Ventral colporectopexy for overt rectal prolapse and obstructed defaecation syndrome: a systematic review

Rectocele with obstructive defecation syndrome: Laparoscopic rectopexy or vaginal repair?

INTRODUCTION

The concomitant presence of a rectocele with obstructive defecation syndrome (ODS) is highly probable. The purpose of this study was to evaluate the effectiveness of native tissue vaginal rectocele repair (VRR) and laparoscopic ventral mesh rectopexy (LVMR) in terms of functional outcome via the medium to long-term ODS score evaluation.

MATERIAL

This was a retrospective cohort study. We identified 30 patients having undergone LVMR for rectocele with defecatory symptoms between January 2015 and December 2021, matched with the same number of patients treated by VRR for the same indication and in the same period. The hypothesis was that both procedures were susceptible to lead to a favorable functional outcome. The main endpoint was ODS score at follow-up. Multivariate analysis was used to assess relationship between ODS score and type of surgery.

RESULTS

Patients' demographics were similar in both groups. However, the preoperative ODS score was significantly higher in the LVMR group (P<0.01). Furthermore, the use of preoperative imaging investigations and diagnosis of an associated rectal intussusception were more frequent in the LVMR group. The mean ODS scores at follow-up (median follow-up 5years) were comparable in the two groups (6.2 for LVMR and 4.43 for VRR). These scores were significantly reduced compared to preoperative values in both groups (P<0.0001).

CONCLUSIONS

There was a significant reduction in ODS scores on medium/long-term follow-up with both surgical techniques. A larger study utilizing randomized comparison of both procedures is needed to confirm our findings.

LEVEL OF EVIDENCE: 4

Analysis of factors that indicated surgery in 400 patients submitted to a complete diagnostic workup for obstructed defecation syndrome and rectal prolapse using a supervised machine learning algorithm

BACKGROUND

Patient selection is extremely important in obstructed defecation syndrome (ODS) and rectal prolapse (RP) surgery. This study assessed factors that guided the indications for ODS and RP surgery and their specific role in our decision-making process using a machine learning approach.

METHODS

This is a retrospective analysis of a long-term prospective observational study on female patients reporting symptoms of ODS who underwent a complete diagnostic workup from January 2010 to December 2021 at an academic tertiary referral center. Clinical, defecographic, and other functional tests data were assessed. A supervised machine learning algorithm using a classification tree model was performed and tested.

RESULTS

A total of 400 patients were included. The factors associated with a significantly higher probability of undergoing surgery were follows: as symptoms, perineal splinting, anal or vaginal self-digitations, sensation of external RP, episodes of fecal incontinence and soiling; as physical examination features, evidence of internal and external RP, rectocele, enterocele, or anterior/middle pelvic organs prolapse; as defecographic findings, intra-anal and external RP, rectocele, incomplete rectocele emptying, enterocele, cystocele, and colpo-hysterocele. Surgery was less indicated in patients with dyssynergia, severe anxiety and depression. All these factors were included in a supervised machine learning algorithm. The model showed high accuracy on the test dataset (79%, p < 0.001).

CONCLUSIONS

Symptoms assessment and physical examination proved to be fundamental, but other functional tests should also be considered. By adopting a machine learning model in further ODS and RP centers, indications for surgery could be more easily and reliably identified and shared.

Comparative study of laparoscopic ventral mesh rectopexy versus perineal stapler resection for external full-thickness rectal prolapse in elderly patients: enhanced outcomes and reduced recurrence rates-a retrospective cohort study

BACKGROUND

In elderly patients with external full-thickness rectal prolapse (EFTRP), the exact differences in postoperative recurrence and functional outcomes between laparoscopic ventral mesh rectopexy (LVMR) and perineal stapler resection (PSR) have not yet been investigated.

METHODS

We conducted a retrospective multicenter study on 330 elderly patients divided into LVMR group (n = 250) and PSR (n = 80) from April 2012 to April 2019. Patients were evaluated before and after surgery by Wexner incontinence scale, Altomare constipation scale, and patient satisfaction questionnaire. The primary outcomes were incidence and risk factors for EFTRP recurrence. Secondary outcomes were postoperative incontinence, constipation, and patient satisfaction.

