Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse

Christopher Maher; Benjamin Feiner; Kaven Baessler; Corina Christmann‐Schmid; Nir Haya; Jane Marjoribanks

doi:10.1002/14651858.CD012079

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Figure 1

PRISMA study flow diagram.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 4

Forest plot of comparison: 1 Any transvaginal permanent mesh versus native tissue repair, outcome: 1.1 Awareness of prolapse (1 to 3 years).

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Figure 5

Forest plot of comparison: 3 Biological repair versus native tissue repair, outcome: 3.1 Awareness of prolapse (1 to 3 years).

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Figure 6

Funnel plot of comparison: 1 Any transvaginal permanent mesh versus native tissue repair, outcome: 1.3 Recurrent prolapse (any) at 1 to 3 years.

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Analysis 1.1

Comparison 1 Any transvaginal permanent mesh versus native tissue repair, Outcome 1 Awareness of prolapse (1‐3 years).

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Analysis 1.2

Comparison 1 Any transvaginal permanent mesh versus native tissue repair, Outcome 2 Repeat surgery (1‐3 years).

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Analysis 1.3

Comparison 1 Any transvaginal permanent mesh versus native tissue repair, Outcome 3 Recurrent prolapse (any) at 1‐3 years.

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Analysis 1.4

Comparison 1 Any transvaginal permanent mesh versus native tissue repair, Outcome 4 Injuries bladder or bowel.

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Analysis 1.5

Comparison 1 Any transvaginal permanent mesh versus native tissue repair, Outcome 5 Objective failure of anterior compartment (cystocoele).

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Analysis 1.6

Comparison 1 Any transvaginal permanent mesh versus native tissue repair, Outcome 6 Objective failure of posterior compartment (rectocoele).

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Analysis 1.7

Comparison 1 Any transvaginal permanent mesh versus native tissue repair, Outcome 7 POPQ assessment (any mesh).

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Analysis 1.8

Comparison 1 Any transvaginal permanent mesh versus native tissue repair, Outcome 8 Bladder function: de novo stress urinary incontinence (1‐3 years).

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Analysis 1.9

Comparison 1 Any transvaginal permanent mesh versus native tissue repair, Outcome 9 De novo voiding disorder, urgency, detrusor overactivity or overactive bladder.

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Analysis 1.10

Comparison 1 Any transvaginal permanent mesh versus native tissue repair, Outcome 10 De novo dyspareunia (1‐3 years).

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Analysis 1.11

Comparison 1 Any transvaginal permanent mesh versus native tissue repair, Outcome 11 Sexual function (1‐3 years).

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Analysis 1.12

Comparison 1 Any transvaginal permanent mesh versus native tissue repair, Outcome 12 Quality of life: continuous data (1‐2 years):.

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Analysis 1.13

Comparison 1 Any transvaginal permanent mesh versus native tissue repair, Outcome 13 Quality of life: dichotomous data "much or very much better".

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Analysis 1.14

Comparison 1 Any transvaginal permanent mesh versus native tissue repair, Outcome 14 Operating time (minutes).

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Analysis 1.15

Comparison 1 Any transvaginal permanent mesh versus native tissue repair, Outcome 15 Blood transfusion.

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Analysis 1.16

Comparison 1 Any transvaginal permanent mesh versus native tissue repair, Outcome 16 Length of stay in hospital (days).

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Analysis 2.1

Comparison 2 Absorbable mesh versus native tissue repair, Outcome 1 Awareness of prolapse (2 year review).

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Analysis 2.2

Comparison 2 Absorbable mesh versus native tissue repair, Outcome 2 Repeat surgery for prolapse (2 years).

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Analysis 2.3

Comparison 2 Absorbable mesh versus native tissue repair, Outcome 3 Recurrent prolapse (3 months ‐2 years).

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Analysis 2.4

Comparison 2 Absorbable mesh versus native tissue repair, Outcome 4 Death.

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Analysis 2.5

Comparison 2 Absorbable mesh versus native tissue repair, Outcome 5 Objective failure of anterior compartment (cystocoele).

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Analysis 2.6

Comparison 2 Absorbable mesh versus native tissue repair, Outcome 6 Objective failure of posterior compartment (rectocoele).

