A Multicenter Collaboration to Assess the Safety of Laparoscopic Ventral Rectopexy

Early safety and efficiency outcomes of a novel interdisciplinary laparoscopic resection rectopexy combined with sacrocolpopexy for women with obstructive defecation syndrome and pelvic organ prolapse: a single center study

BACKGROUND

Obstructive defecation syndrome (ODS) defines a disturbed defecation process frequently associated with pelvic organ prolapse (POP) in women that substantially compromises quality of life. Conservative management offers limited relief and a surgical intervention may be required. This is characterized by individual approaches. AIM OF THE STUDY: This retrospective single center study evaluated the surgical and clinical short-term outcome of a novel interdisciplinary laparoscopic resection rectopexy (L-RRP) with mesh- sacrocolpopexy (L-SCP) for women suffering from ODS and POP.

METHODS

The study participants underwent surgery in an interdisciplinary laparoscopic approach. Safety was the primary endpoint, assessed via postoperative morbidity classified by Clavien-Dindo scale. Secondary outcomes included evaluation of bowel function, fecal and urinary incontinence and pelvic organ prolapse status at 12 months follow-up. Additionally, a biological mesh (BM) was offered to women, who asked for an alternative to synthetic mesh material (SM).

RESULTS

Of the 44 consecutive patients requiring surgery for ODS and POP, 36 patients underwent the interdisciplinary surgical approach; 28 patients with SM and 8 patients with BM. In total 5 complications occurred, four of them were classified as minor. One minor complication was observed in the BM group. One anastomotic leakage occurred in the SM group. The two ODS scores, the bowel dysfunction score, and the incontinence score improved significantly (p = 0.006, p = 0.003, p < 0.001, and p = 0.0035, respectively). Pelvic floor anatomy was fully restored (POP-Q 0) for 29 (80%) patients after surgery. 17 patients (47%) suffered from urinary incontinence before surgery, which was restored in 13 patients (76.5%).

CONCLUSIONS

The interdisciplinary approach with L-RRP and L-SCP and the use of a BM in a small subgroup were technically feasible, safe, and effective in this single center setting. The study's retrospective design, the small sample size and the lack of comparators limit the generalizability of the findings requiring future randomized trials.

TRIAL REGISTRATION

Retrospectively registered at clinicaltrials.gov, trial number NCT05910021, date of registration 06/10/2023.

Laparoscopic resection rectopexy (RRP) combined with mesh sacrocolpopexy (SCP) for obstructed defecation syndrome with pelvic organ prolapse in an interdisciplinary approach

Background

Obstructive defecation syndrome (ODS) is frequently associated with pelvic organ prolapse (POP) and compromises the quality of life in affected patients. In cases conservative treatment fails surgical therapy is required.

Objectives

The video case study combines a laparoscopic resection rectopexy (RRP) with a mesh sacrocolpopexy (SCP) in an interdisciplinary surgical approach.

Materials and Methods

In this video an 86-year-old woman with ODS and POP, suffering from a dolichocolon with rectal intussusception, an apical prolapse after total hysterectomy 1990, and occasional stress urinary incontinence underwent interdisciplinary laparoscopic surgery. A tubular anterior rectal and sigmoid resection with suture rectopexy as in a resection rectopexy (RRP) was combined with a sacrocolpopexy (SCP) using a synthetic mesh.

Main outcome measures

Surgical outcome including postoperative morbidity, functional bowel evacuation, and POP reconstitution as in POP-Q score after surgery were documented.

Results

No intra- or postoperative complications occurred. At 6 months follow-up clinical outcomes for ODS, bowel dysfunction, and faecal control were improved. Anatomical outcome for POP and stress urinary incontinence symptoms were corrected.

Conclusions

We report a promising interdisciplinary surgical approach as a single treatment option for the complex medical condition of women suffering from ODS and POP combining laparoscopic RRP with SCP. This surgical approach proved to be feasible, safe, and effective.

Could robotic-assisted surgery reduce mesh-related complications after ventral mesh rectopexy? Experience of a tertiary centre and systematic review of the literature

AIM

The development of robotic assistance has made dissection and suturing in the deep pelvis much easier. The augmented quality of the images and the articulation of the robotic arms have also enabled a more precise dissection. The aim of this study is to present the data on robotic-assisted ventral mesh rectopexy procedures in a university hospital and examine the literature in terms of mesh erosion.

METHOD

The electronic databases Pubmed, Embase and Cochrane were searched. Studies from January 2004 until January 2023 in the English language were included. Studies which included fewer than 10 patients were excluded. Laparoscopic or robotic-assisted ventral mesh rectopexies were included. Mesh erosion rates following laparoscopic or robotic-assisted ventral mesh rectopexies were measured.

RESULTS

Overall, the systematic review presents 5911 patients from 43 studies who underwent laparoscopic ventral mesh rectopexy compared with 746 patients treated with robotic-assisted ventral mesh rectopexy from six studies and our centre. Mesh erosion was rare in both groups; however, the prevalence was greater in the laparoscopy group (0.90% vs. 0.27%).

CONCLUSION

The mesh erosion rates are very low with robotic-assisted ventral mesh rectopexy. For precise results, more studies and experience in robotic surgery are required.

Laparoscopic modified mesh rectopexy: medium-term results of a novel approach for external rectal prolapse

AIM

Rectal prolapse is a common and significantly debilitating condition. Surgical correction is usually required. The two most common abdominal approaches are ventral mesh rectopexy and posterior suture rectopexy. Both may be complicated, respectively, by either mesh-related complications or significant postoperative constipation. We report the outcome of a novel rectopexy operation which combines aspects of both the aforementioned approaches, for the treatment of external rectal prolapse (ERP).

METHOD

The technique involves laparoscopic partial posterior-lateral rectal mobilization of the rectum with posterior suture fixation to the sacral promontory and placement of an absorbable mesh in the rectovaginal space. Data were collected on postoperative complications, prolapse recurrence, mesh-related complications and the assessment of quality of life.

