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

Table 1 Results of classical transperineal repair (transperineal repair + levatorplasty ± sphincteroplasty)

Ref.	Methodology	n	Age	Follow-up	Diagnosis and assessment	Outcome	Complications
Balata et al[23], 2020 (Egypt)	RCT	32 (entire cohort n = 64)	45.1 ± 3.5	12 mo	Wexner constipation score; Fluoroscopic defecography; ARM; PISQ-12; Satisfaction	Significant improvement (decline) in Wexner score (Pre = 18.3 ± 0.7, PO = 7.2 ± 1.4, P < 0.0001)	Complications (n = 6); Dyspareunia (Pre = 11, PO =13, P = 0.8); Recurrence (n = 2)
						Significant decline in rectocele depth (Pre = 4.6 ± 0.8 cm, PO = 1.4 ± 0.9 cm, P < 0.0001)
						Significant rise of MRP (Pre = 60.7 ± 8.5 mmHg, PO = 67.1 ± 4.2 mmHg, P = 0.0003)
						Significant rise of MSP (Pre = 136.4 ± 3.5 mmHg, PO = 141.2 ± 2.1 mmHg, P < 0.0001)
						Significant improvement (decline) in PISQ-12 score (Pre = 26.4 ± 2.1, PO = 18.2 ± 0.7, P < 0.0001)
						Sexual satisfaction (Pre = 23 patient, PO = 24 patient, P = 0.8)
Emile et al[24], 2020 (Egypt)	Retrospective case series	46	43.2 ± 10.7	13.9 mo (12.0-18.0)	Wexner constipation score; Fluoroscopic defecography; ARM	Significant improvement (n = 30), no improvement (n = 16)	Wound dehiscence (n = 6), hematoma (n = 2)
						Significant improvement (decline) in Wexner score (Pre = 17.8 ± 2.7, PO = 9.2 ± 4.7, P < 0.001)
						Significant decline in rectocele depth (Pre = 4.7 ± 1.2, PO = 2.2 ± 1.4, P < 0.001)
						Significant improvement (decline) in rectal sensation volumes
Tomita et al[25], 2012 (Japan)	Prospective case series	12	63.3 (33.0-82.0)	24 mo	Symptom assessment; Fluoroscopic defecography	Symptom improvement [excellent (n = 6 patient), good (n = 4 patient), fair (n = 2 patient)]	Wound infection (n = 2)
						Significant decline in rectocele depth (Pre = 4 ± 0.8 cm, PO = 0.2 ± 0.5 cm, P <0.001)
						Complete resolution of rectocele (n = 10 patient)
Mills[26], 2011 (South Africa)	Retrospective case series	117	24-85	6 mo (at least)	Symptom assessment; Trans-labial US; Rectocele wall thickness by Harpenden Skinfold Caliper (n = 50 patient); Trans-illumination (n = 50 patient)	Negative trans-illumination immediately after repair (n = 50 patient)	Wound infection (n = 2)
						Rectocele wall thickness increased from 2.4 mm to 4.8 mm immediately after repair (n = 50 patient)
						No PO manifestations of FI (n = 109 patient)
						Patients with combined ODS and FI became normal (n = 43 patient)
Farid et al[27], 2010 (Egypt)	RCT	16 (entire cohort n = 47)	48.4 ± 12.6	6 mo	Modified ODS score; Fluoroscopic defecography; ARM	Significant improvement (decline) in modified ODS score (Pre = 17.3 ± 5.1, PO = 3.8 ± 1.7, P < 0.0001)	Wound infection (6.4%)
						Significant reduction in rectocele depth (Pre = 4.2 ± 0.8 cm, PO = 0.9 ± 0.7 cm, P < 0.0001)
						Significant improvement in rectal sensation volumes; Non-significant decline of dyspareunia (Pre = 6 patients, PO = 3 patients)
						Complete rectal evacuation (n = 13 patient)
						Significant correlation between rectocele depth and ODS score (P = 0.01)
Puigdollers et al[28], 2007 (Spain)	Prospective cohort	24 (entire cohort n = 35)	52 (28-79)	12 mo	Questionnaire based on ROME-II criteria (Y/N)	Significant decline in PO score (Pre = 4.2, PO = 1.9, P < 0.0001)	Hematoma (n = 2)
						Improvement: complete improvement [no symptoms] (42.9%), partial improvement [only one symptom] (5.7%), partial improvement [with ≥ 2 symptom] (31.4%), unchanged (20%)
						Improvement of constipation (n = 11 patient)
						Results were worse after hysterectomy
Hirst et al[29], 2005 (United Kingdom)	Retrospective cohort	33 (entire cohort n = 82)	51, median (25-83)	NP	Clinical assessment; Satisfaction assessment	Surgery outcome: All patients: Cured (n = 21 patient), initial improvement (n = 5 patient), no improvement (n = 7 patient), further surgery (n = 8 patient)	Complications (n = 0); Recurrence (n = 5)
						Patients with rectocele only (n = 6 patients): Cured (n = 5), initial improvement (n = 1), further surgery (n = 0) Satisfaction: (n = 26)
Ayabaca et al[30], 2002 (Italy)	Retrospective cohort	11 (entire cohort n = 60)	56 (21-70)	48 mo (9-122)	Symptom assessment; FI score; ARM	ODS symptoms improvement: Improved (n = 8 patient), lost to follow-up (n = 3 patient)	Urine retention (10%), wound dehiscence (6.6%), wound infection (n = 3.3%), other complications (10%); Recurrence: n = 0
						FI score improved (declined: Pre = 4.9 ± 0.9, PO = 4.2 ± 0.8); Non-significant decline in MRP and MSP in patients with FI
						No improvement of FI (n = 1 patient)
Van Laarhoven et al[31], 1999 (United Kingdom)	Retrospective cohort	10 (entire cohort n = 22)	48 (31-63)	27 mo, median (5-54)	Symptom assessment; Fluoroscopic defecography; Pudendal nerve motor latency	Ability to evacuate rectum: Improved (72.7%), unchanged (22.7%), deteriorated (4.5%)	Wound infection (9.1%)
						Significant decline in rectocele depth (Pre = 2.9 cm, PO = 1.7 cm, P < 0.01)
						Significant decline in rectocele area (Pre = 7.8 cm, PO = 4.3 cm, P < 0.01)
						No correlation between rectocele reduction and symptoms improvement

ARM: Anorectal manometry; FI: Fecal incontinence; MRP: Maximum resting pressure; MSP: Maximum squeeze pressure; NP: Not provided; ODS: Obstructed defecation syndrome; PISQ-12: 12-Item Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire; PO: Postoperative; Pre: Preoperative; RCT: Randomized controlled trial; ROME-II: 2^nd edition of criteria of functional gastrointestinal disorders; US: Ultrasonography.