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Background Below the anterior peritoneal reflection, the anterior rectal wall and mesorectum are separated from the posterior vaginal wall by a virtual rectovaginal space. In this space, the description of a specific and independent rectovaginal septum as a female counterpart of Denonvilliers fascia has been the subject of debate over the years. Objective The aim of this study is to perform an accurate anatomical study of the rectovaginal area in a cadaveric simulation model of total mesorectal excision to evaluate the possible structures and the dissection planes contained within the rectovaginal space. Design and setting This is a cadaveric study performed at the University of Valencia. Patients The pelvises of 25 formalin-preserved female cadavers were dissected. All the included specimens were sectioned in a midsagittal plane, at the level of the middle axis of the anal canal. Main outcome measures Careful and detailed dissection was performed to visualize the anatomical structures and potential dissection planes during anterior mesorectal dissection in cadavers. Histological sections were made of the posterior vaginal wall. Results The rectovaginal space contains loose areolar tissue that allows an easy dissection plane distally. A distinct and independent rectovaginal fascia or septum is not present. The existence of 3 layers fused together in the posterior vaginal wall can be identified more or less precisely because of their different coloration. The histological study confirms this macroscopic arrangement of the posterior vaginal wall in 3 layers: the mucosa, the muscular, and the adventitia. An independent rectovaginal septum can be generated only with a splitting of the adventitia. Limitations The cadaveric pelvic specimens of the oldest donors might have had age-related degeneration. Conclusions The present anatomical study has shown only a plane of loose areolar tissue between the rectal and vaginal wall. We can conclude that there is no independent fascia or septum in the rectovaginal space. See Video Abstract at http://links.lww.com/DCR/B456. ANATOMIA QUIRURGICA DEL ESPACIO RECTOVAGINAL: ?EXISTE UN TABIQUE RECTOVAGINAL INDEPENDIENTE O UNA FASCIA DE DENONVILLIERS EN LAS MUJERES: Debajo del reflejo peritoneal anterior, la pared rectal anterior y el mesorrecto estan separados de la pared vaginal posterior por un espacio rectovaginal virtual. En este espacio, la descripcion de un tabique rectovaginal independiente especifico como contraparte femenina de la fascia de Denonvilliers ha sido objeto de debate a lo largo de los anos.Realizar un estudio anatomico preciso del area rectovaginal en un modelo de simulacion cadaverica de escision mesorrectal total, con el fin de evaluar las posibles estructuras y los planos de diseccion contenidos en el espacio rectovaginal.estudio cadaverico realizado en la Universidad de Valencia.Se disecaron las pelvis de 25 cadaveres femeninos conservados en formalina. Todas las muestras incluidas fueron seccionadas en un plano medio sagital, a la altura del eje medio del canal anal.Se llevo a cabo una diseccion cuidadosa y detallada para visualizar las estructuras anatomicas y los posibles planos de diseccion durante la diseccion mesorrectal anterior en cadaveres. Se realizaron cortes histologicos de la pared vaginal posterior.El espacio rectovaginal contiene tejido areolar laxo que permite un plano de diseccion facil distalmente. No hay fascia o tabique rectovaginal distinto e independiente. La existencia de tres capas fusionadas en la pared vaginal posterior puede identificarse con mayor o menor precision debido a su diferente coloracion. El estudio histologico confirma esta disposicion macroscopica de la pared vaginal posterior en tres capas: la mucosa, la muscular y la adventicia. Un tabique rectovaginal independiente solo se puede generar con una division de la adventicia.Las muestras pelvicas de cadaveres de los donantes mas antiguos pueden haber tenido degeneracion relacionada con la edad.El estudio anatomico actual solo ha mostrado un plano de tejido areolar laxo entre la pared rectal y vaginal. Podemos concluir que no hay fascia o tabique independiente en el espacio rectovaginal. Consulte Video Resumen en http://links.lww.com/DCR/B456. (Traduccion-Dr. Adrian Ortega).

There are several techniques for repairing prolapse in the posterior vaginal compartment, yet there is no general agreement on the best surgical procedure. This study was performed to investigate the outcomes of the common vaginal route technique for posterior vaginal wall prolapse repair in the first Iranian fellowship teaching center for female pelvic floor disorders. This prospective cohort study was performed on women with posterior vaginal wall prolapse with or without prolapse of other vaginal compartments who underwent surgery between 2014 and 2018 in a referral center for female pelvic floor disorders. A follow-up period of 12 months was considered. Patients subjected to the transvaginal technique by attachment of the rectovaginal fascia to the pericervical ring using vaginal native tissue were included. Among the 107 patients, the Pelvic Floor Distress Inventory-20 (PFDI-20) scores were 141.87 ± 34.48 and 100.87 ± 26.48 before and after surgery, respectively, showing the significant improvement of patient’s symptoms after surgery in the 12-month follow-up. Comparing Pelvic Organ Prolapse Quantification (POP-Q) results before and after surgery, a significant improvement in patients’ conditions was seen at the 12-month follow-up. Based on the results of the present study, the surgical procedure of the rectovaginal fascia attachment to the pericervical ring in posterior vaginal wall prolapse repair seems an effective surgical intervention without significant morbidity in the short-term follow-up.

Background Anatomic terminology in both written and verbal forms has been shown to be inaccurate and imprecise. Objective Here, we aimed to (1) review published anatomic terminology as it relates to the posterior female pelvis, posterior vagina, and vulva; (2) compare these terms to “Terminologia Anatomica,” the internationally standardized terminology; and (3) compile standardized anatomic terms for improved communication and understanding. Study Design From inception of the study to April 6, 2018, MEDLINE database was used to search for 40 terms relevant to the posterior female pelvis and vulvar anatomy. Furthermore, 11 investigators reviewed identified abstracts and selected those reporting on posterior female pelvic and vulvar anatomy for full-text review. In addition, 11 textbook chapters were included in the study. Definitions of all pertinent anatomic terms were extracted for review. Results Overall, 486 anatomic terms were identified describing the vulva and posterior female pelvic anatomy, including the posterior vagina. “Terminologia Anatomica” has previously accepted 186 of these terms. Based on this literature review, we proposed the adoption of 11 new standardized anatomic terms, including 6 regional terms (anal sphincter complex, anorectum, genital-crural fold, interlabial sulcus, posterior vaginal compartment, and sacrospinous-coccygeus complex), 4 structural terms (greater vestibular duct, anal cushions, nerve to the levator ani, and labial fat pad), and 1 anatomic space (deep postanal space). In addition, the currently accepted term rectovaginal fascia or septum was identified as controversial and requires further research and definition before continued acceptance or rejection in medical communication. Conclusion This study highlighted the variability in the anatomic nomenclature used in describing the posterior female pelvis and vulva. Therefore, we recommended the use of standardized terminology to improve communication and education across medical and anatomic disciplines.

