Minimally Invasive Surgery for Rectal Procidentia, Is there a Preferred Approach?

Special Article - Minimally Invasive Surgery: Current & Future Developments

Austin J Surg. 2015;2(4): 1065.

Minimally Invasive Surgery for Rectal Procidentia, Is there a Preferred Approach?

Main WPL¹ and Kelley SR²*

Division of General Surgery, TriHealth Institute, USA

Division of Colon and Rectal Surgery, Mayo Clinic, USA

*Corresponding author: Kelley SR, Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA

Received: March 19, 2015; Accepted: June 11, 2015; Published: June 25, 2015

Abstract

Purpose: Rectal procidentia can be repaired with multiple different minimally invasive (laparoscopic and robotic) approaches, though it is unclear if any one approach is preferred. Herein, we have systematically reviewed the literature in an attempt to clarify if one minimally invasive approach is superior to another.

Methods: Utilizing Google Scholar and PubMed a systematic review of the English literature was carried out using the terms minimally invasive, laparoscopic, robotic, and rectopexy, resection rectopexy, mesh, suture, rectal procidentia, and rectal prolapse. Inclusion criteria for our study included all studies strictly evaluating minimally invasive repairs, which provided a total of 32 studies for review.

Results: No significant differences were found between different minimally invasive approaches in regards to recurrence, operative time, estimated blood loss, morbidity, mortality, length of stay, or improvement in preoperative constipation and incontinence.

Conclusion: To our knowledge the literature on minimally invasive repairs of rectal procidentia is sparse and inundated by heterogeneity; with no one approach having significantly better outcomes than another. Prospective randomized controlled trials comparing different minimally invasive repairs are needed.

Keywords: Rectal procidentia / prolapsed; Laparoscopic; Robotic; Repair

Introduction

Rectal procidentia is defined as full thickness circumferential intussusceptions of the rectum through the anal canal. It affects females six times more than males [1]. Common complaints include bleeding, mucous discharge, discomfort, incontinence, and constipation, all of which can significantly affect quality of life.

Laparoscopic rectopexy was introduced by Berman et al. in 1992, and since then numerous studies have reported minimally invasive (laparoscopic and robotic) approaches as being safe and feasible [2- 6]. In addition to equivalent recurrence rates, minimally invasive surgery for rectal procidentia has been shown to result in decreased lengths of stay, analgesic requirements, and earlier tolerance of diet when compared to open repairs [7-13].

There are five commonly performed minimally invasive procedures for rectal prolapse. Anterior mesh rectopexy (Orr-Loygue procedure) involves anterolateral mesh fixation of either side of the rectum to the sacral promontory after anterior rectal mobilization. Posterior mesh rectopexy (modified Wells procedure) consists of posterior rectal dissection, typically with preservation of the lateral stalks, and mesh fixation to the sacral promontory and lateral rectum. Suture rectopexy with (Frykman-Goldberg procedure) or without segmental sigmoid resection involves suture fixation of the rectum to the sacral promontory. Ventral mesh rectopexy (D’Hoore procedure), a variant of anterior mesh rectopexy, secures the anterior rectum to the sacral promontory, and is frequently coupled with colpopexy. By avoiding posterolateral rectal dissection the rectum remains in its normal anatomic configuration preventing the potential disruption of the autonomic nervous system and subsequently postoperative constipation.

Herein the existing literature is reviewed in order to clarify whether one minimally invasive approach is superior to another in terms of operative time, estimated blood loss, conversion to open, morbidity, mortality, length of stay, recurrence, and rates of constipation and incontinence pre and postoperatively since in the literature there is a lack of systematic reviews comparing minimally invasive approaches for rectal prolapse.

Methods

Utilizing Google Scholar and PubMed a systematic review of the English literature was carried out using the terms minimally invasive, laparoscopic, robotic, and rectopexy, resection rectopexy, mesh, suture, rectal procidentia, and rectal prolapse. A total of 48 articles were identified including 26retrospective [5,6,9,11,12,14-34] and 17 prospective studies [8,10,35-49], 3 meta-analyses [1,50,51], and 2 randomized controlled trials [7,13]. Inclusion criteria for our study included all studies strictly evaluating minimally invasive repairs, which provided a total of 32 studies for review. Study and patient demographic information is outlined in Table 1.

Table 1: Study and patient demographic information.





