Long time consequences after STARR procedure: Report of 15 years experience and medico-legal perspective

INTRODUCTION

Stapled transanal rectal resection is the most surgical procedure used for obstructed defecation syndrome, rectal prolapse, rectocele and rectal intussusception worldwide. The aim of this study is to report our experience and long time consequences and to offer a new medico-legal perspective.

MATERIALS AND METHODS

We retrospective review medical charts of patients treated between 2006 and 2021 ​b ​y the same team directed by the same senior surgeon. We consider major complications and long time sequelaeses as main object for the discussion. Inclusion and exclusion criteria were created. IRB approved the study. After revision a medico-legal perspective was done based on major complications.

RESULTS

During the study period 1726 patients, ages between 18 and 71 years old, were treated with 1280 STARR procedures and 446 "Longo" [was stopped on 2012]; all procedures were performed by the senior surgeon and visited by the team at the same control visit at 7days, 30 days and 12 and 18 months after surgery. All patients had 100 ​% compliance at 30 days, while 85 ​% had long time visit (more than 18 months). During the study period 6 ​% (104 subjects) of patients had minor complications while 1 patient (42 ​yrs female) reported total fecal incontinence after 18 months (0,05 ​%). This patient had mental disorder treated with drugs unknown before surgery and long time mental disorder after surgery. We focused on this last case to discuss long time complication DISCUSSION: This survey reports some interesting clinical data; respect to standard complications minor complications such as pain, bleeding and anal discomfort represent less than 10 ​% of procedures that is a good results in this perineal surgery. For those working with rectal mucosal prolapse, obstructed defecation syndrome, rectocele or rectal intussusception is essential to distinguish these diagnosis to have a good counselling with patient before surgery (at least 1 month before). It is essential to check these patients with a close follow-up especially after surgery, to avoid any other mental discomfort related to fecal incontinence; long time fecal incontinence, without anatomical disorders as our case, could be associated and related to drugs consumption or mental disorder, or perineal insensitivity due to surgical procedure. In conclusion it is essential to have good clinical practice to suggest STARR procedure, having idea about different diseases, different surgical approaches and different long time complications.

Maternal and neonatal consequences of cystocele and rectocele in the delivery process

The study aimed to investigate the effects of cystocele and rectocele on the stages of vaginal birth and maternal and newborn outcomes. A total of 672 multiparous pregnant women between the ages of 18 to 40 who underwent normal vaginal delivery in our tertiary center between November 2022 and February 2023, were included in this prospective study. Among the participants, 348 (51.8%) had no abnormalities, 78 (11.6%) had rectocele only, 112 (16.7%) had cystocele only, and 134 (19.9) had both cystocele and rectocele. Patients with the coexistence of cystocele and rectocele experienced a notably extended duration for both the first stage and second stage of labor, although the extension in the second stage was not statistically significant. Among the maternal complications, the development of maternal laceration and chorioamnionitis was significantly more common in the patient group with cystocele and rectocele compared to the other groups. When the groups were assessed for postpartum bleeding, while the bleeding risk increased from the normal group to the rectocele + cystocele group, this increase was not statistically significant. There was no difference between the groups in terms of neonatal outcomes. The delivery time of pregnant women with cystocele and rectocele, in the absence of additional risk factors, was determined to be significantly longer than that of the control group. We think that these patients should receive more vigilant monitoring, and this criterion should be kept in mind when assessing the indication for a cesarean section.

The Clinical Impact of Obesity in Patients With Disorders of Defecation: A Cross-Sectional Study of 1,155 Patients

INTRODUCTION

Obesity is a global epidemic. Its clinical impact on symptoms of fecal incontinence (FI) and/or constipation and underlying anorectal pathophysiology remains uncertain.

METHODS

This is a cross-sectional study of consecutive patients meeting Rome IV criteria for FI and/or functional constipation, with data on body mass index (BMI), attending a tertiary center for investigation between 2017 and 2021. Clinical history, symptoms, and anorectal physiologic test results were analyzed according to BMI categories.

RESULTS

A total of 1,155 patients (84% female) were included in the analysis (33.5% normal BMI; 34.8% overweight; and 31.7% obese). Obese patients had higher odds of FI to liquid stools (69.9 vs 47.8%, odds ratio [OR] 1.96 [confidence interval: 1.43-2.70]), use of containment products (54.6% vs 32.6%, OR 1.81 [1.31-2.51]), fecal urgency (74.6% vs 60.7%, OR 1.54 [1.11-2.14]), urge FI (63.4% vs 47.3%, OR 1.68 [1.23-2.29]), and vaginal digitation (18.0% vs 9.7%, OR 2.18 [1.26-3.86]). A higher proportion of obese patients had Rome criteria-based FI or coexistent FI and functional constipation (37.3%, 50.3%) compared with overweight patients (33.8%, 44.8%) and patients with normal BMI (28.9%, 41.1%). There was a positive linear association between BMI and anal resting pressure (β 0.45, R 2 0.25, P = 0.0003), although the odds of anal hypertension were not significantly higher after Benjamini-Hochberg correction. Obese patients more often had a large clinically significant rectocele (34.4% vs 20.6%, OR 2.62 [1.51-4.55]) compared with patients with normal BMI.

DISCUSSION

Obesity affects specific defecatory (mainly FI) and prolapse symptoms and pathophysiologic findings (higher anal resting pressure and significant rectocele). Prospective studies are required to determine whether obesity is a modifiable risk factor of FI and constipation.

Laparoscopic ventral mesh rectopexy vs. transperineal mesh repair for obstructed defecation syndrome associated with rectocele: comparison of selectively distributed patients

PURPOSE

Obstructed defecation syndrome represents 50-60% of patients with symptoms of constipation. We aimed to compare the two frequently performed surgical methods, laparoscopic ventral mesh rectopexy and transperineal mesh repair, for this condition in terms of functional and surgical outcomes.

METHODS

This study is a retrospective review of 131 female patients who were diagnosed with obstructed defecation syndrome, attributed to rectocele with or without rectal intussusception, enterocele, hysterocele or cystocele, and who underwent either laparoscopic ventral mesh rectopexy or transperineal mesh repair. Patients were evaluated for surgical outcomes based on the operative time, the length of hospital stay, operative complications, using prospectively designed charts. Functional outcome was assessed by using the Initial Measurement of Patient-Reported Pelvic Floor Complaints Tool.

RESULTS

Fifty-one patients diagnosed with complex rectocele underwent laparoscopic ventral mesh rectopexy, and 80 patients diagnosed with simple rectocele underwent transperineal mesh repair. Mean age was found to be 50.35 ± 13.51 years, and mean parity 2.14 ± 1.47. Obstructed defecation symptoms significantly improved in both study groups, as measured by the Colorectal Anal Distress Inventory, Constipation Severity Instrument and Patient Assessment of Constipation-Symptoms scores. Minor postoperative complications including wound dehiscence (n = 3) and wound infection (n = 2) occurred in the transperineal mesh repair group.

