Outcome of laparoscopic ventral mesh rectopexy for external rectal prolapse

Laparoscopic ventral mesh rectopexy in the oldest old is safe: the race is run

BACKGROUND

Laparoscopic ventral mesh rectopexy (LVMR) is considered to be the gold standard for managing rectal prolapse. Nevertheless, concerns have been expressed about the use of this procedure in elderly patients. The aim of the current study was to examine the perioperative safety of primary LVMR operations in the oldest old in comparison to younger individuals and to assess our hospital policy of offering LVMR to all patients, regardless of age and morbidity.

METHODS

A retrospective study analysed demographic information, operation notes, meshes utilised, operation times, lengths of hospital stay (LOS) and American Society of Anesthesiologists (ASA) scores of patients who underwent LVMR at Elisabeth-TweeSteden Hospital between 2012 and 2023.

RESULTS

Eighty-seven female patients underwent LVMR. Nineteen patients were 80 years of age or older (OLD group); the remaining 65 patients were under the age of 80 (YOUNG group). The difference between the groups in terms of age was statistically significant. ASA scores were not significantly different. No mortality was observed. There was no statistically significant difference between the groups in terms of LOS, operation time or morbidity. Moreover, the postoperative morbidity profile was excellent in both groups.

CONCLUSION

LVMR seems to be a safe operation for the "oldest old" patients with comorbidity, despite a single-centre, retrospective trial with limited follow-up. The present study suggests abandoning the dogma that "frail patients with rectal prolapse are not suitable for laparoscopic ventral mesh rectopexy."

Comparison of Safety and Efficacy between Laparoscopic Ventral Rectopexy and Delorme's Procedure for External Rectal Prolapse in Nonagenarians

Objectives

This study evaluates the safety and efficacy of laparoscopic ventral rectopexy (LVR) in nonagenarian patients with external rectal prolapse (ERP) compared to Delorme's procedure.

Methods

We conducted a retrospective analysis of prospectively collected data, including nonagenarian patients who underwent either LVR or Delorme's procedure, comparing outcomes such as morbidity, length of hospital stay (LOS), and recurrence rates.

Results

Between September 2009 and August 2023, 22 patients (median age 91, range 90-94 years) underwent LVR, while 12 patients (median age 91, range 90-96 years) received Delorme's procedure. Baseline characteristics, including sex ratio, parity, American Society of Anesthesiology grade, and Body Mass Index, did not significantly differ between the groups. LVR had a significantly longer operating time but lower blood loss than Delorme's procedure. Postoperative LOS was significantly shorter for LVR patients (median 1, range 1-3 days) compared to Delorme's procedure patients (median 2.5, range 1-13 days; P = 0.001). Notably, no significant morbidity occurred in the LVR group, while one case of delirium and another of solitary rectal ulcer syndrome were observed in the Delorme's procedure group. Recurrence rates were lower in the LVR group, with no recurrences during a median follow-up of 23 months (range 1-65 months), compared to one recurrence at 2 months during a median follow-up of 34 months (range 1-96 months) in the Delorme's procedure group.

Conclusions

LVR is a safe and effective surgical option for nonagenarian ERP patients, showing favorable outcomes in terms of morbidity, LOS, and recurrence rates compared to Delorme's procedure.

Current diagnostic tools and treatment modalities for rectal prolapse

Rectal prolapse is a circumferential, full-thickness protrusion of the rectum through the anus. It is a rare condition, and only affects 0.5% of the general population. Multiple treatment modalities have been described, which have changed significantly over time. Particularly in the last decade, laparoscopic and robotic surgical approaches with different mobilization techniques, combined with medical therapies, have been widely implemented. Because patients have presented with a wide range of complaints (ranging from abdominal discomfort to incomplete bowel evacuation, mucus discharge, constipation, diarrhea, and fecal incontinence), understanding the extent of complaints and ruling out differential diagnoses are essential for choosing a tailored surgical procedure. It is crucial to assess these additional symptoms and their severities using preoperative scoring systems. Additionally, radiological and physiological evaluations may explain some vague symptoms and reveal concomitant pelvic disorders. However, there is no consensus on or standardization of the optimal extent of dissection, type of procedure, and materials used for rectal fixation; this makes providing maximum benefits to patients with minimal complications difficult. Even recent publications and systematic reviews have not recommended the most appropriate treatment options. This review explains the appropriate diagnostic tools for different conditions and summarizes the current treatment approaches based on existing literature and expert opinions.

Outcomes for men undergoing rectal prolapse surgery - a systematic review

AIM

Rectal prolapse is considered rare in men but the prevalence can be high in certain populations. It is unclear which surgical approach offers lower recurrence rates and better functional outcomes in men. The aim of this work was to determine the recurrence rates, complications and functional outcomes after prolapse surgery in men.

METHOD

The MEDLINE, EMBASE and Scopus databases were systematically searched to identify studies on outcomes following surgical management of full-thickness rectal prolapse in men (over 18 years of age) published between 1951 and September 2022. Outcomes of interest included recurrence rate after surgery, bowel function, urinary function, sexual function and postoperative complications.

RESULTS

Twenty-eight studies involving 1751 men were included. Two papers focused exclusively on men. Twelve studies employed a mixture of abdominal approaches, ten employed perineal approaches and six compared both. The recurrence rate varied across studies, ranging from 0% to 34%. Sexual and urinary function were poorly reported, but the incidence of dysfunction appears low.