RESULTS

LVMR was associated with fewer postoperative complications (p < 0.001), lower prolapse recurrence (p < 0.001), lower Wexner incontinence score (p = 0.03), and lower Altomare's score (p = 0.047). Furthermore, LVMR demonstrated a significantly higher surgery-recurrence interval (p < 0.001), incontinence improvement (p = 0.019), and patient satisfaction (p < 0.001) than PSR. Three and 13 patients developed new symptoms in LVMR and PSR, respectively. The predictors for prolapse recurrence were LVMR (associated with 93% risk reduction of recurrence, OR 0.067, 95% CI 0.03-0.347, p = 0.001), symptom duration (prolonged duration was associated with an increased risk of recurrence, OR 1.131, 95% CI 1.036-1.236, p = 0.006), and length of prolapse (increased length was associated with a high recurrence risk (OR = 1.407, 95% CI = 1.197-1.655, p < 0.001).

CONCLUSIONS

LVMR is safe for EFTRP treatment in elderly patients with low recurrence, and improved postoperative functional outcomes.

TRIAL REGISTRATION

Clinical Trial.gov (NCT05915936), retrospectively registered on June 14, 2023.

The patient with obstructed defecatory symptoms: Management differs considerably between physicians and surgeons

BACKGROUND

Patients with obstructed defecatory symptoms (ODS) are commonly referred to either gastroenterologists (GE) or colorectal surgeons (CS). Further management of these patients may be impacted by this choice of referral.

METHODS

An online survey of specialist practice was disseminated to GE and CS in Australia and New Zealand. A case vignette of a patient presenting with ODS was described, with multiple subsequent scenarios designed to delineate the responder's preferred approach to management of this patient.

KEY RESULTS

A total of 107 responders participated in the study, 62 CS and 45 GE. For a female patient with ODS not responding to pharmacological treatment, GE were more likely than CS to refer patients for anorectal manometry, while CS were more likely to refer for dynamic imaging. A quarter of CS and GE referred patients directly to pelvic floor physiotherapy, without any pre-treatment testing. Knowing the result of dynamic imaging, especially if a rectocele was demonstrated, substantially influenced management for both of the specialties: GE became more likely to refer the patients for CS consultation and less likely to refer directly for biofeedback or physiotherapy and CS were more likely to opt for an operative pathway over conservative management than they were prior to knowledge of the imaging findings. The majority (>75%) of GE and CS did not find it necessary to obtain a gynecological consultation, even in the presence of a rectocele.

CONCLUSIONS & INFERENCES

Practice variation across medical specialties affects diagnostic and management recommendations for patients with ODS, impacting treatment pathways. Our findings provide an incentive toward establishing interdisciplinary, uniform, management guidelines.

Tunneling of Mesh during Ventral Rectopexy: Technical Aspects and Long-Term Functional Results

Avoiding the extensive damage of pelvic structures during ventral rectopexy could minimize secondary disfunctions. The objective of our observational study is to assess the safety and functional efficacy of a modified ventral rectopexy. In the modified ventral rectopexy, a retroperitoneal tunnel was created along the right side of rectum, connecting two peritoneal mini-incisions at the Douglas pouch and sacral promontory. The proximal edge of a polypropylene mesh, sutured over the ventral rectum, was pulled up through the retroperitoneal tunnel and fixed to the sacral promontory. In all patients, radiopaque clips were placed on the mesh, making it radiographically "visible". Before surgery and at follow up visits, Altomare, Longo, CCSS, PAC-SYM, and CCFI scores were collected. From March 2010 to September 2021, 117 patients underwent VR. Modified ventral rectopexy was performed in 65 patients, while the standard ventral rectopexy was performed in 52 patients. The open approach was used in 97 cases (55 and 42 patients in modified and standard VR, respectively), while MI surgery was used in 20 cases (10 and 10 patients in modified and standard VR, respectively). A slightly shorter operative time and hospital stay were observed following modified ventral rectopexy (though this was not statistically significant). Similar overall complication rates were registered in the modified vs. standard ventral rectopexies (4.6% vs. 5.8%, p = 0.779). At follow-up, the Longo score (14.0 ± 8.6 vs. 11.0 ± 8.2, p = 0.042) and "delta" values of Altomare (9.2 ± 6.1 vs. 5.9 ± 6.3, p = 0.008) and CCSS (8.4 ± 6.3 vs. 6.1 ± 6.1, p = 0.037) scores were significantly improved in the modified ventral rectopexy group. A similar occurrence of symptoms recurrence was diagnosed in the two groups. Radiopaque clips helped to accurately diagnose mesh detachment/dislocation. The proposed modified VR seems to be feasible and safe. Marking the mesh intraoperatively seems useful.

