Review question

Which surgical interventions for posterior vaginal wall prolapse have the best outcomes, and what are the complications of each intervention?

Background

Posterior vaginal wall prolapse is descent of the rectum or small bowel, causing the back wall of the vagina to bulge into the vagina. This condition can be treated conservatively with pelvic floor muscle training or vaginal pessaries, or it can be managed surgically. Several different operations are currently performed to manage prolapse of the posterior vaginal wall. This review aims to compare these different operations in terms of their effectiveness and safety. Surgery for prolapse of the posterior vaginal wall can be done through the back passage or through the vagina. Different vaginal techniques aim to restore the strong fascial layer at the midline along the whole length of the posterior vaginal wall (midline fascial plication), or to identify and repair specific defects in this strong fascial layer (site-specific repair). Those who perform repairs can use a woman’s own native tissue alone or can add a graft. The graft can be absorbable, biological, or synthetic.

Study characteristics

This review identified 10 randomised controlled trials including 1099 women with posterior vaginal wall prolapse. Four trials compared transanal repairs with transvaginal repairs. One study compared site-specific repair with midline fascial plication – two different techniques for transvaginal native tissue repair. One trial compared absorbable graft and native tissue vaginal repair. Four trials compared biological graft with native tissue, and one trial compared synthetic graft with native tissue. The evidence is current to April 2017.

Key results

Repair through the vagina may be more effective than repair through the back passage for posterior vaginal wall prolapse. However, data on adverse effects are scanty. Evidence was insufficient to permit conclusions about the relative effectiveness or safety of other types of surgery. Evidence does not support using mesh or biological grafts at the time of posterior vaginal repair. Withdrawal of some commercial transvaginal mesh kits from the market may limit the generalisability of our findings.

Quality of the evidence

Evidence quality ranged from very low to moderate. The main limitations in evidence quality were risk of bias (associated mainly with performance, detection, and attrition biases) and imprecision (associated with small overall sample sizes and low event rates).