of posterior vaginal wall prolapse in two trials, despite a higher blood loss and greater use of pain relief (Kahn 1999; Nieminen 2004). However, the data were too few to comment on clinical outcomes such as flatus or faecal incontinence, or dyspareunia. More women had difficulties in bowel evacuation after transanal operation but this did not reach statistical significance. Farid 2010 also demonstrated that the size of the rectocele on defecography was significantly reduced after the transvaginal repair as compared to transanal repair. In total, eight serious adverse effects were reported amongst the 125 women in these three trials.

Two trials compared native tissue repair with porcine small intestine overlay and found that the objective recurrence rate was lower after the native tissue repairs as compared to the biological small intestine graft group on examination. There was no difference in awareness of prolapse or the rate of dyspareunia between the groups (Paraiso 2006; Sung 2012). Only one study (Sand 2001 absorbable mesh) reported on individual outcomes after any transvaginal mesh and the study was too small to draw any conclusions. A small study reported in abstract form only demonstrated a superior anatomical outcome after a fascial repair as compared to a levator ani plication posterior repair (Vijaya 2011 abstract).

Prolapse surgery and mesh augmentation (Comparison 6 and 7)

The use of mesh to augment repair surgery has been successful in other fields such as groin hernia repair (Scott 2001). Particular issues related to its use in vaginal repair are the effects on bowel, bladder and sexual function and the possibility of mesh erosion or infection. Therefore, evidence of an improved anatomical cure and subjective success of prolapse surgery in the anterior compartment using transvaginal polypropylene mesh remains insufficient reason to advocate its routine use. At this time these benefits have to be weighed against the reduced blood loss, operating time, rate of de novo stress urinary incontinence and posterior and apical compartment prolapse, and lower total reoperation rate after the native tissue repair. Obviously improved patient satisfaction and quality of life outcomes with reduced reoperating rates are required prior to advocating the widespread use of permanent mesh in the anterior compartment. Clinicans must evaluate potential benefits and risks on an individual basis until more definitive patient algorithms of management are able to be determined.

In the upper or apical compartment, the use of mesh at open sacral colpopexy as compared to vaginal sacrospinous colpopexy significantly improves outcomes but with increased morbidity and cost. A small randomised controlled trial demonstrated that the peri‐operative morbidity was similar between the open and laparoscopic approaches except for reduced blood loss in the laparoscopic procedure. Visco et al suggested that the mesh erosion or infection rate was increased four‐fold when mesh was introduced vaginally as compared to via the abdominal route in the management of pelvic organ prolapse (Visco 2001). A single trial suggested that laparoscopic sacral colpopexy had better patient satisfaction and anatomical outcomes with reduced reoperation rate and cost as compared to the transvaginal permanent mesh (Maher 2011).

There is no evidence to suggest that the addition of any graft (biological or synthetic) material at the posterior compartment repair resulted in improved outcomes.

The impact of grafts ( biological, and absorbable and non‐absorbable meshes) in the anterior compartment has been described above.

Three trials (Halaska 2012; Iglesia 2010; Withagen 2011) evaluated a combination of total, anterior or posterior compartment polypropylene mesh kits as compared to native tissue repairs and demonstrated an improved anatomical outcome after the transvaginal permanent mesh, however no difference was found in symptoms or quality of life outcomes. The mesh exposure rate was 18%, with one half of these 9% requiring surgical intervention. The total reoperation rate was was significantly higher after the transvaginal permanent mesh at 11% compared to 3.7% following native tissue repair. The evidence at this stage does not support the use of combined total, anterior or posterior mesh kits.

Thus the evidence is not sufficient to support the use of transvaginal permanent meshes or grafts at the time of vaginal apical or posterior compartment repair surgery except in the context of randomised controlled clinical trials. These trials must be adequately powered to evaluate the anatomic and functional outcomes and possible adverse events, with blinding of reviewers and preferably participants to minimise biases in reporting. It is quite extraordinary that after eight years of transvaginal mesh products no economic evaluation of these products in comparison to native tissue repairs is available and there is such a paucity of level one evidence available to aid clinicians in the decision making process regarding the appropriate interventions to assist and treat the women we serve.

Unfortunately much of the data presented in this review fails to allay concerns outlined in the 2011 FDA transvaginal polypropylene mesh report (FDA 2011). One significant discrepancy exists between our findings and of adverse event reports to the FDA. Vaginal pain and dyspareunia accounted for 38.6% of complaints to the FDA however in our review only 3/536 (0.5%) had mesh removed for this indication. Possible explanations for this anomaly could be that only a small percentage of women are affected and due to being significantly distressed they account for a higher percentage of complaints. Alternatively the true incidence of vaginal pain may be under‐reported in these trials. The incidence of vaginal pain associated with polypropylene meshes requires careful evaluation.

Prolapse surgery and bladder function (Comparison 9)

Prolapse surgery and bladder function

The results of performing continence surgery at the time of prolapse in those with prolapse and stress incontinence are conflicting and no recommendation can be made. Following prolapse surgery de novo stress incontinence occurs in 20% of women. This risk can be decreased by performing continence surgery at the time of prolapse surgery in the following subgroups:

all women undergoing prolapse surgery (RR 2.1, 95% CI 1.5 to 2.7; Analysis 9.7.1) (Brubaker 2008; Bump 1996; Colombo 1996; Colombo 1997; Costantini 2008; Meschia 2004; Schierlitz 2007; Wei 2011);
continent women undergoing prolapse surgery (146/460, 32% versus 84/438, 19%) (RR 2.0, 95% CI 1.5 to 2.8; Analysis 9.1.6) (Brubaker 2008; Bump 1996; Colombo 1996; Meschia 2004a; Schierlitz 2007; Wei 2011);
continent women undergoing prolapse surgery who have demonstrated occult stress urinary incontinence (53/124, 43% versus 23/118, 19%) (RR 3.5, 95% CI 1.9 to 6.6; Analysis 9.6.1) (Brubaker 2008; Bump 1996; Meschia 2004; Schierlitz 2007; Wei 2011);
continent women without occult stress incontinence (94/235, 40% versus 52/220, 25%) (RR 2.2, 95% CI 1.4 to 3.3) (Brubaker 2008; Wei 2011).

The benefits of reduced stress incontinence and a single intervention following prolapse surgery when combined with continence surgery need to be weighed against the potential risks of combining prolpapse and continence surgery, which have been poorly reported but include longer operating time, greater voiding difficulties and cost.

Three trials evaluated de novo stress urinary incontinence in women undergoing anterior colporrhaphy as compared to transvaginal mesh for anterior compartment prolapse, who did not have stress urinary incontinence preoperatively (Al‐Nazer 2007; Altman 2011; Nieminen 2008). There is a lower rate of de novo stress urinary incontinence after anterior repair as compared to transvaginal polypropylene mesh (22/305, 7% versus 37/307, 12%) (RR 0.6, 95% CI 0.2 to 0.9; Analysis 2.9.1).

After prolapse surgery, new overactive bladder symptoms were noted in 119 of 1005 (12%) undergoing prolapse surgery in 11 trials (Al‐Nazer 2007; Brubaker 2008; Bump 1996; Colombo 1996; Colombo 1997; Colombo 2000; de Tayrac 2008; Halaska 2012; Maher 2004, Natale 2009; Natale 2010). New voiding dysfunction was reported in 109 of 1209 (9%) women undergoing prolapse surgery in 12 trials (Al‐Nazer 2007; Bump 1996; Colombo 1996; Colombo 1997; de Tayrac 2008; Feldner 2010; Gandhi 2005; Maher 2004; Meschia 2004; Meschia 2007; Natale 2009; Natale 2010).

Overall completeness and applicability of evidence

It was disappointing that few trials were found which evaluated conservative, physical, lifestyle or mechanical means of prolapse treatment (Adams 2004; Hagen 2011), and none which compared these interventions with surgery.

Loss to follow up (dropouts) ranged from 0% to 52%, and there was differential dropout from one arm in one trial. A description of the baseline characteristics of the groups showed that they were comparable in all except four trials. In one trial, 7% of women only had Stage 1 prolapse before operation, which would generally be regarded as a success if recorded post‐operatively.

The majority of trials reported a follow up of between one and five years; it was less than one year in six trials and greater than five years in another four. However, the average time to failure of prolapse surgery requiring repeat operation is 12 years, suggesting that long‐term follow up is required to fully assess new prolapse surgery techniques.

The majority of the trials failed to distinguish between women having primary or subsequent procedures. It is likely that the outcomes would be different in these two groups, not least because women having secondary surgery might have worse prolapse symptoms before agreeing to a further operation.

Quality of the evidence

Amongst the 56 trials that addressed surgical management of pelvic organ prolapse, the quality of the trials was variable. All trials reported an objective evaluation of the specific pelvic floor defect that was repaired, but full vaginal site‐specific outcomes were available for only 12 trials (Altman 2011; Brubaker 2008; Colombo 1996; Colombo 1997; Colombo 2000; Costantini 2008; Maher 2004; Maher 2011; Menefee 2011; Meschia 2004a; Natale 2009; Nguyen 2008; Sivaslioglu 2008; Weber 2001). All but four trials (Ali 2006 abstract; Jeng 2005; Pantazis 2011; Schierlitz 2007) reported a median follow up of greater than one year and four trials reported outcomes at greater than five years (Colombo 1997; Colombo 2000; Culligan 2005; Roovers 2004).

Generally the impact of surgery on associated pelvic floor symptoms including bladder, bowel and sexual function, quality of life, cost and patient satisfaction is improving. Validated pelvic floor questionnaires were reported in 13 trials (Altman 2011; Brubaker 2008; Costantini 2008; de Tayrac 2008; Iglesia 2010; Maher 2004; Maher 2011; Menefee 2011; Nguyen 2008; Roovers 2004; Sivaslioglu 2008; Thijs 2010 abstract; Withagen 2011), cost issues by three trialists (Benson 1996; Maher 2004; Paraiso 2011) and impact of surgery on quality of life and patient satisfaction in five trials (Brubaker 2008; Iglesia 2010; Maher 2004; Maher 2011; Withagen 2011). These variations generally reflect the difficulties associated with defining outcomes and reporting prolapse surgery. One of the principal aims of prolapse surgery is to correct the vaginal protrusion and any associated pelvic floor dysfunction, but the anatomical correction itself is likely to impact upon bladder, bowel and sexual function in unpredictable ways. Until recently, neither standardised history and validated pelvic organ prolapse nor specific quality of life questionnaires or other outcome assessment tools were available.

Only 28 out of 56 trials provided evidence of secure methods of allocation to randomised groups, and one trial which used an open number list was classed as quasi‐randomised. In one trial four women were incorrectly analysed in the group opposite to their allocation, as they received the alternative treatment. Double blinded trials are difficult to perform, however they serve to minimise the risk of performance bias by participants and detection bias amongst assessors; double blinding was performed in eight trials (Allahdin 2008; Brubaker 2008; Culligan 2005; Iglesia 2010; Menefee 2011; Nguyen 2008; Paraiso 2006; Paraiso 2011). Outcome assessments were conducted by non‐surgeons in 13 trials (Allahdin 2008; Benson 1996; Costantini 2008; Culligan 2005; Feldner 2010; Maher 2004; Maher 2011; Meschia 2007; Natale 2009; Paraiso 2006; Paraiso 2011; Roovers 2004; Weber 2001). It is preferable if surgeons designing studies do not have a financial relationship with the company whose product is being evaluated, to minimise the risk of bias. Unfortunately in several studies in this review this conflict was feasible and exacerbated by not ensuring reviewers were blinded, resulting in a possible heightened risk of bias in the outcomes reported (Altman 2011; Carey 2009; Withagen 2011).

Figure 1

PRISMA study flow diagram.

Navigate to figure in ReviewOpen in new tab

Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Navigate to figure in ReviewOpen in new tab

Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.1

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 1 Number of women with prolapse symptoms (subjective failure).

Navigate to figure in ReviewOpen in new tab

Analysis 1.2

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 2 Number of women unsatisfied with surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 1.3

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 3 Number of women who visited a physician after surgery because of pelvic floor symptoms.

Navigate to figure in ReviewOpen in new tab

Analysis 1.4

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 4 Patient global impression Improvment PGI‐I (very much better).

Navigate to figure in ReviewOpen in new tab

Analysis 1.5

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 5 Number of women with any prolapse (objective failure).

Navigate to figure in ReviewOpen in new tab

Analysis 1.6

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 6 Number of women with recurrent vault/uterine prolapse (objective).

Navigate to figure in ReviewOpen in new tab

Analysis 1.7

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 7 Vault distance from hymen (cm) POPQ point C after surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 1.8

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 8 Total vaginal length (cm) after surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 1.9

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 9 Number of women with recurrent cystocele (objective).

Navigate to figure in ReviewOpen in new tab

Analysis 1.10

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 10 Objective anterior compartment prolapse after surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 1.11

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 11 Anterior vaginal wall distance from hymen (cm) POPQ point Ba after surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 1.12

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 12 Number of women with recurrent rectocele (objective).

Navigate to figure in ReviewOpen in new tab

Analysis 1.13

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 13 Objective posterior compartment prolapse after surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 1.14

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 14 Posterior vaginal wall distance from hymen (cm) POPQ point Bp after surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 1.15

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 15 Number of women with post‐operative stress urinary incontinence.

Navigate to figure in ReviewOpen in new tab

Analysis 1.16

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 16 Number of women with de novo stress incontinence.

Navigate to figure in ReviewOpen in new tab

Analysis 1.17

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 17 Number of women with urgency, detrusor overactivity or overactive bladder.

Navigate to figure in ReviewOpen in new tab

Analysis 1.18

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 18 Number of women with de novo (new) urgency, detrusor overactivity or overactive bladder.

Navigate to figure in ReviewOpen in new tab

Analysis 1.19

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 19 Number of women with persistent voiding dysfunction.

Navigate to figure in ReviewOpen in new tab

Analysis 1.20

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 20 Number of women with new voiding dysfunction.

Navigate to figure in ReviewOpen in new tab

Analysis 1.21

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 21 Number of women with de novo nocturia.

Navigate to figure in ReviewOpen in new tab

Analysis 1.22

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 22 Postoperative voiding dysfunction symptoms.

Navigate to figure in ReviewOpen in new tab

Analysis 1.23

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 23 Number of women with faecal incontinence.

Navigate to figure in ReviewOpen in new tab

Analysis 1.24

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 24 Number of women with constipation.

