Complications of Female Incontinence and Pelvic Reconstructive Surgery (Current Clinical Urology) 2nd ed.

4. Posterior Compartment Repair

Benjamin M. Brucker  and Victor W. Nitti1

(1)

Department of Urology, New York University Langone Medical Center, 150 East 32nd Street, Second Floor, New York, NY 10016, USA

Benjamin M. Brucker

Email: Benjamin.brucker@nyumc.org

Abstract

Posterior compartment prolapse is a herniation of the posterior vaginal wall or anterior rectal wall into the lumen of the vagina. These defects may result from pudendal nerve damage or disruption of connective tissue and muscular attachments [1]. Many factors, including childbirth, aging, estrogen withdrawal, chronic abdominal straining, and heavy labor, weaken the pelvic floor and its associated support structures. Childbirth can cause stretching of the prerectal and pararectal fasciae with detachment of the prerectal fascia from the perineal body, allowing rectocele formation. In addition, childbirth damages and weakens the levator musculature and its fascia, attenuating the decussating prerectal levator fibers and the attachment of the levator ani to the central tendon of the perineum. The result is a convex sagging of the levator plate with a loss of the normal horizontal vaginal axis. The vagina becomes rotated downward and posteriorly, no longer providing horizontal support. These anatomic changes allow downward herniation of the pelvic organs along this new vaginal axis. There are also genetic factors that predispose women to this condition.

Introduction

Posterior compartment prolapse is a herniation of the posterior vaginal wall or anterior rectal wall into the lumen of the vagina. These defects may result from pudendal nerve damage or disruption of connective tissue and muscular attachments [1]. Many factors, including childbirth, aging, estrogen withdrawal, chronic abdominal straining, and heavy labor, weaken the pelvic floor and its associated support structures. Childbirth can cause stretching of the prerectal and pararectal fasciae with detachment of the prerectal fascia from the perineal body, allowing rectocele formation. In addition, childbirth damages and weakens the levator musculature and its fascia, attenuating the decussating prerectal levator fibers and the attachment of the levator ani to the central tendon of the perineum. The result is a convex sagging of the levator plate with a loss of the normal horizontal vaginal axis. The vagina becomes rotated downward and posteriorly, no longer providing horizontal support. These anatomic changes allow downward herniation of the pelvic organs along this new vaginal axis. There are also genetic factors that predispose women to this condition.

Posterior compartment prolapse is not ­uncommon. A cross-sectional study (Women’s Health Initiative Hormone Replacement Therapy Clinical Trial) found that 18.6% of 16,616 women with a uterus had a rectocele on a baseline pelvic examination and 18.3% of 10,727 women who had undergone hysterectomy had a rectocele [2]. Rates of anterior prolapse (cystocele) were higher in both groups at 34.3% and 32.9%, respectively. Isolated posterior compartment defects are ­relatively unusual are seen most often in women after severe posterior tears associated with vaginal delivery or in women who have previously undergone correction of the anterior or apical compartment. More frequently, posterior compartment defects are associated with more global pelvic floor dysfunction and vaginal prolapse. Widening of the anogenital hiatus and damage to the urogenital diaphragm and central tendon further facilitates pelvic prolapse by preventing the normal compensatory narrowing of the vaginal opening. Varying degrees of perineal trauma and tears contribute to widening of the vaginal introitus. The repair of the relaxed or disrupted perineum and the repair of a rectocele are two distinct operative procedures, though they are often performed together.

Between the rectum and the vagina there is a layer of dense connective tissue. The homologous tissue in men was first described by Denonvillier. This was called the rectovesical septum and was later seen in female autopsies. This rectovaginal “fascia” is found from the posterior aspect of the cervix and cardial/uretrosacral complex cephelad, to the perineal body caudally. Laterally this reaches to the edges of the levator ani muscles [3].

There are several structures that provide support for the posterior vagina and rectum.

1.

The rectovaginal septum lies between the ­rectum and the vagina. It extends caudad from the posterior cervix and the uterosacral/cardinal complex to the perineal body centrally and the levator fascia laterally on each side. The rectovaginal septum is densest distally where it is composed of dense connective tissue. Its midportion contains fibrous tissue, fat, and neurovascular tissue. Proximally it is mostly composed of fat cells.

2.

The pararectal “fascia” lies between the rectovaginal septum and the rectum. It originates from the pelvic sidewalls and divides into fibrous anterior and posterior sheaths, which envelop the rectum. It also contains blood vessels, nerves, and lymph nodes that supply the rectum.

3.

The levator ani consists of the paired ileococcygeus, puborectalis, and pubococcygeus muscles. These function to maintain constant basal tone and a closed urogenital hiatus. They also provide a reflex contraction in response to increases in intra-abdominal pressure. The puborectalis muscle acts as a sort of sling that causes the posterior vaginal wall to angulate about 45° from the vertical.

4.

The perineal body is the central point between the urogenital and anal triangles. It contains interlacing muscle fibers from the bulbospongiousus and superficial transverse perineal muscles as well as and the anterior portion of the external anal sphincter. There is also a contribution from the longitudinal rectal muscle and the medial fibers of the puborectalis muscle.

