# Rectocele with obstructive defecation syndrome: Laparoscopic rectopexy or vaginal repair?

Nikolaos Evangelopoulos, Pauline Balenghien, Armance Gérard, Aude Brams, Frederic Borie, Renaud de Tayrac

► To cite this version:

Nikolaos Evangelopoulos, Pauline Balenghien, Armance Gérard, Aude Brams, Frederic Borie, et al. Rectocele with obstructive defecation syndrome: Laparoscopic rectopexy or vaginal repair?. The French Journal of Urology, 2024, 34 (14), pp.102803. 10.1016/j.fjurol.2024.102803. hal-05069237

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Original article

# Rectocele with obstructive defecation syndrome: Laparoscopic rectopexy or vaginal repair?

<figure><img src="image_2.png" /></figure>

# Rectocèle avec syndrome d'obstruction défécatoire : rectopexie cœlioscopique ou cure de rectocèle autologue vaginale ?

Nikolaos Evangelopoulos<sup>a,*</sup>, Pauline Balenghien<sup>b</sup>, Armance Gérard<sup>a</sup>, Aude Brams<sup>b</sup>, Frédéric Borie<sup>b</sup>, Renaud de Tayrac<sup>a</sup>

## ARTICLE INFO

**Keywords:**

Laparoscopic rectopexy

Vaginal surgery

Rectocele repair

Obstructive defecation syndrome

## ABSTRACT

**Introduction:** The concomitant presence of a rectocele with obstructive defecation syndrome (ODS) is highly probable. The purpose of this study was to evaluate the effectiveness of native tissue vaginal rectocele repair (VRR) and laparoscopic ventral mesh rectopexy (LVMR) in terms of functional outcome via the medium to long-term ODS score evaluation.

**Material:** This was a retrospective cohort study. We identified 30 patients having undergone LVMR for rectocele with defecatory symptoms between January 2015 and December 2021, matched with the same number of patients treated by VRR for the same indication and in the same period. The hypothesis was that both procedures were susceptible to lead to a favorable functional outcome. The main endpoint was ODS score at follow-up. Multivariate analysis was used to assess relationship between ODS score and type of surgery.

**Results:** Patients' demographics were similar in both groups. However, the preoperative ODS score was significantly higher in the LVMR group (*P* < 0.01). Furthermore, the use of preoperative imaging investigations and diagnosis of an associated rectal intussusception were more frequent in the LVMR group. The mean ODS scores at follow-up (median follow-up 5 years) were comparable in the two groups (6.2 for LVMR and 4.43 for VRR). These scores were significantly reduced compared to preoperative values in both groups (*P* < 0.0001).

**Conclusions:** There was a significant reduction in ODS scores on medium/long-term follow-up with both surgical techniques. A larger study utilizing randomized comparison of both procedures is needed to confirm our findings.

**Level of evidence:** 4.

© 2024 The Authors. Published by Elsevier Masson SAS. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

## RÉSUMÉ

**Mots-clés:**

Rectopexie cœlioscopique

Chirurgie vaginale

Cure de réctocèle

Syndrome d'obstruction défécatoire

**Introduction:** La présence concomitante d'une rectocele et d'un syndrome d'obstruction défécatoire (SOD) est hautement probable. Le but de cette étude était d'évaluer l'efficacité de la plicature prérectale (PPR) par voie vaginale en tissu autologue et de la rectopexie ventrale cœlioscopique (RVC), sur le plan fonctionnel, au moyen de l'évolution postopératoire du score ODS à moyen-long terme.

**Matériel:** Étude de cohorte rétrospective. Nous avons identifié 30 patientes ayant bénéficié d'une RVC pour rectocèle avec constipation terminale entre janvier 2015 et décembre 2021, appariés avec le même nombre de patients traités par PPR pour la même indication et dans la même période. L'hypothèse était que les patientes des deux groupes

<footnote><sup>a</sup> Department of Obstetrics and Gynecology, Nîmes University Hospital, University of Montpellier, Nîmes, France</footnote>

<footnote><sup>b</sup> Department of Digestive Surgery, Nîmes University Hospital, University of Montpellier, Nîmes, France</footnote>

<footnote>* Corresponding author. 4, rue du Professeur-Robert-Debré, 30900 Nîmes, France
E-mail address: nikolaos.evangelopoulos@rhne.ch (N. Evangelopoulos).</footnote>
étaient sujettes à une amélioration sur le plan fonctionnel. *L'outcome* primaire était le score ODS au suivi. Le score ODS en fonction du type de chirurgie a fait sujet d'une analyse multivariée.

