Evidence-based

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Evidence-based surgical treatment of genital
prolapse

Prof Aboubakr Elnashar Benha University Hospital,
Egypt Delta (Mansura) Benha Fertility
Centers Email elnashar53_at_hotmail.com
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EBM is a newly evolved, rapidly growing
discipline for learners researchers. The term
EBM originated at McMaster University in Canada
first appeared in the medical literature in 1992.
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EBM is a systematic approach to utilize the best
available scientific knowledge to make decisions
regarding diagnosis treatment. EBM also relies
on clinical judgment, practical skills also
the patients individual situation desire.
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• The highest level of evidence in therapy studies
  requires at least
• one high quality systematic review or
• 2 high quality RCT.

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Systematic review Review in which all the
evidence pertaining to a particular field of
research has been collected (via a systematic
search of the literature unpublished sources)
evaluated using predefined quality criteria.
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Meta-analysis Systematic reviews in which the
numerical results of different studies have been
combined using standard statistical techniques.
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RCT is the gold standard in clinical research.
RCT is the standard method for answering
questions about the effectiveness of different
therapies RCT provides the strongest evidence for
the cause effect relationship is subject to
the least amount of bias.
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The Cochrane Collaboration Library is an
outstanding effort to provide best evidence. It
is the best single source of evidence about the
effects of health care. It is named after the
British epidemiologist Archie Cochrane
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The library is updated every 3 months. It
contains 4 sets of databases 1.Systematic
reviews 2. Reviews of effectiveness 3.Controlled
trial registry 4.Review methodology
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Treatment modalities of prolapse include
surgery, mechanical devices conservative
therapies (life style advises pelvic floor
training).
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The definitive treatment of prolapse is surgery.
The surgical repair of prolapse is one of the
oldest gynecological procedures. Over 100
operations have been described, although few are
in common use nowadays.
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There are divergent opinions regarding the
effective operation for each type of genital
prolapse. Our objective review the systematic
reviews RCT concerning the surgical treatment
of genital prolapse.
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Materials methods Data sources 1. Chocrane
library. 2. Pub Med Search for RCT concerning
genital prolapse, uterine prolapse, vaginal
prolapse or uterovaginal preolapse.
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Results
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4 Cochrane systematic reviews 14 RCT (out of 922
citations).1.5
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Systematic reviews RCT were reviewed as regard
1. Preoperative care, 2. Anterior vaginal wall
prolapse 3. Uterovaginal prolapse, 4. Vault
prolapse 5. Urinary stress incontinence
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1. Preoperative treatment with oestradiol
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Preoperative low-dose vaginal oestradiol
treatment reduced the incidence of bacteriuria in
the immediate postoperative period but no
long-lasting effects on recurrent cystitis or
relapse (Felding et al, 1992 Mikkelsen et al,
1995).
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2. Anterior vaginal wall prolapse
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Comparison between three surgical techniques.
Standard, standard plus polyglactin 910 mesh, or
ultralateral anterior colporrhaphy (Weber et
al,2001).These 3 techniques of anterior
colporrhaphy provided similar anatomic cure rates
and symptom resolution. The addition of
polyglactin 910 mesh did not improve the cure
rate compared with standard anterior colporrhaphy
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3.Utero-vaginl prolapse
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1. Conservative management of pelvic organ
prolapse in women (Hagen S, Stark D, Maher C,
Adams E, Cochrane S R, 2004). There is no RCT
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2. Mechanical devices for pelvic organ prolapse
in women (Adams E, Thomson A, Maher C, Hagen S,
Cochrane SR 2004) There is no RCT
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3. Manchester procedure vs. vaginal hysterectomy
for uterine prolapse. MP was associated with
shorter operative time, less blood loss similar
operative outcomes when compared to VH (Thomas et
al,1995). This, suggests the use of MP as an
alternative to VH in the absence of uterine
pathology in appropriate candidates with uterine
prolapse.
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4. Vaginal hysterectomy (combined with anterior
and/or posterior colporraphy) versus abdominal
sacro-colpopexy (with preservation of the uterus)
on urogenital function (Roovers et al,
2004). Vaginal hysterectomy with anterior and/or
posterior colporraphy is preferable to abdominal
sacro-colpopexy with preservation of the uterus
as surgical correction in patients with uterine
prolapse stages II-IV.
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At one year after surgery The discomfort/pain,
overactive bladder obstructive micturition
Re-operation were significantly higher in the
abdominal group than in the vaginal group.
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5. Vaginal approach with bilateral sacrospinous
vault suspension and paravaginal repair versus
abdominal approach with colposacral suspension
and paravaginal repair. Abdominal approach was
more effective (Benson et al, 1996).
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The vaginal group had longer catheter use, more
urinary tract infections, more incontinence,
Optimal surgical effectiveness (29 Vs 58)
re-operation (33 Vs 16 ) of the abdominal
group.
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4. Vault prolapse
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Abdominal sacral colpopexy versus vaginal
sacrospinous colpopexy Abdominal sacral
colpopexy and vaginal sacrospinous colpopexy are
both highly effective in the treatment of vaginal
vault prolapse (Roovers et al,2004).
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Two years after the operation In the abdominal
group the subjective success rate (94 Vs 91)
The objective success rate was 76 Vs 69) in
the vaginal group
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The abdominal approach was associated with a
longer operating time, a slower return to
activities of daily living, and a greater cost
than the sacrospinous colpopexy (Plt.01). Both
surgeries significantly improved the patient's
quality of life (Plt.05).
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5. Urinary stress incontinence
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• 1. Anterior vaginal repair for urinary
  incontinence in women (Glazener CMA, Cooper K,
  Cochrane SR 2004)
• No enough data to compare anterior vaginal repair
  with physical therapy or needle suspension for
  primary urinary stress incontinence

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• Open abdominal retropubic suspension is better
  than anterior vaginal repair 1.Subjective cure
  rates in eight trials, even in women who had
  prolapse in addition to stress incontinence (six
  trials).
• 2.The need for repeat incontinence surgery was
  also less after the abdominal operation.

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2. Open retropubic colposuspension for urinary
incontinence in women (Lapitan MC, Cody DJ, Grant
AM, Cochrane SR 2002) Open retropubic
colposuspension is the most effective treatment
modality for SUI especially in the long term.
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Newer minimal access procedures like tension free
vaginal tape look promising in comparison with
open colposuspension but their long-term
performance is not known. Laparoscopic
colposuspension should allow speedier recovery
but its relative safety and effectiveness is not
known yet.
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Conclusions
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1. There are few RCTs sytematic reviews
concerning surgical treatment of genital
prolapse 2. Preoperative low-dose vaginal
oestradiol treatment reduces the incidence of
bacteriuria in the immediate postoperative period.
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3. Techniques of anterior colporrhaphy provide
similar anatomic cure rates and symptom
resolution 4. Manchester operation is an
alternative to vaginal hysterectomy in the
absence of uterine pathology
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5. Vaginal hysterectomy with (anterior and/or
posterior) colporraphy is preferable to abdominal
sacro-colpopexy 6. Abdominal sacral colpopexy
and vaginal sacrospinous colpopexy are both
highly effective in the treatment of vaginal
vault prolapse
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7. Open abdominal retropubic suspension is better
than anterior vaginal repair 8. Newer minimal
access procedures like TVT look promising in
comparison with open colposuspension but their
long-term performance is not known.
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Thank you
Prof Aboubakr Elnashar Benha University Hospital,
Egypt Delta (Mansura) Benha Fertility
Centers Email elnashar53_at_hotmail.com