« Rectocoele » Mesh?

Posterior vaginal compartment Perineum Rectum Peritoneum of the cul-de-sac

Aa: - 3 Ba: -3 C: -6 GH: 4 PB: 3 TVL: / Ap: +1 Bp: +4 D: / X Aa: - 3 Ba: -3 C: -6 GH: 4 PB: 3 TVL: / Ap: +1 Bp: +4 D: /

Mean Score Clinical CCD - RX Aa - 2,4 -2,9 Ba -0,64 -0,32 Ap -2,09 -2,05 Bp -1,27 -0,41

Anatomy Structural anatomy of the posterior pelvic = urogenital diaphragm Structural anatomy of the posterior pelvic compartment as it relates to rectocoele J de Lancey, AJOG 1999

Endopelvic fascia

Endopelvic fascia

Endopelvic fascia

Epidemiology Anterior compartment only 40.1 Posterior compartment only 7.3 Apex only 5.7 Anterior & Posterior compartments 15.6 Anterior compartment & apex 8.6 Posterior compartment & apex 4.7 All compartments 18 Olsen, 1997

Symptoms Note: Ellerkman AJOG 2001

Reviewing the literature DIFFICULT Heterogeneous nature of the problem Variability inclusion/ exclusion criteria Plethora of surgical procedures Non-standardized definitions of surgical outcome Lack of independent, standardized reviews Short term follow-up

Conservative therapy

Aim of surgery Relieve symptoms Restore anatomy Maintain visceral function Maintain sexual function Arnold M, 1990

Vaginal vs Transanal 2 RCT’s: Kahn MA, et al (1999) Posterior colporraphy is superior to the transanal repair for treatment of posterior vaginal wall prolapse. Neurourol Urodyn 18: 70-71 Nieminen K, et al (2003) Transanal or vaginal approach to rectocoele repair: results of a prospective randomised study. Neurourol Urodyn 22: 547-548

Vaginal vs Transanal Kahn MA, et al (1999) 57 women Transanal repair: 33 Transvaginal: 24 Mean follow up: 2 years Repeat surgery required for recto-/enterocoele: Transanal: 9/33 (30%) Vaginal: 2/24 (13%) (p=0.1) More significant improvement of point Ap in the vaginal group

Vaginal vs Transanal Nieminen K, et al (2003) 30 women 15 in each arm 1 year follow up Persistent post vaginal wall prolapse: Transanal: 67% Vaginal: 7% (p=0.01) Symptom improvement: Transanal: 73% Vaginal: 93% (p=0.08) More significant improvement of point Ap in the vaginal group

Vaginal vs Transanal Impaired evacuation: Dyspareunia: Kahn / Nieminen: Symptoms improved in both groups in both studies Dyspareunia: Arnold M, et al (1990), Dis Colon Rectum: retrospective review: more dyspareunia after vaginal repair Kahn: 1 de novo dyspareunia Nieminen: improved sexual function in both groups

Vaginal vs Transanal CONCLUSION: The transvaginal approach to repair the posterior vaginal wall appears superior to the transanal approach.

Methods of vaginal repair Francis W, Jeffcoate T (1961) Dyspareunia following vaginal operations. J Obstet Gynaecol Br Commonw 68: 1-10 Described the traditional levator plication. Milley P, Nichols D (1969) A correlative investigation of the human rectovaginal septum. Anat Rec 163: 443-452 Recommended plication of the rectovaginal fascia. Richardson AC (1993) The rectovaginal septum revisited: its relationship to rectocoele and its importance in rectocoele repair. Clin Obstet Gynecol 36: 976-983 Advocated isolated repair of isolated defects.

Levator Ani Plication

Levator Ani Plication Author n F.U.(mths) Symptom Preop % Postop % Mellgren 25 12 Subj prolapse - Obstr Defec 48 Constipation 96 Dyspareunia 6 19 Kahn 171 42 64 31 22 33 18 27

Discrete Fascial Repair

Discrete Fascial Repair Author n F.U.(mths) Symptom Preop % Postop % Cundiff 69 12 Subj prolapse 62 Obstr Defec 39 25 Constipation 46 13 Dyspareunia 29 19 Kenton 55 86 5 30 15 41 20 28 24 Porter 125 18 100 14 60 50 67

Midline Fascial Plication Author n F.U.(mths) Symptom Preop % Postop % Singh 26 18 Subj prolapse 78 8 Obstr Defec 57 36 Constipation - Sex Dysfunct 31 37 Maher 38 12 100 11 13 76 24 Dyspareunia 14 2

Midline Fascial Plication Abramov n F.U.(mths) Symptom Preop % Postop % Midline Fascial Plication 183 >12 Subj prolapse 100 4 40 Constipation 30 29 33 Discrete Fascial Repair 124 Dyspareunia 7 14 19 Rectocoele recurrence in 44% of the pts with site specific repair versus 18% following midline plication. (p= 0.001)

Bridge technique

Mesh augmentation Sand, AJOG 2001

Mesh augmentation Sand P, AJOG 2001 Dwyer P, BJOG 2004 Vicryl overlay 90% succes in both groups Dwyer P, BJOG 2004 67 pts with Atrium Polypropylene 100% succes No mesh complications Salvatore S, Neurourol Urodyn 2002 31 pts with Prolene mesh 13 % erosions Dyspareunia from 6 to 69%

AJOG, Dec 2006

Colporraphy Site specific repair Graft augmenation Paraiso, AJOG 2006

Sacrocolpopexy to perineal body Fox S, BJOG 2000 Teflon 29 women 14 mths FU 93% success Baessler K, Obstet Gynecol 2001 Goretex in 31 pts 26 mths FU 57% recurrence of rectocoeles

In conclusion: Level II evidence shows that rectocoele repair, done with traditional plication methods, has cure rates of 80-90 %. An RCT to demonstrate an improvement by placement of a prosthesis from this baseline to 90-95% would require 300-400 patients in each arm… Walters M, Int Urogyn J Pelvic Floor Dysfunct 2003