Study Objective This study aimed to describe a novel access route to the sacrospinous ligament and the coccygeal muscle. The overarching goal was to show our team's standard systematization to this technique and state it's safety in low parametric injuries. Design Video description of the novel technique with clear illustrations of each step. Setting N/A. Patients or Participants The surgery was performed in a 27-year-old woman who suffered from deep endometriosis in the pelvic floor. Her diagnosis was performed through physical examination, with innervation compression symptoms, ultrasound and MRI imaging techniques. Interventions After the identification and release of the central structures, we proceed to the lateral approach with the isolation of the internal iliac artery, which should be medially tractioned, enabling the identification of the bifurcation of the common iliac vein into the internal and external iliac vein. We then start the systematization of the approach with the dissection of the avascular space between the "V" shape formed by the umbilical artery and uterine artery, subsequently heading towards the sacrum. Next, we identify the rectovaginal fascia, being the first structure to be identified, extending from the rectovaginal space to the tendon arch. Behind this structure, we can find the coccygeal muscle and the sacrospinous ligament extending from the sciatic spine towards the sacrococcyx. Measurements and Main Results We conclude the systematization of the pelvic floor approach being able to safely perform the resection of the endometriotic nodules with intact innervation, tension-free muscles and greater damage control. Conclusion In summary this novel approach to the pelvic floor is thought to be a simpler and less risky alternative to treat low parametric injuries afflicting the sacrospinous ligament and the coccygeal muscle.

The ventral part of the rectovaginal septum is formed by a connective tissue layer fixed to the vagina. The dorsal part is the connective tissue of the rectum. The roof is the peritoneum and the rectouterine peritoneal pouch (cul-de-sac of Douglas). The caudal margin is the perineal body. The perineal body (or central tendon of perineum), pyramidal fibromuscular mass, is in the middle line of the perineum at the junction between the urogenital triangle and the anal triangle. At the level of the perineal body, rectovaginal fascia, puborectal muscles, transverse perineal muscles and external anal sphincter are joined. It is a very strong structure. The perineal body is fundamental to the integrity of the pelvic floor. Its rupture during vaginal birth leads to widening of the gap between the anterior free borders of levator ani muscle of both sides, thus predisposing the woman to prolapse of the uterus, rectum or even urinary bladder.

The female pelvis is a complex anatomical region comprising the pelvic organs, muscles, neurovascular supplies, and fasciae. The anatomy of the pelvic floor and its fascial components are currently poorly described and misunderstood. This systematic search and review aimed to explore and summarize the current state of knowledge on the fascial anatomy of the pelvic floor in women. Methods: A systematic search was performed using Medline and Scopus databases. A synthesis of the findings with a critical appraisal was subsequently carried out. The risk of bias was assessed with the Anatomical Quality Assurance Tool. Results: A total of 39 articles, involving 1192 women, were included in the review. Although the perineal membrane, tendinous arch of pelvic fascia, pubourethral ligaments, rectovaginal fascia, and perineal body were the most frequently described structures, uncertainties were identified in micro- and macro-anatomy. The risk of bias was scored as low in 16 studies (41%), unclear in 3 studies (8%), and high in 20 studies (51%). Conclusions: This review provides the best available evidence on the female anatomy of the pelvic floor fasciae. Future studies should be conducted to clarify the discrepancies highlighted and accurately describe the pelvic floor fasciae.

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.

To examine the gross and histologic anatomy of the proximal, mid, and distal posterior vaginal compartment and discuss implications for surgical repair.In this cadaver study, pelvic organs were resected en bloc, immersed in formalin solution, and transected in the mid sagittal plane. Measured distances included: posterior vaginal wall length, cervicovaginal junction or vaginal cuff to posterior peritoneal reflection, peritoneal reflection to proximal edge (apex) of perineal body, and perineal body apex to hymenal remnant (height). The posterior vaginal wall was divided into 3 segments along the midsagittal plane and submitted in whole tissue blocks for staining. Histologic analysis included that of 2 young nulliparous women whose tissue was harvested within 12 hours of death.Eleven cadavers were examined. Median (interquartile range [IQR]) posterior vaginal length was 7.6 (2.2) cm. The peritoneum attached to the posterior vaginal wall a median (IQR) of 1.3 cm (0.5 cm) distal to the cervicovaginal junction (n = 8). The rectovaginal space, spanning from the peritoneal reflection to perineal body apex, had a median (IQR) length of 4.7 cm (2.1 cm). Microscopic examination of the mid segment revealed a layer of loose fibroadipose tissue between the vaginal/rectal walls, with no distinct dense fibroconnective tissue layer. The median (IQR) perineal body height was 2.3 cm (1.2 cm). No discrete fibrous capsule was seen surrounding the external anal sphincter muscle.These findings support evidence showing absence of a rectovaginal fascia. The anal sphincter lacks a fibrous capsule, which is important during closure of third-/fourth-degree obstetric lacerations.

Traditionally, it has been believed that posterior vaginal compartment prolapse was largely due to defects in the rectovaginal fascia, with surgical repairs concentrating on addressing this defect. We aimed to determine the relative size of defects at the different vaginal levels (I–III) following a large number of posterior vaginal compartment repairs (PRs) to determine whether this traditional viewpoint is still appropriate. In a cross-sectional study of 300 consecutive PRs, mostly following prior or concomitant hysterectomy, two sets of markers of posterior compartment prolapse were used to measure anatomical defects at levels I–III: (i) from Pelvic Organ Prolapse Quantification (POP-Q) system points C, Ap, Bp, and genital hiatus (GH), and from Posterior Repair Quantification (PR-Q) perineal gap (PG), posterior vaginal-vault descent (PVVD), midvaginal laxity (MVL)—vault undisplaced, and rectovaginal fascial laxity (RVFL). The largest defects were found at level I (PVVD: mean 6.0 cm; point C, mean minus 0.9 cm), and level III (PG, mean 2.9 cm; GH, mean 3.7 cm). Level II defects (MVL—vault undisplaced, mean 1.3 cm; RVFL, mean 1.1 cm; points Ap, Bp, both mean 1.0 cm) were relatively small. This study suggests that the defects found at surgery for posterior vaginal compartment prolapse were more frequent at the vaginal vault (level I) and vaginal introitus (level III) than at midvagina (level II). These findings should have implications for surgical planning.

