Functional and physiological outcome following transanal repair of rectocele

Rectal Prolapse Pathological Features: Findings in Patients With Outlet Obstruction Treated With Stapled Transanal Rectal Resection

BACKGROUND

Obstructed defecation syndrome is a common multifactorial disease for which treatment is based primarily on clinic presentation for the lack of reliable instrumental and anatomopathological criteria.

OBJECTIVE

The study aimed to analyze the pathological findings of the resected rectal specimens after stapled transanal rectal resection in patients affected by outlet obstruction.

DESIGN

Retrospective cohort study.

SETTINGS

University hospital.

PATIENTS

Patients who underwent rectal resection for obstructed defecation syndrome due to internal rectal prolapse were included.

INTERVENTIONS

Specimens of patients with obstructed defecation syndrome were analyzed through conventional histology and morphometric image analysis and compared with those of rectal specimens excised for oncological diseases.

MAIN OUTCOME MEASURES

Analysis of the anatomopathological impairments underlying rectal prolapse.

RESULTS

From January 2017 to December 2020, 46 specimens from the stapled transanal rectal resection group were compared with 40 specimens from the control group. In the stapled transanal rectal resection group, conventional histology revealed 34 samples (73.9%) had moderate- to severe-grade fibrosis with moderate-grade nerve degeneration in 33 cases (71.7%). In the control group, conventional histology revealed the absence of fibrosis in 31 specimens (77.5%), whereas the absence of nerve degeneration was detected in 37 specimens (92.5%). In the stapled transanal rectal resection group, morphometric image analysis showed severe-grade fibrosis in 25 cases (54.4%) compared to only low-grade fibrosis in 11 cases (27.5%).

LIMITATIONS

The small sample size and the retrospective design of the study were limitations. Moreover, there was no chance to use specimens from healthy volunteers as the control group.

CONCLUSIONS

Stapled transanal rectal resection specimens showed a higher rate of fibrosis and nerve dysplasia, an important parameter that is typically not considered preoperatively and could lead patients with rectal prolapse to the best treatment approach. See Video Abstract at http://links.lww.com/DCR/B928 .

CARACTERSTICAS ANATOMOPATOLGICAS EN EL PROLAPSO DE RECTO HALLAZGOS EN PACIENTES CON OBSTRUCCIN DEL TRACTO DE SALIDA TRATADOS CON RESECCIN RECTAL TRANSANAL CON GRAPAS

ANTECEDENTES:El síndrome de obstrucción del tracto de salida, es una afección multifactorial común, cuyo tratamiento está basado principalmente en la presentación clínica, ésto, debido a la falta de criterios confiables tanto instrumentales como anatomopatológicos.OBJETIVO:Analizamos los hallazgos histopatológicos de las piezas de resección rectal obtenidas por vía transanal mediante grapas, realizadas en pacientes que presentaban obstrucción del tracto de salida.DISEÑO:Este fue un estudio de cohorte retrospectivo.AJUSTE:El escenario fue un hospital universitario.PACIENTES:Aquellos sometidos a resección rectal por síndrome obstructivo del tracto de salida causada por un prolapso rectal interno.INTERVENCIONES:Los especímenes de pacientes con síndrome obstructivo defecatorio fueron analizados mediante histología convencional y análisis de imágenes morfométricas, comparados con especímenes rectales resecados por enfermedad oncológica.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario se concentró en la investigación de las deficiencias anatomopatológicas subyacentes del prolapso rectal interno.RESULTADOS:Desde enero de 2017 hasta diciembre de 2020, se compararon 46 especímenes del grupo de resección rectal transanal con grapas con 40 especímenes del grupo de control. En histología convencional, el grupo de resección rectal transanal con grapas, 34 muestras (73,9%) presentaron un grado de fibrosis moderada-severa con un grado moderado de degeneración neurógena en 33 casos (71,7%). En el grupo control, la histología convencional reveló ausencia de fibrosis en 31 especímenes (77,5 %), mientras que la ausencia de degeneración neurógena se detectó en 37 controles (92,5 %). En el grupo de resección rectal transanal con grapas, el análisis de imágenes morfométricas mostró fibrosis moderada y fibrosis severa en 19 (41,3%) y 25 (54,4%) casos, respectivamente. En el grupo control, el análisis de imágenes morfométricas mostró solo un bajo grado de fibrosis en 11 casos (27,5%). Se encontró una diferencia significativa en todos los grados de fibrosis y displasia neurógena entre los grupos en las evaluaciones de análisis de imagen morfométrica e histología convencional (p < 0,001).LIMITACIONES:El pequeño tamaño de la muestra y el diseño retrospectivo del estudio. Además, no existe la posibilidad de utilizar un grupo de control con muestras de voluntarios sanos.CONCLUSIONES:Los especímenes de resección rectal transanal con grapas mostraron una mayor tasa de fibrosis y displasia neurógena, parámetro importante que actualmente no está considerado antes de la operación y en un futuro muy cercano podría orientar a los pacientes con prolapso rectal interno hacia un mejor enfoque de tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B928 . (Traducción-Dr. Xavier Delgadillo ).

Laparoscopic or transanal repair of rectocele? Comparison of a reduction in rectocele size

PURPOSE

This study aimed to compare the reduction in rectocele size after laparoscopic ventral rectopexy (LVR) with that after transanal repair (TAR).