RESULTS

Eighty patients underwent a modified mesh rectopexy for ERP. Seventy-seven were women. The median age was 67.5 years. Almost a third had undergone a previous rectal prolapse repair. Recurrences were seen in 11 (13.8%). No mesh-related complications were seen. Eleven patients reported postoperative constipation.

CONCLUSION

The laparoscopic modified mesh rectopexy may be a safe and effective operation for the treatment of ERP.

The international variability of surgery for rectal prolapse

Objective

There is a lack of consensus regarding the optimal approach for patients with full-thickness rectal prolapse. The aim of this international survey was to assess the patterns in treatment of rectal prolapse.

Design

A 23-question survey was distributed to the Pelvic Floor Consortium of the American Society of Colorectal Surgeons, the Colorectal Surgical Society of Australia and New Zealand, and the Pelvic Floor Society. Questions pertained to surgeon and practice demographics, preoperative evaluation, procedural preferences, and educational needs.

Setting

Electronic survey distributed to colorectal surgeons of diverse practice settings.

Participants

249 colorectal surgeons responded to the survey, 65% of which were male. There was wide variability in age, years in practice, and practice setting.

Main outcome measures

Responses to questions regarding preoperative workup preferences and clinical scenarios.

Results

In preoperative evaluation, 19% would perform anorectal physiology testing and 70% would evaluate for concomitant pelvic organ prolapse. In a healthy patient, 90% would perform a minimally invasive abdominal approach, including ventral rectopexy (56%), suture rectopexy (31%), mesh rectopexy (6%) and resection rectopexy (5%). In terms of ventral rectopexy, surgeons in the Americas preferred a synthetic mesh (61.9% vs 38.1%, p=0.59) whereas surgeons from Australasia preferred biologic grafts (75% vs 25%, p<0.01). In an older patient with comorbidities 81% would perform a perineal approach. Procedure preference (Delormes vs Altmeier) varied according to location (Australasia, 85.9% vs 14.1%; Europe, 75.3% vs 24.7%; Americas, 14.1% vs 85.9%). Most participants were interested in education regarding surgical approaches, however there is wide variability in preferred methods.

Conclusion

There is significant variability in the preoperative evaluation and surgery performed for rectal prolapse. Given the lack of consensus, it is not surprising that most surgeons desire further education on the topic.

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.

Complications of Mesh Sacrocolpopexy and Rectopexy: Imaging Review

Sacrocolpopexy and rectopexy are commonly used surgical options for treatment of patients with pelvic organ and rectal prolapse, respectively. These procedures involve surgical fixation of the vaginal vault or the rectum to the sacral promontory with mesh material and can be performed independently of each other or in a combined fashion and by using an open abdominal approach or laparoscopy with or without robotic assistance. Radiologists can be particularly helpful in cases where patients' surgical histories are unclear by identifying normal sacrocolpopexy or rectopexy mesh material and any associated complications. Acute complications such as bleeding or urinary tract injury or stricture are generally evaluated with CT. More chronic complications such as mesh extrusion or exposure with or without fistulization to surrounding structures are generally evaluated with MRI. Other complications can have a variable time of onset after surgery. Patients with suspected bowel obstruction are generally evaluated with CT. Those with suspected infection, abscess formation, and discitis or osteomyelitis may be evaluated with MRI, although CT evaluation may be appropriate in certain scenarios. The authors review the sacrocolpopexy and rectopexy surgical techniques, discuss appropriate imaging protocols for evaluation of patients with suspected complications, and illustrate the normal appearance and common complications of these procedures. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Pelvic pain is a common prolapse symptom and improvement after ventral mesh rectopexy is more frequent than deterioration or de novo pain

AIM

The aim of this work was to assess the relationship between pelvic pain and rectal prolapse both before prolapse surgery and in the long term after ventral mesh rectopexy (VMR).

METHOD

Patients undergoing VMR between 2004 and 2017 were contacted. Outcomes including the severity of pelvic pain were recorded using a numeric rating scale.

RESULTS

Four hundred and seventy eight of the 749 patients (64%) were successfully contacted. Of these, 39% reported pre-existing pelvic pain prior to VMR (group A) and 61% were pain free (group B). The median follow-up time was 8.0 years (interquartile range 5.0-10.0 years). Symptoms of obstructed defaecation were significantly more common (p = 0.002) in group A (91/187, 49%) than in group B (101/291, 35%). In contrast, faecal incontinence was more common (p = 0.007) in group B (75/291, 26%) than in group A (29/187, 15%). In group A, 76% showed improvement in pelvic pain after VMR: 61% were pain free and 39% had partial improvement in their pre-existing pelvic pain. Patients with persistent pelvic pain were younger (p = 0.01) and more likely to have revisional surgery after VMR (p = 0.0003), but there was no relation to the indication for surgery (p = 0.59). In group B, 15% reported de novo pelvic pain after VMR, and this was more common in women under 50 years old (p = 0.001), when obstructed defaecation was the indication (p = 0.03), in mesh erosion (p = <0.05) and when associated with revisional surgery (p = 0.005).

CONCLUSION

Pelvic pain is common (39%) in patients undergoing prolapse surgery, and VMR improves this pain in most patients (76%). However, a significant number of patients fail to improve (12%), experience worsening of pain (12%) or develop de novo pelvic pain (15%).

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.

Comparison of four surgical approaches for rectal prolapse: multicentre randomized clinical trial

BACKGROUND

Several different procedures have been described for surgical treatment of rectal prolapse and consensus on the optimal approach has not been reached. The Swedish Rectal Prolapse Trial was performed with the aim to compare the outcomes after the most common surgical approaches to rectal prolapse.

