Pelvic organ prolapse (POP) is a dynamic disorder that affects the entire pelvic diaphragm (1). It has been estimated that at least 38% of patients with rectal prolapse suffer from concomitant vaginal/uterine prolapse (2).

There is inclination that abdominal POP surgery and rectopexy should be combined due to the similar dissection required and potential better outcomes (3).

Our aim of the present study is to assess for the safety and 1 year outcome after combined sacrocolpopexy and rectopexy as treatment for multi-compartment POP in a tertiary unit over a 7 years period.

This is a retrospective cohort study of women who underwent combined abdominal surgical procedure for vaginal apical and rectal prolapse, over the period of 2013-2020. Patients were identified from surgical logs and electronic case notes were reviewed.

The primary outcome was patient reported improvement in symptoms on a 4-point Likert scale; ‘cured, improved, no change, worse’. Treatment success was defined as ‘cured’ or ‘improved’. Secondary outcomes included intra-operative and post-operative complications and need for further surgery.

Data on demographics, peri-operative care and follow-up were collected.

41 patients were identified. Electronic notes were obtained for 39 (95%) patients with median follow up of 37 months. Mean age of patients was 53.1 (range: 26-79) and mean BMI 24.9 (range: 19-34).  

32/39 (82%) patients had full thickness rectal prolapse and 18% of patients had symptomatic mucosal prolapse or rectal intussusception. All patients had at least stage 2 vaginal apical descent with 7 patients suffering from stage 3 or 4 vaginal prolapse. 

These combined procedures were performed as primary prolapse surgery (with no previous vaginal or rectal prolapse surgery) in 22/39 (56%) of patients and as secondary prolapse surgery in 17/39 (44%) of patients. There were 22/39 (56%) open and 17/39 (44%) laparoscopic procedures. 

Type 1 polypropylene predesign Y mesh was used in all cases. Mean post-operative hospital stay was around 2.4 days.

Complications:

There were none intraoperatively. 1 patients was readmitted for wound infection and was treated with intravenous antibiotics and discharged 3 days later. There were no mesh related complications reported to date.

Follow up:

33/39 patients attended for face to face follow-up at 3 months postoperatively. 
32/33 (97%) of patients reported “cure” or “significant improvement” in  both vaginal and rectal prolapse symptoms. Two patients reported pain, however, it was reported as the same pre-existing chronic pain which had not changed. None of the patients reported new onset pain. (Table 1) 

6 patients were lost to follow-up either because they failed to attend or due to the COVID-19 restrictions. 

22 (67%) patients attended for follow-up at 1 year post-operatively and all reported “cure” or “significant improvement” of their prolapse symptoms.

No patients in this cohort required further surgery for prolapse to date.

This retrospective study reports outcome  of combined mesh sacrocolpopexy and rectopexy for vaginal apical  prolapse and rectal prolapse in a carefully selected patient group assessed through a multidisciplinary team. Our study reports relatively high success rate of 97% at the 3 months follow-up periodwith no reported re-operations within 1 year. There were no intraoperative complications and the only post-operative complication recorded was wound infection rate of 3% requiring inpatient treatment 

While most of the patients (97%) reported improvement or resolution of their vaginal prolapse, 78% reported improvement of their bladder function and only 63% reported improvement of their bowel symptoms. That highlights the fact that anatomical correction of the vaginal and rectal prolapse may not improve the  functional bowel and bladder symptoms in all patients. That is particularly important in the counselling of patients pre-operatively.

Limitations of this study include the retrospective nature of the study and the relatively small number of patients included. As evidence behind combined sacrocolpopexy and rectopexy surgeries seems to be scanty, a large prospective study with longer follow up will be needed.

Combined sacrocolpopexy and rectopexy can be a safe and effective operation with very low complication rate. Around 97% of patients had significant subjective improvement of their vaginal and rectal symptoms at 3 months follow-up which was maintained at 1 year. However, only 63% of the patients had significant improvement in their bowel function. That will aid in the counselling of this cohort of patients pre-operatively.

Campagna G, Panico G, Caramazza D, Anchora LP, Parello A, Gallucci V, et al. Laparoscopic sacrocolpopexy plus ventral rectopexy as combined treatment for multicompartment pelvic organ prolapse. Tech Coloproctol. 2020;24(6):573-84.
Geltzeiler CB, Birnbaum EH, Silviera ML, Mutch MG, Vetter J, Wise PE, et al. Combined rectopexy and sacrocolpopexy is safe for correction of pelvic organ prolapse. Int J Colorectal Dis. 2018;33(10):1453-9.
Gurland B. Ventral mesh rectopexy: is this the new standard for surgical treatment of pelvic organ prolapse? Dis Colon Rectum. 2014;57(12):1446-7.