Obstructed Defecation Syndrome: analysis of the efficacy and mid-term quality of life of an innovative robotic approach

Obstructed Defecation Syndrome: analysis of the efficacy and mid-term quality of life of an innovative robotic approach | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Obstructed Defecation Syndrome: analysis of the efficacy and mid-term quality of life of an innovative robotic approach Mauro Cervigni, Andrea Fuschi, Andrea Morciano, Lorenzo Campanella, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4014301/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Aim The aim of our study is to prove how the combination of the Rectal wall Plication (RP) and the association with robotic Ventral Mesh Rectopexy (VMR) would result in a safe and effective procedure for patients with Obstructed Defecation Syndrome (ODS) and would provide better outcomes in terms of bowel function and Quality of Life. Methods From January 2018 to December 2021, 78 women affected by ODS and posterior compartment prolapse were enrolled for the study. The minimum follow-up for these patients were 18 months. 30 patients underwent VMR and 33 VMR plus RP. The primary endpoint was to evaluate the effectiveness and the safety of VMR and VMR + RP at median follow-up.The secondary endpoint was to evaluate the impact on quality of life and sexual function of these two surgical procedures. Results In symptomatic evaluation and analysis of post-operative complications ,at the median follow-up, 6 patients (20%) in VMR group vs 1 patient (3%) in VMR+RP group still had constipation (p=0.023). In the VMR+RP group, the number of sexually active patients after surgery and the PISQ-12 results showed an improvement in the quality of sexual life after at least 18 months of follow up. Finally, at the median follow-up the ODS score values were significantly reduced in both groups Conclusion Although long-term f-u and a larger group of pats. is required, the findings we have acquired are encouraging and allowed us to say that in pats with ODS and posterior compartment prolapse the combination of rectal wall plication and ventral mesh rectopexy may improve results in terms of bowel function and quality of life. Robotic Surgery Obstructed Defecation Syndrome Rectal Prolapse Rectal wall Plication INTRODUCTION Rectocele, defined as a protrusion in the posterior vaginal wall caused by an outpouching of the anterior wall of the rectum through a compromised rectovaginal fascia, is often a component of a tricompartmental defect in pelvic organ prolapse (POP) ( 1 )( 2 ). The real incidence of rectocele is not known, though asymptomatic posterior compartment prolapse has been documented in roughly 40% of parous women ( 3 , 4 ). When symptomatic, posterior compartment prolapse manifest with obstructed defecation syndrome (ODS), a clinical condition characterized by difficulty in feces evacuation despite the absence of mechanical impediment, often associated with symptoms such as tenesmus, the need to digitate vaginally or anally, post-defecatory soiling, perineal pain, and, in rare cases, faecal incontinence ( 4 ). Posterior compartment prolapse, together with obstructed defecation syndrome, are two conditions who are simultaneously present in 90% of the patients ( 5 ).On the other hand, around 50% of the population has ODS symptomatology without posterior compartment prolapse( 6 ). The choice of treatment depends on the severity of the syndrome, the symptoms experienced by the patient, and the impact on the patient’s quality of life. Although symptoms can be treated with a conservative first approach, this is not always the best therapeutic choice, and in such case, surgery is still a viable option to explore ( 7 ). Moving towards the evolution of the surgical technique to treat ODS, the transanal resection approach is widely spread among european colorectal surgeons. Despite being regarded as a surgery with a high rate of success (72%), the postoperative complications remain significant. Urgency is the most prevalent result in the early post-surgical phase, with recorded rates as high as 47.8%. However, this symptom fades between 3 and 10% with time. Pain/tenesmus is the second most prevalent short-term effect (ranging from 0.4 to 24%). Anastomotic dehiscence is the most feared complication, with a frequency ranging from 0.4 to 7.1%( 8 , 9 ). Finally, the prevalence of persistent and recurrent constipation ranges from 1 to 24% of patients has a significant impact on patients' quality of life( 10 ). According to recent literature, which supported our previous study in which we employed vaginal plication during sacrocolpopexy in patients with severe posterior vaginal prolapse( 11 ), we further assessed the role of plicating the rectal wall to restore the anatomy and function of the rectum in patients suffering from posterior compartment prolapse and ODS and in contrast to the Transanal technique, no excision was performed. Nowadays Robotic ventral rectopexy, with better ergonomics and precision, includes the mobilization of the rectum down to the level of the levator muscles and its fixation to the sacral promontory by using suture or staples. Furthermore, the insertion of a mesh while performing rectopexy is a common pratice, placing it anteriorly, or around the rectum. Stating that rectocele can be considered a consequence rather than a cause of ODS, therefore it would seem illogical to treat a neuromuscular condition cutting an enlarged rectal wall, instead of restoring the anatomy that in our hypothesis would result in a postoperative reduced bowel transit time and constipation ( 12 , 13 ). In conclusion, the aim of our study is to prove how the simultaneous plication of the rectal wall in combination with robotic mesh rectopexy would result in a safe and effective treatment and would provide better outcomes in terms of bowel function and quality of life. MATERIALS AND METHODS From January 2018 to December 2021, 78 women affected by ODS and posterior compartment prolapse were referred to the Dept. of Surgery/Urology at "La Sapienza" Univ. ICOT Polo Pontino Hospital and Dept. of Urogynecology and Pelvic Floor Reconstructive Surgery of the Sandro Pertini Hospital of Rome and they were enrolled for the study. All data were retrospectively evaluated from a collected urogynecological internal database. Therefore, this study is a retrospective comparing analysis of the two different techniques results. The Institutional Review Boards (IRB) approved the study. An informed written consent was obtained from all women. The research was conducted according to Good Clinical Practice Guidelines. The inclusion criteria were as follows: patients aged between 18 and 75 years, presence of ODS and rectocele ≥ II stage, according to Pelvic Organ Prolapse Quantification System, POP-Q classification, without coexisting significant anterior or apical compartment prolapse and without clinical or latent stress urinary incontinence (SUI). Women with concomitant surgery of a uterine prolapse, cystocele or urinary incontinence were excluded. Exclusion criteria were also malignancies, degenerative neurological diseases, previous pelvic radiotherapy, pregnancy state, megacolon, bowel inflammatory disease, pelvic floor dyssynergia or anal sphincter deficiency and contraindications to surgery or aneasthesia. In presence of sphincter contractile deficiency or dyssynergia, the patients were first treated with pelvic floor rehabilitation and then, after a re-evaluation with anorectal-manometry, scheduled for surgery. The procedures were ever performed by the same surgeon (MC) who had previously performed more than 100 interventions completing the learning curve. The minimum follow-up for these patients were 18 months. Preoperative assessment was done using a standardized questionnaire and a clinical examination. The questionnaire consisted of a history about bowel movements, questions about obstructed defecation, need for vaginal/perineal digitation and prolapse protrusion symptoms (foreign body feeling in the introitus), a history about anal incontinence and sexual function. All patients were candidate for surgical intervention after the failure of medical and dietary therapy and after a complete radiological and functional study. MR or RX defecography and anorectal manometry were always performed to assess the presence of rectocele and rectal intussusceptions in patients who were unable to empty. These examinations were also helpful to identify the presence of pelvic floor dyssynergia or anal sphincter deficiency, which are criteria for exclusion from the surgical treatment. Clinical examination consisted of a proctological and gynaecological examination in the supine lithotomy or lateral position during maximal Valsalva manoeuvre. POP-Q measurement according to the guidelines of the ICS was performed. The degree of posterior compartment defects was evaluated by POP-Q System under maximum straining effort, with the patient in the lithotomy position. The symptoms of ODS that are perceived by the patients were evaluated before and after the intervention using the ODS (Obstructed Defecation Syndrome) score which analyzes constipation using 5 items. The prolapse quality of life questionnaire (P-QoL) was used to quantify the impact of prolapse symptoms on QoL. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12), Pelvic Floor Disability Index (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7) were administered to evaluate quality of life and sexual function before surgical intervention and at median follow up. Before surgery all patients were given low molecular–weight heparin to prevent venous thromboembolism. A short-term antibiotic prophylaxis was performed 30 minutes before surgery. Surgical technique Robotic Ventral Mesh Rectopexy is a procedure utilising da Vinci® technology, involving mobilisation of the front of the rectum all the way to the pelvic floor, and fixation of the front of the rectum and pelvic floor to the bony sacral promontory with a mersilene mesh. This straightens the rectum, and restores its tubular shape. In this technique, the nerves to the rectum that enter from the back and side are preserved with mobilisation only from the front and right side of the rectum, with careful preparation of the rectal fascia and muscular layer. In this step is of utmost importance the preservation of nerve endings, leaving intact the back of the rectum for the normal maintenance of rectal functionality reducing the risk of hind gut neuropathy and resultant constipation. The mersilene mesh is thought to result in a lower recurrence rate than sutured rectopexy whilst avoiding the long-term complications The surgical technique of rectal wall plication is an innovative procedure consisting on placement of 3 sutures utilizing monofilament slow resorption resorbable threads (PDS II 2 − 0) for the plication in the midline of the anterior wall of the rectum starting 1 cm above the perineal body and subsequently at the distance of 1,2 − 1,5 cm before fixing the mesh for the rectopexy. This allows a decrease in the caliber of the rectum with greater stabilization. Operative and postoperative