Pelvic Floor Disorders: Surgical Approach

18. Transperineal Rectocele Correction

Giovanni Milito , Federica Cadeddu and Giorgio Lisi

(1)

Department of Experimental Medicine and Surgery, Tor Vergata University, Rome, Italy

Giovanni Milito

Email: giovanni.milito@virgilio.it

Abstract

A rectocele is a herniation of the rectum through the rectovaginal fascia and posterior vaginal wall causing a protrusion into the vaginal lumen. It is a common disorder in women with a history of multiple vaginal deliveries, and it is asymptomatic in 80% of cases [1]. Symptomatic rectocele is less common, usually affects postmenopausal females, and results in obstructed defecation and constipation (Table 18.1) [23].

18.1 Introduction

A rectocele is a herniation of the rectum through the rectovaginal fascia and posterior vaginal wall causing a protrusion into the vaginal lumen. It is a common disorder in women with a history of multiple vaginal deliveries, and it is asymptomatic in 80% of cases [1]. Symptomatic rectocele is less common, usually affects postmenopausal females, and results in obstructed defecation and constipation (Table 18.1) [23].

Table 18.1

Symptoms associated with rectocele

Symptom

Prevalence (%)

Obstructed defecation

75–100

Manual assistance of defecation

20–75

Rectal pain

12–70

Rectal bleeding

20–60

Incontinence

10–30

Rectocele can be classified according to its position: low, middle, or high; and/or their size: small (< 2 cm), medium (2–4 cm), or large (4 cm). Size is measured anteriorly from a line drawn upward from the anterior wall of the anal canal on proctography [4]. It can also be classified into three clinical stages at straining during defecation proctography (Table 18.2).

Table 18.2

Classification of rectocele

I

Digitiform rectocele of single hernia through the rectovaginal septum

II

Big sacculation, lax rectovaginal septum, anterior rectal mucosal prolapse, deep pouch of Douglas

III

Rectocele associated with intussusception and/or prolapse of the rectum

Surgery should be considered when conservative therapy fails and careful patient selection, based on an accurate morphofunctional assessment, is crucial to obtain a satisfactory outcome [5].

The purposes of surgical repair in the management of rectocele repair are essentially the restoration of normal vaginal anatomy and the restoration or maintenance of normal bladder, bowel, and sexual function.

Transperineal repair of the fascial defect may provide restoration of normal anatomy and symptomatic relief. A variety of synthetic and nonsynthetic graft materials have been used in rectocele repair to enhance anatomical and fuctional results, and improve long-term outcomes. Symptomatic rectocele results in obstructed defecation and constipation. Surgical repair may provide symptomatic relief.

Recent advances in pelvic reconstructive surgery are due, in part, to the availability of new graft materials that allow reinforcement and repair of large pelvic fascial defects, minimizing adverse graft-related effects and postoperative complications [6].

18.2 Pretreatment Evaluation

Although rectoanal intussusception may be observed during physical examination, it is much more likely to be detected during defecography, which remains the most useful diagnostic tool when applied to a symptomatic subject. Defecography is crucial to document the presence of anatomical changes stemming from the symptoms of obstructed defecation. In particular, it is fundamental in order to distinguish between rectoanal intussusceptions and rectal internal mucosal prolapse, and to describe and quantify rectoanal intussusception. It also reveals the presence of other abnormalities, such as the presence of a rectocele or weakened pelvic floor with perineal descent, or failure of the puborectalis to relax during straining and evacuation, which is often associated with pelvic perineal dyssynergia. Rectoanal intussusception, as reported in the literature, appears to be the main reason for obstructed defecation. Defecography seems to be the examination of choice because it allows assessment of not only the rectum, but also the rectovaginal space and vagina in order to investigate the presence of an associated enterocele, or failure of the medium and/or anterior compartment.

However, it should be noted that a transient infolding of the rectal wall can occur during evacuation, even in asymptomatic subjects. In more complex cases in which all pelvic compartments are involved, the introduction of dynamic magnetic resonance imaging has opened up the possibility of better understanding the relationships between the pelvic floor organs and the structures involved. Pelviperineal neurophysiological tests (electromyographic recording of the anal sphincter) and anorectal manometry are also useful, particularly for the evaluation of sphincter tone. Anorectal manometry is very important and it can detect pelviperineal dyssynergia; it provides the basic diagnostic criteria for deciding to carry out pelviperineal rehabilitation.

18.3 Management and Contraindications

Specific selection criteria for the surgical repair of a rectocele are the subject of debate. Surgical repair has been recommended when the rectocele is greater than 3 cm in depth, if there is significant barium trapping or defecography, or if digital assistance of defecation is frequently necessary for satisfactory emptying [89]. However, multiple studies have shown no correlation between the size of a rectocele or the extent of barium trapping and the degree of symptoms or outcome of rectocele repair [1011]. Some authors [5, 6, 12] have shown that the main causes of functional failure after classical rectocele repair are:

1.

2.

3.

