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Journal of Clinical Medicine Jan 2023Background: Rectocele is defined as a defect in the rectovaginal septum, causing symptoms like obstructed defecation syndrome (ODS), vaginal bulging, etc. Once the...
Background: Rectocele is defined as a defect in the rectovaginal septum, causing symptoms like obstructed defecation syndrome (ODS), vaginal bulging, etc. Once the rectocele is larger than 3 cm and/or symptomatic, surgery should be considered. The surgical approach can be either transvaginal, transanal or transperineal. Two of the most common procedures in treating rectocele are posterior colporrhaphy (PC) and stapled trans anal rectal resection (STARR). The purpose of this study was to compare surgical outcomes of both procedures. Methods: This is a retrospective cohort study. Included were patients of the age of 18−85 years that underwent either STARR (n = 49 patients) or PC (n = 24 patients) procedures after a full clinical (defecography and physical exam before and after the surgery) and physiologic (a detailed questionnaire before and after the surgery) surveys. Symptoms of ODS before and after surgery were evaluated by questioners. Results: Preoperatively, the patients in the STARR group had significantly higher rates of ODS: straining (90.9% vs. 65.2%), incomplete evacuation (100% vs. 69.6%), hard stool (57.8% vs. 43.5%), sense of obstruction (76.1% vs. 56.5%), and use of digitation (64.4% vs. 47.8%), or laxatives (70% vs. 47.8%), p < 0.001. Anatomically, the mean rectocele size was smaller for the STARR group, compared to the PC group (3.8 ± 1.4 vs. 5.3 ± 2.2 cm, respectively, p < 0.001). Postoperatively, in the STARR group, higher rates of patients complained about straining (36.4% vs. 21.7%, p < 0.001) and use of digitation (64.4% vs. 26.1%, p < 0.001), whereas lower rates of patients complained about incomplete evacuation (41.2% vs. 56.5%, p = 0.05) and sense of obstruction (17.6%, vs. 34.8%, p = 0.03), compared to the PC group. Among patients who underwent the STARR procedure, a decrease in rates of all symptoms was noted (straining 54.5%, incomplete evacuation 58.8%, hard stool 29.2%, sense of obstruction 58.5%, use of digitation 0.1%, and use of laxatives 31.5%). Both procedures are effective in reducing rectocele size (STARR- 1.9 ± 1 cm, PC- 3.1 ± 1). Conclusions: Both STARR and PC are effective in treating rectocele. It seems that the STARR procedure is superior to the PC procedure in treating symptoms of ODS.
PubMed: 36675607
DOI: 10.3390/jcm12020678 -
Journal of Gynecology Obstetrics and... Mar 2023When a patient presents with symptoms suggestive of pelvic organ prolapse (POP), clinical evaluation should include an assessment of symptoms, their impact on daily life...
When a patient presents with symptoms suggestive of pelvic organ prolapse (POP), clinical evaluation should include an assessment of symptoms, their impact on daily life and rule out other pelvic pathologies. The prolapse should be described compartment by compartment, indicating the extent of the externalization for each. The diagnosis of POP is clinical. Additional exams may be requested to explore the symptoms associated or not explained by the observed prolapse. Pelvic floor muscle training and pessaries are non-surgical conservative treatment options recommended as first-line therapy for pelvic organ prolapse. They can be offered in combination and be associated with the management of modifiable risk factors for prolapse. If the conservative therapeutic options do not meet the patient's expectations, surgery should be proposed if the symptoms are disabling, related to pelvic organ prolapse, detected on clinical examination and significant (stage 2 or more of the POP-Q classification). Surgical routes for POP repair can be abdominal with mesh placement, or vaginal with autologous tissue. Laparoscopic sacrocolpopexy is recommended for cases of apical and anterior prolapse. Autologous vaginal surgery (including colpocleisis) is a recommended option for elderly and fragile patients. For cases of isolated rectocele, the posterior vaginal route with autologous tissue should be preferentially performed over the transanal route. The decision to place a mesh must be made in consultation with a multidisciplinary team. After the surgery, the patient should be reassessed by the surgeon, even in the absence of symptoms or complications, and in the long term by a primary care or specialist doctor.
Topics: Female; Humans; Aged; Pelvic Organ Prolapse; Rectocele; Vagina; Gynecologic Surgical Procedures; Genital Diseases, Female; Pelvic Floor
PubMed: 36657614
DOI: 10.1016/j.jogoh.2023.102535 -
ANZ Journal of Surgery Mar 2023To assess the contemporary trends in the types and incidence of pelvic organ prolapse (POP) surgery in Australia after the removal of transvaginal mesh from the...