  

    
Author 

    
Year 

    
Country 

    
Study Type 

    
Repair 

    
Patients 

      
(n / % female) 

    
Mean Age 

    
Procidentia 

      
(n / %) 

  

  

    
Faucheron et al

    
2012

    
France

    
Pro

    
LAMR

    
175 / 90.2

    
58

    
175/ 100

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Cuschieri et al

    
1994

    
UK

    
Retro

    
LPMR

    
5 / 100

    
64-81^^

    
5 / 100

  

  

    
Darzi et al

    
1995

    
UK

    
Retro

    
LPMR

    
29 / 93.1

    
71

    
27 / 93.1

  

  

    
Poen et al

    
1996

    
Netherlands

    
Retro

    
LPMR

    
12 / 91.6

    
73*

    
12 / 100

  

  

    
Solomon et al

    
1996

    
Australia

    
Retro

    
LPMR

    
21 / 76.1

    
61

    
21 / 100

  

  

    
Himpens et al

    
1999

    
Belgium

    
Pro

    
LPMR

    
37 / 97.2

    
62.5*

    
37 / 100

  

  

    
Zittel et al

    
2000

    
Germany

    
Retro

    
LPMR

    
20 / 90

    
55

    
12 / 60

  

  

    
Dulucq et al

    
2007

    
France

    
Pro

    
LPMR

    
77 / 98.7

    
69

    
77 / 100

  

  

    
Bryne et al

    
2008

    
Australia

    
Retro

    
LPMR

    
126 / NR

    
56.2

    
126 / 100

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Stevenson et al

    
1998

    
Australia

    
Pro

    
LRSR

    
30 / 96.6

    
61*

    
30 / 100

  

  

    
Ashari et al

    
2005

    
Australia

    
Pro

    
LRSR

    
117 / 99.1

    
60*

    
117 / 100

  

  

    
Laubert et al

    
2010

    
Germany

    
Retro

    
LRSR

    
152 / 94.7

    
64.1

    
75 / 49.3

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Graf et al

    
1995

    
Sweden

    
Retro

    
LSR

    
5 / 100

    
44

    
5 / 100

  

  

    
Heah et al

    
2000

    
UK

    
Pro

    
LSR

    
25 / 88

    
72

    
25 / 100

  

  

    
Hsu et al

    
2007

    
USA

    
Pro

    
LSR

    
12 / 66.7

    
45.8

    
12 / 100

  

  

    
Foppa et al

    
2014

    
USA

    
Pro

    
LSR

    
179 / 97.2

    
62*

    
179 / 100

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
D’Hoore et al

    
2004

    
Belgium

    
Retro

    
LVMR

    
42 / NR

    
49.7

    
42 / 100

  

  

    
Wijffels et al

    
2011

    
UK

    
Retro

    
LVMR

    
80 / 97.5

    
84*

    
80 / 100

  

  

    
Formijine-Jonkers et al

    
2013

    
Netherlands

    
Retro

    
LVMR

    
233 / 96.1

    
62

    
36 / 15.4

  

  

    
Powar et al

    
2013

    
Austrailia

    
Pro

    
LVMR

    
120 / 100

    
62.5

    
53 / 44.1

  

  

    
Maggiori et al

    
2013

    
France

    
Pro

    
LVMR

    
33 / 87.8

    
64

    
33 / 100

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Haahr et al

    
2014

    
Denmark

    
Retro

    
RPMR

    
24 / 95.8

    
72*

    
24 / 100

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Munz et al

    
2004

    
UK

    
Retro

    
RSR

    
6 / NR

    
NR

    
6 / 100

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Draaisma et al

    
2007

    
Netherlands

    
Pro

    
RVMR

    
15 / 93.3

    
62

    
15 / 100

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Kessler et al

    
1999

    
USA

    
Retro

    
LSR

    
28 / 90.6 Ë 

    
51.5*

    
32 / 100

  

  

    
 

    
 

    
 

    
 

    
LRSR

    
4 / 90.6 Ë 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Kellokumpu et al

    
2000

    
Finland

    
Pro

    
LSR

    
17 / 91.1Ë 

    
64*

    
16 / 94.1

  

  

    
 

    
 

    
 

    
 

    
LRSR

    
17 / 91.1Ë 

    
55*

    
12 / 70.5

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Bruch et al

    
1999

    
Germany

    
Pro

    
LSR

    
32 / 94.4Ë 

    
62

    
57 / 79.1

  

  

    
 

    
 

    
 

    
 

    
LRSR

    
40 / 94.4Ë 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Benoist et al

    
2001

    
UK

    
Retro

    
LPMR

    
14 / 85.7

    
66.3

    
14 / 100

  