**Résultats:** Les caractéristiques démographiques des patients étaient similaires dans les deux groupes. Cependant, le score ODS préopératoire était significativement plus élevé dans le groupe RVC (p < 0,01). De plus, le recours aux examens d'imagerie préopératoires et le diagnostic d'une intussusception rectale associée étaient plus fréquents dans le groupe RVC. Les scores moyens ODS postopératoires (suivi médian de 5 ans) étaient comparables dans les deux groupes (6,2 pour RVC et 4,43 pour PPR). Ces scores étaient significativement améliorés par rapport aux valeurs préopératoires respectives (p < 0,0001).

**Conclusions:** Les deux abords chirurgicaux ont conduit à une réduction significative du score ODS lors de l'évaluation postopératoire à moyen/long terme. Une plus grande étude randomisée est nécessaire pour confirmer ces résultats.

*Niveau de preuve: 4.*

© 2024 Les Auteurs. Publié par Elsevier Masson SAS. Cet article est publié en Open Access sous licence CC BY (http://creativecommons.org/licenses/by/4.0/). This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

# 1. Introduction

Symptoms associated with rectocele can be numerous and variable. These include a sensation of a vaginal bulge, obstructive defecation or even anal incontinence. Obstructive defecation syndrome (ODS) is a complex problem consisting of a sense of incomplete evacuation, prolonged straining, a persistent desire to defecate and anal incontinence in some cases. Although there tends to be concomitant presence of rectocele and/or intrarectal prolapse in > 90% of ODS cases, it is not clear if this relationship is one of causation, complication, or mere association. This results in controversies amongst professionals as to whether anatomical restoration of the posterior compartment prolapse would improve the patient's ODS symptoms [1].

Rectocele, defined as protrusion of the anterior rectal wall through the posterior wall of the vagina, can be high (supra-levator), often associated with a hernia of the cul-de-sac of Douglas; medium, secondary to a defective rectovaginal septum; or low, suggestive of a perineal body damage. Rectocele mainly affects females, with an estimated prevalence of 30 to 50% amongst multiparous women over 50 years old [2]. Similar to other pelvic floor disorders, the pathophysiology of rectocele is complex and multifactorial but related to damage of the connective tissue support in the rectovaginal area. This results from non-modifiable (e.g. age, estrogen deprivation, genetic predisposition, parity, delivery mode), as well as modifiable factors (e.g. obesity and chronic constipation) [3].

Management of ODS is multidisciplinary, varying from lifestyle changes, biofeedback physiotherapy or surgery. There are no randomized controlled trials comparing expectant management, medical treatment, physiotherapy and surgical options. Moreover, several surgical procedures have been proposed for treating ODS. However, in the presence of rectocele, although not standardized, the two favored options amongst urogynecologists and colorectal surgeons are to reinforce the rectovaginal septum and perform a rectal plication via the vaginal route or a minimally invasive mesh rectopexy respectively.

ODS affects about 7% of the adult population, mainly in females, and one in five of them have a surgical treatment for their symptoms [4]. The procedure and approach of choice tends to depend on rectocele location, associated symptoms, patient's age, comorbidities and the surgeon's experience. Hence, meticulous assessment of patients presenting with a rectocele to identify the level of anatomical defect and associated symptoms is crucial when planning a surgical repair. This is particularly relevant as poor patient selection for surgical treatment leads to unsatisfactory results [5]. The VIGIMESH study aimed to identify short and long term complications following pelvic reinforcement rectocele surgery with or without a prosthetic implant [6]. Similarly, the 2013 Cochrane review on rectocele management provided recommendations, albeit of low of evidence [7]. However, the international ban on the use of transvaginal mesh in 2019 limits the relevance of these studies to current practice. There is paucity of information on long-term functional or surgical treatment for the management of ODS symptoms associated with rectocele. To our knowledge, there are no published studies that compared such outcomes following vaginal surgical repair and ventral

rectopexy. Therefore, the main aim of this study was to evaluate long-term ODS functional outcomes following vaginal rectocele autologous tissue repair (VRR) vs. laparoscopic ventral mesh rectopexy (LVMR) for the management of rectocele with ODS.

