Long time consequences after STARR procedure: Report of 15 years experience and medico-legal perspective.

INTRODUCTION: Stapled transanal rectal resection is the most surgical procedure used for obstructed defecation syndrome, rectal prolapse, rectocele and rectal intussusception worldwide. The aim of this study is to report our experience and long time consequences and to offer a new medico-legal perspective. MATERIALS AND METHODS: We retrospective review medical charts of patients treated between 2006 and 2021 â€‹b â€‹y the same team directed by the same senior surgeon. We consider major complications and long time sequelaeses as main object for the discussion. Inclusion and exclusion criteria were created. IRB approved the study. After revision a medico-legal perspective was done based on major complications. RESULTS: During the study period 1726 patients, ages between 18 and 71 years old, were treated with 1280 STARR procedures and 446 "Longo" [was stopped on 2012]; all procedures were performed by the senior surgeon and visited by the team at the same control visit at 7days, 30 days and 12 and 18 months after surgery. All patients had 100 â€‹% compliance at 30 days, while 85 â€‹% had long time visit (more than 18 months). During the study period 6 â€‹% (104 subjects) of patients had minor complications while 1 patient (42 â€‹yrs female) reported total fecal incontinence after 18 months (0,05 â€‹%). This patient had mental disorder treated with drugs unknown before surgery and long time mental disorder after surgery. We focused on this last case to discuss long time complication DISCUSSION: This survey reports some interesting clinical data; respect to standard complications minor complications such as pain, bleeding and anal discomfort represent less than 10 â€‹% of procedures that is a good results in this perineal surgery. For those working with rectal mucosal prolapse, obstructed defecation syndrome, rectocele or rectal intussusception is essential to distinguish these diagnosis to have a good counselling with patient before surgery (at least 1 month before). It is essential to check these patients with a close follow-up especially after surgery, to avoid any other mental discomfort related to fecal incontinence; long time fecal incontinence, without anatomical disorders as our case, could be associated and related to drugs consumption or mental disorder, or perineal insensitivity due to surgical procedure. In conclusion it is essential to have good clinical practice to suggest STARR procedure, having idea about different diseases, different surgical approaches and different long time complications.

Laparoscopic ventral mesh rectopexy vs. transperineal mesh repair for obstructed defecation syndrome associated with rectocele: comparison of selectively distributed patients.

PURPOSE: Obstructed defecation syndrome represents 50-60% of patients with symptoms of constipation. We aimed to compare the two frequently performed surgical methods, laparoscopic ventral mesh rectopexy and transperineal mesh repair, for this condition in terms of functional and surgical outcomes. METHODS: This study is a retrospective review of 131 female patients who were diagnosed with obstructed defecation syndrome, attributed to rectocele with or without rectal intussusception, enterocele, hysterocele or cystocele, and who underwent either laparoscopic ventral mesh rectopexy or transperineal mesh repair. Patients were evaluated for surgical outcomes based on the operative time, the length of hospital stay, operative complications, using prospectively designed charts. Functional outcome was assessed by using the Initial Measurement of Patient-Reported Pelvic Floor Complaints Tool. RESULTS: Fifty-one patients diagnosed with complex rectocele underwent laparoscopic ventral mesh rectopexy, and 80 patients diagnosed with simple rectocele underwent transperineal mesh repair. Mean age was found to be 50.35 ± 13.51 years, and mean parity 2.14 ± 1.47. Obstructed defecation symptoms significantly improved in both study groups, as measured by the Colorectal Anal Distress Inventory, Constipation Severity Instrument and Patient Assessment of Constipation-Symptoms scores. Minor postoperative complications including wound dehiscence (n = 3) and wound infection (n = 2) occurred in the transperineal mesh repair group. CONCLUSION: Laparoscopic ventral mesh rectopexy and transperineal mesh repair are efficient and comparable techniques in terms of improvement in constipation symptoms related to obstructed defecation syndrome. A selective distribution of patients with or without multicompartmental prolapse to one of the treatment arms might be the preferred strategy.

[Imaging of the pelvic floor (MR defecography) : The surgeon's perspective]. / Bildgebung des Beckenbodens (MR-Defäkographie) : Die Sicht der Chirurgie.