METHODS

Forty-six patients with rectocele who underwent LVR and 45 patients with rectocele who received TAR between February 2012 and December 2022 were included. This was a retrospective analysis of prospectively collected data. All patients had clinical evidence of a symptomatic rectocele. Bowel function was evaluated using the constipation scoring system (CSS) and fecal incontinence severity index (FISI). Substantial symptom improvement was defined as at least a 50% reduction in the CSS or FISI scores. Evacuation proctography was performed before surgery and 6 months postoperatively.

RESULTS

Constipation was substantially improved in 40-70% of the LVR patients and 70-90% of the TAR patients over 5 years. Fecal incontinence was markedly improved in 60-90% of the LVR patients across 5 years and in 75% of the TAR patients at 1 year. Postoperative proctography showed a reduction in rectocele size in the LVR patients (30 [20-59] mm preoperatively vs. 11 [0-44] mm postoperatively, P < 0.0001) and TAR patients (33 [20-55] mm preoperatively vs. 8 [0-27] mm postoperatively, P < 0.0001). The reduction rate of rectocele size in the LVR patients was significantly lower than that in the TAR patients (63 [3-100] % vs. 79 [45-100] %, P = 0.047).

CONCLUSION

The reduction in rectocele size was lower in the patients who underwent LVR than in those who received TAR.

Annual long-term functional outcomes after transanal repair for symptomatic rectocele

Purpose

This study was performed to assess the long-term annual functional outcomes and quality of life (QOL) after transanal rectocele repair.

Methods

We evaluated retrospectively collected data from patients who underwent transanal repair for symptomatic rectocele between February 2012 and December 2018. The Constipation Scoring System (CSS), the Fecal Incontinence Severity Index (FISI), and several QOL questionnaires (e.g., the Patient Assessment of Constipation-QOL [PAC-QOL], Fecal Incontinence QOL, and the 36-Item Short Form Survey [SF-36]) were administered before surgery and annually after surgery. Additionally, physiological assessments and defecography were performed before and after surgery. Substantial symptom improvement, indicated by at least a 50% reduction in the CSS or FISI score, was evaluated postoperatively. All postoperative follow-up results were compared with the preoperative data.

Results

Thirty-two patients were included in the study. The median follow-up period was 5 years (range, 0.5-7 years). Postoperative defecography showed that the rectocele size significantly decreased (P<0.0001). However, the physiological assessment did not reveal postoperative changes. The CSS score 1 year after surgery was significantly lower than the preoperative score (P<0.0001) and remained significantly low until the long-term follow-up. Constipation improved by more than 80% 2 to 5 years postoperatively, and fecal incontinence improved in 2/3 of the patients after 5 years. The PAC-QOL scores significantly improved (all P<0.05) over time until the 3-year and long-term follow-ups, and 6 of the 8 SF-36 scores significantly improved at specific points postoperatively.

Conclusion

Transanal rectocele repair provides long-term improvement for constipation and constipation-specific QOL.

Outcomes of Transvaginal Anterior Levatorplasty with Posterior Colporrhaphy for Symptomatic Rectocele

Objectives:

To clarify the long-term outcomes of transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele with defecographic changes.

Methods:

Consecutive patients undergoing transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele were prospectively registered and retrospectively reviewed using medical records. Symptoms, fecal incontinence, and defecographic findings were evaluated before and after surgery.

Results:

Fifty-seven women (mean age, 68 years) were identified, and the median disease duration was 24 months. Symptoms of vaginal mass (n = 32) and difficult defecation (n = 21) disappeared (90.6% and 71.4%, respectively) or improved (6.3% and 28.6%, respectively) after surgery. However, the feeling of residual stool was unchanged in two of eight patients. Seventeen patients who performed digitation on defecation before surgery discontinued digitation after surgery. The proportion of patients who had fecal incontinence preoperatively (40.4%) decreased significantly after surgery (17.5%) during a median follow-up period of 47 months. Defecography revealed a disappearance or improvement of rectocele in all 18 patients examined. The average rectocele size decreased significantly in six improved patients (p = 0.0006, paired t-test).

Conclusions:

Transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele was a useful option to improve symptoms and anatomical disorders in the long term, but it had limitations in improving defecatory symptoms.

Transanal repair of rectocele: prospective assessment of functional outcome and quality of life

AIM

This study aimed to assess the functional outcome of transanal repair of rectocele using patient symptom scores and quality of life (QOL) instruments.

METHOD

Patients who underwent transanal repair for symptomatic rectocele between February 2012 and August 2017 were included. This study was a retrospective analysis of prospectively collected data. A standard questionnaire including the Constipation Scoring System (CSS), the Fecal Incontinence Severity Index (FISI) and QOL instruments [Patient Assessment of Constipation (PAC)-QOL, Fecal Incontinence QOL Scale, Short-Form 36 Health Survey (SF-36)] was administered before and after the operation. Physiological assessment and proctography were performed before and after the operation.

RESULTS

Thirty patients were included. The median follow-up was 36 (6-72) months. Postoperative proctography showed a reduction in rectocele size [34 mm (14-52 mm) vs 10 mm (0-28 mm), P < 0.0001]. Physiological assessment showed no significant postoperative changes. Constipation was improved in 15/21 patients (71%) at 1 year and 14/20 patients (70%) at the mid-term follow-up. The CSS score reduced at 3 months [12 (8-12) vs 6 (1-12), P < 0.0001] and remained significantly reduced over time until the mid-term follow-up. Faecal incontinence was improved in two-thirds patients at 1 year. Four patients developed new-onset faecal incontinence. All the PAC-QOL scale scores significantly improved over time until 1 year, while two of the eight SF-36 scale scores showed significant postoperative improvement.

