Prof Aboubakr Elnashar Benha University Hospital, Egypt Delta (Mansura) & Benha Fertility Centers

EBM is a newly evolved, rapidly growing discipline for learners & researchers. The term EBM originated at McMaster University in Canada & first appeared in the medical literature in 1992.

EBM is a systematic approach to utilize the best available scientific knowledge to make decisions regarding diagnosis & treatment. EBM also relies on clinical judgment, practical skills & also the patient’s individual situation & desire.

The highest level of evidence in therapy studies requires at least one high quality systematic review or 2 high quality RCT.

Systematic review Review in which all the evidence pertaining to a particular field of research has been collected (via a systematic search of the literature & unpublished sources) & evaluated using predefined quality criteria.

Meta-analysis Systematic reviews in which the numerical results of different studies have been combined using standard statistical techniques.

RCT is the gold standard in clinical research. RCT is the standard method for answering questions about the effectiveness of different therapies RCT provides the strongest evidence for the cause & effect relationship & is subject to the least amount of bias.

The Cochrane Collaboration Library is an outstanding effort to provide best evidence. It is the best single source of evidence about the effects of health care. It is named after the British epidemiologist Archie Cochrane

The library is updated every 3 months. It contains 4 sets of databases 1.Systematic reviews 2. Reviews of effectiveness 3.Controlled trial registry 4.Review methodology

Treatment modalities of prolapse include surgery, mechanical devices & conservative therapies (life style advises & pelvic floor training).

The definitive treatment of prolapse is surgery. The surgical repair of prolapse is one of the oldest gynecological procedures. Over 100 operations have been described, although few are in common use nowadays.

There are divergent opinions regarding the effective operation for each type of genital prolapse. Our objective review the systematic reviews & RCT concerning the surgical treatment of genital prolapse.

Materials & methods Data sources 1. Chocrane library. 2. Pub Med Search for RCT concerning genital prolapse, uterine prolapse, vaginal prolapse or uterovaginal preolapse.

4 Cochrane systematic reviews 14 RCT (out of 922 citations).{1.5%}

Systematic reviews & RCT were reviewed as regard: 1. Preoperative care, 2. Anterior vaginal wall prolapse 3. Uterovaginal prolapse, 4. Vault prolapse 5. Urinary stress incontinence

1. Preoperative treatment with oestradiol

Preoperative low-dose vaginal oestradiol treatment reduced the incidence of bacteriuria in the immediate postoperative period but no long-lasting effects on recurrent cystitis or relapse (Felding et al, 1992; Mikkelsen et al, 1995).

2. Anterior vaginal wall prolapse

Comparison between three surgical techniques. Standard, standard plus polyglactin 910 mesh, or ultralateral anterior colporrhaphy ( Weber et al,2001). These 3 techniques of anterior colporrhaphy provided similar anatomic cure rates and symptom resolution. The addition of polyglactin 910 mesh did not improve the cure rate compared with standard anterior colporrhaphy

3.Utero- vaginl prolapse

1. Conservative management of pelvic organ prolapse in women (Hagen S, Stark D, Maher C, Adams E, Cochrane S R, 2004). There is no RCT

2. Mechanical devices for pelvic organ prolapse in women (Adams E, Thomson A, Maher C, Hagen S, Cochrane SR; 2004) There is no RCT

3. Manchester procedure vs. vaginal hysterectomy for uterine prolapse. MP was associated with shorter operative time, less blood loss & similar operative outcomes when compared to VH (Thomas et al,1995). This, suggests the use of MP as an alternative to VH in the absence of uterine pathology in appropriate candidates with uterine prolapse.

4. Vaginal hysterectomy (combined with anterior and/or posterior colporraphy) versus abdominal sacro-colpopexy (with preservation of the uterus) on urogenital function (Roovers et al, 2004). Vaginal hysterectomy with anterior and/or posterior colporraphy is preferable to abdominal sacro-colpopexy with preservation of the uterus as surgical correction in patients with uterine prolapse stages II-IV.

At one year after surgery: The discomfort/pain, overactive bladder obstructive micturition Re-operation were significantly higher in the abdominal group than in the vaginal group.

5. Vaginal approach with bilateral sacrospinous vault suspension and paravaginal repair versus abdominal approach with colposacral suspension and paravaginal repair. Abdominal approach was more effective (Benson et al, 1996).

The vaginal group had longer catheter use, more urinary tract infections, more incontinence, Optimal surgical effectiveness (29% Vs 58%) re-operation (33% Vs 16% ) of the abdominal group.

4. Vault prolapse

Abdominal sacral colpopexy versus vaginal sacrospinous colpopexy Abdominal sacral colpopexy and vaginal sacrospinous colpopexy are both highly effective in the treatment of vaginal vault prolapse (Roovers et al,2004).

Two years after the operation In the abdominal group: the subjective success rate (94% Vs 91%) The objective success rate was 76% Vs 69%) in the vaginal group

The abdominal approach was associated with a longer operating time, a slower return to activities of daily living, and a greater cost than the sacrospinous colpopexy (P<.01). Both surgeries significantly improved the patient's quality of life (P<.05).

1. Anterior vaginal repair for urinary incontinence in women (Glazener CMA, Cooper K, Cochrane SR; 2004) No enough data to compare anterior vaginal repair with physical therapy or needle suspension for primary urinary stress incontinence

Open abdominal retropubic suspension is better than anterior vaginal repair: 1.Subjective cure rates in eight trials, even in women who had prolapse in addition to stress incontinence (six trials). 2.The need for repeat incontinence surgery was also less after the abdominal operation.

2. Open retropubic colposuspension for urinary incontinence in women (Lapitan MC, Cody DJ, Grant AM, Cochrane SR; 2002) Open retropubic colposuspension is the most effective treatment modality for SUI especially in the long term.

Newer minimal access procedures like tension free vaginal tape look promising in comparison with open colposuspension but their long-term performance is not known. Laparoscopic colposuspension should allow speedier recovery but its relative safety and effectiveness is not known yet.

1. There are few RCT’s & sytematic reviews concerning surgical treatment of genital prolapse 2. Preoperative low-dose vaginal oestradiol treatment reduces the incidence of bacteriuria in the immediate postoperative period.

3. Techniques of anterior colporrhaphy provide similar anatomic cure rates and symptom resolution 4. Manchester operation is an alternative to vaginal hysterectomy in the absence of uterine pathology

5. Vaginal hysterectomy with (anterior and/or posterior) colporraphy is preferable to abdominal sacro-colpopexy 6. Abdominal sacral colpopexy and vaginal sacrospinous colpopexy are both highly effective in the treatment of vaginal vault prolapse

7. Open abdominal retropubic suspension is better than anterior vaginal repair 8. Newer minimal access procedures like TVT look promising in comparison with open colposuspension but their long-term performance is not known.

Prof Aboubakr Elnashar Benha University Hospital, Egypt Delta (Mansura) & Benha Fertility Centers