**8. Conclusion**

There is not a superior technique that can be recommended as the only "gold standard." For this reason, the surgical treatment of the rectocele must be individualized in each case according to the needs of the patient and surgeon's experience.

A transvaginal approach with posterior colporrhaphy and native tissue is recommended in cases of women with ODS who require surgical treatment, reporting the rate of possible post-surgical dyspareunia.

In cases with multicompartmental prolapse or with a very high rectocele, an abdominal approach is more suitable (**Figure 5**).

Non-absorbable mesh should not be used in the vaginal approach due to potential adverse effects.

An improvement in the results with the use of biological materials has not been demonstrated; however, their use increases the surgical costs.

Site-specific repair has a higher recurrence rate and is not recommended as the first technique of choice in patients with constipation.

Transanal approach for the treatment of posterior rectocele is associated with lower resolution of ODS symptoms and a higher recurrence rate with higher infection rates. This approach should be avoided in patients with fecal incontinence or known sphincteric damage, cases in which the association of perineoplasty or levatorplasty may be more indicated.

#### **Figure 5.**

*Option of rectocele treatment algorithm, ODS: Obstructive defecation syndrome, TV: Transvaginal, FI: Fecal incontinence, LVR: Laparoscopic ventral rectopexy, STARR: Stapled transanal rectal resection.*
