The treatment of anterior vaginal wall prolapsed by repair with mesh versus colporrhaphy

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1 Int Urol Nephrol (2016) 48: DOI /s UROLOGY - REVIEW The treatment of anterior vaginal wall prolapsed by repair with mesh versus colporrhaphy Yi Sun 1 Cai Tang 1 Deyi Luo 1 Lu Yang 1 Hong Shen 1 Received: 1 August 2015 / Accepted: 30 November 2015 / Published online: 19 December 2015 Springer Science+Business Media Dordrecht 2015 Abstract Purpose To compare patient outcomes of mesh repair and colporrhaphy for the treatment of anterior vaginal wall prolapse (AVP). Materials and methods We searched PubMed, Embase, and Cochrane Library databases to identify the included studies. The outcome measures included anatomical success, patient satisfaction, patient sexual function, perioperative data, and complications. Statistical analyses were performed using Cochrane Collaboration Review Manager software (RevMan 5.1.4). Results The study inclusion criteria were met by 11 articles involving 1455 patients. Synthesized data indicated that mesh surgery was more complex than colporrhaphy with regard to perioperative condition [mean difference (MD) 0.28, 95 % confidence interval (CI) , p = 0.010]. There were no significant differences for the following complications: urinary retention [relative risk (RR) 1.12, 95 % CI , p = 0.68], urinary incontinence (RR 1.01, 95 % CI , p = 0.96), voiding difficulty (RR 1.11, 95 % CI , p = 0.66), dyspareunia (RR 1.21, 95 % CI , p = 0.26), urinary tract infection (RR 1.15, 95 % CI , p = 0.53), and vaginal bulge (RR 1.08, 95 % CI , p = 0.32). There were instances of more serious complications in group 1, i.e., the mesh group. However, AVP cure rate was Yi Sun and Cai Tang contributed equally to this work and are the co-first authors. * Hong Shen shen1177hx@163.com 1 Department of Urology, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu , Sichuan, People s Republic of China significantly higher in the mesh group (RR 1.44, 95 % CI , p < ). The cure rate was not significantly dependent on patient satisfaction (RR 1.10, 95 % CI , p = 0.16) or postoperative sexual function (RR 1.03, 95 % CI , p = 0.71). Conclusions Surgical repair with the mesh procedure appears to be a better choice for the treatment of anterior vaginal wall prolapse. Keywords Repair with mesh Colporrhaphy Anterior vaginal wall prolapsed Randomized controlled Trial Abbreviations RCT Randomized controlled trial POP Pelvic organ prolapse AVP Anterior vaginal wall prolapsed RR Relative risk CI Confidence interval Introduction Anatomically, the pelvic floor in females consists of multiple layers of muscles and fasciae near the pelvic outlet, with the urethra, vagina, and rectum passing through it in close proximity. The pelvic tissue is important for retaining the uterus, bladder, rectum, and other pelvic organs in their anatomical positions. Weakness in the muscle and fascial layers causes pelvic organ prolapse, particularly anterior vaginal wall prolapse (AVP), a condition characterized by the descent of the pelvic organs, causing vaginal protrusion [1]. The pathogenesis of AVP is not fully understood. Possible causes include childbirth, congenital weakness, iatrogenic factors including hysterectomy, and increased

2 156 Int Urol Nephrol (2016) 48: intra-abdominal pressure caused by obesity or chronic pulmonary disease [2]. The most common symptoms of AVP include vaginal prolapse with or without urinary dysfunction, abnormal defecation, vaginal hemorrhage, and infections, all of which affect the patient quality of life in multiple ways. Conventional surgery for the treatment of AVP is anterior colporrhaphy. However, up to 70 % of individuals have recurrent prolapse after anterior colporrhaphy [3, 4]. Dissatisfaction with the outcomes of colporrhaphy for AVP has resulted in the increased use of mesh repair, which has been reported to have higher success rates in the treatment of AVP [5]. Moreover, mesh repair has become popular in several countries as it is associated with less risk of complications. However, the advantages and disadvantages of mesh repair still require further