Care Pathway for the Management of Pelvic Organ Prolapse (POP) | Australian Commission on Safety and Quality in Health Care

Rectocele (bowel)

Isolated rectocele	GoR*
Posterior Colporrhaphy (PC) is the procedure of choice	B
Levatorplasty associated with high rate of dyspareunia	B
PC reduced prolapse with equal functional outcome compared to transanal approach	B
Fascial plication is superior to site specific posterior vaginal repair	C
No evidence demonstrating benefit for synthetic or biological graft	C
Those with combined vaginal prolapse and bowel symptoms benefit from colorectal and gynaecologist collaboration	C
Ventral rectopexy and vaginal graft is unnecessary for isolated rectocele	D

* Grades of Recommendation

Adapted from International Consultation on Incontinence (ICI). 2017 ICI Surgical Pathway for Pelvic Organ Prolapse. (urogynaecology.com.au)

The Grade of Recommendation has been derived from the ICI (see Int Urogynecol J. 2013 Nov;24(11):1781
https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance.

Vault prolapse

Vault prolapse (post hysterectomy)	GoR*
Sacral colpopexy (SC) has significant anatomical and functional advantages when compared with a broad group of vaginal surgery (± mesh)	A
Transvaginal apical mesh confers no advantage when compared to native tissue repairs	A
Uterosacral and sacrospinous colpopexy have similar efficacy for apical prolapse	B
Laparoscopic SC has advantages over both robotic and open approach however the learning curve with the laparoscopic approach is significant	B
Sacrospinous ligament fixation and abdominal sacrocolpopexy have equivalent success rates	B
Vaginal apical suspensions appropriate in those not suitable for SC (Delphi)	C

* Grades of Recommendation

Adapted from International Consultation on Incontinence (ICI). 2017 ICI Surgical Pathway for Pelvic Organ Prolapse. (urogynaecology.com.au)

The Grade of Recommendation has been derived from the ICI (see Int Urogynecol J. 2013 Nov;24(11):1781
https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance.

Uterine prolapse

	GoR*
Vaginal hysteropexy is equally effective as vaginal hysterectomy with apical suspension and is associated with reduced blood loss and operating time	B
Vaginal hysterectomy with apical suspension has a lower reoperation rate for prolapse than abdominal sacro-hysteropexy	B
Salpingectomy ↓ risk of ovarian cancer in women retaining ovaries at the time of hysterectomy	B
Bilateral salpingo-oophorectomy (BSO) at hysterectomy in post-menopausal women ↓ rate of ovarian cancer without ↑ morbidity	B
SC with hysterectomy is not recommended due to high rate of mesh exposure	B
Supracervical hysterectomy has a lower rate of mesh exposure than hysterectomy and SC	B
Sacro-hysteropexy has a ↑ reoperation rate for prolapse than SC with hysterectomy	C
Supracervical hysterectomy has ↑ rate of recurrent POP compared to SC and hysterectomy	C
Although data is not complete, vaginal based apical suspensions should generally be considered for uterine prolapse reserving SC for recurrent or post hysterectomy prolapse	C

* Grades of Recommendation

Adapted from International Consultation on Incontinence (ICI). 2017 ICI Surgical Pathway for Pelvic Organ Prolapse. (urogynaecology.com.au)

The Grade of Recommendation has been derived from the ICI (see Int Urogynecol J. 2013 Nov;24(11):1781
https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance.

Suture repair (native tissue)

	GoR*
Native tissue repair is recommended, but carries a higher risk of prolapse recurrence	B

* Grades of Recommendation

Adapted from International Consultation on Incontinence (ICI). 2017 ICI Surgical Pathway for Pelvic Organ Prolapse. (urogynaecology.com.au)

The Grade of Recommendation has been derived from the ICI (see Int Urogynecol J. 2013 Nov;24(11):1781
https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance.

