Rectocele Repair Technique

Rectocele repair can be accomplished via many surgical techniques. One randomized controlled trial that compared three different surgical techniques concluded that each method resulted in significant improvement in symptoms, quality of life, and sexual function. ^[11]  The two transvaginal approaches include posterior colporrhaphy and site-specific posterior vaginal repair. These repairs will be explained in the following sections. Both options for transvaginal repair can be conducted with or without a perineorrhaphy for additional Level III support. Graft or mesh augmentation can be used with either technique, although no studies have shown improved outcomes; complications associated with mesh are discussed in a later section. The abdominal and laparoscopic approaches for apical defects associated with posterior compartment defects are not discussed in this review.

Colorectal surgeons often approach rectocele repairs via a transanal approach. Transanal repair has been shown to be less effective than transvaginal repairs. A Cochrane Database systematic review comparing transvaginal repair to transanal repair of rectoceles concluded that transvaginal repair results in lower recurrence rate of symptoms. ^[12]  Two randomized trials have compared vaginal and transanal approaches and concluded that the transvaginal approach yielded a lower reoperation rate and led to better anatomic results based on pelvic organ prolapse (POP-Q) examination during the follow-up period. ^{[13, 14]}   A prospective study demonstrated that endoscopic stapled transanal rectal resection (STARR) is an effective treatment for rectocele causing obstructed defecation syndrome; the study’s findings were significant improvement between the preoperative and postoperative Longo obstructed defecation syndrome scores and significant reduction or disappearance of the rectocele on defecography. ^[15]

The following sections will go into more detail regarding each of the transvaginal approaches to rectocele repair.

To begin either transvaginal technique it is first important to assess the degree of the rectocele and genital hiatus and plan the incision accordingly. Often a perineorrhaphy will be performed in addition to a rectocele repair and the incision will likely incorporate portions of the perineal body in this case. It is important to determine the desired genital hiatus closure and to not extend the incision beyond this point for risk of constricting the vaginal introitus which can result in dyspareunia.   

An Allis clamp is placed on the vaginal epithelium at the most proximal and distal aspect the rectocele. If planning a perineorrhaphy, two additional Allis clamps are placed mucocutaneous junction of the widened introitus at the desired level of closure. The purpose of the Allis clamps are to assist with delineation of the borders for the incision as well as serve as countertraction for dissection purposes. The authors recommend injection of lidocaine with a dilute vasoconstrictor below the vaginal epithelium to aid with hydrodissection and hemostasis.

Using sharp or electrocautery dissection, an incision should be made between the two clamps. If perineorrhaphy is to be incorporated, an inverted isosceles triangle of skin should be denuded from the perineum. If the perineum is short, defined as less than 2 cm, the triangular incision may not be possible. The goal of this incision is to prevent redundant skin that will bunch after the repair is complete.

With the posterior vaginal wall on tension, the vaginal epithelium is dissected off the underlying tissue with sharp dissection. The authors prefer to place the nondominant index finger in the rectum to gauge the thickness of the tissue being dissected. In most cases, the dissection should continue only to the point slightly above the defect and should always be carried out to the sidewalls.

Once the vaginal epithelium has been fully mobilized off the underlying rectocele, the rectovaginal septum is then plicated in the midline using interrupted 2-0 absorbable sutures (see image in media section). Care should be taken to ensure that the rectum was not incidentally incorporated in the sutures and the vagina was not overly constricted. At this point the rectocele should be fully reduced and a perineorrhaphy can be performed, which is discussed below.

Excision of the excess tissue and then closure of the vaginal epithelium completes the procedure. Care should be taken not to overly trim the vaginal epithelium prior to closure to prevent scarring and contracture of the tissue. Reattachment of the rectovaginal connective tissue to the perineal body is recommended in all repairs when separation is observed.

The site-specific defect repair is based on the assumption that there are specific defects in the rectovaginal septum that allow for the serosal layer of an enterocele or rectum to abut the vaginal epithelium directly. ^[16]  Each defect in the vaginal fascia is individually isolated and repaired.

The vaginal epithelium is incised in a similar manner as described in the posterior colporrhaphy section. This procedure is best performed with the surgeon placing one finger in the rectum as guidance in repairing palpable defects. Interrupted delayed absorbable suture is used to plicate the tissue over the surgeon’s rectal finger. With multiple sutures, bulking of this tissue will be felt, eventually resulting in scar formation and creation of a stronger fascial plane (see image in media section).

