Consensus on ventral rectopexy: report of a panel of experts

Moving from Laparoscopic Synthetic Mesh to Robotic Biological Mesh for Ventral Rectopexy: Results from a Case Series

Introduction: Laparoscopic ventral mesh rectopexy (VMR) is the standard procedure for the treatment of posterior pelvic organ prolapse. Despite significant functional improvement and anatomical corrections, severe complications related to mesh augmentation can occur in a few proportions of patients. In order to decrease the number of rare but severe complications, we developed a variant of the conventional VMR without any rectal fixation and using a robotic approach with biological mesh. The aim of this study was to compare the results of laparoscopic ventral rectopexy with synthetic mesh (LVMRS) to those of robotic ventral rectopexy with biological mesh (RVMRB). Methods: Between 2004 and 2021, patients operated on for VMR in our unit were identified and separated into two groups: LVMRS and RVMRB. The surgical technique for both groups consisted of VMR without any rectal fixation, with mesh distally secured on the levator ani muscles. Results: 269 patients with a mean age of 62 years were operated for posterior pelvic floor disorder: rectocele (61.7%) and external rectal prolapse (34.6%). 222 (82.5%) patients received LVMRS (2004-2015), whereas 47 were operated with RVMRB (2015-2021). Both groups slightly differed for combined anterior fixation proportion (LVMRS 39% vs. RVMRB 6.4%, p < 0.001). Despite these differences, the length of stay was shorter in the RVMRB group (2 vs. 3 days, p < 0.001). Postoperative complications were comparable in the two groups (1.8 vs. 4.3%, p = 0.089) and mainly consisted of minor complications. Functional outcomes were favorable and similar in both groups, with an improvement in bulging, obstructed defecation symptoms, and fecal incontinence (NS in subgroup analysis). In the long term, there were no mesh erosions reported. The overall recurrence rate was 11.9%, and was comparable in the two groups (13% LVMRS vs. 8.5, p = 0.43). Conclusions: VMR without rectal fixation is a safe and effective approach in posterior organ prolapse management. RVMRB provides comparable results in terms of recurrence and functional results, with avoidance of unabsorbable material implantation.

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.

Time trend in the surgical management of obstructed defecation syndrome: a multicenter experience on behalf of the Italian Society of Colorectal Surgery (SICCR)

Background

Surgical management of obstructed defecation syndrome (ODS) is challenging, with several surgical options showing inconsistent functional results over time. The aim of this study was to evaluate the trend in surgical management of ODS in a 10-year timeframe across Italian referral centers.

Methods

Surgeons from referral centers for the management of pelvic floor disorders and affiliated to the Italian Society of Colorectal Surgery provided data on the yearly volume of procedures for ODS from 2010 to 2019. Six common clinical scenarios of ODS were captured, including details on patient’s anal sphincter function and presence of rectocele and/or rectal intussusception. Perineal repair, ventral rectopexy (VRP), transanal repair (internal Delorme), stapled transanal rectal resection (STARR), Contour Transtar, and transvaginal repair were considered in each clinical scenario.

Results

Twenty-five centers were included providing data on 2943 surgical patients. Procedure volumes ranged from 10–20 (54%) to 21–50 (46%) per year across centers. The most performed techniques in patients with good sphincter function were transanal repair for isolated rectocele (243/716 [34%]), transanal repair for isolated rectal intussusception (287/677 [42%]) and VRP for combined abnormalities (464/976 [48%]). When considering poor sphincter function, these were perineal repair (112/194 [57.8%]) for isolated rectocele, and VRP for the other two scenarios (60/120 [50%] and 97/260 [37%], respectively). The use of STARR and Contour Transtar decreased over time in patients with impaired sphincter function.

Conclusions

The complexity of ODS treatment is confirmed by the variety of clinical scenarios that can occur and by the changing trend of surgical management over the last 10 years.

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.

Case report: Gross persistent rectal prolapse. A case treated without mesh using deep retrorectal dissection/suturing

A previously well 15-year-old male presented with a history of gross rectal prolapse (GRP) involving full-thickness rectal prolapse of increasing severity and incidence over 6 months that occurred with every bowel motion, varying from 10 to 40 cm. He denied constipation and passed a soft motion once daily, adeptly reducing his prolapsed rectum after each motion. This case illustrates technical challenges and planning for surgical intervention for optimal treatment in keeping with an FDA alert issued April, 2019 banning surgical mesh for pelvic organ prolapse. Preoperative fluoroscopic defecography confirmed rectal prolapse beginning with eversion of the anal verge identified on inspection. For surgery, general anesthesia was induced, he was placed in a Trendelenburg position, and four ports were inserted. The peritoneum was incised and blunt dissection used to expose the levator ani complex (LAC) taking care to prevent lateral nerve injury and preserve regional vascularity. Seven polypropylene sutures were used to fix the seromuscular posterior wall of the rectum to the median raphe of the LAC, the presacral fascia, and the periosteum of the sacral promontory. Operative time was 170 min. Postoperative recovery and progress were unremarkable. Currently, 5 years postoperatively, defecation is regular without recurrence of prolapse. For prolapse involving protrusion of the upper rectum without eversion of the anal verge, rectal fixation to the sacral promontory without further dissection beyond the peritoneal reflection is adequate, but when extensive prolapse is associated with eversion of the anal verge, more extensive blunt dissection from the peritoneal reflection to the LAC with multiple rectopexy sutures is valid for reducing risks for recurrence and eliminating mesh-related complications.