investigation. We conducted a systematic review and meta-analysis to find the optimum method for the surgical repair of AVP and compare the cure rates and complications of mesh repair and colporrhaphy. Method Search strategy We searched the following databases: PubMed (from January 1990 to current year), Embase (from January 1990 to current year), Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. The initial search was performed to find all relevant trials referenced using the following terms: transvaginal mesh, repair with mesh, AVP, and randomized controlled trial, with the last being the most important term. Next, we searched the resultant trials for the terms mesh, colporrhaphy, and randomized controlled trial. Each term was associated with multiple synonyms. In addition, we manually searched the reference lists from relevant publications as well as conference proceedings from the American Urological Association, European Association of Urology, and Société Internationale d Urologie published from 2006 till date. Finally, all available trials that compared mesh repair with colporrhaphy for the treatment of AVP were included in the present study. Computer searches were supplemented with manual searches. Two authors (S.Y. and D.L.) independently screened all citations. Abstracts of potentially relevant studies were identified using this search strategy. Participants We used the pelvic organ prolapse (POP) quantification system recommended by the International Continence Society for identifying the participants. Patients aged 18 years with recurrent or advanced POP stage II were included. All patients were included after obtaining informed consent. The exclusion criteria included patients who were pregnant or contemplating future pregnancy, those with conditions that would compromise healing, those with cancer, those who were unwilling to provide informed consent, and those who had undergone other surgical procedures. Eligibility criteria The baseline eligibility criterion for the articles was that they met our inclusion criteria. The other major eligibility criterion was that the study participants had POP stage II with or without other anatomical and physiological conditions. The eligibility conditions for each article are shown in Table 1. The baseline data of the trials are shown in Table 2. Interventions and comparisons Patients with AVP were divided into group 1 (the mesh group) and group 2 (the colporrhaphy group) according to their treatment history. We compared the outcomes of the treatments between the two groups. Outcome measures The outcomes measured in this review contained objective and subjective results. The objective measures were as follows: the rate of postoperative POP-Q stage, operation time, blood loss, hospital stay duration, and adverse effects, including urinary retention, urinary incontinence, voiding difficulty, dyspareunia, vaginal bulge, urinary tract infections (UTI), and mesh exposure. The subjective measures were as follows: patient satisfaction, postoperative sexual function, and vaginal bulge. The rate of postoperative POP-Q stage and patient satisfaction were used to measure efficiency. The rate of postoperative POP-Q stage <II was determined by the reviewers summary of the articles [1020]; postoperative POP-Q stage was assessed according to the POP-Q system. Anatomical cure was defined as having a stage 0 or stage I cystocele after the followup period. Patient satisfaction was inferred from the articles we included and was measured using a questionnaire such as the P-QOL questionnaire [13] and ICIQ-VS scores [15]. We identified a questionnaire, the Urogenital Distress Inventory, validated for the Dutch population consisting of five domains: urinary incontinence, overactive bladder, pain, voiding difficulty, and POP [6, 7]. Considering postoperative complications among the subjects described in the articles that we included, we decided to focus more on urinary incontinence and voiding difficulty than others and added urinary retention and UTI as general urinary

