Evolution of male rectal prolapse surgery and initial experience of robotic rectopexy in men

High and low take-off external prolapse phenotypes can be characterised preoperatively on defaecation proctography

BACKGROUND

External rectal prolapse is poorly understood, with controversy surrounding the ideal surgical approach. Anecdotal mentions of high and low take-off in the literature hint at different pathological phenotypes of prolapse. However there has been no effort to define and characterise these terms, or to discuss how take-off might relate to the underlying pathophysiology of prolapse. We aimed to determine if defaecation proctography (DPG) could reliably characterise high and low take-off prolapse.

METHODS

The study was a retrospective analysis of prospectively collected data. A total of 88 patients with external rectal prolapse were investigated with a defaecating proctogram as part of their routine evaluation between January 2004 and December 2017. Prolapse take-off was determined by the level of origin on proctography. The rectosigmoid junction position at rest and caudal mobility during straining were also determined, relative to sacrococcygeal bony segmental level.

RESULTS

Take-off was characterised in all 88 patients (median age 64 years old, 92% female), of which 53 (60%) had high take-off and 35 (40%) low take-off prolapse. There was significantly greater rectosigmoid junction caudal mobility (median descent 9 vs 5 cm, p = 0.001, respectively) and a trend to significantly lower resting rectosigmoid position (median sacral level S4 vs S3, p = 0.08, respectively) in the high take-off group compared to low take-off.

CONCLUSION

In this first formalised description and definition of take-off in the literature, we have shown that defaecating proctogram can satisfactorily identify, discriminate between and characterise two distinct external prolapse phenotypes. We propose two distinct causal pathways to external rectal prolapse, connective tissue failure and levator ani factors. Take-off should be a consideration as a prognostic in clinical practice and research trials.

Systematic literature review and meta-analysis of surgical treatment of complete rectal prolapse in male patients

BACKGROUND

Rectal prolapse often affects women but may also affect men. This systematic review aimed to provide outcomes of surgery for complete rectal prolapse reported in studies with a predominantly male population.

METHODS

This PRISMA-compliant systematic literature review searched PubMed and Scopus between January 2000 and February 2024; Google Scholar was queried for studies reporting outcomes of complete rectal prolapse surgery in predominately (> 90%) male populations. Main outcome measures were recurrence, complications, operative time, and bowel function.

RESULTS

Eight studies (452 patients; median age 45.6 years) were included; 80.5% of patients underwent abdominal procedures whereas 19.5% underwent perineal procedures. The prevalence of recurrence was 11.2% after ventral mesh rectopexy (VMR), 0.8% after posterior mesh rectopexy (PMR), 0 after resection rectopexy, and 19.3% after perineal procedures. The prevalence of complications was 13.9% after VMR, 13.1% after PMR, 43.3% after resection rectopexy, and 17.4% after perineal procedures. The most improvement in constipation was noted after resection rectopexy (83.3-100%) and in fecal incontinence (FI) was noted after posterior mesh rectopexy (86.4-90%). Abdominal procedures had lower rates of recurrence (6% vs. 19.3%, RR 0.50, 95% CI 0.21-1.18, p = 0.113), similar complication rates (14.3% vs. 13.6%, RR 0.41, 95% CI 0.06-2.9, p = 0.374), and longer operative times (116 ± 47.2 vs. 74.2 ± 23.6 min, p < 0.001).

CONCLUSIONS

Treatment of rectal prolapse in male patients undergoing abdominal procedures was associated with longer operative times, lower recurrence rates, and similar complications to perineal procedures. PMR and resection rectopexy had the lowest recurrence. The most improvement in FI and constipation was noted after PMR and resection rectopexy, respectively.

Comparison of Delorme-Thiersch Operation Outcomes in Men and Women With Rectal Prolapse

Purpose

The laparoscopic rectopexy has become increasingly popular with verified stability, surgical route selection should be tailored to individual patient characteristics rather than operative risk. The perineal approach is useful in young male patients who need to preserve fertility. This study aimed to compare the characteristics of men and women who underwent Delorme-Thiersch procedures and analyze the postoperative outcomes of the perineal approach by sex.

Methods

We retrospectively reviewed the medical records of 293 patients who underwent Delorme-Thiersch operations in Seoul Song Do Colorectal Hospital between January 2011 and September 2017. Patient clinical characteristics and postoperative complications were analyzed by sex. We analyzed surgical outcomes with preoperative and 3-month postoperative incontinence questionnaires, constipation levels, and anal manometry.

Results

In this study, men with rectal prolapse were younger than women with the same condition. American Society of Anesthesiologists physical status classifications were higher in women and women had more L-spine X-ray and pudendal nerve terminal motor latency test abnormalities. Anorectal manometry pressures were higher in men. Men also had longer operation times and hospital stays and more postoperative complications (8 T ring infections, 6 patients with bleeding, 3 with strictures, 2 with severe pain, and 2 with rectal perforations). The recurrence rate was higher among women.

Conclusion

Men with rectal prolapse were younger, healthier, and had relatively better anorectal function than women. The Delorme-Thiersch operation in men promoted lower recurrence rates and was advantageous in preserving the fertility of young patients, but the incidence of complications was also higher in men. Adequate counseling and preparation for the possibility of complications are needed.

Laparoscopic Posterolateral Rectopexy for the Treatment of Patients With a Full Thickness Rectal Prolapse: Experience With 63 Patients and Short-term Outcomes

Purpose

Although numerous procedures have been proposed for the treatment of patients with a rectal prolapse, the most effective operation has not yet been established. Minimal rectal mobilization can prevent constipation; however, it is associated with increased recurrence rates. We describe our novel method for a laparoscopic posterolateral rectopexy, which includes rectal mobilization with a posterior-right unilateral dissection, suture fixation to the sacral promontory with a polypropylene mesh (Optilene), and a mesorectal fascia propria that is as wide as possible. The present report describes our novel method and assesses the short-term outcomes of patients.

Methods

Between June 2014 and June 2017, 63 patients (28 males and 35 females) with a full-thickness rectal prolapse underwent a laparoscopic posterolateral (LPL) rectopexy. We retrospectively analyzed the clinical characteristics and postoperative complications in those patients. The outcome of surgery was determined by evaluating the answers on fecal incontinence questionnaires, the results of anal manometry preoperatively and 3 months postoperatively, the patients’ satisfaction scores (0–10), and the occurrence of constipation.

Results

No recurrence was reported during follow-up (3.26 months), and 3 patients reported postoperative complications (wound infection, postoperative sepsis, which was successfully treated with conservative management, and retrograde ejaculation). Compared to the preoperative baseline, fecal incontinence at three months postoperatively showed an overall improvement. The mean patient satisfaction score was 9.55 ± 0.10, and 8 patients complained of persistent constipation.

Conclusion

LPL rectopexy is a safe, effective method showing good functional outcomes by providing firm, solid fixation for patients with a full-thickness rectal prolapse.