Preoperative predictors of success after transvaginal rectocoele repair.

PURPOSE: Determine predictors of success for transvaginal rectocoele repair (TVRR). Primary aim is to establish predictors of successful treatment analysing patients' characteristics, baseline symptoms, pelvic floor test results and pre-operative conservative treatment. METHODS: Retrospective single institution study in a tertiary referral centre for pelvic floor disorders. 207 patients underwent TVRR for symptomatic rectocoele. Information about symptoms related to obstructive defaecation, anal incontinence and vaginal prolapse, results of pelvic floor investigations, multimodality conservative management and variation in surgical technique have been recorded. Symptom related information have been collected at surgical follow-up. RESULTS: 115 patients had residual symptoms after surgical repair of rectocoele, while 97 were symptoms free. Factors associated with residual symptoms after surgical repair are previous proctological procedures, urge AI symptoms, absence of vaginal bulge symptoms, use of transanal irrigation and having a concomitant enterocoele repair during procedure. CONCLUSION: Factors able to predict a less favourable outcome after TVRR in patients with concomitant ODS are previous proctological procedures, presence of urge AI, short anal canal length on anorectal physiology, seepage on defaecating proctography, use of transanal irrigation, absence of vaginal bulge symptoms and enterocoele repair during surgery. These information are important for a tailored decision making process and to manage patients' expectations before surgical repair.

Pelvic floor investigations for anal incontinence: Are they useful to predict outcomes from conservative treatment?

AIMS: There are several options for treating anal incontinence (AI), with limited success rate in long-term follow-up. Patients' selection is important to avoid unnecessary investigations and therapies. The aim of this review is to assess the utility of pelvic floor investigations to predict success from conservative treatment in AI. METHODS: Baseline demographics, severity scores, and pelvic floor investigations of 490 patients with AI symptoms were retrospectively reviewed. Patient-reported outcomes were used to define success of conservative treatment. RESULTS: Bivariate analysis showed that gender, St Mark's incontinence score, Bowel continence and quality of life domains of International Consultation on Incontinence Modular Questionnaire-Bowel symptoms score, Bristol stool chart, anal squeeze pressure, enterocoele, leak of contrast at rest, and dyssynergia in defecography were associated with patient's outcomes from conservative treatment (p < 0.05). Multivariate analysis showed that only the Bowel continence score was an independent predictor of patient's success with treatment. CONCLUSIONS: Pelvic floor investigations are of limited value to predict success of conservative treatment and they should be reserved for patients who fail noninvasive management and might require surgical intervention.

Patient pathway in a tertiary referral pelvic floor unit: Telephone triage assessment clinic.

BACKGROUND: To meet the increasing demands for colorectal pelvic floor services, a dedicated telephone triage assessment clinic (TTAC) was set up to establish a more efficient pathway, and reduce waiting times and patient's visits to the hospital. The primary aim of this study was to review TTAC in patients suffering from pelvic floor dysfunction and assess its feasibility. Secondary aims include measurement of waiting times for TTAC, main presenting complaints, and main treatment outcomes, including the need for review by a consultant surgeon. METHODS: Review of data collected retrospectively in a single tertiary referral center collected from an institutional database. KEY RESULTS: Between January 2016 and October 2017, 1192 patients referred to our pelvic floor unit were suitable for TTAC. Of these, 694 patients had complete records. There were 66 without follow-up after the initial TTAC, leaving 628 patients for analysis. In all, 86% were females and 14% were males, with a mean age of 52 years (range: 18-89). The median waiting time for TTAC was 31 days (range: 0-184). The main presenting complaint during the TTAC was obstructive defecation in 69.4%, fecal incontinence in 28.5%, and rectal prolapse in 2.1%. In our study, 611 patients had conservative management (97.3%), with a median of three sessions per patient (range: 1-16), while 82 patients (13.1%) needed a surgical intervention. Only 223 patients (35.5%) were reviewed by a consultant at some stage during the study period. CONCLUSIONS AND INFERENCES: To optimize resources, an adequate triage system allowed us to streamline the pathway for each individual patient with pelvic floor dysfunction according to their symptoms and/or test results with the aim of reducing waiting times and expediting treatment.

Transvaginal rectocoele repair for the surgical treatment of a "symptomatic" rectocoele when conservative measures fail: A 12 year experience of 215 patients.

BACKGROUND: Conservative measures are first-line treatment for a "symptomatic" rectocoele, while surgery to correct the anatomical defect may be considered in selected cases. The standard repair offered in our trust is a native tissue transvaginal rectocoele repair (TVRR) combined with levatorplasty. The primary aim of the study was to conduct a retrospective study to assess the outcome of this procedure, while secondary aims were to assess whether specific characteristics and symptoms were associated with response to surgery. METHODS: We conducted a retrospective review of 215 patients who underwent TVRR in a single tertiary referral center between 2006 and 2018. In total, 97% of patients had symptoms of obstructive defecation syndrome (ODS) and 81% had a feeling of vaginal prolapse/bulge. We recorded in-hospital and 30 days post-operative complications and pre- and post-operative symptoms. KEY RESULTS: The majority of patients selected for surgery had rectocoele above 4 cm or medium size with contrast trapping. Mean length of hospital stay was 3.2 days. The in-hospital complication rate was 11.2% with the most common complications being urinary retention (8.4%). Mean length of follow-up was 12.7 months (SD 13.9, range 1.4-71.5) with global improvement of symptoms reported in 87.9% cases. Feeling of vaginal bulge improved in 80% of patients while ODS-related symptoms improved in 58% of cases. CONCLUSIONS & INFERENCES: The data suggest that TVRR might be a valid option in patients with rectocoele when conservative treatment has failed. Overall patient satisfaction is good, with improvement of ODS symptoms.