Development of a Consensus-Derived Synoptic Operative Report for Rectal Prolapse: A Report From the Pelvic Floor Disorders Consortium.

BACKGROUND: Narrative operative reports may omit or obscure data from an operation. OBJECTIVE: To develop a synoptic operative report for rectal prolapse that includes core descriptors as developed by an international consensus of expert pelvic floor surgeons. DESIGN: Descriptors for patients undergoing rectal prolapse surgery were generated through review. Members of the Pelvic Floor Disorders Consortium were recruited to participate in a 3-round Delphi process using a 9-point Likert scale. Descriptors that achieved 70% agreement were kept from the first round, and descriptors scoring 40% to 70% agreement were recirculated in subsequent rounds. A final list of operative descriptors was determined at a consensus meeting, with a final consensus meeting more than 70% agreement. SETTINGS: This survey was administered to members of the Pelvic Floor Disorders Consortium. PATIENTS: No patient data are included in this study. MAIN OUTCOME MEASURES: Descriptors meeting greater than 70% agreement were selected. RESULTS: One hundred seventy-six surgeons representing colorectal surgeons, urogynecologists, and urologists distributed throughout North America (56%), Latin America (4%), Western Europe (29%), Asia (4%), and Africa (1%) participated in the first round of Delphi voting. After 2 additional rounds and a final consensus meeting, 16 of 30 descriptors met 70% consensus. Descriptors that met consensus were surgery type, posterior dissection, ventral dissection, mesh used, type of mesh used, mesh location, sutures used, suture type, pouch of Douglas and peritoneum reclosed, length of rectum imbricated, length of bowel resected, levatoroplasty, simultaneous vaginal procedure, simultaneous gynecologic procedure, simultaneous enterocele repair, and simultaneous urinary incontinence procedure. LIMITATIONS: The survey represents the views of members of the Delphi panel and may not represent the viewpoints of all surgeons. CONCLUSIONS: This Delphi survey establishes international consensus descriptors for intraoperative variables that have been used to produce a synoptic operative report. This will help establish defined operative reporting to improve clinical communication, quality measures, and clinical research. See Video Abstract . DESARROLLO DE UN PROTOCOLO OPERATORIO SINPTICO DERIVADO DE CONSENSO PARA EL PROLAPSO RECTAL UN INFORME DEL CONSORCIO DE TRASTORNOS DEL PISO PLVICO: ANTECEDENTES:Los protocolos operativos narrativos frecuentemente pueden omitir u oscurecer datos de un procedimiento.OBJETIVO:Nuestro objetivo es desarrollar un protocolo operatorio sinóptico para el prolapso rectal que incluya descriptores básicos desarrollados por un consenso internacional de cirujanos expertos en piso pélvico.DISEÑO:Los descriptores para pacientes sometidos a cirugía de prolapso rectal se generaron mediante revisión. Se reclutó a miembros del Consorcio de Trastornos del Piso Pélvico para participar en un proceso Delphi de 3 rondas utilizando una escala Likert de 9 puntos. Los descriptores que lograron un 70% de acuerdo se mantuvieron en la primera ronda, los descriptores que obtuvieron un 40-70% de acuerdo se recircularon en rondas posteriores. Se determinó una lista final de descriptores operativos en una reunión de consenso, con una reunión de consenso final de más del 70% de acuerdo.ESCENARIO:Esta fue una encuesta administrada a miembros del Consorcio de Trastornos del Piso Pélvico.PRINCIPALES MEDIDAS DE RESULTADO:Se seleccionaron los descriptores que cumplieron más del 70% de acuerdo.RESULTADOS:Ciento setenta y seis cirujanos en representación de cirujanos colorrectales, uroginecólogos y urólogos distribuidos en América del Norte (56%), América Latina (4%), Europa Occidental (29%), Asia (4%) y África (1%) participaron en la primera ronda de votación Delphi. Después de dos rondas adicionales y una reunión de consenso final, 16 de 30 descriptores alcanzaron un 70% de consenso. Los descriptores que alcanzaron consenso fueron: tipo de cirugía, disección posterior, disección ventral, malla utilizada, tipo de malla utilizada, ubicación de la malla, suturas utilizadas, tipo de sutura, cierre del fondo de saco de Douglas y peritoneo, longitud del recto superpuesto, longitud del intestino resecado, plastía de los elevadores , procedimiento vaginal simultáneo, procedimiento ginecológico simultáneo, reparación simultánea de enterocele y procedimiento simultáneo de incontinencia urinaria.LIMITACIONES:La encuesta representa las opiniones de los miembros del panel Delphi y puede no representar los puntos de vista de todos los cirujanos.CONCLUSIONES/DISCUSIÓN:Esta encuesta Delphi establece descriptores de consenso internacional para las variables intraoperatorias que se han utilizado para producir un protocolo operatorio sinóptico. Esto ayudará a establecer protocolos operativos definidos para mejorar la comunicación clínica, las medidas de calidad y la investigación clínica. (Traducción-Dr. Felipe Bellolio ).

Durable Approaches to Recurrent Rectal Prolapse Repair May Require Avoidance of Index Procedure.

