Laparoscopic ventral rectopexy in patients with fecal incontinence associated with rectoanal intussusception: prospective evaluation of clinical, physiological and morphological changes

Robotic-assisted rectosigmoid resection rectopexy with natural orifice specimen extraction (NOSE): technical notes, short-term results, and functional outcome

PURPOSE

Rectosigmoid resection rectopexy has been established as an effective therapy for obstructive defecation syndrome. The addition of the NOSE-technique provides an even less invasive approach avoiding minilaparotomy, but can be technically challenging. Application of a robotic platform has been proposed to facilitate the specimen extraction and fashioning of the intracorporeal anastomosis and has been proven to be effective in left-sided colectomies.

METHODS

After establishing laparoscopic rectosigmoid-resection-rectopexy with NOSE, we modified our technique by addition of the robotic platform. Whenever robotic capacity was available, elective patients scheduled for rectosigmoid resection rectopexy for obstructive defecation syndrome were operated robotically assisted. Demographic and intraoperative data were prospectively collected. Follow up was assessed using the Wexner constipation score, Wexner incontinence score, and Altomare ODS score.

RESULTS

The NOSE-RRR technique was completed in all 31 patients. The mean operative time was 166 min (range 67-230). No conversion was required. The median hospital stay was 5 days (range 3-28). Four patients had minor complications (Clavien I). Two patients were reoperated (Clavien IIIb). Functional scores improved significantly postoperatively. Mean Wexner incontinence score was 7.1 preoperatively, 6.9 after 1 month, and decreased significantly to 3.93 after 3 months (p < 0.001). Mean Altomare ODS score was 17.47 preoperatively and 6.93/5.03 after 1/3 months (p < 0.001). Wexner constipation score (12.83) also showed a significant improvement after 1/3 months (6.97/6.67; p < 0.001).

CONCLUSION

NOSE-RRR can be performed safely with a low rate of manageable complications. The technique provides a significant improvement for ODS-Symptoms.

Annual long-term functional outcomes after transanal repair for symptomatic rectocele

Purpose

This study was performed to assess the long-term annual functional outcomes and quality of life (QOL) after transanal rectocele repair.

Methods

We evaluated retrospectively collected data from patients who underwent transanal repair for symptomatic rectocele between February 2012 and December 2018. The Constipation Scoring System (CSS), the Fecal Incontinence Severity Index (FISI), and several QOL questionnaires (e.g., the Patient Assessment of Constipation-QOL [PAC-QOL], Fecal Incontinence QOL, and the 36-Item Short Form Survey [SF-36]) were administered before surgery and annually after surgery. Additionally, physiological assessments and defecography were performed before and after surgery. Substantial symptom improvement, indicated by at least a 50% reduction in the CSS or FISI score, was evaluated postoperatively. All postoperative follow-up results were compared with the preoperative data.

Results

Thirty-two patients were included in the study. The median follow-up period was 5 years (range, 0.5-7 years). Postoperative defecography showed that the rectocele size significantly decreased (P<0.0001). However, the physiological assessment did not reveal postoperative changes. The CSS score 1 year after surgery was significantly lower than the preoperative score (P<0.0001) and remained significantly low until the long-term follow-up. Constipation improved by more than 80% 2 to 5 years postoperatively, and fecal incontinence improved in 2/3 of the patients after 5 years. The PAC-QOL scores significantly improved (all P<0.05) over time until the 3-year and long-term follow-ups, and 6 of the 8 SF-36 scores significantly improved at specific points postoperatively.

Conclusion

Transanal rectocele repair provides long-term improvement for constipation and constipation-specific QOL.

Stepped-wedge randomized controlled trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation

Background

The effectiveness of laparoscopic ventral mesh rectopexy (LVMR) in patients with defecatory disorders secondary to internal rectal prolapse is poorly evidenced. A UK-based multicenter randomized controlled trial was designed to determine the clinical efficacy of LVMR compared to controls at medium-term follow-up.

Methods

The randomized controlled trial was conducted from March 1, 2015 TO January 31, 2019. A stepped-wedge RCT design permitted observer-masked data comparisons between patients awaiting LVMR (controls) with those who had undergone surgery. Adult participants with radiologically confirmed IRP refractory to conservative treatment were randomized to three arms with different delays before surgery. Efficacy outcome data were collected at equally stepped time points (12, 24, 36, 48, 60, and 72 weeks). Clinical efficacy of LVMR compared to controls was defined as ≥ 1.0-point reduction in Patient Assessment of Constipation-Quality of Life and/or Symptoms (PAC-QOL and/or PAC-SYM) scores at 24 weeks. Secondary outcome measures included 14-day diary data, the Generalized Anxiety Disorder scale (GAD-7), the Patient Health Questionnaire-9 (PHQ-9), St Marks incontinence score, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), the chronic constipation Behavioral Response to Illness Questionnaire (CC-BRQ), and the Brief Illness Perception Questionnaire (BIPQ).

