Transanal surgery for obstructed defecation syndrome: Literature review and a single-center experience

Table 1 Overview and summary of pros of each transanal operative procedure

Procedure	Pros	Ref.
Partial division of puborectalis	Good short-term follow-up outcome	[35-37]
	More effective compared with common non-surgical procedures	[35]
Internal Delorme’s procedure	Good long-term follow-up outcome with advantages as low recurrence rate and without complications such as postoperative constipation	[50,53,58,59]
	Suitable for patients with ODS and postoperative risk of fecal incontinence	[50,53]
PPH-STARR procedure	Overall satisfaction during postoperative long-term follow-up	[52,56,62-65,83-86]
	Without damage to the anal sphincters	[47]
Contour-Transtar procedure	High percent of patient satisfaction during long-term follow-up with advantages such as visualizing the procedure and being suitable for resection of a large volume of prolapsed tissue and without severe complications such as recto-vaginal fistula and fecal incontinence	[41,87,88,91-96]
	With superiority over PPH-STARR procedure	[91]
Bresler procedure and liner stapler and bioabsobable stapler line reinforcement material	High percent of patient satisfaction during long-term follow-up with advantages such as being suitable for resection of a large rectocele with a depth more than 4.5 cm, simple procedure and without severe complications such as recto-vaginal fistula and peritoneal perforation	[9,45,48,99,100]
TRREMS procedure	High percent of patient satisfaction during long-term follow-up with advantages such as being suitable for large prolapses of more than 5.0 cm, a short learning curve and without severe complications	[42-44,101]
TST-STARR procedure	High percent of patient satisfaction during long-term follow-up with advantages such as being suitable for large prolapses of more than 5.0 cm, a short learning curve, direct visualization during surgery and without severe complications	[11]
TERP procedure	Good short-term follow-up outcome	[46]

TRREMS: Transanal repair of rectocele and rectal mucosectomy with a single circular stapler; TST: Tissue selecting therapy; PPH: Procedure for prolapse and hemorrhoids; STARR: Stapled transanal rectal resection.

Table 2 Overview and summary of cons of each transanal operative procedure

Procedure	Cons	Ref.
Partial division of puborectalis	Disappointing short-term follow-up outcome	[34,38,57]
	Increased risk of postoperative fecal incontinence	[34,38,57]
Internal Delorme’s procedure	Unsatisfactory long-term follow-up outcome with disadvantages such as high recurrence rate, long operative time and complications such as constipation, fissure-in-ano, and transient incontinence	[39,53,55,60,61]
	Unsuitable for patients with ODS and diarrhea	[53]
	Requiring additional sphincteroplasty for patients with ODS and severe fecal incontinence	[60]
	Without superiority to stapling procedures in treatment of rectocele induced ODS	[39,55]
PPH-STARR procedure	Disappointing long-term follow-up outcome with disadvantages such as a long learning curve and complications such as bleeding, puborectalis dyssynergia, urinary retention, granuloma of anastomotic stoma and recurrent ODS	[41,63,67-70,79,80]
	With some severe postoperative complications such as severe proctalgia, fecal incontinence and rectovaginal fistula	[75-78]
	With rare complications such as rectal diverticulum and sigmoid volvulus	[81,82]
	Unsuitable for patients with previous pelvic floor surgery or sphincter weakness	[66,68-70,76-80]
	Limitation of resection of a large volume of prolapsed tissue and difficulty in visualizing the procedure	[41]
Contour-Transtar procedure	Disappointing long-term follow-up outcome with disadvantages such as a long learning curve , relatively complicated procedure, high cost and complications such as bleeding, puborectalis dyssynergia, urinary retention, granuloma of anastomotic stoma and recurrent ODS	[65,87,89,90,97]
	With some severe complications such as recto-vaginal fistula, fecal urgency, fecal incontinence and anorectal pain	[87,89,90]
	Unsuitable for patients with previous pelvic floor surgery or sphincter weakness	[65,87,89,90,97]
	Without superiority over PPH-STARR procedure	[65,97]
Bresler procedure and liner stapler and bioabsobable stapler line reinforcement material	Limited effect on rectal intussusception and unsuitable for patients with sphincter weakness	[45,48,99,100]
TRREMS procedure	Limited effect on severe rectocele	[44]
	Unsuitable for patients with sphincter weakness	[42-44,101]
TST-STARR procedure	Unsuitable for patients with sphincter weakness	[11]

TRREMS: Transanal repair of rectocele and rectal mucosectomy with a single circular stapler; TST: Tissue selecting therapy; PPH: Procedure for prolapse and hemorrhoids; STARR: Stapled transanal rectal resection.

Table 3 Comparison of mean operative time, blood loss and mean postoperative hospital stay between the procedure for prolapse and hemorrhoids-stapled transanal rectal resection and Bresler procedures

	STARR procedure	Bresler procedure	P value
Mean operative time (min)	21.5 ± 4.5	21.0 ± 4.0	0.26
Blood loss (mL)	10.0 ± 2.5	9.0 ± 2.0	0.35
Mean postoperative hospital stay (d)	5	5	0.19

STARR: Stapled transanal rectal resection.

Table 4 Comparison of the incidence of postoperative complications between the procedure for prolapse and hemorrhoids-stapled transanal rectal resection and Bresler procedures

	Pain	Fecal incontinence	Bleeding	Total number	Incidence	P value
STARR procedure	2	5	1	30	26.7%	0.774
Bresler procedure	3	4	2	30	30.0%

STARR: Stapled transanal rectal resection.