Recent reviews have compared transanal with transvaginal rectocele repair using the results of two small, randomized control trials (214–217). Women with compromised sphincter function and other symptomatic prolapse were excluded. The results for transvaginal repair were superior to those for transanal repair with respect to subjective failure rate (relative risk [RR] 0.36; 95% CI, 0.13–1.0) and objective failure rate (RR 0.24; 95% CI, 0.09–0.64) (214). In one study, a significant decrease occurred in the depth of rectocele on postoperative defecography for the transvaginal group compared with the transanal group (2.73 vs. 4.13 cm, respectively) (217). The transvaginal group had fewer problems with bowel evacuation, but this finding was not statistically significant. In one study, researchers discovered that 38% of patients developed fecal incontinence following transanal repair (188). In the two randomized trials, no significant differences were seen in the rate of fecal incontinence or dyspareunia, but the studies were underpowered to detect a difference (216,217). Although a vaginal approach has been considered superior to a transanal approach for rectocele repair, studies are retrospective and impossible to compare because the indications for transanal repairs are generally different from those for transvaginal repairs. A prospective, randomized trial with adequate power to evaluate symptomatic outcomes of bowel and sexual function along with anatomic cure is warranted.
Rectocele repair with graft augmentation is becoming more common, despite a paucity of supporting evidence indicating its benefits over standard procedures. The reason for its emergence is the theory that vaginal hernia repairs behave similar to abdominal hernia repairs, which have a documented decrease in recurrence when augmented with grafts. A variety of graft materials have been employed with posterior colporrhaphy and defect-directed repairs including autograft, allograft, xenograft, and synthetic mesh. There are no comparison data to aid in selecting the optimal graft. The purpose of the graft is debatable. It can either be intended to replace existing fascia as a permanent barrier or to provide an absorbable scaffold for collagen deposition, scar formation, and remodeling. The ideal material should have a low erosion rate, be relatively inexpensive, and decrease recurrence rates without causing bowel or sexual dysfunction. The outcomes for rectocele repair using graft materials placed either vaginally or abdominally appear in Table 28.11. High anatomic cure rates of 89% to 100% occurred, and symptoms of constipation, difficult evacuation, and vaginal bulge also appeared to improve.