CONCLUSION

The outcomes of rectal prolapse surgery in men are poorly studied with small sample sizes and variable outcomes reported. There is insufficient evidence to recommend a specific repair approach based on the recurrence rate and functional outcomes. Further studies are required to identify the optimal surgical approach for rectal prolapse in men.

Predictive Factors for Recurrence of External Rectal Prolapse after Laparoscopic Ventral Rectopexy

Objectives:

This study aimed to evaluate factors that contribute to the recurrence of external rectal prolapse (ERP) following laparoscopic ventral rectopexy (LVR).

Methods:

All patients who underwent LVR using synthetic meshes between 2011 and 2018 were prospectively included. A standard questionnaire including the Fecal Incontinence Severity Index (FISI) and Constipation Scoring System (CSS) was administered preoperatively and postoperatively. Defecography was performed 6 months postoperatively. Univariate and backward stepwise multivariate Cox analysis was performed to determine the prognostic factors of recurrence.

Results:

In total, 132 patients with a median follow-up of 46 months were included. The overall recurrence rate was 6.8% (n = 9), as confirmed by defecography at 6 months in six of the patients. None of the patients developed mesh erosion. FISI and CSS scores were significantly reduced at 3 months and remained significantly reduced for 3 years. Multivariate analyses revealed that the predictors of recurrence included male sex (hazards ratio, 11.3; 95% confidence interval, 3.0-43.0) and age >80 years (hazards ratio, 10.7; 95% confidence interval, 1.3-86.3). Eight patients with recurrence underwent surgery via Delorme's procedure (n = 7) and posterior rectopexy (n = 1). Two patients with new-onset rectoanal intussusception and one with uncorrected sigmoidocoele underwent repeat LVR.

Conclusions:

LVR is effective in treating ERP with low morbidity and low recurrence. Male patients and patients older than 80 years are at increased risk of recurrence. Hence, the LVR technique should be modified or coupled with other perineal procedures when treating ERP, especially in male patients.

European Society of Coloproctology guidance on the use of mesh in the pelvis in colorectal surgery

This is a comprehensive and rigorous review of currently available data on the use of mesh in the pelvis in colorectal surgery. This guideline outlines the limitations of available data and the challenges of interpretation, followed by best possible recommendations.

Surgical Techniques for Rectal Prolapse

Complete rectal prolapse or rectal procidentia is a debilitating disease that presents with fecal incontinence, constipation, and rectal discharge. Definitive surgical techniques described for this disease include perineal procedures such as mucosectomy and rectosigmoidectomy, and abdominal procedures such as rectopexy with or without mesh and concomitant resection. The debate over these techniques regarding the lowest recurrence and morbidity rates, and the best functional outcomes for constipation or incontinence, has been going on for decades. The heterogeneity of available studies does not allow us to draw firm conclusions. This article aims to review the surgical techniques for complete rectal prolapse based on the current evidence base regarding surgical and functional outcomes.

Does ventral mesh rectopexy at the time of sacrocolpopexy prevent subsequent posterior wall prolapse?

Objective:

To determine whether ventral mesh rectopexy at the time of sacrocolpopexy reduces the rate of future posterior wall prolapse.

Material and Methods:

This was a retrospective cohort study of women with pelvic organ prolapse (POP) who underwent sacrocolpopexy or without concomitant rectopexy at a single community hospital from December 1, 2015 to June 30, 2019. Preoperative pelvic organ prolapse quantification (POP-Q) and urodynamic testing was used in evaluation of POP. Patients were followed for 12-weeks postoperatively and a 12-week postoperative POP-Q assessment was completed. The incidence of new or recurrent posterior prolapse was compared between cohorts.

Results:

Women with POP (n=150) were recruited, of whom 41 (27.3%) underwent sacrocolpopexy while the remainder (n=109, 72.7%) did not receive rectopexy. Patient demographics did not statistically differ between cohorts. Post-surgical posterior wall prolapse was reduced in the robotic assisted sacrocolpopexy (RASC) + rectopexy group compared to RASC alone, however this did not reach statistical significance. There were no patients who underwent concomitant rectopexy and RASC that needed recurrent posterior wall prolapse surgery, compared to eight-percent of patients that underwent isolated RASC procedures.

Conclusion:

Our findings suggest a reduction in the need for subsequent posterior wall surgery when rectopexy is performed at the time of sacrocolpopexy. In our study, no future surgery for POP was found in the concomitant sacrocolpopexy and rectopexy group, while a small proportion of the RASC only group required future POP surgery. Our study, however, was underpowered to elucidate a statistically significant difference between groups. Future larger studies are needed to confirm a reduced risk of posterior wall prolapse in patients who undergo concomitant RASC and rectopexy.

Laparoscopic approach to recurrence following multiple surgeries for external rectal prolapse: a case report

Introduction

The optimal procedure for recurrent external rectal prolapse remains unclear, particularly in laparoscopic approach. In addition, pelvic organ prolapse (POP) is sometimes concomitant with rectal prolapse. We present a case who underwent laparoscopic procedure for the recurrence of full-thickness external rectal prolapse coexisting POP.

Case presentation

An 81-year-old parous female had a 10-cm full-thickness external rectal prolapse following the two operations: the first was perineal recto-sigmoidectomy and the second was laparoscopic posterior mesh rectopexy. Imaging study revealed that the recurrent rectal prolapse was concomitant with both cystocele and exposed vagina, what we call POP. We planned and successfully performed laparoscopic ventral mesh rectopexy (LVMR) with laparoscopic sacrocolpopexy (LSC) using self-cut meshes without any perioperative complication.