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.

Ventral Prosthesis Rectopexy for obstructed defaecation syndrome: a systematic review and meta-analysis

Obstructed Defecation Syndrome (ODS) is a rather complex entity concerning mainly females and causing primarily constipation. Surgical treatment in the form of Ventral Prosthesis Rectopexy (VPR) has been proposed and seems to have the best outcomes. However, the selection criteria of patients to undergo this kind of operation are not clear and the reported outcomes are mainly short-term and data on long-term outcomes is scarce. This study assesses new evidence on the efficacy of VPR for the treatment of ODS, specifically focusing on inclusion criteria for surgery and the long-term outcomes. A search was performed of MEDLINE, EMBASE, Ovid and Cochrane databases on all studies reporting on VPR for ODS from 2000 to March 2020. No language restrictions were made. All studies on VPR were reviewed systematically. The main outcomes were intra-operative complications, conversion, procedure duration, short-term mortality and morbidity, length of stay, faecal incontinence and constipation, quality of life (QoL) score and patient satisfaction. Quality assessment and data extraction were performed independently by three observers. Fourteen studies including 963 patients were eligible for analysis. The immediate postoperative morbidity rate was 8.9%. A significant improvement in constipation symptoms was observed in the 12-month postoperative period for ODS (p < 0.0001). Current evidence shows that VPR offers symptomatic relief to the majority of patients with ODS, improving both constipation-like symptoms and faecal incontinence for at least 1-2 years postoperatively. Some studies report on functional results after longer follow-up, showing sustainable improvement, although in a lesser extent.

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.

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.

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.

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.

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.

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.

Should we offer ventral rectopexy to patients with recurrent external rectal prolapse?

BACKGROUND

For patients with rectal prolapse undergoing Ventral Rectopexy (VR), the impact of prior prolapse surgery on prolapse recurrence is not well described.

PURPOSE

The purpose of this study was to compare recurrence rates after VR in patients undergoing primary and repeat rectal prolapse repairs.

DESIGN

This study is a prospective cohort study.

METHODS

IRB-approved prospective data registry of consecutive patients undergoing VR for full-thickness external rectal prolapse between 2009 and 2015.

MAIN OUTCOME MEASURES

Rectal prolapse recurrence was defined as either external prolapse through the anal sphincters or symptomatic rectal mucosa prolapse warranting additional surgery. Preoperative and postoperative morbidity and functional outcomes were analyzed. Actuarial recurrence rates were calculated using the Kaplan-Meier method.

RESULTS

A total of 108 VRs were performed during the study period. Seventy-two were primary and 36 repeat repairs. Seven cases were open, 23 laparoscopic, and 78 robotic. Six cases were converted from laparoscopic/robotic to open. In 63 patients, VR was combined with gynecological procedures. There were no statistical differences between primary or recurrent prolapse for the following: demographics, operative time, concomitant gynecologic procedures, complications, blood loss, and graft material type. Length of stay was longer in patients with a history of prior prolapse surgery (p = 0.01). Prolapse recurrence rates for primary repairs were reported at 1.4, 6.9, and 9.7% and for recurrent prolapse procedures 13.9, 25, and 25% at 1, 3, and 5 years (p = 0.13). Mean length of follow-up was similar between groups. Time to recurrence was significantly shorter in patients undergoing repeat prolapse surgery 8.8 vs 30.7 months (p = 0.03).

CONCLUSIONS

VR is a better option for patients undergoing primary rectal prolapse repair.

Surgery for constipation: systematic review and practice recommendations: Results II: Hitching procedures for the rectum (rectal suspension)

AIM

To assess the outcomes of rectal suspension procedures (forms of rectopexy) 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

Eighteen articles were identified, providing data on outcomes in 1238 patients. All studies reported only on laparoscopic approaches. Length of procedures ranged between 1.5 to 3.5 h, and length of stay between 4 to 5 days. Data on harms were inconsistently reported and heterogeneous, making estimates of harm tentative and imprecise. Morbidity rates ranged between 5-15%, with mesh complications accounting for 0.5% of patients overall. No mortality was reported after any procedures in a total of 1044 patients. Although inconsistently reported, good or satisfactory outcome occurred in 83% (74-91%) of patients; 86% (20-97%) of patients reported improvements in constipation after laparoscopic ventral mesh rectopexy (LVMR). About 2-7% of patients developed anatomical recurrence. Patient selection was inconsistently documented. As most common indication, high grade rectal intussusception was corrected in 80-100% of cases after robotic or LVMR. Healing of prolapse-associated solitary rectal ulcer syndrome occurred in around 80% of patients after LVMR.

