Rectovaginal Wall Research Articles

Three years prospective clinical and radiologic follow-up of laparoscopic sacrocolpoperineopexy.

When Rectocele is part of a complex pelvic organ prolapse, a full repair is recommended. The aim of this study was to evaluate the clinical and radiological results after laparoscopic surgery in patients with symptomatic rectocele and III/IV stage vaginal vault prolapse METHODS: This is a prospective cohort study of women with symptomatic rectoceles and middle compartment prolapse operated on between 2013 and 2015, who underwent a laparoscopic sacrocolpoperineopexy with synthetic Y mesh attached to puborectalis muscles, the anterior and posterior vagina wall and the sacrum. The clinical outcomes measured were symptoms of prolapse, obstructive defecation syndrome and quality of life. Radiological outcomes were distance of the vaginal vault below pubococcigeal line and depth of rectovaginal wall protrusion in dynamic pelvic resonance. 33 patients were included. 32 of them remained asymptomatic after a three years follow-up. Significant differences were shown in the obstructed defecation score and quality of life after 6, 12 and 36months compared to preoperatively. No differences were identified when the postoperative results were compared. Significant differences were shown in preoperative vaginal vault prolapse (3.2cms ± 0.8 SD below the pubococcigeal Line) and rectocele size, compared with 1 and 3years after surgery. There were no significant differences in vaginal vault prolapse when compared after 1 and 3years. When rectocele size after 1 and 3years was compared, significant differences were shown, but only one clinical recurrence (3%) was identified after a mean follow-up of 47months. Laparoscopic sacrocolpoperineopexy in patients with symptomatic rectocele and III/IV vaginal vault prolapse solves the constipation and obstructed defecation with an excellent quality of life and low clinical recurrences. Radiological deterioration, especially in rectocele size, was identified in the mid-term follow-up without clinical significance.

Nationwide Trends of Bowel Obstruction and Intussusception in Endometriosis Patients [11H

INTRODUCTION: One of the complications of endometriosis rarely described is bowel obstruction (BO). The purpose of our study was to evaluate the incidence of BO among women with endometriosis, the trend and the demographic characteristics. METHODS: We used the data from the Healthcare Cost and Utilization Project—Nationwide Inpatient Sample (HCUP-NIS). We studied women with endometriosis aged 15 to 55-years from 2005-2014. Those with neoplasms in the genitourinary or gastrointestinal system were excluded. RESULTS: Of a total 278,613 women with endometriosis, 1386 had BO or intussusception resulting in an overall incidence of 0.5%. Although the number of hospital admission related to endometriosis were decreasing, there was a significant increase in the incidence of bowel obstruction/intussusception during the time period from 0.3% to 0.9%. Moreover, women with BO tend to be white and with higher income (P<.05). The incidence of BO in those with endometriosis in the pelvic/peritoneum and the intestine were comparable. Also, those with BO tend to have lower BMI (P<.05). In addition, there was no association between diabetes mellitus, hypertension, dyslipidemia or hospital region, and the incidence of BO. CONCLUSION: Although there is a downtrend in the incidence of hospital admission related to endometriosis, the incidence of endometriosis specifically in the intestine or the rectovaginal wall as well as the incidence of bowel obstruction has been slightly increasing.

Postoperative complications of male to female sex reassignment surgery: A 10-year French retrospective study

In primary male to female (MTF) sex reassignment surgery (SRS), the most frequent postoperative functional complications using the penoscrotal skin technique remain neovaginal stenosis, urinary meatal stenosis and secondary revision surgery. We aimed to retrospectively analyze postoperative functional and anatomical complications, as well as secondary procedures required after MTF SRS by penile skin inversion. All patients operated on for MTF SRS, using the inverted technique, from June 2006 to July 2016, were retrospectively reviewed. The minimum follow-up was one year (five-years maximum follow-up). Soft postoperative dilationprotocol was prescribed until complete healing of the vagina. We did not prescribe long-term hard dilation systematically. Possible short-depth neovaginas were primarily treated with further temporary dilation using a hard bougie. Among the 189 included patients, we reported a 2.6% of rectovaginal wall perforations. In 37% of patients we had repeated compressive dressings and 15% of them required blood transfusions. Eighteen percent of patients presented with hematoma and 27% with early infectious complications. Delayed short-depth neovagina occurred in 21% of patients, requiring additional hard dilatation, with a 95.5% success rate. Total secondary vaginoplasty rate was 6.3% (4.7% skin graft and 3.7% bowel plasty). Secondary functional meatoplasty occurred in 1% of cases. Other secondary cosmetic surgery rates ranged between 3 to 20%. A low rate of secondary functional meatoplasty was showed after MTF SRS by penile skin inversion. Hard dilation was prescribed in case of healed short-depth vagina, with good efficiency in most of cases. Secondary vaginoplasty was required in cases of neovagina stenosis or persisting short-depth neovagina after failure of hard dilation protocol.