BACKGROUND
To assess the contemporary trends in the types and incidence of pelvic organ prolapse (POP) surgery in Australia after the removal of transvaginal mesh from the Australian market.
METHODS
This was a retrospective Australian cohort study utilizing three large Governmental databases covering all private and public POP procedures in Australia. All females ≥25 years old undergoing POP procedures between 2005 and 2021 were included.
RESULTS
From 2005-2006 to 2020-2021 there have been a total of 408 881 POP procedures in Australia. The total number of procedures peaked in 2005-2006 at 537.8 procedures per 100 000 age-standardized female population, decreasing by an average of 3.5% per year to 329.0 procedures per 100 000 in 2018-2019, an overall 38.8% decrease (P < 0.001). A sudden growth in private operative procedures was noted between 2019-2020 and 2020-2021, from 218.2 to 268.6 procedures per 100 000 population, a 23.1% increase (P < 0.001). Laparoscopic and abdominal POP repair has seen a 115.8% increase from 13.7 procedures to 29.6 per 100 000 between 2005-2006 and 2020-2021. Over the last 15 years, the most common age group to undergo a procedure has changed from the 55 to 64 years demographic to a later decade of 65 to 74 years.
CONCLUSION
Over the last 15 years, the total number of POP procedures performed has significantly decreased. There has however been a recent rise in interventions seen in the private sector and the utilization of laparoscopic or abdominal POP repair has increased, which has implications for procedural credentialing to ensure patient safety.
Topics: Female; Humans; Middle Aged; Adult; Cohort Studies; Retrospective Studies; Gynecologic Surgical Procedures; Australia; Pelvic Organ Prolapse; Surgical Mesh; Treatment Outcome
PubMed: 36629143
DOI: 10.1111/ans.18268 -
Urology Mar 2023There is limited data regarding the use of mesh for pelvic organ prolapse (POP) repair in young women of childbearing age who wish to preserve their uterus....
INTRODUCTION AND OBJECTIVE
There is limited data regarding the use of mesh for pelvic organ prolapse (POP) repair in young women of childbearing age who wish to preserve their uterus. Sacrohysteropexy with concurrent rectopexy can be performed in this population with a biologic graft, to decrease the risk of contamination with colorectal surgery and allow for future pregnancy. The objective of this video is to present the surgical management of prolapse repair in a young woman with uterine and rectosigmoid prolapse, causing rectal outlet obstruction.
MATERIALS AND METHODS
Our patient is a 21-year-old woman with over a decade of severe constipation. Her past medical history includes anxiety, depression and sexual abuse. She previously underwent robotic rectopexy for intra-rectal intussusception and mucosal prolapse with immediate improvement in her symptoms; however, two months after rectopexy, she suffered from persistent abdominal pain and severe difficulty passing stool. Dynamic resonance imaging demonstrated descent of the bladder with significant uterine prolapse, causing impingement of rectum and rectocele, blocking the evacuation of stool. The patient was thus indicated for concurrent sacrohysteropexy and rectopexy.
RESULTS
She underwent a robotic procedure. Given her age, in an effort to preserve future child-bearing potential, we performed the surgery with a biologic graft made of fascia lata. For the sacrohysteropexy, the graft was sutured to the posterior cervix. Intraoperatively she was noted to have an intact enterocele repair and posterior rectopexy from her previous surgery; however, there was an angulation at the recto sigmoid. This was corrected by performing a rectopexy to the fascia lata graft. She discharged home the day of surgery without incident.
CONCLUSION
Biologic grafts can be used for multi compartment prolapse repair in women of child-bearing age. Fascia lata provides a safe alternative to mesh to allow for future pregnancy. Also, sacrohysteropexy with concurrent rectopexy can be performed with same day discharge.
Topics: Humans; Pregnancy; Female; Young Adult; Adult; Rectal Prolapse; Robotic Surgical Procedures; Fascia Lata; Treatment Outcome; Rectum; Uterus; Biological Products; Surgical Mesh; Laparoscopy
PubMed: 36577453
DOI: 10.1016/j.urology.2022.12.015 -
Obstetrics & Gynecology Science Mar 2023Pelvic organ prolapse (POP) is a significant public health concern in women and a common cause of gynecological surgery in elderly women. The prevalence of POP has...