CONCLUSION

Evidence supporting rectal suspension procedures is currently derived from poor quality studies. Methodologically robust trials are needed to inform future clinical decision making.

Synthetic Versus Biological Mesh-Related Erosion After Laparoscopic Ventral Mesh Rectopexy: A Systematic Review

Purpose

This review reports the incidence of mesh-related erosion after ventral mesh rectopexy to determine whether any difference exists in the erosion rate between synthetic and biological mesh.

Methods

A systematic search of the MEDLINE and the Ovid databases was conducted to identify suitable articles published between 2004 and 2015. The search strategy capture terms were laparoscopic ventral mesh rectopexy, laparoscopic anterior rectopexy, robotic ventral rectopexy, and robotic anterior rectopexy.

Results

Eight studies (3,956 patients) were included in this review. Of those patients, 3,517 patients underwent laparoscopic ventral rectopexy (LVR) using synthetic mesh and 439 using biological mesh. Sixty-six erosions were observed with synthetic mesh (26 rectal, 32 vaginal, 8 recto-vaginal fistulae) and one (perineal erosion) with biological mesh. The synthetic and the biological mesh-related erosion rates were 1.87% and 0.22%, respectively. The time between rectopexy and diagnosis of mesh erosion ranged from 1.7 to 124 months. No mesh-related mortalities were reported.

Conclusion

The incidence of mesh-related erosion after LVR is low and is more common after the placement of synthetic mesh. The use of biological mesh for LVR seems to be a safer option; however, large, multicenter, randomized, control trials with long follow-ups are required if a definitive answer is to be obtained.

Risk Factors for Recurrence After Laparoscopic Ventral Rectopexy

BACKGROUND

Laparoscopic ventral rectopexy effectively treats posterior compartment prolapse. However, recurrence after laparoscopic ventral rectopexy is poorly understood.

OBJECTIVE

This study aimed to evaluate factors contributing to recurrence after laparoscopic ventral rectopexy.

DESIGN

A retrospective cohort analysis was performed of patients who underwent laparoscopic ventral rectopexy between June 2008 and June 2014. Patients presenting with full-thickness rectal prolapse were compared against the rest. Cox proportional hazards regression was used to determine predictors for recurrence. Operative findings of redo cases were evaluated.

SETTINGS

This study was conducted under the supervision of a single pelvic floor surgeon.

PATIENTS

A total of 231 patients with a median follow-up of 47 months were included.

MAIN OUTCOME MEASURES

Clinicopathological risk factors and technical failures contributing to recurrence were analyzed.

RESULTS

The overall recurrence rate was 11.7% (n = 27). Twenty-five recurrences occurred in patients with full-thickness rectal prolapse, of which 16 were full-thickness recurrences (14.2% (16/113)). Multivariate analyses showed predictors for recurrence to be prolonged pudendal nerve terminal motor latency (HR = 5.57 (95% CI, 1.13 - 27.42); p = 0.04) and the use of synthetic mesh as compared with biologic grafts (HR = 4.24 (95% CI, 1.27-14.20); p = 0.02). Age >70 years and poorer preoperative continence were also associated with recurrence on univariate analysis. Technical failures contributing to recurrence included mesh detachment from the sacral promontory and inadequate midrectal mesh fixation.

LIMITATIONS

Modifications to the operative technique were made throughout the study period. A postoperative defecating proctogram was not routinely performed.

CONCLUSIONS

Recurrence after laparoscopic ventral rectopexy is multifactorial, and risk factors are both clinical and technical. The use of biologic grafts was associated with lower recurrence as compared with synthetic mesh. Patients with full-thickness rectal prolapse who are elderly, have poorer baseline continence, and have prolonged pudendal nerve terminal motor latency are at increased risk of recurrence.

