Current surgical treatment of obstructed defecation among selected European opinion leaders in pelvic floor surgery

Early safety and efficiency outcomes of a novel interdisciplinary laparoscopic resection rectopexy combined with sacrocolpopexy for women with obstructive defecation syndrome and pelvic organ prolapse: a single center study

BACKGROUND

Obstructive defecation syndrome (ODS) defines a disturbed defecation process frequently associated with pelvic organ prolapse (POP) in women that substantially compromises quality of life. Conservative management offers limited relief and a surgical intervention may be required. This is characterized by individual approaches. AIM OF THE STUDY: This retrospective single center study evaluated the surgical and clinical short-term outcome of a novel interdisciplinary laparoscopic resection rectopexy (L-RRP) with mesh- sacrocolpopexy (L-SCP) for women suffering from ODS and POP.

METHODS

The study participants underwent surgery in an interdisciplinary laparoscopic approach. Safety was the primary endpoint, assessed via postoperative morbidity classified by Clavien-Dindo scale. Secondary outcomes included evaluation of bowel function, fecal and urinary incontinence and pelvic organ prolapse status at 12 months follow-up. Additionally, a biological mesh (BM) was offered to women, who asked for an alternative to synthetic mesh material (SM).

RESULTS

Of the 44 consecutive patients requiring surgery for ODS and POP, 36 patients underwent the interdisciplinary surgical approach; 28 patients with SM and 8 patients with BM. In total 5 complications occurred, four of them were classified as minor. One minor complication was observed in the BM group. One anastomotic leakage occurred in the SM group. The two ODS scores, the bowel dysfunction score, and the incontinence score improved significantly (p = 0.006, p = 0.003, p < 0.001, and p = 0.0035, respectively). Pelvic floor anatomy was fully restored (POP-Q 0) for 29 (80%) patients after surgery. 17 patients (47%) suffered from urinary incontinence before surgery, which was restored in 13 patients (76.5%).

CONCLUSIONS

The interdisciplinary approach with L-RRP and L-SCP and the use of a BM in a small subgroup were technically feasible, safe, and effective in this single center setting. The study's retrospective design, the small sample size and the lack of comparators limit the generalizability of the findings requiring future randomized trials.

TRIAL REGISTRATION

Retrospectively registered at clinicaltrials.gov, trial number NCT05910021, date of registration 06/10/2023.

Obstructed defaecation syndrome: European consensus guidelines on the surgical management

Clinical decision-making in the treatment of patients with obstructed defaecation remains controversial and no international guidelines have been provided so far. This study reports a consensus among European opinion leaders on the management of obstructed defaecation in different possible clinical scenarios.

Modified Gant procedure for treatment of internal rectal prolapse in elderly women

BACKGROUND

Although rectal prolapse is not a life-threatening condition, it can cause defecation disorders, anal incontinence, sensory abnormalities, and other problems that can seriously affect quality of life.

AIM

To study the efficacy of the modified Gant procedure for elderly women with internal rectal prolapse.

METHODS

Sixty-three elderly female patients with internal rectal prolapse underwent the modified Gant procedure. The preoperative and postoperative anal symptoms, Patient Assessment of Constipation Quality of Life (PAC-QOL), Wexner incontinence score, incontinence quality of life score, and complications (massive hemorrhage, infection, anorectal stenosis, and anorectal fistula) were compared.

RESULTS

The improvement rates of postoperative symptoms were defecation disorders (84.5%), anal distention (69.6%), defecation sensation (81.4%), frequent defecation (88.7%), and anal incontinence (42.9%) (P < 0.05). All dimensions and total scores of the PAC-QOL after the procedure were lower than those before the operation (P < 0.05). The postoperative anal incontinence score and Wexner score were significantly lower than those before the procedure (P < 0.05). The quality of life and total scores of postoperative anal incontinence were significantly higher than those before the procedure (P < 0.05). There were no serious complications and no deaths.