Navigate to figure in ReviewOpen in new tab

Analysis 1.25

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 25 Number of women with de novo constipation.

Navigate to figure in ReviewOpen in new tab

Analysis 1.26

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 26 Number of women with obstructed defecation.

Navigate to figure in ReviewOpen in new tab

Analysis 1.27

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 27 Postoperative dyspareunia.

Navigate to figure in ReviewOpen in new tab

Analysis 1.28

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 28 Women with de novo (new) postoperative dyspareunia.

Navigate to figure in ReviewOpen in new tab

Analysis 1.29

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 29 Postoperative sexual function score (PISQ‐12).

Navigate to figure in ReviewOpen in new tab

Analysis 1.30

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 30 Blood loss (ml).

Navigate to figure in ReviewOpen in new tab

Analysis 1.31

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 31 Postoperative decrease in Hb (gm/dl).

Navigate to figure in ReviewOpen in new tab

Analysis 1.32

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 32 Adverse effects.

Navigate to figure in ReviewOpen in new tab

Analysis 1.33

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 33 Operating time (minutes).

Navigate to figure in ReviewOpen in new tab

Analysis 1.34

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 34 Length of stay in hospital (days).

Navigate to figure in ReviewOpen in new tab

Analysis 1.35

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 35 Time to return to normal activity ADL (days).

Navigate to figure in ReviewOpen in new tab

Analysis 1.36

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 36 Days to return to work.

Navigate to figure in ReviewOpen in new tab

Analysis 1.37

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 37 Cost (US dollars).

Navigate to figure in ReviewOpen in new tab

Analysis 1.38

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 38 Time to recurrence of prolapse (months).

Navigate to figure in ReviewOpen in new tab

Analysis 1.39

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 39 Women having further prolapse surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 1.40

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 40 Women having further continence surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 1.41

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 41 Women having further related to primary surgery ( prolapse, continence or mesh complications).

Navigate to figure in ReviewOpen in new tab

Analysis 1.42

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 42 mesh exposure.

Navigate to figure in ReviewOpen in new tab

Analysis 1.43

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 43 surgery for mesh exposure.

Navigate to figure in ReviewOpen in new tab

Analysis 1.44

Comparison 1 Surgery for upper vaginal (vault or uterine) prolapse, Outcome 44 Prolapse Quality of Life questionnaire (P‐QOL).

Navigate to figure in ReviewOpen in new tab

Analysis 2.1

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 1 Number of women with prolapse symptoms (subjective failure).

Navigate to figure in ReviewOpen in new tab

Analysis 2.2

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 2 number of women with posterior or apical prolapse.

Navigate to figure in ReviewOpen in new tab

Analysis 2.3

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 3 Severity of prolapse symptoms (measured using visual analogue scale).

Navigate to figure in ReviewOpen in new tab

Analysis 2.4

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 4 Prolapse Quality of Life after surgery (P‐QOL).

Navigate to figure in ReviewOpen in new tab

Analysis 2.5

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 5 Number of women with prolapse (objective failure any site).

Navigate to figure in ReviewOpen in new tab

Analysis 2.6

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 6 Number of women with anterior prolapse / cystocele (objective failure).

Navigate to figure in ReviewOpen in new tab

Analysis 2.7

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 7 Number of women with posterior prolapse / rectocele (objective failure).

Navigate to figure in ReviewOpen in new tab

Analysis 2.8

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 8 Number of women with postoperative stress urinary incontinence.

Navigate to figure in ReviewOpen in new tab

Analysis 2.9

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 9 Number of women with de novo (new) stress urinary incontinence.

Navigate to figure in ReviewOpen in new tab

Analysis 2.10

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 10 Number of women with urgency, detrusor overactivity or overactive bladder.

Navigate to figure in ReviewOpen in new tab

Analysis 2.11

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 11 De novo overactive bladder symptoms.

Navigate to figure in ReviewOpen in new tab

Analysis 2.12

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 12 Postoperative voiding dysfunction symptoms.

Navigate to figure in ReviewOpen in new tab

Analysis 2.14

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 14 Persistent voiding dysfunction.

Navigate to figure in ReviewOpen in new tab

Analysis 2.15

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 15 Time to return to spontaneous voiding (days).

Navigate to figure in ReviewOpen in new tab

Analysis 2.16

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 16 Pelvic Floor Incontinence Questionnaire‐7 after surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 2.17

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 17 Number of women with worse bowel function / constipation.

Navigate to figure in ReviewOpen in new tab

Analysis 2.18

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 18 Number of women with dyspareunia.

Navigate to figure in ReviewOpen in new tab

Analysis 2.19

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 19 Blood loss (ml).

Navigate to figure in ReviewOpen in new tab

Analysis 2.20

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 20 Haemoglobin change.

Navigate to figure in ReviewOpen in new tab

Analysis 2.21

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 21 Number of women with postoperative complications.

Navigate to figure in ReviewOpen in new tab

Analysis 2.22

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 22 Mesh erosion.

Navigate to figure in ReviewOpen in new tab

Analysis 2.23

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 23 Death.

Navigate to figure in ReviewOpen in new tab

Analysis 2.24

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 24 Operating time (minutes).

Navigate to figure in ReviewOpen in new tab

Analysis 2.25

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 25 Length of stay in hospital (days).

Navigate to figure in ReviewOpen in new tab

Analysis 2.26

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 26 Number of women having further prolapse surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 2.27

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 27 Number of women having further incontinence surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 2.28

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 28 number of women with denovo dyspareunia.

Navigate to figure in ReviewOpen in new tab

Analysis 2.29

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 29 Prolapse quality of life (PFDI‐20).

Navigate to figure in ReviewOpen in new tab

Analysis 2.30

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 30 quality of life (PFDI‐7).

Navigate to figure in ReviewOpen in new tab

Analysis 2.31

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 31 urinary distress inventory (UDI).

Navigate to figure in ReviewOpen in new tab

Analysis 2.32

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 32 mesh erosion surgical correction.

Navigate to figure in ReviewOpen in new tab

Analysis 2.33

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 33 new urinary stress incontinence postoperative.

Navigate to figure in ReviewOpen in new tab

Analysis 2.34

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 34 cystotomy.

Navigate to figure in ReviewOpen in new tab

Analysis 2.35

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 35 PISQ‐12 Prolapse and Incontinence Sexual Questionnaire.

Navigate to figure in ReviewOpen in new tab

Analysis 2.36

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 36 Point Ba.

Navigate to figure in ReviewOpen in new tab

Analysis 2.37

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 37 Point Aa.

Navigate to figure in ReviewOpen in new tab

Analysis 2.38

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 38 Point C.

Navigate to figure in ReviewOpen in new tab

Analysis 2.39

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 39 Point Bp.

Navigate to figure in ReviewOpen in new tab

Analysis 2.40

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 40 POPQ Total vaginal length in cm.

Navigate to figure in ReviewOpen in new tab

Analysis 2.41

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 41 Subsequent surgery (prolapse, incontinence, mesh exposure, pain).

Navigate to figure in ReviewOpen in new tab

Analysis 3.1

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 1 Number of women with prolapse symptoms (subjective failure).

Navigate to figure in ReviewOpen in new tab

Analysis 3.2

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 2 Number of women with prolapse (objective failure).

Navigate to figure in ReviewOpen in new tab

Analysis 3.3

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 3 Number of women with faecal incontinence after operation.

Navigate to figure in ReviewOpen in new tab

Analysis 3.4

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 4 Number of women with anal incontinence to flatus after operation.

Navigate to figure in ReviewOpen in new tab

Analysis 3.5

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 5 Number of women with obstructed defecation / constipation after surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 3.6

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 6 Number of women with sexual function not improved after operation.

Navigate to figure in ReviewOpen in new tab

Analysis 3.7

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 7 Number of women with dyspareunia.

Navigate to figure in ReviewOpen in new tab

Analysis 3.8

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 8 Blood loss (ml).

Navigate to figure in ReviewOpen in new tab

Analysis 3.9

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 9 Change in hematocrit.

Navigate to figure in ReviewOpen in new tab

Analysis 3.10

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 10 Difference in haemoglobin.

Navigate to figure in ReviewOpen in new tab

Analysis 3.11

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 11 Postoperative narcotic (morphine) use.

Navigate to figure in ReviewOpen in new tab

Analysis 3.12

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 12 Number of women with postoperative complications.

Navigate to figure in ReviewOpen in new tab

Analysis 3.13

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 13 Persistent postoperative pain.

Navigate to figure in ReviewOpen in new tab

Analysis 3.14

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 14 Operating time (minutes).

Navigate to figure in ReviewOpen in new tab

Analysis 3.15

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 15 Length of stay in hospital (days).

Navigate to figure in ReviewOpen in new tab

Analysis 3.16

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 16 Number of women having further prolapse surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 3.17

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 17 rectocele size (centimetres) on defecography.

Navigate to figure in ReviewOpen in new tab

Analysis 3.18

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 18 modified obstructed defecation syndrome patient questionnaire.

Navigate to figure in ReviewOpen in new tab

Analysis 3.19

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 19 rectocele on examination (point Ap).

Navigate to figure in ReviewOpen in new tab

Analysis 6.1

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 1 Number of women with prolapse symptoms (subjective failure).

Navigate to figure in ReviewOpen in new tab

Analysis 6.2

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 2 Prolapse symptom score at 1 to 5 years.

Navigate to figure in ReviewOpen in new tab

Analysis 6.3

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 3 Quality of life (VAS) for severity of prolapse symptoms.

Navigate to figure in ReviewOpen in new tab

Analysis 6.4

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 4 Number of women with anterior prolapse / cystocele (objective failure).

Navigate to figure in ReviewOpen in new tab

Analysis 6.5

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 5 Objective failure all sites.

Navigate to figure in ReviewOpen in new tab

Analysis 6.6

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 6 Number of women with posterior prolapse / rectocele (objective failure).

Navigate to figure in ReviewOpen in new tab

Analysis 6.7

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 7 Objective failure, any site, no mesh versus any mesh.

Navigate to figure in ReviewOpen in new tab

Analysis 6.8

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 8 Number of women having repeat prolapse surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 6.9

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 9 Number of women with urgency, detrusor overactivity or overactive bladder.

Navigate to figure in ReviewOpen in new tab

Analysis 6.10

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 10 Number of women with postoperative urinary incontinence.

Navigate to figure in ReviewOpen in new tab

Analysis 6.11

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 11 Postoperative voiding dysfunction symptoms.

Navigate to figure in ReviewOpen in new tab

Analysis 6.12

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 12 Persistent voiding dysfunction.

Navigate to figure in ReviewOpen in new tab

Analysis 6.13

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 13 Number of women with dyspareunia.

Navigate to figure in ReviewOpen in new tab

Analysis 6.14

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 14 De novo dyspareunia.

Navigate to figure in ReviewOpen in new tab

Analysis 6.15

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 15 Number of women with postoperative complications.

Navigate to figure in ReviewOpen in new tab

Analysis 6.16

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 16 Death.

Navigate to figure in ReviewOpen in new tab

Analysis 6.17

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 17 Length of stay in hospital (days).

Navigate to figure in ReviewOpen in new tab

Analysis 6.18

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 18 new urinary stress incontinence postoperative.

Navigate to figure in ReviewOpen in new tab

Analysis 6.19

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 19 mesh erosion.

Navigate to figure in ReviewOpen in new tab

Analysis 6.20

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 20 surgery for mesh erosion.

Navigate to figure in ReviewOpen in new tab

Analysis 6.21

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 21 cystotomy.

Navigate to figure in ReviewOpen in new tab

Analysis 6.22

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 22 Patient global impression of improvement (PGI‐I) very much or much better.

Navigate to figure in ReviewOpen in new tab

Analysis 6.23

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 23 PISQ‐12 Prolapse and Incontinence Sexual Questionnaire.

Navigate to figure in ReviewOpen in new tab

Analysis 6.24

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 24 number undergoing further continence surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 6.25

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 25 Subsequent surgery (prolapse, incontinence, mesh exposure, pain).

Navigate to figure in ReviewOpen in new tab

Analysis 6.26

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 26 Blood loss (ml).

Navigate to figure in ReviewOpen in new tab

Analysis 6.27

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 27 Point Ba.

Navigate to figure in ReviewOpen in new tab

Analysis 6.28

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 28 Point Aa.

Navigate to figure in ReviewOpen in new tab

Analysis 6.29

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 29 Point C.

Navigate to figure in ReviewOpen in new tab

Analysis 6.30

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 30 Point Bp.

Navigate to figure in ReviewOpen in new tab

Analysis 6.31

Comparison 6 No graft versus use of graft (synthetic mesh or biological graft), Outcome 31 POPQ Total vaginal length in cm.

Navigate to figure in ReviewOpen in new tab

Analysis 7.2

Comparison 7 One type of graft (synthetic mesh or biological graft) versus another type of graft, Outcome 2 Number of women with anterior prolapse / cystocele (objective failure).

Navigate to figure in ReviewOpen in new tab

Analysis 7.3

Comparison 7 One type of graft (synthetic mesh or biological graft) versus another type of graft, Outcome 3 Number of women having further prolapse surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 7.4

Comparison 7 One type of graft (synthetic mesh or biological graft) versus another type of graft, Outcome 4 Stress urinary incontinence de novo.

Navigate to figure in ReviewOpen in new tab

Analysis 7.5

Comparison 7 One type of graft (synthetic mesh or biological graft) versus another type of graft, Outcome 5 Increased daytime urinary frequency post‐op.

Navigate to figure in ReviewOpen in new tab

Analysis 7.6

Comparison 7 One type of graft (synthetic mesh or biological graft) versus another type of graft, Outcome 6 Dyspareunia post‐op.

Navigate to figure in ReviewOpen in new tab

Analysis 7.7

Comparison 7 One type of graft (synthetic mesh or biological graft) versus another type of graft, Outcome 7 Vaginal mesh erosion.

Navigate to figure in ReviewOpen in new tab

Analysis 7.8

Comparison 7 One type of graft (synthetic mesh or biological graft) versus another type of graft, Outcome 8 Hospital stay (days).

Navigate to figure in ReviewOpen in new tab

Analysis 8.1

Comparison 8 One suture type versus another type of suture, Outcome 1 Number of women with prolapse symptoms up to 1 year (subjective failure).