BACKGROUND: Surgical treatment of recurrent rectal prolapse is associated with unique technical challenges, partially determined by the surgical approach used for the index operation. Success rates are variable, and data to determine the best approach in patients with recurring prolapse are lacking. OBJECTIVE: The study aimed to assess current surgical approaches to patients with prior rectal prolapse repairs and to compare short-term outcomes of de novo and redo procedures, including recurrence of rectal prolapse. DESIGN: Retrospective analysis of a prospective database. SETTINGS: The Multicenter Pelvic Floor Disorders Consortium Prospective Quality Improvement database. De-identified surgeons at more than 25 sites (81% high volume) self-reported patient demographics, prior repairs, symptoms of incontinence and obstructed defecation, and operative details, including history of concomitant repairs and prior prolapse repairs. PATIENTS: Patients who were offered surgery for full thickness rectal prolapse. INTERVENTIONS: Incidence and type of repair used for prior rectal prolapse surgery were recorded. Primary and secondary outcomes of index and redo operations were calculated. Patients undergoing rectal prolapse re-repair (redo) were compared with patients undergoing first (de novo) rectal prolapse repair. The incidence of rectal prolapse recurrence in de novo and redo operations was quantified. OUTCOMES: The primary outcome of rectal prolapse recurrence in de novo and redo settings. RESULTS: Eighty-nine (19.3%) of 461 patients underwent redo rectal prolapse repair. On short-term follow-up, redo patients had prolapse recurrence rates similar to those undergoing de novo repair. However, patients undergoing redo procedures rarely had the same operation as their index procedure. LIMITATIONS: Self-reported, de-identified data. CONCLUSION: Our results suggest that recurrent rectal prolapse surgery is feasible and can offer adequate rates of rectal prolapse durability in the short term but may argue for a change in surgical approach for redo procedures when clinically feasible. See Video Abstract . LOS ENFOQUES DURADEROS PARA LA REPARACIN DEL PROLAPSO RECTAL RECURRENTE PUEDEN REQUERIR EVITAR EL PROCEDIMIENTO NDICE: ANTECEDENTES:El tratamiento quirúrgico del prolapso rectal recurrente se asocia con desafíos técnicos únicos, determinados en parte por el abordaje quirúrgico utilizado para la operación inicial. Las tasas de éxito son variables y faltan datos para determinar el mejor abordaje en pacientes con prolapso recurrente.OBJETIVO:Evaluar los enfoques quirúrgicos actuales para pacientes con reparaciones previas de prolapso rectal y comparar los resultados a corto plazo de los procedimientos de novo y rehacer, incluida la recurrencia del prolapso rectal.DISEÑO:Análisis retrospectivo de una base de datos prospectiva.AJUSTE:Base de datos de mejora prospectiva de la calidad del Consorcio multicéntrico de trastornos del suelo pélvico. Cirujanos no identificados en más de 25 sitios (81% de alto volumen) informaron datos demográficos de los pacientes, reparaciones previas, síntomas de incontinencia y defecación obstruida y detalles operativos, incluido el historial de reparaciones concomitantes y reparaciones previas de prolapso.INTERVENCIONES:Se registro la incidencia y el tipo de reparación utilizada para la cirugía de prolapso rectal previa. Se calcularon los resultados primarios y secundarios de las operaciones de índice y reoperacion. Se compararon los pacientes sometidos a una nueva reparación (reoperacion) de prolapso rectal con pacientes sometidos a una primera reparación (de novo) de prolapso rectal. Se cuantificó la incidencia de recurrencia del prolapso rectal en operaciones de novo y rehacer.RESULTADOS:El resultado primario de recurrencia del prolapso rectal en entornos de novo y redo. Ochenta y nueve (19,3%) de 461 pacientes se sometieron a una nueva reparación del prolapso rectal. En el seguimiento a corto plazo, los pacientes reoperados tuvieron tasas de recurrencia de prolapso similares a los de los sometidos a reparación de novo. Sin embargo, los pacientes sometidos a procedimientos de rehacer rara vez tuvieron la misma operación que su procedimiento índice.LIMITACIONES:Datos no identificados y autoinformados.CONCLUSIONES/DISCUSIÓN:Nuestros resultados sugieren que la cirugía de prolapso rectal recurrente es factible y puede ofrecer tasas adecuadas de durabilidad del prolapso rectal en el corto plazo, pero puede abogar por un cambio en el enfoque quirúrgico para rehacer los procedimientos cuando sea clínicamente factible. (Traducción-Dr. Mauricio Santamaria ).

Core Descriptor Sets for Rectal Prolapse Outcomes Research Using a Modified Delphi Consensus.