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Analysis 2.7

Comparison 2 Absorbable mesh versus native tissue repair, Outcome 7 Stress urinary incontinence.

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Analysis 2.8

Comparison 2 Absorbable mesh versus native tissue repair, Outcome 8 Quality of life (2 years).

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Analysis 3.1

Comparison 3 Biological repair versus native tissue repair, Outcome 1 Awareness of prolapse (1‐3 year).

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Analysis 3.2

Comparison 3 Biological repair versus native tissue repair, Outcome 2 Repeat prolapse surgery (1‐2 years).

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Analysis 3.3

Comparison 3 Biological repair versus native tissue repair, Outcome 3 Recurrent prolapse (1 year).

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Analysis 3.4

Comparison 3 Biological repair versus native tissue repair, Outcome 4 Injuries to bladder or bowel.

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Analysis 3.5

Comparison 3 Biological repair versus native tissue repair, Outcome 5 Objective failure of anterior compartment (cystocele).

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Analysis 3.6

Comparison 3 Biological repair versus native tissue repair, Outcome 6 Objective failure of posterior compartment (rectocele).

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Analysis 3.7

Comparison 3 Biological repair versus native tissue repair, Outcome 7 POPQ assessment.

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Analysis 3.8

Comparison 3 Biological repair versus native tissue repair, Outcome 8 De novo urinary stress incontinence.

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Analysis 3.9

Comparison 3 Biological repair versus native tissue repair, Outcome 9 De novo voiding disorders, urgency, detrusor overactivity or overactive bladder.

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Analysis 3.10

Comparison 3 Biological repair versus native tissue repair, Outcome 10 De novo dyspareunia (1 year).

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Analysis 3.11

Comparison 3 Biological repair versus native tissue repair, Outcome 11 Sexual function (1 year).

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Analysis 3.12

Comparison 3 Biological repair versus native tissue repair, Outcome 12 Quality of life (1 year).

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Analysis 3.13

Comparison 3 Biological repair versus native tissue repair, Outcome 13 Operating time (minutes).

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Analysis 3.14

Comparison 3 Biological repair versus native tissue repair, Outcome 14 Blood transfusion.

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Summary of findings for the main comparison. Any transvaginal permanent mesh versus native tissue repair for vaginal prolapse

Any transvaginal permanent mesh versus native tissue repair for vaginal prolapse
Population: women with vaginal prolapse Settings: surgical Intervention: any transvaginal permanent mesh versus native tissue repair
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Native tissue repair	Any transvaginal permanent mesh
Awareness of prolapse review 1 to 3 years	188 per 1000	124 per 1000 (101 to 152)	RR 0.66 (0.54 to 0.81)	1614 (12 RCTs)	⊕⊕⊕⊝ moderate¹
Repeat surgery ‐ prolapse review 1 to 3 years	32 per 1000	17 per 1000 (10 to 28)	RR 0.53 (0.31 to 0.88)	1675 (12 RCTs)	⊕⊕⊕⊝ moderate¹
Repeat surgery ‐ continence surgery	26 per 1000	28 per 1000 (16 to 48)	RR 1.07 (0.62 to 1.83)	1284 (9 RCTs)	⊕⊕⊝⊝ low^1,2
Repeat surgery ‐ surgery for prolapse, SUI, or mesh exposure review 1 to 3 years	48 per 1000	114 per 1000 (72 to 181)	RR 2.40 (1.51 to 3.81)	867 (7 studies)	⊕⊕⊕⊝ moderate¹
Recurrent prolapse review 1 to 3 years	381 per 1000	152 per 1000 (114 to 202)	RR 0.40 (0.30 to 0.53)	2494 (21 studies)	⊕⊕⊝⊝ low^1,4	I² = 73%
Bladder injury	5 per 1000	21 per 1000 (9 to 51)	RR 3.92 (1.62 to 9.5)	1514 (11 studies)	⊕⊕⊕⊝ moderate¹
De novo dyspareunia (pain during sexual intercourse) review 1 to 3 years	95 per 1000	88 per 1000 (55 to 140)	RR 0.92 (0.58 to 1.47)	764 (11 studies)	⊕⊕⊝⊝ low^1,2
De novo stress urinary incontinence review 1 to 3 years	96 per 1000	133 per 1000 (101 to 174)	RR 1.39 (1.06 to 1.82)	1512 (12 studies)	⊕⊕⊝⊝ low^1,3
Quality of life review 1 to 2 years	The mean quality of life in the mesh groups was 0.05 standard deviations higher (0.20 lower to 0.30 higher). This is an imprecise finding that is consistent with a small benefit in either group, or else no difference between the groups			665 (7 studies)	⊕⊝⊝⊝ very low^{1, 2,4}	I² = 60%
The basis for the assumed risk* is the median control group risk across studies The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; SUI: stress urinary incontinence
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Downgraded one level due to serious risk of bias: most of the studies were at unclear or high risk of bias associated with poor reporting of methods, including failure by many to describe satisfactory methods of allocation concealment or blinding. A minority of studies did not report use of blinding at all. ²Downgraded one level due to serious imprecision: findings compatible with benefit in either group or with no clinically meaningful difference between the groups. ³Downgraded one level due to serious imprecision: findings compatible with benefit in native tissue group or with no clinically meaningful difference between the groups. ⁴Downgraded one level due to serious inconsistency: substantial statistical heterogeneity.