Navigate to figure in ReviewOpen in new tab

Analysis 8.2

Comparison 8 One suture type versus another type of suture, Outcome 2 Number of women with prolapse symptoms at 1 to 5 years (subjective failure).

Navigate to figure in ReviewOpen in new tab

Analysis 8.3

Comparison 8 One suture type versus another type of suture, Outcome 3 Prolapse symptom score up to 1 year.

Navigate to figure in ReviewOpen in new tab

Analysis 8.4

Comparison 8 One suture type versus another type of suture, Outcome 4 Prolapse symptom score at 1 to 5 years.

Navigate to figure in ReviewOpen in new tab

Analysis 8.5

Comparison 8 One suture type versus another type of suture, Outcome 5 Quality of life score due to prolapse (VAS) up to 1 year.

Navigate to figure in ReviewOpen in new tab

Analysis 8.6

Comparison 8 One suture type versus another type of suture, Outcome 6 Quality of life score due to prolapse (VAS) at 1 to 5 years.

Navigate to figure in ReviewOpen in new tab

Analysis 8.7

Comparison 8 One suture type versus another type of suture, Outcome 7 Objective failure all sites.

Navigate to figure in ReviewOpen in new tab

Analysis 8.8

Comparison 8 One suture type versus another type of suture, Outcome 8 Number of women with urinary incontinence at 1 to 5 years.

Navigate to figure in ReviewOpen in new tab

Analysis 8.9

Comparison 8 One suture type versus another type of suture, Outcome 9 ICI Urinary symptom score at 1 to 5 years.

Navigate to figure in ReviewOpen in new tab

Analysis 8.10

Comparison 8 One suture type versus another type of suture, Outcome 10 Number of women with dyspareunia at 1 to 5 years.

Navigate to figure in ReviewOpen in new tab

Analysis 8.11

Comparison 8 One suture type versus another type of suture, Outcome 11 Death.

Navigate to figure in ReviewOpen in new tab

Analysis 8.12

Comparison 8 One suture type versus another type of suture, Outcome 12 Number of women having repeat prolapse surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 9.1

Comparison 9 Prolapse surgery and bladder function, Outcome 1 number with de novo ( new) stress urinary incontinence.

Navigate to figure in ReviewOpen in new tab

Analysis 9.2

Comparison 9 Prolapse surgery and bladder function, Outcome 2 Number with de novo (new) stress urinary incontinence (objective).

Navigate to figure in ReviewOpen in new tab

Analysis 9.3

Comparison 9 Prolapse surgery and bladder function, Outcome 3 Further continence surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 9.4

Comparison 9 Prolapse surgery and bladder function, Outcome 4 Number with denovo (new) urgency, detrusor overactivity or overactive bladder.

Navigate to figure in ReviewOpen in new tab

Analysis 9.5

Comparison 9 Prolapse surgery and bladder function, Outcome 5 Longterm voiding dysfunction.

Navigate to figure in ReviewOpen in new tab

Analysis 9.6

Comparison 9 Prolapse surgery and bladder function, Outcome 6 Number with new or denovo SUI who had occult SUI pre‐operatively.

Navigate to figure in ReviewOpen in new tab

Analysis 9.7

Comparison 9 Prolapse surgery and bladder function, Outcome 7 post prolapse surgery SUI objective.

Navigate to figure in ReviewOpen in new tab

Analysis 9.8

Comparison 9 Prolapse surgery and bladder function, Outcome 8 Incontinence Impact Questionnaire IIQ post.

Navigate to figure in ReviewOpen in new tab

Analysis 9.9

Comparison 9 Prolapse surgery and bladder function, Outcome 9 Urinary Distress Inventory (UDI‐6).

Navigate to figure in ReviewOpen in new tab

Analysis 9.10

Comparison 9 Prolapse surgery and bladder function, Outcome 10 Bothersome SUI (PFDI) post‐operative.

Navigate to figure in ReviewOpen in new tab

Analysis 9.11

Comparison 9 Prolapse surgery and bladder function, Outcome 11 satisfaction (VAS 0‐10).

Navigate to figure in ReviewOpen in new tab

Analysis 9.12

Comparison 9 Prolapse surgery and bladder function, Outcome 12 Pelvic Floor Incontinence questionnaire (PFIQ) bladder domain.

Navigate to figure in ReviewOpen in new tab

Analysis 9.13

Comparison 9 Prolapse surgery and bladder function, Outcome 13 Pelvic organ Prolapse/Urinary incontinence Sexual Function Questionnaire (PISQ).

Navigate to figure in ReviewOpen in new tab

Analysis 9.14

Comparison 9 Prolapse surgery and bladder function, Outcome 14 further Prolapse surgery.

Navigate to figure in ReviewOpen in new tab

Analysis 9.15

Comparison 9 Prolapse surgery and bladder function, Outcome 15 De novo Stress urinary incontinence women with negative preoperative stress test.

Navigate to figure in ReviewOpen in new tab

Analysis 9.16

Comparison 9 Prolapse surgery and bladder function, Outcome 16 blood loss (mls).

Navigate to figure in ReviewOpen in new tab

Analysis 9.17

Comparison 9 Prolapse surgery and bladder function, Outcome 17 POPQ point Aa.

Navigate to figure in ReviewOpen in new tab

Analysis 9.18

Comparison 9 Prolapse surgery and bladder function, Outcome 18 Point Ap.

Navigate to figure in ReviewOpen in new tab

Analysis 9.19

Comparison 9 Prolapse surgery and bladder function, Outcome 19 POP‐Q Point Ba.

Navigate to figure in ReviewOpen in new tab

Analysis 9.20

Comparison 9 Prolapse surgery and bladder function, Outcome 20 POPQ point Bp.

Navigate to figure in ReviewOpen in new tab

Analysis 9.21

Comparison 9 Prolapse surgery and bladder function, Outcome 21 POPQ point C.

Navigate to figure in ReviewOpen in new tab

Analysis 9.22

Comparison 9 Prolapse surgery and bladder function, Outcome 22 POPQ point D.

Navigate to figure in ReviewOpen in new tab

Analysis 9.23

Comparison 9 Prolapse surgery and bladder function, Outcome 23 Total vaginal length (TVL cm).

Navigate to figure in ReviewOpen in new tab

Analysis 9.24

Comparison 9 Prolapse surgery and bladder function, Outcome 24 Pelvic Floor Urinary Impact Questionnaire (PFUIQ).

Navigate to figure in ReviewOpen in new tab

Analysis 9.25

Comparison 9 Prolapse surgery and bladder function, Outcome 25 Number with persisting stress urinary incontinence after prolpase and continence surgery.

Navigate to figure in ReviewOpen in new tab

Table 1. Graft erosion

	Number with erosion	Total number of women
Polyglactin (Vicryl, absorbable synthetic)
Allahdin 2008	2	32
Sand 2001	0	73
Biological (porcine, Pelvicol)
Meschia 2007	1	98
Non‐absorable synthetic polypropylene
Ali 2006 abstract	3	46
Carey 2009	4	62
Menefee 2011	5	28
Nguyen 2008	2	37
Nieminen 2008	18	104
Sivaslioglu 2008	3	43

Table 1. Graft erosion

Navigate to table in Review

Table 2. Polypropylene mesh erosion

Ali 2006	3	46
Carey 2009 NEW	4	62
Iglesia 2010 NEW	5	32
Menefee 2011	5	28
Nguyen 2008	2	37
Nieminen 2008	18	104
Sivaslioglu 2008	3	43
Thijs 2010 NEW	9	48
Vollebregt 2010 NEW	2	53
Withagen 2011 NEW	14	83
Subtotal (95% CI)		536
Total events	65

Table 2. Polypropylene mesh erosion

Navigate to table in Review

Comparison 1. Surgery for upper vaginal (vault or uterine) prolapse

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of women with prolapse symptoms (subjective failure) Show forest plot	6		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	169	Risk Ratio (M‐H, Random, 95% CI)	0.52 [0.25, 1.09]
1.2 abdominal sacro‐hysteropexy versus vaginal hysterectomy plus anterior and/or posterior colporrhaphy at 1 year	1	82	Risk Ratio (M‐H, Random, 95% CI)	3.2 [1.29, 7.92]
1.3 abdominal sacro‐hysteropexy versus vaginal hysterectomy plus anterior and/or posterior colporrhaphy at 8 years	1	84	Risk Ratio (M‐H, Random, 95% CI)	2.6 [1.02, 6.65]
1.4 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	1	66	Risk Ratio (M‐H, Random, 95% CI)	0.67 [0.12, 3.73]
1.5 laparoscopic sacral colpopexy vs total vaginal polypropylene mesh	1	108	Risk Ratio (M‐H, Random, 95% CI)	0.26 [0.03, 2.25]
1.6 uterosacral colpopexy vs vaginal polypropylene mesh	1	59	Risk Ratio (M‐H, Random, 95% CI)	2.36 [0.26, 21.42]
2 Number of women unsatisfied with surgery Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Number of women who visited a physician after surgery because of pelvic floor symptoms Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3.1 abdominal sacro‐hysteropexy versus vaginal hysterectomy plus anterior and/or posterior colporrhaphy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Patient global impression Improvment PGI‐I (very much better) Show forest plot	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.65, 1.42]

4.1 open versus laparoscopic sacral colpopexy	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.65, 1.42]
5 Number of women with any prolapse (objective failure) Show forest plot	8		Risk Difference (M‐H, Fixed, 95% CI)	Totals not selected

5.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy (failed)	1		Risk Difference (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.2 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy (not improved)	1		Risk Difference (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.3 abdominal sacral colpopexy vs vaginal McCall	1		Risk Difference (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.4 cadaveric fascia lata (Tutoplast) vs polypropylene (Trelex)	1		Risk Difference (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.5 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	1		Risk Difference (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.6 sacral colpopexy without colposuspension versus sacral colpopexy with colposuspension	1		Risk Difference (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.7 uterosacral colpopexy versus vaginal polypropylene mesh	1		Risk Difference (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.8 laparoscopic sacral colpopexy versus total vaginal polypropylene mesh kit	1		Risk Difference (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Number of women with recurrent vault/uterine prolapse (objective) Show forest plot	8		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

6.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	169	Risk Ratio (M‐H, Random, 95% CI)	0.23 [0.07, 0.77]
6.2 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	2	111	Risk Ratio (M‐H, Random, 95% CI)	0.31 [0.03, 2.91]
6.3 cadavaric fascia lata (Tutoplast) vs polyprolylene (Trelex)	1	89	Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
6.4 hysterectomy versus sacrospinous hystereopexy	1	65	Risk Ratio (M‐H, Random, 95% CI)	0.16 [0.02, 1.20]
6.5 High levator myorrhaphy vs uterosacral vag vault suspension	1	229	Risk Ratio (M‐H, Random, 95% CI)	1.17 [0.37, 3.72]
6.6 sacral colpopexy versus high uterosacral colpopexy	1	110	Risk Ratio (M‐H, Random, 95% CI)	0.05 [0.00, 0.82]
7 Vault distance from hymen (cm) POPQ point C after surgery Show forest plot	5		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

7.1 sacral colpopexy without colposuspension versus sacral colpopexy with colposuspensio	2	358	Mean Difference (IV, Fixed, 95% CI)	0.41 [0.13, 0.69]
7.2 laparoscopic sacral colpopexy versus total vaginal polpypropylene mesh kit	1	108	Mean Difference (IV, Fixed, 95% CI)	‐1.39 [‐2.39, ‐0.39]
7.3 cadaveric fascia at sacral colpopexy versus monofilament poypropylene mesh at sacral colpopexy	1	58	Mean Difference (IV, Fixed, 95% CI)	0.31 [‐0.41, 1.03]
7.4 open versus laparoscopic sacral colpopexy	1	47	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.74, 0.74]
8 Total vaginal length (cm) after surgery Show forest plot	3		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

8.1 sacral colpopexy without colposuspension versus sacral colpopexy with colposuspensio	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.2 laparoscopic sacral colpopexy versus total vaginal polypropylene mesh kit	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.3 cadaveric fascia at sacral colpopexy versus monofilament poypropylene mesh at sacral co	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Number of women with recurrent cystocele (objective) Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

9.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1	89	Risk Ratio (M‐H, Fixed, 95% CI)	0.47 [0.12, 1.75]
9.2 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	2	111	Risk Ratio (M‐H, Fixed, 95% CI)	1.65 [0.83, 3.27]
9.3 High levator myorrhaphy vs uterosacral vag vault suspension	1	229	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.57, 1.21]
10 Objective anterior compartment prolapse after surgery Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

10.1 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	2	111	Risk Ratio (M‐H, Fixed, 95% CI)	1.65 [0.83, 3.27]
10.2 hysterectomy versus sacrospinous hysteropexy	1	65	Risk Ratio (M‐H, Fixed, 95% CI)	1.29 [0.84, 1.97]
11 Anterior vaginal wall distance from hymen (cm) POPQ point Ba after surgery Show forest plot	4		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

11.1 sacral colpopexy without colposuspension versus sacral colpopexy with colposuspensio	2	296	Mean Difference (IV, Fixed, 95% CI)	0.44 [0.26, 0.63]
11.2 laparoscopic sacral colpopexy versus total vaginal polypropylene mesh kit	1	108	Mean Difference (IV, Fixed, 95% CI)	‐0.70 [‐1.04, ‐0.36]
11.3 cadaveric fascia at sacral colpopexy versus monofilament poypropylene mesh at sacral co	1	58	Mean Difference (IV, Fixed, 95% CI)	0.8 [0.20, 1.40]
12 Number of women with recurrent rectocele (objective) Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

12.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1	89	Risk Ratio (M‐H, Fixed, 95% CI)	2.49 [0.71, 8.79]
12.2 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	2	111	Risk Ratio (M‐H, Fixed, 95% CI)	1.63 [0.55, 4.88]
12.3 High levator myorrhaphy vs uterosacral vag vault suspension	1	229	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.49, 2.31]
13 Objective posterior compartment prolapse after surgery Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

13.1 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	2	111	Risk Ratio (M‐H, Fixed, 95% CI)	1.63 [0.55, 4.88]
13.2 hysterectomy versus sacrospinous hystereopexy	1	65	Risk Ratio (M‐H, Fixed, 95% CI)	1.65 [0.66, 4.09]
14 Posterior vaginal wall distance from hymen (cm) POPQ point Bp after surgery Show forest plot	4		Mean Difference (IV, Random, 95% CI)	Subtotals only