  

    
 

    
 

    
 

    
 

    
LSR

    
16 / 100

    
76.2

    
16 / 100

  

  

    
 

    
 

    
 

    
 

    
LRSR

    
18 / 94.4

    
53.5

    
18 / 100

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Kairaluoma et al

    
2003

    
Finland

    
Pro

    
LSR

    
26 / 88.6Ë 

    
64

    
50 / 89.2

  

  

    
 

    
 

    
 

    
 

    
LRSR

    
27/ 88.6Ë 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Madbouly et al

    
2003

    
USA

    
Retro

    
LPMR

    
11 / 90.9

    
63.9

    
11 / 100

  

  

    
 

    
 

    
 

    
 

    
LRSR

    
13 / 84.6

    
48.6

    
13/ 100

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Perrenot et al

    
2013

    
France

    
Retro

    
RVMR

    
77 / 92.2

    
59.9

    
77 / 100

  

  

    
 

    
 

    
 

    
 

    
RAMR

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
RRSR

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Buchs et al

    
2013

    
Switzerland

    
Retro

    
RSR

    
1 / 100

    
74*

    
5 / 100

  

  

    
 

    
 

    
 

    
 

    
RVMR

    
4 / 100

    
 

    
 

  

  

    
* - denotes median rather than mean; ^^ - denotes range    rather than mean; Ë - did not specify % gender between different approaches

      
LAMR: Laparoscopic Anterior Mesh Rectopexy; LPMR: Laparoscopic    Posterior Mesh Rectopexy; LRSR: Laparoscopic Resection Suture Rectopexy; LSR:    Laparoscopic Suture Rectopexy; LVMR: LaparoscopicVentral Mesh Rectopexy;    n:  Number; NR:  Not Recorded; Pro:  Prospective; RAMR: Robotic Anterior Mesh    Rectopexy; Retro:  Retrospective; RPMR:    Robotic Posterior Mesh Rectopexy; RRSR: Robotic Resection Suture Rectopexy;    RSR: Robotic Suture Rectopexy; RVMR: Robotic Ventral Mesh Rectopexy; UK:    United Kingdom; USA: United States of America 

  










Table 1:  Study and patient demographic information.

Patient demographics

Of the 32 studies we evaluated, patients were predominantly female (1,648 / 94.3%) with ages ranging from 44 to84 years old. All studies presented patients with rectal procidentia; however a small number also included patients with symptomatic rectal intussusceptions, rectocele, enterocele, and/or solitary rectal ulcer syndrome [8,15,20,32,34,36,41,47]. Twenty-four studies described a single minimally invasive approach, while 8 presented more than one. Study and patient demographic information is outlined in Table 1.

Short term outcomes

Short term outcomes including operative time, conversion to open, estimated blood loss, morbidity, mortality, and length of stay are outlined in Table 2.

Table 2: Short term outcomes.





  

    
Author 

    
Repair 

    
Mean operation time (min) 

    
Conversion to open 

      
(n / %) 

    
EBL (mL) 

    
Morbidity 

      
(n / %) 

    
Mortality 

      
(n / %) 

    
LOS 

      
(days) 

  

  

    
Faucheron et al

    
LAMR

    
112

    
3 / 1.7

    
NR

    
9 / 5.1

    
0 / 0

    
2.2

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Cuschieri et al

    
LPMR

    
120-270^^

    
NR

    
NR

    
1 / 20

    
0 / 0

    
<4

  

  

    
Darzi et al

    
LPMR

    
95

    
1 / 3.4

    
NR

    
3 / 10.3

    
0 / 0

    
5

  

  

    
Poen et al

    
LPMR

    
195

    
0 / 0

    
NR

    
0 / 0

    
0 / 0

    
7 *

  

  

    
Solomon et al

    
LPMR

    
198

    
3 / 14.2

    
NR

    
4 / 19

    
0 / 0

    
6.3

  

  

    
Himpens et al

    
LPMR

    
130

    
1 / 2.7

    
75

    
2 / 5.4

    
0 / 0

    
7

  

  

    
Zittel et al

    
LPMR

    
NR

    
NR

    
NR

    
4 / 20

    
0 / 0

    
NR

  

  

    
Dulucq et al

    
LPMR

    
68

    
1 / 1.3

    
35

    
3 / 3.9

    
0 / 0

    
4.9

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Stevenson et al

    
LRSR

    
185

    
0 / 0

    
NR

    
4 / 13.3

    
1 / 3.3

    
5

  

