[Vaginal surgery and transanal approach for posterior vaginal wall prolapse: Guidelines for clinical practice]

Abstract

Objective: The aim was to review the safety and efficacy of surgery for posterior vaginal wall prolapse by vaginal route, in order to identify a therapeutic algorithm based on benefit/risk evaluation of each surgical procedure.

Material and methods: We performed a review of the litterature published up to september 2015 (PubMed, Medline, Cochrane library, Cochrane database of systemactic reviews) according to the HAS methodology. Level evidence (1 to 4) was determined for each study as well as evidence based recommendations (A, B, C or professional agreement).

Results: Posterior vaginal wall prolapse include mid and low rectoceles and high, beyond levator ani, defects (vaginal vault prolapse, enterocele). Patients with these prolapses frequently complain of bowel symptoms. Due to their high incidence in women, these symptoms require a careful evaluation before surgery in order to correlate them to the prolapse. Repair of the rectovaginal fascia without levatorplasty is recommended in mid rectoceles by vaginal route. The transvaginal approach is superior to the transanal approach for repair of posterior wall prolapse. Biological grafts are not recommended. Due to the lack of evaluation and to the morbidity of polypropylene meshes, there is no indication for their use in the first line surgical procedure of posterior compartment prolapse in the transvaginal approach. Superficial colpoperineorraphy must be proposed only in the symptomatic low rectoceles. Sacrocolpopexy is the procedure of choice for vaginal vault prolapse, but there is still a place for non-prothetic vault suspension by vaginal route according to the age of patients, comorbidities and associated surgical procedures.

Conclusions: Surgical option by vaginal route must be proposed only in symptomatic posterior vaginal wall prolapse. An anorectal evaluation can be required before surgery to avoid worsening of preoperative symptoms or a de novo fecal incontinence, which can lead to a dramatic impairment of patients' quality of life in this functional surgery. © 2016 Published by Elsevier Masson SAS.

Keywords: Colpocèle postérieure; Enterocele; Posterior vaginal wall prolapse; Prolapsus du dôme vaginal; Prothèse vaginale; Rectocele; Rectocèle; Résection rectale transanale; Transanal resection; Vaginal mesh; Vaginal vault prolapse; Élytrocèles.