The Sacrospinous Vaginal Vault Suspension: Critical Analysis of Outcomes

One hundred and three women with a preoperative diagnosis of a pelvic support defect underwent right sacrospinous fixation of the vaginal apex. The procedure was performed either therapeutically (in 63 subjects with vaginal vault eversion) or prophylactically (40 patients with severe uterovaginal prolapse), and was associated with other reconstructive procedures to repair the coexisting cystocele, enterocele or rectocele. Preoperative and postoperative assessments of each vaginal site were compared and the results in the cure of stress urinary incontinence, if present, were evaluated with regard to the type of surgery performed. The overall rate of satisfactory results in the repair of the superior vaginal defect was 94%, and good anatomic results were achieved in the repair of either enterocele or rectocele. Conversely, the repair of the anterior vaginal wall was not as good as in the posterior and superior vaginal sites. Stress urinary incontinence was successfully managed in 72% of the women using different anti-incontinence procedures.     

Laparoscopic Surgery for Enterocele, Vaginal Apex Prolapse and Rectocele

Laparoscopy has been applied to all aspects of gynecologic surgery, but few investigators have reported the repair of vaginal apex prolapse, enterocele and rectocele via the laparoscopic route. This article reviews the indications, anatomy, operative technique, clinical results and complications of laparoscopic culdeplasty, enterocele repair, posterior repair, sacral colpopexy and vaginal vault–uterosacral ligament suspension.     

Anatomic and Functional Outcome of Vaginal Paravaginal Repair in the Correction of Anterior Vaginal Wall Prolapse

Over a 2-year period 45 patients with bilateral paravaginal support defects underwent vaginal paravaginal repair. Postoperative evaluations were conducted and anatomic outcome was determined by vaginal examination, with grading of vaginal wall support. Functional outcome was assessed by a standardized quality of life questionnaire, voiding dairy and standing stress test with a full bladder. Thirty-five patients had long-term follow-up with a mean of 1.6 years (range 1–85). The recurrence rates for displacement cystocele, enterocele and rectocele were 3% (1/35), 20% (7/35) and 14% (5/35), respectively. In no patients did vault prolapse develop or recur. Subjective or objective evidence of persistent stress urinary incontinence was found in 57% of patients (12/21). Vaginal paravaginal repair is a safe and effective technique for the surgical correction of anterior vaginal wall prolapse but has limited applicability in the surgical correction of genuine stress incontinence.     

Cystodefecoperitoneography in Patients with Genital Prolapse

The aim of the study was to prospectively evaluate pre- and postoperative findings of cystodefecoperitoneography (CDP) and to correlate the findings to the clinical examination in patients with genital prolapse. Twenty-five female patients were investigated both pre- and postoperatively with a standardized questionnaire, clinical examination and CDP, including contrast medium in the rectum, vagina, bladder, small bowel and peritoneal cavity. At preoperative clinical examination a rectocele was diagnosed in 24 patients, a cystocele in 7 and an enterocele in 2. At the preoperative CDP a rectocele was diagnosed in 21 patients, a cystocele in 22 patients and a peritoneocele in 9, of which six contained small bowel (i.e. an enterocele). Surgery was performed according to the clinical findings. At the postoperative clinical examination no rectocele was diagnosed, a cystocele was diagnosed in 3 patients and an enterocele in 1. Postoperative CDP showed a rectocele in 4 patients, a cystocele in 24 and a peritoneocele in 7 patients, of which three contained small bowel (i.e. an enterocele). CDP may complement the clinical assessment of patients with genital prolapse, in particular to confirm or detect defects involving the posterior compartment. The radiologic definition of cystocele needs further evaluation.     