  

    
Ashari et al

    
LRSR

    
110-180^^

    
1 / 0.85

    
NR

    
10 / 8.5

    
1 / 0.85

    
4-5^^

  

  

    
Laubert et al

    
LRSR

    
204.1

    
1 / 0.7

    
NR

    
35 / 23

    
1 / 0.7

    
11.3

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Graf et al

    
LSR

    
225

    
1 / 20

    
NR

    
0 / 0

    
0 / 0

    
5

  

  

    
Heah et al

    
LSR

    
96

    
4 / 16

    
NR

    
4 / 16

    
NR

    
7*

  

  

    
Hsu et al

    
LSR

    
NR

    
NR

    
NR

    
4 / 33.3

    
NR

    
4

  

  

    
Foppa et al

    
LSR

    
NR

    
NR

    
NR

    
7 / 3.9

    
0 / 0

    
NR

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
D’Hoore et al

    
LVMR

    
115-140^^

    
2 / 4.7

    
NR

    
2 / 4.7

    
0 / 0

    
5.8

  

  

    
Wijffels et al

    
LVMR

    
NR

    
1 / 1.2

    
NR

    
10 / 12.5

    
0 / 0

    
3

  

  

    
Formijine-Jonkers et al

    
LVMR

    
NR

    
6 / 2.5

    
NR

    
11 / 4.6

    
0 / 0

      
 

    
5

  

  

    
owar et al

    
LVMR

    
97

    
0 / 0

    
NR

    
13 / 10.8

    
NR

    
1

  

  

    
Maggiori et al

    
LVMR

    
NR

    
1 / 3

    
NR

    
0 / 0

    
0 / 0

    
5

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Haahr et al

    
RPMR

    
124

    
NR

    
NR

    
1 / 4.1

    
NR

    
4.1

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Munz et al

    
RSR

    
156

    
0 / 0

    
NR

    
0 / 0

    
0 / 0

    
6

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Draaisma et al

    
RVMR

    
160

    
0 / 0

    
50

    
2 / 13.3

    
0 / 0

    
4*

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Kessler et al

    
LSR

      
LRSR

    
150

    
NR

    
100

    
3 / 9.3

    
0 / 0

    
5

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Kellokumpu et al

    
LSR

      
LRSR

    
LSR- 150*

      
LRSR- 255*

    
0 / 0

    
NR

    
LSR- 7 / 41.1

      
LRSR- 1 / 5.8

    
0 / 0

    
LSR- 5

      
LRSR- 5

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Bruch et al

    
LSR

      
LRSR

    
LSR- 227

      
LRSR- 258

    
1 / 1.4

    
NR

    
7 / 9.7

    
0 / 0

    
15

  

  

    
 

    
 

    
 

    
 

    
 


    
 

    
 

    
 

  

  

    
Benoist et al

    
LPMR

      
LSR

      
LRSR

    
LPMR- 113.5

      
LSR- 106.5

      
LRSR- 133

    
LPMR- 0 / 0

      
LSR- 0 / 0

      
LRSR- 0 / 0

    
NR

    
LPMR- 2 / 14.2

      
LSR- 3 / 18.7

      
LRSR- 2 / 11.1

    
LPMR- 0 / 0

      
LSR- 0 / 0

      
LRSR- 0 / 0

    
LPMR- 5.6

      
LSR- 5.7

      
LRSR- 6.7

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Kairaluoma et al

    
LSR

      
LRSR

    
LSR- 127.5

      
LRSR- 210

    
NR

    
LSR- 15

      
LRSR- 35

    
12 / 22.6

    
0 / 0

    
LSR- 4.5

      
LRSR- 5

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Madbouly et al

    
LPMR

      
LRSR

    
LPMR- 69.9

      
LRSR- 128.5

      
 

    
LPMR- 1 / 9

      
LRSR- 1 / 7.6

    
LPMR- 69.9

      
LRSR- 87.7

    
LPMR- 0 / 0

      
LRSR- 3 / 23

    
LPMR- 0 / 0

      
LRSR- 0 / 0

      
 

    
LPMR- 2.2

      
LRSR- 3.6

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Perrenot et al

    
RVMR

      
RAMR

        RRSR

    
223

    
5 / 6

    
NR

    
8 / 10.4

    
0 / 0

    
6.5

  

  

    
 

    
 

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Buchs et al

    
RSR

      
RVMR

    
170

    
0 / 0

    
11

    
1 / 20

    
0 / 0

    
3.6

  

