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

Table 3 Results of modification of classic transperineal repair (with the omission of levatorplasty ± other additions or substitutions)

Ref.	Method-ology	Technique (TPR)	n	Age	Follow-up	Diagnosis and assessment	Outcome	Complications
Omar et al[37], 2020 (Egypt)	Pilot RCT	Omission of levatorplasty only (n = 20) HP instead of classical plication (n = 20)	40	44.9 (± 7.7)	12 mo	Wexner constipation score; Fluoroscopic defecography; ARM	Cure rate: Complete cure: TPR (n = 13 patient), HP (n = 11 patient)	TPR [wound dehiscence (n = 3), bleeding (n = 1), recurrence (n = 3)], HP [wound dehiscence (n = 1), bleeding (n = 1) recurrence (n = 1)]
							Significant improvement TPR (n = 6 patient), HP (n = 8 patient)
							No improvement TPR (n = 1 patient), HP (n = 1 patient)
							Comparable significant improvement (decline) in Wexner score in both
							More decline in rectocele depth with HP [TPR = 2.6 ± 0.5 cm, HP = 1.7 ± 0.5 cm, P < 0.0001]
							More improvement of dyspareunia with HP [TPR = 9 patient, HP = 2 patient, P = 0.03]
Sari et al[38], 2019 (Turkey)	Retrospective cohort	Omission of levatorplasty only (n = 6)+ Implant [prolene mesh without fixation (n = 6)]	12 (entire cohort n = 78)	52 (31-88)	54 mo (3-218)	Symptom assessment Fluoroscopic defecography	Patients free of symptoms (78.2%)	Wound infection (3.8%), bleeding (2.6%); Recurrence (n = 0)
							Patients had remaining urinary or defecatory symptoms or PO pain (21.8%)
Lisi et al[39], 2018 (Italy)	Prospective case series	SSR + Implant [porcine dermal collagen implant (Permacol®)]	25	47 (30-62)	12-24 mo	Watson score; Fluoroscopic defecography; ARMSF-36	No complaint regarding bowel functions at 2 mo and no sexual problemsSignificant decline in Watson score (Pre = 9.9 ± 2.5, PO = 2.1 ± 0.3, P < 0.0001)	UTI (n = 2), delayed wound healing (n = 4), Recurrence (n = 3)
							All PO rectocele depths were < 2 cm
							Non-significant rise in MRP and MSP
							Non-significant improvement of both composites of SF-36
Youssef et al[40], 2017 (Egypt)	RCT	Omission of levatorplasty only (n = 30)+ LIS (n = 30)	60	41.4 (17.0-70.0)	17.8 mo (6.0-36.0)	Wexner score; Fluoroscopic defecography; ARMPAC-QOL	Complete clinical improvement 70% (TPR) vs 93.3% (TPR + LIS)	TPR [ecchymosis (n = 1), wound dehiscence (n = 2), dyspareunia (n = 1), recurrence (n = 3)]
							More decline in Wexner score with addition of LIS (TPR = 11.1 ± 2.1, TPR + LIS = 8 ± 2, P < 0.0001)	TPR + LIS [wound infection (n = 1), wound dehiscence (n = 3), FI (n = 2), dyspareunia (n = 1), recurrence (n = 1)]
							More satisfaction with TPR + LIS
							Score: (TPR = 11.4 ± 2.7, TPR + LIS = 12.9 ± 2.3, P = 0.02); n of patients: (TPR = 21 patient, TPR + LIS = 28 patient, P = 0.04)
							More improvement (decline) in MRP with TPR + LIS (TPR = 87.5 ± 5.1 mmHg, TPR + LIS = 74.4 ± 3.5 mmHg, P < 0.0001)
Farid et al[27], 2010 (Egypt)	RCT	Omission of levatorplasty only	15 (entire cohort n = 47)	48.4 ± 12.6	6 mo	Modified ODS score; Fluoroscopic defecography; ARM	Significant improvement (decline) in ODS score (Pre = 16.4 ± 6.3, PO = 7.7 ± 2.5, P < 0.001)	Wound infection (6.4%)
							Significant decline in rectocele depth (Pre = 3.8 ± 1 cm, PO = 0.9 ± 0.8 cm, P < 0.001)
							Significant improvement in rectal sensations
							Decline of dyspareunia (Pre = 6 patient, PO = 5 patient)
							Complete rectal evacuation (n = 10 patient)
							Significant correlation between rectocele depth and ODS score (P = 0.001)
Milito et al[41], 2010 (Italy)	Retro-spective case series	SSR + Implant [porcine dermal collagen implant (Permacol®)]	10	47.7 (25.0-70.0)	2-20 mo	Watson score; Fluoroscopic defecography; ARMSF-36	Significant decline in Watson score (Pre = 9.6 ± 1.8, PO = 1.6 ± 0.6, P < 0.0001)	UTI (n = 1), delayed wound healing (n = 1); Recurrence (n = 2)
							Significant decline in rectocele depth (Pre = 3.8 cm, PO < 2 cm, P < 0.0001)
Leventoğluet al[42], 2007 (Turkey)	Prospective case series	SSR + Implant [PGA mesh (Soft PGA Felt®)]	83	49, median (29-56)	14 mo, median (6-36)	Watson score; Fluoroscopic defecography (n = 55); POP-Q	Significant improvement of Watson score (Pre = 9.9 ± 1.9, PO = 1.6 ± 0.6, P < 0.0001)	Bleeding (n = 3), wound infection (n = 4), dyspareunia (n = 8); Recurrence (NP)
							Subjective cure rate (n = 83 patient); PO rectocele depth < 2cm (n = 21 patient)
							At 6m, anatomical cure (n = 74 patient), POP-Q stage II (n = 9 patient), at 14 m, POP-Q stage II (n = 10 patient)
							Would redo surgery if symptoms recur (n = 80 patient)

ARM: Anorectal manometry; FI: Fecal incontinence; HP: Horizontal plication; LIS: Limited internal sphincterotomy; MRP: Maximum resting pressure; MSP: Maximum squeeze pressure; NP: Not provided; ODS: Obstructed defecation syndrome; PAC-QoL: Patient Assessment of Constipation Quality of Life; PGA: Polyglycolic acid; PO: Postoperative; POP-Q: Pelvic Organ Prolapse Quantification System; Pre: Preoperative; RCT: Randomized controlled trial; TPR: Transperineal repair (classic vertical plication); SF-36: 36-Item Short Form Survey; SSR: Site-specific repair; UTI: Urinary tract infection.