14.1 sacral colpopexy without colposuspension versus sacral colpopexy with colposuspensio	2	296	Mean Difference (IV, Random, 95% CI)	0.09 [‐0.69, 0.87]
14.2 laparoscopic sacral colpopexy versus total vaginal polypropylene mesh kit	1	108	Mean Difference (IV, Random, 95% CI)	‐0.70 [‐1.03, ‐0.37]
14.3 cadaveric fascia at sacral colpopexy versus monofilament poypropylene mesh at sacral co	1	58	Mean Difference (IV, Random, 95% CI)	0.20 [‐0.11, 0.51]
15 Number of women with post‐operative stress urinary incontinence Show forest plot	7		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

15.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	155	Risk Ratio (M‐H, Fixed, 95% CI)	0.55 [0.32, 0.95]
15.2 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	2	111	Risk Ratio (M‐H, Fixed, 95% CI)	1.33 [0.47, 3.74]
15.3 abdominal sacrocolpopexy alone vs abdominal sacrocolpopexy with Burch colposuspension	1	299	Risk Ratio (M‐H, Fixed, 95% CI)	1.85 [1.32, 2.60]
15.4 High levator myorrhaphy vs uterosacral vag vault suspension	1	116	Risk Ratio (M‐H, Fixed, 95% CI)	0.57 [0.18, 1.85]
15.5 laparoscopic sacral colpopexy versus total vaginal polypropylene mesh kit	1	108	Risk Ratio (M‐H, Fixed, 95% CI)	0.52 [0.23, 1.18]
16 Number of women with de novo stress incontinence Show forest plot	3	226	Risk Ratio (M‐H, Fixed, 95% CI)	1.94 [1.10, 3.43]

16.1 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	1	45	Risk Ratio (M‐H, Fixed, 95% CI)	2.64 [0.11, 61.54]
16.2 high levator myorrhaphy vs uterosacral vag vault suspension	1	116	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [1.47, 6.12]
16.3 uterosacral colpopexy versus vaginal polypropylene mesh	1	65	Risk Ratio (M‐H, Fixed, 95% CI)	0.48 [0.13, 1.78]
17 Number of women with urgency, detrusor overactivity or overactive bladder Show forest plot	6		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

17.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1	83	Risk Ratio (M‐H, Fixed, 95% CI)	1.36 [0.78, 2.38]
17.2 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	2	111	Risk Ratio (M‐H, Fixed, 95% CI)	1.28 [0.67, 2.45]
17.3 abdominal sacrocolpopexy alone vs abdominal sacrocolpopexy with Burch colposuspension	1	304	Risk Ratio (M‐H, Fixed, 95% CI)	1.18 [0.87, 1.59]
17.4 high levator myorrhaphy vs uterosacral vag vault suspension	1	229	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.65, 1.32]
17.5 laparoscopic sacral colpopexy versus total vaginal polypropylene mesh kit	1	108	Risk Ratio (M‐H, Fixed, 95% CI)	1.48 [0.84, 2.62]
18 Number of women with de novo (new) urgency, detrusor overactivity or overactive bladder Show forest plot	4	527	Risk Ratio (M‐H, Fixed, 95% CI)	1.23 [0.84, 1.80]

18.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1	62	Risk Ratio (M‐H, Fixed, 95% CI)	1.61 [0.68, 3.81]
18.2 abdominal sacrocolpopexy alone vs abdominal sacrocolpopexy with Burch colposuspension	1	304	Risk Ratio (M‐H, Fixed, 95% CI)	1.36 [0.87, 2.15]
18.3 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	1	45	Risk Ratio (M‐H, Fixed, 95% CI)	2.64 [0.11, 61.54]
18.4 high levator myorrhaphy vs uterosacral vag vault suspension	1	116	Risk Ratio (M‐H, Fixed, 95% CI)	0.29 [0.06, 1.32]
19 Number of women with persistent voiding dysfunction Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

19.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20 Number of women with new voiding dysfunction Show forest plot	3	236	Risk Ratio (M‐H, Fixed, 95% CI)	1.94 [0.87, 4.32]

20.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1	75	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.07, 15.82]
20.2 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	1	45	Risk Ratio (M‐H, Fixed, 95% CI)	1.75 [0.36, 8.61]
20.3 High levator myorrhaphy vs uterosacral vag vault suspension	1	116	Risk Ratio (M‐H, Fixed, 95% CI)	2.2 [0.82, 5.94]
21 Number of women with de novo nocturia Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

21.1 High levator myorrhaphy vs uterosacral vag vault suspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
22 Postoperative voiding dysfunction symptoms Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

22.1 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	2	111	Risk Ratio (M‐H, Fixed, 95% CI)	1.68 [0.81, 3.50]
23 Number of women with faecal incontinence Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

23.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
23.2 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
24 Number of women with constipation Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

24.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1	89	Risk Ratio (M‐H, Fixed, 95% CI)	1.40 [0.64, 3.10]
24.2 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	2	111	Risk Ratio (M‐H, Fixed, 95% CI)	2.10 [0.66, 6.64]
25 Number of women with de novo constipation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

25.1 High levator myorrhaphy vs uterosacral vag vault suspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
26 Number of women with obstructed defecation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

26.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
27 Postoperative dyspareunia Show forest plot	6		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

27.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	3	106	Risk Ratio (M‐H, Fixed, 95% CI)	0.39 [0.18, 0.86]
27.2 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.13, 71.07]
27.3 vaginal sacrospinous uterine suspension vs vaginal hysterectomy	1	158	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.25, 3.76]
27.4 High levator myorrhaphy vs uterosacral vag vault suspension	1	229	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.51, 1.36]
28 Women with de novo (new) postoperative dyspareunia Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

28.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
28.2 High levator myorrhaphy vs uterosacral vag vault suspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
28.3 uterosacral colpopexy versus vaginal polypropylene mesh	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
29 Postoperative sexual function score (PISQ‐12) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

29.1 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
29.2 sacral colpopexy without colposuspension versus sacral colpopexy with colposuspension	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
30 Blood loss (ml) Show forest plot	7	836	Mean Difference (IV, Random, 95% CI)	17.94 [‐54.02, 89.90]

30.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	213	Mean Difference (IV, Random, 95% CI)	‐121.97 [‐468.88, 224.94]
30.2 abdominal sacrohysteropexy with Gore‐Tex vs vaginal hysterectomy, vaginal repair, uterosacral ligament plicati	1	82	Mean Difference (IV, Random, 95% CI)	‐4.0 [‐22.91, 14.91]
30.3 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	1	66	Mean Difference (IV, Random, 95% CI)	70.0 [56.07, 83.93]
30.4 cadaveric fascia lata (Tutoplast) vs polypropylene (Trelex)	1	100	Mean Difference (IV, Random, 95% CI)	218.0 [132.87, 303.13]
30.5 abdominal sacrocolpopexy alone vs abdominal sacrocolpopexy with Burch colposuspension	1	322	Mean Difference (IV, Random, 95% CI)	‐73.0 [‐115.39, ‐30.61]
30.6 open sacral colpopexy versus laparoscopic sacral colpopexy	1	53	Mean Difference (IV, Random, 95% CI)	184.0 [95.89, 272.11]
31 Postoperative decrease in Hb (gm/dl) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

31.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
31.2 Open sacral‐colpopexy versus laparoscpic sacral‐colpopexy	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
32 Adverse effects Show forest plot	13		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

32.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	3	287	Risk Ratio (M‐H, Random, 95% CI)	1.44 [0.40, 5.19]
32.2 abdominal sacrohysteropexy with Gore‐Tex vs vaginal hysterectomy, vaginal repair, uterosacral ligament plicati	1	82	Risk Ratio (M‐H, Random, 95% CI)	1.2 [0.40, 3.62]
32.3 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	2	111	Risk Ratio (M‐H, Random, 95% CI)	0.73 [0.29, 1.82]
32.4 cadaveric fascia lata (tutoplast) vs polypropylene (Trelex)	1	100	Risk Ratio (M‐H, Random, 95% CI)	0.68 [0.29, 1.59]
32.5 abdominal sacrocolpopexy alone vs abdominal sacrocolpopexy with Burch colposuspension	1	322	Risk Ratio (M‐H, Random, 95% CI)	0.99 [0.59, 1.68]
32.6 vaginal sacrospinous uterine suspension vs vaginal hysterectomy	1	158	Risk Ratio (M‐H, Random, 95% CI)	4.23 [1.25, 14.25]
32.7 abdominal sacral colpopexy vs vaginal McCall	1	47	Risk Ratio (M‐H, Random, 95% CI)	7.29 [0.40, 133.82]
32.8 High levator myorrhaphy vs uterosacral vag vault suspension	1	229	Risk Ratio (M‐H, Random, 95% CI)	0.05 [0.00, 0.87]
32.9 Open sacral‐colpopexy versus laparoscpic sacral‐colpopexy	1	30	Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
32.10 sacral colpopexy versus uterosacral colpopexy	1	110	Risk Ratio (M‐H, Random, 95% CI)	2.85 [0.97, 8.41]
33 Operating time (minutes) Show forest plot	11		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

33.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	3	293	Mean Difference (IV, Fixed, 95% CI)	21.04 [12.15, 29.94]
33.2 abdominal sacrohysteropexy with Gore‐Tex vs vaginal hysterectomy, vaginal repair, uterosacral ligament plicati	1	82	Mean Difference (IV, Fixed, 95% CI)	‐10.0 [‐11.81, ‐8.19]
33.3 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	2	111	Mean Difference (IV, Fixed, 95% CI)	7.58 [4.04, 11.13]
33.4 cadaveric fascia lata (Tutoplast) vs polypropylene (Trelex)	1	100	Mean Difference (IV, Fixed, 95% CI)	6.0 [‐10.92, 22.92]
33.5 abdominal sacrocolpopexy alone vs abdominal sacrocolpopexy with Burch colposuspension	1	322	Mean Difference (IV, Fixed, 95% CI)	‐20.0 [‐32.56, ‐7.44]
33.6 Open sacral‐colpopexy versus laparoscpic sacral‐colpopexy	1	47	Mean Difference (IV, Fixed, 95% CI)	‐12.0 [‐31.00, 9.00]
33.7 laparoscopic sacral colpopexy versus robotic sacral colpopexy	1	67	Mean Difference (IV, Fixed, 95% CI)	‐66.0 [‐88.99, ‐43.01]
33.8 sacral colpopexy versus uterosacral colpoopexy	1	110	Mean Difference (IV, Fixed, 95% CI)	22.0 [12.44, 31.56]
34 Length of stay in hospital (days) Show forest plot	8		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

34.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	3	293	Mean Difference (IV, Fixed, 95% CI)	0.14 [‐0.25, 0.53]
34.2 abdominal sacrohysteropexy with Gore‐Tex vs vaginal hysterectomy, vaginal repair, uterosacral ligament plicati	1	82	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐0.01, 0.21]
34.3 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	2	111	Mean Difference (IV, Fixed, 95% CI)	0.27 [‐0.28, 0.82]
34.4 Open sacral‐colpopexy versus laparoscpic sacral‐colpopexy	1	47	Mean Difference (IV, Fixed, 95% CI)	0.90 [0.12, 1.68]
34.5 sacral colpoopexy versus uterosacral colpopexy	1	110	Mean Difference (IV, Fixed, 95% CI)	1.6 [‐0.67, 3.87]
35 Time to return to normal activity ADL (days) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

35.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
35.2 hysterectomy versus sacrospinous hystereopexy	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
36 Days to return to work Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

36.1 hysterectomy versus sacrospinous hystereopexy	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
37 Cost (US dollars) Show forest plot	3		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

37.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	169	Mean Difference (IV, Fixed, 95% CI)	1333.95 [1027.24, 1640.65]
37.2 laparoscopic sacral colpopexy versus robotic sacral colpopexy	1	68	Mean Difference (IV, Fixed, 95% CI)	‐1954.0 [‐3444.31, ‐463.69]
38 Time to recurrence of prolapse (months) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

38.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
39 Women having further prolapse surgery Show forest plot	11		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

39.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	169	Risk Ratio (M‐H, Fixed, 95% CI)	0.46 [0.19, 1.11]
39.2 abdominal sacrohysteropexy with Gore‐Tex vs vaginal hysterectomy, vaginal repair, uterosacral ligament plicati	1	82	Risk Ratio (M‐H, Fixed, 95% CI)	9.0 [1.19, 67.85]
39.3 hysterectomy versus sacrospinous hystereopexy	1	65	Risk Ratio (M‐H, Fixed, 95% CI)	0.55 [0.11, 2.79]
39.4 abdominal sacral colpopexy vs vaginal McCall	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	0.35 [0.01, 8.11]
39.5 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	1	45	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.13, 5.68]
39.6 sacral colpopexy without colposuspension versus sacral colpopexy with colposuspension	1	311	Risk Ratio (M‐H, Fixed, 95% CI)	2.91 [0.60, 14.17]
39.7 uterosacral colpopexy versus polypropylene mesh	1	65	Risk Ratio (M‐H, Fixed, 95% CI)	0.14 [0.01, 2.58]
39.8 laparoscopic sacral colpopexy versus total vaginal polypropylene mesh kit	1	108	Risk Ratio (M‐H, Fixed, 95% CI)	0.15 [0.01, 2.80]
39.9 sacral colpopexy versus high uterosacral ligament	1	110	Risk Ratio (M‐H, Fixed, 95% CI)	0.31 [0.09, 1.07]
39.10 open versus laparoscopic sacral colpopexy	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.15, 6.25]
40 Women having further continence surgery Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

40.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	3	287	Risk Ratio (M‐H, Fixed, 95% CI)	0.60 [0.21, 1.73]
40.2 laparoscopic sacral colpopexy versus total vaginal polypropylene mesh kit	1	108	Risk Ratio (M‐H, Fixed, 95% CI)	0.35 [0.04, 3.22]
41 Women having further related to primary surgery ( prolapse, continence or mesh complications) Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

41.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	169	Risk Ratio (M‐H, Fixed, 95% CI)	0.47 [0.23, 0.97]
41.2 Abdominal sacro‐hysteropexy versus vaginal hysterectomy plus anterior and/or posterior colporrhaphy at 8 years	1	84	Risk Ratio (M‐H, Fixed, 95% CI)	1.83 [0.75, 4.50]
41.3 laparoscopic sacral colpopexy versus total vaginal polypropylene mesh kit	1	108	Risk Ratio (M‐H, Fixed, 95% CI)	0.26 [0.08, 0.87]
42 mesh exposure Show forest plot	2	155	Risk Ratio (M‐H, Fixed, 95% CI)	0.15 [0.02, 1.16]