# 2. Material and methods

This was a retrospective cohort study, level of evidence 4, carried out in a tertiary university hospital. Patients were identified from the hospital record system. We searched for patients with isolated symptomatic rectocele treated by LVMR, with obstructive defecation being the primary complaint. We then proceeded to identify the same number of patients treated by VRR for the same indication, over the same period, as to be able to study our primary endpoint in a case-control manner. The recruitment was made by order of appearance of an eligible patient record. Patients unable to provide consent, deceased at the time of commencing this work, those who did not present with ODS symptoms, had concomitant procedures for another pelvic floor disorder and those who had VRR with mesh placement were not included in our study.

Vaginal and laparoscopic procedures were performed by experienced urogynecology and colorectal surgeons (RdT and FB respectively). For VRR, the patient is placed in lithotomy position under spinal or general anesthesia. After vaginal subepithelial infiltration with a diluted solution of lidocaine and epinephrine, a midline colpotomy is performed extended to the upper limit of the defect. The posterior vaginal epithelium is dissected bilaterally away from the underlying fibromuscularis and extended to the pelvic sidewall, without opening the pararectal space. The fibromuscularis of the posterior vaginal wall, separated from its epithelium and attached to the rectal serosa, is plicated in the midline with interrupted transversely placed monofilament 2-0 resorbable sutures, starting proximally and progressing toward the hymenal ring. Vaginal epithelium is then trimmed as necessary and closed with a running absorbable suture. The LVMR procedure is performed under general anesthesia. The sacral promontory is exposed and the peritoneum incision is extended downwards to the Douglas pouch. The rectovaginal septum is opened down to the pelvic floor. Posterolateral rectal mobilization is avoided according to D'Hoore [8]. Rectopexy is performed using a large-pore, monofilament, polypropylene mesh fixed to the ventral aspect of the distal rectum and to the pelvic floor bilaterally, with 2-0 polyester sutures (Ethibond Excel®, Ethicon Inc., USA), its other side affixed upon the sacral promontory with two 0 Ethibond sutures. Finally, the peritoneum is closed in order to cover completely the mesh.

The main endpoint for the study was the patient reported ODS score at time of follow-up. Other data collected from hospital records were patients' age, body mass index, history of hysterectomy or pelvic organ prolapse surgery, parity, menopausal status, hormone replacement therapy, sexual activity, previous referral for physiotherapy, associated anal incontinence, imaging studies results (defecography/MRI defecography), ano-rectal manometry results, preoperative ODS score, and hospital stay. Patient reported ODS scores at follow-up were collected by
means of a telephone interview, only if patient provided a verbal consent to participate in the study.

This research complied with the law No. 2012-300 of March 5, 2012 relating to research involving humans, Good Clinical Practices (I.C.H. version 4 of November 9, 2016 and decision of November 24, 2006) and the declaration of Helsinki. Data management was in line with the French Data Protection Act and Freedoms Law and the reference methodology MR-004 relating to data processing in the context of health research. A declaration of non-opposition to participate was collected verbally from all included participants after clear and fair oral information. This work is exempt from CER (French research ethics committee) authorization, as its methodology involves the retrospective utilization of the health related data strictly necessary for this study purposes, thus classified as non-interventional research according to Jardé law.

Data were collected on Microsoft Excel (Microsoft Corporation, Redmond, USA). Continuous variables are expressed as means and standard deviation (SD) or medians and interquartile ranges (IQR) and dichotomous variables expressed as numbers and percentages. Associations between type of surgery and continuous variables were assessed using Mann-Whitney and Welch tests, while the Chi² or Fisher tests were used for dichotomous variables. We carried out a linear regression to assess the relationship between the primary endpoint (ODS score at follow-up), type of surgery and other explanatory variables, like the presence of anal incontinence, BMI, preoperative imaging work-up and duration of follow-up. Candidate covariates were selected by their clinical relevance and only if there were < 20% of patients with missing data or variables with < 5% missing values. The significance level was set at 5% for all the tests used.