CONCLUSION

Laparoscopic ventral mesh rectopexy and transperineal mesh repair are efficient and comparable techniques in terms of improvement in constipation symptoms related to obstructed defecation syndrome. A selective distribution of patients with or without multicompartmental prolapse to one of the treatment arms might be the preferred strategy.

Is posterior compartment prolapse associated with anal incontinence?

OBJECTIVE

It has been claimed that manifestations of posterior compartment prolapse, such as rectocele, enterocele and intussusception, are associated with anal incontinence (AI), but this has not been studied while controlling for anal sphincter trauma. We aimed to investigate this association in women with intact anal sphincter presenting with pelvic floor dysfunction.

METHODS

This retrospective study analyzed 1133 women with intact anal sphincter presenting to a tertiary urogynecological center for pelvic floor dysfunction between 2014 and 2016. All women underwent a standardized interview, including assessment of symptoms of AI, clinical examination and three-/four-dimensional transperineal ultrasound. Descent of the rectal ampulla, true rectocele, enterocele, intussusception and anal sphincter trauma were diagnosed offline.

RESULTS

Mean age was 54.1 (range, 17.6-89.7) years and mean body mass index was 29.4 (range, 14.7-67.8) kg/m2 . AI was reported by 149 (13%) patients, with a median St Mark's anal incontinence score of 12 (interquartile range, 1-23). Significant posterior compartment prolapse was seen in 693 (61%) women on clinical examination. Overall, 638 (56%) women had posterior compartment prolapse on imaging: 527 (47%) had a true rectocele, 89 (7.9%) had an enterocele and 26 (2.3%) had an intussusception. Women with ultrasound-diagnosed enterocele had a significantly higher rate of AI (23.6% vs 12.3%; odds ratio (OR), 2.21 (95% CI, 1.31-3.72); P = 0.002), but when adjusted for potential confounders, this association was no longer significant (OR, 1.56 (95% CI, 0.82-2.77); P = 0.134).

CONCLUSION

In women without anal sphincter trauma, posterior compartment prolapse, whether diagnosed clinically or by imaging, was not shown to be associated with AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

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.

Pathophysiological basis, clinical assessment, investigation and management of patients with obstruction defecation syndrome

Obstructed defecation syndrome (ODS) is a clinical syndrome manifest as difficulty in faecal evacuation despite no mechanical obstruction. It is the final clinical pathway of a number of anatomical and physiological pathologies they can result in considerable misery to the lives of the patients it afflicts. Herein, the authors seek to breakdown the syndrome into its component parts, looking first at normal pelvic floor anatomy and physiology; followed by each pathological element; clinical features and investigation; individual management and management of the patient as a whole. It must be stated that correction of anatomy is not the sine qua non, as this does not always correlate to improvement of symptoms. There is a complex interplay of all elements, and a holistic approach appreciating the gestalt principle of "the whole is greater than the sum of its parts" is paramount. Causes of pelvic pain (levator ani syndrome, coccygodynia, proctalgia fugax and pudendal neuralgia) do not fall into ODS and are beyond the scope of this paper.

Laparoscopic Ventral Mesh Rectopexy Versus Transvaginal Posterior Colporrhaphy in Management of Anterior Rectocele

BACKGROUND

Management of rectocele is challenging. Treatment usually starts with conservative measures and may involve surgical intervention in non-responding patients. We compared the outcomes of transvaginal posterior colporrhaphy (PC) and laparoscopic ventral mesh rectopexy (LVMR) in treatment of anterior rectocele.

METHODS

Patients with anterior rectocele who underwent PC or LVMR were functionally assessed using Cleveland Clinic Constipation Score (CCCS) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Pelvic Organ Prolapse Quantification System (POP-Q) was used for clinical assessment, defecography for anatomic assessment, and manometry for physiologic assessment. In addition, quality of life was assessed.

RESULTS

A total of 231 female patients with a mean age of 39 years were included to the study. One hundred fifty-nine underwent PC and 72 underwent LVMR. The LVMR group showed significantly a better functional outcome as compared with the PC group (p < 0.0001). The mean of CCCS at 1 year after LVMR was 6 ± 2.3 vs 9.2 ± 1.2 after PC. The mean of PISQ-12 at 1 year after LVMR was 39.3 ± 2.8 vs 35.8 ± 2.2 after PC. LVMR showed better anatomic correction by defecography, had significantly higher quality of life scores, and had a longer operative time as compared with PC, yet with comparable incidence of complications.

CONCLUSION

PC and LVMR are both effective treatment options for treatment of rectocele. LVMR was associated with better anatomic correction and greater improvement in constipation, sexual symptoms, and quality of life compared with PC. Although LVMR had a longer operation time than PC, the complication rate of the two procedures was comparable.

Impact of TRREMS on symptoms of obstructed defecation due to rectocele: predictive factors and outcomes

BACKGROUND

The aim of this study was to evaluate the impact of the transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS) on the treatment of obstructed defecation due to rectocele and to identify the predictive factors for unsuccessful results.

METHODS

Consecutive patients with obstructed defecation symptoms (ODS) associated with rectocele who had the TRREMS procedure were included. Each patient was assessed by echodefecography, manometry, and colonic transit time as well as the Cleveland Clinic constipation score (CCS) before therapy and at follow-up after 6 months. Reduction in the CCS score was calculated as a ratio. Factors correlated with a decrease in the CCS were analyzed in a univariate analysis.

RESULTS

A total of 81 patients were included. Nineteen patients had postoperative complications that were not severe: 7 (8.6%) had tenesmus, 6 (7.4%) stenosis (4 treated with digital dilatation and 2 with endoscopic stricturectomy), 4 (4.9%) residual mucosal prolapse treated with rubber band ligation, 1 (1.2%) early bleeding, and 1(1.2%) thrombosis. Seventy-nine (97.5%) patients had a significant clinical response with significant reduction of the CCS constipation score from median 13 (range 17-10) to 4 (range, 8-2) (p = 0.0001); only 2 patients (2.5%) had an unsatisfactory response, complaining of straining and vaginal digitation during the evacuatory effort. Patients with anismus previously treated with biofeedback had a lower reduction ratio of the CCS score compared with patients without anismus (61.2 ± 2.8% versus 70.9% ± 1.5, p = 0.0006). There were no significant differences in the reduction of the CCS according to age, parity, type of delivery, previous hysterectomy, post-menopausal status, rectal mucosal prolapse and/or associated rectal intussusception, grade of rectocele and presence of complications.

CONCLUSIONS

The TRREMS procedure significantly improved evacuation disorders in this study. Appropriate selection of patients is key for the success of this approach. Anismus even if previously treated with biofeedback, was the main predictive factor of unsuccessful treatment.

Khubchandani’s procedure combined with stapled posterior rectal wall resection for rectocele

BACKGROUND

Obstructed defecation syndrome (ODS) is a widespread disease in the world. Rectocele is the most common cause of ODS in females. Multiple procedures have been performed to treat rectocele and no procedure has been accepted as the gold-standard procedure. Stapled transanal rectal resection (STARR) has been widely used. However, there are still some disadvantages in this procedure and its effectiveness in anterior wall repair is doubtful. Therefore, new procedures are expected to further improve the treatment of rectocele.

