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Surgical interventions for posterior compartment prolapse and obstructed defecation symptoms: a systematic review with clinical practice recommendations

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Abstract

Introduction and hypothesis

Several posterior compartment surgical approaches are used to address posterior vaginal wall prolapse and obstructed defecation. We aimed to compare outcomes for both conditions among different surgical approaches.

Methods

A systematic review was performed comparing the impact of surgical interventions in the posterior compartment on prolapse and defecatory symptoms. MEDLINE, Embase, and ClinicalTrials.gov were searched from inception to 4 April 2018. Randomized controlled trials, prospective and retrospective comparative and single-group studies of women undergoing posterior vaginal compartment surgery for vaginal bulge or bowel symptoms were included. Studies had to include both anatomical and symptom outcomes both pre- and post-surgery.

Results

Forty-six eligible studies reported on six surgery types. Prolapse and defecatory symptoms improved with native-tissue transvaginal rectocele repair, transanal rectocele repair, and stapled transanal rectocele repair (STARR) surgeries. Although prolapse was improved with sacrocolpoperineopexy, defecatory symptoms worsened. STARR caused high rates of fecal urgency postoperatively, but this symptom typically resolved with time. Site-specific posterior repairs improved prolapse stage and symptoms of obstructed defecation. Compared with the transanal route, native-tissue transvaginal repair resulted in greater improvement in anatomical outcomes, improved obstructed defecation symptoms, and lower chances of rectal injury, but higher rates of dyspareunia.

Conclusions

Surgery in the posterior vaginal compartment typically has a high rate of success for anatomical outcomes, obstructed defecation, and bulge symptoms, although these may not persist over time. Based on this evidence, to improve anatomical and symptomatic outcomes, a native-tissue transvaginal rectocele repair should be preferentially performed.

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Funding

Funding provided by the Society of Gynecologic Surgeons (SGS) supports assistance by a methods expert in systematic reviews and other logistics.

Author information

Authors and Affiliations

  1. Department of Obstetrics and Gynecology, New York Medical College, Valhalla, NY, USA

    Cara L. Grimes

  2. Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA

    Megan O. Schimpf

  3. Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

    Cecilia K. Wieslander

  4. International Medical Response, Brooklyn, NY, USA

    Ambereen Sleemi

  5. Department of Obstetrics and Gynecology, Department of Urology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA

    Paula Doyle

  6. Department of Obstetrics and Gynecology, London Health Sciences Centre, London, Ontario, Canada

    You (Maria) Wu

  7. Department of Obstetrics and Gynecology, University of Florida College of Medicine—Jacksonville, Jacksonville, FL, USA

    Ruchira Singh

  8. Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, RI, USA

    Ethan M. Balk

  9. Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA

    David D. Rahn

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  1. Cara L. Grimes
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CG provides expert testimony for Johnson and Johnson. The other authors declare that they have no conflicts of interest.

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Registration with PROSPERO and full protocol can be found at: http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018093099

Appendices

Appendix 1: Search terms

(PubMed Search

((“Pelvic Organ Prolapse”[Mesh] OR “Cystocele”[Mesh] OR “Rectal Prolapse”[Mesh] OR “Uterine Prolapse”[Mesh]) OR “Visceral Prolapse”[Mesh]

OR

(prolapse OR fallen) AND (pelvic OR pelvis OR urogenital OR visceral OR viscera OR vagina OR vaginal OR bladder OR urinary OR uterine OR rectal OR rectum OR anus OR anal OR uterine OR uterus OR gynecologic* OR gynaecologic* OR cystocele OR cystocoele OR rectocele OR rectocoele OR proctocele OR proctocoele OR (posterior AND colporrhaphy) OR ((rectocele OR rectocoele) AND repair) OR sacrocolpopexy OR sacrocolpoperineopexy OR perineorrhaphy OR (levator AND plication) OR rectopexy OR (sigmoid AND resection)))

AND

(“Defecation”[Mesh] OR “Fecal Incontinence”[Mesh] OR “Constipation”[Mesh] OR Defecate OR defecation OR (fecal AND incontinence) OR Constipation OR dyschezia OR diarrhea OR obstruction OR obstructed OR splinting OR evacuation OR evacuate)