BACKGROUND: Magnetic resonance defecography (MRD) plays a central role in diagnosing pelvic floor functional disorders by visualizing the entire pelvic floor along with pelvic organs and providing functional assessment of the defecation process. A shared understanding between radiology and surgery regarding indications and interpretation of findings is crucial for optimal utilization of MRD. OBJECTIVES: This review aims to explain the indications for MRD from a surgical perspective and elucidate the significance of radiological findings for treatment. It intends to clarify for which symptoms MRD is appropriate and which criteria should be followed for standardized results. This is prerequisite to develop interdisciplinary therapeutic approaches. MATERIALS AND METHODS: A comprehensive literature search was conducted, including current consensus guidelines. RESULTS: MRD can provide relevant findings in the diagnosis of fecal incontinence and obstructed defecation syndrome, particularly in cases of pelvic floor descent, enterocele, intussusception, and pelvic floor dyssynergia. However, rectocele findings in MRD should be interpreted with caution in order to avoid overdiagnosis. CONCLUSION: MRD findings should never be considered in isolation but rather in conjunction with patient history, clinical examination, and symptomatology since morphology and functional complaints may not always correlate, and there is wide variance of normal values. Interdisciplinary interpretation of MRD results involving radiology, surgery, gynecology, and urology, preferably in the context of pelvic floor conferences, is recommended.

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.

The patient with obstructed defecatory symptoms: Management differs considerably between physicians and surgeons.

BACKGROUND: Patients with obstructed defecatory symptoms (ODS) are commonly referred to either gastroenterologists (GE) or colorectal surgeons (CS). Further management of these patients may be impacted by this choice of referral. METHODS: An online survey of specialist practice was disseminated to GE and CS in Australia and New Zealand. A case vignette of a patient presenting with ODS was described, with multiple subsequent scenarios designed to delineate the responder's preferred approach to management of this patient. KEY RESULTS: A total of 107 responders participated in the study, 62 CS and 45 GE. For a female patient with ODS not responding to pharmacological treatment, GE were more likely than CS to refer patients for anorectal manometry, while CS were more likely to refer for dynamic imaging. A quarter of CS and GE referred patients directly to pelvic floor physiotherapy, without any pre-treatment testing. Knowing the result of dynamic imaging, especially if a rectocele was demonstrated, substantially influenced management for both of the specialties: GE became more likely to refer the patients for CS consultation and less likely to refer directly for biofeedback or physiotherapy and CS were more likely to opt for an operative pathway over conservative management than they were prior to knowledge of the imaging findings. The majority (>75%) of GE and CS did not find it necessary to obtain a gynecological consultation, even in the presence of a rectocele. CONCLUSIONS & INFERENCES: Practice variation across medical specialties affects diagnostic and management recommendations for patients with ODS, impacting treatment pathways. Our findings provide an incentive toward establishing interdisciplinary, uniform, management guidelines.

Anatomic outcomes of sacrohysteropexy without posterior mesh placement in patients with asymptomatic grade 1 and 2 rectoceles: Is a rectouterine mesh really necessary?

OBJECTIVES: To present the anatomic outcomes of sacrohysteropexy surgery without posterior mesh placement in patients with asymptomatic grade 1 and 2 rectoceles. METHODS: The patients who underwent abdominal sacrohysteropexy without posterior mesh placement for the treatment of symptomatic grade 3 and 4 anterior/apical prolapse + asymptomatic grade 1 and 2 rectocele between May 2015 and January 2021 were evaluated retrospectively. The success rate, the anatomic outcomes (for anterior, apical, and posterior pelvic organ prolapse [POP]), and perioperative data of the surgical procedure were assessed. The objective failure criteria after surgery included the presence of grade 1 or higher in any compartment (anatomical criteria), recurrent POP requiring an operation, and/or usage of pessaries. Perioperative adverse events were categorized according to the Clavien-Dindo classification. RESULTS: Fifty-one patients underwent sacrohysteropexy without posterior mesh. The mean age of the patients was 56.8 ± 10 years. The success rates (anatomical outcomes) for the anterior/apical and posterior POP in the study group were 60.7%, 54.9%, and 58.8%, respectively, at a median follow-up time of 40.24 (24-71) months. The median hospital stay was 3.1 (2-6) days. The mean estimated blood loss was 127.6 (80-150) mL. The mean operation time was 114 (90-156) min. The mean urethral and catheter removal times were 1.3 (1, 2) and 2.1 (2-4) days, respectively. The mean recovery time of gastrointestinal motility was 14.4 h (11-35). CONCLUSIONS: Sacrohysteropexy without posterior mesh placement might be associated with less pain, shorter operative time, and shorter recovery time of gastrointestinal motility, without compromising the anatomic success.