Summary of findings for the main comparison. Any transvaginal permanent mesh versus native tissue repair for vaginal prolapse

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Summary of findings 2. Absorbable mesh versus native tissue repair for vaginal prolapse

Absorbable mesh versus native tissue repair for vaginal prolapse
Population: women with vaginal prolapse Settings: surgical Intervention: absorbable mesh Control: native tissue repair
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Native tissue repair	Absorbable mesh
Awareness of prolapse at 2 years	724 per 1000	760 per 1000 (558 to 1000)	RR 1.05 (0.77 to 1.44)	54 (1 study)	⊕⊝⊝⊝ very low^1,2
Repeat surgery for prolapse (stage 2 or more) at 2 years	125 per 1000	59 per 1000 (11 to 300)	RR 0.47 (0.09 to 2.40)	66 (1 study)	⊕⊝⊝⊝ very low^1,2
Recurrent prolapse at 3 months to 2 years	429 per 1000	304 per 1000 (223 to 411)	RR 0.71 (0.52 to 0.96)	292 (3 studies)	⊕⊕⊝⊝ low^3,4
Bladder injury	Not reported in the included studies
De novo dyspareunia (pain during sexual intercourse) review 1 to 3 years	Not reported in the included studies
Stress urinary incontinence at 2 years	593 per 1000	818 per 1000 (563 to 1000)	RR 1.38 (0.95 to 2)	49 (1 study)	⊕⊝⊝⊝ very low^1,2
Quality of life at 2 years	The mean quality of life score was the same in both groups, when measured using a severity score of 1 to 10 (mean difference 0, 95% CI ‐2.82 to 2.82)			54 (1 study)	⊕⊝⊝⊝ very low^1,2
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Downgraded one level due to serious risk of attrition bias: at two years 18% not included in analysis. ²Downgraded two levels due to very serious imprecision: single small trial with confidence interval compatible with benefit in either arm or no effect. Low event rate. ³Downgraded one level due to serious risk of attrition bias in 2/3 studies. ⁴Downgraded one level due to serious imprecision: low overall event rate (n = 101). ⁵Downgraded one level due to serious risk of bias: unclear whether outcome assessment was blinded.

Summary of findings 2. Absorbable mesh versus native tissue repair for vaginal prolapse

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Summary of findings 3. Biological repair versus native tissue repair for vaginal prolapse