Suture repair (native tissue)

	GoR*
Native tissue repair is recommended, but carries a higher risk of prolapse recurrence	B

* Grades of Recommendation

Adapted from International Consultation on Incontinence (ICI). 2017 ICI Surgical Pathway for Pelvic Organ Prolapse. (urogynaecology.com.au)

The Grade of Recommendation has been derived from the ICI (see Int Urogynecol J. 2013 Nov;24(11):1781
https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance.

Vaginal hysterectomy

	GoR*
Vaginal hysterectomy with apical suspension has a lower reoperation rate for prolapse than abdominal sacro-hysteropexy	B

VAGINAL HYSTERECTOMY WITH APICAL SUSPENSION

A. Traction on cervix with circumferential incision of vaginal mucosa (orientation)

B. Delivery of uterus through posterior cul-de-sac with cut pedicles

C. Uterosacral vaginal vault suspension

* Grades of Recommendation

Adapted from International Consultation on Incontinence (ICI). 2017 ICI Surgical Pathway for Pelvic Organ Prolapse. (urogynaecology.com.au)

The Grade of Recommendation has been derived from the ICI (see Int Urogynecol J. 2013 Nov;24(11):1781
https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance.

Vaginal sacrospinous hysteropexy

* Grades of Recommendation

Adapted from International Consultation on Incontinence (ICI). 2017 ICI Surgical Pathway for Pelvic Organ Prolapse. (urogynaecology.com.au)

The Grade of Recommendation has been derived from the ICI (see Int Urogynecol J. 2013 Nov;24(11):1781
https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance.

Laparoscopic sacral colpopexy ± repair

	GoR*
Laparoscopic SC has advantages over both robotic and open approach however the learning curve with the laparoscopic approach is significant	B

* Grades of Recommendation

Adapted from International Consultation on Incontinence (ICI). 2017 ICI Surgical Pathway for Pelvic Organ Prolapse. (urogynaecology.com.au)

The Grade of Recommendation has been derived from the ICI (see Int Urogynecol J. 2013 Nov;24(11):1781
https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance.

Sacrospinous colpopexy (vaginal)

	GoR*
Sacral colpopexy (SC) has significant anatomical and functional advantages when compared with a broad group of vaginal surgery (± mesh)	A
Uterosacral and sacrospinous colpopexy have similar efficacy for apical prolapse	B

* Grades of Recommendation

Adapted from International Consultation on Incontinence (ICI). 2017 ICI Surgical Pathway for Pelvic Organ Prolapse. (urogynaecology.com.au)

The Grade of Recommendation has been derived from the ICI (see Int Urogynecol J. 2013 Nov;24(11):1781
https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance.

Uterosacral colpopexy

	GoR*
Uterosacral and sacrospinous colpopexy have similar efficacy for apical prolapse	B

* Grades of Recommendation

Adapted from International Consultation on Incontinence (ICI). 2017 ICI Surgical Pathway for Pelvic Organ Prolapse. (urogynaecology.com.au)

The Grade of Recommendation has been derived from the ICI (see Int Urogynecol J. 2013 Nov;24(11):1781
https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance.

Cystocele (bladder)

Isolated cystocele	GoR*
Anterior Colporrhaphy (AC) is generally recommended however permanent synthetic mesh could be considered for recurrent prolapse if women understand the risk/benefit profile	A
Non-autologous grafts offer no significant advantage over AC	B
Native tissue repair is recommended, but carries a higher risk of prolapse recurrence	B
Mesh repairs are associated with higher risk of adverse events	B
Mesh repair may be considered for recurrent prolapse after patient informed and accepts the risk/benefit	B
Adjunctive fascial slings may be used to prevent recurrent prolapse in high grade cystoceles	C

* Grades of Recommendation

Adapted from International Consultation on Incontinence (ICI). 2017 ICI Surgical Pathway for Pelvic Organ Prolapse. (urogynaecology.com.au)

The Grade of Recommendation has been derived from the ICI (see Int Urogynecol J. 2013 Nov;24(11):1781
https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance.

