Outcome of laparoscopic rectopexy versus perineal rectosigmoidectomy for full-thickness rectal prolapse in elderly patients

A quantitative study to explore functional outcomes following laparoscopic ventral mesh rectopexy for rectal prolapse

INTRODUCTION

Rectal prolapse is a life-altering problem and laparoscopic ventral mesh rectopexy (LVMR) is emerging as the surgical intervention of choice. However, the literature is ambiguous on its effect on bowel function and sparse as regards bladder and sexual function. This study assesses short-term functional outcomes following LVMR.

MATERIALS AND METHODS

This quantitative retrospective study with a pretest-post-test design included 130 adults who had undergone LVMR from October 2010 to December 2018 in a tertiary centre. Analysis with paired-samples t-test and Wilcoxon matched pairs test was done using SPSS (v26).

RESULTS

The median age was 58 years (interquartile range, 48-74 years); 123 (94.6%) were female. The median length of stay was two days (interquartile range, 1-2 days). A total of 104 (80%) sets of medical notes were reviewed. One patient had recurrence of rectal prolapse. Synthetic mesh was used in 24 patients (23.1%) and biological mesh in 80 (76.9%). One patient had extrusion of a synthetic mesh and required surgery; 31(23.8%) completed the Electronic Patient Assessment Questionnaire for Pelvic Floor. Overall, the improvement in bladder function was not statistically significant (p = 0.670). A statistically significant improvement was seen for all bowel symptoms (p = 0.002) excluding constipation (p = 0.295). Irritable bowel symptoms associated with rectal prolapse improved significantly following LVMR (p = 0.001). Vaginal prolapse (p < 0.0005), dyspareunia (p = 0.001) and bowel symptoms affecting sexual intercourse (p = 0.01) improved, but improvement in overall sexual function was not statistically significant (p = 0.081).

CONCLUSIONS

LVMR improves bowel function overall, although it can worsen constipation. It has the potential to improve sexual function but makes negligible difference to bladder function.

OUP accepted manuscript

Background

External rectal prolapse (ERP) is a debilitating condition in which surgery plays an important role. The aim of this study was to evaluate the outcomes of abdominal approaches (AA) and perineal approaches (PA) to ERP.

Methods

This was a PRISMA-compliant systematic review with meta-analysis. Studies published between 1990 and 2021 were retrieved. The primary endpoint was recurrence at the last available follow-up. Secondary endpoints included factors associated with recurrence and function. All studies were assessed for bias using the Newcastle–Ottawa Scale and Cochrane tool.

Results

Fifteen studies involving 1611 patients (AA = 817; PA = 794) treated for ERP were included, three of which were randomized controlled trials (RCTs; 114 patients (AA = 54; PA = 60)). Duration of follow-up ranged from 12 to 82 months. Recurrence in non-randomized studies was 7.7 per cent in AA versus 20.1 per cent in PA (odds ratio (OR) 0.29, 95 per cent confidence interval (c.i.) 0.17 to 0.50; P < 0.001, I² = 45 per cent). In RCTs, there was no significant difference (9.8 per cent versus 16.3 per cent, AA versus PA (OR 0.82, 95 per cent c.i. 0.29 to 2.37; P = 0.72, I² = 0.0 per cent)). Age at surgery and duration of follow-up were risk factors for recurrence. Following AA, the recurrence rates were 10.1 per cent and 6.2 per cent in patients aged 65 years and older and less than 65 years of age, respectively (effect size [e.s.] 7.7, 95 per cent c.i. 4.5 to 11.5). Following PA, rates were 27 per cent and 16.3 per cent (e.s. 20.1, 95 per cent c.i. 13 to 28.2). Extending follow-up to at least 40 months increased the likelihood of recurrence. The median duration of hospital stay was 4.9 days after PA versus 7.2 days after AA. Overall, incontinence was less likely after AA (OR 0.32), but constipation occurred more frequently (OR 1.68). Most studies were retrospective, and several outcomes from RCTs were not consistent with those observed in non-RCTs.

Conclusion

The overall risk of recurrence of ERP appears to be higher with PA versus AA. Incontinence is less frequent after AA but at the cost of increased constipation. Age at surgery and duration of follow-up are associated with increased risk of recurrence, which warrants adequate reporting of future studies on this topic.

