Surgical management of pelvic organ prolapse in women

Christopher Maher; Kaven Baessler; Cathryn MA Glazener; Elisabeth J Adams; Suzanne Hagen

doi:10.1002/14651858.CD004014.pub2

Surgical management of pelvic organ prolapse in women

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Referencias

References to studies included in this review

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Benson JT, Lucente V, McClellan E. Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defects: a prospective randomized study with long‐term outcome evaluation. American Journal of Obstetrics & Gynecology 1996;175(6):1418‐22.

Bump RC, Hurt WG, Theofrastous JP, Addison WA, Fantl JA, Wyman JF, et al. Randomized prospective comparison of needle colposuspension versus endopelvic fascia plication for potential stress incontinence prophylaxis in women undergoing vaginal reconstruction for stage III or IV pelvic organ prolapse. The Continence Program for Women Research Group. American Journal of Obstetrics & Gynecology 1996;175(2):326‐35.

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Colombo M, Maggioni A, Scalambrino S, Vitobello D, Milani R. Surgery for genitourinary prolpase and stress incontinence: a randomized trial of posterior pubourethral ligament plication and Pereyra suspension. American Journal of Obstetrics & Gynecology 1997;176(2):337‐43.

Colombo M, Vitobello D, Proietti F, Milani R. Randomised comparison of Burch colposuspension versus anterior colporrhaphy in women with stress urinary incontinence and anterior vaginal wall prolapse. British Journal of Obstetrics & Gynaecology 2000;107(4):544‐51.

Kahn MA, Kumar D, Stanton SL. Posterior colporrhaphy vs transanal repair of the rectocele: an initial follow up of a prospective randomized controlled trial. British Journal of Obstetrics & Gynaecology 1998;105 (Supplement 17):57. [6675]

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Maher CF, Qatawneh AM, Dwyer PL, Carey MP, Cornish A, Schluter PJ. Abdominal sacral colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: A prospective randomized study. American Journal of Obstetrics & Gynecology 2004;190(1):20‐6.

Meschia M, Pifarotti P, Spennacchio M, Gattei U, Buonaguidid A. Randomized comparison between posterior IVS and sacrospinous fixation in the management of vault prolapse. Abstract 277 Proceedings International Continence Society. 2003.

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Meschia M, Buonaguidi A, Amicarelli F, Pifarotti P, Gattei U, Stoppelli S. A randomized prospective comparison of TVT and endopelvic fascia plication in the treatment of occult stress urinary incontinence in patients with severe genital prolapse (Abstract). International Urogynecology Journal 2001;12(Suppl 3):S10. [15457]

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Meschia M, Pifarotti P, Gattei U, Ronchetti A, Stoppelli S, Lampugnani F. TVT and prolapse repair for treatment of occult stress urinary incontinence. Abstract 299, Proceedings International Continence Society (ICS), 32nd Annual Meeting, Heidelberg, Germany 28‐30 August. 2002:198‐9.

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Meschia M, Pifarotti P, Spennacchio M, Buonaguidi A, Gattei U, Somigliana E. A randomized comparison of tension‐free vaginal tape and endopelvic fascia plication in women with genital prolapse and occult stress urinary incontinence. American Journal of Obstetrics & Gynecology 2004;190(3):609‐13. [17213]

Meschia M, Spennacchio F, Amicarelli P, Pifarotti P, Cavoretto S, Stoppelli S. A randomized prospective comparison of TVT and endopelvic fascia plication in the treatment of occult stress urinary incontinence in patients with genital prolapse: preliminary data. Neurourology & Urodynamics. 2001; Vol. 20, issue 4:423‐4.

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Roovers JPWR, van der Vaart CH, van der Bom JG, Schagen van Leeuwen JH, Scholten PC, Heintz APM. A randomized controlled trial comparing abdominal and vaginal prolapse surgery of patients with descensus uteri grade II ‐ IV (Abstract). International Urogynaecology Journal 2001;12(Suppl 3):S109. [16341]

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Roovers JPWR, van der Vaart CH, van der Bom JG, van Leeuwen JHS, Scholten PC, Heintz APM. A randomised controlled trial comparing abdominal and vaginal prolapse surgery: effects on urogenital function. British Journal of Obstetrics & Gynaecology 2004;111(1):50‐6.

Sand PK, Koduri S, Lobel RW, Winkler HA, Tomezsko J, Culligan PJ, et al. Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles. American Journal of Obstetrics & Gynecology 2001;184(7):1357‐64.

Weber AM, Walters MD, Piedmonte MR, Ballard LA. Anterior colporrhaphy: a randomized trial of three surgical techniques. American Journal of Obstetrics & Gynecology 2001;185(6 Pt 1):1299‐306.

References to studies excluded from this review

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Bergman A, Koonings PP, Ballard CA. Primary stress urinary incontinence and pelvic relaxation. American Journal of Obstetrics & Gynecology 1989;161(1):97‐101.

Choe JM, Ogan K, Battino B. Antimicrobial mesh versus vaginal wall sling: a comparative outcomes analysis. Journal of Urology 2000;163(6):1829‐34.

Colombo M, Milani R, Vitobello D, Maggioni A. A randomized comparison of Burch colposuspension and abdominal paravaginal defect repair for female stress urinary incontinence. American Journal of Obstetrics & Gynecology 1996;175(1):78‐84.

Cruikshank SH, Kovac SR. Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele. American Journal of Obstetrics & Gynecology 1999;180(4):859‐65.

Debodinance P, Querleu D. Comparison of the Bologna and Ingelman‐Sundberg procedures for stress incontinence associated with genital prolapse: prospective randomized study. European Journal of Obstetrics Gynecology and Reproductive Biology 1993;52(1):35‐40.

Debodinance P. Comparison of the Bologna and Ingelman‐Sundberg procedures for stress incontinence associated with genital prolapse: ten‐year follow‐up of a prospective randomized study. Journal de Gynecologie obstetrique et biologie de la reproduction 2000;29(2):148‐53.

Kwon C, Goldberg R, Sanjay G, Sumana K, Krotz S, Sand P. Protective effect of transvaginal slings on recurrent anterior vaginal wall prolapse after pelvic reconstructive surgery. Neurourology & Urodynamics. 2002; Vol. 21, issue 4:321‐2.

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References to studies awaiting assessment

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Mattos I, Gosalvez A, Ramallo B, Maroun F, Munoz Garrido F, Gallego M, et al. Titanium staples, a new surgical technique for the vaginal vault prolapse: 22 cases experience (Abstract). Proceedings of the International Continence Society, United Kingdom 11th Annual Scientific Meeting, Bournemouth, United Kingdom, 18‐19 March. 2004:44‐5. [17171]

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References to ongoing studies

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Brubaker L, Cundiff G, Fine P, Nygaard I, Richter H, Visco A, et al. A randomized trial of colpopexy and urinary reduction efforts (CARE): design and methods. Controlled Clinical Trials 2003;24(5):629‐42.

Tincello DG, Mayne CJ, Toozs‐Hobson P, Slack M. Randomised controlled trial of colposuspension versus anterior repair plus TVT for urodynamic stress incontinence with anterior vaginal prolapse: proposal (Abstract). Proceedings of the International Continence Society United Kingdom 11th Annual Scientific Meeting, Bournemouth, United Kingdom, 18‐19 March. 2004:46. [17170]

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Additional references

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Adams E, Thomson A, Maher C, Hagen S. Mechanical devices for pelvic organ prolapse in women (Cochrane Review). The Cochrane Library 2004, Issue 2.

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Brubaker L, Bump R, Jacquetin B, Schuessler B, Weidner A, Zimmern P, et al. Pelvic organ prolapse. Incontinence: 2nd International Consultation on Incontinence. 2nd Edition. Plymouth: Health Publication Ltd, 2002:243‐65.

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Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. American Journal of Obstetrics & Gynecology 1996;175(1):10‐7. [MEDLINE: 96304953]

Bump R, Norton P. Epidemiology and natural history of pelvic floor dsysfunction. Obstetrics & Gynecology Clinics of North America 1998;25(4):723‐46. [MEDLINE: 99120121]

Carey MP, Dwyer PL. Genital prolapse: Vaginal versus abdominal route of repair. Current opinion in Obstetrics and Gynecology 2001;13(5):499‐505. [MEDLINE: 21430847]

Flood CG, Drutz HP, Waja L. Anterior colporrhaphy reinforced with Marlex mesh for the treatment of cystoceles. International Urogynaecology Journal and Pelvic Floor Dysfunction 1998;9(4):200‐4.

Gill EJ, Hurt WG. Pathophysiology of pelvic organ prolapse. Obstetrics & Gynecology Clinics of North America 1998;25(4):759‐69. [MEDLINE: 99120123]

Glazener CMA, Cooper K. Bladder neck needle suspension for urinary incontinence in women (Cochrane Review). The Cochrane Library 2004, Issue 3.

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Hagen S, Stark D, Maher C, Adams E. Conservative management of pelvic organ prolapse in women (Cochrane Review). The Cochrane Library 2004, Issue 2.

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Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta‐analyses. British Medical Journal 2003;327(7414):557‐60.

Julian TM. The efficacy of Marlex mesh in the repair of severe, recurrent prolapse of the anterior midvaginal wall. American Journal of Obstetrics & Gynecology 1996;175(6):1472‐5.

MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalance of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. British Journal Obstetrics and Gynaecology 2000;107(12):1460‐70. [MEDLINE: 21029149]

Salvatore S, Soligo M, Meschia M, Luppino G, Piffarotte PVA. Prosthetic surgery for genital prolapse: functional review. Neurourology and Urodynamics 2002;21:296‐7.

