1. « Rectocoele »
Mesh?

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

5. 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: /

9. 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

12. 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

13. Endopelvic fascia

14. Endopelvic fascia

15. Endopelvic fascia

18. 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

19. Symptoms
Note: Ellerkman AJOG 2001

20. 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

21. Conservative therapy

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

23. 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:

24. 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

25. 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

26. 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

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

28. 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:
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:
Advocated isolated repair of isolated defects.

29. Levator Ani Plication

30. 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

31. Discrete Fascial Repair

32. 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

33. 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

34. 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)

35. Bridge technique

36. Mesh augmentation
Sand, AJOG 2001

37. 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%

38. AJOG, Dec 2006

39. Colporraphy
Site specific repair
Graft augmenation
Paraiso, AJOG 2006

40. 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

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