Ambulatory Procedure >>
Posterior Repair with Dermal Graft
Overview
When a patient comes to our office with a rectocele, she describes the symptoms of a vaginal bulge, painful intercourse, and/or chronic constipation. Before the rectocele repair, the patient may also have a generalized pelvic pressure feeling and difficulty emptying stool from the rectum. With a rectocele, she often needs to press down on the vaginal bulge to have a bowel movement. A rectocele is a part of the more generalized pelvic floor relaxation that may manifest with other findings to include a cystocele, enterocele, uterine or vaginal prolapse, and incontinence. Olsen et al. reported that 76% of women with prolapse had a rectocele.
Causes of Rectoceles
 |
Childbirth |
|
Chronic Constipation |
|
Chronic Straining/Coughing/Heavy Lifting |
|
Obesity |
|
Aging |
|
Previous Hysterectomy |
Traditionally, patients that present with a rectocele have 3 options of surgical repair:
|
Posterior colporrhaphy |
|
Levatorplasty operations |
|
Site specific defect repair |
With a basic rectocele repair, most surgeons perform a posterior colporrhaphy, which is a non-specific midline plication or gathering of the vaginal bulge without any emphasis on the exact area of defect in the fascia. Other surgeons overcompensate and perform a levatorplasty. The lateral muscles that create the sidewalls of the vagina are pulled together and sutured over top of the rectum. This rectocele surgery actually pulls the lateral wall muscles out of their normal anatomic position and creates a floor above the rectum. The muscles are acting in place of the fascia. This operation is quite effective in the treatment of the rectocele but often these patients suffer from dyspareunia (painful intercourse) following surgery. This surgery is not very anatomic and Dr. Miklos and Dr. Moore rarely perform this operation. In fact, Drs. Miklos and Moore ! have a publication describing levatorplasty release with reconstruction using dermal graft in young, sexually-active women that could not have intercourse without pain after levatorplasty.
Dr. Miklos and Dr. Moore utilize the site-specific posterior repair and add a dermal graft (when necessary). This rectocele repair restores normal anatomy and minimizes the risk of vaginal narrowing or shortening that is common with other traditional posterior repairs. The vaginal skin is incised and the overlying skin is meticulously dissected from the underlying supportive rectovaginal fascia. The defects in the fascia are identified and repaired (site-specific fascia repair) using suture. Upon completion of the fascia defect repair, a dermal graft is sutured in place after the completion of the site-specific repair in most patients. The skin is then closed using suture. Patients rarely complain postoperatively of painful intercourse or of a narrow vagina.
Drs. Miklos and Moore believe they would achieve the same results with the rectocele surgery as Rush Medical College and the Universities of Duke and Cincinnati (please refer to the chart) if they did not utilize graft-augmentation. By adding the graft, their success rate increases to 93%.
Ambulatory procedures Figure: 1 Rush Medical College Results
Duke University Results
University of Cincinnati Results
Atlanta Urogynecology Results: To be published in The International Urogynecology Journal
Indications
A rectocele should be repaired when it is causing symptoms that affect your lifestyle. Drs. Miklos and Moore can determine whether your symptoms are being caused by the rectocele and/or any other pelvic organ prolapse. Many patients try medical management first unless the vaginal bulge is large. This management would include a high fiber diet along with fiber supplements (Metamucil) and/or a stool softener.
Advantages
Drs. Miklos and Moore increase the success rate to the site-specific rectocele repair by adding a dermal graft. Since 1998, Drs. Miklos and Moore along with Dr. Neeraj Kohli of Harvard University have been reinforcing this repair of rectovaginal fascia with a dermal graft. They have elected to add the skin (dermal) graft for reinforcement in an attempt at increasing the cure rates associated with the rectovaginal fascia repair alone.
Drs. Miklos and Kohli have shown cure rates of 93% by adding the dermal graft to reinforce the area already repaired during the rectocele surgery. This paper will be published in the International Urogynecology Journal.
To date, Drs. Miklos, Moore, and Kohli are leaders in site-specific posterior repair with dermal graft augmentation. In addition to their other papers at the International Urogynecology Annual Meeting in Prague , these authors presented the following topics using dermal graft augmentation:
|
Posterior Repair with Dermal Graft Augmentation |
|
Laparoscopic Uterosacral Colpoperineoplasty Utilizing Dermal Graft for Vaginal Vault Prolapse |
|
Posterior Vaginal Wall Reconstruction Using Pelvicol Dermal Graft: Videotape Presentation |
|
Ambulatory procedures Figure: 2
Normal anatomy - side view |
|
Ambulatory procedures Figure: 3
Rectocele - a defect in the rectovaginal fascia (side view) |
|
