Traitement de la rectocèle par voie périnéale avec prothèse. Une étude prospective

European Society of Coloproctology guidance on the use of mesh in the pelvis in colorectal surgery

This is a comprehensive and rigorous review of currently available data on the use of mesh in the pelvis in colorectal surgery. This guideline outlines the limitations of available data and the challenges of interpretation, followed by best possible recommendations.

Transperineal rectocele repair: a systematic review

BACKGROUND

Transperineal rectocele repairs, either as isolated fascial repair or in combination with mesh augmentation, are hypothesized to reduce the risk of complications compared with alternative techniques.

AIM

The aim of this study was to ascertain long-term success and complication rates following transperineal rectocele repairs.

METHOD

A literature search of PubMed and Embase was performed using the terms 'transperineal rectocele', 'rectocele', 'transperineal' and 'repair'. Prospective studies, case series and retrospective case note analyses from 1 January 1994 to 1 December 2016 were included. Those that detailed outcomes of the transperineal approach or compared it to transanal/transvaginal approaches were included. The main outcome measures were reported complications and functional outcome scores.

RESULTS

A total of 14 studies were included. Of 566 patients, 333 (58.8%) underwent a transperineal rectocele repair and 220 (41.2%) a transanal repair. Complications were identified in 27 (12.3%) of the 220 transanal repairs and in 41 (12.3%) of the 333 transperineal repairs. A significant complication following transperineal repair was noted in eight studies. There are not enough data to make a reliable comparison between mesh and non-mesh transperineal repairs or to compare biological and synthetic mesh use.

LIMITATIONS

Outcome reporting differed between studies, precluding a full meta-analysis.

CONCLUSION

Transperineal rectocele repair offers an effective method of symptom improvement and appears to have a similar complication rate as transanal rectocele repair. Concomitant use of synthetic and biological mesh augmentation is becoming more common; however, high-quality comparative data are lacking, so a direct comparison between surgical approaches is not yet possible.

Posterior pelvic floor disorders and obstructed defecation syndrome: clinical and therapeutic approach

There are no clear recommended imaging guidelines for the assessment of patients presenting primarily with obstructed defecation syndrome and defecation difficulty. The gold standard has always been the defecating proctogram which may require a rather poorly tolerated extended technique involving high-radiation exposure in young women which includes cystography, vaginography, small bowel opacification, and occasional peritoneography. The development of dynamic magnetic resonance imaging has obviated many of these extended techniques and may be supplemented by novel ultrasonographic methods including dynamic transperineal sonography, real-time 3D translabial ultrasound and 3D dynamic echodefecography. Patients potentially suitable for surgical treatment display a multiplicity of pelvic floor and perineal soft-tissue anomalies where one pathology (such as rectocele or enterocele) are considered dominant. Despite the introduction of recent stapled and robotic technologies, there is a dual dialog concerning the functional outcome of these procedures. Imaging and surgical algorithms for these patients are provided.

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.

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.

Outcomes after the repair of rectoceles with transperineal insertion of a bioprosthetic graft

PURPOSE

This study was performed to determine the early outcomes with the use of bioprosthetic grafts for the management of rectoceles and to compare them to those achieved with transanal techniques.

METHODS

A retrospective analysis of prospectively collected data was performed for patients treated for a rectocele. Data collected included age, technique of repair, complications, and functional outcomes. Defecatory function was determined using the Birmingham Bowel and Urinary Symptoms Questionnaire, a validated instrument for the measurement of bowel symptoms. The questionnaire was administered preoperatively and at 12 weeks and 12 months postoperatively.

RESULTS

In this series, 88 women underwent a transanal repair, compared to 32 women who had their rectocele managed with a bioprosthetic graft. After 1 year of follow-up, patients whose rectocele was repaired using a bioprosthetic had significantly fewer complications with comparable functional results between the 2 techniques.

CONCLUSIONS

These data suggest that transperineal, bioprosthetic repair of rectoceles is associated with similar functional results but fewer complications when compared to transanal techniques during the early postoperative period. Randomized studies with longer-term follow-up will be required before the role of bioprosthetic repair of rectoceles can be determined.

Functional outcome after transperineal rectocele repair with porcine dermal collagen implant

PURPOSE

Symptomatic rectocele results in obstructed defecation and constipation. Surgical repair may provide symptomatic relief. This study was designed to assess the safety and efficacy of transperineal rectocele repair with porcine dermal collagen (Permacol).

