Organ Prolapse: Selected Procedures

Number: 0858

Policy

Aetna considers the following procedures medically necessary:

• Dynamic magnetic resonance imaging (MRI) in persons with complex organ prolapse to supplement the physical examination
• Laparoscopic suture rectopexy in persons with rectal prolapse
• Lefort colpocleisis medically necessary for severe utero-vaginal prolapse in elderly persons and chronically ill persons who no longer desire coital function
• Sacrocolpopexy for the treatment of vaginal apical prolapse repair

Aetna considers the following procedures experimental and investigational because their effectiveness has not been established:

• Biologic graft for the treatment of vaginal apical prolapse
• Genetic testing for pelvic organ prolapse
• Vaginal tactile imaging for diagnosis and evaluation of vaginal and pelvic floor conditions (e.g., atrophy, incontinence, pain and prolapse).

See also CPB 0223 - Urinary Incontinence (Pessary for the treatment of pelvic organ (uterine) prolapse).

Background

Pelvic organ prolapse (POP) is a relatively common condition in women that can have a significant impact on quality of life.  Pelvic organ prolapse typically demonstrates multiple abnormalities and may involve the urethra (urethrocele), bladder (cystocele), vaginal vault, rectum (rectocele), and small bowel (enterocele).  Symtpoms may include pain, pressure, urinary and fecal incontinence, constipation, urinary retention, and defecatory dysfunction.  Total vaginal collapse occurs when the upper portion of the vagina loses its normal shape and sags or bulges down into the vaginal canal or outside of the vagina.  It is usually caused by weakness of the pelvic and vaginal tissues and muscles and may occur alone or along with prolapse of other pelvic organs.  The bladder (cystocele), urethra (urethrocele), rectum (rectocele), or small bowel (enterocele).

Magnetic resonance imaging (MRI) uses a strong magnetic field, radio waves, and computers to produce 2- or 3-dimensional images of the inside of a patient's body.  It is non-invasive and there is no ionizing radiation exposure to the patient.  Dynamic MRI differs from standard MRI in that a large number of images are formed successively and rapidly, by continually updating or reacquiring image data.  Based on the clinical evidence, dynamic MRI is an acceptable alternative modality in patients with complex organ prolapse to supplement the physical examination.

Rectal prolapse, or procidentia, is the abnormal protrusion of the rectal mucosa down to or through the anal opening.  The main symptom is a protrusion of a reddish mass from the anal opening, especially following a bowel movement. The rectal mucosa is visible and may bleed slightly.

In a laparoscopic suture rectopexy the rectum is fixed to the presacral fascia with suture as opposed to mesh or an Ivalon sponge.  Based on the long-term clinical outcomes, laparoscopic suture rectopexy can be considered a treatment option for patients with rectal prolapse.

Vaginal prolapse or pelvic organ prolapse, occurs when the structures of the pelvis protrude into or outside of the vaginal canal.  The pelvic organs are the bladder, rectum, or uterus.  The term prolapse means slipping from the normal position.  Pelvic organ prolapse is caused most commonly by pregnancy, labor, and childbirth.  It also can be related to diseases that cause increased pressure in the abdomen, such as obesity, respiratory problems with a long-lasting (chronic) cough, constipation, and pelvic organ cancers.  Pelvic organ prolapse can occur after hysterectomy for another gynecological health problem, such as endometriosis, dysfunctional uterine bleeding, or uterine fibroids. 

In the LeFort colpocleisis, anterior and posterior rectangular flaps of vaginal mucosa are removed, and the denuded areas are reapproximated with horizontal layers of interrupted absorbable sutures, leaving 2 small tunnels laterally for drainage.  Based on the clinical evidence, Lefort colpocleisis should be used only when there is a very good reason not to perform one of the usual operations for prolapse.  It is indicated for severe utero-vaginal prolapse in elderly patients and chronically ill patients who no longer desire coital function.

Levin et al (2012) noted that genetic studies require a clearly defined phenotype to reach valid conclusions.  These researchers characterized the phenotype of advanced prolapse by comparing women with stage III to IV prolapse with controls without prolapse.  Based on the pelvic organ prolapse quantification examination, women with stage 0 to stage I prolapse (controls) and those with stage III to stage IV prolapse (cases) were prospectively recruited as part of a genetic epidemiologic study.  Data regarding socio-demographics; medical, obstetric, and surgical history; family history; and body mass index (BMI) were obtained by a questionnaire administered by a trained coordinator and abstracted from electronic medical records.  There were 275 case patients with advanced prolapse and 206 controls with stage 0 to stage I prolapse.  Based on the recruitment strategy, the women were younger than the controls (64.7 ± 10.1 versus 68.6 ± 10.4 years; p < 0.001); cases were also more likely to have had 1 or more vaginal deliveries (96.0 % versus 82.0 %; p < 0.001).  There were no differences in race, BMI, and constipation.  Regarding family history, cases were more likely to report that either their mother and/or sister(s) had prolapse (44.8 % versus 16.9 %, p < 0.001).  In a logistic regression model, vaginal parity (odds ratio [OR], 4.05; 9 5% confidence interval [CI]: 1.67 to 9.85) and family history of prolapse (OR, 3.74; 95 % CI: 2.16 to 6.46) remained significantly associated with advanced prolapse.  The authors concluded that vaginal parity and a family history of prolapse are more common in women with advanced prolapse compared to those without prolapse.  These characteristics are important in phenotyping advanced prolapse, suggesting that these data should be collected in future genetic epidemiologic studies.