BACKGROUND: There is wide variation in prolapse care. OBJECTIVE: To determine core descriptor sets for rectal prolapse to enhance outcomes research. DESIGN: Descriptors for patients undergoing rectal prolapse surgery were generated through a systematic review and expert opinion. Stakeholders were recruited internationally via listserv and social media. Experts were encouraged to consider the minimum descriptors that could be considered during clinical care, and descriptors were grouped into core descriptor sets. Consensus was defined as greater than 70% agreement. SETTING: A 3-round Delphi process using a 9-point Likert scale based on expert results was distributed via survey. The final interactive meeting used a polling platform. PARTICIPANTS: The Pelvic Floor Disorders Consortium interdisciplinary group convened to advance the clinical care of pelvic floor disorders. MAIN OUTCOME MEASURES: To achieve expert consensus for core descriptor sets for rectal prolapse using a modified Delphi method. RESULTS: A total of 206 providers participated, with survey response rates of 82% and 88%, respectively. Responders were from North America (56%), Europe (29%), and Latin America, Asia, Australia, New Zealand, and Africa (15%). Ninety-one percent of participants identified as colorectal surgeons and 80% reported >5 years of experience (35% reported >15 years). Fifty-seven attendees participated in the final meeting and voted on core descriptor sets. Ninety-three percent of participants agreed that descriptors such as age, BMI, frailty, nutrition, and the American Society of Anesthesiology score correlated to physiologic status. One hundred percent of participants agreed to include baseline bowel function. One hundred percent of participants reported willingness to complete a synoptic operative report. Follow-up intervals 1, 3, and 5 years after surgery (76%) with a collection of recurrence and functional outcomes at those time periods reached an agreement. LIMITATIONS: Individual bias, self-identification of experts, and paucity of knowledge related to rectal prolapse. CONCLUSIONS: This represents the first steps toward international consensus to unify language and data collection processes for rectal prolapse. See Video Abstract . CONJUNTOS DE DESCRIPTORES BSICOS PARA LA INVESTIGACIN DE RESULTADOS DE PROLAPSO RECTAL MEDIANTE UN CONSENSO DELPHI MODIFICADO: ANTECEDENTES:Existe una amplia variación en la atención del prolapso.OBJETIVO:Determinar conjuntos de descriptores básicos para el prolapso rectal para mejorar los resultados de la investigación.DISEÑO:Los descriptores para pacientes sometidos a cirugía de prolapso rectal se generaron a través de una revisión sistemática y la opinión de expertos. Las partes interesadas fueron reclutadas internacionalmente a través de listas de servicio y redes sociales. Se animó a los expertos a considerar los descriptores mínimos que podrían considerarse durante la atención clínica, y los descriptores se agruparon en conjuntos de descriptores básicos. El consenso se definió como > 70% de acuerdo.AJUSTE:Se distribuyó mediante encuesta un proceso Delphi de tres rondas que utiliza una escala Likert de 9 puntos basada en resultados de expertos. La reunión interactiva final utilizó una plataforma de votación.PARTICIPANTES:El grupo interdisciplinario del Consorcio de Trastornos del Suelo Pélvico se reunió para avanzar en la atención clínica de los trastornos del suelo pélvico.MEDIDAS PRINCIPALES DE RESULTADOS:Lograr el consenso de expertos para los conjuntos de descriptores básicos para el prolapso rectal utilizando un método Delphi modificado.RESULTADOS:Participaron 206 proveedores con tasas de respuesta a la encuesta del 82% y 88% respectivamente. Los encuestados procedían de América del Norte (56%), Europa (29%) y América Latina, Asia, Australia, Nueva Zelanda y África (15%). El noventa y uno por ciento se identificó como cirujanos colorrectales y el 80% reportó más de 5 años de experiencia (35% > 15 años). Cincuenta y siete asistentes participaron en la reunión final y votaron sobre conjuntos de descriptores básicos. El noventa y tres por ciento estuvo de acuerdo en que descriptores como edad, índice de masa corporal, fragilidad, nutrición y puntuación de la Sociedad Estadounidense de Anestesiología se correlacionaban con el estado fisiológico. El cien por ciento estuvo de acuerdo en incluir la función intestinal inicial. El 100% refirió disposición para realizar un informe operativo sinóptico. Los intervalos de seguimiento 1,3,5 años después de la cirugía (76%) con un conjunto de recurrencias y los resultados funcionales en esos períodos de tiempo coincidieron.LIMITACIONES:Sesgo individual, autoidentificación de los expertos y escasez de conocimientos relacionados con el prolapso rectal.CONCLUSIONES:Esto representa los primeros pasos hacia un consenso internacional para unificar el lenguaje y los procesos de recolección de datos para el prolapso rectal. (Traducción-Yesenia Rojas-Khalil ).

Combined Robotic Ventral Mesh Rectopexy and Sacrocolpopexy for Multicompartmental Pelvic Organ Prolapse.