CONCLUSION

Transanal repair for rectocele improves constipation and constipation-specific QOL.

Absence of a rectocele may be correlated with reduced internal anal sphincter function in patients with rectal intussusception and fecal incontinence

PURPOSE

Fecal incontinence (FI) is common in patients with rectal intussusception (RI), although the mechanism behind its formation is unclear. Recent data indicate that a reduction in internal sphincter tone may cause FI, which becomes notable with increasing RI levels. However, the roles of other anatomical abnormalities in anal function remain unclear. This study assessed the relationships between various pelvic floor abnormalities and anal sphincter function in patients with RI and FI.

METHODS

Data for patients with RI, collected in a prospective pelvic floor database, were assessed retrospectively. All women with FI, without anal sphincter defect, were included. Data on anorectal physiology and evacuation proctography were analyzed.

RESULTS

Of 397 patients with RI, 85, who had predominantly passive FI, met the inclusion criteria. Maximum resting pressure (MRP) was significantly lower in patients with rectoanal intussusception (RAI) than in those with rectorectal intussusception (RRI) [51.1 (17.9-145.8) vs. 70.7 (34.7-240.6) cmH₂O, P = 0.007]. Moreover, MRP was significantly lower in RI patients without rectocele than in RI patients with rectocele [50.1 (17.9-111.0) vs. 69.9 (34.7-240.6) cmH₂O, P < 0.0001]. Regression analysis showed that RAI rather than RRI and RI without rectocele rather than RI with rectocele were predictive of decreased MRP. However, no variable was significantly associated with decreased maximum squeeze pressure on multivariate analysis.

CONCLUSION

In addition to an advanced level of intussusception, the absence of a rectocele may be correlated with reduced internal anal sphincter function in patients with RI and FI.

Surgical interventions for posterior compartment prolapse and obstructed defecation symptoms: a systematic review with clinical practice recommendations

INTRODUCTION AND HYPOTHESIS

Several posterior compartment surgical approaches are used to address posterior vaginal wall prolapse and obstructed defecation. We aimed to compare outcomes for both conditions among different surgical approaches.

METHODS

A systematic review was performed comparing the impact of surgical interventions in the posterior compartment on prolapse and defecatory symptoms. MEDLINE, Embase, and ClinicalTrials.gov were searched from inception to 4 April 2018. Randomized controlled trials, prospective and retrospective comparative and single-group studies of women undergoing posterior vaginal compartment surgery for vaginal bulge or bowel symptoms were included. Studies had to include both anatomical and symptom outcomes both pre- and post-surgery.

RESULTS

Forty-six eligible studies reported on six surgery types. Prolapse and defecatory symptoms improved with native-tissue transvaginal rectocele repair, transanal rectocele repair, and stapled transanal rectocele repair (STARR) surgeries. Although prolapse was improved with sacrocolpoperineopexy, defecatory symptoms worsened. STARR caused high rates of fecal urgency postoperatively, but this symptom typically resolved with time. Site-specific posterior repairs improved prolapse stage and symptoms of obstructed defecation. Compared with the transanal route, native-tissue transvaginal repair resulted in greater improvement in anatomical outcomes, improved obstructed defecation symptoms, and lower chances of rectal injury, but higher rates of dyspareunia.

CONCLUSIONS

Surgery in the posterior vaginal compartment typically has a high rate of success for anatomical outcomes, obstructed defecation, and bulge symptoms, although these may not persist over time. Based on this evidence, to improve anatomical and symptomatic outcomes, a native-tissue transvaginal rectocele repair should be preferentially performed.

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.

Laparoscopic ventral mesh rectopexy for obstructive defecation syndrome: still the way to go?

Laparoscopic ventral mesh rectopexy (VMR) has become a popular surgical technique for treating women with full-thickness rectal prolapse with a low recurrence rate, as demonstrated by several studies. In addition, it is increasingly applied to female patients with obstructive defecation syndrome (ODS) caused by intussusception ± rectocele. Functional improvement can be achieved in a high number of patients with ODS, but expectations need to be discussed carefully, as a few patients may not benefit at all. In particular, long-term data on functional outcome and complications following laparoscopic VMR for ODS are still lacking in the literature. Notably, laparoscopic VMR appears to be better than alternative operations for prolapse, intussusception, and rectocele in terms of efficacy, recurrence rates, and adverse effects, but there is a lack of evidence directly comparing techniques through randomized controlled trials; thus, its exact role stills needs to be defined in the future.

A transanal procedure using TST STARR Plus for the treatment of Obstructed Defecation Syndrome: 'A mid-term study'

PURPOSE

The aim of this study was to assess the safety, efficacy and outcomes of TST STARR (Stapled Transanal Rectal Resection) plus to treat Obstructed Defecation Syndrome (ODS) at mid-term follow-up.

METHODS

From April 2013 to September 2014, 50 cases (7 male patients) with ODS caused by rectocele and/or internal rectal prolapse were treated with the new TST STARR Plus. Clinical data from the 18 month mid-term follow up, including efficacy and constipations were recorded.