Laparoscopic or transanal repair of rectocele? Comparison of a reduction in rectocele size.

PURPOSE: This study aimed to compare the reduction in rectocele size after laparoscopic ventral rectopexy (LVR) with that after transanal repair (TAR). METHODS: Forty-six patients with rectocele who underwent LVR and 45 patients with rectocele who received TAR between February 2012 and December 2022 were included. This was a retrospective analysis of prospectively collected data. All patients had clinical evidence of a symptomatic rectocele. Bowel function was evaluated using the constipation scoring system (CSS) and fecal incontinence severity index (FISI). Substantial symptom improvement was defined as at least a 50% reduction in the CSS or FISI scores. Evacuation proctography was performed before surgery and 6 months postoperatively. RESULTS: Constipation was substantially improved in 40-70% of the LVR patients and 70-90% of the TAR patients over 5 years. Fecal incontinence was markedly improved in 60-90% of the LVR patients across 5 years and in 75% of the TAR patients at 1 year. Postoperative proctography showed a reduction in rectocele size in the LVR patients (30 [20-59] mm preoperatively vs. 11 [0-44] mm postoperatively, P < 0.0001) and TAR patients (33 [20-55] mm preoperatively vs. 8 [0-27] mm postoperatively, P < 0.0001). The reduction rate of rectocele size in the LVR patients was significantly lower than that in the TAR patients (63 [3-100] % vs. 79 [45-100] %, P = 0.047). CONCLUSION: The reduction in rectocele size was lower in the patients who underwent LVR than in those who received TAR.

A possible physiological mechanism of rectocele formation in women.

BACKGROUND: We aimed to determine the anorectal physiological factors associated with rectocele formation. METHODS: Female patients (N = 32) with severe constipation, fecal incontinence, or suspicion of rectocele, who had undergone magnetic resonance defecography and anorectal function tests between 2015 and 2021, were retrospectively included for analysis. The anorectal function tests were used to measure pressure in the anorectum during defecation. Rectocele characteristics and pelvic floor anatomy were determined with magnetic resonance defecography. Constipation severity was determined with the Agachan score. Information regarding constipation-related symptoms was collected. RESULTS: Mean rectocele size during defecation was 2.14 ± 0.88 cm. During defecation, the mean anal sphincter pressure just before defecation was 123.70 ± 67.37 mm Hg and was associated with rectocele size (P = 0.041). The Agachan constipation score was moderately correlated with anal sphincter pressure just before defecation (r = 0.465, P = 0.022), but not with rectocele size (r = 0.276, P = 0.191). During defecation, increased anal sphincter pressure just before defecation correlated moderately and positively with straining maneuvers (r = 0.539, P = 0.007) and defecation blockage (r = 0.532, P = 0.007). Rectocele size correlated moderately and positively with the distance between the pubococcygeal line and perineum (r = 0.446, P = 0.011). CONCLUSION: Increased anal sphincter pressure just before defecation is correlated with the rectocele size. Based on these results, it seems important to first treat the increased anal canal pressure before considering surgical rectocele repair to enhance patient outcomes.

Tailoring surgery for obstructed defecation syndrome to the 'iceberg diagram': Long-term results.

BACKGROUND: Patients with obstructed defecation syndrome may present with a wide spectrum of disorders. The iceberg diagram, which focuses on the underlying occult diseases, has been proposed for an accurate diagnosis. The iceberg diagram deals with lesions, which, if neglected, may worsen the prognosis. The aim of this study was to evaluate the effect of using the iceberg diagram on the clinical results. METHODS: Patients operated for obstructed defecation syndrome based on the iceberg diagram between 2008 and 2018 were evaluated pre- and postsurgery. All patients underwent psychosomatic assessment, abdominal and perineal examination, proctoscopy, vaginoscopy, transanal ultrasound, and defecography. Postoperative complications were also evaluated. RESULTS: Of the 80 operated patients, 73 were females; median age was 47 (range 26-78) years. All had a rectal internal mucosal prolapse and 85% had a rectocele. The most frequent occult diseases were functional (mental distress [46%]) or organic (colpo-cysto-enterocele [44%]). Surgery was tailored according to the iceberg diagram with prolapsectomy and rectocele repair the most commonly used among 8 different procedures. A total of 14% of patients had a postoperative complication. Median follow-up was 72 months. Obstructed defecation syndrome score significantly decreased from 10.5 ± 4.8 (mean + standard deviation) to 3.4 ± 3.6 (P < .01) and 68% of patients reported to be either improved or cured. CONCLUSION: The use of the iceberg diagram in obstructed defecation syndrome patients assists in identifying latent "submerged lesions' that may negatively impact the functional outcome of surgery. A clinical approach to patients with obstructed defecation syndrome tailored according to the iceberg diagram allows the identification of occult lesions and to achieve good long-term results.