Wu et al (2012) evaluated the association of laminin gamma-1 (LAMC1) and advance pelvic organ prolapse.  These researchers conducted a candidate gene association of patients (n = 239) with stages III to IV prolapse and controls (n = 197) with stages 0 to I prolapse.  They used a “linkage disequilibrium (LD)-tagged” approach to identify single-nucleotide polymorphisms (SNPs) in LAMC1 and focused on non-Hispanic white women to minimize population stratification.  Additive and dominant multi-variable logistic regression models were used to test for association between individual SNPs and advanced prolapse.  A total of 14 SNPs representing 99 % coverage of LAMC1 were genotyped.  There was no association between SNP rs10911193 and advanced prolapse (p = 0.34).  However, there was a trend toward significance for SNPs rs1413390 (p = 0.11), rs20563 (p = 0.11), and rs20558 (p = 0.12).  The authors concluded that although they found that the previously reported LAMC1 SNP rs10911193 was not associated with non-familial prolapse, these results supported further investigation of this candidate gene in the pathophysiology of prolapse.

Ward et al (2014) stated that given current evidence supporting a genetic predisposition for pelvic organ prolapse, they conducted a systematic review of published literature on the genetic epidemiology of pelvic organ prolapse.  Inclusion criteria were linkage studies, candidate gene association and genome-wide association studies in adult women published in English and indexed in PubMed through December 2012, with no limit on date of publication.  Methodology adhered to the PRISMA guidelines.  Data were systematically extracted by 2 reviewers and graded by the Venice criteria for studies of genetic associations.  A meta-analysis was performed on all SNPs evaluated by 2 or more studies with similar methodology.  The meta-analysis suggested that collagen type 3 alpha 1 (COL3A1) rs1800255 genotype AA is associated with pelvic organ prolapse (OR, 4.79; 95 % CI: 1.91 to 11.98; p = 0.001) compared with the reference genotype GG in populations of Asian and Dutch women.  There was little evidence of heterogeneity for rs1800255 (p value for heterogeneity = 0.94; proportion of variance because of heterogeneity, I(2) = 0.00 %).  There was insufficient evidence to determine whether other SNPs evaluated by 2 or more papers were associated with pelvic organ prolapse.  An association with pelvic organ prolapse was seen in individual studies for estrogen receptor alpha (ER-α) rs2228480 GA, COL3A1 exon 31, chromosome 9q21 (heterogeneity logarithm of the odds score 3.41) as well as 6 SNPs identified by a genome-wide association study.  The authors concluded that overall, individual studies were of small sample size and often of poor quality.  They stated that future studies would benefit from more rigorous study design as outlined in the Venice recommendations.

Genetic Testing for Pelvic Organ Prolapse:

Cartwright et al (2015) noted that family studies and twin studies demonstrated that lower urinary tract symptoms (LUTS) and pelvic organ prolapse are heritable.  In this review, these investigators aimed to identify genetic polymorphisms tested for an association with LUTS or prolapse, and to assess the strength, consistency, and risk of bias among reported associations.  PubMed and HuGE Navigator were searched up to May 1, 2014, using a combination of genetic and phenotype key words, including "nocturia", "incontinence", "overactive bladder", "prolapse", and "enuresis".  Major genetics, urology, and gynecology conference abstracts were searched from 2005 through 2013.  These researchers screened 889 abstracts, and retrieved 78 full texts.  In all, 27 published and 7 unpublished studies provided data on polymorphisms in or near 32 different genes.  Fixed and random effects meta-analyses were conducted using co-dominant models of inheritance.  They assessed the credibility of pooled associations using the interim Venice criteria.  In pooled analysis, the rs4994 polymorphism of the ADRB3 gene was associated with overactive bladder (OR, 2.5; 95 % CI: 1.7 to 3.6; n = 419).  The rs1800012 polymorphism of the COL1A1 gene was associated with prolapse (OR, 1.3; 95 % CI: 1.0 to 1.7; n = 838) and stress urinary incontinence (OR, 2.1; 95 % CI: 1.4 to 3.2; n = 190).  Other meta-analyses, including those for polymorphisms of COL3A1, LAMC1, MMP1, MMP3, and MMP9 did not show significant effects.  Many studies were at high-risk of bias from genotyping error or population stratification.  The authors concluded that these meta-analyses provided moderate epidemiological credibility for associations of variation in ADRB3 with overactive bladder, and variation of COL1A1 with prolapse.  Moreover, they stated that clinical testing for any of these polymorphisms cannot be recommended based on current evidence.

