Functional Outcome and Sexual-Related Quality of Life After Transperineal Versus Transvaginal Repair of Anterior Rectocele: A Randomized Clinical Trial.

BACKGROUND: Methods of treatment of rectocele include transperineal, transvaginal, and transanal approaches and ventral rectopexy. OBJECTIVE: The present randomized study aimed to compare the outcome of transperineal repair and transvaginal repair of anterior rectocele. DESIGN: This is a randomized, single-blinded clinical trial. SETTING: This study was conducted at the Colorectal Surgery Unit, Mansoura University Hospitals. PATIENTS: Adult female patients with anterior rectocele reporting obstructed defecation syndrome were selected. INTERVENTIONS: Anterior rectocele was surgically treated via a transperineal or transvaginal approach. MAIN OUTCOME MEASURES: Improvement in constipation, operation time, hospital stay, complications, changes in anal pressures, and improvement in sexual-related quality of life was assessed by use of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, and the incidence of dyspareunia postoperatively was assessed. RESULTS: Sixty-four female patients of a mean age of 43.5 years were entered into the trial. There was no significant difference between the 2 groups regarding the operation time. Patients undergoing transperineal repair had significantly longer hospital stays than those undergoing transvaginal repair (2.4 vs 2.1 days, p = 0.03). There was no significant difference between the 2 groups regarding postoperative complications and recurrence of rectocele. Significant decrease in the constipation scores was recorded in both groups at 6 and 12 months after surgery. The decrease in the constipation scores after transvaginal repair was significantly higher than after transperineal repair at 6 and 12 months postoperatively. Although resting and squeeze anal pressures were significantly increased at 12 months after transperineal repair, they did not show significant change after transvaginal repair. Improvement in sexual-related quality of life was significantly higher in the transvaginal repair group than in the transperineal repair group at 6 and 12 months after surgery. Dyspareunia improved after transvaginal repair and worsened after transperineal repair, yet this change was insignificant. LIMITATIONS: This was a single-center study comprising a relatively small number of patients. CONCLUSION: Transvaginal repair of rectocele achieved better improvement in constipation and sexual-related quality of life than transperineal repair. Changes in dyspareunia after both techniques were not significant. See Video Abstract at http://links.lww.com/DCR/B148. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03801291. RESULTADO FUNCIONAL Y CALIDAD DE VIDA RELACIONADA CON EL SEXO DESPUÉS DE LA REPARACIÓN TRANSPERINEAL VERSUS TRANSVAGINAL DEL RECTOCELE ANTERIOR: UN ENSAYO CLÍNICO ALEATORIZADO: Los métodos de tratamiento del rectocele incluyen los abordajes transperineal, transvaginal y transanal y la rectopexia ventral.El objetivo del presente estudio aleatorizado fue comparar el resultado de la reparación transperineal y la reparación transvaginal del rectocele anterior.Ensayo clínico aleatorizado, simple ciego.Unidad de Cirugía Colorrectal, Hospital Universitario de Mansoura.Pacientes mujeres adultas con rectocele anterior que se quejan de síndrome de defecación obstruida.Tratamiento quirúrgico del rectocele anterior mediante abordaje transperineal o transvaginal.Mejora en el estreñimiento, tiempo de operación, estancia hospitalaria, complicaciones, cambios en la presión anal, mejoría en la calidad de vida relacionada con el sexo evaluada por el cuestionario PISQ-12 e incidencia de dispareunia postoperatoria.Sesenta y cuatro pacientes de sexo femenino de una edad media de 43.5 años ingresaron al ensayo. No hubo diferencias significativas entre los dos grupos con respecto al tiempo de operación. La reparación transperineal tuvo una estancia hospitalaria significativamente más prolongada que la reparación transvaginal (2.4 Vs 2.1 días, p = 0.03). No hubo diferencias significativas entre ambos grupos con respecto a las complicaciones postoperatorias y la recurrencia del rectocele. Se registró una disminución significativa en las puntuaciones de estreñimiento en ambos grupos a los 6 y 12 meses después de la cirugía. La disminución en las puntuaciones de estreñimiento después de la reparación transvaginal fue significativamente mayor que después de la reparación transperineal a los 6 y 12 meses después de la operación. Aunque las presiones anales de reposo y compresión aumentaron significativamente a los 12 meses después de la reparación transperineal, no mostraron cambios significativos después de la reparación transvaginal. La mejora en la calidad de vida relacionada con el sexo fue significativamente mayor en la reparación transvaginal que en el grupo de reparación transperineal a los 6 y 12 meses después de la cirugía. La dispareunia mejoró después de la reparación transvaginal y empeoró después de la reparación transperineal, sin embargo, este cambio fue insignificante.Estudio de un solo centro que comprende un número relativamente pequeño de pacientes.La reparación transvaginal del rectocele logró una mejoría en el estreñimiento y la calidad de vida relacionada con el sexo que la reparación transperineal. Los cambios en la dispareunia después de ambas técnicas no fueron significativos. Consulte Video Resumen en http://links.lww.com/DCR/B148.Ensayos clínicos. Identificador del gobierno: NCT03801291.