Results

Of a calculated sample size of 114, only 28 patients (100% female) were randomized from 6 institutions (due mainly to national pause on mesh-related surgery). Nine were assigned to the T0 arm, 10 to T12, and 9 to T24. There were no substantial differences in baseline characteristics between the three arms. Compared to baseline, significant reduction (improvement) in PAC-QOL and PAC-SYM scores were observed at 24 weeks post-surgery (– 1.09 [95% CI – 1.76, – 0.41], p = 0.0019, and – 0.92 [– 1.52, – 0.32], p = 0.0029, respectively) in the 19 patients available for analysis (9 were excluded for dropout [n = 2] or missing primary outcome [n = 7]). There was a clinically significant long-term reduction in PAC-QOL scores (− 1.38 [− 2.94, 0.19], p = 0.0840 at 72 weeks). Statistically significant improvements in PAC-SYM scores persisted to 72 weeks (− 1.51 [− 2.87, − 0.16], p = 0.0289). Compared to baseline, no differences were found in secondary outcomes, except for significant improvements at 24 and 48 weeks on CC-BRQ avoidance behavior (− 14.3 [95% CI − 23.3, − 5.4], and − 0.92 [− 1.52, − 0.32], respectively), CC-BRQ safety behavior (− 13.7 [95% CI − 20.5, − 7.0], and − 13.0 [− 19.8, − 6.1], respectively), and BIPQ negative perceptions (− 16.3 [95% CI − 23.5, − 9.0], and − 10.5 [− 17.9, − 3.2], respectively).

Conclusions

With the caveat of under-powering due to poor recruitment, the study presents the first randomized trial evidence of short-term benefit of LVMR for internal rectal prolapse.

Trial registration

ISRCTN Registry (ISRCTN11747152).

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-022-02633-w.

Mesh-related complications and recurrence after ventral mesh rectopexy with synthetic versus biologic mesh: a systematic review and meta-analysis

Background

Ventral mesh rectopexy (VMR) is a widely accepted surgical treatment for rectal prolapse. Both synthetic and biologic mesh are used. No consensus exists on the preferred type of mesh material. The aim of this systematic review and meta-analysis was to establish an overview of the current literature on mesh-related complications and recurrence after VMR with synthetic or biologic mesh to aid evidence-based decision making in preferred mesh material.

Methods

A systematic search of the electronic databases of PubMed, Embase and Cochrane was performed (from inception until September 2020). Studies evaluating patients who underwent VMR with synthetic or biologic mesh were eligible. The MINORS score was used for quality assessment.

Results

Thirty-two studies were eligible after qualitative assessment. Eleven studies reported on mesh-related complications including 4001 patients treated with synthetic mesh and 762 treated with biologic mesh. The incidence of mesh-related complications ranged between 0 and 2.4% after synthetic versus 0–0.7% after biologic VMR. Synthetic mesh studies showed a pooled incidence of mesh-related complications of 1.0% (95% CI 0.5–1.7). Data of biologic mesh studies could not be pooled. Twenty-nine studies reported on the risk of recurrence in 2371 synthetic mesh patients and 602 biologic mesh patients. The risk of recurrence varied between 1.1 and 18.8% for synthetic VMR versus 0–15.4% for biologic VMR. Cumulative incidence of recurrence was found to be 6.1% (95% CI 4.3–8.1) and 5.8% (95% CI 2.9–9.6), respectively. The clinical and statistical heterogeneity was high.

Conclusions

No definitive conclusions on preferred mesh type can be made due to the quality of the included studies with high heterogeneity amongst them.

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.

Restored pelvic anatomy is preserved after laparoscopic and robot-assisted ventral rectopexy: MRI-based 5-year follow-up of a randomized controlled trial

AIM

Our aim was to compare the long-term anatomical outcomes between robot-assisted ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR) for external or internal rectal prolapse.

METHOD

This study is a follow-up of a single-centre randomized controlled trial (RCT). Thirty patients were randomly allocated to RVMR (n = 16) or LVMR (n = 14). The primary end-point was maintenance of the restored pelvic anatomy 5 years after the operation, as assessed by magnetic resonance (MR) defaecography. Secondary outcome measures included the Pelvic Organ Prolapse Quantification (POP-Q) measures and functional results assessed using symptom questionnaires.

RESULTS

Twenty-six patients (14 RVMR and 12 LVMR) completed the 5-year follow-up and were included in the study. The MRI results, POP-Q measurements and symptom-specific quality of life measures did not differ between the RVMR and LVMR groups. The MRI measurements of the total study population remained unchanged between 3 months and 5 years. In the Pelvic Floor Distress Inventory (PFDI-20), the RVMR group had lower symptom scores (mean 96.0, SD 70.7) than the LVMR group (mean 160.6, SD 58.9; P = 0.004). In the subscales of pelvic organ prolapse (POPDI-6) (mean 23.2, SD 24.3 vs mean 52.4, SD 22.4; P = 0.001) and the Colorectal-Anal Distress Inventory (CRADI-8) (mean 38.4, SD 23.3 vs mean 58.6, SD 25.4; P = 0.009), the patients in the RVMR group had significantly better outcomes.

