Defining Defect Specific Posterior Repair: A Case Series

Objectives: There is currently no standard technique for the vaginal approach to repair of posterior compartment prolapse. While prior research has demonstrated site-specific vaginal repairs are equivalent to midline plication, described procedures do not restore anatomical suspension of the rectovaginal septum to the apex and pelvic sidewall. This study evaluates the outcomes of a defect-specific posterior vaginal repair.

Methods: This IRB-approved retrospective case series evaluated women undergoing surgical management of symptomatic posterior vaginal prolapse at a single tertiary academic hospital between January 2018 to April 2022 by three Urogynecologic surgeons. This surgical approach involves dissecting the vaginal epithelium from the rectovaginal fascia, assessing for visible defects, and anatomically reattaching the endopelvic tissue to the apex or ATFP as indicated. If no discrete defect is identified, the rectovaginal septum may be reinforced with plication and suspended apically, restoring the posterior suspensory axis. Patients were identified within the electronic medical record (EMR); operative reports were reviewed to verify procedural technique. Postoperative notes were reviewed to assess for duration of follow up and recurrence, including outside recurrences via the EMR health information exchange. Cases utilizing graft material or with a midline plication without documented identification and restoration of rectovaginal connective tissue defects were excluded. The primary outcome was repeat intervention for prolapse within twelve months. Secondary outcomes included any documented repeat intervention, patient reported recurrence of symptoms confirmed on office exam, time to repeat intervention, and duration of follow up. R Studio was used to calculate statistics and survival curves.

Results: Case characteristics and outcomes are depicted in Table 1. One hundred eighty-four cases met inclusion criteria. Eight (4.3%) recurrences required intervention within 12 months of surgery: six repeat surgeries and two pessary placements. Patients with recurrence were more likely to have concurrent hysterectomy (p=0.02), apical suspension via uterosacral ligament suspension (p< 0.001), and lower apical prolapse stage (p< 0.001). Fewer recurrences were seen with surgeon B (p=0.024). Fifteen (8.1%) repeat interventions were noted over the full study time frame, including 3 identified through the health information exchange. Recurrences occurred a median of 338 days following surgery. An additional 18 (9.8%) patients presented with symptoms of recurrence and were confirmed to have a Stage 2 or greater posterior vaginal prolapse on exam but did not pursue further treatment. Median duration of follow up for all patients was 286 (IQR 89 - 730) days following surgery. Recurrence free survival is shown in Graph 1.

Conclusions: Defect specific posterior vaginal repair is effective and durable. Further studies are warranted to directly and prospectively compare the efficacy of this approach with traditional midline plication techniques.