Hypothesis / aims of study
Ventral mesh rectopexy (VMR) is a widely accepted technique for full-thickness rectal prolapse (FTRP) repair, yet data on patient-reported decisional regret remain limited. The study evaluates decisional regret following VMR for FTRP, alongside postoperative outcomes, and age-related differences in regret.
Study design, materials and methods
This retrospective cohort study collected data from patients who underwent VMR for FTRP between February 2014 and February 2025 at a tertiary pelvic floor unit. Baseline characteristics, operative details, and postoperative outcomes were extracted. Patient-reported recurrence and true recurrence (defined as recurrence confirmed on clinical examination +/- defaecating proctogram) were collected. Postoperative symptoms included faecal incontinence (FI) and incomplete emptying. Decisional regret was assessed using the Ottawa Decision Regret Scale, which categorises regret severity: no, mild and moderate-to-severe regret.
Results
Overall Cohort
Eighty patients were included, of whom 75 (93.8%) were female. Mean age was 59.7 (range:24-87). The median follow-up time was 42.5 months (range:6-140). Patient-reported recurrence was 29 (36.3%), but only 12 patients (15.0%) had true recurrence of FTRP. Postoperatively, 33 (41.3%) reported FI symptoms and 54 (67.5%) reported incomplete emptying symptoms.
Forty-nine patients (61.3%) reported no regret, whilst 31 (38.8%) reported regret, of whom 17 (21.3%) reported mild regret, and 14 (17.5%) reported moderate-to-severe regret. Patient-reported and true recurrence were associated with higher regret (p<.0001 and p=.005).
Subgroup analysis by Age Groups
On subgroup analysis, 57 patients (71.3%) were <70, and 23 (28.8%) were ≥70. Within the <70 cohort, 21 (36.8%) had patient-reported recurrence, 6 (10.5%) had a true recurrence, 25 (43.9%) reported FI and 44 (77.2%) reported incomplete emptying symptoms. In the ≥70 cohort, 8 (34.8%) had patient-reported recurrence, 6 (26.1%) had a true recurrence, 8 (34.8%) reported FI and 10 (43.5%) reported incomplete emptying symptoms. Those <70 years reported more frequently of incomplete emptying postoperatively compared to those ≥70 (77.2% vs 43.5%, p=.004). No differences were found between the cohorts on patient-reported, true recurrence or postoperative FI.
Within the <70 cohort, 31 (54.4%) reported no regret and 26 (45.6%) reported regret, of whom 13 (22.8%) had mild regret and 13 (22.8%) had moderate-to-severe regret. Amongst ≥70, 18 (78.3%) reported no regret and 5 (21.7%) reported regret; with 4 (17.4%) reporting mild regret and one (4.3%) reporting moderate-to-severe regret. Regret was more prevalent in <70 cohort compared to ≥70 cohort (45.6% vs 21.7%, p=.047).
Notably, the factors driving regret differed by age group. For <70, those with post operative recurrence were more likely to express regret (100% vs 39.2%, p=.005) and have higher levels of regret (p=.009) compared to those without recurrence. Postoperative FI and incomplete emptying were not associated with regret or regret severity within the <70 cohort. For ≥70, those with postoperative FI were more likely to express regret (50.0% vs 6.7%, p=.016) and have higher levels of regret (p=.033) compared to those without postoperative FI. The incidence of recurrence and postoperative incomplete emptying did not influence regret within the ≥70 cohort.
Interpretation of results
Recurrence rates were higher than typically reported, likely reflecting long follow-up period and complex case-mix of a tertiary referral population. The divergence between patient-reported and true recurrence is notable, as patients may attribute postoperative symptoms to prolapse recurrence even in its absence.
Importantly, the age-stratified analysis revealed distinct drivers of regret, with recurrence predominating in younger patients and postoperative FI in older adults, suggesting that surgical outcomes are appraised differently according to age.