Transanal repair of rectocele: prospective assessment of functional outcome and quality of life.

AIM: This study aimed to assess the functional outcome of transanal repair of rectocele using patient symptom scores and quality of life (QOL) instruments. METHOD: Patients who underwent transanal repair for symptomatic rectocele between February 2012 and August 2017 were included. This study was a retrospective analysis of prospectively collected data. A standard questionnaire including the Constipation Scoring System (CSS), the Fecal Incontinence Severity Index (FISI) and QOL instruments [Patient Assessment of Constipation (PAC)-QOL, Fecal Incontinence QOL Scale, Short-Form 36 Health Survey (SF-36)] was administered before and after the operation. Physiological assessment and proctography were performed before and after the operation. RESULTS: Thirty patients were included. The median follow-up was 36 (6-72) months. Postoperative proctography showed a reduction in rectocele size [34 mm (14-52 mm) vs 10 mm (0-28 mm), P < 0.0001]. Physiological assessment showed no significant postoperative changes. Constipation was improved in 15/21 patients (71%) at 1 year and 14/20 patients (70%) at the mid-term follow-up. The CSS score reduced at 3 months [12 (8-12) vs 6 (1-12), P < 0.0001] and remained significantly reduced over time until the mid-term follow-up. Faecal incontinence was improved in two-thirds patients at 1 year. Four patients developed new-onset faecal incontinence. All the PAC-QOL scale scores significantly improved over time until 1 year, while two of the eight SF-36 scale scores showed significant postoperative improvement. CONCLUSION: Transanal repair for rectocele improves constipation and constipation-specific QOL.

Long-term comparison of physiologic anorectal changes and recurrence between transanal repair and transanal repair with posterior colporrhaphy in rectocele.

BACKGROUND: Rectocele is often associated with chronic constipation. Various surgical techniques have been described to repair rectoceles, but the results vary. The aim of this study was to compare the outcomes of transanal repair (TAR) and transanal repair with posterior colporrhaphy (TAR + PC). METHODS: While 44 patients underwent TAR, 49 patients underwent TAR + PC for surgical repair of rectocele. Patients were followed up 3 months post-surgery for anorectal physiological changes. From the entire cohort of patients who underwent the surgical repair, 22 patients who underwent TAR and 25 patients who underwent TAR + PC agreed to participate in the 3-year post-treatment check-up. RESULTS: Out of the 22 patients who underwent TAR, 3 patients (13.6%) scored more than 15 on the constipation scoring system (CSS), while 1 out of 25 patients who underwent TAR + PC scored more than 15 on the CSS 3 months post-treatment, which is considered as recurrence (p = 0.237). With 7 patients from the TAR group (31.8%) and 2 patients from the TAR + PC group (8.0%) showing recurrence of rectocele at 3-year post-treatment follow-up, this study found that TAR + PC had a much lower rate of recurrence than TAR. Furthermore, TAR + PC was found to be more effective than TAR in terms of rectal sensation, sensory threshold (p = 0.001), and early defecation urge (p = 0.003). CONCLUSIONS: TAR + PC can help alleviate some symptoms by restoring the rectal sensation and improving the rectovaginal septum. It can be inferred that the addition of a simple treatment method can lead to a lower rate of recurrence.

Value of colpo-cysto-entero defecography to predict the post operative results in patients with obstructed defecation.

