Rectal prolapse surgery in males and females: An ACS NSQIP-based comparative analysis of over 12,000 patients

Rectal Prolapse Surgery: Balancing Effectiveness and Safety in Abdominal and Perineal Approaches

The event in which the entire thickness of the rectum protrudes through the anal canal is called rectal prolapse. This ailment is common in the elderly population and especially in females. It causes some disastrous symptoms, including incontinence to feces and flatus, constipation, and discomfort, because of the weakness in the anorectal junction, making it mandatory for surgical correction. Over time, several surgical techniques have been developed; these are broadly classified into two categories: abdominal and perineal techniques. However, the best approach for surgery that minimizes recurrence while maximizing patient quality of life is still up for debate. A comprehensive review was conducted adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines; a systematic search of the PubMed Database was performed to identify studies published between 2000 and 2024 with the keywords ((Rectal Prolapse) AND ("Perineal" OR "Laparotomy")). The inclusion criteria were focused on studies comparing the outcomes between surgical approaches at the abdominal and perineal locations, particularly on the recurrence rate, postoperative complications, and functional outcomes. In total, 21 studies were included in the review: these ranged from retrospective analysis and prospective studies to a multicentric randomized trial. In this review, abdominal approaches, particularly in the form of laparoscopic rectopexy, consistently demonstrated improved results compared to perineal techniques, with a much lower recurrence rate. The rates of mortality and morbidity were also remarkably lower in laparoscopic operations, which were advocated for suitable patients. However, perineal approaches, while still producing higher rates of recurrence, are a valuable alternative for elderly and high-risk patients due to their being relatively less invasive. Laparoscopic rectopexy can be considered a better surgical method for rectal prolapse, as it has a lower recurrence rate and better functional outcomes. In contrast, perineal approaches will have their place in the management of rectal prolapse, given patient selection for patients at high risk with regard to surgery. Future research should be directed toward multicenter trials with long-term outcomes in order further to fine-tune surgery strategy and criteria for patient selection.

Altemeier procedure for strangulated rectal prolapse: A case report

INTRODUCTION AND IMPORTANCE

Strangled rectal prolapse (RP), also known as incarcerated rectal prolapse, is a condition where the RP cannot be manually reduced.

CASE PRESENTATION

This case report describes a 48-year-old man presenting with a painful and irreducible rectal prolapse. Following failed attempts at manual reduction and the development of necrosis, emergency surgery was performed using the Altemeier procedure. This surgical technique involves resection of the rectum and colon, followed by colo-anal anastomosis and a protective ileostomy.

CLINICAL DISCUSSION

The discussion highlights the rarity of RP in young adults and the associated risk factors. It emphasizes the importance of timely intervention in irreducible cases to prevent complications such as strangulation, ulceration, infection, and pain. Various surgical options exist, but in cases of strangulation requiring emergency surgery, the Altemeier procedure is the preferred approach due to its effectiveness and low morbidity. The decision to perform laparoscopic surgery depends on patient factors and surgeon expertise.

CONCLUSION

This case illustrates the successful management of a challenging and uncommon presentation of rectal prolapse, highlighting the value of surgical intervention in cases of strangulation.

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.

OUP accepted manuscript

Background

External rectal prolapse is a relatively rare disease, in which male patients account for a minority. The selection of abdominal repair or perineal repair for male patients has rarely been investigated.

Methods

Fifty-one male patients receiving abdominal repair (laparoscopic ventral rectopexy) or perineal repair (Delorme or Altemeier procedures) at the Sixth Affiliated Hospital of Sun Yat-sen University (Guangzhou, China) between March 2013 and September 2019 were retrospectively analysed. We compared the recurrence, complication rate, post-operative defecation disorder, length of stay, and quality of life between the abdominal and perineal groups.

Results

Of the 51 patients, 45 had a complete follow-up, with a median of 48.5 months (range, 22.8–101.8 months). A total of 35 patients were under age 40 years. The complication rate associated with abdominal repair was less than that associated with perineal repair (0% vs 20.7%, P = 0.031) and the recurrence rate was also lower (9.5% vs 41.7%, P = 0.018). Multivariate analysis showed that perineal repair (odds ratio, 9.827; 95% confidence interval, 1.296–74.50; P = 0.027) might be a risk factor for recurrence. Moreover, only perineal repair significantly improved post-operative constipation status (preoperative vs post-operative, 72.4% vs 25.0%, P = 0.001). There was no reported mortality in either of the groups. No patient's sexual function was affected by the surgery.