AIM

To evaluate the efficacy and safety of a novel rectocele repair combining Khubchandani’s procedure with stapled posterior rectal wall resection.

METHODS

A cohort of 93 patients were recruited in our randomized clinical trial and were divided into two different groups in a randomized manner. Forty-two patients (group A) underwent Khubchandani’s procedure with stapled posterior rectal wall resection and 51 patients (group B) underwent the STARR procedure. Follow-up was performed at 1, 3, 6, and 12 mo after the operation. Preoperative and postoperative ODS scores and depth of rectocele, postoperative complications, blood loss, and hospital stay of each patient were documented. All data were analyzed statistically to evaluate the efficiency and safety of our procedure.

RESULTS

In group A, 42 patients underwent Khubchandani’s procedure with stapled posterior rectal wall resection and 34 were followed until the final analysis. In group B, 51 patients underwent the STARR procedure and 37 were followed until the final analysis. Mean operative duration was 41.47 ± 6.43 min (group A) vs 39.24 ± 6.53 min (group B). Mean hospital stay was 3.15 ± 0.70 d (group A) vs 3.14 ± 0.54 d (group B). Mean blood loss was 10.91 ± 2.52 mL (group A) vs 10.14 ± 1.86 mL (group B). Mean ODS score in group A declined from 16.50 ± 2.06 before operation to 5.06 ± 1.07 one year after the operation, whereas in group B it was 17.11 ± 2.57 before operation and 6.03 ± 2.63 one year after the operation. Mean depth of rectocele decreased from 4.32 ± 0.96 cm (group A) vs 4.18 ± 0.95 cm (group B) preoperatively to 1.19 ± 0.43 cm (group A) vs 1.54 ± 0.82 cm (group B) one year after operation. No other serious complications, such as rectovaginal fistula, perianal sepsis, or deaths, were recorded. After 12 mo of follow-up, 30 patients’ (30/34, 88.2%) final outcomes were judged as effective and 4 (4/34, 11.8%) as moderate in group A, whereas in group B, 30 (30/37, 81.1%) patients’ outcomes were judged as effective, 5 (5/37, 13.5%) as moderate, and 2 (2/37, 5.4%) as poor.

CONCLUSION

Khubchandani’s procedure combined with stapled posterior rectal wall resection is an effective, feasible, and safe procedure with minor trauma to rectocele.

Anal Sphincters Evaluation by Endoanal Ultrasound in Obstructed Defecation

OBJECTIVES

To evaluate anal sphincter abnormalities detected by endoanal ultrasound in obstructed defecation due to rectocele and rectal intussusception.

METHODS

The retrospective analysis includes 45 patients with obstructed defecation syndrome due to rectocele and/or rectal intussusception with or without fecal incontinence, and submitted to endoanal ultrasound.

RESULTS

Ninety-three percent (n = 42) were women (mean age of 63 ± 12 years), and 47% (n = 21) of the patients had fecal incontinence. In total, 29% (n = 13) had a previous anorectal surgery, and 93% (n = 39) of the women had a previous vaginal delivery. An isolated rectal intussusception was diagnosed in 20% (n = 9) of the patients, an isolated rectocele in 24% (n = 11), and rectal intussusception and rectocele in 56% (n = 25). Thirty-six percent of patients had anal sphincter lacerations (n = 16): 12% (n = 2) had only internal laceration, 69% (n = 11) had only external laceration, and 19% (n = 3) had both. Two patients had a thinner internal anal sphincter with 0.9 and 1.2 mm, respectively. In total, 25% of the patients without fecal incontinence had an occult anal sphincter laceration, and all were women with an external sphincter laceration in the anterior quadrant and a previous vaginal delivery. In patients with obstructed defecation and fecal incontinence, 48% had sphincter lacerations. Previous anorectal surgery was a predictor of anal sphincter laceration (odds ratio [OR] 4.8; 95% confidence interval [CI] = 1.214-18.971; P = .025), but fecal incontinence (OR 2.7; 95% CI = 0.774-9.613; P = .119) and previous vaginal delivery (OR 1.250; 95% CI = 0.104-15.011; P = .860) were not.

CONCLUSIONS

Endoanal ultrasound should be considered in obstructed defecation with or without fecal incontinence, especially if surgical correction is planned.

[Laparoscopic resection rectopexy in the treatment of obstructive defecation syndrome]

INTRODUCTION

Obstructive defecation syndrome (ODS) presents a common medical problem, which can be caused by various pelvic disorders; multiple disorders are frequently diagnosed. At the present, a high number of corrective techniques are available via various surgical approaches. Laparoscopic resection rectopexy is a minimally invasive technique, which comprises redundant sigmoidal resection with rectal mobilisation and fixation.

METHODS

The aim of this paper was to evaluate the safety and effectiveness of laparoscopic resection rectopexy in the treatment of patients with ODS. The evaluation was performed via our own patients data analysis and via literature search focused on laparoscopic resection rectopexy.

RESULTS

In total, 12 patients with ODS undergoing laparoscopic resection rectopexy in University Hospital Ostrava during the study period (2012-2015) were included in the study. In our study group, mean age was 64.5 years and mean BMI was 21.9; the group included 11 women (91.6%). ODS was caused by multiple pelvic disorders in all patients. Dolichosigmoideum and rectal prolapse (internal or external) were diagnosed in all included patients. On top of that, rectocoele and enterocoele were diagnosed in several patients. Laparoscopic resection rectopexy was performed without intraoperative complications; mean operative time was 144 minutes. Mean postoperative length of hospital stay was 7 days. Postoperative 30-day morbidity was 16.6%. All postoperative complications were classified as grade II according to Clavien-Dindo classification. Mean preoperative Wexner score was 23.6 points; mean score 6 months after the surgery was 11.3 points. Significant improvement in ODS symptoms was noted in 58.3% of patients, and a slight improvement in 16.6% of patients; resection rectopexy provided no clinical effect in 25% of patients.

CONCLUSION

It is fundamental to carefully select those patients with ODS who could possibly profit from the surgery. Our results, in accordance with published data, suggest that laparoscopic resection rectopexy is a valuable surgical technique in the treatment of patients with ODS caused by multiple pelvic disorders.

KEY WORDS

obstructive defecation syndrome - constipation - resection rectopexy - operative techniques - pelvic floor disorders.

Can we predict urinary stress incontinence by using demographic, clinical, imaging and urodynamic data?

OBJECTIVE

It has been claimed that urethral hypermobility and resting urethral pressure can largely explain stress incontinence in women. In this study we tried to replicate these findings in an unselected cohort of women seen for urodynamic testing, including as many potential confounders as possible.

STUDY DESIGN

This study is a retrospective analysis of data obtained from 341 women. They attended for urodynamic testing due to symptoms of pelvic floor dysfunction. We excluded from the analysis women with a history of previous anti-incontinence and prolapse surgery. All patients had a standardised clinical assessment, 4D transperineal pelvic floor ultrasound and multichannel urodynamic testing. Urodynamic stress incontinence (USI) was diagnosed by multichannel urodynamic testing. Its severity was subjectively graded as mild, moderate and severe. Candidate variables were: age, BMI, symptoms of prolapse, vaginal parity, significant prolapse (compartment-specific), levator avulsion, levator hiatal area, Oxford grading, midurethral mobility, maximum urethral pressure (MUP), maximum cough pressure and maximum Valsalva pressure reached.