METHOD

A multicentre randomized trial was conducted from 2000 to 2009. Patients were randomized between a perineal or an abdominal approach for correction of rectal prolapse (randomization A) if eligible for any procedures. Patients considered unsuitable for random allocation were only included in randomizations B or C. Patients in randomization B (perineal group) were randomized to Delorme's or Altemeier's procedures and those in randomization C (abdominal group) to suture rectopexy or resection rectopexy. Primary outcomes were bowel function and quality of life, measured using Wexner incontinence score and RAND-36, and secondary outcomes were complications and recurrence at 3 years.

RESULTS

During the study period, 134 patients were randomized: 18 in randomization A group, 80 in randomization B group and 54 in randomization C group; of these, 122 patients underwent surgery. Mean follow-up was 2.6 years. Improvements in Wexner and RAND-36 scores were seen but with no significant difference between the groups. Health change scores were significantly improved from baseline up to 1 year after surgery (P < 0.001). At 3 years, recurrence rates were two of seven patients for abdominal versus five of eight patients for perineal approach (P = 0.315), 18 of 31 patients (58 per cent) for Delorme's versus 15 of 30 patients (50 per cent) for Altemeier's (P = 0.611) and four of 19 patients (21 per cent) for suture rectopexy versus two of 21 patients (10 per cent) for resection rectopexy (P = 0.398). There were no significant differences regarding postoperative complications.

CONCLUSION

For all procedures, significant improvements from baseline in health change scores were noted after surgery. Recurrence rates were higher than previously reported. Registration number: NCT04893642 (http://www.clinicaltrials.gov).

Trends in the surgical management of rectal prolapse: An Asian experience

BACKGROUND

Posterior compartment pelvic floor prolapse (PCPFP) leads to anatomical distortion and functional impairment. Definitive management involves surgery. Ventral mesh rectopexy (VMR) has gained increasing popularity in the West as it emerges as a durable approach. Existing literature and evidence on safety and efficacy of PCPFP surgery in the Asian population remains sparse. Our study aims to review our institution's experience in surgery for PCPFP.

METHODS

All cases of PCPFP surgery in Singapore General Hospital between 2014 to 2019 were studied.

RESULTS

Eighty-three patients had surgery performed for PCPFP, with the majority (83%) in the last 3 years. Median age was 63 years and 92% were female. Most patients (64%) had obstructive defecation symptoms, while the remaining had fecal incontinence, rectal bleeding, or anal discomfort. Main anatomical indication for surgery was external rectal prolapse (48%). Other indications were rectocele and/or rectal intussusception. The majority (66%) had abdominal rectopexy, while 28 underwent Delorme's procedure. Forty-five of the 50 VMRs were minimally invasive. Patients undergoing rectopexy were observed to be younger. Median length of stay was 3 days. Nine patients had early operative complications of which ileus was most common. Median length of follow-up was 12 months. The majority (93%) had initial symptom satisfaction. Eleven patients had anatomical recurrence with a median length of 9 months to development. There was no significant difference in outcomes between abdominal vs perineal approach, or laparoscopic vs robotic VMR.

CONCLUSION

Surgery for PCPFP has gained acceptance in our Asian institution with good symptom improvement, alongside low morbidity and recurrence.

Ninety-day morbidity of robot-assisted redo surgery for recurrent rectal prolapse, mesh erosion and pelvic pain: lessons learned from 9 years' experience in a tertiary referral centre

AIM

With increasing follow-up of patients treated with minimally invasive ventral mesh rectopexy (VMR) more redo surgery can be expected for recurrent rectal prolapse, mesh erosion and pelvic pain. The aim of this study is to evaluate the 90-day morbidity of robot-assisted redo interventions.

METHOD

All robot-assisted redo interventions after primary transabdominal repair of rectal prolapse between 2011 and 2019 were retrospectively analysed and compared with the results for patients after primary robot-assisted VMR during the same period. The redo interventions were divided into groups based on the indication for surgery (recurrent prolapse, mesh erosion, pelvic pain). Intraoperative complications and 90-day postoperative morbidity were evaluated.

RESULTS

Three hundred and fifty nine patients were treated with primary VMR, with 73 for recurrent rectal prolapse, 12 for mesh erosion and 14 for pelvic pain. Complications of recurrent prolapse surgeries were comparable to those of primary VMR (p > 0.05). More intraoperative complications, minor and major complications were seen in redo surgery for erosion compared with primary VMR (23% vs. 3%, p = 0.01; 31% vs. 11%, p = 0.055; and 38% vs. 1%, p < 0.01 respectively). The frequency of intraoperative complications after redo surgery for pelvic pain was 7% with minor and major morbidity rates of 14% and 7% (p > 0.05). Half of the patients with pelvic pain experienced relief of their symptoms.

CONCLUSION

Redo surgery for management of recurrent rectal prolapse is safe. Redo surgery for mesh erosion is associated with high morbidity rates. Redo surgery for pelvic pain can have major complications and is only effective in half of the cases.

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.

Update on Robotic Rectal Prolapse Treatment

Rectal prolapse is a condition that can cause significant social impairment and negatively affects quality of life. Surgery is the mainstay of treatment, with the aim of restoring the anatomy and correcting the associated functional disorders. During recent decades, laparoscopic abdominal procedures have emerged as effective tools for the treatment of rectal prolapse, with the advantages of faster recovery, lower morbidity, and shorter length of stay. Robotic surgery represents the latest evolution in the field of minimally invasive surgery, with the benefits of enhanced dexterity in deep narrow fields such as the pelvis, and may potentially overcome the technical limitations of conventional laparoscopy. Robotic surgery for the treatment of rectal prolapse is feasible and safe. It could reduce complication rates and length of hospital stay, as well as shorten the learning curve, when compared to conventional laparoscopy. Further prospectively maintained or randomized data are still required on long-term functional outcomes and recurrence rates.

