[Dynamic magnetic resonance imaging of the pelvic floor: clinical application]. / Dynamische Magnetresonanztomographie des Beckenbodens: Klinische Anwendung.

BACKGROUND: Dynamic magnetic resonance imaging (MRI) of the pelvic floor plays a key role in imaging complex pelvic floor dysfunction. The simultaneous detection of multiple findings in a complex anatomic setting renders correct analysis and clinical interpretation challenging. OBJECTIVES: The most important aspects (anatomy of the pelvic floor, three compartment model, morphological and functional analysis, reporting) for a successful clinical use of dynamic MRI of the pelvic floor are summarized. MATERIALS AND METHODS: Review of the scientific literature on dynamic pelvic MR imaging with special consideration of the joint recommendations provided by the expert panel of ESUR/ESGAR in 2016. RESULTS: The pelvic floor is a complex anatomic structure, mainly formed by the levator ani muscle, the urethral support system and the endopelvic fascia. Firstly, morphological changes of these structures are analysed on the static sequences. Secondly, the functional analysis using the three compartment model is performed on the dynamic sequences during squeezing, straining and defecation. Pelvic organ mobility, pelvic organ prolapse, the anorectal angle and pelvic floor relaxation are measured and graded. The diagnosis of cystoceles, enteroceles, rectoceles, the uterovaginal as well as anorectal decent, intussusceptions and dyssynergic defecation should be reported using a structured report form. CONCLUSIONS: A comprehensive analysis of all morphological and functional findings during dynamic MRI of the pelvic floor can provide information missed by other imaging modalities and hence alter therapeutic strategies.

TKT maintains intestinal ATP production and inhibits apoptosis-induced colitis.

Inflammatory bowel disease (IBD) has a close association with transketolase (TKT) that links glycolysis and the pentose phosphate pathway (PPP). However, how TKT functions in the intestinal epithelium remains to be elucidated. To address this question, we specifically delete TKT in intestinal epithelial cells (IECs). IEC TKT-deficient mice are growth retarded and suffer from spontaneous colitis. TKT ablation brings about striking alterations of the intestine, including extensive mucosal erosion, aberrant tight junctions, impaired barrier function, and increased inflammatory cell infiltration. Mechanistically, TKT deficiency significantly accumulates PPP metabolites and decreases glycolytic metabolites, thereby reducing ATP production, which results in excessive apoptosis and defective intestinal barrier. Therefore, our data demonstrate that TKT serves as an essential guardian of intestinal integrity and barrier function as well as a potential therapeutic target for intestinal disorders.

Posterior rectal pouch after large full-thickness disc excision of deep endometriosis infiltrating the low/mid rectum and relationship with digestive functional outcome.

INTRODUCTION: The aim of our study is to describe MRI appearance of a posterior rectal pouch (PRP) for patients managed for low rectal endometriosis by large full-thickness disc excision and to assess its relationship with postoperative functional digestive symptoms. MATERIAL AND METHODS: Single center retrospective study including patients managed by low/mid rectal disc excision using a semi-circular stapler (the Rouen technique) from June 2009 to October 2016. Intraoperative findings and data provided by standardized gastrointestinal self-questionnaires (GIQLI, KESS, Wexner and Bristol), before and 1 year after the surgery, were prospectively recorded. Postoperative pelvic MRI were reviewed and PRP was assessed in three planes and its volume was estimated on a 3D T2 weighted sequence. RESULTS: Eighteen patients were included in the study. All patients had postoperative PRP while none of them presented with rectal stenosis. The mean (± SD) volume of the PRP was estimated at 66 ± 32 mL. The mean antero-posterior diameter was 56 mm ± 22 mm, mean height at 44 mm ± 15 mm and mean width at 46 mm ± 11 mm. No positive correlation between the volume of the PRP and the GIQLI questionnaire was found at one year after surgery (r = -0.24, 95%CI -0.51-0.69, p = 0.44). CONCLUSION: Large disc excision of low and mid rectum leads to a posterior rectal pouch, with no significant impact on postoperative functional digestive outcomes, but it is not followed by bowel stenosis.

The association between a positive lactulose methane breath test and rectocele in constipated patients.