Biological repair versus native tissue repair for vaginal prolapse
Population: women with vaginal prolapse Settings: surgical Intervention: biological repair Control: native tissue repair
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Native tissue repair	Biological repair
Awareness of prolapse at 1 to 3 years	105 per 1000	102 per 1000 (68 to 151)	RR 0.97 (0.65 to 1.43)	777 (7 studies)	⊕⊕⊝⊝ low^1,2
Repeat prolapse surgery 1 to 2 years	43 per 1000	52 per 1000 (26 to 105)	RR 1.22 (0.61 to 2.44)	306 (5 studies)	⊕⊕⊝⊝ low^3,4
Recurrent prolapse at 1 year	295 per 1000	277 per 1000 (177 to 434)	RR 0.94 (0.60 to 1.47)	587 (7 studies)	⊕⊝⊝⊝ very low^3,5,6
Bladder injury	Not estimable as only 1 event occurred (in the native tissue group)			137 (1 study)
Bowel injury	Not estimable as only 1 event occurred (in the biological repair group)			137 (1 study)
De novo dyspareunia (pain during sexual intercourse) review 1 to 3 years	177 per 1000	150 per 1000 (35 to 648)	RR 0.85 (0.20 to 3.67)	37 (1 study)	⊕⊝⊝⊝ very low^3,8
De novo urinary stress incontinence at 1 year	Not estimable ‐ no events occurred			56 (1 study)
Quality of life at 1 year	The mean quality of life in the biological repair group was 0.05 standard deviations lower (0.48 lower to 0.38 higher). This is an imprecise finding that is consistent with a small benefit in either group, or else no difference between the groups			84 (2 studies)	⊕⊝⊝⊝ very low⁹
The basis for the assumed risk* is the median control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Downgraded one level due to serious risk of bias: four of the studies at high or unclear risk of bias associated with blinding status. ²Downgraded one level due to serious imprecision: confidence intervals compatible with benefit in either group or with no difference between the groups. ³Downgraded one level due to imprecision: confidence interval compatible with benefit in either group or with no difference between groups. ⁴Downgraded one level due to serious risk of bias in 3/5 studies: two studies at high risk of attrition bias, and one study not blinded. ⁵Downgraded one level due to serious risk of bias: three studies rated at high risk of attrition bias, detection bias, and other bias (conflict of interest), respectively. ⁶Downgraded one level due to serious inconsistency: I² = 59% indicating substantial statistical heterogeneity. ⁷Downgraded one level due to serious risk of bias: blinding status unclear. ⁸Downgraded two levels due to very serious imprecision: single small study, only six events. ⁹Downgraded one level due to serious risk of attrition bias, and a further two levels due to very serious imprecision: only 84 participants.

Summary of findings 3. Biological repair versus native tissue repair for vaginal prolapse

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Table 1. Mesh exposure following transvaginal permanent mesh

Study ID	Repair events	Repair total	Exposure events	Exposure total
Ali 2006 abstract	0	43	3	46
Al‐Nazer 2007	0	23	1	21
Altman 2011	0	182	21	183
Carey 2009	0	60	5	62
da Silveira 2014	0	81	18	88
Delroy 2013	0	39	2	40
Gupta 2014	0	54	4	44
Halaska 2012	0	72	16	79
Iglesia 2010	0	33	5	32
Lamblin 2014	0	35	2	33
Menefee 2011	0	24	2	28
Nguyen 2008	0	38	2	37
Nieminen 2008	0	96	18	104
Qatawneh 2013	0	63	4	53
Sivaslioglu 2008	0	42	3	43
Thijs 2010 abstract	0	48	9	48
Turgal 2013	0	20	3	20
Vollebregt 2011	0	51	2	53
Withagen 2011	0	84	14	83
Total			134	1097

Table 1. Mesh exposure following transvaginal permanent mesh

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Table 2. Mesh exposure versus anterior compartment repairs

Study ID	Repair events	Repair total	Exposure events	Exposure total
Ali 2006 abstract	0	43	3	46
Al‐Nazer 2007	0	23	1	21
Altman 2011	0	182	21	183
Delroy 2013	0	39	2	40
Gupta 2014	0	54	4	44
Lamblin 2014	0	35	2	33
Menefee 2011	0	24	2	28
Nguyen 2008	0	38	2	37
Nieminen 2008	0	96	18	104
Qatawneh 2013	0	63	4	53
Sivaslioglu 2008	0	42	3	43
Thijs 2010 abstract	0	48	9	48
Turgal 2013	0	20	3	20
Vollebregt 2011	0	51	2	53
Total			76	753

Table 2. Mesh exposure versus anterior compartment repairs

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Table 3. Mesh exposure versus multi‐compartment repairs

