How could management of rectoceles be optimized?

EFFECTS OF ISOLATED POSTERIOR VAGINAL WALL PROLAPSE ON LOWER URINARY TRACT SYMPTOMS

AIM

To investigate the effects of isolated posterior vaginal compartment prolapse to lower urinary tract symptoms (LUTS).

MATERIALS-METHODS

Patients who were admitted with any kind of LUTS and diagnosed with posterior compartment defects were retrospectively analyzed at urogynecology units of 2 different tertiary referral centers. Patients were included in the analysis if they had isolated posterior vaginal compartment defects with no clinically significant anterior and apical compartment defects. The control group consisted of patients with no pelvic organ prolapse (POP). All pelvic examinations were performed by the same 2 specialists. The responses to a detailed LUTS questionnaire in the unit were assessed.

RESULTS

Of the 340 women with posterior POP, 280 were excluded from the analysis due to combined anterior and/or apical POP with posterior POP and stage 4 POP. When we compared the symptoms between the control group and the remaining 60 patients with isolated posterior POP, there was a statistically significant difference in urge, frequency, nocturia, abnormal emptying, vaginal winding, difficult stool passage (p = 0.031, p < 0.001, p < 0.001, p = 0.022, p = 0.041, and p = 0.039, respectively).

CONCLUSION

Women with posterior POP should be carefully examined not only for anorectal or bulging symptoms but also for LUTS.

Robot-assisted Toupet fundoplication and associated cholecystectomy in symptomatic giant hiatal hernia with situs viscerum inversus-A case report and literature review

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All symptomatic paraesophageal hiatal hernias should be repaired, particularly those with acute obstructive symptoms or which have undergone volvulus.

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Laparoscopic hiatal hernia repair is as effective as open transabdominal repair, with a reduced rate of perioperative morbidity and with shorter hospital stays. It is the preferred approach for the majority of hiatal hernias.

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Robotic Assisted Giant-Paraesophageal Hernia repair remain technically challenging predominantly in the dissecation of the hernia sac from the posterior mediastinum.

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The robotic platform have the same benefits of the laparoscopic approach in terms of complication rate, total surgical time, and hospital length of stay and in particular case is superior.

Introduction

Giant hiatus hernia is defined as migration of >30% of the stomach with or without other intra-abdominal organs into the chest. Situs Viscerum Inversus is a rare congenital condition in which the major visceral organs are reversed from their normal arrangement; they are translated (completely or partially) on the opposite side of the body. Diagnosis is often incidental. We report a Robot-assisted Toupet fundoplication for a giant hiatal hernia with gastro oesophageal reflux disease and cholelithiasis, in a 63-years-old woman with situs viscerum inversus.

Presentation of case

A 63-year-old woman with Situs Viscerum Inversus was diagnosed with giant sliding hiatus hernia. We performed a Robot-assisted procedure of reduction of hiatal hernia in abdomen and Toupet fundoplication with Bio A mesh placement and gastropexy procedure associated to cholecystectomy. The operation time was of 190 min. The patient was discharged on third postoperative day after X-ray check and he tolerated a solid food.

Discussion

Minimally invasive surgery represents, nowadays, the standard approach for hiatal hernia and cholelithiasis.

Conclusion

In challenging cases as the giant hernias ad rare anomaly as situs viscerum inversus, the surgical treatment can be facilitated by the use of robotic technology.

Rectocele plication: description of a novel surgical technique and review of clinical results

INTRODUCTION AND HYPOTHESIS

A rectocele is the bulging of the anterior rectal wall into the posterior vaginal compartment. The route of surgical repair can be transvaginal, transrectal or abdominal. The aim of this retrospective study is to describe a novel transvaginal surgical procedure and investigate the associated subjective and objective clinical outcomes.

METHODS

Database records were retrieved for all women who underwent a rectocele plication for the period from January 2010 until December 2015 in a referral urogynecology unit with a minimum follow-up period of 12 months. This transvaginal technique entails a plication of the anterior rectal wall by suturing of the rectal muscularis layer. Clinical findings and quality of life (QOL) metrics were evaluated and reported on.

