**4. Surgical treatment techniques and approaches**

Once surgery is indicated, the technique will be decided based on the characteristics of the rectocele and the patient, as well as their preferences. The approach could be abdominal or extra-abdominal (perineal) approach and within the latter group: transanal, transperineal, or transvaginal, with variations in each of them [1]. We could summarize them schematically as follows:

The main objective of the surgery is focused on correcting the anatomical defect, and secondarily improving the symptoms of obstructive defecation [15]. There is a wide variety of techniques described in the literature, including those referred to above, which can be associated with the performance of flaps or placement of prosthetic material such as meshes, either biological or synthetic [4].

There is not enough evidence available in most studies to suggest that one surgical technique or approach is better than another, and therefore, despite the data presented, it is important that each surgeon performs the technique with which you are more familiar and have more experience.

Existing data support the recommendation to consider posterior colporrhaphy of native tissue by transvaginal approach as first surgical option in cases of female patients with rectocele and obstructive defecation symptoms and with surgical indication. This improves anatomical defects and obstructive defecation symptoms. Although, evidence shows that the anatomical defect of the prolapse may persist over time, and symptomatic improvement may decrease in long-term follow-up. Despite this, more studies will be needed to recommend a surgical technique as the "gold standard."

Therefore, overall, the advice given to patients may be given under the premise that most of the techniques described have an improvement from both the anatomical and symptomatic point of view in terms of ODS symptoms, without the existence of a single type of surgery that stands out above the others [15].
