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Posterior Colporrhaphy Plus Dermal Graft Eases Bowel Dysfunction


 

RANCHO MIRAGE, CALIF. — Posterior colporrhaphy with AlloDerm graft augmentation significantly improved bowel dysfunction while causing no major complications in a prospective study of 188 women treated for symptomatic rectocele.

Symptoms of constipation, incomplete evacuation, and fecal incontinence improved significantly over a mean 18-month follow-up period. Dyspareunia rates also improved, compared with baseline, but the difference was not statistically significant, Ahsen Chaudhry, M.D., and Robert W. Lobel, M.D., both of Albany, N.Y., reported in a poster at the annual meeting of the Society of Gynecologic Surgeons.

Among the study patients, 5% developed prolapse recurrence, and 4% reported rectal pain occurring more than once per month after the surgery. Rectal pain was not assessed preoperatively so any change in pain status remains unknown.

One patient rejected a 1-by-2-cm portion of the 4-by-7-cm dermal graft and was treated with partial graft excision and topical estrogen. Another patient developed a 2-cm abscess in the posterior vaginal wall and was treated with abscess drainage and antibiotics.

“Posterior colporrhaphy with AlloDerm graft augmentation shows good safety and efficacy. Recurrence of prolapse is minimal,” said Dr. Chaudhry in an oral presentation of the findings. “A randomized controlled trial would improve our knowledge of this operation.”

Gynecologists use various techniques to repair symptomatic rectoceles. Conventional colporrhaphy involving midline plication of rectovaginal fascia carries significant risks for midvaginal stenosis and dyspareunia, he said. Aggressive levatorplasty may lead to levator spasms and dyschezia.

Success rates for conventional posterior colporrhaphy of up to 75% at 1–2 years after surgery decline significantly beyond 3 years. More site-specific repair seems to cause fewer complications, with success rates of 72%–85% at 1 year after surgery, separate data suggest.

Both posterior colporrhaphy and site-specific repair can be hampered by the use of already weakened autologous endopelvic connective tissue, Dr. Chaudhry said. In particular, high rectoceles can be problematic because little or no autologous material is available for fixation.

These factors led the investigators to study the safety and efficacy of posterior colporrhaphy with AlloDerm graft augmentation. The investigators said they have no relationship with the manufacturer of AlloDerm.

The surgeries were performed over a 2-year period on patients with a mean age of 58 years and a mean body mass index of 30. Most patients (72%) were postmenopausal. The rectocele extended to or beyond the hymenal ring in 85% of patients.

The proportion of patients who said they were sexually active did not change significantly from before to after surgery (68% vs. 69%).

Previous surgeries included hysterectomy in 58% of patients, anterior colporrhaphy in 27%, posterior repair in 13%, sacrocolpopexy in 4%, and sacrospinous vaginal vault suspension in 2%.

Concomitant procedures performed at the time of posterior colporrhaphy with dermal graft augmentation included anterior colporrhaphy in 24% of patients, anterior colporrhaphy with AlloDerm graft in 6%, sacrospinous vaginal vault suspension in 59%, abdominal sacrocolpopexy in 22%, subtotal abdominal hysterectomy in 6%, total abdominal hysterectomy in 2%, anal sphincteroplasty in 2%, vaginal hysterectomy in 10%, and surgery for stress urinary incontinence in 59%.

There were no major complications perioperatively.

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