Conclusion

This is the first report of LVMR and LSC for recurrent rectal prolapse with POP following the perineal recto-sigmoidectomy and laparoscopic posterior mesh rectopexy. Even for recurrent rectal prolapse with POP, our experience suggests that LVMR and LSC could be utilized.

Suture rectopexy versus ventral mesh rectopexy for complete full-thickness rectal prolapse and intussusception: systematic review and meta-analysis

Background

This systematic review and meta-analysis aimed to compare recurrence rates of rectal prolapse following ventral mesh rectopexy (VMR) and suture rectopexy (SR).

Methods

MEDLINE, Embase, and the Cochrane Library were searched for studies reporting on the recurrence rates of complete rectal prolapse (CRP) or intussusception (IS) after SR and VMR. Results were pooled and procedures compared; a subgroup analysis was performed comparing patients with CRP and IS who underwent VMR using biological versus synthetic meshes. A meta-analysis of studies comparing SR and VMR was undertaken. The Methodological Items for Non-Randomized Studies score, the Newcastle–Ottawa Scale, and the Cochrane Collaboration tool were used to assess the quality of studies.

Results

Twenty-two studies with 976 patients were included in the SR group and 31 studies with 1605 patients in the VMR group; among these studies, five were eligible for meta-analysis. Overall, in patients with CRP, the recurrence rate was 8.6 per cent after SR and 3.7 per cent after VMR (P < 0.001). However, in patients with IS treated using VMR, the recurrence rate was 9.7 per cent. Recurrence rates after VMR did not differ with use of biological or synthetic mesh in patients treated for CRP (4.1 versus 3.6 per cent; P = 0.789) and or IS (11.4 versus 11.0 per cent; P = 0.902). Results from the meta-analysis showed high heterogeneity, and the difference in recurrence rates between SR and VMR groups was not statistically significant (P = 0.76).

Conclusion

Although the systematic review showed a higher recurrence rate after SR than VMR for treatment of CRP, this result was not confirmed by meta-analysis. Therefore, robust RCTs comparing SR and biological VMR are required.

Redo ventral rectopexy: is it worthwhile?

BACKGROUND

Minimally invasive ventral mesh rectopexy (VMR) is a widely used surgical treatment for posterior pelvic organ prolapse; however, evidence of the utility of revisional surgery is lacking. Our aim was to assess the technical details, safety and outcomes of redo minimally invasive VMR for patients with external rectal prolapse (ERP) recurrence or relapsed symptoms of internal rectal prolapse (IRP).

METHODS

This is a retrospective cohort study of patients with recurrent ERP or symptomatic IRP who underwent redo minimally invasive VMR between 2011 and 2016. The study was conducted at three hospitals in Finland. Data collected retrospectively included patient demographics, in addition to perioperative and short-term postoperative findings. At follow-up, all living patients were sent a questionnaire concerning postoperative disease-related symptoms and quality of life.

RESULTS

A total of 43 redo minimally invasive VMR were performed during the study period. The indication for reoperation was recurrent ERP in 22 patients and relapsed symptoms of IRP in 21 patients. In most operations (62.8%), the previously used mesh was left in situ and a new one was placed. Ten (23.3%) patients experienced complications, including 2 (4.7%) mesh-related complications. The recurrence rate was 4.5% for ERP. Three patients out of 43 were reoperated on for various reasons. One patient required postoperative laparoscopic hematoma evacuation. Patients operated on for recurrent ERP seemed to benefit more from the reoperation.

CONCLUSIONS

Minimally invasive redo VMR appears to be a safe and effective procedure for treating posterior pelvic floor dysfunction with acceptable recurrence and reoperation rates.

Surgical Treatment of Rectal Prolapse in the Laparoscopic Era; A Review of the Literature

Rectal prolapse is associated with debilitating symptoms including the discomfort of prolapsing tissue, mucus discharge, hemorrhage, and defecation disorders of fecal incontinence, constipation, or both. The aim of treatment is to eliminate the prolapse, correct associated bowel function and prevent new onset of bowel dysfunction. Historically, abdominal procedures have been indicated for young fit patients, whereas perineal approaches have been preferred in older frail patients with significant comorbidity. Recently, the laparoscopic procedures with their advantages of less pain, early recovery, and lower morbidity have emerged as an effective tool for the treatment of rectal prolapse. This article aimed to review the current evidence base for laparoscopic procedures and perineal procedures, and to compare the results of various techniques. As a result, laparoscopic procedures showed a relatively low recurrence rate than the perineal procedures with comparable complication rates. Laparoscopic resection rectopexy and laparoscopic ventral mesh rectopexy had a small advantage in the improvement of constipation or the prevention of new-onset constipation compared with other laparoscopic procedures. However, the optimal surgical repair has not been clearly demonstrated because of the significant heterogeneity of available studies. An individualized approach is recommended for every patient, considering age, comorbidity, and the underlying anatomical and functional disorders.

