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.

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.

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.

Rectal Prolapse Pathological Features: Findings in Patients With Outlet Obstruction Treated With Stapled Transanal Rectal Resection.

BACKGROUND: Obstructed defecation syndrome is a common multifactorial disease for which treatment is based primarily on clinic presentation for the lack of reliable instrumental and anatomopathological criteria. OBJECTIVE: The study aimed to analyze the pathological findings of the resected rectal specimens after stapled transanal rectal resection in patients affected by outlet obstruction. DESIGN: Retrospective cohort study. SETTINGS: University hospital. PATIENTS: Patients who underwent rectal resection for obstructed defecation syndrome due to internal rectal prolapse were included. INTERVENTIONS: Specimens of patients with obstructed defecation syndrome were analyzed through conventional histology and morphometric image analysis and compared with those of rectal specimens excised for oncological diseases. MAIN OUTCOME MEASURES: Analysis of the anatomopathological impairments underlying rectal prolapse. RESULTS: From January 2017 to December 2020, 46 specimens from the stapled transanal rectal resection group were compared with 40 specimens from the control group. In the stapled transanal rectal resection group, conventional histology revealed 34 samples (73.9%) had moderate- to severe-grade fibrosis with moderate-grade nerve degeneration in 33 cases (71.7%). In the control group, conventional histology revealed the absence of fibrosis in 31 specimens (77.5%), whereas the absence of nerve degeneration was detected in 37 specimens (92.5%). In the stapled transanal rectal resection group, morphometric image analysis showed severe-grade fibrosis in 25 cases (54.4%) compared to only low-grade fibrosis in 11 cases (27.5%). LIMITATIONS: The small sample size and the retrospective design of the study were limitations. Moreover, there was no chance to use specimens from healthy volunteers as the control group. CONCLUSIONS: Stapled transanal rectal resection specimens showed a higher rate of fibrosis and nerve dysplasia, an important parameter that is typically not considered preoperatively and could lead patients with rectal prolapse to the best treatment approach. See Video Abstract at http://links.lww.com/DCR/B928 . CARACTERSTICAS ANATOMOPATOLGICAS EN EL PROLAPSO DE RECTO HALLAZGOS EN PACIENTES CON OBSTRUCCIN DEL TRACTO DE SALIDA TRATADOS CON RESECCIN RECTAL TRANSANAL CON GRAPAS: ANTECEDENTES:El síndrome de obstrucción del tracto de salida, es una afección multifactorial común, cuyo tratamiento está basado principalmente en la presentación clínica, ésto, debido a la falta de criterios confiables tanto instrumentales como anatomopatológicos.OBJETIVO:Analizamos los hallazgos histopatológicos de las piezas de resección rectal obtenidas por vía transanal mediante grapas, realizadas en pacientes que presentaban obstrucción del tracto de salida.DISEÑO:Este fue un estudio de cohorte retrospectivo.AJUSTE:El escenario fue un hospital universitario.PACIENTES:Aquellos sometidos a resección rectal por síndrome obstructivo del tracto de salida causada por un prolapso rectal interno.INTERVENCIONES:Los especímenes de pacientes con síndrome obstructivo defecatorio fueron analizados mediante histología convencional y análisis de imágenes morfométricas, comparados con especímenes rectales resecados por enfermedad oncológica.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario se concentró en la investigación de las deficiencias anatomopatológicas subyacentes del prolapso rectal interno.RESULTADOS:Desde enero de 2017 hasta diciembre de 2020, se compararon 46 especímenes del grupo de resección rectal transanal con grapas con 40 especímenes del grupo de control. En histología convencional, el grupo de resección rectal transanal con grapas, 34 muestras (73,9%) presentaron un grado de fibrosis moderada-severa con un grado moderado de degeneración neurógena en 33 casos (71,7%). En el grupo control, la histología convencional reveló ausencia de fibrosis en 31 especímenes (77,5 %), mientras que la ausencia de degeneración neurógena se detectó en 37 controles (92,5 %). En el grupo de resección rectal transanal con grapas, el análisis de imágenes morfométricas mostró fibrosis moderada y fibrosis severa en 19 (41,3%) y 25 (54,4%) casos, respectivamente. En el grupo control, el análisis de imágenes morfométricas mostró solo un bajo grado de fibrosis en 11 casos (27,5%). Se encontró una diferencia significativa en todos los grados de fibrosis y displasia neurógena entre los grupos en las evaluaciones de análisis de imagen morfométrica e histología convencional (p < 0,001).LIMITACIONES:El pequeño tamaño de la muestra y el diseño retrospectivo del estudio. Además, no existe la posibilidad de utilizar un grupo de control con muestras de voluntarios sanos.CONCLUSIONES:Los especímenes de resección rectal transanal con grapas mostraron una mayor tasa de fibrosis y displasia neurógena, parámetro importante que actualmente no está considerado antes de la operación y en un futuro muy cercano podría orientar a los pacientes con prolapso rectal interno hacia un mejor enfoque de tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B928 . (Traducción-Dr. Xavier Delgadillo ).