CONCLUSION

The modified Gant procedure has significant advantages in the treatment of elderly women with internal rectal prolapse.

Surgical management of the rectocele - An update

Rectocele is defined as a hernia of the rectum with protrusion of the anterior rectal wall through the posterior wall of the vagina. This condition occurs commonly, with an estimated prevalence of 30-50% of women over age 50. The symptomatology that leads to consultation is variable but consists predominantly of anorectal and/or gynecological complaints such as dyschezia, requiring digital disimpaction maneuvers, pelvic heaviness, anal incontinence, or dyspareunia. Rectocele may be isolated or associated with other disorders of pelvic stasis involving cystocele and uterine prolapse. Complementary exams (dynamic imaging and anorectal manometry) are essential before deciding on the surgical management of this condition. The indications for surgical management of rectocele are based on the intensity of symptoms and the resulting deterioration in quality of life, and surgery should be discussed after failure of medical treatment. Different approaches are possible, although there is currently no real consensus in the literature. The initial approach depends on the type of rectocele: if it involves the low or mid rectum or is isolated, an approach from below (transanal, transperineal, or transvaginal approach) can be proposed, while, in the presence of a high rectocele and/or associated with various disorders of pelvic stasis, transabdominal rectopexy is more suitable.

Abdominal ventral rectopexy with colectomy for obstructed defecation syndrome: An alternative option for selected patients

BACKGROUND

Abdominal ventral rectopexy (AVR) with colectomy is controversial in the treatment of obstructed defecation syndrome (ODS). Literature data on this technique for ODS are very limited.

AIM

To evaluate the safety and efficacy of AVR with colectomy for selected patients with ODS.

METHODS

Consecutive patients who underwent AVR with colectomy for ODS were identified prospectively from 2016 to 2017 in our department. Patient demographics, perioperative surgical results, and postoperative follow-up outcomes were collected and analyzed. Long-term follow-up was evaluated with standardized questionnaires. The severity of symptoms was assessed by the objective Wexner Constipation Score (WCS) and ODS Score. The quality of life was assessed by the Patients Assessment of Constipation Quality of Life score. Functional outcome was compared pre- and post-operatively for each patient. The primary outcomes were determined by the improvement in symptoms and quality of life. Secondary outcome measures were operating time, postoperative length of stay, morbidity and mortality, improvement of pelvic floor structure, and patient satisfaction.

RESULTS

Four patients underwent robotic-assisted surgery, and two patients underwent a laparoscopic-assisted procedure. The mean operating time for the robotic approach was 243 min (range 160-300 min), and the mean operating time for the laparoscopic approach was 230 min (range 220-240 min). The mean postoperative length of stay was 8.2 d (range 6-12 d). There was no conversion to open procedure and no postoperative mortality. No urinary retention, wound infection, prolonged ileus, pelvic infection and anastomosis leakage occurred. Six patients were followed up for 36 mo. The WCS, ODS, and Patients Assessment of Constipation Quality of Life score improved significantly postoperatively (P < 0.05). The WCS and ODS scores showed the best remission and stabilization at 6 to 12 mo after surgery. There was no recurrence or novel constipation after surgery. None of the patients used laxative medication.

CONCLUSION

Robotic and laparoscopic-assisted ventral rectopexy with colectomy is a safe and effective procedure for selected patients with ODS. However, comprehensive preoperative evaluation and careful patient selection are essential.

Short term outcome of laparoscopic ventral mesh rectopexy for rectal and complex pelvic organ prolapse: case series

Objectives

Laparoscopic ventral mesh rectopexy (LVMR) is a technique gaining more recognition for the management of pelvic floor disorders, such as external rectal prolapse (ERP), high grade internal rectal prolapse (IRP) and rectocele. LVMR also allows correction of coexisted pelvic organ prolapse. This study aimed to evaluate the safety, efficacy and functional outcome of LVMR for rectal and complex pelvic organ prolapse.