Objectives: The utilization of barbed sutures in laparoscopic hysterectomy has become popular among gynecologic sur­geons. Our aim was to compare the outcomes of two different techniques for closing the vaginal cuff with barbed sutures in laparoscopic hysterectomies. Material and methods: A retrospective study was completed on 202 patients who underwent laparoscopic hysterectomy for benign diseases at Istanbul Kanuni Sultan Suleyman Training and Research Hospital from April 2014 through June 2016. In group 1 (n = 139), a single-layer continuous suturing method was used; each bite contained the pubocervical fascia and vaginal mucosa anteriorly, and vaginal mucosa and rectovaginal fascia posteriorly. In group 2 (n = 63), a double-layer continuous suturing method was used; only vaginal mucosa was included in the first layer, and a second layer incorporated the pubocervical and rectovaginal fascias. Results: Patient characteristics (age, body mass index, parity, previous abdominal surgery, smoking, comorbidity) were similar between the two groups. There were also no differences in total operation time, length of hospitalization, intraop­erative complications, and perioperative change in hemoglobin levels. There was no difference between the two groups in terms of vaginal cuff dehiscence, which was the primary outcome measure of the study. Secondary outcome measures (presence of granulation tissue, spotting, cuff cellulitis) were also similar between the two groups. Conclusions: We observed no differences in outcomes between single- or double-layer vaginal closure techniques with barbed sutures.

The primary aim of surgery is to restore the body’s normal support structure while returning the prolapsed organ to its normal anatomic position and relieving or improving prolapse symptoms. Depending on the extent and location of prolapse, surgery usually involves a combination of repairs addressing the vaginal apex, anterior and posterior vagina, and perineum.The apex is the keystone of pelvic organ support, therefore surgical correction of the apex is of paramount importance in the context of prolapse repair. There are several good options with relatively high success rates for apical repair. Anterior and posterior vaginal prolapse are traditionally repaired by midline plication of the pubocervical and rectovaginal fascia. Dissection must be forwarded laterally and attention must be given to re-establish continuity between anterior, posterior and apical compartments.

The aim of this study was to assess the effectiveness of vaginal native tissue repair (VNTR) on preexisting Lower Urinary Tract Symptoms (LUTS) in women with symptomatic pelvic organ prolapse (POP). Two hundred patients who underwent VNTR for symptomatic POP from January 2018 to February 2019 were followed up for 6 months. All patients underwent VNTR, but in the posterior compartment, the rectovaginal fascia was reconnected to the uterosacral ligaments and additionally sutured to the iliococcygeus fascia and muscle. To assess the severity and change in storage phase LUTS before and after surgery, all participants were asked to complete 3 questionnaires: the International Consultation on Incontinence Questionnaire- Short Form (ICIQ-SF), Urogenital Distress Inventory-6 (UDI-6), and Incontinence Impact Questionnaire-7 (IIQ-7). The data were assessed with Statistica package version 12.0, using Kalmogorow&ndash, Smirnoff, W Shapiro&ndash, Wilk tests. Furthermore, one-way analysis of variance was applied with post-hoc Tukey test. The study results indicate that the majority of patients with advanced POP suffered from various LUTS. Among storage symptoms, the occurrence of urinary incontinence (UI) and urgency decreased significantly after surgery. Moreover, ICIQ-SF, UDI-6, and IIQ-7 results showed statistically significant improvement in the impact of UI on the quality of life (QoL) in the vast majority of patients after surgery. VNTR is an effective way to treat not only anatomical, but also functional problems in such patients.

The pelvic floor is the support of the pelvic viscera. The levator ani muscle (LA) with its two bundles (pubo- and iliococcygeus) is the major component of this pelvic floor. LA is formed essentially by type I fibers (slow twitch, with high oxidative capability and presence of slow myosin) as in postural muscles. The aerobic metabolism makes LA fragile to excentric contraction and to mitochondrial dysfunction. The innervation of the pelvic floor comes from the 2nd, 3rd, 4th anterior sacral roots; denervation affects pelvic dynamism. Perineum includes the musculofascial structures under the LA: ventrally the striated sphincter of urethra and the ischiocavernosus and bulbospongiosus, caudally the fatty tissue filling the ischioanal fossa. Pelvic fascia covers the muscles ; it presents reinforcements : the uterosacral and cardinal ligaments, the arcus tendineus fascia pelvis (ATFP) and the arcus tendineus levator ani (ATLA). The pelvis statics is supported by the combined action of all this anatomical structures anteriorly forming the perineal "hammock," medially the uterosacral and cardinal ligaments, posteriorly the rectovaginal fascia and the perineal body. The angles formed by the pelvic viscera with their evacuation ducts participate to the pelvic statics. During the pelvic dynamics the modification of these angles expresses the action of the musculofascial structures.

PURPOSE: This prospective study was performed to achieve visualization of the reestablishment of anatomy after reconstructive surgery in the different pelvic compartments with non-absorbable radiopaque meshes, providing valuable anatomic information for surgeons implanting meshes. MATERIALS AND METHODS: A total of 30 female patients with stress urinary incontinence (SUI), anterior and posterior vaginal wall prolapse, or both underwent surgical repair using radiopaque meshes after written informed consent. Patients with SUI underwent five different surgeries. Patients with anterior vaginal prolapse underwent a procedure using a combined pre-pubic and transobturator mesh, and those with posterior vaginal prolapse underwent posterior slingplasty. Three-dimensional reconstruction using helical CT was performed four weeks postoperatively. RESULTS: In all cases, the mesh was clearly visualized. Transobturator slings were shown at the midurethra, and the anchoring tails perforated the obturator foramen at the safety region. Mini-slings were in the proper place, and computed angiography revealed that the anchoring system was away from the obturator vessels. In patients undergoing procedure for anterior vaginal prolapse, both pre-pubic armpit and obturator slings were clearly seen and the mesh was in the proper position, supporting the bladder base and occluding the distal part of the urogenital hiatus. Transcoccygeal sacropexy revealed indirectly a well-supported "neo rectovaginal fascia" and the anchoring tails at the level of ischial spines. CONCLUSION: Three-dimensional helical tomography images of the female pelvis using radiopaque meshes have a potential role in improving our understanding of pelvic floor reconstructive surgeries. These radiopaque meshes might be the basis of a new investigative methodology.