Diagnostic disagreement between tests of evacuatory function: a prospective study of 100 constipated patients

BACKGROUND

Evacuatory dysfunction (ED) is a common cause of constipation and may be sub-classified on the basis of specialist tests. Such tests may guide treatment e.g., biofeedback therapy for 'functional' defecatory disorders (FDD). However, there is no gold standard, and prior studies have not prospectively and systematically compared all tests that are used to diagnose forms of ED.

METHODS

One hundred consecutive patients fulfilling Rome III criteria for functional constipation underwent four tests: expulsion of a rectal balloon distended to 50 mL (BE50 ) or until patients experienced the desire to defecate (BEDDV ), evacuation proctography (EP) and anorectal manometry. Yields and agreements between tests for the diagnosis of ED and FDD were assessed.

KEY RESULTS

Positive diagnostic yields for ED were: BEDDV 18%, BE50 31%, EP 38% and anorectal manometry (ARM) 68%. Agreement was substantial between the two balloon tests (k = 0.66), only fair between proctography and BE50 (k = 0.27), poor between manometry and proctography (k = 0.01), and there was no agreement between the balloon tests and manometry (k = -0.07 for both BE50 and BEDDV ). For the diagnosis of FDD, there was only fair agreement between ARM and EP (k = 0.23), ARM ± BE50 and EP (k = 0.18), ARM and EP ± BE50 (k = 0.30) and ARM ± BE50 and EP ± BE50 (k = 0.23).

CONCLUSIONS & INFERENCES

There is considerable disagreement between the results of various tests used to diagnose ED and FDD. This highlights the need for a reappraisal of both diagnostic criteria, and what represents the 'gold standard' investigation.

Robot-Assisted Sacrocolporectopexy for Multicompartment Prolapse of the Pelvic Floor: A Prospective Cohort Study Evaluating Functional and Sexual Outcome

BACKGROUND

Pelvic floor disorders are a major public health issue. For female genital prolapse, sacrocolpopexy is the gold standard. Laparoscopic ventral mesh rectopexy is a relatively new and promising technique correcting rectal prolapse. There is no literature combining the 2 robotically assisted techniques.

OBJECTIVE

This study was designed to evaluate the safety, quality of life, and functional and sexual outcomes of robot-assisted sacrocolporectopexy for multicompartment prolapse of the pelvic floor.

DESIGN

This was a prospective, observational cohort study.

SETTINGS

The study was conducted in a tertiary care setting.

PATIENTS

All sexually active patients undergoing robot-assisted sacrocolporectopexy at our institution between 2012 and 2014 were included.

INTERVENTION

Robot-assisted sacrocolporectopexy was the study intervention.

MAIN OUTCOME MEASURES

Preoperative and postoperative (12 months) questionnaires using the Urinary Distress Inventory, Pescatori Incontinence Scale, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, and Pelvic Floor Impact Questionnaire were completed. In addition Wexner and Vaizey incontinence scores and the Wexner constipation score were recorded postoperatively.

RESULTS

Fifty-one patients underwent robot-assisted sacrocolporectopexy (median follow-up, 12.5 months). The simplified Pelvic Organ Prolapse Quantification improved significantly (p < 0.0005) for all 4 of the anatomic landmarks. Both median fecal (preoperative and postoperative Pescatori 4 vs 3, p = 0.002) and urinary incontinence scores (Urinary Distress Inventory, 27.8 vs 22.2; p < 0.0005) improved significantly at 12 months. Postoperatively median Wexner (3) and Vaizey incontinence (6) and Wexner Constipation (7) scores were noted. A positive effect on sexual function (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire score 31.8 vs 35.9; p = 0.002) and quality of life for each compartment (p < 0.0005) was observed. One patient (2%) developed mesh erosion. No multicompartment recurrences were detected.

LIMITATIONS

This was a observational study with a limited follow-up, no control group, and no preoperatively validated constipation score.

CONCLUSIONS

Robot-assisted sacrocolporectopexy is a safe and effective technique for multicompartment prolapse in terms of functional outcome, quality of life, and sexual function.

Robot-assisted vs laparoscopic ventral rectopexy for external or internal rectal prolapse and enterocele: a randomized controlled trial

AIM

The purpose of this prospective randomized study was to compare robot-assisted and laparoscopic ventral rectopexy procedures for posterior compartment procidentia in terms of restoration of the anatomy using magnetic resonance (MR) defaecography.

