Horizontal versus vertical plication of the rectovaginal septum in transperineal repair of anterior rectocele: a pilot randomized clinical trial

Abstract

Aim: Anterior rectocele is usually an asymptomatic condition in many women, yet it can be associated with obstructed defaecation syndrome (ODS). Transperineal repair of rectocele (TPR) has been followed by variable rates of improvement in ODS. The present pilot randomized clinical trial aimed to evaluate the outcome of TPR with vertical plication (VP) of the rectovaginal septum compared to horizontal plication (HP).Methods: Adult women with anterior rectocele were recruited to the study and were randomly allocated to one of two equal groups. The first group underwent TPR with VP of the rectovaginal septum and the second group underwent TPR with HP. The main outcome measures were improvement in ODS, recurrence of rectocele, complications and dyspareunia. Results:The trial included 40 female patients with anterior rectocele. There was no significant difference between the two groups regarding the postoperative Wexner score.Complete cure and significant improvement in ODS symptoms were comparable after the two techniques. The reduction in rectocele size after HP was significantly greater than after VP (1.7 vs. 2.6, P < 0.0001). Significant improvement in dyspareunia was recorded after HP (P = 0.001) but not after VP (P = 0.1). There was no significant difference between the two groups with regard to operating time, complications and recurrence. Conclusion:VP and HP of the rectovaginal septum in TPR were associated with a comparable improvement in ODS symptoms and similar complication rates. HP was followed by a greater reduction in the rectocele size and greater improvement in dyspareunia than VP.

Literature review of the outcome of and methods used to improve transperineal repair of rectocele

“…Omission of levatorplasty only ( n = 71): The omission of levatorplasty resulted in postoperative improvement in ODS symptoms in 66.7%-78.2% of patients[ 27 , 37 , 38 - 40 ]. The reduction in ODS scores ranged between 32.8% and 53.0%[ 27 , 37 , 40 ]. A significant reduction in rectocele size was recorded in 45.8%-76.3% of patients[ 27 , 37 ].…”

“…The reduction in ODS scores ranged between 32.8% and 53.0%[ 27 , 37 , 40 ]. A significant reduction in rectocele size was recorded in 45.8%-76.3% of patients[ 27 , 37 ]. Youssef et al [ 40 ] reported an increase in MRP, in contradiction to another study that reported a decrease in anal pressures[ 40 ].…”

“…Satisfaction was reported in 70% of patients[ 40 ]. Two studies reported an improvement in dyspareunia in 16.7%-35.7% of patients[ 27 , 37 ], whereas another study documented de novo dyspareunia[ 40 ]. Two studies reported recurrence rates ranging between 10% and 15%, whereas Sari et al [ 38 ] did not report any recurrence.…”

“…Two studies reported recurrence rates ranging between 10% and 15%, whereas Sari et al [ 38 ] did not report any recurrence. Complications included wound dehiscence, wound infection, bleeding, and hematomas[ 27 , 37 , 38 , 40 ].…”

“…Horizontal plication ( n = 20): Omar et al [ 37 ] replaced the classical vertical plication of the RVS with craniocaudal or horizontal plication. Although the rate of complete cure of rectocele after horizontal plication was lower than the classical plication (55% vs 65%), the postoperative constipation scores were comparable.…”