Table Sugar as a Bridge from Emergency to Elective Perineal Proctosigmoidectomy for Incarcerated Rectal Prolapse

Incarcerated rectal prolapse is a rare pathology and is considered an emergency, using table sugar can shift the emergency surgery to an elective one. If left untreated, rectal prolapse may present as an emergency, be it incarceration or strangulation. In an emergency presentation for incarcerated rectal prolapse every attempt should be taken to reduce the prolapsed rectum, if not successful, emergency surgery is indicated, with perineal approach being the first choice in elderly with multiple comorbidities.

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.

Perioperative Outcomes for Combined Ventral Rectopexy With Sacrocolpopexy Compared to Perineal Rectopexy With Vaginal Apical Suspension

OBJECTIVES

To describe and compare perioperative complications in women undergoing combined ventral rectopexy with sacrocolpopexy compared with perineal rectopexy with vaginal apical suspension.

METHODS

Current Procedural Terminology codes were used to identify women in the National Surgical Quality Improvement Program database who underwent ventral rectopexy with sacrocolpopexy or perineal rectopexy with vaginal apical suspension from 2006 to 2015. Perioperative complication was defined as any of the following within 30 days of surgery: death, return to the operating room, transfusion, or vascular, wound, respiratory, infectious, or renal morbidity. Secondary outcomes included length of hospital stay, operative time, blood loss, readmission, and rate of urinary tract infections. Modified Poisson regression was used to estimate the adjusted relative risks of complication associated with surgical approach, abdominal versus perineal.

RESULTS

Of the 273 women included, 240 (88%) underwent surgery with an abdominal approach, and 33 (12%) underwent surgery with a perineal approach. Perioperative complications occurred in 24 (9%) patients; 19 (8%) in the abdominal group and 5 (15%) in the perineal group. The age-adjusted risk of perioperative complications was not significantly different between those with a perineal approach compared with those with an abdominal approach (adjusted relative risk, 1.78; 95% confidence interval, 0.73-4.33).

CONCLUSIONS

Patients in this database who underwent surgery with a vaginal/perineal approach were not more likely to have a postoperative complication after adjusting for age compared with those undergoing an abdominal approach. Larger studies are needed to determine a more precise estimate of the impact of surgical approach on rates of perioperative complications.

Getting to the bottom of treatment of rectal prolapse in the elderly: Analysis of the National Surgical Quality Improvement Program (NSQIP)

BACKGROUND

Many approaches to treat rectal prolapse exists, yet little is known regarding their safety in the elderly.

METHOD

NSQIP (2008-2014) was queried to identify patients ≥ 70 years who underwent open rectopexy (OR), laparoscopic rectopexy (LR) and perineal rectosigmoidectomy (PR). Patients were selected using NSQIP's estimated probability of morbidity of ≥50^th percentile. Outcomes were 30-day mortality and a composite: mortality, septic shock and organ space abscess and fascial dehiscence.

RESULTS

Overall, 1361 patients underwent OR(18%), LR(15%) and PR(67%) with no difference in outcomes among 3 approaches. After adjustment of other factors, the composite was associated with PR [OR 2.5, CI 1.1, 5.7] and not with older age [OR 1.3, (CI) 0.7, 2.4]. From 2008 to 2014, LR increased from 11% to 19%; and PR decreased from 75% to 72%.

CONCLUSIONS

All 3 surgical approaches carry low morbidity among the sick, elderly. PR remains the predominant approach nationally. A paradigm shift accepting the safety of abdominal approaches is needed. There should also be less focus on age in the decision-making process of surgical treatment.

Altemeier's procedure for complete rectal prolapse; outcome and function in 43 consecutive female patients

Background

The aim of this retrospective study was to evaluate morbidity, mortality, postoperative function and recurrences in patients treated by Altemeier’s rectosigmoidectomy for complete rectal prolapse in a referral center for pelvic floor functional disorders.

Methods

Peri-operative data on 43 consecutive female patients were reviewed. At follow-up any change in pelvic floor function and recurrences were determined. Thirty four patients were assessed at a median interval of 49 (2–135) months, six being deceased for reason not related to the prolapse and three lost to follow-up.

