Laparoscopic Vaginal Suspension and Rectopexy for Rectal Prolapse

Modified robotic ventral rectopexy with folded single titanized mesh suspension for the treatment of complex pelvic organ prolapse

AIM

The incidence of complex pelvic organ prolapse in female patients is about 38%, and this disorder entails social and sexual restrictions. Treatment for this disorder is complex because it can enhance other, latent, problems. The aim of the present study is to describe a new robotic-assisted technique to simultaneously treat prolapses of different compartments with the use of a single titanized polypropylene mesh.

METHOD

All patients referred from January 2018 to March 2019 to the Proctologic and Pelvic Floor Clinical Centre who were affected by complex pelvic organ prolapse underwent modified robotic ventral rectopexy with a folded single mesh (RVR-FSM). The anatomical and functional outcomes were respectively evaluated using the Pelvic Organ Prolapse Quantification (POP-Q) grading system and Wexner scores of constipation and incontinence. The satisfaction rate was investigated using a five-point scale (1 = not satisfied to 5 = extremely satisfied).

RESULTS

Twenty-two women underwent RVR-FSM with a homogeneous follow-up of 12 months. The mean total operation time was 148 min, without any robot-related or other intraoperative complications. No mesh-related complications occurred. The POP-Q grade improved for every patient, with complete resolution of bulging symptoms in 21 patients (95.4%) at 1 year of follow-up. The Wexner constipation score showed a significant improvement, while the incontinence score slightly improved at 1 year after surgery.

CONCLUSION

The use of a single mesh that can be folded was shown to provide significant improvement in functional and anatomical results associated with patient satisfaction. The robotic approach allows surgeons to perform an easier procedure with correct and deep mesh fixation.

Natural Orifice Transanal Endoscopic Rectopexy for Complete Rectal Prolapse: Prospective Evolution of a New Technique and Short-term Outcomes

BACKGROUND

Endoluminal surgery for the management of rectal prolapse remains largely experimental.

OBJECTIVE

To evaluate the evolution and short-term outcomes of a new endoluminal technique for the management of complete rectal prolapse.

DESIGN

This was a prospective study.

SETTINGS

This study was conducted at a single tertiary care teaching center.

PATIENTS

A total of 29 patients were included. The first 12 patients underwent the procedure with our initial technique, and the last 17 patients were subjected to the new modified procedure. The follow-up duration was 3 years for the older technique and 26 months for the newer technique.

INTERVENTION

This technique involves: 1) ventral "suture" rectopexy: rectum is fixed anteriorly to the anterior abdominal wall using percutaneously placed sutures. 2) Posterior rectum is fixed to the sacral promontory using tackers through a submucosal tunnel.

MAIN OUTCOME MEASURES

Safety, recurrence, functional outcomes, morbidity, and mortality were the main outcome measures.

RESULTS

There were improvements in constipation and incontinence scores, anal manometric pressures, anorectal angle, anorectal descent, and quality of life postoperatively in both groups. In patients undergoing the modified procedure, there was a significant decrease in duration of surgery (220 ± 48.89 vs 110 ± 12.51 min), shortened hospital stay (4.6 ± 1.71 vs 2.6 ± 0.65 d), decreased recurrence (25% vs 5.8%), and complications (surgical-site infection and retrorectal abscess).

LIMITATIONS

Short follow-up, small sample size, and single-center study were the limitations.

CONCLUSION

This is a novel endoluminal technique for treating rectal prolapse obviating perirectal dissection, abdominal incisions, or a mesh. This can now be performed under complete endoscopic and fluoroscopic vision. It avoids general anesthesia and therefore can be an alternative for patients with comorbid conditions in whom the standard abdominal procedure may not be well tolerated. Larger randomized multicentric studies with longer follow-ups are warranted. See Video Abstract at http://links.lww.com/DCR/C59.

RECTOPEXIA ENDOSCPICA TRANSANAL POR ORIFICIO NATURAL PARA EL PROLAPSO RECTAL COMPLETO EVOLUCIN PROSPECTIVA DE UNA NUEVA TCNICA Y RESULTADOS A CORTO PLAZO