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.

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.

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.

Long term outcomes of laparoscopic sacro/colpo-hysteropexy with and without rectopexy for the treatment of prolapse

INTRODUCTION AND HYPOTHESIS

Laparoscopic sacrohysteropexy (LSH), sacrocolpopexy (LSC) and ventral rectopexy (LVR) with mesh are advocated for surgical treatment of pelvic and rectal prolapse. Our study aims at showing the feasibility of concomitant laparoscopic prolapse repair by comparing perioperative and long-term outcomes of LSH or LSC with and without LVR.

METHODS

This is a retrospective study carried out on 348 women operated on between July 2009 and July 2019. Patients were divided into four groups: (1) LSH only, (2) LSC only, (3) LSH + LVR and (4) LSC + LVR. POP-Q scores and satisfaction questionnaires were recorded at baseline and then annually. Outcomes were defined as subjective failure (vaginal/rectal prolapse symptoms), objective failure (prolapse to/beyond the hymen, full thickness rectal prolapse) or retreatment for prolapse. Complications were collected and graded according to the Clavien-Dindo classification.

RESULTS

Three hundred forty-eight women underwent laparoscopic repair for pelvic and rectal prolapse (219, 44, 66 and 19 in group 1, 2, 3 and 4, respectively). Median follow-up was 24 (4-174) months. Success rate for both rectal and pelvic prolapse was 90.2%. Recurrence rates were not significantly different between the groups (12.3%, 6.8%, 9.1% and 10.5% for groups 1, 2, 3 and 4, respectively). Significant improvement was noticed in satisfaction questionnaires in all groups. There was no difference in perioperative and late complications.

CONCLUSION

The combined laparoscopic procedure appears to be safe and efficient in treating pelvic and rectal prolapse. Appropriate patient selection and available surgical expertise should determine whether to perform these procedures combined or separately.

Evaluation of the learning curve of robot-assisted laparoscopic ventral mesh rectopexy

BACKGROUND

The current standard treatment for external rectal prolapse and symptomatic high-grade internal rectal prolapse is surgical correction with minimally invasive ventral mesh rectopexy using either laparoscopy or robotic assistance. This study examines the number of procedures needed to complete the learning curve for robot-assisted ventral mesh rectopexy (RVMR) and reach adequate performance.

METHODS

A retrospective analysis of all primary RVMR from 2011 to 2019 performed in a tertiary pelvic floor clinic by two colorectal surgeons (A and B) was performed. Both surgeons had previous experience with laparoscopic rectopexy, but no robotic experience. Skin-to-skin operating times (OT) were assessed using LC-CUSUM analyses. Intraoperative and postoperative complications were analyzed using CUSUM analyses.

RESULTS

A total of 182 (surgeon A) and 91 (surgeon B) RVMRs were performed in total. There were no relevant differences in patient characteristics between the two surgeons. Median OT was 75 min (range 46-155; surgeon A) and 90 min (range 63-139; surgeon B). The learning curve regarding OT was completed after 36 procedures for surgeon A and 55 procedures for surgeon B. Both before and after completion of the learning curve, intraoperative and postoperative complication rates remained below a predefined acceptable level of performance.

CONCLUSIONS

36 to 55 procedures are required to complete the learning curve for RVMR. The implementation of robotic surgery does not inflict any additional risks on patients at the beginning of a surgeon's learning curve.

Autologous Fascia Lata for Combined Sacrocolpopexy and Rectopexy

ABSTRACT

We present a case series and video of our technique using autologous fascia lata for combined sacrocolpopexy and rectopexy, with or without resection.

Abdominal ventral rectopexy with colectomy for obstructed defecation syndrome: An alternative option for selected patients

BACKGROUND

Abdominal ventral rectopexy (AVR) with colectomy is controversial in the treatment of obstructed defecation syndrome (ODS). Literature data on this technique for ODS are very limited.

AIM

To evaluate the safety and efficacy of AVR with colectomy for selected patients with ODS.

METHODS

Consecutive patients who underwent AVR with colectomy for ODS were identified prospectively from 2016 to 2017 in our department. Patient demographics, perioperative surgical results, and postoperative follow-up outcomes were collected and analyzed. Long-term follow-up was evaluated with standardized questionnaires. The severity of symptoms was assessed by the objective Wexner Constipation Score (WCS) and ODS Score. The quality of life was assessed by the Patients Assessment of Constipation Quality of Life score. Functional outcome was compared pre- and post-operatively for each patient. The primary outcomes were determined by the improvement in symptoms and quality of life. Secondary outcome measures were operating time, postoperative length of stay, morbidity and mortality, improvement of pelvic floor structure, and patient satisfaction.