CONCLUSION

After VMR, the corrected anatomy was preserved. There were no clinically significant differences in anatomical results between the RVMR and LVMR procedures 5 years after surgery based on MR defaecography. However, functional outcomes were better after RMVR.

Transanal repair of rectocele: prospective assessment of functional outcome and quality of life

AIM

This study aimed to assess the functional outcome of transanal repair of rectocele using patient symptom scores and quality of life (QOL) instruments.

METHOD

Patients who underwent transanal repair for symptomatic rectocele between February 2012 and August 2017 were included. This study was a retrospective analysis of prospectively collected data. A standard questionnaire including the Constipation Scoring System (CSS), the Fecal Incontinence Severity Index (FISI) and QOL instruments [Patient Assessment of Constipation (PAC)-QOL, Fecal Incontinence QOL Scale, Short-Form 36 Health Survey (SF-36)] was administered before and after the operation. Physiological assessment and proctography were performed before and after the operation.

RESULTS

Thirty patients were included. The median follow-up was 36 (6-72) months. Postoperative proctography showed a reduction in rectocele size [34 mm (14-52 mm) vs 10 mm (0-28 mm), P < 0.0001]. Physiological assessment showed no significant postoperative changes. Constipation was improved in 15/21 patients (71%) at 1 year and 14/20 patients (70%) at the mid-term follow-up. The CSS score reduced at 3 months [12 (8-12) vs 6 (1-12), P < 0.0001] and remained significantly reduced over time until the mid-term follow-up. Faecal incontinence was improved in two-thirds patients at 1 year. Four patients developed new-onset faecal incontinence. All the PAC-QOL scale scores significantly improved over time until 1 year, while two of the eight SF-36 scale scores showed significant postoperative improvement.

CONCLUSION

Transanal repair for rectocele improves constipation and constipation-specific QOL.

Absence of a rectocele may be correlated with reduced internal anal sphincter function in patients with rectal intussusception and fecal incontinence

PURPOSE

Fecal incontinence (FI) is common in patients with rectal intussusception (RI), although the mechanism behind its formation is unclear. Recent data indicate that a reduction in internal sphincter tone may cause FI, which becomes notable with increasing RI levels. However, the roles of other anatomical abnormalities in anal function remain unclear. This study assessed the relationships between various pelvic floor abnormalities and anal sphincter function in patients with RI and FI.

METHODS

Data for patients with RI, collected in a prospective pelvic floor database, were assessed retrospectively. All women with FI, without anal sphincter defect, were included. Data on anorectal physiology and evacuation proctography were analyzed.

RESULTS

Of 397 patients with RI, 85, who had predominantly passive FI, met the inclusion criteria. Maximum resting pressure (MRP) was significantly lower in patients with rectoanal intussusception (RAI) than in those with rectorectal intussusception (RRI) [51.1 (17.9-145.8) vs. 70.7 (34.7-240.6) cmH₂O, P = 0.007]. Moreover, MRP was significantly lower in RI patients without rectocele than in RI patients with rectocele [50.1 (17.9-111.0) vs. 69.9 (34.7-240.6) cmH₂O, P < 0.0001]. Regression analysis showed that RAI rather than RRI and RI without rectocele rather than RI with rectocele were predictive of decreased MRP. However, no variable was significantly associated with decreased maximum squeeze pressure on multivariate analysis.

CONCLUSION

In addition to an advanced level of intussusception, the absence of a rectocele may be correlated with reduced internal anal sphincter function in patients with RI and FI.

A prospective pilot study on MRI visibility of iron oxide-impregnated polyvinylidene fluoride mesh after ventral rectopexy

Background

Magnetic resonance imaging (MRI) provides excellent information about pelvic anatomy after ventral rectopexy, but the position of the conventional mesh is not seen constantly. Iron oxide-impregnated polyvinylidene fluoride (PVDF) meshes are proven to have MRI visibility in hernia or vaginal reconstructive surgery. This prospective pilot study was designed to assess the visualization, position, and shape of the magnetic resonance (MR)–visible synthetic pelvic mesh used in minimally invasive ventral rectopexy.

Methods

Eight patients with pelvic organ prolapse were recruited for laparoscopic (LVMR) or robotic-assisted ventral mesh rectopexy (RVMR) with a synthetic MR–visible PVDF mesh. A follow-up visit was scheduled at 3 months after surgery. MR imaging was performed to evaluate the position and dimensions of the mesh and anatomical result. The visibility of the mesh in each sequence was assessed subjectively.

Results

The visibility of the mesh was best on T1-weighted flash images. The mesh was also well visualized on T2-weighted sagittal images. T2-weighted images, in general, provided best visualization of the surrounding anatomical structures and enabled assessment of the mesh fixation.

Conclusions

T2 sagittal and T1-weighted flash images provide the best information about the position and integrity of the iron oxide-impregnated PVDF mesh after LVMR or RVMR with a short examination time.