ANTECEDENTES:La cirugía endoluminal para el tratamiento del prolapso rectal ha permanecido en gran parte experimental.OBJETIVO:Este estudio tiene como objetivo evaluar la evolución y los resultados a corto plazo de una nueva técnica endoluminal para el manejo del prolapso rectal completo.DISEÑO:Estudio prospectivo.ÁMBITOS:Único centro docente de tercer nivel de atención.PACIENTES:Se incluyeron un total de 29 pacientes (19 hombres y 10 mujeres) con prolapso rectal completo. Los primeros 12 pacientes fueron sometidos al procedimiento con nuestra técnica anteriormente descrita y los últimos 17 pacientes fueron sometidos al nuevo procedimiento modificado. La duración del seguimiento es de 3 años para la técnica más antigua y de 26 meses para la técnica más nueva.INTERVENCIÓN:Esta técnica implica: A) Rectopexia de "sutura" ventral: el recto se fija anteriormente a la pared abdominal anterior mediante suturas colocadas percutáneamente. B) El recto posterior se fija al promontorio sacro mediante grapas a través de un túnel submucoso.PRINCIPALES MEDIDAS DE RESULTADO:Seguridad, recurrencia, resultados funcionales, morbilidad y mortalidad.RESULTADOS:Hubo mejorías en las puntuaciones de estreñimiento (ODS) e incontinencia (SMIS), presiones manométricas anales (reposo y contracción), ángulo anorrectal, descenso anorrectal y calidad de vida post operatoria en ambos grupos. En los pacientes sometidos al procedimiento modificado hubo una significativa disminución en la duración de la cirugía (220 + 48,89 vs 110 + 12,51 minutos), acortamiento de la estancia hospitalaria (4,6 + 1,71 vs 2,6 + 0,65 días), disminución de la recurrencia (25% vs 5,8%) y complicaciones (infecciónes del sitio quirúrgico y abscesos retrorrectales).LIMITACIONES:Seguimiento corto, tamaño de muestra pequeña, estudio de un solo centro.CONCLUSIÓNES:La rectopexia endoscópica transanal por orificio natural (NOTER) es una novedosa técnica endoluminal para el tratamiento del prolapso rectal que evita la disección perirrectal, las incisiones abdominales o la fijación de una malla. Este procedimiento puede realizar hoy día bajo visión completa endoscópica y fluoroscópica. Evita la anestesia general y, por lo tanto, puede ser una alternativa para pacientes con condiciones comórbidas donde el procedimiento abdominal estándar puede no ser bien tolerado. Se justifican estudios multicéntricos aleatorios más grandes con un seguimiento más prolongado para validar aún más esta nueva técnica. Consulte Video Resumen en http://links.lww.com/DCR/C59. (Traducción-Dr Osvaldo Gauto).

A quantitative study to explore functional outcomes following laparoscopic ventral mesh rectopexy for rectal prolapse

INTRODUCTION

Rectal prolapse is a life-altering problem and laparoscopic ventral mesh rectopexy (LVMR) is emerging as the surgical intervention of choice. However, the literature is ambiguous on its effect on bowel function and sparse as regards bladder and sexual function. This study assesses short-term functional outcomes following LVMR.

MATERIALS AND METHODS

This quantitative retrospective study with a pretest-post-test design included 130 adults who had undergone LVMR from October 2010 to December 2018 in a tertiary centre. Analysis with paired-samples t-test and Wilcoxon matched pairs test was done using SPSS (v26).

RESULTS

The median age was 58 years (interquartile range, 48-74 years); 123 (94.6%) were female. The median length of stay was two days (interquartile range, 1-2 days). A total of 104 (80%) sets of medical notes were reviewed. One patient had recurrence of rectal prolapse. Synthetic mesh was used in 24 patients (23.1%) and biological mesh in 80 (76.9%). One patient had extrusion of a synthetic mesh and required surgery; 31(23.8%) completed the Electronic Patient Assessment Questionnaire for Pelvic Floor. Overall, the improvement in bladder function was not statistically significant (p = 0.670). A statistically significant improvement was seen for all bowel symptoms (p = 0.002) excluding constipation (p = 0.295). Irritable bowel symptoms associated with rectal prolapse improved significantly following LVMR (p = 0.001). Vaginal prolapse (p < 0.0005), dyspareunia (p = 0.001) and bowel symptoms affecting sexual intercourse (p = 0.01) improved, but improvement in overall sexual function was not statistically significant (p = 0.081).

CONCLUSIONS

LVMR improves bowel function overall, although it can worsen constipation. It has the potential to improve sexual function but makes negligible difference to bladder function.

Postoperative complications and pelvic organ prolapse recurrence following combined pelvic organ prolapse and rectal prolapse surgery compared with pelvic organ prolapse only surgery

BACKGROUND

There is a growing interest in combined pelvic organ prolapse and rectal prolapse surgery for concomitant pelvic floor prolapse despite a paucity of data regarding complications and clinical outcomes of combined repair.

