Transvaginal posterior colporrhaphy combined with laparoscopic ventral mesh rectopexy for isolated Grade III rectocele: a prospective study of 27 patients

Mesh-associated complications in minimally invasive ventral mesh rectopexy: a systematic review

BACKGROUND

Ventral mesh rectopexy (laparoscopic and robotic) is a common and well established treatment of rectal prolapse. Although described as safe and effective, complications, especially mesh-associated ones are often mentioned. Additionally, there is no consensus regarding the mesh type and fixation method as well as the materials used for this purpose. The aim of this systematic review was to identify the total amount of complications and of those the mesh-associated ones.

METHODS

Pubmed, Web of Science and Cochrane Central Register were screened for complications in general and in detail regarding the mesh(es) and a systematic review was performed.

RESULTS

Following qualitative evaluation, 40 studies were identified for further investigation. Across 6269 patients, complications were found in 9.2% (622 patients). Mesh-related complications were described in 1.4% (88 patients) of which 64.8% were erosions, 11.4% fistulas and 13.6% mesh releases. The complication rate according to the different materials were low with 1% in biological and synthetic meshes and 1.8% in not further described or mixed mesh type. Non-absorbable material to fixate the mesh was most frequently used to fixate the mesh.

CONCLUSION

Laparoscopic ventral mesh rectopexy is a safe operation with a low-complication rate, regardless of mesh type.

Rectocele with obstructive defecation syndrome: Laparoscopic rectopexy or vaginal repair?

INTRODUCTION

The concomitant presence of a rectocele with obstructive defecation syndrome (ODS) is highly probable. The purpose of this study was to evaluate the effectiveness of native tissue vaginal rectocele repair (VRR) and laparoscopic ventral mesh rectopexy (LVMR) in terms of functional outcome via the medium to long-term ODS score evaluation.

MATERIAL

This was a retrospective cohort study. We identified 30 patients having undergone LVMR for rectocele with defecatory symptoms between January 2015 and December 2021, matched with the same number of patients treated by VRR for the same indication and in the same period. The hypothesis was that both procedures were susceptible to lead to a favorable functional outcome. The main endpoint was ODS score at follow-up. Multivariate analysis was used to assess relationship between ODS score and type of surgery.

RESULTS

Patients' demographics were similar in both groups. However, the preoperative ODS score was significantly higher in the LVMR group (P<0.01). Furthermore, the use of preoperative imaging investigations and diagnosis of an associated rectal intussusception were more frequent in the LVMR group. The mean ODS scores at follow-up (median follow-up 5years) were comparable in the two groups (6.2 for LVMR and 4.43 for VRR). These scores were significantly reduced compared to preoperative values in both groups (P<0.0001).

CONCLUSIONS

There was a significant reduction in ODS scores on medium/long-term follow-up with both surgical techniques. A larger study utilizing randomized comparison of both procedures is needed to confirm our findings.

LEVEL OF EVIDENCE: 4

Laparoscopic or transanal repair of rectocele? Comparison of a reduction in rectocele size

PURPOSE

This study aimed to compare the reduction in rectocele size after laparoscopic ventral rectopexy (LVR) with that after transanal repair (TAR).

METHODS

Forty-six patients with rectocele who underwent LVR and 45 patients with rectocele who received TAR between February 2012 and December 2022 were included. This was a retrospective analysis of prospectively collected data. All patients had clinical evidence of a symptomatic rectocele. Bowel function was evaluated using the constipation scoring system (CSS) and fecal incontinence severity index (FISI). Substantial symptom improvement was defined as at least a 50% reduction in the CSS or FISI scores. Evacuation proctography was performed before surgery and 6 months postoperatively.

RESULTS

Constipation was substantially improved in 40-70% of the LVR patients and 70-90% of the TAR patients over 5 years. Fecal incontinence was markedly improved in 60-90% of the LVR patients across 5 years and in 75% of the TAR patients at 1 year. Postoperative proctography showed a reduction in rectocele size in the LVR patients (30 [20-59] mm preoperatively vs. 11 [0-44] mm postoperatively, P < 0.0001) and TAR patients (33 [20-55] mm preoperatively vs. 8 [0-27] mm postoperatively, P < 0.0001). The reduction rate of rectocele size in the LVR patients was significantly lower than that in the TAR patients (63 [3-100] % vs. 79 [45-100] %, P = 0.047).

CONCLUSION

The reduction in rectocele size was lower in the patients who underwent LVR than in those who received TAR.