Place du traitement chirurgical par « voie haute »

Indications for surgical repair of rectocele are symptomatic large rectocele, patient with obstructive defecation syndrome (i.e. incomplete evacuation and digital support during defecation), patient with a rectocele of a depth of > 3 cm, or barium paste remaining trapped in the cavity after evacuation. Rectocele often coexists with other pelvic organ prolapses, such as cystocele, vaginal vault prolapse and enterocele. For these reasons, surgical rectocele treatment is designed to reduce specific symptoms and requires a multidisciplinary approach. What constitutes the optimal surgical approach has been debated for some considerable time. Various surgical techniques with a transanal, transperineal, transvaginal or abdominal approach have been used for rectocele. No randomized trial has clearly established the best approach. A laparoscopic sacral colpopexy approach is effective for genito-urinary prolapse associated with rectocele. Furthermore, laparoscopic ventral recto(colpo)pexy is a innovative technique that avoids any posterolateral rectal mobilization, thus minimizing the risk of autonomic neural damage. The unique anterior placement of the mesh with reinforcement of the rectovaginal septum restores normal rectal evacuation. The abdominal approach seems the most suitable for rectocele in sexually active women because it is not associated with dyspareunia. Two surgical techniques may be proposed, either laparoscopic double sacral colpopexy using prosthetic materials, or laparoscopic ventral recto(colpo)pexy.     

The Anatomic and Functional Variability of Rectoceles in Women

Fluoroscopic parameters of the rectum in women with pelvic organ prolapse were studied. Ninety-eight consecutive women undergoing reconstructive pelvic surgery completed a urogynecologic history with physical examination and pelvic floor fluoroscopy. The presence of rectocele and contrast trapping was determined on each fluoroscopic study. Each frame of the study was measured to determine the rectal width. Seventy-eight per cent of the women had fluoroscopically demonstrated rectoceles. Their maximum and minimum rectal widths were larger than those of women without rectoceles. Contrast-retaining rectoceles were larger than non-contrast retaining rectoceles. Fluoroscopic evidence of contrast retention did not relate to patient symptoms. There was no difference in the grade of posterior wall prolapse in women with and without rectoceles. Rectoceles have anatomic and functional variability. Fluoroscopy may be a valuable adjunct to the physical examination in assisting gynecologic surgeons to refine their surgical approach for rectocele repair.     

The surgical anatomy of rectocele and anterior rectal wall intussusception

The aim of the study was to analyse the dynamic anatomical supports of the posterior vaginal wall from the perspective of rectocele and rectal intussusception repair. Two groups of patients were studied. Group 1 (n = 24) with genuine stress incontinence but no major vault prolapse had vagino/proctomyograms and transperineal ultrasound examinations. Group 2 with vaginal vault prolapse, clinical rectoceles and obstructive defecation symptoms (n = 19 had single-contrast defecating proctography before and after posterior-sling surgery. The posterior vaginal wall is suspended between perineal body, which underlies half its length, and uterosacral ligaments, which also support the anterior wall of rectum. Muscle forces stretch the vagina and rectum against the perineal body and uterosacral ligaments, creating shape and strength, like a suspension bridge. Postoperative proctogram studies indicated that anterior rectal wall intussusception has the same etiology as rectocele, deficient recto-vaginal ligamentous support. Repair to uterosacral ligaments and perineal body should be considered with large rectoceles, anterior rectal wall intussusception and obstructive defecation disorders.     

Rectocele in children: a case report

Rectocele is an abnormal protrusion of the anterior wall of the rectum into the vagina. When symptomatic, it will typically cause obstructed defecation. It is almost exclusively found in females with rare reports in males and never been described in the literature in children younger than 18 years of age so far. We are presenting 3 cases of rectocele with obstructed defecation in the pediatric population. These children presented with the complaints of constipation along with refractory straining. They were diagnosed by defecography. Two were treated surgically and one conservatively. Surgical intervention completely cured the problem with uneventful postoperative course. Further multicenter studies with the aid of radiologic studies on children with “hard to treat” constipation should be considered to better define that disorder in the pediatric age group. A more vigilant approach may have implications in the prevention of more severe rectal and uterovaginal prolapse in the future.     

