case series the use of mesh - technique descriptionand the pelvic ﬂoor via perineal and vaginal routeswithout Repair of the middle and posterior compartmentsof Coloproctology Journal of

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w w w . j c o l . o r g . b r

Journal of

Coloproctology

Original Article

Repair of the middle and posterior compartments of the pelvic ﬂoor via perineal and vaginal routes without the use of mesh - technique description and case series

Raquel Ferreira Nogueira

^∗

, Renata Soares Paolinelli Botinha Macedo, Sinara Mônica de Oliveira Leite

HospitalGovernadorIsraelPinheiro,BeloHorizonte,MG,Brazil

a r t i c l e i n f o

Articlehistory:

Received10May2020 Accepted11July2020

Availableonline17September2020

Keywords:

Rectocele

Pelvicﬂoordescent Transperinealsurgery Transvaginalsurgery Pelvicorganprolapse

a bs t r a c t

Introduction:Currently, problems such as constipation due to outlet obstruction, rectal/vaginal prolapseandfecalandurinaryincontinencehavebecomeincreasinglymore frequentbecauseofthepopulationagingprocess,withgreatimpactonthequalityoflife.

Objective:Todescribeatechniqueforsurgicalrepairofmiddle/posteriorpelvicﬂoorcom- partmentsandextra-mucosalrectalwalltreatmentbytransperinealandvaginalapproach, usingnativetissuesandpresenttheresultsintwentypatientssubmittedtothissurgical technique.

Method:Patientswithsymptomssecondarytomiddle/posteriorpelvicﬂoordescentand anatomicalchangesconﬁrmedbyproctologicalexamandpelvicMRIdefecography.Results wereevaluatedthroughtheAgachanconstipationscore,usingpre-andpost-operativeques- tionnaires.

Results:Immediaterepairofrectoceleandmusculature,withpromptimprovementofcon- stipation,sustainedby42months.Therewerenoseverecomplicationsinthepostoperative period.

Conclusion: Thisisaneffectivetechnique,withadequateanatomicrepair,improvementof constipationscoresandwithlowrisk.

licenses/by-nc-nd/4.0/).

∗ Correspondingauthor.

E-mail:raquelfnogueira140@gmail.com(R.F.Nogueira).

https://doi.org/10.1016/j.jcol.2020.07.008

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depelvequeconfirmaramasalteraçõesanatômicas.Aavaliaçãodosresultadosfoifeita comquestionáriosnopréepós-operatório,comautilizaçãodoescoredeAgachanpara constipaçãointestinal.

Resultado: Correção imediatada retocelee damusculatura, commelhoraimediata da constipação intestinal,sustentadaaolongode 42 meses.Sem complicaçõesgraves no pós-operatório.

Conclusão: Técnicaeficaz,comcorreçãoanatômicaadequada,associadaamelhorasigni- ficativadosescoresdeconstipaçãoedebaixorisco.

´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

Introduction

Pelvicﬂoordisordershavebecomeincreasinglycommon in recentyears.Greaterlongevityandthesearchforabetterqual- ityoflifeinapopulationthatremainsactiveforlongerleads tothesearchformoreeffectivetreatmentsfortheseproblems, whichhaveamajornegativeimpactonthisquality.^1–3

Thereareseveralfactorsrelatedtoagingthatworsenthe evacuation functions: deterioration of the muscles, inade- quatediet,physicalinactivity,alterationinperistalsiscaused byseveral diseases (neurological,diabetes, menopause,for instance)and several medications (commonlyused atthis age).Theobstetrichistory,withlateandprolongedbirthsand previouspelvicsurgeries,suchashysterectomy,aggravatethe problem.⁴

Thepatientsreportthatthestoolreachestheanus,butthey areunabletoeliminateit,requiringmucheffort.Asaresult, analproblemssuchashemorrhoidsandﬁssuresworsen,as well as rectal intussusception and, ultimately, prolapse of pelvicorgans.⁴

Pelvic ﬂoor dysfunction is a complex condition. This muscle-ligamentstructuredividedintothreecompartments –anterior(bladderandurethra),middle(uterusandvagina) and posterior (rectum) – must be understood as a unit.