  

    
* - denotes median instead of mean; ^^ -denotes range    rather than mean

      
EBL: Estimated Blood Loss; LAMR: Laparoscopic Anterior    Mesh Rectopexy; LOS:  Length of Stay;    LPMR:  Laparoscopic Posterior Mesh    Rectopexy; LRSR - Laparoscopic Resection Suture Rectopexy; LSR: Laparoscopic    Suture Rectopexy; LVMR: Laparoscopic Ventral Mesh Rectopexy; min: minutes; n:    Number; NR - Not Recorded; RAMR: Robotic Anterior Mesh Rectopexy; RPMR: Robotic    Posterior Mesh Rectopexy; RRSR: Robotic Resection Suture Rectopexy; RSR: Robotic    Suture Rectopexy; RVMR: Robotic Ventral Mesh Rectopexy

      
 

      
 

  










Table 2:  Short term outcomes.

Operative time

Operative times for all approaches ranged from 68 to 270 minutes, with no significant differences noted between the different types of repairs. Only one study evaluated laparoscopic anterior mesh rectopexy, with a mean operative time of 112 minutes documented [46]. Operative times for laparoscopic posterior mesh rectopexy ranged from 68 to 270 minutes [14,44] and resection suture rectopexy from 128.5 to 258 minutes [24,36]. Suture rectopexy ranged from 96 to 227 minutes [36,38], and ventral mesh rectopexy was completed between 97 and 223 minutes [26,47]. In the 5 studies evaluating robotic approaches operative times were not significantly different from laparoscopic repairs and ranged from 112 to 223 minutes [5,6,26,29,30].

Conversion rate

Twenty-four studies documented conversion rates, which ranged from 0-20% and were primarily the result of presacral bleeding and pelvic adhesions from prior surgery [5,15-18,22,24-26,32-37,41- 44,46-48]. The highest rates were appreciated in early studies, rates decreased with increased experience, and no one approach was significantly higher than another.

Estimated Blood Loss (EBL)

Estimated blood loss ranged from 11 - 100 milliliters, though was only recorded in 7 studies [5,8,19,24,37,43,44]. Of the approaches reported no one had a significantly higher blood loss than another.

Morbidity

Complications recorded included postoperative hemorrhage, port site hernia, abdominal wall hematoma, deep vein thrombosis, urinary tract infection, urinary retention, pneumonia, erectile dysfunction, surgical site infection, pseudomembranous colitis, small bowel obstruction, ureteral or small bowel injury, and anastomotic leak [5,6,15-19,22,24-26,31-37,41-44,46-48]. Morbidity for laparoscopic approaches ranged from 0 - 41.1%, and robotic from 0 - 20%.No one approach had a significantly higher morbidity than another.

Mortality

Mortality rates were low with most studies reporting none and only 3 studies reporting one each [32,35,42]. All recorded mortalities occurred in patients undergoing laparoscopic resection suture rectopexy and were due to aspiration pneumonia.

Length of stay

The majority of studies reported a length of stay between 5-7 days, with no significant differences noted between the different types of repairs. Powar et al. reported the shortest mean length of stay of 1 day [47], and their prospective study design focused on laparoscopic ventral rectopexy being performed as a same-day procedure. Bruch et al. reported the longest mean length of stay at 15 days, which was attributed to social arrangements in the elderly patient population and financial aspects of the German healthcare system [36].

Long term outcomes

Long term outcomes including follow up, recurrence, and rates of pre and postoperative constipation and incontinence are outlined in Tables 3 and 4.

Follow up (Table 3)

Thirty one studies reported follow up with 28 describing a mean ranging from 6 - 70 months, 2 reporting a range from 4 - 48 months, and one defining a median of 23 months [5,6,8,14-20,22,24-26,30- 37,42-48].

Table 3: Follow up and recurrence.