OBJECTIVES: Rectocele with constipation might be related to methane (CH4) producing intestinal bacteria. We investigated the breath CH4 levels and the clinical characteristics of colorectal motility in constipated patients with rectocele. METHODS: A database of consecutive female outpatients was reviewed for the evaluation of constipation according to the Rome III criteria. The patients underwent the lactulose CH4 breath test (LMBT), colon marker study, anorectal manometry, defecography and bowel symptom questionnaire. The profiles of the lactulose breath test (LBT) in 33 patients with rectocele (with size ≥ 2 cm) and 26 patients with functional constipation (FC) were compared with the breath test results of 30 healthy control subjects. RESULTS: The mean size of rectocele was 3.52 ± 1.06 cm. The rate of a positive LMBT (LMBT+) was significantly higher in patients with rectocele (33.3%) than in those with FC (23.1%) or healthy controls (6.7%) (p = 0.04). Breath CH4 concentration was positively correlated with rectosigmoid colon transit time in rectocele patients (γ = 0.481, p < 0.01). A maximum high pressure zone pressure > 155 mmHg was a significant independent factor of LMBT+ in rectocele patients (OR = 8.93, 95% CI = 1.14-71.4, p = 0.04). CONCLUSIONS: LMBT+ might be expected in constipated patients with rectocele. Moreover, increased rectosigmoid colonic transit or high anorectal pressure might be associated with CH4 breath levels. Breath CH4 could be an important therapeutic target for managing constipated patients with rectocele.

Functional pelvic floor anatomy in Nepali women attending a general gynaecology clinic.

INTRODUCTION AND HYPOTHESIS: Limited existing evidence suggests that there is a high prevalence of female pelvic organ prolapse (POP) amongst Nepali women. However, to date, no comprehensive assessment of pelvic floor functional anatomy has been undertaken in this population. Our study aimed to determine functional pelvic floor anatomy in Nepali women attending a general gynaecology clinic. METHODS: One hundred and twenty-nine consecutive women attending the clinic were offered an interview, clinical examination [International Continence Society Pelvic Organ Prolapse Quantification system (ICS/POP-Q)] and 4D translabial ultrasound (TLUS). Most presented with general gynaecological complaints. Five were excluded due to previous pelvic surgery, leaving 124. RESULTS: A POP-Q exam was possible in 123 women, of whom 29 (24%) were diagnosed with a significant cystocele, 50 (41%) significant uterine prolapse and seven (6%) significant posterior compartment prolapse. Evaluation of 4D TLUS data sets was possible in 120 women, of whom 25 (21%) had a significant cystocele, 45 (38%) significant uterine prolapse and ten (8%) significant descent of the rectal ampulla. In 13 cases, there was a rectocele with a mean depth of 14 (10-28) mm. Of 114 women in whom uterine position could be determined, 68 (60%) had a retroverted uterus associated with significant uterine prolapse (P 0.038). CONCLUSIONS: POP is common in Nepali women attending a general gynaecology clinic, with a high prevalence of uterine prolapse (40%). Uterine retroversion was seen in 60% and was associated with uterine prolapse. Patterns of POP in Nepal seem to be different from patterns observed in Western populations.

Vaginal Changes Due to Varying Degrees of Rectocele Prolapse: A Computational Study.

Pelvic organ prolapse (POP), downward descent of the pelvic organs resulting in a protrusion of the vagina, is a highly prevalent condition, responsible for 300,000 surgeries in the U.S. annually. Rectocele, a posterior vaginal wall (PVW) prolapse of the rectum, is the second most common type of POP after cystocele. A rectocele usually manifests itself along with other types of prolapse with multicompartment pelvic floor defects. To date, the specific mechanics of rectocele formation are poorly understood, which does not allow its early stage detection and progression prediction over time. Recently, with the advancement of imaging and computational modeling techniques, a plethora of finite element (FE) models have been developed to study vaginal prolapse from different perspectives and allow a better understanding of dynamic interactions of pelvic organs and their supporting structures. So far, most studies have focused on anterior vaginal prolapse (AVP) (or cystocele) and limited data exist on the role of pelvic muscles and ligaments on the development and progression of rectocele. In this work, a full-scale magnetic resonance imaging (MRI) based three-dimensional (3D) computational model of the female pelvic anatomy, comprising the vaginal canal, uterus, and rectum, was developed to study the effect of varying degrees (or sizes) of rectocele prolapse on the vaginal canal for the first time. Vaginal wall displacements and stresses generated due to the varying rectocele size and average abdominal pressures were estimated. Considering the direction pointing from anterior to posterior side of the pelvic system as the positive Y-direction, it was found that rectocele leads to negative Y-direction displacements, causing the vaginal cross section to shrink significantly at the lower half of the vaginal canal. Besides the negative Y displacements, the rectocele bulging was observed to push the PVW downward toward the vaginal hiatus, exhibiting the well-known "kneeling effect." Also, the stress field on the PVW was found to localize at the upper half of the vaginal canal and shift eventually to the lower half with increase in rectocele size. Additionally, clinical relevance and implications of the results were discussed.