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??Solitary rectal prolapse and concomitant genital prolapse: Classification and new surgical therapy Antonio Longo. Department of Coloproctology and Pelvic Diseases, Via Maqueda. 8, 90134 Palermo, Italy
Abstract Constipation is a pathology in which there are many confusing definitions. The ITT (Intestinal Transit Time) is not an absolute and constant value, highly variable, even in the same person. It is often a consequence of obstructed defecation syndrome (ODS) and not a primary cause of constipation. Patients with pelvic dyssynergia (PD) increase the abdominal strain, in an attempt to increase the endopelvic pressure to create the defecation stimulus. It would lead to dynamic to anatomical alterations as following: perineum hyperdescending, the Douglas pouch deepening or an enterocele occurrence, the rectum and bladder dilating towards the vagina, uterine and vaginal prolapse, etc. With the stapled transanal rectal resection (STARR) technique, pre and postoperative dynamic defecography show the regression of such alterations.     

Female Pelvic Organ Prolapse and Voiding Function

It is accepted that pelvic organ prolapse impairs voiding, in particular as regards the anterior vaginal wall. The influence of central and posterior prolapse is more controversial. Mechanical effects, i.e. urethral distortion and compression, have been advanced as causative mechanisms. This study attempts to further elucidate the effect of prolapse on voiding. We investigated 228 patients with symptoms of lower urinary tract dysfunction and/or prolapse using independent flowmetry, clinical and ICS prolapse assessment and translabial ultrasound. As expected, age (P<0.001), previous hysterectomy (P= 0.002) and/or incontinence surgery (P<0.001) negatively influenced flow. As regards prolapse, only enterocele had a consistently negative effect on flow (P<0.001 for clinical staging, P= 0.002 for ICS assessment, P= 0.005 for ultrasound imaging). The relationship between anterior vaginal wall prolapse and voiding was complex: funneling and opening of the retrovesical angle on ultrasound was associated with improved voiding (P<0.001), but a cystocele with intact retrovesical angle had the opposite effect (P<0.001).     

Prospective clinical and functional results of combined rectal and urogynecologic surgery in complex pelvic floor disorders

Background

The aim of this prospective study was to evaluate the results of combined rectal and urogynecologic surgery in women with associated obstructed defecation, urinary incontinence, or genital prolapse.

Methods

One hundred forty-two selected patients with obstructed defecation in isolation or associated with urinary incontinence, enterocele, or genital prolapse were consecutively operated on by stapled transanal rectal resection alone or associated with transobturator tape, vaginal repair of the enterocele, or vaginal hysterectomy, respectively, and followed up by clinical controls and defecography.

Results

At 2 years, all symptom, quality-of-life, and defecographic parameters had significantly improved in all groups (P < .001). The association with hysterectomy showed higher risk for severe complications, longer operative time, hospital stay, and time of inability (P < .001). Recurrence of urinary incontinence was observed in 3 of 24 patients, while 2 of 21 showed residual vaginal prolapse.

Conclusion

The combination of rectal and urogynecologic surgery is effective, with higher morbidity in the association with vaginal hysterectomy. Randomized trials comparing surgery in 1 and more stages and longer follow-up are necessary for a definitive conclusion.     

Correlation between posterior vaginal wall defects assessed by clinical examination and by defecography

To estimate the accuracy of clinical examination and the indications for defecography in patients with primary posterior wall prolapse. Fifty-nine patients with primary pelvic organ prolapse were evaluated with a questionnaire, clinical examination and defecography. Defecography was used as reference standard. There was no relation between bowel complaints and posterior wall prolapse evaluated by clinical examination (p = 0.33), nor between bowel complaints and rectocele (p = 0.19) or enterocele (p = 0.99) assessed by defecography. The diagnostic accuracy of clinical examination in diagnosing rectocele was 0.42, sensitivity was 1.0 and specificity was 0.23. The diagnostic accuracy of clinical examination in diagnosing enterocele was 0.73, with a sensitivity of 0.07 and a specificity of 0.95. Clinical examination is not accurate to assess anatomic defects of the posterior vaginal wall. Defecography is recommended as a helpful diagnostic tool in the work-up of patients with posterior vaginal wall prolapse if surgical repair is considered.     