The pelvic floor is the support of the pelvic visceras. The levator ani muscle (LA) with its two bundles (pubo- and ilio-coccygeus) is the major component of this pelvic floor. LA is formed essentially by type I fibers (with high oxidative capability and presence of slow myosin) as in postural muscles. The aerobic metabolism makes LA susceptible to injury caused by excentric contraction and mitochondrial dysfunction. The innervation of the pelvic floor comes from the 2nd, 3rd, 4th anterior sacral roots; denervation affects pelvic dynamism. Perineum includes the musculofascial structures under the LA: ventrally the striated urethral sphincter and the ischio-cavernous and bulbospongious, caudally the fatty tissue filling the ischioanal fossa. Pelvic fascia covers the muscles; it presents reinforcements: the uterosacral and cardinal ligaments, the arcus tendineus fascia pelvis (ATFP) and the arcus tendineus levator ani (ATLA). The pelvis statics is supported by the combined action of all this anatomical structures anteriorly forming the perineal "hammock", medially the uterosacral and cardinal ligaments, posteriorly the rectovaginal fascia and the perineal body. The angles formed by the pelvic visceras with their evacuation ducts participate to the pelvic statics. During the pelvic dynamics the modification of these angles expresses the action of the musculofascial structures.

The objective of the study was to compare preoperative and postoperative sexual function between women undergoing rectocele repair with porcine dermis graft and women undergoing site-specific repair of rectovaginal fascia. A standardized, validated questionnaire (Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire [PISQ]) was used to collect preoperative sexual function data from 100 patients with rectocele pelvic organ prolapse quantification stage 2 or greater. Fifty women underwent rectocele repair utilizing porcine dermis graft (group 1) and 50 women underwent a site-specific repair of the rectovaginal fascia (group 2). The same questionnaire was administered to all subjects 6 months after surgery. The two groups were similar in age, race, parity, prior hysterectomy, and postmenopausal hormone use. Preoperative sexual function scores were similar in the two groups (group 1 81.4 ± 7.3 and group 2: 83.6 ± 8.2, p = 1.0). Six months after surgery, PISQ scores in group 1 significantly increased (score increase 19.9 ± 2.2, p = 0.01). The mean increase in PISQ scores for group 2 was 6.9 ± 3.1 (p = 0.08). When compared with group 2, subjects undergoing rectocele repair with porcine dermis graft scored significantly higher on the PISQ 6 months after surgery (group 1 101.3 ± 6.4 and group 2 89.7 ± 7.1, p = 0.01). We conclude that rectocele repair using porcine dermis graft is associated with improved sexual functioning when compared with site-specific rectovaginal fascia repair.

We describe a new technique in the surgical treatment of rectocele using a dermal allograft to augment site-specific fascial defect repair of the rectovaginal fascia. The posterior vaginal wall is opened and discrete defects in the rectovaginal fascia are repaired in a site-specific fashion using delayed absorbable suture. A second layer of support is created using a rectangular dermal allograft placed over the site-specific repair and secured to the normal anatomic attachments of the rectovaginal fascia using permanent sutures. The vagina is then closed and routine perineorrhaphy performed as indicated. Forty-three women with advanced posterior vaginal wall prolapse underwent dermal graft augmentation of site-specific rectocele repair over a 1-year period. No major intraoperative or postoperative complications were reported. Thirty women were available for follow-up examination at an average of 12.9 months (range 8-17). The average patient age in the follow-up group was 63.6 +/- 10.9 years (range 33-79) and average parity was 2.8 +/- 1.5 (range 0-7). Using the Pelvic Organ Prolapse Quantification score, the average measurement of point A(p) was 0.25 preoperatively and -2.4 postoperatively, whereas point B(p )was 0.9 preoperatively and -2.5 postoperatively. Using a point A(p) measurement of -0.5 or greater to define surgical failure, 28/30 (93%) of women were noted to have surgical cure on follow-up. Site-specific rectocele repair augmented with dermal allograft is associated with high cure rates and minimal complications. It recreates normal anatomic support and is easily adapted into current surgical procedures for rectocele repair.

Background: The existence, development, and function of the rectovaginal fascia has been discussed in literature. In women, a defect in the fascia leads to rectoceles and severe constipation. In pediatric textbooks for anorectal or urogenital surgery, however, it is not mentioned. Does the fascia exist in children? Methods: The pelvises of 31 female and, as controls, 31 male fetuses (age from 9 weeks of gestation to newborn) were plastinated. Sections (transversal, sagittal, and frontal) were stained with azure II/ methylenblue/ basic fuchsin and viewed at a magnification of 6.5× to 80×. In addition, the authors investigated macroscopically and microscopically the rectovaginal fascia in 1 fetal and 1 adult cadaver. Results: At the beginning of the fetal period the authors recognized the anlage of the rectovaginal fascia caudal from the rectouterine excavation. Later, a fascia of connective tissue develops. It is connected directly to areolar connective tissue at the dorsal wall of the vagina. Neurovascular bundles are situated ventrolaterally of the rectal wall. At the level of the anorectal flexure this fascia separates the rectum and the vagina. Conclusions: Our investigations indicate that the rectovaginal fascia is completely developed in newborns, through differentiation of mesenchyme, which develops into a fascia. It protects different compartments and serves as an abutment to the rectal wall. Thus, it is important for adequate bowel emptying. For the surgeon it is a leading structure for preventing nerve damage of the autonomic nerve supply of the pelvic organs. It should be known, protected, and, if necessary, reconstructed. J Pediatr Surg 37:634-638. Copyright 2002, Elsevier Science (USA). All rights reserved.