42.1 laparoscopic sacral colpopexy versus total vaginal polypropylene mesh kit	1	108	Risk Ratio (M‐H, Fixed, 95% CI)	0.15 [0.02, 1.16]
42.2 open versus laproscopic sacral colpopexy	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
43 surgery for mesh exposure Show forest plot	1	108	Risk Ratio (M‐H, Fixed, 95% CI)	0.09 [0.01, 1.66]

43.1 laparoscopic sacral colpopexy versus total vaginal polypropylene mesh kit	1	108	Risk Ratio (M‐H, Fixed, 95% CI)	0.09 [0.01, 1.66]
44 Prolapse Quality of Life questionnaire (P‐QOL) Show forest plot	1	47	Mean Difference (IV, Fixed, 95% CI)	0.70 [‐19.04, 20.44]

44.1 open versus laparoscopic sacral colpopexy	1	47	Mean Difference (IV, Fixed, 95% CI)	0.70 [‐19.04, 20.44]

Comparison 1. Surgery for upper vaginal (vault or uterine) prolapse

Navigate to table in Review

Comparison 2. One method of anterior prolapse repair versus another surgical method

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of women with prolapse symptoms (subjective failure) Show forest plot	11		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 anterior colporrhaphy vs cadaveric fascia lata (Tutoplast)	1	112	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.33, 2.81]
1.2 traditional anterior colporraphy vs abdominal Burch colposuspension	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	0.08 [0.00, 1.39]
1.3 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1	23	Risk Ratio (M‐H, Fixed, 95% CI)	2.18 [0.23, 20.84]
1.4 polypropylene mesh (Prolene soft) vs Pelvicol	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.5 anterior colporrhaphy vs armed transobturtor mesh	2	555	Risk Ratio (M‐H, Fixed, 95% CI)	1.77 [1.32, 2.37]
1.6 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	2.0 [0.69, 5.80]
1.7 fascial plication vs fascial plication with Pelvicol inlay	1	201	Risk Ratio (M‐H, Fixed, 95% CI)	1.37 [0.62, 3.07]
1.8 armed polypropylene mesh (Gynemesh) vs Pelvicol	1	190	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.20, 4.73]
1.9 anterior colporrhaphy versus any transvaginal polypropylene mesh	4	712	Risk Ratio (M‐H, Fixed, 95% CI)	1.64 [1.24, 2.16]
1.10 Anterior colporrhaphy versus porcine Small Intensine Submucosa (SIS)	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.11 anterior colporrhaphy versus pericardial bovine collagen graft	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.12 anterior colporrhaphy with vivryl mesh versus vaginal paravaginal repair with vicryl mesh	1	69	Risk Ratio (M‐H, Fixed, 95% CI)	0.34 [0.04, 3.14]
1.13 anterior colporrhaphy versus repair with biological or permanent graft	5	903	Risk Ratio (M‐H, Fixed, 95% CI)	1.47 [1.16, 1.86]
1.14 anterior colporrhaphy versus biological graft	2	313	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [0.64, 2.30]
2 number of women with posterior or apical prolapse Show forest plot	2	300	Risk Ratio (M‐H, Fixed, 95% CI)	1.85 [1.01, 3.37]

3 Severity of prolapse symptoms (measured using visual analogue scale) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3.1 fascial plication vs Pelvicol overlay	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Prolapse Quality of Life after surgery (P‐QOL) Show forest plot	2	141	Std. Mean Difference (IV, Fixed, 95% CI)	0.09 [‐0.24, 0.42]

4.1 anterior colporrhaphy versus armed transobturator polypropylene mesh	1	85	Std. Mean Difference (IV, Fixed, 95% CI)	0.22 [‐0.21, 0.65]
4.2 Anterior colporrhaphy versus porcine Small Intensine Submucosa (SIS)	1	56	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.10 [‐0.63, 0.42]
5 Number of women with prolapse (objective failure any site) Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

5.1 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	0.66 [0.34, 1.27]
5.2 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.37, 2.05]
5.3 AC versus polypropylene mesh	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	6.0 [0.79, 45.42]
6 Number of women with anterior prolapse / cystocele (objective failure) Show forest plot	23		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

6.1 anterior colporrhaphy vs polypropylene mesh overlay	3	181	Risk Ratio (M‐H, Random, 95% CI)	3.01 [1.51, 5.98]
6.2 traditional anterior colporrhaphy vs ultralateral anterior colporraphy	1	57	Risk Ratio (M‐H, Random, 95% CI)	1.29 [0.84, 1.98]
6.3 traditional anterior colporrhaphy vs anterior colporrhaphy + polyglactin mesh reinforcement	2	202	Risk Ratio (M‐H, Random, 95% CI)	1.41 [0.98, 2.05]
6.4 ultralateral anterior colporraphy vs anterior colporraphy + polyglactin mesh reinforcement	1	50	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.57, 1.54]
6.5 traditional anterior colporrhaphy vs abdominal Burch colposuspension	1	68	Risk Ratio (M‐H, Random, 95% CI)	0.09 [0.01, 0.64]
6.6 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	138	Risk Ratio (M‐H, Random, 95% CI)	0.60 [0.26, 1.42]
6.7 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Random, 95% CI)	0.96 [0.14, 6.57]
6.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Random, 95% CI)	1.17 [0.46, 2.98]
6.9 fascial plication vs Porcine dermis Pelvicol overlay	3	305	Risk Ratio (M‐H, Random, 95% CI)	1.57 [1.05, 2.35]
6.10 anterior colporrhaphy vs cadaveric fascia lata (Tutoplast)	1	154	Risk Ratio (M‐H, Random, 95% CI)	1.40 [0.80, 2.44]
6.11 Vicryl vs Pelvicol	1	125	Risk Ratio (M‐H, Random, 95% CI)	3.22 [1.38, 7.52]
6.12 polypropylene mesh (Prolene soft) vs Pelvicol	0	0	Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
6.13 armed polypropylene mesh (Gynemesh) vs Pelvicol	1	190	Risk Ratio (M‐H, Random, 95% CI)	0.64 [0.43, 0.96]
6.14 anterior colporrhaphy versus any transvaginal polypropylene mesh	7	976	Risk Ratio (M‐H, Random, 95% CI)	3.23 [2.55, 4.10]
6.15 anterior colporrhaphy versus commercial transobturator polypropylene mesh kits	3	549	Risk Ratio (M‐H, Random, 95% CI)	3.83 [2.34, 6.26]
6.16 anterior colporrhaphy versus self styled transobturator polypropylene mesh	2	285	Risk Ratio (M‐H, Random, 95% CI)	3.41 [2.05, 5.68]
6.17 anterior colporrhaphy versus armed transobturator polypropylene mesh	5	834	Risk Ratio (M‐H, Random, 95% CI)	3.39 [2.62, 4.38]
6.18 AC versus polypropylene mesh plus AC	3	365	Risk Ratio (M‐H, Random, 95% CI)	3.38 [2.14, 5.34]
6.19 anterior colporrhaphy versus pericardial bovine collagen graft	1	44	Risk Ratio (M‐H, Random, 95% CI)	1.57 [0.59, 4.23]
6.20 Anterior colporrhaphy versus porcine Small Intensine Submucosa (SIS)	1	56	Risk Ratio (M‐H, Random, 95% CI)	2.95 [1.07, 8.17]
6.21 anterior colporrhaphy with vivryl mesh versus vaginal para	1	69	Risk Ratio (M‐H, Random, 95% CI)	1.24 [0.62, 2.47]
6.22 AC verus polypropylene mesh repair without AC	4	598	Risk Ratio (M‐H, Random, 95% CI)	3.59 [2.38, 5.40]
6.23 anterior colporrhaphy versus any biological graft	5	490	Risk Ratio (M‐H, Random, 95% CI)	1.56 [1.13, 2.14]
6.24 anterior colporrhaphy versus repair with any graft ( synthetic, or allografts)	12	1455	Risk Ratio (M‐H, Random, 95% CI)	2.82 [2.19, 3.62]
7 Number of women with posterior prolapse / rectocele (objective failure) Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

7.1 traditional anterior colporrhaphy vs anterior colporrhaphy + polyglactin mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.2 Gynemesh vs Pelvicol	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.3 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Number of women with postoperative stress urinary incontinence Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

8.1 fascial plication vs fascial plication with Pelvicol overlay	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.2 anterior colporrhaphy versus armed transobturator polypropylene mesh	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.3 traditional anterior colporrhaphy vs abdominal Burch colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Number of women with de novo (new) stress urinary incontinence Show forest plot	9		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

9.1 anterior colporrhaphy versus armed transobturator polypropylene mesh	4	644	Risk Ratio (M‐H, Random, 95% CI)	0.58 [0.36, 0.94]
9.2 Gynemesh vs Pelvicol	1	190	Risk Ratio (M‐H, Random, 95% CI)	1.96 [0.18, 21.23]
9.3 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Random, 95% CI)	0.96 [0.25, 3.64]
9.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	102	Risk Ratio (M‐H, Random, 95% CI)	2.02 [0.08, 50.63]
9.5 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Random, 95% CI)	9.00 [1.23, 65.85]
10 Number of women with urgency, detrusor overactivity or overactive bladder Show forest plot	7	749	Risk Ratio (M‐H, Fixed, 95% CI)	0.79 [0.53, 1.19]

10.1 fascial plication vs fascial plication with Pelvicol overlay	1	201	Risk Ratio (M‐H, Fixed, 95% CI)	1.14 [0.61, 2.14]
10.2 Prolene soft vs Pelvicol	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10.3 traditional anterior colporrhaphy vs abdominal Burch colposuspension	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.07, 16.27]
10.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.20, 4.49]
10.5 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.06, 14.96]
10.6 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.04, 2.99]
10.7 armed polypropylene mesh (Gynemesh) vs Pelvicol	1	190	Risk Ratio (M‐H, Fixed, 95% CI)	0.56 [0.29, 1.07]
11 De novo overactive bladder symptoms Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

12 Postoperative voiding dysfunction symptoms Show forest plot	2	349	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.79, 1.69]

12.1 fascial plication vs fascial plication with Pelvicol overlay	1	201	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.53, 1.94]
12.2 prolene soft vs Pelvicol	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
12.3 anterior colporrhaphy vs cadaveric fascia lata (Tutoplast)	1	148	Risk Ratio (M‐H, Fixed, 95% CI)	1.26 [0.79, 2.01]
13 Urodynamic voiding dysfunction	0		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
13.1 Prolene soft vs pelvicol	0		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14 Persistent voiding dysfunction Show forest plot	8	553	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.64, 1.36]

14.1 anterior colporrhaphy vs cadaveric fascia lata (Tutoplast)	1	105	Risk Ratio (M‐H, Fixed, 95% CI)	1.18 [0.73, 1.91]
14.2 traditional anterior colporrhaphy vs abdominal Burch colposuspension	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.3 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.49, 2.26]
14.4 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.09 [0.00, 1.54]
14.5 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.04, 2.99]
14.6 anterior colporrhaphy versus transvaginal polypropylene mesh	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.13, 69.52]
14.7 anterior colporrhaphy versus SIS graft	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.11, 4.74]
15 Time to return to spontaneous voiding (days) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

15.1 fascial plication vs fascial plication with Pelvicol overlay	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
15.2 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
16 Pelvic Floor Incontinence Questionnaire‐7 after surgery Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

16.1 anterior colporrhaphy versus armed transobturator polypropylene mesh	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
17 Number of women with worse bowel function / constipation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

17.1 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
17.2 Prolene soft vs Pelvicol	0		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
18 Number of women with dyspareunia Show forest plot	8		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

18.1 fascial plication vs fascial plication with Pelvicol overlay	1	95	Risk Ratio (M‐H, Fixed, 95% CI)	0.70 [0.24, 2.05]
18.2 Prolene Soft vs Pelvicol	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
18.3 armed polypropylene mesh (Gynemesh) vs Pelvicol	1	190	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.37, 1.80]
18.4 traditional anterior colporrhaphy vs abdominal Burch colposuspension	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	6.78 [1.72, 26.81]
18.5 cystopexy vs cystopexy + pubourethral ligament plication	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	0.15 [0.04, 0.58]
18.6 anterior colporrhaphy versus any vaginal polypropylene mesh	3	457	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.45, 1.69]
18.7 Anterior colporrhaphy versus porcine Small Intensine Submucosa (SIS)	1	56	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.35, 3.89]
19 Blood loss (ml) Show forest plot	6		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

19.1 fascial plication vs Pelvicol overlay	2	258	Mean Difference (IV, Fixed, 95% CI)	0.56 [‐19.57, 20.70]
19.2 anterior colporrhaphy versus armed transobturator polypropylene mesh	2	569	Mean Difference (IV, Fixed, 95% CI)	‐64.04 [‐80.39, ‐47.69]
19.3 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Mean Difference (IV, Fixed, 95% CI)	‐11.0 [‐61.10, 39.10]
19.4 anterior colporrhaphy versus repair with any graft (permanent or biological)	5	871	Mean Difference (IV, Fixed, 95% CI)	‐35.32 [‐47.55, ‐23.09]
20 Haemoglobin change Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

20.1 anterior colporrhaphy versus armed transobturator polypropylene mesh	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
20.2 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
21 Number of women with postoperative complications Show forest plot	7		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

21.1 fascial plication vs fascial plication with Pelvicol overlay	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21.2 traditional anterior colporrhaphy vs ultra‐lateral anterior colporraphy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21.3 traditional anterior colporrhaphy vs anterior colporrhaphy + polyglactin mesh reinforcement	2		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21.4 ultralateral anterior colporraphy vs anterior colporraphy + polyglactin mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21.5 traditional anterior colporrhaphy vs abdominal Burch colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21.6 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21.7 cystopexy vs cystopexy + pubourethral ligament plication	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21.9 Prolene soft vs Pelvicol	0		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
22 Mesh erosion Show forest plot	10		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

22.1 anterior colporrhaphy versus polypropylene mesh	9	1110	Risk Ratio (M‐H, Fixed, 95% CI)	0.07 [0.03, 0.18]
22.2 armed polypropylene mesh (Gynemesh) vs Pelvicol	1	190	Risk Ratio (M‐H, Fixed, 95% CI)	12.73 [0.73, 222.87]
23 Death Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

