Which surgical approach for rectocele? A multicentric report from Italian coloproctologists
ABSTRACT The most effective surgical technique for rectocele has not yet been clearly established. A retrospective multicentric study was carried out to compare the long-term results of 3 endorectal techniques (Block, Sarles and stapled) and the perineal levatorplasty, alone and in association, in a series of patients with symptomatic rectocele. From January 1992 to December 1999, 2212 patients with defecation disorders were referred to 5 Italian coloproctology units. An anterior rectocele was clinically diagnosed in 1045 patients and confirmed with defecography. On the basis of clinical and radiological parameters, 317 patients (312 women; mean age, 52.4+/-20.1 years) were selected for surgery. Group 1 consisted of 141 patients (136 women; mean age, 50.4+/-18.8 years) who were submitted to endorectal operations. Group 2 consisted of 126 women (mean age, 52.5+/-19.7 years) who received perineal levatorplasty. Finally, 50 women (mean age, 54.3+/-21.9 years) in Group 3 received endorectal operations associated with perineal levatorplasty. A total of 269 patients were followed postoperatively (mean period, 24.2+/-3.1 months, 27.5+/-5.4 months and, 22.8+/-2.8 months, respectively) with the same questionnaire and clinical examination. Three months after surgery, a defecography examination and anorectal manometry were performed in 136 and 132 patients, respectively. Operative time, hospital stay and time to return to work were significantly higher in Group 3 (p<0.001). There was one death in Group 3 due to severe sepsis. Main postoperative complications were: in Group 1, hemorrhage (7.8%, all Sarles), dehiscence of the endorectal suture (5.0%, all Block), distal rectal stenosis (2.1%, 1 stapled, 2 block), and rectovaginal fistula (1.4%, all Sarles); in Group 2, delayed healing of the perineal wound (16.4%); in Group 3 delayed healing of the perineal wound (22.0%), hemorrhage (6%, all Sarles), dehiscence (4.0%), stenosis (2.0%). 17.3% of patients of Group 2 and 22.5% of Group 3 complained of dyspareunia. Postoperative defecography showed a complete absence of the rectocele in 44.1% of patients and reduction of size in the others, without significant differences among the three groups. Manometric pattern was not significantly modified by surgery. Significant symptoms recurred in 5.9% of the patients in Group 1, 6.4% in Group 2, and 5.0% in Group 3. Perineal levatorplasty did not significantly improve obstructed defecation, as it did not allow to excise the rectal mucosal prolapse, and was followed by an high incidence of delayed healing of the perineal wound and dyspareunia. Sarles procedure achieved better control of mucosal prolapse but carried a higher complication rate compared to the others. The association of the perineal levatorplasty with an endorectal technique required significantly longer operative time, and led to a longer hospital stay and time to return to work. In conclusion, the investigated techniques showed different patterns of postoperative complications: bleeding after Sarles, dehiscence after Block, dyspareunia after perineoplasty and fatal gangrene after stapled, but non of them showed a clear superiority over the others in term of clinical or functional results 2 years after surgery.
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ABSTRACT: Outlet dysfunction is responsible for 25% of all cases of chronic constipation. The aim of this article was to report our outcomes and investigate the efficacy of the different treatments that we have adopted to solve it. One hundred and twenty-six patients were treated with either surgery and/or biofeedback therapy. Ninety-seven of the 126 patients underwent surgery; 48 with hidden rectal prolapse: 44 underwent a stapled transanal rectal resection using a double stapler PPH-01 and 4 a single stapler PPH-01; 31 with rectocele and 18 with both hidden rectal prolapse and rectocele, respectively, underwent a stapled transanal rectal resection using a double stapler PPH-01. Thirteen of 97 patients showing outlet dysfunction in spite of surgery progressed to biofeedback therapy. 29 of the 126 patients were treated with biofeedback training only. Surgery helped 51.6% of treated for rectocele, 75% of those treated for hidden rectal prolapse, and 78% of patients treated for both rectocele and hidden rectal prolapse, respectively. Approximately 80% of patients treated with biofeedback alone and 67.8% of those treated with both surgery and biofeedback reported an improvement, respectively. Treatment of the outlet dysfunction can be difficult. The therapeutic option chosen for each subject in spite of a careful functional patient examination may not prove to be the most appropriate one. Our experience suggests that the surgery of the obstructed defecation could achieve better outcomes if a course of biofeedback therapy precedes it, above all in patients with both organic and functional disorders, and the repair of rectocele with stapled transanal rectal resection fails to resolve the outlet dysfunction in several cases.Chirurgia italiana 01/2008; 60(4):509-18.
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ABSTRACT: Sometimes dyschezia may be due to rectocele and/or recto-anal intussusception. Stapled transanal rectal resection (STARR) is a surgical option for dyschezia caused by rectocele and/or recto-anal intussusception. We reported four cases of patients evaluated for persistent symptoms of impaired defecation after STARR. Goals of the study were to identify the causes of failure, to outline an effective rehabilitative treatment program and to evaluate the post-rehabilitation results. Four females (mean age: 48.5 ± 3.3 years old), who had a previous STARR and who were symptomatic for dyschezia, underwent clinical evaluation, defecography, and anorectal manometry. A rehabilitative treatment was successively planned on the basis of the diagnostic instrumental data. A post-rehabilitative clinical evaluation was performed and the instrumental data of patients were compared with those of ten healthy women (mean age 54 years, range 43-67) with normal bowel habits. Clinical evaluation, defecographic X-rays, and anorectal manometry made diagnosis of outlet obstruction, supported by pelvic floor dyssyner- gia. The pelvic floor dyssynergia was also preoperatively present in all patients. An appropriate cycle of rehabilitation was outlined for each patient. After the rehabilitation the patients were clinically evaluated and Agachan constipation score lowered in all 4 cases. The persistent dyschezia after STARR was caused by pelvic floor dyssynergia, which was present pre-operatively. Rehabilitation was a useful therapeutic option in these patients.
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ABSTRACT: ausgehen sollte. Nur aufbauend auf genauer Diag- nostik und präziser operativer Technik kann ein zu- friedenstellendes Resultat erzielt werden. Dabei ist es wichtig hervorzuheben, dass eine erfolgreiche Behandlung von rektovaginalem Fistelleiden nicht nur einen sicheren Fistelverschluss bedeutet, son- dern auch das Wiedererlangen analer Kontinenz. Abstract: Management of Rectovaginal Fis- tulas. Rectovaginal fistulas present a distress- ing problem for the patient and a challenge for the treating physician. The management of RVF depends on cause, size and location, anal sphincter function and overall health status of the patient. Careful preoperative assessment of the fistula, surrounding tissues, and anal sphinc- ter and exclusion of associated disease are es- sential. Obstetrical fistulas can be treated suc- cessfully by local approaches transvaginally. Episioproctotomy may be considered if there is an associated sphincter defect. Complicated fis- tulas due to inflammatory bowel disease (IBD) or after radiation need a detailed approach. Crohn's related fistulas may require proctectomy if the rectum is severely involved. Local repair can be considered in instances where the rec- tum is relatively healthy and local sepsis has been controlled. Radiation-induced fistulas may be secondary to cancer recurrence, which must be excluded. With thorough evaluation, thought- ful consideration of treatment options, and me- ticulous operative technique, patients can be assured of an optimal outcome. Success in treatment of patients with RVF should be meas- ured not just in terms of successful closure of the fistula but also in terms of patient satisfac- tion with postoperative anal continence. J Urol Urogynäkol 2009; 16 (4): 5-9.