Pelvic Organ Prolapse The variety of surgical treatment techniques for the repair of rectocele include posterior colporrhaphy, defect-directed repair, posterior fascial replacement, transanal repair, and abdominal repair with sacral colpopexy. When an enterocele is present, a culdoplasty is usually performed. In cases of perineal descent, abdominal sacral colpoperineopexy is the procedure of choice. Suture rectopexy can be performed in conjunction with sacral colpoperineopexy if rectal prolapse is present. Despite the routine use of these procedures, data are limited regarding symptomatic improvement of disordered defecation. Greater detail regarding the specific techniques for many of these procedures is provided in Chapter 27 This section will focus on surgical outcomes, including anatomic cure of prolapse, improvement of defecatory dysfunction symptoms, and morbidity associated with the procedure.
Posterior Colporrhaphy Posterior colporrhaphy has been the surgical procedure for rectocele repair preferred by gynecologic surgeons for more than 100 years. Traditional posterior colporrhaphy narrows the vaginal caliber through plication of the rectovaginal septum and usually includes a perineorrhaphy, which narrows the introitus. Despite it broad use, there are few data regarding long-term anatomic success, symptomatic improvement, and sexual function following the procedure. The outcomes of several studies are summarized in Table 28.11 (189–207). Anatomic cure and relief of vaginal bulge occurred in 76% to 96% of patients. In these studies, the procedure was ineffective at treating constipation, vaginal digitations (splinting), and fecal incontinence. Dyspareunia developed in 8% to 26% of patients with and without levator plication (188–192,207). As early as 1961, high rates of dyspareunia have been reported with this procedure in as many as 50% of patients (208).
Many feel that the successful anatomic support obtained with this procedure is offset by the modest relief of functional symptoms and high rate of de novo dyspareunia. However, a recent prospective case series of 38 women undergoing posterior colporrhaphy along with concomitant procedures for rectocele and obstructed defecation revealed markedly different results (209). Fascial plication was performed without levator plication, and perineal body reconstruction rather than routine perineorrhaphy was employed when indicated. Anatomic cure rate was 87% at 12 months and 79% at 24 months. Subjective cure rate was 97% at 12 months and 89% at 24 months. There was significant improvement in preoperative and postoperative symptoms for constipation (76% vs. 24%), digitations (100% vs. 16%), awareness of prolapse (100% vs. 5%), obstructed defecation (100% vs. 13%), and dyspareunia (37% vs. 5%). There was no difference in fecal incontinence and only one case of de novo dyspareunia. The authors attribute their improved anatomic and functional outcomes and combined improvement in dyspareunia to exclusion of levator plication, perineorrhaphy, and excision of vaginal epithelium. An additional benefit may be derived during mobilization of the vaginal epithelium, when scar tissue from prior episiotomy or surgery is divided. They also found that preoperative defecating proctography was
Table 28.11 Rectocele Repairs
Table 28.11 (Continued ) aProspective.bIn sexually active patients. cCombined transanal and transvaginal repair.
of limited value and have stopped its routine use as part of the preoperative evaluation for women with symptomatic rectoceles and obstructive defecation.