When abdominal sacrocolpopexy is planned for apical vaginal prolapse and concomitant rectocele is present, some have advocated extending the posterior graft down the posterior vaginal wall to correct the defect (116). The technique of sacral colpoperineopexy is used to replace the normal vaginal suspensory ligaments and to augment or replace the posterior fibromuscular plane with graft material that runs from the sacrum to the perineal body (116). Its purpose is to correct the posterior compartment defects and to suspend the perineal body, thus preventing descent and opening of the genital hiatus. It has been performed transabdominally or as a combined abdominal and vaginal procedure with both Mersilene mesh and dermal allografts (116,117). Mesh erosion occurred frequently when the vagina was open: 16% for vaginal placed sutures and 40% for transvaginally placed mesh (117). The use of dermal allografts results in an anatomical cure rate of 82% with short-term follow-up and a mean of 12 months following surgery (116,117). Significant improvements also were seen in bowel symptoms. One author reported results on 205 of 236 subjects who underwent an abdominal sacral colpoperineopexy with polypropylene mesh (Marlex) without opening the vagina (118). This procedure included two straps of mesh attached from the lateral anterior vagina to Cooper’s ligament. Ten-year satisfaction rates were 68%, and erosion rates were 5%.
Laparoscopic Approach Laparoscopic rectocele repair involves the dissection of the rectovaginal space to the perineal to Posterior Repair body with either plication of levator fascia or suturing absorbable or permanent mesh in place (119,120). A few small case series have been reported with variable results.
The standard approach to transabdominal apical vaginal suspension procedures is the abdominal sacrocolpopexy. A complete review of published data on these procedures developed by the Pelvic Floor Disorders Network, which is sponsored by the National Institute of Child Health and Human Development (NICHD), has been published (121). These procedures use graft material attached to the prolapsed region of the anterior and posterior vaginal walls at or encompassing the vaginal apex and suspended to the anterior longitudinal ligament of the sacrum. Cervical sacral suspensions may also be performed when uterine or cervical conservation is desired. Surgical variations abound and include configuration of the graft on the vagina, the extent to which the anterior and posterior vagina are attached to the graft, variable graft and suture materials, presence or absence of peritoneal closure over the graft, and obliteration of the culde-sac for treatment or prevention of the enterocele or sigmoidocele. A thorough preoperative evaluation is important to exclude more distal defects or stress incontinence, which should be repaired concurrently, and other lower urinary tract or anorectal problems. In published reports, cure rates for apical prolapse range from 78% to 100% (most greater than 90%); when cure is defined as no postoperative prolapse, the range widens from 56% to 100%, although subsequent anterior or posterior vaginal prolapse has not been as consistently reported as has apical prolapse (122–131). Potential advantages of this procedure over transvaginal procedures are less paravaginal scarring and denervation than may be present with transvaginal approaches, and fixation of the entire vaginal apical area by a permanent piece of material to a stable structure (the anterior sacral ligament), which may be more durable than the transvaginal techniques that use the patient’s own connective tissue.