OBJECTIVE

The primary objective of this study was to compare the <30-day postoperative complication rate in women undergoing combined POP + RP surgery with that of women undergoing pelvic organ prolapse-only surgery. The secondary objectives were to describe the <30-day postoperative complications, compare the pelvic organ prolapse recurrence between the 2 groups, and determine the preoperative predictors of <30-day postoperative complications and predictors of pelvic organ prolapse recurrence.

STUDY DESIGN

This was a multicenter, retrospective cohort study at 5 academic hospitals. Patients undergoing combined pelvic organ prolapse and rectal prolapse surgery were matched by age, pelvic organ prolapse stage by leading compartment, and pelvic organ prolapse procedure compared with those undergoing pelvic organ prolapse-only surgery from March 2003 to March 2020. The primary outcome measure was <30-day complications separated into Clavien-Dindo classes. The secondary outcome measures were (1) subsequent pelvic organ prolapse surgeries and (2) pelvic organ prolapse recurrence, defined as patients who complained of vaginal bulge symptoms postoperatively.

RESULTS

Overall, 204 women underwent combined surgery for pelvic organ prolapse and rectal prolapse, and 204 women underwent surgery for pelvic organ prolapse only. The average age (59.3±1.0 vs 59.0±1.0) and mean parity (2.3±1.5 vs 2.6±1.8) were similar in each group. Of note, 109 (26.7%) patients had at least one <30-day postoperative complication. The proportion of patients who had a complication in the combined surgery group and pelvic organ prolapse-only surgery group was similar (27.5% vs 26.0%; P=.82). The Clavien-Dindo scores were similar between the groups (grade I, 10.3% vs 9.3%; grade II, 11.8% vs 12.3%; grade III, 3.9% vs 4.4%; grade IV, 1.0% vs 0%; grade V, 0.5% vs 0%). Patients undergoing combined surgery were less likely to develop postoperative urinary tract infections and urinary retention but were more likely to be treated for wound infections and pelvic abscesses than patients undergoing pelvic organ prolapse-only surgery. After adjusting for combined surgery vs pelvic organ prolapse-only surgery and parity, patients who had anti-incontinence procedures (adjusted odds ratio, 1.85; 95% confidence interval, 1.16-2.94; P=.02) and perineorrhaphies (adjusted odds ratio, 1.68; 95% confidence interval, 1.05-2.70; P=.02) were more likely to have <30-day postoperative complications. Of note, 12 patients in the combined surgery group and 15 patients in the pelvic organ prolapse-only surgery group had subsequent pelvic organ prolapse repairs (5.9% vs 7.4%; P=.26). In the combined surgery group, 10 patients (4.9%) underwent 1 repair, and 2 patients (1.0%) underwent 2 repairs. All patients who had recurrent pelvic organ prolapse surgery in the pelvic organ prolapse-only surgery group had 1 subsequent pelvic organ prolapse repair. Of note, 21 patients in the combined surgery group and 28 patients in the pelvic organ prolapse-only surgery group reported recurrent pelvic organ prolapse (10.3% vs 13.7%; P=.26). On multivariable analysis adjusted for number of previous pelvic organ prolapse repairs, combined surgery vs pelvic organ prolapse-only surgery, and perineorrhaphy at the time of surgery, patients were more likely to have a subsequent pelvic organ prolapse surgery if they had had ≥2 previous pelvic organ prolapse repairs (adjusted odds ratio, 6.06; 95% confidence interval, 2.10-17.5; P=.01). The average follow-up times were 307.2±31.5 days for the combined surgery cohort and 487.7±49.9 days for the pelvic organ prolapse-only surgery cohort. Survival curves indicated that the median time to recurrence was not statistically significant (log-rank, P=.265) between the combined surgery group (4.2±0.4 years) and the pelvic organ prolapse-only surgery group (5.6±0.4 years).

CONCLUSION

In this retrospective cohort study, patients undergoing combined pelvic organ prolapse and rectal prolapse surgery had a similar risk of <30-day postoperative complications compared with patients undergoing pelvic organ prolapse-only surgery. Furthermore, patients who underwent combined surgery had a similar risk of recurrent pelvic organ prolapse and subsequent pelvic organ prolapse surgery compared with patients who underwent pelvic organ prolapse-only surgery.

European Society of Coloproctology guidance on the use of mesh in the pelvis in colorectal surgery

This is a comprehensive and rigorous review of currently available data on the use of mesh in the pelvis in colorectal surgery. This guideline outlines the limitations of available data and the challenges of interpretation, followed by best possible recommendations.

