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38 Rectal Prolapse: Rectopexy vs Perineal Proctosigmoidectomy
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functional outcomes including constipation, FI, and global quality of life measures
regardless of the surgical approach, though differences seemed to favor the robotic
platform.
429
Anterior Versus Posterior Rectopexy
Data comparing rectopexy techniques has been updated with two SR/MAs, longterm results from a randomized controlled trial (RCT), and a retrospective review
including a large number of male patients.
A SR and MA by Lobb etal. evaluated anterior suture rectopexy versus VMR
from 22 studies including 976 patients. Subgroup analysis was performed to compare VMR with biologic versus synthetic mesh [12]. Included were randomized and
non-randomized studies of open or laparoscopic techniques with follow-up of at
least 12 months. Hajibandeh et al. performed SR and MA of laparoscopic mesh
rectopexy (anterior or posterior) versus posterior suture rectopexy, including 5 comparative studies and 307 patients [13]. Follow-up ranged from 1 to 6years.
Hidaka etal. reported long-term outcomes of an RCT comparing outcomes following laparoscopic ventral mesh rectopexy and laparoscopic posterior suture rectopexy [14]. The studies randomized 75 patients in total and assessed outcomes
with median follow-up of 6.1years. Previously, 1-year outcomes from this study
including complications were reported by Lundby etal. [15]. Madbouly etal. compared laparoscopic VMR to posterior rectopexy and included 74 patients, 19% of
which were male [16]. All ventral rectopexy cases incorporated mesh. The minimum follow-up was 2years with a range of 2–7years.
Morbidity
Lobb etal. reported an overall complication rate following anterior suture rectopexy
of 8.8% and following VMR of 7.9% (p=0.509) [12]. The most common postoperative complication following suture rectopexy was surgical site infection (1.9%)
and following VMR was urinary tract infection (2.4%). Hajibandeh reported no
signicant difference between laparoscopic mesh rectopexy (anterior or posterior)
and laparoscopic posterior suture rectopexy in complications including surgical site
infection (OR 1.48, p=0.71) [13]. There was no signicant difference in length of
stay (MD: −1.54, p=0.47). No mesh erosion was reported in any of the studies at
maximum follow-up.
Lundby etal. reported a similar rate of overall complications in their RCT, with
1/37 following posterior suture rectopexy and 1/38 following VMR [15]. Madbouly
etal. reported similar morbidity in the 2 cohorts, 3/41in VMR and 2/33in laparoscopic posterior rectopexy (p = 0.99) [16]. The most common complications of
VMR were urinary tract infection and prolonged ileus, and 1 patient experienced
mesh erosion into the vagina. The most common complication after posterior suture
rectopexy was wound infection. Conversion to open was necessary in 2/41 VMR
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patients and in no posterior suture rectopexy patients (p= 0.001). Operative time
was signicantly longer for VMR (122min) compared to posterior suture rectopexy
(105min) (p=0.001). Length of stay was signicantly longer for VMR (4.5days)
versus posterior suture rectopexy (3.7days) (p=0.04).
S. A. Vogler and K. A. Ban
Recurrence
In their SR, Lobb etal. reported a recurrence rate of 8.6% after suture rectopexy
compared to 3.7% for VMR (p<0.001) [12]. Results from the MA showed high
heterogeneity, and the difference in recurrence rates was not found to be statistically
signicant (p=0.76). On subgroup analysis, there was no difference in recurrence
rate comparing VMR with biologic versus synthetic mesh (4.1% versus 3.6%,
respectively, p = 0.789). Hajibandeh et al. reported signicantly lower recurrence
after laparoscopic rectopexy with mesh (anterior or posterior approach) compared
to laparoscopic posterior suture rectopexy (OR 0.28, p=0.009) [13].
In their RCT, Lundby etal. reported early recurrence within one year in 5% of
patients undergoing posterior suture rectopexy and in no patients undergoing VMR
(p=0.305) [15]. Long-term recurrence rates from the same RCT at a median of
6.1years were reported by Hidaka et al. as 23% following posterior suture rectopexy and 9% following VMR [14]. Authors note the study was not powered to
assess recurrence, and this difference was not signicant. Madbouly etal. reported
similar recurrence after laparoscopic VMR (1/41) compared to laparoscopic posterior suture rectopexy (1/33) (p=0.93) [16].