  

    
Author 

    
Repair 

    
Mean follow up (months) 

    
Recurrence 

      
(n / %) 

  

  

    
Faucheron et al

    
LAMR

    
70

    
5 / 3

  

  

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

  

  

    
Cuschieri et al

    
LPMR

    
4-27^^

    
0 / 0

  

  

    
Darzi et al

    
LPMR

    
8

    
0 / 0

  

  

    
Poen et al

    
LPMR

    
18

    
0 / 0

  

  

    
Solomon et al

    
LPMR

    
NR

    
NR

  

  

    
Himpens et al

    
LPMR

    
6-48^^

    
0 / 0

  

  

    
Zittel et al

    
LPMR

    
22

    
1 / 3.8

  

  

    
Dulucq et al

    
LPMR

    
34

    
1 / 1.2

  

  

    
Bryne et al

    
LPMR

    
60

    
5 / 3.6

  

  

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

  

  

    
Stevenson et al

    
LRSR

    
18

    
0 / 0

  

  

    
Ashari et al

    
LRSR

    
62

    
2 / 2.5

  

  

    
Laubert et al

    
LRSR

    
47.7

    
10 / 11.1

  

  

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

  

  

    
Graf et al

    
LSR

    
10

    
0 / 0

  

  

    
Heah et al

    
LSR

    
26

    
0 / 0

  

  

    
Hsu et al

    
LSR

    
32

    
0 / 0

  

  

    
Foppa et al

    
LSR

    
120

    
20 / 11.1

  

  

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

  

  

    
D’Hoore et al

    
LVMR

    
61

    
2 / 4.7

  

  

    
Wijffels et al

    
LVMR

    
23*

    
2 / 2.5

  

  

    
Formijine-Jonkers et al

    
LVMR

    
30

    
6 / 2.6

  

  

    
Powar et al

    
LVMR

    
7.6

    
3 / 2.5

  

  

    
Maggiori et al

    
LVMR

    
42

    
2 / 6.6

  

  

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

  

  

    
Haahr et al

    
RPMR

    
10

    
2 / 11.1**

  

  

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

  

  

    
Munz et al

    
RSR

    
6

    
0 / 0

  

  

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

  

  

    
Draaisma et al

    
RVMR

    
61

    
1 / 6.6

  

  

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

  

  

    
Kessler et al

    
LSR

      LRSR

    
33

    
2 / 6.2

  

  

    
 

    
 

    
 

    
 

  

  

    
Kellokumpu et al

    
LSR

      LRSR

    
24

    
LSR- 2 / 11.7

      
LRSR- 0 / 0

  

  

    
 

    
 

    
 

    
 

  

  

    
Bruch et al

    
LSR

      
LRSR

    
30

    
0 / 0

  

  

    
 

    
 

    
 

    
 

  

  

    
Benoist et al

    
LPMR

      
LSR

        LRSR

    
LPMR- 47

      
LSR- 24

      
LRSR- 20

    
LPMR- 0 / 0

      
LSR- 0 / 0

      
LRSR- 0 / 0

  

  

    
 

    
 

    
 

    
 

  

  

    
Kairaluoma et al

    
LSR

      
LRSR

    
12

    
3 / 5.6

  

  

    
 

    
 

    
 

    
 

  

  

    
Madbouly et al

    
LPMR

      
LRSR

    
18.1

    
LPMR- 0 / 0

      
LRSR- 0 / 0

  

  

    
 

    
 

    
 

    
 

  

  

    
Perrenot et al

    
RVMR

      
RAMR

        RRSR

    
19.5

    
9 / 12.8

  

  

    
 

    
 

    
 

    
 

  

  

    
Buchs et al

    
RSR

      
RVMR

    
6

    
0 / 0

  

  

    
* - denotes median rather than mean; ^^    - denotes range rather than mean: ** - denotes subjective recurrence

      
LAMR: Laparoscopic Anterior Mesh    Rectopexy; LPMR: Laparoscopic Posterior Mesh Rectopexy; LRSR: Laparoscopic    Resection Suture Rectopexy; LSR: Laparoscopic Suture Rectopexy; LVMR: Laparoscopic    Ventral Mesh Rectopexy; n: Number; NR: Not Recorded; RAMR: Robotic Anterior    Mesh Rectopexy; RPMR: Robotic Posterior Mesh Rectopexy; RRSR: Robotic Resection    Suture Rectopexy; RSR: Robotic Suture Rectopexy

      
 

  










Table 3:  Follow up and recurrence.

Recurrence (Table 3)

There was no significant difference in recurrence between the various repairs, which overall ranged from 0 to 12.8%. One study evaluating laparoscopic anterior mesh rectopexy revealed a recurrence rate of 3% [46]. Laparoscopic recurrence rates were 0 - 3.8% for posterior mesh rectopexy, 0 - 11.1% for resection suture rectopexy, 0 - 11.7% for suture rectopexy, and 2.5 - 6.6% for ventral mesh rectopexy. Robotic approaches did not differ significantly from laparoscopic approaches with rates ranging from 0 - 12.8%. Haahr et al. reported that 11.1% of their robotic posterior mesh rectopexy patients noted a recurrence. However, that was subjective and determined by telephone follow up instead of being found objectively on examination or with imaging [6].

