Literature review of the outcome of and methods used to improve transperineal repair of rectocele

Rectocele with obstructive defecation syndrome: Laparoscopic rectopexy or vaginal repair?

INTRODUCTION

The concomitant presence of a rectocele with obstructive defecation syndrome (ODS) is highly probable. The purpose of this study was to evaluate the effectiveness of native tissue vaginal rectocele repair (VRR) and laparoscopic ventral mesh rectopexy (LVMR) in terms of functional outcome via the medium to long-term ODS score evaluation.

MATERIAL

This was a retrospective cohort study. We identified 30 patients having undergone LVMR for rectocele with defecatory symptoms between January 2015 and December 2021, matched with the same number of patients treated by VRR for the same indication and in the same period. The hypothesis was that both procedures were susceptible to lead to a favorable functional outcome. The main endpoint was ODS score at follow-up. Multivariate analysis was used to assess relationship between ODS score and type of surgery.

RESULTS

Patients' demographics were similar in both groups. However, the preoperative ODS score was significantly higher in the LVMR group (P<0.01). Furthermore, the use of preoperative imaging investigations and diagnosis of an associated rectal intussusception were more frequent in the LVMR group. The mean ODS scores at follow-up (median follow-up 5years) were comparable in the two groups (6.2 for LVMR and 4.43 for VRR). These scores were significantly reduced compared to preoperative values in both groups (P<0.0001).

CONCLUSIONS

There was a significant reduction in ODS scores on medium/long-term follow-up with both surgical techniques. A larger study utilizing randomized comparison of both procedures is needed to confirm our findings.

LEVEL OF EVIDENCE: 4

Obstructed Defecation Syndrome: Analysis of the Efficacy and Mid-Term Quality of Life of an Innovative Robotic Approach

Background: The goal of our research is to demonstrate how the combination of Rectal wall Plication (RP) and robotic Ventral Mesh Rectopexy (VMR) results in a safe and effective operation that provides superior outcomes for patients with Obstructed Defecation Syndrome (ODS). Methods: In a total of 78 women with ODS with posterior compartment prolapse, 30 had VMR whereas 33 received VMR plus RP. We assessed VMR and VMR + RP's efficacy and safety, as well as their influence on quality of life and sexual function. Results: At the median follow-up, both groups' POP-Q categorization scores for the posterior compartment decreased (p < 0.001). In terms of quality of life, the PISQ-12 showed an increase in sexual quality (30.12 ± 7.12 vs. 35.98 ± 5.98 in the VMR group and 29.65 ± 6.45 vs. 29.65 ± 6.45 in the VMR + RP group, p = 0.041). In the VMR + RP group, the number of sexually active patients with at least two sexual interactions per month rose (p = 0.033). At the median follow-up, the ODS score values differed significantly (7.11 ± 1.65 vs. 1.88 ± 1.89, p = 0.013). Conclusions: The combination of rectal wall plication and ventral mesh rectopexy may result in improved bowel function and quality of life.

Assessment of manometric results following posterior pericervical repair or level I to III surgical procedures

Constipation and obstructive bowel disorders are the most common symptoms of prolapse and posterior defects. Prolapse and obstructive defecation disorders are treated using various surgical techniques to repair posterior defects. This study aimed to evaluate the manometry results of patients before and after reconstructive surgery of the posterior compartment. This retrospective cohort study included 40 women with defecation disorders referred to the Imam Khomeini Hospital Complex, an academic center affiliated with Tehran University of Medical Sciences, Tehran, Iran, from 2020 to 2021. Data were collected through medical records and a checklist developed by the researcher before and after surgery. All analyses were performed using SPSS software (version 26), with significance at p<0.05. Forty women with a mean age of 49.47±9.66 years participated in this study. The manometry results showed significant differences in patients before and after surgery in parameters such as maximum resting pressure, push test, constipation, straining during defecation, finger support necessity, sensation of incomplete defecation, dyspareunia, and husband's sexual satisfaction (p<0.001). In addition, all patients had a grade 2 or higher posterior compartment prolapse, which improved in all cases after surgery (p<0.0001). Patients' symptoms significantly improved during the 12-month follow-up after DeLancey level 3 to 1 surgery. This type of surgery proved to be an effective surgical intervention without significant complications in the short-term follow-up.

Higher Symptom Score, Larger Residual Rectocele, and Lower Rectal Compliance Predict Failure of Improvement after Surgical Treatment of Rectocele

Background Rectocele is a frequent finding in women and is usually asymptomatic. However, it is sometimes associated with symptoms of obstructed defecation syndrome (ODS). While most patients with ODS due to rectocele respond well to conservative treatment, some may require surgical treatment. The aim of the study was to determine the predictors of failure of symptom improvement after rectocele repair.

Methods The study included adult women with rectocele who underwent surgical treatment by transperineal repair (TPR) or transvaginal repair (TVR). The preoperative and postoperative assessment was done using the Wexner constipation score, anorectal manometry, and defecography.

Results A total of 93 female patients with a mean age of 43.7 years were included. Among them, 65.6% of patients underwent TPR and 34.4% underwent TVR; 22 (23.7%) patients reported failure of significant improvement in ODS symptoms after surgery. The independent predictors of failure of improvement were higher preoperative Wexner score (odds ratio, OR: 1.4, 95% confidence interval, CI: 1.09–1.84, p = 0.009), larger residual rectocele after repair (OR: 2.95, 95% CI: 1.43–6.08, p = 0.003), and lower postoperative maximum tolerable volume (OR: 0.949, 95% CI: 0.907–0.992, p = 0.02). The predictive cutoff point for the preoperative Wexner score was 15.

Conclusions Patients with a preoperative Wexner score higher than 15 and larger residual rectocele after surgery may experience little improvement in symptoms after rectocele repair. Although TPR was associated with a poorer relief of symptoms than did TVR; it was not an independent predictor of failure.

Obstruktives Defäkationssyndrom

Das obstruktive Defäkationssyndrom (ODS) ist eine Form der Verstopfung, die mit einer Stuhlentleerungsstörung verbunden ist. Das Krankheitsbild ist noch nicht vollständig verstanden, dementsprechend ist die Evidenz zur Pathogenese und Therapie limitiert. Prinzipiell werden funktionelle Ursachen, wie der Anismus oder das Puborektalissyndrom, von anatomischen Ursachen unterschieden. Häufige mechanische Hindernisse sind die Rektozele oder eine Intussuszeption, die zu einer erschwerten Defäkation führen können. Zur Auswahl der passenden Therapie ist entscheidend, die kausale Ursache festzustellen. Konservative Behandlungsversuche sollten primär angewendet werden und umfassen unter anderem das Beckenbodentraining, die Biofeedbacktherapie, den Einsatz von Laxanzien oder die anale Irrigation. Es gibt eine große Zahl chirurgischer Therapieoptionen mit unterschiedlichen Vor- und Nachteilen. Gute Fachkenntnis und Erfahrung sind entscheidend, um die geeignete Therapie für den Betroffenen auszuwählen.