## 3. Results

Sixty women were included in our study, 30 in each of the LVMR and VRR groups. The procedures were performed between January 2015 and December 2021. The mean age of our cohort was 62.4 years (61.3 and 63.5 years in the LVMR and VRR respectively; *P* = 0.55). The median parity of the study population was 2 and 85% were menopausal with no in-between group differences. Half of the patients were sexually active in the VRR group vs. 82% in the cohort of patients who had a ventral

rectopexy, however, this difference was not statistically significant (*P* = 0.16). The median BMI was greater in the VRR group (25 vs. 22; *P* = 0.014). A total of 16 patients (8 in each group) previously had a hysterectomy while, 43% and 53% had a previous pelvic organ prolapse repair procedure in the LVMR and VRR groups respectively (*P* = 0.61). All these procedures were for the repair of an anterior and/or middle compartment prolapse except for one case in the VRR group who previously had an LVMR for a posterior compartment defect (Table 1).

Preoperative ODS scores were available for 19 (63.3%) and 27 (90%) in the LVMR and VRR groups respectively, and the mean score was significantly higher in the LVMR group [13.4 (3.92) vs. 9.41 (3.52); *P* < 0.01]. ODS scores at the follow-up timepoint were available for all our study cohort. Compared to the mean preoperative score, the mean ODS score at follow-up were significantly reduced (*P* < 0.0001 for both groups), 6.20 (6.58) for the LVMR and 4.43 (5.15) for VRR, but not statistically different between the two groups (*P* = 0.33) (Fig. 1). A total of 19 and 27 patients had both preoperative and follow-up ODS scores in the LVMR and VRR groups respectively. Of these, 15 (78.9%) in the LVMR and 21 (77.8%) in the VRR had functional improvement in their scores. In contrast, 4 (21%) and 6 (22.2%) reported deterioration in their scores (Fig. 2).

The presence of intrarectal prolapse was more frequent in the LVMR group (93% vs 58%; *P* = 0.02). Similarly, preoperative imaging studies (defecography or MRI defecography), were performed more frequently in the LVMR than in the VRR group (90% vs. 43% cases respectively; *P* < 0.001) (Fig. 3). Rectocele size, as assessed by preoperative imaging studies, was available for 26 patients (*n* = 15 for LVMR; *n* = 11 for VRR) and the median size was slightly higher in the VRR group, but this difference did not reach statistical significance (5 cm vs. 4 cm; *P* = 0.19). Hospital stay was similar in the two groups with a median of 3 days. The time interval between surgery and the follow-up ODS score was 5 years for the whole study cohort (*n* = 60), ranging from 1 to 7 years, not different between the groups, 5.5 years [range 1 to 7 years] for the LVMR group and 5 years [range 2 to 7 years] in the VRR group (*P* = 0.48).

Finally, our multivariate analysis did not demonstrate significant relationship between postoperative ODS scores in the study groups and any of the included variables (Fig. 4, Table 2).

