The influence of defaecating proctograms on clinical decision-making in pelvic floor disorders.

AIM: Defaecating proctogram (DP) studies have become an integral part of the evaluation of patients with pelvic floor disorders. However, their impact on treatment decision-making remains unclear. The aim of this study was to assess the concordance of decision-making by colorectal surgeons and the role of the DP in this process. METHOD: Four colorectal surgeons were presented with online surveys containing the complete history, examination and investigations of 106 de-identified pelvic floor patients who had received one of three treatment options: physiotherapy only, anterior Delorme's procedure or anterior mesh rectopexy. The survey assessed the management decisions made by each of the surgeons for the three treatments both before and after the addition of the DP to the diagnostic work-up. RESULTS: After the addition of the DP results; treatment choice changed in 219 (52%) of 424 surgical decisions and interrater agreement improved significantly from κ = 0.26 to κ = 0.39. Three of the four surgeons reported a significant increase in confidence. Agreement with the actual treatments patients received increased from κ = 0.21 to κ = 0.28. Intra-anal rectal prolapse on DP was a significant predictor of a decision to perform anterior mesh rectopexy. CONCLUSION: The DP improves interclinician agreement in the management of pelvic floor disorders and enhances the confidence in treatment decisions. Intra-anal rectal prolapse was the most influential DP parameter in treatment decision-making.

Value of Defecography in the Diagnostic and Therapeutic Management of the Modified Wells Procedure for Rectal Prolapse.

The main aim of this study was to explore the role of defecography in the preoperative diagnosis and postoperative evaluation of rectal prolapse surgery (modified Wells procedure). We collected and summarized the X-ray performance and then analyzed the results of 107 patients with defecatory dysfunction who underwent defecography from January 2020 to March 2021. Furthermore, the preoperative and 6-month postoperative defecography results and clinical symptoms of 25 patients who underwent rectal prolapse surgery (modified Wells procedure) were compared. Results showed that among the 107 patients with defecation dysfunction, women had worse defecography results than men (P < 0.01). A total of 25 patients successfully completed the surgery without complications such as infection and intestinal fistula and there was no recurrence at 12 months of follow-up. Compared with the preoperative results, anorectal angle during defecation, the depth of rectocele, and perineal descent were significantly improved after the surgery (P < 0.01). Moreover, the patient's feeling of obstructed defecation and incomplete defecation was significantly relieved compared to that before the procedure (P < 0.01). In conclusion, defecography can be used to diagnose rectal prolapse preoperatively and evaluate the surgical effect combined with clinical symptoms postoperatively, which provides a clinical reference.

Natural Orifice Endosonographic Colposuspension With Rectopexy for Combined Pelvic Organ Prolapse: A Feasibility Study.

BACKGROUND: We describe a natural orifice technique for simultaneous endoluminal lateral suspension of apical vaginal wall and rectal prolapse fixation with ultrasound and fluoroscopic assistance. IMPACT OF INNOVATION: The technique is minimally invasive, can be performed under regional anaesthesia, and avoids laparotomy or use of a mesh in addition to preserving the uterus. TECHNOLOGY MATERIALS AND METHODS: This technique involves suprapubic transvaginal ventral suture colposuspension, fixation of the anterior rectal wall to the undersurface of the anterior abdominal wall and tack fixation of the posterior rectal wall to the underlying sacral promontory through a submucosal tunnel performed endoscopically with fluoroscopic and ultrasound assistance. PRELIMINARY RESULTS: Seven patients with a mean age of 63 years were followed between 3 to 11 months. CONCLUSIONS: This is a novel minimally invasive transluminal procedure that repairs concomitant rectal and vaginal prolapse in the same sitting. FUTURE DIRECTIONS: Improvement in the instrument design and incorporation of endoluminal robotic systems will enhance the technical ease. The study needs validation in larger series of patients with longer follow-up.

Solitary rectal ulcer syndrome (SRUS): observational case series findings on MR defecography.

