This retrospective study clearly demonstrates that performing NS-SCP to correct a multicompartment prolapse including posterior vaginal descent of at least stage II leads to an excellent anatomical correction of the apical, anterior as well as posterior compartment. These findings are in line with existing data in the literature, showing similar results [11,23].
We found a brilliant surgical success of the apical compartment (100%), while mild objective signs of prolapse anteriorly and/or posteriorly were seen in a few women. Even though a distinct objective descent was present, Ba and/or Bp was ≤0 in all women, which can be considered as surgical success, as bothersome symptoms and the impact on pelvic organ function and quality of life most commonly first occur with a descent beyond the hymenal ring [24].
Together with the anatomical correction, subjective reported symptoms improved significantly pre- to postoperatively.
Interestingly, only one half of all investigated women affected by rectocele of at least stage II, reported bothersome bowel symptoms preoperatively. This suggests that a rectocele is not necessarily associated with bowel symptoms, which could be shown previously [25]. The lack of difference in Bp values between the two groups with and without bowel symptoms preoperatively in the subgroup analysis supports this thesis.
Even though posterior descent seems not to lead to bowel symptoms in all cases, our findings suggest, that, if present, they improve with surgical correction. Fortunately, on the other hand, surgical intervention did not lead to de novo bowel symptoms in case of no preoperatively observed complaints in our cohort. This may, among other factors, be attributed to the performed surgical technique, in which the mesh is sutured to the vaginal wall and not to the levator ani muscle, which has been discussed previously [26]. The latter surgical technique is controversial, because the fixation of the muscle may cause increased pain and may lead to bowel symptoms [27] and experts tend to prefer a fixation of the mesh to the posterior vaginal surface alone [28]. Moreover, the implemented nerve-sparing approach is recognized for its favorable outcomes in preventing de novo pelvic floor dysfunction, including bowel complaints [19].
We found a significant amelioration in symptoms like straining to defecate, fecal urgency, incontinence for normal stool, feeling of incomplete evacuation and need for digital assistance to defecate. No difference was found in constipation symptoms and more laxative use was found postoperatively, which is evident, as this was one of our postoperative recommendations, based on the known fact, that SCP is generally associated with constipation in the early postoperative phase [27]. No difference for unvoluntary loss of wind and fluid stool was found. An anticipated fact, as it is known that severe anal incontinence is not associated with posterior compartment prolapse [29].
The results of our conducted retrospective study indicate that NS-SCP alone leads to an adequate correction of the posterior compartment and results in a resolution of bowel complaints, if any were present.
The circumstance that only a minority of all women of this cohort had primary (10%) or subsequent (4%) PR, suggests that simultaneously performed PR together with a SCP in women with concomitant rectocele cannot to be justified automatically.
Our results are consistent with previous findings, suggesting that a concomitantly performed PR does not lead to an additional benefit [30]. To substantiate these statements, a comparison of objective and subjective outcomes between patients with SCP alone and with SCP plus PR would be interesting. The small sample size in the group of SCP plus PR in our cohort does not permit such comparisons. A limitation of our study is the vaguely defined criteria for concomitant PR during NS-SCP. Although the small overall proportion and low percentage of secondary PR procedures suggest that a symptomatic, persistent posterior defect following NS-SCP is not a major concern, it remains debatable to what extent concomitant PR influences the postoperative results of NS-SCP.
The most limiting factor of our study is the short observation time. Based on the generally low recurrence rate of SCP [23], we extrapolate ongoing favorable improvement in subjective symptoms without discernible changes in anatomical correction over time, which needs to be evaluated in further studies.
The strength of the study is the relatively high sample size and the standardized surgical technique and clinical evaluation pre- and postoperatively. The use of the POP-Q quantification system and the standardized GFPFQ made it possible to generate high reproducible, objective, and comparable results.
Based on the results of this study, from a cohort of 112 women, we can conclude, that NS-SCP in women with symptomatic multicompartment prolapse, including rectocele, results in excellent anatomical correction and improvement in bowel symptoms, if present preoperatively. Simultaneous or secondary PR is rarely necessary. These findings suggest that sacrocolpopexy alone is a reasonable treatment option for above described prolapse cases. Future research in a prospective setting is needed to further investigate its long-term efficacy and impact on quality of life.