Polyvinylidene Fluoride Mesh Use in Laparoscopic Ventral Mesh Rectopexy in Patients with Obstructive Defecation Syndrome for the First Time

BACKGROUND

Obstructive defecation syndrome (ODS) affects quality of life of patients to a great extent by disturbing defecation. Laparoscopic ventral mesh rectopexy (LVMR) has gained much attention in the recent years. Common synthetic used meshes have a risk of erosion for adjacent pelvic organs leading to some complications. The aim of this study was to assess the outcomes of LVMR using polyvinylidene fluoride (PVDF) mesh in patients with ODS for the first time.Methods and Materials: In this experimental study, patients with a history of ODS and associated signs and symptoms such as descending perineum, rectocele, enterocele, intussusception, rectal prolapse or a combined disorder were recruited. The patients underwent LVMR using a PVDF mesh. They were followed using the Constipation Scoring System (CSS) score. Participants were followed up for 12 months after surgery. Complications and CSS for each patient and its changes were the main outcomes of this study.

RESULTS

Of 156 patients, 155 had a 12-month complete follow-up. Thirty-nine (25.2%) were male and 116 (74.8%) female. Mean ± SD age of participants was 45.61 ± 14.02 years. The overall complication rate was 3.87%. No major mesh-related complications were recorded. Four cases (2.58%) of trocar site hernia were reported. Also, two cases (1.29%) of postoperative bleeding occurred. CSS before the operation and 1, 3, and 12 months after it were 11.04 ± 5.93, 7.98 ± 4.85, 5.46 ± 3.70 and 4.09 ± 2.98, respectively (p < 0.001).

CONCLUSION

Synthetic meshes might cause severe erosion in pelvic organs. However, at least in short-term follow-up, PVDF mesh seems to be safe and effective in LVMR, with the advantage of being cheaper.

Simplified Laparoscopic Suture Rectopexy for Idiopathic Rectal Prolapse In Children: Technique and Results

BACKGROUND

Laparoscopic suture rectopexy is safe and effective treatment option for pediatric rectal prolapse. We performed this study to compare the outcome of modified laparoscopic suture rectopexy (MLSR) versus Classical Laparoscopic suture rectopexy (CLSR).

MATERIAL AND METHODS

The study was conducted between June 2015 to May 2019 including all the patients with persistent rectal prolapse who underwent surgery managed by either MLSR (Group A) or CLSR (Group B). The groups were compared for constipation, operative time, blood loss, length of stay, postoperative complications.

RESULTS

19 patients from MLSR and 22 patients from CLSR were evaluated. The mean operative time in MLSR group was 41.5 ± 6.2 min which was significantly lesser than CLSR group with a mean operative time of 78.6 ± 14.2 (p = 0.001). The blood loss was also less in MLSR group compared to CLSR group (p = 0.013). At three months of follow up, the constipation was less in MLSR group compared to CLSR group (p = 0.041).

CONCLUSION

The modification makes the procedure technically easy, minimizes the chances of complications and retaining all the advantages of suture rectopexy.

LEVEL OF EVIDENCE

Level II.

Midterm functional outcome after laparoscopic ventral rectopexy for external rectal prolapse

INTRODUCTION

Although long-term crude outcomes of laparoscopic ventral rectopexy for external rectal prolapse (ERP) have been documented, repetitive functional and quality of life (QOL) assessments are scarce. This study assessed midterm annual functional results and QOL after laparoscopic ventral rectopexy for ERP.

METHODS

This study consisted of 58 patients and was a retrospective analysis of prospectively collected data. The Fecal Incontinence Severity Index, the Constipation Scoring System, and QOL instruments (ie 36-item Short-Form Health Survey and Fecal Incontinence Quality of Life scale) were administered before and after operation.

RESULTS

There was no mortality or major morbidity. After a median follow-up of 49 months (6-92 months), recurrence of ERP was noted in one patient (2%). There were no mesh-related complications. The median Fecal Incontinence Severity Index score was significantly reduced at 3 months (34 [10-61] vs 12 [0-50], P < 0.0001) and remained significantly reduced for 5 years. The median Constipation Scoring System score was significantly reduced at 3 months (14 [9-20] vs 7 [0-16], P < 0.0001) and remained significantly reduced for 4 years. No patients developed new-onset constipation. All of the Fecal Incontinence Quality of Life scales significantly improved overtime for 4 years. All of the 36-item Short-Form Health Survey scales were significantly improved at 3 and 6 months, but none of the scales significantly improved after 2 years.

CONCLUSION

Laparoscopic ventral rectopexy for ERP was associated with low morbidity, low recurrence, and a midterm improvement in function and fecal incontinence-specific QOL.

Outcome of laparoscopic ventral mesh rectopexy for full-thickness external rectal prolapse: a systematic review, meta-analysis, and meta-regression analysis of the predictors for recurrence

BACKGROUND

Laparoscopic ventral mesh rectopexy (LVMR) has proved effective in the treatment of internal and external rectal prolapse. The present meta-analysis aimed to determine the predictive factors of recurrence of full-thickness external rectal prolapse after LVMR.

METHODS

An organized, systematic search of electronic databases including PubMed/Medline, Embase, Scopus, and Cochran library was conducted in adherence to PRISMA guidelines. Studies that reported the outcome of LVMR in patients with full-thickness external rectal prolapse were included according to predefined criteria. A meta-regression analysis and sub-group meta-analyses were performed to recognize the patient and technical factors that were associated with higher recurrence rates.

RESULTS

Seventeen studies comprising 1242 patients of a median age of 60 years were included. The median operation time was 122.3 min. Conversion to open surgery was required in 22 (1.8%) patients. The weighted mean complication rate across the studies was 12.4% (95% CI 8.4-16.4) and the weighted mean rate of recurrence of full-thickness external rectal prolapse was 2.8% (95% CI 1.4-4.3). The median follow-up duration was 23 months. Male gender (SE = 0.018, p = 0.008) and length of the mesh (SE = - 0.007, p = 0.025) were significantly associated with full-thickness recurrence of rectal prolapse. The weighted mean rates of improvement in fecal incontinence and constipation after LVMR were 79.3% and 71%, respectively.

