Minimally Invasive Therapy for Urinary Incontinence and Pelvic Organ Prolapse (Current Clinical Urology) 2014th

19. Pelvic Organ Prolapse: Posterior Repairs

Bhavin N. Patel1 and Kathleen C. Kobashi 

(1)

Department of Urology, Virginia Mason Medical Center, 1100 9th Avenue, Mailstop C7-URO, Seattle, WA 98101, USA

Kathleen C. Kobashi

Email: Kathleen.Kobashi@vmmc.org

Abstract

Rectoceles are defined as a herniation of the rectum through the posterior vaginal wall, resulting from weakness in the rectovaginal fascia that leads to compromised posterior compartment support. Although not life threatening, rectoceles, like other forms of pelvic organ prolapse, can have a negative effect on daily living and quality of life. Patients may complain of stool trapping/difficulty with bowel movements, pain or difficulty with intercourse, pelvic pain/pressure, or lower back pain. The symptoms of a rectocele are most often the factor that drives patients to desire repair. The purpose of this chapter is to review the anatomy, pathophysiology, and surgical considerations or rectocele repairs.

Rectoceles are defined as a herniation of the rectum through the posterior vaginal wall, resulting from weakness in the rectovaginal fascia that leads to compromised posterior compartment support. Although not life-threatening, rectoceles, like other forms of pelvic organ prolapse (POP), can have a negative effect on daily living and quality of life. Patients may complain of stool trapping/difficulty with passage of bowel movements, pain or difficulty with intercourse, pelvic pain/pressure, or lower back pain. The symptoms of a rectocele are most often the factor that drives patients to desire repair. The purpose of this chapter is to review the anatomy, pathophysiology, and surgical considerations or rectocele repairs.

Anatomy

Support of the posterior compartment is provided primarily by a thickened layer of tissue that lies beneath the posterior vaginal epithelium. This layer, often referred to as the rectovaginal fascia, is thought to be the female analog of Denonvillier’s fascia in the male. This layer is a thick layer of subepithelial tissue of the posterior vagina composed mostly of smooth muscle, collagen, and elastin [1]. This tissue is anchored on all sides, apically by the cardinal-uterosacral complex, laterally by the posterior arcus tendineus fascia pelvis, and distally by the perineal body [23].

Defects in the rectovaginal septum or its anchoring connections can result in a rectocele, with the location of the rectocele depending on the level of the defect. High rectoceles often result from an injury or defect of the upper third of the vagina and its attachment to the cardinal-uterosacral ligament complex. These rectoceles can be associated with uterine prolapse or enteroceles. Mid-level rectoceles are often associated with tears in the rectovaginal septum or in the attachment of the rectovaginal septum to the posterior arcus tendineus. Distal or low rectoceles are thought to be due to injury to or disruption of the perineal body and are often associated with widening of the posterior hiatus.

Etiology

The exact causes of compromised posterior vaginal support and rectoceles are not clear. Known risk factors include childbirth, defecation disorders, age/postmenopausal status, history of hysterectomy, and connective tissue disorders [4]. Although a rare patients with a rectocele may not have any of these risk factors, the majority of patients often have more than one risk factor.

Vaginal childbirth contributes to weakened posterior support as it is known to cause neural, muscular, and connective tissue injury. Together these factors allow for vaginal laxities that can result in POP. Defecatory disorders, such as constipation, can damage support mechanisms through associated abdominal straining which may lead to nerve damage and stretch injury to the posterior vaginal support [4]. Prior hysterectomy may affect normal vaginal anatomy altering vaginal pressure vectors and causing pelvic denervation that can lead to weakened muscular support. Age is a risk factor for POP as aging females accrue increasing damage with time to their pelvic support. Finally, disorders of the connective tissues result in weakened or lax vaginal support that can lead to the development of POP.

Prevalence

Population-based studies on POP are difficult to accomplish as they require vaginal examinations on asymptomatic women. Furthermore, there is a difference in the prevalence of anatomic and functional rectoceles. For both of these reasons the true prevalence of rectoceles, symptomatic or not, is difficult to define as is the true prevalence of symptomatic rectoceles. In a study of primarily middle-aged and older women, Swift et al. found that 75 % of patients presenting to a gynecologist for their annual exam had some form of POP-Q gradable POP [5]. Furthermore, up to 76 % of women with POP had a documented rectocele [6]. Together these studies suggest a high prevalence of anatomic rectoceles in middle-aged and older women, which follows our clinical experience.