Objective: This study was undertaken to determine the effects of rectovaginal fascia reattachment on symptoms and vaginal topography. Study Design: Standardized preoperative and postoperative assessments of vaginal topography (the Pelvic Organ Prolapse staging system of the International Continence Society, American Urogynecologic Society, and Society of Gynecologic Surgeons) and 5 symptoms commonly attributed to rectocele were used to evaluate 66 women who underwent rectovaginal fascia reattachment for rectocele repair. All patients had abnormal fluoroscopic results with objective rectocele formation. Results: Seventy percent (n = 46) of the women were objectively assessed at 1 year. Preoperative symptoms included the following: protrusion, 85% (n = 39); difficult defecation, 52% (n = 24); constipation, 46% (n = 21); dyspareunia, 26% (n = 12); and manual evacuation, 24% (n = 11). Posterior vaginal topography was considered abnormal in all patients with a mean Ap point (a point located in the midline of the posterior vaginal wall 3 cm proximal to the hymen) value of –0.5 cm (range, –2 to 3 cm). Postoperative symptom resolution was as follows: protrusion, 90% (35/39; P P P = .02); dyspareunia, 92% (11/12; P = .01); and manual evacuation, 36% (4/11; P = .125). Vaginal topography at 1 year was improved, with a mean Ap point value of –2 cm (range, –3 to 2 cm). Conclusion: This technique of rectocele repair improves vaginal topography and alleviates 3 symptoms commonly attributed to rectoceles. It is relatively ineffective for relief of manual evacuation, and constipation is variably decreased. (Am J Obstet Gynecol 1999;181:1360-4.)

In patients with posthysterectomy prolapse of the vaginal vault, the posterior intravaginal slingplasty (posterior IVS, Tyco Healthcare, USA) has been suggested as an alternative to traditional vaginal vault suspensions. The goal of this technique is to recreate the uterosacral ligaments and to reinforce the rectovaginal fascia with the use of prosthetic material. We report the case of a 53-year-old woman with a history of 27 months of perineal suppurative discharge after she underwent a vaginal vault prolapse and rectocele repair using a posterior IVS (Tyco Healthcare®, USA). The IVS tape was reinforced by interposing a rectovaginal monofilament polypropylene mesh (Parietex®, Sofradim®, France). Imaging studies and surgical exploration confirmed infection of the IVS mesh with the formation of a gluteo-vaginal fistula while the rectovaginal mesh was intact.

The aim of this study was to describe the anatomic and functional results of the discrete fascial defect rectocele repair.Sixty-nine women underwent rectocele repair at Duke University Medical Center during a 3-year period beginning January 1, 1994. Repair was limited to reapproximation of discrete defects in the rectovaginal fascia, without levator plication or perineorrhaphy. Outcome measures included Pelvic Organ Prolapse Quantitation measurements, prolapse stage, and a symptom questionnaire. Univariate and nonparametric tests were used as appropriate.Before the operation 46% patients (32/69) reported constipation, 39% (27/69) reported splinting, 32% (22/69) reported tenesmus, and 13% (9/69) reported fecal incontinence. The median preoperative posterior Pelvic Organ Prolapse Quantitation stage was 2 (1-4). Pelvic Organ Prolapse Quantitation stage had improved for all but 2 women at 6 weeks. Eighteen percent (8/43) had recurrent rectoceles at 12 months. Mean values for the points describing the posterior vaginal wall improved2 cm (P.0001). Although perineorrhaphy was not performed, the genital hiatus decreased by 2. 3 cm (P.0001), with no significant change in the length of the perineal body. Functional results mirrored anatomic results, with statistically significant improvements for all symptoms.The discrete defect rectocele repair provides anatomic correction of rectoceles with alleviation of associated symptoms for most women.

Rectoceles are defined as a herniation of the rectum through the posterior vaginal wall, resulting from weakness in the rectovaginal fascia that leads to compromised posterior compartment support. Although not life threatening, rectoceles, like other forms of pelvic organ prolapse, can have a negative effect on daily living and quality of life. Patients may complain of stool trapping/difficulty with bowel movements, pain or difficulty with intercourse, pelvic pain/pressure, or lower back pain. The symptoms of a rectocele are most often the factor that drives patients to desire repair. The purpose of this chapter is to review the anatomy, pathophysiology, and surgical considerations or rectocele repairs.

A rectocele is a herniation of the rectum through the rectovaginal fascia and posterior vaginal wall causing a protrusion into the vaginal lumen. It is a common disorder in women with a history of multiple vaginal deliveries, and it is asymptomatic in 80% of cases [1]. Symptomatic rectocele is less common, usually affects postmenopausal females, and results in obstructed defecation and constipation (Table 18.1) [2, 3].

The aim of this study was to investigate the functional and anatomical outcome after a new rectovaginal fascial plication technique in patients with rectoceles or rectal pockets and obstructed defecation. In a prospective study 54 of 87 patients were examined pre- and postoperatively using the Pelvic Organ Prolapse Quantification (POP-Q) system of the International Continence Society (ICS). Bowel and protrusion symptoms as well as quality of life (QOL) were evaluated by a standardized questionnaire. Surgical therapy consisted of a posterior vaginal wall incision in the midline, a dissection of the vaginal epithelium from the underlying rectovaginal fascia while the rectocele was brought under tension by the index finger in the rectum. Under rectal digital control the surgically exposed rectovaginal fascia was sutured in a cranio-caudal fashion with sagittally positioned running absorbable sutures followed by a careful reapproximation of the laterally separated perineal body in the midline. Obstructed defecation symptoms were cured or improved in 72.2 % [95 % confidence interval (CI) 59.1–82.4]. Anatomical cure rate was 92.1 % (95 % CI 79.2–97.3) and protrusion symptoms were resolved in 73.6 % (95 % CI 58.0–85.0). Of the patients who had intercourse, 5.2 % reported de novo dyspareunia postoperatively; in none of these patients was an anatomical cause found. There were no major intra- or postoperative complications. Sagittal rectovaginal fascial plication in symptomatic rectoceles or functionally relevant rectal pockets is associated with a satisfactory anatomical and functional cure rate without impacting sexual function.