Results

Post-operative complications at 30 days occurred in 18 patients (38%). Major complication occurred in only one patient that was pneumonia with lung failure. Major complications were not related to the ASA score, BMI or age [average age 76.4]. There was no post-operative mortality at 30 days.

At long-term follow-up functional results demonstrate a statistically significant decrease in the Obstructive Defecation Syndrome (ODS) score, but no statistically significant changes in the Vaizey score, the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) score and the urinary retention score. ODS score decreased with respect to levatorplasty and the change was statistically significant instead of Vaizey score in which were not.

At the same follow-up there were 12 (35%) cases of recurrence with an estimated risk at 48 months of 40%. There were no statistically significant differences between patients with and without recurrence regarding age (p = 0.188), BMI (p = 0.864), ASA score (p = 0.433), previously repaired prolapse (p = 0.398), previous hysterectomy (p = 0.705), length of resected bowel (p = 0.126), and levatorplasty (p = 0.304). Patient satisfaction showed a mean of 8.8 and 6.4 respectively in patients without and with recurrences (p = 0.012).

Conclusions

Altemeier’s procedure had in our series low complications rate and no mortality. It offered improved evacuation in constipated patients while didn’t improve fecal and urinary continence. Recurrence of prolapse was 40% at four years.

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0463-7) contains supplementary material, which is available to authorized users.

Massive chronic irreducible rectal prolapse successfully treated with Altemeier's procedure

The guideline for the treatment of rectal prolapse recommends that surgeons select appropriate surgical procedures individually based on each patient's overall status. However, in cases of irreducible or incarcerated rectal prolapse, surgical options are quite limited. Here we present a case of an elderly woman with massive chronic irreducible rectal prolapse. An 87-year-old woman presented to our hospital with a complaint of massive rectal prolapse. The prolapsed rectum was over 20 cm long, and completely irreducible. She underwent perineal rectosigmoidectomy with levatorplasty known as Altemeier's procedure. More than 30 cm of rectosigmoid colon was resected. After the operation, rectal prolapse was resolved completely. Her postoperative course was uneventful, and her quality of life and bowel movements improved. She has since been healthy without recurrence for over 2 years. Altemeier's procedure is applicable even in cases of irreducible rectal prolapse and features acceptable safety and a satisfactory outcome.

Perineal resectional procedures for the treatment of complete rectal prolapse: A systematic review of the literature

BACKGROUND AND AIM

Several procedures for the treatment of complete rectal prolapse (CRP) exist. These procedures are performed via the abdominal or perineal approach. Perineal procedures for rectal prolapse involve either resection or suspension and fixation of the rectum. The present review aimed to assess the outcomes of the perineal resectional procedures including Altemeier procedure (AP), Delorme procedure (DP), and perineal stapled prolapse resection (PSR) in the treatment of CRP.

PATIENTS AND METHODS

A systematic search of the current literature for the outcomes of perineal resectional procedures for CRP was conducted. Databases queried included PubMed/MEDLINE, SCOPUS, and Cochrane library. The main outcomes of the review were the rates of recurrence of CRP, improvement in bowel function, and complications.

RESULTS

Thirty-nine studies involving 2647 (2390 females) patients were included in the review. The mean age of patients was 69.1 years. Recurrence of CRP occurred in 16.6% of patients. The median incidences of recurrence were 11.4% for AP, 14.4% for DP, and 13.9% for PSR. Improvement in fecal incontinence occurred in 61.4% of patients after AP, 69% after DP, and 23.5% after PSR. Complications occurred in 13.2% of patients. The median complication rates after AP, DP and PSR were 11.1%, 8.7%, and 11.7%, respectively.

CONCLUSION

Perineal resectional procedures were followed by a relatively high incidence of recurrence, yet an acceptably low complication rate. Definitive conclusions on the superiority of any procedure cannot be reached due to the significant heterogeneity of the studies.

Abdominal Approaches to Rectal Prolapse

Rectal prolapse is a debilitating condition with a complex etiology. Symptoms are most commonly prolapse of the rectum and pain with bowel movements or straining, with worsening fecal incontinence over time due to progressive stretching of the anal sphincters. Physical findings are fairly consistent from patient to patient-most notably diastasis of the levator ani muscles, deep pouch of Douglas, redundant sigmoid colon, a mobile mesorectum, and occasionally a solitary rectal ulcer. Evaluation includes a physical exam or imaging demonstrating the prolapse, and evaluating for other causes of pelvic floor dysfunction. Multiple surgical repairs are available, but treatment must be individualized based on patient symptoms and the presence or absence of constipation or other pelvic floor disorders. Mesh repairs have shown promising results, but carry the added risks of mesh erosion, infection, and mesh migration. The optimal repair has not been clearly demonstrated at this time.

