Comparative study of laparoscopic ventral mesh rectopexy versus perineal stapler resection for external full-thickness rectal prolapse in elderly patients: enhanced outcomes and reduced recurrence rates—a retrospective cohort study

To the best of our knowledge no previous study has compared the recurrent prolapse (RP), FI, and ODS after LVMR and PSR in elderly patients. This study demonstrated that LVMR was an efficacious intervention for managing EFTRP in elderly patients, with a favorable profile of low complication rates, reduced recurrence rate, and acceptable postoperative functional outcomes. LVMR demonstrates superior benefits compared to PSR in elderly patients with EFTRP.

The risk of RP following LVMR varies depending on the study design, characteristics of the studied population, and duration of follow-up time [26], with recurrent incidence of 2.8% [4], 9.6% [27], and 6.6% [28], respectively. The incidence of recurrent prolapse during follow-up after LVMR (5/250, 2%) in our study was lower than previously reported. At the same time, the RP after PSR in our study was reported to be 20% (16/80). A previous report showed that incidence of recurrent prolapse increased during long-term follow-up [29], similar to the data in our study. Several factors may have contributed to the lower incidence of recurrent prolapse after LVMR in our study. First, we strictly defined recurrence to include only EFTRP and no other forms of recurrence, such as mucosal prolapse or internal intussusception [30]. The second factor is the use of polypropylene mesh, which has a low incidence of recurrence. In fact we ensure a standardized width and length mesh, fixed to the ventral rectal wall with two rows of stitches, placed in the mid rectum, as low as possible to the pelvic muscles plane which minimized recurrence [31]. We used synthetic non-absorbable polypropylene mesh because of the cost of biological mesh from one side, and we covered the mesh with the peritoneum to avoid mesh exposure and subsequent complications. Glasgow et al. [32] found that recurrence following perineal surgery was related to prolapse of more than 1 year before surgery. In our study, recurrence is higher in PSR than LVMR, probably as a result of many factors: dolichocolon was higher in the PSR than in the LVMR group. The PSR does not require fixation of the long colon and has a higher recurrence rate [18]. The duration of symptoms before surgery and prolapse length were other factors that caused a higher recurrence of PSR. Another factor that increased the incidence of RP after PSR was an underlying weakness in the sphincter mechanism (evidenced by preoperative and postoperative Wexner scores) or because the presence of prolapse protruding for a longer time in PSR than in LVMR through the anal canal leads to a poor sphincter function [33]. Male sex, mesh length [4], old age, and poor preoperative continence [31] are risk factors for RP after LVMR. Our multivariate logistic regression analysis showed that recurrent prolapse was associated with PSR, similar to the results of a previous study [34]. Additionally, prolonged symptom duration before surgery and preoperative prolapse length were risk factors for recurrent prolapse. Furthermore, PSR is associated with earlier prolapse recurrence than LVMR.