Clinical Aspects

Clinical Presentation and Evaluation

Many patients with anatomic POP are asymptomatic. Patients with rectoceles are no exception. However, symptomatic rectoceles can present with a variety of symptoms. General symptoms of POP include pelvic pressure or heaviness, visualization of a vaginal bulge, pelvic pain or discomfort, and difficulty with intercourse [7]. Other symptoms such as dyspareunia may also occur. Symptoms specific to rectoceles include a sensation of incomplete defecation and need to distally splint the vaginal wall or perineum to facilitate emptying [7].

Patients are seen and evaluated in the clinic. A thorough history is obtained with a focus on risk factors for POP, symptoms of POP, comorbidities, and previous pelvic surgeries. Patients are examined using the POP-Q system at rest and with strain. Levator ani muscle tone and strength are assessed. A rectal exam is done to evaluate for perineal body weakness and anal sphincter tone. The authors do not routinely order imaging, but in complex cases, dynamic MRI or endoanal ultrasonography may provide useful adjunctive information.

Indications/Patient Selection

The surgical indications for rectocele vary from provider to provider. Most pelvic floor surgeons will elect to proceed with repair of a rectocele if the patient has bothersome symptoms related to the posterior prolapse. These symptoms include those mentioned in the previous section. This repair is often performed in conjunction with other vaginal compartment repairs or anti-incontinence procedures.

The proper management of an asymptomatic rectocele present at the time of repair of anterior or apical compartment prolapse repair is controversial. Some clinicians feel that if a posterior compartment defect is left unrepaired while other compartments are repaired, then postoperatively the rectocele is exposed to higher abdominal force which may worsen the posterior defect [8]. Others believe that poor posterior vaginal wall support may provide improved resistance to urethral and bladder neck hypermobility, thereby increasing the success of anti-incontinence procedures [9]. Neither of these statements is supported by the literature. In the practice of the authors, rectoceles are generally only repaired if they are symptomatic or in asymptomatic cases if they have progressed beyond the hymen. In the latter scenario, it is our concern that in spite of being asymptomatic, a rectocele of this degree likely poses an increased risk of becoming symptomatic later in the patient’s life.

Procedures

Vaginal Approaches

Vaginal approaches to rectocele repair include the traditional posterior colporrhaphy, plication of the prerectal and pararectal fascia with levator ani reconstruction, defect-specific repair, graft-augmented repair, and kit-based repairs. These approaches are all vaginal-based approaches that do not require abdominal access. As such, these procedures are reasonably well tolerated and suited for outpatient surgery.

Our preoperative and surgical preparations are the same for transvaginal rectocele repair techniques. All anticoagulant is stopped prior to surgery such that bleeding parameters have normalized prior to the day of surgery. The patient is asked to fast starting the night prior to surgery. Prior to beginning the procedure, the patient is given prophylactic antibiotics per the AUA best practice guidelines [10], which typically entails cefazolin intravenously administered 1 h prior to surgical incision.

Spinal anesthetic, laryngeal mask anesthetic, or general endotracheal anesthesia is used. Bilateral sequential compression devices are placed on the lower extremities for venous thromboembolism prophylaxis [11]. Once anesthesia is induced, the patient is placed in the dorsal lithotomy position. The lower extremities are padded and positioned appropriately to prevent nerve or muscle injury. The surgical field is then clipped with clippers, a betadine preparation is used to prepare the vagina, and a chlorahexadine-based preparation is used to prepare the surrounding perineal and lower abdominal skin. Once the patient is adequately draped, the Lone Star retractor (CooperSurgical™, Stafford, TX) is centered on the vaginal introitus and affixed to the perineum using penetrating towel clips. A Foley catheter is placed and the procedure is begun.

Once the vaginal procedure is completed, a vaginal packing is placed and the patients are transferred to the post-anesthesia care unit. One hour after arriving, the vaginal packing is removed and the patients are given a trial of void if they have had an associated anti-incontinence procedure or anterior compartment repair. Once they have recovered from the anesthetic and their pain is adequately controlled, they are discharged home with a prescription for pain medication, 24 h of oral antibiotic coverage, and an oral stool softener. They are given instructions to refrain from vaginal intercourse, avoid constipation, and avoid lifting greater than 10 lb or doing exercises that may put undue straining on the repair for 6 weeks.