BACKGROUND: Multispecialty management should be the preferred approach for the treatment of pelvic floor dysfunction because there is often multicompartmental prolapse. OBJECTIVE: To assess the safety of combined robotic ventral mesh rectopexy and either uterine or vaginal fixation for the treatment of multicompartmental pelvic organ prolapse at our institution. DESIGN: Retrospective analysis. SETTINGS: Tertiary referral academic center. PATIENTS: All patients who underwent a robotic approach and combined procedure and whose cases were discussed at a biweekly pelvic floor multidisciplinary team meeting. MAIN OUTCOME MEASURES: Operative time, intraoperative blood loss and complications, postoperative pelvic organ prolapse quantification score, length of stay, 30-day morbidity, and readmission. RESULTS: From 2018 to 2021, there were 321 operations for patients with multicompartmental prolapse. The mean age was 63.4 years. The predominant pelvic floor dysfunction was rectal prolapse in 170 cases (60%). Pelvic organ prolapse quantification scores were II in 146 patients (53%), III in 121 patients (44%), and IV in 9 patients (3%); 315 of 323 cases included robotic ventral mesh rectopexy (98%). Sacrocolpopexy or sacrohysteropexy was performed in 281 patients (89%). Other procedures included 175 hysterectomies (54%), 104 oophorectomies (32%), 151 sling procedures (47%), 149 posterior repairs (46%), and 138 cystocele repairs (43%). The operative time for ventral mesh rectopexy was 211 minutes and for combined pelvic floor reconstruction was 266 minutes. Average length of stay was 1.6 days. Eight patients were readmitted within 30 days: 1 with a severe headache and 7 with postoperative complications (2.5%), such as pelvic collection and perirectal collection, both requiring radiologic drainage. Four complications required reoperation: epidural abscess, small-bowel obstruction, missed enterotomy requiring resection, and urinary retention requiring sling revision. There were no mortalities. LIMITATIONS: Retrospective single-center study. CONCLUSIONS: A combined robotic approach for multicompartmental pelvic organ prolapse is a safe and viable procedure with a relatively low rate of morbidity and no mortality. This is the highest volume series of combined robotic pelvic floor reconstruction in the literature and demonstrates a low complication rate and short length of stay. See Video Abstract . RECTOPEXIA Y SACROCOLPOPEXIA ROBTICA VENTRAL COMBINADAS CON MALLA PARA EL PROLAPSO DE RGANOS PLVICOS MULTICOMPARTIMENTALES: ANTECEDENTES:El tratamiento multiespecializado debe ser el enfoque preferido para el tratamiento de la disfunción del suelo pélvico, ya que a menudo hay prolapso multicompartimental.OBJETIVO:Evaluar la seguridad de la rectopexia robótica combinada con malla ventral y fijación uterina o vaginal para el tratamiento del prolapso multicompartimental de órganos pélvicos en nuestra institución.DISEÑO:Análisis retrospectivo.AJUSTES:Centro académico de referencia terciarioPACIENTES:Todos los pacientes que se sometieron a un enfoque robótico y un procedimiento combinado y se discutieron en una reunión quincenal del equipo multidisciplinario sobre el piso pélvico.MEDIDAS DE RESULTADO:Tiempo operatorio, pérdida de sangre intraoperatoria y complicaciones. Puntuación de cuantificación del prolapso de órganos pélvicos posoperatorio, duración de la estancia hospitalaria, morbilidad a 30 días y reingreso.RESULTADOS:De 2018 a 2021, se realizaron 321 operaciones de pacientes con prolapso multicompartimental. La edad media fue 63.4 años. La disfunción del suelo pélvico predominante fue el prolapso rectal en 170 casos (60%). Las puntuaciones de cuantificación del prolapso de órganos pélvicos fueron II en 146 pacientes (53%), III en 121 (44%) y IV en 9 (3%); 315 de los 323 casos incluyeron rectopexia robótica de malla ventral (98%). Se realizó sacrocolpopexia o sacrohisteropexia en 281 pacientes (89%). Otros procedimientos incluyeron 175 histerectomías (54%), 104 ooforectomías (32%), 151 procedimientos de cabestrillo (47%), 149 reparaciones posteriores (46%) y 138 reparaciones de cistocele (43%). El tiempo operatorio para la rectopexia con malla ventral fue de 211 minutos y la reconstrucción combinada del piso pélvico de 266 minutos. La estancia media fue de 1.6 días. Ocho pacientes reingresaron dentro de los 30 días, 1 con dolor de cabeza intenso y 7 pacientes con complicaciones posoperatorias (2.5%): colección pélvica y colección perirrectal, ambas requirieron drenaje radiológico. Cuatro complicaciones requirieron reoperación: absceso epidural, obstrucción del intestino delgado, enterotomía omitida que requirió resección y retención urinaria que requirió revisión del cabestrillo. No hubo mortalidades.LIMITACIONES:Estudio retrospectivo unicéntrico.CONCLUSIONES:Un enfoque robótico combinado para el prolapso multicompartimental de órganos pélvicos es un procedimiento seguro y viable con una tasa relativamente baja de morbilidad y ninguna mortalidad. Esta es la serie de mayor volumen de reconstrucción robótica combinada del suelo pélvico en la literatura y demuestra una baja tasa de complicaciones y una estancia hospitalaria corta. (Traducción-Dr. Aurian Garcia Gonzalez )See Editorial on page 195.

Recurrence Rates and Risk Factors in the Altemeier Procedure for Rectal Prolapse: A Multicenter Study.

