Comparison between perineal and anal repair of rectocele in obstructed defecation patients

multiparous females women with obstructed defecation due to rectocele will be randomly allocated into three groups: transperineal repair with levatorplasty (TPR-LP); transperineal repair without levatorplasty (TPR); and transanal repair (TAR. The study includes defecographic assessment, anal manometry, and score on a function questionnaire. Assessments will be done preoperatively and six months postoperatively. In the transanal approach,a Hill-Ferguson retractor was inserted into the anal canal, and the anterior rectal wall was exposed. With a finger inserted in the vagina, the true borders of the rectocele were delineated. After submucosal infiltration of a 1:200000 adrenaline solution in saline, the mucosal flap in the whole area of the rectocele (starting 1 cm above the dentate line) was elevated and excised. Horizontal plication of the muscular layer was performed with 2/0 Vicryl sutures, and the continuity of the mucosa was restored with one row of interrupted 3/0 Vicryl sutures (half Delorme procedure). Rectal packing was not used, and normal feeding was allowed on the second day after the operation. In the transperineal approach, a transverse incision was made in the perineum above the subcutaneous anal sphincter, and dissection was performed between the rectum and the vagina. Suturing of the rectal submucosal area was done with 3/0 Vicryl sutures. Then the deeper transverse or deeper perineal tissues were approximated to reinforce the rectovaginal septum, and to take tension off the first layer of sutures. When levatorplasty was done, tissues of the perineal body, including the puborectalis muscle, were approximated in the midline to provide an additional layer of tissue between the vaginal and rectal wall and to reinforce the closure. Each procedure takes about 45 - 60 minutes