RESULTS

On binary logistic regression, the following parameters were statistically significant in predicting urodynamic stress incontinence: age (P=0.03), significant rectocele (P=0.02), max. abdominal pressure reached (negatively, P<0.0001), midurethral mobility (P=0.0004) and MUP (negatively, P<0.0001). On multivariate analysis, accounting for multiple interdependencies, the following predictors remained significant: max. abdominal pressure reached (negatively, P<0.0001), cough pressure (P=0.006), midurethral mobility (P=0.003) and MUP (negatively, P<0.0001), giving an R(2) of 0.24.

CONCLUSIONS

Mid-urethral mobility and MUP are the main predictors of USI. Demographic and clinical data are at best weak predictors. Our results suggest the presence of major unrecognised confounders.

Internal Delorme vs. STARR procedure for correction of obstructed defecation from rectocele and rectal intussusception

PURPOSE

"Outlet obstruction" is a complex functional disorder compelling patients to exhausting uneffective attempts to void. This study was designed to compare the effectiveness and a safety of the endorectal proctopexy (internal Delorme) vs STARR procedure in two groups of patients.

METHODS

A total of 66 patients with rectocele and associated mucosal prolapse or anorectal intussusception between January 2006 and June 2010 were randomly assigned to Group # 1 Endorectal proctopexy with levatorplasty (ERPP) and Group # 2 STARR. Patients were assessed one week, six and twelve months after the operation. Operative time, postoperative pain, day of discharge and late complications was recorded. The time of recovery of work was also assessed. The continence score was updated with a constipation questionnaire. Quality of life after the operation and the overall grade of satisfaction were assessed and compared with radiological findings. All patients were reassessed after one year.

RESULTS

The results in the two groups of patients show no significant difference between ERPP and STARR: the improvement in symptoms is similar but significant and well definite in both groups with a low incidence of postoperative complications. STARR procedure is just faster to perform even if more expensive. Dyspareunia slightly improved mainly in ERPP group, due probably to scar distention.

CONCLUSION

The results of our experience indicate a significant improvement of symptoms with both techniques. The overall incidence rate of postoperative complications is low and similar between the two groups. As economical consideration, ERPP is less expensive.

Lessons learned after more than 400 laparoscopic ventral rectopexies

BACKGROUND

Laparoscopic ventral recto(colpo)pexy (LVR) is a minimally invasive, autonomic nerve-sparing technique to treat rectal prolapse syndromes. The position of the mesh on the anterior aspect of the rectum in the rectovaginal septum allows correction of concomitant rectocele and enterocele.

METHODS

Demographic, perioperative, and follow-up data of consecutive patients were analyzed in order to audit our 10-years' experience with the technique.

RESULTS

From January 1999 to December 2008, 405 patients (93% female) underwent LVR for internal rectal prolapse (45.9%, n = 186), total rectal prolapse (43%, n = 174) and rectocele or enterocele (11.1%, n = 45). Mean age was 54.6 years (SD 15). The median hospital stay was 4 days (range 2-21). Conversion rate was 2%. There was no postoperative mortality. At a mean follow-up of 25.3 months, recurrence was observed in 4.6% (19 patients). Most often detachment of the mesh at the sacral promontory was found. Late complications occurred in 18% of patients. In five patients, LVR combined with perineotomy was complicated by mesh erosion into the vagina. Mesh erosion was not observed after LVR without perineotomy. Symptomatic improvement was observed in 85% of patients with total rectal prolapse and in 70% of patients with internal rectal prolapse (p < 0.050). The difference was mainly due to a lesser effect on obstructed defecation symptoms.

CONCLUSIONS

LVR, with or without perineotomy, appears to be safe and feasible, with relatively low morbidity. Functional outcome data support its efficacy. The indication for LVR in patients with internal rectal prolapse could be optimised.

Changes in bowel symptoms 1 year after rectocele repair

OBJECTIVE

We sought to evaluate changes in bowel symptoms after rectocele repair and identify risk factors for persistent symptoms.

STUDY DESIGN

We conducted ancillary analysis of a randomized surgical trial for rectocele repair. Subjects underwent examinations and completed questionnaires for bowel symptoms at baseline and 12 months postoperatively. Outcomes included resolution, persistence, or de novo bowel symptoms. We used multiple logistic regression to identify risk factors for bowel symptom persistence.

RESULTS

A total of 160 women enrolled: 139 had baseline bowel symptoms and 85% had 12-month data. The prevalence of bowel symptoms decreased after rectocele repair (56% vs 23% splinting, 74% vs 37% straining, 85% vs 19% incomplete evacuation, 66% vs 14% obstructive defecation; P < .001 for all). On multiple logistic regression, a longer history of splinting was a risk factor for persistent postoperative splinting (adjusted odds ratio, 2.25; 95% confidence interval, 1.02-4.93).

CONCLUSION

Bowel symptoms may improve after rectocele repair, but almost half of women will have persistent symptoms.

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

STUDY OBJECTIVE

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

DESIGN

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

SETTING

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

PATIENTS

Thirty-six women with rectocele with intractable constipation.

INTERVENTION

Posterior vaginal mesh suspension.

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSION

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

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

INTRODUCTION AND HYPOTHESIS

The aim of this study was to investigate the functional and anatomical outcome after a new rectovaginal fascial plication technique in patients with rectoceles or rectal pockets and obstructed defecation.

METHODS

In a prospective study 54 of 87 patients were examined pre- and postoperatively using the Pelvic Organ Prolapse Quantification (POP-Q) system of the International Continence Society (ICS). Bowel and protrusion symptoms as well as quality of life (QOL) were evaluated by a standardized questionnaire. Surgical therapy consisted of a posterior vaginal wall incision in the midline, a dissection of the vaginal epithelium from the underlying rectovaginal fascia while the rectocele was brought under tension by the index finger in the rectum. Under rectal digital control the surgically exposed rectovaginal fascia was sutured in a cranio-caudal fashion with sagittally positioned running absorbable sutures followed by a careful reapproximation of the laterally separated perineal body in the midline.

RESULTS

Obstructed defecation symptoms were cured or improved in 72.2 % [95 % confidence interval (CI) 59.1-82.4]. Anatomical cure rate was 92.1 % (95 % CI 79.2-97.3) and protrusion symptoms were resolved in 73.6 % (95 % CI 58.0-85.0). Of the patients who had intercourse, 5.2 % reported de novo dyspareunia postoperatively; in none of these patients was an anatomical cause found. There were no major intra- or postoperative complications.

CONCLUSIONS

Sagittal rectovaginal fascial plication in symptomatic rectoceles or functionally relevant rectal pockets is associated with a satisfactory anatomical and functional cure rate without impacting sexual function.