CONCLUSION

LVMR is an effective and safe option in treatment of full-thickness external rectal prolapse with low recurrence and complication rates. Male patients and length of the mesh may potentially have a significant impact on recurrence of rectal prolapse after LVMR.

Adverse obstetric history is not a risk factor for poor outcome after ventral rectopexy for obstructive defaecation syndrome

AIM

Ventral rectopexy (VR) has gained popularity in the management of obstructive defaecation syndrome (ODS) due to a symptomatic rectocele ± intussusception. Data on the efficacy and safety of VR are variable and there are few predictors of successful outcome. This study aimed to examine whether or not an adverse obstetric history influenced the functional outcome following VR for ODS.

METHOD

This was a retrospective study of a cohort of 76 consecutive patients who had undergone VR for ODS at a tertiary referral centre between 2012 and 2015. Patients were followed up by telephone questionnaire. The obstetric history and pre- and postoperative symptoms of ODS and faecal incontinence (FI) were obtained from telephone interviews.

RESULTS

In this cohort, symptoms of ODS were significantly improved by surgery, with 56% of patients showing a reduction of symptoms of 50% or more (P < 0.001). Subgroup analysis demonstrated that a lower body mass index (BMI; 24.4 vs 27.3 kg/m² ; P < 0.05) and shorter duration of symptoms (7 vs 10 years; P < 0.05) led to a better outcome. VR had no effect on FI. Obstetric factors such as foetal weight, instrumental delivery, episiotomy, perineal tear and total number of deliveries did not influence outcomes.

CONCLUSION

Patients with a less straightforward obstetric history can be reassured that this should not adversely influence the functional outcome after VR for ODS. Colorectal surgeons who offer this surgery should warn patients with an elevated BMI or with longstanding symptoms that the operation may be less successful than for those with a lower BMI or shorter duration of symptoms.

Laparoscopic Ventral Mesh Rectopexy: Functional Outcomes after Surgery

Aims  Rectal prolapse is a debilitating and unpleasant condition adversely affecting the quality of life. Laparoscopic ventral mesh rectopexy (LVMR) is recognized as one of the treatment options. The aim of this study was to evaluate the functional outcomes after a standardized LVMR.

Methods  A cohort of patients who underwent LVMR from 2011 to 2015 were contacted and asked to fill questionnaires about their symptoms before and after the surgery. Three questionnaires based on measurement of Wexner fecal incontinence (WFI), obstructive defecation syndrome (ODS), and Birmingham Bowel and Urinary Symptom (BBUS) scores were used to assess the changes in postoperative functional outcomes. Some additional questions were also added to further assess bowel dysfunction.

Results  There were 58 female patients with a mean age of 62.74 ± 15.20 (26–86) years in this cohort. About 70% of the patients participated in the study and returned the filled questionnaires. There was a significant overall improvement across all three scores (WFI: p  = 0.001, ODS: p  = 0.001, and BBUS: p  = 0.001). Some individual components in the scoring systems did not improve to patient's satisfaction. No perioperative complication or conversion to an open procedure was reported in this study. Three recurrences were seen in the redo cases.

Conclusion  LVMR is a promising way of dealing with rectal prolapse. A careful patient selection, appropriate preoperative workup, and a meticulous surgical technique undoubtedly transform the postoperative outcomes.

One decade of rectal prolapse surgery: a national study

PURPOSE

We aimed to investigate the development of common procedures used as treatment for rectal prolapse over a decade and to determine if the choice of primary operation affects the reoperation rate.

METHODS

This is a retrospective analysis of operative data from a National Data Registry, Landspatientregisteret (LPR), from the period of January 1, 2004 to December 31, 2014. All hospitalized surgical treatments are registered in LPR.

RESULTS

Sixteen hundred and twenty-five patients with rectal prolapse underwent 1834 operations. There were 94% women and mean age at surgery was 71.6 ± 18.1 years, with no difference over the 11 years. The types of operations performed differed (p < 0.0001), with an increase in overall number of operations and increasing use of laparoscopic procedures. There were 209 reoperations, of which 129 patients were primarily operated with a perineal procedure. The mean age at reoperation was 72.8 ± 17.3 years. The most frequently used reoperation was laparoscopic rectopexy. The overall reoperation rate was 16%: 10% for both open and laparoscopic rectopexy, and for perineal procedures 26% (p < 0.001). The overall 30-day mortality was 2.1% and there was no difference in mortality between the procedures (p = 0.23).

CONCLUSIONS

The overall number of rectal prolapse operations was increasing. There was a clear trend towards extended use of laparoscopic rectopexy both as primary procedure and as reoperation. The highest reoperation rates were for the perineal procedures.

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.

Laparoscopic Rectopexy with Urinary Bladder Xenograft Reinforcement

BACKGROUND AND OBJECTIVES

Rectal prolapse is often repaired laparoscopically, frequently with the use of reinforcement material. Both synthetic and biologically derived materials reduce recurrence rate compared to primary suture repair. Synthetic mesh introduces potential complications such as mesh erosion, fibrosis, and infection. Urinary bladder matrix (UBM) represents a biologically derived material for reinforcement of rectal prolapse repair with the potential to improve durability without risks of synthetic materials. The objective of the study is to evaluate the effectiveness, durability, and functional result of laparoscopic rectopexy using urinary bladder matrix xenograft reinforcement at three years follow up.