Admixture mapping of pelvic organ prolapse in African Americans from the Women's Health Initiative Hormone Therapy trial.

Evidence suggests European American (EA) women have two- to five-fold increased odds of having pelvic organ prolapse (POP) when compared with African American (AA) women. However, the role of genetic ancestry in relation to POP risk is not clear. Here we evaluate the association between genetic ancestry and POP in AA women from the Women's Health Initiative Hormone Therapy trial. Women with grade 1 or higher classification, and grade 2 or higher classification for uterine prolapse, cystocele or rectocele at baseline or during follow-up were considered to have any POP (N = 805) and moderate/severe POP (N = 156), respectively. Women with at least two pelvic exams with no indication for POP served as controls (N = 344). We performed case-only, and case-control admixture-mapping analyses using multiple logistic regression while adjusting for age, BMI, parity and global ancestry. We evaluated the association between global ancestry and POP using multiple logistic regression. European ancestry at the individual level was not associated with POP risk. Case-only and case-control local ancestry analyses identified two ancestry-specific loci that may be associated with POP. One locus (Chromosome 15q26.2) achieved empirically-estimated statistical significance and was associated with decreased POP odds (considering grade ≥2 POP) with each unit increase in European ancestry (OR: 0.35; 95% CI: 0.30, 0.57; p-value = 1.48x10-5). This region includes RGMA, a potent regulator of the BMP family of genes. The second locus (Chromosome 1q42.1-q42.3) was associated with increased POP odds with each unit increase in European ancestry (Odds ratio [OR]: 1.69; 95% confidence interval [CI]: 1.28, 2.22; p-value = 1.93x10-4). Although this region did not reach statistical significance after considering multiple comparisons, it includes potentially relevant genes including TBCE, and ACTA1. Unique non-overlapping European and African ancestry-specific susceptibility loci may be associated with increased POP risk.

A transanal procedure using TST STARR Plus for the treatment of Obstructed Defecation Syndrome: 'A mid-term study'.

PURPOSE: The aim of this study was to assess the safety, efficacy and outcomes of TST STARR (Stapled Transanal Rectal Resection) plus to treat Obstructed Defecation Syndrome (ODS) at mid-term follow-up. METHODS: From April 2013 to September 2014, 50 cases (7 male patients) with ODS caused by rectocele and/or internal rectal prolapse were treated with the new TST STARR Plus. Clinical data from the 18 month mid-term follow up, including efficacy and constipations were recorded. RESULTS: The average duration of surgery was 21 ± 4 min (range 12-35 min). The average postoperative hospital stay was 5 days (range 4-8 days). The pathological findings showed that the specimens contained full-thickness rectal tissue in all patients. The mean volume of resected specimen was 12.3 cm(3). Postoperative complications included five cases with transient faecal urgency that dissipated after 3 months; one patient suffered anastomotic bleeding on the sixth day after surgery, with successful haemostasis achieved through conservative therapy. The Wexner constipation score improved in patients affected by ODS from 13.96 ± 2.37 preoperatively to 7.00 ± 3.90, 7.28 ± 3.91, 8.10 ± 4.05 and 8.44 ± 4.08 at 3,6,12 and 18 months postoperatively, respectively, with all p < 0.05. Overall outcome was reported as ''excellent'' in 42% of patients, ''good'' in 36% of patients, ''adequate'' in 12% of patients, and ''poor'' in 10% of patients after 18 months of follow-up. CONCLUSIONS: The TST STARR Plus is a simple, safe, and effective option for selected patients with ODS. Long-term prospective clinical studies are needed to validate the advantages of this emerging, novel procedure.

Robot-assisted vs laparoscopic ventral rectopexy for external or internal rectal prolapse and enterocele: a randomized controlled trial.