Function andQuality ofLife
Lobb etal. reported variable ndings in the comparison of functional outcomes after
anterior suture rectopexy versus VMR [12]. Of ve studies comparing outcomes, two
found no statistical difference in FI, and one reported a signicant difference favoring
VMR.Regarding constipation, two studies reported a signicant difference favoring
VMR. Hajibandeh et al. reported no signicant difference in Cleveland Clinic
Incontinence Score (CCIS) (MD: −1.02, p=0.50) or Cleveland Clinic Constipation
Score (CCCS) (MD: −1.54, p=0.47) between laparoscopic mesh rectopexy (anterior
or posterior) versus laparoscopic posterior suture rectopexy [13].
Lundby et al. reported short-term outcomes of their RCT [15]. Patients who
underwent laparoscopic VMR had a signicant pre- to post-operative improvement
in obstructive defecation syndrome (ODS) score (1.97, 95% CI 0.01–3.93), and a
non-signicant improvement following laparoscopic posterior suture rectopexy
(2.18, 95% CI −0.14–4.49). The difference between the two groups was not signicant. Long-term outcomes from this RCT reported by Hidaka et al. found total
Patient Assessment of Constipation Quality of Life Questionnaire (PAC-QoL) score
was signicantly lower in the VMR cohort (0.26, 0.14–0.83) compared to posterior
suture rectopexy (0.93, 0.32–1.61) (p = 0.008). The total constipation symptom
38 Rectal Prolapse: Rectopexy vs Perineal Proctosigmoidectomy
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score measured by Patient Assessment of Constipation-Symptoms (PAC-SYM) was
signicantly lower in the VMR cohort (0.5, 0.21–0.87) compared to posterior suture
rectopexy (1.0, 0.5–1.5) (p=0.031). Except for the CCIS, other scores including the
ODS and the CCCS signicantly favored the VMR group (p=0.011 and p=0.017,
respectively). Madbouly etal. found signicant improvement in incontinence (measured by Wexner incontinence scale) and obstructed defecation (measured by
Wexner constipation scale) after both laparoscopic VMR and laparoscopic posterior
suture rectopexy [16]. After 1year, GIQoL improved signicantly in all patients in
both cohorts but was signicantly higher after VMR (p=0.05). After VMR, 50% of
patients reported improvement in pre-existing constipation compared to 23% of
patients after posterior suture rectopexy, which was signicant (p=0.04). There
was no signicant difference in fecal incontinence between the two procedures.
431
Altemeier Versus Delorme Procedure
Two factorial randomized trials, PROSPER and the more recent trial reported by
Smedberg etal., performed additional comparison of outcomes after Altemeier vs.
Delorme procedures [2, 3].
Morbidity
The PROSPER trial did not compare postoperative complications but described outcomes in both cohorts [2]. Four mortalities were reported following perineal procedures, 2 following Altemeier and 2 following Delorme. Other serious complications
included 4 anastomotic leakages in the Altemeier group, though one of the patients
had been randomized to receive Delorme. Three of these patients were men and were
demographically distinct from most of the study population. Overall morbidity was
similar in the randomized trial reported by Smedberg etal. [3]. Most complications
were Clavien-Dindo Grade I or II, with 5 total complications reported in the Delorme
cohort and 10 total complications reported in the Altemeier cohort (p=0.331) including one mortality 11days after discharge deemed unrelated to the surgery.
Recurrence
The PROSPER trial found fewer recurrences after Altemeier compared to Delorme
(25% versus 31%), but this difference was not signicant (p=0.4) [2]. Smedberg
et al. reported recurrence rates favoring Altemeier over Delorme, but at no time
point were these differences signicant [3]. Authors reported recurrence rates at 3
months, 1year, 3years, and in longer-term follow-up. Recurrence at 1year was
50% following Delorme and 32% following Altemeier (p=0.203). Recurrence at
more than 3 years was 58% following Delorme and 47% following Altemeier
(p=0.345).
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S. A. Vogler and K. A. Ban
Function andQuality ofLife
The PROSPER trial reported no signicant differences in bowel function and quality of life scores following Delorme versus Altemeier procedures as measured by
the Vaizey score, the Bowel thermometer, and the EQ-5D [2]. In both cases, scores
improved from baseline to 6weeks, and were maintained at 1 and 3years postoperatively. Smedberg etal. had higher baseline Wexner incontinence scores in patients
randomized to Delorme (14.9) versus Altemeier (10.7) (p= 0.005), but reported
similar scores at 3months, 1 and 3years with long-term scores of 8.6in both groups
(p=0.995) [3].
Recommendations
Surgical treatment options for rectal prolapse continue to expand and evolve. There
is not a single gold-standard approach. There are numerous factors that inuence a
surgeon’s recommended surgical approach.