3 Int Urol Nephrol (2016) 48: Table 1 Condition of the trials References Year No. mesh/ colporrhaphy No. dropout Design Level of evidence Length of follow-up (months) Quality assessment Vollebregt et al. [10] /53 14 Randomized controlled 1a 6 RCT Altman et al. [11] / Randomized controlled 1a 12 RCT Cao et al. [12] /74 15 Retrospective 2b 12 Delroy et al. [13] /39 0 Randomized controlled 1a 12 RCT Dias et al. [14] /33 18 Randomized controlled 2b 24 RCT Tamanini et al. [15] /50 8 Randomized controlled 1a 24 RCT Nazer et al. [16] /20 5 Randomized controlled 2b 24 RCT Nieminen et al. [17] /95 22 Randomized controlled 1a 36 RCT Rudnicki et al. [18] /78 15 Randomized controlled 1a 12 RCT Tamanini et al. [19] /54 3 Randomized controlled 1a 12 RCT Vollebregt et al. [20] /55 15 Randomized controlled 1a 12 RCT symptoms. Details regarding operation time, blood loss, and hospital stay duration were also crucial for surgery. Dyspareunia was used to represent the postoperative sexual dysfunction in the study sample. We also included vaginal bulge and mesh exposure as important complications to analyze and determine which surgical method had better outcomes. Other complications were also summarized, but the sample size for these was too small to tabulate. Data extraction Two authors (Y.S. and C.T.) extracted the data independently using a pre-designed data extraction form. Data extracted included data source, eligibility, methods, participant characteristics, interventions, and results. The two authors then met to synthesize their findings, and the information was subsequently entered into RevMan Any discrepancy in extracted data was resolved via discussion, and if disagreements persisted after discussion, they were resolved in consultation with a third author (H.S.). Quality assessment The quality of the included studies was assessed by two authors (Y.S. and H.S.) according to Cochrane Collaboration Reviewers Handbook and Quality of Reporting of Meta-analyses guidelines [8, 9]. The quality items used included randomized sequence generation, ing method, allocation concealment, withdrawal and dropout description, published bias, sensitivity analysis, and intentto-treat analysis. Data analysis We used the RevMan program to perform our metaanalysis. Dichotomous data were presented as relative risk (RR), and continuous outcomes were presented as weighted mean difference (MD) with a 95 % confidence interval (CI). We decided to employ the fixed effects method or random effects method for our meta-analysis, depending on the presence or absence of significant heterogeneity. The fixed

4 158 Int Urol Nephrol (2016) 48: Table 2 Baseline of the trials and patients pre-surgery References Group POP-Q Age Parity (range) BMI (kg/m 2 ) Postmenopausal Diabetes Hypertension Dyspareunia Smoker Vollebregt et al. [10] Altman et al. [11] Group 1 Stage II 60.0 ± () 25.2 ± 2.9 Group 2 Stage II 59.0 ± () 24.7 ± 3.1 Group 1 Stage II 64.3 ± (06) 26.2 ± (57) 25 ± 12.5 Group 2 Stage II 65.1 ± (07) 25.0 ± (56) 22 ± 11.6 Cao et al. [12] Group 1 Stage II 63.5 ± ± ± (2.4) 10 (111.9) Group 2 Stage II 65.0 ± ± ± (4.1) 15 (20.3) Delroy et al. Group 1 Stage II 62.1 ± (0.79.9) 27.6 ± (95) [13] Group 2 Stage II 59.6 ± 10 4 (26) 27.3 ± (82.1) Dias et al. [14] Group 1 Stage II 61.7 ± ± ± (95.3) 4 (9.3) Group 1 Stage II 59.4 ± ± ± (81.4) 5 (11.6) Tamanini et al. Group 1 Stage II 66.8 ± ± (95.6) 6 (13.3) 16 (35.6) [15] Group 1 Stage II 63.4 ± ± (99.8) 13 (23.6) 28 (50.9) Nazer et al. Group 1 Stage II 42.3 ± ± ± (25) 7 (41) 3 (15) [16] Group 2 Stage II 39.5 ± ± ± (15) 8 (44) 1 (5) Nieminen et al. Group 1 Stage II 66.0 ± (011) 26.5 ± (9) 48 (46) 14 (13) [17] Group 2 Stage II 65.0 ± (110) 27.2 ± (6) 41 (41) 14 (14) Rudnicki et al. Group 1 Stage II 64.9 ± ± 1.0 (07) 26.5 ± (100) 1 (1) 29 (37) [18] Group 2 Stage II 64.7 ± ± 1.0 (05) 25.7 ± (100) 4 (5) 26 (32) Tamanini et al. Group 1 Stage II 66.8 ± ± (95.6) [19] Group 2 Stage II 63.4 ± ± (99.8) Vollebregt et al. Group 1 Stage II 60.0 ± ± ± 2.9 [20] Group 2 Stage II 59.0 ± ± ± 3.6 POP-Q pelvic organ prolapse quality, BMI body mass index