RESULTS

One hundred thirty-nine women met the initial inclusion criteria with full data available for 123. The presenting symptoms included a vaginal bulge in 73 (52.5%), overactive bladder (OAB) in 73 (52.5%), obstructed defecation (OD) in 49 (35.3%) and anal incontinence (AI) in 35 (25.2%). The majority of women (n = 72, 51.8%) had stage 3-4 posterior prolapse. The mean follow-up period was 27 ± 15 months. The postoperative symptoms were significantly improved for all, except AI (p = 0.43). There was a significant improvement in posterior prolapse (p < 0.001) with the majority of women noted to have a stage 0 or 1 (n = 109; 88.6%) posterior prolapse at follow-up.

CONCLUSIONS

The rectocele plication is a novel surgical technique with good subjective and objective clinical outcomes in the medium term.

Defecating Disorders: A Common Cause of Constipation in Women

Defecating disorders are a common and complex problem. There are a range of anatomical and functional bowel abnormalities that can lead to this condition. Treatment is difficult and needs a multidisciplinary approach. First line treatment for defecating disorders is conservative. For those that fail conservative treatment, some may respond to surgical therapy but with variable results. The aim of this review is to offer an overview of defecating disorders as well as provide an algorithm on how to diagnose and treat them with the help of a multidisciplinary and multimodal approach.

In patients with rectoceles and obstructed defecation syndrome, surgery should be the option of last resort

BACKGROUND

The indications for operation in patients with obstructed defecation syndrome (ODS) with rectocele are not well defined.

METHODS

A total of 90 female patients with ODS and rectocele were prospectively evaluated and treated with fiber supplements and biofeedback training. Univariate and multivariate regression was used to determine factors predictive of failing medical management.

RESULTS

Obstructive symptoms were the most prevalent presenting complaint (82.2%). Ultimately, 71.1% of patients responded to medical management and biofeedback. Multivariate regression analysis suggested that the presence of internal intussusception was associated with a lower chance of undergoing surgery to address ODS symptoms [odds ratio 0.18; P = .05], whereas inability to expel balloon, contrast retention on defecography, and splinting were not (P ≥ .15).

CONCLUSION

Rectoceles with concomitant intussusception in patients with ODS appear to portend a favorable response to biofeedback and medical management. We argue that all patients considered for surgery for rectoceles because of ODS should first undergo appropriate bowel retraining.

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.

Midline fascial plication under continuous digital transrectal control: which factors determine anatomic outcome?

Introduction and hypothesis

The aim of the study was to report anatomic and functional outcome of midline fascial plication under continuous digital transrectal control and to identify predictors of anatomic failure.

Methods

Prospective observational cohort. Anatomic success defined as POP-Q stage ≤ I of the posterior compartment. Validated questionnaires to measure bother and impact on quality of life. Logistic regression to identify risk factors for anatomic failure.

Results

Two hundred thirty-three patients with posterior pelvic organ prolapse (POP) stage ≥ II underwent midline fascial plication under continuous digital transrectal control. Median follow-up was 14 months (12–35 months), and anatomic success was 80.3% (95% CI 75–86). Independent predictors of failure were posterior compartment POP stage ≥ III [OR 8.7 (95% CI 2.7–28.1)] and prior colposuspension [OR 5.6 (95% CI 1.1–27.8)]. Sixty-three percent of patients bothered by obstructed defaecation experienced relief after surgery.

Conclusions

Anatomic and functional outcomes were good. Risk factors for anatomic failure were initial size of posterior POP (stage ≥ III) and prior colposuspension.

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.

Functional disorders: rectocele

The baseline prevalence of rectocele is not well defined as many women are asymptomatic and do not seek medical help. Gynecologists tend to perform posterior wall repairs more commonly than colorectal surgeons because they also address patients with vaginal symptoms in addition to those with defecatory dysfunction. Overall, surgical correction success rates for rectocele correction are quite high when using a vaginal approach. Vaginal dissection, as opposed to transrectal or transperineal approaches, results in better visualization and access to the endopelvic fascia and levator musculature, allowing for more firm anatomic correction. In addition, the maintenance of rectal mucosal integrity may reduce the risk of postoperative complications such as infection and fistula formation. With the rapidly growing popularity of synthetic and biologic implant kits in the field of pelvic reconstruction, outcomes data reporting is increasing and allowing surgeons to better understand the effect of various surgical techniques on vaginal, sexual, and defecatory symptoms.