Study ID	Repair events	Repair total	Exposure events	Exposure total
Carey 2009	0	60	5	62
da Silveira 2014	0	81	18	88
Halaska 2012	0	72	16	79
Iglesia 2010	0	33	5	32
Withagen 2011	0	84	14	83
Total			58	344

Table 3. Mesh exposure versus multi‐compartment repairs

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Table 4. Surgery for mesh exposure following any transvaginal permanent mesh

Study ID	Surgery for mesh exposure	Total number of women in mesh group
Altman 2011	6	186
Carey 2009	3	62
da Silveira 2014	7	88
De Tayrac 2013	4	66
Delroy 2013	2	40
Gupta 2014	2	44
Halaska 2012	10	79
Iglesia 2010	3	32
Lamblin 2014	2	33
Nguyen 2008	2	37
Nieminen 2008	14	104
Qatawneh 2013	4	53
Rudnicki 2014	5	78
Sivaslioglu 2008	3	43
Svabik 2014	2	36
Tamanini 2014	7	42
Thijs 2010 abstract	4	48
Turgal 2013	3	20
Vollebregt 2011	2	53
Withagen 2011	5	83
Total	100	1227

Table 4. Surgery for mesh exposure following any transvaginal permanent mesh

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Comparison 1. Any transvaginal permanent mesh versus native tissue repair

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Awareness of prolapse (1‐3 years) Show forest plot	12	1614	Risk Ratio (M‐H, Fixed, 95% CI)	0.66 [0.54, 0.81]

1.1 Anterior compartment:mesh vs native tissue	9	1172	Risk Ratio (M‐H, Fixed, 95% CI)	0.65 [0.51, 0.84]
1.2 Multicompartment: mesh vs native tissue	4	442	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.46, 0.97]
2 Repeat surgery (1‐3 years) Show forest plot	14		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 Prolapse	12	1675	Risk Ratio (M‐H, Fixed, 95% CI)	0.53 [0.31, 0.88]
2.2 Continence surgery	9	1284	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.62, 1.83]
2.3 Surgery for prolapse, SUI or mesh exposure	7	867	Risk Ratio (M‐H, Fixed, 95% CI)	2.40 [1.51, 3.81]
3 Recurrent prolapse (any) at 1‐3 years Show forest plot	21	2494	Risk Ratio (M‐H, Random, 95% CI)	0.40 [0.30, 0.53]

3.1 Anterior compartment repair: mesh versus native tissue	15	1748	Risk Ratio (M‐H, Random, 95% CI)	0.33 [0.26, 0.40]
3.2 Multi‐compartment repair: mesh versus native tissue	6	746	Risk Ratio (M‐H, Random, 95% CI)	0.59 [0.40, 0.87]
4 Injuries bladder or bowel Show forest plot	11		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.1 Bladder injury	11	1514	Risk Ratio (M‐H, Fixed, 95% CI)	3.92 [1.62, 9.50]
4.2 Bowel injury	1	169	Risk Ratio (M‐H, Fixed, 95% CI)	3.26 [0.13, 78.81]
5 Objective failure of anterior compartment (cystocoele) Show forest plot	13	1406	Risk Ratio (M‐H, Fixed, 95% CI)	0.45 [0.36, 0.55]

5.1 Anterior compartment repair: mesh versus native tissue	9	1004	Risk Ratio (M‐H, Fixed, 95% CI)	0.36 [0.28, 0.47]
5.2 Multi‐compartment repair: mesh versus native tissue	4	402	Risk Ratio (M‐H, Fixed, 95% CI)	0.73 [0.51, 1.06]
6 Objective failure of posterior compartment (rectocoele) Show forest plot	3	226	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.29, 1.42]

6.1 Mesh vs native tissue	3	226	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.29, 1.42]
7 POPQ assessment (any mesh) Show forest plot	10		Mean Difference (IV, Random, 95% CI)	Subtotals only

