Perioperative interventions in pelvic organ prolapse surgery.

Abstract

Background: Pelvic organ prolapse (POP) is a common condition, with a significant proportion of women requiring surgical treatment. While the evidence supporting the surgical management of pelvic organ prolapse is well established, the evidence for perioperative interventions remains porous. The main goal of perioperative interventions is to reduce the rate of adverse events while improving women's outcomes following surgical intervention for prolapse.

Objectives: To compare the safety and effectiveness of a range of perioperative interventions versus other interventions or no intervention (control group) at the time of surgery for POP.

Search methods: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from CENTRAL, MEDLINE, two major international clinical trials registers, and handsearching of journals and conference proceedings (searched 30 April 2024). We also contacted researchers in the field.

Selection criteria: We included randomised controlled trials (RCTs) of women undergoing surgical treatment for symptomatic POP that compared a perioperative intervention related to POP surgery versus no treatment or another intervention.

Data collection and analysis: We used standard methodological procedures recommended by Cochrane. Our primary outcomes were awareness of prolapse, repeat surgery for prolapse and objective failure at any site. We also measured adverse events and patient-reported outcomes. We used the GRADE approach to assess the certainty of the evidence.

Main results: This review includes 49 RCTs that compared 19 different intervention groups versus a control. The trials were conducted in 15 countries, and involved 5657 women. The certainty of the evidence ranged from low to moderate. Most interventions could not be blinded, thus introducing a risk of bias. POP surgery with or without pelvic floor muscle training (PFMT): seven RCTs with 1032 women There may be no clinically relevant difference in awareness of prolapse following POP surgery with or without PFMT (odds ratio (OR) 1.07, 95% confidence interval (CI) 0.61 to 1.87; 1 study, 305 women; low-certainty evidence). This suggests that if 20% of women are aware of prolapse after surgery without PFMT, 13% to 31% are likely to be aware after POP surgery with PFMT. Similarly, there may be no clinically relevant difference in repeat surgery for prolapse with or without PFMT (OR 0.86, 95% CI 0.23 to 3.26; 1 study, 316 women; low-certainty evidence). Additionally, there may be no clinically relevant difference in objective failure at any site with or without PFMT (OR 1.24, 95% CI 0.67 to 2.29; P = 0.49; 1 study, 307 women; low-certainty evidence). Finally, there may be no clinically relevant difference in patient-reported outcomes measures with or without PFMT, including Pelvic Floor Distress Inventory-20 (PFDI-20) scores (mean difference (MD) -4.11, 95% CI -8.97 to 0.76; I² = 0%; 3 studies, 512 women; low-certainty evidence), Urinary Distress Inventory (UDI) (MD -0.23, 95% CI -4.59 to 4.14; I² = 81%, 3 studies, 289 women; low-certainty evidence), Pelvic Organ Prolapse - Distress Inventory (POP-DI) (MD 0.00, 95% CI -1.22 to 1.22; I² = 0%; 2 studies, 143 women; low-certainty evidence) and Colorectal Anal Distress Inventory (CRADI) (MD -1.70, 95% CI -7.91 to 4.51; I² = 96%; 3 studies, 291 women; low-certainty evidence). POP surgery with in-dwelling catheter (IDC) removal before 24 hours versus at 24 hours postoperatively: five RCTs with 478 women There was probably no clinically relevant difference in urinary tract infections (UTIs) between women with IDC removal before 24 hours versus at 24 hours postoperatively (OR 0.63, 95% CI 0.37 to 1.08; I² = 61%; 4 studies, 381 women; moderate-certainty evidence). Similarly, there may be no clinically relevant difference in the number of women discharged with a catheter between the two groups (OR 0.80, 95% CI 0.22 to 2.95; 1 study, 64 women; low-certainty evidence). Furthermore, there may be no clinically relevant difference in the length of stay (days) between women with IDC removal before 24 hours versus at 24 hours postoperatively (MD 0.00, 95% CI -0.10 to 0.11; I² = 45%; 3 studies, 181 women; low-certainty evidence). Finally, there may be little to no difference in total catheter days between the two groups (MD 0.10, 95% CI -0.64 to 0.84; 2 studies, 124 women; low-certainty evidence). POP surgery with IDC removal day at more than 24 hours postoperatively versus at 24 hours: two RCTs with 277 women Women may be more likely to have a large increase in UTI risk if they had an IDC for longer than one day (OR 9.25, 95% CI 3.60 to 23.75; I² = 0%; 2 studies, 274 women; low-certainty evidence). This suggests that if 4% of women get a UTI with IDC removal at 24 hours, 12% to 47% will get a UTI with IDC removal at more than 24 hours following POP surgery. Similarly, having an IDC for longer than 24 hours probably increases the length of hospital stay (MD 1.18, 95% CI 0.92 to 1.44; 2 studies, 274 women; moderate-certainty evidence). Finally, having an IDC for longer than 24 hours may result in a large increase in total catheter days (MD 2.45, 95% CI 2.14 to 2.76; 1 study, 197 women; low-certainty evidence). There were no clinically relevant differences between study groups in the few available results for the following interventions at the time of POP surgery: with or without bowel preparation, short-acting versus long-acting bupivacaine, with or without vasoconstrictors, with chlorhexadine 2% vaginal preparation versus other vaginal antiseptic solutions, with or without vaginal packing, with restricted versus liberal postoperative activity instructions, with or without vaginal oestrogen, and with or without cranberry supplementation.

Authors' conclusions: There remains a paucity of data on perioperative interventions in POP surgery. We were unable to establish a clinically meaningful reduction in adverse events or increase in patient satisfaction across most of the perioperative interventions. Women may be more likely to have a large increase in UTI risk if they have an IDC for longer than one day.