Ring pessary has long been used to treat uterine prolapse. We attempted to identify patients in whom a ring pessary is well fitted without expulsion. We studied 69 consecutive Japanese patients with uterine prolapse treated with ring pessary (Wallace Ring Pessary, Smiths Medical International Ltd, Hythe, Kent, UK) by the first author (T.Y.) between January 2004 and December 2008. Disease severity was evaluated by the POP‐Q system (stage I‐IV) (Bump 1996). Pessary size was determined by trial-and-error: the size was initially chosen in an empirical manner. All patients returned after 2 weeks: if the pessary was expelled during this period, we inserted a larger size. The median size of the pessary finally fitted was 70 mm (range: 56‐80). When the pessary remained 4 weeks after the initial fitting, the fit was considered successful; expulsion was defined as unsuccessful. We compared patient age, parity, history of hysterectomy, stage and the presence of rectocoele or cystocoele between patients with successful vs unsuccessful fitting. As shown in Table I, 53 (77%) had successful fitting, while 16 (23%) were unsuccessful. In the unsuccessful group, the frequencies of rectocoele and POP-Q stage IV were significantly higher, but the frequency of cystocoele was the same (63% vs 60%). We have no data on whether patients with rectocoele had defecation-related symptoms more frequently than those without. Age, parity and the frequency of hysterectomy did not differ. The presence of rectocoele, but not cystocoele, predicted unsuccessful fitting, which, to our knowledge, has not previously been described. Differing from our findings, previous studies showed that older age (Clemons 2004) and hysterectomy (Mutone 2005) increased the frequency of unsuccessful fitting. Different study populations may account for this discrepancy. Rectocoele is associated with weakening of the rectovaginal fascia: the posterior side of the vaginal wall is then devoid of structure to retain the pessary. Contrarily, a cystocoele is associated with attenuation of the pubocervical fascia: however, the pubic bone at the anterior side of the vagina may provide structure to support the pessary. We do not suggest that patients with rectocoele should be excluded from ring pessary treatment. Rather, we recommend caution when managing patients with rectocoele. We only used the Wallace type of pessary. It has not been determined whether another type may provide a better fit for patients with rectocoele. We recently showed that a ring pessary may be not only palliative but also curative for prolapse, even after its removal (Matsubara and Ohki 2010). Ring pessary treatment has long been used to treat prolapse and advances in fitting may facilitate successful treatment.

Using the descriptions of Uhlenhuth, and Milley and Nichols, we have been able to identify a sheet of strong connective-type tissue between the rectum and vagina. This layer has been named the rectovaginal septum, referred to, by some, as the rectovaginal fascia. As it is considered to be analogous to the rectovesical septum in men, first described by Denovilliers, some refer to it as Denonvilliers' fascia in the female. This layer is immediately beneath the vaginal mucosa and clearly is what many would consider part of the vaginal wall. Its principal attachments are peripheral--it merges superiorly with the cardinal/uterosacral complex, fuses laterally with the fascia over the levator muscle, and merges distally into the perineal body. Histologically, it contains collagen that is quite dense in places, some strands of smooth muscle, and a very dense network of heavy elastin fibers. It is this layer that acts as a supporting structure for the perineal body and prevents the rectum from bulging into the vagina. Rectoceles represent a defect in this layer that allows the rectum to bulge inward. The defects are usually isolated breaks that can be repaired directly with excellent and predictable results.

Background. The aim of this study is to describe the results of the discrete fascial defect rectocele repair with special emphasis on dyspareunia after the operation. Methods. Sixty-seven women underwent rectocele repair from October 1997 to January 1999. Repair was limited to reapproximation of discrete defects in the rectovaginal fascia when possible and a small perineorrhaphy. Each patient was evaluated as to whether or not a discrete defect was present and the location of the fascial defect. Outcome measures were complications, recurrent prolapse after 3 months, changes in defecation problems and dyspareunia after the operation. Results. In 96% (64/67) of the patients a discrete defect was present. Before the operation 40% (27/67) reported problems with evacuation of the rectum and 12% (8/67) dyspareunia or problems with intercourse because of the prolapse. The patients were evaluated 3 months after the operation. Only three patients still complained of evacuation problems and only two patients with prior dyspareunia still had problems, which were cured after a further 3 months. Two patients had de novo dyspareunia but in only one patient was an anatomical defect found. Conclusions. The discrete defect rectocele repair offers an anatomical correction of the rectocele, which alleviates the symptoms but, most important, does not give the woman dyspareunia. Long term results of the operation are awaited.

Objectives: To assess the effectiveness, perioperative safety and invasiveness of the Tissue Fixation System (TFS) sling operation when used for repair of uterovaginal prolapse with uterine preservation. Methods: Operations using the TFS anchor system were performed on 25 women aged between 44 and 84 years (average 65) for grade 3 or 4 uterine prolapse with or without urinary incontinence. Details of the procedures were as follows: midurethral sling (n = 2); posterior sling of the uterosacral ligaments (n = 25); U-sling for lateral/central anterior vaginal wall defects (n = 24). The defect of the perineal body and rectovaginal fascia were repaired in all cases. Results: All patients were followed up for a minimum of 3 months. The mean ± standard deviation of the operating time and loss of blood were 94.2 (±19.3) minutes and 98.1 (±129.6) mL, respectively. Twelve patients (48%) were discharged on the same day of surgery and 13 patients (52%) on the following day, with a return to normal activities within 1–7 days. There were no intra- or postoperative complications. At the 3-month follow up, cure rates of symptoms due to pelvic laxity were: urinary frequency 85.7% (n = 14); nocturia 66.6% (n = 12); urgency 93.3% (n = 15); and dragging pain 100% (n = 6). There was one recurrent uterovaginal prolapse and one recurrent cystocele. Conclusion: The TFS procedure delivers satisfactory results for uterine prolapse repair with uterine preservation. The procedure is useful because of the short duration of the operation, the short term of recovery, its safety profile and minimal invasiveness. There is a significant improvement in the quality of life, especially for older women. However, long-term results are currently unknown.

