Endorectal repair of rectocele revisited

Transperineal rectocele repair with biomesh: updating of a tertiary refer center prospective study

PURPOSE

Symptomatic rectocele results in obstructed defecation and constipation. Surgical repair may provide symptomatic relief. A variety of surgical procedures have been used in the rectocele repair to enhance anatomical and functional results and to improve long-term outcomes.

METHODS

In this prospective study, we treated 25 selected women suffering from simple symptomatic rectocele with transperineal repair using porcine dermal acellular collagen matrix Biomesh (Permacol®). Watson score and SF-36 questionnaire were used to evaluate postoperative outcomes and quality of life.

RESULTS

Follow-up ranged from 12 to 24 months, the mean total Watson score was significantly lower than the preoperative score (P < 0.001), and every patient has improved functional outcomes. There were no major intraoperative or postoperative complications. Two cases of urinary infection and 4 patients delayed wound healing were reported. Those patients who were sexually active prior to surgery have not experienced problems with sexual function or dyspareunia.

CONCLUSIONS

Despite lack of comparative study in literature, rectocele repair with Permacol® by the transperineal approach seems an effective and safe procedure that avoids some of the complications associated with synthetic mesh use.

Surgery for constipation: systematic review and practice recommendations: Results IV: Recto-vaginal reinforcement procedures

AIM

To assess the outcomes of recto-vaginal reinforcement procedures in adults with chronic constipation.

METHOD

Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements with a summative Oxford Centre for Evidence-Based Medicine (2009) level.

RESULTS

Forty-three articles were identified, providing data on outcomes in 3346 patients. Average length of procedures ranged between 20 and 169 min, and length of stay between 1 and 15 days. Complications typically occurred after 7-17% of procedures (range 0-61%). Post-operative bleeding was uncommon (0-4%) as well as haematoma or sepsis (0-2%). Fistulation did not occur in most studies. Two procedure-related deaths were observed for 3209 patients. Although inconsistent, 78% of patients reported a satisfactory or good outcome, with 30-50% experiencing reduced symptoms of straining, incomplete emptying or reduced vaginal digitation. About 17% of patients developed anatomical recurrence. Considering measures of harm and global satisfaction rating scales, there was insufficient evidence to prefer one type of procedure over another. There was no evidence to support better outcomes based on selection of patients with a particular size or grade of rectocoele.

CONCLUSION

Evidence supporting recto-vaginal reinforcement procedures is currently derived from observational studies and comparisons, with only one high quality study. Large trials are needed to inform future clinical decision making.

Clinical observation of a modified surgical method: posterior vaginal mesh suspension of female rectocele with intractable constipation

STUDY OBJECTIVE

To explore the feasibility and effectiveness of a modified posterior vaginal mesh suspension method in treating female rectocele with intractable constipation.

DESIGN

Descriptive study (Canadian Task Force classification II-3).

SETTING

The study was performed in the Study Center for Female Pelvic Dysfunction Disease, Department of Obstetrics and Gynecology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China. The Study Center includes 15 physicians, most of whom have received advanced training in pelvic floor dysfunctional disease and can skillfully perform many types of operations in patients with such disease. Almost 1500 operations to treat pelvic floor dysfunctional disease are performed every year at the center.

PATIENTS

Thirty-six women with rectocele with intractable constipation.

INTERVENTION

Posterior vaginal mesh suspension.

MEASUREMENTS AND MAIN RESULTS

All patients were followed up for 15 to 36 months. In 29 patients, the condition was cured completely; in 5 patients it had improved; and in 2 patients, the intervention had no effect. Insofar as recovery and improved results, the overall effectiveness rate was 94.4%.

CONCLUSION

Posterior vaginal mesh suspension is an effective, harmless, and convenient method for treatment of female rectocele with intractable constipation. It has positive short-term curative effects, with few complications and sequelae. However, the long-term effects of posterior vaginal mesh suspension should be evaluated.

A new rectovaginal fascial plication technique for treatment of rectocele with obstructed defecation: a proof of concept study

INTRODUCTION AND HYPOTHESIS

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Transanal repair for treatment of rectocele in obstructed defaecation: manual or stapled

AIM

Our aim is to evaluate the results of transanal repair of rectocele, either manual or stapled, considering the anatomic, manometric and symptomatic improvement.

METHODS

Forty-five female patients with obstructed defaecation due to anterior rectocele were operated on in the Colorectal Surgery Unit, Mansoura University Hospital, after history taking, detailed questionnaire analysis, barium enema, anorectal manometric studies, EMG studies, anal endosonography, balloon expulsion test, colonic transit time and defaecographic studies. Transanal manual repair was performed for 23 patients (group 1), and transanal stapled repair (group 2) was performed for 22 patients. Postoperative complications were recorded, and the patients were followed up for 1 year. Functional results were evaluated at 3, 6 and 12 months after surgery by questionnaire, anorectal manometry and evacuation proctography.

