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Posterior Repair Quantification (pr-Q) Using Key Anatomical Indicators (kai) – Preliminary Report

Bernard T. Haylen, Dianne Avery, Tin Lok Chiu, Warwick Birrell

International Urogynecol J, 25(12):1665-1772; Neurourol Urodyn 33(6):900-901. Dual Publication

Abstract:
Introduction: Posterior (PR) vaginal compartment repairs have traditionally involved a subjective approach. We aim to quantify (PR-Q) such repairs using key anatomical indicators (KAI).

Materials and Methods:
At 50 consecutive PRs:

• Perineal gap (PG);
• Posterior vaginal vault descent (PVVD);
• Mid-vaginal laxity (MVL – vault undisplaced/displaced);
• Recto-vaginal fascial Laxity (RVFL) were measured. The total posterior vaginal length (TPVL) and from POP-Q, TVL, GH, Ap, Bp C, D were also measured. Surgical details deemed appropriate to each repair were recorded.

Results:
A mean preoperative PG of 2.5cm was reduced to 0.0cm postoperatively by excision (100% cases) with an average 21.6% increase in total vaginal length over that if the repair was commenced at the hymen. There was an average 25.0% reduction in the genital hiatus (GH).

Mean PVVD was (i) 5.3cm overall; (ii) 6.4cm for 31/50 (62%) undergoing sacrospinous colpopexy; (iii) 3.5cm for 19/50 (38%) with no ligamentous vault fixation. An approximate “cutoff” for PVVD of 5cm might assist differentiating cases where vault fixation may be desirable.

Up to 52% (1.4/2.7cm) of preoperative MVL displaced was due to vaginal vault descent. The MVL undisplaced (mean 1.3cm) may better guide vaginal mucosal trimming.

RVFL averaged just 0.8cmm with 22/50 (44%), RVFL generally 0.5cm or less, not requiring any RVF plicatory sutures.

Conclusions: It is possible to use KAI to assist the planning and execution of posterior vaginal compartment surgery. The PG, PVVD, MVL and RVFL can indicate surgical measures in the perineum, vaginal vault, vaginal skin and recto-vaginal space respectively.

Introduction:
It has been suggested that posterior pelvic floor problems have historically been neglected in urogynecology^1. The inaccuracy of clinical examination emphasizes the need to develop new clinical and/or imaging methods to evaluate posterior vaginal wall defects^{2, 3}. At present the clinical findings must be considered a poor representation of surgical findings².  As one of the two most common surgeries in gynecology and urogynecology^{4, 5}, the posterior colporrhaphy has received relatively little analysis of how to optimize surgical technique. The traditional posterior colpoperineorrhaphy has been questioned as ineffective at relieving symptoms and for the potential to cause new symptoms⁶. Success rates for posterior repairs have been described as modest^{7, 8, 9}.  The rates for recurrent rectocoele / posterior vaginal vault prolapse after posterior colporrhaphy are not inconsequential^{8, 9, 10}. Such criticisms, we acknowledge, might seem a biased analysis of the literature, failing to recognize reports of successful posterior repair series, though it does indicate sufficient concern to warrant further analysis of the posterior vaginal compartment repair.

Surgery in the posterior vaginal compartment generally is the last part of multi-compartment vaginal pelvic organ prolapse (POP) surgery. Very often, it is preceded by an anterior colporrhaphy and possibly a vaginal hysterectomy. Perhaps because of the sequence of surgeries, there is the danger for time-factor or other reasons that less attention might be given to optimizing or even performing a “posterior repair (PR)”. There may at times be the attitude or observation “the back wall doesn’t look too bad” without a more careful inspection, let alone measurement, of the different potential defects. Numerous native tissue repairs have been suggested for the posterior compartment¹¹. These are often general surgical repair techniques with no reference to any particular case-at-hand. Loss of any or all of Level I (vaginal vault), Level II (mid-vaginal) and Level III (perineal) support can lead to posterior vaginal compartment prolapse¹². The posterior repair needs to assess and address defects in each of these areas.

