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.

Table 2 Results of modification of classic transperineal repair

Ref.	Methodology	Technique	n	Age	Follow-up	Diagnosis and Assessment	Outcome	Complications
Ellis[32], 2010 (United States)	Retrospective cohort	TPI [porcine intestinal submucosal collagen implant (Surgisis®)] ± SP	32 (entire cohort n = 120)	58.7 ± 8.9	12 mo	BBUSQ-22	Improvement of BBUSQ-22 individual items (total improvement 30.9%): Significant improvement (decline) in 6 items	Urine retention (n = 2), Recurrence (n = 0)
							Significant deterioration (raise) in pain with bowel movements
							Non-significant changes in 2 items
Smart and Mercer-Jones[33], 2007 (United Kingdom)	Prospective case series	TPI [porcine dermal collagen implant (Permacol®)]> Suction drain (last 8 patients)	10	51, median (33-71)	9 mo, median (5-16)	Watson score	All patients (100%) had improvement in 2 or more symptoms, and 70% in three or more	Hematoma (n = 2)
							Decline of Watson score (Pre = 10.5, PO = 4.5)
Hirst et al[29], 2005 (United Kingdom)	Retrospective cohort	TPR + LP + Implant	7 (entire cohort n = 82)	51, median (25-83)	NP	Clinical assessment	Surgery outcome: cured (n = 5 patient), initial improvement (n = 1 patient), no improvement (n = 1 patient), further surgery (n = 2 patient); Satisfaction: n = 6 patient	Mesh erosion (n = 1); Recurrence (n = 1)
Mercer-Jones et al[34], 2004 (United Kingdom)	Retrospective case series	TPI ± SPProlene mesh (n = 14),Prolene + PGA mesh [Vypro II®] (n = 8)	22	53, median (28-66)	12.5 mo (3.0-47.0)	Watson score	Decline in Watson score (Pre = 11.1, PO = 3.9); Significant (P < 0.05) symptomatic improvement (n = 20 patient)	Wound infection (n = 2), wound infection and dehiscence (n = 1), dyspareunia (n = 1) Recurrence (n = 1)
							Subjective outcome (P < 0.05) in favor of Vypro II® mesh: Moderate to excellent [Prolene (n = 9 patient), Vypro II® (n = 8 patient)]
							Poor [prolene (n = 5 patient), Vypro II® (n = 0 patient)]
Azanjac and Jorovic[35], 1999 (Serbia)	Prospective case series	TPI [prolene mesh (Atrium®)]	6	56 (46-68)	11 mo (7-18)	Symptom assessment; Satisfaction assessment	Successful rectal evacuation without digitation (n = 6 patient); Symptom improvement [markedly (n = 2 patient), completely (n = 4 patient)]	Urine retention (n = 1)
							Satisfaction [very satisfied (n = 5 patient), somewhat (n = 1 patient)]
Watson et al[36], 1996 (United Kingdom)	Prospective case series	TPR + LP + Implant [prolene mesh (Marlex®)]	9	50, median (32-61)	29 mo, median (8-36)	Watson scoreFluoroscopic defecography	Significant decline in PO score (Pre = 11.7, PO = 1.9, P < 0.05); No further need for digital evacuation (n = 8); Significant decline in rectocele depth (Pre = 3.7, PO = 2.4, P < 0.05)	Wound infection (n = 1); Dyspareunia: Resolved (n = 1), abstained (n = 2), acquired (n = 1)
							Significant decline in barium trapping (Pre = 14%, PO = 5%, P < 0.005)

BBUSQ-22: 22-Item Birmingham Bowel and Urinary Symptoms Questionnaire; NP: Not provided; PGA: Polyglycolic acid; PO: Postoperative; Pre: Preoperative; SP: Sphincteroplasty; TPI: Transperineal implant; TPR: Transperineal repair (classic vertical plication); LP: Levatorplasty.

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.