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Visco AG, Weidner AC, Barber MD, Myers ER, Cundiff GW, Bump RC, et al. Vaginal mesh after abdominal sacral colpopexy. American Journal of Obstetrics & Gynecology 2001;184(3):297‐302.

Ware JE, Sherbourne CD. The MOS 36‐item short‐form health survey (SF‐36). I. Conceptual framework and item selection. Medical Care 1992;30(6):473‐83. [MEDLINE: 92278120]

Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica 1983;67(6):361‐70. [MEDLINE: 83279108]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

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Benson 1996

Methods	Single centre RCT for uterine or vault prolapse Number table held by nonsurgical co‐author Follow up A+B 2.5 years
Participants	101 randomised 13 withdrawals (10 did not want surgery, 3 in A wanted vaginal surgery) 88 analysed 8 lost to follow up Inclusion: cervix to or beyond hymen, vaginal vault inversion >50% length and anterior wall to or beyond introitus Exclusion: uterus >12 weeks, adnexal mass, short vagina, central cystocele, >2 abdominal surgeries, obesity, prior inflammatory bowel or pelvic disease
Interventions	A (40): Abdominal group: sacral colpopexy (mesh not specified), paravaginal repair, Halban, posterior vaginal wall repair with colposuspension or sling for stress urinary incontinence, non standardised continence surgery B (48): vaginal group: bilateral sacrospinous colpopexy, vaginal paravaginal repair, McCall culdoplasty, needle suspension or sling; permanent sutures
Outcomes	Optimal: asymptomatic vaginal apex > levator plate: no vaginal tissue beyond the hymen A: 22/38, B: 12/42 Satisfactory: asymptomatic for prolapse and prolapse improved from preoperative: Symptomatic: prolapse apex descent >50% of its length or vaginal tissue beyond hymen Incontinence A: 10/38, B: 16/42 Dyspareunia A: 0/15, B: 15/26 Peri‐operative outcome: Febrile: A 8% /38, B 4% /42 Hospital stay: A 5.4, B 5.1 days Incontinence: A 23% /38, B 44% /42 Cost: Hospital charge: A US$8048, B US$6537 Further prolapse surgery: A 6, B 14 Further continence surgery: A 1, B 5
Notes	After interim analysis study ceased early Satisfactory randomisation? 63% vaginal group underwent continence surgery as compared to 40% abdominal group: 21% slings vaginal group as compared to 5% abdominal group suggesting unequal randomisation Women with a cystocele to the introitus postoperatively were considered to have optimal outcome when this was also part of inclusion criteria Objective outcome not reported No stratification No blinding Standardised surgery, but continence surgery not standardised No intention to treat No CONSORT statement No validated questionnaires No quality of life measures
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	Low risk	A ‐ Adequate

Bump 1996a

Methods	Dual centre RCT: needle suspension or plication of urethrovesical junction endopelvic fascia for cystocele and potential stress incontinence Computer generated randomisation, blocks of 4 to 6 Follow up A+B 2.9 years
Participants	32 women Withdrawal: 0 Inclusion: stage 3 or 4 anterior vaginal wall prolapse and bladder neck hypermobility Lost to follow up: 4
Interventions	A (14): Needle suspension according to Muzsnai with non‐absorbable sutures B (15): Plication of urethrovesical junction endopelvic fascia according to Hurt with non‐absorbable suture
Outcomes	Definition of cure: no stress urinary incontinence, no overactive bladder symptoms, no voiding dysfunction Postoperative urodynamic stress incontinence that was not present preoperatively: A 2/14, B 1/15 New overactive bladder symptoms: A 2/14, B 1/15 Describes site specific pelvic organ prolapse
Notes	No blinding No stratification No intention to treat No CONSORT Potential stress incontinence was identified in 20/29 preoperatively The definition of potential stress urinary incontinence included a positive barrier test or pressure transmission ratio of <90% for proximal 3/4 of the urethra Validated questionnaires
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	Low risk	A ‐ Adequate

Colombo 1996a

Methods	Single centre RCT (computer generated, unclear if allocation concealed) Cystopexy or cystopexy and pubourethral ligament plication for cystocele Follow up: A 2.6 years, B 2.9 years
Participants	107 randomised Lost to follow up: 4 , 1 died 102 analysed Inclusion: cystocele grade 2 or more Exclusion: positive stress test with or without prolapse reduced, overactive bladder symptoms, MUCP <30, previous incontinence surgery
Interventions	A (52): Cystopexy alone: interrupted non‐absorbable sutures of fascia B (50): Cystopexy and pubourethral ligament plication according to Hurt with absorbable suture McCall culdoplasty and posterior repair in all women
Outcomes	Objective cure of cystocele less than grade 2: A: 50/52, B: 48/50 Successful prevention stress urinary incontinence: A: 48/52, B 46/50 Dyspareunia: A 2/24, B 13/23 New postoperative overactive bladder symptoms Voiding dysfunction Days in hospital
Notes	No blinding No intention to treat Power calculation post hoc No CONSORT No validated symptom or QOL questionnaire Informed consent not required before randomisation Surgery standardised Who reviewed outcomes was unclear
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	Unclear risk	B ‐ Unclear

Colombo 1997

Methods	Single centre RCT (computer generated, allocation concealment unclear) Follow up: A 6.3 years, B 6.7 years
Participants	109 randomised 109 analysed for 5 years postoperatively 9 died 3‐7 years postoperatively Inclusion: positive stress test with or without prolapse reduced, cystourethrocele > grade 2 Exclusion: negative stress test, overactive bladder symptoms, MUCP <30, previous incontinence surgery
Interventions	A (55): Cystopexy with interrupted non‐absorbable sutures of fascia pubourethral ligament plication with absorbable sutures B (54): Pereyra with non‐absorbable sutures McCall culdoplasty and posterior colporrhaphy in all women
Outcomes	Objective cure of cystocele less than grade 2: A 55/55, B 52/54 Subjective cure SUI: A 43/55, B 48/54 Objective cure SUI: A 24/55, B 37/54 Objective cure of occult SUI: A 20/40, B 25/43 New postoperative overactive bladder symptoms, voiding dysfunction, days in hospital
Notes	No blinding No intention to treat Power calculation performed post hoc No consort No validated symptom or quality of life measures Informed consent not required before randomisation Surgery standardised Who reviewed outcomes unclear
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	Unclear risk	B ‐ Unclear

Colombo 2000

Methods	Single centre RCT (computer generated open number list ) Burch or anterior repair for pelvic organ prolapse and stress urinary incontinence PC‐open list Follow up: A 14.2, B 13.9 years
Participants	71 randomised Lost to follow up: 3 (A 2, B 1) 68 analysed Inclusion: USI, cystocele >2 or 3, swab test >30% Exclusion: detrusor overactivity, previous pelvic floor surgery, high risk for abdominal operation
Interventions	A (35): Burch group: total abdominal hysterectomy and vault to uterosacral ligament, Moschcowitz, Burch with 3‐4 Ethibond B (33): Anterior colporrhaphy: Vaginal hysterectomy, Pouch of Douglas obliteration and anchoring of vaginal cuff to uterosacral ligament, catgut plication
Outcomes	Definition of cure: no subjective stress urinary incontinence, or no positive stress test Objective cure cystocele: A 23/35, B 32/33 Subjective cure stress urinary incontinence: A 30/35, B 17/32 Objective cure stress urinary incontinence: A 26/35, B 14/32 Overactive bladder symptoms, voiding, dyspareunia Total vaginal length: A 7.9 cm, B 4.7 cm
Notes	No blinding No intention to treat No CONSORT No stratification No power calculation No validated symptom or QOL questionnaire Surgery standardised
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	High risk	C ‐ Inadequate

Kahn 1999

Methods	Single centre RCT (number table randomisation, concealment unclear) Follow up: 25 months (8‐37) A+B
Participants	63 randomised Withdrawal: 4 (A 2, B 2) Excluded: 2 (one no rectocele surgery because posterior vaginal wall cyst, one did not get the surgery performed) Inclusion: symptomatic rectocele or sense of impaired rectal emptying with >15% trapping on isotope defecography
Interventions	A (24): posterior colporrhaphy with levator plication, enterocele repair, hysterectomy, anterior repair as required B (33): transanal repair by single colorectal surgeon, circular muscle plicated longitudinally, permanent suture
Outcomes	Objective cure of recto/enterocele: A: 21/24, B: 23/33 Change in POP‐Q (Ap or Bp) score: A: 1 stage, B: 0 Improved or cured obstructed defecation A: 12/20, B: 14/24 Need for vaginal digitation
Notes	No blinding No stratification No CONSORT Who reviewed outcomes unclear No validated symptom or QoL questionnaires
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	Unclear risk	B ‐ Unclear