RESULTS

Time of operation and hospital stay were significantly shorter in group 2. Postoperatively, there was no mortality or major morbidity. Two patients in group 1 experienced temporary anal incontinence (A3 and B1 stages). There were no reported adverse effects on sexual life, but significant clinical improvement was observed in both groups after surgery. Manometrically, there was a significant improvement in MARP, FLAC, RS, UTDV and MTV in both groups (significantly better in the early postoperative period in the stapled group). Also, follow-up defaecographic findings showed a significant decrease in the rectocele size in all the patients.

CONCLUSION

Transanal repair of rectocele is a safe and effective technique in improving symptomatic rectocele. Stapled repair offers the advantage of short operative time, no comorbidity, and shorter hospital stay.

Safety and efficacy of laparoscopic ventral mesh rectopexy for complex rectocele

AIM

Laparoscopic ventral mesh rectopexy, previously described for external rectal prolapse, was evaluated for symptomatic complex rectocoele.

METHOD

From January 2004 to December 2008, 84 (50.9%) patients (mean age 64 ± 5 years) underwent laparoscopic ventral mesh rectopexy for symptomatic complex rectocoele, confirmed preoperatively on dynamic defaecography, with 26 (31%) patients having a concurrent cystocoele. The operative technique was standardized, and those with cystocoele underwent bladder mesh suspension during the same procedure. Prospectively collected data were analysed for preoperative symptoms, operative and functional results [constipation, faecal incontinence (FI), dyspareunia and satisfaction score].

RESULTS

The conversion rate was 3.6% and perioperative morbidity 4.8% with no mortality. At a median follow up of 29 (4-59) months, there was a significant decrease in vaginal discomfort (86-20%) and obstructed defaecation symptoms (83-46%), P < 0.001. There was no significant change in FI (20-16%), no worsening of preoperative symptoms or new complaints of constipation, dyspareunia or FI. Overall, 88% of patients reported an improvement in overall well-being.

CONCLUSION

Laparoscopic ventral mesh rectopexy is a safe and effective method for treating symptomatic complex rectocoele.

Disappointing long-term outcomes after stapled transanal rectal resection for obstructed defecation

BACKGROUND

The aim of this study was to assess both short and long-term functional outcomes and the quality of life of patients treated with stapled transanal rectal resection (STARR) for obstructed defecation syndrome (ODS).

METHODS

Forty-six patients with ODS as a result of rectocele and/or rectal intussusceptions were treated with STARR. Data collected included demographics, OR time, pain score using a visual analog scale (VAS), and complications. The study included defecographic assessment and anal manometry [urge-to-defecate volume (UTDV) and maximum tolerable volume (MTV)], both done preoperatively and 1 year postoperatively. A modified obstructed-defecation syndrome questionnaire (MODS), constipation quality of life (PAC-QOL) score, and CCF continence score were all recorded preoperatively and every 6 months during follow-up.

RESULTS

Mean age of the patients was 48.4 years. Forty-five patients had mild postoperative pain (VAS = 1-2). Only one male patient had severe pain (VAS = 7). Three patients developed stenosis at the staple line 6 months after surgery and were dilated manually. Follow-up ranged from 18 to 48 months and the median follow-up was 42 months. The recurrence rate was 6.5% after 18 months, 10.8% after 36 months, and 13% after 42 months. Significant reduction in MTV and UTDV was recorded. MODS and PAC-QOL showed significant improvement after 6 months; this improvement was maintained for 18 months and then there was a rapid decline until the end of the follow-up period.

CONCLUSIONS

STARR is a safe surgical procedure that effectively restores the anatomy and function of the anorectum in patients with ODS. This correction improves functional and QOL scores; however, a high rate of symptomatic recurrence and QOL score decline are expected after 18 months.

Long-term results of stapled transanal rectal resection (STARR) for obstructive defecation syndrome

BACKGROUND

Rectocele and distal rectal intussusception are organic causes of obstructive defecation syndrome and can be corrected surgically once conservative treatment remedies have been exhausted. Stapled transanal rectal resection (STARR) procedure was introduced as a new treatment approach. This study presents the first long-term results of this procedure. PATIENTS AND PROCEDURES: A STARR procedure was performed in 14 patients (two male, 12 female, age 53 ± 12 years) between January 2003 and August 2005. The indication for surgery was a severe, conservatively treated stool evacuation disorder secondary to symptomatic rectocele and/or distal intussusception.

RESULTS

The mean follow-up period was 68 ± 10 (49-83) months. The defecation score (0-20 points) decreased from a preoperative 13.4 ± 3.4 to 3.2 ± 2.0 after 3 months and increased slightly to 4.7 ± 3.4 by the time of the final examination. In 12 patients (85.7%), the obstructive defecation syndrome was significantly improved. These positive results were also maintained in the long-term. Five patients (38.5%) reported a slight worsening of continence in terms of urge incontinence. The most affected patients were those with preoperative normal continence. Procedure-related anal reoperations were required in two patients (14.3%).

CONCLUSION

Even in long-term, transanal rectal wall resection seems to be an effective therapy for obstructive defecation syndrome. However, it is associated with a substantial number of reoperations and in some patients with persistent urge incontinence.

Clinical and functional evaluation of patients with rectocele and mucosal prolapse treated with transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS)

Background

The aim of the present study was to make a preoperative and postoperative clinical and functional evaluation of patients who underwent transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS procedure) as treatment for obstructed defecation syndrome (ODS) caused by rectocele and rectal mucosal prolapse (RMP).