Khadzhieva and colleagues (2017) stated that POP is a highly disabling condition common for a vast number of women worldwide.  These investigators performed a systematic review of expression studies on both specific gene and whole-genome/proteome levels and an in silico analysis of publicly available datasets related to POP development.  The most extensively investigated genes in individual studies were related to extra-cellular matrix (ECM) organization.  A total of 3 pre-menopausal and 2 post-menopausal sets from 2 Gene Expression Omnibus (GEO) studies (GSE53868 and GSE12852) were analyzed; Gene Ontology (GO) terms related to tissue repair (locomotion, biological adhesion, immune processes and other) were enriched in all 5 datasets.  Co-expression was higher in cases than in controls in 3 pre-menopausal sets.  The shared between 2 or more datasets up-regulated genes were enriched with those related to inflammatory bowel disease (IBD) in the NHGRI GWAS Catalog.  ECM-related genes were not over-represented among differently expressed genes.  The authors concluded that up-regulation of genes related to tissue renewal probably reflected compensatory mechanisms aimed at repair of damaged tissue; and inefficiency of this process may have different origins including age-related deregulation of gene expression.

The authors stated that this study had some drawbacks with the main limitation being in a small number of datasets and a small number of samples in these datasets.  These data appeared to be insufficient for construction of co-expression networks.  The results of the enrichment analysis for the overlapping up-regulated genes with GWAS association signals should be discussed as preliminary.  They stated that these results raised a question rather than provided an answer on a possible shared genetic component for IBD and POP.  The authors noted that this analysis provided some in-depth data important for understanding POP pathogenesis.  In terms of genetic overlap between IBD and POP, the work has translational impact.  Moreover, they noted that the study findings are biologically plausible; however, they require verification in independent studies.

Bilateral Abdominal Sacrocolpopexy with Polyvinylidene Fluoride Mesh:

Rajshekhar and colleagues (2016) evaluated the safety and effectiveness of a modified technique of bilateral abdominal sacrocolpopexy in which both utero-sacral ligaments are replaced with polyvinylidene fluoride mesh to provide support to the cervix (cervico-sacropexy [CESA]) or vaginal vault (vagino-sacropexy [VASA]). In a retrospective, observational study, a total of 50 women with post-hysterectomy vault prolapse or recurrent apical prolapse following previous vaginal repair underwent bilateral sacrocolpopexy between July 1, 2013, and December 31, 2014.  Before surgery and 3 months afterwards, prolapse was assessed using the Pelvic Organ Prolapse Quantification scale and functional outcomes were recorded using the International Consultation on Incontinence Questionnaire for vaginal symptoms and urinary incontinence.  At 3 months, 47 (94 %) patients reported no bulge symptoms and the mean point C was -7.6.  Complications comprised bladder injury in 1 (2 %) and minor wound problems in 3 (6 %) patients.  No mesh erosion was reported.  The authors concluded that bilateral abdominal sacrocolpopexy appeared to be a safe and effective option for apical prolapse.  However, they stated that longer-term follow-up is needed to detect prolapse recurrence and mesh-related complications.

Biologic Graft:

On behalf of the Society of Gynecologic Surgeons Systematic Review Group, Shimpf and associates (2016) updated clinical practice guidelines on graft and mesh use in transvaginal pelvic organ prolapse repair based on systematic review. Eligible studies, published through April 2015, were retrieved through ClinicalTrials.gov, Medline, and Cochrane databases and bibliography searches.  These investigators included studies of transvaginal prolapse repair that compared graft or mesh use with either native tissue repair or use of a different graft or mesh with anatomic and symptomatic outcomes with a minimum of 12 months of follow-up.  Study data were extracted by 1 reviewer and confirmed by a 2nd reviewer.  Studies were classified by vaginal compartment (anterior, posterior, apical, or multiple), graft type (biologic, synthetic absorbable, synthetic non-absorbable), and outcome (anatomic, symptomatic, sexual function, mesh complications, and return to the operating room).  They found 66 comparative studies reported in 70 articles, including 38 randomized trials; quality of the literature has improved over time, but some outcomes still show heterogeneity and limited power.  In the anterior vaginal compartment, synthetic non-absorbable mesh consistently showed improved anatomic and bulge symptom outcomes compared with native tissue repairs based on meta-analyses.  Other subjective outcomes, including urinary incontinence or dyspareunia, generally did not differ.  Biologic graft or synthetic absorbable mesh use did not provide an advantage in any compartment.  Synthetic mesh use in the posterior or apical compartments did not improve success.  Mesh erosion rates ranged from 1.4 to 19 % at the anterior vaginal wall, but 3 to 36 % when mesh was placed in multiple compartments.  Operative mesh revision rates ranged from 3 to 8 %.  The authors concluded that synthetic mesh augmentation of anterior wall prolapse repair improved anatomic outcomes and bulge symptoms compared with native tissue repair.  On the other hand, biologic grafts did not improve prolapse repair outcomes in any compartment; mesh erosion occurred in up to 36 % of patients, but re-operation rates were low.