Time trend in the surgical management of obstructed defecation syndrome: a multicenter experience on behalf of the Italian Society of Colorectal Surgery (SICCR).

BACKGROUND: Surgical management of obstructed defecation syndrome (ODS) is challenging, with several surgical options showing inconsistent functional results over time. The aim of this study was to evaluate the trend in surgical management of ODS in a 10-year timeframe across Italian referral centers. METHODS: Surgeons from referral centers for the management of pelvic floor disorders and affiliated to the Italian Society of Colorectal Surgery provided data on the yearly volume of procedures for ODS from 2010 to 2019. Six common clinical scenarios of ODS were captured, including details on patient's anal sphincter function and presence of rectocele and/or rectal intussusception. Perineal repair, ventral rectopexy (VRP), transanal repair (internal Delorme), stapled transanal rectal resection (STARR), Contour Transtar, and transvaginal repair were considered in each clinical scenario. RESULTS: Twenty-five centers were included providing data on 2943 surgical patients. Procedure volumes ranged from 10-20 (54%) to 21-50 (46%) per year across centers. The most performed techniques in patients with good sphincter function were transanal repair for isolated rectocele (243/716 [34%]), transanal repair for isolated rectal intussusception (287/677 [42%]) and VRP for combined abnormalities (464/976 [48%]). When considering poor sphincter function, these were perineal repair (112/194 [57.8%]) for isolated rectocele, and VRP for the other two scenarios (60/120 [50%] and 97/260 [37%], respectively). The use of STARR and Contour Transtar decreased over time in patients with impaired sphincter function. CONCLUSIONS: The complexity of ODS treatment is confirmed by the variety of clinical scenarios that can occur and by the changing trend of surgical management over the last 10 years.

Rectocele: Incidental or important? Observe or operate? Contemporary diagnosis and management in the multidisciplinary era.

BACKGROUND: More common in older women than younger women, rectoceles may be secondary to pelvic floor weakness and/or pelvic floor dysfunction with impaired rectal evacuation. Rectoceles may be small (<2 cm), medium (2-4 cm), or large (>4 cm). Arguably, large rectoceles are more likely to be associated with symptoms (e.g., difficult defecation). It can be challenging to ascertain the extent to which a rectocele is secondary to pelvic floor dysfunction and/or whether a rectocele, rather than associated pelvic floor dysfunction, is responsible for symptoms. Surgical repair should be considered when initial treatment measures (e.g., bowel modifying agents and pelvic floor biofeedback therapy) are unsuccessful. PURPOSE: We summarize the clinical features, diagnosis, and management of rectoceles, with an emphasis on outcomes after surgical repair. This review accompanies a retrospective analysis of outcomes after multidisciplinary, transvaginal rectocele repair procedures undertaken by three colorectal surgeons in 215 patients at a large teaching hospital in the UK. A majority of patients had a large rectocele. Some patients also underwent an anterior levatorplasty and/or an enterocele repair. All patients were jointly assessed, and some patients underwent surgery by colorectal and urogynecologic surgeons. In this cohort, the perioperative data, efficacy, and harms outcomes are comparable with historical data predominantly derived from retrospective series in which patients had a good outcome (67%-78%), symptoms of difficult defecation improved (30%-50%), and patients had a recurrent rectocele 2 years after surgery (17%). Building on these data, prospective studies that rigorously evaluate outcomes after surgical repair are necessary.

Higher symptom score, larger residual rectocele, and lower rectal compliance predict failure of improvement after surgical treatment of rectocele