Methods

This prospective study included 35 female patients, 34 multiparous and one nulliparous, with an average age of 47.5 years (range 31–67 years), rectocele grade II (n = 13/37.1%) or grade III (n = 22/62.9%), associated with RMP. The study parameters included ODS, constipation, functional continence scores and pre- and postoperative cinedefecographic findings.

Results

The average preoperative ODS score, the constipation score and the functional continence score were significantly reduced after surgery from 10.63 to 2.91 (p = 0.001), 15.23 to 4.46 (p = 0.001) and 2.77 to 1.71 (p = 0.001), respectively. Between the first and the eighth postoperative day, the average visual analog scale pain score fell from 5.23 to 1.20 (p = 0.001). Satisfaction with treatment outcome was 79.97, 86.54, 87.65 and 88.06 at 1, 3, 6 and 12 months, respectively. Cinedefecography revealed average reductions in rectocele size from 19.23 ± 8.84 mm (3–42) to 6.68 ± 3.65 mm (range 0–7) at rest and from 34.89 ± 12.30 mm (range 20–70) to 10.94 ± 5.97 mm (range 0–25) during evacuation (both P = 0.001).

Conclusion

The TRREMS procedure is a safe and efficient technique associated with satisfactory anatomic and functional results and with a low incidence of postoperative pain and complications.

Overview of pelvic floor disorders

Disorders of the pelvic floor are common sources of morbidity, decreased quality of life, and are unfortunately increasing in incidence. Owing to their complex and often coexistent nature, a comprehensive, multidisciplinary strategy of testing and care is required. Many nonoperative and operative approaches for management of the symptoms of pelvic floor disorders are available. This article reviews the evaluation and management for these difficult disorders.

Clinical and morphologic correlation after stapled transanal rectal resection for obstructed defecation syndrome

PURPOSE

The clinical and morphologic outcome of patients with obstructed defecation syndrome after stapled transanal rectal resection was prospectively evaluated.

METHODS

Twenty-four consecutive patients (22 women; median age, 61 (range, 36-74) years) who suffered from obstructed defecation syndrome and with rectal redundancy on magnetic resonance defecography were enrolled in the study. Constipation was assessed by using the Cleveland Constipation Score. Morphologic changes were determined by using closed-configuration magnetic resonance defecography before and after stapled transanal rectal resection.

RESULTS

After a median follow-up of 18 (range, 6-36) months, Cleveland Constipation Score significantly decreased from 11 (range, 1-23) preoperatively to 5 (range, 1-15) postoperatively (P = 0.02). In 15 of 20 patients, preexisting intussusception was no longer visible in the magnetic resonance defecography. Anterior rectoceles were significantly reduced in depth, from 30 mm to 23 mm (P = 0.01), whereas the number of detectable rectoceles did not significantly change. Complications occurred in 6 of the 24 patients; however, only two were severe (1 bleeding and 1 persisting pain requiring reintervention).

CONCLUSIONS

Clinical improvement of obstructed defecation syndrome after stapled transanal rectal resection correlates well with morphologic correction of the rectal redundancy, whereas correction of intussusception seems to be of particular importance in patients with obstructed defecation syndrome.

Transperineal rectocele repair with polyglycolic acid mesh: a case series

PURPOSE

This study was designed to evaluate the outcome of transperineal rectocele repair using polyglycolic acid mesh.

METHODS

Eighty-three consecutive females with predominant, symptomatic Stage II or Stage III rectocele underwent transperineal rectocele repair using polyglycolic acid (Soft PGA Felt(R)) mesh and finished their six-month follow-up. No additional interventions, including levatoroplasty or perineorraphy, were performed. The preoperative and postoperative symptom scores and stages of the posterior vaginal wall prolapse were recorded. The end points were reassessed at six months, postoperatively.

RESULTS

Preoperatively, 39 patients had Stage II and 44 patients had Stage III rectocele. The mean total symptom score was 9.87 +/- 1.93, which was reduced to 1.62 +/- 0.59 postoperatively (P < 0.0001). Objective evaluation of anatomic repair revealed that 74 patients (89.2 percent) had anatomic cure. Surgical complications were seen in a total of seven patients (8.4 percent), including hemorrhage (3.6 percent) and wound infection (4.8 percent). Mesh erosion, mesh infection, or worsening of sexual function was not noted.

CONCLUSIONS

Transperineal repair of rectocele with the polyglycolic acid mesh is an efficient therapy for patients with rectocele. It is highly successful in eliminating symptoms of obstructed defecation, and it is free of significant complications.

Evaluation of the stapled transanal rectal resection technique with two staplers in the treatment of obstructive defecation syndrome

BACKGROUND

This study was designed to assess the safety and effectiveness of stapled transanal rectal resection (STARR) and to compare the results of two staplers.

STUDY DESIGN

From February 2001 to June 2005, 37 patients diagnosed with obstructive defecation syndrome were treated with the STARR technique. We analyzed variables related to the patient, diagnosis based on anorectal exploration, surgical technique used, and clinical and radiologic results. We compared these results in patients with procedure prolapsed hemorrhoids (PPH)33-01 (group 1, n = 17) or PPH33-03 (group 2, n = 20). The patients were followed postoperatively at 1, 3, and 6 months, and annually.