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

AIM: Rectal prolapse is a common and significantly debilitating condition. Surgical correction is usually required. The two most common abdominal approaches are ventral mesh rectopexy and posterior suture rectopexy. Both may be complicated, respectively, by either mesh-related complications or significant postoperative constipation. We report the outcome of a novel rectopexy operation which combines aspects of both the aforementioned approaches, for the treatment of external rectal prolapse (ERP). METHOD: The technique involves laparoscopic partial posterior-lateral rectal mobilization of the rectum with posterior suture fixation to the sacral promontory and placement of an absorbable mesh in the rectovaginal space. Data were collected on postoperative complications, prolapse recurrence, mesh-related complications and the assessment of quality of life. RESULTS: Eighty patients underwent a modified mesh rectopexy for ERP. Seventy-seven were women. The median age was 67.5 years. Almost a third had undergone a previous rectal prolapse repair. Recurrences were seen in 11 (13.8%). No mesh-related complications were seen. Eleven patients reported postoperative constipation. CONCLUSION: The laparoscopic modified mesh rectopexy may be a safe and effective operation for the treatment of ERP.

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

AIM: The aim of this work was to assess the relationship between pelvic pain and rectal prolapse both before prolapse surgery and in the long term after ventral mesh rectopexy (VMR). METHOD: Patients undergoing VMR between 2004 and 2017 were contacted. Outcomes including the severity of pelvic pain were recorded using a numeric rating scale. RESULTS: Four hundred and seventy eight of the 749 patients (64%) were successfully contacted. Of these, 39% reported pre-existing pelvic pain prior to VMR (group A) and 61% were pain free (group B). The median follow-up time was 8.0 years (interquartile range 5.0-10.0 years). Symptoms of obstructed defaecation were significantly more common (p = 0.002) in group A (91/187, 49%) than in group B (101/291, 35%). In contrast, faecal incontinence was more common (p = 0.007) in group B (75/291, 26%) than in group A (29/187, 15%). In group A, 76% showed improvement in pelvic pain after VMR: 61% were pain free and 39% had partial improvement in their pre-existing pelvic pain. Patients with persistent pelvic pain were younger (p = 0.01) and more likely to have revisional surgery after VMR (p = 0.0003), but there was no relation to the indication for surgery (p = 0.59). In group B, 15% reported de novo pelvic pain after VMR, and this was more common in women under 50 years old (p = 0.001), when obstructed defaecation was the indication (p = 0.03), in mesh erosion (p = <0.05) and when associated with revisional surgery (p = 0.005). CONCLUSION: Pelvic pain is common (39%) in patients undergoing prolapse surgery, and VMR improves this pain in most patients (76%). However, a significant number of patients fail to improve (12%), experience worsening of pain (12%) or develop de novo pelvic pain (15%).

Outcomes for men undergoing rectal prolapse surgery - a systematic review.

AIM: Rectal prolapse is considered rare in men but the prevalence can be high in certain populations. It is unclear which surgical approach offers lower recurrence rates and better functional outcomes in men. The aim of this work was to determine the recurrence rates, complications and functional outcomes after prolapse surgery in men. METHOD: The MEDLINE, EMBASE and Scopus databases were systematically searched to identify studies on outcomes following surgical management of full-thickness rectal prolapse in men (over 18 years of age) published between 1951 and September 2022. Outcomes of interest included recurrence rate after surgery, bowel function, urinary function, sexual function and postoperative complications. RESULTS: Twenty-eight studies involving 1751 men were included. Two papers focused exclusively on men. Twelve studies employed a mixture of abdominal approaches, ten employed perineal approaches and six compared both. The recurrence rate varied across studies, ranging from 0% to 34%. Sexual and urinary function were poorly reported, but the incidence of dysfunction appears low. CONCLUSION: The outcomes of rectal prolapse surgery in men are poorly studied with small sample sizes and variable outcomes reported. There is insufficient evidence to recommend a specific repair approach based on the recurrence rate and functional outcomes. Further studies are required to identify the optimal surgical approach for rectal prolapse in men.

Laparoscopic ventral mesh rectopexy vs. transperineal mesh repair for obstructed defecation syndrome associated with rectocele: comparison of selectively distributed patients.