Abdominal prolapse repairs continue to have a lower recurrence rate compared
to perineal approaches (evidence quality strong). As minimally invasive abdominal
approaches continue to mature with shorter operative time, minimal postoperative
pain and faster return to normal activity, this approach can be performed on highrisk patients with minimal morbidity (evidence quality moderate; weak recommendation). Perineal proctosigmoidectomy (Altemeier) confers greater advantage over
Delorme repair with lower recurrence rate as well as improved function and quality
of life (evidence quality moderate; weak recommendation). There is insubstantial
evidence to guide the choice of perineal repair versus ventral mesh rectopexy. There
is no advantage proven in surgical approach (laparoscopic versus robotic) for rectopexy (evidence quality moderate; weak recommendation). Ventral rectopexy consistently improves functional outcomes relating to constipation, mechanical outlet
obstruction, and fecal incontinence (evidence quality moderate, weak recommendation). Ventral mesh rectopexy is favored over posterior suture rectopexy in functional outcome improvement (evidence quality moderate, weak recommendation).
The risk of mesh related complications after ventral mesh rectopexy is <1%.
However, the risk of recurrent after ventral mesh rectopexy is lower than suture
rectopexy. The risks and benets of prolapse repair using mesh should be specically discussed with patients preoperatively (evidence quality moderate, strong
recommendation).
Personal View
The evaluation and treatment approach to rectal prolapse has evolved rapidly over
the last 5years as the surgical treatment for pelvic oor related disorders and symptoms has improved. The fact that all surgical treatment options continue to carry a
risk of recurrent prolapse indicates that there is still more to learn and better
38 Rectal Prolapse: Rectopexy vs Perineal Proctosigmoidectomy
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433
techniques and approaches that can be performed. Minimally invasive abdominal
approaches for repair of rectal prolapse are safe for high-risk patients and continue
to have a lower risk of recurrence. Thus, the appeal of perineal approaches has faded
rapidly. In fact, we reserve Altemeier repairs for young men with full thickness
rectal prolapse who have low anal tone. Perineal repairs have the lowest risk of
injury to nerves of sexual function. Additionally, this population of patients tends to
have a signicant behavioral component of habitually straining which is less likely
to result in deterioration of repair after Altemeier compared to all of the “pexy”
procedures.
Women in the fth to seventh decade of life are most aficted by rectal prolapse.
This patient population is also the most likely to experience symptoms of urinary
incontinence and urgency, pelvic pressure, fecal urgency, bowel habit irregularity,
and incomplete defecation. This constellation of symptoms is commonly associated
with multicompartment pelvic organ prolapse. Occasionally, pelvic organ prolapse
will include laxity in one or more compartments that is frankly visible on resting
exam. But commonly, laxity in one or more pelvic compartments is not visible on
exam, and pelvic oor testing is the only means of identifying the extent of pelvic
oor laxity. Studies such as defecography, anal manometry, and urodynamics can be
used to identify points of weakness that contribute to a patient’s constellation of
symptoms. Identifying all points of dysfunctional laxity may require multidisciplinary collaboration for evaluation and treatment. Neglecting to address dysfunctional laxity in one compartment while xing another compartment may compromise
the repair or exacerbate dysfunction in the untreated compartment. The growing
enthusiasm to evaluate and treat pelvic organ prolapse in a multidisciplinary fashion
has likely been instrumental in the increased frequency of robotic approach utilization since port site layout and instruments can more easily be shared between specialists compared to the laparoscopic approach.
VMR has earned a spot amongst the most commonly performed and most effective surgeries for treatment of rectal prolapse. This approach targets strengthening
of the tissue in the rectovaginal septum. The anterior rectum and posterior vagina
are incredibly dynamic in women during defecation. Conversely, men have inherent stability along the anterior rectal wall due to the prostate. In women with normal pelvic oor coordination, ballooning of the anterior rectal wall into a large
rectocele during defecation can be the initial structural laxity that results in internal
intussusception of the anterior rectal wall and subsequent prolapse. Similarly, loss
of support of the uterus can result in exaggerated posterior and inferior positioning
of the uterus, cervix and/or bladder. This exaggerated posterior positioning results
in increased pressure and stress to the anterior rectal wall, which can also contribute to rectal intussusception and prolapse. Ultimately, the only female pelvic structures that are uniformly sturdy with age are the pubic bone and tailbone. Pelvic
organ laxity and loss of connective tissue strength with age require surgical repairs
that provide new strength and structure to the most susceptible areas. VMR is ideal
for providing support to the anterior rectal wall and posterior vagina. When combined with sacrocolpopexy, this surgery can provide even greater support in
the pelvis.