Perineorrhaphy should be performed with any posterior repair where there is separation of the perineal muscles. This is done by dissecting the free ends of the bulbocavernosus and transverse perineal muscles. Each muscle group should be plicated in the midline and reattached to the rectovaginal septum with a 2-0 absorbable suture. Careful attention should be taken during this step to allow for three finger-breadths genital hiatus at the finish of the repair for adequate sexual function.

Several randomized studies have shown no benefit in adding graft or mesh augmentation to posterior colporrhaphy. A systematic review found no difference in anatomic and quality-of-life outcomes when using a biologic graft or synthetic mesh for transvaginal posterior compartment repairs. ^[17]  Routine use of synthetic mesh or biologic grafts should be avoided in transvaginal rectocele repairs for the primary repair of posterior vaginal wall prolapse. ^[11]  If it is used, prior to closure of the vaginal epithelium, the graft is placed over the fibromuscularis plication in the traditional posterior colporrhaphy or over the corrected defects after the site-specific repair. The graft can be attached to the apical support sutures if the patient is undergoing an apical repair at the time of posterior repair. The graft material should also be attached bilaterally to the endopelvic attachment on the levator ani muscles. The surgeon should rule out tension on the graft, as this will cause further contracture during the healing process. Finally, the distal portion of the graft is attached to the perineal body.

In 2011, the Food and Drug Administration (FDA) issued a statement that serious complications are not rare with the use of surgical mesh in transvaginal repair of pelvic organ prolapse. The FDA reviewed the literature from 1996-2011 to evaluate safety and effectiveness and found surgical mesh in the transvaginal repair of pelvic organ prolapse does not improve symptoms or quality of life more than nonmesh repair. The review found that the most common complication was erosion of the mesh through the vagina, which may require multiple surgeries to repair and can be debilitating in some women. Mesh contraction, which causes vaginal shortening, tightening, and pain, was also reported.

The FDA’s update states, "Both mesh erosion and mesh contraction may lead to severe pelvic pain, painful sexual intercourse, or an inability to engage in sexual intercourse. Also, men may experience irritation and pain to the penis during sexual intercourse when the mesh is exposed in mesh erosion." See the full update regarding surgical mesh in pelvic organ prolapse here: FDA Safety Communication: Update on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse

In 2016, the FDA reclassified surgical mesh for transvaginal repair of pelvic organ prolapse from a moderate-risk device (class II) to a high-risk one (class III) and gave manufacturers 30 months to prove that their products are safe and effective. ^[18]

On April 16, 2019, the FDA mandated that all manufacturers of surgical mesh intended for transvaginal repair of anterior compartment prolapse (cystocele) stop selling and distributing their products. ^[19] The FDA has determined that the vaginal mesh kit manufacturers have not demonstrated reasonable assurance of safety and effectiveness for these devices, which is the premarket standard that now applies to them since the FDA reclassified them into class III (high risk) in 2016. Please note that the FDA restrictions for transvaginal mesh for pelvic organ prolapse do not affect the abdominally or laparoscopically placed mesh for pelvic organ prolapse (sacrocolpopexy mesh), nor the mesh sling used to treat stress urinary incontinence.

One complication of rectocele repair during the operation includes fecal contamination. To prevent this, an adhesive drape can be placed on the perineum above the anus. Some surgeons use a purse-string suture prior to the case to close the anus, but this prevents concomitant rectal examination and may cause ballooning of the distal rectum. In addition, bowel preparation prior to transvaginal approach is not recommended, as it may increase the risk of contamination of the field. It is suggested the surgeon evacuate the rectal vault as needed prior to beginning the operation.

An important consideration to discuss with the patient is the potential for postoperative dyspareunia. This may occur in patients who undergo levator plication. ^[17] It is generally not recommended as part of a posterior vaginal prolapse repair for patients who wish to remain sexually active. Special attention should be made to avoid trimming the vaginal epithelium excessively, as tissue scarring and contracture occurs along the incision during the healing process, which can increase the risk of dyspareunia. ^[20]

There is no conclusive evidence that one transvaginal approach is better than the other for surgical outcomes. One study concludes that site-specific rectocele repair is associated with higher anatomic recurrence rates than a standard posterior colporrhaphy and similar rates of dyspareunia and bowel symptoms. ^[21]   A prospective, randomized controlled trial concluded that posterior colporrhaphy and site-specific rectocele repair result in similar anatomic and functional outcomes and that the addition of porcine-derived graft did not improve outcomes. ^[11]  Bowel, sexual function, and quality of life significantly improved in all three groups. ^[11]