OBJECTIVE: Radiological findings in solitary rectal ulcer syndrome (SRUS) are well described for evacuation proctography (EP) but sparse for magnetic resonance defecography (MRD). In order to rectify this, we describe the spectrum of MRD findings in patients with histologically proven SRUS. MATERIALS AND METHODS: MRD from twenty-eight patients (18 female; 10 males) with histologically confirmed SRUS were identified. MRD employed a 1.5-T magnet and a standardized technique with the rectal lumen filled with gel and imaged sagittally in the supine position, before, during, and after attempted rectal evacuation. A single radiologist observer with 5 years' experience in pelvic floor imaging made the anatomical and functional measurements. RESULTS: Sixteen patients (10 female) demonstrated internal rectal intussusception and 3 patients (11%) demonstrated complete external rectal prolapse. Anterior rectoceles were noted in 12 female patients (43%). Associated anterior and middle compartment weakness (evidenced by excessive descent) was observed in 18 patients (64%). Cystocele was found in 14 patients (50%) and uterine prolapse was noted in 7 patients (25%). Enterocoeles were detected in 5 patients (18%) and peritoneocoele in 5 patients (18%). None had sigmoidocoele. Sixteen patients (57%) demonstrated delayed voiding and 13 patients (46%) incomplete voiding, suggesting defecatory dyssynergia. CONCLUSION: MRD can identify and grade both rectal intussusception and dyssynergia in SRUS, and also depict associated anterior and/or middle compartment descent. Distinction between structural and functional findings has important therapeutic implications. KEY POINTS: MRD can identify and grade both rectal intussusception and dyssynergia in patients with SRUS. MRD is an acceptable substitute to evacuation proctography in assessing anorectal dysfunctions when attempting to avoid ionizing radiation. SRUS influences the pelvic floor globally. MRD depicts associated anterior and/or middle compartment prolapse.

Rectal mucosal prolapse with an emphasis on endoscopic ultrasound appearance.

AIM: The diagnosis of mucosal prolapse syndrome (MPS) continues to be a challenge. Endoscopic ultrasound (EUS) is of clinical value in anorectal diseases. This study seeks to investigate the use of EUS in the diagnosis of MPS. METHODS: A total of 39 patients diagnosed with MPS between June 2015 to December 2019 were included in this study. Their clinical histories, endoscopic images, EUS images, and pathological data were retrospectively collected, and the EUS images were reviewed to summarize the characteristics of MPS. RESULTS: In total, 39 MPS patients were enrolled. The main presenting symptoms were bleeding (61.5%) and constipation (53.8%). Gross appearance of the rectal lesions was mainly classified into three types: 51.3% of the lesions were polypoidal/nodular, 33.3% were ulcerative and 15.4% were flat with erythematous mucosa only. A total of 10 patients underwent EUS operation. With regard to the EUS appearance of MPS, four patients with polypoidal/nodular lesions showed thickening of the mucosa on EUS. The diffuse thickening of the mucosa-submucosa layer and disappearance of the architectural structure was observed in four patients with ulcerative lesions. Finally, the thickening of the muscularis propria was observed in two flat lesions. The serosal layers were intact in all the MPS patients. Neither blood flow signals nor regional lymph nodes were observed on EUS. CONCLUSION: The EUS characteristics for MPS corresponding to different gross appearance can be classified into three types. These findings suggest that EUS is useful in the diagnosis of MPS.

Restored pelvic anatomy is preserved after laparoscopic and robot-assisted ventral rectopexy: MRI-based 5-year follow-up of a randomized controlled trial.