RESULTS

The average duration of surgery was 21 ± 4 min (range 12-35 min). The average postoperative hospital stay was 5 days (range 4-8 days). The pathological findings showed that the specimens contained full-thickness rectal tissue in all patients. The mean volume of resected specimen was 12.3 cm(3). Postoperative complications included five cases with transient faecal urgency that dissipated after 3 months; one patient suffered anastomotic bleeding on the sixth day after surgery, with successful haemostasis achieved through conservative therapy. The Wexner constipation score improved in patients affected by ODS from 13.96 ± 2.37 preoperatively to 7.00 ± 3.90, 7.28 ± 3.91, 8.10 ± 4.05 and 8.44 ± 4.08 at 3,6,12 and 18 months postoperatively, respectively, with all p < 0.05. Overall outcome was reported as ''excellent'' in 42% of patients, ''good'' in 36% of patients, ''adequate'' in 12% of patients, and ''poor'' in 10% of patients after 18 months of follow-up.

CONCLUSIONS

The TST STARR Plus is a simple, safe, and effective option for selected patients with ODS. Long-term prospective clinical studies are needed to validate the advantages of this emerging, novel procedure.

Surgery for obstructed defecation syndrome-is there an ideal technique

Obstructive defecation syndrome (ODS) is a common disorder with a considerable impact on the quality of life of affected patients. Surgery for ODS remains a challenging topic. There exists a great variety of operative techniques to treat patients with ODS. According to the surgeon’s preference the approach can be transanal, transvaginal, transperineal or transabdominal. All techniques have its advantages and disadvantages. Notably, high evidence based studies are significantly lacking in literature, thus making accurate assessments difficult. Careful patient’s selection is crucial to achieve optimal functional results. It is mandatory to assess not only defecation disorders but also evaluate overall pelvic floor symptoms, such as fecal incontinence and urinary disorders for choosing an appropriate and tailored strategy. Radiological investigation is essential but may not explain complaints of every patient.

[Transanal procedure for functional bowel diseases]

The transanal operative procedure for the treatment of obstructive defecation syndrome (ODS) can be secondarily applied in cases of failure or ineffectiveness of conservative treatment. Clinically established transanal procedures are rectocele resection (RR), mucosectomy for internal rectal prolapse according to the Rehn-Delorme procedure (MR) and stapled transanal rectal resection (STARR Contour Transtar). Only few studies have indicated the value of RR and MR in the treatment of obstructive diseases and in general study quality and evidence level are low. There might be an indication in rectocele-associated symptoms, such as incomplete evacuation, straining and digitation. In contrast the STARR procedure has been well characterized by a large number of high quality studies providing an elevated evidence level for the treatment of ODS. Functional results are available with a follow-up of 1 year up to 68 months postoperatively. Response rates of up to 90% were reported whereas recurrence rates were given as a maximum of 18% at 68 months follow-up. In summary the STARR procedure provides good functional results for conservative refractory outlet obstruction with minor morbidity and outcome seems to remain stable in the long-term follow-up.

Transvaginal posterior colporrhaphy combined with laparoscopic ventral mesh rectopexy for isolated Grade III rectocele: a prospective study of 27 patients

AIM

The aim of this study was to evaluate prospectively transvaginal posterior colporrhaphy (TPC) combined with laparoscopic ventral mesh rectopexy (LVR) in patients with a symptomatic isolated rectocele.

METHOD

Patients with these complaints underwent dynamic and static MRI. All consecutive patients with a Grade III (4 cm or more) rectocele and without internal/external rectal prolapse, enterocele and external sphincter damage were operated on. The patients completed the Obstructed Defecation Syndrome (ODS) score and the Cleveland Clinic Incontinence Score (CCIS). All tests were repeated after treatment. Dynamic disorders of the pelvic floor detected by MRI were recorded.

RESULTS

In 27 patients [median age 67 (46-73) years], TPC combined with LVR was feasible. Complications were limited to port site infection in two patients. Sexual discomfort (n = 8) due to prolapse diminished in six (75%) patients and in one (4%) de novo dyspareunia developed after treatment. The median follow-up was 12 (10-18) months. The median CCIS was 12 (10-16) before treatment and 8 (7-10) after (P < 0.0001). The median ODS score was 19 (17-23) before and 6 (3-10) after treatment (P < 0.0001). There was no change in urinary symptoms.

CONCLUSION

TPC combined with LVR for obstructed defaecation and faecal incontinence in patients with Grade III rectocele significantly relieves the symptoms of these disorders.

A transanal procedure using an endoscopic linear stapler for obstructed defecation syndrome: the first Chinese experience

BACKGROUND

Transanal surgery using an endoscopic linear stapler is a recognized, but not widely performed technique for the treatment of obstructed defecation syndrome (ODS). A study of consecutive patients was conducted to evaluate the safety and effectiveness of the technique for the treatment of ODS in Chinese patients.

METHODS

From November 2008 to December 2010, 43 female patients with ODS caused by rectocele and/or rectal intussusception underwent transanal surgery using an endoscopic linear stapler in three Chinese hospitals. Clinical and functional data including the Wexner constipation score and outcome classification were analyzed retrospectively.

