Transvaginal Rectopexy for Obstructed Defecation

Obstructed defecation syndrome (ODS) occurs in approximately 7% of adult females and 30-50% of those with constipation [1,2]. ODS frequently coexists with pelvic floor disorders such as pelvic organ prolapse, fecal incontinence, and urinary incontinence (1,3). Studies have demonstrated that among women presenting for urogynecologic care, 83% had at least one bowel symptom with incomplete evacuation and straining becoming most prevalent (3,4). Most often, obstructive defecation results from anatomic defects in rectal structure and support (1,3). Different surgical approaches have been described to correct rectal support defects that can be diagnosed as rectal prolapse, intussusception, enterocele or rectocele (5). Transvaginal sacrospinous rectopexy has previously been published as a minimally invasive option in the treatment for rectal partial prolapse detected by dynamic rectal imaging (1). In this video, we will review prior studies on ODS diagnosis and suture-based transvaginal sacrospinous rectopexy, present a case report presenting to our clinic for evaluation, and demonstrate the surgical steps and technique of this novel approach. In this video, we present a case report utilizing a transvaginal approach to sacrospinous rectopexy with a suture-based repair utilizing the sacrospinous ligaments for ODS in a 69-year-old female. A novel surgical technique was designed based on the anatomical location of rectum relative to sacrospinous ligament which is used for sacrospinous suspension. For this surgical technique, dissection is performed and carried down to the sacrospinous ligament and sutures are placed using a suture capturing device into each ligament approximately 2-2.5cm medial to the ipsilateral ischial spine. With one finger inside the rectum, the 0-PDS suture was passed through the lateral rectal ligament and rectal muscular layer as a two bite- running suture at a point 7-8cm cephalad to the anal verge. This suture is tied down and the procedure is repeated on the contralateral side. Application of dynamic pelvic floor ultrasound enhanced our understanding of underlying anatomical defects for obstructed defecation symptoms and opened the opportunity to create a novel minimally-invasive, mesh-free solution for this prevalent problem in the urogynecologic patient population. In our prior study evaluating the safety, efficacy and durability of the transvaginal sacrospinous rectopexy for obstructed defecation syndrome, greater than 90% of patients described improvement in all obstructed defecation symptoms and subjective improvement overall at 2 and 12 months after the surgery and improved rectal support detected via dynamic ultrasound (1). The overall safety and efficacy profile of this novel approach is highly promising based on our experience thus far and will be further defined by long term studies currently in progress.