We wish to nominate four key anatomical indicators (KAI) as a starting point for both planning individual surgeries and deciding which surgical component techniques might be appropriate or even necessary to achieve a sound anatomical and functional result. There has been, at times, a debate between two-layer (pre-rectal fascia and vaginal mucosa) and three-layer (the addition of sutures plicating the levator fascia) posterior vaginal repairs. A recent review¹¹ concluded that midline fascial plication without levatorplasty was the procedure of choice for posterior compartment prolapse with no evidence to support the use of prostheses and grafts in this compartment. It might be the situation that such an approach overtreats some areas of the posterior compartment and ignores other areas.

Selecting the KAI individually is the challenge which must precede collating them into a schema. The POP-Q^{13, 14} has four main reference points for the posterior vaginal wall, Ap, Bp and Point C (representing the cervix, or vaginal vault if cervix is absent) and point D (posterior fornix if cervix is present) whilst the total vaginal length (TVL) and the genital hiatus (GH) might also be relevant. These are all referenced to the hymenal ring. There is, however, additional posterior compartment distal to hymenal ring at the top of the perineum which is not taken into account by the above POP-Q^{13, 14} measurements. It is this area that is most often the subject of defects following childbirth and/or episiotomy and/or previous posterior vaginal surgeries. It is also the area where there is no clear description as to where to begin the posterior compartment repair.

The following four anatomical indicators are nominated for consideration for terming them “key”. Some of these can only really be assessed accurately and all are best measured at the time of surgery for posterior vaginal prolapse. More often than not, there will be an anterior colporrhaphy and/or vaginal hysterectomy immediately preceeding this assessment. We call these four indicators:

• The perineal “gap” (PG);
• Posterior vaginal vault descent (PVVD);
• Mid-vaginal laxity (MVL-vault undisplaced);
• Recto-vaginal fascial laxity (RVFL). Each will be described in the methodology and medically illustrated. A surgical marker pen and surgical ruler is required for each (pre- and post) operative examination.

Patients and Methods
A consecutive series of 50 female patients were involved in the study. Each was assessed intraoperatively (pre- and immediately post) for consideration of a repair of any section (Levels I-III¹²) of the posterior vaginal compartment from posterior vaginal vault to perineum. Each had undergone at least an anterior colporrhaphy immediately prior to this intraoperative assessment with some having undergone an additional vaginal hysterectomy. Each was examined for the presence and size of the proposed key anatomical indicators (KAI). Each measurement was checked and verified by an observer/surgical assistant. Bladder was re-emptied prior to this examination to prevent any limitation of the extent of prolapse aspects by the presence of a full bladder¹⁵.

4: Recto-vaginal fascial laxity (RVFL):
Whilst there is some debate over the nature (existence) of this fascia overlying the rectum and beneath the vaginal mucosa¹¹, this potential defect was nonetheless assessed once posterior vaginal surgery was commenced. The perineal gap (if present) had been excised and a midline incision had been made in the posterior vaginal wall from excised perineal gap up to the Moynihan (or vulsellum). Artery forceps support both sides of the posterior vaginal wall incision. The forcep at the apex of the posterior vaginal wall incision was again held under slight tension towards the vaginal vault. As with the MVL, the surgeon/ surgical assessor placed anterior traction using Gillies forceps (perpendicular to the recto-vaginal fascia) on the best estimate of the midline of the midpoint of the recto-vaginal fascia supero-inferiorly. The recto-vaginal laxity was the length (cm to one decimal point) of the any displaced recto-vaginal fascia (midline) over the lateral fascia.

KAI 4: Recto-vaginal fascial laxity: Laxity of the mid-vaginal fascia.

Notes were made of the actual different surgical components:

• Excision of perineal gap;
• Excision of mid-vaginal (mucosal) laxity (A: 0cm; B: 1-5mm; C: 6-10mm; D: over 10mm on either side);
• Number of recto-vaginal fascial (RVF) sutures employed;
• Posterior vaginal vault support to the right sacrospinous ligament (sacrospinous colpopexy) using a Capio Slim device (Boston Scientific, Boston, U.S.A) and minimalized dissection right posterior fornix submucosally.