<table><caption>**Table 1**

Population characteristics by group.</caption><thead><tr><th></th><th></th><th>Group LVMR</th><th>Group VRR</th><th>n</th><th>P</th><th>Test</th></tr></thead><tbody><tr><td>Mean age (standard deviation)</td><td></td><td>61.3 (13.8)</td><td>63.5 (13.9)</td><td>60</td><td>0.71</td><td>Mann-Whitney</td></tr><tr><td>BMI, median [Q25-75]</td><td></td><td>22.0 [20.0; 25.8]</td><td>25.0 [22.0; 30.0]</td><td>59</td><td>0.014</td><td>Mann-Whitney</td></tr><tr><td>Parity, median [Q25-75]</td><td></td><td>2.00 [2.00; 3.00]</td><td>2.00 [2.00; 3.00]</td><td>44</td><td>0.72</td><td>Mann-Whitney</td></tr><tr><td>Menopause, n</td><td></td><td>27 (90%)</td><td>24 (80%)</td><td>51</td><td>0.47</td><td>Fisher</td></tr><tr><td>Preoperative ODS score</td><td>N</td><td>19</td><td>27</td><td>46</td><td>&lt; 0.01</td><td>Welch</td></tr><tr><td>mean (SD)</td><td></td><td>13.4 (3.92)</td><td>9.41 (3.52)</td><td></td><td></td><td></td></tr><tr><td>ODS score at follow-up, mean (SD)</td><td></td><td>6.20 (6.58)</td><td>4.43 (5.15)</td><td>60</td><td>0.33</td><td>Mann-Whitney</td></tr><tr><td>Follow-up duration (years), median [IQR]</td><td></td><td>5.50 [4.00; 6.00]</td><td>5.00 [4.00; 6.00]</td><td>60</td><td>0.48</td><td>Mann-Whitney</td></tr><tr><td>Rectocele size (cm)</td><td>N</td><td>15</td><td>11</td><td>26</td><td>0.19</td><td>Mann-Whitney</td></tr><tr><td>median [IQR]</td><td></td><td>4.00 [3.00; 6.00]</td><td>5.00 [4.75; 5.38]</td><td></td><td></td><td></td></tr><tr><td>Anal incontinence, n</td><td>N</td><td>30</td><td>28</td><td>58</td><td>0.88</td><td>Chi²</td></tr><tr><td></td><td></td><td>8 (27%)</td><td>7 (25%)</td><td>15</td><td></td><td></td></tr><tr><td>h/o hysterectomy, n</td><td>N</td><td>30</td><td>30</td><td>60</td><td>1</td><td>Chi²</td></tr><tr><td></td><td></td><td>8 (27%)</td><td>8 (27%)</td><td>16</td><td></td><td></td></tr><tr><td>h/o prolapse surgery, n</td><td>N</td><td>30</td><td>30</td><td>60</td><td>0.61</td><td>Fisher</td></tr><tr><td></td><td>None</td><td>17 (57%)</td><td>14 (47%)</td><td>31</td><td></td><td></td></tr><tr><td></td><td>AC, ApC</td><td>13 (43%)</td><td>15 (50%)</td><td>28</td><td></td><td></td></tr><tr><td></td><td>PC</td><td>0 (0%)</td><td>1 (3%)</td><td>1</td><td></td><td></td></tr><tr><td>Intrarectal prolapse, n</td><td>N</td><td>27</td><td>12</td><td>39</td><td>0.02</td><td>Fisher</td></tr><tr><td></td><td></td><td>25 (93%)</td><td>7 (58%)</td><td>32</td><td></td><td></td></tr><tr><td>Preoperative imaging study, n</td><td>N</td><td>30</td><td>30</td><td>60</td><td>&lt; 0.001</td><td>Chi²</td></tr><tr><td></td><td></td><td>27 (90%)</td><td>13 (43%)</td><td>40</td><td></td><td></td></tr><tr><td>Rectal manometry, n</td><td>N</td><td>30</td><td>15</td><td>45</td><td>1</td><td>Fisher</td></tr><tr><td></td><td></td><td>22 (73%)</td><td>11 (73%)</td><td>33</td><td></td><td></td></tr><tr><td>Sexually active, n</td><td>N</td><td>8</td><td>22</td><td>22</td><td>0.16</td><td>Fisher</td></tr><tr><td></td><td></td><td>4 (50%)</td><td>18 (82%)</td><td></td><td></td><td></td></tr></tbody></table>

AC: anterior compartment; ApC: apical compartment; PC: posterior compartment; h/o: history of.
<figure><img src="image_3.png" /><figcaption>Fig. 1. Chart illustrating mean ODS scores by group, preoperative and at follow-up.</figcaption></figure>

• VRR group

<figure><img src="image_4.png" /></figure>

• LVMR group

<figure><img src="image_5.png" /><figcaption>Fig. 2. Chart illustrating individual ODS score change by surgery group.</figcaption></figure>

4. Discussion

Our primary aim was to evaluate the functional impact of the two,
commonly practiced, procedures for rectocele repair, in a cohort of
patients with defecatory symptoms. We did not have sufficient data on
preoperative conservative management, including physiotherapy, to
report on their effect. Both procedures resulted in a significant

improvement in ODS scores at follow-up compared to preoperative ones
(P < 0.0001). However, there were no significant differences in the mean
ODS scores between both procedures at follow-up. Nonetheless, it is
important to highlight that the mean preoperative ODS score was
significantly higher in the LVMR group [13.4 (3.92) vs. 9.41 (3.52);
P < 0.01]. Although the primary complaint of all the cohort was
obstructed defecation, it is possible that there was a preference to use
<figure><img src="image_6.png" /><figcaption>Fig. 3. Chart illustrating preoperative rectocele imaging work-up and rectal intussusception prevalence by group.</figcaption></figure>