ODS and FI are prominent symptoms associated with rectal prolapse [35]. Numerous studies have indicated that LVMR is more effective than alternative approaches for addressing FI [36]. EFTRP may result in anal sphincter stretching, compromising sphincter integrity and leading to FI [37]. Regarding ODS, our findings align with a previously published study [38], demonstrating that both LVMR and PSR approaches contribute to ODS improvement, although only LVMR repair reached statistical significance based on the Altomare score. Additionally, the two groups showed significant differences in patient satisfaction, reinforcing the value of the LVMR approach. LVMR has gained popularity owing to its autonomic nerve-sparing technique, which results in favorable functional outcomes and low morbidity and RR [39]. During follow-up, there was a significant improvement in preoperative FI and ODS in favor of LVMR compared with PSR, and the improvement was significant in FI in LVMR (106/111, 95% vs. 31/37, 83.8%, p = 0.01), while improvement in ODS did not reach a significant difference in either group (48/52, 92.3% vs. 14/17, 82.4%, p = 0.238). Wexner incontinence and Altomare scores were better 3 months postoperatively in the LVMR group and continued to improve significantly until the end of the study. Our data provide adequate evidence supporting the efficacy and reliability of LVMR for the treatment of EFTRP compared to PSR [30, 40]. Consten et al. reported that among patients who underwent LVMR, 63% (62 out of 98) experienced improvements in FI (FI), and 60% (50 out of 82) showed improvements in ODS. The median follow-up period was 34 months [39]. Similarly, other studies have also demonstrated favorable outcomes following LVMR, with reported improvements in FI ranging from 70% to 90% and ODS ranging from 60% to 80% [38, 41]. In our assessment for LVMR, although there were differences in symptom improvement compared to other studies, postoperative FI showed a significant improvement of 95.5% at the 4-year follow-up, whereas ODS demonstrated a significant improvement of 92.3%. These findings are consistent with another study [42]. The observed improvement in ODS symptoms after LVMR can be attributed to the autonomic nerve-sparing surgical technique [9]. Furthermore, this procedure facilitates the restoration of rectal anatomy, enhanced physiological function of the rectum, restored sensitivity to feces, and improved FI symptoms [43]. The improved outcomes observed in our centers can be attributed to the establishment of specialized multidisciplinary pelvic floor units staffed by skilled surgeons proficient in pelvic floor surgery; an increase in awareness among both patients and physicians regarding rectal prolapse and its treatment options was also important. Incidence rates of de novo OD and FI after LVMR have been reported to be 3.7% and 6.0%, respectively [38, 39]. Our present study showed new-onset symptoms in 3 patients (3/250, 1.2%) after LVMR and 13 patients (13/80, 16.5%) after PSR. Three patients (1.2%) developed new constipation following LVMR, while urge to defecate and constipation were observed in six (7.5%) and seven (9%) after PSR, respectively. PSR has been associated with an increased risk of urgency, which is attributed to a reduced rectal ampulla volume. A study reported a 1-year incidence of 26.8% among patients in the European Stapled Transanal Rectal Resection Registry [44]. By contrast, our LVMR study found no cases of postoperative urgency. This absence of urgency is likely due to the absence of rectal resection in the LVMR. The primary advantage of LVMR is the surgeon’s ability to minimize rectal mobilization and avoid lateral dissection, potentially leading to ascending parasympathetic sacral nerve damage. Such damage could result in denervation of left colon and rectum with inertia and the subsequent new onset of constipation [45]. In our study, new constipation developed after LVMR, possibly due to associated rectal stenosis that improved with dilation or due to an associated dolichocolon. In our study, we did not perform a resection of the redundant colon. However, resection of the redundant colon significantly reduces constipation [46]. The limitations of this study include its retrospective design and small sample size (which may have introduced selection bias). Postoperative sexual function changes were not collected. The relatively short-term follow-up is another limitation. Follow-up predominantly relied on telephone interviews, with fewer elderly patients evaluated in clinical settings. The absence of complete data on preoperative and postoperative manometry for all patients is a limitation of this study. We depended on clinical evaluation scores, namely the Wexner and Altomare scores, in postoperative evaluation rather than manometric or radiological evaluation. Additionally, this study evaluated one form of recurrent rectal prolapse which is EFTRP and did not include other forms of prolapse such as partial rectal prolapse and internal rectal prolapse. Although we recognize the existing body of evidence favoring LVMR, we believe that our study makes a valuable contribution by refining and contextualizing these findings in the current clinical landscape. The field of rectal prolapse surgery in the elderly is dynamic and surgical techniques are constantly evolving. Our study provides contemporary evidence considering recent advancements in surgical approaches and contributes to the current understanding of the comparative effectiveness of LVMR and PSR. Our study adds value by offering insights into the clinical implications and considerations when selecting between LVMR and PSR in certain situations. This information may be particularly relevant to clinicians who make decisions in real-world practice.