Ultrasound in the investigation of posterior compartment vaginal prolapse and obstructed defecation

Recent developments in diagnostic imaging have made gynecologists, colorectal surgeons and gastroenterologists realize as never before that they share a common interest in anorectal and pelvic floor dysfunction. While we often may be using different words to describe the same phenomenon (e.g. anismus/vaginismus) or attributing different meanings to the same words (e.g. rectocele), we look after patients with problems that transcend the borders of our respective specialties. Like no other diagnostic modality, imaging helps us understand each other and provides new insights into conditions we all need to learn to investigate better in order to improve clinical management. In this review we attempt to show what modern ultrasound imaging can contribute to the diagnostic work-up of patients with posterior vaginal wall prolapse, obstructed defecation and rectal intussusception/prolapse. In summary, it is evident that translabial/perineal ultrasound can serve as a first-line diagnostic tool in women with such complaints, replacing defecation proctography and MR proctography in a large proportion of female patients. This is advantageous for the women themselves because ultrasound is much better tolerated, as well as for healthcare systems since sonographic imaging is much less expensive. However, there is a substantial need for education, which currently remains unmet.

[Surgical treatment of rectocele with the use of mesh implants by the obstructive defecation syndrome]

The aim of current study was to evaluate in complex the effectiveness of transvaginal mesh implants in women with obstructed defecation (OD) syndrome based on the comparison of preoperative and postoperative results of objective diagnostic tools and quality of life parameters.

METHODS

from prospectively collected database of patients treated in our department those who were treated for OD by means of transvaginally placed mesh implants were chosen. The comparison of pre- and postoperative results of objective evaluation (prolapse stage according to POP-Q system, X-ray defecography - XR-DG and MRI defecography - MRI-DG) as well quality of life parameters (Wexner constipation score and validated Russian version of King's Health Questionnaire) was undertaken. Treatment effectiveness was evaluated using Сlinical Global Impression - Improvement (CGI-I) и Patient Global Impression - Improvement (PGI-I) scales.

RESULTS

In 2007-2011 40 women (mean age 51.8±10.7 years) underwent transvaginal pelvic floor reconstruction with mesh implants. All of them had ≤3 stage pelvic prolapse (POP-Q) and rectocele. Preoperative XR-DG and MRI-DG helped reveal rectocele >4 cm in 85 and 43% of women respectively, 68% of patients had cystocele and 18% - genital prolapse. In 21 case mesh implants for posterior pelvic floor reinforcement were used, in other cases mesh implants for total pelvic floor repair were placed. At a mean of 19 months after the operation manual examination revealed that 90% of women had 1 stage posterior pelvic proplapse, at XR-DG and MRI-DG significant reduction of rectocele size and depth of pelvic floor descent was noted. Besides that significant decrease in mean values of Wexner constipation score and King's health questionnaire was demonstrated. Though mean values of global treatment effectiveness assessment on CGI-I and PGI-I scales didn't significantly differ (2.13±0.85 и 2.68±1.42, р=0.06), the rate of agreement between these scales measured at each single case was very low (κ-0.154), this reflects that clinician has more positive perception of disease dynamics due to treatment than the patient. When mean values of dynamics in different indexes of King's health questionnaire were compared it was demonstrated that the index of quality of life influence (3.53±0.96) was significantly higher than the indexes of OD influence (2.63±1.08) and mechanical symptoms (2.58±1.04), this suggests that while the manifestations of OD syndrome are significantly improved patient quality of life doesn't change substantially.

CONCLUSIONS

XR-DG is more specific than MRI-DG in evaluating the size of rectocele and the depth of pelvic floor descent; the use of mesh implants in surgical treatment of OD syndrome results in significant reduction of rectocele and prolapse stage in 90% of patients; clinical evaluation of treatment effectiveness based on objective examination is more optimistic than subjective perception of treatment results by the patient, this indicates that anatomic correction does not always lead to quality of life improvement.

[Starr0ne: transanal procedure for rectal resection with only one stapler. Case report]

AIM

Stapled Trans-Anal Rectal Resection methods (STARR double-PPHO1 J&J and Transtar CCS30 J&J) designed and proposed by Antonio Longo, widley used, present some problems and difficulties. Many Authors have sought alternatives able to optimize the results, to limit the risk of complications, to facilitate the operations, to reduce the operating times, to lower the economic costs. Resection whit single stapler of prolapse and rectocele only on anterior rectal wall, have been proposed: they often have caused asymmetry and bad functional results: they have not received acknowledge.

MATERIAL OF STUDY

On the bases of personal experience (1398 stapled anopexys + 239 STARR/Transtar) the author propose the technique of trans-anal resection using single stapler (8 cases performed) defined StarrOne (Stapled TransAnal Rectal Resection only-One Stapler). The main times of the technique are briefly described, pointing out the characteristics of the device (stapler CPH 34-32 Chex-Healtcare) and the benefits that this entails.

RESULTS

A significant case is reported, particularly complex, with operation performed in patient already treated, some years before, with Sarles technique, unsuccessfully.

CONCLUSIONS

Only further experiences and careful evaluation of results will can indicate the validity of the method.

Improving evidence-based practice: use of the POP-Q system for the assessment of pelvic organ prolapse

The focus of improving health care outcomes today relies on utilizing evidence-based practice. Pelvic organ prolapse affects women of all ages and negatively impacts their quality of life. Evidence-based tools for consistent assessment of prolapses have been developed, validated, and used by many clinicians. Use of these tools needs to become standard of practice for all clinicians who work in the women's health arena. The Brink scale and the POP-Q assessment tool can assist clinicians, direct quality care, and provide evidence-based practice.

Long-term follow-up of simultaneous abdominoperineal repair of enterorectocele and internal mucosal prolapse

BACKGROUND

Enterorectocele with recto-rectal intussusception and internal mucosal prolapse (ER-RI-MP) may require surgery for obstructed defecation, but symptoms tend to recur if only one lesion is corrected. This prospective study was designed to investigate the results of an abdominoperineal procedure aimed at treating all these lesions in one stage.

METHODS

Thirteen women with constipation (median age, 58 years) and ER-RI-MP underwent Douglas pouch suture, mesh obliteration of the pelvic inlet with or without rectopexy, and omentoplasty plus rectocele and prolapse obliteration. Constipation was scored on a scale from 0 to 20. Proctoscopy, enterocolpodefecography, manometry, anal-vaginal-perineal ultrasound, and psychological evaluation were performed before and after surgery.

RESULTS

Bleeding requiring transfusion, pelvic hygroma, and ureteric stricture requiring adhesiolysis occurred in three patients. Constipation score significantly decreased from a mean (+/- standard error of the mean) of 16 +/- 0.6 before to 7 +/- 0.9 after surgery (P < 0.0001). Seven patients were considered cured, five improved, and one remained unchanged at a median follow-up of 42 months. Anorectal physiology and imaging returned to normal in seven patients. Four patients had successful rehabilitation and psychotherapy for anismus, rectal hyposensation, and depression.

CONCLUSIONS

Simultaneous abdominoperineal ER-RI-MP repair integrated with conservative treatment of associated dysfunctions achieved a satisfactory long-term outcome. The results need to be confirmed in larger series.