Apical Support

	GoR*
Apical suspension at AC or PC significantly reduces the need for subsequent prolapse surgery	B

* Grades of Recommendation

Adapted from International Consultation on Incontinence (ICI). 2017 ICI Surgical Pathway for Pelvic Organ Prolapse. (urogynaecology.com.au)

The Grade of Recommendation has been derived from the ICI (see Int Urogynecol J. 2013 Nov;24(11):1781
https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance.

Obliterative Surgery

	GoR*
Effective low morbidity surgery for women not wishing to retain coital activity	C

* Grades of Recommendation

Adapted from International Consultation on Incontinence (ICI). 2017 ICI Surgical Pathway for Pelvic Organ Prolapse. (urogynaecology.com.au)

The Grade of Recommendation has been derived from the ICI (see Int Urogynecol J. 2013 Nov;24(11):1781
https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance.

Reconstructive surgery

Prolapse surgery and lower urinary tract functions	GoR*
Women with POP + SUI
Surgery for POP + SUI shows a higher rate of cure of urinary incontinence in the short term	A
Combined POP + SUI surgery carries a higher risk of adverse events	A
Women with POP + occult SUI
POP + occult SUI equals POP and continence surgery (consider staged procedure)	B
Women with POP + occult SUI are at risk of development of incontinence post POP repair alone, with some proceeding to additional SUI surgery at a later date	A
Combined POP + SUI surgery reduces the risk of post operative incontinence	A
Combined POP + SUI surgery increases the risk of adverse events	A
Continent women with POP
POP without occult SUI does not require concomitant continence surgery	B
Women with POP and Overactive Bladder (OAB)
There is low level (inconsistent) evidence to suggest that operative repair can improve OAB symptoms	C

* Grades of Recommendation

Adapted from International Consultation on Incontinence (ICI). 2017 ICI Surgical Pathway for Pelvic Organ Prolapse. (urogynaecology.com.au)

The Grade of Recommendation has been derived from the ICI (see Int Urogynecol J. 2013 Nov;24(11):1781
https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance.

Risk factors for recurrent prolapse

* Grades of Recommendation

Adapted from International Consultation on Incontinence (ICI). 2017 ICI Surgical Pathway for Pelvic Organ Prolapse. (urogynaecology.com.au)

The Grade of Recommendation has been derived from the ICI (see Int Urogynecol J. 2013 Nov;24(11):1781
https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance.

Colposuspension (native tissue)

	GoR*
Inferior outcomes to pubovaginal slings for primary repair, possibly with less voiding dysfunction	B
Outcomes similar or slightly less than synthetic MUS however longer operating time and recovery, slower return to activities of daily living and more prolapse in medium term	B
Laparoscopic approach when performed same technique as open has similar success rate with less morbidity than open approach	B
Lower rates of success, with higher retreatment rates, when compared to pubovaginal slings for primary repair	B

* Grades of Recommendation

This pathway is adapted from UroGynaecological Society of Australasia (UGSA) Surgical treatment of SUI pathway (2016)

The Grade of Recommendation has been derived from the 5th International Consultation on Incontinence (see Int Urogynecol J. 2013 Nov;24(11):1781 https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance

Mini-sling

The Therapeutic Goods Administration (TGA) considers there is a lack of adequate scientific evidence for it to be satisfied that the risks to patients associated with the use of single incision mini‐slings for the treatment of SUI outweigh their benefits. These products have been removed from the Australian Register of Therapeutic Goods (ARTG)

* Grades of Recommendation

This pathway is adapted from UroGynaecological Society of Australasia (UGSA) Surgical treatment of SUI pathway (2016)

The Grade of Recommendation has been derived from the 5th International Consultation on Incontinence (see Int Urogynecol J. 2013 Nov;24(11):1781 https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance

Mid-urethral sling (MUS) (synthetic mesh)

* Grades of Recommendation

This pathway is adapted from UroGynaecological Society of Australasia (UGSA) Surgical treatment of SUI pathway (2016)

