Surgical Treatment for Rectocele by Posterior Colporrhaphy Compared to Stapled Transanal Rectal Resection.

Background: Rectocele is defined as a defect in the rectovaginal septum, causing symptoms like obstructed defecation syndrome (ODS), vaginal bulging, etc. Once the rectocele is larger than 3 cm and/or symptomatic, surgery should be considered. The surgical approach can be either transvaginal, transanal or transperineal. Two of the most common procedures in treating rectocele are posterior colporrhaphy (PC) and stapled trans anal rectal resection (STARR). The purpose of this study was to compare surgical outcomes of both procedures. Methods: This is a retrospective cohort study. Included were patients of the age of 18−85 years that underwent either STARR (n = 49 patients) or PC (n = 24 patients) procedures after a full clinical (defecography and physical exam before and after the surgery) and physiologic (a detailed questionnaire before and after the surgery) surveys. Symptoms of ODS before and after surgery were evaluated by questioners. Results: Preoperatively, the patients in the STARR group had significantly higher rates of ODS: straining (90.9% vs. 65.2%), incomplete evacuation (100% vs. 69.6%), hard stool (57.8% vs. 43.5%), sense of obstruction (76.1% vs. 56.5%), and use of digitation (64.4% vs. 47.8%), or laxatives (70% vs. 47.8%), p < 0.001. Anatomically, the mean rectocele size was smaller for the STARR group, compared to the PC group (3.8 ± 1.4 vs. 5.3 ± 2.2 cm, respectively, p < 0.001). Postoperatively, in the STARR group, higher rates of patients complained about straining (36.4% vs. 21.7%, p < 0.001) and use of digitation (64.4% vs. 26.1%, p < 0.001), whereas lower rates of patients complained about incomplete evacuation (41.2% vs. 56.5%, p = 0.05) and sense of obstruction (17.6%, vs. 34.8%, p = 0.03), compared to the PC group. Among patients who underwent the STARR procedure, a decrease in rates of all symptoms was noted (straining 54.5%, incomplete evacuation 58.8%, hard stool 29.2%, sense of obstruction 58.5%, use of digitation 0.1%, and use of laxatives 31.5%). Both procedures are effective in reducing rectocele size (STARR- 1.9 ± 1 cm, PC- 3.1 ± 1). Conclusions: Both STARR and PC are effective in treating rectocele. It seems that the STARR procedure is superior to the PC procedure in treating symptoms of ODS.

Computed Tomography-Guided Placement of Sacral Electrodes.

BACKGROUND: The current approach to performing sacral neuromodulation consists of a two-stage procedure, the first of which includes insertion of the sacral electrode under fluoroscopic visualization of the S3 foramen. Alternatively, in certain situations computed tomography (CT)-guided insertion can be used. OBJECTIVES: To evaluate the use of CT in cases of reinsertion of the electrode due to infection, dislocation, or rupture. METHODS: Medical records of patients who underwent neuromodulation device reinsertion between 2005 and 2016 for fecal incontinence were reviewed. Study outcomes included procedure course, successful placement, and long-term treatment success. RESULTS: During the study period, we inserted a neuromodulation device in 67 patients. A CT-guided insertion of a sacral electrode was performed in 10 patients. In nine patients, the insertion and the final location of the electrode were successful. In one patient, the electrode migrated upward due to a malformation of the S3 foramen on both sides and had to be placed in S4. In a mean follow-up of 68.4 ± 30.0 months following the re-insertion, there was a significant reduction in the number of incontinence episodes per day (P < 0.001) and the number of pads used per day (P = 0.002). CONCLUSIONS: CT-guided insertion of a sacral electrode is a safe and promising option, especially in recurrent and or selected cases.

Effects of Sacral Neuromodulation on Urinary and Fecal Incontinence.

BACKGROUND: Fecal incontinence is defined as involuntary passage of stool through the anus. It may vary from soiling to complete evacuation. This involuntary loss of feces, flatus or urge incontinence adversely affects quality of life. Urinary urge incontinence is characterized by symptoms of frequency, urgency and urge incontinence (either alone or in combination). Urgency frequency syndrome is defined as symptoms of frequency and urgency without incontinence episodes. OBJECTIVES: To evaluate the efficacy of sacral neuromodulation on these pathologies. METHODS: Following a detailed investigation, 51 patients with either urinary or fecal incontinence, or both, who did not respond to medical and behavioral treatment were offered the temporary implant. Of the 51 patients 40 showed improvement and advanced for a permanent device. RESULTS: After a mean follow-up of 5 years (range 1-8), there was a significant reduction in the number of incontinence episodes (P < 0.0001), and the number of pads used also declined significantly (P < 0.0001). A marked improvement in quality of life was reported by 71.4% of the women and 58.3% of the men. CONCLUSIONS: Sacral neuromodulation as shown in this study appears to be a promising treatment for urinary and fecal incontinence and can dramatically improve patients' quality of life.

A prospective, randomized, three arm, open label study comparing the safety and efficacy of PP110, a novel treatment for hemorrhoids to preparation-H® maximum strength cream in the treatment of grade 2-3 hemorrhoids.

BACKGROUND: Hemorrhoids are a common disorder that affects the quality of life of millions of people worldwide. The effectiveness of OTC medication is limited and they mainly provide symptomatic relief. In order to treat this ailment, we formulated PP110 Gel and Wipes, as a novel treatment for hemorrhoids. PP110 is based on known active ingredients with a topical film-forming agent designed to provide physical protection and prolonged tissue contact with the active ingredients. METHODS: PP110 Gel, PP110 Wipes and the comparator Preparation-H® were used on three patient cohorts. Treatment was administered once daily for PP110, and three-four times daily for Preparation-H®, for 14 days. Six different clinical parameters relating to common symptoms of hemorrhoids were monitored. RESULTS: PP110 Gel was significantly better than Preparation-H® in reducing bleeding (Δ = 6 %), providing pain relief (Δ = 10 %) and controlling itching (Δ = 11 %). These three parameters are considered as the most common distressing symptoms for hemorrhoids patients, demonstrating that PP110 is superior to conventional treatment. CONCLUSION: This study demonstrated the efficacy of the PP110 Gel in treating hemorrhoids and its superiority to conventional treatments. The PP110 film-based formulation provides a slow-release mechanism and as a consequence, a prolonged therapeutic window. PP110 was both more effective in reducing hemorrhoids symptoms and more convenient to use, in that it only required application once per day.

Contour Transtar in true rectal prolapse.

BACKGROUND: A new device, the CCS-30 Contour Transtar, was recently launched for the treatment of obstructed defecation syndrome (ODS). OBJECTIVES: To evaluate the efficacy of the Contour Transtar in resection of true rectal prolapse in relation to age and concomitant urogynecologic procedures. METHODS: During a 50 (median) month period 15 women with rectal prolapse of ≥ 5 cm and complaints of obstructed defecation underwent perineal resection of rectal prolapse with the Contour Transtar. RESULTS: In 3 of the 15 patients (20%) rectal prolapse recurred. Amelioration of ODS symptoms and improved continence were noted in 82% and 75%, respectively, following surgery. CONCLUSIONS: The Contour Transtar procedure for full-thickness rectal prolapse is a safe and promising procedure and is likely suitable for elderly poor risk patients.