Perineal hernia: a case of outlet dysfunction

This article describes and discusses a successfully treated case of a primary posterior perineal hernia which is a rare cause of outlet dysfunction. A 46-year-old female patient had a 6 cm left para-anal protrusion and a 7-year history of outlet dysfunction. The perineal hernia orifice was closed via an abdominal approach using both a polypropylene mesh and a Parietex Composite Net. A rectopexy to the promontory of the sacrum was then performed. Moreover, after 6 months' follow-up, the patient presented a sense of incomplete evacuation and underwent a prolassectomy to treat a hidden rectal prolapse. This clinical case shows that the surgical treatment of a pelvic pathology can be successful for the correction of a serious functional defect such as outlet dysfunction.

[Functional obstructed defecation syndrome]

The complex neural coordination and physiology of normal defecation has not yet been completely explained. A defecation event can be disturbed for many reasons, the most common being associated with pregnancy and childbirth, gynaecological descent or neurogenic disturbances of the brain-bowel axis. Causes of obstructed defecation are elucidated by functional imaging and functional investigations of the pelvic floor. Biofeedback treatment can be applied to paradoxal puborectal contraction (anismus), a coordination disturbance of pelvic floor muscles. A new surgical procedure has been developed for the treatment of rectal invagination and rectocele.

[Repair of rectovaginal septum with pedicled fascia flap]

OBJECTIVE

To observe the clinical effect of repairing rectovaginal septum with graft of fascia flap with blood vessels.

METHODS

From August 2004 to August 2006, 12 female patients with rectocele were treated, aging 49-73 years. The disease course was from 5 to 30 years(mean, 5.6 years). All patients suffered dysporia. X-ray films showed severe rectocele (> or = 30 mm), or with the descendent perineum syndrome (> or = 40 mm), and inner pendant rectal mucosa (3 cases) and/or narrow anal canal (9 cases). The size of fascia flap ranged from 15 cm x 3 cm to 18 cm x 5 cm.

RESULTS

The bleeding amount was 800 ml in 2 cases, and 500 ml in 10 cases. All fascia flaps survived. In the 12 patients, 11 had a primary wound healing (Stage I), 1 had a delayed wound healing (Stage II). The donor sites healed at Stage II. Twelve patients could defecate normally 4-6 days after surgery. The legs edema occurred in 2 cases, urinary retention combined with infection occurred in 1 case. And all recovered completely after treatment. Eleven patients were followed up for 6 to 12 months. Digital anorectal examination showed prerectal pouch disappearance, glaze surface and good elasticity. X-ray films and CT showed that the rectocele disappeared.

CONCLUSION

The operation of repairing rectovaginal septum with graft of fascia with blood vessels can effectively recover anatomy of rectovaginal septum and its normal biological function.

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.

Bowel symptoms 1 year after surgery for prolapse: further analysis of a randomized trial of rectocele repair

OBJECTIVE

The purpose of this study was to analyze change in bowel function and its relationship to vaginal anatomy 1 year after rectocele repair and pelvic reconstruction in a randomized trial of 3 techniques of rectocele repair.

STUDY DESIGN

The study is an ancillary analysis of data from a randomized trial of 3 techniques of rectocele repair: posterior colporrhaphy, site-specific repair, and site-specific repair with Fortagen graft augmentation. Pelvic examination and validated questionnaires were obtained at baseline, 6 months, and 1 year after surgery. Bowel symptoms included straining, splinting, incomplete emptying, painful defecation, fecal urgency, and fecal incontinence. Logistic regression was used to identify predictors of bothersome postoperative symptoms.

RESULTS

One hundred six women with Stage > or = 2 POP, which included a rectocele, were enrolled in the study. Ninety-nine underwent prolapse surgery that included a rectocele repair and completed at least 1 follow-up visit. Ninety-six percent of subjects underwent concomitant prolapse surgery. No differences in change in bowel symptoms were noted between treatment groups. On average, all bowel symptoms evaluated were significantly improved 1 year after surgery. The development of new "bothersome" bowel symptoms after surgery was uncommon (11%). After controlling for age, treatment group, comorbidities, and preoperative bowel symptoms, corrected postoperative vaginal support (Stage 0/1) was associated with a reduced risk of postoperative straining (adj. OR 0.17 95% CI 0.03 to 0.9) and feeling of incomplete emptying (adj. OR 0.1 95% CI 0.01 to 0.52). Normal support of the posterior vaginal wall (Bp < or = -2) was associated with a reduced risk of bothersome incomplete emptying (OR 0.08 95% CI 0.004 to 0.58) but not with other symptoms.

CONCLUSION

Resolution or improvement in bowel symptoms can be expected in the majority of women after rectocele repair and pelvic reconstruction. While all symptoms improved after surgery, a reduction in bothersome postoperative straining and incomplete emptying were specifically associated with cure of posterior vaginal wall prolapse.

A prospective evaluation of occult disorders in obstructed defecation using the 'iceberg diagram'

OBJECTIVE

Surgical treatment of constipation and obstructed defecation (OD) carries frequent recurrences, as OD is an 'iceberg syndrome' characterized by 'underwater rocks' or occult diseases which may affect the outcome of surgery. The aim of this study was to evaluate occult disorders, in order to alert the clinician of these and minimize failures.

METHOD

One hundred consecutive constipated patients with OD symptoms, 81 women, median age 52 years, underwent perineal examination, proctoscopy, anorectal manometry and anal/vaginal ultrasound (US). Anorectal physiology and imaging tests were also carried out when indicated, as well as psychological and urogynaecological consultations. Symptoms were graded using a modified 1-20 constipation score. Both evident (e.g. rectocele) and occult (e.g. anismus) diseases were prospectively evaluated using a novel 'iceberg diagram'. The type of treatment, whether conservative or surgical, was also recorded.

RESULTS

Fifty-four (54%) patients had both mucosal prolapse and rectocele. All patients had at least two occult OD-related diseases, 66 patients had at least three of them: anxiety-depression, anismus and rectal hyposensation were the most frequent (66%, 44% and 33%, respectively). The median constipation score was 11 (range 2-20), the median number of 'occult disorders' was 5 (range 2-8). Conservative treatment was carried out in most cases. Surgery was carried out in 14 (14%) patients.

CONCLUSION

The novel 'iceberg diagram' allowed the adequate evaluation of OD-related occult diseases and better selection of patients for treatment. Most were managed conservatively, and only a minority were treated by surgery.

Persistent symptoms of functional outlet obstruction after rectocele repair

BACKGROUND

Rectocele is frequently associated with constipation, but it is not known whether a causal relationship exists.

OBJECTIVE

To determine the effect of rectocele repair on symptoms of constipation.

METHOD

Thirty-five women (28-79 years) consecutively operated for rectocele repair (11 transanal approach and 24 transperineal) were included in the prospective study. Using a structured questionnaire, the following criteria for constipation were evaluated: (a) straining, (b) sensation of anal blockage, (c) sensation of incomplete evacuation, (d) manual manoeuvres to facilitate defecation, (e) stool consistency and (f) stool frequency. The evaluation was performed before and 1 year after rectocele repair.