Ventral Prosthesis Rectopexy for obstructed defaecation syndrome: a systematic review and meta-analysis

Obstructed Defecation Syndrome (ODS) is a rather complex entity concerning mainly females and causing primarily constipation. Surgical treatment in the form of Ventral Prosthesis Rectopexy (VPR) has been proposed and seems to have the best outcomes. However, the selection criteria of patients to undergo this kind of operation are not clear and the reported outcomes are mainly short-term and data on long-term outcomes is scarce. This study assesses new evidence on the efficacy of VPR for the treatment of ODS, specifically focusing on inclusion criteria for surgery and the long-term outcomes. A search was performed of MEDLINE, EMBASE, Ovid and Cochrane databases on all studies reporting on VPR for ODS from 2000 to March 2020. No language restrictions were made. All studies on VPR were reviewed systematically. The main outcomes were intra-operative complications, conversion, procedure duration, short-term mortality and morbidity, length of stay, faecal incontinence and constipation, quality of life (QoL) score and patient satisfaction. Quality assessment and data extraction were performed independently by three observers. Fourteen studies including 963 patients were eligible for analysis. The immediate postoperative morbidity rate was 8.9%. A significant improvement in constipation symptoms was observed in the 12-month postoperative period for ODS (p < 0.0001). Current evidence shows that VPR offers symptomatic relief to the majority of patients with ODS, improving both constipation-like symptoms and faecal incontinence for at least 1-2 years postoperatively. Some studies report on functional results after longer follow-up, showing sustainable improvement, although in a lesser extent.

Outcomes of Transvaginal Anterior Levatorplasty with Posterior Colporrhaphy for Symptomatic Rectocele

Objectives:

To clarify the long-term outcomes of transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele with defecographic changes.

Methods:

Consecutive patients undergoing transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele were prospectively registered and retrospectively reviewed using medical records. Symptoms, fecal incontinence, and defecographic findings were evaluated before and after surgery.

Results:

Fifty-seven women (mean age, 68 years) were identified, and the median disease duration was 24 months. Symptoms of vaginal mass (n = 32) and difficult defecation (n = 21) disappeared (90.6% and 71.4%, respectively) or improved (6.3% and 28.6%, respectively) after surgery. However, the feeling of residual stool was unchanged in two of eight patients. Seventeen patients who performed digitation on defecation before surgery discontinued digitation after surgery. The proportion of patients who had fecal incontinence preoperatively (40.4%) decreased significantly after surgery (17.5%) during a median follow-up period of 47 months. Defecography revealed a disappearance or improvement of rectocele in all 18 patients examined. The average rectocele size decreased significantly in six improved patients (p = 0.0006, paired t-test).

Conclusions:

Transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele was a useful option to improve symptoms and anatomical disorders in the long term, but it had limitations in improving defecatory symptoms.

Factors Predicting the Presence of Concomitant Enterocele and Rectocele in Female Patients With External Rectal Prolapse

Purpose

External rectal prolapse (ERP) is frequently associated with other pelvic disorders, such as enterocele, rectocele, and perineal descent. Evacuation proctography makes it possible to visualize the development of such anatomical abnormalities. The aim of this study was to identify the variables that would predict associated abnormalities in patients with ERP.

Methods

Between February 2010 and August 2019, 124 female patients with ERP, who were evaluated using proctography were included in this study. Enterocele was diagnosed when the extension of the loop of the small bowel was located between the vagina and rectum. A significant rectocele was defined as >20 mm in diameter. Multivariate analysis was used to establish which morphological parameters best predicted the presence of enterocele or rectocele.

Results

Sixty-five patients had ERP alone, while 59 patients (47.6%) had additional findings on proctography. The most frequently associated abnormality was enterocele with 48 of the patients (38.7%) having this condition. Rectocele was detected in 17 of the 124 patients (13.7%). The median length of the ERP was 30 mm (range, 7 to 147 mm). The results of the stepwise multiple regression analysis showed that a history of hysterectomy and the length of the ERP were significantly associated with the presence of enterocele. The analysis showed that the longer the prolapse, the higher the incidence of enterocele. A history of hysterectomy was also significantly associated with the presence of rectocele.

Conclusion

Patients with ERP often have associated anatomical abnormalities and should be investigated thoroughly before planning surgical treatment.

Laparoscopic ventral mesh rectopexy for obstructive defecation syndrome: Follow-up in the Indian population

Context:

Obstructive defecation syndrome (ODS) is a poorly understood cause of constipation. In selected patients not responding to conservative management, surgical options may be offered. Laparoscopic ventral mesh rectopexy (LVMR) is another surgical option which gained popularity in the past decade.

Aim:

This study aims to identify the efficacy of LVMR in the Indian population.