assessment After surgery, a bladder catheter and a vaginal pack were positioned and were removed after 48 hours. Operative time, blood transfusions, spontaneous voiding, perioperative complications, postoperative hospital stay and postoperative complications (early within 30 days and late after 30 days) were considered. The following questionnaires were administered after surgery at median follow up: P-QoL, PFDI-20 PFIQ-7 and PISQ-12. A clinical examination and the compilation of questionnaires were performed at least 18 months after surgery. Administering these questionnaires is a standard care in our Urogynecology and Proctology clinic. The same team performed surgery and postoperative evaluation. Objective cure for prolapse was defined as a remaining posterior defects of stage 0-I, evaluated by POP-Q classification under maximum straining effort with the patient in the lithotomy position. Recurrence of prolapse was defined as stage II or higher, based on the POP-Q classification. Patients with a significant worsening of defecatory function or with a suspect of a prolapse recurrence were subjected to a MR defecography. Patients who complained of fecal incontinence were studied with anorectal manometry. ODS (Obstructed Defecation Syndrome) score after surgery to evaluate constipation symptoms was used. The primary endpoint was to evaluate the effectiveness and the safety of RVMR and RVMR + RP at median follow-up. The secondary endpoint was to evaluate the impact on quality of life and sexual function of these two surgical procedures. We analyzed the incidence of each event to define its statistical significance using Fisher's exact test. Odds ratio (OR) and 95% confidence intervals (CIs) were calculated for each comparison. Normality tests (D’Agostino and Pearson test) were performed to determine whether data were sampled from a Gaussian distribution. The T-test and Mann-Whitney U test were used to compare continuous parametric and non-parametric variables (when data do not fit into the normal distribution), respectively. Correlations between numerical parameters were computed using the Spearman rank correlation coefficient. Matched T-test was applied to determine the change in questionnaires (ODS Score, P-QoL, PFDI-20 PFIQ-7 and PISQ-12) values. All analyses were conducted using the Statistical Package for the Social Sciences (SPSS) 22.0 for Mac (SSPS, Chicago, IL, USA). Significance was set at a p-value of 2) and 3 were lost to follow up hence 63 women were analyzed. A total of 63 patients were analyzed. Demographic Clinic and Pathological characteristics were showed in table 1, no significant differences were reported between the 2 groups. No significant difference in terms of operating time occurred (132 minutes vs 123 minutes; p=0.121). All included patients (63/63) showed at preoperative defecography the simultaneous presence of rectocele and recto-anal or recto-rectal intussusceptions. Similar results were shown in terms of blood loss, intraoperative complications, ureteral injuries, bowel injuries, bladder injuries, hemoperitoneum, and rectal abscesses. One patient in group A and 1 patients in group B needed a blood transfusion during the surgical intervention. There were no ureteral, bladder or intestinal lesions in the two groups. In symptomatic evaluation and analysis of post-operative complications, no significant differences were reported. But at the median follow up 6 patients (20%) in VMR group vs 1 patient (3%) in VMR+RP group still have constipation (p=0.023) Median follow up was 23 months (18-26). POP-Q classification score for posterior compartment showed a significant average decrease for both groups (p<0.001) at median follow up and there wasn’t a significant difference between the two groups. Five (16.6%) women in the VMR group and 0 (0%) in the VMR+RP group used vaginal digitation (p=0.041) at least 18 months after surgery. Questionnaires assessing quality of life associated with gastrointestinal symptoms did not demonstrate significant differences at median follow-up. (table 3) In the VMR+RP group, the number of sexually active patients after surgery with at least two sexual intercourses per month increased (p=0.033) and consequently the PISQ-12 showed an improvement in the quality of sexual life after at least 18 months of follow up (30.12±7.12 before surgery and 35.98±5.98 after surgery in VMR group vs 29.65±6.45 before surgery and 29.65±6.45 after surgery in VMR+RP group, p=0.041). (table 3) At PGI-I evaluation no significant differences occurred. (table 4) At 6 months of follow up the ODS score showed no significant difference (6.31±2.69 in VMR group vs 2.37±1.59 in VMR+RP group, p=0.11). While at the median follow up the ODS score values were significantly different: (7.11±1.65 vs 1.88±1.89, p=0.013). The other values of the intermediate follow up (12 and 18 months) are shown in table 5. DISCUSSION Tor our knowledge, this is the first study reporting simultaneous rectal wall plication with the combination of robotic mesh rectopexy in patients suffering from ODS and rectocele. This concept was inspired by our recent research( 11 ), where we hypothesized that patients with severe posterior compartment prolapse would benefit from a laparoscopic sacral colpopexy plus plication of the vaginal fascia in order to help restore their anatomical and functional outcomes. In fact, we hypothesized that restoring the rectal wall architecture would result in decreased stool transit time and constipation postoperatively, as well as improved bowel function and quality of life in these patients. Laplace's rule, as the foundation of our clinical reasoning, explains how strength and tightness of the rectal lumen would provide us with more contractile strength to ensure fecal emptying( 14 ). According to our findings, this new technique involving rectal plication and mesh rectopexy had fewer postoperative complications than the mesh-only group, as well as a significant improvement in quality of life, sexual activity, and ODS symptomatology, which was significantly reduced at the postoperative median follow-up. Colorectal surgeons commonly performed transanal access to treat ODS, with different degrees of effectiveness. Arnold et al. ( 15 ) observed poor postoperative outcomes, with 54% of patients complaining of constipation. According to Roman et al. ( 16 ) functional result declined with increasing period of follow-up, reaching a recurrence rate of 50% after 5.5 years. Furthermore, roughly one-third of female patients experienced a new beginning of anal incontinence. Regarding the clinical outcome, a retrospective multicentric study of the Italian Society of Colo-Rectal surgery ( 17 ) found that at 18 months after STARR, 55% of the patients still had at least 3 symptoms of ODS, and that 19% of the cases needed a reintervention due to either postoperative complications or recurrence of symptoms. Dealing withe the postoperative complications, Defecation urgency is still the most frequent longer-term adverse effect, occurring in up to 10% of patients on average. Rectal stenosis is an uncommon complication that usually affects fewer than 1% of patients over the longer term (12 months or more) and less than 2% of patients usually develop longer-term discomfort. Anastomotic dehiscence and post-operative sepsis, although they are uncommon side effects, could occur in patients undergoing rectal resection. Patient global satisfaction ratings, while not always constant, generally indicated an acceptable outcome for around 73–80% of patients although, In around 68–76% of patients, there was an inconsistent decrease of 53–91% in the ODS score for obstructed defecation syndrome. Due to the high postoperative complication rate in transanal approach, robotic ventral rectopexy was proposed. Thanks to the absence of resection of the rectal mucosa to treat the primary component and the consequent neuromuscular condition underlying the development of ODS syndrome, it could become the first line treatment for patients suffering from rectocele and associated ODS. According to De Hoog et al. ( 18 ) and Mehmood et al.'s recent clinical experiment ( 19 ), this procedure is associated with lower constipation and fecal incontinence compared to perineal procedures ( 20 , 21 , 22 ). Furthermore, a reported median Cleveland Clinic Constipation Score (CCCS) gain of 3.2 points after robotic surgery and Wexner incontinence score were noticeably lower than thdat of the other procedures with a noteworthy improvement in blocked defecation ( 23 ). Even in patients undergoing rectopexy, several studies ( 24 , 25 ) found radiological recurrence of rectocoele, with rates ranging from 0–15% together with the rate of postoperative constipation where the findings were 12-22.5%. According to D'Hoore et al ( 26 ), our treatment solely comprised anterior rectal wall mobilization. As a result, posterior and lateral rectum mobilization were no longer required in order to reduce the risk of nerve injury. According to studies ( 27 , 28 ), constipation following rectal resection and posterior suture rectopexy is less prevalent than after posterior rectopexy without resection. In our study, as demonstrated by our findings, this new technique involving rectal plication and mesh rectopexy had fewer postoperative complications than the control group, emphasizing how postoperative constipation, in particular, was significantly lower in the plication group than in the mesh-only group. At median follow-up, the POP-Q categorization score for the posterior compartment decreased significantly for both groups with no significant difference between the two groups. In VMR the sexual function before and after surgery and the rates of sexual dysfunction were 29.6–85.7% and 4.9–20.2%, respectively. In the present study, contrariwise, QoL surveys and sexual activity in the group that received the plication were considerably better than those in the mesh-only group, indicating that the patients' quality of life had improved as a result of the new treatment. Finally, at the follow-up time of 18 months postoperatively, the ODS score was significantly lower from the beginning value in both groups who received mesh rectopexy alone and mesh rectopexy together with rectal plication, possibly as a result of a long term readapatation of muscle fibers. This study's limitation is the retrospective design, but the good number of patients and the medium-time follow-up lead to powerful conclusions. Further randomized studies are necessary to confirm the data on the efficacy and safety of the technique combining robotic rectopexy with mesh with simultaneous plication of the rectal wall. Declarations Author Contributions: Conceptualization, Schiavi MC, Morciano A, Cervigni M, Carbone A, Fuschi A, Campanella L.; methodology, Schiavi MC, Campanella L., Cervigni M; software, Schiavi MC.; validation, Schiavi MC .; formal analysis, Schiavi MC; investigation, Schiavi MC. , Cervigni M and Campanella L.; resources, Schiavi MC., Cervigni M and Campanella L.; data curation, Schiavi MC., Cervigni M and Campanella L.; writing—original draft preparation, Schiavi MC., Cervigni M and Campanella L.; writing—review and editing, Schiavi MC., Cervigni M and Campanella L.; supervision, Cervigni M; project administration, Cervigni M. All authors have read and agreed to the published version of the manuscript. Funding : This research received no external funding Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patients to publish this paper Conflicts of Interest: The authors declare no conflicts of interest.The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. References Lefevre R, Davila GW. Functional Disorders: Rectocele. Clin Colon Rectal Surg. maggio 2008;21(2):129–37. Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An international urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for female pelvic floor dysfunction. 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Is robotic superior? Int J Colorectal Dis. 2014 Sep;29(9):1113-8. Erratum in: Int J Colorectal Dis. 2019 Feb 9; Formisano G, Ferraro L, Salaj A, Giuratrabocchetta S, Pisani Ceretti A, Opocher E, Bianchi PP. Update on Robotic Rectal Prolapse Treatment. J Pers Med. 2021 Jul 23;11(8):706. Madiba TE, Baig MK, Wexner SD. Surgical management of rectal prolapse. Arch Surg. 2005 Jan;140(1):63-73. Cadeddu F, Sileri P, Grande M, De Luca E, Franceschilli L, Milito G. Focus on abdominal rectopexy for full-thickness rectal prolapse: meta-analysis of literature. Tech Coloproctol. 2012 Feb;16(1):37-53. Mantoo S, Podevin J, Regenet N, Rigaud J, Lehur PA, Meurette G. Is robotic-assisted ventral mesh rectopexy superior to laparoscopic ventral mesh rectopexy in the management of obstructed defaecation? Colorectal Dis. 2013 Aug;15(8) Tsunoda A. Surgical Treatment of Rectal Prolapse in the Laparoscopic Era; A Review of the Literature. J Anus Rectum Colon. 2020 Jul 30;4(3):89-99. Fathy M, Elfallal AH, Emile SH. Literature review of the outcome of and methods used to improve transperineal repair of rectocele. World J Gastrointest Surg. 2021 Sep 27;13(9):1063-1078. D'Hoore A, Cadoni R, Penninckx F. Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg. 2004 Nov; 91(11): 1500-5. Hidaka J, Elfeki H, Duelund-Jakobsen J, Laurberg S, Lundby L. Functional Outcome after Laparoscopic Posterior Sutured Rectopexy Versus Ventral Mesh Rectopexy for Rectal Prolapse: Six-year Follow-up of a Double-blind, Randomized Single-center Study. EClinicalMedicine. 2019 Aug 29;16:18-22. Yehya A, Gamaan I, Abdelrazek M, Shahin M, Seddek A, Abdelhafez M. Laparoscopic Suture versus Mesh Rectopexy for the Treatment of Persistent Complete Rectal Prolapse in Children: A Comparative Randomized Study. Minim Invasive Surg. 2020 Jan 22;2020:3057528. Tables Table 1: Clinic Pathological characteristics and Surgical procedures in 151 patients Clinical Variables VMR (30) VMR + RP (33) p Mean Age (SD) 62.34 (4.75) 60.89 (4.09) 0.21 Median Vaginal Delivery (range) 2 (1-5) 2 (1-4) 0.67 Mean BMI (SD) 27.34 (3.82) 27.89 (4.03) 0.21 Menopause Status (%) 25 (83%) 30 (90%) 0.55 Smokers (%) 4 (13%) 6 (18%) 0.45 Pelvic Organ Prolapse Stage (posterior compartment) Stage II (%) 12 (40%) 12 (36%) 0.63 Stage III (%) 12 (40%) 15 (45%) 0.23 Stage IV (%) 6 (20%) 6 (18%) 0.78 Previous Surgical Procedure Hysterectomy (%) 1( 3%) 1 (3%) 0.34 Bilateral Adnexectomy (%) 2 (6%) 1(3%) 0.22 Shull Suspension (%) 1 (3%) 1 (3%) 0.71 Abdominal Sacrocolpopexy (%) 1 (3%) 1(3%) 0.59 Anterior Colphorraphy (%) 1 (3%) 1 (3%) 0.88 Posterior Colphorraphy (%) 2 (6%) 3 (9%) 0.29 Continence Surgery (%) 2 (6%) 1 (3%) 0.65 Abbreviations: SD: Standard Deviation; BMI: Body Mass Index; TOT: transobturator tape Table 2: Complications in 151 patients after surgery (median follow-up)* Complications VMR (30) 1 month VMR (30) Median FU VMR+RP (33) 1 month VMR+RP (33) Median FU p Rectal stenosis (%) 0 (0) 0 (0) 0 (0) 0 (0) ns Proctalgia, pain (%) 1 (3.3) 0 (0) 2 (6) 1 (3) ns Obstructed defecation syndrome after surgery (%) 1 (3.3) 1 (3.3) 1 (3) 1 (3) ns Tenesmus (%) 0 (0) 0 (0) 1 (3) 0 (0) ns Post-defecatory soiling (%) 1 (3.3) 0 (0) 1 (0) 0 (0) ns Dyspareunia (%) 1 (3.3) 0 (0) 0 (0) 0 (0) ns Fecal Urgency (%) 4 (13.3) 1(3.3) 2 (6) 1 (3) ns Constipation (%) 12 (40) 6 (20) 2 (6) 1 (3) 0.023 Fecal Incontinence (%) 0 (0) 0 (0) 0 (0) 0 (0) ns Recto-Vaginal Fistula (%) 0 (0) 0 (0) 0 (0) 0 (0) ns Difficult voiding (%) 0 (0) 0 (0) 0 (0) 0 (0) ns Overactive Bladder (%) 0 (0) 0 (0) 1 (3) 0 (0) ns Stress urinary incontinence (%) 0 (0) 0 (0) 0 (0) 0 (0) ns Urge urinary incontinence (%) 0 (0) 0 (0) 0 (0) 0 (0) ns Recurrent Urinary Tract Infections (%) 1 (3.3) 1 (3.3) 1 (3) 1 (3) ns *: 23 months (18-26) Table 3 : Pre and Postoperative (Bp) POP-Q score Classification, Quality of Life and Sexual Function Variables Preoperative VMR (30) Median Follow-up p Preoperative VMR+RP (33) Median Follow-up p VMR vs VMR +RP Posterior Compartment (Bp) 1.52±1.85 -2.63±0.34 <0.001 1.48±0.42 -2.41±0.64 <0.001 0.45 Vaginal Digitation (%) 21 (70) 5 (16.6) 0.034 23 (69.7) 0 (0) <0.001 0.041 Vaginal Bulge (%) 25 (83.3) 1 (3.3) <0.001 25 (75.7) 1 (3) <0.001 0.76 P-QoL 65.85±17.12 32.03±8.57 0.004 64.22±16.23 27.54±8.56 < 0.001 0.54 PFDI-20 146.34±65.27 41.76±27.89 <0.001 144.87±63.88 38.87±29.65 <0.001 0.67 PFIQ-7 71.34±54.87 12.76±17.98 <0.001 70.98±53.79 11.74±23.65 <0.001 0.50 Sexual Activity (%) * 12 (40) 19 (63.3) 0.047 11 (33.3) 25 (75.7) 0.007 0.033 PISQ-12 30.12±7.12 35.98±5.98 0.034 29.65±6.45 29.65±6.45 < 0.001 0.041 Abbreviations: POP-Q score: Pelvic Organ Prolapse Quantification score; P-QoL: prolapse quality of life questionnaire; PFDI-20: Pelvic Floor Disability Index ; PFIQ-7: Pelvic Floor Impact Questionnaire; PISQ-12: Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form. *: Sexual activity was not advised until one month after surgery; at least two sexual intercourses a month. Table 4: Patient impression of global improvement (PGI-I) at the Median Follow Up Variables VMR (30) VMR +RP (33) p 1: very much better 21 (70%) 24 (72%) NS 2: much better 3 (10%) 5 (15%) NS 3: a little better 3 (10%) 3 (9%) NS 4: no improvement 3 (10%) 1 (3%) NS 5: a little worse 0 0 NS 6: much worse 0 0 NS 7: very much worse 0 0 NS Success 24 (80%) 29 (87%) NS Table 5: ODS Score Mean ODS score VMR 30 VMR+RP 33 p Preoperative 23.17±4.82 22.23±3.87 0.34 Postoperative 6 mos 6.31±2.69 2.37±1.59 0.11 12 mos 5.11±1.88 1.23±1.14 0.03 18 mos 7.22±1.54 1.57±1.14 0.02 Median follow up 7.11±1.65 1.88±1.89 0.013 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4014301","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":276738741,"identity":"75cc032c-b31a-43db-9793-e3dfb47510f7","order_by":0,"name":"Mauro Cervigni","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Mauro","middleName":"","lastName":"Cervigni","suffix":""},{"id":276738742,"identity":"63cb5705-534e-4c39-8346-83b8b0c48a57","order_by":1,"name":"Andrea Fuschi","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Fuschi","suffix":""},{"id":276738743,"identity":"75f804bc-2263-4a36-a484-f39836d63f2e","order_by":2,"name":"Andrea Morciano","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Morciano","suffix":""},{"id":276738744,"identity":"acaee9e9-4e1e-48a7-96b4-9985ae8b8952","order_by":3,"name":"Lorenzo Campanella","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Lorenzo","middleName":"","lastName":"Campanella","suffix":""},{"id":276738745,"identity":"cff56894-c449-4b8c-b8b6-7e06e3c41c64","order_by":4,"name":"Antonio Carbone","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"","lastName":"Carbone","suffix":""},{"id":276738746,"identity":"21b56f16-da66-4cf3-9675-93cfd14c7990","order_by":5,"name":"Michele Carlo Schiavi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIie3PPUvDQBjA8SccnMtJ1xMl+QTCUwLRQfpZGgp2acUxINhAIVmUrMnHcMl8xw0ukawZO3VyaDaFQr1IQcHkZof7T/f24+4AbLb/GAEKcN+NGAgA7uqluJu6estA8If4AM438YEMmV+kK4yPRA/6yWVKtpsd3oCXvknxmVzPs0wmu3YxceKTkegjgaJX4xxvAau7qXxO+DJvwnVRlDMy9LBAMXrOUAFyhoJVfBk3zpqcloQayR4P4OUM5b7ic6+WHVkxIwHUj270XSziUxRhRxQfJjQ4e8IZw2qB6iLi4xf9F6coX5ESgr2kVlv+EU1cL6389h0fPbdWCtryYZWN5Kb3mmPs7xI1nbfZbDabsS/tI1bbZyJ2JwAAAABJRU5ErkJggg==","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Michele","middleName":"Carlo","lastName":"Schiavi","suffix":""}],"badges":[],"createdAt":"2024-03-04 20:35:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4014301/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4014301/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57969093,"identity":"208c5a6b-42b0-4f58-b8b0-b64128fb5ea0","added_by":"auto","created_at":"2024-06-08 08:31:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":850449,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4014301/v1/ba2db324-988a-4e7b-acca-7da8aca89bc6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Obstructed Defecation Syndrome: analysis of the efficacy and mid-term quality of life of an innovative robotic approach","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eRectocele, defined as a protrusion in the posterior vaginal wall caused by an outpouching of the anterior wall of the rectum through a compromised rectovaginal fascia, is often a component of a tricompartmental defect in pelvic organ prolapse (POP) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The real incidence of rectocele is not known, though asymptomatic posterior compartment prolapse has been documented in roughly 40% of parous women (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). When symptomatic, posterior compartment prolapse manifest with obstructed defecation syndrome (ODS), a clinical condition characterized by difficulty in feces evacuation despite the absence of mechanical impediment, often associated with symptoms such as tenesmus, the need to digitate vaginally or anally, post-defecatory soiling, perineal pain, and, in rare cases, faecal incontinence (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePosterior compartment prolapse, together with obstructed defecation syndrome, are two conditions who are simultaneously present in 90% of the patients (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).On the other hand, around 50% of the population has ODS symptomatology without posterior compartment prolapse(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe choice of treatment depends on the severity of the syndrome, the symptoms experienced by the patient, and the impact on the patient\u0026rsquo;s quality of life. Although symptoms can be treated with a conservative first approach, this is not always the best therapeutic choice, and in such case, surgery is still a viable option to explore (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMoving towards the evolution of the surgical technique to treat ODS, the transanal resection approach is widely spread among european colorectal surgeons. Despite being regarded as a surgery with a high rate of success (72%), the postoperative complications remain significant. Urgency is the most prevalent result in the early post-surgical phase, with recorded rates as high as 47.8%. However, this symptom fades between 3 and 10% with time. Pain/tenesmus is the second most prevalent short-term effect (ranging from 0.4 to 24%). Anastomotic dehiscence is the most feared complication, with a frequency ranging from 0.4 to 7.1%(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFinally, the prevalence of persistent and recurrent constipation ranges from 1 to 24% of patients has a significant impact on patients' quality of life(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to recent literature, which supported our previous study in which we employed vaginal plication during sacrocolpopexy in patients with severe posterior vaginal prolapse(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), we further assessed the role of plicating the rectal wall to restore the anatomy and function of the rectum in patients suffering from posterior compartment prolapse and ODS and in contrast to the Transanal technique, no excision was performed.