METHOD

Sixteen female patients (four with total prolapse, twelve with intussusception) underwent robot-assisted ventral mesh rectopexy (RVMR) and 14 female patients (two with prolapse, twelve with intussusception) laparoscopic ventral mesh rectopexy (LVMR). Primary outcome measures were perioperative parameters, complications and restoration of anatomy as assessed by MR defaecography, which was performed preoperatively and 3 months after surgery.

RESULTS

Patient demographics, operation length, operating theatre times and length of in-hospital stay were similar between the groups. The anatomical defects of rectal prolapse, intussusception and rectocele and enterocele were similarly corrected after rectopexy in either technique as confirmed with dynamic MR defaecography. A slight residual intussusception was observed in three patients with primary total prolapse (two RVMR vs one LVMR) and in one patient with primary intussusception (RVMR) (P = 0.60). Rectocele was reduced from a mean of 33.0 ± 14.9 mm to 5.5 ± 8.4 mm after RVMR (P < 0.001) and from 24.7 ± 17.5 mm to 7.2 ± 3.2 mm after LVMR (P < 0.001) (RVMR vs LVMR, P = 0.10).

CONCLUSION

Robot-assisted laparoscopic ventral rectopexy can be performed safely and within the same operative time as conventional laparoscopy. Minimally invasive ventral rectopexy allows good anatomical correction as assessed by MR defaecography, with no differences between the techniques.

A novel technique of introducing the mesh at the distal dissection while performing laparoscopic ventral rectopexy

AIM

Laparoscopic ventral rectopexy (LVR) is considered an effective treatment for rectal prolapse and/or rectoanal intussusception. After the dissection of the rectovaginal septum down to the pelvic floor, a strip of mesh is introduced and should be secured as distally as possible. We have developed a novel technique of introducing the mesh at the distal dissection.

METHOD

A nylon thread with straight needle was passed through the posterior wall of vagina at the distal extent of the dissection, which was caught in the abdominal cavity and fixed at the end of the mesh extracorporeally. The mesh was then introduced, pulled toward the pelvic floor and settled at the pierced site by the perineal operator.

RESULTS

Sixty-eight female patients underwent LVR using this technique. There were no intra-operative and postoperative mesh-related complications. The mean distance from the vaginal ostium to the point of passing a nylon thread through the posterior wall of the vagina was 2 cm. Postoperative proctography showed the anatomical correction in 47 of the 48 patients who were examined.

CONCLUSION

The surgeon can confirm that the mesh is introduced and secured at the distal dissection by using this technique while performing LVR.

[Alloplastic material in prolapse surgery : Indications and postoperative outcome of ventral rectopexy]

BACKGROUND

In rectopexy the use of meshes provides stability by mechanical support as well as by the induction of scar formation; however, one of the problems of conventional methods of mesh rectopexy is that many patients postoperatively suffer from functional disorders, such as fecal incontinence and stool evacuation disorders. One reason is the damage of vegetative nerves following dorsal and lateral mobilization of the rectum, which is required for positioning of the mesh. In 2004 D'Hoore and Penninckx first described the method of ventral rectopexy, a new technique of mesh rectopexy which allows preservation of the autonomic nerves.

OBJECTIVE

Does ventral rectopexy provide advantages regarding functional outcome, complications and recurrence rates?

MATERIAL AND METHODS

A search was carried out in the databases PubMed and Medline for studies on ventral rectoplexy. Presentation and analysis of the current state of relevant studies relating to ventral rectopexy.

RESULTS

Ventral rectopexy is characterized by a low complication rate and good functional results in terms of improvement of incontinence, constipation and stool evacuation disorders. The indications for ventral rectopexy are considered in patients with external prolapse of the rectum. Also in a well-selected patient population internal prolapse, rectocele as well as enterocele accompanied by obstructive defecation syndrome represent relative indications for ventral rectopexy.

CONCLUSION

In order to obtain a valid assessment of the value of this procedure it is crucial to improve the current lack of evidence (level 3) by prospective randomized studies that compare ventral rectopexy with other surgical techniques and nonsurgical treatment options.