RESULTS

Intraoperative hemorrhage at the stapled suture occurred in 13 patients from group 1 and in 6 patients from group 2 (p = 0.03). The degree of postoperative pain was not different between the two groups. During the followup period, radiologic and clinical correction of the rectocele and intussusception was found in 94.6% of the patients, with a recurrence in 1 patient from each group. One patient from group 1 developed stenosis of the anastomosis, which improved with digital dilatations. Six patients from group 1 and none from group 2 (p < 0.05) had granulomas on the staple line at the sites of the reabsorbable reinforcing stitches, which were related to postoperative bleeding and anal discomfort.

CONCLUSIONS

STARR is an effective alternative for treatment of obstructive defecation syndrome, with a low morbidity and a shorter hospital stay. The use of PPH33-03 instead of PPH33-01 decreases the risk of hemorrhagic complications and enables more secure implantation as an outpatient procedure.

[Surgical treatment of rectocele and enterocele: an integrated view of disorders of the posterior vaginal compartment]

Genital prolapse, whether associated or not with urinary, anal or sexual dysfunction, should be evaluated globally to select the appropriate treatment. Rectocele and enterocele are defects of the posterior vaginal compartment, although they can be secondary to abnormalities of the central compartment, since lesions of the perineal raphe and rectovaginal septum can occur in isolation or accompanied by others that also affect the tissues involved in pelvic support. The various surgical approaches to rectocele alone or associated with other defects are reviewed. Likewise, the distinct pathogenic types of enterocele are discussed. Laparoscopic sacrocolpoperineopexy is a promising intervention for the simultaneous correction of defects of the posterior and central compartments. New and better designed studies are required to evaluate the distinct surgical approaches and interventions for genital prolapse.

Laparoscopic or transanal repair of rectocele? A retrospective matched cohort study

PURPOSE

The aim of the study was to analyze the functional and physiologic outcome of patients undergoing laparoscopic rectocele repair compared to a matched cohort undergoing transanal repair.

METHODS

Forty patients with a rectocele who had undergone laparoscopic pelvic floor repair by a laparoscopic gynecologist were matched for age and rectocele size with 40 patients who had undergone a transanal repair by a colorectal surgeon. All patients had clinical evidence of a symptomatic rectocele. All patients were assessed postoperatively with a quality of life (SF-36) score, a modified St. Mark's continence score, a urinary dysfunction score, a Watt's sexual dysfunction score, and a linear analog patient satisfaction score. Fifteen patients in each group had also undergone preoperative and postoperative anal manometry.

RESULTS

At 44 months median follow-up, the transanal approach resulted in significantly more patients reporting bowel symptom alleviation (P < 0.002) and higher patient satisfaction (P < 0.003). The bowel symptom improvement was also sustained over a significantly longer period (P < 0.03). Only 11 patients (28 percent) in the laparoscopic group reported more than 50 percent improvement in their bowel symptoms compared to 25 patients (63 percent) in the transanal group. On univariate analysis of 50 percent bowel symptom improvement, a larger rectocele (P < 0.009), transanal repair (P < 0.02), and presenting with obstructive defecation rather than fecal incontinence (P < 0.03) were statistically significant. Rectocele size (P < 0.012) and treatment cohort (P < 0.006) remained significant on multivariate analysis. Postoperatively, bowel symptom alleviation correlated with patient satisfaction in both groups (P < 0.015). Although not statistically significant, five patients (13 percent) in the transanal group developed postoperative fecal incontinence, which was associated with a low maximum anal resting pressure preoperatively that was further diminished postoperatively (P > 0.06). Only one patient (3 percent) in the laparoscopic group reported a decline in fecal continence, but four patients (10 percent) reported worsening of their symptoms of obstructed defecation. Postoperative dyspareunia was reported by 24 patients in total (30 percent), with significantly more in the transanal group (P > 0.05).

CONCLUSIONS

The transanal repair results in a statistically greater alleviation of bowel symptoms and greater patient satisfaction scores. However, this approach may have a greater degree of functional co-morbidity than the laparoscopic rectocele repair.

Long-term results of the anterior Délorme's operation in the management of symptomatic rectocele

PURPOSE

Although the results of surgery for symptomatic rectocele seem satisfactory initially, there is a trend toward deterioration with time. This study was designed to assess the long-term outcome of Anterior Délorme's operation for rectocele.

METHODS

Questionnaires were sent to all females who had Anterior Délorme's operation performed in Auckland between 1990 and 2000. The questionnaires included obstructed defecation symptoms and a validated fecal incontinence severity index questionnaire and fecal incontinence quality of life questionnaire. Preoperative and postoperative obstructed defecation symptoms and incontinence score were compared.