RESULTS

Four patients underwent robotic-assisted surgery, and two patients underwent a laparoscopic-assisted procedure. The mean operating time for the robotic approach was 243 min (range 160–300 min), and the mean operating time for the laparoscopic approach was 230 min (range 220-240 min). The mean postoperative length of stay was 8.2 d (range 6-12 d). There was no conversion to open procedure and no postoperative mortality. No urinary retention, wound infection, prolonged ileus, pelvic infection and anastomosis leakage occurred. Six patients were followed up for 36 mo. The WCS, ODS, and Patients Assessment of Constipation Quality of Life score improved significantly postoperatively (P < 0.05). The WCS and ODS scores showed the best remission and stabilization at 6 to 12 mo after surgery. There was no recurrence or novel constipation after surgery. None of the patients used laxative medication.

CONCLUSION

Robotic and laparoscopic-assisted ventral rectopexy with colectomy is a safe and effective procedure for selected patients with ODS. However, comprehensive preoperative evaluation and careful patient selection are essential.

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.

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.

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.

A systematic review of management options in pediatric rectal prolapse

PURPOSE

Rectal prolapse is a relatively common condition in infants and young children with a multifactorial etiology. Despite its prevalence, there remains clinical equipoise with respect to secondary treatment in pediatric surgery literature. We conducted a systematic review to evaluate methods of secondary treatment currently used to treat rectal prolapse in children.

METHODS

We searched Pubmed, Medline, and Scopus with the terms "rectal prolapse" and "children" for papers published from 1990 to April 2017. Papers satisfying strict criteria were analyzed for patient demographics, intervention, efficacy, and complications. Procedures were grouped by like type. Pooled success rates were calculated.

RESULTS

Twenty-seven studies documenting 907 patients were included. Injection sclerotherapy had an overall initial success rate of 79.5%. Ethyl alcohol seemed the best sclerosing agent due to a high first-injection success rate, low complication rate, and ready accessibility. Several perineal repairs were found, with operative success rates ranging from 60.8%-100%. Laparoscopic rectopexy with mesh was the most commonly reported transabdominal procedure and had an overall success rate of 96.1%. Postoperative complications from all procedures were comparable.

CONCLUSION

Though many secondary treatment options have been reported for rectal prolapse, sclerotherapy and laparoscopic rectopexy predominate in contemporary literature and appear to have high success and low complication rates.

LEVEL OF EVIDENCE

IV.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopic Ventral Rectopexy Versus Stapled Transanal Rectal Resection for Treatment of Obstructed Defecation in the Elderly: Long-term Results of a Prospective Randomized Study

BACKGROUND

Obstructed defecation is a common complaint in coloproctology. Many anal, abdominal, and laparoscopic procedures are adopted to correct the underlying condition.

OBJECTIVE

The purpose of this study was to compare long-term functional outcome, recurrence rate, and quality of life between laparoscopic ventral rectopexy and stapled transanal rectal resection in the treatment of obstructed defecation.

DESIGN

This was a prospective randomized study.

SETTING

This study was performed at academic medical centers.

PATIENTS

Patients were included if they had obstructed defecation attributed to pelvic structural abnormalities that did not to respond to conservative measures. Exclusion criteria included nonrelaxing puborectalis, previous abdominal surgery, other anal pathology, and pudendal neuropathy.

INTERVENTION

Patients were randomly allocated to either laparoscopic ventral rectopexy (group 1) or stapled transanal rectal resection (group 2).

MAIN OUTCOME MEASURES

The primary outcome measures were improvement of modified obstructed defecation score and recurrences after ≥3 years of follow-up. Secondary outcomes were postoperative complications, continence status using Wexner incontinence score, and quality of life using Patient Assessment of Constipation-Quality of Life Questionnaire.

RESULTS

The study included 112 patients (56 in each arm). ASA score II was reported in 32 patients (18 in group 1 and 14 in group 2; p = 0.12), whereas 3 patients in each group had ASA score III. Minor postoperative complications were seen in 11 patients (20%) of group 1 and 14 patients of group 2 (25%; p = 0.65). During follow-up, 3 patients had fecal urgency after stapled transanal rectal resection but no sexual dysfunction in either procedure. After 6 months, modified obstructed defecation score improvement >50% was reported in 73% versus 82% in groups 1 and 2 (p = 0.36). After a mean follow-up of 41 months, recurrences of symptoms were reported in 7% in group 1 versus 24% in group 2 (p = 0.04). Six months postoperation, perineal descent improved >50% in defecogram in 80% of group 1 versus no improvement in group 2. Quality of life significantly improved in both groups after 6 months; however a significant long-term drop (>36 months) was seen only in group 2.

LIMITATIONS

Possible limitations of this study are the presence of a single operator and the absence of blindness of the technique for both patient and assessor.