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S. A. Vogler and K. A. Ban
Unfortunately, the constellation of symptoms typical of pelvic organ prolapse are
non-specic and can also be secondary to other pelvic oor disorders. Thus, it is
imperative to conrm the underlying cause of symptoms with examination and testing. Failure to accurately identify the underlying cause of symptoms and inappropriate patient selection for surgery will result in poor outcomes and even
complications. For example, obstructive defecation caused by pelvic oor tension
and failure of appropriate muscle coordination results in poor relaxation with
Valsalva and symptoms of incomplete defecation, overow seepage, and urgency.
All of these symptoms mimic internal prolapse. However, treating a patient that has
signicant pelvic tension and poor coordination with placement of mesh will worsen
the stiffness and lack of pelvic movement. Again, caution and a systematic approach
to the diagnosis of pelvic oor disorder symptoms is imperative.
In conclusion, we fully expect that the data presented in this chapter will continue to evolve as our understanding of rectal prolapse and associated pelvic organ
prolapse improves. Longstanding perineal approaches will continue to be a safe
option for repair, yet the patients who will benet most from this approach may
change over time. We think the most exciting advance in rectal prolapse treatment
is the recognition that this problem rarely occurs in isolation of other pelvic compartment laxity. This recognition has led to new operative approaches, new surgical
techniques, and multidisciplinary collaboration.
References
1. Kim DS, et al. Complete rectal prolapse: evolution of management and results. Dis Colon
Rectum. 1999;42(4):460–6; discussion 466–9.
2. Senapati A, etal. PROSPER: a randomised comparison of surgical treatments for rectal prolapse. Color Dis. 2013;15(7):858–68.
3. Smedberg J, Graf W, Pekkari K, Hjern F.Comparison of four surgical approaches for rectal
prolapse: multicentre randomized clinical trial. BJS Open. 2022 Jan 6;6(1):zrab140.
4. Deen KI, etal. Abdominal resection rectopexy with pelvic oor repair vs. perineal rectosigmoidectomy and pelvic oor repair for full-thickness rectal prolapse. Br J Surg. 1994;81(2):302–4.
5. Emile SH, Elbanna H, Youssef M, Thabet W, Omar W, Elshobaky A, Abd El-Hamed TM, Farid
M.Laparoscopic ventral mesh rectopexy vs Delorme’s operation in management of complete
rectal prolapse: a prospective randomized study. Color Dis. 2017 Jan;19(1):50–7.
6. Ng ZQ, etal. Long-term outcomes of surgical management of rectal prolapse. ANZ J Surg.
2019;89(6):E231–5.
7. Hu B, Zou Q, Xian Z, Su D, Liu C, Lu L, Luo M, Chen Z, Cai K, Gao H, Peng H, Cao W,
Ren D.External rectal prolapse: abdominal or perineal repair for men? A retrospective cohort
study. Gastroenterol Rep (Oxf). 2022 Feb 21;10(1):goac007.
8. Bao X, Wang H, Song W, Chen Y, Luo Y.Meta-analysis on current status, efcacy, and safety
of laparoscopic and robotic ventral mesh rectopexy for rectal prolapse treatment: can robotic
surgery become the gold standard? Int J Color Dis. 2021 Aug;36(8):1685–94.
9. Albayati S, Chen P, Morgan MJ, Toh JWT.Robotic vs. laparoscopic ventral mesh rectopexy
for external rectal prolapse and rectal intussusception: a systematic review. Tech Coloproctol.
2019 Jun;23(6):529–35.
10. Emile SH, Elfeki H, Shalaby M, Sakr A, Sileri P, Wexner SD. Outcome of laparoscopic
ventral mesh rectopexy for full-thickness external rectal prolapse: a systematic review,
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meta- analysis, and meta-regression analysis of the predictors for recurrence. Surg Endosc.
2019 Aug;33(8):2444–55.
11. Flynn J, Larach JT, Kong JCH, Warrier SK, Heriot A. Robotic versus laparoscopic ventral mesh rectopexy: a systematic review and meta-analysis. Int J Colorectal Dis. 2021
Aug;36(8):1621–31.
12. Lobb HS, Kearsey CC, Ahmed S, Rajaganeshan R.Suture rectopexy versus ventral mesh rectopexy for complete full-thickness rectal prolapse and intussusception: systematic review and
meta-analysis. BJS Open. 2021 Jan 8;5(1):zraa037.
13. Hajibandeh S, Hajibandeh S, Arun C, Adeyemo A, McIlroy B, Peravali R.Meta-analysis of
laparoscopic mesh rectopexy versus posterior sutured rectopexy for management of complete
rectal prolapse. Int J Color Dis. 2021 Jul;36(7):1357–66.