Material and Methods

All patients who underwent LVMR from February 2014 to October 2017 were included into the study. The patients were evaluated preoperatively and three months postoperatively. Surgical complications and functional results in terms of fecal incontinence (measured with the Wexner Incontinence Score= WIS) and constipation (measured with the Wexner Constipation Score= WCS) were analyzed.

Results

Thirty (4 males) patients underwent LVMR. Seventeen (56.6%) patients had complex pelvic organ prolapse according to MRI findings. Median operative time and postoperative stay were 110 minutes and 4 days, respectively. No mesh-related complication and recurrence were observed. Before surgery, 21 (70%) patients had complained about symptoms of obstructed defecation. WCS decreased significantly from median 19 to 6 (p <0.001). Preoperative median WIS of 9 patients was 14 and went down to 6 postoperatively (p= 0.008). WCS significantly improved after LVMR in patients with symptomatic rectocele combined with enterocele or sigmoidocele (p= 0.005), and significant improvement was also observed in patients with symptomatic rectocele combined with gynecologic organ prolapse, preoperative median WCS was 18 and the postoperative value fell to 8 (p= 0.005).

Conclusion

LVMR is an effective surgical option for rectal and complex pelvic organ prolapse with short-term follow-up.

Laparoscopic Ventral Rectopexy Versus Stapled Transanal Rectal Resection for Treatment of Obstructed Defecation in the Elderly: Long-term Results of a Prospective Randomized Study

BACKGROUND

Obstructed defecation is a common complaint in coloproctology. Many anal, abdominal, and laparoscopic procedures are adopted to correct the underlying condition.

OBJECTIVE

The purpose of this study was to compare long-term functional outcome, recurrence rate, and quality of life between laparoscopic ventral rectopexy and stapled transanal rectal resection in the treatment of obstructed defecation.

DESIGN

This was a prospective randomized study.

SETTING

This study was performed at academic medical centers.

PATIENTS

Patients were included if they had obstructed defecation attributed to pelvic structural abnormalities that did not to respond to conservative measures. Exclusion criteria included nonrelaxing puborectalis, previous abdominal surgery, other anal pathology, and pudendal neuropathy.

INTERVENTION

Patients were randomly allocated to either laparoscopic ventral rectopexy (group 1) or stapled transanal rectal resection (group 2).

MAIN OUTCOME MEASURES

The primary outcome measures were improvement of modified obstructed defecation score and recurrences after ≥3 years of follow-up. Secondary outcomes were postoperative complications, continence status using Wexner incontinence score, and quality of life using Patient Assessment of Constipation-Quality of Life Questionnaire.

RESULTS

The study included 112 patients (56 in each arm). ASA score II was reported in 32 patients (18 in group 1 and 14 in group 2; p = 0.12), whereas 3 patients in each group had ASA score III. Minor postoperative complications were seen in 11 patients (20%) of group 1 and 14 patients of group 2 (25%; p = 0.65). During follow-up, 3 patients had fecal urgency after stapled transanal rectal resection but no sexual dysfunction in either procedure. After 6 months, modified obstructed defecation score improvement >50% was reported in 73% versus 82% in groups 1 and 2 (p = 0.36). After a mean follow-up of 41 months, recurrences of symptoms were reported in 7% in group 1 versus 24% in group 2 (p = 0.04). Six months postoperation, perineal descent improved >50% in defecogram in 80% of group 1 versus no improvement in group 2. Quality of life significantly improved in both groups after 6 months; however a significant long-term drop (>36 months) was seen only in group 2.

LIMITATIONS

Possible limitations of this study are the presence of a single operator and the absence of blindness of the technique for both patient and assessor.

