One randomized trial used absorbable vaginal mesh for rectocele repair (192). Patients were randomly assigned to fascial replacement with polyglactin 910 mesh at the time of anterior and posterior colporrhaphy. There were no differences in recurrence rates when comparing 70 women with a traditional colpoperineorrhaphy with 73 women having a traditional repair plus mesh: 10% versus 8%, respectively. This study did not describe changes in bowel or sexual function, and there were no mesh-related adverse events. As previously noted, the randomized controlled trial comparing posterior colporrhaphy, defect-directed repair, and defect-directed repair with porcine small intestine submucosal graft augmentation revealed higher anatomical failure rates in the graft-augmented group compared to the site-specific alone or the posterior colporrhaphy group (46% vs. 22% and 14%, respectively; P = .02), with no difference in symptom outcomes (210). Importantly, the risks of vaginal mesh erosion and severe complications may be relatively low but carry significant morbidity, including rectovaginal fistula, persistent vaginal bleeding and discharge, dyspareunia, and the need for additional surgery (199,207). Nonsynthetic grafts appear to be safer, with fewer erosions compared with synthetic grafts; however, there is no evidence to suggest that the addition of a graft to the posterior compartment improves outcomes (210,218,219).
The abdominal approach to rectocele repair may be of value when a superior defect in the rectovaginal fascia occurs in a patient with accompanying enterocele, uterine prolapse, or vault prolapse. If a patient is undergoing an abdominal or laparoscopic procedure such as a sacral colpopexy, the graft can be extended along the posterior vaginal wall to correct proximal defects in the rectovaginal septum (220). There are limited data regarding the efficacy of abdominal rectocele repair. The indication for this procedure, as well as the need for additional vaginal repair of distal defects, is often determined intraoperatively. An ancillary study from the Pelvic Floor Disorders Network evaluating bowel symptoms 1 year after sacrocolpopexy found that the majority of bothersome bowel symptoms resolve after this procedure. There was no difference in postoperative bowel symptoms among those who underwent a concomitant rectocele repair and those who did not. It is important to note that the study was not developed to evaluate the impact of concomitant rectocele repair on bowel symptom resolution, and those who underwent a rectocele repair had more severe baseline bowel symptoms including worse obstructive symptom (221).
Sacral colpoperineopexy is a modification of sacral colpopexy aimed at correction of apical prolapse combined with rectocele and perineal descent (39). A continuous graft is placed from the anterior longitudinal ligament of the sacrum down to the perineal body. This procedure can be accomplished either through a total abdominal approach or a combined abdominal and vaginal procedure. If performing a total abdominal approach, the rectovaginal space is opened, and the rectum is dissected off the posterior vaginal wall and rectovaginal septum toward the perineal body. The graft is then sutured to the perineal body or as close to it as possible. A rectovaginal examination with the surgeon’s nondominant hand facilitates this attachment by supporting the perineal body. The graft is secured to additional points along the posterior vaginal wall and apex, and sacral colpopexy is completed in the usual fashion.