Additional notes were made of the findings immediately post-PR in terms of the

• PG;
• PVVD;
• MVL (undisplaced/displaced);
• TPVL. Pre- and immediately post-PR measurements were made of POP-Q^{13, 14} measurements;
  • GH (genital hiatus);
  • TVL (total vaginal length);
  • Point C;
  • Point D;
  • Ap;
  • Bp.

It can be assumed repairs to reconstitute the posterior vagina mucosa were performed on all patients down to the surgical marks for the PG using a 1 Vicyl suture. For the perineum (including 1 or 2 deeper sutures), 2/0 vicryl rapide was used. Rectovaginal fascial plication (0 vicryl) was performed in the percentage of cases indicated. Dissection in the recto-vaginal space was minimalized or nil; in no case was levator or levator fascial plication used.

Institutional ethical approval was received for the study. All patients were subject to informed consent as part of this audit of surgical practice. Methods, definitions and units conform to standards jointly recommended by the International Continence Society and the International Urogynecological Society, except where specifically noted¹⁴. 

Results
Table 1 shows the demographic of the group of 50 patients including prior and intercurrent surgeries (apart from the intercurrent PR).

Table 2 shows the mean pre- and post-operative (cm to one decimal point) KAI:

• PG,
• PVVD;
• MVL – vault undisplaced and displaced);
• RVFL as well as the TPVL and the POP-Q measurements^{13, 14} of
• GH,
• TVL,
• Point C,
• Point D;
• Ap
• Bp.

Table 3 shows the surgeries performed. Average number of rectovaginal sutures inserted overall (50 women) was 2.2 or 3.8 for each of the 28 (56%) women receiving recto-vaginal fascial plication. Twenty-two (44%) women had no such suturing.  The width of vaginal skin excised on each side as part of the repair was approximately:

• Omm (8%);
• 1-5mm (72%);
• 5-10mm (20%);
• Over 10mm (0%).

Discussion
This study suggests a possible role for the PG, PVVD, MVL (undisplaced), RVFL as “key (anatomical/surgical) indicators (KAI)” to quantify specific defects in at different levels of posterior vaginal compartment surgery (PR), namely the perineum, posterior vaginal vault, vaginal mucosa and rectovaginal space respectively. From these indicators, specific surgical actions might be considered:

• PG – consider excision;
• PVVD – consider SSC vault fixation if say the PVVD is over 5cm;
• MVL (undisplaced) – consider limiting vaginal mucosal trimming to under half this measurement bilaterally;
• RVFL – consider no dissection and no suturing if under 5mm. The TPVL (TVL to a lesser degree) was of some value in indicating the very little overall (1.4-2.2%) impact of the surgery on the posterior vaginal length. The TPVL is also needed to calculate the PVVD. Similarly the GH measurements confirmed anteriorized support to the perineum though no specific surgical points or actions. We saw no role as a surgical indicator for the POP-Q^{13, 14} measurements: Ap, Bp or Points C and D.  We acknowledge others may find these measurements useful intraoperatively..

The results challenge the traditional concept of a “rectocoele” as a Level II defect¹² of rectovaginal fascia (septum)^{11, 16, 17, 18}and accompanying vaginal mucosal laxity. Mean MVL (indisplaced) was only 1.3cm and mean RVFL was only 0.8cm. The results suggest that the “bigger” issues in the posterior vaginal compartment are at the perineum (Level III¹² – mean PG of 2.5cm) and vaginal vault (Level I¹² – mean PVVD of 5.3cm). The implication of this is that in the traditional posterior repair, the mid-vagina may have perhaps received to date more intervention than required with the vaginal vault and perineum perhaps receiving less surgical attention than needed. MRI evidence⁷ also supports the view that there is overall weakening and generalized deformation of pelvic floor tissues rather specific fascial defects, pointing to this as a reason for the relatively modest success rates of posterior vaginal repairs^{8, 9}.