There are several critical components of pelvic floor relaxation that are associated with rectocele formation. Loss of the normal horizontal axis of the levator plate and vagina, weakness of the urogenital and pelvic floor diaphragms, detachment of the levator ani from the central tendon of the perineum, and widening of the anogenital hiatus allow intra-abdominal forces to be transmitted directly to pelvic organs without normal underlying compensatory mechanisms. In addition, the rectovaginal septum becomes attenuated or disrupted, allowing intra-vaginal herniation of the rectum. Isolated breaks in the rectovaginal septum facilitate rectocele formation. There are several areas along the rectovaginal septum where breaks are commonly found. The most common site is a transverse separation immediately above the attachment of this septum to the perineal body, resulting in a low or distal rectocele (seen just inside the introitus). A midline vertical defect is equally common and most likely represents a poorly repaired or poorly healed episiotomy. Rarely, one can see lateral separation on one side. Defects can occur in isolation or in combination. Identification of specific defects is important when one is considering performing a site-specific posterior repair. Therefore, each of these components of pelvic floor relaxation must be addressed at the time of rectocele or posterior vaginal wall repair. Identification of this pathophysiology is critical when evaluating female patients with symptoms or signs of pelvic floor relaxation, including stress incontinence, cystocele and/or uterine prolapse. Maintenance of the normal horizontal vaginal axis is an important goal of surgical repair of pelvic floor relaxation, in order to allow compensatory mechanisms to be reestablished. Corrective surgery for posterior vaginal wall prolapse may include correction of the rectocele by reinforcement of the rectovaginal septum, prerectal and pararectal fasciae, repair of the levator muscle defect to restore the levator hiatus, restoration of the horizontal supporting plate of the proximal vagina, and repair of the perineum.

Up to 80% of rectoceles seen on physical examination are asymptomatic [4]. In cases of isolated rectoceles, or small rectoceles, with concomitant anterior and/or apical prolapse, that are asymptomatic any surgical intervention should be cautiously approached because of the potential complications that will be discussed below. However, when rectoceles are symptomatic surgical correction may be a very reasonable option. Symptoms associated with rectocele include ­constipation, incomplete rectal emptying, rectal pressure, vaginal bulge [5]. Some patients will also describe stool being trapped in the rectocele pocket and the need to apply perineal or vaginal pressure in order to facilitate take defecation, this is known as splinting.

Nonsurgical Therapies

Although it is not the intent of this chapter to discuss the evidence behind alternative therapies, these must be considered when trying to avoid surgical complications. This is because if no surgical therapies are successful the need for surgery may be obviated.

Observation, or watchful waiting, may be appropriate if the patient has little bother or minor symptoms from her posterior compartment laxity. A support device such as a pessary can also be considered in a woman with symptoms from pelvic organ prolapse. In the authors’ experience, posterior compartment prolapsed symptoms can be difficult to treat with these devices. However, if the decision is made to trial a pessary, the process of fitting a pessary in a women with posterior compartment predominant prolapse should not be anymore difficult than fitting other women with anterior or apical prolapse [6]. If a woman derives symptomatic improvement, she can be taught how to remove and clean the pessary, or it can be changed on a regular basis in a physician’s office. In either case, routine examination is necessary to ensure that there is no unwanted irritation or granulation tissue development.

Pelvic floor muscle rehabilitation can also be considered as a therapy for posterior compartment prolapsed. There is a paucity of data to support its use in preventing progression or improvement of rectocele specific symptoms. However rectoceles are often not isolated findings. The pelvic floor disorders that may coexist may be effectively addressed with nonsurgical options. For example, pelvic floor exercises are useful in the treatment of stress urinary incontinence. Women with concomitant disorders of the pelvic floor may favor the nonsurgical route for the treatment of the rectocele because the improvement in the symptoms of other conditions.

In summary, nonsurgical therapies should be discussed with all patients. Given the favorable side effect profile, there is no great downside to attempting these therapies if a women so desires. The nonsurgical options are also important in counseling patients that are poor surgical candidates secondary to medical comorbidities.

Surgical Approaches

Rectocele repairs can be approached via the abdominal, transanal, and transvaginal approach. Urologists and Gynecologists most often perform the repair transvaginally [1]. There is no definitive evidence that suggests which surgical approach is best. Surgeon’s skills, patient’s desires, anatomic and functional outcomes are all important to consider. As importantly, the potential unwanted outcomes, or complications, must be considered.

As we are considering potential complications, which vary based on each different surgical approach, some relative indications for the route of repair that is selected should be considered. The vaginal approach is useful if there is other genital prolapse, compromised anal sphincter function (and the surgeon would like to avoid anal dilation from the retractor utilized from the transanal approach), or a high rectocele is present (may not be able to be reached through a transanal approach) [7]. The transrectal approach is utilized if there is other perianal or rectal pathology that needs to be treated concurrently. These pathologies include redundant rectal mucosa, hemorrhoids, etc. A disadvantage of this transrectal approach is that the patient is placed in the prone jackknife position, and it can be difficult to perform a simultaneous perineorrhaphy if needed. The abdominal approach may be indicated in cases where a rectal prolapse is concomitantly noted. The abdominal approach has also become more popular with the widespread use of the robotic technology. This has lead to more publications describing the abdominal approach for rectocele repair [8].

A Cochran review in 2010 that suggested that for posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele or enterocele or both than the transanal approach (RR 0.24, 95% CI 0.09–0.64) [9]. The review noted a higher postoperative narcotic use and blood loss in this vaginal repair group.

In addition to the approach used, there are other questions that remain. Should a surgeon utilize mesh or graft material? Are traditional repairs vs. site-specific repairs more appropriate? The chapter will address some of the more common complications, and in doing so may help answer some of these questions, or at least inspire future investigation to those questions that remain unanswered. Technique selection and operative plan are always the first step to consider when aiming to minimize and manage complications.