Traditional Posterior Colporrhaphy

The standard or traditional posterior colporrhaphy is a method of rectocele repair that relies on reapproximation of the levator ani muscles and the rectovaginal fascia over the prolapsing rectum to provide posterior support. The patient is prepared and positioned as described above. Prior to rectocele repair all other concomitant pelvic floor surgeries, such as anti-incontinence procedures, cystocele repair, and hysterectomy, are done.

The posterior repair is begun by placing two Allis clamps on the posterior vaginal forchette at the 4 and 8 o’clock positions. The lateral positions of the Allis clamps are defined such that when the clamps are brought together in the midline, the introitus allows the passage of two fingers comfortably or three fingers snuggly. This avoids a stenotic introitus. An ellipse of tissue comprising the junction between the vaginal epithelium and the perineal skin is excised between the Allis clamps creating a diamond defect (Fig. 19.1). The previously described initial dissection is the same for all of the following vaginal approaches for rectocele repair.

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Fig. 19.1

An ellipse of tissue comprising the junction between the vaginal epithelium and the perineal skin between the Allis clamps is excised creating a defect at the posterior forchette. A V-shaped incision is made from the apical portion of the rectocele to the lateral aspects of the perineal incision. With counter-traction facilitated by placement of an Allis on the vaginal epithelium and working from the apex toward the perineum, the vaginal epithelium is dissected off of the rectovaginal septum in the white shiny layer (From Vaginal prolapse, in Raz S: Atlas of Transvaginal Surgery. Philadelphia, WB Saunders, 1992, with permission of Elsevier)

Attention is then turned to the apical-most portion of the rectocele. From this point a V-shaped incision is made from the apical portion of the rectocele to the lateral aspects of the perineal incision. Working from the apex toward the introitus the vaginal epithelium is dissected off the rectovaginal septum. Dissection in the white shiny layer is aided by counter-traction with an appropriately placed Allis clamp (Fig. 19.1). Once the incision and dissection are completed, the excised vaginal epithelium is discarded. Flaps are created by undermining the vaginal epithelium toward the levator ani muscles. Once the dissection laterally is completed hemostasis is achieved. Interrupted figure-of-eight sutures are placed in the levators and tied such that the levators meet in the midline along the entire rectocele defect (Fig. 19.2). The prerectal fascia is closed with a running suture anterior to this layer. One should inspect the repair to ensure there are no ridges or acute drop-offs as these can be the source of postoperative pain or discomfort. The vaginal epithelium is then reapproximated in the midline and a vaginal packing is placed for 1 h and removed in the postoperative care unit prior to discharge.

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Fig. 19.2

Flaps are created by undermining the vaginal epithelium toward the levator ani muscles. Once the dissection laterally is completed hemostasis is achieved. Interrupted figure-of-eight sutures are placed in the levators and tied such that the levators meet in the midline along the entire rectocele defect (From Vaginal prolapse, in Raz S: Atlas of Transvaginal Surgery. Philadelphia, WB Saunders, 1992, with permission of Elsevier)

In one of the largest published series on traditional posterior colporrhaphy, Abramov et al. reported on 183 women who underwent traditional posterior colporrhaphy [12]. These authors reported a 96 % cure rate at 1-year follow-up, with cure defined as no prolapse beyond the hymenal ring. In a more recent study using strict anatomic definitions and validated questionnaires, Paraiso et al. [13] reported on 37 patients randomized to traditional posterior colporrhaphy versus site-specific repair. With a strict definition of anatomic cure, POP-Q point Bp less than or equal to −2 at 1 year from surgery, they found that posterior colporrhaphy was associated with an 86 % anatomic cure rate. Seven percent of patients had posterior wall prolapse to the level of or beyond the hymen. Overall patients had statistically significant improvements in the prolapse and colorectal scales of PFDI-20 and PFIQ-7 after surgery indicating improvement in quality of life. There was no statistical difference in patients with dyspareunia pre- and postoperatively.