AIM: The purpose of this prospective randomized study was to compare robot-assisted and laparoscopic ventral rectopexy procedures for posterior compartment procidentia in terms of restoration of the anatomy using magnetic resonance (MR) defaecography. METHOD: Sixteen female patients (four with total prolapse, twelve with intussusception) underwent robot-assisted ventral mesh rectopexy (RVMR) and 14 female patients (two with prolapse, twelve with intussusception) laparoscopic ventral mesh rectopexy (LVMR). Primary outcome measures were perioperative parameters, complications and restoration of anatomy as assessed by MR defaecography, which was performed preoperatively and 3 months after surgery. RESULTS: Patient demographics, operation length, operating theatre times and length of in-hospital stay were similar between the groups. The anatomical defects of rectal prolapse, intussusception and rectocele and enterocele were similarly corrected after rectopexy in either technique as confirmed with dynamic MR defaecography. A slight residual intussusception was observed in three patients with primary total prolapse (two RVMR vs one LVMR) and in one patient with primary intussusception (RVMR) (P = 0.60). Rectocele was reduced from a mean of 33.0 ± 14.9 mm to 5.5 ± 8.4 mm after RVMR (P < 0.001) and from 24.7 ± 17.5 mm to 7.2 ± 3.2 mm after LVMR (P < 0.001) (RVMR vs LVMR, P = 0.10). CONCLUSION: Robot-assisted laparoscopic ventral rectopexy can be performed safely and within the same operative time as conventional laparoscopy. Minimally invasive ventral rectopexy allows good anatomical correction as assessed by MR defaecography, with no differences between the techniques.

Laparoscopic Mesh Sacropexy for Voluminous Rectocele.

The rectocele represents a protrusion of the rectum through the rectovaginal fascia, which appears as a bulge in the posterior vaginal wall. Surgical treatment includes many procedures which can be performed by four types of approaches: transvaginal, transanal, transperineal and transabdominal.Voluminous rectocele cases are rare and often represent a surgical challenge. Only two types of approaches are proved to be feasible for the treatment of a voluminous rectocele, the transvaginal and the transabdominal approaches. To resolve these cases, the authors propose laparoscopic mesh sacropexy.The procedure implies retrorectal dissection and rectovaginal dissection down to the pelvic floor, followed by a rectovaginopexy to the sacral promontory, using an y-shaped polypropylene mesh. One arm of the mesh is fixed to the anterior rectal wall using four stitches and the other arm is sutured to the posterior vaginal wall. The end of the mesh is fixed to the promontory. Thus, the anchoring of the prolapsed rectum and the posterior vaginal fornix to the sacral ligamentis achieved, the damaged rectovaginal fascia being substituted by the polypropylene mesh. The main symptom that was tracked, difficulty in defecation, was significantly improved, none of the patients needed any longer digital maneuvers to empty the rectum. The good results of the first experience make us believe that this procedure is an attractive solution to resolve these difficult cases.

Surgery for posterior vaginal wall prolapse.

INTRODUCTION AND HYPOTHESIS: The aim was to review the safety and efficacy of surgery for posterior vaginal wall prolapse. METHODS: Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or "majority evidence" from RCTs. Grade C recommendation usually depends on level 4 studies or "majority evidence from level 2/3 studies or Delphi processed expert opinion. Grade D "no recommendation possible" would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi. RESULTS: Level 1 and 2 evidence suggest that midline plication posterior repair without levatorplasty might have superior objective outcomes compared with site-specific posterior reopair (grade B). Higher dyspareunia rates are reported when levatorplasty is employed (grade C). The transvaginal approach is superior to the transanal approach for repair of posterior wall prolapse (grade A). To date, no studies have shown any benefit of mesh overlay or augmentation of a suture repair for posterior vaginal wall prolapse (grade B). While modified abdominal sacrocolpopexy results have been reported, data on how these results would compare with traditional transvaginal repair of posterior vaginal wall prolapse are lacking. CONCLUSION: Midline fascial plication without levatorplasty is the procedure of choice for posterior compartment prolapse. No evidence supports the use of polypropylene mesh or biological graft in posterior vaginal compartment prolapse surgery.

Live anatomy of the perineal body in patients with third-degree rectocele.