RESULTS

The average duration of surgery was 23 ± 4 min (range 15-30 min). Blood loss was 10 ± 2 ml (range 5-15 ml). The average postoperative hospital stay was 5 days (range 4-6 days). The pathologic findings showed that the specimen contained rectal muscle in all patients. Postoperative complications included 4 patients with transient fecal urgency, 3 patients with anorectal pain, and one patient with mild bleeding from the stapled suture line. Three patients reported minor fecal incontinence (Wexner score less than 3). During a median follow-up of 12 months (range, 3-26 months), the mean constipation score improved from preoperative 13.56 to postoperative 5.07 at 1 year (P < 0.05). The outcome at 1 year was excellent in 18 of 43 patients, good in 13, fairly good in 7, and poor in 5. Postoperative defecography was performed in 28 patients. Rectocele disappeared in 15 patients. Rectocele depth was reduced from 34 ± 4 mm preoperatively to 17 ± 3 mm postoperatively (P < 0.05).

CONCLUSION

The transanal procedure using an endoscopic linear stapler is an easy, safe, and effective option for selected patients with ODS. Long-term prospective, randomized, controlled studies are needed to confirm the advantages of this procedure in comparison with the traditional transanal and stapled transanal rectal resection (STARR) techniques.

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.

Randomized controlled trial between perineal and anal repairs of rectocele in obstructed defecation

OBJECTIVE

The present study was designed to evaluate functional outcome of perineal repair with and without levatorplasty versus transanal repair of rectocele in obstructed defecation.

METHODS AND PATIENTS

A total of 48 multiparous women with obstructed defecation caused by a rectocele were randomly allocated to three groups: transperineal repair with levatorplasty (TPR-LP; n = 16); transperineal repair without levatorplasty (TPR; n = 16); and transanal repair (TAR; n = 16). The study included defecographic assessment, anal manometry, symptom improvement, sexual function, and score on a function questionnaire. Assessments were done preoperatively and 6 months postoperatively.

RESULTS

Defecography showed significant reduction in size of rectocele in all groups. Constipation improved significantly in both groups with transperineal repair but not in the group with transanal repair. Significant reductions in mean anal resting pressure, maximum reflex volume, and urge-to-defecate volume were observed only with the transperineal approach (with and without levatorplasty). Functional score improved significantly in the transperineal groups (with levatorplasty, P < 0.001; without levatorplasty, P < 0.01), but not in the transanal group (P = 0.142). Levatorplasty added to transperineal repair significantly improved the overall functional score compared with transperineal repair alone (P < 0.01) and transanal repair TAR (P < 0.001).

CONCLUSIONS

Rectocele repair appears to improve anorectal function by improving rectal urge sensitivity. Transperineal repair of rectocele is superior to transanal repair in both structural and functional outcome. Levatorplasty improves functional outcome, but potential effects on dyspareunia should be discussed with the patient.

Functional outcome and quality of life after stapled transanal rectal resection for obstructed defecation syndrome

PURPOSE

Clinical studies have demonstrated that stapled transanal rectal resection with Contour Transtar (Transtar procedure) is a safe and effective treatment for patients with obstructive defecation syndrome. The aim of this study was to determine functional outcome and quality of life after the procedure.

METHODS

Female patients with obstructive defecation syndrome were enrolled prospectively for the Transtar procedure. Intussusception and anterior rectocele were confirmed by clinical investigation and by magnetic resonance defecography. Functional outcome was measured by obstructed defecation syndrome score, severity of symptoms score, and Wexner score preoperatively and postoperatively. Quality of life was assessed by the Cleveland Clinic constipation score, the fecal incontinence quality of life scale, and the SF-36v2 health survey.

RESULTS

Between January 2007 and November 2008, 52 consecutive patients (median age: 64 years) were included in the study. Before the surgery, 12 patients experienced fecal incontinence. Functional scores improved significantly: 6 weeks after surgery, the obstructed defecation syndrome score decreased from a median of 16 (range, 9-22) to 5 (range, 2-10) and the severity of symptoms score, from 16 (range, 9-21) to 4 (range, 0-9) (each P < .0001). After 6 weeks, 10 patients had fecal incontinence and 12 patients experienced fecal urgency. At 3 months, 6 patients were still incontinent, 3 of whom were treated successfully with sacral neuromodulation. Fecal urgency resolved in all cases after 6 months. Quality of life improved, particularly in the mental components.

CONCLUSION

Despite the described postoperative symptoms, most of which can be treated conservatively, the Transtar procedure is an effective treatment for patients with obstructive defecation syndrome and improves quality of life significantly.

Outcomes after transanal repair of rectoceles

PURPOSE

To determine the outcomes of patients after transanal rectocele repair.

METHODS

The Birmingham Bowel and Urinary Symptoms Questionnaire (BBUSQ-22), a validated instrument to evaluate bowel and urinary symptoms, was completed preoperatively by all patients undergoing transanal rectocele repair and postoperatively at a median interval of 8 months. The BBUSQ-22 was also administered to a control group of 50 asymptomatic female patients. The preoperative and postoperative BBUSQ-22 results for the 9 items pertaining to bowel function were compared to each other and to the responses from the control group.

RESULTS

Between April 1, 2001 and December 31, 2003, 88 women underwent transanal rectocele repair. Compared to the control group, patients with rectocele were significantly more symptomatic on all of the questions except the ability to hold bowel movements longer than 5 minutes. A significant improvement was reported postoperatively in all areas except pain with bowel movement and ability to hold bowel movements longer than 5 minutes. When the postoperative responses were compared to the control group, there were no significant differences except for a more frequent need for digital assistance and painful defecation in the surgical group.