INTRODUCTION: The conventional video colpo-cysto entero defecography describing the morpho- functional imaging features, physiological and pathological of the recto-anal region and pelvic floor . It represents the gold standard examination for the identification and staging of morphological and functional disorders of the recto-anal region and pelvic floor in evacuation dysfunctions. MATERIALS AND METHODS: Between January 2010 to January 2013 88 patients underwent STARR procedure for obstructed defecation syndrome (ODS) caused by single rectocele or internal rectal intussusception. We retrospectively analyzed the collected data,in particular we reviewed the defecography results before surgery. RESULTS: At defecography imaging , 30 patients (34 %) had an anal canal opening between 0 and 5 seconds, 44 (50 %) between 6 and 10 seconds and 14 patients (16 %) over 10 seconds at defecography imaging. The defecography showed an enterocele in 30 patients (34 %) The enterocele was functional in 25 (28,4 %) and stable in 5 (5,6 %) patients. 53 patients have a II° rectocele (60,2 %) and 35 patients a III° rectocele (39,7 %). The average preoperative ODS score was 14 . The average ODS score revaluated at 1 year was 3.1, 4.3 at 3 years an 6,4 after 5 years. The improvement of the ODS score was lower in the subgroup of patients presenting a slow opening of the anal canal (> 10 sec): 7.5 at one year, 9.1 at 3 years and 11 after 5 years follow-up. Also in the subgroup of patients with stable enterocele (5,6 %) the improvement was less evident: 6.7 at 1 year, 8 at 3 years and 9.7 after 5 years follow-up. DISCUSSION AND CONCLUSION: We have observed that a coexistence of a long opening time of the anal canal and / or the presence of a stable enterocele are factors that significantly reduce the effectiveness of the surgery leading over time to ODS score values close to those present before surgery. In the fisrt case we suggest a pre and post-operative perineal physiotherapy, in the second case a Dougla's platsy KEY WORDS: Defecography, Obstructed defecation syndrome, Rectocele, Recto-anal prolapse.

Structural, functional, and symptomatic differences between women with rectocele versus cystocele and normal support.

BACKGROUND: Prolapse of the anterior and posterior vaginal walls has been generally associated with apical descent and levator ani muscle defects. However, the relative contributions of these factors to the pathophysiology of descent in the different vaginal compartments is not well understood. Furthermore, symptoms uniquely associated with prolapse in these compartments have not been well characterized. OBJECTIVES: The objectives of the study were to compare the associations between the following: (1) apical support, (2) levator ani muscles, and (3) pelvic floor symptoms in women with posterior-predominant prolapse, anterior-predominant prolapse, and normal support. STUDY DESIGN: This is a cross-sectional study with 2 case arms: 60 women with posterior prolapse, 90 with anterior prolapse, and a referent control arm with 103 asymptomatic subjects with normal support, determined from pelvic organ prolapse quantification examinations. Levator muscle defects were graded from magnetic resonance imaging. Vaginal closure forces above resting were measured with an instrumented speculum during maximal contraction. Pelvic floor symptoms were measured via the Pelvic Floor Distress Inventory-Short Form. RESULTS: Mean point C location in controls was -6.9 cm [1.5] (mean [standard deviation]); and was higher in posterior prolapse (-4.7 cm [2.7], 2.2 cm below controls) than the anterior prolapse group (-1.2 cm [4.1]; 5.6 cm below controls, P < .001 for all comparisons). Normal-appearing muscles (ie, muscle without a visible defect) occurred at similar frequencies in posterior prolapse (45%) and controls (51%, P = .43) but less often in anterior prolapse (28%, P ≤ .03 for pairwise comparisons). Major levator ani defects occurred at similar rates in women with posterior (33%) and anterior prolapse (42%, P = .27) but less often in controls (16%, P ≤ .012 for both pairwise comparisons). Similarly, there were significant differences in generated vaginal closure forces across the 3 groups, with the prolapse groups generating weaker closure forces than the control group (P = .004), but the differences between the 2 prolapse groups were not significant after controlling for prolapse size (P = .43). Pelvic floor symptoms were more severe for the posterior (mean Pelvic Floor Distress Inventory score, 129) and anterior prolapse groups (score, 128) than the controls (score, 40.2, P < .001 for both comparisons); the difference between the 2 prolapse groups was not significant (P = .83). CONCLUSION: Posterior-predominant prolapse involves an almost 3-fold less apical descent below normal than anterior-predominant vaginal prolapse. Levator ani defects and muscle impairment also have a lower impact. Pelvic floor symptoms reflect the presence and size of prolapse more than the predominant lax vaginal compartment.

Clinical outcomes of stapled transanal rectal resection for obstructed defaecation syndrome at 10-year follow-up.

AIM: The long-term efficacy of stapled transanal rectal resection (STARR) for surgical management of obstructed defaecation syndrome (ODS) has not been evaluated. Therefore, we investigated the long-term efficacy (> 10 years) of STARR for treatment of ODS related to rectocele or rectal intussusception and the factors that predict treatment outcome. METHOD: This study was a retrospective cohort analysis conducted on prospectively collected data. Seventy-four consecutive patients who underwent STARR for ODS between January 2005 and December 2006 in two Italian hospitals were included. RESULTS: Seventy-four patients [66 women; median age 61 (29-77) years] underwent STARR for ODS. No serious postoperative complications were recorded. Ten years postoperatively, 60 (81%) patients completed the expected follow-up. Twenty-three patients (38%) reported persistent perineal pain and 13 (22%) experienced the urge to defaecate. ODS symptoms recurred in 24 (40%) patients after 10 years. At the 10-year follow-up, 35% of patients were very satisfied and 28% would recommend STARR and undergo the same procedure again if necessary. In contrast, 21% of patients would not select STARR again. Previous uro-gynaecological or rectal surgery and high constipation scores were identified as risk factors for recurrence. CONCLUSIONS: Stapled transanal rectal resection significantly improves the symptoms of ODS in the short term. In the long term STARR is less effective, however.