Traitement médical de l’endométriose : prise en charge de la douleur et de l’évolution des lésions par traitement hormonal et perspectives thérapeutiques

Endometriosis is a chronic painful disease, for which hormone therapy is usually offered as a first line option to women not willing to conceive. To analyse and synthesize the literature, from 2006 onwards, on pain control, and disease evolution in oemn using combined hormonal contraceptives, progestins and GnRH analogs. Data on other current and future treatment perspectives is included as well. Medline (Pubmed), the Cochrane Library, and endometriosis treatment recommendations published by European Society of Human Reproduction and Embryology (ESHRE), National Institute for health and Care Excellence (NICE), American College of Obstetricians and Gynecologists (ACOG), Royal College of Obstetricians and Gynaecologists (RCOG) and Société des Obstétriciens et Gynécologues du Canada (SOGC). Meta-analysis and clinical trials are included. Study quality is heterogeneous in general. Hormone therapy inconstantly allows pain relief and prevention of endometrioma and rectovaginal wall nodules recurrence. Available molecules and routes of administration as well as risk benefit balance are evaluated. Data on future perspectives are limited to date and do not allow use in routine. Hormonal treatment of endometriosis relies on combined hormonal contraceptives (using different routes of administration), progestins and particularly the levonorgestrel-releasing IUS, and GnRH analogs as a last option, in combination with an add-back therapy. Promising alternatives are currently under preclinical and clinical evaluation.

40 - Partial Vaginectomy for Excision of Rectovaginal Endometriosis

Rectovaginal endometriosis, a variant of deep infiltrating endometriosis, can cause dyspareunia and dyschezia when it involves the rectovaginal wall. It most commonly affects the posterior vaginal fornix and nodularity is often palpable in the posterior cul-de-sac on pelvic exam. Oftentimes, surgical excision is necessary to provide symptomatic relief. This video will demonstrate the excision of rectovaginal endometriosis through two examples – A) after completion of a total laparoscopic hysterectomy and B) performed conservatively when the uterus is left in-situ. We demonstrate advanced surgical techniques and tips in laparoscopic retroperitoneal dissection and laparoscopic suturing for reconstruction of the vagina to ensure complete excision in the definitive treatment of this lesion.

Interposition grafts for rectovaginal fistula repair in the New Zealand white rabbit

The objective was to use an animal model to study different types of interposition grafts for rectovaginal fistula repair. Twelve New Zealand white rabbits underwent surgical creation of a rectovaginal fistula, followed by repair. Four repair techniques were studied; three with interposition grafts and one control group without a graft. Animals were euthanized at 4-week intervals and underwent gross and histologic analysis. The mean rectovaginal wall thickness was greatest in the control group (5.6 mm) and thinnest in the autologous rectus fascia (4.2 mm) and porcine small intestine submucosa (5.1 mm) groups. The polypropylene graft had a mean thickness of 5.4 mm and elicited a strong, protracted inflammatory response. All fistulas were successfully closed except one porcine small intestine submucosa repair. There is no benefit from interposition graft use for rectovaginal fistula repair in our New Zealand white rabbit model.