Unlike surgery to treat urinary stress or fecal incontinence, for which a patient usually undergoes careful preoperative evaluation, the gynecologic preoperative evaluation of a symptomatic posterior vaginal bulge typically includes only a history and physical examination. Gynecologists have not adopted the performance of defecography or other evaluation techniques for the evaluation of this anatomic defect. Although 80% of colorectal surgeons use defecography, only 6% of gynecologists use it. In addition, differentiation between enterocele and rectocele components of posterior vaginal wall prolapse is typically performed on a clinical and intraoperative basis, rather than radiographically. It is unclear at this time whether surgical therapy outcomes are negatively impacted by the lack of preoperative evaluation beyond a history and physical exam. Most gynecologists consider repair of the rectocele to be commonly necessary during routine pelvic reconstructive procedures, and it is associated with low morbidity for their patients. Herniation of the rectum or posterior vaginal wall into the vaginal canal, resulting in a vaginal bulge, is commonly termed a rectocele. Women may complain of perineal and vaginal pressure, obstructive defecation, constipation, and the need to splint or digitally reduce the vagina in order to effectuate a bowel movement. These anatomic defects arise from a superior, inferior, or lateral tear or central stretching of the rectovaginal fascia. If the weakness is present below the levator musculature, it is termed a rectocoele. If the weakness occurs above the levator muscles, it is more likely an enterocele. Very commonly, both anatomic defects coexist. Although anatomic cure rates with surgery are high, there are conflicting reports with regard to functional outcome, postoperative defecatory symptoms, and sexual dysfunction including dyspareunia. Marked differences exist between the management approaches followed by urogynecologists and colorectal surgeons. Rectocele repair, or posterior colporrhaphy, represents one of the most commonly performed gynecologic pelvic reconstructive procedures. In a recent survey, 100% of gynecologists surveyed managed rectoceles, whereas 68% of colorectal surgeons manage them. There are a large number of gynecologic indications for rectocele repair (Table 19.1). The restoration of normal anatomy to the posterior vaginal wall is referred to as an enterocele repair if it involves the upper posterior vaginal wall, and as a posterior repair or colporrhaphy if the lower wall is involved. Although sometimes used interchangeably with the term rectocele 19 Surgical Treatment of Rectocele: Gynecologic Approaches

Rectoceles are frequently found in patients with intractable evacuatory disorders. Typically, the patients complain of difficulties in evacuation, incomplete evacuation, and sometimes, assisted digitation to aid defecation, fecal incontinence, ‘‘constipation’’, feeling of a mass in the pelvis, pelvic pain and pain on intercourse. Occult rectal prolapse has been found in 33 % of patients with rectoceles and defecatory dysfunction [1]. In 2008, Abendstein et al. [2] performed a three-level repair in patients with ‘‘obstructive defecation’’: posterior sling for repair of the uterosacral ligaments, repair of the rectovaginal fascia and where relevant, repair of the perineal body. He reported normalization of defecation in 45 (94 %) of 48 patients. Of the 27 patients with fecal incontinence, 18 (66 %) reported cure, 5 (19 %) > 50 % improvement and 4, no change. Postoperative proctograms showed resolution of the rectal intussusception in 89 and 94 % reported completely normal defecation after surgery. Abendstein explained cure of the prolapse by reference to Baden Walker’s tent theory [3]: laxity of the ligaments/ fascial structures supporting the vaginal apex/anterior rectal wall allowed the anterior rectal wall to prolapse inwards, resulting in anterior rectal wall intussusception. While Abendstein attributed the prolapse mainly to the uterosacral ligaments (USL), in our opinion, simultaneous repair of all 3 supporting layers, USL (level 1), rectovaginal fascia (level 2) and perineal body (level 3) was the key to his success, as it is explained by the musculo-elastic theory [4]. We inserted a 3 9 6 cm cylindrical Pro Dry pessary (Innocept, Gladbeck, Germany), designed to support the vaginal apex, in a 63-year-old multiparous patient with 3 vaginal deliveries who presented with constipation associated with 1st degree uterine prolapse, 2nd degree rectocele and anterior rectal wall intussusception. Symptoms improved dramatically after pessary insertion. The patient was tested by transperineal ultrasound with a 3.5 MHz curvilinear probe (Bruel & Kjaer Medical, Peabody MA, USA). On testing with transperineal ultrasound, anterior rectal wall intussusception was seen at rest (Fig. 1). After insertion of a pessary, on straining, the pessary is seen to elevate the posterior vaginal fornix with ‘‘stretching’’ up of the intussusceptions (Fig. 1). The ‘‘tent’’ analogy describes how a pessary can restore apical vaginal prolapsed and rectal intussusception. If a tent is not tightly stretched, its apex and walls can prolapse inwards. The 6 9 3 cm ProDry pessary is pushed backwards into the posterior fornix of vagina pushing back the prolapsed apex and simultaneously with it, the attached and prolapsed anterior wall of rectum. The ProDry pessary mimicked the effect of stretching the vaginal apex upwards with a posterior sling [5]. From an anatomical perspective, the close attachment of rectum to the upper part of the posterior vaginal wall and the suspensory USL means that if the ligaments are loose, both rectum and apex may prolapse simultaneously, leading sometimes to anterior rectal wall intussusception. We have shown previously that a firm uterosacral ligament is important in the mechanics of defecation, as it anchors the downward vector which opens out the anorectum [6], which in turn decreases the internal A. Gunnemann Department of Urology, Klinikum Lippe, Detmold, Germany e-mail: alfons.gunnemann@klinikum-lippe.de

Ehlers-Danlos syndrome (EDS) is a heterogeneous group of connective tissue disorders involving various organ systems. We report the case of a female patient with Ehlers-Danlos syndrome type III (EDS III) presenting with a recurrent rectocele in whom porcine small intestinal submucosa mesh was used successfully to correct the defect in the rectovaginal fascia.

Objective The study was undertaken to further define the anatomy of the arcus tendineus fascia pelvis (ATFP). Study design Thirty cadavers were dissected to find the average length, SD, and range of the ATFP. Comparisons were made to height and pelvis type. The average distance between the ischial spine and the attachment of the fascia of the rectovaginal septum (RVF) to the ATFP was measured. Results The average length, SD, and range in centimeters for the ATFP are 9.0, 0.70, and 7 to 10.5, respectively. The length of the ATFP increased with height. No associations could be made regarding pelvis type. The average distance between the ischial spine and the attachment of the RVF to the ATFP is 2.15 cm with a SD and range of 0.21 and 1.75 to 2.5, respectively. Conclusion In this study, an average length for the ATFP is established and the distance between the ischial spine and the attachment of the RVF to the ATFP is redefined.