Lo 1998

Methods	Single centre RCT (using random number tables) Follow up: 1 to 5.2 years (median 2.1)
Participants	138 randomised, 20 withdrew due to age or not willing to be followed up Inclusion: prolapse at least Grade III (ICS classification) Exclusion: urinary incontinence Past medical history: previous pelvic surgery A: 19, B: 22 Sexually active: A: 11, B: 18
Interventions	A (52): abdominal sacral colpopexy with Mersiline mesh: + 7 posterior repair; + 12 posterior repair and abdominal hysterectomy; + 21 abdominal hysterectomy B (66): vaginal sacrospinous colpopexy with 1‐0 nylon: + 20 anterior and posterior repair and vaginal hysterectomy; + 44 anterior and posterior repair Postoperatively, all women had oestrogen treatment
Outcomes	Success defined as ICS grade II or less Objective success rate (all prolapse): A: 49/52, B: 53/66 Operation time (min): A: 157 (SD 35), B: 141 (37) Blood loss (ml): A: 150 (137), B: 448 (258) Hospital stay (days): A: 7.24 (2.07), B: 8.77 (3.8) Prolonged catheter use: A: 0/52, B: 17/66 Postoperative UTI: A: 2/52, B: 4/66 Dyspareunia: A: 1/11, B: 11/18 (4 of the 11 severe) New urinary incontinence requiring later operation: A: 2/52, B: 1/66 Adverse effects requiring re‐operation: A: 4/52, B: 7/66 Adverse effects A: 2 continence operations, 1 retroperitoneal infection and mesh removal, 1 ureteral injury Adverse effects B: 1 continence operation, 1 rectovaginal fistula, 2 vaginal vault strictures, 3 perineal infections
Notes	Groups stated to be comparable at baseline on age, parity, weight and previous pelvic surgery No blinding No CONSORT Who reviewed outcomes unclear No validated symptom or QoL questionnaires
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	Unclear risk	B ‐ Unclear

Maher 2004

Methods	RCT (stratified by SUI) Multicentre, multi‐surgeon Computer generated randomisation held by nonsurgical co‐author Follow up: A: 24 months, B: 22
Participants	95 women Withdrawals: 0 Lost to follow‐up: 6 (A: 1, B: 5) Inclusion: Vault prolapse to introitus Exclusion: prior sacral colpopexy, unfit for general anaesthetic, foreshortened vagina
Interventions	A (46): abdominal group = sacral colpopexy prolene mesh, paravaginal repair, Moschcowitz, posterior vaginal repair and colposuspension for SUI B (43): vaginal group: R sided sacrospinous colpopexy, enterocele and anterior and post repair, colposuspension for SUI, PDS (slowly absorbable sutures) Both groups: colposuspension for occult or potential SUI
Outcomes	Subjective cure (no prolapse symptoms): A: 43/46, B: 39/43 Objective cure (site specific stage 2 or greater failure at any site) : A: 35/46: B: 29/42 Satisfied with surgery: A: 39/46, B: 35/43 Number of women sexually active: A: 19/42, B: 17/37 Dyspareunia: A: 6/19, B: 7/17 Dyspareunia (de novo): A: 2/19, B: 3/17 Preoperative SUI cured: A: 11/14, B: 13/15 De novo SUI postoperatively: A: 2/22, B: 8/24 Preoperative voiding dysfunction cured A 7/9: B 4/5 Peri‐operative outcomes: Blood loss (ml): A: n=47, mean=362 (SD 239), B: 48, 306 (201) Operating time (minutes): A: 47, 106 (37), B: 48, 76 (42) Postoperative complications: A: 1 mesh infection requiring removal, 2 incisional hernia, B: 0 Further prolapse surgery: Further prolapse or continence surgery: A: 4/46, B: 5/43 Cost: (US dollars) A: 4515: B: 3202 Hospital stay (days): A: 47, 5.4 (2.2), B: 48, 4.8 (1.4) Time to return to normal activity: A: 47, 34 (12), B: 48, 25.7 (9.7)
Notes	No blinding Intention to treat Non surgeon follow up No CONSORT Validated symptom & QoL questionnaires
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	Low risk	A ‐ Adequate

Meschia 2003

Methods	RCT (computer generated number table, opaque envelopes) comparing intravaginal slingplasty and sacrospinous colpopexy for uterine or vault prolapse Median follow up: A 12 months, B 11 months
Participants	47 women Inclusion: pelvic organ prolapse of the cuff, stage 2 or more No withdrawals or losses to follow up Women at 6 month review: A 16, B 16
Interventions	A (23): sacrospinous colpopexy B (24): infracoccygeal sacropexy Anterior and posterior repair, and ligation of enterocele as required
Outcomes	Objective cure of pelvic organ prolapse: Vault A: 16/16, B: 16/16 Anterior vaginal wall A: 13/16, B: 14/16 Posterior vaginal wall A: 15/16, B: 15/16 Complications, peri‐operative data
Notes	Abstract only No stratification No consort No intention to treat No power analysis No validated QoL or pelvic floor questionnaires
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	Low risk	A ‐ Adequate

Meschia 2004

Methods	RCT (sealed envelopes with numbers assigned from a computer‐generated random number list) Comparing TVT and plication of urethrovesical junction endopelvic fascia in addition to prolapse repair Single centre (Milan, Italy) Follow up (median):A: 26 months (range 15 to 31 months), B: 24 (15 to 31)
Participants	50 women Inclusion: severe symptomatic genital prolapse and occult stress urinary incontinence Exclusion: age >70 years, BMI > 30, diabetes, previous pelvic or continence surgery, symptoms of SUI, detrusor overactivity, cotton‐swab test > 30 degrees Age: mean 65 years (SD 8) Parity: 2.2 (0.8) BMI: 25 (3)
Interventions	A (25): prolapse repair and TVT (with Prolene tape) B (25): prolapse repair and urethrovesical plication (with 2‐0 permanent‐braided polyester sutures) All women also had vaginal hysterectomy, McCall culdoplasty and cystocele repair Cystocele (anterior repair) with 2‐0 delayed absorbable sutures (polydioxanone) No sacrospinous ligament fixation performed Rectocele repair: A: 20/25, B: 23/25
Outcomes	Subjective prolapse symptoms, failure rate: A: 4/25, B: 8/25 Objective failure (overall): A: 8/25, B: 7/25 Objective failure (anterior): A: 6/25, B: 7/25 Objective failure (posterior): A: 3/25, B: 3/25 Objective failure (apex): A: 0/25, B: 3/25 Further prolapse surgery: offered to 2 women but groups not specified Further continence surgery: A: 0/25, B: 3/25 SUI subjective: A: 1/25, B: 9/25 SUI objective: A: 2/25, B: 11/25 OAB de novo (new): A: 3/25, B: 1/25 Voiding dysfunction and recurrent UTIs: A: 3/25, B: 1/25 Adverse effects: A: 2 (bladder perforation, retropubic haematoma), B: 0 Peri‐operative outcomes Operation time (minutes): A: 131 (SD 13), B: 112 (21) Blood loss (ml): 188 (77), B: 177 (102) Hb change: A: 1.8 (1.6), B: 1 (1.2) Days in hospital: A: 6.4 (1.5), B: 6.1 (1.5) Time to spontaneous voiding (days): A: 4.4 (1.7), B: 3.8 (2)
Notes	Power calculation provided Groups comparable at baseline
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	Low risk	A ‐ Adequate

Nieminen 2004

Methods	Single centre RCT (nurse took card from envelope with 15 vaginal and 15 transanal cards) Follow up: A 12 months, B 12 months
Participants	30 women Inclusion: symptomatic rectoceles Exclusion: any other prolapse or compromised anal sphincter function 42 eligible women participated 12 excluded due to compromised anal sphincter function 30 analysed No loss to follow up
Interventions	A (15): midline rectovaginal fascia plication Vicryl repair B (15): transanal repair performed by 2 colorectal surgeons Vertical & horizontal Vicryl sutures, enterocele repaired
Outcomes	Improvement symptoms A: 14/15: B 11/15 (P=0.08) Postoperative mean reduction Ap A 2.7: B 1.3 (P=0.01) Depth rectocele defecography Recurrent posterior wall prolapse (rectocele or enterocele): A 1/15, B 10/15 (P=0.01) Continuing need to digitally assist rectal emptying postoperatively A: 1/11, B 4/10 Sexually active: A 12/15, B 11/15 Dyspareunia: A 4/12, B 2/11 Incontinence to flatus: A 4/15, B 3/15 Incontinence to faeces: A 0/15, B 0/15 Peri‐operative outcomes: Operating time: A 35 minutes: B 35 minutes Blood loss ml: A 120, B 60 Discharged from hospital in 48 hours: A 13/15: B 11/15
Notes	Full text as yet unpublished ICS abstract No intention to treat No CONSORT
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	Unclear risk	B ‐ Unclear

Roovers 2004

Methods	RCT (computer‐ generated random number table, allocation concealed) comparing abdominal and vaginal surgery for uterine prolapse Follow up: A 12, B 12 months
Participants	82 women Inclusion: uterine prolapse stage 2‐4 on POP‐Q Exclusion: adnexal mass, 2 or more abdominal surgeries, body mass index >35, prior inflammatory bowel or pelvic disease 124 offered participation 3 excluded 39 refused to participate 2 withdrew from abdominal group as wanted vaginal surgery 82 analysed 8 lost to follow up (A 6, B 2)
Interventions	A (41): Abdominal: sacrocolpopexy with preservation uterus colposuspension for SUI B (41): Vaginal: vaginal hysterectomy with vaginal repair and uterosacral ligament plication: bladder neck needle suspension for SUI
Outcomes	Reoperation performed or planned: A 9/41, B 1/41 Urogenital distress inventory: no significant mean differences between A and B in domain score for genital prolapse (mean difference 4.1, 95% CI ‐5.4 to 13.6) Scores on the UDI for: discomfort/pain domain (mean difference 7.1, 95% CI 1.1 to 13.2), overactive bladder domain (mean difference 8.7, 95% CI 0.5 to 16.9), obstructed micturition domain (mean difference 10.3, 95% CI 0.6 to 20.1) were significantly higher in A than in B Peri‐operative outcomes: Operating time: A 97 (SD 3.6) min, B 107 (SD 4.7) min Blood loss: A 244 (51.5) ml, B 248 (34.1) ml Days in hospital: A 7.7 (0.2) B 7.6 (0.3)
Notes	RCT compared vaginal hysterectomy in vaginal group with uterine preservation in abdominal group No blinding No stratification Intention to treat According to CONSORT Non surgeon review Validated questionnaire: UDI No sexual and bowel function outcomes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	Low risk	A ‐ Adequate