Background: Rectocele is a frequent finding in women and is usually asymptomatic. However, it is sometimes associated with symptoms of obstructed defecation syndrome (ODS). While most patients with ODS due to rectocele respond well to conservative treatment, some may require surgical treatment. The aim of the study was to determine the predictors of failure of symptom improvement after rectocele repair. Methods: The study included adult women with rectocele who underwent surgical treatment by transperineal repair (TPR) or transvaginal repair (TVR). The preoperative and postoperative assessment was done using the Wexner constipation score, anorectal manometry, and defecography. Results: A total of 93 female patients with a mean age of 43.7 years were included. Among them, 65.6% of patients underwent TPR and 34.4% underwent TVR; 22 (23.7%) patients reported failure of significant improvement in ODS symptoms after surgery. The independent predictors of failure of improvement were higher preoperative Wexner score (odds ratio, OR: 1.4, 95% confidence interval, CI: 1.09-1.84, p = 0.009), larger residual rectocele after repair (OR: 2.95, 95% CI: 1.43-6.08, p = 0.003), and lower postoperative maximum tolerable volume (OR: 0.949, 95% CI: 0.907-0.992, p = 0.02). The predictive cutoff point for the preoperative Wexner score was 15. Conclusions: Patients with a preoperative Wexner score higher than 15 and larger residual rectocele after surgery may experience little improvement in symptoms after rectocele repair. Although TPR was associated with a poorer relief of symptoms than did TVR; it was not an independent predictor of failure. (AU)

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.

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.

Rectocele: victim of availability bias? Results of a Belgian survey of colorectal and gynecological surgeons.

INTRODUCTION AND HYPOTHESIS: Women with a symptomatic rectocele may undergo different trajectories depending on the specialty consulted. This survey aims to evaluate potential differences between colorectal surgeons and gynecologists concerning the management of a rectocele. METHODS: A web-based survey was sent to abdominal surgeons (CS group) and gynecologists (G group) asking about their perceived definition, diagnostic workup, multidisciplinary discussion (MDT) and surgical treatment of rectoceles. The answers of both groups were analyzed with the chi-square test or Fisher's exact test at p < 0.050. RESULTS: A rectocele was defined as a prolapse of the posterior vaginal wall by 78% of the G and 41% of the CS group. All gynecologists and 49% of the CS group evaluated a rectocele clinically in dorsal decubitus, with 91% of gynecologists using a speculum and 65% using the Pelvic Organ Prolapse-Quantification (POP-Q) scoring system, compared to < 1/3 of colorectal surgeons. A digital rectal examination was performed by 90% of the CS group and 57% of the G group. A transvaginal ultrasound was only used by the G group, while anal manometry was opted for by the CS group (65%) and minimally by the G group (14%). In the G group, a posterior repair was the preferred surgical technique (78%), whereas 63% of the CS group preferred a rectopexy. Multidisciplinary discussions (MDT) were mostly organized ad hoc. CONCLUSIONS: An availability bias is seen in different aspects of rectocele evaluation and treatment. Colorectal surgeons and gynecologists are acting based on their training and experience. Motivation for pelvic floor MDT starts with creating awareness of the availability bias.

Midline rectovaginal fascial plication: Anatomical and functional outcomes at one year.

OBJECTIVES: To evaluate anatomical and functional results at one year of midline rectovaginal fascial plication (MFP) for rectocele. MATERIAL AND METHODS: Single-center observational study performed in a gynecologic-obstetrics department of a university hospital. Inclusion criteria were patients with isolated or associated rectocele treated by MFP. The success rate defined by a Bp point < 0 cm, improvement of symptoms, and satisfaction were evaluated at one year. Quality of life questionnaires were distributed pre- and postoperatively at one year. RESULTS: 34/46 (74%) patients were interviewed pre and postoperatively including a POPQ evaluation in only 30 patients. Anatomical success rate was 28/30 (93%) (p < 0.0001). There was an improvement in the sensation of vaginal bulge with 22/34 patients (65%) no longer having this symptom (p < 0.0001) and only one patient (1/34, 3%) underwent surgery for recurrence of the rectocele. 24/34 patients (71%) were satisfied with their surgery at one year. CONCLUSION: Anatomical and functional results of MFP for rectocele are encouraging and must be confirmed on a longer follow up.

Does Rectocele Repair Combined with Other Perineal Surgeries Affect Outcome Compared to Solo Rectocele Repair?

