Posterior Repair with Graft
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
- Chronic Constipation
- Chronic Straining / Cough / Heavy Lifting
- 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 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 graft (typically Dr Moore and Miklos now use a light, soft mesh graft designed for vaginal surgery) 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%.
Atlanta Urogynecology Results: Published in The International Urogynecology Journal
Indications of Rectocele Surgery
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 of Rectocelee Surgery with Drs. Miklos and Moore
Drs. Miklos and Moore increase the success rate to the site-specific rectocele repair by adding a mesh graft when indicated. Since 1998, Drs. Miklos and Moore along with Dr. Neeraj Kohli of Harvard University have been reinforcing the repair of rectovaginal fascia with a graft. They did most of the initial work in graft augmented repair of rectoceles and laid the groundwork for graft use in prolapse surgery, which has become mainstream today. They initially utilized biologic dermal grafts (human cadaveric tissue or porcine dermis) and presented and published many of the first papers in the world on these type of repairs.
The initial cure rates with these type of repairs were very encouraging (greater that 90%), however some of the longer term studies on biologic grafts have shown that the results do not seem to be maintaining this high cure rate over time. This most likely is due to the fact that as many as 20-30% of women may have collegenases that breakdown the biologic graft prior to tissue in-growth occurring. Additionally, Dr Miklos and Moore feel like these lower cure rates are also due to the fact that many of these centers were not doing a site-specific repair of the fascia under the graft and therefore once the graft broke down, there was no other back-up support.
Given these findings, and the fact that mesh technology has improved greatly, Dr Moore and Miklos now use a permanent mesh graft when they feel extra support is indicated. The current mesh they are utilizing (a Type I, macroporous, soft polypropylene mesh) actually has been found to have less complications than many of the biologic grafts on the market. In addition to mesh technology improvements, there have been improvements in surgical techniques,such as full-thickness dissections, that have decreased complications even further. Mesh extrusions have dropped below 2% with the newer lighter mesh and Dr Moore and Miklos see issues such as pain with intercourse occurring very rarely. The benefit of using mesh instead of a biologic graft is that it is permanent and will not disappear over time.
To date, Drs. Miklos and Moore are leaders in site-specific posterior repair with graft augmentation. . In addition to their other papers at the International Urogynecology Annual Meeting in Prague , they have presented studies and papers on the following topics at major scientific meetings throughout the US and the world including the American UrogynecologyAssoc Annual Meetings, American Association of Gyn Laparoscopists Annual Global Meeting, as well as meetings in France, Russia, Brazil, Argentina, Portugal, Spain, Italy and others as seen below:.
- Posterior Repair with Dermal Graft Augmentation
- Laparoscopic Uterosacral Colpoperineoplasty Utilizing Dermal Graft for Vaginal Vault Prolapse
- Site-specific rectocele repair with dermal graft augmentation: comparison of porcine dermal xenograft (Pelvicol) and human dermal allograft.
- Posterior repair with perforated porcine dermal graft.
- Posterior repair and vault suspension with mesh graft
Dr Moore and Miklos also recently published a major review paper on Mesh use in pelvic surgery which has been cited as one of the “best and most comprehensive reviews” on this topic. Click here to download the paper.
For more information on mesh use in vaginal surgery, please also see the Anterior Elevate and Posterior Elevate sections (highlight both for two different links).
Normal Vaginal Anatomy– side view
Rectocele –A defect in the rectovaginal fascia (side view)
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