Defect or site-specific posterior repairs are restorative procedures by which posterior defects are corrected. These repairs begin with midline posterior vaginal incision through the epithelium and continue with separation of the epithelium from the fibromuscular wall. After irrigation to provide better exposure, a finger is inserted into the rectum to help define defects of the rectal wall and the fibromuscular layer that has been dissected from the vaginal wall submucosa. The specific defects are closed with either interrupted or running sutures (preferably the delayed absorbable type). Defect closure is accomplished in such a way as to minimize tension on the surrounding tissue and may involve vertical, horizontal, or oblique approximation. When fibromuscular tissue has separated from the perineum, the upper anterior rectum, or a well-supported cervix or vaginal cuff, it is important to reapproximate these connections. Repairs of coexistent perineal and apical support defects are important. The object of the surgery is to reestablish an intact plane of connective tissue that positions the rectum against the pelvic ﬂoor and obliterates any potential space between a well-supported cervix or vaginal cuff and the cephalad edge of the tissue plane and upper rectum. The technique should minimize tension and potential strictures, which may be more likely to occur with traditional posterior colporrhaphy (97).
Initial case series reveal anatomical cure rates with mean follow-up times less than 18 months from 82% to 100% and de novo dyspareunia rates of 2% to 7%, which are much lower than those seen with traditional repairs (99–103). Symptom relief appears to be as good or better than that seen with traditional repairs. The greatest concern with these and other procedures has been durability. A recent report indicates that the recurrence rate of rectocele beyond the midvaginal plane was higher with defect-specific posterior repairs than with side-to-side plication procedures using laterally attached fascia pulled to the midline (33% vs. 14%) and beyond the hymenal ring (11% vs. 4%) (97). The study was not randomized; however, the procedures were performed during the same period with consistent follow-up evaluations 1 year after surgery. Symptoms (dyspareunia, constipation, and fecal incontinence) after surgery did not differ between the two groups. Long-term follow-up of previously reported case series that had good short-term success or prospective randomized trials looking at modifications of traditional repairs versus defect-specific repairs should clearly delineate durability of these procedures.
The aim of transanal rectocele repair, usually performed by colorectal surgeons rather than gynecologists, is to remove or plicate redundant rectal mucosa, to decrease the size of the rectal vault, and to plicate the rectal muscularis. The rectovaginal adventitia and septum are plicated as well, probably along with the posterior vaginal muscularis. The vaginal epithelium is not incised or excised with this procedure, which probably accounts for the reported lack of adverse affects on sexual function in contrast to the vaginal approach to posterior repair. Two randomized trials and several case series from transanal repairs with mean follow-up intervals of 12 to 52 months report anatomic cure rates of 70% to 98%, improved constipation and fecal incontinence, with less need for vaginal digitation to expel stool (104–108). Complications included infections and rectovaginal fistulas, which are surprisingly rare in the reported series. From the gynecologic perspective, transanal posterior repair is an option only when the procedure is performed for defecatory dysfunction and not for prolapse of the posterior vaginal wall. The question remains whether the transanal approach with defect excision and repair improves defecatory dysfunction better than a defect-specific transperineal or transvaginal approach with imbrication of tissues to correct palpable weakness in the rectal wall and its adjacent connective tissues.