CONCLUSIONS

In elderly patients even with comorbidities, both laparoscopic ventral rectopexy and stapled transanal rectal resection are safe and can improve function of the anorectum in patients with obstructed defecation attributed to structural abnormalities. Laparoscopic ventral rectopexy has better long-term functional outcome, less complications, and less recurrences compared with stapled transanal rectal resection. Perineal descent only improves after laparoscopic ventral rectopexy. Stapled transanal rectal resection was shown not to be the first choice in elderly patients with obstructed defecation unless they had a medical contraindication to laparoscopic procedures. See Video Abstract at http://links.lww.com/DCR/A788.

Complex pelvic organ prolapse: decision-making algorithm

PURPOSE

The pelvic floor is considered as a single anatomical and functional unit, consisting of several structures that suspend the pelvic organs maintaining their function. For this reason, a multi-compartmental prolapse is a common disease that needs a multidisciplinary pelvic floor team in order to be treated. The aim of the authors is to suggest a treatment algorithm to better approach complex pelvic organ prolapse.

METHODS

A multidisciplinary pelvic floor team was set up 7 years ago. Starting from the literature review integrated with a team experience, a decision-making algorithm was drawn up. It was used to guide all the shared treatment for the complex pelvic floor disorders.

RESULTS

An accurate preoperative assessment with a shared diagnosis among the specialist is the base to follow the proposed algorithm. It leads to combine different surgical procedures considering advantages and disadvantages which may have an influence on the final outcome.

CONCLUSIONS

The proposed algorithm provides an integrated surgical view of complex pelvic floor disorders. It shows how is it feasible to associate surgical treatments of different compartments to obtain good pelvic floor anatomical and functional results and leading to an improvement of the patients' quality of life.

Laparoscopic Protack™ rectopexy: Early experience of a novel technique for full thickness rectal prolapse in children

BACKGROUND/PURPOSE

To review our early experience of laparoscopic ProTack™ rectopexy (LPR) in the management of full thickness rectal prolapse (FTRP) in children.

METHODS

Prospective case series of patients undergoing LPR between 2013 and 2017. Full laparoscopic mobilization of the rectum was performed from the sacral promontory to the pelvic floor. 'Wings' of the lateral mesorectal peritoneum left attached to the rectum are then fixed to the sacral promontory using ProTack™. Demographics, associated conditions, previous procedures for FTRP, follow up time, length of stay (LOS), short and long term complications and clinical improvement were assessed.

RESULTS

Seven consecutive patients with FTRP underwent LPR. The mean age was 9 years old (2-17) with a male to female ratio of 6:1. Median LOS was 1 day (1-2 days). Median follow up time was 17 months (10-38 months). All patients had complete resolution of symptoms within the follow up period.

CONCLUSIONS

LPR is a simple, safe and effective procedure showing promising results in children. It negates the risks associated with the use of mesh and has the potential to avoid the higher risk of failure associated with suture rectopexy. It is important to ensure patients receive adequate analgesia and management of postoperative constipation.

Laparoscopic Posterolateral Rectopexy for the Treatment of Patients With a Full Thickness Rectal Prolapse: Experience With 63 Patients and Short-term Outcomes

Purpose

Although numerous procedures have been proposed for the treatment of patients with a rectal prolapse, the most effective operation has not yet been established. Minimal rectal mobilization can prevent constipation; however, it is associated with increased recurrence rates. We describe our novel method for a laparoscopic posterolateral rectopexy, which includes rectal mobilization with a posterior-right unilateral dissection, suture fixation to the sacral promontory with a polypropylene mesh (Optilene), and a mesorectal fascia propria that is as wide as possible. The present report describes our novel method and assesses the short-term outcomes of patients.

Methods

Between June 2014 and June 2017, 63 patients (28 males and 35 females) with a full-thickness rectal prolapse underwent a laparoscopic posterolateral (LPL) rectopexy. We retrospectively analyzed the clinical characteristics and postoperative complications in those patients. The outcome of surgery was determined by evaluating the answers on fecal incontinence questionnaires, the results of anal manometry preoperatively and 3 months postoperatively, the patients’ satisfaction scores (0–10), and the occurrence of constipation.

Results

No recurrence was reported during follow-up (3.26 months), and 3 patients reported postoperative complications (wound infection, postoperative sepsis, which was successfully treated with conservative management, and retrograde ejaculation). Compared to the preoperative baseline, fecal incontinence at three months postoperatively showed an overall improvement. The mean patient satisfaction score was 9.55 ± 0.10, and 8 patients complained of persistent constipation.

Conclusion

LPL rectopexy is a safe, effective method showing good functional outcomes by providing firm, solid fixation for patients with a full-thickness rectal prolapse.

Short- and long-term clinical and patient-reported outcomes following laparoscopic ventral mesh rectopexy using biological mesh for pelvic organ prolapse: a prospective cohort study of 224 consecutive patients

AIM

Laparoscopic ventral mesh rectopexy (LVMR) is potentially a safe and effective operation to correct pelvic organ prolapse and to treat obstructive defaecation and solitary rectal ulcer syndrome. This study aimed to evaluate, in a prospective, consecutive cohort of patients, the long-term clinical outcomes following LVMR, patient-reported functional and quality of life outcomes, and urinary and sexual dysfunction.