Setting and Design:

It is a retrospective analysis of prospectively collected data of patients who underwent LVMR from January 2015 to January 2017 at a tertiary centre in India.

Subjects and Methods:

Thirty patients fulfilled the inclusion criteria. Patients were periodically followed for 2 years. Pre- and post-operative modified Longo's ODS scores were recorded and compared. Furthermore, other complications were noted and evaluated.

Statistical Analysis Used:

Relevant statistical tests were used to analyse the collected data.

Results:

Thirty patients (28 females, 2 males, mean age: 52.4 years) underwent LVMR for ODS due to anatomical abnormality like rectorectal intussusceptions (RRIs) (36.7%), rectocele (13.3%), or combined RRI with rectocele (50%). The mean pre-operative modified Longo's ODS score was 23.17 ± 4.82 which decreased to 2.37 ± 1.59 at the end of 6 months and 1.23 ± 1.14 and 1.57 ± 1.14 at the end of 12 months and 2 years, respectively. The mean modified Longo's ODS score showed a significant fall of 94.7% at 12-month follow-up and 93.2% fall on 2-year follow-up. The mean operative time was 115 min and the average hospital stay of patients who underwent LVMR was 3.26 days.

Conclusion:

LVMR is a safe surgical procedure with minimal complications and good functional results for ODS patients due to rectal anatomical abnormality. Further larger studies are required to decide the best treatment modality for ODS.

STARR with Contour Transtar for Obstructed Defecation Syndrome: Long-Term Results

INTRODUCTION

Obstructed defecation syndrome (ODS) is a widespread and disabling syndrome. With this study, we want to evaluate the long-term results of stapled transanal rectal resection (STARR) performed with Contour Transtar device in the treatment for ODS. A re-evaluation of 113 patients subjected to STARR from June 2007 to January 2010 was conducted.

METHODS

All the patients treated for symptomatic ODS with STARR with Contour Transtar were included in the study. We re-evaluate all patients treated in the study period with clinical examination and specific questionnaire to verify the stability of the functional results and the satisfaction at 5 years from surgery. Constipation was graded using the Agachan-Wexner constipation score; eventual use of aids to defecate and patient satisfaction were assessed preoperatively, 6 months and 5 years after surgery. Long-term complications were also investigated.

RESULTS

Constipation intensity decreased from the preoperative value of 15.8 (±4.9) to 5.2 (±3.9) (p < 0.0001) at 6 months and remained stable after 5 years (7.4 ± 4.1; p < 0.01). Patients who use laxatives and enema decrease from 74 (77%) and 27 (28%) to only 16 (17%; p < 0.001) and 5 (5%; p < 0.001), respectively, at 5-year follow-up. None continue to help themselves with digitations after surgery. Also the satisfaction rate remained stable (3.64 vs 3.81) during the 5 years of the study.

CONCLUSION

The long-term results have demonstrated the efficacy of the STARR with Contour Transtar in treating ODS and the stability over time of the defecatory improvements.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov NCT02971332.

Surgery for constipation: systematic review and practice recommendations: Results IV: Recto-vaginal reinforcement procedures

AIM

To assess the outcomes of recto-vaginal reinforcement procedures in adults with chronic constipation.

METHOD

Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements with a summative Oxford Centre for Evidence-Based Medicine (2009) level.

RESULTS

Forty-three articles were identified, providing data on outcomes in 3346 patients. Average length of procedures ranged between 20 and 169 min, and length of stay between 1 and 15 days. Complications typically occurred after 7-17% of procedures (range 0-61%). Post-operative bleeding was uncommon (0-4%) as well as haematoma or sepsis (0-2%). Fistulation did not occur in most studies. Two procedure-related deaths were observed for 3209 patients. Although inconsistent, 78% of patients reported a satisfactory or good outcome, with 30-50% experiencing reduced symptoms of straining, incomplete emptying or reduced vaginal digitation. About 17% of patients developed anatomical recurrence. Considering measures of harm and global satisfaction rating scales, there was insufficient evidence to prefer one type of procedure over another. There was no evidence to support better outcomes based on selection of patients with a particular size or grade of rectocoele.

CONCLUSION

Evidence supporting recto-vaginal reinforcement procedures is currently derived from observational studies and comparisons, with only one high quality study. Large trials are needed to inform future clinical decision making.

Laparoscopic ventral mesh rectopexy for obstructive defecation syndrome: still the way to go?