14. Hidaka J, Elfeki H, Duelund-Jakobsen J, Laurberg S, Lundby L.Functional outcome after
laparoscopic posterior sutured rectopexy versus ventral mesh rectopexy for rectal prolapse:
six-year follow-up of a double-blind, randomized single-center study. eClinicalMedicine.
2019;16:18–22.
15. Lundby L, Iversen LH, Buntzen S, Wara P, Hoyer K, Laurberg S.Bowel function after laparoscopic posterior sutured rectopexy versus ventral mesh rectopexy for rectal prolapse: a doubleblind, randomized single-centre study. Gastroenterol Hepatol. 2016 Dec;1(4):291–7.
16. Madbouly KM, Youssef M. Laparoscopic ventral rectopexy versus laparoscopic wells rectopexy for complete rectal prolapse: long-term results. J Laparoendosc Adv Surg Tech A. 2018
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Optimal Management
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oftheTranssphincteric Anal Fistula
ShahroseRahman andVassilikiLianaTsikitis
Introduction
The management of complex anal stulas can be quite challenging for the surgeon
and frustrating for the patient. These stulas arise as an abnormal epithelial-line
tract which connects the anal canal to the perianal skin and are mainly caused by
cryptoglandular disease followed by inammatory bowel disease. Up to 50% of
anorectal abscesses will eventually develop into a stula-in-ano. They are characterized using the Park’s classication, established in 1976, which separates anal stulas into four types based on its relation to the sphincter muscle: intersphincteric,
transsphincteric, suprasphincteric, and extrasphincteric. The goals for the surgical
management of stulas are to (1) control sepsis, (2) dene the anatomy, (3) preserve
sphincter function, and (4) minimize the risk of recurrence. Over the years, a number “sphincter sparing” procedures have been developed to improve healing and
reduce the risk of incontinence. The goal of this chapter is to review the literature
pertaining specically to transsphincteric stulas and offer our opinion on best
management options.
39
S. Rahman
Department of Surgery, Oregon Health & Science University, Portland, OR, USA
e-mail: Rahmasha@ohsu.edu
V. L. Tsikitis (*)
Division of Gastrointestinal and General Surgery, School of Medicine, Oregon Health &
Science University, Portland, OR, USA
e-mail: Tsikitis@ohsu.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
K. Umanskiy, N. Hyman (eds.), Difcult Decisions in Colorectal Surgery,
Difcult Decisions in Surgery: An Evidence-Based Approach,
https://doi.org/10.1007/978-3-031-42303-1_39
437
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S. Rahman and V. L. Tsikitis
Search Strategy
In this chapter, we review the data behind the use of stulotomy, seton placement,
brin glue, brin plug, endorectal advancement ap (ERAF), ligation of intersphincteric stula tract (LIFT), stula laser closure (FiLaC), and video assisted anal
stula treatment (VAAFT). Table 39.1 summarizes the clinical results from the
studies reviewed and analyzed.
We performed a literature search in the MEDLINE database (using PUBMED)
under the search titles “transsphincteric stula” (TSF) or “stula-in-ano”. Emphasis
was placed on more recent studies published with in the last 7-years. Some older
studies were included given absence of more recent data of some of the techniques
that were evaluated. Table39.2 outlines our search strategy.
39 Optimal Management oftheTranssphincteric Anal Fistula
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Incontinence rate
pre vs post-
intervention: 86
vs 66%
pre vs post-
intervention: 88
vs 86%
Median
follow-up
(months) Healing rate Recurrence Rate
439
(continued)
Table 39.1 Summary of evidence reviewed
Number of
subjects
High transsphincteric 62 12 Wexner score <5
Procedure Population
Abramowitz (2015) Seton &
Author (year)
Low transsphincteric 133 Wexner score <5
Fistulotomy
(2-stage)
Fistulotomy
(1-stage)
29 18 96% 4% 20%
Low/mid-
Fistulotomy
Papaconstantinou
21 11.9 100% 0% 0%
Low transsphincteric
transsphincteric in
(2017)
stula
Crohn’s
followed by
Wang (2016) Serial seton
Transsphincteric 121 5.1 97% 7%
(vessel loop)
stulotomy
Rosen (2016) Cutting seton
115 155.5 76.2% 23.8% 16.9%
Transsphincteric low
High transsphincteric 72 12 97.2% 2.8% 1.4%
High transsphincteric 251 16 89.6% 10.3% 3.2%
(silk #2)
#1)
Diaz (2021) ERAF, with
Ali (2022) Cutting seton
Emile (2017) Loose seton (silk
& medium: 83.4%
High: 16.5%
stulectomy
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