METHOD

Data on 224 patients who underwent LVMR with Permacol™ biological mesh were collected prospectively from May 2008 to October 2016. Outcome measures were complications, recurrence, mortality, patient satisfaction, patient-reported functional and quality of life outcomes, and urinary and sexual dysfunction. Scores were compared using the two-tailed Wilcoxon signed rank test. P < 0.05 was considered statistically significant.

RESULTS

There was no mortalities associated with LVMR in this series; complications occurred in 10.7% of patients (4.9% early, 5.8% late). Mesh-related morbidity was 0.45% and vaginal suture-related morbidity was 1.33%. Recurrence occurred in 25 patients (11.4%), 5% at 12 months, 10.7% at 5 years. Significant improvement in patient-reported functional outcomes were seen (P < 0.001) for both constipation and faecal incontinence symptoms. Furthermore, significant improvement in quality of life outcomes for patients with constipation, faecal incontinence and prolapse persisted through follow-up (P < 0.001). Patient satisfaction was positive for > 90% of patients during follow-up. Symptoms of stress urinary incontinence, urge incontinence and dyspareunia improved significantly postoperatively (P < 0.001).

CONCLUSION

LVMR using Permacol is associated with low morbidity and mortality, recurrence and, additionally, significantly improved constipation, faecal incontinence and prolapse functional and quality of life outcomes, with associated improvement in urogynaecological symptoms.

Trends in the treatment of rectal prolapse: a population analysis

PURPOSE

Rectal prolapse is a common condition, with conflicting opinions on optimal surgical management. Existing literature is predominantly composed of case series, with a dearth of evidence demonstrating current, real-world practice. This study investigated recent national trends in management of rectal prolapse in the Republic of Ireland (ROI).

METHODS

This population analysis used a national database to identify patients admitted in the ROI primarily for the management of rectal prolapse, as defined by the International Classification of Diseases, 10th Revision (ICD-10). Demographics, procedures, comorbidities, and outcomes were obtained for patients admitted from 2005 to 2015 inclusive.

RESULTS

There were 2648 admissions with a primary diagnosis of rectal prolapse; 39.3% underwent surgical correction. The majority were treated with either a perineal resection (47.2%) or an abdominal rectopexy ± resection (45.1%). The population-adjusted rate of operative intervention increased over the study period, from 25 to 42 per million (p < 0.001), with no change in the mean age of patients over time (p = 0.229). The application of a laparoscopic approach increased over time (p = 0.001). Patients undergoing an abdominal rectopexy were younger than those undergoing a perineal procedure (64.1 ± 17.3 versus 75.2 ± 15.5 years, p < 0.001) despite having a similar Charlson Comorbidity Index (p = 0.097). The mortality rate for elective repair was 0.2%.

CONCLUSIONS

Despite the popularization of ventral mesh rectopexy over the study period, perineal resection Delorme's procedure remains the most common procedure employed for the correction of rectal prolapse in the ROI, with specific approach determined by age.

Laparoscopic ventral rectopexy: A viable option in procidentia with redundant sigmoid - An Indian perspective

Introduction:

Laparoscopic ventral mesh rectopexy (LVMR) has gained widespread acceptance for the management of complete rectal prolapse (CRP). However, there have been concerns considering its use in patients with a redundant sigmoid colon. This study was conducted to evaluate the anatomical and functional results following LVMR, particularly in cases of CRP with a redundant sigmoid colon.

Materials and Methods:

Retrospective analysis of 25 patients who underwent LVMR from January 2011 to September 2016 was performed. Patients were divided into two groups according to the duration of follow-up. Group A (long-term) with follow-up >3 years and Group B (mid-term) <3 years.

Results:

The study included 25 patients (M:F = 1.5:1) with a median age of 38 years. Eighty-eight percent of the patients had a redundant sigmoid colon. Significant improvement in post-operative Wexner score as compared to pre-operative values was seen in patients with pre-existing constipation (P < 0.0001). In patients presenting with faecal incontinence (FI), significant improvement in post-operative St. Mark's incontinence score was observed. Functional outcomes remain consistent in long-term follow-up (>3 years).

Conclusions:

LVMR seems to be a feasible surgical procedure with minimum morbidity and good long-term functional outcomes. It provides satisfactory results in patients with redundant sigmoid colon and improves pre-existing constipation and FI.

Stepped-wedge randomised trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation: study protocol for a randomized controlled trial

Background

Laparoscopic ventral mesh rectopexy (LVMR) is an established treatment for external full-thickness rectal prolapse. However, its clinical efficacy in patients with internal prolapse is uncertain due to the lack of high-quality evidence.