METHODS

The 20 cases presented describe rectal prolapse repair by means of laparoscopic rectopexy with presacral UBM reinforcement. Patients were followed up for an average of 3 years and assessed with interviews, physical examination, manometry, and the fecal incontinence severity index (FISI).

RESULTS

Each repair was completed laparoscopically. UBM exhibited favorable handling characteristics when sutured to the sacrum and the lateral rectal walls. One patient underwent laparoscopic drainage of a postoperative abscess; no other complications occurred. In 3 years of follow-up, there have been no full-thickness recurrences, erosions, reoperations, or long-term complications. Two patients exhibited a small degree of mucosal prolapse on follow-up physical examination that did not require surgery. Three-year FISI scores averaged 8 (range, 0-33 of a possible 61), indicating low fecal incontinence symptomatology. Follow-up anorectal manometry was performed in 9 patients, showing mixed results.

CONCLUSION

Surgeons may safely use laparoscopic rectopexy with UBM reinforcement for repair of rectal prolapses. In this series, repairs with UBM grafts have been durable at 3-year follow-up and may be an alternative to synthetic mesh reinforcement of rectal prolapse repairs. Future studies may compare the advantages and cost-effectiveness of reinforcement materials for rectal prolapse repair.

Synthetic Versus Biological Mesh-Related Erosion After Laparoscopic Ventral Mesh Rectopexy: A Systematic Review

Purpose

This review reports the incidence of mesh-related erosion after ventral mesh rectopexy to determine whether any difference exists in the erosion rate between synthetic and biological mesh.

Methods

A systematic search of the MEDLINE and the Ovid databases was conducted to identify suitable articles published between 2004 and 2015. The search strategy capture terms were laparoscopic ventral mesh rectopexy, laparoscopic anterior rectopexy, robotic ventral rectopexy, and robotic anterior rectopexy.

Results

Eight studies (3,956 patients) were included in this review. Of those patients, 3,517 patients underwent laparoscopic ventral rectopexy (LVR) using synthetic mesh and 439 using biological mesh. Sixty-six erosions were observed with synthetic mesh (26 rectal, 32 vaginal, 8 recto-vaginal fistulae) and one (perineal erosion) with biological mesh. The synthetic and the biological mesh-related erosion rates were 1.87% and 0.22%, respectively. The time between rectopexy and diagnosis of mesh erosion ranged from 1.7 to 124 months. No mesh-related mortalities were reported.

Conclusion

The incidence of mesh-related erosion after LVR is low and is more common after the placement of synthetic mesh. The use of biological mesh for LVR seems to be a safer option; however, large, multicenter, randomized, control trials with long follow-ups are required if a definitive answer is to be obtained.

Risk Factors for Recurrence After Laparoscopic Ventral Rectopexy

BACKGROUND

Laparoscopic ventral rectopexy effectively treats posterior compartment prolapse. However, recurrence after laparoscopic ventral rectopexy is poorly understood.

OBJECTIVE

This study aimed to evaluate factors contributing to recurrence after laparoscopic ventral rectopexy.

DESIGN

A retrospective cohort analysis was performed of patients who underwent laparoscopic ventral rectopexy between June 2008 and June 2014. Patients presenting with full-thickness rectal prolapse were compared against the rest. Cox proportional hazards regression was used to determine predictors for recurrence. Operative findings of redo cases were evaluated.

SETTINGS

This study was conducted under the supervision of a single pelvic floor surgeon.

PATIENTS

A total of 231 patients with a median follow-up of 47 months were included.

MAIN OUTCOME MEASURES

Clinicopathological risk factors and technical failures contributing to recurrence were analyzed.

RESULTS

The overall recurrence rate was 11.7% (n = 27). Twenty-five recurrences occurred in patients with full-thickness rectal prolapse, of which 16 were full-thickness recurrences (14.2% (16/113)). Multivariate analyses showed predictors for recurrence to be prolonged pudendal nerve terminal motor latency (HR = 5.57 (95% CI, 1.13 - 27.42); p = 0.04) and the use of synthetic mesh as compared with biologic grafts (HR = 4.24 (95% CI, 1.27-14.20); p = 0.02). Age >70 years and poorer preoperative continence were also associated with recurrence on univariate analysis. Technical failures contributing to recurrence included mesh detachment from the sacral promontory and inadequate midrectal mesh fixation.

LIMITATIONS

Modifications to the operative technique were made throughout the study period. A postoperative defecating proctogram was not routinely performed.

CONCLUSIONS

Recurrence after laparoscopic ventral rectopexy is multifactorial, and risk factors are both clinical and technical. The use of biologic grafts was associated with lower recurrence as compared with synthetic mesh. Patients with full-thickness rectal prolapse who are elderly, have poorer baseline continence, and have prolonged pudendal nerve terminal motor latency are at increased risk of recurrence.

Laparoscopic ventral mesh rectopexy vs Delorme's operation in management of complete rectal prolapse: a prospective randomized study

AIM

Various surgical operations have been devised for the treatment of rectal prolapse, yet no ideal procedure has been described. The present study aims to compare the clinical and functional outcome of laparoscopic ventral mesh rectopexy (LVMR) and Delorme's operation for complete rectal prolapse.