23.1 traditional anterior colporrhaphy vs ultralateral anterior colporrhaphy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
23.2 traditional anterior colporrhaphy vs anterior colporrhaphy + polyglactin mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
23.3 ultralateral anterior colporrhaphy vs anterior colporrhaphy + polyglactin mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
24 Operating time (minutes) Show forest plot	6		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

24.1 anterior colporrhaphy versus armed transobturator polypropylene mesh	2	569	Mean Difference (IV, Fixed, 95% CI)	‐18.57 [‐21.16, ‐15.98]
24.2 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Mean Difference (IV, Fixed, 95% CI)	‐19.0 [‐28.68, ‐9.32]
24.3 anterior colporrhaphy versus pelvicol overlay	1	57	Mean Difference (IV, Fixed, 95% CI)	‐9.0 [‐13.57, ‐4.43]
24.4 Anterior colporrhaphy versus porcine Small Intensine Submucosa (SIS)	1	56	Mean Difference (IV, Fixed, 95% CI)	‐16.0 [‐25.35, ‐6.65]
24.5 anterior colporrhaphy versus any type of graft (biological or synthetic)	6	776	Mean Difference (IV, Fixed, 95% CI)	‐14.58 [‐16.60, ‐12.55]
24.6 anterior colporrhaphy versus polypropylene synthetic mesh repair	3	613	Mean Difference (IV, Fixed, 95% CI)	‐15.75 [‐18.15, ‐13.35]
25 Length of stay in hospital (days) Show forest plot	6		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

25.1 fascial plication vs fascial plication with Pelvicol overlay	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.2 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.3 cystopexy vs cystopexy + pubourethral ligament plication	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.4 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.5 anterior colporrhaphy versus transvaginal polypropylene mesh	2		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
26 Number of women having further prolapse surgery Show forest plot	15		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

26.1 Vicryl vs Pelvicol	1	125	Risk Ratio (M‐H, Fixed, 95% CI)	3.05 [0.87, 10.73]
26.2 anterior colporrhaphy versus transobturator mesh	6	930	Risk Ratio (M‐H, Fixed, 95% CI)	2.18 [0.93, 5.10]
26.3 traditional anterior colporraphy vs abdominal Burch colposuspension	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
26.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.06, 2.71]
26.5 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
26.6 anterior colporrhaphy versus pelvicol overlay	2	107	Risk Ratio (M‐H, Fixed, 95% CI)	0.46 [0.11, 1.95]
26.7 Anterior colporrhaphy versus porcine Small Intensine Submucosa (SIS)	1	56	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
26.8 anterior colporrhaphy versus pericardial bovine collagen graft	1	44	Risk Ratio (M‐H, Fixed, 95% CI)	1.57 [0.59, 4.23]
27 Number of women having further incontinence surgery Show forest plot	8		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

27.1 anterior colporrhaphy versus armed transobturator polypropylene mesh	4	748	Risk Ratio (M‐H, Fixed, 95% CI)	1.29 [0.63, 2.63]
27.2 traditional anterior colporrhaphy vs abdominal Burch colposuspension	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	3.18 [0.35, 29.08]
27.3 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
27.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1	109	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
27.5 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	7.0 [0.38, 128.87]
28 number of women with denovo dyspareunia Show forest plot	5	429	Risk Ratio (M‐H, Fixed, 95% CI)	0.61 [0.28, 1.32]

29 Prolapse quality of life (PFDI‐20) Show forest plot	1	74	Mean Difference (IV, Fixed, 95% CI)	11.0 [‐3.36, 25.36]

29.1 anterior colporrhaphy versus polypropylene mesh kit	1	74	Mean Difference (IV, Fixed, 95% CI)	11.0 [‐3.36, 25.36]
30 quality of life (PFDI‐7) Show forest plot	1	68	Mean Difference (IV, Fixed, 95% CI)	9.0 [‐3.86, 21.86]

30.1 anterior colporrhaphy versus polypropylene mesh kit	1	68	Mean Difference (IV, Fixed, 95% CI)	9.0 [‐3.86, 21.86]
31 urinary distress inventory (UDI) Show forest plot	1	369	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐1.57, 1.57]

31.1 anterior colporrhaphy versus transvaginal mesh	1	369	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐1.57, 1.57]
32 mesh erosion surgical correction Show forest plot	6	931	Risk Ratio (M‐H, Fixed, 95% CI)	0.09 [0.03, 0.29]

32.1 anterior colporrhaphy versus transvaginal polypropylene mesh	6	931	Risk Ratio (M‐H, Fixed, 95% CI)	0.09 [0.03, 0.29]
33 new urinary stress incontinence postoperative Show forest plot	5	684	Risk Ratio (M‐H, Fixed, 95% CI)	0.62 [0.40, 0.98]

33.1 native tissue vaginal repair versus transvaginal polypropylene mesh	5	684	Risk Ratio (M‐H, Fixed, 95% CI)	0.62 [0.40, 0.98]
34 cystotomy Show forest plot	4	647	Risk Ratio (M‐H, Fixed, 95% CI)	0.19 [0.04, 1.06]

34.1 anterior colporrhaphy versus transvaginal polypropylene mesh	4	647	Risk Ratio (M‐H, Fixed, 95% CI)	0.19 [0.04, 1.06]
35 PISQ‐12 Prolapse and Incontinence Sexual Questionnaire Show forest plot	2	463	Mean Difference (IV, Fixed, 95% CI)	0.08 [‐0.18, 0.35]

36 Point Ba Show forest plot	1	44	Mean Difference (IV, Fixed, 95% CI)	0.9 [0.25, 1.55]

37 Point Aa Show forest plot	1	44	Mean Difference (IV, Fixed, 95% CI)	0.70 [0.25, 1.15]

38 Point C Show forest plot	1	44	Mean Difference (IV, Fixed, 95% CI)	0.60 [0.06, 1.14]

39 Point Bp Show forest plot	1	44	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.62, 0.62]

40 POPQ Total vaginal length in cm Show forest plot	1	44	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.43, 0.43]

41 Subsequent surgery (prolapse, incontinence, mesh exposure, pain) Show forest plot	9	1273	Risk Difference (M‐H, Random, 95% CI)	‐0.05 [‐0.08, ‐0.03]

Comparison 2. One method of anterior prolapse repair versus another surgical method

Navigate to table in Review

Comparison 3. One method of posterior prolapse repair versus another surgical method

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of women with prolapse symptoms (subjective failure) Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 posterior vaginal colporrhaphy vs transanal repair	2	87	Risk Ratio (M‐H, Fixed, 95% CI)	0.36 [0.13, 1.00]
1.2 posterior vaginal colporrhaphy vs site specific repair	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	1.17 [0.35, 3.93]
1.3 posterior vaginal colporrhaphy vs site specific repair with porcine small intestine graft inlay	2	181	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.45, 2.62]
2 Number of women with prolapse (objective failure) Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 posterior vaginal colporrhaphy vs transanal repair (rectocele)	2	87	Risk Ratio (M‐H, Fixed, 95% CI)	0.32 [0.07, 1.34]
2.2 posterior vaginal colporrhaphy vs transanal repair (enterocele)	2	87	Risk Ratio (M‐H, Fixed, 95% CI)	0.23 [0.07, 0.83]
2.3 posterior vaginal colporrhaphy vs transanal repair (rectocele or enterocele))	2	87	Risk Ratio (M‐H, Fixed, 95% CI)	0.24 [0.09, 0.64]
2.4 posterior vaginal colporrhaphy vs posterior colporrhaphy with mesh reinforcement for rectocele	1	132	Risk Ratio (M‐H, Fixed, 95% CI)	1.13 [0.40, 3.19]
2.5 posterior vaginal colporrhaphy vs site specific repair	1	55	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.20, 2.03]
2.6 posterior vaginal colporrhaphy vs site specific repair with porcine small intestine graft inlay	2	191	Risk Ratio (M‐H, Fixed, 95% CI)	0.47 [0.24, 0.94]
3 Number of women with faecal incontinence after operation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3.1 posterior vaginal colporrhaphy vs transanal repair	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Number of women with anal incontinence to flatus after operation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4.1 posterior vaginal colporrhaphy vs transanal repair	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Number of women with obstructed defecation / constipation after surgery Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

5.1 posterior vaginal colporrhaphy vs transanal repair	2	65	Risk Ratio (M‐H, Fixed, 95% CI)	0.73 [0.37, 1.42]
6 Number of women with sexual function not improved after operation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

6.1 posterior vaginal colporrhaphy vs transanal repair	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Number of women with dyspareunia Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

7.1 posterior vaginal colporrhaphy vs transanal repair	2	80	Risk Ratio (M‐H, Fixed, 95% CI)	3.13 [0.87, 11.23]
7.2 Posterior colporrhaphy vs site specific repair	1	42	Risk Ratio (M‐H, Fixed, 95% CI)	1.65 [0.71, 3.81]
7.3 posterior colporrhaphy vs site specific augmented with porcine small intestine submucosa graft	2	152	Risk Ratio (M‐H, Fixed, 95% CI)	1.26 [0.59, 2.68]
8 Blood loss (ml) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

8.1 posterior vaginal colporrhaphy vs transanal repair	2	87	Mean Difference (IV, Fixed, 95% CI)	79.38 [39.69, 119.08]
9 Change in hematocrit Show forest plot	1	142	Mean Difference (IV, Fixed, 95% CI)	‐0.48 [‐1.64, 0.68]

9.1 posterior colporrhaphy vs site specific repair	1	74	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐1.61, 1.61]
9.2 posterior colporrhaphy vs site specific with porcine small intestine submucosa graft	1	68	Mean Difference (IV, Fixed, 95% CI)	‐1.0 [‐2.67, 0.67]
10 Difference in haemoglobin Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

10.1 posterior vaginal colporrhaphy vs transanal repair	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Postoperative narcotic (morphine) use Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

11.1 posterior vaginal colporrhaphy vs transanal repair	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
12 Number of women with postoperative complications Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

12.1 posterior vaginal colporrhaphy vs transanal repair	2	87	Risk Ratio (M‐H, Fixed, 95% CI)	3.56 [0.80, 15.74]
12.2 posterior vaginal colporrhaphy vs site specific repair	1	74	Risk Ratio (M‐H, Fixed, 95% CI)	1.38 [0.87, 2.17]
12.3 posterior vaginal colporrhaphy vs site specific repair with porcine small intestine graft inlay	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.69, 1.53]
13 Persistent postoperative pain Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

13.1 posterior vaginal colporrhaphy vs transanal repair	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14 Operating time (minutes) Show forest plot	3		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

14.1 posterior vaginal colporrhaphy vs transanal repair	2	87	Mean Difference (IV, Fixed, 95% CI)	‐3.64 [‐7.43, 0.15]
14.2 posterior colporrhaphy vs site specific repair	1	74	Mean Difference (IV, Fixed, 95% CI)	‐1.0 [‐32.22, 30.22]
14.3 posterior colporrhaphy versus site specific and porcine small intestine submucosa graft	1	69	Mean Difference (IV, Fixed, 95% CI)	‐19.0 [‐49.68, 11.68]
15 Length of stay in hospital (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

15.1 posterior vaginal colporrhaphy vs transanal repair	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
16 Number of women having further prolapse surgery Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

16.1 posterior vaginal colporrhaphy vs site specific repair	1	70	Risk Ratio (M‐H, Fixed, 95% CI)	0.56 [0.05, 5.90]
16.2 posterior vaginal colporrhaphy vs site specific repair with porcine small intestine graft inlay	1	62	Risk Ratio (M‐H, Fixed, 95% CI)	0.29 [0.03, 2.66]
17 rectocele size (centimetres) on defecography Show forest plot	1	48	Mean Difference (IV, Fixed, 95% CI)	‐1.14 [‐1.96, ‐0.32]

18 modified obstructed defecation syndrome patient questionnaire Show forest plot	1	32	Mean Difference (IV, Fixed, 95% CI)	‐5.10 [‐9.63, ‐0.57]

19 rectocele on examination (point Ap) Show forest plot	1	52	Mean Difference (IV, Fixed, 95% CI)	‐0.68 [‐1.08, ‐0.28]

Comparison 3. One method of posterior prolapse repair versus another surgical method

Navigate to table in Review

Comparison 6. No graft versus use of graft (synthetic mesh or biological graft)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of women with prolapse symptoms (subjective failure) Show forest plot	10		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 anterior and posterior colporrhaphy versus colporrhaphy with Vicryl mesh overlay	1	54	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.70, 1.31]
1.2 fascial plication vs fascial plication with Pelvicol overlay	1	201	Risk Ratio (M‐H, Fixed, 95% CI)	1.37 [0.62, 3.07]
1.3 anterior colporrhaphy vs cadaveric fascia lata (Tutoplast)	1	112	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.33, 2.81]
1.4 posterior colporrhaphy or site specific repair versus site specific repair with porcine intestine graft inlay	1	88	Risk Ratio (M‐H, Fixed, 95% CI)	0.7 [0.28, 1.78]
1.5 anterior or posterior repair versus repair with polypropylene mesh	6	930	Risk Ratio (M‐H, Fixed, 95% CI)	1.44 [1.15, 1.80]
1.6 uterosacral vaginal repair versus polyprolene mesh kit	1	59	Risk Ratio (M‐H, Fixed, 95% CI)	2.36 [0.26, 21.42]
1.7 native tissue repair versus repair with any graft ( synthetic, or allografts)	9	1331	Risk Ratio (M‐H, Fixed, 95% CI)	1.36 [1.10, 1.67]
1.8 colporrhaphy vs biological graft repair	3	401	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.61, 1.75]
1.9 native tissue versus combined total or anterior or posterior vaginal mesh	2	218	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.59, 1.93]
2 Prolapse symptom score at 1 to 5 years Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2.1 anterior and posterior colporrhaphy versus colporrhaphy with Vicryl mesh overlay	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Quality of life (VAS) for severity of prolapse symptoms Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3.1 fascial plication vs fascial plication with Pelvicol overlay	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 anterior or posterior repair alone versus repair with polyglactin (Vicryl) mesh inlay	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Number of women with anterior prolapse / cystocele (objective failure) Show forest plot	6		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.1 traditional or ultralateral anterior colporraphy vs anterior colporraphy + polyglactin mesh reinforcement	2	226	Risk Ratio (M‐H, Fixed, 95% CI)	1.39 [1.02, 1.90]
4.2 fascial plication vs fascial plication with Pelvicol overlay	2	230	Risk Ratio (M‐H, Fixed, 95% CI)	2.09 [1.08, 4.06]
4.3 anterior colporrhaphy vs cadaveric fascia lata (Tutoplast)	1	154	Risk Ratio (M‐H, Fixed, 95% CI)	1.40 [0.80, 2.44]
4.4 Anterior colporrhaphy versus porcine Small Intensine Submucosa (SIS)	1	56	Risk Ratio (M‐H, Fixed, 95% CI)	2.95 [1.07, 8.17]
5 Objective failure all sites Show forest plot	4	420	Risk Ratio (M‐H, Fixed, 95% CI)	1.32 [1.07, 1.64]