Current status of laparoscopic and robotic ventral mesh rectopexy for external and internal rectal prolapse

External and internal rectal prolapse with their affiliated rectocele and enterocele, are associated with debilitating symptoms such as obstructed defecation, pelvic pain and faecal incontinence. Since perineal procedures are associated with a higher recurrence rate, an abdominal approach is commonly preferred. Despite the description of greater than three hundred different procedures, thus far no clear superiority of one surgical technique has been demonstrated. Ventral mesh rectopexy (VMR) is a relatively new and promising technique to correct rectal prolapse. In contrast to the abdominal procedures of past decades, VMR avoids posterolateral rectal mobilisation and thereby minimizes the risk of postoperative constipation. Because of a perceived acceptable recurrence rate, good functional results and low mesh-related morbidity in the short to medium term, VMR has been popularized in the past decade. Laparoscopic or robotic-assisted VMR is now being progressively performed internationally and several articles and guidelines propose the procedure as the treatment of choice for rectal prolapse. In this article, an outline of the current status of laparoscopic and robotic ventral mesh rectopexy for the treatment of internal and external rectal prolapse is presented.

[Complications after rectal prolapse surgery]

Major complications only rarely occur after rectal prolapse surgery. Generally, the spectrum of possible complications should always be considered depending on the selected surgical procedure. Minor complications in all techniques have been described in up to 36 %. The commonest complication is bleeding with 2-5 %, urinary tract infections and wound infections. Finally, the risk of recurrence must be considered, which shows substantial differences (4-40 %); therefore, no operation technique can be given preference based solely on the risk of recurrence. Therapy decisions are always more individualized and must take the personal environment of the patient as well as the experience of the surgeon into consideration.

[Rectosacropexy in rectal prolapse management]

AIM

To compare results of rectosacropexy and posterior-loop rectopexy in rectal prolapse management.

MATERIAL AND METHODS

Study included 122 patients operated for rectal prolapse for the period January 2007 to August 2014. Patients' age ranged from 19 to 85 years (mean 47.3±16.1). Main group consisted of 60 (49.2%) patients who underwent rectosacropexy (D'Hoore's procedure). Control group included 62 (50.8%) patients in whom posterior-loop rectopexy was applied (Wells's procedure).

RESULTS

Long-term results were followed-up in 94 (77.0%) patients including 48 and 46 from main and control group respectively. Recurrent prolaple incidence after rectosacropexy and posterior-loop rectopexy was 2% and 8.7% respectively. Multivariant analysis statistically confirmed that postoperative impaired colon motility was independent risk factor of recurrence. Recurrent disease is observed 5.7 times more often in this case. Rectosacropexy does not significantly impair colon motility because of ileus occurs in 8.3% of operated patients. Impovement of anal continence does not depend on rectopexy method and occurs in all patients with degree 1-2 of anal sphincter failure.

CONCLUSION

Rectosacropexy may be preferred in rectal prolapse. However, further highly significant studies are necessary to optimize rectal prolapse management.

Long-term Outcome After Laparoscopic Ventral Mesh Rectopexy: An Observational Study of 919 Consecutive Patients

OBJECTIVE

This multicenter study aims to assess long-term functional outcome, early and late (mesh-related) complications, and recurrences after laparoscopic ventral mesh rectopexy (LVR) for rectal prolapse syndromes in a large cohort of consecutive patients.

BACKGROUND

Long-term outcome data for prolapse repair are rare. A high incidence of mesh-related problems has been noted after transvaginal approaches using nonresorbable meshes.

METHODS

All patients treated with LVR at the Meander Medical Centre, Amersfoort, the Netherlands and the University Hospital Leuven, Belgium between January 1999 and March 2013 were enrolled in this study. All data were retrieved from a prospectively maintained database. Kaplan-Meier estimates were calculated for recurrences and mesh-related problems.

RESULTS

919 consecutive patients (869 women; 50 men) underwent LVR. A 10-year recurrence rate of 8.2% (95% confidence interval, 3.7-12.7) for external rectal prolapse repair was noted. Mesh-related complications were recorded in 18 patients (4.6%), of which mesh erosion to the vagina occurred in 7 patients (1.3%). In 5 of these patients, LVR was combined with a perineotomy. Both rates of fecal incontinence and obstructed defecation decreased significantly (P < 0.0001) after LVR compared to the preoperative incidence (11.1% vs 37.5% for incontinence and 15.6% vs 54.0% for constipation).

CONCLUSIONS

LVR is safe and effective for the treatment of different rectal prolapse syndromes. Long-term recurrence rates are in line with classic types of mesh rectopexy and occurrence of mesh-related complications is rare.