\u003c/p\u003e \u003cp\u003eNowadays Robotic ventral rectopexy, with better ergonomics and precision, includes the mobilization of the rectum down to the level of the levator muscles and its fixation to the sacral promontory by using suture or staples. Furthermore, the insertion of a mesh while performing rectopexy is a common pratice, placing it anteriorly, or around the rectum.\u003c/p\u003e \u003cp\u003eStating that rectocele can be considered a consequence rather than a cause of ODS, therefore it would seem illogical to treat a neuromuscular condition cutting an enlarged rectal wall, instead of restoring the anatomy that in our hypothesis would result in a postoperative reduced bowel transit time and constipation (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn conclusion, the aim of our study is to prove how the simultaneous plication of the rectal wall in combination with robotic mesh rectopexy would result in a safe and effective treatment and would provide better outcomes in terms of bowel function and quality of life.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eFrom January 2018 to December 2021, 78 women affected by ODS and posterior compartment prolapse were referred to the Dept. of Surgery/Urology at \"La Sapienza\" Univ. ICOT Polo Pontino Hospital and Dept. of Urogynecology and Pelvic Floor Reconstructive Surgery of the Sandro Pertini Hospital of Rome and they were enrolled for the study.\u003c/p\u003e \u003cp\u003eAll data were retrospectively evaluated from a collected urogynecological internal database. Therefore, this study is a retrospective comparing analysis of the two different techniques results. The Institutional Review Boards (IRB) approved the study. An informed written consent was obtained from all women. The research was conducted according to Good Clinical Practice Guidelines.\u003c/p\u003e \u003cp\u003eThe inclusion criteria were as follows: patients aged between 18 and 75 years, presence of ODS and rectocele\u0026thinsp;\u0026ge;\u0026thinsp;II stage, according to Pelvic Organ Prolapse Quantification System, POP-Q classification, without coexisting significant anterior or apical compartment prolapse and without clinical or latent stress urinary incontinence (SUI).\u003c/p\u003e \u003cp\u003eWomen with concomitant surgery of a uterine prolapse, cystocele or urinary incontinence were excluded. Exclusion criteria were also malignancies, degenerative neurological diseases, previous pelvic radiotherapy, pregnancy state, megacolon, bowel inflammatory disease, pelvic floor dyssynergia or anal sphincter deficiency and contraindications to surgery or aneasthesia. In presence of sphincter contractile deficiency or dyssynergia, the patients were first treated with pelvic floor rehabilitation and then, after a re-evaluation with anorectal-manometry, scheduled for surgery.\u003c/p\u003e \u003cp\u003eThe procedures were ever performed by the same surgeon (MC) who had previously performed more than 100 interventions completing the learning curve.\u003c/p\u003e \u003cp\u003eThe minimum follow-up for these patients were 18 months.\u003c/p\u003e \u003cp\u003ePreoperative assessment was done using a standardized questionnaire and a clinical examination. The questionnaire consisted of a history about bowel movements, questions about obstructed defecation, need for vaginal/perineal digitation and prolapse protrusion symptoms (foreign body feeling in the introitus), a history about anal incontinence and sexual function.\u003c/p\u003e \u003cp\u003eAll patients were candidate for surgical intervention after the failure of medical and dietary therapy and after a complete radiological and functional study.\u003c/p\u003e \u003cp\u003eMR or RX defecography and anorectal manometry were always performed to assess the presence of rectocele and rectal intussusceptions in patients who were unable to \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eempty.\u003c/span\u003e These examinations were also helpful to identify the presence of pelvic floor dyssynergia or anal sphincter deficiency, which are criteria for exclusion from the surgical treatment.\u003c/p\u003e \u003cp\u003eClinical examination consisted of a proctological and gynaecological examination in the supine lithotomy or lateral position during maximal Valsalva manoeuvre. POP-Q measurement according to the guidelines of the ICS was performed.\u003c/p\u003e \u003cp\u003eThe degree of posterior compartment defects was evaluated by POP-Q System under maximum straining effort, with the patient in the lithotomy position.\u003c/p\u003e \u003cp\u003eThe symptoms of ODS that are perceived by the patients were evaluated before and after the intervention using the ODS (Obstructed Defecation Syndrome) score which analyzes constipation using 5 items.\u003c/p\u003e \u003cp\u003eThe prolapse quality of life questionnaire (P-QoL) was used to quantify the impact of prolapse symptoms on QoL. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12), Pelvic Floor Disability Index (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7) were administered to evaluate quality of life and sexual function before surgical intervention and at median follow up.\u003c/p\u003e \u003cp\u003eBefore surgery all patients were given low molecular\u0026ndash;weight heparin to prevent venous thromboembolism. A short-term antibiotic prophylaxis was performed 30 minutes before surgery.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSurgical technique\u003c/b\u003e \u003c/p\u003e \u003cp\u003eRobotic Ventral Mesh Rectopexy is a procedure utilising da Vinci\u0026reg; technology, involving mobilisation of the front of the rectum all the way to the pelvic floor, and fixation of the front of the rectum and pelvic floor to the bony sacral promontory with a mersilene mesh. This straightens the rectum, and restores its tubular shape.\u003c/p\u003e \u003cp\u003eIn this technique, the nerves to the rectum that enter from the back and side are preserved with mobilisation only from the front and right side of the rectum, with careful preparation of the rectal fascia and muscular layer. In this step is of utmost importance the preservation of nerve endings, leaving intact the back of the rectum for the normal maintenance of rectal functionality reducing the risk of hind gut neuropathy and resultant constipation. The mersilene mesh is thought to result in a lower recurrence rate than sutured rectopexy whilst avoiding the long-term complications\u003c/p\u003e \u003cp\u003eThe surgical technique of rectal wall plication is an innovative procedure consisting on placement of 3 sutures utilizing monofilament slow resorption resorbable threads (PDS II 2\u0026thinsp;\u0026minus;\u0026thinsp;0) for the plication in the midline of the anterior wall of the rectum starting 1 cm above the perineal body and subsequently at the distance of 1,2\u0026thinsp;\u0026minus;\u0026thinsp;1,5 cm before fixing the mesh for the rectopexy. This allows a decrease in the caliber of the rectum with greater stabilization.\u003c/p\u003e \u003cp\u003e \u003cb\u003eOperative and postoperative assessment\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAfter surgery, a bladder catheter and a vaginal pack were positioned and were removed after 48 hours. Operative time, blood transfusions, spontaneous voiding, perioperative complications, postoperative hospital stay and postoperative complications (early within 30 days and late after 30 days) were considered.\u003c/p\u003e \u003cp\u003eThe following questionnaires were administered after surgery at median follow up: P-QoL, PFDI-20 PFIQ-7 and PISQ-12. A clinical examination and the compilation of questionnaires were performed at least 18 months after surgery.\u003c/p\u003e \u003cp\u003eAdministering these questionnaires is a standard care in our Urogynecology and Proctology clinic. The same team performed surgery and postoperative evaluation.\u003c/p\u003e \u003cp\u003eObjective cure for prolapse was defined as a remaining posterior defects of stage 0-I, evaluated by POP-Q classification under maximum straining effort with the patient in the lithotomy position. Recurrence of prolapse was defined as stage II or higher, based on the POP-Q classification.\u003c/p\u003e \u003cp\u003ePatients with a significant worsening of defecatory function or with a suspect of a prolapse recurrence were subjected to a MR defecography. Patients who complained of fecal incontinence were studied with anorectal manometry.\u003c/p\u003e \u003cp\u003eODS (Obstructed Defecation Syndrome) score after surgery to evaluate constipation symptoms was used.\u003c/p\u003e \u003cp\u003eThe primary endpoint was to evaluate the effectiveness and the safety of RVMR and RVMR\u0026thinsp;+\u0026thinsp;RP at median follow-up.\u003c/p\u003e \u003cp\u003eThe secondary endpoint was to evaluate the impact on quality of life and sexual function of these two surgical procedures.\u003c/p\u003e \u003cp\u003eWe analyzed the incidence of each event to define its statistical significance using Fisher's exact test.\u003c/p\u003e \u003cp\u003eOdds ratio (OR) and 95% confidence intervals (CIs) were calculated for each comparison. Normality tests (D\u0026rsquo;Agostino and Pearson test) were performed to determine whether data were sampled from a Gaussian distribution. The T-test and Mann-Whitney U test were used to compare continuous parametric and non-parametric variables (when data do not fit into the normal distribution), respectively. Correlations between numerical parameters were computed using the Spearman rank correlation coefficient. Matched T-test was applied to determine the change in questionnaires (ODS Score, P-QoL, PFDI-20 PFIQ-7 and PISQ-12) values. All analyses were conducted using the Statistical Package for the Social Sciences (SPSS) 22.0 for Mac (SSPS, Chicago, IL, USA). Significance was set at a p-value of \u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eSeventy-eight pats were evaluated. Nine women refused the treatment, 3 were excluded because they had poor performance status (ECOG \u0026gt;2) and 3 were lost to follow up hence 63 women were analyzed. A total of 63 patients were analyzed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDemographic Clinic and Pathological characteristics were showed in table 1, no significant differences were reported between the 2 groups. No significant difference in terms of operating time occurred (132 minutes vs 123 minutes; p=0.121).