Table 4 Results of modification of classic transperineal repair (with the omission of rectovaginal septum plication ± other additions or substitutions)

Ref.	Methodology	Technique	n	Age	Follow-up	Diagnosis and assessment	Outcome	Complications
Fischer et al[43], 2005 (Germany)	Retrospective cohort	TPLP	10(entire cohort n = 36)	59 (30-79)	36 mo (8-110)	Symptom assessment; Fluoroscopic defecography; ARM	Symptom improvement (cured): n = 9 patientAll patients (n = 7) showed improvement in FI	RVF (n = 1), wound infection (n = 1), dyspareunia (n = 1)
							3 out of 6 patients showed no rectocele with defecography
							Non-significant rise of both MRP and MSP
							Satisfaction with functional outcomes: n = 9 patient
Boccasanta et al[44], 2001 (Italy)	Retrospective cohort	TPLP (addition of prolene mesh in 2 patients)	126(entire cohort n = 317)	52.4 (28.0-80.0)	22.8 – 27.5 mo	Symptom assessment; Fluoroscopic defecography; ARM	Outcome (n = 110 patient) at 12 m: excellent (n = 45 patient), fair (n = 58 patient), poor (n = 7 patient)	Vaginal stenosis (n = 2)
							PO defecography: complete absence (44.1%), residual (55.9%); Non-significant rise of both MRP and MSP
Lamah et al[45], 2001 (United Kingdom)	Retrospective case series	TPLP ± SP> suction drain	44	57.5 (35.0-82.0)	42 mo (6-84)	Symptom assessment; Continence assessment; Sexual function assessment; Satisfaction assessment	Symptom assessment: TPLP (n = 33 patient): improvement of lump sensation (n = 28 patient), improvement of defecation (n = 29 patient); TPLP + SP (n = 11 patient): improvement of one or both (n = 8 patient)	Wound infection (n = 2), deteriorated FI (n = 1), dyspareunia (n = 2)
							Continence (n = 11 patient): at Pre [continent (n = 0), incontinent (n = 11)], at 12 mo [continent (n = 5), incontinent (n = 6)], at 24 mo [continent (n = 3), incontinent (n = 8)], > 36 mo [continent (n = 3), incontinent (n = 8)]
							Sexual function: TPLP [Improved (n = 8), unchanged (n = 9), deteriorated (n = 2), declined (n = 10)]; TPLP + SP [Improved (n = 2), unchanged (n = 2), deteriorated (n = 0), declined (n = 5)]
							Satisfaction (satisfied / total): TPLP [at 2 yr: (n = 30/33), at 3.2 yr (n = 21/24)]; TPLP + SP [at 2 yr (10/11), at 3.2 yr (6/11)]
Van Laarhoven et al[31], 1999 (United Kingdom)	Retrospective cohort	TPI + LP [prolene mesh (Marlex®)]	5 (entire cohort n = 22)	52.1 (31.0-81.0)	27 mo, median (5-54)	Symptom assessmentFluoroscopic defecographyPudendal nerve motor latency	Ability to evacuate rectum: improved (72.7%), unchanged (22.7%), deteriorated (4.5%); Significant decline in feeling of incomplete evacuation (Pre = 86.4%, PO = 45.5%, P = 0.01); 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	Wound infection (9.1%)
Parker and Phillips[46], 1993 (United Kingdom)	Retrospective case series	TPI + LP [prolene mesh (Marlex®)]	4	42-65	14 mo (6-18)	Symptom assessment	Successful rectal evacuation without digitation (n = 3), digitation occasionally (n = 1); Satisfaction (n = 4)	NP

ARM: Anorectal manometry; FI: Fecal incontinence; LP: Levatorplasty; MRP: Maximum resting pressure; MSP: Maximum squeeze pressure; NP: Not provided; PO: Postoperative; Pre: Preoperative; RVF: Rectovaginal fistula; SP: Sphincteroplasty; TPI: Transperineal implant; TPLP: Transperineal levatorplasty.