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.

Short-term outcomes of laparoscopic ventral rectopexy for obstructed defecation in patients with overt pelvic structural abnormalities-a Chinese pilot study.

AIM: As laparoscopic ventral rectopexy (LVR) gained increasing popularity in the past decade, studies from non-western area remain rare. The aim of this pilot study is to evaluate the efficacy and safety of LVR for obstructed defecation (OD) in Chinese patients with overt pelvic structural abnormalities. METHODS: A series of 19 consecutive patients is presented undergoing LVR for OD. All patients showed various forms of pelvic structural abnormalities which were verified by dynamic defecography exam. Data was prospectively recorded and the functional outcomes were evaluated using the Cleveland Clinic Constipation Score (CCCS) and Patients Assessment of Constipation Quality of Life Score (PAC-QoL). RESULTS: Pelvic structural abnormalities of the 19 patients included external rectal prolapse (ER) in 10.5% (2/19), high grade internal rectal prolapse (IR) in 57.8% (11/19), rectocele in 52.6% (10/19), enterocele in 15.7% (3/19), cystocele/vaginal prolapse in 15.7 (3/19), descending perineum (DP) in 63.5% (12/19). 89.4% patients (17/19) showed at least two co-existed abnormalities and 15.7% (3/19) showed multicompartmental abnormalities. The mean follow-up was 9 months (range 1-18). No mesh-related complication was observed. At last available follow-up (LAFU), improvement of OD symptom was observed in 15 (78.9%) patients, the mean scores of CCCS decreased from 17 to 10 (p < 0.05), all four subsets of PAC-QoL scores improved, and three of them (physical discomfort, worries and concerns, satisfaction) showed statistical significance (p < 0.05). CONCLUSION: Laparoscopic ventral rectopexy appears to be a safe and effective procedure for obstructed defecation in Chinese patients with overt pelvic structural abnormalities in short-term follow-up.

Transvaginal Mesh and Transanal Resection to Treat Outlet Obstruction Constipation Caused by Rectocele.

BACKGROUND The aim of this study was to evaluate the curative effect of transvaginal mesh repair (TVMR) and stapled transanal rectal resection (STARR) in treating outlet obstruction constipation caused by rectocele. MATERIAL AND METHODS Patients who had outlet obstruction constipation caused by rectocele were retrospectively analyzed and 39 patients were enrolled the study. Patients were assigned to either the TVMR or STARR group. Postoperative factors such as complications, pain, recurrence rate, and operative time were compared between the 2 groups. RESULTS Total effective rate was 100% in both groups. No long-term chronic pain occurred and discomfort rate of tenesmus was higher in the STARR group than in the TVMR group. Postoperative defecography showed that the rectocele depth was significantly reduced, and the prolapse of the rectal mucosa and the lower rectal capacity was also decreased. Four cases had mesh exposure in the TVMR group and 2 cases in the STARR group had anastomotic bleeding after the surgery. CONCLUSIONS For outlet obstruction constipation caused by rectocele, TVMR and STARR both obtained satisfactory results. Although TVMR is complex with longer operative time and hospitalization period, its long-term effect is better than that of STARR.

Intraoperative cervix location and apical support stiffness in women with and without pelvic organ prolapse.