RESULTS

A total of 150 females (mean age, 56 (range, 30-83) years) who had an Anterior Délorme's operation for a rectocele were identified. One hundred seven patients (71.5 percent; mean age, 56 years) completed the questionnaire. Median follow-up was four (range, 2-11) years. The number of patients with obstructed defecation reduced from 87 preoperatively to 23 postoperatively using Rome II criteria (P < 0.0001). Postoperatively there was a reduction in the number of patients with each of the symptoms of obstructed defecation from 83 to 27 for straining, 87 to 33 for incomplete emptying, 64 to 14 for feeling of blockage, 41 to 10 for digitation (P < 0.0001 for all). The median incontinence score reduced from 20 of 61 preoperatively to 12 of 61 postoperatively (P = 0.0001).

CONCLUSIONS

In patients with symptomatic rectocele, Anterior Délorme's operation provides long-term benefit for patients with obstructed defecation and leads to a significant improvement of incontinence scores.

Stapled mucosectomy for rectocele repair: a preliminary report

There is no optimum surgical method of repair for rectoceles; however, recent interest in the use of the circular hemorrhoidal stapler gun to treat rectoceles has stirred interest. We describe our early results using the circular hemorrhoidal stapler gun for repair of rectoceles. Seven patients (median age, 45 (range, 31-62) years; all females) have been treated. All seven patients presented with incomplete or difficult defecation, four patients required digital vaginal manipulation, and all patients had tried a variety of aperients to aid defecation. The procedure involved two purse-strings and one firing of the circular hemorrhoidal stapler gun. No perioperative complications were encountered. At a median of six (range, 1-10) months follow-up, all patients were able to defecate without difficulty or manipulation. None of the patients required any medication to aid bowel evacuation after surgery. These promising early results support the use of stapled mucosectomy for the repair of rectoceles.

Transanal or vaginal approach to rectocele repair: a prospective, randomized pilot study

PURPOSE

This study was designed to compare outcomes of transanal and vaginal techniques for rectocele repair.

METHODS

Thirty females with symptomatic rectocele were enrolled in a prospective, randomized study. Fifteen underwent transanal rectoceleplasty, the other 15 underwent vaginal posterior colporrhaphy. Patients were assessed by clinical interview and examination, defecography, colon transit study, and anorectal manometry before randomization and 12 months postoperatively. Patients with compromised anal sphincter function or other symptomatic prolapse were excluded.

RESULTS

The study groups were comparable in terms of demographic factors and rectocelerelated symptoms and signs. Eleven (73 percent) patients in the vaginal group and 10 (66 percent) in the transanal group digitally assisted rectal emptying preoperatively. The mean depth of the rectocele was 6.0 +/- 1.6 cm vs. 5.6 +/- 1.8 cm (P = 0.53) in the respective groups. At follow-up, 14 (93 percent) patients in the vaginal group and 11 (73 percent) in the transanal group reported improvement in symptoms (P = 0.08). Need to digitally assist rectal emptying decreased significantly in both groups, to one (7 percent) for the vaginal group and four (27 percent) for the transanal group (P = 0.17 between groups). The respective recurrence rates of rectocele were one (7 percent) vs. six (40 percent) (P = 0.04), and enterocele rates were zero vs. four (P = 0.05). In the vaginal group defecography showed a significant decrease in rectocele depth whereas in the transanal group the difference did not reach statistical significance. None of the patients reported de novo dyspareunia, but 27 percent reported improvement.

CONCLUSION

Patients' symptoms were significantly alleviated by both operative techniques. The transanal technique was associated with more clinically diagnosed recurrences of rectocele and/or enterocele. Adverse effects on sexual life were avoided by use of both techniques.

Does the need to self-digitate or the presence of a large or nonemptying rectocoele on proctography influence the outcome of transanal rectocoele repair?

INTRODUCTION

Transanal repair of anterior rectocoele is a well described technique with variable success rate. In our department we offer repair to patients who fit the following criteria; the need to self digitate (transvaginal or perineal); a large rectocoele; a nonemptying rectocoele. Using these selection criteria previous authors have shown excellent results. The aim of our study was to review our results using this selective approach and also to determine whether the need to self digitate, the presence of a large rectocoele and the degree of emptying could predict which patients would achieve a successful result.

METHODS

Fifty-five patients underwent repair over a three-year period. The main presenting symptom was noted for each patient and also whether self-digitation was required in order to achieve successful evacuation. Dynamic evacuation proctography was performed on all patients. Size of rectocoele, percentage of paste expelled and other proctographic abnormalities were noted for each patient. Follow up was at 6 weeks and 6 months at which point patients were asked whether their symptoms had resolved, improved, remained the same or had worsened.

RESULTS

Complete data were available for 48 of the patients (median age 52 years, IQR 43-63). The presenting complaint was constipation in 22 patients, obstructive defaecation in 15, incomplete evacuation in 5, postdefaecation soiling in 4 and dyspareunia in 2. Thirty-eight patients noted the need to self-digitate, 10 did not. Proctography revealed a large rectocoele (> 4 cm) in 22 patients and a medium or small rectocoele (< 4 cm) in 26 patients. There was a rectocoele alone in 34 patients, in combination with perineal descent in 11 and with intussusception in 3. Median percentage of paste expelled was 70% (range 20-95). At 6 weeks postoperatively, 43 patients had complete resolution of their symptoms whilst 5 reported only some or no improvement. At 6 months, 37 patients sustained complete resolution of their symptoms and 11 did not. Pre-operative factors were compared for these two groups of patients. There was no difference in age (P > 0.05, Mann-Whitney U-test) between the two groups There was also no difference in size of rectocoele, degree of emptying, the presence of another proctographic abnormality and the need to self-digitate between the two groups (P > 0.05, Fisher's exact test).