Conclusions

Both surgical approaches were safe in men. Compared with perineal repair, the complication rate and recurrence rate for abdominal repair were lower. However, perineal repair was better able to correct constipation.

A comparative study on the surgical options for male rectal prolapse

Purpose:

Rectal prolapse is known to be a rare condition in males compared to females. This study aimed to analyse the frequency of male rectal prolapse and compare the results of different surgical approaches performed at a single centre.

Patients and Methods:

The authors included patients who underwent surgical treatment for rectal prolapse from March 2016 to February 2021. The proportion of males, mean age and recurrence rates were calculated. Patients were divided into two groups, transanal approach and laparoscopic abdominal approach group, to identify the para-operative parameters including functional tests.

Results:

A total of 56 males, comprising 23.7% (56/236) of all patients. The mean age was 60.8 years, with a recurrence rate of 7 cases (12.5%) during 7.2 months of follow-up. Forty patients underwent transanal procedures, and fifteen underwent laparoscopic abdominal procedures. The mean operative time was longer in the laparoscopic group (transanal vs. abdominal, 57.5 vs. 70.6 min, P < 0.003), and intra-operative bleeding was greater in the transanal group (12.4 vs. 3.4 ml, P < 0.001). Full-layer prolapse (36.8 vs. 81.2% P = 0.003) and longer length (5.6 vs. 7.8 cm, P = 0.048) were more common in laparoscopic group. Time to feeding resumption was shorter after the transanal group (1.2 vs. 1.7 days, P = 0.028). There was no difference between the groups in terms of post-operative complications and recurrence rates. Both Wexner's constipation and incontinence scores showed significant improvement postoperatively.

Conclusion:

The frequency of male rectal prolapse was 23.7%, and perioperative factors differed between transanal and abdominal approaches, but recurrence rates and functional test results did not differ significantly.

Preliminary Report From the Pelvic Floor Disorders Consortium: Large-Scale Data Collection Through Quality Improvement Initiatives to Provide Data on Functional Outcomes After Rectal Prolapse Repair

BACKGROUND

The surgical management of rectal prolapse is constantly evolving, yet numerous clinical trials and meta-analyses studying operative approaches have failed to make meaningful conclusions.

OBJECTIVE

The purpose of this study was to report on preliminary data captured during a large-scale quality improvement initiative to measure and improve function in patients undergoing rectal prolapse repair.

DESIGN

This was a retrospective analysis of prospectively collected surgical quality improvement data.

SETTINGS

This study was conducted at 14 tertiary centers specializing in pelvic floor disorders from 2017 to 2019.

PATIENTS

A total of 181 consecutive patients undergoing external rectal prolapse repair were included.

MAIN OUTCOME MEASURES

Preoperative and 3-month postoperative Wexner incontinence score and Altomare obstructed defecation score were measured.

RESULTS

The cohort included 112 patients undergoing abdominal surgery (71 suture rectopexy/56% minimally invasive, 41 ventral rectopexy/93% minimally invasive). Those offered perineal approaches (n = 68) were older (median age, 75 vs 62 y; p < 0.01) and had more comorbidities (ASA 3-4: 51% vs 24%; p < 0.01) but also reported higher preintervention rates of fecal incontinence (Wexner 11.4 ± 6.4 vs 8.6 ± 5.8; p < 0.01). Patients undergoing perineal procedures had similar incremental improvements in function after surgery as patients undergoing abdominal repair (change in Wexner, -2.6 ± 6.4 vs -3.1 ± 5.6, p = 0.6; change in Altomare, -2.9 ± 4.6 vs -2.7 ± 4.9, p = 0.8). Similarly, patients undergoing posterior suture rectopexy and ventral mesh rectopexy had similar incremental improvements in overall scores; however, patients undergoing ventral mesh rectopexy had a higher decrease in the need to use pads after surgery.

LIMITATIONS

The study was limited by its retrospective data analysis and 3-month follow-up.

CONCLUSIONS

Functional outcomes improved in all of the patients undergoing prolapse surgery. Larger cohorts are necessary to show superiority among surgical procedures. Quality improvement methods may allow for systematic yet practical acquisition of information and data analysis. We call for the creation of a robust database to benefit this patient population. See Video Abstract at http://links.lww.com/DCR/B581.

