The data of all 304 patients who underwent LVR for symptomatic pelvic floor anatomical abnormalities (including rectocele and/or RI or ERP) and all 49 patients who underwent TAR for symptomatic rectocele between February 2012 and December 2022 were prospectively entered into a pelvic floor database. Of these, the data of patients with rectocele ≥ 2 cm in size were extracted. Consequently, 46 patients who underwent LVR and 45 patients who received TAR were retrospectively analyzed (Fig. 1).
Table 1 shows the indications for rectocele surgery. LVR was primarily indicated for patients with rectocele along with ERP, enterocele, or RI that was accompanied with FI symptoms [14]. TAR was indicated for patients with rectocele alone or rectocele with RI. Patients with rectoceles associated with other pelvic floor disorders were not indicated for TAR [8]. Rectocele was considered symptomatic when the patient had at least one OD symptom (i.e., straining, incomplete evacuation, sensation of anorectal obstruction, digitation at least once a week, and repeated visits to the toilet) or a sensation of a vaginal bulge or mass, or mucus discharge, or post-evacuation FI. Furthermore, the diagnosis of rectocele was confirmed using evacuation proctography.
Bowel function was evaluated using two different scores: Constipation Scoring System (CSS) [15] and FI Severity Index (FISI) [16]. A colonic transit study was not routinely performed. The indications for surgery were rectocele at the time of proctography with symptoms of OD and/or FI, or vaginal bulge and failed standard conservative management, including dietary advice, education on defecation habits, and medication. Biofeedback treatment was not provided to patients, because of the lack of well-trained physiotherapists in the clinic.
Surgical Technique
The surgical procedure of LVR was performed as described by D’Hoore and Penninckx [9]. In this procedure, the dissection was conducted exclusively anterior to the rectum, preserving the lateral ligaments. The rectovaginal septum was carefully dissected down to the pelvic floor, with a distal extent usually 2–3 cm from the anal verge, as confirmed by digital rectal examination. This dissection spares the hypogastric and parasympathetic nerves in the lateral ligaments and avoids mobilization of the mesorectum. Next, a strip of polypropylene mesh (3 × 18 cm) was introduced and positioned as distally as possible on the anterior side of the rectum. The mesh was sutured on the rectal wall with six interrupted non-absorbable sutures (2 − 0 Ticron; Covidien Ltd., Tokyo, Japan). The posterior wall of the vagina was fixed to the mesh using two additional sutures of the same type. A modified technique for introducing the mesh was used, wherein the perineal operator passed a nylon thread using a straight needle through the posterior wall of the vagina at the distal extent of the dissection [17]. The thread was caught in the abdominal cavity, extracted from one of the trocars, and fixed extracorporeally at the end of the mesh. The mesh was then introduced and pulled towards the pelvic floor using a nylon thread. This technique allowed the mesh to be secured at the distal dissection, which might reinforce almost the total extent of the rectovaginal septum and eliminate the rectocele. Thereafter, the mesh was attached to the rectum and vagina, as described above, and secured tension-free to the sacral promontory using a ProTack device (Autosuture; Tyco Healthcare, Mansfield, MA, USA). The mesh was peritonealized by suturing the free edge of the previously divided peritoneum over the mesh to avoid small-bowel adhesions. The nylon thread was cut transvaginally at the end of the surgery.
TAR of rectocele was performed in a uniform manner using a self-retained anal retractor, with the patient in the prone jackknife position under spinal anesthesia. The apex of the repair was determined by manual palpation and was marked with diathermy. The submucosal plane was infiltrated with 1:200,000 epinephrine solution. Mucosectomy was performed using diathermy with a 7–8 cm elliptical incision made from 1 cm above the dentate line up to the anterior rectal wall. Vertical plication of the muscle wall using interrupted absorbable sutures was then performed. Finally, the mucosa was repaired with the same sutures.
Evacuation Proctography
A standardized proctography technique was used. The proctograms were evaluated using the criteria proposed by Shorvon et al. [18]. Briefly, rectoceles ≥ 2 cm in diameter were considered abnormal. The size was calculated in a standard procedure in the anteriorposterior dimension by measuring the distance between the most ventral part of the anterior rectal wall and an extrapolated line indicating the expected position of the rectal wall [19]. ERP was diagnosed if the full-thickness of the rectum protruded through the anal orifice. Based on the images taken during maximal straining defecation, rectoanal intussusception (RAI) was diagnosed when the apex of the RI impinged on the internal anal orifice or was intra-anal. In contrast to RAI, rectorectal intussusception (RRI) was diagnosed if the apex remained intrarectal and did not impinge on the internal anal orifice. Enterocele was diagnosed when the extension of the bowel loop was located between the vagina and rectum. The proctograms were analyzed by one of the authors (T. T.) who was experienced in this evaluation and blinded to the symptomatology of the individual patients.
Physiological Assessment
The procedure used for anorectal manometry and rectal sensation was described previously [8]. Anal pressure was measured using a catheter-tip pressure transducer. The capacity of the rectum was measured by balloon distension with reporting volumes for defecatory desire volume and maximum tolerated volume.
Follow-up
The patients were followed -up at 6 and 12 months, and then annually. The CSS and FISI scores were obtained at each follow-up visit. The questionnaires were delivered to the patients by a nurse and self-recorded in the outpatient clinic. Patients who did not visit the clinic for the follow-up examination were asked to report their CSS and FISI scores by phone and return the questionnaires by mail. Anorectal physiology was repeated at 6 and 12 months postoperatively. The patients underwent proctography at 6 months postoperatively as standard care.
Statistical analysis
Quantitative data are expressed as median and range. Analysis was performed using the Mann–Whitney U test for unpaired data and Wilcoxon signed-rank test for paired data (two-sided P test). The chi-square or Kruskal–Wallis test was used for categorical variables. Substantial improvement in functional outcome was defined as at least a 50% reduction in the CSS or FISI scores. Data were analyzed using the software package SPSS™ v26 for Windows (IBM Corp., Armonk, NY, USA). A P-value of < 0.05 was considered statistically significant.