Methods

An individual level, stepped-wedge randomised trial has been designed to allow observer-blinded data comparisons between patients awaiting LVMR with those who have undergone surgery. Adults with symptomatic internal rectal prolapse, unresponsive to prior conservative management, will be eligible to participate. They will be randomised to three arms with different delays before surgery (0, 12 and 24 weeks). Efficacy outcome data will be collected at equally stepped time points (12, 24, 36 and 48 weeks). The primary objective is to determine clinical efficacy of LVMR compared to controls with reduction in the Patient Assessment of Constipation Quality of Life (PAC-QOL) at 24 weeks serving as the primary outcome. Secondary objectives are to determine: (1) the clinical effectiveness of LVMR to 48 weeks to a maximum of 72 weeks; (2) pre-operative determinants of outcome; (3) relevant health economics for LVMR; (4) qualitative evaluation of patient and health professional experience of LVMR and (5) 30-day morbidity and mortality rates.

Discussion

An individual-level, stepped-wedge, randomised trial serves the purpose of providing an untreated comparison for the active treatment group, while at the same time allowing the waiting-listed participants an opportunity to obtain the intervention at a later date. In keeping with the basic ethical tenets of this design, the average waiting time for LVMR (12 weeks) will be shorter than that for routine services (24 weeks).

Trial registration

ISRCTN registry, ISRCTN11747152. Registered on 30 September 2015. The trial was prospectively registered (first patient enrolled on 21 March 2016).

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2456-3) contains supplementary material, which is available to authorized users.

Does Ventral Rectopexy Improve Pelvic Floor Function in the Long Term?

BACKGROUND

Information is needed on long-term functional results, sequelas, and outcome predictors for laparoscopic ventral mesh rectopexy.

OBJECTIVE

The purpose of this study was to evaluate long-term function postventral rectopexy in patients with external rectal prolapse or internal rectal prolapse in a large cohort and to identify the possible effects of patient-related factors and operative technical details on patient-reported outcomes.

DESIGN

This was a retrospective review with a cross-sectional questionnaire study.

SETTINGS

Data were collated from prospectively collected registries in 2 university and 2 central hospitals in Finland.

PATIENTS

All 508 consecutive patients treated with ventral rectopexy for external rectal prolapse or symptomatic internal rectal prolapse in 2005 to 2013 were included.

INTERVENTIONS

A questionnaire concerning disease-related symptoms and effect on quality of life was used.

MAIN OUTCOME MEASURES

Defecatory function measured by the Wexner score, the obstructive defecation score, and subjective symptom and quality-of-life evaluation using the visual analog scale were included. The effects of patient-related factors and operative technical details were assessed using multivariate analysis.

RESULTS

The questionnaire response rate was 70.7% (330/467 living patients) with a median follow-up time of 44 months. The mean Wexner scores were 7.0 (SD = 6.1) and 6.9 (SD = 5.6), and the mean obstructive defecation scores were 9.7 (SD = 7.6) and 12.3 (SD = 8.0) for patients presenting with external rectal prolapse and internal rectal prolapse. Subjective symptom relief was experienced by 76% and reported more often by patients with external rectal prolapse than with internal rectal prolapse (86% vs 68%; p < 0.001). Complications occurred in 11.4% of patients, and the recurrence rate for rectal prolapse was 7.1%.

LIMITATIONS

This study was limited by its lack of preoperative functional data and suboptimal questionnaire response rate.

CONCLUSIONS

Ventral mesh rectopexy effectively treats posterior pelvic floor dysfunction with a low complication rate and an acceptable recurrence rate. Patients with external rectal prolapse benefit more from the operation than those with symptomatic internal rectal prolapse. See Video Abstract at http://links.lww.com/DCR/A479.

Robot-Assisted Ventral Mesh Rectopexy for Rectal Prolapse: A 5-Year Experience at a Tertiary Referral Center

BACKGROUND

Laparoscopic ventral mesh rectopexy is being increasingly performed internationally to treat rectal prolapse syndromes. Robotic assistance appears advantageous for this procedure, but literature regarding robot-assisted ventral mesh rectopexy is limited.

OBJECTIVE

The primary objective of this study was to assess the safety and effectiveness of robot-assisted ventral mesh rectopexy in the largest consecutive series of patients to date.

DESIGN

This study is a retrospective cross-sectional analysis of prospectively collected data.

SETTINGS

The study was conducted in a tertiary referral center.

PATIENTS

All of the patients undergoing robot-assisted ventral mesh rectopexy for rectal prolapse syndromes between 2010 and 2015 were evaluated.

MAIN OUTCOME MEASURES

Preoperative and postoperative (mesh and nonmesh) morbidity and functional outcome were analyzed. The actuarial recurrence rates were calculated using the Kaplan-Meier method.

RESULTS

A total of 258 patients underwent robot-assisted ventral mesh rectopexy (mean ± SD follow-up = 23.5 ± 21.8 mo; range, 0.2 - 65.1 mo). There were no conversions and only 5 intraoperative complications (1.9%). Mortality (0.4%) and major (1.9%) and minor (<30 d) early morbidity (7.0%) were acceptably low. Only 1 (1.3%) mesh-related complication (asymptomatic vaginal mesh erosion) was observed. A significant improvement in obstructed defecation (78.6%) and fecal incontinence (63.7%) were achieved for patients (both p < 0.0005). At final follow-up, a new onset of fecal incontinence and obstructed defecation was induced or worsened in 3.9% and 0.4%. The actuarial 5-year external rectal prolapse and internal rectal prolapse recurrence rates were 12.9% and 10.4%.