Sand 2001

Methods	Single centre RCT (computer generated number table) Vaginal repair with or without Vicryl mesh overlay for cystocele and rectocele Follow up: A 12, B 12 months
Participants	143 women Inclusion: cystocele to or beyond hymenal ring on standing Exclusion: less than 18 years of age, pregnancy, contemplating pregnancy within one year, paravaginal defect only, anterior enterocele 161 randomised 1 excluded (anterior enterocele) 17 lost to follow up
Interventions	A (70): No mesh: Vicryl plication of anterior endopelvic fascia B (73): Mesh: as above with Vicryl mesh folded underneath trigone and cuff and secured Vicryl to fascia: also added to posterior wall if posterior repair performed Posterior repair performed: A: 67/70, B: 65/73
Outcomes	Cure: POP‐Q less than grade 2 Objective cure of cystocele: A 40/70, B 55/73 (P=0.02) Objective failure for rectocele: A 7/67, B 6/65
Notes	No subjective success No urinary, bowel or sexual function data No peri‐operative data No intention to treat analysis No CONSORT No blinding Standardised concomitant surgery Review by surgeon
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	Unclear risk	B ‐ Unclear

Weber 2001

Methods	RCT (computer‐ generated random number tables. Sealed envelopes concealed assignment) comparing 3 surgical techniques 3 arms, 1 centre Length of follow up: A+B+C, 23.3 months
Participants	83 women Inclusion: all women undergoing cystocele repair Exclusion: continence surgery ie colposuspension or sling 114 randomised 5 withdrawals 26 lost to follow up ( A 2:B 15: C 9:) leaving 83 in trial
Interventions	A (33): anterior repair: midline plication without tension 0 PDS B (24): ultralateral: dissection to pubic rami laterally, plication paravaginal with tension 0 PDS interrupted C: (26) anterior repair plus mesh: standard plication midline Vicryl mesh overlay, Vicryl sutures
Outcomes	Objective Aa & Ba less than or at 1 cm from introitus: A 10/33, B 11/24, C 11/26 Remaining data reported related to 83 women as a whole and did not differentiate between groups
Notes	Number and level of surgeons unknown Adequate power Non‐standardised concomitant surgery Intention to treat yes No CONSORT No stratification Significant disparity in total numbers in Table 1 and actual numbers with prolapse reported Except for point Aa POP‐Q, no individual outcome data reported in the 3 groups
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	Low risk	A ‐ Adequate

BMI = Body Mass Index
Hb = Haemoglobin
ICS = International Continence Society
MUCP = Maximum urethral catheter pressure
OAB = Overactive bladder
PDS = Absorbable Polydioxanone Surgical Suture (PDS)
POP = Pelvic organ prolapse
POP‐Q = Pelvic organ prolapse quantification (according to ICS)
QoL = Quality of Life
RCT = Randomised controlled trial
SUI = Stress Urinary Incontinence (symptom diagnosis)
TVT = Tension‐free vaginal tape
UDI = Urogenital Distress Inventory
UTI = Urinary tract infection

Characteristics of excluded studies [ordered by study ID]

Ir a:

estudios incluidos
estudios en curso

Study	Reason for exclusion
Bergman 1989	RCT on anterior colporrhaphy, Pereyra or Burch colposuspension, no data on pelvic organ prolapse given
Choe 2000	RCT on mesh versus vaginal wall sling for stress incontinence. Not all women had pelvic organ prolapse before the operation
Colombo 1996b	RCT on Burch colposuspension and paravaginal defect repair for stress incontinence, no report on treatment of associated anterior vaginal wall prolapse
Cruikshank 1999	RCT on three operations for prevention of enterocele. Study does not include treatment of prolapse
Debodinance 1993	Comparison of two different procedures for stress incontinence and prolapse but no results on pelvic organ prolapse are reported postoperatively
Debodinance 2000	Comparison of two different procedures for stress incontinence and prolapse but no results on pelvic organ prolapse are reported postoperatively
Kwon 2002	Poster presentation at ICS 2002. Preliminary data, subgroup of an ongoing RCT on additional transvaginal sling for prevention of recurrent anterior vaginal wall prolapse

RCT = Randomised Controlled Trial
ICS = International Continence Society

Characteristics of ongoing studies [ordered by study ID]

Ir a:

estudios incluidos
estudios excluidos

Brubaker 2004

Trial name or title	CARE trial
Methods
Participants	Women with prolapse and occult (potential) urinary incontinence
Interventions	Abdominal sacrocolpopexy with or without prophylactic Burch colposuspension
Outcomes	Stress urinary incontinence, need for further operations
Starting date	April 2002, recruiting for 3 years
Contact information
Notes

Tincello 2004

Trial name or title	TVT and Colposuspension
Methods
Participants	Women with urodynamic stress incontinence and anterior vaginal wall prolapse of at least Stage 2 on POPQ
Interventions	TVT or Colposuspension with anterior repair
Outcomes	3 day urinary diary, 24 hour pad test, King's Health questionnaire, POPQ assessment Follow up at 3 and 12 months
Starting date	2004
Contact information
Notes

CARE =
TVT = tension‐free vaginal tape

Data and analyses

Open in table viewer

Comparison 1. Surgery for upper vaginal (vault/uterine) prolapse

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of women with prolapse symptoms (subjective failure) Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.1 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 1 Number of women with prolapse symptoms (subjective failure).
1.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	169	Risk Ratio (M‐H, Fixed, 95% CI)	0.53 [0.25, 1.09]
1.2 abdominal sacrohysteropexy with Gore‐Tex vs vaginal hysterectomy, vaginal repair, uterosacral ligament plicati	1	82	Risk Ratio (M‐H, Fixed, 95% CI)	3.2 [1.29, 7.92]
2 Number of women with any prolapse (objective failure) Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.2 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 2 Number of women with any prolapse (objective failure).
2.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy (failed)	1	88	Risk Ratio (M‐H, Fixed, 95% CI)	0.77 [0.39, 1.53]
2.2 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy (not improved)	1	118	Risk Ratio (M‐H, Fixed, 95% CI)	0.29 [0.09, 0.97]
2.3 posterior intravaginal slingplasty vs sacrospinous colpopexy	1	32	Risk Ratio (M‐H, Fixed, 95% CI)	0.8 [0.26, 2.45]
3 Number of women with recurrent vault prolapse (objective) Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.3 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 3 Number of women with recurrent vault prolapse (objective).
3.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	169	Risk Ratio (M‐H, Fixed, 95% CI)	0.23 [0.07, 0.77]
4 Number of women unsatisfied with surgery Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.4 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 4 Number of women unsatisfied with surgery.
4.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1	89	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.32, 2.06]
5 Number of women with post‐operative stress urinary incontinence Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.5 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 5 Number of women with post‐operative stress urinary incontinence.
5.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	155	Risk Ratio (M‐H, Fixed, 95% CI)	0.55 [0.32, 0.95]
6 Number of women with urgency, detrusor overactivity or overactive bladder Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.6 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 6 Number of women with urgency, detrusor overactivity or overactive bladder.
6.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Number of women with de novo (new) urgency, detrusor overactivity or overactive bladder Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.7 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 7 Number of women with de novo (new) urgency, detrusor overactivity or overactive bladder.
7.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Number of women with persistent voiding dysfunction Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.8 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 8 Number of women with persistent voiding dysfunction.
8.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Number of women with new voiding dysfunction Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.9 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 9 Number of women with new voiding dysfunction.
9.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Number of women with constipation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.10 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 10 Number of women with constipation.
10.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Number of women with faecal incontinence Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.11 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 11 Number of women with faecal incontinence.
11.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11.2 posterior intravaginal slingplasty vs sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
12 Number of women with obstructed defecation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.12 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 12 Number of women with obstructed defecation.
12.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Postoperative dyspareunia Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.13 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 13 Postoperative dyspareunia.
13.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	3	106	Risk Ratio (M‐H, Fixed, 95% CI)	0.39 [0.18, 0.86]
13.2 posterior intravaginal slingplasty vs sacrospinous colpopexy	1	32	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 7.62]
14 Women with de novo (new) postoperative dyspareunia Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.14 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 14 Women with de novo (new) postoperative dyspareunia.
14.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15 Blood loss (ml) Show forest plot	4		Mean Difference (IV, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.15 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 15 Blood loss (ml).
15.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	213	Mean Difference (IV, Fixed, 95% CI)	‐156.52 [‐212.71, ‐100.32]
15.2 abdominal sacrohysteropexy with Gore‐Tex vs vaginal hysterectomy, vaginal repair, uterosacral ligament plicati	1	82	Mean Difference (IV, Fixed, 95% CI)	‐4.0 [‐22.91, 14.91]
15.3 posterior intravaginal slingplasty vs sacrospinous colpopexy	1	32	Mean Difference (IV, Fixed, 95% CI)	‐50.00 [‐77.48, ‐26.52]
16 Postoperative decrease in Hb (gm/dl) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.16 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 16 Postoperative decrease in Hb (gm/dl).
16.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
17 Operating time (minutes) Show forest plot	5		Mean Difference (IV, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.17 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 17 Operating time (minutes).
17.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	3	293	Mean Difference (IV, Fixed, 95% CI)	21.04 [12.15, 29.94]
17.2 abdominal sacrohysteropexy with Gore‐Tex vs vaginal hysterectomy, vaginal repair, uterosacral ligament plicati	1	82	Mean Difference (IV, Fixed, 95% CI)	‐10.0 [‐11.81, ‐8.19]
17.3 posterior intravaginal slingplasty vs sacrospinous colpopexy	1	32	Mean Difference (IV, Fixed, 95% CI)	‐14.0 [‐25.28, ‐2.72]
18 Length of stay in hospital (days) Show forest plot	4		Mean Difference (IV, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.18 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 18 Length of stay in hospital (days).
18.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	3	293	Mean Difference (IV, Fixed, 95% CI)	0.14 [‐0.25, 0.53]
18.2 abdominal sacrohysteropexy with Gore‐Tex vs vaginal hysterectomy, vaginal repair, uterosacral ligament plicati	1	82	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐0.01, 0.21]
19 Time to return to normal activity (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.19 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 19 Time to return to normal activity (days).
19.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
20 Cost (US dollars) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.20 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 20 Cost (US dollars).
20.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	169	Mean Difference (IV, Fixed, 95% CI)	1333.95 [1027.24, 1640.65]
21 Women having further prolapse surgery Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.21 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 21 Women having further prolapse surgery.
21.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	169	Risk Ratio (M‐H, Fixed, 95% CI)	0.46 [0.19, 1.11]
21.2 abdominal sacrohysteropexy with Gore‐Tex vs vaginal hysterectomy, vaginal repair, uterosacral ligament plicati	1	82	Risk Ratio (M‐H, Fixed, 95% CI)	9.0 [1.19, 67.85]
22 Women having further continence surgery Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.22 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 22 Women having further continence surgery.
22.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	3	287	Risk Ratio (M‐H, Fixed, 95% CI)	0.60 [0.21, 1.73]
23 Women having further prolapse or continence surgery Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.23 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 23 Women having further prolapse or continence surgery.
23.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	169	Risk Ratio (M‐H, Fixed, 95% CI)	0.47 [0.23, 0.97]
24 Time to recurrence of prolapse (months) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.24 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 24 Time to recurrence of prolapse (months).
24.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25 Adverse events Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.25 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 25 Adverse events.
25.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	3	287	Risk Ratio (M‐H, Fixed, 95% CI)	1.30 [0.63, 2.69]
25.2 abdominal sacrohysteropexy with Gore‐Tex vs vaginal hysterectomy, vaginal repair, uterosacral ligament plicati	1	82	Risk Ratio (M‐H, Fixed, 95% CI)	1.2 [0.40, 3.62]
25.3 posterior intravaginal slingplasty vs sacrospinous colpopexy	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	1.28 [0.32, 5.10]
26 Number of women with recurrent rectocele (objective) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.26 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 26 Number of women with recurrent rectocele (objective).
26.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1	89	Risk Ratio (M‐H, Fixed, 95% CI)	2.49 [0.71, 8.79]
27 Number of women with recurrent cystocele (objective) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.27 Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 27 Number of women with recurrent cystocele (objective).
27.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1	89	Risk Ratio (M‐H, Fixed, 95% CI)	0.47 [0.12, 1.75]