Althoughthesymptoms arevaried,affectingonecompart- mentmoresigniﬁcantlythantheothers,thediagnosisshould be made by studying all three compartments, in addition toconsideringtheclinicalconditionsofeach patient.⁵ This variability makes it difﬁcult to standardize the conduct, requiringknowledgeandexperienceforanappropriatedeci- sion.

Thetechniquethatwillbedescribedappliestothetreat- ment of patients with ruptures in the middle/posterior compartmentsofthepelvicﬂoor,withlacerationoftheper- inealfasciaandfasciapropriarecti,whichcausesdilationof therectalampullawiththeformationofrectoceleandrectal intussusception.Italsoallowstheassociationofsmallente- rocelerepair,vaginaldomeprolapse,ruptureoftheperineal bodyandoriﬁceprocedures,suchasrectalmucosalprolapse repair,hemorrhoidectomyandsphincteroplasty.

Thisstudyisabouttheanatomicalrepairofdefects,viaper- inealandvaginalroutes,usingnativetissues,withoutmesh use.Detailedsurgicalplanning,basedonﬁndingsofphysical andimagingexams,iscrucialforasuccessfultreatment.

Methods

Thisstudywasanobservational,descriptiveandretrospective analysiscarriedoutwith20womenpresentingsymptomatic rectocele(intestinalconstipationwithdefecationeffort and perianaluseoffingerstoaidintheremovalofstool)andother analproblems(suchasmucosalprolapse,hemorrhoids,anal fissure)fromJune2015toMarch2020.Allpatientsunderwent repair of the middle/posterior compartmentsof the pelvic floorviaperinealandvaginalroutes,asdescribedbelow.The patientsansweredastandardizedquestionnaire,basedonthe Agachan⁶constipationscoreappliedpreoperatively,oneyear after the procedure and at the present time, bytelephone interview.

Thediagnosiswasattainedinallpatientsviaproctolog- ical examinationand defecographybymagnetic resonance

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Fig.1–PelvicMRIdefecographyshowingarectoceleduringtheevacuationphase.

imagingofthepelvis(Fig.1).Patientswho metthecriteria forcolorectalcancerpreventionunderwentacolonoscopy.

Inclusionandexclusioncriteria

Allpatientswithsymptomsofobstructeddefecation,includ- ingthosesubmittedtovaginal,perianaloranalsurgeriesor sometypeofabdominalsurgerytotreatpelvicﬂoordescent, suchascystopexyorrectopexy,wereincluded.Thepatients whodidnotagreetoparticipatebyansweringthequestion- nairewereexcluded.

Thestudywasapprovedbytheinstitution’sResearchEthics CommitteeandallpatientssignedtheFreeandInformedCon- sentform.

TheSPSSsoftwareversion20.0 byIBMwasusedforthe statisticalanalysis.Quantitativevariablesweredescribedas mean±SD whentherewasanormaldistributionorasthe medianwhen the distribution was non-normal(the distribution was verified by the Shapiro-Wilk test). Categorical variables were described through absolutefrequenciesand percentage.Thecorrelationanalysesofthevariableswereper- formedusing Spearman’scorrelationwhenthedistribution wasnon-normalorPearson’scorrelationwhenthedistribu- tionwasnormal,verifiedbytheShapiro-Wilktest.Thelevel ofsignificancewassetat5%.

Surgicaltechnique

Duringthepre-anestheticexams,menopausalpatientswith- outhormonereplacementtherapywereadvisedtousevaginal estrogenfor6weeks(withthegynecologist’sapproval).

Thepreoperativepreparationincludedfastingandretro- gradepreparationoftherectum,withasmallenemaonthe morningofthesurgery.Ceftriaxoneandmetronidazolewere usedasprophylacticantibioticsattheoperating table.The anesthesiaconsistedofaregionalanestheticblockassociated withintravenoussedation.Thesurgeryisperformedinthe lithotomyposition.Along-termindwellingurinarycatheters wasused.