Complications of Posterior Repair

Hemorrhage

Excessive bleeding or hemorrhage is a complication of rectocele repair regardless of the surgical approach. The rectovaginal septum and pararectal fascia are rich in blood vessels. In cases where the tissue is “loose or disrupted,” as it often is in cases of posterior prolapse, these vessels have a tendency to retract after they are cut, making identification difficult. This complication should be considered during the preoperative evaluation, intra-operatively and in the postoperative management of patients. Blood loss to a more mild degree is relatively unavoidable result when surgical repair is selected. The surgeon’s role, however, should be aimed at preventing hemorrhage by attempting to be aware during all phases of patient care.

Avoidance

Avoidance of excessive bleeding or hemorrhage starts with the preoperative evaluation. A thorough history and physical exam can help identify any bleeding diatheses or hereditary bleeding problems that may require further workup. Taking the time to review medication and dietary supplement that the patient is taking can identify agents that may contribute to intra-operative and postoperative bleeding. Stopping antiplatelet agents approximately 7 days prior to surgery will reduce the risk of bleeding. These agents include medications such as aspirin, NSAIDs, clopidogrel, and supplements such as fish oil. Stopping these medications must be weighed against potential adverse outcomes arising from the relative hypercoagulable state. Consultation is recommended in cases where the safety to stopping antiplatelet agents is in question. This is especially important in patients with coronary artery disease, veinocclusive disease, history of cerebral vascular accidents. A recently published study suggests higher adverse outcomes (2.4 times more likely to experience acute coronary syndrome or death) during the first 90 days of discontinuing clopidogrel therapy compared to days 91–180 [10]. A general rule is that the risk of bleeding must be weighed against the risk of adverse outcomes resulting from stopping these medications, i.e., thrombocclusion [1112].

Care must also be taken as well with other medications that affect the clotting cascade. Medications such as Coumadin/warfarin should also prompt consultation to decide on appropriate perioperative management.

Preoperative lab tests can help identify patients with bleeding diatheses especially if it is suggested by history. Depending on institutional regulations, surgeon’s preference, and patient’s history, PT/INR/PTT and platelet counts can be evaluated preoperatively.

Physical examination is also very important in attempting to avoid surgical bleeding complications. Inspection for prior surgical scars, as well as signs of potential vascular abnormalities, should be routine. This information can aid in selection of which approach is most appropriate, as well as the need for other preoperative evaluations. For example, vulvar varicosities (though rare) may lead a surgeon to evaluate the patient with imaging to rule out aberrant vasculature or pelvic congestion syndrome. In a patient with abnormal vasculature, blind passage of trochars (i.e., those found in mesh repairs) should be used with extreme caution [13].

Identification of Hemorrhage

Surgeons have various techniques at their disposal to treat patients with rectoceles. With each technique there are differences in expected blood loss. The tactics to avoid or identify hemorrhage also differ. Good surgical techniques should aim to establish excellent intra-operative hemostatic control. This should also reduce the risk of ­excessive “oozing” in the postoperative period. Obviously, stopping bleeding by controlling injured vessels is preferred over managing bleeding from uncontrolled vessels. Good visualization can help achieve this goal. This is provided by suction, irrigation, lap pads and lights, etc. In cases where pneumoperitoneum is utilized (i.e., laparoscopy, with or without robotic assistance) inspection after intra-abdominal pressure has been decreased to physiologic levels is helpful to identify any bleeding areas that may be masked by the affects of the positive pressure that pneumoperitoneum provides. Other general intra-operative considerations (use of electrocautery, suturing technique, etc.) will not be further discussed here.

Abdominal approaches to the repair of pelvic organ prolapse routinely required dissection and identification of the sacral promontory. The presacral venous plexus that runs on the anterior aspect of the sacrum can result in significant bleeding that can be difficult to control using conventional measures such as suturing, clipping or electrocautery. Especially when patients are in the lithotomy position, the hydrostatic pressure can increase 2–3 times that of the inferior vena [14]. Intra-operative management of presacral bleeding with the use of hemostatic matrix (FloSeal; Baxter Healthcare Corporation, Fremont, CA) and an absorbable hemostat (Surgicel Fibrillar; Ethicon, Somerville, NJ) has been advocated by some as first line treatment for presacral bleeding if it is encountered intra-operatively [15]. More traditionally, things like long periods of compression, sterile thumbtacks or the use of a fat bolster have also been utilized.

Another question is whether the use of robotic assistance decreases the risk of bleeding ­compared to pure laproscopy. A recent study compared the abdominal techniques (robotic assisted and pure laproscopic) for the repair of a rectocele. The laparoscopic group did have a higher intra-operative blood loss compared to the robotic group (mean, 45  ±  91 mL vs. 6  ±  23 mL; p  =  0.048), however the authors acknowledge that this is likely not clinically significant [8].

Stapled Transanal Rectal Resection (STARR) can be used for the treatment of internal rectal prolapse, as well as rectocele. Postoperative bleeding is not rare following a stapled hemorrhoidopexy, as it occurs in about 5% of cases [16]. The bleeding usually occurs at the level of the endorectal suture line. After a stapled rectal resection, reinforcing this staple line with a hand sewn suture has been suggested to decrease this risk of hemorrhage [17]. Careful inspection is important to identify any bleeding vessel after a procedure such as this.