CONCLUSION

Transanal rectocele repair results in significant improvement in defecation and continence, with postoperative bowel function comparable to control patients in 7 of the 9 areas evaluated.

[Transcoccigeal colpopexy with polyprolylene mesh with helper orifices for the treatment of posterior vaginal wall prolapse: anatomical and functional results]

OBJECTIVE

The creation of neo utero-sacral neoligaments, decribed by Petros, evolved into a new procedure allowing for the anatomical reconstruction of the three levels proposed by DeLancey. The aim of this study is evaluate the anatomical and functional outcomes of this minimally invasive procedure.

PATIENTS AND METHOD

From December 2004 to March 2007, a total of 34 patients with posterior defect grade III or higher underwent this procedure. The minimum follow up was 13 months Mean age was 63 years. The site of fixation was the Sacrospinous ligament.

SURGICAL TECHNIQUE

The ischiorectal fossa is dissected. Next two small skin incisions are made 3 cm lateral and inferior to the center of the anus. A proper needle is introduced, vertically towards the sacrospinal ligament at the level of the ischial spine, guided by the surgeon index finger, 2 cm medially avoiding the Alcok canal. The armpit of the mesh is connected to the tip of the needle and brought to the perineal region. No site specific correction is made.

RESULTS

The cure rate was 94,7% and recurrence rate was 5,3%. No visceral, nerurovascular injuries were observed. The mesh exposure rate (less than 1 cm2) was (14.7%) and all patients were treated conservatively with no impact on the outcome. There were transient dyspareunia in 2 (11.8%) of the 17 sexually active patient and persistent in 1 case (5.9%).

CONCLUSIONS

This procedure is an attractive minimally invasive alternative for the anatomical and functional reconstruction of the posterior and apical defects.

Measuring the space between vagina and rectum as it relates to rectocele

AIM: To measure the normal space between the posterior wall of the vagina and the anterior wall of the respectively rectum using computed tomography (CT) and reveal its were relationship to rectocele.

METHODS: A total of twenty female volunteers without rectocele were examined by CT scan. We performed a middle level continuous horizontal pelvic scan from the upper part to the lower part and collected the measurement data to analyze the results using t-test.

RESULTS: Twenty volunteers were enrolled in the study. The space between the posterior wall of the vagina and the anterior wall of the rectum was measured at three levels (upper 1/3, middle, lower 1/3 level of vagina). The results showed that the space from the posterior wall of the vagina to the anterior wall of the rectum at the upper 1/3 level and the middle level was 3.896 ± 0.3617 mm and 4.6575 ± 0.3052 mm, respectively. When the two groups of data were compared, we found the space at the upper 1/3 level was shorter than at the middle level (P < 0.01). Moreover, at the lower 1/3 level the space measured was 10.058 ± 0.4534 mm. The results revealed that the space at the lower 1/3 level was longer than that at the middle level (P < 0.01).

CONCLUSION: These measurement data may be helpful in assessing rectocele clinical diagnosis and functional outcomes of rectocele repair.

Surgery and sacral nerve stimulation for constipation and fecal incontinence

Fecal continence is a complex bodily function, which requires the interplay of sensation, rectal capacity, and anal neuromuscular function. Fecal incontinence affects approximately 2% of the population and has a prevalence of 15% in elderly patients. Constipation is one of the most common gastrointestinal disorders. The variety of symptoms and risk factors suggest a multifactorial origin. Before any invasive intervention, the surgeon should have a thorough understanding of the etiology of these conditions. Appropriate medical management can improve symptoms in the majority of patients. Surgery is indicated when all medical possibilities are exhausted. This review discusses the most used surgical procedures emphasizing the latest experiences. Sacral nerve stimulation (SNS) is a promising option for patients with fecal incontinence and constipation. The procedure affords patients improved continence and quality of life. The mechanism of action is still poorly understood. This treatment has been used before in other more invasive surgical procedures or even after their failure to improve patients' symptoms and avoid a definitive stoma. Before any invasive intervention, the surgeon should have a thorough understanding of the etiology of these conditions. Appropriate medical management can improve symptoms in the majority of patients. Surgery is indicated when all medical possibilities are exhausted. This review discusses the most used surgical procedures emphasizing the latest experiences. Sacral nerve stimulation (SNS) is a promising option for patients with fecal incontinence and constipation. The procedure affords patients improved continence and quality of life. The mechanism of action is still poorly understood. This treatment has been used before in other more invasive surgical procedures or even after their failure to improve patients' symptoms and avoid a definitive stoma.

Prospective multicentre clinical trial of stapled transanal rectal resection for obstructive defaecation syndrome

BACKGROUND

This prospective multicentre study assessed the safety and effectiveness of stapled transanal rectal resection (STARR) for treatment of obstructive defaecation syndrome (ODS).

METHODS

Between February 2001 and June 2006, 104 patients diagnosed with ODS were treated with STARR. Follow-up was scheduled for 1, 3 and 6 months after surgery, and annually thereafter. Variables related to the patient, surgical technique and outcome were analysed.