Laparoscopic ventral mesh rectopexy (VMR) has become a popular surgical technique for treating women with full-thickness rectal prolapse with a low recurrence rate, as demonstrated by several studies. In addition, it is increasingly applied to female patients with obstructive defecation syndrome (ODS) caused by intussusception ± rectocele. Functional improvement can be achieved in a high number of patients with ODS, but expectations need to be discussed carefully, as a few patients may not benefit at all. In particular, long-term data on functional outcome and complications following laparoscopic VMR for ODS are still lacking in the literature. Notably, laparoscopic VMR appears to be better than alternative operations for prolapse, intussusception, and rectocele in terms of efficacy, recurrence rates, and adverse effects, but there is a lack of evidence directly comparing techniques through randomized controlled trials; thus, its exact role stills needs to be defined in the future.

Laparoscopic surgery for rectal prolapse and pelvic floor disorders

Pelvic floor disorders are different dysfunctions of gynaecological, urinary or anorectal organs, which can present as incontinence, outlet-obstruction and organ prolapse or as a combination of these symptoms. Pelvic floor disorders affect a substantial amount of people, predominantly women. Transabdominal procedures play a major role in the treatment of these disorders. With the development of new techniques established open procedures are now increasingly performed laparoscopically. Operation techniques consist of various rectopexies with suture, staples or meshes eventually combined with sigmoid resection. The different approaches need to be measured by their operative and functional outcome and their recurrence rates. Although these operations are performed frequently a comparison and evaluation of the different methods is difficult, as most of the used outcome measures in the available studies have not been standardised and data from randomised studies comparing these outcome measures directly are lacking. Therefore evidence based guidelines do not exist. Currently the laparoscopic approach with ventral mesh rectopexy or resection rectopexy is the two most commonly used techniques. Observational and retrospective studies show good functional results, a low rate of complications and a low recurrence rate. As high quality evidence is missing, an individualized approach is recommend for every patient considering age, individual health status and the underlying morphological and functional disorders.

Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists

Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.

Ventral colporectopexy for overt rectal prolapse and obstructed defaecation syndrome: a systematic review

AIM

Laparoscopic ventral rectopexy (VR) with the use of prosthesis has been advocated for both overt rectal prolapse (ORP) and obstructed defaecation syndrome (ODS). The present study reviews the short-term and functional results of laparoscopic VR.

METHOD

A search was performed of MEDLINE, EMBASE, Ovid and Cochrane databases on all studies reporting on VR for ORP, ODS and other anatomical abnormalities of the pelvic floor from 2004 until February 2013. No language restrictions were made. All studies on VR were reviewed systematically. The main outcomes were intra-operative complications, conversion, procedure duration, short-term mortality and morbidity, length of stay, recurrence of ORP, recurrence of anatomical disorder, faecal incontinence and constipation, quality of life (QoL) score and patient satisfaction. Quality assessment and data extraction were performed independently by three observers.

RESULTS

Twenty-three studies including 1460 patients were eligible for analysis. The conversion rate ranged from 0 to 14.3%. No mortality was reported. The immediate postoperative morbidity rate was 8.6%. Length of stay ranged from 1 to 7 days. A significant improvement in constipation and incontinence symptoms was observed in the postoperative period for both ORP and ODS (chi-square test, P < 0.0001).

CONCLUSION

Laparoscopic VR is a safe and effective procedure for ORP and ODS. Longer follow-up is required, and studies comparing VR with standard rectopexy and stapled transanal rectal resection are not yet available.

Synthetic or biological mesh use in laparoscopic ventral mesh rectopexy--a systematic review

AIM

Laparoscopic ventral mesh rectopexy (VMR) is a surgical option for internal and external rectal prolapse with low perioperative morbidity and low recurrence rates. Use of synthetic mesh in the pelvis may be associated with complications such as fistulation, erosion and dyspareunia. Biological meshes may avoid these complications, but the long-term outcome is uncertain. Debate continues as to which type of mesh is optimal for laparoscopic VMR.

METHOD

A literature search was performed of electronic databases including MEDLINE, Embase and Scopus (2000-12). Studies describing outcomes relating to the mesh were included for review. Only English language studies were included.

RESULTS

Thirteen observational studies reported the outcome of 866 patients following laparoscopic VMR. Eleven reported the outcome using synthetic mesh with a median follow-up ranging from 7 to 74 months. Two studies reported the outcome with biological mesh with a median follow-up of 12 months. Pooled analysis of the studies demonstrated that 767 patients had a repair with synthetic mesh and 99 with a biological implant. There was no difference in recurrence (3.7 vs 4.0%, P = 0.78) or mesh complications (0.7 vs 0%, P = 1.0%) between synthetic and biological mesh repair.

CONCLUSION

Biological meshes appear to be as effective as synthetic meshes in the short term for laparoscopic VMR. Mesh complication rates are low in both groups. Long-term follow-up is required to ascertain if these findings persist.