METHODS

Ten females with symptomatic rectocele had a transperineal repair using Permacol. Median age was 51 (range, 33-71) years. Patients were followed with detailed interviews at a median time of 9 (range, 5-16) months. Objective preoperative and postoperative assessment was by outcomes for five symptoms: constipation, excessive straining, incomplete evacuation, vaginal bulging, and vaginal digitations (always, usually, occasionally, never), and Medical Outcomes Study Short Form 36 questionnaires. Subjective outcomes were assessed as excellent, good, moderate, and poor.

RESULTS

All patients had an improvement in two or more symptoms and 70 percent of patients in three or more symptoms. Postoperatively 80 percent reported an improvement in excessive straining (P = 0.0078) and in incomplete evacuation (P = 0.0078); 70 percent reported an improvement in vaginal bulging (P = 0.0156). Improvements in vaginal digitations and Medical Outcomes Study Short Form 36 scores were not statistically significant. Subjective outcomes were reported as excellent or good by 80 percent of patients. No patients had rectal perforation or infection, and no Permacol has been removed.

CONCLUSIONS

Rectocele repair with Permacol((R)) by the transperineal approach is a safe technique that avoids some of the complications associated with synthetic mesh use. Objective and subjective results are excellent in the majority of patients.

Prolapsus isolé de l'étage postérieur posthystérectomie : résultats préliminaires d'une technique utilisant les voies vaginales et transobturatrice basses

OBJECTIVE

The aim of this study is the description and anatomical and functional outcome assessment of a novel surgical procedure, based on rectovaginal fascia defect repair with polypropylene mesh using the tension-free transobturator and infracoccygeal route based on the integral theory developed by Petros.

MATERIALS AND METHOD

Prospective, consecutive and single centre study performed between February 2003 and April 2005. Inclusion criteria were symptomatic posthysterectomy stage three to four regarding posterior compartment prolapse according to the Baden and Walker classification, with no anterior and/or apical prolapse. Principles and description of this new surgical procedure are described.

RESULTS

Fourteen patients, with a mean age of 63.5 years and a mean body mass index of 29.2, were included in the study. All the patients had previous hysterectomy, 64.3% reported at least one previous surgery for pelvic organ prolapse, 44.5% reported at least one reoperation. All patients complained of rectocele and/or enterocele stage three. No perioperative or postoperative complication occurred. With a median follow-up of 13 months (range 3-32.9), no recurrence and no anterior or apical compartment prolapse occurred. No vaginal erosion an infection of the mesh was observed. The mean level of subjective satisfaction was 9.23 on a visual analogical scale (0-very disappointed, 10-very satisfied).

CONCLUSION

This new surgical procedure is effective and safe for the repair of posthysterectomy large posterior compartment prolapse. A long-term follow-up is required to confirm these promising results.

Les prothèses synthétiques dans la cure de prolapsus génitaux par la voie vaginale : bilan en 2005

Since 1996, prosthetic meshes have become increasingly popular for transvaginal surgical cure of genital prolapse. In light of the growing number of proposed techniques and materials we reviewed the experience of the pioneers in order to provide surgeons with the most objective information available. We reviewed the literature indexed in Meline/PubMed and Current Contents retaining all work concerning resorbable and non-resorbable meshes. For the larger class of non-resorbable meshes we also reviewed articles by category of material, each type of mesh being carefully defined: different compositions of polypropylene, polyester, composite meshes and also insertion kits. Resorbable meshes were evaluated in two randomized studies which did not demonstrate better results than with simple folding known to have a high rate of recurrence. For polypropylene meshes, Marlex was studied in six trials which demonstrated a high rate of cure at one year but also a high rate of erosion which reached 25%. Use of Atrium was mentioned in three studies with a 6 to 12% recurrence rate and an erosion rate nearly reaching 20%. The majority of studies used Prolene and Gynemesh. Seventeen authors reported their experience, generally reviewing retrospective series, with recurrence rates of less than 10% for follow-up periods rarely greater than two years. A large variety of forms and sizes have been used, hindering comparisons. The rate of erosion was also quite variable, as high as 45%, demonstrating the need for a precise definition of erosion. Only recently have authors shown interest in the impact of prosthetic meshes on quality of life and sexual activity. An improvement is generally noted for defecation but the rate of dyspareunia has reached as high as 60%. Here again grades of prosthetic retraction should be better defined. Proposed to improve these phenomena, soft Prolene recently used by several authors does not appear to fulfil expectations. Since 2005, several precut polypropylene meshes have been proposed with an insertion kit. The Prolift kit has been followed prospectively in 100 patients undergoing regular surveillance. Surgipro has been used sporadically in small series but follow-up is still too short for proper assessment. Polyester meshes (Mersilene and Paritex) have been presented by three authors who have found them useful but reports have been vague concerning results and complications. Polytetrafluoroethylene has not been evaluated for transvaginal surgery, probably because of the poor tolerance of suburetral bands. For composite meshes, Vypro has been used by four authors who noted about 10% erosion but with a short follow-up insufficient to draw conclusions about the functional and anatomic outcome. Surfaced meshes, advocated for transvaginal treatments, have been studied in only two reports. Plevitex is a polypropylene mesh coated with collagen; another polyester composite with polyglactin 910. The rate of dyspareunia varied from 14 to 24%. Other composites with antiadherents or antiseptics are also proposed for transvaginal insertion but have not been studied. This work demonstrated the lack of sufficient evidence from prospective randomized trials and the lack of standardized techniques to draw any definite conclusions. While evidence is being accumulated on the lower rate of recurrence for anterior compartment prolapse, the lack of data on the rate of complications and patient quality of life is unacceptable for this functional surgery. We still have reservations about widespread use of synthetic meshes. A special chapter is detailed in appendix on post-operative complications. These new specific complications call to a new semiology, with a classification in 4 types and under-types, proposed by authors. Type 1: defects of healing. Type 2: the infection of the graft. Type 3: the shrinkage of the mesh. Type 4: erosions. Authors detail the symptoms of these 4 types as well as the prevention and the treatment of these complications.