Patterns of constipation in urogynecology: clinical importance and pathophysiologic insights

OBJECTIVE

We have analyzed the prevalence and patterns of constipation in women with urinary symptoms and/or genital prolapse.

STUDY DESIGN

Seven hundred and eighty-six consecutive urogynecologic patients underwent a questionnaire and structured clinical assessment. Comparison between constipated and nonconstipated women was made. Fisher exact test, Wilcoxon rank sum test, and logistic regression were used for statistical analysis (P < .05 for significance).

RESULTS

Thirty-two percent of women were constipated (172 difficult stool passage, 13 reduced stool frequency, 64 both). A genital prolapse > or = 2 degree Half Way System (HWS) was present in 44% of women. A posterior colpocele was more frequent in constipated women (35% vs 19%; P < .0001), resulting in a risk factor for constipation (OR 2.31; 95% CI 1.63-3.27). By contrast, higher degrees of anterior colpocele appeared to protect against constipation (OR 0.80; 95% CI 0.66-0.96). No differences in prevalence of constipation were observed for urinary symptoms or urodynamic diagnosis.

CONCLUSION

Bowel dysfunction correlates exclusively with posterior aspects of the pelvic floor support.

Stapled transanal rectal resection (STARR): a new option in the treatment of obstructive defecation syndrome

BACKGROUND

Rectocele and distal intussusception are organic causes of outlet obstruction. A new surgical option called the stapled transanal rectal resection (STARR) is described within a prospective study.

PATIENTS AND METHODS

Fourteen patients with symptomatic rectocele (four females), rectocele with coexistent intussusception (eight females), and intussusception (two males) underwent STARR procedure. The symptoms were measured by means of a defecation score (0-20 points).

RESULTS

Complications included local bleeding postoperatively in two cases, and temporary ischuria in four cases. The subjective sense of pain was low; from day 1 postoperatively five patients did not need any analgetics. Only one female patient had prolonged pelvic pain, without any organic reason. All patients showed improvement in rectal evacuation. The mean score of defecation (0-20 points) decreased from 13+/-3 to 4+/-3 after 1 month (p<0.05) and remained low. The overall follow-up was 19+/-9 months. Only one male patient with intussusception had defecation disorder again 6 months after surgery. Three patients had temporary urge incontinence.

CONCLUSION

STARR is an effective therapy for obstructive defecation disorder due to a symptomatic rectocele and/or a distal intussusception.

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.

Evaluation and treatment of women with rectocele: focus on associated defecatory and sexual dysfunction

Pelvic organ prolapse is a common and growing condition for which women seek help and frequently undergo surgical management. Prolapse of the posterior vaginal wall, alone or in combination with other compartment defects, can be a challenge for the pelvic surgeon. A clear understanding of the normal anatomy, interactions of the connective tissue and muscular supports of the pelvis, and the relationship or lack of relationship between anatomy and function is required. Vaginal support defects occur with and without symptoms, and many of the symptoms attributed to pelvic organ prolapse can result from other causes. Pelvic pressure, the need to splint the perineum to defecate, impaired sexual relations, difficult defecation, and fecal incontinence are some of the symptoms that have been correlated with rectoceles. Whether the prolapse is the cause of these symptoms or is a result of straining and stretching of support tissues in women with defecation disorders is still unknown. We will present the current literature on these relationships and what evaluations are useful when caring for a woman with a rectocele and defecation disorders. Either pessaries or surgery can be used for treating rectoceles. Several surgical techniques have been described, including transvaginal, transanal, abdominal, and the use of graft materials to treat both anatomical defects and functional symptoms. The success, rationale, and complications of each approach, including anatomic cure, impact on defecation, and sexual function, are presented.