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PREVENTION RECURRENCE AND INCREASING THE EFFECTIVENESS OF
SURGICAL CORRECTION OF THE RECTOCELE
Xakimov I.S.
PhD , Associate Professor of 1- Elective and Hospital Surgery Andijan State Medical
Institute.
Abstract
. The problem of prolapse and prolapse of the internal genitalia in women has
remained relevant for many years. In almost all cases, patients with OIVVD have functional
disorders of the pelvic organs, the so-called complicated form of OIVPO, characterized by
the involvement of the bladder and intestines in the process. Rectocele is a pathological
condition that is etiologically and pathogenetically associated with pelvic organ prolapse.
Proctologists define a rectocele as a diverticulum-like protrusion of the anterior wall of the
rectum towards the vagina [1], and in gynecological literature, this term refers only to the
prolapse or prolapse of the posterior vaginal wall [2]. The clinical picture of rectocele in
OIVVPO consists of several groups of symptoms: symptoms of impaired motor-evacuation
function of the colon, symptoms of genital prolapse, sexual dysfunction. The main signs
characterizing rectal dysfunction are the symptoms of obstructive defecation: prolonged
constipation, the need to use a finger aid (transvaginal, transrectal or perineal) in order to
eliminate the prolabrating anterior wall of the rectum and facilitate its emptying. The patient
has to strain for a long time with the active involvement of the abdominal press, patients are
bothered by frequent and ineffective urges to defecate, a feeling of discomfort with
downward pressure.[5] Disruption of the fecal evacuation process is accompanied by
inflammatory changes in the distal parts of the colon and the occurrence of concomitant
proctological diseases. This is manifested by the discharge of blood from the anus, prolapse
of internal hemorrhoids, flatulence, and pain during defecation [1, 7]. For the treatment of
rectocele, many conservative therapy regimens are used aimed at normalizing the stool and
strengthening the pelvic floor muscles, but the main method of treatment remains
surgical.[3,4] Traditional reconstructive plastic surgery on the pelvic floor is aimed at
eliminating the diverticulum-like protrusion of the anterior wall of the rectum into the
vagina and strengthening the rectovaginal septum.
Key words:
Rectocele; pelvic organ prolapse; evacuation dysfunction of the rectum; 3-D
ultrasound of the pelvic floor.
Evaluation of the efficacy of retroperitoneal vaginal colpopexy using the Prolift prolene
system for the treatment of rectocele in women who were evaluated using a specific
diagnostic algorithm.
Study Inclusion Criteria:
• rectocele of the 2nd-3rd degree in stage II-IV prolapse of the posterior vaginal wall;
• recurrence of rectocele after traditional pelvic floor surgeries. Study exclusion criteria:
• An OIVPO uncomplicated by the presence of a rectocele;
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• patients with polyvalent allergy due to the high risk of developing a rejection reaction of
synthetic material. Examination before and after surgery, as well as surgical treatment of
patients.
Materials and methods.
