**7. Techniques comparison**

Even though there is no clear conclusion that one surgical technique is superior to the rest, there are numerous studies that compare existing techniques to address the need for consensus on what the recommendation should be.

The inferiority of the site-specific repair technique is clear, since posterior colporrhaphy has shown better anatomical results and in terms of symptoms in comparison, so this technique should not be used as a first-choice technique.

Regarding the transperineal approach, it has been recommended in combination with sphincteroplasty or levatorplasty for the treatment of symptomatic rectocele. These procedures have resulted in improved evacuation and continence in 75% of patients. Regarding the transvaginal repair, it provides better results of anatomical repair of the rectocele and fewer recurrences. Both techniques are associated with significant postoperative dyspareunia rates [15].

In a 2020 randomized study [2, 13] comparing the transperineal approach with the transvaginal approach for the treatment of anterior rectocele, it was determined that the transvaginal repair of the rectocele achieved an improvement in constipation and quality of life related to function sexual compared with the transperineal approach. There were no significant changes in dyspareunia. From the point of view of intraoperative time, postoperative complications, and recurrence, no significant differences were found.

Posterior transvaginal colporrhaphy with native tissue compared with the transanal approach presents better anatomical results in vaginal examination but not in defecography, with improvement in terms of constipation and incomplete evacuation without changes in terms of digitation needs, with similar rates of complications [15].

It is important to consider certain anatomical aspects such as in the case of the transvaginal approach, there is no direct interference with the anal canal, so that the involvement of the anal sphincter is very unlikely, compared with the transanal approach. Therefore, this technique can be given priority in patients with previous damage or pathologies in the anal sphincter.

Certain authors attach importance to the caliber of the vagina in the face of postsurgical dyspareunia. This is not a trivial complication, and it occurs in more than

*Perspective Chapter: Surgical Management of Symptomatic Rectocele DOI: http://dx.doi.org/10.5772/intechopen.105505*

33% of sexually active women after performing different rectocele repair techniques. Other comparisons show a significant improvement in the sexual satisfaction of patients after a transvaginal approach but not after a trans perineal approach, possibly due to the change in the anatomy of the vagina or "rejuvenation" that occurs in the first technique and not in the second [15].

When it comes to the use of native tissue versus biological flaps, no anatomical improvements of the posterior compartment or symptomatic improvements of ODS have been observed, and there are no differences in terms of complications. There are also no better anatomical or symptomatic results with the use of synthetic meshes. Their use presents complications such as dyspareunia or erosions and even mesh extrusion in the case of a transvaginal approach.
