Hypothesis / aims of study
A weakened pelvic floor and attenuated structural support can result in the simultaneous prolapse of both the rectum and adjacent pelvic organs. In patients presenting with rectal prolapse (RP), the concurrent rate of pelvic organ prolapse (POP) is 21% to 34%. In recent years, the awareness that these two disorders share a common pathophysiology has led to the pioneering of surgical techniques to address multi-compartment prolapse in a single surgery. Surgical treatment for concurrent prolapse can be performed via an abdominal route, where the abdominal route can involve a combined ventral rectopexy and sacrocolpopexy, or can be performed via a perineal/transvaginal approach, specifically in those patients who are medically frail or have had multiple abdominal surgeries. There are major gaps in the literature on which surgical approach is favored for the individual patient. In addition, complications and outcomes following combined surgical repair are poorly described. We sought to describe medium term outcomes and compare surgical complications between abdominal and perineal/transvaginal approaches to combined RP and POP surgery.
Study design, materials and methods
We performed an IRB-approved retrospective review of all female patients who received combined RP and POP surgery at a single tertiary care center from 2008-2019. We documented the approach (abdominal versus perineal) for RP repair, as well as the approach (abdominal versus transvaginal) for POP repair. We identified the reported complications and recurrence as documented by the need for subsequent repeat RP or POP surgery over a maximum period of nine years. We then compared the demographics and outcomes of three different surgical groups (perineal RP repair and transvaginal POP repair, abdominal RP repair and transvaginal POP repair and abdominal RP repair and POP repair). Pearson Chi-squared test and 2-sided Fischer’s exact tests were used to compare the categorical variables. Means and standard deviations were calculated with a confidence interval of 95% for continuous variables. P-values below 0.05 were considered significant.
A total of 59 patients were included in this study with mean age of 65.0 years (range 26-90), mean parity of 2.4 children (range 0-6), and a mean BMI of 25.6 (range 13.6-48) (Table 1). Twenty-nine patients (49.2%) had a perineal RP repair and transvaginal POP repair, 9 (15.3%) had an abdominal RP repair and transvaginal POP repair and 21 (35.6%) had an abdominal RP and POP repair. BMI, parity, and smoking status were not significantly different between groups. A higher proportion of patients undergoing perineal RP and transvaginal POP repair had pulmonary disease (p >0.01) and were older with a mean age of 77 (p> 0.01). A higher proportion of patients with combined abdominal RP repair and abdominal POP repair had a prior POP surgery (p=0.02). The average follow-up time from combined surgery to last surgical appointment was 325 days (range 5-3478 days). 18.3% of patients who underwent combined RP and POP surgery had <30 day complications (55% Clavien-Dindo Grade 1; 27% Clavien-Dindo Grade 2; 18% Clavien-Dindo Grade 4) (Figure 1). Combined perineal RP and transvaginal POP had the highest number of post-operative <30-day complications (20.7%) compared to perineal RP and transvaginal POP (11%) and abdominal RP repair and abdominal POP repair (19%), although this did not reach statistical significance. In a sub-group analysis of those undergoing abdominal surgeries, 16 (53%) had laparotomies and 14 (47%) had minimally-invasive surgery (MIS) including either robotic or laparoscopic procedures. No <30-day complications were noted in the MIS group, whereas 31.3% of the laparotomy abdominal surgeries had a <30-day complication (p > 0.01). Overall, in those patients who underwent combined RP and POP surgery, the need for subsequent rectal prolapse surgery for recurrent RP was 14% and the need for subsequent vaginal prolapse surgery for recurrent vaginal POP was 6.8%. Subsequent rectal prolapse surgery (33.3%) and vaginal prolapse surgery (11%) were highest in those patients who underwent abdominal RP and transvaginal POP surgery (Table 2).
Interpretation of results
In this study, we describe the demographics of patients who underwent combined RP and POP repair. Patients who underwent perineal RP and transvaginal POP were more likely to be poor surgical candidates with advanced age and pulmonary disease, suggesting that surgeons may select a non-abdominal approach in frail patients. The need for subsequent surgery for recurrent RP or recurrent POP after combined RP and POP was similar to previously published recurrence rates, suggesting that patients undergoing combined RP and POP surgery have similar outcomes to those patients who undergo either an RP and POP surgery alone. The < 30 day complication rate of combined RP and POP surgery was similar to reported complication rates of combined RP and POP surgery in the literature but major complications (Claviden-Dindo 3-5) were rare (3.2%). The number of <30 day complications was statistically higher in patients who underwent an abdominal prolapse repair via laparotomy compared to a minimally-invasive procedure. This is consistent with the current literature reporting a decreased complication rate with MIS procedures compared to procedures requiring laparotomy.
This retrospective study compares abdominal versus perineal/transvaginal approaches to combined RP and POP surgery at a tertiary care center. Surgeons may choose a perineal/transvaginal approach in those patients who had a higher number of medical comorbidities. Additionally, patients undergoing combined RP and POP surgery are not more likely to need subsequent surgery for recurrent prolapse than those patients who undergo RP and POP surgery alone. Major complications following combined RP and POP surgery are low and most occur after laparotomies for abdominal prolapse repair. To date in the literature, this is the largest cohort of patients undergoing combined RP and POP surgery with an average follow-up time of almost one year. We are currently studying surgical complications and outcomes of combined RP and POP in a prospective cohort which should further provide more insight into the risk profile, complications, recurrence rates, and reoperation rates of combined RP and POP surgery.