AIM: Our aim was to compare the long-term anatomical outcomes between robot-assisted ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR) for external or internal rectal prolapse. METHOD: This study is a follow-up of a single-centre randomized controlled trial (RCT). Thirty patients were randomly allocated to RVMR (n = 16) or LVMR (n = 14). The primary end-point was maintenance of the restored pelvic anatomy 5 years after the operation, as assessed by magnetic resonance (MR) defaecography. Secondary outcome measures included the Pelvic Organ Prolapse Quantification (POP-Q) measures and functional results assessed using symptom questionnaires. RESULTS: Twenty-six patients (14 RVMR and 12 LVMR) completed the 5-year follow-up and were included in the study. The MRI results, POP-Q measurements and symptom-specific quality of life measures did not differ between the RVMR and LVMR groups. The MRI measurements of the total study population remained unchanged between 3 months and 5 years. In the Pelvic Floor Distress Inventory (PFDI-20), the RVMR group had lower symptom scores (mean 96.0, SD 70.7) than the LVMR group (mean 160.6, SD 58.9; P = 0.004). In the subscales of pelvic organ prolapse (POPDI-6) (mean 23.2, SD 24.3 vs mean 52.4, SD 22.4; P = 0.001) and the Colorectal-Anal Distress Inventory (CRADI-8) (mean 38.4, SD 23.3 vs mean 58.6, SD 25.4; P = 0.009), the patients in the RVMR group had significantly better outcomes. CONCLUSION: After VMR, the corrected anatomy was preserved. There were no clinically significant differences in anatomical results between the RVMR and LVMR procedures 5 years after surgery based on MR defaecography. However, functional outcomes were better after RMVR.

Role of Endoanal Ultrasonography in Grading Anal Sphincter Integrity in Rectal Prolapse and in Predicting Improvement in the Continence State After Surgical Treatment.

BACKGROUND: Rectal prolapse can be associated with fecal incontinence (FI) that may not completely resolve after surgical treatment. We aimed to examine the utility of endoanal ultrasonography (EAUS) in identifying the pattern of anal sphincter injury in rectal prolapse and in predicting the improvement in continence state after surgical treatment. METHODS: Records of patients of rectal prolapse who underwent surgical treatment and were evaluated with EAUS before surgery were screened. According to the degree of anal sphincter injury preoperative EAUS, 4 grades of anal sphincter injury were recognized (0 to III). The preoperative patient characteristics and outcome of surgery in each group were compared. RESULTS: Fifty-nine patients (33 male), mean age 36.2 years, were included in the study. Forty-four (74.5%) patients complained of FI preoperatively. There were 12 (20.3%) patients with grade 0 injury, 29 (49.1%) with grade I, 7 (11.8%) with grade II, and 11 (18.6%) with grade III. Patients with grade III presented more with external rectal prolapse had a significantly longer duration of symptoms and had undergone previous surgery for rectal prolapse significantly more than the patients of the other 3 grades. Patients with grade II and grade III anal sphincter injury had significantly higher incontinence scores and lower anal pressures than grade 0 and grade I patients. CONCLUSION: Preoperative EAUS is a useful tool for the assessment of anal sphincter injury in patients with rectal prolapse and for predicting improvement in FI after surgical treatment as higher grades of sphincter injury were associated with less improvement in continence than lower grades.

Complete rectal prolapse in wild anubis baboons (Papio anubis).

This report describes two cases of rectal prolapse in wild anubis baboons (Papio anubis), with one spontaneous resolution. Both occurred after individuals consumed low-water, high-fibre dried maize during provisioning prior to capture, while one also experienced distress during capture.

Improved Detection of Pelvic Organ Prolapse: Comparative Utility of Defecography Phase Sequence to Nondefecography Valsalva Maneuvers in Dynamic Pelvic Floor Magnetic Resonance Imaging.

PURPOSE: To evaluate the utility of a defecography phase (DP) sequence in dynamic pelvic floor MRI (DPMRI), in comparison to DPMRI utilizing only non-defecography Valsalva maneuvers (VM). MATERIALS AND METHODS: Inclusion criteria identified 237 female patients with symptoms and/or physical exam findings of pelvic floor prolapse. All DPMRI exams were obtained following insertion of ultrasound gel into the rectum and vagina. Steady-state free-precession sequences in sagittal plane were acquired in the resting state, followed by dynamic cine acquisitions during VM and DP. In all phases, two experienced radiologists performed blinded review using the H-line, M-line, Organ prolapse (HMO) system. The presence of a rectocele, enterocele and inferior descent of the anorectal junction, bladder base, and vaginal vault were recorded in all patients using the pubococcygeal line as a fixed landmark. RESULTS: DPMRI with DP detected significantly more number of patients than VM (p<0.0001) with vaginal prolapse (231/237, 97.5% vs. 177/237, 74.7%), anorectal prolapse (227/237, 95.8% vs. 197/237, 83.1%), cystocele (197/237, 83.1% vs. 108/237, 45.6%), and rectocele (154/237, 65% vs. 93/237, 39.2%). The median cycstocele (3.2cm vs. 1cm), vaginal prolapse (3cm vs. 1.5cm), anorectal prolapse (5.4cm vs. 4.2cm), H-line (8cm vs. 7.2cm) and M-line (5.3cm vs. 3.9cm) were significantly higher with DP than VM (p<0.0001). CONCLUSIONS: Addition of DP to DPMRI demonstrates a greater degree of pelvic floor instability as compared to imaging performed during VM alone. Pelvic floor structures may show mild descent or appear normal during VM, with marked prolapse on subsequent DP images.