Surgery is started by an inverted “T” incision, with a transversal perineal incision (just anterior to the anal

Fig.2–Normalanatomy.

sphincter), horizontal measuring 4–5cm and longitudinal –colpoperineotomy–inthemiddleofthisincision,towards themidlineontheposteriorvaginalwall.Thissecondincision isperformedprogressively,whilereleasingtheanteriorwall oftherectumfromtheposteriorvaginalwall,alwaysadhered toavaryingdegreedependingonpreviousobstetric/surgical trauma.Thisdissectionisperformedwithaconcomitantrec- talexaminationtoensurethatthesurgicalplanbemaintained withoutinjuringtherectalwall,whichisoftenverythin,as wellasthevaginalwallinelderlypatients.Thecraniallimit ofthecolpotomywasapproximately4−5cmbelowthecervix ortheclosedvaginalapex.Then,therectaldissectionbegins laterally,fromtheperinealbodytothecraniallimit(bottomof theDouglaspouch).Thelaterallimitistheobservationofthe tendinousarchofthepelvis,wherethelevator animuscles areinserted.Itisacarefuldissection,withcarefulhemosta- sis,whichhasvariabledegreesofdifﬁculty,duetoprevious localtrauma.Attheendofthedissection,themiddle-distal rectumismobilizedanteriorlyandlaterally(Figs.2–4).After thisrelease,itiseasy toidentifythefasciapropriarection thesidesanditsmedialmobilizationoccurswithouttension, correctingthetraumathatoccurred.Then,theextramucosal rectalwallandthefasciapropriarectiareplicated,fromcaudal

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Fig.3–Post-trauma:lacerationoftherectusfascia.Dueto thetrauma,therectusfasciaandrecto-vaginalfasciaare injured.Therectumwidens,occupyingthepelvis(rectocele) anddescends(favoringintussusception)-arrows.

Fig.4–Post-dissectionoftherectumlatero-craniallytothe left.

tocranialtothebottomoftheDouglaspouch,withseparated polyglactin2−0suturesin“X”(Figs.5and6).Astheplica- tion isperformed, itcan beobservedthat the rectovaginal fasciaandthelevatoranimusclesapproachthemidline,nat- urally.Ifnecessary,theperitoneumisopenedatthebottom ofthe Douglaspouchand plicated,reducingit.Afterwards, theclosingoftheposteriorvaginalwallbeginsattheapexof itsopening,fromcranialtocaudal,withcontinuoussutures using2−0catgut,interruptedevery3cm.Thisstepisimpor- tant,becauseifthatislefttobeclosedaftertherectovaginal fasciarepairandtheapproximationofthemusculature,the accessbecomesdifﬁcult.Therectovaginalfasciaistheniden- tiﬁedandplicatedusingcontinuouspolyglactin2−0sutures.

Then,thepuborectalismusclesareplicatedifthereisnoten- sionin the midline (Fig. 7). If there is tension, it is better nottoperformtheapproximation.Theposteriorvaginalwall isprogressivelysutured.Finally,theperinealmusculatureis repairedenbloc.Then,thesphinctermusculatureisobserved, andits repairisassessed,withtheﬁxation ofthe external sphinctertotheperinealbody–thenormalsiteofitsinser- tion.Thevaginalandperinealclosureiscompleted.Then,itis alreadypossibletoobservethecompleterepairoftherectocele andtheperinealmusclemass,aswellasthereductionofhem-

Fig.5–Post-repairofthefascialandsphincterrectocele defectandelongationoftherectalwall(reducingthe possibilityofintussusception)-arrows.

Fig.6–Completeplicationoftheanteriorwallofthe rectum,withrectocelerepair.

Fig.7–Plicationofthelevatormuscles.

orrhoidalorrectalmucosalprolapse.Ifthisprolapseexists,it ispossibletocorrectit,removingonlythatwhichprolapses.