Therefore it is mandatory that rectocele correction via the transperineal approach must be used only in simple type 1 rectocele, otherwise it would be impossible to correct a rectal intussusception or rectal prolapse by repairing only the fascial defect and normal anatomy would not be restored.

18.4 Surgical Treatment

Anatomofuctional abnormalities can be independent of clinical symptoms, and their surgical treatment must be considered carefully. The risk following careful morphological and physiological investigation is overestimation of the disturbance, and overindication for treatment. Stool softeners, laxatives, and behavioral measures help some patients, but often do not offer satisfactory long-term results. However, the most severely symptomatic patients may be candidates for surgery.

The aims of surgical repair in the management of rectocele repair are essentially: the restoration of normal vaginal anatomy, and the restoration or maintenance of normal bladder and sexual function. Formerly, colorectal surgeons used traditional methods to repair rectoceles per anus by mucosal resection and anterior rectal wall plication. Gynecologists adopted a vaginal approach, excising part of the posterior vaginal wall combined with an anterior levatorplasty [13].

There are significant drawbacks to both techniques. Transanal repair has been shown to significantly reduce both resting and squeeze pressures postoperatively, despite minimizing the amount of anal retraction [14], and it results in a higher rate of enterocele recurrence compared with posterior vaginal wall repair. Conversely, posterior vaginal wall repair may result in dyspareunia and higher postoperative analgesic requirement, and it might not eliminate the symptom of incomplete evacuation [15]. Richardson [16] recognized that repair of the fascial defect is more important than imbricating the vaginal or rectal walls and was the first to describe repair via a posterior vaginal wall incision and apposition of edges of the defect with interrupted sutures. Consequently, augmentation of transvaginal repair with mesh interposition has been advocated [121718].

18.4.1 Technique

A transverse perineal incision is made (Fig. 18.1). The plane between the external anal sphincter and the posterior vaginal wall is developed with diathermy to ensure meticulous hemostasis. The dissection is extended to the vaginal apex to expose the rectocele, the perirectal fascia, and the levator arc (Fig. 18.2).

A978-88-470-5441-7_18_Fig1_HTML.jpg

Fig. 18.1

Transverse perineal incision

A978-88-470-5441-7_18_Fig2_HTML.jpg

Fig. 18.2

The plane between the rectum and the posterior vaginal wall is dissected to the vaginal apex, the perineal fascia, and the median margins of the elevator plates

The plane between the rectum and the posterior vaginal wall is dissected until the vaginal apex, the perineal fascia and the median margins of the elevator plates.

Previously, following the site-specific repair, four to five absorbable sutures were placed in the levator arc, beginning near the vaginal apex and continuing distally toward the perineal body, and a vaginal pack was placed in situ. Today, it has been demonstrated that in using this technique, suture points and a vaginal pack are not required [4619].

The biomesh is affixed to the sutures and laid in place in the rectovaginal space (Fig. 18.3).

A978-88-470-5441-7_18_Fig3_HTML.jpg

Fig. 18.3

Transperineal rectocele repair with biomesh. The mesh is placed in the rectovaginal space and fixed with interrupted sutures to the levator ani plate on both sides

Using the same type of sutures, the graft is sutured to the levator arc on the opposite side, followed by closure of perineal incision (Fig. 18.4). A urinary catheter is positioned for the first 24 hours.

A978-88-470-5441-7_18_Fig4_HTML.jpg

Fig. 18.4

Four to five absorbable sutures are placed in levator plate laterally on each side, beginning near the vaginal apex and continuing distally toward the perineal body

A978-88-470-5441-7_18_Fig5_HTML.jpg

Fig. 18.5

A vaginal pack and urinary catheter are put in place for the first 24 h

Prophylactic antibiotics and antimicrobial irrigation solution are used to decrease the risk of postoperative infection. Patients receive metronidazole 500 mg intravenously three times daily at the beginning of the operation and for 5 days after surgery [6].

18.4.2 Comments

The goals of surgery in the management of rectocele are the restoration of normal anatomy and the restitution or maintenance of normal bowel and sexual function [1320].

Three different approaches have been reported for rectocele repair: (1) the transanal approach, which consists of mucosal resection and anterior rectal wall plication; (2) the transvaginal approach, which includes excision of part of the posterior vaginal wall and anterior levatorplasty; and (3) the transperineal approach, which consists of extraluminal anterior access to the rectocele, and biomesh placement in the rectovaginal space [6821].

Both transanal and transvaginal repairs have shown several limitations: resting and squeeze pressure reduction after transanal repair, and dyspareunia and obstructed defecation persistence after transvaginal repair [21]. Rectovaginal septum reinforcement using biomesh via the transperineal approach has shown a good functional outcome (Table 18.3).

Table 18.3

Reported patient series that have used the transperineal approach

Study [Reference]

No. Pts.

Follow-up

Cure rate

Complications %

Kohli et al. (2003) [18]

43

12

100

-

Leventoglu et al. (2007) [22]

84

14

100

8.4

De Tayrac et al. (2007) [23]

143

13

96.5

6.8

Smart et al. (2007) [5]

10

-

91

7

Milito et al. (2010) [6]

10

24

100

1 urinary infection

Although only a few clinical studies of transperineal rectocele repair with biomesh have been reported, a review of the literature shows that good results have been reported by all the authors.