Modified laparoscopic anterior resection of the rectum for rectal prolapse in elderly patients

AIM: To assess the clinical effects, feasibility and safety of modified laparoscopic anterior resection of the rectum for rectal prolapse in elderly patients.

METHODS: The clinical data for 20 elderly patients suffering from rectal prolapse who underwent modified laparoscopic anterior resection of the rectum (laparoscopic group) and 20 elderly patients who underwent modified anterior resection of the rectum (open group) from 2005 to 2013 were collected. Comparative analysis of the two surgical groups was done.

RESULTS: Surgery was successful in all of the 40 cases. The mean length of the resected specimen was 21.7 cm ± 2.2 cm vs 22.3 cm ± 2.1 cm and showed no significant difference between the two groups. Mean intraoperative blood loss (118.0 mL ± 40.8 mL vs 156.0 mL ± 33.5 mL), time to recovery of intestinal function (2.3 d ± 0.9 d vs 3.9 d ± 0.7 d), mean duration of postoperative hospital stay (6.3 d ± 1.1 d vs 9.9 d ± 1.7 d) and mean operational time (146.0 min ± 22.3 min vs 115.0 min ± 16.5 min) differed significantly between the two groups. There was also a significant difference between the two groups in the rate of complications (15% vs 45%). All the cases were followed for 36.0 mo ± 11.3 mo and the recurrence rate was 10.0% vs 5.0%, showing no significant difference between the two groups.

CONCLUSION: Modified laparoscopic anterior resection of the rectum for rectal prolapse in elderly patients is safe, effective, and satisfactory, with low recurrence rate and minimal invasiveness. Laparoscopic procedure should be considered first for rectal prolapse in elderly patients.

Risk factors and clinical characteristics of rectal prolapse in young patients

BACKGROUND

Rectal prolapse is a relatively common condition in children and elderly patients but uncommon in young adults less than 30 years old. The aim of this study is to identify risk factors and characteristics of rectal prolapse in this group of young patients and determine surgical outcome.

METHODS

Adult patients younger than 30 years old with rectal prolapse treated surgically between September 1994 and September 2012 were identified from an IRB-approved database. Demographics, risk factors, associated conditions, clinical characteristics, surgical management and follow-up were recorded.

RESULTS

Forty-four (females 32) patients were identified with a mean age of 23 years old. Eighteen (41%) had chronic psychiatric diseases requiring treatment and these patients experienced significantly more constipation than non-psychiatric patients (83% vs. 50%; P=0.024). Thirteen (30%) patients had previous pelvic surgery. The most common symptom at presentation was a prolapsed rectum in 40 (91%) and hematochezia in 24 (55%). Twenty-four (55%) underwent a laparoscopic rectopexy, 14 (32%) open abdominal repair, and 6 (14%) had perineal surgery. The most common procedure was resection rectopexy in 21 (48%; 7 open; 14 laparoscopic). At a median follow-up of 11 (range 1-165) months, 6 patients (14%) developed a recurrence.

CONCLUSIONS

Medication induced constipation in psychiatric patients and possible pelvic floor weakness in patients with previous pelvic surgery may be contributing factors to rectal prolapse in this group of patients.

Surgical treatments for rectal prolapse: how does a perineal approach compare in the laparoscopic era?

BACKGROUND

Patients with rectal prolapse often have significant comorbidities that lead surgeons to select a perineal resection for treatment despite a reported higher recurrence rate over abdominal approaches. There is a lack of data to support this practice in the laparoscopic era. The objective of this study was to evaluate if risk-adjusted morbidity of perineal surgery for rectal prolapse is actually lower than laparoscopic surgery.

DESIGN

A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database as performed for patients undergoing surgical treatment of rectal prolapse between 2005 and 2011. Outcomes were analyzed according to procedure-type: laparoscopic rectopexy (LR), laparoscopic resection/rectopexy (LRR), open rectopexy (OR), open resection/rectopexy (ORR), and perineal resection (PR). A multivariate logistic regression was used to compare risk-adjusted morbidity and mortality between each procedure. Main outcome measures were 30-day morbidity and mortality.