RESULTS

Before the operation all patients had two or more constipation criteria, including sensation of anal blockage. One year after the operation, the incidence of all symptoms significantly improved (from 3.9 +/- 0.2 to 1.9 +/- 0.3; P < 0.01). However, in 18 patients two or more criteria of constipation persisted, two patients presented one criterion, and only 15 patients became asymptomatic. Neither parity nor the type of surgical approach (endorectal vs transperineal) was related to the response to treatment. In eight patients who had a previous hysterectomy the result was significantly worse.

CONCLUSION

In a considerable proportion of patients, constipation persists after rectocele repair, suggesting that these symptoms are related to an underlying dysfunction.

Rectocele repair: a randomized trial of three surgical techniques including graft augmentation

OBJECTIVE

This study was undertaken to compare outcomes of 3 different rectocele repair techniques.

STUDY DESIGN

One hundred six women with stage II or greater posterior vaginal wall prolapse were randomly assigned to either posterior colporrhaphy (n = 37), site-specific rectocele repair (n = 37), or site-specific rectocele repair augmented with a porcine small intestinal submucosa graft (Fortagen, Organogenesis, Inc, Canton, MA; n = 32). Subjects underwent a physical examination and completed 3 validated pelvic floor instruments at baseline and 6 months, 1 year, and 2 years after surgery. Anatomic failure was defined as pelvic organ prolapse quantitation system (POPQ) point Bp > or = -2 at 1 year.

RESULTS

Of 106 subjects who enrolled, 105 underwent surgery and of those 105, 98 subjects returned (93%) with a mean follow-up of 17.5 +/- 7 months. After 1 year, those subjects who received graft augmentation had a significantly greater anatomic failure rate (12/26; 46%) than those who received site-specific repair alone (6/27; 22%) or posterior colporraphy (4/28; 14%), P = .02. There was a significant improvement in prolapse and colorectal scales and overall summary scores of the Pelvic Floor Distress Inventory short form 20 (PFDI-20), the Pelvic Floor Impact Questionnaire short form 7 (PFIQ-7) after surgery in all groups (P < .001 for each) with no differences between groups. The proportion of subjects with functional failures was 15% overall, and not significantly different between groups. There was no significant change in the rate of dyspareunia 1 year after surgery and there were no differences between groups. Overall sexual function as measured by the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12) improved significantly in all groups postoperatively (P < . 001), with no differences between groups.

CONCLUSION

Posterior colporraphy and site-specific rectocele repair result in similar anatomic and functional outcomes. The addition of a porcine-derived graft does not improve anatomic outcomes. All 3 methods of rectocele repair result in significant improvements in symptoms, quality of life, and sexual function.

A prospective evaluation of occult disorders in obstructed defecation using the 'iceberg diagram'

OBJECTIVE

Surgical treatment of constipation and obstructed defecation (OD) carries frequent recurrences, as OD is an 'iceberg syndrome' characterized by 'underwater rocks' or occult diseases which may affect the outcome of surgery. The aim of this study was to evaluate occult disorders in order to alert the clinician of these and minimize failures.

METHOD

One hundred consecutive constipated patients with OD symptoms, 81 female patients, median age 52 years, underwent perineal examination, proctoscopy, anorectal manometry, and anal/vaginal ultrasound. Anorectal physiology and imaging tests were also carried out when indicated, as well as psychological and urogynaecological consultation. Symptoms were graded using a modified 1-20 constipation score. Both evident (e.g. rectocele) and occult (e.g. anismus) diseases were prospectively evaluated using a novel 'iceberg diagram'. The type of treatment, whether conservative or surgical, was also recorded.

RESULTS

Fifty-four (54%) patients had both mucosal prolapse and rectocele. All patients had at least two occult OD-related diseases, 66 patients had at least three: anxiety-depression, anismus and rectal hyposensation were the most frequent (66%, 44% and 33% respectively). The median constipation score was 11 (range 2-20), the median number of 'occult disorders' was 5 (range 2-8). Conservative treatment was carried out in most patients. Surgery was carried out in 14 (14%) patients.

CONCLUSION

The novel 'iceberg diagram' allowed the adequate evaluation of OD-related occult diseases and better selection of patients for treatment. Most were managed conservatively, and only a minority were treated by surgery.

Dynamic pelvic three-dimensional computed tomography for investigation of pelvic abnormalities in patients with rectocele and rectal prolapse

BACKGROUND

Dynamic three-dimensional computed tomography (D-3DCT: high-speed helical scanning during defecation) was used for morphological evaluation of intrapelvic structures in patients with rectal prolapse and rectocele.

METHODS

Twenty-five patients with rectal prolapse or rectocele diagnosed by conventional defecography (CD) or clinical findings were additionally investigated with D-3DCT. D-3DCT images were acquired using a multislice CT system with a 16-row detector during simulated defecation. Helical scanning was performed with a slice thickness of 1 mm, a helical pitch of 15 s/rotation, and a table movement speed of 35 mm/s. The contrast medium, 100 ml of iopamidol (370 mg/ml), was injected at a rate of 2.5 ml/s to enhance contrast with other structures, and scan start was triggered by using a function for automatically determining the optimal scan timing.

RESULTS

Among the eight patients with rectocele, additional intrapelvic disorders were diagnosed in five (enterocele, 4; cystocele, 1; and uterine prolapse, 1) with D-3DCT. In the 17 patients with rectal prolapse, concomitant intrapelvic disorders were found in six (intussusception, 3; cystocele, 2; uterine prolapse, 2; rectocele, 1; and vaginal prolapse, 1).

CONCLUSIONS

D-3DCT can be a useful diagnostic tool for investigation of pelvic pathology in patients with rectocele and rectal prolapse.

Incidence of concomitant surgery for pelvic organ prolapse in patients surgically treated for stress urinary incontinence

OBJECTIVE

To examine the concomitant incidence of surgery for pelvic organ prolapse in patients undergoing a surgical procedure to correct stress urinary incontinence in both an academic and private urogynecology practices.

STUDY DESIGN

A retrospective chart review was performed on all patients undergoing surgical correction of stress urinary incontinence over a 1-year period at 2 centers.

RESULTS

Among 150 surgical procedures for stress urinary incontinence in the academic practice, 116 (77%) patients underwent at least 1 additional procedure for a pelvic support defect, and 72 (48%) patients required 2 or more concomitant reconstructive pelvic procedures. In the private urogynecology practice, 182 surgical procedures for stress urinary incontinence were performed, 153 (84%) patients required at least 1 additional procedure for a pelvic support defect, and 86 (47%) patients required 2 or more concomitant reconstructive pelvic procedures.

CONCLUSION

Women who require surgical correction of stress urinary incontinence have a high incidence of concomitant pelvic support defects that require surgical repair. The incidence of concomitant surgery for pelvic organ prolapse between the 2 sites was not significantly different.

The effects of isolated posterior compartment defects on lower urinary tract symptoms and urodynamic findings

OBJECTIVES

To determine any significant patterns among subjective and/or objective storage or voiding variables in women with isolated rectoceles or posterior enteroceles.

