Comparative Evaluation of Methods for Restoration of the Rectovaginal Septum and Perineal Body in the Treatment of Rectocele

Исследование посвящено сравнительному анализу методов восстановления ректовагинальной перегородки и тела промежности при лечении ректоцеле. Проблема тазового пролапса затрагивает значительный контингент пациентов и требует разработки эффективных хирургических подходов, обеспечивающих не только анатомическое, но и функциональное восстановление. В работе проведён проспективный сравнительный анализ традиционной трансвагинальной леваторопластики и аллопластики ректовагинальной перегородки с использованием проленовой сетки, оценены анатомические и функциональные результаты оперативного лечения, включая влияние на дефекацию и сексуальную функцию.

Pelvic organ prolapse, owing to the multifactorial nature of defects in the supporting structures, is a widely prevalent condition that is difficult to treat. Operations for pelvic prolapse account for 10–20% of all major gynecological interventions [1,2,4,5,8,10]. At the same time, one quarter of patients undergo repeated interventions due to recurrences [3,6,7,9,11,12,13]. Rectocele is a form of pelvic prolapse involving the posterior vaginal wall and the anterior wall of the rectum.

In the past, surgical treatment of rectocele was directed primarily at eliminating the prolapse of the posterior vaginal wall. Due to an insufficient understanding of the relationship between anatomical support and the function of pelvic organs, functional outcomes were not examined in detail [16]. With the growth of the elderly population and the increase in their activity level, the measure of surgical efficacy has expanded from exclusively anatomical restoration to the improvement of visceral and sexual functions and the related quality of life [15].

The traditional method of rectocele correction is restoration of the rectovaginal septum via levatorplasty through various approaches. The operation yields a good anatomical effect [18]. However, defecation difficulty associated with rectocele may persist or even worsen regardless of the presence or absence of recurrence [17].

One possible cause of unfavorable functional outcomes may be a concomitant puborectalis muscle syndrome, in which excessive contractility of these muscles impedes the straightening of the anorectal angle during defecation, thereby making it difficult [20]. In such cases, anterior levatorplasty aggravates functional obstruction of the rectum and may lead to unfavorable long-term outcomes with regard to defecation quality.

Hence arises the necessity of searching for a method of rectovaginal septum restoration without tensioning the puborectalis muscles. Several methods have been proposed to achieve this goal — the use of porcine collagen mesh, synthetic mesh, skin allograft, and identification and suturing of defects of the rectovaginal fascia [22].

Based on the above, there is a need to study the long-term anatomical and functional outcomes of traditional and non-tension methods of rectovaginal septum restoration.

Research Objective

The objective of the research is to improve the results of surgical treatment of patients with rectocele.

Research Tasks

1. To conduct an analysis of the anatomical outcomes of various methods of rectovaginal septum and perineal body restoration in the treatment of rectocele.

2. To assess the functional anatomy of the rectum before and after various methods of operative rectovaginal septum restoration using defecography.

3. To identify the causes of unfavorable functional outcomes when using tension methods of rectovaginal septum restoration.

4. To compare the anatomical and functional efficacy of various methods of operative treatment of rectocele.

Scientific Novelty

A prospective comparative analysis of the anatomical and functional outcomes of the traditional and relatively new method of rectovaginal septum restoration using prolene mesh without approximation of the puborectalis muscles has been conducted.

The cause of worsening obstructive defecation after anatomically effective anterior levatorplasty — the appearance or worsening of puborectal spasm — has been studied.

Using defecography, the anatomical efficacy and functional safety of allograft repair of the rectovaginal septum have been investigated.

An important aspect of the problem of posterior pelvic compartment prolapse — the state of the perineal body — has been examined.

Practical Significance

A number of relevant scientific and practical tasks related to the operative treatment of rectocele have been addressed in the work. The anatomical insufficiency of the most traditional method of rectocele treatment — transvaginal levatorplasty — has been demonstrated.

The cause of the persistence, worsening, or appearance of obstructive defecation after anatomically effective levatorplasty — iatrogenic puborectal spasm — has been identified.

High anatomical and functional efficacy of allograft repair of the rectovaginal septum with restoration of the perineal body has been revealed.

Based on the application of the Wexner Constipation Score and defecography, the absence of prognostic significance of the latter has been discovered, rendering it unnecessary in routine rectocele diagnosis.

Dissertation Defense

Reports on the research topic were delivered at:

1. The XII Scientific-Practical Conference Clinical Readings at the Mytishchi City Clinical Hospital (June 2, 2006): «Experience in the Use of the Wexner Constipation Score in Patients with Rectocele».

2. The 29th Session of the Section of Military Field Surgery of the Surgical Society of Moscow and the Moscow Region: «Comparative Evaluation of Methods of Rectovaginal Septum and Perineal Body Restoration in the Treatment of Rectocele» (May 16, 2007).

Publications

Six printed works have been published on the dissertation topic.

Volume and Structure of the Dissertation

The dissertation is presented across 104 typed pages and consists of an introduction, a literature review, materials and methods of research, a description of operations, research results, conclusion, conclusions, practical recommendations, and a bibliography of 202 sources (20 domestic and 182 foreign authors). The work is illustrated with figures and tables.