Levatorplasty Release and Reconstruction of Rectovaginal Septum using Allogenic Dermal Graft

The goal of reconstructive vaginal surgery include: restoration of normal anatomy, as well as maintaining visceral and sexual function. Rectocele repair can be performed utilizing a number of techniques, however some of these techniques severely distort the posterior vaginal wall anatomy and subsequently may result in dyspareunia. We report two patients with postoperative dyspareunia following levatorplasty technique for the treatment of rectocele. The patients elected to have their levatorplasty released and their rectovaginal septum reconstructed utilizing allogenic dermal graft. Postoperatively both patients are sexually active without evidence of dyspareunia or rectocele.     

Rectal Prolapse

Case Report

A 56-year-old male presented to the emergency department with a feeling of heaviness and a protruding mass at the anal verge associated with pruritus in this area. The patient did not feel any pain and did not report experiencing faecal incontinence. Physical examination resulted in the visual diagnosis of a total rectal prolapse. Immediate manual repositioning through gentle pressure succeeded and the patient was scheduled for an elective laparoscopic ventral rectopexy.

Discussion

Total rectal prolapse, or full-thickness rectal prolapse (procidentia), is defined as protrusion of the rectum beyond the anus. The entire rectal wall can be palpated in the externalized tissue exhibiting circular plication. Thus, a less distinct rectal prolapse can be distinguished visually from an anal mucosal prolapse as the latter shows stellate plication. Symptomatic patients having difficulties in reduction, substantial incontinence or obstructed defecation are to be referred for consideration of surgery.     

PPH技术在出口梗阻性排便障碍中的应用(附60例分析)

目的：探讨PPH技术治疗出口梗阻性排便障碍的手术方法及疗效。方法：回顾分析了60例出口梗阻性排便障碍病例，其中直肠黏膜脱垂患者45例，直肠前突患者5例，直肠黏膜脱垂 直肠前突患者10例，均行PPH手术。结果：58例一次PPH术后症状明显缓解，治愈率96．7％。结论：PPH技术对于治疗出口梗阻性排便障碍具有明显疗效。     

Incontinence and voiding difficulties associated with prolapse

Purpose

Prolapse is the protrusion of a pelvic organ beyond its normal anatomical confines. It represents the failure of fibromuscular supports.

Materials and Methods

A MEDLINE search was done using the keywords cystocele, uterine prolapse, vault prolapse, enterocele or rectocele in combination with urinary incontinence. We reviewed 97 articles. From this material the definition, classification, incidence, symptoms and evaluation are described.

Results

Prolapse and urinary incontinence often occur concomitantly and cystocele, rectocele, enterocele, uterine descent or vaginal vault prolapse may also be present. The pathophysiology of prolapse encompasses direct and indirect injury, metabolic abnormalities and chronic high intra-abdominal pressure. Anterior vaginal wall prolapse may present as stress incontinence. A large cystocele may cause urethral kinking and overflow incontinence. Uterine descent can cause lower back and sacral pain. Enterocele may cause only vague symptoms of vaginal discomfort. A rectocele can lead to incomplete evacuation of stool. A thorough history and physical examination are the most important means of assessment. A voiding diary helps determine functional bladder capacity. Uroflow examination determines the average and maximum flow rates, and the shape of the curve can help identify Valsalva augmented voiding. Multichannel urodynamics or videourodynamics with prolapse reduced can be important. The advantages of dynamic magnetic resonance imaging include excellent depiction of the soft tissues and pelvic organs, and their fluid content during various degrees of pelvic strain. To our knowledge whether it is cost-effective in this manner has not been determined.

Conclusions

Correction of prolapse must aim to restore vaginal function and any concomitant urinary incontinence.     

Urogenitals prolapse: revision of concepts

The prolapse is the exteriorization of the pelvic organs through the vagina, this condition may affect the quality of life. The prolapse was diagnosed in 50% of multiparous women. It is estimated that a woman throughout her life, has 11% risk of needing surgery for correction of pelvic organ prolapse or urinary incontinence. The prolapse may occur at the anterior vaginal wall (cystocele) at the vaginal, uterus (histerocele) or at the posterior wall (or rectocele enterocele). For the unfit patient obliteratives procedures may be indicated and recontructives for pacients wih good performance status. It is important for reconstructive surgery a correct diagnosis, for the specific defect repair. When indicated, meshes can be used to add strength to the poor quality tissues.     