Postoperative complications and recurrence rates after rectal prolapse surgery versus combined rectal prolapse and pelvic organ prolapse surgery

INTRODUCTION AND HYPOTHESIS

Our primary objectives were to compare < 30-day postoperative complications and RP recurrence rates after RP-only surgery and combined surgery. Our secondary objectives were to determine preoperative predictors of < 30-day complications and RP recurrence.

METHODS

A prospective IRB-approved cohort study was performed at a single tertiary care center from 2017 to 2020. Female patients with symptomatic RP underwent either RP-only surgery or combined surgery based on the discretion of the colorectal and FPMRS surgeons. Primary outcome measures were < 30-day complications separated into Clavien-Dindo (CD) classes and rectal prolapse on physical examination.

RESULTS

Seventy women had RP-only surgery and 45 had combined surgery with a mean follow-up time of 208 days. Sixty-eight percent underwent abdominal RP repair, and 32% underwent perineal RP repair. Twenty percent had one or more complications, 14% in the RP-only group and 29% in the combined surgery group (p = 0.06). On multivariate analysis, combined surgery patients had a 30% increased risk of complications compared to RP-only surgery patients (RR = 1.3). Most of these complications were minor (14/17, 82.4%) and categorized as CD I or II, including urinary retention and UTI. Twelve percent of this cohort had RP recurrence, 11% in the RP-only group and 13% in the combined surgery group (p = 0.76). Preoperative risk factors for RP recurrence included a primary complaint of rectal bleeding (RR 5.5) and reporting stools consistent with Bristol Stool Scale of 1 (RR 2.1).

CONCLUSION

Patients undergoing combined RP + POP surgery had a higher risk of complications and equivalent RP recurrence rates compared to patients undergoing RP-only surgery.

Clinical efficacy of integral theory–guided laparoscopic integral pelvic floor/ligament repair in the treatment of internal rectal prolapse in females

BACKGROUND

Internal rectal prolapse (IRP) is one of the most common causes of obstructive constipation. The incidence of IRP in women is approximately three times that in men. IRP is mainly treated by surgery, which can be divided into two categories: Abdominal procedures and perineal procedures. This study offers a better procedure for the treatment of IRP.

AIM

To compare the clinical efficacy of laparoscopic integral pelvic floor/ligament repair (IPFLR) combined with a procedure for prolapse and hemorrhoids (PPH) and the laparoscopic IPFLR alone in the treatment of IRP in women.

METHODS

This study collected the clinical data of 130 female patients with IRP who underwent surgery from January 2012 to October 2014. The patients were divided into groups A and B. Group A had 63 patients who underwent laparoscopic IPFLR alone, and group B had 67 patients who underwent the laparoscopic IPFLR combined with PPH. The degree of internal rectal prolapse (DIRP), Wexner constipation scale (WCS) score, Wexner incontinence scale (WIS) score, and Gastrointestinal Quality of Life Index (GIQLI) score were compared between groups and within groups before surgery and 6 mo and 2 years after surgery.

RESULTS

All laparoscopic surgeries were successful. The general information, number of bowel movements before surgery, DIRP, GIQLI score, WIS score, and WCS score before surgery were not significantly different between the two groups (all P > 0.05). The WCS score, WIS score, GIQLI score, and DIRP in each group 6 mo, and 2 years after surgery were significantly better than before surgery (P < 0.001). In group A, the DIRP and WCS score gradually improved from 6 mo to 2 years after surgery (P < 0.001), and the GIQLI score progressively improved from 6 mo to 2 years after surgery (P < 0.05). In group B, the DIRP, WCS score and WIS score significantly improved from 6 mo to 2 years after surgery (P < 0.05), and the GIQLI score 2 years after surgery was significantly higher than that 6 mo after surgery (P < 0.05). The WCS score, WIS score, GIQLI score, and DIRP of group B were significantly better than those of group A 6 mo and 2 years after surgery (all P < 0.001, Bonferroni) except DIRP at 2 years after surgery. There was a significant difference in the recurrence rate of IRP between the two groups 6 mo after surgery (P = 0.011). There was no significant difference in postoperative grade I-III complications between the two groups (P = 0.822).

CONCLUSION

Integral theory–guided laparoscopic IPFLR combined with PPH has a higher cure rate and a better clinical efficacy than laparoscopic IPFLR alone.

A Collaborative Approach to Multicompartment Pelvic Organ Prolapse

Multicompartment pelvic organ prolapse is common yet frequently underreported and unrecognized. Although not life-threatening, the impact on quality of life and daily functioning can be significant. Multidisciplinary evaluation and treatment with specialists in colorectal and female pelvic medicine and reconstructive surgery (FPMRS) help to identify patients who will benefit from surgical treatment of vaginal and rectal prolapse. Both abdominal and perineal combined procedures can be offered to patients with a single operation and concurrent recovery period without increasing complications.