REPORTE PRELIMINAR DEL CONSORCIO DE TRASTORNOS DEL PISO PLVICO RECOLECCIN DE DATOS A GRAN ESCALA MEDIANTE INICIATIVAS DE MEJORAMIENTO DE LA CALIDAD PARA PROPORCIONAR INFORMACIN SOBRE LOS RESULTADOS FUNCIONALES

ANTECEDENTES:El tratamiento quirúrgico del prolapso rectal está evolucionando constantemente, sin embargo, numerosos estudios clínicos y metaanálisis que evalúan los tratamientos quirúrgicos no han logrado demostrar conclusiones significativas.OBJETIVO:Reportar datos preliminares obtenidos a gran escala durante una iniciativa de mejoramiento de la calidad para medir y mejorar la función en pacientes sometidos a reparación de prolapso rectal.DISEÑO:Análisis retrospectivo de datos recolectados prospectivamente de mejoramiento de la calidad quirúrgica.ENTORNO CLINICO:Este estudio se realizó en 14 centros terciarios especializados en trastornos del piso pélvico del 2017 al 2019.PACIENTES:Un total de 181 pacientes consecutivos sometidos a reparación de prolapso rectal externo.PRINCIPALES MEDIDAS DE VALORACION:Escala de incontinencia de Wexner y de defecación obstruida de Altomare preoperatoria y tres meses postoperatoria.RESULTADOS:El cohorte incluyó 112 pacientes sometidos a cirugía abdominal (71 rectopexia con sutura / 56% minimally invasive, 41 rectopexia ventral / 93% minimally invasive). Aquellos a los que se les realizaron abordajes perineales (n = 68) eran mayores (edad media de 75 vs. 62, p <0,01) y tenían mayorcomorbilidades (ASA 3-4: 51% vs. 24%, p <0,01), además reportaron una mayor tasa de incontinencia fecal previo a la intervención (Wexner 11,4 ± 6,4 vs. 8,6 +/- 5,8, p <0,01). Posterior a la cirugía, los pacientes sometidos a procedimientos perineales tuvieron mejoría progresiva en la función similar que los pacientes sometidos a reparación abdominal (cambio en Wexner -2,6 ± 6,4 vs. -3,1 ± 5,6, p = 0,6; cambio en Altomare -2,9 ± 4,6 vs. -2,7 ± 4,9, p = 0,8). De manera similar, los pacientes con rectopexia posterior con sutura y rectopexia ventral con malla tuvieron mejoría progresiva similares en las escalas generales; no obstante, pacientes con rectopexia ventral con malla tuvieron una mayor disminución en la necesidad de usar paños protectores después de la cirugía.LIMITACIONES:Análisis de datos retrospectivo y seguimiento de tres meses.CONCLUSIONES:Los resultados funcionales mejoraron en todos los pacientes sometidos a cirugía de prolapso. Se necesitan cohortes más grandes para demostrar superioridad entre los procedimientos quirúrgicos. Métodos de mejoramiento de la calidad pueden permitir la adquisición sistemática, pero práctica de información y análisis de datos. Hacemos un llamado para la creación de una base de datos sólida para beneficiar a esta población de pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B581. (Traducción- Dr Francisco M. Abarca-Rendon).

Strangled rectal prolapse in young adults: A case report

Background

Rectal prolapse (RP) is an uncommon perineal disease. It is defined as a complete protrusion or intussusception of the rectum through the anus. Strangulation of the RP is rare. This complication presents requires an emergent surgery. This case presentation aims to report the therapeutic management and results of this condition.

Observation

A 29-year-old men, who consulted for a sudden, painful, irreducible rectal prolapse. At the anus, there was an irreducible, edematous, without signs of ischemia or necrosis rectal prolapse measuring 25*10 cm wide. The laboratory data showed a high white blood cell count and elevated C-reactive protein. After a failure of external manual reduction under general anesthesia, the patient underwent emergent surgery. The procedure consisted of a rectosigmoidectomy with coloanal anastomosis using a perineal approach according to the Altemeier technique associated to a diverting ileostomy. The postoperative follow-up was uneventful. The patient was discharged at post-operative day five.

Conclusion

Strangulated RP is a rare complication. Altemeier procedure remains the intervention of choice in this situation.

•

An uncommon perineal disease.

•

Therapeutic surgical management and issues.

•

Socio-psychological impact of this disease.