La perineoplastia protésica del tabique rectovaginal, vía transvaginal, en el tratamiento del rectocele y enterocele. Resultados de 77 casos

OBJECTIVE

Anatomical and functional outcomes after transvaginal perineoplasty of the vaginal septum using polypropylene mesh in 77 patients with rectocele, enterocele, or both were studied. The frequency of other associated pelvic floor defects was also analyzed.

PATIENTS AND METHOD

Between 1997 and May 2005, 77 patients underwent surgery (30 for enterocele, 33 for rectocele and 14 for both defects). In all patients, complete dissection of the rectovaginal space, resection of the redundant vaginal wall tissue, suturing of the polypropylene mesh to the lateral bundles of the puborectal muscle, and posterior colporrhaphy were performed. In enteroceles, Douglas' pouch was resected before the mesh was placed.

RESULTS

During follow-up, there were 3 minimal vaginal dehiscences requiring partial extirpation of the mesh in 2 (12.1%), and 1 (1.2%) rectocele recurrence. No subsequent mesh extrusions or recurrences were detected during follow-up. The frequency of associated pelvic floor disorders was 92%.

CONCLUSIONS

In our experience, placement of polypropylene mesh in the rectovaginal septum with lateral suturing to puborectal muscle bundles provides excellent results compared with other approaches and meshes that are not sutured and fixed in the rectovaginal space, leading to mesh infection, extrusion or complete removal.

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%).

Three-dimensional anal endosonography may improve diagnostic confidence of detecting damage to the anal sphincter complex

The aim of study was to investigate the differences between three-dimensional (3D) endosonography and two-dimensional (2D) endosonography in visualizing damage to the anal sphincter complex. 33 patients with a history of damage to the anal sphincters were examined with a 10 MHz rotating endoprobe. Cross-sectional images of the anal sphincters were stored on a 3D system during retraction of the endoprobe through the anal canal. Cross-sectional images (2D) were compared with reconstructed projections (3D) according to five parameters relating to damage of different parts of the sphincter muscles as well as scar-tissue formation in the rectovaginal septum. Depending on whether the investigator felt confident in diagnosis of scar tissue being present or not a numerical value of 1 or 0 was assigned. In this way a scale from 0 to 5 points was achieved, which ideally should be identical in 3D and 2D. Overall both observers felt diagnostic confidence in a median of five parameters (range 4-5) using 3D, compared with a median of four parameters (range 3-5) using 2D (p=0.001). When only assessing the four parameters relating to damage of different parts of the sphincter-muscles the observers felt diagnostic confidence in eight more cases using 3D than 2D. This difference did not reach statistical significance. The overall agreement between the two observers comparing all five parameters was 98.2% using 3D and 87.9% using 2D. 3D anal endosonography improves diagnostic confidence in detecting damage to the anal sphincter complex. The agreement between the two observers was acceptable using 2D but better when using 3D. The 3D method may improve the selection of patients for surgical repair of the anal sphincter complex.