BACKGROUND: It is unknown how initial cervix location and cervical support resistance to traction, which we term "apical support stiffness," compare in women with different patterns of pelvic organ support. Defining a normal range of apical support stiffness is important to better understand the pathophysiology of apical support loss. OBJECTIVE: The aims of our study were to determine whether: (1) women with normal apical support on clinic Pelvic Organ Prolapse Quantification, but with vaginal wall prolapse (cystocele and/or rectocele), have the same intraoperative cervix location and apical support stiffness as women with normal pelvic support; and (2) all women with apical prolapse have abnormal intraoperative cervix location and apical support stiffness. A third objective was to identify clinical and biomechanical factors independently associated with clinic Pelvic Organ Prolapse Quantification point C. STUDY DESIGN: We conducted an observational study of women with a full spectrum of pelvic organ support scheduled to undergo gynecologic surgery. All women underwent a preoperative clinic examination, including Pelvic Organ Prolapse Quantification. Cervix starting location and the resistance (stiffness) of its supports to being moved steadily in the direction of a traction force that increased from 0-18 N was measured intraoperatively using a computer-controlled servoactuator device. Women were divided into 3 groups for analysis according to their pelvic support as classified using the clinic Pelvic Organ Prolapse Quantification: (1) "normal/normal" was women with normal apical (C < -5 cm) and vaginal (Ba and Bp < 0 cm) support; (2) normal/prolapse had normal apical support (C < -5 cm) but prolapse of the anterior or posterior vaginal walls (Ba and/or Bp ≥ 0 cm); and (3) prolapse/prolapse had both apical and vaginal wall prolapse (C > -5 cm and Ba and/or Bp ≥ 0 cm). Demographics, intraoperative cervix locations, and apical support stiffness values were then compared. Normal range of cervix location during clinic examination and operative testing was defined by the total range of values observed in the normal/normal group. The proportion of women in each group with cervix locations within and outside the normal range was determined. Linear regression was performed to identify variables independently associated with clinic Pelvic Organ Prolapse Quantification point C. RESULTS: In all, 52 women were included: 14 in the normal/normal group, 11 in the normal/prolapse group, and 27 in the prolapse/prolapse group. At 1 N of traction force in the operating room, 50% of women in the normal/prolapse group had cervix locations outside the normal range while 10% had apical support stiffness outside the normal range. Of women in the prolapse/prolapse group, 81% had cervix locations outside the normal range and 8% had apical support stiffness outside the normal range. Similar results for cervix locations were observed at 18 N of traction force; however the proportion of women with apical support stiffness outside the normal range increased to 50% in the normal/prolapse group and 59% in the prolapse/prolapse group. The prolapse/prolapse group had statistically lower apical support stiffness compared to the normal/normal group with increased traction from 1-18 N (0.47 ± 0.18 N/mm vs 0.63 ± 0.20 N/mm, P = .006), but all other comparisons were nonsignificant. After controlling for age, parity, body mass index, and apical support stiffness, cervix location at 1 N traction force remained an independent predictor of clinic Pelvic Organ Prolapse Quantification point C, but only in the prolapse/prolapse group. CONCLUSION: Approximately 50% of women with cystocele and/or rectocele but normal apical support in the clinic had cervix locations outside the normal range under intraoperative traction, while 19% of women with uterine prolapse had normal apical support. Identifying women whose apical support falls outside a defined normal range may be a more accurate way to identify those who truly need a hysterectomy and/or an apical support procedure and to spare those who do not.

Integrated total pelvic floor ultrasound in pelvic floor defaecatory dysfunction.

AIM: Imaging for pelvic floor defaecatory dysfunction includes defaecation proctography. Integrated total pelvic floor ultrasound (transvaginal, transperineal, endoanal) may be an alternative. This study assesses ultrasound accuracy for the detection of rectocele, intussusception, enterocele and dyssynergy compared with defaecation proctography, and determines if ultrasound can predict symptoms and findings on proctography. Treatment is examined. METHOD: Images of 323 women who underwent integrated total pelvic floor ultrasound and defaecation proctography between 2011 and 2014 were blindly reviewed. The size and grade of rectocele, enterocele, intussusception and dyssynergy were noted on both, using proctography as the gold standard. Barium trapping in a rectocele or a functionally significant enterocele was noted on proctography. Demographics and Obstructive Defaecation Symptom scores were collated. RESULTS: The positive predictive value of ultrasound was 73% for rectocele, 79% for intussusception and 91% for enterocele. The negative predictive value for dyssynergy was 99%. Agreement was moderate for rectocele and intussusception, good for enterocele and fair for dyssynergy. The majority of rectoceles that required surgery (59/61) and caused barium trapping (85/89) were detected on ultrasound. A rectocele seen on both transvaginal and transperineal scanning was more likely to require surgery than if seen with only one mode (P = 0.0001). If there was intussusception on ultrasound the patient was more likely to have surgery (P = 0.03). An enterocele visualized on ultrasound was likely to be functionally significant on proctography (P = 0.02). There was, however, no association between findings on imaging and symptoms. CONCLUSION: Integrated total pelvic floor ultrasound provides a useful screening tool for women with defaecatory dysfunction such that defaecatory imaging can avoided in some.

Transverse incision transvaginal rectocele repair combined with levatorplasty and biological graft insertion: technical details and case series outcomes.