Sacrocolpopexy:

Alas and Anger (2015) stated that pelvic organ prolapse is a prevalent condition, with up to 12 % of women requiring surgery in their lifetime. These investigators reviewed the therapeutic options for apical prolapse, specifically.  Both conservative and surgical management options are acceptable and should be based on patient preferences.  Pessaries are the most commonly used conservative management options.  Guided pelvic floor muscle training is more beneficial than self-taught Kegel exercises, though may not be effective for high stage or apical prolapse.  Surgical options include abdominal and vaginal approaches, the latter of which can be performed open, laparoscopically, and robotically.  A systematic review has demonstrated that sacrocolpopexy has better long-term success for treatment of apical prolapse than vaginal techniques, but vaginal surgery can be considered an acceptable alternative.  Recent data has demonstrated equal effectiveness between uterosacral ligament suspension and sacrospinous ligament suspension at 1 year.  To-date, 2 randomized controlled trials (RCTs) have demonstrated equal effectiveness between robotic and laparoscopic sacrocolpopexy.  Though abdominal approaches may have increased long-term durability, when counseling their patients, surgeons should consider longer operating times and increased pain and cost with these procedures compared to vaginal surgery.

The authors concluded the following:

• Pelvic floor physical therapy (PFPT) with a physical therapist is the best approach to conservative management of apical prolapse
• Pessaries should be managed with regular follow-up care to minimize complications
• Minimally invasive sacrocolpopexy appears as effective as the gold standard abdominal sacrocolpopexy (ASC)
• Robotic assisted sacrocolpopexy (RASC) and laparoscopic assisted sacrocolpopexy (LASC) are equally effective and should be utilized by pelvic floor surgeons based on their skill level and expertise in laparoscopy
• Uterosacral ligament suspension (USLS) and sacrospinous ligament suspension (SSLS) are considered equally effective procedures and can be combined with a vaginal hysterectomy
• Obliterative procedures are effective but are considered definitive surgery
• The use of transvaginal mesh has been shown in some studies to be superior to native tissue repairs with regard to anatomic outcomes, but complication rates are higher. Transvaginal mesh should be reserved for surgeons with adequate training so that complications are minimized

Costantini and colleagues (2016) noted that sacrocolpopexy is considered a reference operation for pelvic organ prolapse repair but its indications and technical aspects are not standardized. A faculty of urogynecology surgeons critically evaluated the peer-reviewed literature published until September 2015 aiming to produce evidence-based recommendations.  PubMed, Medline, and the Cochrane Library were searched for RCTs published in English language.  The modified Oxford data grading system was used to access quality of evidence and grade recommendations.  The Delphi process was implemented when no data was available.  A total of 13 RCTs were identified, that provided levels I to III of evidence on various aspects of sacrocolpopexy.  Sacrocolpopexy is the preferred procedure for vaginal apical prolapse (Grade A), monofilament polypropylene mesh is the graft of choice and the laparoscopic approach is the preferred technique (Grade B).  Grade B recommendation supports the performance of concomitant procedures at the time of sacrocolpopexy.  Grade C recommendation suggests either permanent or delayed sutures for securing the mesh to the vagina, permanent tackers or sutures for securing the mesh to the sacral promontory and closing the peritoneum over the mesh.  A Delphi process Grade C recommendation supports proceeding with sacrocolpopexy after uncomplicated, intra-operative bladder or small bowel injuries.  The authors concluded that there is insufficient or conflicting data on hysterectomy (subtotal or total) or uterus preservation during sacrocolpopexy (Grade D).  They stated that sacrocolpopexy remains an excellent option for vaginal apical prolapse repair.  The issue of uterine preservation or excision during the procedure requires further clarification.  Variations exist in the performance of most technical aspects of the procedure.