AIM: In many pelvic floor disorders, the perineal body is damaged or destroyed. There is still a considerable variation in anatomical descriptions of the perineal body and even more debate with regard to its attachments and relationships. Cadaveric dissections do not always reflect the functional behaviour of structures in the pelvis and description of live anatomy on imaging studies is not always reliable. This study aimed to define the anatomy of the perineal body in patients with rectocele during the live dissection required for minimally invasive surgical repair. METHOD: From January 2007 to December 2009 consecutive patients requiring surgery for third-degree rectocele and symptoms of obstructed defaecation were recruited. Participants underwent dissection of the perineal body, rectum and vagina preliminary to a tissue fixation system, an operation which inserts a tensioned tape to repair the perineal body. RESULTS: Thirty Caucasian female patients, mean age 61 (range 47-87) years, mean parity 2.6 (range 1-5), were included. Live dissection demonstrated that the perineal body was divided into two parts, joined by a stretched central part, anchored laterally by the deep transverse perineii muscle to the descending ramus of the pubic bone. The mean longitudinal length of the perineal body was 4.5 (3.5-5.5) cm, accounting for 50% of the posterior vaginal support. CONCLUSION: In women with low rectocele, the perineal body appears to be divided into two parts, severely displaced behind the ischial tuberosities.

[Significance of nontraumatic anal sphincter relaxation for the success of plastic and miniinvasive interventions in coloproctology].

The investigation objective was to estimate the role of nontraumatic anal sphincter (AS) stretching, as a leading factor of success in minimally invasive and/or plastic proctological interventions. One-centre randomized investigation was performed in 83 patients: In 22 of them the AS fissura was revealed (in 16), suprasphincteric fistula (in 3) and coexistent rectocele 2-3 Ap (according to POP-Q classification) with thinning of the AS anterior segment, the degree III hemorrhoids and anterior AS fissure presence. Ninety units of botulotoxin preparation (Disport) were injected between internal and external AS portions 5-15 days preoperatively. The treatment results without botulotoxin injection were compared retrospectively. After botulotoxin injection performance the AS spasm elimination was noted, leading to the pain subsiding promotion before and postoperatively in all the patients observed. The spasm elimination have permitted to escape the anal high fistula recurrence as a result of the mucosal flap shift after intraluminal closure of the fistula or because of the fistula intermuscular electrowelding "suture" rupture, also have guaranteed the plastic sutures on AS, even while the stage II-III rectocele presence, not depending of performance of its simultant surgica correction.

[Ideation of a new operative anoscope in proctology]. / Ideazione di un nuovo anoscopio operativo in proctologia.

BACKGROUND: Rectocele is defined as an erniation of the anterior rectal and vaginal wall in the vaginal lumen due to the loss of recto-vaginal septum. Rectal mucosal prolapse was characterized by the protrusion of the mucosa alone in the rectal lumen. The Authors, herein, reported the results of a new surgical technique defined Sequential Transfixed Stitch Technique (STST) using a new anoscope. MATERIALS AND METHODS; A total of 30 consecutive patients symptomatic III or IV stage rectocele assessed with clinical and instrumental criteria were submitted to STST using the new anoscope. The new anoscope, consisting of non-toxic metallic material, designed and realized according to surgery needs and tested by the authors, increases the vision of the anal canal can be fixed according to the operator's needs. RESULTS: STST was correctly performed in all the cases without early and late complications. The mean value was of 17 according to the Agachan-Wexner for patients with rectocele, significantly improved score in comparison to pre-operatory condition (p<0.05). Surgical procedure of rectocele repair was judged satisfactory in 80% of the cases. CONCLUSIONS: The new operative anoscope was useful in III and IV stage rectocele repair with STST, ensuring ease of implementation of the binding repair in the absence of side effects for the patient.

Transvaginal perineal body repair for low rectocele.

We describe our technique of low rectocele repair which is based on the approximation and lifting of the laterally displaced perineal bodies (PBs) using the Tissue Fixation System, a 7-mm-wide tensioned macropore polypropylene sling. In low rectocele, the PB between the rectum and vagina is thinned and laterally displaced but still attached to the deep transverse perineal (DTP) muscle. Our technique is described with the aid of a video. The vagina and rectum are dissected off the laterally displaced PBs. The DTP attachment of each PB to the descending ramus is identified per rectum. A tunnel is created in the DTP on both sides to insert the polypropylene mesh attached to an anchor. The loop of tape between the anchors is shortened via the one-way system at the base of the anchor to elevate the inferolaterally displaced PBs to a more medial position. This is infiltrated by collagen over time, creating a "neo-central tendon." The musculofascial layer of the rectum, the vagina, and superficial layers of the PBs are approximated. Our cure rate for low rectocele repair was in excess of 90 %, even with an early version of this procedure. Our method differs from rectocele repair with large mesh in that it precisely mimics the damaged structure and uses only very short thin strips of tape to approximate and reinforce PBs weakened by birth injury and age.