Anatomical and Functional Features of the Internal Rectal Prolapse With Outlet Obstruction Determined With 3D Endorectal Ultrasonography and High-Resolution Anorectal Manometry: An Observational Case-Control Study.

OBJECTIVES: To investigate correlation between rectal wall thickness (RWT) and anorectal pressures, in obstructed defecation syndrome (ODS) patients caused by internal rectal prolapse. METHODS: ODS patients and healthy volunteers (HVs) underwent 3D endorectal ultrasound (3D-EUS) and high-resolution anorectal manometry (HRAM); RWT, total rectal wall volume (TRWV), pushing endorectal pressure (PEP), recto-anal gradient were determined RESULTS: We enrolled 35 ODS patients and 25 HVs. Patients showed markedly decreased TRWV, PEP, and recto-anal gradient. Linear correlation was found between markedly reduced TRWV and markedly hypotonic PEP. CONCLUSIONS: HRAM and 3D-EUS could be performed in ODS assessment, to better understand rectal function.

The clinical value of magnetic resonance defecography in males with obstructed defecation syndrome.

BACKGROUND: The aim of the present study was to assess the relationship between symptoms of obstructed defecation and findings on magnetic resonance (MR) defecography in males with obstructed defecation syndrome (ODS). METHODS: Thirty-six males with ODS who underwent MR defecography at our institution between March 2013 and February 2016 were asked in a telephone interview about their symptoms and subsequent treatment, either medical or surgical. Patients were divided into 2 groups, one with anismus (Group 1) and one with prolapse without anismus (Group 2). The interaction between ODS type and symptoms with MR findings was assessed by multivariate analysis for categorical data using a hierarchical log-linear model. MR imaging findings included lateral and/or posterior rectocele, rectal prolapse, intussusception, ballooning of levator hiatus with impingement of pelvic organs and dyskinetic puborectalis muscle. RESULTS: There were 21 males with ODS due to anismus (Group 1) and 15 with ODS due to rectal prolapse/intussusception (Group 2). Mean age of the entire group was 53.6 ± 4.1 years (range 18-77 years). Patients in Group 1 were slightly older than those in Group 2 (age peak, sixth decade in 47.6 vs 20.0%, p < 0.05). Symptoms most frequently associated with Group 1 patients included small volume and hard feces (85.0%, p < 0.01), excessive strain at stool (81.0%, p < 0.05), tenesmus and fecaloma formation (57.1 and 42.9%, p < 0.05); symptoms most frequently associated with Group 2 patients included mucous discharge, rectal bleeding and pain (86.7%, p < 0.05), prolonged toilet time (73.3%, p < 0.05), fragmented evacuation with or without digitation (66.7%, p < 0.005). Voiding outflow obstruction was more frequent in Group 1 (19.0 vs 13.3%; p < 0.05), while non-bacterial prostatitis and sexual dysfunction prevailed in Group 2 (26.7 and 46.7%, p < 0.05). At MR defecography, two major categories of findings were detected: a dyskinetic pattern (Type 1), seen in all Group 1 patients, which was characterized by non-relaxing puborectalis muscle, sand-glass configuration of the anorectum, poor emptying rate, limited pelvic floor descent and final residue ≥ 2/3; and a prolapsing pattern (Type 2), seen in all Group 2 patients, which was characterized by rectal prolapse/intussusception, ballooning of the levator hiatus with impingement of the rectal floor and prostatic base, excessive pelvic floor descent and residue ≤ 1/2. Posterolateral outpouching defined as perineal hernia was present in 28.6% of patients in Group 1 and were absent in Group 2. The average levator plate angle on straining differed significantly in the two patterns (21.3° ± 4.1 in Group 1 vs 65.6° ± 8.1 in Group 2; p < 0.05). Responses to the phone interview were obtained from 31 patients (18 of Group 1 and 13 of Group 2, response rate, 86.1%). Patients of Group 1 were always treated without surgery (i.e., biofeedback, dietary regimen, laxatives and/or enemas) which resulted in symptomatic improvement in 12/18 cases (66.6%). Of the patients in Group 2, 2/13 (15.3) underwent surgical repair, consisting of stapled transanal rectal resection (STARR) which resulted in symptom recurrence after 6 months and laparoscopic ventral rectopexy which resulted in symptom improvement. The other 11 patients of Group 2 were treated without surgery with symptoms improvement in 3 (27.3%). CONCLUSIONS: The appearance of various abnormalities at MR defecography in men with ODS shows 2 distinct patterns which may have potential relevance for treatment planning, whether conservative or surgical.