Pelvic organ prolapse (POP) is a significant public health concern in women and a common cause of gynecological surgery in elderly women. The prevalence of POP has increased with an increase in the aging population. POP is usually diagnosed based on pelvic examination. However, an imaging study may be necessary for more accurate diagnosis. Translabial ultrasound (TLUS) was used to assess diverse types of POP, particularly posterior-compartment POP. It is beneficial to distinguish between true and false rectocele, and detect the rectocele as clinically apparent. TLUS can also establish whether the underlying cause is a problem of the rectovaginal septum, perineal hypermobility, or isolated enterocele. TLUS also plays a role in differentiating POP from conditions that mimic POP. It is a simple, inexpensive, and non-harmful diagnostic modality that is appropriate for most gynecologic clinics.
PubMed: 36575051
DOI: 10.5468/ogs.22227 -
Ultrasound in Obstetrics & Gynecology :... May 2023It has been claimed that manifestations of posterior compartment prolapse, such as rectocele, enterocele and intussusception, are associated with anal incontinence (AI),...
OBJECTIVE
It has been claimed that manifestations of posterior compartment prolapse, such as rectocele, enterocele and intussusception, are associated with anal incontinence (AI), but this has not been studied while controlling for anal sphincter trauma. We aimed to investigate this association in women with intact anal sphincter presenting with pelvic floor dysfunction.
METHODS
This retrospective study analyzed 1133 women with intact anal sphincter presenting to a tertiary urogynecological center for pelvic floor dysfunction between 2014 and 2016. All women underwent a standardized interview, including assessment of symptoms of AI, clinical examination and three-/four-dimensional transperineal ultrasound. Descent of the rectal ampulla, true rectocele, enterocele, intussusception and anal sphincter trauma were diagnosed offline.
RESULTS
Mean age was 54.1 (range, 17.6-89.7) years and mean body mass index was 29.4 (range, 14.7-67.8) kg/m . AI was reported by 149 (13%) patients, with a median St Mark's anal incontinence score of 12 (interquartile range, 1-23). Significant posterior compartment prolapse was seen in 693 (61%) women on clinical examination. Overall, 638 (56%) women had posterior compartment prolapse on imaging: 527 (47%) had a true rectocele, 89 (7.9%) had an enterocele and 26 (2.3%) had an intussusception. Women with ultrasound-diagnosed enterocele had a significantly higher rate of AI (23.6% vs 12.3%; odds ratio (OR), 2.21 (95% CI, 1.31-3.72); P = 0.002), but when adjusted for potential confounders, this association was no longer significant (OR, 1.56 (95% CI, 0.82-2.77); P = 0.134).
CONCLUSION
In women without anal sphincter trauma, posterior compartment prolapse, whether diagnosed clinically or by imaging, was not shown to be associated with AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
Topics: Pregnancy; Humans; Female; Middle Aged; Male; Rectocele; Intussusception; Retrospective Studies; Body Mass Index; Prolapse; Anal Canal; Fecal Incontinence; Ultrasonography
PubMed: 36565432
DOI: 10.1002/uog.26145 -
European Journal of Obstetrics,... Jan 2023To study mesh exposure rates among obese (BMI ≥ 30 kg/m) vs non-obese women after mid-urethral sling (MUS) operation.
OBJECTIVE
To study mesh exposure rates among obese (BMI ≥ 30 kg/m) vs non-obese women after mid-urethral sling (MUS) operation.
STUDY DESIGN
This retrospective cohort study included all patients who underwent MUS surgery for stress urinary incontinence April 2014-April 2021 in a tertiary-level university hospital. Data from obese and non-obese patients were compared.
RESULTS
A total of 120 (41 %) obese patients and 172 (59 %) non-obese patients who had mid-urethral sling surgery were compared. Of the cohort, 265 (90.7 %) underwent TVT-obturator, 15 (5.1 %) mini-sling TVT, and 12 (4.1 %) retro-pubic TVT. Diabetes mellitus was significantly more prevalent in the obese group (p =.01), without other demographic differences. Mesh post-operative exposure rate was 5.4 % during the study. The obese group had lower incidence of mesh exposure than the non-obese group (1.6 % vs 8.1 % respectively, p =.018). Mean follow-up was 51 months (range 8-87 months) without significant differences between groups (49.9 ± 21.2 vs 51.5 ± 22.3, p =.548). Pelvic organ prolapse, cystocele, and rectocele stages were significantly higher in non-obese patients. Similar numbers of post-menopausal women were in each group.