At least one study compared intra-operative blood across rectocele repair techniques. There was less intra-operative blood loss from the STARR group compared to standard vaginal rectocele repair (transvaginal rectocele repair, 108 mL vs. STARR, 43 mL; p  =  0.0015) [18]. However, the study showed a higher complication rate from the transanal resection group (STARR 61.1% vs. transvaginal rectocele repair 18.9%, p  =  0.0001). The complication of postoperative bleeding, for example, was three times higher in the STARR group. Obviously a single outcome such as intra-operative blood loss must not be the only driving factor for selecting an appropriate procedure.

Utilizing the vaginal approach for an isolated posterior prolapse repair does not allow for a substantial space for blood to accumulate without the surgeon being aware. In cases where it is difficult to identify specific site of bleeding, temporary packing can be very useful. This not only allows the patient’s innate clotting cascade to begin to work, but it also allows the surgical staff to obtain equipment necessary to assist in visualization. Lighted retractors (i.e., Miyazaki retractor) (see Fig. 4.1) can be quite useful in the vaginal surgery if visualize of bleeding is difficult. Although mentioned above, hemostatic agents such as FloSeal (Baxter Healthcare Corporation, Fremont, CA) can also be quite effective in vaginal surgery if specific sites of bleeding cannot be identified or traditional methods are unsuccessful at stopping bleeding.

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Fig. 4.1

The Miyazaki retractor is shown here. This retractor has a fiber optic light on the end that is useful when the surgeon is working in a narrow space and visualization is poor

Vasoconstrictive agents (such as lidocaine with epinephrine or pitressin) are used by some surgeons during the vaginal dissection. Not only can this help, but the vasoconstriction can also potentially minimize intra-operative blood loss. The down side of this technique is that bleeding vessels may be “hidden” while the epinephrine is active and become problematic postoperatively. There is also the question of the distortion of tissue plans if a site-specific repair is selected. Surgeon preference is unfortunately all that is available to base the decision on the use vasoactive agents on.

If extensive dissection is carried out during a vaginal repair, or if there is a high suspicion that postoperative bleeding may occur, placing of a vaginal packing while the patient is still anesthetized allows for a tighter packing with less discomfort to the patient. The packing can be removed the next morning if patients are staying overnight or in the recovery room prior to discharge if patients are set to be discharged the same day.

If a vaginal repair is selected and uses blind passage of trocars or anchoring sutures (such as are seen in “mesh kits”) appropriate identification of landmarks, intimate knowledge of anatomy, as well as high suspicion of anatomic variations are extremely important to minimize the risk of vessel injury.

Treatment of Hemorrhage After Posterior Repair

It is important to identify postoperative hemorrhage in a timely manner so treatment and resuscitation can prevent other unwanted complications. Good communication with recovery room staff and education of recovery room staff are necessary to help identify patients who may require intervention. Monitoring heart rate, blood pressure, and inspecting surgical incisions or pads should be a standard part of the recovery room protocol in the immediate postoperative period.

Patients who are hemodynamically stable, but that are noted to have excessive oozing from the surgical site should have a vaginal packing placed in order to help tamponade bleeding vessels and minimize the potential space for blood loss. Aside from packing gauze, other compressive devices have utilized balloons (i.e., Foley catheters) to allow for appropriate pressure. These maneuvers are not applicable to abdominal repairs, as the potential space is often too large to contain and cannot be effectively compressed.

When conservative measures of fluid resuscitation and packing are not sufficient more invasive measures may be necessary. This is especially true if a patient become hemodynamically unstable. Traditionally these patients were reexplored in order to identify bleeding vessels and obtained hemostatic control. This can be effective; however one must carefully make this decision to reexplore. Bleeding that has slowed from tamponade (intrinsic or iatogenic) now become brisker or uncontrolled after clot evacuation relieves pressure on the vessel or vessels.

Another option for uncontrolled bleeding is the use of selective embolization of bleeding vessels. Depending on availability and expertise, super-selective embolization may be successfully performed [1920].

The use of cross-sectional imaging (i.e., CT scan) before re/exploration and/or intravascular intervention can be considered, however it should not be done if it will delay definitive treatment in a patient who is hemodynamically unstable and a bleeding source is suspected. A flow chart (Fig. 4.2) is provided as a reference for clinicians to use if postoperative bleeding is suspected. The assessment and managing of bleeding complications from posterior compartment repairs must obviously be managed in an individual manor based on clinical scenario and available recourses.

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Fig. 4.2

Bleeding flow chart

Dyspareunia

Sexual function is a very complex process that involves many organs of the female pelvis. Further, there is an intricate interaction with the central nervous system, hormonal axis, peripheral nerves, blood vessels, etc. Women with pelvic organ prolapse may present with varying degrees of sexual dysfunction and one of the aims of the pelvic organ prolapsed surgery is to restore function. Another aim is to avoid creating (or worsening) any sexual dysfunction. In spite of best efforts, painful intercourse, or dyspareunia, is a potential complication of any pelvic organ prolapsed repair and this section will focus on this potential outcome from posterior prolapse repair.

Preoperative Selection

It is very important when taking a history preoperatively to assess a patient’s sexual activity and current function, because dyspareunia (pain with intercourse) is another potential complication of posterior compartment repair. There are numerous questionnaires that can be utilized to objectively classify a woman’s sexual function both pre and postoperatively. For example, the Sexual History Form and the Female Sexual Function Index are validated measures [2122]. Some questionnaires are for general sexual function and others have been validated specifically in the pelvic organ prolapse population. This preoperative assessment is important to help counsel the patient on the appropriate repair. It is also useful so that there is a baseline to compare postoperative outcomes against if results are not satisfactory.