Radiological Changes After Resection Rectopexy in Patients with Rectal Prolapse-Influence on Clinical Symptoms and Quality of Life.

BACKGROUND: Resection rectopexy is performed to correct the anatomic defect associated with rectal prolapse. The aim of the study was to determine whether the change in the radiological prolapse grade has an influence on patients' symptoms and quality of life. METHODS: The study investigated 40 patients who underwent resection rectopexy for rectal prolapse. The following were determined before and after surgery: radiological prolapse grade, anorectal angle and pelvic floor position in defecography, clinical symptoms (Cleveland Clinic Incontinence and Constipation Scores, Kelly-Hohlschneider Score), quality of life. RESULTS: Defecography revealed postoperative improvement in the prolapse grade and pelvic floor position (p < 0.05). The clinical symptoms and quality of life improved in both, the total population (n = 40) and in patients with improved radiological prolapse grade (n = 30): all clinical scores (p < 0.05), SF-36 (vitality, social role, mental health p < 0.05), and Fecal Incontinence Quality of Life Scale (lifestyle, coping, embarrassment p < 0.05). Patients without improved radiological findings showed no change in their symptoms or quality of life. CONCLUSION: Our study demonstrates that the radiological prolapse grade is improved by resection rectopexy. Correction of the anatomic defect was associated with improvement in symptoms and quality of life. Defecography may therefore be useful in the postoperative assessment of persistent symptoms or reduced quality of life.

Magnetic resonance defecography versus clinical examination and fluoroscopy: a systematic review and meta-analysis.

BACKGROUND: Magnetic resonance defecography (MRD) allows for dynamic visualisation of the pelvic floor compartments when assessing for pelvic floor dysfunction. Additional benefits over traditional techniques are largely unknown. The aim of this study was to compare detection and miss rates of pelvic floor abnormalities with MRD versus clinical examination and traditional fluoroscopic techniques. METHODS: A systematic review and meta-analysis was conducted in accordance with recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were accessed. Studies were included if they reported detection rates of at least one outcome of interest with MRD versus EITHER clinical examination AND/OR fluoroscopic techniques within the same cohort of patients. RESULTS: Twenty-eight studies were included: 14 studies compared clinical examination to MRD, and 16 compared fluoroscopic techniques to MRD. Detection and miss rates with MRD were not significantly different from clinical examination findings for any outcome except enterocele, where MRD had a higher detection rate (37.16% with MRD vs 25.08%; OR 2.23, 95% CI 1.21-4.11, p = 0.010) and lower miss rates (1.20 vs 37.35%; OR 0.05, 95% CI 0.01-0.20, p = 0.0001) compared to clinical examination. However, compared to fluoroscopy, MRD had a lower detection rate for rectoceles (61.84 vs 73.68%; OR 0.48 95% CI 0.30-0.76, p = 0.002) rectoanal intussusception (37.91 vs 57.14%; OR 0.32, 95% CI 0.16-0.66, p = 0.002) and perineal descent (52.29 vs 74.51%; OR 0.36, 95% CI 0.17-0.74, p = 0.006). Miss rates of MRD were also higher compared to fluoroscopy for rectoceles (15.96 vs 0%; OR 15.74, 95% CI 5.34-46.40, p < 0.00001), intussusception (36.11 vs 3.70%; OR 10.52, 95% CI 3.25-34.03, p = 0.0001) and perineal descent (32.11 vs 0.92%; OR 12.30, 95% CI 3.38-44.76, p = 0.0001). CONCLUSIONS: MRD has a role in the assessment of pelvic floor dysfunction. However, clinicians need to be mindful of the risk of underdiagnosis and consider the use of additional imaging.