Also, an UpToDate review on “Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse)” (Kenton, 2016) states that “No high quality evidence is available to guide surgeons regarding uterine preservation at the time of vaginal apical suspension procedures … Apical prolapse repair via open abdominal sacral colpopexy is more effective at restoring vaginal topography than traditional vaginal repairs, although subjective outcomes are similar after the two types of procedures. We suggest abdominal sacral colpopexy rather than transvaginal repair for most women undergoing apical prolapse repair.  Laparoscopic sacrocolpopexy is as effective as open sacrocolpopexy, but results in decreased blood loss and shorter hospital stays.  For women with apical prolapse undergoing abdominal sacral colpopexy, we recommend synthetic mesh over biografts.  Synthetic mesh use in sacral colpopexy reduces the risk of recurrent apical prolapse … For women undergoing repair of apical prolapse, a concomitant continence procedure is often performed to treat or prevent stress urinary incontinence.  Mid-urethral slings are the preferred concomitant procedure if a vaginal route is used for prolapse repair; some surgeons also place a mid-urethral sling at the time of abdominal sacral colpopexy”.

Furthermore, and UpToDate review on “Pelvic organ prolapse in women: Choosing a primary surgical procedure” (Jelovsek, 2016) states that “The common wisdom has been that retaining the uterus increases the risk of recurrent prolapse, although there are no data to support this. The role of hysterectomy at the time of surgery for POP is currently debatable and there are no data supporting hysterectomy at the time of surgery for POP.  There are 3 under-powered studies that describe uterine preservation at the time of surgery for POP and uterine preservation did not affect the risk of POP recurrence”.

Surgical Treatment of Primary Pelvic Organ Prolapse:

On behalf of 5 French academic societies (Association Française d'Urologie, Collège National des Gynécologues et Obstétriciens Français, Société Interdisciplinaire d'Urodynamique et de Pelvi-Périnéologie, Société Nationale Française de Colo-proctologie, and Société de Chirurgie Gynécologique et Pelvienne), Le Normand and colleagues (2016) developed guidelines for surgery for primary POP.  The guidelines listed the following:

• It is useful to evaluate symptoms, their impact, women's expectations, and to describe the prolapse prior to surgery (grade C).
• In the absence of any spontaneous or occult urinary sign, there is no reason to perform urodynamics (grade C).
• When a sacrocolpopexy is indicated, laparoscopy is recommended (grade B).
• A bowel preparation before vaginal (grade B) or abdominal surgery (grade C) is not recommended.
• There is no argument to systematically use a rectovaginal mesh to prevent rectocele (grade C).
• The use of a vesico-vaginal mesh by vaginal route should be discussed taking into account an uncertain long-term risk-benefit ratio (grade B).
• Levator myorrhaphy is not recommended as a 1st-line rectocele treatment (grade C).
• There is no indication for a vaginal mesh as a 1st-line rectocele treatment (grade C).
• There is no reason to systematically perform a hysterectomy during prolapse repair (grade C).
• It is possible to not treat stress incontinence at the time of prolapse repair, if the woman is advised of the possibility of a 2-step surgical treatment (grade C).

Trans-Labial Ultrasound for the Assessment of Levator Ani Defects and Levator Ani Biometry in Pelvic Organ Prolapse:

In a systematic review, Notten and colleagues (2017) evaluated the diagnostic accuracy and clinical implications of trans-labial 3-dimensional (3D) ultrasound for the assessment of levator ani defects and biometry in women with POP.  These investigators performed a systematic literature search through computerized databases including Medline (via PubMed), Embase (via OvidSP), and the Cochrane Library using both medical subject headings and text terms from January 1, 2003, to December 25, 2015.  They included articles that reported on POP status and diagnostic accuracy measurements with trans-labial 3D ultrasound or trans-perineal ultrasound for the detection of levator ani defects or for measuring pelvic floor biometry, that is, levator ani hiatus, or reported on the clinical relevance of using trans-labial 3D ultrasound for levator ani defects or measuring pelvic floor biometry in women with POP.  A total of 31 articles were selected in accordance with parts of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines that can be applied to studies of diagnostic accuracy; 22 articles (71 %) were co-authored by 1 expert in this field.  Detecting levator ani defects with trans-labial 3D ultrasound compared with MRI showed a moderate-to-good agreement, whereas measuring hiatal biometry on trans-labial 3D ultrasound compared with MRI showed a moderate-to-very good agreement.  The inter-observer agreement for diagnosing levator ani defects and measuring the levator hiatal area showed a moderate-to-very good agreement.  Furthermore, levator ani defects increase the risk of cystocele and uterine prolapse, and levator ani defects were associated with recurrent POP.  Finally, a larger hiatus was associated with POP and recurrent POP.  The authors concluded that trans-labial 3D ultrasound is reproducible for diagnosing levator ani defects and ballooning hiatus.  Both levator ani defects and a larger hiatal area were, in a selected population of patients with pelvic floor dysfunction, associated with POP and recurrent POP.  However, these researchers stated that more research is needed regarding external validation since most of the data in this review were co-authored by 1 expert in this field.

