Systematic reviews of apical prolapse surgery: are we being misled down a dangerous path?

BIwastoldIhadthebestprocedureformycondition.IsittrueI could have had vaginal surgery without mesh?^ This ques-tionwasposedbythe43-year-oldwomannowfacingtheneedfor adhesiolysis and trachelectomy due to pelvic pain andcyclic bleeding two years after undergoing laparoscopicsupracervical hysterectomy and mesh sacrocervicopexy forstage 3 uterine prolapse (Fig. 1).Theclaimofsuperiorityofsacrocolpopexy(SC)overotherpelvic organ prolapse (POP) procedures was initiated by theresults ofthree randomizedcontrolledtrials(RCTs)involvinga total of 287 patients comparing abdominal SC (ASC) andsacrospinous ligament fixation (SSLF) published in 1996,1998and2004[1–3].Thesestudiesreportedsuperioranatom-ic outcomes with ASC when compared with SSLF, but alsoshowed higher short-term morbidity with ASC. The claim ofsuperiorityofASCoverSSLFwasfurtherreinforcedwiththepublication ofthe first CochranesystematicreviewofsurgeryforPOPpublishedin2004,whichsummarizedthefindingsofthe three previously mentioned studies stating Babdominalsacral colpopexy was better than vaginal sacrospinouscolpopexy in terms of a lower rate of recurrent vault prolapseand less dyspareunia, but the trend towards a lower re-operation rate for prolapse following abdominalsacrocolpopexy was not statistically significant^ [4]. SincetheseinitialRCTscomparingASCwithSSLF,severalsystem-atic reviews have shown the same findings of superior ana-tomic outcomes associated with ASC compared with SSLF[4–11]. These reviews reinforce the perception that there is alarge body of evidence supporting ASC as the best option fortreating POP.Laparoscopic SC (LSC) and robot-assisted SC have beendeveloped to reduce the short-term morbidity associated withASC [12, 13]. Many surgeons consider these less invasiveapproaches to SC (and variations such as sacrocervicopexy)equivalenttoASCintermsofanatomicoutcomeleadingthemtoclaimthatLSCandroboticSCapproachesarenowthebestoptions for treating POP. The most recent Cochrane reviewpublished in 2013 concludes Bsacral colpopexy has superioroutcomes to a variety of vaginal procedures includingsacrospinous colpopexy, uterosacral colpopexy andtransvaginal mesh^ implyingthatall formsofSC are superiorto all other surgical options for treating apical prolapse [9].A close look at the current literature, however, reveals thatthereareactuallyveryfewlevel1studiesfromwhichtoderivesuch a bold conclusion concerning SC compared with otheroptionsfortreatingPOP.OnlytwostudiescomparingSCwithother procedures have been added to the Cochrane reviewover the past decade and both of these are controversial. Oneis a trial comparing LSC with total vaginal mesh (TVM) thatshowedsuperiorityofLSCcomparedtoTVM[14].Thestudyis controversial because the reported success rate for TVMwassignificantlylowerthantherateachievedbyotherauthorsand because of this low rate, LSC was reported as superior.The other is an abstract of a trial comparing ASC withuterosacral ligament suspension (USLS) that showed superi-ority of ASC, but this study is yet to be published as a fullpeer-reviewed article limiting the ability to assess the qualityand potential confounding factors affecting the results [15]. Itistheadditionofthesetwocontroversial studieswhich result-edinthechangeofwordingintheCochraneReviewsummaryfrom the more specific statement that BASC is superior to