RESULTS

Mean operating time was 46.7 min. Haemorrhage at the staple line occurred in 55 patients (52.9 per cent). Three patients required surgical revision in the first 48 h owing to persistent bleeding. The median postoperative pain score was 2.4 on a scale from 1 to 10. Mean hospital stay was 2.2 days. The mean constipation score improved from 13.5 before surgery to 5.1 at 1-year follow-up (P = 0.006). Twenty-three patients reported faecal incontinence at 4 weeks after surgery, but only nine still had minor residual incontinence by 1 year. At a median follow-up of 26 (range 12-72) months, ODS had recurred or persisted radiologically and/or clinically in 11 patients.

CONCLUSION

STARR is associated with low morbidity and a short hospital stay, and is an effective alternative treatment for ODS.

Anorectal three-dimensional endosonography and anal manometry in assessing anterior rectocele in women: a new pathogenesis concept and the basic surgical principle

OBJECTIVE

The anatomy of the anal canal, the anorectal junction and the lower rectum was studied with 3-D ultrasound.

METHOD

Seventeen women with normal bowel transit, without rectocele (group 1) and 17 female patients with a large anterior rectocele (group 2) were examined with a B&K Medical Rawk. Mean age was 44.5 and 51.6 years respectively. In group 1, one (5.8%) patient was nuliparous, five (29.4%) had a caesarian section, 11 (64.7%) had a vaginal delivery while in group 2, two (11.7%) patients were nuliparous, four (23.5%) had a caesarian section and 11 (64.7%) had a vaginal delivery. Images were reconstructed in midline longitudinal (ML) and transverse (T) planes. The external (EAS) and internal (IAS) anal sphincters were measured in both projections.

RESULTS

In the ML plane, the EAS length was longer in group 1 (1.94 cm vs 1.61 cm, P < 0.05), the gap length was shorter (1.54 cm vs 1.0 cm P < 0.01) and the wall thickness was shorter in group 2 (0.40 cm vs 0.50 cm P < 0.01). The IAS (0.18 cm vs 0.23 cm P < 0.01) and EAS thickness (0.68 cm vs 0.77 cm, P < 0.05) (left lateral of the posterior quadrant) was greater in group 2. In group 1, the anterior upper anal canal wall in normal females was an extension of the rectal wall and the circular muscle was thicker in the mid-anal canal to form the IAS. In group 2, however, the wall layers were not identified and the IAS was found to be more distal. The differences were not statistically significant in the anal canal resting and squeeze pressures in the two groups.

CONCLUSION

Obstetric trauma does not seem to play any role in rectocele pathogenesis because the anal sphincter muscles are anatomically and functionally normal and rectocele is also present in nuliparous and in women with caesarian sections. It seems that it is associated with the absence of EAS and thinner IAS in the anterior upper anal canal. Herniation starts at the upper anal canal extending to the lower rectum in high or large rectoceles and maybe produced by rectal intussusception because of excessive and prolonged straining during defecation. In fact, the denomination 'rectocele' should be changed to 'anorectocele'.

Gynaecological operations: Do they improve sexual life?

Aim of the study was to determine if gynaecological operations have an effect on sexual function using the current medlined literature. We performed a Medline search using the terms "sexual life/function after operative gynaecological treatment", "sexual life/function after operations for gynaecological problems", "sexual life/function after hysterectomy", "sexual life/function, incontinence" and "sexual life/function, pelvic organ prolapse". Reviews were excluded. We divided the operations into four groups of (1) combined prolapse and incontinence operations, (2) prolapse operations only, (3) incontinence operations only and (4) hysterectomy and compared pre-to postoperative sexual outcome. Thirty-six articles including 4534 patients were identified. Only 13 studies used a validated questionnaire. The other authors used self-designed and non-validated questionnaires or orally posed questions by the examiner to determine sexual function. Prolapse operations particularly posterior repair using levator plication seem to deteriorate sexual function, incontinence procedure have some worsening effect on sexual function and hysterectomy seems to improve sexual function with no differences between subtotal or total hysterectomy. Gynaecological operations do influence sexual function. However, little validated data are available to come to this conclusion.

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.

Clinical and physiologic outcomes after transvaginal rectocele repair

PURPOSE

This study was designed to evaluate the clinical and physiologic outcomes after transvaginal rectocele repair.

METHODS

Between June 2000 and January 2003, 30 females (mean age, 62 (range, 45-78) years) with a symptomatic large rectocele (>3 cm) underwent transvaginal rectocele repair (anterior levatorplasty). Six months after surgery, a physiologic evaluation was performed by using defecography (depth of rectocele) and anorectal manometry (maximum resting pressure, maximum squeeze pressure, rectal threshold, and maximum tolerable volume). Using a questionnaire, a clinical evaluation was performed one year after surgery to analyze symptoms, including difficult evacuation, digital support, sexual discomfort, as well as patient satisfaction. Follow-up of all patients was conducted during a median duration of 38 (range, 23-54) months.

RESULTS

There were no operative complications, such as hematoma, wound infection, or rectovaginal fistula. Difficult evacuation improved in 27 of 30 patients (90 percent) and completely disappeared in 9 patients. Postoperatively, digital support was no longer necessary during evacuation in 15 of 21 patients (71 percent). Overall patient satisfaction reached 25 of 30 (83 percent). Although mild sexual discomfort was observed in nine patients, it disappeared gradually and only one patient complained of persistent symptoms. No patient reported symptomatic recurrences at the end of the follow-up. The radiologic mean depth of the rectocele was significantly reduced: preoperative, 3.9 cm; postoperative, 0.5 cm. None of the physiologic parameters significantly changed after surgery.

