There exists a great variety of operative techniques to treat patients with ODS. According to the surgeon’s preference the approach can be transanal, transvaginal, transperineal or transabdominal.

All techniques have its advantages and disadvantages; thus, we believe that satisfying functional outcomes can only be achieved by offering a tailored approach to each individual patient. Consequently, it is essential for pelvic floor surgeons to focus on more than one operative technique to optimize treatment for defecatory disorders.

A number of studies have been published about the surgical management of symptomatic rectoceles in the last decade. However, high evidence based studies are still lacking, and most data were analyzed retrospectively with a low number of included patients. Additionally, there are few well-designed randomized controlled trials available comparing different surgical techniques. Thus, the interpretation of data should be performed with caution, as selection bias cannot be ruled out. Selection of patients is an essential aspect and poorly described in literature. It is often not stated, whether patients have a symptomatic singular rectocele, or show other associated pathologies such as intussusception and enterocele. This fact needs to be taken into account when choosing the appropriate approach. The use of objective validated measurements is also significantly lacking in the vast majority of studies, but certainly helpful to define and evaluate the role of each technique. Perineal techniques are certainly less common than other procedures, thus are not discussed in detail here. It can be combined with a sphincteroplasty in selected patients with both ODS and fecal incontinence due to sphincter defects[10].

Posterior colporraphy often with plication of the levator muscle represents the treatment modality most favored by gynecologists. Although the transvaginal approach is a safe procedure with a low complication rate, functional results are highly conflicting[11-15]. Moreover, the indication for surgery is often based on the feeling of a vaginal bulge, without assessing all aspects of pelvic floor symptoms. In addition, gynecologists tend not to perform defecography for further detailed evaluation.

One of the largest series on posterior colporraphy was published by Kahn et al[12] including 231 female patients. After mean follow up of 42.5 mo, the authors reported a reasonable improvement of prolapse symptoms due to rectocele. However, constipation, incomplete bowel emptying, incontinence of feces and sexual dysfunction deteriorated after the operation.

One randomized controlled trial with only 15 patients in each group compared the functional outcome between the transanal and transvaginal approach[13]. Both techniques led to an improvement of symptoms. Notably, the need for digital assistance for rectal emptying and the rate of recurrent rectoceles were higher in the transanal group following surgery.

We consider the transvaginal approach suitable for patients with an isolated rectocele without significant internal prolapse. It is associated with an acceptable morbidity rate and improves complaints in selected patients. In addition, it can be combined with further gynecological prolapse procedures if deemed necessary[10].

The transanal access to treat ODS is routinely conducted by colorectal surgeons, with varying success rates[11,13,16-18]. Arnold et al[16] reported poor postoperative results as 54% of patients still complaint about constipation. The authors pointed out that the disappointing results were probably due to a relatively unselective approach. Roman et al[19] revealed that functional outcome decreased with increased length of follow up, reaching a recurrence rate of 50% at 5.5 years. In addition, new onset of anal incontinence occurred in nearly one third of female patients. In contrast, Murthy et al[5] found excellent results after transanal rectocele repair by operating on patients only with defined criteria: sensation of vaginal mass requiring digital support for defecation, contrast retention on defecography and the presence of a large rectocele.

The stapled transanal rectal resection (STARR) gained some popularity when it was first introduced for treating ODS caused by both rectocele and intern rectal mucosa prolapse. By using either two firings of the PPH-01^® circular stapler or the CONTOUR^® TRANSSTAR, a full thickness rectal resection can be conducted[20,21]. A high number of studies reported promising results with significant improvement of ODS reflected by objective scorings systems[20,22-24]. On the contrary, there have also been reports about serious complications including rectal-vaginal fistula and rectal perforation[25]. Moreover, fecal urgency, possibly related to change in rectal ampulla volume and sensitivity, frequently occurs postoperatively, but may decline with time[26]. Fecal incontinence following STARR procedure has been reported as well[26,27].

Altogether, STARR is certainly an alternative technique for treating ODS, when performed by experienced colorectal surgeons. Care must be taken in patients with already existing weakness of anal sphincter muscle. Furthermore, patients also need to be aware and informed about the possibility of new fecal urgency or even de-novo onset of fecal incontinence.

The transabdominal approach is mainly suitable for patients with ODS caused by complex rectocele in association with high-grade intussusception. Different rectopexy techniques have been described with or without mesh application[28-30]. Laparoscopic resection rectopexy is one standard procedure achieving good long term results with an improvement of defecation symptoms[30,31]. Especially patients with a symptomatic sigmoidocele tend to benefit from this operation.

Recently, laparoscopic ventral mesh rectopexy (VMR) has gained much attraction among colorectal surgeon[32]. This technique has initially been described by D’Hoore et al[33] for treating external rectum prolapse, but its indication has been extended for internal prolapse causing ODS. Here, the rectum is purely mobilized ventrally without division of the lateral ligaments and subsequent rectal denervation. Several centers reported promising functional outcomes with a significant reduction of ODS and a low morbidity rate[32,34,35]. Moreover, in contrast to transanal procedures, lap. VMR is unlikely to impair fecal continence.

Nevertheless, long-term data are still lacking and late mesh related complications may increase with longer follow-up periods. In addition, laparoscopic VMR seems to have a considerable learning curve if it is not taught in a mentored environment[36].