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll included patients (63/63) showed at preoperative defecography the simultaneous presence of rectocele and recto-anal or recto-rectal intussusceptions.\u003c/p\u003e\n\u003cp\u003eSimilar results were shown in terms of blood loss, intraoperative complications, ureteral injuries, bowel injuries, bladder injuries, hemoperitoneum, and rectal abscesses. One patient in group A and 1 patients in group B needed a blood transfusion during the surgical intervention. There were no ureteral, bladder or intestinal lesions in the two groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn symptomatic evaluation and analysis of post-operative complications, no significant differences were reported.\u003c/p\u003e\n\u003cp\u003eBut at the median follow up 6 patients (20%) in VMR group vs 1 patient (3%) in VMR+RP group still have constipation (p=0.023)\u003c/p\u003e\n\u003cp\u003eMedian follow up was 23 months (18-26).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePOP-Q classification score for posterior compartment showed a significant average decrease for both groups (p\u0026lt;0.001) at median follow up and there wasn\u0026rsquo;t a significant difference between the two groups. Five (16.6%) women in the VMR group and 0 (0%) in the VMR+RP group used vaginal digitation (p=0.041) at least 18 months after surgery. Questionnaires assessing quality of life associated with gastrointestinal symptoms did not demonstrate significant differences at median follow-up. (table 3)\u003c/p\u003e\n\u003cp\u003eIn the VMR+RP group, the number of sexually active patients after surgery with at least two sexual intercourses per month increased (p=0.033) and consequently the PISQ-12 showed an improvement in the quality of sexual life after at least 18 months of follow up (30.12\u0026plusmn;7.12 before surgery and \u0026nbsp;35.98\u0026plusmn;5.98 after surgery in VMR group vs 29.65\u0026plusmn;6.45 before surgery and 29.65\u0026plusmn;6.45 after surgery in VMR+RP group, \u0026nbsp;p=0.041). (table 3)\u003c/p\u003e\n\u003cp\u003eAt PGI-I evaluation no significant differences occurred. (table 4)\u003c/p\u003e\n\u003cp\u003eAt 6 months of follow up the ODS score showed no significant difference (6.31\u0026plusmn;2.69 in VMR group vs 2.37\u0026plusmn;1.59 in VMR+RP group, p=0.11).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile at the median follow up the ODS score values were significantly different: (7.11\u0026plusmn;1.65 vs 1.88\u0026plusmn;1.89, p=0.013).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe other values of the intermediate follow up (12 and 18 months) are shown in table 5.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eTor our knowledge, this is the first study reporting simultaneous rectal wall plication with the combination of robotic mesh rectopexy in patients suffering from ODS and rectocele.\u003c/p\u003e \u003cp\u003eThis concept was inspired by our recent research(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), where we hypothesized that patients with severe posterior compartment prolapse would benefit from a laparoscopic sacral colpopexy plus plication of the vaginal fascia in order to help restore their anatomical and functional outcomes.\u003c/p\u003e \u003cp\u003eIn fact, we hypothesized that restoring the rectal wall architecture would result in decreased stool transit time and constipation postoperatively, as well as improved bowel function and quality of life in these patients.\u003c/p\u003e \u003cp\u003eLaplace's rule, as the foundation of our clinical reasoning, explains how strength and tightness of the rectal lumen would provide us with more contractile strength to ensure fecal emptying(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to our findings, this new technique involving rectal plication and mesh rectopexy had fewer postoperative complications than the mesh-only group, as well as a significant improvement in quality of life, sexual activity, and ODS symptomatology, which was significantly reduced at the postoperative median follow-up.\u003c/p\u003e \u003cp\u003eColorectal surgeons commonly performed transanal access to treat ODS, with different degrees of effectiveness. Arnold et al. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) observed poor postoperative outcomes, with 54% of patients complaining of constipation. According to Roman et al. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) functional result declined with increasing period of follow-up, reaching a recurrence rate of 50% after 5.5 years. Furthermore, roughly one-third of female patients experienced a new beginning of anal incontinence.\u003c/p\u003e \u003cp\u003eRegarding the clinical outcome, a retrospective multicentric study of the Italian Society of Colo-Rectal surgery (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) found that at 18 months after STARR, 55% of the patients still had at least 3 symptoms of ODS, and that 19% of the cases needed a reintervention due to either postoperative complications or recurrence of symptoms. Dealing withe the postoperative complications, Defecation urgency is still the most frequent longer-term adverse effect, occurring in up to 10% of patients on average. Rectal stenosis is an uncommon complication that usually affects fewer than 1% of patients over the longer term (12 months or more) and less than 2% of patients usually develop longer-term discomfort.\u003c/p\u003e \u003cp\u003eAnastomotic dehiscence and post-operative sepsis, although they are uncommon side effects, could occur in patients undergoing rectal resection.\u003c/p\u003e \u003cp\u003ePatient global satisfaction ratings, while not always constant, generally indicated an acceptable outcome for around 73\u0026ndash;80% of patients although, In around 68\u0026ndash;76% of patients, there was an inconsistent decrease of 53\u0026ndash;91% in the ODS score for obstructed defecation syndrome.\u003c/p\u003e \u003cp\u003eDue to the high postoperative complication rate in transanal approach, robotic ventral rectopexy was proposed. Thanks to the absence of resection of the rectal mucosa to treat the primary component and the consequent neuromuscular condition underlying the development of ODS syndrome, it could become the first line treatment for patients suffering from rectocele and associated ODS.\u003c/p\u003e \u003cp\u003eAccording to De Hoog et al. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) and Mehmood et al.'s recent clinical experiment (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), this procedure is associated with lower constipation and fecal incontinence compared to perineal procedures (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Furthermore, a reported median Cleveland Clinic Constipation Score (CCCS) gain of 3.2 points after robotic surgery and Wexner incontinence score were noticeably lower than thdat of the other procedures with a noteworthy improvement in blocked defecation (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEven in patients undergoing rectopexy, several studies (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) found radiological recurrence of rectocoele, with rates ranging from 0\u0026ndash;15% together with the rate of postoperative constipation where the findings were 12-22.5%.\u003c/p\u003e \u003cp\u003eAccording to D'Hoore et al (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), our treatment solely comprised anterior rectal wall mobilization. As a result, posterior and lateral rectum mobilization were no longer required in order to reduce the risk of nerve injury. According to studies (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), constipation following rectal resection and posterior suture rectopexy is less prevalent than after posterior rectopexy without resection.\u003c/p\u003e \u003cp\u003eIn our study, as demonstrated by our findings, this new technique involving rectal plication and mesh rectopexy had fewer postoperative complications than the control group, emphasizing how postoperative constipation, in particular, was significantly lower in the plication group than in the mesh-only group.\u003c/p\u003e \u003cp\u003eAt median follow-up, the POP-Q categorization score for the posterior compartment decreased significantly for both groups with no significant difference between the two groups.\u003c/p\u003e \u003cp\u003eIn VMR the sexual function before and after surgery and the rates of sexual dysfunction were 29.6\u0026ndash;85.7% and 4.9\u0026ndash;20.2%, respectively.\u003c/p\u003e \u003cp\u003eIn the present study, contrariwise, QoL surveys and sexual activity in the group that received the plication were considerably better than those in the mesh-only group, indicating that the patients' quality of life had improved as a result of the new treatment.\u003c/p\u003e \u003cp\u003eFinally, at the follow-up time of 18 months postoperatively, the ODS score was significantly lower from the beginning value in both groups who received mesh rectopexy alone and mesh rectopexy together with rectal plication, possibly as a result of a long term readapatation of muscle fibers.\u003c/p\u003e \u003cp\u003eThis study's limitation is the retrospective design, but the good number of patients and the medium-time follow-up lead to powerful conclusions.\u003c/p\u003e \u003cp\u003eFurther randomized studies are necessary to confirm the data on the efficacy and safety of the technique combining robotic rectopexy with mesh with simultaneous plication of the rectal wall.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, Schiavi MC, Morciano A,\u0026nbsp;Cervigni M,\u0026nbsp;Carbone A,\u0026nbsp;Fuschi A,\u0026nbsp;Campanella L.; methodology, Schiavi MC, Campanella L., Cervigni M; software,\u0026nbsp;Schiavi MC.; validation, Schiavi MC .; formal analysis, Schiavi MC; investigation, Schiavi MC.\u0026nbsp;, Cervigni M\u0026nbsp;and Campanella L.; resources, Schiavi MC., Cervigni M\u0026nbsp;and Campanella L.; data curation, Schiavi MC., Cervigni M and Campanella L.; writing\u0026mdash;original draft preparation, Schiavi MC., Cervigni M and Campanella L.; writing\u0026mdash;review and editing, Schiavi MC., Cervigni M and Campanella L.; supervision,\u0026nbsp;Cervigni M; project administration,\u0026nbsp;Cervigni M. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research received no external funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all subjects involved in the study.\u0026nbsp;Written informed consent has been obtained from the patients to publish this paper\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLefevre R, Davila GW. Functional Disorders: Rectocele. Clin Colon Rectal Surg. maggio 2008;21(2):129\u0026ndash;37.\u003c/li\u003e\n\u003cli\u003eHaylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An international urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourology and Urodynamics. 2010;29(1):4\u0026ndash;20.\u003c/li\u003e\n\u003cli\u003eWeber AM, Richter HE. Pelvic organ prolapse. Obstet Gynecol. settembre 2005;106(3):615\u0026ndash;34.