Magnetic resonance defecography versus videodefecography in the study of obstructed defecation syndrome: Is videodefecography still the test of choice after 50 years?

BACKGROUND: The aim of the present study was to evaluate the diagnostic accuracy of magnetic resonance (MR) defecography and compare it with videodefecography in the evaluation of obstructed defecation syndrome. METHODS: This was a prospective cohort test accuracy study conducted at one major tertiary referral center on patients with a diagnosis of obstructed defecation syndrome who were referred to the colorectal surgery clinic in a consecutive series from 2009 to 2012. All patients underwent a clinical examination, videodefecography, and MR defecography in the supine position. We analyzed diagnostic accuracy for MR defecography and performed an agreement analysis using Cohen's kappa index (κ) for each diagnostic imaging examination performed with videodefecography and MR defecography. RESULTS: We included 40 patients with Rome III diagnostic criteria of obstructed defecation syndrome. The degree of agreement between the two tests was as follows: almost perfect for anismus (κ = 0.88) and rectal prolapse (κ = 0.83), substantial for enterocele (κ = 0.80) and rectocele grade III (κ = 0.65), moderate for intussusception (κ = 0.50) and rectocele grade II (κ = 0.49), and slight for rectocele grade I (κ = 0.30) and excessive perineal descent (κ = 0.22). Eighteen cystoceles and 11 colpoceles were diagnosed only by MR defecography. Most patients (54%) stated that videodefecography was the more uncomfortable test. CONCLUSIONS: MR defecography could become the imaging test of choice for evaluating obstructed defecation syndrome.

Rectal axis and enterocele on proctogram may predict laparoscopic ventral mesh rectopexy outcomes for rectal intussusception.

BACKGROUND: Laparoscopic ventral mesh rectopexy (LVMR) has become a well-established treatment for symptomatic high-grade internal rectal prolapse. The aim of this study was to identify proctographic criteria predictive of a successful outcome. METHODS: One hundred and twenty consecutive patients were evaluated from a prospectively maintained pelvic floor database. Pre- and post-operative functional results were assessed with the Wexner constipation score (WCS) and Fecal Incontinence Severity Index (FISI). Proctogram criteria were analyzed against functional results. These included grade of intussusception, presence of enterocele, rectocele, excessive perineal descent and the orientation of the rectal axis at rest (vertical vs. horizontal). RESULTS: Ninety-one patients completed both pre- and post-operative follow-up questionnaires. Median pre-operative WCS was 14 (range 10-17), and median FISI was 20 (range 0-61), with 28 patients (31%) having a FISI above 30. The presence of an enterocele was associated with more frequent complete resolution of obstructed defecation (70 vs. 52%, p = 0.02) and fecal incontinence symptoms (71 vs. 38%, p = 0.01) after LVMR. Patients with a more horizontal rectum at rest pre-operatively had significantly less resolution of symptoms post-operatively (p = 0.03). CONCLUSIONS: These data show that proctographic findings can help predict functional outcomes after LVMR. Presence of an enterocele and a vertical axis of the rectum at rest may be associated with a better resolution of symptoms.

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.

[Robot assisted Frykman-Goldberg procedure. Case report]. / Procedimiento de Frykman-Goldberg asistido por robot. Reporte de caso.