When interviewing patients for objectification of complaints, quantitative interpretation of
symptoms of intestinal dysfunction and control of the effectiveness of the treatment, a
scoring system was used to assess the degree of disorders of the evacuation function of the
colon: 1st degree rectocele is defined as a small pocket of the anterior wall of the rectum
only by finger examination of it; Stage 2 – protrusion of the rectal wall is detected when the
labia are spread apart and when the patient strains. The stretched anterior wall of the rectum
reaches the level of the external sphincter of the anus or the vestibule of the vagina. 3rd
degree – characterized by protrusion of the anterior wall of the rectum beyond the genital
fissure and anal pulp when straining and/or at rest. The data of the objective examination
were supplemented by instrumental examination of the patients, which included 3-D
ultrasound of the pelvic floor and evacuation X-ray proctography. Ultrasound examination
of each patient was carried out on the Voluson-730 expert (GE) device with a vaginal probe
with a frequency of 6.5 MHz, located in the vaginal vestibule, in the position of the patient
lying on her back with a full bladder. In cross-section, the anal sphincter and the adjacent
structures of the pelvic floor triangle were evaluated: the tendon center of the perineum, the
muscle bundles of the levators, and ultrasound signs of pelvic floor muscle insufficiency
were revealed. In the sagittal section, the presence of a rectocele at rest and during straining
was diagnosed, in the postoperative period, the location of implants in the pelvic cavity and
the position of the lower edge were assessed. The analysis of the data obtained was carried
out using the SPSS statistical software package. The significance of the differences in the
tables was assessed using the chi-square test and the exact one-sided Fisher test. Quantitative
indicators were compared using nonparametric sign tests and Wilcoxon (for related samples)
and Wald-Wolfowitz and Mann-Whitney (for independent samples). Estimates of
correlation coefficients for quantitative and ordinal indicators were performed according to
Spearman. To assess the impact of various risk factors on the likelihood of relapse, a step-
by-step logistic regression procedure was applied. The difference at p<R is moderate,
R>0.65=7 is a strong correlation
Results of the study
The study involved 82 patients aged 37–77 years, the average average age of the examined
was 58.0±3.2 years. The duration of OIVVO in patients of the 1st group took a time interval
from 2 to 20 years, the median was 6 years. At the same time, a worsening of the course of
the disease with the onset of menopause was noted in 26 (42.0%) patients, which indicates a
negative impact of estrogen deficiency on the anatomical and functional state of the pelvic
ligamentous apparatus and the mucous membrane of the urogenital tract. When analyzing
the questionnaire reflecting the violation of the motor-evacuation function of the large
intestine, it was revealed that almost all patients with rectocele in the 1st group complained
of difficulties in defecation, a feeling of incomplete emptying of the rectum. At the same
time, 60.0% of patients used a finger aid during defecation, which was performed by
pressing on the perineum, the back wall of the vagina or the gluteal region. Tables 2 and 3
present the main manifestations and severity of motor-evacuation dysfunction of the rectum
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in the examined patients with rectocele before and after surgical treatment. After surgical
treatment, there was a statistically significant improvement in the motor-evacuation function
of the rectum in patients with rectocele. Clinical examination data (stages of prolapse of the
posterior vaginal wall (point Bp) by POP-Q and rectocele degree) in patients with OIVVPO
and rectocele are shown in Tables 4 and 5. Thus, clinically "excellent" anatomical results
after surgical treatment of rectocele were achieved in 55 (88.8%) patients (absence of
rectocele), and "excellent" results of PTO correction were obtained in 51 (81.3%) patients
(prolapse of the posterior vaginal wall 0 according to POP-Q). "Good" results of rectocele
treatment (grade 1 rectocele) were noted in 4 (6.4%) patients, as well as a "good" result of
correction of prolapse of the posterior vaginal wall (stage I or stage II in the presence of
stage III–IV before surgery) was obtained in 8 (12.9%) patients. Recurrence of rectocele of
the 3rd degree, i.e. an "unsatisfactory" result in combination with prolapse of the posterior
vaginal wall of stage III, was noted in 3 (4.8%) women.
Discussion of the results of the study
Analyzing the results of surgical treatment of rectocele with retroperitoneal vaginal
colpopexy using the Prolift system, it is necessary to note the fairly high anatomical and
functional effectiveness of this method of treatment. In our study, the restoration of normal
anatomical relationships between the rectum and the structures of the pelvic floor was
achieved in 95.2% of cases, and the improvement of rectal function was achieved in 95.1%
of cases. The use of a scoring system for the severity of motor-evacuation dysfunction of the
rectum was necessary to assess the severity of intestinal dysfunction, prescribe conservative
therapy before and after surgical treatment, and assess the anatomical and functional result
of treatment.[6]
References
1.
Dynamic transperineal ultrasound vs. defecography in patients with evacuatory
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3.
Karasick S., Karasick D., Karasick S. R. Functional disorders of the anus and rectum:
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Piloni V. L., Spazzafumo L. Sonography of the female pelvic floor: clinical
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