Traitement par colle biologique des fistules postopératoires en chirurgie colorectale

Fistula morbidity after colorectal surgery is high and such fistulae are hard to treat. There have occasionally been reports of closures using biological glue. This work presents the results of a prospective study concerning 14 patients.Patients and methodsBetween June 2004 and January 2008, all patients presenting with a postoperative fistula were included in the study, except if the fistula involved the vagina, was over 1 cm or communicated with a non-draining cavity. 14 patients (10 male) were treated, the average age being 63.5 years: 11 rectal cancers, 2 cases of diverticulitis and one stromal tumour of the recto-vaginal wall. Three out of 13 had had preoperative radiotherapy. The cases involved were 6 low and 4 high colorectal anastomoses (CRA), of which 9 were lateroterminal, 3 coloanal anastomoses (CA) and one rectal suture without anastomosis. Seven patients had spontaneous stoma (CA + low CRA). Diagnosis of the fistula was made by imaging in 11 cases (scan, MRI), twice by endoscopy and once by clinical exam; in nine cases, diagnosis was made early on (< 14 days) and in five cases it was late (> 57 days). In six cases, all diagnosed early, it was necessary to create a second stoma. Glueing was carried out one and a half times on average, using 1–3 mls of glue (Beriplast®); effectiveness was measured by CAT-scan or MRI.ResultsImaging showed the fistula to be closed in 12 cases and the stoma was removed an average of 389 days after it had been created, 44 days on average after the first glueing attempt for the later forms and 168 for the early forms. In two cases, despite closure of the fistula, presacral infiltration could be seen on the scan, without recurrence of the tumour. Late closures may have been connected with postoperative chemotherapy.ConclusionThis series, the most extensive report on gluing fistulas after colorectal laparoscopie surgery, shows that treatment by endoscopy is effective. The primary advantages of this technique are its absence of morbidity and real effectiveness, particularly considering the chronic fistula associated with the surgical alternative. Twelve of the 14 fistulae were successfully closed.

Concurrent chemoradiation (CCR) for locally advanced or relapsed vulvar carcinoma (VC) treatment: An alternative to pelvic exenteration (PE)

15021 Background: PE is the standard treatment for locally advanced or relapsed VC that involves the anus or rectovaginal wall, with high morbidity and the consequent loss of Qol. Objective: Locoregional response, toxicity, disease free survival (DFS) and survival (SV) achieved with concurrent chemoradiation in locally advanced or relapsed VC was prospectively evaluated. Methods: From 7/93 to 05/05, 32 pts which would have required some kind of PE were treated with mitomycin C (10 mg./m2 d1) + 5-Fluoruracil (800 mg/m2 d 1–4) IV continuous infusion, plus concurrent external radiotherapy (50 Gy) to the vulva, pelvis and groin. An additional boost (15–20 Gy) was added when a less than complete clinical response (CR) was achieved. Multiple biopsies of the tumor bed were performed to confirm complete pathologic responses (CPR). Results: 30 pts (94%) completed treatment as planned. Overall, locoregional response was obtained in 25/30 (83.3%) pts: 20 (66.6%) CR, 5 (16.6%) partial response (PR). 3 (10%) pts had stable disease and 2 (6.6%) progresive disease. 14/30 (46.6%) had CPR. Radical vulvectomy or radical local excision was performed in 7 pts for residual disease after CCR (4/6 with CR and microscopic residual disease and 3/5 with PR), 2 pts with PR were lost after having completed CCR and 2 pts with CR and microscopic residual disease refused further treatment. None of the responding patients required PE. Treatment was well tolerated with mild to moderate toxicity, attributed to radiotherapy. No treatment deaths were recorded. 28 pts with a median follow-up of 25.5 months (range 6–126) showed a 5-year cumulative DFS (34%) and SV (49%). Conclusion: CCR is a safe therapeutic option with results comparable to those obtained with PE, with significant improvement of Qol. CCR has become the standard treatment for locally advanced or relapsed VC at our center. No significant financial relationships to disclose.

