Rectocele repair by anterolateral rectopexy: long-term functional outcome.

INTRODUCTION: Rectoceles are frequently associated with feelings of pelvic discomfort and symptoms of obstructed defaecation (OD). Repair by a transvaginal or transanal approach might result in de novo dyspareunia in up to approximately 40% of the cases. This study was designed to investigate whether anterolateral rectopexy provides an adequate rectocele repair without dyspareunia as a side effect. METHOD: A consecutive series of 33 women (median age 55 years; range: 37-73) with a symptomatic rectocele (depth > 3 cm) underwent anterolateral rectopexy. Before the operation, all patients underwent evacuation proctography (EP), which was repeated 6 months after the repair in all but three patients. A standardized questionnaire concerning pelvic discomfort, OD and dyspareunia was used to assess the long-term effect of rectocele repair. The response rate was 91%. RESULTS: Six months after the procedure, EP revealed a recurrent or persistent rectocele in six patients (20%). However, in four of these six patients, the depth of the rectocele was < 3 cm. The median duration of follow-up was 74 months (range: 2-96). Among the patients with an adequate repair, signs of OD persisted in 55%. None of the patients encountered de novo dyspareunia after the procedure. CONCLUSION: Anterolateral rectopexy provides an effective tool for anatomical correction of rectoceles and does not result in dyspareunia as a side effect. However, despite adequate repair, OD persist in the majority of patients.

Enterocele repair by abdominal obliteration of the pelvic inlet: long-term outcome on obstructed defaecation and symptoms of pelvic discomfort.

OBJECTIVE: Enterocele is defined as a herniation of the peritoneal sac between the vagina and the rectum. This may contain either sigmoid colon or small bowel. It has been reported that enterocele is associated with obstructed defaecation and symptoms of pelvic discomfort. The aim of the present study was to evaluate the long-term effect of enterocele repair. METHOD: In the time period between 1994 and 2003, 54 women (median age 54 years; range: 31-80) with a symptomatic enterocele underwent obliteration of the pelvic inlet with a U-shaped Mersilene mesh. All patients underwent evacuation proctography (EP), which was repeated 6 months after the repair. In addition, they were contacted over the telephone to assess the long-term effect of enterocele repair. Forty-nine patients were willing to answer questions over the telephone. Five patients were lost to follow-up (response rate: 91%). RESULTS: Six months after the procedure, EP revealed a recurrent or persistent enterocele in five (9%) patients, which was symptomatic in two, both of whom underwent a second repair. Among the 49 patients without an enterocele after 6 months, 10 (23%) women encountered recurrent symptoms of pelvic discomfort at a median follow-up of 85 months (range: 3-137). Despite adequate correction of the enterocele, obstructed defaecation persisted in 21 (75%) patients of 28, who presented with this problem before the procedure. De novo dyspareunia occurred in 5% of the women after the procedure. CONCLUSION: Obliteration of the pelvic inlet with a U-shaped Mersilene mesh provides an effective tool for anatomical correction of enteroceles. However, in the long term one of four patients encounters recurrent symptoms of pelvic discomfort. It seems unlikely that enterocele contributes to obstructed defaecation, as evacuation difficulties persist in around three quarters of the patients.

Puborectal sling interposition for the treatment of rectovaginal fistulas.

BACKGROUND: Several techniques are available for the surgical treatment of rectovaginal fistulas, however often the results are rather disappointing. Interposition of healthy, well vascularized tissue may be the key to rectovaginal fistula healing. The present study was aimed at evaluating the outcome of puborectal sling interposition in the treatment of rectovaginal fistulas. METHODS: Between 2001 and 2004, 26 consecutive patients (median age, 40.5 years; range, 15-69 years) with a rectovaginal fistula underwent a puborectal sling interposition. The etiology of the fistulas was: obstetric injury (n=11), complications after prior surgery (n=2), bartholinitis (n=4), cryptoglandular perineal abscess (n=2), inflammatory bowel disease (n=2) and idiopathic causes (n=5). The patients received a questionnaire about fecal continence (before and after surgery) and dyspareunia (after surgery). RESULTS: The median follow-up was 14 months. The recto-vaginal fistula healed in 16 (62%) of 26 patients. In patients who had undergone one or more previous repairs, the healing rate was only 31% versus 92% in patients without previous repairs (p<0.01). The median Rockwood fecal incontinence severity index score did not change as a result of the surgery. Seventeen percent of patients experienced painful intercourse before the operation; after the procedure this problem was encountered by 57% of the patients. CONCLUSIONS: The puborectal sling interposition is only successful in patients without previous repairs and in those with an uneventful postoperative course, however dyspareunia is a major drawback of this procedure.