Site Specific Repair: Any Role in Posterior Compartment Defect

“I think there are few subjects in operative gynecology (prolapse’s surgery) in which men are more inclined to be led by the fashion of the moment, and to adopt it without due consideration of its ultimate result, and without attaching sufficient importance to its anatomical effects.”

-  Henry Jellett-Irish Gynaecologist/1914

Prolapses through the vagina’s posterior wall (most often  anterior rectal wall herniations - rectoceles) are less prevalent than those of the anterior, and have fewer recurrences. Paradoxically, the pathophysiological basis of its surgical treatment (how to fix them and existence or not of a Denonvilliers’ fascia between the rectum and the vagina) still lacks full understanding and robust evidence. Actually, we in charge of surgical treatment carry out anatomical compensation that will have repercussions on the patient's quality of life. 

With regard to evidence and guidelines in this matter, they can be elusive, but associations of pelvic floor specialists (ICS, AUGS, IUGA, ACOG, EAU) or those generating evidence (The Cochrane Collaboration and UpToDate) are in agreement about the basic principles of surgical treatment for posterior vaginal defects:  

• Many women with POP on physical examination do not report symptoms. Treatment is indicated only if prolapse is causing bothersome bulge and pressure or sexual, lower urinary tract, or defecatory dysfunctions.
• Posterior vaginal prolapse repair is more effective when performed through a transvaginal incision than a transanal one.
• Synthetic mesh or biologic grafts should not be placed routinely through posterior vaginal wall incisions to correct POP for primary repair of posterior vaginal prolapse. They do not improve outcomes and there are increased associated complications of unpredictable potential.
• Levator plication should be avoided to reduce the risk of dyspareunia.
• A perineorrhaphy often completes the vaginal approach repair.

Following these guidelines, two ancient techniques have stood the test of time: the traditional posterior colporrhaphy and the site-specific repair. How do we apply these techniques in light of  21st century knowledge?

We have learned cumulatively from authors such as Nichols, Richardson, Leffler and Buttler, DeLancey, Zimmermann, Haylen and others, that the basic treatment of the vaginal tube’s posterior defects must follow the anatomy and reconstructive surgery general principles:

• Native tissue’s site-specific reinforcement of eventual connective-muscular ruptures (rectum vaginal septum), located between the rectum and the vagina.
• Anatomical reconstitution of the fascial tissue that supports the posterior pelvic wall:
  • The longitudinal axis, from the insertions in the perineal body, passing through the pericervical ring and uterosacral ligaments, ending in the presacral fascia (DeLancey’s Level I to III).
  • The transveral axis, attaching the lower half of the rectovaginal fascia to the aponeurosis of the levator ani muschle along a line referred to as the arcus tendineus fascia rectovaginalis, bilaterally (DeLancey’s level II).

Native tissues techniques are the gold standard in posterior prolapse  and in doubt, surgery offers the practitioner a way out: follow patient-centered outcomes  and you'll find the answers.

REFERENCES

References are available from the author at This email address is being protected from spambots. You need JavaScript enabled to view it.