7.1 Point Ba POPQ	10	1125	Mean Difference (IV, Random, 95% CI)	‐0.93 [‐1.27, ‐0.59]
7.2 Point C POPQ	8	925	Mean Difference (IV, Random, 95% CI)	‐0.45 [‐1.13, 0.23]
7.3 Point Bp	7	832	Mean Difference (IV, Random, 95% CI)	0.05 [‐0.34, 0.44]
7.4 total vaginal length	5	611	Mean Difference (IV, Random, 95% CI)	0.07 [‐0.25, 0.40]
8 Bladder function: de novo stress urinary incontinence (1‐3 years) Show forest plot	12	1512	Risk Ratio (M‐H, Fixed, 95% CI)	1.39 [1.06, 1.82]

8.1 Anterior compartment: mesh vs native tissue	8	1205	Risk Ratio (M‐H, Fixed, 95% CI)	1.45 [1.00, 2.11]
8.2 Multi compartment : mesh vs native tissue	4	307	Risk Ratio (M‐H, Fixed, 95% CI)	1.31 [0.90, 1.92]
9 De novo voiding disorder, urgency, detrusor overactivity or overactive bladder Show forest plot	3	236	Risk Ratio (M‐H, Fixed, 95% CI)	0.75 [0.35, 1.63]

10 De novo dyspareunia (1‐3 years) Show forest plot	11	764	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.58, 1.47]

10.1 Anterior compartment: mesh vs native tissue	8	643	Risk Ratio (M‐H, Fixed, 95% CI)	1.08 [0.60, 1.93]
10.2 Multicompartment: mesh vs native tissue	3	121	Risk Ratio (M‐H, Fixed, 95% CI)	0.65 [0.29, 1.42]
11 Sexual function (1‐3 years) Show forest plot	7		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

11.1 PISQ score	7	857	Mean Difference (IV, Fixed, 95% CI)	‐0.13 [‐0.40, 0.13]
12 Quality of life: continuous data (1‐2 years): Show forest plot	7	665	Std. Mean Difference (IV, Random, 95% CI)	0.05 [‐0.20, 0.30]

12.1 PQOL end score	3	331	Std. Mean Difference (IV, Random, 95% CI)	0.09 [‐0.31, 0.49]
12.2 Pelvic floor impact questionnaire end score	4	334	Std. Mean Difference (IV, Random, 95% CI)	0.02 [‐0.34, 0.37]
13 Quality of life: dichotomous data "much or very much better" Show forest plot	1	168	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.80, 1.25]

13.1 PGI‐I	1	168	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.80, 1.25]
14 Operating time (minutes) Show forest plot	13		Mean Difference (IV, Random, 95% CI)	Totals not selected

14.1 Anterior compartment: mesh vs native tissue	10		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
14.2 Multicompartment: mesh vs native tissue	3		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
15 Blood transfusion Show forest plot	6	723	Risk Ratio (M‐H, Fixed, 95% CI)	1.55 [0.88, 2.72]

16 Length of stay in hospital (days) Show forest plot	7	953	Mean Difference (IV, Random, 95% CI)	‐0.06 [‐0.30, 0.18]

Comparison 1. Any transvaginal permanent mesh versus native tissue repair

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Comparison 2. Absorbable mesh versus native tissue repair

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Awareness of prolapse (2 year review) Show forest plot	1	54	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.77, 1.44]

2 Repeat surgery for prolapse (2 years) Show forest plot	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.47 [0.09, 2.40]

3 Recurrent prolapse (3 months ‐2 years) Show forest plot	3	292	Risk Ratio (M‐H, Fixed, 95% CI)	0.71 [0.52, 0.96]

3.1 Any site stage 2 or more	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.53 [0.10, 2.70]
3.2 Anterior compartment	2	226	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.53, 0.98]
4 Death Show forest plot	2	175	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

4.1 absorbable mesh versus native tissue repair	2	175	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Objective failure of anterior compartment (cystocoele) Show forest plot	2	226	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.53, 0.98]

5.1 Anterior compartment repair: absorbable mesh versus native tissue	1	83	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.62, 1.34]
5.2 Multi‐compartment repair: absorbable mesh versus native tissue	1	143	Risk Ratio (M‐H, Fixed, 95% CI)	0.58 [0.35, 0.93]
6 Objective failure of posterior compartment (rectocoele) Show forest plot	1	132	Risk Ratio (M‐H, Fixed, 95% CI)	1.13 [0.40, 3.19]