CONCLUSIONS

In elderly patients even with comorbidities, both laparoscopic ventral rectopexy and stapled transanal rectal resection are safe and can improve function of the anorectum in patients with obstructed defecation attributed to structural abnormalities. Laparoscopic ventral rectopexy has better long-term functional outcome, less complications, and less recurrences compared with stapled transanal rectal resection. Perineal descent only improves after laparoscopic ventral rectopexy. Stapled transanal rectal resection was shown not to be the first choice in elderly patients with obstructed defecation unless they had a medical contraindication to laparoscopic procedures. See Video Abstract at http://links.lww.com/DCR/A788.

Does Ventral Rectopexy Improve Pelvic Floor Function in the Long Term?

BACKGROUND

Information is needed on long-term functional results, sequelas, and outcome predictors for laparoscopic ventral mesh rectopexy.

OBJECTIVE

The purpose of this study was to evaluate long-term function postventral rectopexy in patients with external rectal prolapse or internal rectal prolapse in a large cohort and to identify the possible effects of patient-related factors and operative technical details on patient-reported outcomes.

DESIGN

This was a retrospective review with a cross-sectional questionnaire study.

SETTINGS

Data were collated from prospectively collected registries in 2 university and 2 central hospitals in Finland.

PATIENTS

All 508 consecutive patients treated with ventral rectopexy for external rectal prolapse or symptomatic internal rectal prolapse in 2005 to 2013 were included.

INTERVENTIONS

A questionnaire concerning disease-related symptoms and effect on quality of life was used.

MAIN OUTCOME MEASURES

Defecatory function measured by the Wexner score, the obstructive defecation score, and subjective symptom and quality-of-life evaluation using the visual analog scale were included. The effects of patient-related factors and operative technical details were assessed using multivariate analysis.

RESULTS

The questionnaire response rate was 70.7% (330/467 living patients) with a median follow-up time of 44 months. The mean Wexner scores were 7.0 (SD = 6.1) and 6.9 (SD = 5.6), and the mean obstructive defecation scores were 9.7 (SD = 7.6) and 12.3 (SD = 8.0) for patients presenting with external rectal prolapse and internal rectal prolapse. Subjective symptom relief was experienced by 76% and reported more often by patients with external rectal prolapse than with internal rectal prolapse (86% vs 68%; p < 0.001). Complications occurred in 11.4% of patients, and the recurrence rate for rectal prolapse was 7.1%.

LIMITATIONS

This study was limited by its lack of preoperative functional data and suboptimal questionnaire response rate.

CONCLUSIONS

Ventral mesh rectopexy effectively treats posterior pelvic floor dysfunction with a low complication rate and an acceptable recurrence rate. Patients with external rectal prolapse benefit more from the operation than those with symptomatic internal rectal prolapse. See Video Abstract at http://links.lww.com/DCR/A479.

Robot-Assisted Ventral Mesh Rectopexy for Rectal Prolapse: A 5-Year Experience at a Tertiary Referral Center

BACKGROUND

Laparoscopic ventral mesh rectopexy is being increasingly performed internationally to treat rectal prolapse syndromes. Robotic assistance appears advantageous for this procedure, but literature regarding robot-assisted ventral mesh rectopexy is limited.

OBJECTIVE

The primary objective of this study was to assess the safety and effectiveness of robot-assisted ventral mesh rectopexy in the largest consecutive series of patients to date.

DESIGN

This study is a retrospective cross-sectional analysis of prospectively collected data.

SETTINGS

The study was conducted in a tertiary referral center.

PATIENTS

All of the patients undergoing robot-assisted ventral mesh rectopexy for rectal prolapse syndromes between 2010 and 2015 were evaluated.

MAIN OUTCOME MEASURES

Preoperative and postoperative (mesh and nonmesh) morbidity and functional outcome were analyzed. The actuarial recurrence rates were calculated using the Kaplan-Meier method.