BACKGROUND: The purpose of this report is twofold: first, to detail our operative approach to rectocele repair, and second, to report on the outcomes. METHODS: Transverse incision transvaginal rectocele repair combined with levatorplasty and biological graft placement is detailed using hand-drawn sketches and intraoperative photographs. All patients with symptoms of functional constipation and non-emptying rectocele operated on from May 2007 to March 2013 at our institution were enrolled in this study. Data from a prospectively maintained database were retrospectively analyzed. Preoperative and postoperative functional outcomes were studied using a validated 31-point obstructed defecation (OD) scoring system. Follow-up was 1 year. RESULTS: Twenty-three patients underwent the procedure. The mean age of patients was 55 years (range 28-79 years). The OD severity score improved from the preoperative mean of 21.6 to postoperative mean of 5.5 (p = 0.001). Three out of four patients with initial symptoms of dyspareunia (75%) reported significant improvement in dyspareunia, while 2 out of 19 patients without initial symptoms of dyspareunia (11%) reported mild dyspareunia following the repair. One patient (4%) required operative drainage of a hematoma. Another patient (4%) developed symptomatic recurrence which was confirmed radiologically. CONCLUSIONS: In properly selected patients, the technique described leads to significant improvement in symptoms of OD and low recurrence without an increased rate of dyspareunia.

Association of compartment defects in anorectal and pelvic floor dysfunction with female outlet obstruction constipation (OOC) by dynamic MR defecography.

OBJECTIVE: Chronic constipation affects more than 17% of the global population worldwide, and up to 50% of patients were outlet obstruction constipation (OOC). Women and the elderly are most likely to be affected, due to female-specific risk factors, such as menopause, parity and multiparity. The aim of our study was to investigate the association of compartment defects in anorectal and pelvic floor dysfunction with female outlet obstruction constipation (OOC) by MR defecography. PATIENTS AND METHODS: Fifty-six consecutive women diagnosed with outlet obstruction constipation from October 2009 to July 2011 were included. They were categorized into the following groups: anorectal disorder only group (27 patients) and anorectal disorder plus multi-compartment pelvic disorder group (29 patients). Relevant measurements were taken at rest, during squeezing and straining. RESULTS: Anismus was significantly more common in the anorectal disorder group compared to the multi-compartment pelvic disorder group. Conversely, rectocele, rectal prolapse, and descending perineum were significantly more common in the multi-compartment pelvic disorder group compared to the anorectal disorder group. Of the total 56 OOC patients, 34 (60.7%) exhibited anismus and 38 (67.9%) rectocele. Among the anismus patients, there were 8 patients (23.5%) with combined cystocele, and 6 patients (17.6%) with combined vaginal/cervical prolapse. Among the rectocele patients, there were 23 patients (60.5%) with combined cystocele and 18 patients (47.4%) with combined vaginal/cervical prolapse. With respect to anorectal defects, 13 anismus patients (38.2%) were with signal posterior pelvic defects, 4 rectocele patients (10.5%) presented with signal posterior pelvic defects. CONCLUSIONS: Inadequate defecatory propulsion due to outlet obstruction constipation is often associated with multi-compartment pelvic floor disorders, whereas not about dyssynergic defecation.

A multi-compartment 3-D finite element model of rectocele and its interaction with cystocele.

We developed a subject-specific 3-D finite element model to understand the mechanics underlying formation of female pelvic organ prolapse, specifically a rectocele and its interaction with a cystocele. The model was created from MRI 3-D geometry of a healthy 45 year-old multiparous woman. It included anterior and posterior vaginal walls, levator ani muscle, cardinal and uterosacral ligaments, anterior and posterior arcus tendineus fascia pelvis, arcus tendineus levator ani, perineal body, perineal membrane and anal sphincter. Material properties were mostly from the literature. Tissue impairment was modeled as decreased tissue stiffness based on previous clinical studies. Model equations were solved using Abaqus v 6.11. The sensitivity of anterior and posterior vaginal wall geometry was calculated for different combinations tissue impairments under increasing intraabdominal pressure. Prolapse size was reported as pelvic organ prolapse quantification system (POP-Q) point at point Bp for rectocele and point Ba for cystocele. Results show that a rectocele resulted from impairments of the levator ani and posterior compartment support. For 20% levator and 85% posterior support impairments, simulated rectocele size (at POP-Q point: Bp) increased 0.29 mm/cm H2O without apical impairment and 0.36 mm/cm H2O with 60% apical impairment, as intraabdominal pressures increased from 0 to 150 cm H2O. Apical support impairment could result in the development of either a cystocele or rectocele. Simulated repair of posterior compartment support decreased rectocele but increased a preexisting cystocele. We conclude that development of rectocele and cystocele depend on the presence of anterior, posterior, levator and/or or apical support impairments, as well as the interaction of the prolapse with the opposing compartment.