In commenting specifically on the proposed key surgical indicators we firstly discuss KAI 1: Perineal Gap (PG). The results indicate that in women undergoing surgery for posterior vaginal wall prolapse, a thinned out area of the anterior perineum, PG can be detected, measured and considered for excision in all patients, with the thicker lateral tissue to be brought into the midline for restoration of a thicker anterior perineum. This was a mean 2.5cm wide preoperatively reducing to 0.0cm postoperatively.  The results show vaginal length up to 21.6% longer than if the repair was started at the hymen with a 25.0% reduction in the GH. The GH has been noted to have a strong correlation with prolapse severity¹⁹. This restoration of the thickness of this area, the decreased GH and the accompanying anteriorization of the axis of the posterior vagina may be beneficial in terms of support for accompanying anterior colporrhaphies, with the latter seeming much higher in the vagina and less visible or invisible at the introitus post-PR. The new introitus is soft with no sign of a flap or other impediment to an anticipated return to comfortable sexual function. Further studies will be needed to confirm this. We have noted the restoration of a “ring” of labia minora around the entire vaginal introitus as a result of excision of the perineal gap.

KAI 2: Posterior vaginal vault descent (PVVD): With the mean PVVD of 5.3cm overall and 6.4cm for 31/50 (62%) undergoing vault fixation using a sacrospinous colpopexy (SSC), the results indicate a significant posterior vaginal vault laxity (Level I defect¹²⁾ in the majority of the women undergoing the PR. It is understandable that in the cases of those who did not have a concomitant hysterectomy that most would be cases of recurrent POP, 87% requiring SSC due to vault defects. In may initially be more surprising that 12/27 (44%) of those having a concomitant vaginal hysterectomy would require a SSC. We have previously suggested²⁰ that the vaginal vault should be considered as an “area” rather than an “apex”, the former with anterior, posterior and lateral aspects. The majority of support from those uterine supportive ligaments, the uterosacral (USL) and cardinal, has been shown to be directed towards the anterior vaginal vault and wall with very little influence on the posterior vaginal vault and wall^{20, 21, 22}. Even though the first pedicle of the vaginal hysterectomy, the cardinal-uterosacral confluence (CUSC)²¹would have been routinely attached and tied to the lateral vaginal vault bilaterally to provide post-hysterectomy support, additional posterior vaginal vault support was required, here by SSC, in 44% cases. A McCall culdoplasty procedure has also been used in this circumstance²³ seemingly with satisfactory longer term results²⁴.

There was a mean PVVD of 3.5cm for 19/50 (38%) with no ligamentous vault fixation. In these patients, one arm of the closing suture for the posterior vaginal mucosa was however left long so that it could be laid submucosally extending from apex to perineum. The mucosa was closed over that arm, thus giving the apex some looser non-ligamentous support. We acknowledge surgeons will have alternate non-SSC vault fixation techniques.

What level of PVVD indicates than posterior vaginal vault fixation, e.g. by an SSC is desirable. We would suggest an approximate “cutoff” of 5cm. Above 5cm PVVD, an SSC is more anatomically and surgically desirable; below that figure, the posterior vaginal vault support is less in question and it is much harder for the vaginal vault to reach the sacrospinous ligament. The 62% rate for SSC in our study suggests more vault fixation may be required generally. In a study by Kenton et al²⁵, 71% cases involved anterior colporrhaphy and 45% posterior colporrhaphy, yet only 4% had vault suspensions (3% SSC and 1% sacrocolpopexy).

KAPD 3: Mid- Vaginal Laxity (MVL): In the anterior compartment, much of the mid-vaginal (Level II¹²⁾ laxity (cystocele) has been shown to be due to vaginal vault descent²⁶. We have shown, to our knowledge for the first time quantitatively by intraoperative measurement, that the majority (52%) of mid-vaginal mucosal laxity posteriorly is due to vaginal vault descent. This was demonstrated by the difference in measurements of MVL if the vault was reduced (MVL- non-displaced) versus the equivalent measure if the vault was under traction (MVL-displaced). There is the danger, if this is not recognized, with effective vaginal vault support, as necessary, of over-excising the posterior vaginal wall which might cause dyspareunia¹⁸ due to restricted dimensions. Lowder et al³ had shown a 30% correction of posterior vaginal prolapse defects by simulated clinical restoration of the vaginal vault support using a speculum.