LIMITATIONS

This was a retrospective study including patients with minimal follow-up. No validated scores were used to assess function. The study was monocentric, and there was no control group.

CONCLUSIONS

Robot-assisted ventral mesh rectopexy is a safe and effective technique to treat rectal prolapse syndromes, providing an acceptable recurrence rate and good symptomatic relief with minimal morbidity. See Video Abstract at http://links.lww.com/DCR/A427.

Temporary successful results of ventral rectopexy for enterocele surgical correction, about 138 patients

PURPOSE

This work aimed to analyse short- and long-term results of enterocele surgical treatment by ventral rectopexy.

METHODS

All females who underwent ventral rectopexy for enterocele in our department were included. All patients underwent standardized preoperative evaluation. Data was retrospectively collected, after examination of patients or by telephone survey. Postoperative evaluation was performed by an independent observer.

RESULTS

One hundred thirty-eight females (median age = 63 years [21-86 years]) were included. They were postmenopausal and multiparous in 94 and 70% of cases, respectively. Pelvic pressure, vaginal prolapse, or the both were observed in 28, 16 or 56% of the patients, respectively. The most frequent associated symptoms were dyschezia (63%) and faecal incontinence (30%). On preoperative workup, enterocele was isolated in two cases. Rectocele, internal rectal prolapse and cervicocystoptosis were the most frequently associated pelvic floor disorders. Ventral rectopexy was performed through laparoscopy in 128 patients (93%). In the short term, all pelvic symptoms were significantly improved, except urinary incontinence. At the end of follow-up (56 months [7-125]), specific symptoms and dyschezia were still significantly improved. Secondary failure was reported in 31% of patients. By multivariate analysis, two predictive factors for long-term failure were found: diagnosis of rectocele on preoperative MRI (odd ratio = 15; 95% CI 1.4-163; p = 0.03) and conversion into open surgery (odd ratio = 8; 95% CI 1.4-43; p = 0.02).

CONCLUSION

This study suggests that ventral rectopexy is an effective treatment of enterocele, but secondary failure can be observed. Patients should be informed of the potential risk of long-term degradation.

Short-term outcomes of laparoscopic ventral rectopexy for obstructed defecation in patients with overt pelvic structural abnormalities-a Chinese pilot study

AIM

As laparoscopic ventral rectopexy (LVR) gained increasing popularity in the past decade, studies from non-western area remain rare. The aim of this pilot study is to evaluate the efficacy and safety of LVR for obstructed defecation (OD) in Chinese patients with overt pelvic structural abnormalities.

METHODS

A series of 19 consecutive patients is presented undergoing LVR for OD. All patients showed various forms of pelvic structural abnormalities which were verified by dynamic defecography exam. Data was prospectively recorded and the functional outcomes were evaluated using the Cleveland Clinic Constipation Score (CCCS) and Patients Assessment of Constipation Quality of Life Score (PAC-QoL).

RESULTS

Pelvic structural abnormalities of the 19 patients included external rectal prolapse (ER) in 10.5% (2/19), high grade internal rectal prolapse (IR) in 57.8% (11/19), rectocele in 52.6% (10/19), enterocele in 15.7% (3/19), cystocele/vaginal prolapse in 15.7 (3/19), descending perineum (DP) in 63.5% (12/19). 89.4% patients (17/19) showed at least two co-existed abnormalities and 15.7% (3/19) showed multicompartmental abnormalities. The mean follow-up was 9 months (range 1-18). No mesh-related complication was observed. At last available follow-up (LAFU), improvement of OD symptom was observed in 15 (78.9%) patients, the mean scores of CCCS decreased from 17 to 10 (p < 0.05), all four subsets of PAC-QoL scores improved, and three of them (physical discomfort, worries and concerns, satisfaction) showed statistical significance (p < 0.05).

CONCLUSION

Laparoscopic ventral rectopexy appears to be a safe and effective procedure for obstructed defecation in Chinese patients with overt pelvic structural abnormalities in short-term follow-up.

Surgery for constipation: systematic review and practice recommendations: Results III: Rectal wall excisional procedures (Rectal Excision)

AIM

To assess the outcomes of rectal excisional procedures in adults with chronic constipation.

METHOD

Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements with a summative Oxford Centre for Evidence-Based Medicine (2009) level.

RESULTS

Forty-seven studies were identified, providing data on outcomes in 8340 patients. Average length of procedures was 44 min and length of stay (LOS) was 3 days. There was inadequate evidence to determine variations in procedural duration or LOS by type of procedure. Overall morbidity rate was 16.9% (0-61%), with lower rates observed after Contour Transtar procedure (8.9%). No mortality was reported after any procedures in a total of 5896 patients. Although inconsistently reported, good or satisfactory outcome occurred in 73-80% of patients; a reduction of 53-91% in Longo scoring system for obstructive defecation syndrome (ODS) occurred in about 68-76% of patients. The most common long-term adverse outcome is faecal urgency, typically occurring in up to 10% of patients. Recurrent prolapse occurred in 4.3% of patients. Patients with at least 3 ODS symptoms together with a rectocoele with or without an intussusception, who have failed conservative management, may benefit from a rectal excisional procedure.