5.1 anterior and posterior colporrhaphy versus colporrhaphy with Vicryl mesh overlay	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	1.88 [0.37, 9.58]
5.2 anterior and posterior colporrhaphy versus colporrhaphy with polypropylene mesh overlay	2	289	Risk Ratio (M‐H, Fixed, 95% CI)	1.38 [1.07, 1.79]
5.3 uterosacral colpopexy versus vaginal polypropylene mesh	1	65	Risk Ratio (M‐H, Fixed, 95% CI)	1.12 [0.79, 1.58]
6 Number of women with posterior prolapse / rectocele (objective failure) Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

6.1 traditional anterior colporraphy vs anterior colporraphy + polyglactin mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.2 posterior colporrhaphy or site specific repair versus site specific repair with porcine intestine graft inlay	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Objective failure, any site, no mesh versus any mesh Show forest plot	20	6003	Risk Ratio (M‐H, Random, 95% CI)	1.95 [1.66, 2.28]

7.1 No mesh versus any absorbable synthetic mesh	3	292	Risk Ratio (M‐H, Random, 95% CI)	1.35 [0.94, 1.95]
7.2 No mesh versus any biological mesh	6	565	Risk Ratio (M‐H, Random, 95% CI)	1.35 [0.74, 2.46]
7.3 No mesh versus any non‐absorbable polypropylene mesh	11	1155	Risk Ratio (M‐H, Random, 95% CI)	2.45 [1.64, 3.67]
7.4 native tissue repair versus any graft ( biological, absorbable or permanent mesh)	18	1912	Risk Ratio (M‐H, Random, 95% CI)	1.84 [1.37, 2.46]
7.5 native tissue repair versus any transobturator mesh	7	848	Risk Ratio (M‐H, Random, 95% CI)	2.47 [1.46, 4.18]
7.6 native tissue repair versus self‐styled transobturator mesh	2	285	Risk Ratio (M‐H, Random, 95% CI)	3.41 [2.05, 5.68]
7.7 native tissue repair versus commercial transobturator mesh kit	5	563	Risk Ratio (M‐H, Random, 95% CI)	2.22 [1.22, 4.03]
7.8 native tissue versus combined total or anterior or posterior vaginal mesh	3	383	Risk Ratio (M‐H, Random, 95% CI)	1.39 [0.97, 2.00]
8 Number of women having repeat prolapse surgery Show forest plot	15		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

8.1 anterior or posterior repair alone versus repair with polyglactin (Vicryl) mesh inlay	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	1.88 [0.37, 9.58]
8.2 native tissue vaginal repair versus transvaginal polpropylene mesh kit	10	1365	Risk Ratio (M‐H, Fixed, 95% CI)	1.95 [1.00, 3.81]
8.3 native tissue vaginal repair versus biological graft repair	5	306	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.41, 1.63]
8.4 native tissue versus combined total or anterior or posterior vaginal mes	3	383	Risk Ratio (M‐H, Fixed, 95% CI)	1.62 [0.54, 4.85]
9 Number of women with urgency, detrusor overactivity or overactive bladder Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

9.1 fascial plication vs fascial plication with Pelvicol overlay	1	201	Risk Ratio (M‐H, Fixed, 95% CI)	1.14 [0.61, 2.14]
10 Number of women with postoperative urinary incontinence Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

10.1 fascial plication vs fascial plication with Pelvicol overlay	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10.2 anterior or posterior repair alone versus repair with polyglactin (Vicryl) mesh inlay	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Postoperative voiding dysfunction symptoms Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

11.1 fascial plication vs fascial plication with Pelvicol overlay	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11.2 anterior colporrhaphy vs cadaveric fascia lata (Tutoplast)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
12 Persistent voiding dysfunction Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

12.1 anterior colporrhaphy vs cadaveric fascia lata (Tutoplast)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Number of women with dyspareunia Show forest plot	6		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

13.1 fascial plication vs fascial plication with Pelvicol overlay	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
13.2 posterior colporrhaphy or site specific repair versus site specific repair with porcine intestine graft inlay	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
13.3 anterior and posterior colporrhaphy versus Anterior and posterior polypropylene Mesh overlay	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
13.4 anterior or posterior repair alone versus repair with polyglactin (Vicryl) mesh inlay	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
13.5 native tissue vaginal repair versus transvaginal polpropylene mesh	2		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14 De novo dyspareunia Show forest plot	9	851	Risk Ratio (M‐H, Fixed, 95% CI)	1.24 [0.86, 1.77]

14.1 anterior and posterior colporrhaphy versus Anterior and posterior polypropylene Mesh overlay	2	188	Risk Ratio (M‐H, Fixed, 95% CI)	1.23 [0.64, 2.36]
14.2 native tissue repair vs mesh repair	9	663	Risk Ratio (M‐H, Fixed, 95% CI)	1.24 [0.80, 1.90]
15 Number of women with postoperative complications Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

15.1 fascial plication vs fascial plication with Pelvicol overlay	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15.2 traditional or ultralateral anterior colporraphy vs anterior colporraphy + polyglactin mesh reinforcement	2		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15.3 posterior colporrhaphy or site specific repair versus site specific repair with porcine intestine graft inlay	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
16 Death Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

16.1 traditional or ultralateral anterior colporraphy vs anterior colporraphy + polyglactin mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
16.2 anterior or posterior repair alone versus repair with polyglactin (Vicryl) mesh inlay	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
17 Length of stay in hospital (days) Show forest plot	3		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

17.1 fascial plication vs fascial plication with Pelvicol overlay	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
17.2 native tissue versus transvaginal polypropylene mesh	2		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
18 new urinary stress incontinence postoperative Show forest plot	4	326	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.96, 1.19]

18.1 native tissue vaginal repair versus transvaginal polpropylene mesh kit	4	326	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.96, 1.19]
19 mesh erosion Show forest plot	13	1998	Risk Ratio (M‐H, Fixed, 95% CI)	0.06 [0.03, 0.12]

19.1 native tissue vaginal repair versus transvaginal polypropylene mesh	13	1615	Risk Ratio (M‐H, Fixed, 95% CI)	0.06 [0.03, 0.14]
19.2 native tissue versus combined total or anterior or posterior vaginal mesh	3	383	Risk Ratio (M‐H, Fixed, 95% CI)	0.04 [0.01, 0.21]
20 surgery for mesh erosion Show forest plot	3	383	Risk Ratio (M‐H, Fixed, 95% CI)	0.08 [0.02, 0.42]

20.1 native tissue versus combined total or anterior or posterior vaginal mesh	3	383	Risk Ratio (M‐H, Fixed, 95% CI)	0.08 [0.02, 0.42]
21 cystotomy Show forest plot	6	1361	Risk Ratio (M‐H, Fixed, 95% CI)	0.24 [0.09, 0.59]

21.1 native tissue versus combined total or anterior or posterior vaginal mesh	4	427	Risk Ratio (M‐H, Fixed, 95% CI)	0.26 [0.06, 1.19]
21.2 native tissue vaginal repair versus transvaginal polypropylene mesh	5	934	Risk Ratio (M‐H, Fixed, 95% CI)	0.22 [0.07, 0.70]
22 Patient global impression of improvement (PGI‐I) very much or much better Show forest plot	2	235	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.87, 1.23]

22.1 native tissue vaginal repair versus transvaginal polpropylene mesh kit	2	235	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.87, 1.23]
23 PISQ‐12 Prolapse and Incontinence Sexual Questionnaire Show forest plot	4	588	Mean Difference (IV, Fixed, 95% CI)	0.09 [‐0.17, 0.36]

24 number undergoing further continence surgery Show forest plot	5	808	Risk Ratio (M‐H, Fixed, 95% CI)	1.18 [0.59, 2.33]

25 Subsequent surgery (prolapse, incontinence, mesh exposure, pain) Show forest plot	3	383	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [1.02, 1.15]

26 Blood loss (ml) Show forest plot	5		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

26.1 fascial plication vs Pelvicol overlay	2	258	Mean Difference (IV, Fixed, 95% CI)	0.56 [‐19.57, 20.70]
26.2 native tissue versus armed transobturator polypropylene mesh	2	569	Mean Difference (IV, Fixed, 95% CI)	‐64.04 [‐80.39, ‐47.69]
26.3 native tissue versus repair with any graft (permanent or biological)	5	871	Mean Difference (IV, Fixed, 95% CI)	‐35.32 [‐47.55, ‐23.09]
27 Point Ba Show forest plot	1	44	Mean Difference (IV, Fixed, 95% CI)	0.9 [0.25, 1.55]

28 Point Aa Show forest plot	1	44	Mean Difference (IV, Fixed, 95% CI)	0.70 [0.25, 1.15]

29 Point C Show forest plot	1	44	Mean Difference (IV, Fixed, 95% CI)	0.60 [0.06, 1.14]

30 Point Bp Show forest plot	1	44	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.62, 0.62]

31 POPQ Total vaginal length in cm Show forest plot	1	44	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.43, 0.43]

Comparison 6. No graft versus use of graft (synthetic mesh or biological graft)

Navigate to table in Review

Comparison 7. One type of graft (synthetic mesh or biological graft) versus another type of graft

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of women with prolapse symptoms (subjective failure)	0		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.1 Prolene soft vs Pelvicol	0		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Number of women with anterior prolapse / cystocele (objective failure) Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2.1 Vicryl vs Pelvicol	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 Monofilament Polypropylene Mesh versus Porcine Dermis Graft	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Number of women having further prolapse surgery Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3.1 Vicryl vs Pelvicol	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 Monofilament Polypropylene Mesh versus Porcine Dermis Graft	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Stress urinary incontinence de novo Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4.1 Monofilament Polypropylene Mesh versus Porcine Dermis Graft	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Increased daytime urinary frequency post‐op Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

5.1 Monofilament Polypropylene Mesh versus Porcine Dermis Graft	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Dyspareunia post‐op Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

6.1 Monofilament Polypropylene Mesh versus Porcine Dermis Graft	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Vaginal mesh erosion Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

7.1 Monofilament Polypropylene Mesh (Prolene soft) versus Porcine Dermis Graft	0		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.2 armed polypropylene mesh versus porcine dermis graft	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Hospital stay (days) Show forest plot	1	190	Mean Difference (IV, Fixed, 95% CI)	‐0.40 [‐0.90, 0.10]

8.1 Monofilament Polypropylene Mesh versus Porcine Dermis Graft	1	190	Mean Difference (IV, Fixed, 95% CI)	‐0.40 [‐0.90, 0.10]

Comparison 7. One type of graft (synthetic mesh or biological graft) versus another type of graft

Navigate to table in Review

Comparison 8. One suture type versus another type of suture

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of women with prolapse symptoms up to 1 year (subjective failure) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 Polydioxanone (PDS) suture versus polyglactin (Vicryl) suture	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Number of women with prolapse symptoms at 1 to 5 years (subjective failure) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2.1 Polydioxanone (PDS) suture versus polyglactin (Vicryl) suture	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Prolapse symptom score up to 1 year Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3.1 Polydioxanone (PDS) suture versus polyglactin (Vicryl) suture	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Prolapse symptom score at 1 to 5 years Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4.1 Polydioxanone (PDS) suture versus polyglactin (Vicryl) suture	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Quality of life score due to prolapse (VAS) up to 1 year Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5.1 Polydioxanone (PDS) suture versus polyglactin (Vicryl) suture	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Quality of life score due to prolapse (VAS) at 1 to 5 years Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6.1 Polydioxanone (PDS) suture versus polyglactin (Vicryl) suture	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Objective failure all sites Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

7.1 Polydioxanone (PDS) suture versus polyglactin (Vicryl) suture	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Number of women with urinary incontinence at 1 to 5 years Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

8.1 Polydioxanone (PDS) suture versus polyglactin (Vicryl) suture	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 ICI Urinary symptom score at 1 to 5 years Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

9.1 Polydioxanone (PDS) suture versus polyglactin (Vicryl) suture	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Number of women with dyspareunia at 1 to 5 years Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

10.1 Polydioxanone (PDS) suture versus polyglactin (Vicryl) suture	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Death Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

11.1 Polydioxanone (PDS) suture versus polyglactin (Vicryl) suture	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
12 Number of women having repeat prolapse surgery Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

12.1 Polydioxanone (PDS) suture versus polyglactin (Vicryl) suture	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 8. One suture type versus another type of suture

Navigate to table in Review

Comparison 9. Prolapse surgery and bladder function

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 number with de novo ( new) stress urinary incontinence Show forest plot	15	2731	Risk Ratio (M‐H, Random, 95% CI)	1.16 [0.86, 1.56]

1.1 sacral colpopexy versus vaginal colpopexy	1	46	Risk Ratio (M‐H, Random, 95% CI)	0.27 [0.06, 1.15]
1.2 cystopexy versus cystopexy with pubourethral ligament plication	1	102	Risk Ratio (M‐H, Random, 95% CI)	0.96 [0.25, 3.64]
1.3 prolapse repair with urethrovesical plication versus prolapse repair with needle suspension	2	102	Risk Ratio (M‐H, Random, 95% CI)	2.02 [0.08, 50.63]
1.4 sacral colpopexy versus sacral colpopexy and colposuspension	2	364	Risk Ratio (M‐H, Random, 95% CI)	1.04 [0.38, 2.82]
1.5 prolapse repair versus prolapse repair +suburethral tape (TVT)	2	387	Risk Ratio (M‐H, Random, 95% CI)	2.44 [0.75, 7.95]
1.6 prolapse surgery without continence surgery versus prolapse surgery with continence surgery	6	832	Risk Ratio (M‐H, Random, 95% CI)	1.81 [1.21, 2.71]
1.7 native tissue repair versus armed transobturator polypropylene mesh	6	898	Risk Ratio (M‐H, Random, 95% CI)	0.67 [0.48, 0.93]
2 Number with de novo (new) stress urinary incontinence (objective) Show forest plot	4	522	Risk Ratio (M‐H, Random, 95% CI)	1.81 [1.02, 3.22]