BACKGROUND: Perineal proctosigmoidectomy (Altemeier) is a surgical procedure that is commonly used for the treatment of rectal prolapse. However, there is a diverse range of recurrence rates after Altemeier procedure repair that has been reported in the literature. OBJECTIVE: To identify primary and subsequent recurrence rates after perineal proctosigmoidectomy and to define potential risk factors for recurrence. DESIGN: Cohort study. SETTINGS: Conducted at 6 hospitals affiliated with the Cleveland Clinic. PATIENTS: The study included patients who were older than 18 years and were treated with the Altemeier procedure for rectal prolapse between 2007 and 2022. MAIN OUTCOME MEASURES: Primary outcomes were rates of primary and subsequent recurrences. Secondary outcomes included potential risk factors for recurrence previously mentioned in the literature. RESULTS: We identified 182 patients, of whom 95.1% were women, with a mean age of 79 years (SD 11.4). Overall, procedures were elective in 92.1% of patients, and 14.3% had previously undergone prolapse repairs (Delorme, Thiersch, abdominal suture rectopexy, and abdominal mesh rectopexy). At a mean follow-up period of 27.5 months (SD 45.7), 37.9% of patients experienced recurrence, with 16.5% of patients having multiple recurrences. A subsequent Altemeier procedure was performed in 72.5% of instances. Other treatments included Delorme, abdominal suture rectopexy, abdominal mesh rectopexy, or conservative management. This study identified connective tissue disorders and time since surgery as significant risk factors for recurrence. LIMITATIONS: Retrospective design and varying follow-up periods. CONCLUSIONS: Perineal proctosigmoidectomy is associated with a significant risk of recurrence. The risk of recurrence increased with the presence of a connective tissue disorder and in proportion to the elapsed time since surgery. These discoveries assist health care professionals in counseling and managing patients who undergo perineal proctosigmoidectomy for rectal prolapse. See Video Abstract . TASAS DE RECURRENCIA Y FACTORES DE RIESGO EN EL PROCEDIMIENTO DE ALTEMEIER PARA EL PROLAPSO RECTAL UN ESTUDIO MULTICNTRICO: ANTECEDENTES:La proctosigmoidectomía perineal (Altemeier) es un procedimiento quirúrgico que se utiliza comúnmente para el tratamiento del prolapso rectal. Sin embargo, existe una amplia gama de tasas de recurrencia después de la reparación con el procedimiento de Altemeier que se han informado en la literatura.OBJETIVO:Nuestro objetivo fue identificar las tasas de recurrencia primaria y posterior después de la proctosigmoidectomía perineal, así como definir los posibles factores de riesgo de recurrencia.DISEÑO:Estudio de cohorte.AJUSTES:Realizado en 6 hospitales afiliados a la Clínica Cleveland.PACIENTES:Se incluyeron pacientes mayores de 18 años que fueron tratados con procedimiento de Altemeier por prolapso rectal entre 2007 y 2022.PRINCIPALES MEDIDAS DE VALORACIÓN:Los resultados primarios fueron las tasas de recurrencias primarias y posteriores. Los resultados secundarios incluyeron factores de riesgo potenciales de recurrencia mencionados anteriormente en la literatura.RESULTADOS:Se identificaron 182 pacientes, de los cuales el 95,1% eran mujeres con una edad media de 79 años (DE 11,4). En general, el 92,1% fueron electivos y el 14,3% se habían sometido previamente a reparaciones de prolapso (Delorme, Thiersch, rectopexia con sutura abdominal y rectopexia con malla abdominal). En un período de seguimiento medio de 27,5 meses (DE 45,7), el 37,9% de los pacientes experimentó recurrencia, y el 16,5% de los pacientes tuvo recurrencias múltiples. En el 72,5% de los casos se realizó un procedimiento de Altemeier posterior. Otros tratamientos incluyeron Delorme, rectopexia con sutura abdominal, rectopexia con malla abdominal o manejo conservador. Este estudio identificó los trastornos del tejido conectivo y el tiempo transcurrido desde la cirugía como factores de riesgo importantes de recurrencia.LIMITACIONES:Diseño retrospectivo y períodos de seguimiento variables.CONCLUSIÓN:La proctosigmoidectomía perineal se asocia con un riesgo significativo de recurrencia. El riesgo de recurrencia aumentó con la presencia de un trastorno del tejido conectivo y en proporción al tiempo transcurrido desde la cirugía. Estos descubrimientos ayudan a los profesionales de la salud a asesorar y tratar a los pacientes que se someten a proctosigmoidectomía perineal por prolapso rectal. (Traducción-Dr. Ingrid Melo ).

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

AIM: The development of robotic assistance has made dissection and suturing in the deep pelvis much easier. The augmented quality of the images and the articulation of the robotic arms have also enabled a more precise dissection. The aim of this study is to present the data on robotic-assisted ventral mesh rectopexy procedures in a university hospital and examine the literature in terms of mesh erosion. METHOD: The electronic databases Pubmed, Embase and Cochrane were searched. Studies from January 2004 until January 2023 in the English language were included. Studies which included fewer than 10 patients were excluded. Laparoscopic or robotic-assisted ventral mesh rectopexies were included. Mesh erosion rates following laparoscopic or robotic-assisted ventral mesh rectopexies were measured. RESULTS: Overall, the systematic review presents 5911 patients from 43 studies who underwent laparoscopic ventral mesh rectopexy compared with 746 patients treated with robotic-assisted ventral mesh rectopexy from six studies and our centre. Mesh erosion was rare in both groups; however, the prevalence was greater in the laparoscopy group (0.90% vs. 0.27%). CONCLUSION: The mesh erosion rates are very low with robotic-assisted ventral mesh rectopexy. For precise results, more studies and experience in robotic surgery are required.

Validity of task-specific metrics for assessment in perineal proctectomy.

BACKGROUND: Perineal proctectomy is a complex procedure that requires advanced skills. Currently, there are no simulators for training in this procedure. As part of our objective of developing a virtual reality simulator, our goal was to develop and validate task-specific metrics for the assessment of performance for this procedure. We conducted a three-phase study to establish task-specific metrics, obtain expert consensus on the appropriateness of the developed metrics, and establish the discriminant validity of the developed metrics. METHODS: In phase I, we utilized hierarchical task analysis to formulate the metrics. In phase II, a survey involving expert colorectal surgeons determined the significance of the developed metrics. Phase III was aimed at establishing the discriminant validity for novices (PGY1-3) and experts (PGY4-5 and faculty). They performed a perineal proctectomy on a rectal prolapse model. Video recordings were independently assessed by two raters using global ratings and task-specific metrics for the procedure. Total scores for both metrics were computed and analyzed using the Kruskal-Wallis test. A Mann-Whitney U test with Benjamini-Hochberg correction was used to evaluate between-group differences. Spearman's rank correlation coefficient was computed to assess the correlation between global and task-specific scores. RESULTS: In phase II, a total of 23 colorectal surgeons were recruited and consensus was obtained on all the task-specific metrics. In phase III, participants (n = 22) included novices (n = 15) and experts (n = 7). There was a strong positive correlation between the global and task-specific scores (rs = 0.86; P < 0.001). Significant between-group differences were detected for both global (χ2 = 15.38; P < 0.001; df = 2) and task-specific (χ2 = 11.38; P = 0.003; df = 2) scores. CONCLUSIONS: Using a biotissue rectal prolapse model, this study documented high IRR and significant discriminant validity evidence in support of video-based assessment using task-specific metrics.

