Chapter 33: Posterior Compartment Surgery

INTRODUCTION

Posterior vaginal wall prolapse includes rectoceles, enteroceles, and sigmoidoceles and often occurs in combination with other pelvic support problems. Isolated rectoceles are quite rare. Figures 33-1 and 33-2 demonstrate an isolated rectocele.

POSTERIOR COMPARTMENT SURGERY

Posterior Colporrhaphy

Posterior colporrhaphy, also known as transvaginal rectocele repair, refers to a variety of approaches, that is, the traditional posterior colporrhaphy with transverse midline plication of the rectovaginal fascia, with or without levator ani plication, and the site-specific posterior repair, either of which can include graft augmentation. Ultimately, the goal of rectocele repair is to improve prolapse symptoms, bowel function, and sexual function.

PREOPERATIVE

Patient Evaluation

The primary indication for performing a posterior colporrhaphy is symptomatic posterior compartment prolapse, which most commonly manifests as the sensation of a vaginal bulge. Outlet dysfunction constipation may also be present, causing stool trapping in the area where the rectum herniates into the vagina. In this scenario, patients may have to splint (place fingers inside the vagina or on the perineal body) in order to defecate. The symptoms of vaginal bulge and splinting are fairly specific for posterior compartment prolapse, and are the symptoms most likely to be cured by this procedure. Surgical repair of asymptomatic posterior vaginal prolapse is not recommended. Concurrent pelvic support defects are often present, and should be addressed concomitantly at the time of posterior compartment surgery.

By plicating the posterior vaginal muscularis or medial aspect of the levator ani muscles in the midline, the posterior vaginal wall width is decreased, the fibromuscularis in the midline is increased, and the vaginal tube is narrowed. A perineorrhaphy is typically included in this repair.

Consent

In general, anatomic cure rates are excellent,^1-3 with overall improvement in bowel symptoms, regardless of the type of repair. A recent randomized trial of 106 patients compared three surgical techniques of rectocele repair: traditional colporrhaphy, site-specific repair, and site-specific rectocele repair augmented with a porcine-derived, acellular collagen matrix graft (Fortagen^®).⁴

At one year after surgery, anatomic cure of prolapse (defined as < Stage 2) was comparable in the posterior colporrhaphy group (86%) and the site-specific group (78%). The cure rates of both traditional and site-specific rectocele repair groups were statistically significantly better than the graft-augmented site-specific repair (54%).

Posterior wall prolapse to or beyond the hymen developed in 20% in those who received graft augmentation, compared with 7.1% in the posterior colporrhaphy group and 7.4% in ...