Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis

Dr. Ghetti reports no financial relationships relevant to this field of study.

SYNOPSIS: This is a summary of the 2017 International Consultation on Incontinence recommendations for surgical treatment of pelvic organ prolapse.

SOURCE: Maher CF, et al. Summary: 2017 International Consultation on Incontinence Evidence-Based Surgical Pathway for Pelvic Organ Prolapse. Female Pelvic Med Reconstr Surg 2018; Apr 28. doi: 10.1097/SPV.0000000000000591. [Epub ahead of print].

The objective of this work was to develop an evidence-based consensus pathway for the surgical management of pelvic organ prolapse (POP). The committee searched English-language, peer-reviewed articles relating to POP surgery that were published before December 2016. Although they preferred level 1 evidence (randomized, controlled trials [RCTs] or systematic reviews of RCTs), level 2 or level 3 evidence was included if level 1 was not available. After evaluating the literature and reaching consensus, the committee made recommendations based on the highest level of evidence available according to the Oxford evidence-based method: grade A (based on consistent level 1 evidence); grade B (based on consistent level 2 and/or 3 studies or “majority evidence” from RCTs); grade C (based on level 3 studies or “majority evidence” from level 2/3 studies or expert opinion); and grade D, “no recommendation possible” (used when the evidence was inadequate or conflicting). The committee developed a clinically applicable surgical pathway for women undergoing POP surgery based on the quality of the recommendations at various decision points.

The recommendations that make up the pathway are summarized here. The first decision point for reconstructive surgery involves attention to apical support. For women with vaginal vault prolapse, sacrocolpopexy is the preferred apical suspension procedure when compared to transvaginal repairs for vaginal vault prolapse (GrA). Uterosacral and sacrospinous colpopexies have similar efficacy for apical prolapse (GrB). For uterine prolapse, the pathway diverges between uterine preservation and hysterectomy. The options for hysterectomy include vaginal hysterectomy with apical suspension or abdominal procedures including sacrocolpopexy with hysterectomy or supracervical hysterectomy. The committee acknowledged the lack of data for uterine prolapse pathway, and the recommendation favored vaginal hysterectomy with apical support over abdominal-based procedures for uterine prolapse undergoing hysterectomy (GrC). In the uterine preservation pathway, the committee’s recommendations prefer vaginal sacrospinous hysteropexy to abdominal intervention for uterine-preserving surgery (GrB-C). In the pathway for anterior and posterior compartment prolapse, native tissue repair (AC) is recommended for anterior compartment prolapse and similarly for posterior compartment prolapse. The committee developed a web-based application, which is available at: http://www.urogynaecology.com.au/ici-2017- pathway-prolapse-surgery/.

COMMENTARY

The published pathway was developed in response to findings of significant international variation in surgical treatment of prolapse. Despite predictions of an aging population and increased rates of surgery for prolapse, some researchers have reported decreasing rates of surgical interventions for prolapse in Denmark and the United States.^1,2 Other researchers have reported on dramatic differences in rates and types of procedures performed by country.³ For example, transvaginal mesh was used eight times more frequently in Germany than England, and sacral colpopexy was used 13 times more frequently in France than in Sweden.

The pathway was developed to help standardize the approach to POP surgery and provide a benchmark by which to compare clinical practice worldwide. The first decision point of the pathway reflects the importance of achieving apical support to improve the success rates of prolapse surgery. While Liu et al reported that American urologists are performing fewer anterior repairs without apical support,⁴ continued attention to providing adequate apical support at the time of prolapse repair is paramount.

The main recommendations include sacrocolpopexy as the preferred procedure for women with post-hysterectomy or vault prolapse and vaginal-based suspensions for the management of uterine prolapse. In addition, the pathway does not support the use of transvaginal mesh in vaginal repairs. The pathways are limited by the quality of data available and highlight the significant deficiencies in the data. Specifically, data are lacking regarding various options for the surgical management of uterine prolapse and for the use of transvaginal mesh interventions. As more data become available, these recommendations will need to be reevaluated.

Although the presented treatment pathway uses an evidence-based grading system, it is not a formal decision tree model. The evidence-based pathway can function as an important tool in the decision-making process for women with POP. While many individual factors are not included in the pathway, it helps strengthen the shared decision-making process between patient and clinician by guiding them to evidence-based surgical options.

REFERENCES

1. Løwenstein E, et al. Incidence and lifetime risk of pelvic organ prolapse surgery in Denmark from 1977 to 2009. Int Urogynecol J 2015;26:49-55.
2. Lisonkova S, et al. Temporal trends in obstetric trauma and inpatient surgery for pelvic organ prolapse: An age-period-cohort analysis. Am J Obstet Gynecol 2016;215:208.e1-208.e12.
3. Haya N, et al. Prolapse and continence surgery in countries of the Organization for Economic Cooperation and Development in 2012. Am J Obstet Gynecol 2015;212:755.e1-755.e27.
4. Liu JS, et al. Prolapse repair with and without apical resuspension — practice patterns among certifying American urologists. Neurourol Urodyn 2017;36:344-348.