Rapid Onset of De Novo Rectal Prolapse Following Colpocleisis.

INTRODUCTION: The aim of this video case series is to demonstrate our experience of the clinical findings and the surgical management of the rapid onset de novo rectal prolapse (RP) following colpocleisis METHODS: This is a case series of three patients who developed de novo RP within 1 month after colpocleisis, which was repaired by laparoscopic ventral mesh rectopexy (LVMR). The video shows the physical, radiological, and intraoperative findings of these patients. A retrospective review of our surgical cases of RP was also performed to analyze the onset timing of de novo RP after various pelvic organ prolapse (POP) procedures. RESULTS: The pathological condition of all three patients' RP was evacuation enterocele, and LVMR was feasible without postoperative complications or recurrences. In the retrospective case review of 158 RP surgeries in our institution (June 2015 to September 2023), 18 cases (11.4%) occurred following POP surgery. De novo RP following colpocleisis developed significantly earlier than those following other procedures (average: 6.1 vs 66.4 months, p = 0.010). CONCLUSIONS: Although de novo RP following colpocleisis is relatively rare, this complication could have a detrimental effect on patients' quality of life. Preoperative informed consent may be advisable before planning colpocleisis.

Determinants of Dissatisfaction After Laparoscopic Cure of Vaginal and/or Rectal Prolapse using Mesh: a Comprehensive Retrospective Cohort Study.

INTRODUCTION AND HYPOTHESIS: The primary objective is to identify determinants of dissatisfaction after surgical treatment of vaginal prolapse ± rectal prolapse, using laparoscopic mesh sacrohysteropexy (LSH) or sacrocolpopexy (LSC) ± ventral mesh rectopexy (VMR). The secondary objective is the evaluation of complications and objective/subjective recurrence rates. METHODS: The study performed was a single-surgeon retrospective review of prospectively collected data. LSH/LSC ± VMR were performed between July 2005 and September 2022. Primary investigated outcome was patients' satisfaction, assessed using the Patient Global Impression of Improvement (PGI-I) score and the bother visual analog scale (VAS) obtained postoperatively (at a 1-month interval and on a 6-month/yearly basis thereafter). We looked for a correlation between the level of satisfaction (as reflected by the VAS) and potential determinants. RESULTS: There were 355 patients with a mean age of 62 ±12 years. Nearly all the patients (94.3%) had a stage 3 or 4 prolapse according to the POP-Q classification. The mean postoperative bother VAS was 1.8, with only 12.7% of patients reporting a bother VAS score ≥ 3/10, indicating a dissatisfaction. PGI-I showed improvement in the vast majority of patients (96.4% scoring 1 to 3). Patients with anal incontinence preoperatively scored higher on the bother VAS postoperatively (r=0.175, p < 0.05). The use of a posterior arm mesh (for posterior vaginal prolapse) correlated with better satisfaction overall (r= -0.178, p = 0.001), whereas the performance of VMR was associated with a bothering sensation (r = 0.232, p < 0.001). A regression analysis confirmed the impact of posterior mesh and VMR on satisfaction levels, with odds of dissatisfaction being 2.18 higher when VMR was combined with LSH/LSC. CONCLUSIONS: Posterior mesh use improves patient satisfaction when the posterior compartment is affected. In patients with concomitant vaginal and rectal prolapse, combining VMR with anterior LSC/LSH appears to negatively impact patients' satisfaction. Preoperative anal incontinence was demonstrated to be a risk factor for postoperative dissatisfaction.

Mental health disorders as a risk factor in young patients with rectal prolapse.

BACKGROUND: Rectal prolapse (RP) typically presents in the elderly, though it can present in younger patients lacking traditional risk factors. The current study compares medical and mental health history, presentation, and outcomes for young and older patients with RP. METHODS: This is a single-center retrospective review of patients who underwent abdominal repair of RP between 2005 and 2019. Individuals were dichotomized into two groups based on age greater or less than 40 years. RESULTS: Of 156 patients, 25 were < 40. Younger patients had higher rates of diagnosed mental health disorders (80% vs 41%, p < 0.001), more likely to take SSRIs (p = .02), SNRIs (p = .021), anxiolytics (p = 0.033), and antipsychotics (p < 0.001). Younger patients had lower preoperative incontinence but higher constipation. Both groups had low rates of recurrence (9.1% vs 11.6%, p = 0.73). CONCLUSIONS: Young patients with RP present with higher concomitant mental health diagnoses and represent unique risk factors characterized by chronic straining compared to pelvic floor laxity.

Ventral mesh rectopexy for recurrent rectal prolapse after Altemeier perineal proctosigmoidectomy: feasibility and outcomes.