Long-term results of prolapse recurrence and functional outcome after vaginal hysterectomy.

OBJECTIVE: To evaluate the incidence of prolapse and prolapse-related symptoms following vaginal hysterectomy. METHODS: Data were reviewed from women who underwent vaginal hysterectomy between 1988, and 1995, at St George's Hospital, London, UK, and attended long-term follow-up. Outcome measures included a questionnaire for prolapse, urinary, bowel, and sexual symptoms; and a vaginal examination. RESULTS: Among 94 women attending long-term evaluation, the mean follow-up time was 100.7 months (range 67.0-156.0 months). Before vaginal hysterectomy, urgency was noted among 23 (24.5%), urge incontinence among 11 (11.7%), and stress incontinence among 8 (8.5%) women. At follow-up, these symptoms were observed among 23 (24.5%), 13 (13.8%), and 6 (6.4%) women, respectively. De novo urge incontinence and de novo stress incontinence were observed among 3 (3.2%) and 2 (2.1%) women, respectively. Vaginal examination data were compared for 70 women, of whom 18 (25.7%) had grade 1, 40 (57.1%) had grade 2, and 6 (8.6%) had grade 3 uterine prolapsed before surgery. Postoperatively, vaginal vault prolapse occurred in 7 (10.0%) women and correlated with degree of posterior prolapse (P=0.007), but not with severity of uterine descent (P=0.205) or previous prolapse surgery (P=0.573). CONCLUSION: The incidence of post-hysterectomy vault prolapse correlated with the degree of preoperative rectocele.

Posterior vaginal prolapse shape and position changes at maximal Valsalva seen in 3-D MRI-based models.

INTRODUCTION AND HYPOTHESIS: Two-dimensional magnetic resonance imaging (MRI) of posterior vaginal prolapse has been studied. However, the three-dimensional (3-D) mechanisms causing such prolapse remain poorly understood. This discovery project was undertaken to identify the different 3-D characteristics of models of rectocele-type posterior vaginal prolapse (PVP(R)) in women. METHODS: Ten women with (cases) and ten without (controls) PVP(R) were selected from an ongoing case-control study. Supine, multiplanar MR imaging was performed at rest and maximal Valsalva. Three-dimensional reconstructions of the posterior vaginal wall and pelvic bones were created using 3D Slicer v. 3.4.1. In each slice the posterior vaginal wall and perineal skin were outlined to the anterior margin of the external anal sphincter to include the area of the perineal body. Women with predominant enteroceles or anterior vaginal prolapse were excluded. RESULTS: The case and control groups had similar demographics. In women with PVP(R) two characteristics were consistently visible (10/10): (1) the posterior vaginal wall displayed a folding phenomenon similar to a person beginning to kneel ("kneeling" shape) and (2) a downward displacement in the upper two thirds of the vagina. Also seen in some, but not all of the scans were: (3) forward protrusion of the distal vagina (6/10), (4) perineal descent (5/10), and (5) distal widening in the lower third of the vagina (3/10). CONCLUSIONS: Increased folding (kneeling) of the vagina and an overall downward displacement are consistently present in rectocele. Forward protrusion, perineal descent, and distal widening are sometimes seen as well.

Rectocele--does the size matter?