Anatomo-functional outcomes of the laparoscopic Frykman-Goldberg procedure for rectal prolapse in a tertiary referral centre

Rectal prolapse is a common disorder that represents a burden for patients due to the associated symptoms that may include both incontinence and constipation. Currently, a huge variation in techniques exist. The aim of this study was to evaluate the anatomo-functional results of the laparoscopic Frykman-Goldberg procedure (LFGP) for the treatment of both internal (IRP) and complete rectal prolapse (CRP). Between July 2004 and October 2019, 45 patients with IRP and CRP underwent a LFGP. The Cleveland Clinic Constipation Score (CCCS), Obstructed Defecation Syndrome Score (ODSS) and Vaizey Score (VS) were assessed preoperatively, 3 months before the procedure, 12 months after the procedures and at the final follow-up visit. The patients' mean age was 51.4 ± 17.9 (15-93) years, and the mean follow-up was 9.24 ± 4.57 (1.6-16.3) years. The VS, CCCS and ODSS significantly improved (p = 0.008; p < 0.001; p < 0.001) from median preoperative values of 3, 20 and 18 to 2, 6 and 5, respectively. Furthermore, the improvements in scores during follow-up remained constant and significant over time when considering the two groups separately (time effect for ODSS p < 0.001, for VS p = 0.026, for CCCS p < 0.001) and when the patients were divided by age (< 40, 41-60 and > 60; p < 0.001). The overall complication rate was 8.9% (4/45), and no intraoperative complications or anastomotic leakage occurred. Conversion to the open approach was not necessary in any case. The overall success rate was 97.7%, and only one recurrence in the IRP group occurred after 14 months. LRGP can be considered a safe, effective and long-lasting procedure in young patients with IRP or CRP, a history of ODS and a redundant sigmoid colon.

SURGICAL TREATMENT OF IATROGENIC COMPLEX RECURRENT EXTRASPHINCTER ANORECTAL FISTULA: A CLINICAL CASE

Background: Anorectal fistula is a benign disease with an average prevalence of 1.69/10,000 population. The disease significantly reduces the life quality and has a tendency to relapse. Repeated surgical treatment can lead to anal sphincter impairment. Paraproctitis is the main anorectal fistulas cause. However, there are also iatrogenic traumatic fistulas that occur after various anorectal surgical interventions.Clinical case: A 44-year old female patient applied to the MSU University clinic in March 2020 with perineal wound with permanent purulent discharge. During examination perianal soft tissue defect was determined, the external fistula opening (40x25x25cm) was visualized at the wound bottom, the internal fistula opening (2x3mm) was visualized at 12h of the clock dial. The perianal area is deformed due to scarring. In 2016 the patient underwent surgical «rectocele elimination, posterior colporaphy, levatoroplasty, plastic surgery of the anterior rectal wall». Obstructive defecation syndrome developed during postoperative period, and repeated surgical treatment was performed – anterior anosfincterolevatoroplasty, Milligan-Morgan hemorrhoidectomy.On the 9th day, there was a «perianal soft tissue rupture» with bleeding and «local anterior rectal wall damage in the suprasphincter zone». Then «the rectal defect suturing» was performed. The perineal wound was left open. The patient was reoperated in 3 months due to a rectovaginal fistula with no effect. A fistulectomy was performed at the Moscow State University Medical Center with the removal of the anal canal defect by mucosal-submucosal flap. The surgical wound heals by secondary tension.Conclusion: The current studies describe a small number of cases of anorectal fistulas secondary to anorectal surgery. At the same time, there is no data on the further surgical management of such patients. It is important to present the iatrogenic anorectal fistulas cases, not only to analyze the fistula cause, but also to describe the surgical treatment method and its efficacy.

Sciatic hernia: repair after recurrence

Sciatic hernia is a rare pelvic floor hernia. A variety of treatment modalities were proposed, but a guideline is lacking although a mesh-based tension-free repair may be preferred. A 67-year-old woman with an uncomplicated sciatic hernia received primarily closing of the hernia orifice that was covered with a preperitoneal mesh in March 2019. Six months later, she developed a clinical and radiographical recurrence requiring remedial surgery. Due to the previous mesh fixation, the preperitoneal plane was obliterated. Therefore, the pouch of Douglas was closed, leaving the hernia sac in place, by folding two opposing peritoneal layers and covering it with a Ventralight ST mesh. After 9 months, the hernia had not recurred and the patient was symptom-free. It is concluded that recurrent sciatic hernia may be treated by obliterating the Douglas pouch and subsequent mesh coverage.

Laparoscopic Ventral Mesh Rectopexy (LVMR) for Internal and External Rectal Prolapse: An Analysis of 122 Consecutive Patients

BACKGROUND

Even though several reports have been published on the results of laparoscopic ventral mesh rectopexy (LVMR) in Asia, there are few mid-term or long-term results of LVMR. The authors aimed to evaluate the results of LVMR in patients with internal rectal prolapse (IRP) external rectal prolapse (ERP).

MATERIALS AND METHODS

From September 2013 to January 2019, 122 patients with IRP (n=48) or ERP (n=74) underwent LVMR. Constipation and fecal incontinence (FI) scores were evaluated using the Cleveland Clinic Florida score preoperatively and postoperatively. The questionnaire for the change of obstructed defecation or FI symptoms after surgery was also administered to grade the results as cured, improved, unchanged, or worsened for each survey.

RESULTS

The mean age of the patients was 61.9 years. The mean operation time was 116.5 minutes, and the mean hospital stay was 5.1 days. The mean follow-up was 42.1 months. There were no mesh-related complications. Eight patients (10.7%) among the ERP group required additional surgery for recurrent full-thickness prolapse. Eleven patients (14.7%) who had mucosal prolapse within 2 cm underwent stapled hemorrhoidopexy after LVMR. In the postoperative 6-month period, the overall constipation score (7.12) significantly improved compared with the preoperative score (13.03) (P<0.001), whereas the FI score significantly improved after surgery (12.16 to 8.92; P<0.001).