Although these 1-year follow-up studies show a high rate of anatomic success, longer term follow-up demonstrates lower rates of anatomic success and decreased functional bowel control after rectocele repair. With a mean follow-up of 3.5 years, Kahn and Stanton demonstrated a 76 % overall anatomic cure rate, with anatomic cure defined as grade 0 or I prolapse on the Baden-Walker scale, after traditional posterior colporrhaphy [14]. On interview, there was an improvement of bulge-related symptoms (64 % vs. 31 %), but despite this, most patients had worsening of bowel-related symptoms including constipation (22 % vs. 33 %), sensation of incomplete bowel emptying (27 % vs. 38 %), and incontinence of stool (4 % vs. 11 %). There was also an increased prevalence of sexual dysfunction postoperatively (18 % vs. 27 %).

Plication of Prerectal and Pararectal Fascia with Levator Reconstruction

In this repair a single layer of suture incorporates prerectal and pararectal fascia (rectal pillars) from the apex of the rectocele down to the lower third of the vagina. Distally, the same layers are incorporated, but the levator ani is included to reapproximate and support the levator hiatus. After the induction of anesthesia, the patient is placed in the dorsal lithotomy position. The patient is prepared in the dorsal lithotomy position as previously described. Prior to rectocele repair all other concomitant pelvic floor surgeries, such as anti-incontinence procedures, cystocele repair, and hysterectomy, are done.

The posterior repair is begun as previously described by excising an ellipse of tissue at the junction of the vaginal epithelium and perineal skin (Fig. 19.1). The subepithelial plane is developed with Metzenbaum scissors from the introitus to the apex of the rectocele and an incision in the midline overlying this dissected tissue is made. During this portion of the case, it is important to keep the tip of the scissors pointing anteriorly to avoid inadvertent damage to the rectal wall.

The reconstructive procedure is begun by using a 2-0 vicryl suture to reapproximate the vaginal epithelium, the pararectal fascia/rectal pillar, and the prerectal fascia from the level of the rectocele apex to the distal third of the vagina. The layers are incorporated with a running, interlocking suture. The running suture is tied down at the beginning of the distal third of the vagina. The remainder of the vaginal defect is closed with interrupted figure-of-eight sutures of 2-0 vicryl including the vaginal epithelium, the pararectal fascia, and the prerectal fascia as before, but the levator ani is also included to reduce and support the levator hiatus. Additionally, these distal vaginal sutures will help restore the vaginal axis. In performing this distal portion of the rectocele repair, one should ensure that the introitus is not too narrow and that there are no deformities or ridges created posteriorly as these can result in pain postoperatively. The remainder of the incision is closed to reapproximate the perineal skin and a vaginal packing is placed for 1 h and removed in the postoperative care unit prior to discharge.

There is limited published data on the outcomes of patients after plication of prerectal and pararectal fascia with levator reconstruction. Vasavada and colleagues reported that in 380 patients seen at a mean follow-up of 22 months after repair, there was a 96 % anatomic success rate with success being defined as a grade I or less posterior wall prolapse. There was a noted functional improvement as well with 67 % of those with preoperative constipation noting improvement in constipation postoperatively. It should be noted that in this study 69 % had asymptomatic rectoceles [4].

Defect-Specific Repair

In the defect-specific rectocele repair, the surgeon dissects the rectovaginal fascia and identifies deficiencies that are primarily repaired. The rectovaginal fascia, as previously mentioned, is a layer of collagen, elastin, and smooth muscle that separates the vagina and rectum. Injury to this layer of support from vaginal childbirth, constipation, abdominal straining, etc. can cause site-specific defects/damage that may result in rectocele. Damage to this posterior support may manifest as a tear in the body of the fascia, a lateral separation of the fascia from the iliococcygeus and pubococcygeus muscles, apical separation from its connection to the sacrum, or distal separation from the rectovaginal fascia’s attachment to the perineal body [15].

The posterior repair is begun as previously described by excising an ellipse of tissue at the junction of the vaginal epithelium and perineal skin (Fig. 19.1). The subepithelial plane is developed with Metzenbaum scissors from the introitus to the apex of the rectocele and an incision in the midline overlying this dissected tissue is made. During this portion of the case, it is important to keep the tip of the scissors pointing anteriorly to avoid inadvertent damage to the rectal wall. Dissection is carried laterally allowing for appropriate exposure to the rectovaginal fascia. This exposure should allow for inspection of the rectovaginal fascia from the vaginal apex to the perineal body and out laterally to the tendinous arc of the levator ani.