PURPOSE: Obstructed defecation syndrome represents 50-60% of patients with symptoms of constipation. We aimed to compare the two frequently performed surgical methods, laparoscopic ventral mesh rectopexy and transperineal mesh repair, for this condition in terms of functional and surgical outcomes. METHODS: This study is a retrospective review of 131 female patients who were diagnosed with obstructed defecation syndrome, attributed to rectocele with or without rectal intussusception, enterocele, hysterocele or cystocele, and who underwent either laparoscopic ventral mesh rectopexy or transperineal mesh repair. Patients were evaluated for surgical outcomes based on the operative time, the length of hospital stay, operative complications, using prospectively designed charts. Functional outcome was assessed by using the Initial Measurement of Patient-Reported Pelvic Floor Complaints Tool. RESULTS: Fifty-one patients diagnosed with complex rectocele underwent laparoscopic ventral mesh rectopexy, and 80 patients diagnosed with simple rectocele underwent transperineal mesh repair. Mean age was found to be 50.35 ± 13.51 years, and mean parity 2.14 ± 1.47. Obstructed defecation symptoms significantly improved in both study groups, as measured by the Colorectal Anal Distress Inventory, Constipation Severity Instrument and Patient Assessment of Constipation-Symptoms scores. Minor postoperative complications including wound dehiscence (n = 3) and wound infection (n = 2) occurred in the transperineal mesh repair group. CONCLUSION: Laparoscopic ventral mesh rectopexy and transperineal mesh repair are efficient and comparable techniques in terms of improvement in constipation symptoms related to obstructed defecation syndrome. A selective distribution of patients with or without multicompartmental prolapse to one of the treatment arms might be the preferred strategy.

Outcomes of rectal prolapse surgery in patients with benign joint hypermobility syndrome.

BACKGROUND: Rectal prolapse is a debilitating disorder of the pelvic floor, and treatment outcomes are variable. Previous studies have identified underlying benign joint hypermobility syndrome (BJHS) in some patients. We sought to determine the outcomes of these patients after undergoing ventral rectopexy surgery (VMR). METHODS: All consecutive patients who were referred to the pelvic floor unit at our institution between February 2010 and December 2011 were considered for recruitment into the study. Following recruitment, they were assessed using the Beighton criteria to determine the presence or absence of benign joint hypermobility syndrome. Both groups underwent similar surgical interventions and were then followed up. The need for revisional surgery was recorded in both groups. RESULTS: Fifty-two patients [34 normal; M:F, 1:6; median age 61 (range 22-84) years; 18 BJHS; M:F, 0:1; median age 52 (range 25-79) years] were recruited. A total of 42 patients completed the full 1-year follow-up (26 normal, 16 benign joint hypermobility syndrome). Patients with benign joint hypermobility syndrome were significantly younger (median age 52 versus 61 years, p < 0.001) with male to female ratio of 0:1 versus 1:6, respectively. In addition, they were significantly more likely to require revisional surgery than those without the condition (31% versus 8% p < 0.001). In most cases, this was in the form of a posterior stapled transanal resection of the rectum procedure. CONCLUSIONS: Patients with BJHS presenting for rectal prolapse surgery were younger and are more likely to require further surgery for rectal prolapse recurrence than those without the condition.

A network meta-analysis of surgical treatments of complete rectal prolapse.

PURPOSE: Surgical treatment of complete rectal prolapse can be undertaken via an abdominal or a perineal approach. The present network meta-analysis aimed to compare the outcomes of different abdominal and perineal procedures for rectal prolapse in terms of recurrence, complications, and improvement in fecal incontinence (FI). METHODS: A PRISMA-compliant systematic review of PubMed, Scopus, and Web of Science was conducted. Randomized clinical trials comparing two or more procedures for the treatment of complete rectal prolapse were included. The risk of bias was assessed using the ROB-2 tool. The main outcomes were recurrence of full-thickness rectal prolapse, complications, operation time, and improvement in FI. RESULTS: Nine randomized controlled trials with 728 patients were included. The follow-up ranged between 12 and 47 months. Posterior mesh rectopexy had significantly lower odds of recurrence than did the Altemeier procedure (logOR, - 12.75; 95% credible intervals, - 40.91, - 1.75), Delorme procedure (- 13.10; - 41.26, - 2.09), resection rectopexy (- 11.98; - 41.36, - 0.19), sponge rectopexy (- 13.19; - 42.87, - 0.54), and sutured rectopexy (- 13.12; - 42.58, - 1.50), but similar odds to ventral mesh rectopexy (- 12.09; - 41.7, 0.03). Differences among the procedures in complications, operation time, and improvement in FI were not significant. CONCLUSIONS: Posterior mesh rectopexy ranked best with the lowest recurrence while perineal procedures ranked worst with the highest recurrence rates.