AND

((“Cohort Studies”[Mesh] OR cohort OR “Clinical Trial” [Publication Type] OR “Clinical Trials as Topic”[Mesh] OR (follow-up or followup) OR longitudinal OR “Placebos”[Mesh] OR placebo* OR “Research Design”[Mesh] OR “Evaluation Studies” [Publication Type] OR “Evaluation Studies as Topic”[Mesh] OR “Comparative Study” [Publication Type] OR ((comparative or Intervention) AND study) OR Intervention Stud* OR pretest* OR pre test* OR posttest* OR post test* OR prepost* OR pre post* OR “before and after” OR interrupted time* OR time serie* OR intervention* OR ((“quasi-experiment*” OR quasiexperiment* OR quasi or experimental) and (method or study or trial or design*)) OR “Case-Control Studies”[Mesh] OR (case and control)) OR (“Random Allocation”[Mesh] OR “Double-Blind Method”[Mesh] OR “Single-Blind Method”[Mesh] OR random* OR “Clinical Trial” [Publication Type] OR “Clinical Trials as Topic”[Mesh] OR “Placebos”[Mesh] OR placebo OR ((clinical OR controlled) and trial*) OR ((singl* or doubl* or trebl* or tripl*) and (blind* or mask*)) OR rct OR crossover OR cross-over OR cross over) OR (systematic[sb] OR meta-analysis[pt] OR meta-analysis as topic[mh] OR meta-analysis[mh] OR meta analy* OR metanaly* OR metaanaly* OR met analy* OR (systematic AND (review* OR overview*)) OR “Review Literature as Topic”[Mesh] OR cochrane[tiab] OR embase[tiab] OR (psychlit[tiab] or psyclit[tiab]) OR (psychinfo[tiab] or psycinfo[tiab])OR (cinahl[tiab] or cinhal[tiab]) OR science citation index[tiab] OR bids[tiab] OR cancerlit[tiab] OR reference list*[tiab] OR bibliograph*[tiab] OR hand-search*[tiab] OR relevant journals[tiab] OR manual search*[tiab] OR selection criteria[tiab] OR data extraction[tiab]) OR (“Epidemiologic Studies”[Mesh] OR “Case-Control Studies”[Mesh] OR “Cohort Studies”[Mesh] OR “Case control” OR cohort OR (observational and (study or studies)) OR Longitudinal OR Retrospective OR “Prospective Studies”[Mesh] OR “Longitudinal Studies”[Mesh] OR “Follow-Up Studies”[Mesh] OR ((follow-up or followup or “follow up”) and (study or studies))))

NOT

((“addresses”[pt] or “autobiography”[pt] or “bibliography”[pt] or “biography”[pt] or “case reports”[pt] or “comment”[pt] or “congresses”[pt] or “dictionary”[pt] or “directory”[pt] or “editorial”[pt] or “festschrift”[pt] or “government publications”[pt] or “historical article”[pt] or “interview”[pt] or “lectures”[pt] or “legal cases”[pt] or “legislation”[pt] or “letter”[pt] or “news”[pt] or “newspaper article”[pt] or “patient education handout”[pt] or “periodical index”[pt] or “comment on” or (“Animals”[Mesh] NOT “Humans”[Mesh]) OR rats[tw] or cow[tw] or cows[tw] or chicken*[tw] or horse[tw] or horses[tw] or mice[tw] or mouse[tw] or bovine[tw] or sheep or ovine or murinae))

Appendix 2: Summary of comparative studies

All comparisons are native-tissue posterior colporrhaphy versus comparative arm (Tables 3, 4, and 5).

Table 3 Traditional native-tissue posterior colporrhaphy versus biologic graft augmentation
Full size table
Table 4 Traditional native-tissue posterior colporrhaphy versus site-specific defect repair
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Table 5 Traditional native-tissue posterior colporrhaphy versus transanal approach
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Appendix 3: Summary of surgical approaches and impact on anatomical and symptom changes after surgery

Table 6 Laparoscopic sacrocolpoperineopexy
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Table 7 Graft augmentation
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Table 8 Site-specific defect repair
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Table 9 Traditional posterior colporrhaphy
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Table 10 Transanal repair
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Table 11 Stapled transanal rectal resection (STARR)
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Grimes, C.L., Schimpf, M.O., Wieslander, C.K. et al. Surgical interventions for posterior compartment prolapse and obstructed defecation symptoms: a systematic review with clinical practice recommendations. Int Urogynecol J 30, 1433–1454 (2019). https://doi.org/10.1007/s00192-019-04001-z

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