5 Int Urol Nephrol (2016) 48: Fig. 1 Flow diagram of systematic review effects method is designed for combining results when statistically significant heterogeneity is absent, whereas the random effects method is for when heterogeneity is present. In this study, the fixed effects method was appropriate. Statistical heterogeneity among the trials was evaluated using the I 2 test with significance set at p < Publication bias was evaluated using a funnel plot. In addition, sensitivity analysis was performed if low-quality trials were included. Results Description of studies A total of 842 reports were initially identified from the databases and manual searches. After removing the redundant publications, reviews, and meta-analyses and after scanning the titles and abstracts for unrelated records, 816 reports were excluded from the study. After referring to the full texts, 10 randomized controlled trials (RCTs) and 1 retrospective cohort involving 1455 patients were included in this study [1020]. Two studies, Cao et al. [12] and Nazer et al. [16], were at the 2b level of evidence, and the other studies were at the 1a level of evidence. The eligibility conditions in these articles are presented in Table 1, and the baseline data of the trials and patient pre-surgery statuses are presented in Table 2. Figure 1 shows the search flow diagram. There were no significant differences in the baseline data across the included articles. The overall results are presented in Table 3. Perioperative condition Six studies investigated perioperative conditions [1114, 16, 20], and only one was excluded from our discussion due to dissimilar methods [20]. The operation time for mesh surgery was longer than that for colporrhaphy (MD 15.25, 95 % CI , p < ) [1114, 16], and the blood loss of group 1 was more than that of group 2 (MD 33.35, 95 % CI , p < ) [11, 12, 16]. Duration of hospital stay was not significantly different between the two groups (MD 0.16, 95 % CI 0.05 to

6 160 Int Urol Nephrol (2016) 48: Table 3 Prior and concomitant treatments References Group Prior prolapse surgery Prior hormone therapy Prior incontinence surgery Prior hysterectomy Concomitant hysterectomy Concomitant posterior colporrhaphy Combined perineal correction Vollebregt et al. [10] Altman et al. [11] Group 1 Group 2 Group 1 16 (8) 113 (57) 5 (2.5) 46 (23) Group 2 24 (13) 105 (56) 3 (1.6) 36 (19) Cao et al. [12] Group 1 Group 2 Delroy et al. Group 1 8 (20) 8 (20) 1 (2.5) 8 (20) 17 (42.5) [13] Group 2 13 (33.3) 12 (30.8) 3 (7.6) 14 (35.9) 28 (100) Dias et al. [14] Group 1 8 (18.6) 8 (18.6) 3 (7) Group 2 13 (30.2) 13 (30.2) 3 (7) Tamanini et al. Group 1 3 (6.7) 17 (37.8) 17 (37.8) [15] Group 2 6 (10.9) 24 (43.6) 22 (40) Nazer et al. Group 1 [16] Group 2 Nieminen Group 1 25 (23) 90 (86) 4 (4) 23 (22) 63 (61) 75 (72) et al. [17] Group 2 26 (26) 81 (84) 4 (4) 27 (28) 47 (48) 67 (69) Rudnicki et al. Group 1 0 (0) 52 (67) 6 (8) 6 (8) [18] Group 2 1 (1) 53 (65) 12 (15) 12 (15) Tamanini et al. [19] Group 1 3 (6.7) Vollebregt et al. [20] Group 2 Group 1 Group 2 6 (10.9) 27 (46) 34 (55) 4 (7) 3 (5) 3 (4) 4 (7) 0.38, p = 0.13) [11, 12, 14, 16]. These results are shown in Fig. 2ac, respectively. Furthermore, the overall perioperative condition revealed that the mesh surgery was more complex (MD 0.28, 95 % CI , p = 0.010) (Table 4). Postoperative POP Q stage <II Nine RCTs investigated the rate of postoperative POP-Q stage as <II [1015, 17, 18, 20] (Table 4). The average rate of postoperative POP-Q stage <II was 81.3 % in group 1 ( %) and 56.6 % in group 2 ( %). Mesh repair procedures were shown to be significantly more effective than colporrhaphy in terms of the POP cure rate (RR 1.44, 95 % CI , p < ), according to the rate of postoperative POP-Q stage <II (Fig. 3a). Patient satisfaction Four RCTs investigated patient satisfaction [10, 11, 14, 16] (Table 4). The average rate of patient satisfaction was 60.4 % in group 1 ( %) and 52.7 % in group 2 ( %). No significant differences were observed between the two groups (RR 1.10, 95 % CI , p = 0.16) (Fig. 3b). Patient level of sexual activity Seven RCTs investigated postoperative sexual function [1214, 1618, 20] (Table 4). The average rate of postoperative sexual function was 49.3 % in group 1 ( %) and 48.6 % in group 2 ( %). No significant differences were observed between the two groups (RR 1.03, 95 % CI , p = 0.71) (Fig. 3c).