When levatorplasty is performed it is believed that the de novo dyspareunia is a result of the pressure atrophy of the included muscle, and the subsequent scaring that takes place [23]. However it has been suggested that dyspareunia is associated with posterior colporrhaphy even if there is no concomitant levatorplasty or synthetic material used.

A cohort study of women who underwent anti-incontinence surgeries and pelvic organ prolapsed repairs looked at those women who had a posterior repair and those that did not. Although bother groups had improvements postoperatively in their Pelvic Organ Prolapse-Urinary incontinence Sexual Function Questionnaire (PISQ) score the women that did not have posterior repairs were noted to have a lower incidence of dyspareunia than those who had posterior repairs [24]. Another study compared site-specific repairs to a more traditional posterior colporrhaphy and found the site-specific repair had a higher recurrence rate, with similar rates of dyspareunia and bowel symptoms [25].

Women with rectoceles can present with ­dyspareunia, along with other aspects of sexual dysfunction. As noted above, in many cases after posterior repair there is an improvement in some of the sexual function domains. A selective group of 68 women with sexual dysfunction, all arranged to undergo fascial suture rectocele repairs, were noted to have dyspareunia as a presenting symptom in 86%. After the repair, patients showed significant improvement for desire (p  >  0.001), satisfaction (p  >  0.0001), and pain (p  >  0.0001). There was no significant changes for arousal (p  =  0.0897), lubrication (p  =  1), or orgasm (p  =  0.0893). Only one patient experienced de novo dyspareunia. This was attributed to a postoperative infection resulting in excessive scar tissue of the posterior wall of the vagina. The follow-up was 6 months [26].

Another option that the surgeon has if a transvaginal repair is performed is the use of an absorbable mesh. After randomization to synthetic absorbable mesh (polyglactin 910) to reinforce a posterior colporrhaphy vs. a nonmesh repair no difference in rectocele recurrence rates was seen. Unfortunately this randomized study did not consider functional outcomes such as dyspareunia. They did not report any erosions, now defined as extrusions [27].

The use of biologic graphs has also been considered and there is some data considering sexual function. This study was a comparison of posterior colporrhaphy, site-specific repair and site-specific repair with porcine small intestine submucosa graft [28]. There was no difference in postoperative sexual function (PISQ-12 and asking “Do you feel pain during intercourse?”). There were also no differences in quantity of life measures or bowel function. Perioperative and postoperative morbidity also did not show a difference, albeit the study was underpowered to discern differences in these events. Importantly, however, they reported a lower failure rate of traditional repair techniques compared to the site-specific repair with porcine small intestine submucosa graft for rectoceles. This study suggests that sexual complications are not any different based on repair type, but biologic agents did have higher failure rates.

Permanent meshes are also used in prolapse repair. One study that looked at posterior repair with permanent mesh (composite polyglactin 910-polypropylene) with 3-year follow-up found de novo dyspareunia in 27% of women [29]. With the long-term follow-up they discovered that there was actually no improvement from baseline in preoperative dyspareunia. This was in contrast to previously published short-term results showing an improvement. The combination of persistent dyspareunia and de novo dyspareunia the prevalence of dyspareunia was a staggering 60%. The repair described in the study avoided a rectovaginal placation, and trimming of vaginal wall. Presumably these maneuvers (that they avoided) could result in vaginal narrowing, and ultimately dyspareunia. The “extrusion” rate was 30% and the recurrence rate was 22%.

A prospective study of monofilament polypropylene meshes for posterior repair reported a statistically significant increase of dyspareunia from 6% preoperatively to 69% postoperatively (mean follow-up 17 months) [30]. In this study, the surgeon dissected laterally to the rectal pillars, performed a placation of the rectovaginal fascial tissues, and secured the mesh. Excess vaginal wall was also trimmed prior to closing the posterior vaginal wall.

Traditionally, colorectal surgeons prefer the transanal repair of rectocele. A randomized study compared the transanal with a transvaginal rectocele repair and although none of the subjects reported de novo dyspareunia, 27% reported improvement of sexual function, slightly in favor to the transanal repair [31]. The higher recurrence rates from the transanal approach are noted in the sections above.

Surgeon and patient factors ultimately factor into the type of repair performed, however if a vaginal approach is elected, based on the available studies, we would caution if considering the use of biological agents or permanent mesh (in posterior repairs) given the high incidence recurrence and dyspareunia, respectively. Further the International Urogynecological Association Grafts Roundtable [32] (that convened in 2005) suggested the following patient factors as relative contraindications for the use of biomaterials in pelvic floor reconstructions: pelvic irradiation, severe urogenital atrophy, immunosuppression, active infection, and comorbidities such as poorly controlled diabetes, morbid obesity, and heavy smoking and we would agree with this relative contraindication for the use in posterior repairs. It is our opinion that because the data of the use of mesh in the posterior compartment would not support its routine use (no significant reduction in recurrence rate with a higher complication rate) we reserve it for the rare case when the ­rectovaginal septum is completely obliterated.

Intra-operative

There are no good studies that prospectively evaluate specific surgical techniques that should be used to decrease risk of dyspareunia. However expert opinion would suggest avoiding excessive tightening of the posterior vaginal during a rectocele repair. If a concomitant perineal body repair is needed it is also important to avoid excessive tightening of the introits as this can contribute significantly to sexual dysfunction after surgery. The surgeon’s fingers can be used intra-operatively to calibrate the vagina to an appropriate size. Some advocate calibrating the vagina to 2–3 fingers breaths, which should prevent anatomic difficulties with vaginal penetration in women who are interested in resuming this type of sexual activity [33].