Open in table viewer

Comparison 2. One method of anterior prolapse repair versus another surgical method

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of women with prolapse symptoms (subjective failure) Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.1 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 1 Number of women with prolapse symptoms (subjective failure).
1.3 traditional anterior colporraphy vs abdominal Burch colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Number of women with prolapse (objective failure) Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 2.2 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 2 Number of women with prolapse (objective failure).
2.3 traditional anterior colporraphy vs abdominal Burch colposuspension	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	0.06 [0.01, 0.39]
2.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	0.66 [0.34, 1.27]
2.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.37, 2.05]
3 Number of women with anterior prolapse / cystocele (objective failure) Show forest plot	7		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 2.3 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 3 Number of women with anterior prolapse / cystocele (objective failure).
3.1 traditonal anterior colporrhaphy vs abdominal paravaginal repair	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 traditional anterior colporraphy vs ultralateral anterior colporraphy	1	57	Risk Ratio (M‐H, Fixed, 95% CI)	1.29 [0.84, 1.98]
3.3 traditional anterior colporraphy vs anterior colporraphy + mesh reinforcement	2	202	Risk Ratio (M‐H, Fixed, 95% CI)	1.48 [1.07, 2.04]
3.4 ultralateral anterior colporraphy vs anterior colporraphy + mesh reinforcement	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.57, 1.54]
3.5 traditional anterior colporraphy vs abdominal Burch colposuspension	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	0.09 [0.01, 0.64]
3.6 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	0.55 [0.23, 1.29]
3.7 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.14, 6.57]
3.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	1.17 [0.46, 2.98]
4 Number of women with posterior prolapse / rectocele (objective failure) Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.4 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 4 Number of women with posterior prolapse / rectocele (objective failure).
4.1 traditional anterior colporraphy vs anterior colporraphy + mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Number of women with pre‐operative stress incontinence not cured Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.6 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 6 Number of women with pre‐operative stress incontinence not cured.
6.3 traditional anterior colporraphy vs abdominal Burch colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Number of women with de novo (new) stress urinary incontinence Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 2.7 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 7 Number of women with de novo (new) stress urinary incontinence.
7.3 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.25, 3.64]
7.5 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	102	Risk Ratio (M‐H, Fixed, 95% CI)	2.62 [0.63, 10.91]
7.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	9.0 [1.23, 65.85]
8 Number of women with urgency, detrusor overactivity or overactive bladder Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 2.8 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 8 Number of women with urgency, detrusor overactivity or overactive bladder.
8.3 traditional anterior colporraphy vs abdominal Burch colposuspension	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.07, 16.27]
8.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.20, 4.49]
8.5 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.06, 14.96]
8.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.04, 2.99]
9 Number of women with dyspareunia Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.9 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 9 Number of women with dyspareunia.
9.3 traditional anterior colporraphy vs abdominal Burch colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9.4 cystopexy vs cystopexy + pubourethral ligament plication	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Operating time (minutes) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.10 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 10 Operating time (minutes).
10.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Blood loss (ml) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.11 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 11 Blood loss (ml).
11.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
12 Haemoglobin change Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.12 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 12 Haemoglobin change.
12.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Time to return to spontaneous voiding (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.13 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 13 Time to return to spontaneous voiding (days).
13.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
14 Number of women with postoperative complications Show forest plot	6		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.14 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 14 Number of women with postoperative complications.
14.2 traditional anterior colporraphy vs ultralateral anterior colporraphy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.3 traditional anterior colporraphy vs anterior colporraphy + mesh reinforcement	2		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.4 ultralateral anterior colporraphy vs anterior colporraphy + mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.5 traditional anterior colporraphy vs abdominal Burch colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.6 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.7 cystopexy vs cystopexy + pubourethral ligament plication	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15 Length of stay in hospital (days) Show forest plot	3		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.15 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 15 Length of stay in hospital (days).
15.3 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
15.4 cystopexy vs cystopexy + pubourethral ligament plication	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
15.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
18 Number of women having further prolapse surgery Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 2.18 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 18 Number of women having further prolapse surgery.
18.3 traditional anterior colporraphy vs abdominal Burch colposuspension	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
18.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.06, 2.71]
18.5 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
19 Number of women having further surgery for incontinence Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.19 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 19 Number of women having further surgery for incontinence.
19.3 traditional anterior colporraphy vs abdominal Burch colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
19.4 cystopexy vs cystopexy + pubourethral ligament plication	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
19.5 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
19.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20 Persistent voiding dysfunction Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 2.20 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 20 Persistent voiding dysfunction.
20.3 traditional anterior colporraphy vs abdominal Burch colposuspension	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.49, 2.26]
20.5 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.09 [0.00, 1.54]
20.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.04, 2.99]
21 Number of women with worse bowel function Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.21 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 21 Number of women with worse bowel function.
21.1 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
23 Death Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.23 Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 23 Death.
23.1 traditional anterior colporraphy vs ultralateral anterior colporraphy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
23.2 traditional anterior colporraphy vs anterior colporraphy + mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
23.3 ultralateral anterior colporraphy vs anterior colporraphy + mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Open in table viewer

Comparison 3. One method of posterior prolapse repair versus another surgical method