Attheend,avaginalexaminationisperformed,makingitpos- sible toobservethe horizontalizationofthe vaginaand its elongation.Attherectalexamination,thereisnomorerec-

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toceleand alongitudinalinvaginationon theanterior wall ofthe rectum,measuringapproximately8−10cm long,can beobserved,beingtheresultoftheextramucosalplication performed.Atthreemonthspostoperatively,thisinvagination becomesimperceptible.Acompressiondressingispositioned usingavaginalplugwithgauzedressingsembeddedinxylo- cainegel.Theaveragesurgerytimeis120min.

A free diet is allowed in the postoperative period, and analgesicsareprescribed.Onthefollowingday,thedressing andin-dwellingcatheterareremoved;ambulationispermit- ted,and diuresisand thepresenceofbleeding areveriﬁed.

Discharge occurs on the 2nd POD with dietary advice to avoidconstipation.Normalhygieneduringshowerisrecom- mended,aswellasavoidingcarryingweight,squattingand sexualintercoursefor30−40days,dependingonthepatient’s healingstatus.

Results

Duringthisperiod,20patientsagedbetween37and81years (mean63.9years)who hadclassicsymptomsofobstructed defecationunderwentsurgery. Asforthediet,19 ofthe20 patientsdeclaredadailyﬁberintakeand40%ingestedless than1200mLofwateraday.Onlyonepatientwasnulligesta and 5 patients (20%)did not havea vaginal delivery, with an average of 3 deliveries per patient. Regarding previous surgeries,onethirdofthepatientshadalreadyundergonehys- terectomy,10%had undergonehemorrhoidectomyand35%

hadundergone aperineoplasty.Only3ofthe patientshad undergonemorethanoneprocedure,namelyperineoplasty and hysterectomy,and 12 patientshad notundergone any surgeryintheperinealregion(Table1).

Therewerenocomplicationsintheimmediatepostoper- ativeperiod.Onlyonepatienthadarectovaginalﬁstulaon the8thpostoperativeday,whichresolvedspontaneouslyup tothe30thpostoperativeday.Partialdehiscenceoftheper- inealclosurewascommon(5patients),withhealingbysecond intention.Twopatientsdiedintheperiodduetocomorbidi- tiesnotassociatedwiththesurgery(1and4yearsafterthe surgicalprocedure).

Allpatientssubmittedtothequestionnaireinthepreoper- ativeandpostoperativeperiodin1yearshowedimprovement intheAgachanscore,withasigniﬁcantdecreaseinthemean value(p<0.00001).Allofthemansweredtheywouldundergo thesurgeryagain,if necessary,and weresatisﬁedwiththe results.Ofthe13patientswhoansweredthecurrentassess- ment,whenaskedhowtheyfelt–worse,thesameorbetter– atthecurrenttimecomparedtothepostoperativeperiod,11 reportedfeelingbetterand2reportedfeelingthesame,thelat- terduetotheneedtostilluselaxativemedicationtomaintain goodevacuationhabits.

TwelvepatientshadtheAgachanscoreestablishedpreop- eratively–theminimumvaluewas5andthemaximumvalue was21, withanaverage of12.67. Thesepatients, at1year postoperatively,had anaverageAgachanscoreof6.75 with p<0.001(minimumvalues of1andmaximumof12).Thir- teenpatientsansweredthecurrentquestionnaireandhadan Agachanscorerangingfrom0to15,withameanvalueof6.65

Table1–Characterizationofpatients.

Variables n=20

PODinmonths,median(Q1;Q3) 42.00(21.00;51.00)

Age(mean±SD) 63.86±11.10

Consumptionofglassesofwater,n (%)

1to3 4(20.0)

4to6 4(20.0)

>6 12(60.0)

Frequencyofﬁberconsumption

2×aweek 1(5.0)

Daily 19(95.0)

Pregnancies/Deliveriesperpatient, median(Q1;Q3)

3.00(2.00;4.00) Vaginaldeliveriesperpatient,

median(Q1;Q3)

2.00(0.50;3.50) Caesareandeliveriesperpatient,

median(Q1;Q3)

0.00(0.00;1.00) Hysterectomy

Yes 6(30.0%)

No 14(70.0%)

Hemorrhoidectomy

Yes 2(10.0%)

No 18(90.0%)

Perineoplasty

Yes 7(35.0%)

No 13(65.0%)

PreoperativeAgachan(mean±SD) 12.67±4.38 PostoperativeAgachanscore,

1year(mean±SD)

6.70±4.24 CurrentpostoperativeAgachan

score(mean±SD)

6.65±4.39 Surgicalresult:thesame,betteror

worse

Thesame 2(15.4%)

Better 11(84.6%)

Total 13(100.0)

andamedian(Q1;Q3)of6.00(2.00;10.00),correlatingwiththe postoperativeAgachanat1year.