Furthermore, an UpToDate review on “Pelvic organ prolapse in women: Diagnostic evaluation” (Fashokun and Rogers, 2017) does not mention ultrasonography as a diagnostic tool.

Use of Mesh Repair for Prolapse of Anterior Compartment of the Vagina:

In a Cochrane review, Maher and colleagues (2017) determined the safety and effectiveness of surgery for anterior compartment prolapse.  These investigators searched the Cochrane Incontinence Group Specialised Register, including the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Medline In Process (August 23, 2016), hand-searched journals and conference proceedings (February 15, 2016) and searched trial registers (August 1, 2016); RCTs that examined surgical operations for anterior compartment prolapse were selected for analysis  Two review authors independently selected trials, assessed risk of bias and extracted data.  Primary outcomes were awareness of prolapse, repeat surgery and recurrent prolapse on examination.  These researchers included 33 trials (3,332 women).  The quality of evidence ranged from very low-to-moderate.  Limitations were risk of bias and imprecision.  They summarized results for the main comparisons.  Native tissue versus biological graft --  Awareness of prolapse: Evidence suggested few or no differences between groups (risk ratio (RR) 0.98, 95 % CI: 0.52 to 1.82; 5 RCTs; 552 women; I2 = 39 %; low-quality evidence), indicating that if 12 % of women were aware of prolapse after biological graft, 7 % to 23 % would be aware after native tissue repair.  Repeat surgery for prolapse: Results showed no probable differences between groups (RR 1.02, 95 % CI: 0.53 to 1.97; 7 RCTs; 650 women; I2 = 0 %; moderate-quality evidence), indicating that if 4 % of women required repeat surgery after biological graft, 2 % to 9 % would do so after native tissue repair.  Recurrent anterior compartment prolapse: Native tissue repair probably increased the risk of recurrence (RR 1.32, 95 % CI: 1.06 to 1.65; 8 RCTs; 701 women; I2 = 26 %; moderate-quality evidence), indicating that if 26 % of women had recurrent prolapse after biological graft, 27 % to 42 % would have recurrence after native tissue repair.  Stress urinary incontinence (SUI): Results showed no probable differences between groups (RR 1.44, 95 % CI: 0.79 to 2.64; 2 RCTs; 218 women; I2 = 0 %; moderate-quality evidence).  Dyspareunia: Evidence suggested few or no differences between groups (RR 0.87, 95 % CI: 0.39 to 1.93; 2 RCTs; 151 women; I2 = 0 %; low-quality evidence).  Native tissue versus polypropylene mesh Awareness of prolapse: This was probably more likely after native tissue repair (RR 1.77, 95 % CI: 1.37 to 2.28; 9 RCTs; 1,133 women; I2 = 0 %; moderate-quality evidence), suggesting that if 13 % of women were aware of prolapse after mesh repair, 18 % to 30 % would be aware of prolapse after native tissue repair.  Repeat surgery for prolapse: This was probably more likely after native tissue repair (RR 2.03, 95 % CI: 1.15 to 3.58; 12 RCTs; 1,629 women; I2 = 39 %; moderate-quality evidence), suggesting that if 2 % of women needed repeat surgery after mesh repair, 2 % to 7 % would do so after native tissue repair.  Recurrent anterior compartment prolapse: This was probably more likely after native tissue repair (RR 3.01, 95 % CI: 2.52 to 3.60; 16 RCTs; 1,976 women; I2 = 39 %; moderate-quality evidence), suggesting that if recurrent prolapse occurred in 13 % of women after mesh repair, 32 % to 45 % would have recurrence after native tissue repair.  Repeat surgery for prolapse, SUI or mesh exposure (composite outcome): This was probably less likely after native tissue repair (RR 0.59, 95 % CI: 0.41 to 0.83; 12 RCTs; 1,527 women; I2 = 45 %; moderate-quality evidence), suggesting that if 10 % of women require repeat surgery after polypropylene mesh repair, 4 % to 8 % would do so after native tissue repair.  De novo SUI: Evidence suggested few or no differences between groups (RR 0.67, 95 % CI: 0.44 to 1.01; 6 RCTs; 957 women; I2 = 26 %; low-quality evidence).  No evidence suggested a difference in rates of repeat surgery for SUI.  Dyspareunia (de novo): Evidence suggested few or no differences between groups (RR 0.54, 95 % CI: 0.27 to 1.06; 8 RCTs; n = 583; I2 = 0 %; low-quality evidence).  Native tissue versus absorbable mesh.  Awareness of prolapse: It is unclear whether results showed any differences between groups (RR 0.95, 95 % CI: 0.70 to 1.31; 1 RCT; n = 54; very low-quality evidence).  Repeat surgery for prolapse: It is unclear whether results showed any differences between groups (RR 2.13, 95 % CI: 0.42 to 10.82; 1 RCT; n = 66; very low-quality evidence).  Recurrent anterior compartment prolapse: This is probably more likely after native tissue repair (RR 1.50, 95 % CI: 1.09 to 2.06; 3 RCTs; n = 268; I2 = 0 %; moderate-quality evidence), suggesting that if 27 % have recurrent prolapse after mesh repair, 29 % to 55 % would have recurrent prolapse after native tissue repair.   SUI: It is unclear whether results showed any differences between groups (RR 0.72, 95 % CI: 0.50 to 1.05; 1 RCT; n = 49; very low-quality evidence).  Dyspareunia: No data were reported.  The authors concluded that biological graft repair or absorbable mesh provided minimal advantage compared with native tissue repair.  Native tissue repair was associated with increased awareness of prolapse and increased risk of repeat surgery for prolapse and recurrence of anterior compartment prolapse compared with polypropylene mesh repair.  However, native tissue repair was associated with reduced risk of de-novo SUI, reduced bladder injury, and reduced rates of repeat surgery for prolapse, SUI and mesh exposure (composite outcome).  They stated that current evidence does not support the use of mesh repair compared with native tissue repair for anterior compartment prolapse owing to increased morbidity.  Many transvaginal polypropylene meshes have been voluntarily removed from the market, and newer light-weight transvaginal meshes that are available have not been assessed by RCTs.  These investigators stated that clinicians and women should be cautious when utilizing these products, as their safety and effectiveness have not been established.