CONCLUSION

LVMR is a feasible and safe technique and favorable recurrence for ERP. Functional outcomes of obstructed defecation and FI were improved and the satisfaction of LVMR was high after the surgery. LVMR can be considered a recommended surgical option to treat ERP and IRP.

Thulium laser to endoscopically manage a rectal erosion and intraluminal mesh migration after ventral rectopexy

Rectal erosions after ventral rectopexy (VR) is an uncommon but challenging adverse event and can be associated with partial migration of the mesh into the intestinal cavity. Re-do surgery is difficult and often provides colostomy and/or anterior rectal resections. However, no alternative solutions are described in the available literature. An 82-year-old woman presented to our hospital for rectal erosion and intraluminal migration of the mesh placed at a 1-year laparoscopic VR. We performed an innovative totally endoscopic approach, using thulium laser and two endoscopes, that led to a successful removal of the mesh. The described mini-invasive technique can be an effective alternative to surgery in tertiary referral centres.

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

Context:

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

Aim:

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

Setting and Design:

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

Subjects and Methods:

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

Statistical Analysis Used:

Relevant statistical tests were used to analyse the collected data.

Results:

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

Conclusion:

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

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.

Minimally invasive organ-preserving approaches in the management of mesh erosion after laparoscopic ventral mesh rectopexy

AIM

This is a systematic approach for minimally invasive methods in the management of mesh erosion after laparoscopic ventral mesh rectopexy.

METHODS

All patients managed with organ-preserving techniques for mesh erosion were identified from a prospective database and clinical records were reviewed. Each patient was contacted via telephone and a structured questionnaire was applied. A Likert score was used to assess patient symptoms and overall satisfaction with management. One or more of the following techniques were used: (i) transanal or transvaginal trimming/excision of exposed mesh and sutures, with or without using transanal endoscopic micro surgery or transanal minimally invasive surgery; (ii) laparoscopic pelvic assessment and detachment of mesh from the sacral promontory.

RESULTS

Eleven patients were managed for mesh erosion with organ-preserving techniques. All were women with a median age of 60 years [interquartile range (IQR) 53.5-68.5]. Vaginal, rectal, perineal erosion and recto-vaginal fistulation occurred in five, four, one and one patient respectively. Vaginal erosions presented at a median of 51 months (IQR 36-56) after index laparoscopic ventral mesh rectopexy compared to 17.5 months (IQR 14.5-27.25) for the rectal erosions. Median follow-up time was 24 months (IQR 19-49). Four of the meshes (36%) were removed completely whereas seven (63%) were partially removed. Vaginal erosions required a median of two procedures to achieve resolution as opposed to five for rectal. Out of 11 patients, eight were satisfied with the outcome of their management, whereas two were not and one remained ambivalent.

CONCLUSION

An organ-sparing minimally invasive approach is feasible in managing mesh erosions but requires multiple procedures and months to complete.

Position statement by the Pelvic Floor Society on behalf of the Association of Coloproctology of Great Britain and Ireland on the use of mesh in ventral mesh rectopexy

The following position statement forms part of a response to the current concerns regarding use of mesh to perform rectal prolapse surgery. It highlights the actions being pursued by the Pelvic Floor Society (TPFS) regarding clinical governance in relation to ventral mesh rectopexy (VMR). The following are summary recommendations. Available evidence suggests that mesh morbidity for VMR is far lower than that seen in transvaginal procedures (the main subject of current concern) and lower than that observed following other abdomino-pelvic procedures for urogenital prolapse, e.g. laparoscopic sacrocolpopexy. VMR should be performed by adequately trained surgeons who work within a multidisciplinary team (MDT) framework. Within this, it is mandatory to discuss all patients considered for surgery at an MDT meeting. Clinical outcomes of surgery and any complications resulting from surgery should be recorded in the TPFS-hosted national database (registry) available for this purpose; in addition, all patients should be considered for entry into ongoing and planned UK/European randomized studies where this is feasible. A move towards accreditation of UK units performing VMR will improve performance and outcomes in the long term. An enhanced programme of training including staged porcine, cadaveric and preceptorship sessions will ensure the competence of surgeons undertaking VMR. Enhanced consent forms and patient information booklets are being developed, and these will help both surgeons and patients. There is weak observational evidence that technical aspects of the procedure can be optimized to reduce morbidity rates. Suture material choice may contribute towards morbidity. The available evidence is insufficient to support the use of one mesh over another (biologic vs synthetic); however, the use of polyester mesh is associated with increased morbidity.

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.

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.

Impact of Suture Type on Erosion Rate After Laparoscopic Ventral Mesh Rectopexy: A Case-Matched Study

BACKGROUND

There has been increasing concern and scrutiny in the use of mesh for certain pelvic organ prolapse procedures. However, mesh erosion was often associated with sites of suture fixation of the mesh to the rectum or vagina. Thus, in response to this finding, we replaced our suture material with absorbable monofilament suture.

OBJECTIVE

The purpose of this study was to compare the rates of mesh-related complications after laparoscopic ventral mesh rectopexy, according to the type of suture used in fixation of mesh.

DESIGN

This was retrospective cohort study.

SETTINGS

This study was performed at a high-volume, tertiary care center. It was conducted using a prospective database including patients who underwent laparoscopic ventral mesh rectopexy over a 7-year period.

PATIENTS

A total of 495 cases were included; 296 (60%) laparoscopic ventral mesh rectopexies were performed using a nonabsorbable suture compared with 199 (40%) with an absorbable suture in a case-matched analysis. In addition, 151 cases of laparoscopic ventral mesh rectopexy with nonabsorbable were matched based on age, sex, and time of follow-up, with an equal number of patients using absorbable monofilament suture.

