Combined approach for the correction of symptomatic rectocele and associated rectal intussusception.

Aim. Rectocele is a frequent asimptomatic finding occurring quite exclusively in women. It can be often associated with a mucosal prolapse or recto-anal intussusception producing the so called “outlet obstruction”. Many approaches are reported with different functional results in order to correct such a defect including transvaginal, transanal, transabdominal and combined techniques and more recently the use of graft materials has been introduced by gynaecologists to reinforce the tissue reconstruction. The use of a combined approach in order to correct both the defects (rectocele and ano-rectal prolapse) has been re-evaluated with the use of a circular stapler to perform an anterior mucosectomy through a transanal approach associated with a posterior colpoperineorrhaphy. Methods. Thirty-six patients suffering from rectocele and associated mucosal prolapse or rectal intussusception underwent single stapler transanal mucosectomy and posterior colpoperineorrhaphy. All patients were female and complained for ano-rectal symptoms of obstructed defecation: they were scheduled by clinical evaluation included Wexner continence score, colpocistodefecography and manometric assessment: The size of rectocele considered was more or equal than 2 cm. After the operation a complete reassessment was performed at six months with a clinical, radiological and manometric evaluation of the results. Moreover all patients were requested to give a subjective evaluation by a short questionnaire. Another follow-up was performed one year after surgery perfprmed. All the results were statistically evaluated. Results. There was a significant improvement of symptoms with a low rate (11%) of persistent incomplete evacuation or perineal heaviness. The need of digitating completely disappeared. There was a little but statistically not significant increase in dyspareunia from 5.5% to 16%. The overall satisfaction grade was very high. A good correspondence between preoperative radiological findings and clinical symptoms was evidenced; in the follow-up colpocistodefecography revealed a persistence of rectocele or mucosal prolapse even in absence of clinical signs of obstructed defecation. Conclusions. A combined transanal and transvaginal approach is an effective treament for the correction of rectocele and associated anorectal intussusception with obstucted defecation simptoms. It provides good results with a low complications rate. Physiological changes in ano-rectal functions after surgery are poor and the subjective statisfaction grade high. Due to the use of a single staplig device it is also less expensive than other transanal operations.