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of women with prolapse symptoms (subjective failure) Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 3.1 Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 1 Number of women with prolapse symptoms (subjective failure).
1.1 posterior vaginal colporrhaphy vs transanal repair	2	87	Risk Ratio (M‐H, Fixed, 95% CI)	0.36 [0.13, 1.00]
2 Number of women with prolapse (objective failure) Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 3.2 Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 2 Number of women with prolapse (objective failure).
2.1 posterior vaginal colporrhaphy vs transanal repair (rectocele)	2	87	Risk Ratio (M‐H, Fixed, 95% CI)	0.32 [0.07, 1.34]
2.2 posterior vaginal colporrhaphy vs transanal repair (enterocele)	2	87	Risk Ratio (M‐H, Fixed, 95% CI)	0.23 [0.07, 0.83]
2.3 posterior vaginal colporrhaphy vs transanal repair (rectocele or enterocele))	2	87	Risk Ratio (M‐H, Fixed, 95% CI)	0.24 [0.09, 0.64]
2.4 posterior vaginal colporraphy vs posterior colporraphy with mesh reinforcement for rectocele	1	132	Risk Ratio (M‐H, Fixed, 95% CI)	1.13 [0.40, 3.19]
4 Number of women with faecal incontinence after operation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.4 Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 4 Number of women with faecal incontinence after operation.
4.1 posterior vaginal colporrhaphy vs transanal repair	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Number of women with anal incontinence to flatus after operation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.5 Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 5 Number of women with anal incontinence to flatus after operation.
5.1 posterior vaginal colporrhaphy vs transanal repair	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Number of women with obstructed defecation / constipation after surgery Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 3.6 Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 6 Number of women with obstructed defecation / constipation after surgery.
6.1 posterior vaginal colporrhaphy vs transanal repair	2	65	Risk Ratio (M‐H, Fixed, 95% CI)	0.73 [0.37, 1.42]
7 Number of women with sexual function not improved after operation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.7 Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 7 Number of women with sexual function not improved after operation.
7.1 posterior vaginal colporrhaphy vs transanal repair	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Number of women with dyspareunia Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 3.8 Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 8 Number of women with dyspareunia.
8.1 posterior vaginal colporrhaphy vs transanal repair	2	80	Risk Ratio (M‐H, Fixed, 95% CI)	3.13 [0.87, 11.23]
9 Blood loss (ml) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 3.9 Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 9 Blood loss (ml).
9.1 posterior vaginal colporrhaphy vs transanal repair	2	87	Mean Difference (IV, Fixed, 95% CI)	79.38 [39.69, 119.08]
10 Difference in haemoglobin Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.10 Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 10 Difference in haemoglobin.
10.1 posterior vaginal colporrhaphy vs transanal repair	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Operating time (minutes) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 3.11 Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 11 Operating time (minutes).
11.1 posterior vaginal colporrhaphy vs transanal repair	2	87	Mean Difference (IV, Fixed, 95% CI)	‐3.64 [‐7.43, 0.15]
12 Postoperative narcotic (morphine) use Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.12 Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 12 Postoperative narcotic (morphine) use.
12.1 posterior vaginal colporrhaphy vs transanal repair	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Number of women with postoperative complications Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 3.13 Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 13 Number of women with postoperative complications.
13.1 posterior vaginal colporrhaphy vs transanal repair	2	87	Risk Ratio (M‐H, Fixed, 95% CI)	3.56 [0.80, 15.74]
14 Persistent postoperative pain Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.14 Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 14 Persistent postoperative pain.
14.1 posterior vaginal colporrhaphy vs transanal repair	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15 Length of stay in hospital (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.15 Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 15 Length of stay in hospital (days).
15.1 posterior vaginal colporrhaphy vs transanal repair	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

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Comparison 7. Prolapse repair and new urinary symptoms

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of women with de novo (new) stress urinary incontinence (subjective diagnosis) Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 7.1 Comparison 7 Prolapse repair and new urinary symptoms, Outcome 1 Number of women with de novo (new) stress urinary incontinence (subjective diagnosis).
1.1 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.25, 3.64]
1.2 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	102	Risk Ratio (M‐H, Fixed, 95% CI)	2.62 [0.63, 10.91]
1.4 abdominal colpopexy vs vaginal colpopexy	1	46	Risk Ratio (M‐H, Fixed, 95% CI)	0.27 [0.06, 1.15]
1.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	9.0 [1.23, 65.85]
2 Number of women with de novo (new) stress urinary incontinence (objective diagnosis) Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 7.2 Comparison 7 Prolapse repair and new urinary symptoms, Outcome 2 Number of women with de novo (new) stress urinary incontinence (objective diagnosis).
2.2 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Number of women with urgency, detrusor overactivity or overactive bladder Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 7.3 Comparison 7 Prolapse repair and new urinary symptoms, Outcome 3 Number of women with urgency, detrusor overactivity or overactive bladder.
3.6 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Number of women with de novo (new) urgency, detrusor overactivity or overactive bladder Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 7.4 Comparison 7 Prolapse repair and new urinary symptoms, Outcome 4 Number of women with de novo (new) urgency, detrusor overactivity or overactive bladder.
4.1 abdominal colpopexy vs vaginal colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 cystopexy vs cystopexy + pubourethral ligament plication	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.3 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Long term new voiding dysfunction Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 7.5 Comparison 7 Prolapse repair and new urinary symptoms, Outcome 5 Long term new voiding dysfunction.
5.1 abdominal colpopexy vs vaginal colpopexy	1	75	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.07, 15.82]
5.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.49, 2.26]
5.5 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.09 [0.00, 1.54]
5.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.04, 2.99]
6 Number of women having further surgery for incontinence Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 7.6 Comparison 7 Prolapse repair and new urinary symptoms, Outcome 6 Number of women having further surgery for incontinence.
6.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	207	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.28, 3.95]
6.2 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.3 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1	73	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.4 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	7.0 [0.38, 128.87]

Open in table viewer

Comparison 8. Use of native tissue versus mesh or foreign material

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of women with anterior prolapse / cystocele (objective failure) Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 8.1 Comparison 8 Use of native tissue versus mesh or foreign material, Outcome 1 Number of women with anterior prolapse / cystocele (objective failure).
1.1 traditional or ultralateral anterior colporraphy vs anterior colporraphy + mesh reinforcement	2	226	Risk Ratio (M‐H, Fixed, 95% CI)	1.39 [1.02, 1.90]
2 Number of women with posterior prolapse / rectocele (objective failure) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 8.2 Comparison 8 Use of native tissue versus mesh or foreign material, Outcome 2 Number of women with posterior prolapse / rectocele (objective failure).
2.1 traditional anterior colporraphy vs anterior colporraphy + mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Number of women with postoperative complications Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 8.3 Comparison 8 Use of native tissue versus mesh or foreign material, Outcome 3 Number of women with postoperative complications.
3.3 traditional or ultralateral anterior colporraphy vs anterior colporraphy + mesh reinforcement	2	252	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.09, 10.08]
4 Death Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 8.4 Comparison 8 Use of native tissue versus mesh or foreign material, Outcome 4 Death.
4.1 traditional or ultralateral anterior colporraphy vs anterior colporraphy + mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Analysis 1.1

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 1 Number of women with prolapse symptoms (subjective failure).

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Analysis 1.2

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 2 Number of women with any prolapse (objective failure).

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Analysis 1.3

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 3 Number of women with recurrent vault prolapse (objective).

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Analysis 1.4

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 4 Number of women unsatisfied with surgery.

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Analysis 1.5

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 5 Number of women with post‐operative stress urinary incontinence.

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Analysis 1.6

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 6 Number of women with urgency, detrusor overactivity or overactive bladder.

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Analysis 1.7

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 7 Number of women with de novo (new) urgency, detrusor overactivity or overactive bladder.

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Analysis 1.8

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 8 Number of women with persistent voiding dysfunction.

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Analysis 1.9

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 9 Number of women with new voiding dysfunction.

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Analysis 1.10

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 10 Number of women with constipation.

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Analysis 1.11

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 11 Number of women with faecal incontinence.

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Analysis 1.12

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 12 Number of women with obstructed defecation.

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Analysis 1.13

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 13 Postoperative dyspareunia.

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Analysis 1.14

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 14 Women with de novo (new) postoperative dyspareunia.

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Analysis 1.15

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 15 Blood loss (ml).

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Analysis 1.16

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 16 Postoperative decrease in Hb (gm/dl).

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Analysis 1.17

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 17 Operating time (minutes).

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Analysis 1.18

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 18 Length of stay in hospital (days).

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Analysis 1.19

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 19 Time to return to normal activity (days).

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Analysis 1.20

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 20 Cost (US dollars).

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Analysis 1.21

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 21 Women having further prolapse surgery.

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Analysis 1.22

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 22 Women having further continence surgery.

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Analysis 1.23

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 23 Women having further prolapse or continence surgery.

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Analysis 1.24

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 24 Time to recurrence of prolapse (months).

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Analysis 1.25

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 25 Adverse events.

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Analysis 1.26

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 26 Number of women with recurrent rectocele (objective).

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Analysis 1.27

Comparison 1 Surgery for upper vaginal (vault/uterine) prolapse, Outcome 27 Number of women with recurrent cystocele (objective).

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Analysis 2.1

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 1 Number of women with prolapse symptoms (subjective failure).

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Analysis 2.2

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 2 Number of women with prolapse (objective failure).

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Analysis 2.3

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 3 Number of women with anterior prolapse / cystocele (objective failure).

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Analysis 2.4

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 4 Number of women with posterior prolapse / rectocele (objective failure).

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Analysis 2.6

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 6 Number of women with pre‐operative stress incontinence not cured.

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Analysis 2.7

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 7 Number of women with de novo (new) stress urinary incontinence.

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Analysis 2.8

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 8 Number of women with urgency, detrusor overactivity or overactive bladder.

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Analysis 2.9

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 9 Number of women with dyspareunia.

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Analysis 2.10

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 10 Operating time (minutes).

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Analysis 2.11

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 11 Blood loss (ml).

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Analysis 2.12

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 12 Haemoglobin change.

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Analysis 2.13

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 13 Time to return to spontaneous voiding (days).

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Analysis 2.14

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 14 Number of women with postoperative complications.

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Analysis 2.15

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 15 Length of stay in hospital (days).

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Analysis 2.18

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 18 Number of women having further prolapse surgery.

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Analysis 2.19

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 19 Number of women having further surgery for incontinence.

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Analysis 2.20

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 20 Persistent voiding dysfunction.

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Analysis 2.21

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 21 Number of women with worse bowel function.

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Analysis 2.23

Comparison 2 One method of anterior prolapse repair versus another surgical method, Outcome 23 Death.

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Analysis 3.1

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 1 Number of women with prolapse symptoms (subjective failure).

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Analysis 3.2

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 2 Number of women with prolapse (objective failure).