A comparison of perineal stapled prolapse resection and the Altemeier procedure at 2 Canadian academic hospitals.

BACKGROUND: The preferred perineal repair method for full-thickness rectal prolapse is the Altemeier procedure, a perineal proctosigmoidectomy with handsewn anastomosis. A recently described variant of this procedure combines the resection and anastomosis into 1 step by means of linear and transverse stapling. There are few published data comparing the characteristics and outcomes of these 2 approaches. METHODS: This retrospective review, performed at 2 Canadian academic hospitals, compares surgical and cost outcomes between the perineal stapled prolapse resection (PSPR) and the Altemeier procedure. All patients who underwent these procedures between 2015 and 2019 were included. RESULTS: There were 25 patients in the PSPR group and 19 in the Altemeier group. Patients in the PSPR group were significantly older than those in the Altemeier group (81 [95% confidence interval (CI) 70-92] yr v. 74 [95% CI 63-85] yr; p = 0.047), had a lower body mass index (21.4 [95% CI 17.7-25.1] v. 24.4 [95% CI 18.5-30.3]; p = 0.042) and had equivalent American Society of Anesthesiologists scores (2.84 [95% CI 2.09-3.59] v. 2.68 [95% CI 1.93-3.43]; p = 0.49). The operative time for PSPR was significantly less (30.3 [95% CI 16.3-44.3] min v. 67 [95% CI 43-91] min; p < 0.001), as were the operative costs. Recurrence (28.0% v. 36.8%; p = 0.53) and complication rates were equivalent. CONCLUSION: PSPR is a safe, efficient and effective approach to perineal proctosigmoidectomy. It is associated with surgical outcomes comparable to those of the Altemeier procedure, but with a significant reduction in operative time and cost.

Multiple lymphomatous polyposis: rectal prolapse as an atypical presentation of the disease.

Multiple lymphomatous polyposis is a rare entity that can involve different types of both B-cell and T-cell lymphomas, including mantle cell lymphoma. A 57-year-old male patient is presented with prolapse of the rectal canal associated with data of lower digestive tract bleeding. A colonoscopy and subsequent upper endoscopy were performed with findings compatible with lymphomatous polyposis. After a biopsy study, mantle cell lymphoma was diagnosed and chemotherapy treatment was started. The endoscopic finding of multiple lymphomatous polypoposis associated with an adequate histopathological diagnosis improves the treatment success rate in patients with different types of gastrointestinal lymphomas.

Does Concomitant Pelvic Organ Prolapse Repair at the Time of Rectopexy Impact Rectal Prolapse Recurrence Rates? A Retrospective Review of the Prospectively Collected Pelvic Floor Disorders Consortium Quality Improvement Database Pilot.

BACKGROUND: Pelvic organ prolapse is reported in 30% of women presenting with rectal prolapse. Combined repair is a viable option to avoid the need for future pelvic floor interventions. However, the added impact of adding a modicum of middle compartment suspension by closing the pouch of Douglas during a rectal prolapse repair has not been studied. OBJECTIVE: The study aimed to assess the impact of middle compartment suspension on the durability of rectal prolapse repair. We also aimed to determine whether adding some form of pouch of Douglas closure to achieve middle compartment suspension leads to any improvements in the rates or severity of postoperative constipation or in the rates or severity of postoperative fecal incontinence. DESIGN: This study was a retrospective analysis of a multicenter prospective database. SETTING: Data were analyzed from the Pelvic Floor Disorders Consortium Quality Improvement in Rectal Prolapse Surgery database. Deidentified surgeons at more than 20 sites (75% academic, 81% high volume) self-reported patient demographics, previous repairs, symptoms of fecal incontinence and obstructed defecation, and operative details, including addition of concomitant gynecologic repairs, use of mesh, posterior or ventral dissection, and sigmoidectomy. PATIENTS: Patients were included who underwent abdominal repair for rectal prolapse. INTERVENTIONS: Abdominal rectopexy procedures with and without middle compartment suspension were compared. Middle compartment suspension was defined as excision and closure of the pouch of Douglas with some degree of colpopexy or culdoplasty. MAIN OUTCOME MEASURES: The primary outcome of prolapse recurrence and secondary outcomes of incontinence and constipation were calculated via univariate and multivariable regression by comparing those who underwent rectopexy with and without middle compartment suspension. RESULTS: Of the 198 patients (98% female, age 60.2 ± 15.6 years) who underwent abdominal repairs (59% robotic), 138 patients (70%) underwent some concomitant middle compartment suspension. Patients who had an added middle compartment suspension seemed to have lower early rectal prolapse recurrences. On multivariable regression to control for age, previous repairs, and the use of mesh, addition of some form of pouch of Douglas repair was associated with a decrease in short-term recurrences. LIMITATIONS: Our data need to be interpreted cautiously. Future studies are critically needed to further explore this observation, with an a priori, prospective definition of middle compartment suspension, validated measurement of concomitant pathology, and longer follow-up. CONCLUSION: Our results suggest that some middle compartment suspension at the time of rectal prolapse repair may improve short-term durability of rectal prolapse repair. See Video Abstract at http://links.lww.com/DCR/C30 . LA REPARACIN CONCOMITANTE DEL PROLAPSO DE RGANOS PLVICOS EN EL MOMENTO DE LA RECTOPEXIA AFECTA LAS TASAS DE RECURRENCIA DEL PROLAPSO RECTAL UNA REVISIN RETROSPECTIVA DE UNA BASE DE DATOS RECOPILADA PROSPECTIVAMENTE DEL CONSORCIO SOBRE LA MEJORA DE LA CALIDAD DE TRASTORNOS DEL PISO PLVICO: ANTECEDENTES:El prolapso de órganos pélvicos se informa en el 30 % de las mujeres que presentan prolapso rectal y la reparación combinada es una opción viable para evitar la necesidad de futuras intervenciones del suelo pélvico. Sin embargo, no se ha estudiado el impacto adicional de agregar un mínimo de suspensión del compartimento medio cerrando el fonde de saco de Douglas durante una reparación de prolapso rectal.OBJETIVO:Nuestro objetivo fue evaluar el impacto de la suspensión del compartimento medio con respecto a la durabilidad de la reparación del prolapso rectal. Quisimos de igual manera determinar si el agregado de algún tipo de cierre del fondo de saco de Douglas para lograr la suspensión del compartimento medio conduce a alguna mejora en las tasas o la gravedad del estreñimiento posoperatorio así como en las tasas o la gravedad de la incontinencia fecal posoperatoria.DISEÑO:Análisis retrospectivo de una base de datos prospectiva.ESCENARIO:Base de datos Multicenter Pelvic Floor Disorders Consortium Prospective Quality Improvement. Cirujanos no identificados en >20 sitios (75% académicos, 81% de alto volumen) datos demográficos de pacientes auto informados, reparaciones previas, síntomas de incontinencia fecal y defecación obstruida, y detalles quirúrgicos, incluida la suma de reparaciones ginecológicas concomitantes, uso de malla, disección anterior o posterior y sigmoidectomía.INTERVENCIONES:Se compararon los procedimientos de rectopexia abdominal con y sin suspensión del compartimento medio). La suspensión del compartimento medio se definió como la escisión y cierre del fondo de saco de Douglas con algún grado de colpopexia o culdoplastia.RESULTADOS:El resultado principal de la recurrencia del prolapso y los resultados secundarios de incontinencia y estreñimiento se calcularon mediante regresión uni y multivariable al comparar los que fueron sometidos a rectopexia con y sin suspensión del compartimento medio.PACIENTES:Pacientes sometidos a reparación abdominal por prolapso rectal.RESULTADOS:De los 198 pacientes (98% mujeres, edad 60,2 ± 15,6 años) sometidas a reparaciones abdominales (59% robótica), 138 (70%) fueron sometidas igualmente y de manera concomitante a alguna suspensión del compartimento medio. Los pacientes a los que se les añadió una suspensión del compartimento medio parecían tener menores recurrencias tempranas del prolapso rectal y, en la regresión multivariable para controlar la edad, las reparaciones previas y el uso de malla, la adición de alguna forma de reparación del fondo de saco de Douglas se asoció con una disminución de las recurrencias a corto plazo.LIMITACIONES:Nuestros datos deben interpretarse con cautela. Se necesitan de manera critica, estudios futuros para explorar más a fondo esta observación, con una definición prospectiva a priori de la suspensión del compartimento medio, una medición validada de la patología concomitante y un seguimiento más prolongado.CONCLUSIONES:Nuestros resultados sugieren que alguna suspensión del compartimento medio en el momento de la reparación del prolapso rectal puede mejorar la durabilidad a corto plazo de la reparación del prolapso rectal. Consulte Video Resumen en http://links.lww.com/DCR/C30 . (Traducción-Dr. Osvaldo Gauto ).

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

BACKGROUND: The current standard treatment for external rectal prolapse and symptomatic high-grade internal rectal prolapse is surgical correction with minimally invasive ventral mesh rectopexy using either laparoscopy or robotic assistance. This study examines the number of procedures needed to complete the learning curve for robot-assisted ventral mesh rectopexy (RVMR) and reach adequate performance. METHODS: A retrospective analysis of all primary RVMR from 2011 to 2019 performed in a tertiary pelvic floor clinic by two colorectal surgeons (A and B) was performed. Both surgeons had previous experience with laparoscopic rectopexy, but no robotic experience. Skin-to-skin operating times (OT) were assessed using LC-CUSUM analyses. Intraoperative and postoperative complications were analyzed using CUSUM analyses. RESULTS: A total of 182 (surgeon A) and 91 (surgeon B) RVMRs were performed in total. There were no relevant differences in patient characteristics between the two surgeons. Median OT was 75 min (range 46-155; surgeon A) and 90 min (range 63-139; surgeon B). The learning curve regarding OT was completed after 36 procedures for surgeon A and 55 procedures for surgeon B. Both before and after completion of the learning curve, intraoperative and postoperative complication rates remained below a predefined acceptable level of performance. CONCLUSIONS: 36 to 55 procedures are required to complete the learning curve for RVMR. The implementation of robotic surgery does not inflict any additional risks on patients at the beginning of a surgeon's learning curve.

Laparoscopic ventral rectopexy plus sacral colpopexy: continuous locked suture for mesh fixation. A randomized clinical trial.

PURPOSE: Laparoscopic ventral rectopexy (LVR) plus sacral colpopexy (LSC) is a high-complexity surgical procedure. The aim of the present study was to evaluate a new approach to rectal-mesh fixation during LVR with continuous locked suture. METHODS: This is a prospective randomized double-blinded clinical trial enrolling 80 patients with severe POP and obstructed defecation syndrome (ODS) from November 2016 to January 2021. Patients underwent a "two-meshes" LSC plus LVR and were randomized, regarding rectal mesh fixation, in Group A (extracorporeal interrupted 0 delayed absorbable sutures) and Group B ("U-shaped" running locked 0 delayed absorbable suture). Our primary endpoints were the operative times (OT); the secondary endpoints were the incidence of anatomical failures, vaginal mesh erosions and surgical complications. RESULTS: A total of 75 patients completed the study. Baseline characteristics were similar between the groups. Overall OT (156 vs 138 min; p < 0.05; treatment reduction of 11.5%) and LVR mesh fixation time (29 vs 16 min; p < 0.05; treatment reduction of 44%), resulted in significantly lower in Group B. No differences were found in terms of anatomic failure, vaginal mesh erosion or intra- or post-operative complications. PGI-I, FSDS and Wexner questionnaires resulted significantly improved after surgery, without statistical differences between the studied surgical procedures. CONCLUSION: Laparoscopic continuous locked 0 absorbable suture for LVR mesh fixation guaranteed a faster and effective alternative to multiple interrupted sutures. The significant OT reduction linked to this technique should be considered even more helpful when performing a highly complex surgery such as LVR. CLINICAL TRIAL REGISTRATION: NCT05254860 (13/02/2017).

Mesh-related complications and recurrence after ventral mesh rectopexy with synthetic versus biologic mesh: a systematic review and meta-analysis.

BACKGROUND: Ventral mesh rectopexy (VMR) is a widely accepted surgical treatment for rectal prolapse. Both synthetic and biologic mesh are used. No consensus exists on the preferred type of mesh material. The aim of this systematic review and meta-analysis was to establish an overview of the current literature on mesh-related complications and recurrence after VMR with synthetic or biologic mesh to aid evidence-based decision making in preferred mesh material. METHODS: A systematic search of the electronic databases of PubMed, Embase and Cochrane was performed (from inception until September 2020). Studies evaluating patients who underwent VMR with synthetic or biologic mesh were eligible. The MINORS score was used for quality assessment. RESULTS: Thirty-two studies were eligible after qualitative assessment. Eleven studies reported on mesh-related complications including 4001 patients treated with synthetic mesh and 762 treated with biologic mesh. The incidence of mesh-related complications ranged between 0 and 2.4% after synthetic versus 0-0.7% after biologic VMR. Synthetic mesh studies showed a pooled incidence of mesh-related complications of 1.0% (95% CI 0.5-1.7). Data of biologic mesh studies could not be pooled. Twenty-nine studies reported on the risk of recurrence in 2371 synthetic mesh patients and 602 biologic mesh patients. The risk of recurrence varied between 1.1 and 18.8% for synthetic VMR versus 0-15.4% for biologic VMR. Cumulative incidence of recurrence was found to be 6.1% (95% CI 4.3-8.1) and 5.8% (95% CI 2.9-9.6), respectively. The clinical and statistical heterogeneity was high. CONCLUSIONS: No definitive conclusions on preferred mesh type can be made due to the quality of the included studies with high heterogeneity amongst them.

Stepped-wedge randomized controlled trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation.

BACKGROUND: The effectiveness of laparoscopic ventral mesh rectopexy (LVMR) in patients with defecatory disorders secondary to internal rectal prolapse is poorly evidenced. A UK-based multicenter randomized controlled trial was designed to determine the clinical efficacy of LVMR compared to controls at medium-term follow-up. METHODS: The randomized controlled trial was conducted from March 1, 2015 TO January 31, 2019. A stepped-wedge RCT design permitted observer-masked data comparisons between patients awaiting LVMR (controls) with those who had undergone surgery. Adult participants with radiologically confirmed IRP refractory to conservative treatment were randomized to three arms with different delays before surgery. Efficacy outcome data were collected at equally stepped time points (12, 24, 36, 48, 60, and 72 weeks). Clinical efficacy of LVMR compared to controls was defined as ≥ 1.0-point reduction in Patient Assessment of Constipation-Quality of Life and/or Symptoms (PAC-QOL and/or PAC-SYM) scores at 24 weeks. Secondary outcome measures included 14-day diary data, the Generalized Anxiety Disorder scale (GAD-7), the Patient Health Questionnaire-9 (PHQ-9), St Marks incontinence score, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), the chronic constipation Behavioral Response to Illness Questionnaire (CC-BRQ), and the Brief Illness Perception Questionnaire (BIPQ). RESULTS: Of a calculated sample size of 114, only 28 patients (100% female) were randomized from 6 institutions (due mainly to national pause on mesh-related surgery). Nine were assigned to the T0 arm, 10 to T12, and 9 to T24. There were no substantial differences in baseline characteristics between the three arms. Compared to baseline, significant reduction (improvement) in PAC-QOL and PAC-SYM scores were observed at 24 weeks post-surgery (- 1.09 [95% CI - 1.76, - 0.41], p = 0.0019, and - 0.92 [- 1.52, - 0.32], p = 0.0029, respectively) in the 19 patients available for analysis (9 were excluded for dropout [n = 2] or missing primary outcome [n = 7]). There was a clinically significant long-term reduction in PAC-QOL scores (- 1.38 [- 2.94, 0.19], p = 0.0840 at 72 weeks). Statistically significant improvements in PAC-SYM scores persisted to 72 weeks (- 1.51 [- 2.87, - 0.16], p = 0.0289). Compared to baseline, no differences were found in secondary outcomes, except for significant improvements at 24 and 48 weeks on CC-BRQ avoidance behavior (- 14.3 [95% CI - 23.3, - 5.4], and - 0.92 [- 1.52, - 0.32], respectively), CC-BRQ safety behavior (- 13.7 [95% CI - 20.5, - 7.0], and - 13.0 [- 19.8, - 6.1], respectively), and BIPQ negative perceptions (- 16.3 [95% CI - 23.5, - 9.0], and - 10.5 [- 17.9, - 3.2], respectively). CONCLUSIONS: With the caveat of under-powering due to poor recruitment, the study presents the first randomized trial evidence of short-term benefit of LVMR for internal rectal prolapse. TRIAL REGISTRATION: ISRCTN Registry (ISRCTN11747152).

Predictive factors for functional failure of ventral mesh rectopexy in the treatment of rectal prolapse and obstructed defecation.

BACKGROUND: Ventral mesh rectopexy (VMR) is widely accepted for the treatment of rectal prolapse or obstructed defecation. However, despite good anatomical results, the improvement of functional symptoms (constipation or incontinence) cannot always be obtained and in some cases these symptoms may even worsen. The aim of the present study was to identify possible predictors of functional failure after VMR. METHODS: Data of all consecutive patients who had VMR for the treatment of rectal prolapse and/or obstructed defecation between January 2017 and December 2020 in three different pelvic floor surgical centres in Italy were analysed to identify possible predictors of functional failure, intended as persistence, worsening or new onset of constipation or faecal incontinence. Symptom severity was assessed pre- and postoperatively with the Wexner Constipation score and Obstructed Defecation Syndrome score. Quality of life was assessed, also before and after treatment, with the Patients Assessment of Constipation Quality of Life questionnaire, the Pelvic Floor Disability Index and the Pelvic Floor Impact Questionnaire. Faecal incontinence was evaluated with the Cleveland Clinic Incontinence Score. The functional outcomes before and after surgery were compared. RESULTS: Sixty-one patients were included (M:F ratio 3:60, median age 64 years [range 33-88 years]). Forty-two patients (68.9%) had obstructed defecation syndrome, 12(19.7%) had faecal incontinence and 7 patients (11.5%) had both. A statistically significant reduction between pre- and postoperative Obstructed Defecation Syndrome and Wexner scores was reported (p < 0.0001 in both cases). However, the postoperative presence of constipation occurred in 22 patients (36.1%) (this included 3 cases of new-onset constipation). The presence of redundant colon and the pre-existent constipation were associated with an increased risk of persistence of constipation postoperatively or new-onset constipation (p = 0.004 and p < 0.0001, respectively). The use of postoperative pelvic floor rehabilitation (p = 0.034) may reduce the risk of postoperative constipation. CONCLUSIONS: VMR is a safe and effective intervention for correcting the anatomical defect of rectal prolapse. The degree of prolapse, the presence of dolichocolon and pre-existing constipation are risk factors for the persistence or new onset of postoperative constipation. Postoperative rehabilitation treatment may reduce this risk.

Solitary rectal ulcer syndrome (SRUS): observational case series findings on MR defecography.

OBJECTIVE: Radiological findings in solitary rectal ulcer syndrome (SRUS) are well described for evacuation proctography (EP) but sparse for magnetic resonance defecography (MRD). In order to rectify this, we describe the spectrum of MRD findings in patients with histologically proven SRUS. MATERIALS AND METHODS: MRD from twenty-eight patients (18 female; 10 males) with histologically confirmed SRUS were identified. MRD employed a 1.5-T magnet and a standardized technique with the rectal lumen filled with gel and imaged sagittally in the supine position, before, during, and after attempted rectal evacuation. A single radiologist observer with 5 years' experience in pelvic floor imaging made the anatomical and functional measurements. RESULTS: Sixteen patients (10 female) demonstrated internal rectal intussusception and 3 patients (11%) demonstrated complete external rectal prolapse. Anterior rectoceles were noted in 12 female patients (43%). Associated anterior and middle compartment weakness (evidenced by excessive descent) was observed in 18 patients (64%). Cystocele was found in 14 patients (50%) and uterine prolapse was noted in 7 patients (25%). Enterocoeles were detected in 5 patients (18%) and peritoneocoele in 5 patients (18%). None had sigmoidocoele. Sixteen patients (57%) demonstrated delayed voiding and 13 patients (46%) incomplete voiding, suggesting defecatory dyssynergia. CONCLUSION: MRD can identify and grade both rectal intussusception and dyssynergia in SRUS, and also depict associated anterior and/or middle compartment descent. Distinction between structural and functional findings has important therapeutic implications. KEY POINTS: MRD can identify and grade both rectal intussusception and dyssynergia in patients with SRUS. MRD is an acceptable substitute to evacuation proctography in assessing anorectal dysfunctions when attempting to avoid ionizing radiation. SRUS influences the pelvic floor globally. MRD depicts associated anterior and/or middle compartment prolapse.

A step-by-step approach to endorectal proctopexy (ERPP): how we do it.

There are many surgical treatments aimed at correcting internal mucosal prolapse and rectocele associated with obstructed defecation syndrome (ODS). Perineal procedures can be considered as first options in young men in whom an abdominal approach poses risks of sexual dysfunction and in selected women with isolated posterior compartment prolapse who failed conservative treatment. About 20 years ago, we described endorectal proctopexy (ERPP) also known as internal Delorme procedure. The aim of the present study was to describe, with attention to technical details and the aid of a video, the different steps of ERPP for the treatment of ODS. A retrospective analysis of our last 100 cases confirms our initial good results. Complications included suture line dehiscence with consequent stricture in four patients (4%). Bleeding occurred in four (4%) patients and was conservatively treated. Transient anal continence impairment consisting of urgency and soiling occurred in 12 (12%) and 6 (6%) patients, respectively. At 6-month follow-up the Cleveland Clinic Constipation Score and ODS score improved from a median preoperative value of 18.9 and 18.5 to 5 and 5, respectively (p < 0.0001). The mean follow-up was 36.05 ± 13.3 (range 12-58) months and anatomical recurrence rate was 6 (%). Due to its excellent safety profile and the ability to tailor the procedure to different disease presentations, we think that ERPP should be part of the basic armamentarium of all colorectal surgeons operating on the pelvic floor.