Defect-Directed Repair The goal of a defect-directed repair or site-specific repair is to restore normal anatomy (36). This procedure can be combined with a perineal body reconstruction, if necessary, but usually does not routinely involve perineorrhaphy. Table 28.11 lists the anatomic and functional outcomes for this type of repair. Anatomic cure rates range from 82% to 100%, which are similar to those for posterior colporrhaphy. This procedure also resulted in modest improvement for symptoms of difficult evacuation, vaginal bulge, and vaginal digitations, which appear to be slightly better than for posterior colporrhaphy (193–197,207). Constipation symptoms significantly decreased in only one study (193). All studies reported low rates of de novo dyspareunia with good functional and anatomic outcomes, but the long-term durability of the procedure is unknown. All but one of these studies included concomitant prolapse and urinary incontinence procedures.
A randomized clinical trial of 106 women with stage II or greater posterior vaginal wall prolapse compared posterior colporrhaphy, defect-directed rectocele repair, and defect-directed repair augmented with a porcine small intestinal submucosal (210). Participants completed validated pelvic ﬂoor instruments at baseline and 6 months, 1 year, and 2 years after surgery. Anatomic failure was defined as POP-Q system point Bp greater than or equal to −2 at 1 year. There was a significant improvement in prolapse and colorectal scales in all groups with no differences between groups. The proportion of subjects with functional failures was 15% overall and not significantly different between groups. Posterior colporrhaphy and defect-directed repairs resulted in similar anatomic and functional outcomes, although the addition of a porcine-derived graft did not improve anatomic outcomes. On average, all bowel symptoms evaluated were significantly improved 1 year after surgery, with no differences between treatment groups. The development of new “bothersome” bowel symptoms after surgery was uncommon (11%). After controlling for age, treatment group, comorbidities, and preoperative bowel symptoms, corrected postoperative vaginal support (stage 0 or I) was associated with a reduced risk of postoperative straining (adjusted OR 0.17; 95% CI, 0.03–0.9) and feeling of incomplete emptying (adjusted OR 0.1; 95% CI, 0.01–0.52). This led the authors to conclude that resolution or improvement in bowel symptoms can be expected in the majority of women after rectocele repair (211).
Transanal repair involves repair of the rectocele through a transanal incision with excision of redundant rectal mucosa and plication of the rectovaginal septum and rectal wall. The procedure was developed and is primarily used by colorectal surgeons to treat constipation or obstructed defecation associated with “low” or distal rectoceles. The advantages of this approach include excision of redundant rectal mucosa and the ability to treat other anorectal pathology, such as hemorrhoids or anterior rectal wall prolapse (212). Disadvantages include the inability to repair higher rectoceles, enteroceles, cystoceles, uterine prolapse, and defects in the perineal body or anal sphincter (213). Major complications of infection (6%) and rectovaginal fistula (3%) are relatively rare (203). Most studies did not require vaginal bulging or protrusion symptoms as a prerequisite for surgery. The results of several studies are summarized in Table 28.11. The anatomic cure rate was 70% to 98%, and symptoms of constipation, difficult evacuation, and vaginal digitations appear to improve (202–207).