OBJECTIVES: Large rectoceles (>2 cm) are believed to be associated with difficulty in evacuation, constipation, rectal pain, and rectal bleeding. The aim of our study was to determine whether rectocele size is related to patient's symptoms or defecatory parameters. METHODS: We conducted a retrospective study on data collected on patients referred to our clinic for the evaluation of evacuation disorders. All patients were questioned for constipation, fecal incontinence, and irritable bowel syndrome and were assessed with dynamic perineal ultrasonography and conventional anorectal manometry. RESULTS: Four hundred eighty-seven women were included in our study. Rectocele was diagnosed in 106 (22%) women, and rectocele diameter >2 cm in 93 (87%) women. Rectocele size was not significantly related to demographic data, parity, or patient's symptoms. The severity of the symptoms was not correlated to the size or to the position of the rectocele. The diagnosis of irritable bowel syndrome was neither related to the size of the rectocele. Rectocele location, occurrence of enterocele, and intussusception were not related to the size of the rectocele. Full evacuation of rectoceles was more common in small rectoceles (79% vs. 24%, p = 0.0001), and no evacuation was more common in large rectoceles (37% vs. 0, p = 0.01). Rectal hyposensitivity and anismus were not related to the size of the rectocele. CONCLUSION: In conclusion, only the evacuation of rectoceles was correlated to the size of the rectoceles, but had no clinical significance. Other clinical, anatomical factors were also not associated to the size of the rectoceles. Rectoceles' size alone may not be an indication for surgery.

Robotic versus laparoscopic rectopexy for complex rectocele: a prospective comparison of short-term outcomes.

PURPOSE: The role of robotic assistance in pelvic floor prolapse surgery is debatable. This study aims to report our early experience of robotic-assisted ventral mesh rectopexy in the treatment of complex rectocele and to compare this with the laparoscopic approach in terms of safety and short-term postoperative outcomes. METHODS: We analyzed a cohort of 63 consecutive patients operated on for complex rectocele from March 2008 to December 2009. A complex rectocele was defined as a rectocele that had one or more of the following features: larger than 3 cm in diameter, associated with an enterocele or internal rectal prolapse. The patients underwent either the robotic procedure or laparoscopic procedure, based only on the availability of the robotic system. Procedures involved either a single-mesh fixation for posterior-compartment prolapse (concurrent rectocele and enterocele) or a double-mesh fixation for a concurrent anterior compartment prolapse (with cystocele). A transvaginal tape was inserted at the same surgery in patients with urinary incontinence. RESULTS: All patients were female; 40 underwent the laparoscopic procedure and 23 underwent the robotic procedure. Both groups were similar in age (mean, 59 ± 13 vs 61 ± 11; P = .440), ASA status, and previous abdominal surgery, respectively. Patients undergoing the robotic procedure had a significantly higher body mass index (mean, 27 ± 4 vs 24 ± 4; P = .03), more frequent double-mesh implantation (17/23 vs 14/40; P = .003), and longer operative time (mean, 221 ± 39 min vs 162 ± 60 min; P = .0001). Patients undergoing a laparoscopic procedure had slightly more blood loss (mean, 45 ± 91mL vs 6 ± 23 mL, P = .05). The number of transvaginal-tape procedures performed (6/40 vs 3/23, P > .999), conversion rate (10% vs 5%; P = .747), and duration of hospitalization were similar (mean, 5 ± 2 d vs 5 ± 1.6 d; P = .872). There were no mortalities or recurrences at the 6-month postoperative review. CONCLUSION: In our experience, the robotic approach for the treatment of complex rectocele is as safe as the laparoscopic approach, with favorable short-term results.

Safety and efficacy of laparoscopic ventral mesh rectopexy for complex rectocele.

AIM: Laparoscopic ventral mesh rectopexy, previously described for external rectal prolapse, was evaluated for symptomatic complex rectocoele. METHOD: From January 2004 to December 2008, 84 (50.9%) patients (mean age 64 ± 5 years) underwent laparoscopic ventral mesh rectopexy for symptomatic complex rectocoele, confirmed preoperatively on dynamic defaecography, with 26 (31%) patients having a concurrent cystocoele. The operative technique was standardized, and those with cystocoele underwent bladder mesh suspension during the same procedure. Prospectively collected data were analysed for preoperative symptoms, operative and functional results [constipation, faecal incontinence (FI), dyspareunia and satisfaction score]. RESULTS: The conversion rate was 3.6% and perioperative morbidity 4.8% with no mortality. At a median follow up of 29 (4-59) months, there was a significant decrease in vaginal discomfort (86-20%) and obstructed defaecation symptoms (83-46%), P < 0.001. There was no significant change in FI (20-16%), no worsening of preoperative symptoms or new complaints of constipation, dyspareunia or FI. Overall, 88% of patients reported an improvement in overall well-being. CONCLUSION: Laparoscopic ventral mesh rectopexy is a safe and effective method for treating symptomatic complex rectocoele.