Constipation and incontinence (Table 4)

A total of 22 studies compared pre and postoperative constipation and incontinence. All studies evaluating laparoscopic posterior mesh rectopexy, except one [24], revealed a worsening of constipation postoperatively, while incontinence improved [6,14,17,20,22,37,44]. Preoperative constipation ranged from 0-40% and increased to 16.6-64.2% postoperatively. Preoperative incontinence ranged from 32.4-100%, improving to 2.7-42.8% postoperatively. Laparoscopic resection suture rectopexy consistently reduced constipation and incontinence rates, and some studies preferentially performed resection rectopexy on patients with severe constipation [22,24,41]. Preoperatively constipation ranged from 53.8 - 100% compared to 0 - 44.4% postoperatively. Preoperative and postoperative incontinence were 0 - 69.2% and 0 - 27.7%, respectively. Laparoscopic suture rectopexy improved incontinence from 33.3-64.7% preoperatively to 11.7-31.2% postoperatively. Preoperative and postoperative constipation ranged between 0-58.8% and 16.6-62.5%, respectively, and improved [8,41] as well as worsened [22,38,45] in equal numbers of patients. In the studies evaluating laparoscopic ventral mesh rectopexy constipation and incontinence both improved [25,26,34,48]. Preoperative constipation ranged from 52.7- 60% compared to 16.6-23.3% postoperatively. Preoperative and postoperative incontinence rates were 59.2-73.8% and 10-35.7%, respectively. Only one study evaluating robotic repairs reported on pre and postoperative constipation and incontinence, which showed improvement in both categories.

Table 4: Constipation and incontinence.





  

    
Author

    
Repair

    
Preoperative constipation

      
(n / %)

    
Postoperative constipation

      
(n / %)

    
Preoperative incontinence

      
(n / %)

    
Postoperative incontinence

      
(n / %)

  

  

    
Cuschieri et al

    
LPMR

    
0 / 0

    
2 / 40

    
5 / 100

    
1 / 20

  

  

    
Poen et al

    
LPMR

    
0 /0

    
2 / 16.6

    
9 / 75

    
2 / 16.6

  

  

    
Himpens et al

    
LPMR

    
2 / 5.4

    
12 / 32.4

    
12 / 32.4

    
1 / 2.7

  

  

    
Zittel et al

    
LPMR

    
8 / 40

    
10 / 50

    
11 / 55

    
7 /35

  

  

    
Dulucq et al

    
LPMR

    
22 / 28.5

    
28 / 36.3

    
38 / 49.3

    
19 / 24.6

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Stevenson et al

    
LRSR

    
14 / 53.8

    
5 / 19.2

    
18 / 69.2

    
6 / 23

  

  

    
Ashari et al

    
LRSR

    
53 / 68.8

    
20 / 25.9

    
29 / 37.6

    
9 / 11.6

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Heah et al

    
LSR

    
9 / 36

    
11 / 44

    
15 / 60

    
7 / 28

  

  

    
Hsu et al

    
LSR

    
0 / 0

    
2 / 16.6

    
4 / 33.3

    
2 / 16.6

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
D’Hoore et al

    
LVMR

    
23 / 54.7

    
7 / 16.6

    
31 / 73.8

    
15 /35.7

  

  

    
Formijine-Jonkers et al

    
LVMR

    
123 / 52.3

    
44 / 18.8

    
138 / 59.2

    
32 / 13.7

  

  

    
Powar et al

    
LVMR

    
41 / 34.1

    
NR

    
65 / 54.1

    
NR

  

  

    
Maggiori et al

    
LVMR

    
18 / 60

    
7 / 23.3

    
20 / 66.7

    
3 / 10

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Haahr et al

    
RPMR

    
NR

    
NR

    
8 / 44.4

    
3 / 16.6

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Munz et al

    
RSR

    
NR

    
0/ 0

    
NR

    
1 / 16.6

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Kessler et al

    
LSR

      
LRSR

    
NR

    
2 / 6.2

      
 