BACKGROUND: Rectal prolapse is defined as the protrusion of the rectal wall through the anal canal; with a prevalence of less than 0.5%. The most frequent symptoms include pain, incomplete defecation sensation with blood and mucus, fecal incontinence and/or constipation. The surgical approach can be perineal or abdominal with the tendency for minimal invasion. Robot-assisted procedures are a novel option that offer technique advantages over open or laparoscopic approaches. CASE REPORT: 67 year-old female, who presented with rectal prolapse, posterior to an episode of constipation, that required manual reduction, associated with transanal hemorrhage during defecation and occasional fecal incontinence. A RMI defecography was performed that reported complete rectal and uterine prolapse, and cystocele. A robotic assisted Frykman-Goldberg procedure wass performed. DISCUSSION: There are more than 100 surgical procedures for rectal prolapse treatment. We report the first robot assisted procedure in Mexico. Robotic assisted surgery has the same safety rate as laparoscopic surgery, with the advantages of better instrument mobility, no human hand tremor, better vision, and access to complicated and narrow areas. CONCLUSION: Robotic surgery as the surgical treatment is a feasible, safe and effective option, there is no difference in recurrence and function compared with laparoscopy. It facilitates the technique, improves nerve preservation and bleeding. Further clinical, prospective and randomized studies to compare the different minimal invasive approaches, their functional and long term results for this pathology are needed.

Resolution of Rectal Prolapse by Vaginal Reconstruction.

BACKGROUND: Rectal prolapse is a disorder of the pelvic floor in which the layers of the rectal mucosa protrude outward through the anus. Surgical repair is the mainstay of treatment. Options include intra-abdominal procedures such as rectopexy and perineal procedures such as the Delorme and Altemeier perineal rectosigmoidectomy. Rectal and vaginal prolapse can often coexist. However, to our knowledge, there are no reported cases of rectal prolapse resolved by the repair of a compressive enterocele abutting the anterior rectal wall through a vaginal approach alone. We present a novel case of rectal prolapse that resolved by correction of the vaginal defect. CASE: A 53-year-old female with prior history of abdominal hysterectomy, presented to the urogynecology clinic with complaints of vaginal bulge, urge urinary incontinence, and rectal bulge on straining with no fecal incontinence for several years. On physical examination, she was found to have stage 2 anterior, posterior, and apical vaginal prolapse and reducible rectal prolapse. Colorectal surgery (CRS) evaluation was requested, which revealed minimal anterior mucosal prolapse on Valsalva with no full-thickness prolapse. Magnetic resonance imaging (MRI) defecogram was performed, which demonstrated a large rectocele, enterocele, and small bowel prolapsing between the rectum and vagina during the evacuation phase, with no rectal prolapse. The decision to proceed with vaginal prolapse surgery without concomitant rectal prolapse repair was made, as the patient had no fecal incontinence, and the degree of rectal prolapse was minimal. On the day of surgery, which was 2 months later, she presented with a 2-cm anterior rectal prolapse with no incontinence. Colorectal surgery was consulted again, but unavailable. After counseling, the patient wished to proceed with her planned surgery. It was felt that correcting the anterior rectocele and enterocele, thereby eliminating the descent of the bowel on the anterior rectal wall, might cause resolution of the rectal prolapse. She then underwent a sacrospinous ligament fixation with mesh through an anterior vaginal approach, enterocele repair, Moschcowitz culdoplasty, and posterior colporraphy. She had an uneventful postoperative course and noted resolution of both vaginal and rectal prolapse. At 54 weeks, she continues without any complaints of rectal prolapse, which was confirmed on physical examination. CONCLUSIONS: Usually, the choice of surgical approach is tailored to each individual based on anatomy, age, comorbidity, and patient factors. Correcting both vaginal and rectal prolapse at the same time with a minimally invasive approach is an advantage to the patient. Restoring the apical, anterior, and posterior vaginal wall anatomy and an enterocele repair through the vaginal route caused resolution of the rectal prolapse. Further research is required as to whether rectal prolapse caused by anterior rectal compression needs an additional procedure or repair of the vaginal prolapse and enterocele alone will suffice.