CONCLUSIONS

Transvaginal rectocele repair can provide excellent long-term symptomatic relief and a high rate of patient satisfaction without any alteration in anorectal physiologic function.

A Three-Year Prospective Assessment of Rectocele Repair Using Porcine Xenograft

OBJECTIVE

To prospectively evaluate clinical outcome of rectocele repair using xenograft 3 years after surgery.

METHODS

Twenty-three patients who completed evaluation preoperatively and 1 year after surgery were assessed at a 3-year follow-up. Clinical examination was performed preoperatively, and at the 1- and 3-year follow-ups, with the pelvic organ prolapse quantification system. Symptom assessment was performed with a validated bowel function questionnaire including questions on sexual function.

RESULTS

There were no graft-related complications during the 3 years following surgery. Preoperatively, all patients had stage II prolapse of the posterior vaginal wall and a rectocele verified at defecography. At the 1-year follow-up, 11 of 29 patients (38%) had rectocele of stage II or more, and 4 patients were reoperated. At 3-year follow-up 7 of 23 patients (30%) had rectocele of stage II or more. When including the 4 early anatomical recurrences, a total of 11 of 27 patients (41%) had rectocele of stage II or more at 3-year follow-up. Preoperatively, all patients reported varying degrees of rectal emptying difficulties and symptoms of bowel dysfunction. There was a significant decrease in rectal emptying difficulties (P < .01), sense of incomplete evacuation (P < .01), need for manually assisted defecation (P < .05), and symptoms of pelvic heaviness (P < .001) at the 3-year follow-up compared with preoperatively. Cure of rectal emptying difficulties was reported by fewer than 50% of patients. There were no significant changes in anal incontinence scores or symptoms of sexual dysfunction at the 3-year follow-up compared with preoperatively.

CONCLUSION

Rectocele repair using porcine dermal graft was associated with an unsatisfactory anatomical cure rate and persistent bowel-emptying difficulties in the majority of patients 3 years postoperatively.

LEVEL OF EVIDENCE

II-3.

Rectocele Repair Using Biomaterial Augmentation: Current Documentation and Clinical Experience

Although the etiology of rectocele remains debated, surgical innovations are currently promoted to improve anatomic outcome while avoiding dyspareunia and alleviating rectal emptying difficulties following rectocele surgery. Use of biomaterials in rectocele repair has become widespread in a short time, but the clinical documentation of their effectiveness and complications is limited. Medline and the Cochrane database were searched electronically from 1964 to May 2005 using the Pubmed and Ovid search engines. All English language publications including any of the search terms "rectocele," "implant," "mesh," "biomaterial," "prolapse," "synthetical," "pelvic floor," "biological," and "compatibility" were reviewed. This review outlines the basic principles for use of biomaterials in pelvic reconstructive surgery and provides a condensation of peer-reviewed articles describing clinical use of biomaterials in rectocele surgery. Historical and new concepts in rectocele surgery are discussed. Factors of importance for human in vivo biomaterial compatibility are presented together with current knowledge from clinical studies. Potential risks and problems associated with the use of biomaterials in rectocele and pelvic reconstructive surgery in general are described. Although use of biomaterials in rectocele and other pelvic organ prolapse surgery offers exciting possibilities, it raises treatment costs and may be associated with unknown and potentially severe complications at short and long term. Clinical benefits are currently unknown and need to be proven in clinical studies.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

TARGET AUDIENCE

After completion of this article, the reader should be able to explain that the objective of surgical treatment is to improve anatomic outcome and alleviate rectal emptying difficulties, describe the efficacy of biomaterials in rectocele repair, and summarize the potential risks and problems associated with use of biomaterials in rectocele and pelvic reconstructive surgery.

A 2-year anatomical and functional assessment of transvaginal rectocele repair using a polypropylene mesh

This study reports the 2-year results of an original technique for rectocele repair by the vaginal route, using a combined sacrospinous suspension and a polypropylene mesh. Twenty-six women were successively operated between October 2000 and February 2003. Mean age was 63.7 years [range 35-92]. 19 women had had previous pelvic surgery for prolapse and/or urinary incontinence (73.1%), but none had had a previous rectocele repair. Patients underwent physical examination staging of prolapse in the international pelvic organ prolapse staging system. Eleven women had stage 2 posterior vaginal wall prolapse (42.3%), seven had stage 3 (26.9%) and eight had stage 4 (30.8%). The procedure included a bilateral sacrospinous suspension and a polypropylene mesh (GyneMesh, Gynecare, Ethicon France) attached from the sacrospinous ligaments to the perineal body. We did not perform any associated posterior fascial repair, nor myorraphy. Patients were followed up for 10-44 months, with a median follow-up (+/- SD) of 22.7 +/- 9.2 months. Functional results and sexual function were evaluated using the PFDI, the PFIQ and the PISQ-12 self-questionnaires. Twenty-five women returned for follow-up (96.2%). At follow-up, 24 women were cured (92.3%) and one had asymptomatic stage 2 rectocele. All the patients but one had symptoms and impact on quality of life improved. No postoperative infection of the mesh or rectovaginal fistula was found, but there were three vaginal erosions (12%) and one out of 13 had de novo dyspareunia (7.7%).