A double glove is now placed on the non-dominant hand and the index finger of the non-dominant hand is placed transanally to elevate the anterior rectal wall. With lateral movement of the index finger, defects in the rectovaginal fascia are seen. Healthy, durable rectovaginal fascia is then plicated over the anterior rectal wall to address the defects resulting in correction of the rectocele. Once completed the vaginal epithelium is closed and if indicated a perineal body repair is undertaken.

A variation to the defect-specific repair adds another layer of support along the posterior vaginal wall. After the site-specific repair is completed, figure-of-eight sutures are placed to bring the lateral levator ani muscles together in the midline. The addition of the levator ani plication is thought to result in stronger posterior compartment support [16].

In one of the largest published series on site-specific defect repair, Abramov et al. reported on 124 women [12]. These authors reported an 89 % cure rate at 1-year follow-up, with cure defined as no prolapse beyond the hymenal ring. In a series of 89 women, with slightly longer follow-up, 1.5 years, Porter et al. had an anatomic success rate of 82 % [17]. Anatomic success was defined as no prolapse or a rectocele that did not descend beyond the hymenal ring on maximal straining. There were also functional improvements noted in stooling difficulties, pelvic pressure/pain, vaginal bulge/mass, and in need for splinting in the majority of patients. In the previously quoted series by Paraiso et al., 37 patients underwent defect-specific rectocele repair [13]. They described anatomic cure at 1 year as 78 %. Seven percent of patients had posterior wall prolapse to the level of or beyond the hymen. Overall patients had statistically significant improvements in the prolapse and colorectal scales of PFDI-20 and PFIQ-7 after surgery indicating improvement in quality of life. There was no statistical difference in patients with dyspareunia pre- and postoperatively.

Graft-Augmented Repairs

Grafts have been used to repair all compartments of vaginal prolapse and have been used as either a stand-alone support mechanism or an adjunctive to native-tissue repair. Grafts are classified as biologic or synthetic and are available either in a delivery kit or as stand-alone materials that are tailored by the surgeon at the time of surgery use. For rectocele repairs, the authors have used biological graft material as a stand-alone support mechanism. As previously mentioned, although surgeons have used a wide array of graft materials, it has been the authors’ preference to use biologic graft over synthetic graft. The authors believe that the benefits of currently available synthetic (polypropylene) meshes do not outweigh the risks of vaginal exposure [18], rectal erosion [19], and mesh contraction [20] do not outweigh the benefits of currently available polypropylene mesh. On the other hand, biologic grafts provide adequate support [21] with little risk of graft contraction or vaginal narrowing. Additionally, vaginal epithelium more readily heals over exposed biologic graft when compared to exposed mesh, the latter of which often requires operative excision of exposed areas.

The posterior repair is begun as previously described by excising an ellipse of tissue at the junction of the vaginal epithelium and perineal skin (Fig. 19.1). Attention is then turned to the apical-most portion of the rectocele. From this point a V-shaped incision is made from the apical portion of the rectocele to the lateral aspect of the perineal incision. Working from the apex toward the introitus the vaginal epithelium is dissected off the rectovaginal septum. Dissection in the white shiny layer is aided by counter-traction with an appropriately placed Allis clamp (Fig. 19.1). Once the incision and dissection are completed, the excised vaginal epithelium is discarded. Flaps are created by undermining the vaginal epithelium in the white shiny layer toward the levator ani muscles.

A perineal repair is performed first, followed by placement of six 0 vicryl sutures prior to the graft being brought into the surgical field. Two sutures are placed proximally and distally in the levator ani/arcus complex bilaterally. One additional suture is placed at the apex of the rectocele and a final suture is placed at the perineal body. The pre-soaked cadaveric fascia (4 cm × 7 cm, Tutoplast, Mentor Corporation, Santa Barbara, CA) is brought into the field and folded in half to maximize suture pull-out strength. It is then secured into place using the preplaced sutures thereby reducing the rectocele. The vagina is closed and a vaginal packing is left in place to be removed 1 h after the procedure. Using this technique with non-frozen cadaveric fascia lata, Kobashi et al. reported a 90 % rate of anatomic cure in 50 patients at a mean follow-up of 14 months [21]. Cure was defined as no gradable posterior wall prolapse. Of the 10 % of patients that failed, 40 % had a Baden-Walker grade I recurrence and 60 % had a Baden-Walker grade II recurrence. There were functional improvements in stool trapping, splinting, and dyspareunia.