With the mean MVL (non-displaced) of 1.3cm and the majority (72%) vaginal mucosal trimming in the 1-5mm group, the results suggest that trimming was “conservative” and limited to under half the MVL (non-displaced) on each side. With the postoperative MVL (non-displaced and displaced) both around 0.3cm, it is possible that the “under half MVL (non-displaced)” guideline for mucosal trimming can be improved upon.

KAI 4: Recto-vaginal fascial laxity (RVFL): The mean “fascial” defect with the posterior vaginal wall opened was only 0.8cm. Traditionally, as already noted, posterior vaginal defects including rectocoeles have been thought to involve primarily rectovaginal facial defects^{11, 16, 17, 18}. Such defects appeared far less than expected with 22/50 (44%) not deemed to have sufficient RVFL to warrant a repair. This results in mid-vaginal component of the PR being one-layer (mucosa-only). In the other 28, the average number of sutures was 3.8.  It creates a much less invasive posterior repair if the entire recto-vaginal space is not opened by dissection only then to be followed by an attempt at restoration. Whilst this is an observational study of immediate preoperative and postoperative anatomy and not one of longer term surgical and functional outcomes, it does raise the possibility that standardized two or three layer repairs¹¹ may be an “overtreatment” for the existing Level II¹² defects.

This section of the study would have been significantly compromised unless a minimally invasive sacrospinous colpopexy (SSC) technique was available which, in the great majority of cases did not unduly disturb the recto-vaginal space. The use of the Capio Slim^© suture applicator (Boston Scientific, Boston. U.S.A) allowed the insertion of an O Ethibond via a relatively small tunnel in the right fornix submucosally down to the right sacrospinous ligament. We plan to report on and illustrate this technique separately.

We believe one of the strengths of this study is to focus attention of surgical techniques for posterior vaginal prolapse appropriate to the measurements/defects present, rather than employing a “one-size-fits-all” standardized repair. The latter, by not being individualized to the patient’s anatomy, might leave some defects unresolved. It also has the potential to create new defects⁶. The weakness of the study is that it does not, at this stage, include longer term anatomical and functional outcomes. We will, in subsequent studies, be addressing these weaknesses. Other validation studies are also planned.  In this study we have used the PG as the introital reference point, rather than the hymenal ring, for the different measurements and as the starting point for the PR. It remains to be noted over time, whether this will prove beneficial functionally as well as anatomically, though we have no reason, at this stage, for suggesting otherwise.

The emphasis in publications on the cure of recto-vaginal defects as prime to posterior compartment surgeries was not supported by our study. The prime defect areas seemed to be perineal (100%) and vaginal vault (63%) with recto-vaginal fascial defects found in 56%. These did not appear to require a full recto-vaginal space dissection and the required suturing was generally not extensive. Limited defect-directed rectocoele repairs have been shown to have better functional^27-30, though not necessarily anatomical¹¹, results. In our view, the functional result might well be due to the more limited dissection. Follow-up surgical studies will be required to determine whether our more minimalist approach to the recto-vaginal space based on the limited defects encountered and thus less apparent risk of adverse functional outcomes (based on the defect-directed rectocele repair data^27-30) will be as anatomically successful. It will have the advantage that the more numerous Level 1¹² and level III¹² defects will have been addressed as required.

The importance of posterior vaginal compartment surgery may have been underestimated over time¹. Three Levels of defects are applicable to the majority of PRs compared with perhaps only one Level (II) defect anteriorly, provided the vault component of any anterior defect is resolved by the posterior vault repair (e.g. SSC).. Not only do the component surgeries identified in this study address the defects of the posterior vagina and posterior vaginal vault, they may have an impact, if performed effectively, in providing ongoing support for the anterior vaginal wall and assisting in preventing recurrences. We encourage pelvic floor surgeons to consider the KAI we have outlined or at least to recognize the need to compartmentalize the different defects and PR surgical components. We have been encouraged by the reproducibility of the immediate postoperative anatomical results, in particular the reductions in PG, MVL and PVVD and GH as well as the maintenance of TPVL (TVL).

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