    
NR

    
5 / 15.6

      
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Kellokumpu et al

    
LSR

      
LRSR

    
LSR- 10 / 58.8

      
LRSR- 14 / 82.3

    
LSR- 4 / 23.5

      
LRSR- 7 / 41.1

    
LSR- 11 / 64.7

      
LRSR- 10 /58.8

    
LSR- 2 / 11.7

      
LRSR- 2 / 11.7

      
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Benoist et al

    
LPMR

      
LSR

      
LRSR

    
LPMR- 5 / 35.7

      
LSR- 6 / 37.5

      
LRSR- 11 / 61.1

    
LPMR- 9 / 64.2

      
LSR- 10 / 62.5

      
LRSR- 2 / 11.1

    
LPMR- 6 / 42.8

      
LSR- 9 / 56.2

      
LRSR- 5 / 27.7

    
LPMR- 6 / 42.8

      
LSR- 5 / 31.2

      
LRSR- 5 / 27.7

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Kairaluoma et al

    
LSR

      
LRSR

    
LSR- 13 / 50

      
LRSR- 20 / 74

    
LSR- 7 / 26.9

      
LRSR- 12 / 44.4

    
LSR- 9 / 34.6

      
LRSR- 15 / 55.5

    
LSR- 4 / 15.3

      
LRSR- 1 / 3.7

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Madbouly et al

    
LPMR

      
LRSR

    
LPMR- 1 / 9

      
LRSR- 13 / 100

    
LPMR- 1 / 9

      
LRSR- 0 / 0

    
LPMR- 5 / 45.4

      
LRSR- 0 / 0

    
LPMR- 1 / 9

      
LRSR- 0 / 0

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Perrenot et al

    
RVMR

      
RAMR

        RRSR

    
24 / 34.2

      
 

    
19 / 27.1

      
 

    
65 / 92.8

      
 

    
56 / 80

      
 

  

  

    
 

    
 

    
 

    
 

    
 

    
 

  

  

    
Buchs et al

    
RSR

      
RVMR

    
NR

    
0 / 0

      
 

    
NR

    
0 / 0


      
 

  

  

    
LPMR: Laparoscopic Posterior Mesh Rectopexy; LRSR:    Laparoscopic Resection Suture Rectopexy; LSR: Laparoscopic Suture Rectopexy;    LVMR: Laparoscopic Ventral Mesh Rectopexy; n: Number; NR: Not Recorded; RAMR:    Robotic Anterior Mesh Rectopexy; RPMR: Robotic Posterior Mesh Rectopexy; RRSR:    Robotic Resection Suture Rectopexy; RSR: Robotic Suture Rectopexy; RVMR: Robotic    Ventral Mesh Rectopexy

      
 

  










Table 4:  Constipation and incontinence.

Discussion

This review of 32 studies evaluating minimally invasive repairs of rectal procidentia revealed no significant differences between the various approaches utilized.

Numerous studies comparing minimally invasive and open repairs for rectal prolapse have shown improved short term outcomes with laparoscopic approaches including length of hospital stay, robot-assisted rectopexy could be performed safely [29]. They divided patients into two groups, one with an average age of 53 and the other 80 years. They found no difference in terms of morbidity, operative time, conversion rate, or length of stay. Recurrence rates were similar at 5-year follow up.

The PROSPER trial, published in 2013, is the largest randomized controlled trial to date comparing surgical approaches for the treatment of rectal prolapse [53]. Although this trial is not specific for minimally invasive repairs it does highlight the difficulty performing prospective randomized controlled trials for rectal prolapse. The trial had difficulty recruiting patients and trained surgeons, thus emphasizing the regionalization of surgical repairs for rectal procidentia.

Cost Analysis

Cost analysis was not included in our review secondary to a paucity of studies evaluating cost. One study evaluating cost analysis revealed the total cost for laparoscopic rectopexy was £357 less per patient than open rectopexy (P=0.042), which was primarily attributed to a decreased hospital length of stay in the laparoscopic group (3.9 vs. 6.6 days, P=0.001) [13]. Cost analysis by Heemskerk et al. revealed the robotic approach to be $745.09 more expensive per patient compared to a laparoscopic repair (P=0.012) [52].

Conclusion

Compared to open, minimally invasive surgery for rectal procidentia has been shown to be safe with improved short-term outcomes and comparable recurrence rates. In the right patient population it can be completed as a same day surgery and can also be safely performed in elderly patients. The literature on minimally invasive repairs of rectal procidentia is sparse and inundated by heterogeneity; with no one approach having significantly better outcomes than another. Prospective randomized controlled trials comparing different minimally invasive repairs are needed.

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Citation: Main WPL and Kelley SR. Minimally Invasive Surgery for Rectal Procidentia, Is there a Preferred Approach?. Austin J Surg. 2015;2(4): 1065. ISSN : 2381-9030