Only33%ofpatientshadanAgachanscore≤10preopera- tively,while80%ofpatientshadAgachan<10postoperatively (one yearorcurrent). ThehigherAgachanscoreinthepre- operativeperiodwas associatedwithahigherscore inthe postoperativeperiod.

Discussion

Disordersofthemiddle/posteriorpelvicfloorarecomplex,and it isdifficulttocorrelatethe symptoms(incompleteevacu- ation,fecal impaction,use offingerstoaid intheremoval ofstoolanddefecationeffort)andtheassociatedanatomical defects.Grimesetal.⁴comparedthesurgicalrepairofthevagi- nalposteriorwallprolapseassociatedornotwithotherpelvic proceduresandconcludedthatthisanatomicalrepairofthe posteriorcompartmentsignificantlyimprovedallsymptoms associatedwithevacuationdifficulties,includingfecalincon- tinence.Inthestudy,40%ofthepatientshadpreviouspelvic surgeryand59%ofthemreportedatleastsomesymptomof obstructeddefecation.⁴Inthepresentstudy,themeanageof thepatientswas63.8years.Fifteenpatients(75%)hadvaginal deliveries,withanaverageof3deliveries/patient.Sixpatients

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Preoperative Agachan (mean±SD)

1-yearpostoperative Agachanscore (mean±SD)

p-value^a

12.67±4.38 6.75±3.194 <0.001

a Pairedt-test.

hadaprevioushysterectomyand1/3hadalreadyundergone aperineoplasty.

TheAgachanscoreassessesconstipation–evacuationfre- quency, difficulty during evacuation, feeling of incomplete evacuation,abdominalpain,timeneededtoevacuate,useof laxativesoruseoffingerstoaidintheremovalofstool,fre- quencyoffailure,historyofconstipationintimeofsymptom (years).Thehigherthescore,theworsethe clinicalpicture (from0to30).⁶Inthisstudy,thepreoperativeAgachanscore rangedfrom 5to21(mean 12.67)and inthe postoperative period(1year),themeanAgachanscorewas6.75withp<0.001 (minimumof1;maximumof12)(Tables2and3).Thecurrent Agachanremainsequivalenttothatof1year–mean=6.65– confirmingthatthetreatmentresultwasmaintainedthrough- outtheperiod(42monthsofmeanfollow-up).

Abendsteinetal.⁵recommendacomprehensiveevaluation ofstructuresthroughimagingexamination.Inthisstudy,in additiontothedetailedproctologicalexamination(atrestand dynamic),thepatientsunderwentdefecographybymagnetic resonanceimagingofthepelvis.Atthetimeofthesurgery, afteranesthesiaandpositioningofthepatient,acarefulexam- inationwasonceagainperformed,andthesurgicalplanning wasconﬁrmed.Thetechniquemustbeindividualizedaccord- ingtotheanatomicalalteration.

Thefoundation ofthe described techniquerespectsthe principle oftrauma surgery:restoring anatomicalintegrity.