7 Int Urol Nephrol (2016) 48: Fig. 2 The condition of patients a operate time with two surgeries, b blood loss with two surgeries, c hospital stay with two surgeries Urinary complications Seven RCTs investigated the rates of urinary retention [11 16, 18] (Table 4). The average rate of urinary retention was 5.2 % in group 1 and 4.4 % in group 2. No significant differences were observed between the two groups (RR 1.12, 95 % CI , p = 0.68) (Fig. 4a). Five RCTs investigated the rate of urinary incontinence [14, 1619], with the average rate being 10.3 % in group 1 and 10.7 % in group 2. No significant differences were observed between the two groups (RR 1.01, 95 % CI , p = 0.96) (Fig. 4b). Six RCTs investigated the rate of voiding difficulty [11, 13, 1619], and the average rate of voiding difficulty was 6.9 % in group 1 (016.1 %) and 6.3 % in group 2 (053.3 %). Again, no significant differences were observed between the two groups (RR 1.11, 95 % CI , p = 0.66) (Fig. 4c). Dyspareunia Eight RCTs investigated the rate of dyspareunia [1116, 18, 20] (Table 4). The average rate of dyspareunia was 12.2 % in group 1 and 10.0 % in group 2. No significant differences were observed between the two groups (RR 1.21, 95 % CI , p = 0.26) (Fig. 4d). Vaginal bulge Four RCTs investigated the rate of vaginal bulge [10, 14, 16, 17] (Table 4). The average rate of vaginal bulge was 43.5 % in group 1 and 39.4 % in group 2. No significant differences were observed between the two groups (RR 1.08, 95 % CI , p = 0.32) (Fig. 4e). Urinary tract infection Six RCTs investigated the rate of UTI [1114, 16, 18] (Table 4), and the average rate was 8.8 % in group 1 and 7.5 % in group 2. No significant differences were observed between the two groups (RR 1.15, 95 % CI , p = 0.53) (Fig. 4f). Exposure of the mesh There was no risk of exposure in the colporrhaphy group as no mesh was used, and the rate of exposure in the mesh group was 5.4 %. Regarding the size of the exposure (Table 4), Vollebregt et al. [10] reported only one patient with 1 cm exposure in the mesh group. The study by Delroy et al. [13] found that exposure sizes were <1 cm and patients were asymptomatic. Rudnicki et al. [18] showed the largest exposure of 1.5 cm at the 12-month follow-up. In the study by Vollebregt et al. [20], all the exposures were treated.

8 162 Int Urol Nephrol (2016) 48: Table 4 Condition of perioperative period and the result of treatments References Group POP-Q stage <II Operation time Blood loss Hospital stay Urinary retention Urinary incontinence Voiding difficulties Dyspareunia Sexually active UTI Vaginal bulge Patient s satisfaction Mesh exposures Vollebregt et al. [10] Altman et al. [11] Cao et al. [12] Delroy et al. [13] Dias et al. [14] Tamanini et al. [15] Nazer et al. [16] Nieminen et al. [17] Rudnicki et al. [18] Tamanini et al. [19] Vollebregt et al. [20] Group 2/54 44/47 1/54 Group 2 15/53 25/27 0 Group 1 153/ ± ± ± (1.5) 16 (8.0) 46 (23) 3 (1.5) 135/179 89/186 6 (3.0) Group 2 87/ ± ± ± (1.1) 6 (3.2) 36 (19) 1 (0.5) 108/174 73/182 0 Group 1 78 (92.9) ± ± ± (16.7) 7 (8.3) 26/84 12 (14.3) 3 (3.6) Group 59 (79.7) ± ± ± (12.2) 3 (4.1) 7/74 9 (12.2) 0 2 Group 3/ (2.5) 1 (2.5) 2 (5) 19/40 8 (20) 2 (5) Group 2 22/ (5.1) 0 4 (10.2) 19/39 5 (13.8) 0 Group 1 17/ ± ± (0.5) 0 2/37 21/37 8/37 2/37 36/37 5/37 Group 2 17/ ± ± (1.5) 2/14 4/37 23/33 5/37 3/33 30/37 0 Group 1 40 (95.2) 3 (6.9) 1 (2.3) 3 (7.1) Group 2 43 (86) 2 (3.6) 0 0 Group ± ± ± (20) 1 (6.7) 3 (42.9) 18/20 3 (15) 1 (5.3) 3/15 1 (5) Group ± ± ± (5) 4 (40) 6 (53.3) 4 (45.8) 17/20 2 (10) 6 (26.7) 7/10 0 Group 1 91/ (14) 11 (10) 51/ (10) 2.4 ± 0.9 Group 2 55/96 15 (16) 17 (18) 44/97 18 (19) 2.2 ± 1.1 Group 1 67 (88.1) 3 (3.8) 4 (5.3) 2 (2.7) 2 (2.7) 36/76 5 (6.7) 10 (13.3) Group 2 31 (39.8) 2 (2.4) /78 10 (13.0) 0 Group 1 7 (16.3) 0 (0) Group 2 Group 1 Group 2 45/55 50/55 48 (2590) 41 (2080) 77 (5400) 69 (5800) 9 (16.6) 0 (0) 3 (15) 2 (9) 32/50 31/48 1 (2) 0 UTI urinary tract infection