CONCLUSION
This follow-up after MUS surgery showed an association between obesity and lower rate of mesh exposure. Further research is needed to evaluate correlations between estrogen and mesh exposure.
Topics: Humans; Female; Suburethral Slings; Follow-Up Studies; Retrospective Studies; Surgical Mesh; Urinary Incontinence, Stress; Obesity; Treatment Outcome
PubMed: 36442380
DOI: 10.1016/j.ejogrb.2022.11.014 -
Annals of Coloproctology Nov 2022This study was performed to assess the long-term annual functional outcomes and quality of life (QOL) after transanal rectocele repair.
PURPOSE
This study was performed to assess the long-term annual functional outcomes and quality of life (QOL) after transanal rectocele repair.
METHODS
We evaluated retrospectively collected data from patients who underwent transanal repair for symptomatic rectocele between February 2012 and December 2018. The Constipation Scoring System (CSS), the Fecal Incontinence Severity Index (FISI), and several QOL questionnaires (e.g., the Patient Assessment of Constipation-QOL [PAC-QOL], Fecal Incontinence QOL, and the 36-Item Short Form Survey [SF-36]) were administered before surgery and annually after surgery. Additionally, physiological assessments and defecography were performed before and after surgery. Substantial symptom improvement, indicated by at least a 50% reduction in the CSS or FISI score, was evaluated postoperatively. All postoperative follow-up results were compared with the preoperative data.
RESULTS
Thirty-two patients were included in the study. The median follow-up period was 5 years (range, 0.5-7 years). Postoperative defecography showed that the rectocele size significantly decreased (P<0.0001). However, the physiological assessment did not reveal postoperative changes. The CSS score 1 year after surgery was significantly lower than the preoperative score (P<0.0001) and remained significantly low until the long-term follow-up. Constipation improved by more than 80% 2 to 5 years postoperatively, and fecal incontinence improved in 2/3 of the patients after 5 years. The PAC-QOL scores significantly improved (all P<0.05) over time until the 3-year and long-term follow-ups, and 6 of the 8 SF-36 scores significantly improved at specific points postoperatively.
CONCLUSION
Transanal rectocele repair provides long-term improvement for constipation and constipation-specific QOL.
PubMed: 36377333
DOI: 10.3393/ac.2022.00283.0040 -
Journal of Visceral Surgery Jun 2023Ventral mesh rectopexy (VMR) is the gold standard for rectal prolapse surgery, but the type of mesh reinforcement is still a matter of debate. The aim of this study was...
INTRODUCTION
Ventral mesh rectopexy (VMR) is the gold standard for rectal prolapse surgery, but the type of mesh reinforcement is still a matter of debate. The aim of this study was to assess the anatomic and functional results of a single center cohort of patients receiving ventral rectopexy with biological mesh compared to a reference group who had implantation of synthetic mesh. We also assessed the predictive factors for recurrence.
PATIENTS AND METHODS
Seventy patients (2015-2021) were included in the biological mesh group and were compared to a reference group of 345 patients operated on with a synthetic mesh (2004-2017).
RESULTS
In the biological mesh group, the mean age of patients was 65 years (53-72). The main disorders of the posterior pelvic floor were rectal prolapse (30 cases) or rectocele (37 cases). Two patients had solitary rectal ulcer syndrome and one had internal prolapse. VMR was performed by a laparoscopic approach with robotic assistance in 93%. After a median follow-up of 12 (4.5-23) months, the anatomic recurrence rate was 10%. The median satisfaction score assessed in a telephone interview by a semi-quantitative scale from 0 to 10 was 7. Compared to the synthetic group, neither the morbidity rate (Dindo>2) (0.6% synthetic versus 1.4% biological mesh), nor the recurrence rate (12% synthetic versus 10% biological (ns) with an average interval of 13.5 versus 14 months, respectively) were statistically significantly different.
CONCLUSION
VMR with biological mesh represents an alternative to synthetic mesh. Despite its resorbable nature, biological mesh does not seem to increase the risk of recurrence and offers satisfying functional results after a medium term follow-up.
Topics: Female; Humans; Middle Aged; Aged; Rectal Prolapse; Pelvic Floor Disorders; Surgical Mesh; Laparoscopy; Treatment Outcome; Rectum
PubMed: 36344359
DOI: 10.1016/j.jviscsurg.2022.09.009 -
Techniques in Coloproctology Jun 2023
Topics: Humans; Rectocele
PubMed: 36333612
DOI: 10.1007/s10151-022-02726-6