High-grade hemorrhoids requiring surgical treatment are common after laparoscopic ventral mesh rectopexy

Purpose

To describe patients developing grade III and IV hemorrhoids requiring surgery after laparoscopic ventral mesh rectopexy (LVMR) and to explore the relationship between developing such hemorrhoids and recurrence of rectal prolapse after LVMR.

Methods

All consecutive patients receiving LVMR at the Meander Medical Centre, Amersfoort, the Netherlands, between 2004 and 2013 were analyzed. Kaplan–Meier estimates were calculated for recurrences.

Results

A total of 420 patients underwent LVMR. Sixty-five of these patients (actuarial 5-year incidence 24.3, 95 % confidence interval (CI) 18.6–30.0) developed symptomatic grade III/IV hemorrhoids requiring stapled or excisional hemorrhoidectomy. Re-do surgery for recurrent grade III/IV hemorrhoids was required for 15 of the 65 patients (actuarial 5-year recurrence rate 40.6, 95 % CI 23.2–58.0) after the primary hemorrhoidectomy. Three of the 65 patients developed an external rectal prolapse (ERP) recurrence and eight an internal rectal prolapse (IRP) recurrence. This generated a 5-year recurrence rate of 25.3 % (95 % CI 0–53.9) for ERP recurrence and 24.4 % (95 % CI 9.1–39.7) for IRP recurrence. The rest of the LVMR cohort not receiving additional surgery for hemorrhoids (n = 355) showed significantly lower actuarial 5-year ERP (0.8 %, p = 0.011) and IRP (11 %, p = 0.020) recurrence rates.

Conclusion

High-grade hemorrhoids requiring surgery may be common after LVMR. The development of high-grade hemorrhoids after LVMR might be considered a predictor of rectal prolapse recurrence.

Laparoscopic surgery for rectal prolapse and pelvic floor disorders

Pelvic floor disorders are different dysfunctions of gynaecological, urinary or anorectal organs, which can present as incontinence, outlet-obstruction and organ prolapse or as a combination of these symptoms. Pelvic floor disorders affect a substantial amount of people, predominantly women. Transabdominal procedures play a major role in the treatment of these disorders. With the development of new techniques established open procedures are now increasingly performed laparoscopically. Operation techniques consist of various rectopexies with suture, staples or meshes eventually combined with sigmoid resection. The different approaches need to be measured by their operative and functional outcome and their recurrence rates. Although these operations are performed frequently a comparison and evaluation of the different methods is difficult, as most of the used outcome measures in the available studies have not been standardised and data from randomised studies comparing these outcome measures directly are lacking. Therefore evidence based guidelines do not exist. Currently the laparoscopic approach with ventral mesh rectopexy or resection rectopexy is the two most commonly used techniques. Observational and retrospective studies show good functional results, a low rate of complications and a low recurrence rate. As high quality evidence is missing, an individualized approach is recommend for every patient considering age, individual health status and the underlying morphological and functional disorders.

Is robotic ventral mesh rectopexy better than laparoscopy in the treatment of rectal prolapse and obstructed defecation? A meta-analysis

Ventral mesh rectopexy is an approach in the treatment of internal and external rectal prolapse and rectocele. Our aim was to assess whether robotic surgery confers any significant advantages over laparoscopy, and the associated complication rate. Two reviewers performed a literature search using MEDLINE and PubMed databases for studies comparing robotic versus laparoscopic surgery. Five prospective, non-randomised studies were identified and included. A total of 244 patients (101 robotic and 143 laparoscopic) were included in the analysis. Operative time was shorter with laparoscopic surgery, mean weighted difference 27.94 [confidence interval (CI) 19.30-36.57; p < 0.00001]. The conversion rate was not significantly different between groups. There was a trend towards a reduction in length of inpatient stay and early post-operative complications in the robotic group; however, these did not reach statistical significance. Recurrence rates were similar between groups (odds ratio 0.91, CI 0.32-2.63; p = 0.87). Functional results were comparable between groups. Early studies show that robotic ventral rectopexy is a safe option compared to the laparoscopic approach, with overall comparable results. There appeared to be a trend towards a reduction in length of inpatient stay and post-operative complications. These perceived benefits may offset the longer operative times and outlay costs. Larger randomised controlled trials are needed to further evaluate clinical value and cost-effectiveness.