\u003c/li\u003e\n\u003cli\u003eBunni J, Laugharne MJ. Pathophysiological basis, clinical assessment, investigation and management of patients with obstructed defecation syndrome. Langenbecks Arch Surg. 2 febbraio 2023;408(1):75. \u003c/li\u003e\n\u003cli\u003eRipamonti, L., Guttadauro, A., Lo Bianco, G., Rennis, M., Maternini, M., Cioffi, G., Chiarelli, M., De Simone, M., Cioffi, U., \u0026amp; Gabrielli, F. (2022). Stapled Transanal Rectal Resection (Starr) in the Treatment of Obstructed Defecation: A Systematic Review. Frontiers in surgery, 9, 790287. \u003c/li\u003e\n\u003cli\u003eS\u0026aacute;kra, L., \u0026amp; \u0026Scaron;iller, J. (2017). ODS Obstrukčn\u0026iacute; defekačn\u0026iacute; syndrom - souhrnn\u0026eacute; sdělen\u0026iacute; [Obstructed defecation syndrome - review article]. Rozhledy v chirurgii : mesicnik Ceskoslovenske chirurgicke spolecnosti, 96(6), 247\u0026ndash;251.\u003c/li\u003e\n\u003cli\u003eMaher CF, Qatawneh AM, Baessler K, Schluter PJ. Midline rectovaginal fascial plication for repair of rectocele and obstructed defecation. Obstet Gynecol. 2004 Oct;104(4):685-9.\u003c/li\u003e\n\u003cli\u003eXynos E. (2012). Functional results after surgery for obstructed defecation. Acta chirurgica Iugoslavica, 59(2), 25\u0026ndash;29. \u003c/li\u003e\n\u003cli\u003eZehler, O., Vashist, Y. K., Bogoevski, D., Bockhorn, M., Yekebas, E. F., Izbicki, J. R., \u0026amp; Kutup, A. (2010). Quo vadis STARR? A prospective long-term follow-up of stapled transanal rectal resection for obstructed defecation syndrome. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, 14(9), 1349\u0026ndash;1354\u003c/li\u003e\n\u003cli\u003eIslam, M. T., Sheikh, S. H., Reza, E., Ferdaus, A. M., Islam, F., Fatema, B., Kamal, M. Z., Rahman, M., \u0026amp; Siddiquee, M. A. (2022). Evaluation of Short Term Outcome of Stapled Transanal Rectal Resection (STARR) for ODS (Obstructed Defecation Syndrome) by Comparing Pre and Post-operative ODS Score. Mymensingh medical journal : MMJ, 31(2), 355\u0026ndash;359.\u003c/li\u003e\n\u003cli\u003eMorciano, A., Ercoli, A., Caliandro, D., Campagna, G., Panico, G., Giaquinto, A., Zullo, M. A., Tinelli, A., Scambia, G., Marzo, G., \u0026amp; Cervigni, M. (2023). Laparoscopic posterior vaginal plication plus sacral colpopexy for severe posterior vaginal prolapse: A randomized clinical trial. Neurourology and urodynamics, 42(1), 98\u0026ndash;105. \u003c/li\u003e\n\u003cli\u003eHicks, C. W., Weinstein, M., Wakamatsu, M., Pulliam, S., Savitt, L., \u0026amp; Bordeianou, L. (2013). Are rectoceles the cause or the result of obstructed defaecation syndrome? A prospective anorectal physiology study. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland, 15(8), 993\u0026ndash;999. \u003c/li\u003e\n\u003cli\u003eMustain WC. Functional Disorders: Rectocele. Clin Colon Rectal Surg. 2017 Feb;30(1):63-75. \u003c/li\u003e\n\u003cli\u003eBunni, J., \u0026amp; Laugharne, M. J. (2023). Pathophysiological basis, clinical assessment, investigation and management of patients with obstruction defecation syndrome. Langenbeck\u0026apos;s archives of surgery, 408(1), 75. \u003c/li\u003e\n\u003cli\u003eArnold MW, Stewart WR, Aguilar PS. Rectocele repair. Four years\u0026rsquo; experience. Dis Colon Rectum 1990; 33: 684-687\u003c/li\u003e\n\u003cli\u003eRoman H, Michot F. Long-term outcomes of transanal rectocele repair. Dis Colon Rectum 2005; 48: 510-517\u003c/li\u003e\n\u003cli\u003eBove, A., Bellini, M., Battaglia, E., Bocchini, R., Gambaccini, D., Bove, V., Pucciani, F., Altomare, D. F., Dodi, G., Sciaudone, G., Falletto, E., \u0026amp; Piloni, V. (2012). Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment). World journal of gastroenterology, 18(36), 4994\u0026ndash;5013.\u003c/li\u003e\n\u003cli\u003ede Hoog DE, Heemskerk J, Nieman FH, van Gemert WG, Baeten CG, Bouvy ND. Recurrence and functional results after open versus conventional laparoscopic versus robot-assisted laparoscopic rectopexy for rectal prolapse: a case-control study. Int J Colorectal Dis. 2009 Oct;24(10):1201-6.\u003c/li\u003e\n\u003cli\u003eMehmood RK, Parker J, Bhuvimanian L, Qasem E, Mohammed AA, Zeeshan M, Grugel K, Carter P, Ahmed S. Short-term outcome of laparoscopic versus robotic ventral mesh rectopexy for full-thickness rectal prolapse. Is robotic superior? Int J Colorectal Dis. 2014 Sep;29(9):1113-8. Erratum in: Int J Colorectal Dis. 2019 Feb 9;\u003c/li\u003e\n\u003cli\u003eFormisano G, Ferraro L, Salaj A, Giuratrabocchetta S, Pisani Ceretti A, Opocher E, Bianchi PP. Update on Robotic Rectal Prolapse Treatment. J Pers Med. 2021 Jul 23;11(8):706.\u003c/li\u003e\n\u003cli\u003eMadiba TE, Baig MK, Wexner SD. Surgical management of rectal prolapse. Arch Surg. 2005 Jan;140(1):63-73.\u003c/li\u003e\n\u003cli\u003eCadeddu F, Sileri P, Grande M, De Luca E, Franceschilli L, Milito G. Focus on abdominal rectopexy for full-thickness rectal prolapse: meta-analysis of literature. Tech Coloproctol. 2012 Feb;16(1):37-53.\u003c/li\u003e\n\u003cli\u003eMantoo S, Podevin J, Regenet N, Rigaud J, Lehur PA, Meurette G. Is robotic-assisted ventral mesh rectopexy superior to laparoscopic ventral mesh rectopexy in the management of obstructed defaecation? Colorectal Dis. 2013 Aug;15(8)\u003c/li\u003e\n\u003cli\u003eTsunoda A. Surgical Treatment of Rectal Prolapse in the Laparoscopic Era; A Review of the Literature. J Anus Rectum Colon. 2020 Jul 30;4(3):89-99.\u003c/li\u003e\n\u003cli\u003eFathy M, Elfallal AH, Emile SH. Literature review of the outcome of and methods used to improve transperineal repair of rectocele. World J Gastrointest Surg. 2021 Sep 27;13(9):1063-1078.\u003c/li\u003e\n\u003cli\u003eD\u0026apos;Hoore A, Cadoni R, Penninckx F. Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg. 2004 Nov; 91(11): 1500-5.\u003c/li\u003e\n\u003cli\u003eHidaka J, Elfeki H, Duelund-Jakobsen J, Laurberg S, Lundby L. Functional Outcome after Laparoscopic Posterior Sutured Rectopexy Versus Ventral Mesh Rectopexy for Rectal Prolapse: Six-year Follow-up of a Double-blind, Randomized Single-center Study. EClinicalMedicine. 2019 Aug 29;16:18-22.\u003c/li\u003e\n\u003cli\u003eYehya A, Gamaan I, Abdelrazek M, Shahin M, Seddek A, Abdelhafez M. Laparoscopic Suture versus Mesh Rectopexy for the Treatment of Persistent Complete Rectal Prolapse in Children: A Comparative Randomized Study. Minim Invasive Surg. 2020 Jan 22;2020:3057528.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1:\u0026nbsp;\u003c/strong\u003eClinic Pathological characteristics and Surgical procedures in 151 patients\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"699\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eClinical Variables\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVMR (30)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVMR + RP (33)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Age (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e62.34 (4.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e60.89 (4.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian Vaginal Delivery (range)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e2 (1-5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e2 (1-4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean BMI (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e27.34 (3.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e27.89 (4.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMenopause Status (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e25 (83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e30 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmokers (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e4 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e6 (18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u003cem\u003ePelvic Organ Prolapse Stage (posterior compartment)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage II (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;12 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e12 (36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage III (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;12 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;15 \u0026nbsp; \u0026nbsp; (45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage IV (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;6 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e6 (18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Previous Surgical Procedure\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHysterectomy (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1(\u003c/strong\u003e3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBilateral Adnexectomy (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e2 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e1(3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eShull Suspension (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbdominal Sacrocolpopexy (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e1(3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnterior Colphorraphy (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePosterior Colphorraphy (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e2 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e3 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.23175965665236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eContinence Surgery (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e2 (6%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44206008583691%\" valign=\"top\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAbbreviations:\u0026nbsp;\u003c/strong\u003eSD: Standard Deviation; BMI: Body Mass Index; TOT: transobturator tape\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u0026nbsp;\u003c/strong\u003eComplications in 151 patients after surgery (median follow-up)*\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"896\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.39664804469274%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVMR (30)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e1 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVMR (30)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMedian FU\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.865921787709498%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVMR+RP (33)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e1 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.743016759776536%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVMR+RP (33)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMedian FU\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.497206703910615%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.39664804469274%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRectal stenosis (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.865921787709498%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.743016759776536%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.497206703910615%\" valign=\"top\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.39664804469274%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eProctalgia, pain (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.865921787709498%\" valign=\"top\"\u003e\n \u003cp\u003e2 