6.1 Multi‐compartment repair: absorbable mesh versus native tissue	1	132	Risk Ratio (M‐H, Fixed, 95% CI)	1.13 [0.40, 3.19]
7 Stress urinary incontinence Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

7.1 Postoperative SUI	1	49	Risk Ratio (M‐H, Fixed, 95% CI)	1.38 [0.95, 2.00]
8 Quality of life (2 years) Show forest plot	1	54	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐2.82, 2.82]

8.1 VAS QoL	1	54	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐2.82, 2.82]

Comparison 2. Absorbable mesh versus native tissue repair

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Comparison 3. Biological repair versus native tissue repair

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Awareness of prolapse (1‐3 year) Show forest plot	7	777	Risk Ratio (M‐H, Fixed, 95% CI)	0.97 [0.65, 1.43]

1.1 Anterior compartment repair: biological graft vs native tissue	4	429	Risk Ratio (M‐H, Fixed, 95% CI)	0.75 [0.45, 1.23]
1.2 Multicompartment repair: biological graft vs native tissue	1	126	Risk Ratio (M‐H, Fixed, 95% CI)	4.55 [1.04, 19.92]
1.3 Posterior compartment repair: biological graft vs native tissue	2	222	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.41, 1.94]
2 Repeat prolapse surgery (1‐2 years) Show forest plot	5	306	Risk Ratio (M‐H, Fixed, 95% CI)	1.22 [0.61, 2.44]

3 Recurrent prolapse (1 year) Show forest plot	7	587	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.60, 1.47]

3.1 Anterior compartment repair: biological graft vs native tissue	5	369	Risk Ratio (M‐H, Random, 95% CI)	0.75 [0.54, 1.05]
3.2 Posterior compartment repair: biological graft vs native tissue	2	218	Risk Ratio (M‐H, Random, 95% CI)	2.09 [1.18, 3.70]
4 Injuries to bladder or bowel Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.1 bladder injury	1	137	Risk Ratio (M‐H, Fixed, 95% CI)	0.35 [0.01, 8.40]
4.2 bowel injury	1	137	Risk Ratio (M‐H, Fixed, 95% CI)	3.13 [0.13, 75.57]
5 Objective failure of anterior compartment (cystocele) Show forest plot	6	570	Risk Ratio (M‐H, Random, 95% CI)	0.66 [0.46, 0.96]

6 Objective failure of posterior compartment (rectocele) Show forest plot	3	283	Risk Ratio (M‐H, Random, 95% CI)	1.16 [0.39, 3.51]

7 POPQ assessment Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

7.1 Ba POPQ	1	56	Mean Difference (IV, Fixed, 95% CI)	‐0.5 [‐0.98, ‐0.02]
7.2 Point C	1	56	Mean Difference (IV, Fixed, 95% CI)	‐0.60 [‐1.28, 0.08]
7.3 Bp POPQ	1	56	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐0.27, 0.47]
7.4 total vaginal length	1	56	Mean Difference (IV, Fixed, 95% CI)	0.60 [0.06, 1.14]
8 De novo urinary stress incontinence Show forest plot	1	56	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

9 De novo voiding disorders, urgency, detrusor overactivity or overactive bladder Show forest plot	2	93	Risk Ratio (M‐H, Fixed, 95% CI)	0.81 [0.29, 2.26]

10 De novo dyspareunia (1 year) Show forest plot	1	37	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.20, 3.67]

11 Sexual function (1 year) Show forest plot	1	35	Mean Difference (IV, Fixed, 95% CI)	1.0 [‐2.33, 4.33]

11.1 PISQ	1	35	Mean Difference (IV, Fixed, 95% CI)	1.0 [‐2.33, 4.33]
12 Quality of life (1 year) Show forest plot	2	84	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.05 [‐0.48, 0.38]

12.1 PQOL score	1	56	Std. Mean Difference (IV, Fixed, 95% CI)	0.10 [‐0.42, 0.63]
12.2 PFDI‐20	1	28	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.36 [‐1.11, 0.39]
13 Operating time (minutes) Show forest plot	4	232	Mean Difference (IV, Fixed, 95% CI)	10.34 [6.31, 14.36]

14 Blood transfusion Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	2.13 [0.14, 32.90]

Comparison 3. Biological repair versus native tissue repair

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