Kit Repairs

There are many commercially available kits for POP repair. The kits combine graft material with needles passes in a package for treatment of prolapse or stress incontinence. These “all-inclusive” kits do not require tailoring of graft material or harvesting of tissues from patients. Furthermore, kits are designed to be minimally invasive, using passers to traverse anatomically “safe” spaces rather than requiring larger incisions and dissections. For these reasons, kits have been theorized to potentially reduce operative time and morbidity. The disadvantages of using kits to address prolapse or incontinence are the increased cost [22] and lack of long-term data on efficacy and complications related to each of the available kits. In the United States the following posterior repair kits are currently available: Prolift, Apogee, Posterior Elevate, and Pinnacle.

Gynecare Prolift™ PosteriorEthicon ® (SomervilleNJ). The Gynecare Prolift™ uses a pre-tailored piece of the Gynemesh PS™, Ethicon’s soft prolene mesh. The newer generation model, the Prolift + M™, uses a partially absorbable monocryl mesh. As in previous surgical procedures, the patient is positioned in the dorsal lithotomy position, a catheter is placed to drain the bladder, and Lone Star retractor (CooperSurgical™, Stafford, TX) is used for vaginal exposure. As previously described, the epithelium at the posterior forchette is excised and a midline incision is made in the posterior vagina. Vaginal flaps are created with lateral dissection toward the levator ani muscles. Care is taken to avoid rectal injury. The dissection is carried superiorly and posteriorly exposing the pararectal space to the level of the sacrospinous ligament bilaterally. At this point, plication of the rectovaginal fascia can be performed if desired, but this step is not mandatory.

Four-millimeter incisions are made at the skin 3 cm lateral and 3 cm posterior to the anus bilaterally. The cannula-equipped guide is placed into the incision and advanced to the posterior aspect of the sacrospinous ligament 3–4 cm medial to the ischial spine. The index finger of the non-dominant hand should ensure that as the guide is passed it stays posterior to the plane of the levator ani and lateral to the rectum. The guide is then passed through the ligament and the cannula is removed keeping the guide in place. The retrieval guide is passed down the cannula and brought through the vaginal dissection. The retrieval device is affixed to the arms of the mesh provided in the Prolift kit. The retrieval device is withdrawn, advancing the mesh arms from the posterior dissection, through the sacrospinous ligament and out toward the 4 mm skin incision. The mesh is tensioned at the level of the skin to eliminate redundancy or folding and the excess mesh is excised and the cannulas are removed. The lateral aspects of the mesh are sutured to the superior surface of the levator ani muscles to ensure proper positioning and the vaginal incision is closed.

In a large multicenter retrospective study, Abdel-Fattah and Ramsay reported on 70 women who underwent posterior compartment repair with the Prolift™ kit [23]. They reported 3-month outcomes and noted cure, Baden-Walker grade 1 or less, in 97 % of patients. There were five cases (7 %) of vaginal mesh exposures that all required mesh excision. In a study with 12-month follow-up, Lo noted that in combination prolapse cases repaired with anterior and posterior Prolift™ kits, there was a 95 % rate of success which was defined as POP-Q stage 1 or less recurrent prolapse [24]. Two patients developed recurrent rectoceles; they were both POP-Q grade II.

Apogee™, AMS® (MinnetonkaMN). The Apogee™ kit uses either a piece of IntePro® Lite™ prolene mesh or InteXen® LP™ cross-linked porcine dermis. Patient set up and exposure with the Lone Star (CooperSurgical™, Stafford, TX) retractor is the same as described with the other kits. As previously described, epithelium at the posterior forchette is excised and a midline incision is made in the posterior vagina to the apex of the rectocele. Vaginal flaps are created with lateral dissection toward the levator ani muscles. Care is taken to avoid rectal injury. The dissection is carried superiorly and posteriorly exposing the pararectal space to the level of the sacrospinous ligament bilaterally. At this point, plication of the rectovaginal fascia can be performed if desired, but this step is not mandatory.