OBJECTIVES: Rectocele is common in female patients. To date, there is no literature comparing outcomes of rectocele repairs in combination with other perineal surgeries. We aim to analyze perioperative morbidity and mortality as well as long-term outcome of rectocele repair in combination with other perineal surgeries (RR combination) and compare this with solo rectocele repair (solo RR). DESIGN: The type of study was case-control. Data of patients who received solo rectocele repair or rectocele repair in combination with other perineal surgeries between January 2011 and December 2015 were identified and reviewed in a prospectively maintained and IRB-approved database. Ninety-eight patients were included, including 41 patients in the solo RR group and 57 patients in the RR combination group. The demographics, characteristics of patients, short-term complications, long-term complications, and morbidity of the 2 groups were observed. METHODS: The demographics, characteristics of patients, short-term complications, long-term complications, and morbidity of the 2 groups were compared, respectively. Covariate adjustment was analyzed by multivariate logistic and Cox regression analysis. RESULTS: Ninety-eight patients with a median age of 57 were included, involving 41 patients in the solo RR group and 57 patients in the RR combination group. Other than the operative approach (p < 0.01), demographics and preoperative characteristics of the 2 groups were comparable. All variables, including length of stay, estimated blood loss, self-limiting rectal bleeding, transfusion, urinary retention, rectal stricture, rectal and perineal infection, rectovaginal abscess, reoperation, effective resolution of obstructive defecation symptoms, residual symptoms rate, and recurrence rate, were comparable among the 2 groups except for operative time (p = 0.03). LIMITATIONS: This study is a single-center study, which may cause bias. In addition, the sample size is limited. Staging of rectocele and routine imaging studies were not performed. CONCLUSIONS: Rectocele repair in combination with other perineal surgeries is feasible, and outcomes are comparable with solo rectocele repair. Transanal versus transvaginal repairs appear to have no influence on outcomes.

Long-term annual functional outcome after laparoscopic ventral rectopexy for rectoanal intussusception and/or rectocele: evaluation of sustained improvement.

BACKGROUND: The aim of this study was to assess the long-term annual functional results and quality of life (QOL) after laparoscopic ventral rectopexy (LVR) for rectoanal intussusception (RAI) and/or rectocele. METHODS: This study was a retrospective analysis of prospectively collected data. The study was conducted on patients who underwent LVR for RAI and/or rectocele at our institution between February 2012 and July 2015. The Fecal Incontinence Severity Index (FISI), Constipation Scoring System (CSS), and QOL instruments (i.e., 36-item Short-form Health Survey [SF-36], Patient Assessment of Constipation-QOL [PAC-QOL] scale, and Fecal Incontinence-QOL [FIQL]) were administered before and annually after surgery. The sustainability of substantial symptom improvement (reduction of at least 50% in CSS or FISI scores) postoperatively was evaluated. RESULTS: Fifty-one patients (median age 76 [range 60-93] years, 48 women [94%]) were analyzed. No mortality or major morbidity occurred. After a median follow-up of 60 months (range 12-84 months), no mesh-related complications occurred. The median CSS and FISI scores were significantly reduced at 1 year and remained significantly reduced for 7 years. In patients who reported symptom scores ≥ 3 times postoperatively, sustained improvement of constipation and fecal incontinence was found in about 50% (18/38) and 75% (26/35) of relevant patients, respectively. All PAC-QOL and FIQL scales significantly improved over time for 5 years. Of the SF-36 scales, four showed significant improvement at 1 year but none was significantly improved after 3 years, except for the social functioning scale. CONCLUSIONS: LVR for RAI and/or rectocele was associated with low morbidity and long-term improvement in symptom-specific QOL. The sustainability of postoperative improvement in fecal incontinence was satisfactory, and that in constipation was fair.

A step-by-step approach to endorectal proctopexy (ERPP): how we do it.

There are many surgical treatments aimed at correcting internal mucosal prolapse and rectocele associated with obstructed defecation syndrome (ODS). Perineal procedures can be considered as first options in young men in whom an abdominal approach poses risks of sexual dysfunction and in selected women with isolated posterior compartment prolapse who failed conservative treatment. About 20 years ago, we described endorectal proctopexy (ERPP) also known as internal Delorme procedure. The aim of the present study was to describe, with attention to technical details and the aid of a video, the different steps of ERPP for the treatment of ODS. A retrospective analysis of our last 100 cases confirms our initial good results. Complications included suture line dehiscence with consequent stricture in four patients (4%). Bleeding occurred in four (4%) patients and was conservatively treated. Transient anal continence impairment consisting of urgency and soiling occurred in 12 (12%) and 6 (6%) patients, respectively. At 6-month follow-up the Cleveland Clinic Constipation Score and ODS score improved from a median preoperative value of 18.9 and 18.5 to 5 and 5, respectively (p < 0.0001). The mean follow-up was 36.05 ± 13.3 (range 12-58) months and anatomical recurrence rate was 6 (%). Due to its excellent safety profile and the ability to tailor the procedure to different disease presentations, we think that ERPP should be part of the basic armamentarium of all colorectal surgeons operating on the pelvic floor.