The use of mesh to augment posterior repairs was discussed above as a potential contributor to postoperative dyspareunia. If the surgeon and patient do elect to use a permanent mesh selecting the appropriate type of mesh is an intra-operative decision that can help minimize ­morbidity. Macroporous, monofilament, polypropylene mesh (type 1) has been found to have the most favorable biocompatibility profile of the synthetics meshes that are currently available. The lack of interstices allows native collagen to growth in to the material and the large pores size allow for entry of macrophages and the body’s other immune mediators [34].

Mesh also has been show to retract or contract after placement, and some have shown up to a 66% decrease in size [35]. This is important to remember that the mesh may contract when it is placed or tailored intra-operatively so as to avoid excessive tightening after this occurs. To date there is no clear evidence that this gradual decrease in mesh sized is associated with dyspareunia, but it is a potential explanation for those that believe that mesh augmentation of posterior compartment can worsen sexual outcomes.

Also, though mostly based on expert opinion, there are a few areas of surgical technique that should be considered when placing mesh posteriorly. Care must also be used to ensure the appropriate planes of dissection. Improper dissection can potentially lead to thinned vaginal wall that is used to cover the mesh and can increase the chance of mesh extrusions. Further, care must be used to ensure appropriate placement of mesh so that it does not bunch or role in the vagina. This can form areas of inflammatory reactions that can be uncomfortable for women, but can also be felt by male partners. Another potential cause of dyspareunia is vaginal narrowing that can occur secondary to excessive trimming of the vaginal wall. This also contributes to vaginal narrowing and also result in tenuous coverage of any foreign material utilized.

Posterior prolapse can also be addressed abdominally. Patients are often selected for an abdominal repair because of a predominance of apical decent. This should be remembered when reviewing the literature. The studies may include women with some degree of posterior prolapsed, but this is often not the predominant defect.

Dyspareunia is seen even with the abdominal approach. Sergent et al. [36] found that sacrocolopexy with polyester mesh had a de novo dyschezia rate of 1.7 and dyspareunia rate of 0.8%. Claerhout et al. utilized polypropylene mesh and found a rate of 5% and 19%, respectively [37]. A comparison of these two small studies is not meant to replace a large randomized studies (with the power to show differences in these domains), but rather to illustrate that different mesh types used abdominally may result in different dyspareunia rates.

We also recommend the use of copious irrigation and the use of perioperative antibiotics. These simple methods are meant to avoid ­infections. Infection has a host of complication that we will not explicitly discuss here. However excessive scarring and inflammation may lead more directly to painful intercourse.

Postoperative Identification and Management

In order to identify dyspareunia postoperatively specific questions on patient’s sexual function should be asked. Careful physical examination is also extremely useful to identify the specific cause of dyspareunia. Patient’s bother and time from surgery must be considered when discussing potential treatments of this outcome. Palpation for tight bands of tissue, extrusions, tender pelvic muscles are all aspects of the physical exam that can help with the management of this complication.

If there is significant bother and a patient elects for therapy for dyspareunia conservative treatment options exist. Topical lubricants, vaginal estrogen, and even topical local anesthetics have been described to help lessen or alleviate some of the more mild symptoms. If physical examination reveals pain from palpation of the specific trigger points injections with local anesthetics and/or steroids can be considered. The use of systemic or local anxiolytics such as benzodiazepines has also been utilized to help relax pelvic floor muscles. Physical therapy with the optional use of dilators is another method that can help address symptoms.

The physical examination may also identify a discrete band of tissue attached to the vaginal wall that has been incorporated into levator ani muscles. If this is the case operative release of this tissue can help alleviate symptoms of pain during intercourse. Excessive narrowing of the vaginal introitus or canal may also require surgical intervention. Aside from the release of excessively tight and tissue, graft material may be necessary if there is a paucity of local tissue to reconstruct an adequate vaginal lumen.

Other therapies have also been studied for the treatment of dyspareunia. There is level III evidence to support the use of botulinum toxin in the treatment of severe refractory vaginismus. This comes from a study of 24 women were the etiology of vaginismus was not specified in the inclusion criteria. After failing other therapies these women were injected with 150–400 units of botulinum toxin type A into three sites on each side in the puborectalis muscle. After a mean follow-up of 12 months, none of the patients had recurrent vaginismus, and 75% were able to achieve satisfactory intercourse [38]. More specifically there are case reports describing the use of botulinum toxin in a postoperative patient who experienced de novo dyspareunia and vaginismus [39].

Rectal Injury

Injury to surrounding structures is always a potential complication of surgical intervention. The defect present in a rectocele is of the tissue between the vagina and rectum. This intimate relationship of the rectum and the rectocele defect make the rectum a potential source of inadvertent injury.

Preoperative Avoidance in Preparation

Once again, there are multiple ways to address posterior repairs, and when thinking about the approach, the chance of rectal injury deserves consideration. Depending on surgeon preference, and surgical approach, bowel prep may be used preoperatively. A bowel prep does not necessarily decrease the risk of rectal injury; however it does decrease the risk of gross contamination if in fact a rectal injury is made. Women with symptomatic rectoceles can have a significant of constipation and trapping of stool at baseline. In cases where women have excessive amounts of stool in the rectal vault, intra-operative rectal exam can be a more challenging proposition. An enema given preoperatively can be an effective way of cleaning out the rectal vault. Enemas are generally well tolerated and do not dehydrate patients the same way a full bowel prep would.

