editorial comment re: surgical management of pelvic organ prolapse in women: a short version...

Neurourology and Urodynamics 27:2 (2008)

Editorial Comment Re: Surgical Managementof Pelvic Organ Prolapse in Women:A Short Version Cochrane Review

Adrian Grant,1 Cathryn Glazener,1 and Chris Maher21University of Aberdeen, UK

2Royal Women’s and Maternity Hospitals, Brisbane, Australia

Around 1 in 10 women will need a surgical vaginal prolapserepair in their lifetime, and 50% of parous women will haveprolapse with symptoms. With our ageing population, this isset to increase. On pages 3 to 12 we publish a precisedversion of a recently updated Cochrane review on surgery forvaginal prolapse. This shows that despite the prevalence of theproblem, and an estimated failure rate for primary surgery of30%, there is a disappointing lack of evidence about the bestsurgical techniques.

The authors of the Cochrane systematic review, usingexhaustive search techniques, found only 22 randomised orquasi-randomised trials on 2368 women undergoing prolapserepair. Most of the trials were small or of poor quality, andaddressed disparate operations or types of prolapse, resultingin limited and diffuse evidence. Important take homemessages include: abdominal sacrocolpopexy results in abetter anatomical outcome than the vaginal sacrospinouscolpopexy in women with upper vaginal prolapse, but athigher cost; mesh inlays might improve the objective successrate for anterior repair, but there was no long term evidence ofeffect on quality of life or failure; and traditional posteriorrepair is superior to transanal repair for posterior vaginal wallprolapse. In particular, the trials were short on subjective,patient-determined outcomes, which are what matter towomen having the surgery. The authors illustrated howlimited the current evidence base is for prolapse surgery.

This is a particular concern at a time when new procedures,particularly involving mesh or grafts, with or without intro-ducer kits, and laparoscopic approaches, are being promotedwithout any rigorous evidence about their effectiveness orsafety. This raises questions about how well the interests ofwomen are being safeguarded. In particular, the plethora ofmesh or graft material, ranging from absorbable (synthetic

and biological) to non-absorbable materials, indicates howuncertain we are about the best management. If these werenew drugs they would require much more stringent evalua-tion before widespread use.

What should we do? One attitude is to just say that there isnothing that can be done, as any research started now will beoutdated by the time it is completed. The alternative is to gettogether as a community, identify the fundamental differ-ences in approaches and to mount collaborative randomisedtrials to find out which are the most effective, cost-effectiveand safe. We could also lobby the regulatory authorities toconsider introducing safeguards over the introduction of newdevices at least until basic safety and efficacy is established.

Current impediments at the moment are: lack of stand-ardised, validated outcomes; lack of collaborative clinicalnetworks; a perception that it is not possible to evaluate newsurgical procedures (for cost reasons, the long time scale untilevidence is available, learning and skill issues, and theintroduction of newer procedures before the older ones havebeen evaluated); and as a result of all these factors, nointernational track record in mounting such trials.

AUTHOR DISCLOSURES

C. Maher is an author of one of the included trials (Maher2004). C. Glazener is an author of an ongoing trial (Allahdin2007).

REFERENCE

1. Maher C, Baessler K, Glazener CMA, Adams EJ, Hagen S. Surgical management ofpelvic organ prolapse in women. Cochrane Database of Systematic Reviews 2007,Issue 3. Art. No.: CD004014. DOI: 10.1002/14651858.CD004014.pub3.

Published online in Wiley InterScience(www.interscience.wiley.com)DOI 10.1002/nau.20541

� 2007 Wiley-Liss, Inc.