1. trans-vaginal POP repair surgery with mesh and concurrent sling use (vaginal mesh plus sling group),
2. transvaginal POP repair with mesh and no concurrent sling use (vaginal mesh group),
3. transvaginal POP repair without mesh but concurrent sling use for SUI (POP sling group), and
4. sling for SUI alone (SUI sling group). 

The primary outcome was the occurrence of mesh complications and repeated invasive intervention within 1 year after the initial mesh implantation.  A time-to-event analysis was performed to examine the occurrence of mesh erosions and subsequent re-intervention.  Secondary analyses of an age association (less than 65 versus greater than or equal to 65 years) were conducted.  The study identified 41,604 women who underwent 1 of the 4 procedures. The mean (SD) age of women at their initial mesh implantation was 56.2 (13.0) years. The highest risk of erosions was found in the vaginal mesh plus sling group (2.72%; 95% CI, 2.31%-3.21%) and the lowest in the SUI sling group (1.57 %; 95 % CI: 1.41 % to 1.74 %).  The risk of repeated surgery with concomitant erosion diagnosis was also the highest in the vaginal mesh plus sling group (2.13 %; 95 % CI: 1.76 % to 2.56 %) and the lowest in the SUI sling group (1.16 %; 95 % CI: 1.03 % to 1.31 %).  The authors concluded that the combined use of POP mesh and SUI mesh sling was associated with the highest erosion and repeated intervention risk, while mesh sling alone had the lowest erosion and repeated intervention risk.  They stated that there is evidence for a dose-response relationship between the amount of mesh used and subsequent mesh erosions, complications, and invasive repeated intervention.

Vaginal Tactile Imaging:

1. how does tissue elasticity affect the development of POP, and
2. how can functional elasticity be maintained through reconstructive surgery.

These researchers designed a prototype of vaginal tactile imager (VTI) for visualization and assessment of elastic properties of pelvic floor tissues.  In a pilot study (n =13), these investigators analyzed applicability of VTI for evaluation of reconstructive surgery results and characterization of normal and POP conditions.  The authors concluded that this trial demonstrated that VTI allowed imaging of vaginal walls with increased rigidity due to implanted mesh grafts following reconstructive pelvic surgery and VTI had the potential for prolapse characterization and detection.

van Raalte and Egorov (2015) stated that VTI records pressure patterns from vaginal walls under an applied tissue deformation and during pelvic floor muscle (PFM) contractions.  These researchers validated VTI and muscle contraction parameters (markers) sensitive to the female pelvic floor conditions.  A total of 22 women with normal and prolapse conditions were examined by a VTI probe.  They identified 9 parameters that were sensitive to prolapse conditions (p < 0.05 for 1-way ANOVA and/or p < 0.05 for t-test with correlation factor r from -0.73 to -0.56).  The list of parameters included pressure, pressure gradient and dynamic pressure response during PFM at identified locations.  The authors concluded that these parameters may be used for biomechanical characterization of female pelvic floor conditions to support an effective management of pelvic floor prolapse.  Moreover, they stated that further studies with larger sample sizes, investigating a variety of other pelvic floor conditions, and use in the evaluation of interventions including physical therapy, conservative management options and surgical correction are needed to further explore diagnostic values of VTI.