Transvaginal rectopexy using the Flex® Colorectal Drive Robotic System: a proof-of-concept approach to rectal prolapse

BACKGROUND

The aim of this study was to demonstrate a proof-of-concept approach to rectopexy that would provide the durability of the transabdominal procedure through use of sacral rectopexy with the decreased morbidity of a perineal procedure. This was done by utilizing a transvaginal approach and developing the rectovaginal space to accommodate sacral rectopexy placement using the Flex^® Colorectal Drive Robotic System by Medrobotics (Medrobotics Corp., Raynham, MA, USA).

METHODS

A fresh female cadaver was acquired and placed in the high lithotomy position. The rectovaginal space was developed to accommodate the trocar of the Flex robot using blunt and sharp dissection between the posterior vaginal wall and anterior rectum. A piece of mesh was introduced into the space and using an endoscopic tacker, which was secured to the sacral promontory. The mesh was secured to the anterior rectal wall using interrupted vicryl sutures. The purse string suture was removed and the rectovaginal orifice was closed using a running vicryl suture. At the completion of the procedure, a low midline laparotomy was conducted to verify anchoring of the mesh appropriately at the sacral promontory.

RESULTS

This proof-of-concept protocol is the first description of the Flex^® Colorectal Drive being used successfully to perform a transvaginal rectopexy for rectal prolapse in a cadaver. This is also the first description of the Flex^® Colorectal Drive robot being used transvaginally.

CONCLUSIONS

This proof-of-concept approach demonstrates that transvaginal rectopexy using the Flex^® Colorectal Drive is a potential surgical option to address rectal prolapse that could provide patients the durability of a transabdominal approach with the decreased morbidity of a perineal approach. While early results are promising, additional cadaveric studies are required before this procedure can be attempted in vivo.

Comparison of Delorme-Thiersch Operation Outcomes in Men and Women With Rectal Prolapse

Purpose

The laparoscopic rectopexy has become increasingly popular with verified stability, surgical route selection should be tailored to individual patient characteristics rather than operative risk. The perineal approach is useful in young male patients who need to preserve fertility. This study aimed to compare the characteristics of men and women who underwent Delorme-Thiersch procedures and analyze the postoperative outcomes of the perineal approach by sex.

Methods

We retrospectively reviewed the medical records of 293 patients who underwent Delorme-Thiersch operations in Seoul Song Do Colorectal Hospital between January 2011 and September 2017. Patient clinical characteristics and postoperative complications were analyzed by sex. We analyzed surgical outcomes with preoperative and 3-month postoperative incontinence questionnaires, constipation levels, and anal manometry.

Results

In this study, men with rectal prolapse were younger than women with the same condition. American Society of Anesthesiologists physical status classifications were higher in women and women had more L-spine X-ray and pudendal nerve terminal motor latency test abnormalities. Anorectal manometry pressures were higher in men. Men also had longer operation times and hospital stays and more postoperative complications (8 T ring infections, 6 patients with bleeding, 3 with strictures, 2 with severe pain, and 2 with rectal perforations). The recurrence rate was higher among women.

Conclusion

Men with rectal prolapse were younger, healthier, and had relatively better anorectal function than women. The Delorme-Thiersch operation in men promoted lower recurrence rates and was advantageous in preserving the fertility of young patients, but the incidence of complications was also higher in men. Adequate counseling and preparation for the possibility of complications are needed.

Clinical Outcome and Surgical Technique of Laparoscopic Posterior Rectopexy Using the Mesh With Anti-adhesion Coating

We herein present an innovative technique of laparoscopic posterior mesh rectopexy (LPMR) for full-thickness rectal prolapse and report the clinical outcomes in our institution. Ten consecutive patients who were treated with our latest LPMR technique using mesh with an anti-adhesion coating from June 2014 to May 2017 were retrospectively analyzed. All patients were women with a mean age of 63.6 years (range, 39 to 82 y). The median operative time and blood loss volume were 197.5 minutes (range, 156 to 285 min) and 0 mL (range, 0 to 152 mL), respectively. No perioperative complications occurred, including surgical site infection, pneumonia, urinary dysfunction, and intestinal obstruction. The median follow-up duration was 768 days (range, 396 to 1150 d). During the follow-up, the cumulative incidence of full-thickness rectal prolapse and any mesh-related complications was 0. It may be possible to eliminate retroperitoneal closure using a mesh with an anti-adhesion coating. Our LPMR technique appears safe and acceptable.