METHOD

Fifty patients with complete rectal prolapse were enrolled in this study. Patients were randomly selected to undergo either LVMR or Delorme's procedure after clinical, manometric and radiological evaluation. Patient characteristics, operative data, postoperative complications, recurrence of rectal prolapse and continence state were evaluated. Patients were followed for a mean duration of 18 months.

RESULTS

Thirty-one (62%) patients were women and 19 (38%) patients were men with a mean age of 39.7 ± 6.9 years. Patients were allocated into two equal groups: LVMR group and Delorme's group. Thirty-three (66%) complained of faecal incontinence preoperatively. Patients were followed for 18 months. There was no major postoperative complication or treatment death. Improvement in continence was reported in 80.9% of patients (83.3% in group 1 vs 71.4% in group 2). Recurrent prolapse was observed in 16% of patients in group 2 and 8% in group 1 (P = 0.66). The operation time was significantly greater in group 1 and the length of stay greater in group 2. There was no difference in the fall of constipation score between the groups.

CONCLUSION

There was no statistically significant difference in the incidence of recurrence of complete rectal prolapse or postoperative improvement of symptoms between the two groups. Hospital stay was longer after Delorme's procedure but the operation time was shorter. Neither procedure proved definite superiority regarding the clinical and functional outcome at 18 months of follow-up.

Robot-assisted vs laparoscopic ventral rectopexy for external or internal rectal prolapse and enterocele: a randomized controlled trial

AIM

The purpose of this prospective randomized study was to compare robot-assisted and laparoscopic ventral rectopexy procedures for posterior compartment procidentia in terms of restoration of the anatomy using magnetic resonance (MR) defaecography.

METHOD

Sixteen female patients (four with total prolapse, twelve with intussusception) underwent robot-assisted ventral mesh rectopexy (RVMR) and 14 female patients (two with prolapse, twelve with intussusception) laparoscopic ventral mesh rectopexy (LVMR). Primary outcome measures were perioperative parameters, complications and restoration of anatomy as assessed by MR defaecography, which was performed preoperatively and 3 months after surgery.

RESULTS

Patient demographics, operation length, operating theatre times and length of in-hospital stay were similar between the groups. The anatomical defects of rectal prolapse, intussusception and rectocele and enterocele were similarly corrected after rectopexy in either technique as confirmed with dynamic MR defaecography. A slight residual intussusception was observed in three patients with primary total prolapse (two RVMR vs one LVMR) and in one patient with primary intussusception (RVMR) (P = 0.60). Rectocele was reduced from a mean of 33.0 ± 14.9 mm to 5.5 ± 8.4 mm after RVMR (P < 0.001) and from 24.7 ± 17.5 mm to 7.2 ± 3.2 mm after LVMR (P < 0.001) (RVMR vs LVMR, P = 0.10).

CONCLUSION

Robot-assisted laparoscopic ventral rectopexy can be performed safely and within the same operative time as conventional laparoscopy. Minimally invasive ventral rectopexy allows good anatomical correction as assessed by MR defaecography, with no differences between the techniques.

Life after PROSPER. What do people do for external rectal prolapse?

AIM

A questionnaire completed by members of the ACPGBI in 1997 was a precursor to the PROSPER trial. It showed a significant variation in favoured practice for the surgical treatment of external rectal prolapse. We repeated the same questionnaire to assess how practice has changed since the completion of the trial and its publication.

METHOD

An online survey was circulated to all members of the ACPGBI with identical questions to those used in the original in 1997.

RESULTS

Similar numbers of recipients responded (122/791 [15.4%] in 2014;153/600 [25.5%] in 1997). The median number of operations per surgeon per year was unchanged (6 [0-30] vs 6 [0-25]). The percentage of surgeons who favoured an abdominal approach in fit patients in 1997 rose significantly from 63.5% to 81.7% in 2014 (P < 0.01). Delorme's remains the most popular perineal procedure (78.5% vs 93.3%), but the Altemeier procedure increased from 14.9% to 39.3%. Ventral rectopexy was the preferred abdominal approach in 2014 (48.6% vs 5.9% [P < 0.01]), with 96.3% of these being performed laparoscopically. The number of surgeons carrying out posterior rectopexy decreased from 92.6% to 45.9% (P < 0.01). Only 9.9% of surgeons still undertook resection rectopexy compared with 39.7% in 1997 (P < 0.01). The numbers of surgeons favouring a perineal approach decreased (18.3% vs 36.5%) although the use of a perineal procedure in elderly or unfit patients was unchanged (38.5% vs 37.9%).

CONCLUSION

The surgical management of external rectal prolapse had changed. More surgeons favoured a laparoscopic abdominal approach in 2014 than in 1997 and the use of perineal approaches had decreased. Of these Delorme's operation remained the most popular but the incidence of the use of Altmeier's procedure had increased.

Current status of laparoscopic and robotic ventral mesh rectopexy for external and internal rectal prolapse

External and internal rectal prolapse with their affiliated rectocele and enterocele, are associated with debilitating symptoms such as obstructed defecation, pelvic pain and faecal incontinence. Since perineal procedures are associated with a higher recurrence rate, an abdominal approach is commonly preferred. Despite the description of greater than three hundred different procedures, thus far no clear superiority of one surgical technique has been demonstrated. Ventral mesh rectopexy (VMR) is a relatively new and promising technique to correct rectal prolapse. In contrast to the abdominal procedures of past decades, VMR avoids posterolateral rectal mobilisation and thereby minimizes the risk of postoperative constipation. Because of a perceived acceptable recurrence rate, good functional results and low mesh-related morbidity in the short to medium term, VMR has been popularized in the past decade. Laparoscopic or robotic-assisted VMR is now being progressively performed internationally and several articles and guidelines propose the procedure as the treatment of choice for rectal prolapse. In this article, an outline of the current status of laparoscopic and robotic ventral mesh rectopexy for the treatment of internal and external rectal prolapse is presented.