9 Int Urol Nephrol (2016) 48: Fig. 3 The condition of patients a POP-Q after two surgeries, b satisfaction after two surgeries, c sexually active after two surgeries Discussion AVP, the most common type of POP, is a gynecological condition caused by the weakness of pelvic floor tissues as a result of various anatomical or physiological conditions. It causes pelvic organs to descend toward the pelvic floor, which adversely affects organ function. Statistics predict that approximately 11 % of adult women undergo surgery for POP, especially AVP, and approximately 30 % of them undergo repeat surgery after approximately 4 years. The conventional surgery for AVP treatment is anterior colporrhaphy. Anterior colporrhaphy, in which the woman s own tissue is used for the repair of the pelvic wall, has been the standard technique [21, 22]. It is performed through a midline vaginal incision and involves separation of the vaginal wall from the fibromuscular layer, midline plication of the fibromuscular layer using horizontal sutures, excision of excess vaginal mucosa, and closure with continuous suture [17]. Recurrence following anterior colporrhaphy is reported in 2070 % of women [3]. This demonstrates that the anatomical and functional recovery following this procedure is unsatisfactory. In recent years, mesh repair has gained popularity. In this procedure, a midline vaginal incision is made through the full thickness of the vaginal fibromuscular wall. Following the reinforcement of the wall with a synthetic mesh fiber, the incision is closed without any resection of the vaginal tissue [21]. In 2004, the US Food and Drug Administration approved the first commercially available system of polypropylene mesh for the reinforcement of vesicovaginal and rectovaginal spaces (Prolift; Gynecare/Ethicon, Somerville, NJ, USA). From our search, we found that several controlled trials demonstrate better anatomical outcomes, lower failure rates, and fewer subsequent surgeries after mesh repair than after colporrhaphy. However, highquality meta-analyses are scarce.

10 164 Int Urol Nephrol (2016) 48: Fig. 4 The condition of patients a urinary retention after two surgeries, b urinary incontinence after two surgeries, c voiding difficulties after two surgeries, d dyspareunia after two surgeries, e vaginal bulge after two surgeries, f UTI after two surgeries, g mesh exposure after two surgeries

11 Int Urol Nephrol (2016) 48: In the present studies, postoperative POP-Q stage <II was considered the criterion for cure rate for each type of surgery. When we augmented the size of our samples by combining data from the reviewers we included, we observed that the rate of postoperative POP-Q stage <II was significantly higher in the mesh group (observed in 81.3 % patients, %) than in the colporrhaphy group (observed in 56.6 % patients, %); this difference was statistically significant (RR 1.44, 95 % CI , p < ); however, the subjective results measured by patient satisfaction and vaginal bulge were similar between the two groups. Mesh surgery appears to be more complex because of the longer operation time and greater blood loss, but this may be due to different operating techniques by different surgeons and does not have a great impact on the efficiency. Moreover, according to our investigation, observational studies showed the use of mesh to be anatomically effective; however, there were concerns regarding the risk of complications [23]. In addition, although the rate of postoperative POP-Q stage <II was significantly higher in the mesh group than that in the colporrhaphy group, our study found that the rate of complications in the mesh group was not significantly higher than that in the colporrhaphy group except for mesh exposure. Exposure was defined when the mesh was seen or palpated in the incision line in the vagina [24]. Mesh exposure, sometimes accompanied by severe complications such as dyspareunia and voiding difficulty, always significantly decreases the patient quality of life [25, 26]. This prompted the Food and Drug Administration to issue a warning regarding the complications associated with its use in vaginal surgery [27]. However, a systematic review recently demonstrated that younger age, higher number of pregnancies, pre-menopausal/ert, diabetes mellitus, smoking, concomitant hysterectomy, and surgery performed by an inexperienced surgeon were significant risk factors for mesh exposure [28]. The documented exposure rate is % [29]; we observed a consistent rate of 5.38 %, which is in agreement with the range described in the literature. This low rate of exposure may be attributed to the following reasons. For instance, Vollebregt et al. [20] demonstrated that such a low exposure rate could be attributed to the uncombined use of mesh and hysterectomy and/or the collagen coating on the Avaulta mesh. Although mesh surgery was more