<figure><img src="image_7.png" /><figcaption>Fig. 4. Forest plot of multivariate analysis for ODS score at follow-up.</figcaption></figure>

<table><caption>**Table 2**

Multivariate analysis of postoperative ODS score.</caption><thead><tr><th></th><th></th><th>Coefficients</th><th>P</th></tr></thead><tbody><tr><td>Group</td><td>VRR vs. LVMR</td><td>-0.839 [-5.25; 2.35]</td><td>0.63</td></tr><tr><td>Anal incontinence</td><td>Yes vs. no</td><td>-1.88 [-4.97; 1.96]</td><td>0.31</td></tr><tr><td>BMI</td><td></td><td>0.0249 [-0.292; 0.301]</td><td>0.9</td></tr><tr><td>Preoperative imaging study</td><td>No vs. yes</td><td>-2.19 [-5.77; 1.98]</td><td>0.24</td></tr><tr><td>Follow-up duration (years)</td><td></td><td>-0.110 [-1.08; 1.01]</td><td>0.82</td></tr></tbody></table>

LVMR if defecatory symptoms were more prominent. Vaginal bulge related to the rectocele was an associated complaint to the quasi totality of our cohort. Given the fact that this study focused on the impact of the surgery on the ODS, we did not otherwise collect data on the prolapse repair objective or subjective outcome.

Despite a significant improvement on mean ODS scores in both groups, we should highlight a deterioration in one fifth of the patients of each group (Fig. 2). In a series of 231 female patients who had posterior colporraphy for rectocele with ODS and a mean follow-up of 42.5 months, the authors reported improvements in prolapse symptoms, nonetheless,

bowel and sexual dysfunction symptoms deteriorated in many cases postoperatively [9]. These results support the notion that the management approach for ODS syndrome should be multidisciplinary and personalized, with surgical management only playing a secondary role. In contrast, the results of a large nationwide cohort study supported the correlation of posterior wall anatomy and ODS, highlighting the relevance of surgical repair in ODS management [10]. Other authors suggest that despite the frequent association of posterior vaginal prolapse with defecatory symptoms, their relationship, whether a cause or effect, are mere assumptions due to current conflicting evidence [11]. Hence, reaching consensus amongst clinicians regarding a standardized evidence-based management pathway for ODS is a challenge. Our data did not support any further analysis on the subgroup of patients presenting a postoperative deterioration of their ODS score, whether it involves anatomic correlation or identification of other risk factors of failure.

Gouvas et al. reported improvement in constipation and anal incontinence after LVMR for ODS with overt rectal prolapse and rectocele (P < 0.0001) [12]. However, despite the popularity of the procedure for the management of ODS associated with rectal intussusception and rectocele, and the initial promising results, long-term data are still
awaited [13]. Native tissue posterior colporrhaphy has been demonstrat-
ed to improve a wide range of ODS-related symptoms including
obstructive defecation, vaginal digitation and sensation of incomplete
evacuation [3,14]. Furthermore, it is a traditional gynecological
procedure with established safety profile, hence, recommended as the
first choice treatment in patients with rectocele and obstructed defecation
symptoms requiring surgical intervention [15].

VRR has the advantage of being a fast, minimally invasive surgery that
could be performed under spinal anesthesia, which is an argument for
proposing it to elderly and fragile patients. Indeed, this was reflected in
our cohort where older patients were more likely to have a VRR. Patient's
sexual activity is another age-related factor that tends to be taken into
consideration when choosing the procedure. A study comparing the
transvaginal route to the transanal route in patients with symptomatic
rectocele reported that the majority of sexually active patients felt that
surgical management improved their sex life [2]. The review by Gouvas
et al. also examined the effect of ventral rectopexy on sexual dysfunction
(n = 152), finding a significant improvement in sexual function
(P < 0.0001) [12]. In our study there seemed to be tendency to treat
sexually active patients by laparoscopic rectopexy but this difference was
not statistically significant, probably due to the small sample size. Due to
this limitation, we were not able to assess the superiority of one procedure
over the other with regards to sexual function in our dataset.