Long-term Outcome After Laparoscopic Ventral Mesh Rectopexy: An Observational Study of 919 Consecutive Patients. Ann Surg. 2015;262:742-747; discussion 747-748. [PMID: 26583661 DOI: 10.1097/sla.0000000000001401]

OBJECTIVE

This multicenter study aims to assess long-term functional outcome, early and late (mesh-related) complications, and recurrences after laparoscopic ventral mesh rectopexy (LVR) for rectal prolapse syndromes in a large cohort of consecutive patients.

BACKGROUND

Long-term outcome data for prolapse repair are rare. A high incidence of mesh-related problems has been noted after transvaginal approaches using nonresorbable meshes.

METHODS

All patients treated with LVR at the Meander Medical Centre, Amersfoort, the Netherlands and the University Hospital Leuven, Belgium between January 1999 and March 2013 were enrolled in this study. All data were retrieved from a prospectively maintained database. Kaplan-Meier estimates were calculated for recurrences and mesh-related problems.

RESULTS

919 consecutive patients (869 women; 50 men) underwent LVR. A 10-year recurrence rate of 8.2% (95% confidence interval, 3.7-12.7) for external rectal prolapse repair was noted. Mesh-related complications were recorded in 18 patients (4.6%), of which mesh erosion to the vagina occurred in 7 patients (1.3%). In 5 of these patients, LVR was combined with a perineotomy. Both rates of fecal incontinence and obstructed defecation decreased significantly (P < 0.0001) after LVR compared to the preoperative incidence (11.1% vs 37.5% for incontinence and 15.6% vs 54.0% for constipation).

CONCLUSIONS

LVR is safe and effective for the treatment of different rectal prolapse syndromes. Long-term recurrence rates are in line with classic types of mesh rectopexy and occurrence of mesh-related complications is rare.

High-grade hemorrhoids requiring surgical treatment are common after laparoscopic ventral mesh rectopexy

Purpose

To describe patients developing grade III and IV hemorrhoids requiring surgery after laparoscopic ventral mesh rectopexy (LVMR) and to explore the relationship between developing such hemorrhoids and recurrence of rectal prolapse after LVMR.

Methods

All consecutive patients receiving LVMR at the Meander Medical Centre, Amersfoort, the Netherlands, between 2004 and 2013 were analyzed. Kaplan–Meier estimates were calculated for recurrences.

Results

A total of 420 patients underwent LVMR. Sixty-five of these patients (actuarial 5-year incidence 24.3, 95 % confidence interval (CI) 18.6–30.0) developed symptomatic grade III/IV hemorrhoids requiring stapled or excisional hemorrhoidectomy. Re-do surgery for recurrent grade III/IV hemorrhoids was required for 15 of the 65 patients (actuarial 5-year recurrence rate 40.6, 95 % CI 23.2–58.0) after the primary hemorrhoidectomy. Three of the 65 patients developed an external rectal prolapse (ERP) recurrence and eight an internal rectal prolapse (IRP) recurrence. This generated a 5-year recurrence rate of 25.3 % (95 % CI 0–53.9) for ERP recurrence and 24.4 % (95 % CI 9.1–39.7) for IRP recurrence. The rest of the LVMR cohort not receiving additional surgery for hemorrhoids (n = 355) showed significantly lower actuarial 5-year ERP (0.8 %, p = 0.011) and IRP (11 %, p = 0.020) recurrence rates.

Conclusion

High-grade hemorrhoids requiring surgery may be common after LVMR. The development of high-grade hemorrhoids after LVMR might be considered a predictor of rectal prolapse recurrence.

New-onset rectoanal intussusception may not result in symptomatic improvement after laparoscopic ventral rectopexy for external rectal prolapse

BACKGROUND

This study was designed to assess defecatory function in patients who underwent laparoscopic ventral rectopexy (LVR) for external rectal prolapse (ERP).

METHODS

Thirty-one patients who underwent evacuation proctography 6 months postoperatively were assessed. Preoperative proctography had been performed in 21 patients of these patients. Defecatory function was evaluated using the constipation scoring system (CSS) and fecal incontinence severity index (FISI).

RESULTS

The findings of postoperative proctography revealed no full-thickness ERP in any patient, although in 10 patients the ERP was replaced by rectoanal intussusception (RAI). Of the 31 patients, 30 presented with fecal incontinence preoperatively. Ten of 30 had new-onset RAI. Six months postoperatively, a reduction of at least 50 % in the FISI score of the patients with new-onset RAI tended to be significantly smaller than in the patients without RAI (6/10 vs. 18/20, p = 0.141). Seventeen patients presented with obstructed defecation preoperatively. Seven of them had new-onset RAI. Six months postoperatively, a reduction of at least 50 % in their CSS score in the patients with new-onset RAI was significantly smaller than in patients without RAI (0/7 vs. 8/10, p = 0.002).

CONCLUSIONS

Evacuation proctography showed new-onset RAI in some patients with ERP who underwent LVR, which was associated with a lack of symptomatic improvement.