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Analysis 3.4

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 4 Number of women with faecal incontinence after operation.

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Analysis 3.5

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 5 Number of women with anal incontinence to flatus after operation.

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Analysis 3.6

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 6 Number of women with obstructed defecation / constipation after surgery.

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Analysis 3.7

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 7 Number of women with sexual function not improved after operation.

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Analysis 3.8

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 8 Number of women with dyspareunia.

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Analysis 3.9

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 9 Blood loss (ml).

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Analysis 3.10

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 10 Difference in haemoglobin.

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Analysis 3.11

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 11 Operating time (minutes).

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Analysis 3.12

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 12 Postoperative narcotic (morphine) use.

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Analysis 3.13

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 13 Number of women with postoperative complications.

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Analysis 3.14

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 14 Persistent postoperative pain.

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Analysis 3.15

Comparison 3 One method of posterior prolapse repair versus another surgical method, Outcome 15 Length of stay in hospital (days).

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Analysis 7.1

Comparison 7 Prolapse repair and new urinary symptoms, Outcome 1 Number of women with de novo (new) stress urinary incontinence (subjective diagnosis).

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Analysis 7.2

Comparison 7 Prolapse repair and new urinary symptoms, Outcome 2 Number of women with de novo (new) stress urinary incontinence (objective diagnosis).

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Analysis 7.3

Comparison 7 Prolapse repair and new urinary symptoms, Outcome 3 Number of women with urgency, detrusor overactivity or overactive bladder.

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Analysis 7.4

Comparison 7 Prolapse repair and new urinary symptoms, Outcome 4 Number of women with de novo (new) urgency, detrusor overactivity or overactive bladder.

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Analysis 7.5

Comparison 7 Prolapse repair and new urinary symptoms, Outcome 5 Long term new voiding dysfunction.

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Analysis 7.6

Comparison 7 Prolapse repair and new urinary symptoms, Outcome 6 Number of women having further surgery for incontinence.

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Analysis 8.1

Comparison 8 Use of native tissue versus mesh or foreign material, Outcome 1 Number of women with anterior prolapse / cystocele (objective failure).

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Analysis 8.2

Comparison 8 Use of native tissue versus mesh or foreign material, Outcome 2 Number of women with posterior prolapse / rectocele (objective failure).

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Analysis 8.3

Comparison 8 Use of native tissue versus mesh or foreign material, Outcome 3 Number of women with postoperative complications.

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Analysis 8.4

Comparison 8 Use of native tissue versus mesh or foreign material, Outcome 4 Death.

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Comparison 1. Surgery for upper vaginal (vault/uterine) prolapse

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of women with prolapse symptoms (subjective failure) Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	169	Risk Ratio (M‐H, Fixed, 95% CI)	0.53 [0.25, 1.09]
1.2 abdominal sacrohysteropexy with Gore‐Tex vs vaginal hysterectomy, vaginal repair, uterosacral ligament plicati	1	82	Risk Ratio (M‐H, Fixed, 95% CI)	3.2 [1.29, 7.92]
2 Number of women with any prolapse (objective failure) Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy (failed)	1	88	Risk Ratio (M‐H, Fixed, 95% CI)	0.77 [0.39, 1.53]
2.2 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy (not improved)	1	118	Risk Ratio (M‐H, Fixed, 95% CI)	0.29 [0.09, 0.97]
2.3 posterior intravaginal slingplasty vs sacrospinous colpopexy	1	32	Risk Ratio (M‐H, Fixed, 95% CI)	0.8 [0.26, 2.45]
3 Number of women with recurrent vault prolapse (objective) Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	169	Risk Ratio (M‐H, Fixed, 95% CI)	0.23 [0.07, 0.77]
4 Number of women unsatisfied with surgery Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1	89	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.32, 2.06]
5 Number of women with post‐operative stress urinary incontinence Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

5.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	155	Risk Ratio (M‐H, Fixed, 95% CI)	0.55 [0.32, 0.95]
6 Number of women with urgency, detrusor overactivity or overactive bladder Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

6.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Number of women with de novo (new) urgency, detrusor overactivity or overactive bladder Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

7.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Number of women with persistent voiding dysfunction Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

8.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Number of women with new voiding dysfunction Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

9.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Number of women with constipation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

10.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Number of women with faecal incontinence Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

11.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11.2 posterior intravaginal slingplasty vs sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
12 Number of women with obstructed defecation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

12.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Postoperative dyspareunia Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

13.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	3	106	Risk Ratio (M‐H, Fixed, 95% CI)	0.39 [0.18, 0.86]
13.2 posterior intravaginal slingplasty vs sacrospinous colpopexy	1	32	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 7.62]
14 Women with de novo (new) postoperative dyspareunia Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

14.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15 Blood loss (ml) Show forest plot	4		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

15.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	213	Mean Difference (IV, Fixed, 95% CI)	‐156.52 [‐212.71, ‐100.32]
15.2 abdominal sacrohysteropexy with Gore‐Tex vs vaginal hysterectomy, vaginal repair, uterosacral ligament plicati	1	82	Mean Difference (IV, Fixed, 95% CI)	‐4.0 [‐22.91, 14.91]
15.3 posterior intravaginal slingplasty vs sacrospinous colpopexy	1	32	Mean Difference (IV, Fixed, 95% CI)	‐50.00 [‐77.48, ‐26.52]
16 Postoperative decrease in Hb (gm/dl) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

16.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
17 Operating time (minutes) Show forest plot	5		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

17.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	3	293	Mean Difference (IV, Fixed, 95% CI)	21.04 [12.15, 29.94]
17.2 abdominal sacrohysteropexy with Gore‐Tex vs vaginal hysterectomy, vaginal repair, uterosacral ligament plicati	1	82	Mean Difference (IV, Fixed, 95% CI)	‐10.0 [‐11.81, ‐8.19]
17.3 posterior intravaginal slingplasty vs sacrospinous colpopexy	1	32	Mean Difference (IV, Fixed, 95% CI)	‐14.0 [‐25.28, ‐2.72]
18 Length of stay in hospital (days) Show forest plot	4		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

18.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	3	293	Mean Difference (IV, Fixed, 95% CI)	0.14 [‐0.25, 0.53]
18.2 abdominal sacrohysteropexy with Gore‐Tex vs vaginal hysterectomy, vaginal repair, uterosacral ligament plicati	1	82	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐0.01, 0.21]
19 Time to return to normal activity (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

19.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
20 Cost (US dollars) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

20.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	169	Mean Difference (IV, Fixed, 95% CI)	1333.95 [1027.24, 1640.65]
21 Women having further prolapse surgery Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

21.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	169	Risk Ratio (M‐H, Fixed, 95% CI)	0.46 [0.19, 1.11]
21.2 abdominal sacrohysteropexy with Gore‐Tex vs vaginal hysterectomy, vaginal repair, uterosacral ligament plicati	1	82	Risk Ratio (M‐H, Fixed, 95% CI)	9.0 [1.19, 67.85]
22 Women having further continence surgery Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

22.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	3	287	Risk Ratio (M‐H, Fixed, 95% CI)	0.60 [0.21, 1.73]
23 Women having further prolapse or continence surgery Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

23.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	169	Risk Ratio (M‐H, Fixed, 95% CI)	0.47 [0.23, 0.97]
24 Time to recurrence of prolapse (months) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

24.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25 Adverse events Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

25.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	3	287	Risk Ratio (M‐H, Fixed, 95% CI)	1.30 [0.63, 2.69]
25.2 abdominal sacrohysteropexy with Gore‐Tex vs vaginal hysterectomy, vaginal repair, uterosacral ligament plicati	1	82	Risk Ratio (M‐H, Fixed, 95% CI)	1.2 [0.40, 3.62]
25.3 posterior intravaginal slingplasty vs sacrospinous colpopexy	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	1.28 [0.32, 5.10]
26 Number of women with recurrent rectocele (objective) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

26.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1	89	Risk Ratio (M‐H, Fixed, 95% CI)	2.49 [0.71, 8.79]
27 Number of women with recurrent cystocele (objective) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

27.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	1	89	Risk Ratio (M‐H, Fixed, 95% CI)	0.47 [0.12, 1.75]

Comparison 1. Surgery for upper vaginal (vault/uterine) prolapse

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Comparison 2. One method of anterior prolapse repair versus another surgical method

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of women with prolapse symptoms (subjective failure) Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.3 traditional anterior colporraphy vs abdominal Burch colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Number of women with prolapse (objective failure) Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.3 traditional anterior colporraphy vs abdominal Burch colposuspension	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	0.06 [0.01, 0.39]
2.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	0.66 [0.34, 1.27]
2.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.37, 2.05]
3 Number of women with anterior prolapse / cystocele (objective failure) Show forest plot	7		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 traditonal anterior colporrhaphy vs abdominal paravaginal repair	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 traditional anterior colporraphy vs ultralateral anterior colporraphy	1	57	Risk Ratio (M‐H, Fixed, 95% CI)	1.29 [0.84, 1.98]
3.3 traditional anterior colporraphy vs anterior colporraphy + mesh reinforcement	2	202	Risk Ratio (M‐H, Fixed, 95% CI)	1.48 [1.07, 2.04]
3.4 ultralateral anterior colporraphy vs anterior colporraphy + mesh reinforcement	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.57, 1.54]
3.5 traditional anterior colporraphy vs abdominal Burch colposuspension	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	0.09 [0.01, 0.64]
3.6 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	0.55 [0.23, 1.29]
3.7 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.14, 6.57]
3.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	1.17 [0.46, 2.98]
4 Number of women with posterior prolapse / rectocele (objective failure) Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4.1 traditional anterior colporraphy vs anterior colporraphy + mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Number of women with pre‐operative stress incontinence not cured Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