Patients that are undergoing intra-abdominal repairs of rectocele, may benefit from a modified bowel prep. The authors of this chapter have not found this particularly helpful in routine laproscopic/robotic cases. Other laparoscopic surgeons have suggested this decreases distention secondary to bulky stool or excessive bowel gas that can make dissection more challenging and interfere with visualization.

Intra-operative

Utilizing a drape or a draping technique that allows for digital rectal examinations during rectocele repair is very valuable to help avoid or recognize rectal injury during dissection and or suture/trocar placement. The finger allows the surgeon to ensure that the rectal wall is not violated. Further, after repair palpation via rectal exam, the surgeon can identify the presence of suture or mesh material that may have been inadvertently placed.

If an abdominal approach with laproscopic or robotic assistance is selected good basic laparoscopic technique should be observed. Use of these measures is aimed at minimizing risk of injury to hollow viscous organs. These practices include utilizing an OGT or NGT, and placement of a Foley catheter. We also avoid the use of nitrous oxide to prevent distention of the bowel. Decompression of bowel and bladder is especially important when gaining access to the abdominal cavity and thus these measures are not necessarily aimed at reducing rectal injury. However intra-operatively they allow for better visualization and can prevent inadvertent injury during dissection.

In a retrospective look at rectal injury during vaginal surgery Hoffman et al. found that over an 11-year period they had a 0.7% injury rate utilizing a vaginal approach for a variety of surgical indication including prolapse [40]. They felt that after reviewing the cases prevention of injury required careful sharp dissection, preliminary dissection on either side of the midline, and occasionally the insertion of a finger into the rectum. They suggest that Injection of sodium chloride solution or a dilute vasoconstrictor may also facilitate dissection. The authors of this chapter do not routinely utilize this technique during the posterior dissection because of the potential for distortion of the already thin tissue planes.

Preoperative use of estrogen in postmenopausal women can also be considered to thicken the vagina and this may facilitate dissection. However this has not been investigated directly to make evidence-based recommendations.

Mesh prolapse repair kits may require placement via blind trocar passage and this has led some to investigate the risk of rectal injury during posterior mesh kit repair. One series of mesh prolapsed repair kits, with only short-term follow-up, the authors found that they had a 1.1% rectal injury rate [41]. Interestingly, both of the patients were noted to have sustained the rectal injury during the initial dissection and not from the trocar passage. Both patients had the injury repaired primarily and one did eventually have a posterior mesh placed and the other was converted to a more traditional colporrhaphy. Though there is not much data regarding the placement of mesh after rectal injury, we would argue against it. The same study did have 1.6% intra-operative bladder injury rate. Conversely these injuries were secondary to the trocar placement and not dissection.

However, injury to the rectum has been noted in other series of patients treated with mesh kits where rectal injury was not caused by the initial dissection [42]. In this series the rectal injury was found 1 week postoperatively when a rectoscopy, done for refractory dedicatory pain, reveled an arm of the prolapse repair kit mesh traversing the lumen of the rectum. The series had 62 patients with at least part of the surgery including a posterior repair resulting in a 1.6% rectal injury rate.

Patient with pelvic organ prolapsed may elect to undergo treatment by an abdominal approach (open laproscopic with or without robotic assistance). These patients can have a significant amount of posterior defects that the surgeon can attempt to address from the abdominally route. To achieve this, the dissection is carried down toward the perineal body between the vaginal wall and rectum. In one series of 165 women with vaginal vault prolapse undergoing laparoscopic sacrocolpopexy (using a polypropylene mesh) three sigmoid perforations were noted. These were injuries were all noted in women being treated for rectocele, presumably during the posterior dissection. The injuries were all successfully treated by laparoscopy suture repair of the injury that was recognized intra-operatively [43].

Another series of 124 laparoscopic sacrocolpopexy (using multifilament polyethylene terephthalate-polyester) noted two intra-operative rectal injuries (1.6%). There were three bladder injuries (2.4%) noted as well. One of the rectal injuries was immediately recognized and successfully repaired; the procedure proceeded as planed with uneventful follow-up for this patient. There was however one patient that developed a rectovaginal fistula following an occult rectal perforation. This was noted 3 weeks after the surgery and the fistula was debrided and closed with suture. A transitory colostomy was concomitantly performed. This patient unfortunately also developed a lumbosacral spondylodiscitis diagnosed at 4 months, and required prolonged antibiotic therapy before complete resolution [36].

Recognition of a rectal injury, regardless of approach, remains paramount in trying to minimize the morbidity to the patient. Once the injury is realized the surgeon must perform an adequate mobilization of the injured area. The mobilization allows for appropriate exposure so that the injury can be closed in entirety. The mobilization of the rectum away from other tissue is also usually necessary to allow the surgeon to complete the prolapse repair. Lastly this mobilization is critical to allow for a tension free repair.

Next, a two layer closure should be performed. The first layer uses delayed absorbable sutures to close the rectal mucosal defect (usually in a running fashion). The second layer is an imbricated sero-muscular layer using a permanent suture in a Lembert-type fashion. It should also be noted that during the dissection required to mobilize the injured bowel, it is often possible to identify additional tissue (fat, fascia) that can be used to cover the two layered closure.

