Pelvic organ prolapse (POP) is defined as the herniation of the uterus, bladder, rectum, and/or bowel through the vaginal orifice. The posterior vaginal wall prolapse refers to a rectal herniated into the vagina (rectocele) and bowel protrusion from the posterior fornix (enterocele). The incident rate of rectocele or enterocele is unclear. Patients with rectocele or enterocele may be symptomatic with constipation, fecal incontinence, and obstructed defecation syndrome.
  
The posterior vaginal wall compartment repair is frequently operated with another vaginal compartment prolapse repair. A systematic review suggested that transvaginal repair may be more effective than trans-anal repair for posterior wall prolapse in preventing the recurrence of prolapse. Evidence does not support the utilization of any mesh or graft materials at the time of posterior vaginal repair. In literature, various surgical treatments such as site-specific fascia repair, mid-line fascia plication, and levator ani muscle plication for the rectocele or enterocele have been described. The anatomical success rate of the above methods was around 70~90%, which was not very satisfactory, especially in advanced posterior wall prolapse. 

Since the second-half year of 2019, our group developed a new surgical technique with a rotational vaginal flap to achieve better anatomical and functional correction of posterior vaginal compartment prolapse.

We reviewed charts of all patients who underwent pelvic reconstruction of symptomatic pelvic organ prolapse in our institution between January 2018 and December 2022, and included patients who had  stage 2 posterior vaginal wall prolapse (rectocele or enterocele) with at least 24 months of follow-up.

There were two different surgical methods in posterior vaginal wall repair : posterior colporrhaphy(group A) and posterior reconstruction with vaginal flap reconstruction (group B). The vaginal flap reconstruction in posterior compartment contained three entities from the muscle and fascia component of levator ani muscle and perineal body. We named these fascia flaps by tissue origin or targeted tissue site. We called fascia of levator ani muscle by trans-coccygeal flaps(pubo-coccygeal flap and ilio-coccygeal flap), which was named by the tissue origin. While we call fascia from the perineal body the uterosacral flap(so-called USL flap), which means this rotational vaginal flap would finally target the position of the uterosacral ligament.

A total of 117 patients who underwent posterior reconstruction were included in this study. There were 2 groups according to different methods of posterior vaginal wall repair : Group A(traditional posterior colporrhaphy, 54 cases) and Group B (posterior reconstruction with rotational flaps, 63 cases). The median follow-up duration of each group was 43.39(25-64) and 30.11(24-43) months. Total recurrence rate in group A and B is 20.37% versus 6.35% (p=0.0258). Specific recurrence rate in group A and B is 16.67% versus 3.17% (p=0.0225). 
  In bowel function assessment, we used questionnaires before operation and post-operative 2 months to assess the constipation or incontinence condition. Improvement of constipation in each group is 50.00% versus 66.67%(p=.6656) and improvement of fecal incontinence in each group is 85.71% versus 66.67% (p=.6027). Both traditional posterior colporrhaphy and vaginal flap reconstruction can make bowel function improved.

Vaginal flap reconstruction in posterior vaginal wall prolapse is associated with higher anatomic successful rates than standard posterior colporrhaphy. Both vaginal flap reconstruction and standard posterior colporrhaphy make bowel function improve.

Mowat A, Maher D, Baessler K, Christmann-Schmid C, Haya N, Maher C. Surgery for women with posterior compartment prolapse. Cochrane Database of Systematic Reviews 2018, Issue 3. Art. No.: CD012975. DOI: 10.1002/14651858.CD012975
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