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.743016759776536%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.497206703910615%\" valign=\"top\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.39664804469274%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eObstructed defecation syndrome after surgery (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.865921787709498%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.743016759776536%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.497206703910615%\" valign=\"top\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.39664804469274%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTenesmus (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.865921787709498%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.743016759776536%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.497206703910615%\" valign=\"top\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.39664804469274%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-defecatory soiling (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.865921787709498%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.743016759776536%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.497206703910615%\" valign=\"top\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.39664804469274%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDyspareunia (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.865921787709498%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.743016759776536%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.497206703910615%\" valign=\"top\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.39664804469274%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFecal Urgency (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e4 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e1(3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.865921787709498%\" valign=\"top\"\u003e\n \u003cp\u003e2 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.743016759776536%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.497206703910615%\" valign=\"top\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.39664804469274%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eConstipation (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e12 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e6 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.865921787709498%\" valign=\"top\"\u003e\n \u003cp\u003e2 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.743016759776536%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.497206703910615%\" valign=\"top\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.39664804469274%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFecal Incontinence (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.865921787709498%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.743016759776536%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.497206703910615%\" valign=\"top\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.39664804469274%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecto-Vaginal Fistula (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.865921787709498%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.743016759776536%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.497206703910615%\" valign=\"top\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.39664804469274%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDifficult voiding (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.865921787709498%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.743016759776536%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.497206703910615%\" valign=\"top\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.39664804469274%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOveractive Bladder (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.865921787709498%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.743016759776536%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.497206703910615%\" valign=\"top\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.39664804469274%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStress urinary incontinence (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.865921787709498%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.743016759776536%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.497206703910615%\" valign=\"top\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.39664804469274%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUrge urinary incontinence (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.865921787709498%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.743016759776536%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.497206703910615%\" valign=\"top\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.39664804469274%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecurrent Urinary Tract Infections (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.748603351955307%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.865921787709498%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.743016759776536%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.497206703910615%\" valign=\"top\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;*: 23 months (18-26)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e: Pre and Postoperative (Bp) POP-Q score Classification, Quality of Life and Sexual Function\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"869\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.94361334867664%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.852704257767549%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative VMR (30)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055235903337168%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative VMR+RP (33)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.622554660529344%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian Follow-up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.47180667433832%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.436133486766398%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVMR vs VMR +RP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.94361334867664%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePosterior Compartment (Bp)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.852704257767549%\" valign=\"top\"\u003e\n \u003cp\u003e1.52\u0026plusmn;1.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e-2.63\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055235903337168%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e1.48\u0026plusmn;0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.622554660529344%\" valign=\"top\"\u003e\n \u003cp\u003e-2.41\u0026plusmn;0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.47180667433832%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.436133486766398%\" valign=\"top\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.94361334867664%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVaginal Digitation (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.852704257767549%\" valign=\"top\"\u003e\n \u003cp\u003e21 (70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e5 (16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055235903337168%\" valign=\"top\"\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e23 (69.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.622554660529344%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.47180667433832%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.436133486766398%\" valign=\"top\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.94361334867664%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVaginal Bulge (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.852704257767549%\" valign=\"top\"\u003e\n \u003cp\u003e25 (83.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055235903337168%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e25 (75.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.622554660529344%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.47180667433832%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.436133486766398%\" valign=\"top\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.94361334867664%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-QoL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.852704257767549%\" valign=\"top\"\u003e\n \u003cp\u003e65.85\u0026plusmn;17.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e32.03\u0026plusmn;8.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055235903337168%\" valign=\"top\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e64.22\u0026plusmn;16.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.622554660529344%\" valign=\"top\"\u003e\n \u003cp\u003e27.54\u0026plusmn;8.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.47180667433832%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.436133486766398%\" valign=\"top\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.94361334867664%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePFDI-20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.852704257767549%\" valign=\"top\"\u003e\n \u003cp\u003e146.34\u0026plusmn;65.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e41.76\u0026plusmn;27.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055235903337168%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e144.87\u0026plusmn;63.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.622554660529344%\" valign=\"top\"\u003e\n \u003cp\u003e38.87\u0026plusmn;29.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.47180667433832%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.436133486766398%\" valign=\"top\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.94361334867664%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePFIQ-7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.852704257767549%\" valign=\"top\"\u003e\n \u003cp\u003e71.34\u0026plusmn;54.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e12.76\u0026plusmn;17.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055235903337168%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e70.98\u0026plusmn;53.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.622554660529344%\" valign=\"top\"\u003e\n \u003cp\u003e11.74\u0026plusmn;23.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.47180667433832%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.436133486766398%\" valign=\"top\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.94361334867664%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual Activity (%)\u003c/strong\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.852704257767549%\" valign=\"top\"\u003e\n \u003cp\u003e12 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e19 (63.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055235903337168%\" valign=\"top\"\u003e\n \u003cp\u003e0.047\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e11 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.622554660529344%\" valign=\"top\"\u003e\n \u003cp\u003e25 (75.