PURPOSE: Recurrence of rectal prolapse following the Altemeier procedure is reported with rates up to 40%. The optimal surgical management of recurrences has limited data available. Ventral mesh rectopexy (VMR) is a favored procedure for primary rectal prolapse, but its role in managing recurrences after Altemeier is unclear. VMR for recurrent prolapse involves implanting the mesh on the colon, which has a thinner wall, more active peristalsis, no mesorectum, less peritoneum available for covering the mesh, and potential diverticula. These factors can affect mesh-related complications such as erosion, migration, or infection. This study assessed the feasibility and perioperative outcomes of VMR for recurrent rectal prolapse after the Altemeier procedure. METHODS: We queried our prospectively maintained database between 01/01/2008 and 06/30/2022 for patients who had experienced a recurrence of full-thickness rectal prolapse following Altemeier's perineal proctosigmoidectomy and subsequently underwent ventral mesh rectopexy. RESULTS: Ten women with a median age of 67 years (range 61) and a median BMI of 27.8 kg/m2 (range 9) were included. Five (50%) had only one Altemeier, and five (50%) had multiple rectal prolapse surgeries, including Altemeier before VMR. No mesh-related complications occurred during a 65-month (range 165) median follow-up period. Three patients (30%) experienced minor postoperative complications unrelated to the mesh. Long-term complications were chronic abdominal pain and incisional hernia in one patient, respectively. One out of five (20%) patients with only one previous prolapse repair had a recurrence, while all patients (100%) with multiple prior repairs recurred. CONCLUSION: Mesh implantation on the colon is possible without adverse reactions. However, high recurrence rates in patients with multiple previous surgeries raise doubts about using VMR for secondary or tertiary recurrences.

Ventral mesh rectopexy. Does a descending perineum impact functional results and quality of life?

PURPOSE: The impact of perineal descent (PD) on functional outcome and quality of life after ventral mesh rectopexy (VMR) is unknown. The purpose of this study was to analyze the effect of PD on the functional outcome and quality of life (QOL) after VMR. METHODS: A retrospective analysis was performed on fifty-five patients who underwent robotic VMR between 2018 and 2021. Pre and postoperative data along with radiological studies were gathered from a prospectively maintained database. The Cleveland Clinic Constipation score (CCCS), the Rome IV criteria and the 36-Item Short-Form Health Survey (SF-36), were used to measure functional results and QOL. RESULTS: All 55 patients (mean age 57.8 years) were female. Most patients had radiological findings of severe PD (n = 31) as opposed to mild/moderate PD (n = 24). CCCS significantly improved at 3 months and 1 year post-VMR (mean difference = -4.4 and -5.4 respectively, p < 0.001) with no significant difference between the two groups. The percentage of functional constipation Rome IV criteria only showed an improved outcome at 3 months for severe PD and at 1 year for mild/moderate PD (difference = -58.1% and -54.2% respectively, p < 0.05). Only the SF-36 subscale bodily pain significantly improved in the mild/moderate PD group (mean difference = 16.7, p = 0.002) 3 months post-VMR which subsided after one year (mean difference = 5.5, p = 0.068). CONCLUSION: Severe PD may impact the functional outcome of constipation without an evident effect on QOL after VMR. The results, however, remain inconclusive and further research is warranted.

Reduced port laparoscopic rectopexy for full-thickness rectal prolapse.

BACKGROUND: Laparoscopic rectopexy is an established treatment option for full-thickness rectal prolapse. Recently, reduced port surgery (RPS) has emerged as a novel concept, offering reduced postoperative pain and improved cosmetic outcomes compared with conventional multiport surgery (MPS). This study aimed to evaluate the feasibility and safety of RPS for full-thickness rectal prolapse. METHODS: From October 2012 to December 2018, 37 patients (MPS: 10 cases, RPS: 27 cases) underwent laparoscopic rectopexy for full-thickness rectal prolapse. Laparoscopic posterior mesh rectopexy (Wells procedure) is the standard technique for full-thickness rectal prolapse at our hospital. RPS was performed using a multi-channel access device, with an additional 12-mm right-hand port. Short-term outcomes were retrospectively compared between MPS and RPS. RESULTS: No significant differences were observed between MPS and RPS in the median operative time, the median blood loss volume, the postoperative complication rates, and median hospital stay duration after surgery. CONCLUSION: Reduced port laparoscopic posterior mesh rectopexy may serve as an effective therapeutic option for full-thickness rectal prolapse. However, to establish the superiority of RPS over MPS, a prospective, randomized, controlled trial is warranted.

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.

Laparoscopic ventral mesh rectopexy in the oldest old is safe: the race is run.

BACKGROUND: Laparoscopic ventral mesh rectopexy (LVMR) is considered to be the gold standard for managing rectal prolapse. Nevertheless, concerns have been expressed about the use of this procedure in elderly patients. The aim of the current study was to examine the perioperative safety of primary LVMR operations in the oldest old in comparison to younger individuals and to assess our hospital policy of offering LVMR to all patients, regardless of age and morbidity. METHODS: A retrospective study analysed demographic information, operation notes, meshes utilised, operation times, lengths of hospital stay (LOS) and American Society of Anesthesiologists (ASA) scores of patients who underwent LVMR at Elisabeth-TweeSteden Hospital between 2012 and 2023. RESULTS: Eighty-seven female patients underwent LVMR. Nineteen patients were 80 years of age or older (OLD group); the remaining 65 patients were under the age of 80 (YOUNG group). The difference between the groups in terms of age was statistically significant. ASA scores were not significantly different. No mortality was observed. There was no statistically significant difference between the groups in terms of LOS, operation time or morbidity. Moreover, the postoperative morbidity profile was excellent in both groups. CONCLUSION: LVMR seems to be a safe operation for the "oldest old" patients with comorbidity, despite a single-centre, retrospective trial with limited follow-up. The present study suggests abandoning the dogma that "frail patients with rectal prolapse are not suitable for laparoscopic ventral mesh rectopexy."