CONCLUSION

Rectal excisional procedures are safe with little major morbidity. It is not possible to advise which excisional technique is superior from the point of view of efficacy, peri-operative variables, or harms. Future study is required.

Laparoscopic ventral rectopexy for rectal prolapse and rectal intussusception using a biological mesh

AIM

Laparoscopic ventral rectopexy (LVR) is a nerve-sparing technique for the treatment of rectal prolapse. Concerns about the use of synthetic meshes in the pelvis and the associated risk of erosion have led to the recent use of biological meshes in some colorectal units. This retrospective study aims to assess the outcomes of patients undergoing LVR using a noncross-linked nondermal biological mesh.

METHOD

The medical notes of all patients who underwent LVR between 1 December 2011 and 31 May 2014 were reviewed. The rate of obstructed defaecation before surgery was retrospectively determined from medical records using the Rome III criteria. The rates of obstructed defaecation and faecal incontinence following surgery were determined using a self-reported questionnaire.

RESULTS

A total of 51 patients had LVR between 1 December 2011 and 31 May 2014. Their mean age was 57.3 ± 2.5 years and the mean follow-up was 23 ± 1 months. There were seven (13.7%) postoperative complications. In total, 45 (88%) patients completed the functional outcome questionnaires. Before surgery, 33 (73.3%) patients complained of symptoms of obstructed defaecation. At the end of follow-up, 22 (48.8%, P = 0.001) patients continued to have some symptoms of obstructed defaecation. Before surgery, 12 (26.7%) patients complained of faecal incontinence. At the end of follow-up, only three (6.7%, P = 0.004) patients reported faecal incontinence. At the end of follow-up, recurrence of symptoms had occurred in six (13.3%) patients.

CONCLUSION

LVR using a biological mesh is safe and results in significant reduction in symptoms associated with external rectal prolapse and rectal intussusception.

Internal rectal prolapse: Definition, assessment and management in 2016

Internal rectal prolapse (IRP) is a well-recognized pelvic floor disorder mainly seen during defecatory straining. The symptomatic expression of IRP is complex, encompassing fecal continence (56%) and/or evacuation disorders (85%). IRP cannot be characterized easily by clinical examination alone and the emergence of dynamic defecography (especially MRI) has allowed a better comprehension of its pathophysiology and led to the proposition of a severity score (Oxford score) that can guide management. Decision for surgical management should be multidisciplinary, discussed after a complete work-up, and only after medical treatment has failed. Information should be provided to the patient, outlining the goals of treatment, the potential complications and results. Stapled trans-anal rectal resection (STARR) has been considered as the gold standard for IRP treatment. However, inconsistent results (failure observed in up to 20% of cases, and fecal incontinence occurring in up to 25% of patients at one year) have led to a decrease in its indications. Laparoscopic ventral mesh rectopexy has substantial advantages in solving the functional problems due to IRP (efficacy on evacuation and resolution of continence symptoms in 65-92%, and 73-97% of patients, respectively) and is currently considered as the gold standard therapy for IRP once the decision to operate has been made.

Incidence and surgical treatment of synthetic mesh-related infectious complications after laparoscopic ventral rectopexy

BACKGROUND

Prosthetic-related infection and erosion occurring after a laparoscopic ventral rectopexy (LVR) are rare complications, and their importance is often underestimated. The aim of this study was to compare the incidence rate and surgical management of these complications in LVR patients with polyester (PE) or polypropylene (PP) prostheses.

METHODS

From January 2004 to June 2012, 149 patients underwent LVR with PE and 176 underwent LVR with PP. Surgical management and rate of infectious and erosive prosthesis-related complications, depending on the type of prosthesis, were described and compared. Functional results after complications were assessed.

RESULTS

Five patients from the PE prosthesis group (3.3 %), compared with two patients from the PP prosthesis group (1.1 %), experienced prosthesis-related infection or erosion (p = 0.16). The rate of erosion alone was 3.3 % in patients with a PE prosthesis, and 0.55 % in patients with a PP prosthesis (p = 0.06). The average time until clinical diagnosis of a prosthesis-related complication was identical for both groups: 31 months (range 3-62 months). All patients underwent surgical removal of the prosthesis: For the five patients from the PE group, complete removal was performed by laparoscopy associated with a transanal procedure. For the two patients in the PP mesh group, laparoscopy was ineffective in removing the mesh which was partially removed through a subsequent transanal procedure. None of the patients had a protective stoma, and in all patients the complication had resolved 12 months after removal. Only one patient had worsening functional symptoms (fecal incontinence) after prosthesis removal.

CONCLUSIONS

When a prosthesis-related infection or erosion occurs, treatment consists in the surgical removal of the prosthesis by laparoscopy/and/or a transanal procedure. Functional symptoms do not routinely recur after prosthesis removal.