RESULTS

Among 3,254 cases sampled, a laparoscopic approach was used in 22 %, an open abdominal approach in 30 %, and PR in 48 %. Patients undergoing PR were older (76) and had a higher ASA (3) compared to laparoscopic (58, 2) and open abdominal procedures (58, 2). Risk-adjusted mortality could not be assessed due to a low overall incidence of mortality (0.01 %). Overall morbidity was 9.3 %. ORR was associated with a higher risk-adjusted morbidity compared to PR (OR: 1.89 CI (1.19-2.99), p = 0.03). There were no significant differences in risk-adjusted morbidity found between LR and LRR compared to PR (OR 0.44 CI (0.19-1.03), p = 0.18; OR 1.55 CI (0.86-2.77), p = 0.18). Laparoscopic cases averaged 27 min longer than open cases (p < 0.001).

CONCLUSION

Laparoscopic rectal prolapse surgery has comparable morbidity and mortality to perineal surgery. A randomized trial is indicated to validate these findings and to assess recurrence rates and functional outcomes.

Rectal prolapse and intussusception

Rectal prolapse continues to be problematic for both patients and surgeons alike, in part because of increased recurrence rates despite several well-described operations. Patients should be aware that although the prolapse will resolve with operative therapy, functional results may continue to be problematic. This article describes the recommended evaluation, role of adjunctive testing, and outcomes associated with both perineal and abdominal approaches.

Changing approaches to rectal prolapse repair in the elderly

Aim: The abdominal approach to rectal prolapse is associated with lower rates of recurrence but a higher chance of complications and has been traditionally reserved for younger patients. However, longer life expectancy and wider use of laparoscopic techniques necessitates another look at the abdominal approach in older patients.

Methods: This was a retrospective review of data from patients undergoing abdominal repair of rectal prolapse between 2005 and 2011.

Results: Forty-six abdominal repairs (laparoscopic or open suture rectopexy, sigmoidectomy and rectopexy and low anterior resection) were performed during the study period. Twenty-nine repairs (63%) were performed in patients under the age of 70 (average age 51) and 17 (37%) in patients older than 70 (average age 76; range 71–89). Most of the cases performed during the initial 3 years of the study were via laparotomy. However, in the last 4 years, the laparoscopic approach was used in 83% of younger patients and 69% of older patients. Average length of stay was 2.6 days for younger and 3.8 days for older patients. Both groups had similar rates of re-admission: 20% vs 23%. The rate of wound infection was higher in the younger patients (5% vs nil). However, rates of urinary tract infection, two instances (10%) vs four (30%), urinary retention, one instance (5%) vs two (15.4%), ileus, one instance (5%) vs two (15.4%) were higher in the older group.

Conclusion: Wider use of laparoscopy has precipitated a change in the approach to rectal prolapse in older patients. Although associated with a slightly higher rate of post-operative complications, the abdominal approach to rectal prolapse is feasible, safe and effective in patients older than 70 years.

Is robotic-assisted ventral mesh rectopexy superior to laparoscopic ventral mesh rectopexy in the management of obstructed defaecation?

AIM

Function, morbidity and recurrence of symptoms after robotic-assisted ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR) for pelvic floor disorders (PFDs) were compared.

METHOD

Forty-four patients operated on for PFD with RVMR were compared with 74 of 144 patients who had had LVMR performed between 2008 and 2011. The groups were matched for age, body mass index, American Society of Anesthesiologists status and previous hysterectomy. The same surgical technique and type of mesh were used. Early postoperative morbidity and function [obstructed defaecation syndrome (ODS), incontinence scores (CCF) and sexual activity] were compared.

RESULTS

Operation time was longer in RVMR compared with LVMR (191 ± 26 vs 163 ± 39 min; P = 0.0002). RVMR showed less blood loss (8 ± 34 vs 42 ± 88 ml; P = 0.012) and fewer early complications (2% vs 11%; P = 0.019). ODS and CCF scores improved in both groups. Patients after RVMR reported a better improvement in digitation, straining and satisfaction after defaecation. There was a statistically significant difference in the postoperative ODS score in favour of RVMR (P = 0.004). Sexually active patients in both groups reported a similar improvement. There was no difference in early recurrence (P = 0.692).