Relationship between intra-abdominal pressure and vaginal wall movements during Valsalva in women with and without pelvic organ prolapse: technique development and early observations.

OBJECTIVES: To develop and test a method for measuring the relationship between the rise in intra-abdominal pressure and sagittal plane movements of the anterior and posterior vaginal walls during Valsalva in a pilot sample of women with and without prolapse. METHODS: Mid-sagittal MRI images were obtained during Valsalva while changes in intra-abdominal pressure were measured via a bladder catheter in 5 women with cystocele, 5 women with rectocele, and 5 controls. The regional compliance of the anterior and posterior vagina wall support systems were estimated from the ratio of displacement (mm) of equidistant points along the anterior and posterior vaginal walls to intra-abdominal pressure rise (mmHg). RESULTS: The compliance of both anterior and posterior vaginal wall support systems varied along different regions of vaginal wall for all three groups, with the highest compliance found near the vaginal apex and the lowest near the introitus. Women with cystocele had more compliant anterior and posterior vaginal wall support systems than women with rectocele. The movement direction differs between cystocele and rectocele. In cystocele, the anterior vaginal wall moves mostly toward the vaginal orifice in the upper vagina, but in a ventral direction in the lower vagina. In rectocele, the direction of the posterior vaginal wall movement is generally toward the vaginal orifice. CONCLUSIONS: Movement of the vaginal wall and compliance of its support is quantifiable and was found to vary along the length of the vagina. Compliance was greatest in the upper vagina of all groups. Women with cystocele demonstrated the most compliant vaginal wall support.

[Transanal procedure for functional bowel diseases]. / Transanale Verfahren bei funktionellen Darmerkrankungen.

The transanal operative procedure for the treatment of obstructive defecation syndrome (ODS) can be secondarily applied in cases of failure or ineffectiveness of conservative treatment. Clinically established transanal procedures are rectocele resection (RR), mucosectomy for internal rectal prolapse according to the Rehn-Delorme procedure (MR) and stapled transanal rectal resection (STARR Contour Transtar). Only few studies have indicated the value of RR and MR in the treatment of obstructive diseases and in general study quality and evidence level are low. There might be an indication in rectocele-associated symptoms, such as incomplete evacuation, straining and digitation. In contrast the STARR procedure has been well characterized by a large number of high quality studies providing an elevated evidence level for the treatment of ODS. Functional results are available with a follow-up of 1 year up to 68 months postoperatively. Response rates of up to 90% were reported whereas recurrence rates were given as a maximum of 18% at 68 months follow-up. In summary the STARR procedure provides good functional results for conservative refractory outlet obstruction with minor morbidity and outcome seems to remain stable in the long-term follow-up.

Stapled transanal rectal resection with contour transtar for obstructed defecation syndrome: lessons learned after more than 3 years of single-center activity.

BACKGROUND: Obstructed defecation syndrome is a widespread and disabling disease. OBJECTIVE: We aim to evaluate the safety and efficacy of stapled transanal rectal resection performed with a new dedicated curved device in the treatment of obstructed defecation syndrome. DESIGN: A retrospective review of 187 stapled transanal rectal resections performed from June 2007 to February 2011 was conducted. SETTINGS: The entire study was conducted at a university hospital. PATIENTS: : All the patients with symptomatic obstructed defecation syndrome and the presence of a rectocele and/or a rectorectal or rectoanal intussusception, in the absence of sphincter contractile deficiency, were included in the treatment protocol. INTERVENTIONS: All procedures were performed with the use of the Contour Transtar device. We analyzed the functional results of this technique, the incidence and features of the surgical and functional complications, and ways to prevent or treat them. MAIN OUTCOME MEASURES: Constipation was graded by using the Agachan-Wexner constipation score; use of aids to defecate and patient satisfaction were assessed preoperatively and 6 months after surgery. Intraoperative and postoperative complications were also investigated. RESULTS: The constipation intensity was statistically reduced from the preoperative mean value of 15.8 (± 4.9) to 5.2 (± 3.9) at 6 months after surgery (p < 0.0001). Of the 151 (80.3%) patients who took laxatives and the 49 (26.2%) who used enemas before treatment, only 25 (13.2%; p < 0.0001) and 7 (3.7%; p < 0.0001) continued to do so after surgery. None of the 17 (9.1%) patients who had previously helped themselves with digitations needed to continue this practice. Almost all patients showed a good satisfaction rate (3.87/5) after the procedure. LIMITATIONS: Limitations are the short follow-up of 1 year and the design of the study that may introduce potential selection bias. CONCLUSIONS: The results of this study show that stapled transanal rectal resection performed with the use of the Contour Transtar is a safe and effective procedure to treat obstructed defecation syndrome.