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.47180667433832%\" valign=\"top\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.436133486766398%\" valign=\"top\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.94361334867664%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePISQ-12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.852704257767549%\" valign=\"top\"\u003e\n \u003cp\u003e30.12\u0026plusmn;7.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e35.98\u0026plusmn;5.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055235903337168%\" valign=\"top\"\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.80897583429229%\" valign=\"top\"\u003e\n \u003cp\u003e29.65\u0026plusmn;6.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.622554660529344%\" valign=\"top\"\u003e\n \u003cp\u003e29.65\u0026plusmn;6.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.47180667433832%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.436133486766398%\" valign=\"top\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAbbreviations:\u003c/strong\u003e POP-Q score: Pelvic Organ Prolapse Quantification score; P-QoL: prolapse quality of life questionnaire; PFDI-20: Pelvic Floor Disability Index\u003cstrong\u003e;\u0026nbsp;\u003c/strong\u003ePFIQ-7: Pelvic Floor Impact Questionnaire; PISQ-12: Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form.\u003c/p\u003e\n\u003cp\u003e*: Sexual activity was not advised until one month after surgery; at least two sexual intercourses a month.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4:\u0026nbsp;\u003c/strong\u003ePatient impression of global improvement (PGI-I) at the Median Follow Up\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"642\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.03265940902022%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.618973561430794%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVMR (30)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.995334370139968%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVMR +RP (33)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35303265940902%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.03265940902022%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1: very much better\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.618973561430794%\" valign=\"top\"\u003e\n \u003cp\u003e21 (70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.995334370139968%\" valign=\"top\"\u003e\n \u003cp\u003e24 (72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35303265940902%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.03265940902022%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2: much better\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.618973561430794%\" valign=\"top\"\u003e\n \u003cp\u003e3 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.995334370139968%\" valign=\"top\"\u003e\n \u003cp\u003e5 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35303265940902%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.03265940902022%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3: a little better\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.618973561430794%\" valign=\"top\"\u003e\n \u003cp\u003e3 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.995334370139968%\" valign=\"top\"\u003e\n \u003cp\u003e3 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35303265940902%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.03265940902022%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e4: no improvement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.618973561430794%\" valign=\"top\"\u003e\n \u003cp\u003e3 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.995334370139968%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35303265940902%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.03265940902022%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e5: a little worse\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.618973561430794%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.995334370139968%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35303265940902%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.03265940902022%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e6: much worse\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.618973561430794%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.995334370139968%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35303265940902%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.03265940902022%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e7: very much worse\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.618973561430794%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.995334370139968%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35303265940902%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.03265940902022%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuccess\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.618973561430794%\" valign=\"top\"\u003e\n \u003cp\u003e24 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.995334370139968%\" valign=\"top\"\u003e\n \u003cp\u003e29 (87%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35303265940902%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5:\u0026nbsp;\u003c/strong\u003eODS Score\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"642\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.246105919003114%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean ODS score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.330218068535826%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVMR\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e30\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.73208722741433%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVMR+RP\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e33\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.69158878504673%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.246105919003114%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.330218068535826%\" valign=\"top\"\u003e\n \u003cp\u003e23.17\u0026plusmn;4.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.73208722741433%\" valign=\"top\"\u003e\n \u003cp\u003e22.23\u0026plusmn;3.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.69158878504673%\" valign=\"top\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.246105919003114%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.753894080996886%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.246105919003114%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e6 mos\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.330218068535826%\" valign=\"top\"\u003e\n \u003cp\u003e6.31\u0026plusmn;2.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.73208722741433%\" valign=\"top\"\u003e\n \u003cp\u003e2.37\u0026plusmn;1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.69158878504673%\" valign=\"top\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.246105919003114%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e12 mos\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.330218068535826%\" valign=\"top\"\u003e\n \u003cp\u003e5.11\u0026plusmn;1.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.73208722741433%\" valign=\"top\"\u003e\n \u003cp\u003e1.23\u0026plusmn;1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.69158878504673%\" valign=\"top\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.246105919003114%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e18 mos\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.330218068535826%\" valign=\"top\"\u003e\n \u003cp\u003e7.22\u0026plusmn;1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.73208722741433%\" valign=\"top\"\u003e\n \u003cp\u003e1.57\u0026plusmn;1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.69158878504673%\" valign=\"top\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.246105919003114%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian follow up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.330218068535826%\" valign=\"top\"\u003e\n \u003cp\u003e7.11\u0026plusmn;1.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.73208722741433%\" valign=\"top\"\u003e\n \u003cp\u003e1.88\u0026plusmn;1.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.69158878504673%\" valign=\"top\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Robotic Surgery, Obstructed Defecation Syndrome, Rectal Prolapse, Rectal wall Plication","lastPublishedDoi":"10.21203/rs.3.rs-4014301/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4014301/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eAim \u003c/strong\u003eThe aim of our study is to prove how the combination of the Rectal wall Plication (RP) and the association with robotic Ventral Mesh Rectopexy (VMR) would result in a safe and effective procedure for patients with Obstructed Defecation Syndrome (ODS) and would provide better outcomes in terms of bowel function and Quality of Life.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods \u003c/strong\u003eFrom January 2018 to December 2021, 78 women affected by ODS and posterior compartment prolapse were enrolled for the study. The minimum follow-up for these patients were 18 months. 30 patients underwent VMR and 33 VMR plus RP. The primary endpoint was to evaluate the effectiveness and the safety of VMR and VMR + RP at median follow-up.The secondary endpoint was to evaluate the impact on quality of life and sexual function of these two surgical procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eIn symptomatic evaluation and analysis of post-operative complications ,at the median follow-up, 6 patients (20%) in VMR group vs 1 patient (3%) in VMR+RP group still had constipation (p=0.023). In the VMR+RP group, the number of sexually active patients after surgery and the PISQ-12 results showed an improvement in the quality of sexual life after at least 18 months of follow up. Finally, at the median follow-up the ODS score values were significantly reduced in both groups\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003eAlthough long-term f-u and a larger group of pats. is required, the findings we have acquired are encouraging and allowed us to say that in pats with ODS and posterior compartment prolapse the combination of rectal wall plication and ventral mesh rectopexy may improve results in terms of bowel function and quality of life.\u003c/p\u003e","manuscriptTitle":"Obstructed Defecation Syndrome: analysis of the efficacy and mid-term quality of life of an innovative robotic approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-07 05:47:03","doi":"10.21203/rs.3.rs-4014301/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3f116d4f-f934-4e23-8bbb-de3dfa277aba","owner":[],"postedDate":"March 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-08T08:23:35+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-07 05:47:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4014301","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4014301","identity":"rs-4014301","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}