18.5 Summary

In summary, transperineal rectocele repair with biomesh appears to be an effective and safe procedure that avoids complications associated with synthetic mesh, as it avoids using rectal sutures and preserves both the rectum and the vagina [24].

Using biomesh seems especially helpful in the perineal repairs that are at high risk of wound contamination, with the possibility of chronic infection and fistulation [1925].

References

1.

Dietz HP, Steensma AB (2006) The role of childbirth in the aetiology of rectocele. BJOG 113:264–267PubMedCrossRef

2.

Dietz HP, Lanzarone V (2005) Levator trauma after vaginal delivery. Obstet Gynecol 18:707–712CrossRef

3.

Ellis CN (2005) Treatment of obstructed defecation. Clin Colon Rectal Surg 18:85–95PubMedCrossRef

4.

Jorge JM, Wexner SD (1993) Etiology and management of fecal incontinence. Dis Colon Rectum 36:77–97PubMedCrossRef

5.

Smart NJ, Mercer-Jones MA (2007) Functional outcome after transperineal rectocele repair with porcine dermal collagen implant. Dis Colon Rectum 50:1–6

6.

Milito G, Cadeddu F, Large M et al (2010) Transperineal rectocele repair with porcine dermal collagen implant. A two-years clinical experience. Pelviperineology 29:76–78

7.

Givel JC, Mortensen N, Roche B (eds) (2010) Anorectal and colonic diseases: a practical guide to their management. Springer, Berlin

8.

Murthy VK, Orkin BA, Smith LE, Glassman LM (1996) Excellent outcome using selective criteria for rectocele repair. Dis Colon Rectum 39:374–378PubMedCrossRef

9.

Karlborm U, Graf W, Nilsson S, Pahlman L (1996) Does surgical repair of a rectocele improve rectal emptyng? Dis Colon Rectum 39:1296–1302CrossRef

10.

Haligan S, Bartram CI (1995) Is barium trapping in rectoceles significant? Dis Colon Rectum 38:764–768CrossRef

11.

Dam J H van, Ginai AZ, Gosselink MJ et al (1997) Role of defecography in predicting clinical outcome of rectocele repair. Dis Colon Rectum 40:201–207PubMedCrossRef

12.

D’Hoore A, Vanbeckevoort D, Penninckx F (2008) Clinical, physiological and radiological assessment of rectovaginal septum reinforcement with mesh for complex rectocele. Br J Surg 10:1264–1272CrossRef

13.

Maher C, Baessler K, Glazener CM et al (2004) Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev 4:CD00401414.

14.

Ho YH, Ang M, Nyam D et al (1997) Transanal approach to rectocele repair may compromise anal sphincter pressures. Dis Colon Rectum 41:354–358CrossRef

15.

Kahn MA, Stanton S (1997) Posterio colporrhanphy: its effects on bowel and sexual function. Br J Obset Gynaecol 104:82–86CrossRef

16.

Richardson AC (1993) The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol 36:976–983PubMedCrossRef

17.

Dell JR, O’Kelley KR (2005) Pelvisoft BioMesh augmentation of rectocele repair: the initial clinical experience in 35 patients. Int Urogynecol J Pelvic Floor Dysfunct 16:44–47PubMedCrossRef

18.

Kohli N, Miklos J (2003) Dermal graft — augmented rectocele repair. Int Uregynecol Pelvic Floor Dysfunct 14:146–149CrossRef

19.

Milito G, Cadeddu F, Grande M et al (2009) Advances in treatment of obstructed defecation: Biomesh transperineal repair. Dis Colon Rectum 52:2051PubMedCrossRef

20.

Brandt LJ, Prather CM, Quigley EM et al (2005) Systematic review on the management of chronic constipation in North America. Am J Gastroenterol 1:S5–S21CrossRef

21.

Pescatori M, Milito G, Fiorito M, Cadeddu F (2009) Complications and reinterventions after surgery for obstructed defecation. Int J Colorectal Dis 24:951–959PubMedCrossRef

22.

Leventoglu S, Mentes BB, Akin M et al (2007) Transperineal rectocele repair with polyglycolic acid mesh: a case series. Dis Colon Rectum 50:2085–2092PubMedCrossRef

23.

De Tayrac R, Devoldere G, Renaudie J et al (2007) Prolapse repair by vaginal route using a new protected low-weight polypropylene mesh: 1-year fuctional and anatomical outcome in a prospective multicenter study. Int Urogynecol J Pelvic Florr Dysfunct 18:251–256CrossRef

24.

Hanson JM, Aspin B, Spalding LJ, Varma JS (2004) Transperineal repair of rectocele using porcine collagen. Colorectal Dis 6:36

25.

Altman D, Zatterstrom J, Mellgren A et al (2006) A three-year prospective assessment of rectocele repair using porcine xenograft. Obset Gynecol 107:59–65CrossRef