6.3 traditional anterior colporraphy vs abdominal Burch colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Number of women with de novo (new) stress urinary incontinence Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

7.3 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.25, 3.64]
7.5 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	102	Risk Ratio (M‐H, Fixed, 95% CI)	2.62 [0.63, 10.91]
7.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	9.0 [1.23, 65.85]
8 Number of women with urgency, detrusor overactivity or overactive bladder Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

8.3 traditional anterior colporraphy vs abdominal Burch colposuspension	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.07, 16.27]
8.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.20, 4.49]
8.5 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.06, 14.96]
8.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.04, 2.99]
9 Number of women with dyspareunia Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

9.3 traditional anterior colporraphy vs abdominal Burch colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9.4 cystopexy vs cystopexy + pubourethral ligament plication	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Operating time (minutes) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

10.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Blood loss (ml) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

11.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
12 Haemoglobin change Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

12.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Time to return to spontaneous voiding (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

13.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
14 Number of women with postoperative complications Show forest plot	6		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

14.2 traditional anterior colporraphy vs ultralateral anterior colporraphy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.3 traditional anterior colporraphy vs anterior colporraphy + mesh reinforcement	2		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.4 ultralateral anterior colporraphy vs anterior colporraphy + mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.5 traditional anterior colporraphy vs abdominal Burch colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.6 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.7 cystopexy vs cystopexy + pubourethral ligament plication	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15 Length of stay in hospital (days) Show forest plot	3		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

15.3 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
15.4 cystopexy vs cystopexy + pubourethral ligament plication	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
15.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
18 Number of women having further prolapse surgery Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

18.3 traditional anterior colporraphy vs abdominal Burch colposuspension	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
18.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.06, 2.71]
18.5 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
19 Number of women having further surgery for incontinence Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

19.3 traditional anterior colporraphy vs abdominal Burch colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
19.4 cystopexy vs cystopexy + pubourethral ligament plication	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
19.5 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
19.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20 Persistent voiding dysfunction Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

20.3 traditional anterior colporraphy vs abdominal Burch colposuspension	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.49, 2.26]
20.5 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.09 [0.00, 1.54]
20.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.04, 2.99]
21 Number of women with worse bowel function Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

21.1 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
23 Death Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

23.1 traditional anterior colporraphy vs ultralateral anterior colporraphy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
23.2 traditional anterior colporraphy vs anterior colporraphy + mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
23.3 ultralateral anterior colporraphy vs anterior colporraphy + mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 2. One method of anterior prolapse repair versus another surgical method

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Comparison 3. One method of posterior prolapse repair versus another surgical method

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of women with prolapse symptoms (subjective failure) Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 posterior vaginal colporrhaphy vs transanal repair	2	87	Risk Ratio (M‐H, Fixed, 95% CI)	0.36 [0.13, 1.00]
2 Number of women with prolapse (objective failure) Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 posterior vaginal colporrhaphy vs transanal repair (rectocele)	2	87	Risk Ratio (M‐H, Fixed, 95% CI)	0.32 [0.07, 1.34]
2.2 posterior vaginal colporrhaphy vs transanal repair (enterocele)	2	87	Risk Ratio (M‐H, Fixed, 95% CI)	0.23 [0.07, 0.83]
2.3 posterior vaginal colporrhaphy vs transanal repair (rectocele or enterocele))	2	87	Risk Ratio (M‐H, Fixed, 95% CI)	0.24 [0.09, 0.64]
2.4 posterior vaginal colporraphy vs posterior colporraphy with mesh reinforcement for rectocele	1	132	Risk Ratio (M‐H, Fixed, 95% CI)	1.13 [0.40, 3.19]
4 Number of women with faecal incontinence after operation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4.1 posterior vaginal colporrhaphy vs transanal repair	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Number of women with anal incontinence to flatus after operation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

5.1 posterior vaginal colporrhaphy vs transanal repair	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Number of women with obstructed defecation / constipation after surgery Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

6.1 posterior vaginal colporrhaphy vs transanal repair	2	65	Risk Ratio (M‐H, Fixed, 95% CI)	0.73 [0.37, 1.42]
7 Number of women with sexual function not improved after operation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

7.1 posterior vaginal colporrhaphy vs transanal repair	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Number of women with dyspareunia Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

8.1 posterior vaginal colporrhaphy vs transanal repair	2	80	Risk Ratio (M‐H, Fixed, 95% CI)	3.13 [0.87, 11.23]
9 Blood loss (ml) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

9.1 posterior vaginal colporrhaphy vs transanal repair	2	87	Mean Difference (IV, Fixed, 95% CI)	79.38 [39.69, 119.08]
10 Difference in haemoglobin Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

10.1 posterior vaginal colporrhaphy vs transanal repair	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Operating time (minutes) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

11.1 posterior vaginal colporrhaphy vs transanal repair	2	87	Mean Difference (IV, Fixed, 95% CI)	‐3.64 [‐7.43, 0.15]
12 Postoperative narcotic (morphine) use Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

12.1 posterior vaginal colporrhaphy vs transanal repair	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Number of women with postoperative complications Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

13.1 posterior vaginal colporrhaphy vs transanal repair	2	87	Risk Ratio (M‐H, Fixed, 95% CI)	3.56 [0.80, 15.74]
14 Persistent postoperative pain Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

14.1 posterior vaginal colporrhaphy vs transanal repair	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15 Length of stay in hospital (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

15.1 posterior vaginal colporrhaphy vs transanal repair	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 3. One method of posterior prolapse repair versus another surgical method

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Comparison 7. Prolapse repair and new urinary symptoms

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of women with de novo (new) stress urinary incontinence (subjective diagnosis) Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.25, 3.64]
1.2 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	102	Risk Ratio (M‐H, Fixed, 95% CI)	2.62 [0.63, 10.91]
1.4 abdominal colpopexy vs vaginal colpopexy	1	46	Risk Ratio (M‐H, Fixed, 95% CI)	0.27 [0.06, 1.15]
1.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	9.0 [1.23, 65.85]
2 Number of women with de novo (new) stress urinary incontinence (objective diagnosis) Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2.2 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Number of women with urgency, detrusor overactivity or overactive bladder Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3.6 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Number of women with de novo (new) urgency, detrusor overactivity or overactive bladder Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4.1 abdominal colpopexy vs vaginal colpopexy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 cystopexy vs cystopexy + pubourethral ligament plication	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.3 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Long term new voiding dysfunction Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

5.1 abdominal colpopexy vs vaginal colpopexy	1	75	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.07, 15.82]
5.4 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.49, 2.26]
5.5 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.09 [0.00, 1.54]
5.8 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.04, 2.99]
6 Number of women having further surgery for incontinence Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

6.1 abdominal sacral colpopexy vs vaginal sacrospinous colpopexy	2	207	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.28, 3.95]
6.2 cystopexy vs cystopexy + pubourethral ligament plication	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.3 prolapse repair + urethrovesical plication vs prolapse repair + needle colposuspension	1	73	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.4 prolapse repair + urethrovesical endopelvic fascia repair vs prolapse repair + TVT	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	7.0 [0.38, 128.87]

Comparison 7. Prolapse repair and new urinary symptoms

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Comparison 8. Use of native tissue versus mesh or foreign material

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of women with anterior prolapse / cystocele (objective failure) Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 traditional or ultralateral anterior colporraphy vs anterior colporraphy + mesh reinforcement	2	226	Risk Ratio (M‐H, Fixed, 95% CI)	1.39 [1.02, 1.90]
2 Number of women with posterior prolapse / rectocele (objective failure) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2.1 traditional anterior colporraphy vs anterior colporraphy + mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Number of women with postoperative complications Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.3 traditional or ultralateral anterior colporraphy vs anterior colporraphy + mesh reinforcement	2	252	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.09, 10.08]
4 Death Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4.1 traditional or ultralateral anterior colporraphy vs anterior colporraphy + mesh reinforcement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 8. Use of native tissue versus mesh or foreign material

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Referencias

References to studies included in this review

Benson 1996 {published and unpublished data}

Bump 1996a {published data only}

Colombo 1996a {published data only}

Colombo 1997 {published data only}

Colombo 2000 {published data only}

Kahn 1999 {published and unpublished data}

Lo 1998 {published data only}

Maher 2004 {published and unpublished data}

Meschia 2003 {published data only}

Meschia 2004 {published data only}

Nieminen 2004 {published and unpublished data}

Roovers 2004 {published and unpublished data}

Sand 2001 {published data only}

Weber 2001 {published data only}

References to studies excluded from this review

Bergman 1989 {published data only}

Choe 2000 {published data only}

Colombo 1996b {published data only}

Cruikshank 1999 {published data only}

Debodinance 1993 {published data only}

Debodinance 2000 {published data only}

Kwon 2002 {unpublished data only}

References to studies awaiting assessment

Mattos 2004 {published data only}

References to ongoing studies

Brubaker 2004 {published data only}

Tincello 2004 {published data only}

Additional references

Adams 2004

Alderson 2004

Baden 1972

Beck 1991

Brubaker 2002

Bump 1996b

Bump 1998

Carey 2001

Flood 1998

Gill 1998

Glazener 2004

Hagen 2004

Higgins 2003

Julian 1996

MacLennan 2000

Salvatore 2002

Scott 2004

Visco 2001

Ware 1992

Zigmond 1983

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Characteristics of excluded studies [ordered by study ID]

Characteristics of ongoing studies [ordered by study ID]

Data and analyses

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