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Surgical Repair of Rectocoele: Vaginal vs. Transanal Approach

This study explores the structural anatomy of the posterior pelvic compartment related to rectocoele and compares the effectiveness of vaginal and transanal approaches in rectocoele repair. The study also discusses the challenges in studying rectocoele and the lack of standardized definitions and reviews. Various surgical procedures and conservative therapies are reviewed, along with their outcomes and long-term follow-up.

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Surgical Repair of Rectocoele: Vaginal vs. Transanal Approach

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  1. « Rectocoele » Mesh?

  2. Posterior vaginal compartment • Perineum • Rectum • Peritoneum of the cul-de-sac

  3. X

  4. Anatomy = urogenital diaphragm Structural anatomy of the posterior pelvic compartment as it relates to rectocoele J de Lancey, AJOG 1999

  5. Endopelvic fascia

  6. Endopelvic fascia

  7. Endopelvic fascia

  8. Epidemiology Olsen, 1997

  9. Symptoms Note: Ellerkman AJOG 2001

  10. Reviewing the literature • DIFFICULT • Heterogeneous nature of the problem • Variability inclusion/ exclusion criteria • Plethora of surgical procedures • Non-standardized definitions of surgical outcome • Lack of independent, standardized reviews • Short term follow-up

  11. Conservative therapy

  12. Aim of surgery • Relieve symptoms • Restore anatomy • Maintain visceral function • Maintain sexual function Arnold M, 1990

  13. Vaginal vs Transanal • 2 RCT’s: • Kahn MA, et al (1999) Posterior colporraphy is superior to the transanal repair for treatment of posterior vaginal wall prolapse. Neurourol Urodyn 18: 70-71 • Nieminen K, et al (2003) Transanal or vaginal approach to rectocoele repair: results of a prospective randomised study. Neurourol Urodyn 22: 547-548

  14. Vaginal vs Transanal • Kahn MA, et al (1999) • 57 women • Transanal repair: 33 • Transvaginal: 24 • Mean follow up: 2 years • Repeat surgery required for recto-/enterocoele: • Transanal: 9/33 (30%) • Vaginal: 2/24 (13%) (p=0.1) • More significant improvement of point Ap in the vaginal group

  15. Vaginal vs Transanal • Nieminen K, et al (2003) • 30 women • 15 in each arm • 1 year follow up • Persistent post vaginal wall prolapse: • Transanal: 67% • Vaginal: 7% (p=0.01) • Symptom improvement: • Transanal: 73% • Vaginal: 93% (p=0.08) • More significant improvement of point Ap in the vaginal group

  16. Vaginal vs Transanal • Impaired evacuation: • Kahn / Nieminen: Symptoms improved in both groups in both studies • Dyspareunia: • Arnold M, et al (1990), Dis Colon Rectum: retrospective review: more dyspareunia after vaginal repair • Kahn: 1 de novo dyspareunia • Nieminen: improved sexual function in both groups

  17. Vaginal vs Transanal • CONCLUSION: The transvaginal approach to repair the posterior vaginal wall appears superior to the transanal approach.

  18. Methods of vaginal repair • Francis W, Jeffcoate T (1961) Dyspareunia following vaginal operations. J Obstet Gynaecol Br Commonw 68: 1-10 Described the traditional levator plication. • Milley P, Nichols D (1969) A correlative investigation of the human rectovaginal septum. Anat Rec 163: 443-452 Recommended plication of the rectovaginal fascia. • Richardson AC (1993) The rectovaginal septum revisited: its relationship to rectocoele and its importance in rectocoele repair. Clin Obstet Gynecol 36: 976-983 Advocated isolated repair of isolated defects.

  19. Levator Ani Plication

  20. Levator Ani Plication

  21. Discrete Fascial Repair

  22. Discrete Fascial Repair

  23. Midline Fascial Plication

  24. Midline Fascial Plication Rectocoele recurrence in 44% of the pts with site specific repair versus 18% following midline plication. (p= 0.001)

  25. Bridge technique

  26. Sand, AJOG 2001 Mesh augmentation

  27. Mesh augmentation • Sand P, AJOG 2001 • Vicryl overlay • 90% succes in both groups • Dwyer P, BJOG 2004 • 67 pts with Atrium Polypropylene • 100% succes • No mesh complications • Salvatore S, Neurourol Urodyn 2002 • 31 pts with Prolene mesh • 13 % erosions • Dyspareunia from 6 to 69%

  28. AJOG, Dec 2006

  29. Colporraphy Site specific repair Graft augmenation Paraiso, AJOG 2006

  30. Sacrocolpopexy to perineal body • Fox S, BJOG 2000 • Teflon 29 women • 14 mths FU • 93% success • Baessler K, Obstet Gynecol 2001 • Goretex in 31 pts • 26 mths FU • 57% recurrence of rectocoeles

  31. In conclusion: • Level II evidence shows that rectocoele repair, done with traditional plication methods, has cure rates of 80-90 %. • An RCT to demonstrate an improvement by placement of a prosthesis from this baseline to 90-95% would require 300-400 patients in each arm… Walters M, Int Urogyn J Pelvic Floor Dysfunct 2003

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