The final factor in ensuring the best possible outcome from an intra-operative repair of a rectal injury is given patient appropriate postoperative instructions. Ensuring that the patient is having soft BM is paramount. Also patients should avoid anything per rectum for approximately 6 weeks. Fecal diversion is usually not necessary.

Postoperative Identification and Management

One of the concerns about the use of mesh for vaginal prolapse repairs is late complications with mesh extrusion or erosion. This problem can occur in the vaginal lumen, which is much more likely to be discovered on routine pelvic examinations during follow-up. Mesh can also erode into the rectal lumen, which may not be routinely visualized or palpated during a postoperative speculum examination of the vagina. A digital rectal examine should thus be considered part of the postoperative physical exam (especially if a posterior repair was preformed). It requires a high index of suspicion to diagnose problems such as mesh extrusion into the rectum. There are case reports and prolapsed repair series that describe a small, but real, number of women that develop mesh extrusions erosions or misplacements into the rectum recognized postoperatively [4445]. Women may present with rectal bleeding, change in bowel habits, worsening dyspareunia several months after posterior prolapsed repair with mesh. Physical examination may be all that is needed to confirm suspicion of a mesh complication but more involved testing with a rigid sigmoidoscope may also be necessary. Figure 4.3 shows an example mesh seen by and endoscope in the rectal wall. Borrowing from the trauma literature on penetrating rectal injuries, we know that rigid sigmoidoscopy is much more sensitive than digital rectal exam for uncovering rectal injury. This is a different population with a different mechanism of injury, however if suspicion is high that a rectal injury occurred (or developed) digital rectal exam alone may not be adequate [46].

A213469_1_En_4_Fig3_HTML.jpg

Fig. 4.3

Posterior mesh complication. (a) View during a sigmoidoscopy of an eroded (or misplaced) mesh visualized in the lumen of the rectal wall. (b) An intra-operative photo of the mesh removal via a transvaginal approach. The surgeons finger is placed in the rectum to aid in the removal of the mesh. Reproduced from Hurtado et al. [44]

Cases of rectal vaginal fistula have also been reported with the use of mesh to augment a posterior colporrhaphy and posterior intravaginal slingplasty (see Fig. 4.4) [47]. Women with rectovaginal fistula may present with foul smelling vaginal discharge, systemic signs of infection, and possibly pelvic/perineal adenopathy. Repairs of these fistulas are more involved than repairs of a straight forward mesh extrusions. These repairs often require local tissue flaps. In more complicated cases diverting colostomy may be considered.

A213469_1_En_4_Fig4_HTML.jpg

Fig. 4.4

Rectovaginal fistula.(a) Rectovaginal fistula demonstrated by a lacrimal duct probe entering the vagina and exiting the anus. (b) Posterior intravaginal sling plasty polypropylene mesh protruding though the dissected rectovaginal fistula. Reproduced from Hilger and Cornella [47]

Once discovered, attempts to treat the mesh complication can be done endoscopically. This is usually done by cutting the exposed mesh and allowing the injury to heal by secondary intention. However if this is unsuccessful, not possible, or if a more definitive approach is desired a transvaginal excision of mesh is warranted.

In the event that a transvaginal excision of synthetic mesh is needed the goal is to remove as much (if not all) of the mesh as possible and to repair any violations of the rectum that were discovered or occurred. Based on the extent of the injury and comfort of surgeon these procedures can be done in conjunction with a colorectal surgeon. The authors of this chapter have favored a posterior midline vaginal incision to allow for complete exposure. The vaginal epithelium should then be dissected from the fibromuscularis laterally. The mesh should be identified and in order to facilitate the initial dissection grasping it with an instrument such as an Allis clamp is useful. Ideally the distal edge of the mesh is now identified and freed sharply. At this point the mesh should be dissected off of the rectovaginal septum in a cephalad direction. The use of a finger in the rectum can help the surgeon appreciate the appropriate depth of dissection as well as the area(s) of rectal violation. Further the rectal exam can identify the location of the anal sphincter. Awareness of this location allows us to avoid unnecessary sphincter injury. The mesh should be removed laterally to the pelvic sidewalls to as great an extent as possible. This is often aided by incising the mesh down the middle allowing for dissection above and below the synthetic mesh, freeing it completely. In many case mesh can become incorporated into the rectal submucosa, or is place through the rectal mucosa and in order to remove it may be necessary to resect a full-thickness portion of the anterior rectal wall. The defect should be closed in at leas two layers in a water tight fashion. A proctoscope or other means of irrigating the rectum (i.e., a catheter) should be used to ensure that the closure is adequate. After the mesh removal and defect repair the rectocele may be present and should be closed without another synthetic material. The vaginal epithelium is then closed.

Other Complications

Mesh extrusion (previously described as erosions) into the vaginal epithelium can also be seen if mesh is used to augment posterior repairs [48]. Dwyer et al. had a 9% overall erosion rate noted with the use of monofilament polypropylene mesh placed in the anterior and posterior compartment found (and one patient who developed a rectovaginal fistula). Posterior vaginal mesh extrusion is handled in much the same way that any mesh extrusion is handled as discussed elsewhere in this book. Observation may be warranted if asymptomatic. Topical local estrogen is another conservative approach, and finally local excision closure of the vaginal epithelium may be necessary.

Lim et al. retrospectively noted a 12.9% incidence of vaginal mesh erosion at 1 year, when a vicryl-prolene mesh was used with posterior colporrhaphy. The authors noted that all of these erosions were dealt with by easily trimming the area, without the need of mesh removal, in the outpatient setting.

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