Interpretation of findings
A large proportion of the existing literature on AS repairs relates to
trans-perineal anterior sphincteroplasty often with no concurrent
perineal body repair. The study demonstrates that, following a
transvaginal repair, long-term functional results are better than
previously reported in the literature. Gutierrez et al published on 182
patients undergoing an anterior
sphincteroplasty without perineal body repair.
57% were still incontinent of
solid stool at 10 year follow up (15). Barossa et al had 370 patients
from a Danish registry with 54% still incontinent of solid stools at
follow up (13). In our cohort we showed that only 26.8% of women were
incontinent of solid stool at follow up. Furthermore, our study showed
that 69.3% had a clinically significant improvement in their symptoms
with 46.5% of patients showing a marked improvement in their
incontinence. Whether this is causally related to the transvaginal route
with a concurrent posterior repair is hard to determine in a
retrospective observational study.
Perineal body thickness is a predictor of FI (16). It would make sense
that reconstructing the perineal body with a perineorrhaphy at the time
of surgery would improve continence score although further studies are
needed to confirm this.
Briel et al compared complex repairs (with perineorrhaphy and restoring
rectovaginal septum) vs simple repairs. This trial did not show any
difference, the numbers were small and patients receiving simple repairs
were done >10 yr prior to the complex repairs (17). Chase
et al showed that all patients that had a levatorplasty at time of
sphincter repair did well following sphincter repair, although this is
based on only 6 patients (18).
We believe that a concomitant pelvic floor repair with the AS repair can
improve results, as the pelvic floor and perineal body plays an
important part in continence. Excessive vaginal narrowing from overtight
levator sutures and introital stenosis resulting in dyspareunia in
sexually active women should be avoided.
Successful anatomic repair of the defect would likely be a factor in
predicting long-term functional outcomes; however, no series of
long-term follow-up of patients with postoperative imaging exists (1).
Engel et al compared US pre and post with a median follow up of 15
months. It showed that the postoperative squeeze pressure was increased,
and the external sphincter was more frequently intact in those with a
good outcome (19). In our case series, women with a persistent defect
had a higher post-operative St Marks score compare to the women with no
defect, but the numbers were small. Endoanal ultrasound may have the
ability to identify those patients with poor results from an initial
repair who may benefit from repeat repair (20).
An increasingly popular method to treat AI is with sacral
neuromodulation. This has also been evaluated in women with sphincter
defects. A prospective study on the efficiency of SNS for faecal
incontinence following OASIS has shown that SNS can reduce weekly faecal
incontinence, regardless of the extent of the sphincter defect (21). A
Cochrane systematic review from 2015 showed favourable mid‐ and
long‐term positive outcomes for SNS. The review reported the success
rates for SNS (based on at least 50% improvement in FI episodes per
week) were 63%, and 36% of participants achieved complete faecal
continence. The quality of evidence was low and there was no consistent
outcome reporting between studies making the analysis difficult (22).
These figures may be reduced further when results are reanalysed using
all available participants on an intention‐to‐treat basis. Furthermore,
SNS has a high surgical revision rate of up to 32.5% for complications
relating to the device such as pain and lead migration (23). A
prospective comparative trial in women with sphincter defects would
beneficial to help guide women and clinicians in the treatment of AI in
the setting of sphincter defects.