Thedamageisidentiﬁed,thestructuresaredissectedtoiden- tifythem,andtheyarereconstructedinplanesuntilcomplete repair,usingnativetissues.Ifthereisnotissueavulsion,there isnoreasonforﬂaprotation.Thetissuesareallthere,albeit sectionedandhealederroneously.“Repairthestructureand youwillcorrectthedysfunction”.^7,8

In a Cochrane review, the transvaginal repair was con- sidered the most effective technique to prevent prolapse recurrence, when compared to the transanal repair, both in objective and subjective indexes.⁹ A recent systematic review,afterreviewingstudiesthatincludedsixdifferentsur- gical techniques (abdominal, vaginal and trans-anal ones)

posteriorvaginalwallisaconsequenceofthe rectalpouch that isformed bythe rupture ofthe supportingstructures and repeateddefecationefforts,withincreasedpressurein therectalampulla.Correctingonlythevaginalwalldoesnot adequatelycorrectthisenlargementoftherectalampulla.As forthelevatorplication–onlyperformedwhenthemuscles naturallyapproachthemidlineaftertherectalplication–it improves thefunctionaloutcome andtheriskofdyspareu- niashouldbediscussedwiththepatients.^11,12 JhaandGray performed asystematicreviewand meta-analysisfocusing ondyspareuniaassociatedtotransvaginalrepair.Theycon- cludedthatthesexualfunctionissigniﬁcantlyimproved,and dyspareuniaisreducedafterthesurgery.¹³

Thisdescribedtechniquedoesnotrepairtheanteriorcom- partment.Thus,urinaryincontinencemayappearagain,after theexitisnolongerobstructedduetothemiddle/posterior repair. Haﬁdh et al. found an incidence of 4% and better prospectivestudiesarenecessarytoassessthistopic.¹⁴

Bladderretention,fecalurgencyand/orincontinenceand partialdehiscenceofthe perinealwoundmayoccur inthe postoperativeperiod.Inthepresentstudy,therewerenocom- plicationsthatrequiredthepatientstoreturntotheoperating room. Thebenefitregardingthedefecationact,withoutthe needforeffortorusingthefingerstoaidthedefecation,was observedasearlyasinthefirstevacuation.

Theproblemwithusingnativetissuesistheriskofrecur- rence.Oversandetal.foundasubjectivesatisfactionrateof 94%inoneyear,withareoperationrateof2.6%in5years.¹⁵ Inthe 1990s,theuseoftransvaginalmeshestocorrectthe prolapseofpelvicorgansbegantoreducerecurrences.How- ever,duetothenumerousadverseeventsassociatedwiththis procedure, in2019theFDA(FoodandDrugAdministration) banned the sale and distribution ofmesh fortransvaginal surgical repair.^16–18 Wechose touse native tissuesfor the perineal/vaginalaccessprocedure.Webelievethatthelon- gitudinalrepairoftheanteriorrectalwallreducestherectal ampullaandcorrectsthefrequentlyassociatedrectalintus- susception,withaconsequentimprovementinevacuation– afactconﬁrmedbythesigniﬁcantlybetterAgachanscoresin thepostoperativeperiod.Associatedwithperineoplasty,this rectalrepaircancontributetoreducesymptomrecurrence.

Thisstudyhaslimitations:thevariabilityofdefectsiden- tiﬁedinthepatients,theirsubjectivitywhenansweringthe questionnaires,thefactthatitisaretrospectivestudyandit wasperformedbyasinglegroup.Functionalproblems,suchas constipation,arecausedbyfactorsthatarenotonlymechan-

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ical,but alsoneurofunctionaland thismakesit difﬁcultto actuallyevaluatetheresults.Wedidnotcomparethestandard colpoperineoplastywiththatassociatedwithrectalwallpli- cation,aswebelievethereisgreatereffectivenesswithrectal repair–whichiswhatwedo.Thecomparisonoftheperiods beforeandafterthesurgicalprocedureinthesamepatient, consideringthatthetreatmentgoalistoimprovequalityof life,makes usvalue the results, as this improvementwas reportedbythepatients,withresultsbeingsustainedthrough- out42months.Agreaterunderstandingoftheproblemwill allowabetterevaluationinfuturestudies,whichareneces- sary.

Conclusion

Therepair of the middle / posterior compartments ofthe pelvicﬂoorviaperinealandvaginalrouteswithouttheuseofa mesh,withassociatedplicationoftherectalwall,isadequate forthetreatmentofobstructeddefecationdisordercausedby rectocele,withlowrisk.

Conﬂicts of interest

Theauthorsdeclarenoconﬂictsofinterest.

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