MAIN OUTCOMES MEASURES

Primary outcome was symptomatic mesh erosion after rectopexy. Secondary outcomes included other mesh-related complications and/or reoperations.

RESULTS

The erosion rate was 2% (6/495) in the nonabsorbable suture group, including 4 erosions into the rectum and 2 into the vagina. There was no erosion in the group with absorbable suture. This difference was maintained after matching: after a median follow-up of 6 (12) months, there was no erosion in the absorbable suture group versus 3.3% erosion (n = 5) in the nonabsorbable suture group (p = 0.03).

LIMITATIONS

This study was limited by its retrospective design.

CONCLUSIONS

Mesh-related complications are reduced using absorbable sutures compared with nonabsorbable sutures when performing laparoscopic ventral mesh rectopexy with synthetic mesh without an increase in rectopexy failures. See Video Abstract at http://links.lww.com/DCR/B49. IMPACTO DEL TIPO DE SUTURA EN LA TASA DE EROSIóN DESPUéS DE LA RECTOPEXIA VENTRAL LAPAROSCóPICA CON MALLA: UN ESTUDIO DE CASOS EMPAREJADOS: Ha habido una creciente preocupación y escrutinio en el uso de la malla para ciertos procedimientos de prolapso de órganos pélvicos. Sin embargo, la erosión de la malla a menudo se asoció con sitios de fijación de sutura de la malla al recto o la vagina. Por lo tanto, en respuesta a este hallazgo, reemplazamos nuestro material de sutura con sutura de monofilamento absorbible.Comparar las tasas de complicaciones relacionadas con la malla después de la rectopexia laparoscópica de malla ventral, de acuerdo al tipo de sutura utilizada en la fijación de la malla.Este fue un estudio de cohorte retrospectivo.Este estudio se realizó en un centro de atención de tercer nivel de alto volumen. Se realizó utilizando una base de datos prospectiva que incluía pacientes que se sometieron a una rectopexia de malla ventral laparoscópica durante un período de 7 años.Se incluyeron un total de 495 casos; 296 (60%) rectopexias de malla ventral laparoscópica utilizando una sutura no reabsorbible en comparación con 199 (40%) con una sutura absorbible en un análisis de casos emparejados. Además, 151 casos de rectopexia ventral laparoscópica con malla no absorbible se emparejaron según la edad, el sexo y el tiempo de seguimiento con un número igual de pacientes que usaban sutura de monofilamento absorbible.La medida de resultado primaria fue la erosión sintomática de la malla después de la rectopexia. La medida de resultado secundarias incluyeron otras complicaciones y/o reoperaciones relacionadas con la malla.La tasa de erosión fue del 2% (6/495) en el grupo de sutura no absorbible; 4 erosiones en el recto y 2 en la vagina. No hubo erosión en el grupo con sutura absorbible. Esta diferencia se mantuvo después del emparejamiento: después de una mediana de seguimiento de 6 (12) meses, no hubo erosión en el grupo de sutura absorbible versus 3.3% de erosión (n = 5) en el grupo de sutura no absorbible (p = 0.03).Este estudio estuvo limitado por su diseño retrospectivo.Las complicaciones relacionadas con la malla se reducen utilizando suturas absorbibles en comparación con las suturas no absorbibles cuando se realiza la rectopexia de malla ventral laparoscópica con malla sintética, sin un aumento en los fracasos de rectopexia. Vea el Resumen del Video en http://links.lww.com/DCR/B49.

Functional Outcome after Laparoscopic Posterior Sutured Rectopexy Versus Ventral Mesh Rectopexy for Rectal Prolapse: Six-year Follow-up of a Double-blind, Randomized Single-center Study

BACKGROUND

Laparoscopic ventral mesh rectopexy (LVMR) for rectal prolapse has been implemented to reduce postoperative bowel symptoms. The preoperative-to-postoperative change in a double-blinded, randomized study comparing it to laparoscopic posterior sutured rectopexy (LPSR) found no significant difference between the two procedures after one year. The aim of this study was to investigate the long-term functional outcomes.

METHODS

From November 2006-January 2014, 75 patients were randomized to LVMR (n = 37) or LPSR (n = 38). In March 2017, questionnaires containing constipation symptom score (PAC-SYM), quality of life score (PAC-QoL), obstructed defecation score (ODS), Cleveland clinic constipation and incontinence scores (CCCS, CCIS) were mailed to all the patients included in the RCT. Prolapse recurrences and mesh complications were recorded.

FINDING

Sixty-nine patients were available for long-term follow-up. Questionnaires were completed by 64 patients (94.4%). The median follow-up was 6.1 years. The total PAC-QoL was significantly lower in the LVMR group 0.26 (0.14-0.83) compared to the LPSR group 0.93(0.32-1.61)(P = 0.008). The total PAC-SYM was significantly lower in the LVMR group 0.5 (0.21-0.87) compared to the LPSR group 1.0 (0.5-1.5)(P = 0.031). Except for CCIS, the ODS and the CCCS significantly favored the LVMR group at six years (P = 0.011 & 0.017). Only three(8.82%) patients in the LVMR group developed recurrence compared to seven(23.33%) in the LPSR group (P = 0.111).

INTERPRETATION

The long-term functional outcome after LVMR is superior to that after LPSR. Larger multicenter studies are warranted.

FUNDING

None.

Surgical decision-making for rectal prolapse: one size does not fit all

BACKGROUND

Surgery remains the only known treatment option for rectal prolapse. Although over 100 abdominal and perineal procedures are available, there is no consensus as to which intervention is best suited for an individual. This retrospective cohort study describes the patient- and disease-related factors involved in making surgical recommendations around rectal prolapse in a single surgeon experience.

METHODS

91 consecutive patients ≥18 years old diagnosed with external and/or high-grade internal rectal prolapse were assessed and were prospectively entered into an IRB approved registry. Information on patient symptoms, comorbidities, exam findings, surgeon judgment, and patient preference was collected. Treatment recommendations (abdominal, perineal, or no operation) were analyzed and compared.

