Surgical treatment of rectocele with the use of mesh implants by the obstructive defecation syndrome

UNLABELLED: The aim of current study was to evaluate in complex the effectiveness of transvaginal mesh implants in women with obstructed defecation (OD) syndrome based on the comparison of preoperative and postoperative results of objective diagnostic tools and quality of life parameters. METHODS: from prospectively collected database of patients treated in our department those who were treated for OD by means of transvaginally placed mesh implants were chosen. The comparison of pre- and postoperative results of objective evaluation (prolapse stage according to POP-Q system, X-ray defecography - XR-DG and MRI defecography - MRI-DG) as well quality of life parameters (Wexner constipation score and validated Russian version of King's Health Questionnaire) was undertaken. Treatment effectiveness was evaluated using Сlinical Global Impression - Improvement (CGI-I) и Patient Global Impression - Improvement (PGI-I) scales. RESULTS: In 2007-2011 40 women (mean age 51.8±10.7 years) underwent transvaginal pelvic floor reconstruction with mesh implants. All of them had ≤3 stage pelvic prolapse (POP-Q) and rectocele. Preoperative XR-DG and MRI-DG helped reveal rectocele >4 cm in 85 and 43% of women respectively, 68% of patients had cystocele and 18% - genital prolapse. In 21 case mesh implants for posterior pelvic floor reinforcement were used, in other cases mesh implants for total pelvic floor repair were placed. At a mean of 19 months after the operation manual examination revealed that 90% of women had 1 stage posterior pelvic proplapse, at XR-DG and MRI-DG significant reduction of rectocele size and depth of pelvic floor descent was noted. Besides that significant decrease in mean values of Wexner constipation score and King's health questionnaire was demonstrated. Though mean values of global treatment effectiveness assessment on CGI-I and PGI-I scales didn't significantly differ (2.13±0.85 и 2.68±1.42, р=0.06), the rate of agreement between these scales measured at each single case was very low (κ-0.154), this reflects that clinician has more positive perception of disease dynamics due to treatment than the patient. When mean values of dynamics in different indexes of King's health questionnaire were compared it was demonstrated that the index of quality of life influence (3.53±0.96) was significantly higher than the indexes of OD influence (2.63±1.08) and mechanical symptoms (2.58±1.04), this suggests that while the manifestations of OD syndrome are significantly improved patient quality of life doesn't change substantially. CONCLUSIONS: XR-DG is more specific than MRI-DG in evaluating the size of rectocele and the depth of pelvic floor descent; the use of mesh implants in surgical treatment of OD syndrome results in significant reduction of rectocele and prolapse stage in 90% of patients; clinical evaluation of treatment effectiveness based on objective examination is more optimistic than subjective perception of treatment results by the patient, this indicates that anatomic correction does not always lead to quality of life improvement.