2.1 prolapse repair +urethrovesical plication versus prolapse repair + needle suspension	1	83	Risk Ratio (M‐H, Random, 95% CI)	1.19 [0.75, 1.91]
2.2 Prolapse repair without TVT versus prolapse repair and suburethral tape	3	439	Risk Ratio (M‐H, Random, 95% CI)	3.72 [0.91, 15.20]
3 Further continence surgery Show forest plot	9	1491	Risk Ratio (M‐H, Fixed, 95% CI)	4.04 [2.69, 6.07]

3.1 Prolapse surgery without continence surgery versus prolapse surgery with continence surgery	3	456	Risk Ratio (M‐H, Fixed, 95% CI)	1.97 [1.20, 3.23]
3.2 prolapse surgery ( continent women) versus prolapse surgery with TVT	1	52	Risk Ratio (M‐H, Fixed, 95% CI)	2.79 [0.12, 65.38]
3.3 cystopexy versus cystopexy with pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.4 sacral colpopexy versus vaginal sacrospinous colpopexy	2	207	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.28, 3.95]
3.5 prolapse repair + urethrovesical plication versus prolapse repair and needle suspension	1	73	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.6 prolapse surgery (incontinent women) +urethrovesical plication versus prolapse surgery and suburethral tape (TVT)	1	181	Risk Ratio (M‐H, Fixed, 95% CI)	99.12 [6.21, 1581.10]
3.7 Prolpase repair +urethrovesical fascial repair versus prolpase repair +TVT	3	420	Risk Ratio (M‐H, Fixed, 95% CI)	6.37 [1.46, 27.72]
4 Number with denovo (new) urgency, detrusor overactivity or overactive bladder Show forest plot	10	1005	Risk Ratio (M‐H, Fixed, 95% CI)	1.12 [0.80, 1.55]

4.1 sacral colpopexy versus vaginal colpopexy	1	62	Risk Ratio (M‐H, Fixed, 95% CI)	1.61 [0.68, 3.81]
4.2 cystopexy versus cystopexy with pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.06, 14.96]
4.3 prolapse repair with urethrovesical plication versus prolapse repair with needle suspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.20, 4.49]
4.4 Prolene soft versus Pevicol	1	37	Risk Ratio (M‐H, Fixed, 95% CI)	0.47 [0.05, 4.78]
4.5 prolapse repair versus prolapse repair +suburethral tape (TVT)	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.04, 2.99]
4.6 native tissue repair versus transvaginal mesh	1	151	Risk Ratio (M‐H, Fixed, 95% CI)	1.10 [0.43, 2.77]
4.7 abdominal sacrocolpopexy alone vs abdominal sacrocolpopexy with Burch colposuspension	1	304	Risk Ratio (M‐H, Fixed, 95% CI)	1.36 [0.87, 2.15]
4.8 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	1	45	Risk Ratio (M‐H, Fixed, 95% CI)	2.64 [0.11, 61.54]
4.9 high levator myorrhaphy vs uterosacral vag vault suspension	1	116	Risk Ratio (M‐H, Fixed, 95% CI)	0.29 [0.06, 1.32]
5 Longterm voiding dysfunction Show forest plot	12	1209	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.67, 1.28]

5.1 sacral colpopexy versus vaginal colpopexy	1	75	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.07, 15.82]
5.2 cystopexy versus cystopexy with pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.09 [0.00, 1.54]
5.3 prolapse repair with urethrovesical plication versus prolapse repair with needle suspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.49, 2.26]
5.4 High levator myorrhaphy vs uterosacral vag vault suspension	1	116	Risk Ratio (M‐H, Fixed, 95% CI)	2.2 [0.82, 5.94]
5.5 prolapse repair versus prolapse repair +suburethral tape (TVT)	2	368	Risk Ratio (M‐H, Fixed, 95% CI)	0.20 [0.04, 1.12]
5.6 vaginal sacrospinous colpopexy vs posterior intravaginal slingplasty	1	45	Risk Ratio (M‐H, Fixed, 95% CI)	1.75 [0.36, 8.61]
5.7 anterior colporrhaphy vs cadaveric fascia lata (Tutoplast)	1	105	Risk Ratio (M‐H, Fixed, 95% CI)	1.18 [0.73, 1.91]
5.8 traditional anterior colporraphy vs abdominal Burch colposuspension	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.9 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.09 [0.00, 1.54]
5.10 anterior colporrhaphy versus transvaginal polypropylene mesh	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.13, 69.52]
5.11 anterior colporrhaphy versus SIS graft	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.11, 4.74]
6 Number with new or denovo SUI who had occult SUI pre‐operatively Show forest plot	4	242	Risk Ratio (M‐H, Random, 95% CI)	2.61 [0.81, 8.42]

7 post prolapse surgery SUI objective Show forest plot	10	1582	Risk Ratio (M‐H, Random, 95% CI)	1.92 [1.23, 3.00]

7.1 Prolapse surgery with and without continence surgery	8	1010	Risk Ratio (M‐H, Random, 95% CI)	1.63 [1.07, 2.47]
7.2 Prolapse surgery no TVT versus prolapse surgery with TVT	1	52	Risk Ratio (M‐H, Random, 95% CI)	8.33 [1.14, 61.15]
7.3 sacral colpopexy without colposuspension in continent women versus sacral colpopexy + colposuspension	1	292	Risk Ratio (M‐H, Random, 95% CI)	1.83 [1.29, 2.61]
7.4 Prolapse surgery alone (incontinent women) versus prolapse surgery with continence surgery	2	228	Risk Ratio (M‐H, Random, 95% CI)	3.29 [0.09, 115.01]
8 Incontinence Impact Questionnaire IIQ post Show forest plot	1	47	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐1.96, 1.96]

8.1 sacral colpopexy without colposuspension versus sacral colpopexy with colposuspension	1	47	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐1.96, 1.96]
9 Urinary Distress Inventory (UDI‐6) Show forest plot	2	358	Mean Difference (IV, Fixed, 95% CI)	0.35 [‐1.06, 1.76]

9.1 sacral colpopexy without colposuspension (continent women) versus sacral colpopexy with colposuspension	1	311	Mean Difference (IV, Fixed, 95% CI)	10.7 [2.93, 18.47]
9.2 sacral colpoopexy without colpopsuspension ( incontinent women) versus sacral colpopexy with colpsuspension	1	47	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐1.43, 1.43]
10 Bothersome SUI (PFDI) post‐operative Show forest plot	2	483	Risk Ratio (M‐H, Fixed, 95% CI)	4.74 [3.05, 7.37]

10.1 Prolapse surgery without TVT versus prolapse surgery with TVT	1	181	Risk Ratio (M‐H, Fixed, 95% CI)	15.50 [5.90, 40.72]
10.2 sacral colpopexy without colpsuspension versus sacral colpopexy with colposuspension	1	302	Risk Ratio (M‐H, Fixed, 95% CI)	2.18 [1.29, 3.67]
11 satisfaction (VAS 0‐10) Show forest plot	1	47	Mean Difference (IV, Fixed, 95% CI)	1.0 [0.07, 1.93]

11.1 sacral colpopexy without colposuspension versus sacral colpopexy with colposuspension	1	47	Mean Difference (IV, Fixed, 95% CI)	1.0 [0.07, 1.93]
12 Pelvic Floor Incontinence questionnaire (PFIQ) bladder domain Show forest plot	1	311	Mean Difference (IV, Fixed, 95% CI)	2.90 [0.16, 5.64]

12.1 sacral colpopexy without colpsuspension versus sacral colpopexy with colposuspension	1	311	Mean Difference (IV, Fixed, 95% CI)	2.90 [0.16, 5.64]
13 Pelvic organ Prolapse/Urinary incontinence Sexual Function Questionnaire (PISQ) Show forest plot	1	194	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐1.38, 1.58]

13.1 Sacral colpopexy without continence surgery versus sacral colpopexy with colposuspension	1	194	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐1.38, 1.58]
14 further Prolapse surgery Show forest plot	1	311	Risk Ratio (M‐H, Fixed, 95% CI)	2.91 [0.60, 14.17]

14.1 Sacral colpopexy with colposuspension versus sacral colpopexy with colposuspension	1	311	Risk Ratio (M‐H, Fixed, 95% CI)	2.91 [0.60, 14.17]
15 De novo Stress urinary incontinence women with negative preoperative stress test Show forest plot	2	455	Risk Ratio (M‐H, Random, 95% CI)	1.68 [1.22, 2.32]

16 blood loss (mls) Show forest plot	1	311	Mean Difference (IV, Fixed, 95% CI)	‐70.0 [‐113.02, ‐26.98]

16.1 sacral colpopexy without colposuspension versus sacral colpopexy with colposuspension	1	311	Mean Difference (IV, Fixed, 95% CI)	‐70.0 [‐113.02, ‐26.98]
17 POPQ point Aa Show forest plot	1	47	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.43, 0.43]

17.1 sacral colpopexy without colposuspension versus sacral colpopexy with colposuspension	1	47	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.43, 0.43]
18 Point Ap Show forest plot	1	47	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.43, 0.43]

18.1 sacral colpopexy without colposuspension versus sacral colpopexy with colposuspension	1	47	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.43, 0.43]
19 POP‐Q Point Ba Show forest plot	2	296	Std. Mean Difference (IV, Fixed, 95% CI)	0.48 [0.25, 0.71]

19.1 sacral colpopexy without colposuspension versus sacral colpopexy with colposuspension	2	296	Std. Mean Difference (IV, Fixed, 95% CI)	0.48 [0.25, 0.71]
20 POPQ point Bp Show forest plot	2	296	Mean Difference (IV, Fixed, 95% CI)	‐0.01 [‐0.23, 0.21]

20.1 sacral colpopexy without colposuspension versus sacral colpopexy with colposuspension	2	296	Mean Difference (IV, Fixed, 95% CI)	‐0.01 [‐0.23, 0.21]
21 POPQ point C Show forest plot	2	358	Mean Difference (IV, Fixed, 95% CI)	0.41 [0.13, 0.69]

21.1 sacral colpopexy without colposuspension versus sacral colpopexy with colposuspension	2	358	Mean Difference (IV, Fixed, 95% CI)	0.41 [0.13, 0.69]
22 POPQ point D Show forest plot	1	47	Mean Difference (IV, Fixed, 95% CI)	‐0.5 [‐0.86, ‐0.14]

22.1 sacral colpopexy without colposuspension versus sacral colpopexy with colposuspension	1	47	Mean Difference (IV, Fixed, 95% CI)	‐0.5 [‐0.86, ‐0.14]
23 Total vaginal length (TVL cm) Show forest plot	1	47	Mean Difference (IV, Fixed, 95% CI)	0.5 [‐0.09, 1.09]

23.1 sacral colpopexy without colposuspension versus sacral colpopexy with colposuspension	1	47	Mean Difference (IV, Fixed, 95% CI)	0.5 [‐0.09, 1.09]
24 Pelvic Floor Urinary Impact Questionnaire (PFUIQ) Show forest plot	1	301	Mean Difference (IV, Fixed, 95% CI)	2.30 [‐13.21, 17.81]

25 Number with persisting stress urinary incontinence after prolpase and continence surgery Show forest plot	4	312	Risk Ratio (M‐H, Fixed, 95% CI)	3.42 [2.37, 4.92]

25.1 Anterior colporrhaphy versus colposuspension	1	67	Risk Ratio (M‐H, Fixed, 95% CI)	2.19 [1.15, 4.15]
25.2 Anterior colporrhaphy versus biological graft	1	17	Risk Ratio (M‐H, Fixed, 95% CI)	1.79 [0.73, 4.36]
25.3 prolaspe surgery without TVT versus prolapse surgery with TVT	1	181	Risk Ratio (M‐H, Fixed, 95% CI)	15.50 [5.90, 40.72]
25.4 sacral colpopexy/hysteropexy no colposuspension versus sacral colpopexy/ hysteropexy with colposuspension	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.39, 1.35]

Comparison 9. Prolapse surgery and bladder function

Navigate to table in Review

Cochrane Review language

Website language

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

PICOs

PICOs

Population

Intervention

Comparison

Outcome

Plain language summary

Surgical management of pelvic organ prolapse in women

Visual summary

Authors' conclusions

Implications for practice

Implications for research

Background

Description of the condition

Description of the intervention

Why it is important to do this review

Objectives

1. One type of upper vaginal prolapse (uterine and vaginal vault) repair versus another

2. One type of anterior vaginal wall prolapse repair versus another

3. One type of posterior vaginal wall prolapse repair versus another

4. Any type of surgical prolapse repair versus conservative treatment

5. Any type of surgical prolapse repair versus mechanical devices

6. No graft versus use of graft (synthetic mesh or biological graft)

7. One type of graft (synthetic mesh or biological graft) versus another type of graft

8. One type of suture versus another type of suture

9. Prolapse surgery and bladder function

A. One type of POP surgery alone versus another type of POP surgery alone

B. POP surgery alone versus POP surgery with an additional continence procedure

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Types of outcome measures

Primary outcomes

Women's observations related to prolapse

Clinicians' observations related to prolapse

Secondary outcomes

Quality of life

Measures of associated symptoms (objective or subjective)

Surgical outcome measures

Complications

Economic measures

Search methods for identification of studies

Electronic searches

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Data synthesis

Subgroup analysis and investigation of heterogeneity

Results

Description of studies

Results of the search

Excluded studies

Risk of bias in included studies

Allocation

Blinding

Incomplete outcome data

Other potential sources of bias

Effects of interventions

1. One type of upper vaginal prolapse (uterine and vaginal vault) repair versus another (Comparison 1)

Abdominal sacral colpopexy versus vaginal sacrospinous colpopexy

Sacral colpopexy and abdominal hysterectomy versus vaginal Mayo McCall culdoplasty and vaginal hysterectomy

Uterine suspension (preservation) versus vaginal hysterectomy

Abdominal uterine preservation versus vaginal hysterectomy and repair

Long‐term follow up

Vaginal sacrospinous uterine suspension versus vaginal hysterectomy

Hysterectomy with high levator myorrhaphy (HLM) versus hysterectomy with uterosacral vaginal vault suspension (UVVS)

Open abdominal sacral colpopexy versus laparoscopic sacral colpopexy (LSC)