RESULTS

Surgical intervention was recommended to 93% of patients. Of those, 66% were recommended robotic abdominal procedures: 75%, robotic ventral mesh rectopexies; 16%, resection rectopexies; and 9%, suture rectopexies. On univariate analysis, patients with older age, higher ASA scores, presence of cardiopulmonary morbidity, pain as a primary rectal prolapse symptom, rectal prolapse always descended, and surgeon concern for frailty and general anesthesia were associated with recommendations for perineal operations (p < 0.05 for all). However, on multivariate analysis, only age and concern over prolonged anesthesia remained correlated with a recommendation for perineal surgery. Of patients >80 years of age, 15% were recommended an abdominal approach.

CONCLUSIONS

With multiple options available for the treatment of rectal prolapse, treatment recommendations remain surgeon-dependent and may be influenced by many factors. In our practice, robotic ventral mesh rectopexy was the most commonly recommended operation and was offered to carefully selected patients of advanced age. Although robotic surgery and ventral mesh rectopexy may not be accessible to all patients and surgeons, this represents a single surgeon's practice bias. This study reinforces the importance of perineal procedures for higher-risk individuals.

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.

Long-term mesh erosion rate following abdominal robotic reconstructive pelvic floor surgery: a prospective study and overview of the literature

Introduction and hypothesis

The use of synthetic mesh in transvaginal pelvic floor surgery has been subject to debate internationally. Although mesh erosion appears to be less associated with an abdominal approach, the long-term outcome has not been studied intensively. This study was set up to determine the long-term mesh erosion rate following abdominal pelvic reconstructive surgery.

Methods

A prospective, observational cohort study was conducted in a tertiary care setting. All consecutive female patients who underwent robot-assisted laparoscopic sacrocolpopexy and sacrocolporectopexy in 2011 and 2012 were included. Primary outcome was mesh erosion. Preoperative and postoperative evaluation (6 weeks, 1 year, 5 years) with a clinical examination and questionnaire regarding pelvic floor symptoms was performed. Mesh-related complications were assessed using a transparent vaginal speculum, proctoscopy, and digital vaginal and rectal examination. Kaplan–Meier estimates were calculated for mesh erosion. A review of the literature on mesh exposure after minimally invasive sacrocolpopexy was performed (≥12 months’ follow-up).

Results

Ninety-six of the 130 patients included (73.8%) were clinically examined. Median follow-up time was 48.1 months (range 36.0–62.1). Three mesh erosions were diagnosed (3.1%; Kaplan–Meier 4.9%, 95% confidence interval 0–11.0): one bladder erosion for which mesh resection and an omental patch interposition were performed, and two asymptomatic vaginal erosions (at 42.7 and 42.3 months) treated with estrogen cream in one. Additionally, 22 patients responded solely by questionnaire and/or telephone; none reported mesh-related complaints. The literature, mostly based on retrospective studies, described a median mesh erosion rate of 1.9% (range 0–13.3%).

Conclusions

The long-term rate of mesh erosion following an abdominally placed synthetic graft is low.

Electronic supplementary material

The online version of this article (10.1007/s00192-019-03990-1) contains supplementary material, which is available to authorized users

Short term outcome of laparoscopic ventral mesh rectopexy for rectal and complex pelvic organ prolapse: case series

Objectives

Laparoscopic ventral mesh rectopexy (LVMR) is a technique gaining more recognition for the management of pelvic floor disorders, such as external rectal prolapse (ERP), high grade internal rectal prolapse (IRP) and rectocele. LVMR also allows correction of coexisted pelvic organ prolapse. This study aimed to evaluate the safety, efficacy and functional outcome of LVMR for rectal and complex pelvic organ prolapse.

Material and Methods

All patients who underwent LVMR from February 2014 to October 2017 were included into the study. The patients were evaluated preoperatively and three months postoperatively. Surgical complications and functional results in terms of fecal incontinence (measured with the Wexner Incontinence Score= WIS) and constipation (measured with the Wexner Constipation Score= WCS) were analyzed.

Results

Thirty (4 males) patients underwent LVMR. Seventeen (56.6%) patients had complex pelvic organ prolapse according to MRI findings. Median operative time and postoperative stay were 110 minutes and 4 days, respectively. No mesh-related complication and recurrence were observed. Before surgery, 21 (70%) patients had complained about symptoms of obstructed defecation. WCS decreased significantly from median 19 to 6 (p <0.001). Preoperative median WIS of 9 patients was 14 and went down to 6 postoperatively (p= 0.008). WCS significantly improved after LVMR in patients with symptomatic rectocele combined with enterocele or sigmoidocele (p= 0.005), and significant improvement was also observed in patients with symptomatic rectocele combined with gynecologic organ prolapse, preoperative median WCS was 18 and the postoperative value fell to 8 (p= 0.005).

Conclusion

LVMR is an effective surgical option for rectal and complex pelvic organ prolapse with short-term follow-up.

Long-term outcomes of robotic ventral mesh rectopexy for external rectal prolapse

INTRODUCTION

Nowadays in Europe, laparoscopic ventral mesh rectopexy is the gold standard treatment of external rectal prolapse (ERP). The benefits of robot ventral mesh rectopexy (RVMR) are not clearly defined. The primary objective of the study was to evaluate the long-term results of RVMR. The secondary objective was to determine predictive factors of recurrence.

DESIGN

Monocentric, retrospective study. Data, both pre-operative and peri-operative, were collected, and follow-up data were assessed prospectively by a telephone questionnaire. The study was performed in a tertiary referral center.