Four-millimeter incisions are made at the skin 3 cm lateral and 3 cm posterior to the anus bilaterally. With the handle of the trocar pointed at the 12 o’clock position the trocar tip is advanced from the skin incision, below the levator ani muscles toward the ischial spine. One centimeter distal to the ischial spine the trocar handle is turned and the trocar tip is brought through the levator ani muscle. This procedure is repeated on the contralateral side. The mesh arms are connected to the trocar tip and the tip is then brought back to the level of the skin incision. Tension on the mesh arms is adjusted so the mesh or biologic used is free of redundancy and folding. The middle part of the superior portion of the graft is sutured to the vaginal apex. The excess mesh arms are trimmed at the skin and the vaginal epithelium is closed.

In a series of 195 patients who underwent Apogee™ kit for posterior compartment repair with IntePro® mesh, Lukban et al. reported that the success rate at a mean follow-up of 10.9 months was 96 % [25]. Success was defined as POP-Q grade I or less recurrent posterior wall prolapse. In a multicenter review, Abdel-Fattah and Ramsay [23] found a 94 % cure rate at 3 months in 30 patients treated with Apogee™. As mentioned previously, cure was defined as Baden-Walker grade 0 or I prolapse.

Posterior Elevate ®AMS ® (MinnetonkaMN). Like the Apogee kit, the Posterior Elevate kit uses either a piece of IntePro® Lite™ prolene mesh or InteXen® LP™ cross-linked porcine dermis. Patient set up and exposure are the same as previous described. An elliptical portion of the posterior forchette epithelium is excised. Vaginal flaps are created toward the levator ani muscle. The dissection is carried superoposteriorly until the sacrospinous ligaments are palpable. At this point two apical sutures are placed with 3-0 vicryl suture. The tined arms are placed into the sacrospinous ligament and the graft is secured to the tined arms. The preplaced apical sutures are then passed through the superior portion of the graft to provide apical support. The graft is then advanced along the tined mesh arms toward the sacrospinous ligament and locked into place. The excess mesh arms are excised and lateral sutures are placed from the graft to the levator ani laterally to allow the graft to lay flat. The vaginal epithelium is then closed. At the time of this review, published outcomes on the Posterior Elevate® are lacking.

Pinnacle ®Boston Scientific (NatickMA). The Pinnacle® kit provides a prolene mesh-based kit for posterior prolapse repair that uses the Capio® (Boston Scientific) needle driver for sacrospinous fixation. Once positioned and prepped, an ellipse of the posterior forchette is excised and this is carried into a midline vaginal dissection creating flaps laterally toward the levator ani muscles. Dissection is continued entering the pararectal space until the sacrospinous ligament is palpable bilaterally. A 3-0 vicryl suture is placed in the rectovaginal septum at the apex of the incision. The Capio® needle driver is used to deliver the mesh arms of the Pinnacle® kit through the sacrospinous ligament a finger breadth medial to the ischial spine. The preplaced apical suture is affixed to the mesh and the mesh arms are advanced until the graft is appropriately tensioned. 3-0 vicryl sutures are used to affix the lateral portions of the mesh to the levator ani muscles and excess mesh is trimmed. The vaginal incision is then closed. At the time of this review, published outcomes on the Pinnacle® kit are lacking.

Laparoscopic or Robotic-Assisted-Laparoscopic Rectocele Repairs

With the widespread use of the vaginal approach, laparoscopic rectocele repairs are relatively uncommon procedures. Although classified as a minimally invasive approach, laparoscopic repair does involve entering the peritoneal cavity and may be considered difficult to perform as it involves laparoscopic suturing and a potentially difficult exposure. The advent of the da Vinci robot (Intuitive Surgical®, Sunnyvale, CA) has allowed for improved visualization and easier suturing; however, as a stand-alone procedure, laparoscopic rectocele repair is rarely done.