efficient than anterior colporrhaphy, the problem of exposure still exists and needs more attention. Some methods were tested by few researchers to solve this problem, including the use of a different mesh material, or undertaking further surgery to remove whole or part of the mesh. In addition, most of the patients with exposure in our included studies were asymptomatic, and this condition was mostly treated surgically by simple excision of the exposed mesh or not removing the whole mesh. Some researchers have used 165 various methods to avoid this complication. Vollebregt el al. [10] believed that local estrogen may diminish the chance of mesh exposure, and the low exposure rate they found might be associated with its use in the mesh group. Some authors have evaluated the use of polypropylene; others have advocated that coating the mesh may decrease complications such as erosions or mesh exposure as demonstrated by Gauruder-Burmester et al. [30]; however, Rudnicki et al. [18] found that coated mesh does not appear to have any additional advantages over non-coated mesh. Moreover, Altman et al. [11] demonstrated that surgical re-intervention to correct mesh exposure during the follow-up period was performed in 3.2 % of 186 patients in their mesh repair group; however, other reviewers had not reported on this aspect. Nevertheless, all methods used should aim to prevent the need for further surgical intervention, and the issue of mesh exposure still needs additional investigation. There were some limitations in this study, with regard to the mesh itself. Different studies have used different materials, such as polypropylene mesh (GYNECARE GYNEMESH, Ethicon Women s Health and Urology, Somerville, NJ, USA) [12], Trocar-guided kit Nazca TCTM1 (Promedon, Cordoba, Argentina) [13, 14], AVW closed with Vicryl [15], trapezoid piece of single-layered Prolene mesh [16], monofilament polypropylene patch (Parietene light; Sofradim Co, Trévoux, France) [17], Avaulta Plus anterior biosynthetic system [18], NAZCA TC Kit (Promedon, Cordoba, Argentina) [19], and Avaulta anterior system (Bard, Covington, LA, USA) [20]. Therefore, further studies are warranted to analyze the relationship between the material used and the surgical results. Second, the follow-up duration after the surgery was short. Only in the study by Nieminen et al. [17], it continued for 36 months, whereas in the studies by Dias et al. [14], Tamanini et al. [15], and Nazer et al. [16], it continued for 24 months, and in other reviews, it was for just 1 year [1113, 19, 20] and 6 months [10]. Postoperative sexual function was investigated in only nine studies [1118, 20] and dyspareunia in only seven of them [1115, 18, 20], and both postoperative sexual function and dyspareunia were investigated in only seven studies [1214, 1618, 20]. Only Altman et al. [11] reported on the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12, and only Vollebregt et al. [10] reported on the Female Sexual Function Index and Male Sexual Health Questionnaire. Further investigations are required to specify the extent of problems associated with sexual function following mesh surgery. Findings suggest similar outcomes in terms of urinary problems regardless of surgical technique; however, further study is needed to help doctors decide on the appropriate treatment for their patients. If a large sample size can be identified, we hope to conduct research in our hospital to

12 166 Int Urol Nephrol (2016) 48: study other complications to help surgeons choose the best surgical method for patients with AVP. Conclusions The meta-analysis of the randomized controlled clinical trials in this systematic review suggests that mesh repair is significantly superior in the treatment of AVP. There were no significant differences in complication rates; however, the rate of postoperative POP-Q stage <II was significantly higher for mesh repair than for colporrhaphy. Therefore, we recommend that mesh repair be the preferred surgical option for patients with AVP. Funding This study was supported by the Prostate Cancer Foundation Young Investigator Award 2013, the National Natural Science Foundation of China (Grant No ); the National Science Foundation for Young Scholars of China (Grant No ); and Pillar Program from Science and Technology Department of Sichuan Province (Grant No. 2014JY0219). 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