PATIENTS AND METHODS

We retrospectively reviewed the charts of 23 women with isolated posterior compartment defects. Patient histories, physical examination findings, catheterized postvoid residual urine volume (PVR) after uroflowmetry, and urodynamic evaluations were reviewed. Lower urinary tract symptoms (LUTS) were classed as pure storage (urgency, frequency, nocturia, etc.), pure voiding (hesitancy, straining, positional voiding, etc.), or mixed.

RESULTS

The mean (range) age of the women was 67 (48-85) years. On physical examination, 15 women had a grade 3 defect, and eight a grade 2 defect. Thirteen women reported symptoms related to their prolapse (vaginal bulge, splinting with defecation): nine reported pure storage symptoms, one pure voiding symptoms, and 12 mixed symptoms; two women relied on catheterization for bladder emptying. Only one woman reported no LUTS. An elevated PVR (>100 mL) was found in 11 women (48%). Urodynamic studies were available for 17 women, and revealed detrusor overactivity in nine of them. There were low maximum urinary flow rates (Qmax < or = 15 mL/s) in 12 of the 17 women, and high voiding pressures at Qmax (P(det.Qmax) > or = 20 cmH2O) in 10. Both findings were present in seven of the 17 women. There was evidence of abdominal straining to void in nine of the 17 women.

CONCLUSIONS

The overwhelming majority of women with isolated posterior compartment defects reported bothersome LUTS and most had abnormal urodynamic variables. The findings suggest that significant posterior prolapse defects can cause bladder outlet obstruction.

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.

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.

Role of pelvicography and colpocystodefecography in diagnosis of outlet obstructive constipation

AIMS

The aim was to research the changes in pelvic floor morphology and corresponding visceras in patients with outlet obstructive constipation (OOC).

PATIENTS AND METHODS

Thirty-eight patients with OOC and 12 healthy volunteers were enrolled in this study. With simultaneous pelvicography and colpocystodefecography (PCCD), including pelvicography, vaginal opacification, voiding cystography and defecography, pelvic floor morphology was observed and the anorectal angle, the level of the perineum, peritoneum and bladder were measured.

RESULTS

Thirty-seven cases of internal rectal prolapse (IRP), 5 cases of rectocele (RC) and 5 cases of spastic pelvic floor syndrome SPFS were diagnosed by PCCD. 12 IRP, 4 RC and 1 SPFS were detected by common physical examination. All of these were confirmed by PCCD. Moreover, PCCD found 9 pelvic floor hernia or peritoneoceles, 6 cystoceles, 3 descending perineum syndromes and 10 uterine prolapses. Compared with controls, OOC patients had a significantly large anorectal angle during defecation, abnormal descending of the perineum at rest and during defecation, and a deep pouch of Douglas during defecation. Some patients with urinary system symptoms may have had an abnormal descent of the bladder during rest and defecation.

CONCLUSION

Simultaneous PCCD has a higher positive ratio than the common physical examination in diagnosing IRP and RC, and provides information for the diagnosis of pelvic floor hernia or peritoneocele, cystocele or uterine prolapse. PCCD is helpful in the selection of a proper surgical procedure.

Enterocele associated with rectocele revealed by dynamic pelvic CT

Enterocele is often associated with other pelvic floor disorders but it is not always possible to detect by clinical examination. Defecography with peritoneography and/or barium meal intake has recently been developed as a new method to identify enterocele, but this method is an invasive procedure. Multislice computed tomography was performed at rest and during simulated defecation to evaluate an 80-year-old female patient who had a defecation disorder and was diagnosed as having rectocele based on results from defecography and clinical findings. Multiplanar reconstruction images were generated for image evaluation. Using this novel method of dynamic pelvic computed tomography, a third-degree enterocele was clearly demonstrated in this case.

The role of rectocele repair in targeted patients with obstructed defaecation

INTRODUCTION

Obstructed defaecation is a complex disorder that poses serious management challenges. The purpose of this study is to review the functional results of surgery in women undergoing rectocele repair for obstructed defaecation, and in a targeted subgroup in which the rectocele was the only identifiable cause of their symptoms.

METHODS

All case notes were reviewed. Demographic details, preoperative symptoms, details of previous pelvic surgery, radiological and anorectal physiology results, operative procedure, post operative symptoms, length of follow-up and details of further pelvic reconstructive surgery were recorded. To enter the targeted group, patients (i) had not undergone previous pelvic surgery, (ii) had presented with obstructive defaecation, (iii) had a proctogram that demonstrated a rectocele with no or partial intrarectal intussusception and (iv) had no other functional abnormality in colonic transit studies, endoanal ultrasound or anorectal physiology.

RESULTS

Eighty-two case notes were reviewed. All experienced obstructed defaecation. Forty-two women underwent a per-anal plication of the rectocele, 33 had a transperineal plication and levatorplasty and seven a mesh repair. A total of 63 (77%) women were pleased with the result, though symptoms later returned in 17 (27%) of them. 26 (31%) had further surgery in an attempt to improve their defaecatory difficulties. Sixteen women were eligible for the targeted group. All had a good early result though symptoms returned in three women. Two (12%) had further surgery.

CONCLUSION

Careful preoperative patient selection is vital to improve outcomes. Preoperative counselling of all patients undergoing rectocele repair is of extreme importance, in particular explaining the evolving nature of pelvic floor dysfunction and the possible need for further reconstructive surgery.

Incarceration of bowel through opening of a 5-mm port

An 85-year-old woman presented with genital prolapse (rectocele and cystocele) with stress urinary incontinence. Three days after laparoscopic promonto fixation, bowel became incarcerated in the opening of a 5-mm port site. This clinical case forces us to reconsider the harmlessness of 5-mm ports. We recommend making sure that their openings are well closed.

Impact of vaginal surgery for stress urinary incontinence on female sexual function: Is the use of polypropylene mesh detrimental?

OBJECTIVES

To evaluate prospectively the impact of a distal urethral polypropylene sling on sexual function using a validated questionnaire. Suburethral slings are currently the most common anti-incontinence surgery performed. Although the use of polypropylene is safe and effective, concern exists that the presence of the material in the vagina may adversely affect sexual function.

METHODS

A total of 29 patients agreed to participate in this prospective study. The patients were evaluated with the Female Sexual Function Index, a validated, 19-item questionnaire that assesses six domains of sexual function: desire, arousal, lubrication, orgasm, satisfaction, and pain. The questionnaires were administered at 6-month intervals during the follow-up visits.

RESULTS

The mean patient age was 52 years (range 38 to 72). The mean duration of follow-up was 19.4 months (range 7 to 37). No statistically significant difference was found in sexual function after placement of a distal urethral polypropylene sling. Of the 29 patients, 14% were not sexually active before or after surgery. No statistically significant difference was found between preoperative and postoperative desire, arousal, lubrication, orgasm, satisfaction, and pain.

CONCLUSIONS

No change was found in overall sexual function in women undergoing placement of a mid to distal polypropylene urethral sling. Specifically, neither a deleterious effect nor statistically significant improvement was found in sexual desire, arousal, lubrication, orgasm, satisfaction, or pain compared with the preoperative baseline values.