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.

Transabdominal levatorplasty technique in laparoscopic mesh rectopexy for rectal prolapse.

Rectal prolapse is characterized by a full-thickness intussusception of the rectal wall and is associated with a spectrum of coexisting anatomic abnormalities. We developed the transabdominal levatorplasty technique for laparoscopic rectopexy, inspired by Altemeier's procedure. In this method, following posterior mesorectum dissection, we expose the levator ani muscle just behind the anorectal junction. Horizontal sutures, using nonabsorbable material, are applied to close levator diastasis associated with rectal prolapse. The aim of the transabdominal levatorplasty is to (i) reinforce the pelvic floor, (ii) narrow the anorectal hiatus, and (iii) reconstruct the anorectal angle. We report a novel transabdominal levatorplasty technique during laparoscopic rectopexy for rectal prolapse. The laparoscopic mesh rectopexy with levatorplasty technique was performed in eight cases: six underwent unilateral Orr-Loygue procedure, one modified Wells procedure, and one unilateral Orr-Loygue procedure combined with sacrocolpopexy for uterine prolapse. The median follow-up period was 178 (33-368) days, with no observed recurrences. Six out of seven patients with fecal incontinence experienced symptomatic improvement. Although the sample size is small and the follow-up period is short, this technique has the potential to reduce the recurrence rate and improve functional outcomes, as with levatorplasty of Altemeier's procedure. We believe that this technique may have the potential to become an option for rectal prolapse surgery.

Outcomes of robotic versus laparoscopic ventral mesh rectopexy for rectal prolapse.

INTRODUCTION: Minimally invasive ventral mesh rectopexy is considered the standard of care in the surgical management of rectal prolapse syndromes in fit patients. We aimed to investigate the outcomes after robotic ventral mesh rectopexy (RVR) and compare them with our laparoscopic series (LVR). Additionally, we report the learning curve of RVR. As the financial aspect for the use of a robotic platform remains an important obstacle to allow generalized adoption, cost-effectiveness was also evaluated. PATIENTS AND METHODS: A prospectively maintained data set including 149 consecutive patients who underwent a minimally invasive ventral rectopexy between December 2015 and April 2021 was reviewed. The results after a median follow-up of 32 months were analyzed. Additionally, a thorough assessment of the economic aspect was performed. RESULTS: On a total of 149 consecutive patients 72 underwent a LVR and 77 underwent a RVR. Median operative time was comparable for both groups (98 min (RVR) vs. 89 min (LVR); p = 0.16). Learning curve showed that an experienced colorectal surgeon required approximately 22 cases in stabilizing the operative time for RVR. Overall functional results were similar in both groups. There were no conversions or mortality. There was, however, a significant difference (p < 0.01) in hospital stay in favor of the robotic group (1 day vs. 2 days). The overall cost of RVR was higher than LVR. CONCLUSIONS: This retrospective study shows that RVR is a safe and feasible alternative for LVR. With specific adjustments in surgical technique and robotic materials, we developed a cost-effective way of performing RVR.

Combination of Anterior and Posterior Vaginal Mesh Implants and Delorme Procedure in a 94-year-old female with Pelvic Organ Prolapse.

Pelvic organ prolapse refers to the descent of pelvic floor organs resulting from the weakening of pelvic muscles, fascia and connective tissue. The overall prevalence of pelvic organ prolapse is approximately 41%, including bladder prolapse (25%-34%), uterine prolapse (4%-14%) and rectal prolapse (13%-19%). Various methods are currently employed to repair damaged structures and improve patient symptoms, consequently enhancing their quality of life. This report focuses on a 94-year-old female diagnosed with pelvic organ prolapse, specifically Grade 3 bladder prolapse, Grade 3 uterine prolapse and complete rectal prolapse. A comprehensive surgical treatment was carried out to repair the pelvic organs on all three levels (rectum, uterus and bladder) by combining the Delorme procedure with synthetic graft implants. The surgical outcomes were good, illustrating immediate improvement in symptoms without early complications. A multispeciality approach helps functionally repair pelvic organ prolapse while preserving structural integrity.

[Treatment of rectal prolapse after proctoplasty in a child with rectal atresia]. / Lechenie vypadeniya pryamoi kishki posle proktoplastiki u rebenka s atreziei pryamoi kishki.

Rectal prolapse is a common disease in childhood and observed mainly at the age of 1-4 years old (95% of cases). If conservative treatment is ineffective, surgical correction of rectal prolapse in children without previous anorectal surgery is performed at the age of over a year. There is a single report on examination of patients aged 4-16 years after surgical correction of anorectal malformations with postoperative rectal prolapse. We present diagnosis and successful surgical treatment of rectal prolapse in an infant who underwent previous perineal proctoplasty for fistulous form of anorectal malformation.