Changes in Dynamic Pelvic Floor Magnet Resonance Imaging and Patient Satisfaction after Resection Rectopexy for Obstructed Defecation Syndrome

Abstract

Purpose: Resection rectopexy (RR) provides good functional results and low recurrence rates for the treatment of obstructed defecation syndrome based on rectal prolapse and cul-de-sac syndrome, whereas little is known about changes in pelvic floor dynamics and patient satisfaction after surgery.

Materials and Methods: Within three years 26 consecutive female patients were prospectively included. Indications for RR (22 laparoscopic, 3 primary open and 1 converted-to-open) were rectal prolapse III° in 11 patients and cul-de-sac syndrome in 15 patients. Patients’ quality of life (QOL), fecal behavior and defecation-associated pain were investigated before and after surgical treatment using anamnesis and clinical examination, Rand 36-idem health survey (SF-36), Cleveland-Clinic Incontinence Score (CCIS) and the visual analog scale for defecation-associated pain (VAS). Dynamic pelvic floor magnet resonance imaging (dPF-MRI) was used for the investigation of changes in pelvic floor anatomy and function before and after surgery.

Results: RR improved the rate of fecal incontinence (p < 0.01) and CCIS (p = 0.01). The use of laxatives (p = 0.01), the need for self-digitation (p = 0.02) and VAS (p < 0.01) were decreased, leading to improvements in QOL (overall p < 0.01). RR led to shortening of the H-line but not of the M-line under rest (p < 0.01) and during defecation (p = 0.04). A rectocele was co-incident in all patients in dPF-MRI before surgery. RR led to a reduction (p < 0.01) and declined protrusion (p = 0.03) of the rectocele. This results in a decreased rate of cul-de-sac (p < 0.01) and increased rate of complete defecation (p < 0.01) after surgery. At the 36-month follow-up no recurrence was observed.

Conclusion: RR promises high rates of patient satisfaction and improvement in pelvic floor anatomy in select patients.

Key Points:

• RR improves the pelvic floor anatomy of patients suffering from ODS

• RR improves the QOL of patients suffering from ODS

• An improvement in pelvic floor anatomy led to an improved QOL

• RR is an adequate treatment for select patients suffering from ODS

Citation Format:

• Reichert M, Busse A, Hecker A et al. Changes in Dynamic Pelvic Floor Magnet Resonance Imaging and Patient Satisfaction after Resection Rectopexy for Obstructed Defecation Syndrome. Fortschr Röntgenstr 2016; 188: 38 – 44

Zusammenfassung

Ziel: Die Resektionsrektopexie (RR) kann mit guten funktionellen postoperativen Ergebnissen und niedrigen Rezidivraten bei Patienten mit ODS (obstructed defecation syndrome) durch einen Rektumprolaps oder Sigmoidozele eingesetzt werden. Dabei ist jedoch wenig über die postoperativen dynamischen Veränderungen des Beckenbodens bekannt.

Material und Methoden: Innerhalb von drei Jahren wurden 26 Patientinnen prospektiv in die Studie eingeschlossen. Indikationen zur RR (22 laparoskopisch, 3 primär offen und 1 konvertiert) waren der Rektumprolaps III° bei 11 und die Sigmoidozele bei 15 Patientinnen. Lebensqualität (QOL), Stuhlgewohnheiten und defäkations-assoziierte Schmerzen wurden vor und nach der chirurgischen Therapie erfasst durch Anamnese, klinische Untersuchung, Rand 36-idem health survey (SF-36), Cleveland-Clinic Incontinence Score (CCIS) und visuelle Analogskala für defäkations-assoziierte Schmerzen (VAS). Veränderungen in der Beckenbodenanatomie und -funktion wurden mittels dynamischen Beckenboden-MRT (dPF-MRI) vor und nach RR erfasst.

Ergebnisse: Die RR verbessert den Grad der Stuhlinkontinenz (p < 0,01) und den CCIS (p = 0,01). Der Laxanzienabusus (p = 0,01), die Notwendigkeit der manuellen Stuhlausräumung (p = 0,02) und die VAS (p < 0,01) waren postoperativ reduziert, was in einer Verbesserung der QOL (overall p < 0,01) resultierte. MRT-morphologisch zeigte sich postoperativ eine Verkürzung der H-, jedoch nicht der M-Linie in Ruheposition (p < 0,01) und während des Defäkationsprozesses (p = 0,04). Bei allen Patienten wurde im präoperativen dPF-MRI eine Rektozele diagnostiziert, die sich postoperativ signifikant kleiner darstellte (p < 0,01). Durch die Veränderungen kam es postoperativ zu einer Verbesserung der Rate an kompletter Stuhlentleerung im dPF-MRI (p < 0,01). Im Follow-up von 36 Monaten konnten keine Rezidive beobachtet werden.

Schlussfolgerung: Die RR führt zu Verbesserungen der QOL und Beckenbodenanatomie sowie -funktion in ausgewählten Patienten mit ODS.

Kernaussagen:

• Die RR verbessert die Beckenbodenanatomie von Patienten mit ODS

• Die RR verbessert die Lebensqualität von Patienten mit ODS

• Verbesserungen in der Beckenbodenanatomie führen zu einer höheren QOL

• Die RR ist eine geeignete Therapieoption für ausgewählte Patienten mit ODS

Key words

abdomen - anus - rectum - defecography - laparoscopy - MR-functional imaging

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