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Posterior compartment vaginal prolapse can be approached with multiple surgical techniques, including transvaginally, transperineally, and transanally, repaired with either native tissue or with the addition of an augment.
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Augment material for posterior compartment prolapse includes biologic graft (dermal, porcine submucosal), absorbable mesh (Vicryl polyglactin), or nonabsorbable synthetic mesh (polypropylene).
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Anatomic success rates for posterior compartment repair with augment has ranged from
Surgery for Posterior Compartment Vaginal Prolapse: Graft Augmented Repair
Section snippets
Key points
Anatomy of posterior vaginal prolapse
Posterior pelvic organ prolapse is characterized primarily by 3 independent defects: rectocele, enterocele, and perineal body defects.1 The key anatomic structures involved are the peritoneum of the cul-de-sac (also known as the rectouterine pouch, or “pouch of Douglas”), the rectum, and the perineum.1 The perineum is the most inferior part of the pelvis.11 The vagina is a fibromuscular potential space lined by vaginal epithelium.12 This potential space requires significant support to remain
Surgical technique
There is considerable variation within the technical details, but here we describe a general approach to the augmented repair of posterior compartment prolapse. A longitudinal incision is made at the posterior wall of the vagina starting at the hymenal ring and extended toward the vaginal apex. The rectovaginal fascia is then dissected off the mucosa until the puborectalis muscles are located. The defects in the fascia are then corrected with a central plication of the fascia with delayed
Absorbable mesh versus native tissue
There is an overall paucity of literature regarding repair of posterior compartment prolapse using just absorbable mesh. As is the case with most studies regarding pelvic organ prolapse, the literature for absorbable mesh repair is confounded by combining multicompartment prolapse repair results,17 repair for stress urinary incontinence, and the variability in surgeon technique that results due to the number of defects present. In addition, the mesh used in other studies also had variability,
Biological graft versus native tissue
Oster and Astrup22 were the first to report use of a dermal autograft for the repair of posterior compartment prolapse. Fifteen patients with large rectoceles were selected for repair using a 10 × 5-cm graft, and were followed for 1 to 4 years. All patients were symptomatically improved, and only 1 of 15 had anatomic failure.
Glazener and colleagues23 performed a large multicenter, randomized trial (PROSPECT) that included a total of 1352 women, 735 of whom were included in comparing biological
Synthetic versus native tissue
Although there are numerous studies regarding synthetic mesh placement in the posterior compartment, not many have separated the results of anterior and posterior compartment repair. Even fewer studies have directly compared augmented repair with native tissue repair (Table 2), making it difficult to make any conclusions regarding the efficacy of synthetic mesh.
The PROSPECT study23 compared synthetic mesh with native tissue repair in a total of 865 women with pelvic organ prolapse, among whom
Complications
The use of vaginal mesh has come under public scrutiny due to debilitating complications such as erosion, chronic pain, and dyspareunia. Vaginal mesh erosion was reported in 12.0% to 36.0% of patients, de novo dyspareunia in 3.4% to 27.0%, worsened dyspareunia in up to 63.0%, and rectocele recurrence in 22.0%.27, 31, 36, 37 The FDA issued a safety concern in 2008, and again in 2011, regarding the complications associated with transvaginal mesh, stating that serious complications associated with
Current recommendations
The Society of Gynecologic Surgeons Systematic Review group40, 41 previously published a systematic review noting the relative lack of data regarding the use of graft and mesh for pelvic organ prolapse. Since then, the number of studies regarding the use of transvaginal augment material has increased. Schimpf and colleagues42 performed a review of outcomes of augmented posterior compartment prolapse, stating that there is no difference in anatomic and quality-of-life outcomes using any of the
Summary
With the given results and recommendations, native tissue repair may be preferable to the use of mesh or graft for posterior compartment prolapse, as the use of augment material has not shown to have superior outcomes.
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2021, Surgical EndoscopyJoint report on terminology for surgical procedures to treat pelvic organ prolapse
2020, International Urogynecology JournalJoint report on terminology for surgical procedures to treat pelvic organ prolapse
2020, Female Pelvic Medicine and Reconstructive SurgeryCurrent surgical management of pelvic organ prolapse: Strategies for the improvement of surgical outcomes
2019, Investigative and Clinical Urology
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