The Grade of Recommendation has been derived from the 5th International Consultation on Incontinence (see Int Urogynecol J. 2013 Nov;24(11):1781 https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance

Obturator tape

Retropubic versus transobturator mid-urethral sling	GoR*
In the short-term there are similar success rates for retropublic and transobturator	A
Obturator tapes slightly quicker, with less blood loss, bladder perforation and voiding dysfunction difficulties. Most of these differences were small and the complications are readily able to be managed.	A
However in the medium term (>5 years) the reoperation for recurrent SUI greater in obturator group and a small number developed groin pain (3-4%) that is difficult to treat.	B
Retropubic considered as the preferred procedure with transobturator reserved for those patients with a hostile abdomen	C

* Grades of Recommendation

This pathway is adapted from UroGynaecological Society of Australasia (UGSA) Surgical treatment of SUI pathway (2016)

The Grade of Recommendation has been derived from the 5th International Consultation on Incontinence (see Int Urogynecol J. 2013 Nov;24(11):1781 https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance

Retropubic tape

Retropubic versus transobturator mid-urethral sling	GoR*
In the short‐term there are similar success rates for retropubic and transobturator mid urethral slings	A
Obturator tapes are slightly quicker, with less blood loss, bladder perforation and voiding dysfunction difficulties. Most of these differences were small and the complications are readily able to be managed.	A
However in the medium term (>5 years) the reoperation for recurrent SUI greater in obturator group and a small number developed groin pain (3-4%) that is difficult to treat.	B
Retropubic considered as the preferred procedure with transobturator reserved for those patients with a hostile abdomen	C

* Grades of Recommendation

This pathway is adapted from UroGynaecological Society of Australasia (UGSA) Surgical treatment of SUI pathway (2016)

The Grade of Recommendation has been derived from the 5th International Consultation on Incontinence (see Int Urogynecol J. 2013 Nov;24(11):1781 https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance

Pubovaginal sling (native tissue)

Pubovaginal (fascial) sling	GoR*
Similar success rates compared to MUS with longer operating time and possibly higher voiding dysfunction; fascial sling has lower rates of chronic pelvic pain, no risk of erosion or extrusion, and higher rates of post‐operative morbidity	B
Lower rate of bladder perforation during surgery compared to MUS.	B
Fascial sling has higher patient satisfaction and treatment success compared to colposuspension	B
Involves a longer operation, post‐operative hospital stay (2–3 days) and recovery period than MUS	B
Consider in women wishing to avoid mesh‐related complications	–

* Grades of Recommendation

This pathway is adapted from UroGynaecological Society of Australasia (UGSA) Surgical treatment of SUI pathway (2016)

The Grade of Recommendation has been derived from the 5th International Consultation on Incontinence (see Int Urogynecol J. 2013 Nov;24(11):1781 https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance

Bulking Agent

	GoR*
May be a useful option for recurrent SUI with a well supported urethra	B
Greater symptomatic improvement was observed with surgical treatments, although the advantage needs to be balanced against risk of intervention	C
Consider in women wishing to avoid mesh‐related complications	–

* Grades of Recommendation

This pathway is adapted from UroGynaecological Society of Australasia (UGSA) Surgical treatment of SUI pathway (2016)

The Grade of Recommendation has been derived from the 5th International Consultation on Incontinence (see Int Urogynecol J. 2013 Nov;24(11):1781 https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance

	GoR*
Perioperative physiotherapy did not reduce the rate of recurrent prolapse	A
Stage 3 or Stage 4 prolapse	B
Low volume surgeons have ↑ rate of complications compared to high volume surgeons	B
Patient age < 60 years	C
Less experienced surgeons have higher rates of recurrent prolapse after transvaginal surgery	C
Preoperative widened genital hiatus or levator defects on urinary signs and symptoms: data are inconclusive	D

	GoR*
The most extensively researched option for SUI establishing efficacy and safety profile	A
As effective or more effective than colposuspension or pubovaginal sling with less perioperative and post-operative morbidity	B
Recommended surgical treatment female SUI	C