The vaginal technique used in our center corresponds to that described
by Miley and Nichols, which entails complete folding of the rectovaginal
fascia [16] and not that described by Richardson, which involves elective
strengthening of weak areas in the rectovaginal septum as assessed by
digital rectal examination [17]. A retrospective study comparing these
last two techniques found similar results in terms of improvement of
constipation and preoperative anal incontinence [2]. We decided not to
include patients treated by the transanal approach (STARR), a favored
procedure amongst surgeons for the treatment of rectocele, in view of the
previously reported, relatively high, complication rates [18,19]. Borie
et al. studied STARR versus ventral rectopexy and demonstrated
comparable significant ODS score improvements for both methods
[20]. Moreover, an RCT comparing transanal rectoceleplasty with VRR
for the treatment of rectocele with ODS, found similar results. However,
there was a trend towards fewer symptoms in the vaginal group and less
recurrences [21].

In our cohort, significantly more preoperative defecographies or MRI
defecographies were performed in the laparoscopic rectopexy group. This
could be related to the fact that patients with most prominent defecatory
dysfunction and higher ODS score are primarily examined by colorectal
surgeons and often selected for a ventral rectopexy. The issue of the use
and type of imaging modality for the preoperative assessment of patients
presenting with rectocele and symptoms suggestive of ODS is still a matter
of debate, with some authors reporting that both defecography and MRI
defecography have similar detection accuracy in posterior compartment
disorders with ODS [22]. In contrast, others question the value of these
tests because they tend to oversimplify the underlying problem [23].

To our knowledge, no randomized trial nor prospective cohort have
-treated this subject yet. A retrospective study published in 2021, similarly
found significant functional and anatomic amelioration for both groups,
but significantly in favor of the LVMR technique (n = 72) for virtually all
variables, when compared to the VRR group (n = 139). However, the 1-
year limited follow-up, the concomitant posterolateral internal sphinc-
terotomy according to preoperative anal manometry, the associated
treatment of other pelvic floor disorders and the ambidirectional design of
the study exposed these otherwise clear results to a considerable bias risk,
limiting their value [24]. Van der Hagen and associates evaluated
transvaginal posterior colporrhaphy combined with laparoscopic ventral
mesh rectopexy for isolated grade III symptomatic rectocele and reported
improved ODS scores at the short-term. However, they did not compare
the two techniques separately [25].

Consequently, we consider the present study a meaningful contribu-
tion to the present scarce literature in the subject, especially when it

comes to longer follow-up periods. The medium at long-term follow-up
and the significant results for the primary endpoint, in our opinion,
balance for its several limitations, to cite the most important ones the
relatively small sample size, the retrospective design, the potential risk of
selection bias regarding to treatment choice and the lacunary data in some
categories, with special mention to the preoperative ODS score.

5. Conclusion

Both native tissue vaginal rectocele repair and laparoscopic ventral
mesh rectopexy significantly improved ODS scores in patients with
rectocele and associated defecatory symptoms on long-term follow-up.
Hence, this study demonstrates the sustained effectiveness of either
procedure in the management of obstructive defecation syndrome.
However, due to the nature of our retrospective design and small sample
size, a larger study utilizing randomized comparison of both procedures
and long-term follow-up is needed to confirm these findings.

Ethics approval and consent to participate

All participants provided informed consent prior to their enrolment
into the study. This is a non-interventional research study. involving
retrospective utilization of health related data, thus exempt from French
research ethics committee authorization.

Consent for publication

Not applicable.

Availability of data and materials

The datasets of the current study are available from the corresponding
author on reasonable request.

Disclosure of interest

The authors declare that they have no competing interest.

Funding

No funding received for this study.

Authors' contributions

NE: statistical analysis, manuscript writing and editing, PB: data
collection, AG: data collection, AB: data collection, project development,
manuscript editing, FB: project development, manuscript editing, RdT:
project development, manuscript writing and editing.

Acknowledgements

The authors would like to thank Superviseme Ltd - medical writing
services (http://www.superviseme.eu) for their help with the medical
writing and editing of the manuscript.

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