Innervation of the rectovaginal wall in patients with rectocele compared to healthy controls

To evaluate if pelvic floor innervation differed in patients with rectocele compared to control subjects and to assess if nerve fiber density of the rectovaginal wall correlated to the clinical presentation of rectocele. Biopsies from 24 female patients with posterior vaginal wall prolapse stage II (ICS-classification) and rectocele verified at defecography were compared to specimens from age and parity-matched control subjects without posterior vaginal wall prolapse. Nerve fiber density was measured using protein gene product (PGP-9.5) antibodies at immunohistochemistry. Anorectal symptoms were recorded using bowel and anorectal function questionnaires. The two groups were comparable in age and parity. Mean nerve fiber immunofluorescence intensity was 150.3 +/- 12.5 SD in the patient group compared to 139.3 +/- 8.5 SD in the control group (P < 0.01). Symptoms of anorectal dysfunction were more common in the patient group compared to control subjects (P < 0.01) but there was no difference in anal continence. At logistic regression analysis, nerve fiber immunofluorescence intensity showed no significant correlation to age, menopausal age, parity, body mass index (BMI), prolapse quantification, or any specific self-reported anorectal symptom. Increased nerve fiber immunofluorescence intensity was correlated to increased perineal descent (OR 1.3, 95% CI 1.1-2.1) although not to the size of the rectocele (OR 0.5, 95% CI 0.9-1.2). Our results show that rectocele may be associated with increased rectovaginal innervation, suggestive of reinnervation of the rectovaginal wall. Nerve fiber density correlated poorly with findings at clinical and radiological examination. Neurochemical characterization of the rectovaginal wall may provide further understanding of the pathogenesis of rectocele.

Maladie de Crohn révélée par des lésions anopérinéales : intérêt de l’ IRM

The authors report a case of perineal Crohn disease with three anal fissures. Because of a persistant fever without any clinical aspect of abscess they practiced MRI examination that discovered an abscess of the recto-vaginal wall. The patient was operated under general anaesthesia. This clinical case shows the interest of radiologic examens, particularly pelvic MRI for the precise lesional diagnosis of anoperineal lesions of Crohn’s disease, that is still complexe and difficult to treat.

Ｒｅｃｔｏｃｅｌｅに対する経こう門的直腸粘膜焼灼・直腸ちつ壁縫縮法に関する臨床的検討

Rectoceleは,主に女性において直腸前壁の弛緩のために,便秘・排便困難・残便感などの排便障害を呈する疾患である.rectoceleには内痔核・裂肛等の肛門部病変を伴うことが多く(約65%),その処置も必要な場合があること,愁訴が排便に関するものであるため,経肛門的手術のほうが受け入れやすいなどの理由から,当院においては「経肛門的」手術を行っている.すなわち経肛門的に,rectoceleの存在範囲およびその周囲の直腸粘膜上皮を電気メスにて焼灼し,直腸粘膜下層・直腸固有筋層・rectoceleの両側に存在する肛門挙筋に対し,横方向の結節縫合を施行し直腸腟中隔を補強,ドレナージ創を作製するという術式である.1997年4月から1999年3月の間に72例のrectocele手術症例を経験し,有症状例60例は全例に症状の改善が得られた(excellent 39例(65%),good 18例(30%),fair 3例(5%),poor 0例(0%)).全治4週間程度であり,合併症は認めず.有効な手術方法であると考えられる.

Surgical treatment of benign, myomatous rectal tumors.

Between 1972 and 1990, 36 patients with leiomyoma of the rectum underwent surgery at the Proctology Institute (Moscow). There were 13 male (36.1 percent) and 23 female (63.9 percent) patients. Their median age was 52.1 years. Electroexcision of the tumors measuring below 1 cm was performed through the endoscope in 12 patients. Leiomyomas with a diameter of 2.5 to 5 cm were removed transanally in 10 patients. Six patients underwent excision of the tumor through the pararectal approach, whereas leiomyomas located in the rectovaginal wall were removed through the vagina in one patient. Abdominoperineal extirpation and abdominoanal resection of the rectum was performed in seven patients with tumors measuring from 8 to 20 cm. Recurrences were noted in nine patients after transanal, pararectal, or transvaginal excision of leiomyomas. In seven of them, malignant transformation of the tumor occurred at terms ranging from 9 months to 9.5 years.

Rupture of the Recto-Vaginal Wall

Rupture of the Recto-Vaginal Wall

Disease and Sloughing of the Recto-Vaginal Wall

Disease and Sloughing of the Recto-Vaginal Wall

Laceration of the Recto-Vaginal Wall

Laceration of the Recto-Vaginal Wall