CONCLUSION

Although not a randomized comparison, this study shows that ventral mesh rectopexy performed by the robot was followed by better function then LVMR.

Curative colorectal resections in patients aged 80 years and older: clinical characteristics, morbidity, mortality and risk factors

BACKGROUND

The management of colorectal cancer in the elderly presents unique challenges. The objective of this study was to determine outcomes following curative colorectal resection in patients aged 80 years and older.

PATIENTS AND METHODS

Study design is retrospective. Data were extracted from the university hospital database and medical records of patients aged 80 years and older operated between April 2004 and December 2009. Intervention was curative colorectal resection. Main outcome measures include postoperative morbidity, mortality and individual risk factors associated with them.

RESULTS

Three hundred fifty-eight patients (43.8% males, age = 84 ± 3 years) were included; 72.6% received elective surgery. A significantly higher complication rate and 30 day, 1 year and 4 year mortality were present for emergency operations compared to elective (p < 0.001). One-year survival was 65.0% for elective resections and 55.1% for emergency. At 4 years of follow-up, survival was 49.2% for the elective vs. 27.6% for emergency. The American Society of Anesthesiologists (ASA) score is the only factor associated with the 30-day mortality at the multivariate analysis (p < 0.01), Dukes staging with overall mortality (p < 0.005), sex and mode of the operation with major complications (p < 0.05). A limitation of the study is that is retrospective.

CONCLUSIONS

The highest mortality rates following colorectal surgery in the elderly are in the early postoperative period, especially for emergency operations and patients with significant comorbidities. However, the 1-year survival following elective curative resection for colorectal cancer approaches 65 %. ASA score and modality of the operation (elective vs. emergency) impacted on postoperative mortality and morbidity and could be used to select patients with more favourable outcomes.

Resection rectopexy--laparoscopic neuromapping reveals neurogenic pathways to the lower segment of the rectum: preliminary results

PURPOSE

Nerve sparing in functional pelvic floor surgery is strongly recommended as intraoperative damage to the autonomic nerves may predispose to persistent or worsened anorectal and urogenital function. The aim of this study was to investigate the intraoperative neural topography above the pelvic floor in patients undergoing laparoscopic resection rectopexy in combination with electrophysiologic neuromapping.

METHODS

Ten consecutive female patients underwent laparoscopic resection rectopexy for rectal prolapse. Intraoperative identification of pelvic autonomic nerves was carried out with a novel intraoperative neuromonitoring system based on electric stimulation under simultaneous electromyography of the internal anal sphincter and manometry of the bladder. Neuromonitoring results were compared to patients' preoperative anorectal and urogenital function and their functional results at the 3-month follow-up.

RESULTS

Laparoscopy in combination with electrophysiologic neuromapping revealed neurogenic pathways to the lower segment of the rectum during surgical mobilization. In all procedures, intraoperative neuromonitoring finally confirmed functional nerve integrity to the internal anal sphincter and the bladder. Patients with preoperatively diagnosed fecal incontinence were continent at the 3-month follow-up. The Wexner score improved in median from preoperative 4 (range 1-18) to 1 (range 0-3) at follow-up (p = 0.012). Cleveland Clinical Constipation Score improved in median from 10 (range 5-17) to 3 (range 1-7; p = 0.005). In none of the investigated patients a new onset of urinary dysfunction did occur. No change in sexual function was observed.

CONCLUSIONS

Laparoscopy in combination with electrophysiologic neuromapping during nerve-sparing resection rectopexy identified and preserved neurogenic pathways heading to the lower segment of the rectum above the level of the pelvic floor.

Rectal prolapse

Optimal management of rectal prolapse requires multiple clinical considerations with respect to treatment options, particularly for surgeons who must counsel and give realistic expectations to rectal prolapse patients. Rectal prolapse outcomes are good with respect to recurrence. Although posterior rectopexy remains most popular in the United States, increasingly surgeons perform ventral rectopexy to repair rectal prolapse. Functional outcomes vary and are fair after rectal prolapse repair. Although incarceration with rectal prolapse is rare, it is potentially life threatening and requires immediate and effective measures to adequately address in the acute setting.