RESULTS

A total of 258 patients underwent robot-assisted ventral mesh rectopexy (mean ± SD follow-up = 23.5 ± 21.8 mo; range, 0.2 - 65.1 mo). There were no conversions and only 5 intraoperative complications (1.9%). Mortality (0.4%) and major (1.9%) and minor (<30 d) early morbidity (7.0%) were acceptably low. Only 1 (1.3%) mesh-related complication (asymptomatic vaginal mesh erosion) was observed. A significant improvement in obstructed defecation (78.6%) and fecal incontinence (63.7%) were achieved for patients (both p < 0.0005). At final follow-up, a new onset of fecal incontinence and obstructed defecation was induced or worsened in 3.9% and 0.4%. The actuarial 5-year external rectal prolapse and internal rectal prolapse recurrence rates were 12.9% and 10.4%.

LIMITATIONS

This was a retrospective study including patients with minimal follow-up. No validated scores were used to assess function. The study was monocentric, and there was no control group.

CONCLUSIONS

Robot-assisted ventral mesh rectopexy is a safe and effective technique to treat rectal prolapse syndromes, providing an acceptable recurrence rate and good symptomatic relief with minimal morbidity. See Video Abstract at http://links.lww.com/DCR/A427.

Long-Term Functional Outcome after Internal Delorme's Procedure for Obstructed Defecation Syndrome, and the Role of Postoperative Rehabilitation

PURPOSE

To evaluate long-term functional outcomes of Internal Delorme's Procedure (IDP) in patients refractory to conservative treatment for Obstructed Defecation Syndrome (ODS), and to compare those who received postoperative rehabilitation with those who did not.

MATERIALS AND METHODS

All patients with ODS refractory to nonoperative therapy were identified across three regional pelvic floor referral hospitals, and IDP was performed. Postoperatively selected patients received biofeedback therapy. Functional outcomes were established using the Cleveland Clinic Constipation (CCC) score and obstructed defecation score (OD score) preoperatively at 12 months and at the last available follow-up. Patient satisfaction was assessed with a visual analogue score.

RESULTS

From October 2006 to September 2013, IDP was performed in 170 patients: 77 received postoperative biofeedback and 93 did not. Mean follow-up was 6.3 years (range 1-8 years). CCC and OD scores improved significantly in both groups after 12 months and at the last follow-up (p > 0.05). When comparing two groups while there was no significant difference between CCC and OD scores at 12 months, score was significantly better in the group that received rehabilitation at the last follow-up (p = 0.001). Patient satisfaction was higher in the rehabilitation group (67%) compared with those without rehabilitation (55%). Clinical recurrence was recorded in nine patients who did not have postoperative rehabilitation.

CONCLUSIONS

It has been demonstrated that IDP is associated with good long-term functional outcomes. Patients receiving rehabilitation had a better long-term follow-up, a higher overall satisfaction, and lower recurrence rate when compared with the patients who did not receive postoperative rehabilitation.

Internal rectal prolapse: Definition, assessment and management in 2016

Internal rectal prolapse (IRP) is a well-recognized pelvic floor disorder mainly seen during defecatory straining. The symptomatic expression of IRP is complex, encompassing fecal continence (56%) and/or evacuation disorders (85%). IRP cannot be characterized easily by clinical examination alone and the emergence of dynamic defecography (especially MRI) has allowed a better comprehension of its pathophysiology and led to the proposition of a severity score (Oxford score) that can guide management. Decision for surgical management should be multidisciplinary, discussed after a complete work-up, and only after medical treatment has failed. Information should be provided to the patient, outlining the goals of treatment, the potential complications and results. Stapled trans-anal rectal resection (STARR) has been considered as the gold standard for IRP treatment. However, inconsistent results (failure observed in up to 20% of cases, and fecal incontinence occurring in up to 25% of patients at one year) have led to a decrease in its indications. Laparoscopic ventral mesh rectopexy has substantial advantages in solving the functional problems due to IRP (efficacy on evacuation and resolution of continence symptoms in 65-92%, and 73-97% of patients, respectively) and is currently considered as the gold standard therapy for IRP once the decision to operate has been made.