1. its small sample size (n = 22),
2. the lack of data to correlate PFM assessment with the site of prolapse, degree of symptom severity for detected prolapse or associated urinary or fecal continence symptoms. It was thought a sub-analysis may be misleading given the limited sample size and should be reserved for future studies.  There may be very important differences in functional PFM recordings between a patient with a large distention defect of the vaginal wall versus a primary apical defect, symptomatic versus asymptomatic prolapse or among patients with associated urinary or rectal complaints.  For future studies, it would be important to evaluate symptom severity for pelvic floor disorders to examine if there is a correlation between PFM evaluation, resting tone and associated elasticity measurements of the underlying tissue.  This may help clinicians further differentiate types of pelvic floor conditions, their underlying severity and how to tailor treatments to best care for the individual patient,
3. the clinician obtaining the VTI measurements was not blinded to the POP quantification system (POP-Q) measurements.  The procedure for VTI recording was standardized and would be difficult to bias the recording based on expectations of the measurements, however this did remain a potential bias.  To diminish the potential influence of this bias, the images were evaluated and parameter values were extracted by another observer who did not have the clinical information available until the data scaling versus prolapse stage, age and parity.

1. the female pelvic floor organs are suspended by ligaments against which muscles contract to open or close the outlets, and
2. damaged ligaments weaken the support and may reduce the force of muscle contraction,

these researchers made an attempt to characterize multiple pelvic floor structures from VTI data.  All of the 138 women enrolled in the study were successfully examined with the VTI.  The participants have had normal pelvic support or POP (stages I to IV).  The average age of this group of subjects was 60 ± 15 years.  These investigators transposed a set of 31 VTI parameters into a quantitative characterization of pelvic muscles and ligamentous structures.  Interpretation of the acquired VTI data for normal pelvic floor support and prolapse conditions is proposed based on biomechanical assessment of the functional anatomy.  The authors concluded that VTI allowed biomechanical characterization of female pelvic floor structures and tissues in-vivo, which may help to optimize treatment of the diseased conditions such as prolapse, incontinence, atrophy, and some forms of pelvic pain.

The authors stated that among the VTI limitations were image dependence on operator’s skill level, contact conditions, and probe size.  In general, an examination with a VTI probe is operator-dependent, similar to colonoscopy.  Operator training is needed to improve and standardize operator skills.  Minimization or elimination of the operator dependence is also achieved by intentional probe design, data processing algorithms, and real-time feedback to the operator.  The VTI intra- and inter-operator measurement reproducibility study with 12 subjects demonstrated intra-class correlation coefficients in the range from 0.80 to 0.92 and median tactile image deviations from 6.6 % to 15.6 %.  The lubrication helps to keep contact conditions reproducible.  Tactile imaging probes with different size and contact area of 15 μm(2), and 20 cm(2) demonstrated different absolute values of P(x,y,z) acquired for the same tissue.  But comparison of the 2 image data sets revealed a lot of similarity and common features; both probes showed close relative distribution within P(x,y,z) and enabled similar tissue characterization.

1. maximum resistance force to insertion (Newtons),
2. insertion work (milliJoules),
3. maximum stress-to-strain ratio (elasticity; kiloPascals per millimeter),
4. maximum pressure at rest (kiloPascals),
5. anterior-posterior force at rest (Newtons),
6. left-right force at rest (Newtons),
7. maximum pressure at muscle contraction (kiloPascals), and
8. muscle contraction force (Newtons). 

These researchers observed low-to-moderate correlation of these parameters with subject age and no correlation with subject weight; 6 of 8 parameters demonstrated a p value of less than 0.05 for 2 subject subsamples divided by age (less than or equal to 52 versus greater than 52 years), which meant 6 VTI parameters change with age.  The authors concluded that VTI allowed biomechanical and functional characterization of the vaginal conditions that can be used for

1. understanding "normal" vaginal conditions,
2. quantification of the deviation from normality,
3. personalized treatment (radiofrequency, laser, or plastic surgery), and
4. assessment of the applied treatment outcome. 

Moreover, they stated that further research with a more representative sample will show more comprehensive distributions and peculiar features for normal values.  This study had 2 major drawbacks:

1. its relatively small sample size (n = 42), and
2. despite normal pelvic floor support (no prolapse), some analyzed subjects came to the urogynecologic office with some problematic conditions affecting the pelvic floor.
   
   

The above policy is based on the following references: