Background
Rectal prolapse is a debilitating condition that affects 1% of people older than 60 years. Surgical approaches to its treatment include a perineal approach and an abdominal approach. [1, 2] Laparoscopic rectopexy was initially described in the early 1990s and has since become the abdominal procedure of choice for rectal prolapse. [3] This review describes three of the current laparoscopic approaches in the management of rectal prolapse and rectocele.
Indications
Once rectal prolapse is diagnosed, surgical repair is indicated to prevent worsening fecal incontinence and discomfort.
Laparoscopic rectopexy has been recommended as the first option for rectal prolapse. [4]
Technical Considerations
Modifications of classic laparoscopic suture rectopexy have been developed. Pandey et al compared modified laparoscopic suture rectopexy with classic laparoscopic suture rectopexy in children and determined that the former was associated with shorter operating times, reduced blood loss, and less constipation at 3-month follow-up. [5]
Mesh erosion is one of the distressing problems associated with laparoscopic ventral mesh rectopexy (LVMR). [6] Minimally invasive organ-preserving techniques—such as transanal or transvaginal trimming or excision of exposed mesh and sutures (with or without transanal endoscopic microsurgery [TEMS] or transanal minimally invasive surgery [TAMIS]) and laparoscopic pelvic assessment and detachment of mesh from the sacral promontory—are used for the management of mesh erosions. These techniques are multistaged and require months to complete; however, they are effective and feasible.
Laparoscopic pelvic organ prolapse suspension surgery (POPS) has been employed to treat rectal prolapse. In a study comparing POPS (n = 60) with LVMR (n = 60) in patients with this condition, Farag et al found that whereas postoperative pain and length of hospital stay were not significantly different between the two groups, the POPS group had a shorter operating time and the LVMR group had lower complication and recurrence rates. [7] The authors suggested that POPS could be an easier and faster alternative to LVMR.
Outcomes
Abdominal rectopexy yields low recurrence rates (< 5%) and some improvement of incontinence. However, this approach can cause constipation and does not resolve existing constipation, [8, 9] possibly owing to rectal denervation after the posterolateral dissection of the rectum.
In contrast, perineal approaches, including Altemeier and Delorme procedures, are associated with a higher recurrence rate but lower morbidity than open abdominal approaches. Although these are considered safer operations, with the rate of recurrence approaching 18% and minimal improvement in continence, better alternatives have been investigated. [8]
The small incisions, lack of anastomosis, and low recurrence rates of the minimally invasive approach have reduced the morbidity of the abdominal approach without affecting efficacy. In a randomized control trial, laparoscopic rectopexy had fewer complications, shorter length of hospital stay, and decreased in pain compared with open abdominal rectopexy. [10] In addition, it was comparable to perineal procedures in terms of morbidity.
Compared with the classic open posterior rectopexy, laparoscopic rectopexy has similar functional outcomes with respect to constipation. Satisfactory long-term results have been reported with laparoscopic "ventral" rectopexy, and new constipation is prevented because of the lack of posterior dissection. [11, 12, 13, 14, 4]
In a prospective study of 224 patients who underwent LVMR, McLean et al assessed long-term clinical outcomes, patient-reported functional and quality-of-life outcomes, and urinary and sexual dysfunction. [15] No mortality was reported. The overall complication rate was 10.7%, mesh-related morbidity was 0.45%, and vaginal suture-related morbidity was 1.33%. The overall recurrence rate was 11.4%. Significant improvements in patient-reported functional outcomes were seen for both constipation and fecal incontinence symptoms.Significant improvements in quality-of-life outcomes persisted in patients with constipation, fecal incontinence and prolapse.
Tsunoda et al assessed 58 patients who underwent laparoscopic ventral rectopexy for external rectal prolapse on the basis of the Fecal Incontinence Severity Index, the Constipation Scoring System, and quality-of-life (QoL) instruments both before and after operation. [16] The median Fecal Incontinence Severity Index and Constipation Scoring System scores were significantly reduced at 3 months and remained so for 4-5 years. The midterm analysis revealed low morbidity, low recurrence, and an improvement in function and fecal incontinence-specific QoL.
A systematic review and meta-analysis (17 studies; N = 1242) by Emile et al addressed predictors of recurrence of full-thickness external rectal prolapse after LVMR. [17] Male sex and the length of the mesh were found to be significant contributors to recurrence. There was a 71% inprovement in constipation rates after LVMR, as well as a 79.3% improvement in fecal incontinence rates. The low recurrence and complications rates make LVMR an effective and safe treatment option.
Madbouly et al compared functional outcomes, recurrence rates, and QoL for laparoscopic ventral rectopexy (n = 41) versus laparoscopic Wells rectopexy (n = 33) in patients with complete rectal prolapse. [18] Both procedures successfully and safely corrected prolapse and prevented recurrence, though laparoscopic ventral rectopexy was associated with significantly longer operating time and length of stay. Laparoscopic ventral rectopexy appeared to be more suitable for patients with a high constipation score and abnormal perineal descent.
Hidaka et al compared the long-term functional outcomes of LVMR with those of laparoscopic posterior sutured rectopexy (LPSR) for rectal prolapse, using multiple questionnaires assessing prolapse recurrences and mesh-related complications. [19] LVMR was found to be superior to LPSR with respect to long-term functional outcomes.
Tsiaousidou et al assessed the safety of the use of biologic mesh in 86 patients who underwent LVMR for rectal prolapse; of these, 40 were treated for obstructive defecation, 38 for mixed symptoms (obstructive defecation and incontinence), five for pain and bleeding, and three for incontinence. [20] Median Wexner score for constipation decreased from 14.5 preoperatively to 4 postoperatively and median Wexner score for fecal incontinence from 11 preoperatively to 2 postoperatively. There were four recurrences, two instances of suture erosion through the rectum, and one case of diskitis. There were no mesh complications or deaths.
Compared with the results of laparoscopic rectopexy, the results of robotic rectopexy have been similar in terms of length of stay, postoperative pain, recurrence rates, and mortality. In contrast, robotic rectopexy has been associated with a longer operating time and higher costs. [21, 22, 23, 24] However, a randomized controlled trial that included 30 patients reported no significant difference in operating time between robot-assisted and conventional laparoscopic ventral rectopexy. [25]
In a multicenter comparative matched-pair study (N = 401), Laitakari et al compared the midterm functional and QoL outcomes of LMVR (n = 214) with those of robotic ventral mesh rectopexy (RMVR; n = 187). [26] Postoperative QoL measures did not differ between groups. The RVMR group had a lower median postoperative Wexner Incontinence Score (5 vs 8), a lower incidence of significant ongoing incontinence symptoms (30.6% vs 49.0%), and a lower median level of postoperative fecal incontinence discomfort on the visual analogue scale (11 vs 39). RVMR patients had a shorter hospital stay (2.2 vs 3.8 days) but a higher frequency of de-novo pelvic pain (31.8% vs 11.8%).