METHODS

Between August 2007 and August 2017, we evaluate all consecutive patients who underwent RVMR for ERP by three different surgeons. The primary outcome was the recurrence rate perceived by patients. Secondary outcome were functional results based on Knowles-Eccersley-Scott-Symptom score for constipation and Wexner score for incontinence, compared before and after surgery.

RESULTS

During the study period 96 patients (86 women) underwent RVMR. The mean age was 62.3 years (range 16-90). Twelve patients had a history of ERP repair. Sixty-nine patients were analyzed for long-term outcomes with a mean follow-up of 37 months (range 2.3-92 months). Recurrence rate was 12.5%. After surgery, constipation was significantly reduced: 44 patients were constipated before surgery versus 23 after surgery. Six patients described de novo constipation (6.25%). Fecal incontinence was significantly reduced: 59 patients were incontinent before surgery versus 14 after surgery. No predictive factor for recurrence was identified after multivariate analysis. No mesh related complications were related.

CONCLUSIONS

In conclusion, RVMR presents good long-term functional result and a recurrence rate similar to LVMR as published in the literature. The rate of mesh related complications seems lower.

Long-Term Outcomes After Ventral Rectopexy With Sacrocolpo- or Hysteropexy for the Treatment of Concurrent Rectal and Pelvic Organ Prolapse

OBJECTIVE

The primary objective is to describe the long-term anatomic and subjective outcomes in women undergoing ventral rectopexy with sacrocolpo- or hysteropexy. The secondary objective is to describe the perioperative adverse events.

METHODS

This is a retrospective cohort of women who underwent ventral rectopexy with either concurrent sacrocolpo- or hysteropexy at a tertiary care center between 2009 and 2015. A composite outcome for recurrent pelvic organ prolapse and rectal prolapse was defined as subjective failure (vaginal or rectal prolapse symptoms), objective failure (prolapse to or beyond the hymen or full thickness rectal prolapse), or any retreatment for prolapse. Patient's Global Impression of Change was recorded at baseline and at all follow-up visits. Perioperative adverse events were defined a priori and collected up to 6 weeks after surgery.

RESULT

A total of 59 patients underwent a ventral rectopexy, either a sacrocolpopexy (48/59, 81.3%) or sacrohysteropexy (11/59, 18.6%). The median follow-up after surgery for all patients was 17 months (range, 1-76) with a composite success rate for both pelvic organ prolapse and rectal prolapse (estimated by Kaplan-Meier method) of 57.4%. Forty (91%) of 44 patients reported a Patient's Global Impression of Change score of 6 or 7, indicating significant improvement after surgery. Of the patients, 15 (25.4%) experienced a perioperative adverse event. Use of biologic graft was associated with a higher rate of adverse event (40.0% [95% confidence interval, 24.6-57.5] vs 10.3% [95% confidence interval, 3.6-26.3]; P < 0.01).

CONCLUSIONS

Ventral rectopexy with sacrocolpo- or hysteropexy is associated with significant improvement in anatomic and subjective outcomes. One in 4 women experienced a perioperative adverse event.

Spondylodiscitis after minimally invasive recto- and colpo-sacropexy: Report of a case and systematic review of the literature

Background:

Rectopexy and colpopexy are established surgical techniques to treat pelvic organ prolapse. Spondylodiscitis (SD) after rectopexy and colpopexy represents a rare infectious complication with severe consequences. We presented a case of SD after rectopexy and performed a systematic review.

Methods:

A systematic literature search was performed to identify case reports or case series reporting on SD after rectopexy or colpopexy. The main outcomes measures were time from initial surgery to SD, presenting symptoms, occurrence of mesh erosion or fistula formation and type of treatment.

Results:

Forty-one females with a median age of 59 (54–66) years were diagnosed with SD after a median of 76 (30–165) days after initial surgery. Most common presenting symptoms were back pain (n = 35), fever (n = 20), pain radiation in the legs (n = 9) and vaginal discharge (n = 6). A mesh erosion (n = 8) or fistula formation (n = 7) was detected in a minority of cases. The treatment of SD consisted of conservative treatment with antibiotics alone in 29%, whereas 66% of the patients had to undergo additional surgical treatment. If a revision surgery was necessary, more than one intervention was performed in 40%. Mesh and tack excision was performed in most cases (n = 21), whereas a neurosurgical intervention was necessary in 10 patients.

Conclusion:

Although a rare complication, surgeons performing rectopexy and colpopexy must be aware of the potential risk of SD Careful suture or tack placement into the anterior longitudinal ligament at the level of the promontory while avoiding the disc space is of paramount importance. Prompt diagnosis and multidisciplinary management are the cornerstones of a successful treatment.

Resection Rectopexy is Still an Acceptable Operation for Rectal Prolapse

The aim of this study was to compare resection rectopexy (RR) with ventral mesh rectopexy (VMR). This institutional review board–approved retrospective study compared patients with rectal prolapse, who underwent RR or VMR from 2009 to 2016. The primary end point was the comparison of complications and prolapse recurrence rates. Seventy-nine RR and 108 VMR patients qualified. Using propensity score matching, the two groups were not significantly different (P = 0.818). There were no differences regarding gender (female 103 vs 72; P = 0.4) and age (59.3 vs 53.9; P = 0.054). Patients in the VMR group had a greater body mass index (25.5 vs 22.9; P = 0.001) and poorer physical status (American Society of Anesthesiologists 3 57.4% vs 41.8%; P = 0.04). The VMR group had more: robotic approaches (69.4% vs 8.9%; P < 0.001), concomitant urogynecological procedures (63 vs 19; P < 0.001), and longer operative time (269 vs 206 minutes; P < 0.001) but a reduced length of stay (2 vs 5 days; P < 0.001). The median follow-up (16 vs 26 months; P = 0.125) and the median time of recurrence (14 vs 38 months; P = 0.163) were similar. No differences were observed for complications or recurrence (10.2% vs 10.1%; P = 0.43). We failed to identify superiority based on surgical technique.