On the pathogenesis of rectocele: the concept of the rectovaginal pressure gradient

Coughing or straining evokes reflex bulbocavernosus (BCM) and puborectalis (PRM) muscle contraction, which apparently transforms the vagina into a closed high-pressure cavity [13]. This elevated vaginal pressure counteracts the increased intra-abdominal pressure and the tendency of the uterus to prolapse, and also supports the rectovaginal septum against the high straining-induced intrarectal pressure and possible consequent rectocele (posterior vaginal prolapse) formation. We investigated the hypothesis that a weak BCM and PRM share in the genesis of rectocele by changing the rectovaginal pressure gradient. Twenty-three women with rectocele (mean age 43.2±6.6 years) and 12 healthy women volunteers (mean age 41.6±6.2 years) were studied. The response of the intrarectal (intra-abdominal) and intravaginal pressure, as well as the EMG activity of the BCM and PRM to straining or coughing, was recorded. In the healthy volunteers the rectal and vaginal pressures showed a significant increase on coughing or straining, with no significant difference between the rectal or vaginal pressures. Also, the BCM and PRM EMG activity exhibited a significant increase. Rectocele patients showed a significantly low resting vaginal pressure. The increase in rectal and vaginal pressure, as well as of the EMG activity of the BCM and PRM on straining or coughing, was significantly lower and the latency of the EMG response was significantly longer than those of the healthy volunteers. A difference in the rectovaginal pressure gradient showing a significant increase in the rectal against the vaginal pressure, particularly on coughing or straining, is suggested to be the basic factor in the genesis of rectocele. This pressure difference appears to be caused by diminished BCM and PRM contractile activity. A disrupted rectovaginal septum is not a prerequisite for rectocele formation, as the septum appears normal in obstructed defecation despite the common occurrence of rectocele. A histopathologic study of the septum in rectocele seems necessary.Abbreviations BCM Bulbocavernosus muscle - PRM Puborectalis muscle - EMG Electromyogram Editorial Comment: The investigation demonstrated decreased EMG activity and vaginal pressure in the women with rectoceles, especially during increased intra-abdominal pressure, compared to normal controls. Based on these data, the authors theorize that the decreased vaginal pressure results from poor tone and blunted reflex contraction of the BCM and PRMS during increases in intra-abdominal pressure, which in normal women closes the vaginal hiatus causing an equilibration of increased intra-abdominal pressure on the rectal and vaginal sides of the rectovaginal septum. This is a novel theory for the pathogenesis of rectocele and is supported by these preliminary data. The fact that the subjects had a stool frequency of less than twice weekly is more consistent with defecatory dysfunction secondary to a motility disorder rather than outlet obstruction. This raises the question of whether the rectocele is a result of the defecatory dysfunction rather than causative, and affects the external validity of the study population. Additionally, the theory fails to explain the association of paradox with rectocele. Nevertheless, this theory merits further investigation as one of several potential etiologies of rectocele.     

Selection criteria for surgery in patients with obstructed defecation, rectocele and anorectal prolapse

The aim of this study was to evaluate the impact of applying strict selection criteria to patients with symptoms of obstructed defecation, rectocele and rectal prolapse who were candidates for surgery. From June 2001 to September 2003, 20 patients underwent surgery in our clinic for symptomatic rectocele and anorectal prolapse. They were evaluated prospectively using a dedicated questionnaire (KESS), a proctological and gynaecological examination, colpo-cysto-defecography and anorectal manometry before surgery and 6 months postoperatively. Strict selection criteria were used for surgery. After 6 months the questionnaire showed an important improvement in symptoms. The symptoms of obstructed defecation and vaginal bulging improved significantly. The average KESS score dropped from 17.65 preoperatively to 5.8 six months after surgery. In the treatment of pelvic floor disease, it is important to evaluate both the uro-gynaecological and the proctological symptoms with the utmost care, obtaining an accurate clinical picture with the aid of dedicated questionnaires and a thorough clinical examination. Evaluation of the effectiveness of surgery for constipation necessarily includes assessing the strength of the indications for surgery, irrespective of the surgical technique adopted, but there is currently no standardised test method for recording and comparing the symptoms of constipation.