[MR defaecography for the diagnosis of obstructive defaecation disorders]. / MR-Defäkografie bei obstruktiven Defäkationsstörungen.

As a consequence of demographic changes, outlet obstruction represents an increasingly common disease. The presence and ample interactions of morphological and functional pathologies contribute to the complexity of pelvic floor dysfunction. Additionally, multiple compartments of the pelvic floor are frequently affected. MR defaecography allows for the simultaneous and detailed assessment of morphological as well as functional changes of the pelvic floor. Hence, this approach constitutes an integral part of the diagnostic work-up and preoperative evaluation of the anorectum. The supine patient position can be regarded as a drawback compared to conventional defaecography, as sufficient emptying of the rectum can be impaired or even rendered impossible in individual cases. This inherent disadvantage is, however, compensated by the high anatomic resolution, the possibility of multiplanar imaging, easy execution and especially the lack of ionising radiation. Consequently, MR defaecography is considered the method of choice for the routine evaluation of functional anorectal disorders.

Prevalence of and risk factors for pelvic organ prolapse and lower urinary tract symptoms among women in rural Nepal.

OBJECTIVE: To evaluate the prevalence and associated risk factors of pelvic organ prolapse (POP) and lower urinary tract symptoms (LUTS) among women seeking healthcare services in 3 discrete rural areas in Nepal. METHODS: A cross-sectional study was conducted using a Nepalese-specific questionnaire to obtain demographic and personal information. Urinary symptoms were examined using the Urogenital Distress Inventory Short form questionnaire, while POP severity was staged according to the POP-Q system. The χ(2) test and multivariate logistic regression analysis were used to determine POP risk factors. RESULTS: Of the 174 women included in the analysis, 106 (60.9%) had stage II POP or greater. In all, 93 women (53.4%) had cystocele, 63 (36.2%) had rectocele, and 37 (21.3%) had uterine prolapse. Univariate analysis identified high parity; young age at first delivery; menopause; squatting or standing position during delivery; and early return to work after delivery as risk factors for POP. Multivariate logistic regression revealed that delivery in a lying position presented a lower risk for cystocele than squatting or standing (odds ratio 0.34; P<0.01). CONCLUSION: Both LUTS and POP are common among women in rural Nepal. Cystocele is the most frequent, advanced, and symptomatic form of POP observed in this population.

Efficacy of two different surgical techniques combined in the treatment of rectocele.

Rectocele is defined as the herniation of rectal wall due to a rectovaginal septum defect in direction of the vagina. In most of cases it is a result of vaginal delivery or repeated increases of intra-abdominal pressure due to chronic constipation. Some patients can develop rectocele as a consequence of congenital or inherited weakness of the pelvic support system. The rectopexy procedure by a single mechanical stapler allows to ablate the exceeding tissue. This surgery is performed through transanal access without laparotomy, by means of a circular stapler which simultaneously resects portion of the rectal wall and re-anastomizes it. Also the technique of sequential transfixed stitches (TSTS) represents a minimally invasive procedure for the rectocele treatment, allowing the performance of a complete plasty of rectal wall through transanal access. Hence, starting from a more effective stadiation of rectocele, the authors of this study will show the advantages of an endorectal approach for the treatment of the above-mentioned disease using both methods. A total of 25 female patients attending our colonproctology outpatient department, with an age ranging between 38 and 63 years, have been selected for our study; following a careful assessment of stadiation, they have undergone rectopexy with circular stapler first, thereafter fulfilling the surgery with TSTS. the mean duration of hospital stay was 2.5 days (range 2-3). Twelve patients out of 25 have shown early complications, and 11 patients late ones. Among the early complications, 3 patients reported pain (12 %), 3 patients urinary retention (12 %), and 2 patients bleeding (8 %). Among late complications, 5 cases of urgency defecation disorders (>4 months) (20 %), 1 intestinal flatus incontinence (4 %), 1 stenosis (4 %), 2 prolonged pain and 2 cases of persistent obstructive defecation syndrome were reported. No cases of life-threatening local or pelvic sepsis as well as of rectovaginal fistulae were reported. At the 6 months post-surgery evaluation, neither rectocele recurrence nor prolapse was observed. The association of circular stapler and TSTS in the rectopexy treatment of rectocele showed its short-term efficacy, producing an improvement of patient's clinical conditions, without inducing further alterations of pelvic statics, of the sphincteric tone as well as of rectum emptiness deficit.