The infracoccygeal sacropexy, or posterior intravaginal slingplasty, was first reported by Petros as a minimally invasive procedure for the treatment of vault prolapse. This report is a prospective observational study that confirms the efficacy and safety of this new procedure. In this operation the IVS Tunneller (Tyco Healthcare, USA) is used to insert an 8 mm polypropylene tape between the perineum and the vaginal vault. The resulting artificial neoligament reinforces the atrophied uterosacral ligaments. The rectovaginal fascia and perineal body are then repaired by a technique that includes using a bridge of vaginal epithelium to strengthen the central vaginal epithelium at the point of maximum weakness. The symptomatic cure rates for prolapse were 91%, urgency 79%, nocturia 82% and pelvic pain 78%. All patients were discharged home within 24 hours. There were minimal surgical complications and no transfusions were required. The technique is safe, minimally invasive, has a short learning curve, and the skills needed are those of any competent pelvic surgeon.

We retrospectively reviewed 106 cases of defect-directed rectocele repair. Preoperative standardized evaluation of rectovaginal septum support was performed. Support defects were identified at surgery by visually identifying breaks in the rectovaginal fascia. Clinical and surgical findings were compared using the chi2 test. Logistic regression analysis was used to identify predictive variables. Clinical examination concurred with surgical findings in 59.4% (63/106) and differed in 40.6% (43/106). Predictors of agreement between clinical examination and intraoperative findings were the presence of multiple defects in the rectovaginal fascia at surgery (OR 4.42, 95% CI 1.89, 10.35) and stage II or III prolapse (OR 0.0007, 95% CI 0.00059, 0.003 and 0.0003, 95% CI 0.00033, 0.0017, respectively). The sensitivity and positive predictive value for all defects was less than 40%. The inaccuracy of clinical examination emphasizes the need to develop new clinical and/or imaging methods to evaluate posterior vaginal support defects.

The relative contributions of muscle forces and vaginal suspensory ligaments to the anatomical support of the vagina have been long disputed. The aim of this study was to gain further insights into the role of striated muscle forces. Fifty consecutive patients presenting to a pelvic floor clinic were tested with perineal ultrasound, lateral X-rays at rest and on straining, 10 ml of radio-opaque dye having been injected into bladder, vagina, rectum and, in 12 patients, into the levator plate also. The relevance of muscle forces to the three anatomical levels of support, the cardinal/uterosacral ligament complex (level 1), the rectovaginal fascia (level 2) and the perineal body (level 3), was analyzed. Biopsies of the suspensory ligaments were performed per vaginam. During effort, the upper part of the vagina was stretched backwards and downwards against the perineal body. Compression of level 2 on standing lateral X-ray appeared to be related to the angle of the upper vagina to the horizontal at rest. In 23 patients in whom the angle was 45 degrees or more to the horizontal, only 2 demonstrated significant angulation of the upper vagina and therefore compression of level 2 on straining. In contast, all 27 patients with an angle less than 45 degrees to the horizontal demonstrated both vaginal angulation and compression. Histology demonstrated smooth muscle and nerves in the suspensory ligaments, indicating an active contractile role for these structures. Analysis of the directional forces suggests that inability ot angulate the vagina sufficiently may predispose to herniations of the walls of the vagina owing to the twin influences of gravity and downward muscle forces exerted by the levator muscles.

Objective: To describe the lateral attachment of the rectovaginal fascia to the pelvic sidewall. Study Design: A descriptive study was performed with use of 10 embalmed female cadaveric pelves, each sectioned in the midsagittal plane. The lateral attachments of the pubocervical fascia and the rectovaginal fascia to the pelvic sidewall were examined. Results: The rectovaginal fascia attaches to the pelvic sidewall along a well-defined line. It extends from the perineal body toward the arcus tendineus fasciae pelvis with which it converges approximately midway between the pubis and the ischial spine to form a y configuration. This point of convergence occurs an average of 4.8 cm from the ischial spine, 3.75 cm from the pubic symphysis, and 4.15 cm from the posterior fourchette. Conclusion: The rectovaginal fascia supports the posterior compartment analogous to the pubocervical fascia in the anterior compartment. Moreover, landmarks are identified that will aid suture placement during repair of posterior compartment defects. (Am J Obstet Gynecol 2001;185:41-3.)

A paradigm shift has occurred in the approach to enterocele repair and vaginal vault suspension. This change in our approach is based on anatomic dissections that demonstrate that the loss of the upper suspensory fibers of the paracolpium and parametrium lead to uterine prolapse and vaginal prolapse after hysterectomy. In addition, the separation of the pubocervical from the rectovaginal fascia results in apical enterocele where the peritoneum is in contact with the vaginal mucosa. These fascial defects are hernias, and appropriate herniorraphy techniques will correct these defects and result in successful reconstruction of the vaginal tube and its reattachment to the suspensory cardinal uterosacral complex.

Pelvic organ prolapse remains a difficult problem for pelvic reconstructive surgery. Before new surgical procedures can be developed a good understanding of pelvic anatomy is necessary. It is widely held that the etiology of pelvic organ prolapse is secondary to stretch neuropathy following childbirth and chronic cough or constipation. Several transvaginal and transabdominal procedures have been developed over the years. With the increasing use of laparoscopy, a new variation on existing culdeplasty techniques has been developed. Following anatomical principles, the apical vault repair reestablishes the pericervical ring at the vaginal apex. The incorporation of pubocervical fascia, uterosacral-cardinal ligament and the rectovaginal fascia provides a strong anchor for the vaginal apex. In addition, the repair should help prevent future transverse cystocele, rectocele, enterocele and apical vault prolapse. Early outcome studies suggest that the apical vault repair should be used routinely with laparoscopic urethropexy, laparoscopic hysterectomy and the repair of pelvic organ prolapse. Good apical vault support is considered the cornerstone of pelvic reconstruction.

Symptomatic rectoceles are simply and effectively treated by the transrectal repair of the lower rectovaginal fascia and perineal body defects.

Cystocele is hernia resulting from a transverse tear in the vesicovaginal fascia. The tear is almost universally from near the site of the cervix. Closure of the ring and restoration of the fascia to its normal location will cure the urethrocele. Plastic repair of the broad ligaments insures firm closure of the ring. The operation is simple if treated as a distinct hernia and failures should generally mean faulty technic or judgment. High rectocele is a transverse tear in the rectovaginal fascia. The site of the lesion is near the cervix. With thorough dissection the torn edges of the fascia can be easily exposed and sutured into normal position. In perineal lacerations the fascia and muscles are also often injured near the rami of the pubes but this class of lesion is not presented for discussion at this time.