DISCUSSION

No factors were seen to distinguish between the successful and unsuccessful groups of patients following rectocoele repair, however, an overall success rate of 75% was achieved using our selection criteria. This figure is in keeping with reported success rates in the literature.

Results of anterior levatorplasty for rectocele

OBJECTIVE

Transanal and transvaginal repair of rectocele have been advocated in the treatment of rectocele, with mixed results. The aim of this study was to assess our experience using anterior levatorplasty in the surgical management of rectocele.

PATIENTS AND METHODS

Sixty of 90 women who had undergone anterior levatorplasty for rectocele over a seven year period were traced, and 44 (33 with rectocele only and 11 with rectocele and faecal incontinence) responded to a standardized questionnaire 6 months to 7 years (mean 3.5 years) after anterior levatorplasty. Results were expressed in general and specific improvement of symptoms and were classified as excellent, good, fair, or poor. The effects on social activities, sexual function, and employment were also assessed.

RESULTS

General satisfaction with the operation was rated as good or excellent in 27 of 33 (82%) and 18 of 24 (75%) patients with rectocele only at 2 and 3.2 years follow-up, respectively, and in 7 of 11 (64%) and 5 of 11 (45%) patients with rectocele and faecal incontinence at 2 and 4 years follow-up, respectively. 31 (70%) and 34 (77%) of all patients reported an improvement in sensation and the ability to defaecate, respectively. An improvement in social activities, sexual satisfaction and employment was noted in 10 of 21 (48%), 10 of 23 (43%), and 7 of 12 (58%) patients, respectively.

CONCLUSION

Anterior levatorplasty provides good short and long-term symptomatic improvement in patients with rectocele and avoids complications associated with rectal or vaginal approaches.

Anterior rectocele due to obstructed defecation relieved by botulinum toxin

Background. Surgical repair of rectocele does not always alleviate symptoms related to difficulty in defecation, and some patients have impaired fecal continence after surgical treatment. To avoid complications of surgical repair, we investigated the efficacy of botulinum toxin in treating patients with symptomatic rectocele. Methods. Fourteen female patients with anterior rectocele were included in the study. The patients were studied by using anorectal manometry and defecography, and then treated with a total of 30 units of type A botulinum toxin, injected into 3 sites, 2 on either side of the puborectalis muscle and the third anteriorly in the external anal sphincter, under ultrasonographic guidance. Results. After 2 months, symptomatic improvement was noted in 9 patients (P =.0003). At the same time, rectocele depth (mean +/- SD) was reduced from 4.3 +/- 0.6 cm to 1.8 +/- 0.5 cm (P =.0000001) and rectocele area from 9.2 +/- 1.3 cm(2) to 2.8 +/- 1.6 cm(2) (P =.0000001). Anorectal manometry demonstrated decreased tone during straining from 70 +/- 28 mm Hg at baseline to 41 +/- 19 mm Hg at 1 month (P =.003) and to 41 +/- 22 mm Hg at 2 months (P =.005). No permanent complications were observed in any patient for a mean follow-up period of 18 +/- 4 months. At 1 year evaluation, incomplete or digitally assisted rectal voiding was not reported by any patient, and a rectocele was not found at physical examination. Four recurrent, asymptomatic rectoceles were noted at defecography. Conclusions. Botulinum toxin injections should be considered as a simple therapeutic approach in patients with anterior rectocele. The treatment is safe and less expensive than surgical repair. A more precise method of toxin injections under transrectal ultrasonography accounts for the high success rate. Repeated injections may be necessary to maintain the clinical improvement.

Surgical treatment of constipation and fecal incontinence

Fecal incontinence is a disabling and distressing condition. Many patients are reluctant to discuss the condition with a physician. A thorough history, good physical examination, and detailed anorectal physiologic investigations can help in the therapeutic decision-making algorithm. Patients with isolated anterior sphincter defects are candidates for overlapping repair. In the presence of unilateral or bilateral pudendal neuropathy, the patient should be counseled preoperatively regarding a [table: see text] lower anticipation of success. If the injury occurred shortly before the planned surgery and neuropathy is present, it may be prudent to wait because neuropathy sometimes can resolve within 6 to 24 months of the injury. Pudendal nerve study may help determine surgical timing. An anterior sphincter defect combined with a rectovaginal fistula can be approached by overlapping sphincter repair and a concomitant transanal advancement flap. Patients who had undergone multiple such procedures may benefit from concomitant fecal diversion at the time of repeat sphincter repair. Patients with global or multifocal sphincter injury may be candidates for a neosphincter procedure. The stimulated graciloplasty and artificial bowel sphincter are reasonable options. In the absence of the availability of these techniques or because of financial constraints, consideration could be given to bilateral gluteoplasty or unilateral or bilateral nonstimulated graciloplasty. The postanal repair still serves a role in patients with isolated decreased resting pressures with or without neuropathy or external sphincter injury with minimal degrees of incontinence. Biofeedback and the Procon device may play a role in these patients. Lastly, fecal diversion must be considered as a means of improving the quality of life because the patient can participate in the activities of daily living without the fear of fecal incontinence.