For laparoscopic or robotic cases the patient is positioned in the low lithotomy position so that vaginal access is maintained once general endotracheal anesthesia is induced. Once prepared, access to the peritoneal cavity is gained and ports are placed. The cuff of the vagina is identified with the aid of a vaginal dilator. The dilator is then used to displace the cuff of the vagina anteriorly toward the umbilicus and an incision is made in the peritoneum overlying the vaginal cuff. With a combination of sharp and blunt dissection the posterior vaginal wall is dissected off of the rectovaginal septum and the rectum. In certain cases identification of the rectum is facilitated by placement of a betadine-soaked kerlex into the rectum at the start of the case. The dissection is carried down to the perineal body.

If placed, the rectal kerlex is removed and a vicryl suture is used to reapproximate the perineal body to the rectovaginal fascia. At this point, specific defects in the rectovaginal fascia or its lateral connections are repaired. Another approach involves a running plication of the rectovaginal fascia. Next, figure-of-eight sutures are placed in the levator ani muscles and they are bought together in the midline reinforcing the repair. Care should be taken to avoid painful ridges that can develop with aggressive repair. Introital width should also be assessed during the case to ensure that the posterior forchette of the vagina is not overly narrowed; the introitus should allow the passage of two fingers comfortably or three fingers snuggly.

Modifications to this procedure have been made to include mesh. Lee and colleagues report a method of laparoscopic prolene-augmented mesh repair. In this procedure, mesh is placed in the dissected bed between the vagina and the rectovaginal septum. It is placed flat and sutured laterally with permanent suture to the levator ani muscles. The superior-most portion is fixed to the uterosacral ligaments in the same fashion. The mesh is then retroperitonealized [26].

Transanal Repairs: Stapled Transanal Rectal Resection

In an attempt to minimize the risks of dyspareunia, wound complications, and rectocele recurrence, Longo described the stapled transanal rectal resection (STARR) as a means of rectocele repair in 2004 [27]. Rather than augmenting support of the rectovaginal fascia, the STARR procedure focuses on reducing the bulging rectocele.

Prior to the procedure the patients undergo a mechanical colon preparation with an enema and are given preoperative antibiotics covering colonic bacterial flora. After the induction of spinal or general anesthetic the patient is positioned in the Lloyd-Davis position (Trendelenburg position with the legs apart). A transparent anuscope is inserted into the anus and secured to the skin. Purse-string sutures are placed in the redundant, prolapsing rectum. A circular hemorrhoidectomy stapler (Ethicon®, Somerville, NJ) is fired along the anterior rectum, incorporating the mucosa, submucosa, and rectal wall, while excluding the posterior rectum. The procedure is repeated on the posterior rectal wall, but only incorporating the mucosa and submucosa.

At a mean follow-up of 24 months 95 % of patients treated for rectocele or intussusception were clinically and radiographically free of recurrence [8]. In a retrospective review, comparing STARR to traditional transvaginal rectocele repair, the STARR procedure had less blood loss and a faster operating time when compared to transvaginal rectocele repair, but a significantly higher complication rate (61 % vs. 19 %) [9]. Recurrence rates, failure rates, and postoperative dyspareunia rates were not statistically different [9]. Complications in the STARR group include rectal bleeding, rectal pressure/tenesmus, fecal incontinence, diarrhea, pruritus ani, rectal pain, and Clostridium difficile infection [9]. This and other methods of transanal repairs are not indicated in high rectoceles or rectoceles associated with enteroceles. When compared to the traditional vaginal approach, transanal repairs are associated with less pain [28].

Conclusion

Rectoceles are the result of defects in posterior vaginal wall support. The exact mechanisms that lead to posterior vaginal weakness are not clear, although advancing age, defecation disorders, connective tissue disorders, and childbirth injury may play a role. Although many patients with rectoceles are asymptomatic, symptomatic patients with rectoceles may present with pelvic pressure, pelvic bulge, pelvic pain, dyspareunia, and/or difficulty with defecation.

The indications for surgery vary from surgeon to surgeon. Common surgical procedures for rectocele repairs include traditional posterior colporrhaphy, plication of rectal fascia with levator reconstruction, site-specific defect repair, graft-augmented repairs, and kit-based repairs. Transanal approaches and endoscopic approaches to rectocele repair are described, but are less commonly done. Although data exists on the effectiveness of these procedures, true long-term data with report of functional and anatomic outcomes is lacking. Prospective, randomized trials with long-term follow-up are needed to compare these surgical procedures with regard to patient outcome and complication.

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