Critical thresholds of combined transvaginal mesh and transanal resection for rectocele repair in East Asian women

This study aimed to establish rectocele severity thresholds for East Asian populations using defecography, examine associations between rectocele morphology and symptoms of obstructive defecation syndrome, compare the 3-year efficacy and safety of transvaginal mesh with transanal resection versus tissue-selecting therapy stapler procedure, and identify predictors of postoperative constipation, recurrence, and reoperation. A prospective cohort study (2019–2024), included total of 138 women with rectocele-associated obstructive defecation syndrome at Tianjin Union Medical Center. Transvaginal mesh combined with transanal resection versus tissue-selecting therapy stapler procedure was performed. Primary outcomes were rectocele morphology classification using Li-Geng angle quantification, identification of concomitant pelvic floor lesions on defecography for R 11 confirmation, and severity thresholds derived from receiver operating characteristic analysis. Secondary outcomes were surgical safety (complication rates) and effectiveness (Wexner constipation score >12) at a median 3-year follow-up. Four rectocele morphologies were identified: funnel (12.3%), pouch (57.2%), boot-shaped (27.5%), and papillary types (2.9%). Severe rectocele was defined as depth ≥30.5 mm or distance between anorectal junction and pubococcygeal line (≥37.5 mm), with high diagnostic accuracy. Threshold for the combined procedure included depth ≥22.5 mm and Li-Geng angle ≤81.5°. Compared with stapler procedure, the combined approach was associated with significantly lower long-term morbidity ( P =0.01), lower recurrence ( P =0.01), and reduced reoperation rates ( P =0.03). The R 11 phenotype independently predicted postoperative constipation recurrence ( P =0.02). The combined approach provided superior long-term outcomes compared with stapler procedure. The R 11 phenotype may help identify patients at high risk of postoperative constipation recurrence and support personalized surgical strategies.