To evaluate long-term subjective outcomes of porcine small intestine submucosa (SIS) graft-augmented compared to native tissue rectocele repair. This is a follow up study of a previously published multi-center, randomized trial in which 159 women with stage 2 or greater posterior wall prolapse were randomized to SIS graft-augmented versus native tissue repair, completed in 2009. Exclusion criteria were concurrent sacral-colpopexy, porcine allergy, or past pelvic radiation. We mailed surveys to all participants at one institution (147) and conducted follow-up phone calls. Surveys assessed the Pelvic Floor Distress Inventory (PFDI) and interval care-seeking, treatment and surgery for bowel or prolapse symptoms. Failure was defined as presence of mild, moderate or severe bother (“bother”) associated with: 1) vaginal bulge 2) “bowel symptoms” defined as straining, splinting, sensation of incomplete evacuation on the PFDI; and/or 3) stool trapping. Post hoc power calculation estimated the detectable difference in failure by response rate to be 33-37% (response rate 40%, two-sided alpha 0.05, power 80%, graft:native tissue - 1:1). We used Students’ t-test and Wilcoxon rank sum test to compare groups. Of the 147 subjects, we mailed surveys to 122 (25 - not located). We received 57 completed surveys (25/81 graft, 32/78 native tissue); the overall response rate was 36%, with no difference between groups (p=0.2). The duration between surgery and follow-up was 8-13 years. Among responding subjects, there was one demographic difference between groups: a higher proportion of the graft group reported preoperative incomplete evacuation with bowel movement compared to native tissue (96% vs. 70%, respectively; p=0.03). At 8-13 years, 12% of responders reported bother with vaginal bulge, 63% with bowel symptoms, and 35% with stool trapping; these did not differ between groups. Twenty percent reported interval care-seeking for bowel or bulge symptoms, 5% reported non-surgical treatment and 5% reported surgical repair for any prolapse symptoms, with no differences between groups. Of the women who did not report bothersome symptoms at 12 months, by 8-13 years, 12% (6) developed new bothersome vaginal bulge, 54% (15) developed bowel symptoms, and 31% (14) developed stool trapping symptoms; there were no differences between groups. Of the women who reported bothersome symptoms at 12 months, at 8-13 years, no women reported worsening vaginal bulge symptoms, 50% (14) reported worsening bowel symptoms and 27% (3) reported worsening stool trapping. However, without any interval treatment, 75% (3) reported improvement/resolution of vaginal bulge, 25% (7) had improvement of bowel symptoms, and 45% (5) had improvement of stool trapping. There were no differences between groups. Among women randomized to graft-augmented versus native tissue rectocele repair, 30-50% of patients with no rectocele symptom bother at 12 months postoperative developed bothersome symptoms at long-term follow up. However, 25-75% of symptomatic women had spontaneous symptom improvement by 8-13 years postoperative.