Rectal prolapse, rectal intussusception, rectocele, and solitary rectal ulcer syndrome

Rectal prolapse can be diagnosed easily by having the patient strain as if to defecate. A laparoscopic rectopexy should be recommended. Intussusception is more an epiphenomenon than a cause of defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining, and therapy should include restoring a normal defecation habit. Rectocele should be left alone; an operation may be considered if it is larger than 3 cm and is causing profound symptoms despite maximizing medical therapy for the associated defecation disorder.

Analysis of patients with poor outcome of rectocele repair

PURPOSE

The aim of the present study was to analyze the prognostic value of clinical data and physiologic tests in patients undergoing rectocele repair for obstructed defecation.

METHODS

Between 1988 and 1996, 89 consecutive female patients with obstructed defecation caused by a rectocele were enrolled in the study. Median age at time of presentation was 55 (range, 35-81) years. All patients underwent a combined transvaginal and transanal rectocele repair. End evaluation to assess long-term results was performed by an independent observer after a median duration of follow up of 52 (range, 12-92) months. The presence of the following five symptoms was evaluated: prolonged and unsuccessful straining at stool, feelings of incomplete evacuation, manual assistance during defecation, false urge to defecate, and a stool frequency of less than three times per week. When none or just one of these symptoms was present, outcome of rectocele repair was considered successful. The outcome was considered as a failure when two or more of these symptoms were recorded. Furthermore, all patients were asked to score the outcome of their operations as excellent, good, moderate, or poor. Clinical data and the results of physiologic tests obtained in patients with a poor outcome of surgery were compared with those obtained in patients with a successful outcome.

RESULTS

Objective outcome of rectocele repair, based on the presence of symptoms, was found to be successful in 63 (71 percent) patients. Sixty-one patients considered outcome of surgery excellent or good (69 percent). Graded subjective outcomes between the two groups showed significantly better grades in cases of success. Duration of symptoms, number of symptoms, age, parity, and previous hysterectomy had no influence on the final outcome of surgery. Defecographic parameters, such as size of the rectocele, barium trapping in the rectocele, poor rectal evacuation, or intussusception, had no prognostic value. Signs of anismus based on defecography, electromyography, and balloon-expulsion studies did not influence outcome of surgery. The presence of symptoms such as defecation frequency, manual assistance, severe straining, false urge to defecate, or feelings of incomplete evacuation had no impact on the outcome. However, in patients without a daily urge to defecate or with a stool frequency of less than once per week, results of rectocele repair were significantly worse than in patients with a daily urge to defecate or a defecation frequency of more than once per week or both. In 14 of 26 patients with a poor outcome, colonic transit studies were performed. A delayed passage was observed throughout the entire colon in seven patients, in the left part of the colon and the rectosigmoid colon in four patients, and in the rectosigmoid colon in one patient. In two patients colonic transit was normal.

CONCLUSIONS

Combined transvaginal and transanal rectocele repair is beneficial for the majority of patients with obstructed defecation. In patients without a daily urge to defecate or a stool frequency of less than once per week, indicating colonic malfunctioning, the outcome of rectocele repair seems to be poor.

[Surgical treatment of anterior rectoceles in women. The transanal approach]

Anterior rectocele is a herniation of the anterior rectal wall into the vagina, which may be either isolated or associated with other pelvic floor disorders. Rectocele could result in outlet obstruction with dyschezia, manual extraction of faeces and/or false incontinence. Rectocele is diagnosed clinically, and can be confirmed by defecography. Other tests may demonstrate associated causes of constipation. Symptomatic rectoceles can be treated via a transrectal route, with two or three layers of plication of the rectal wall and excision of the redundant mucosal flap. The results of transrectal repair are good: short hospital stay, no mortality, morbidity less than 5%, good short- and mid-term results in approximately 80% of cases. Selection criteria in favour of the transrectal approach have not been clearly identified.

Treatment of impaired defecation associated with rectocele by behavorial retraining (biofeedback)

PURPOSE

Large rectoceles have been associated with symptoms of impaired rectal evacuation, often leading to rectocele repair. However, these symptoms, or the anatomic abnormality, may be caused, at least in part, by a primary disturbance of rectoanal coordination. This study aimed to determine the efficacy of biofeedback therapy in such patients.

METHODS

Thirty-two female patients (median age, 52 years) complaining of impaired rectal evacuation and with a rectocele greater than 2 cm at proctography were evaluated by structured questionnaire before, immediately after treatment, and at follow-up. Physiologic and proctographic findings were related to outcome.

RESULTS

Immediate results were available in 32 patients and medium-term follow-up (median, 10; range, 2-30 months) in 25 patients. At follow-up 14 (56 percent) patients felt a little and 4 (16 percent) patients felt major improvement in symptoms, including 3 (12 percent) with complete symptom relief. Immediately after biofeedback there was a modest reduction in need to strain (from 72 to 50 percent), feeling of incomplete evacuation (from 78 to 59 percent), need to assist defecation digitally (from 84 to 63 percent), and need to use an evacuant (from 47 to 28 percent), and this was maintained at follow-up. Bowel frequency was significantly normalized at follow-up (P = 0.02). Pretreatment presence of symptoms of digitally assisting defecation, pelvic floor incoordination, and proctographic rectocele size and contrast trapping, did not predict outcome.

CONCLUSIONS

Behavioral therapy, including biofeedback, leads to major symptom relief in a minority, and partial symptom relief in a majority, of patients with a feeling of impaired defecation and the presence of a large rectocele. Residual symptoms are common. Biofeedback may be a reasonable first-line treatment for such patients.

Transanal repair of rectocele corrects obstructed defecation if it is not associated with anismus

PURPOSE

Rectocele is often associated with anorectal symptoms. Various surgical techniques have been described to repair the rectocele. The surgical results are variable. This study evaluated the results of transanal repair of rectocele, with particular emphasis on the impact of concomitant anismus on postoperative functional outcome.

METHODS

Fifty-nine consecutive females who underwent transanal repair of rectocele for obstructed defecation were prospectively reviewed. All 59 patients were parous with a median parity of 2 (range, 1-6) and a median age of 58 (range, 46-68) years. The median length of follow-up was 19 (range, 6-40) months. Anismus was detected by anorectal physiology and defecography. The functional outcome was assessed by a standard questionnaire, physical examination, anorectal manometry, neurophysiology, and defecography. The quality-of-life index was obtained using a visual analog scale (from 1-10, with 10 being the best).

RESULTS

The functional outcome of transanal repair of rectocele was superior in patients without anismus. Forty (93 percent) of the 43 patients without anismus showed improved evacuation after repair compared with 6 (38 percent) of the 16 patients with anismus (P<0.05). The quality-of-life index improved (9 vs. 4) if anismus was not present (P<0.05). There were minimal complications. Hemorrhage requiring blood transfusion (2 units) occurred in one patient and urinary retention in another.

CONCLUSION

Transanal repair of rectocele is safe and, in the absence of anismus, effectively corrects obstructed defecation.

Management of pelvic organ prolapse

The wide variety of available pessaries permits rather precise choice of pessary to meet a given patient's needs. Different approaches are reviewed. A paradigm for choosing a surgical repair based on the fascial and muscular support defects, as well as the functional demands and limitations of the patient is presented.

An anatomic and functional assessment of the discrete defect rectocele repair

OBJECTIVE

The aim of this study was to describe the anatomic and functional results of the discrete fascial defect rectocele repair.

STUDY DESIGN

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.

RESULTS

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 improved >2 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.

CONCLUSIONS

The discrete defect rectocele repair provides anatomic correction of rectoceles with alleviation of associated symptoms for most women.

Techniques of rectocele repair and their effects on bowel function

Gynecologists have traditionally evaluated rectocele repair by its effect on vaginal function; coloproctologists have traditionally evaluated its effect on bowel function. Hence different operative criteria and surgical techniques have arisen, but with very little prospective, objective evaluation. The purpose of this review is to describe the surgical techniques used to repair the rectocele and the most common investigations used during its evaluation. Anorectal investigations identify concomitant pathology, may explain pathophysiology, provide objective outcome criteria and attempt to predict the patients that will most benefit from surgery. However, because of the complex neuromuscular, physiological and mechanical interactions that contribute to impaired rectal emptying, their usefulness in improving functional outcome has been limited. Many patients experience improvement, but still are left with some symptoms of impaired defecation despite anatomic correction.

Transanal approach to rectocele repair may compromise anal sphincter pressures

PURPOSE

This study prospectively assessed the functional results, particularly anal sphincter impairment, following transanal repair of rectocele for chronic intractable constipation.

METHOD

Twenty-one consecutive women (mean age, 47.7 (standard error of the mean, 2.7) years) had the diagnosis of rectocele obstructing defecation made on synchronized anal manometry, electromyography, and cinedefecography. All underwent a standardized transanal repair with controlled anal stretching (maximum of 4 cm) from self-retaining anal retractors. The clinical function and anorectal manometry were assessed before surgery and were repeated six months later.

RESULTS

All 21 patients were subjectively satisfied with the relief from constipation after surgery. There were significant improvements in the straining at defecation (before, n = 19; after, n = 3; P = 0.001), need to digitate per vagina (before, n = 16; after, n = 0; P = 0.001), stool frequency (before, 3.8 (0.7) times weekly; after, 8.6 (1.2); P = 0.004), and laxative requirements (before, n = 7; after, n = 0; P = 0.03). Although none were clinically incontinent, there was a mean 28 mmHg impairment in resting (P < 0.05) and 42.6 mmHg impairment in maximum squeeze anal pressures (P < 0.05) after operations. There was no other morbidity.

CONCLUSION

Transanal rectocele repair effectively improves constipation problems, at the risk of impaired anal sphincter function. Although clinical incontinence was minimum, an alternative approach to rectocele repair should be considered when anal sphincters are lax.