Laparoscopic posterior rectopexy for complete rectal prolapse: Is it the ideal procedure for males?

Background: Rectal prolapse is more common in elderly women worldwide, but in India, it predominantly occurs in young- and middle-aged males. While ventral mesh rectopexy is proposed as the preferred procedure in females, the debate on the best procedure in men is still wide open.
Methods: A retrospective review of all adult male patients operated for external rectal prolapse (ERP) between January 2005 and December 2019 was performed. Patients either underwent modified laparoscopic posterior mesh rectopexy (LPMR) or laparoscopic resection rectopexy (LRR). The outcome was analysed in terms of recurrence, post-operative constipation, sexual dysfunction and other complications.
Results: A total of 118 male patients were included (LPMR: 106, LRR: 12). The mean age was 46.2 years (standard deviation [SD] 11.8, range: 21-88). The mean operating time was 108 min (SD: 24). The mean length of hospital stay was 4.8 days (SD: 1.4, range: 3-11 days). There was no anastomotic leak in the LRR group. Other complications included wound infection (n = 2), mesh infection with sigmoid colon perforation (n = 1), constipation (n = 4), sexual dysfunction (n = 2), urinary urgency (n = 3) and retention of urine (n = 4). There was no mortality in both the groups. During a mean follow-up of 5.2 years, recurrent ERP was noted in one patient and partial mucosal prolapse was seen in three patients.
Conclusion: LPMR/LRR is a safe and effective treatment for ERP in men with very low recurrence rates. Randomised trials comparing modified LPMR with LVMR are needed to establish the better procedure in males.

INTRODUCTION

Numerous approaches have been described in the treatment of external rectal prolapse (ERP), but the most effective procedure is not yet known.[1] In general, pelvic floor disorders are more common in women. Conventionally, perineal approach was favoured in men due to the risk of pelvic autonomic nerve damage and its consequences.[2] Considering the significantly reduced recurrence rates with abdominal rectopexy compared to perineal procedures, the former has become the gold standard recently.[34]

Laparoscopic ventral rectopexy (LVR) described by D’Hoore et al.[5] is widely practised currently in the treatment of rectal prolapse. However, most of the data available on the effectiveness of LVR are based on operations performed on female patients.[678] LVR has also been performed in male patients. Owais et al.[9] showed that laparoscopic ventral mesh rectopexy (LVMR) was effective in men leading to a significant improvement in the quality of life and function. However, in this study, a major proportion of patients had internal rectal prolapse (only 26% of males had ERP). Rautio et al.[10] noticed a high reoperation rate due to recurrent rectal and residual mucosal prolapse after performing LVR in men. A recent meta-analysis has shown that LVR was associated with significantly high recurrence rates in men.[11]

Ventral rectopexy is not favoured by many surgical units for ERP in men due to the perceived risk of sexual dysfunction. The cavernous nerves carry parasympathetic fibres and their damage can result in erectile impotence. The cavernous nerves are at risk during deep dissection of the extraperitoneal rectum from the seminal vesicles and prostate.[12] The cavernous nerves run in neurovascular bundles at the lateral border of Denonvilliers’ fascia.[13] They eventually run anterior to the Denonvilliers’ fascia at the posterolateral border of the apex and base of the prostate, closely related to the anterior wall of the rectum.

Posterior rectopexy has the advantage of eliminating the risk of cavernous nerve injury. Posterior rectal dissection is said to be associated with rectal denervation resulting in deterioration of constipation in up to one-third of patients.[1415] Reports have shown that post-operative constipation can be minimised by preservation of the lateral stalks.[16] Posterior rectopexy is also said to improve the faecal incontinence in patients with ERP after surgery.[1617]

Our opinion is that the current literature evidence probably favours posterior rectopexy performed with nerve preservation in male patients. Patients with ERP in India are mostly young- or middle-aged men, suggesting that prolapse may affect a different population in India from those seen in the West.[2] The aim of this study is to report our experience of posterior rectopexy in male patients with a detailed analysis of our technique and outcome.

METHODS

All adult male patients who underwent abdominal surgery for rectal prolapse in a single tertiary care centre between January 2005 and December 2019 were included in the study. Data were retrospectively retrieved from the discharge summaries and outpatient records. Demographic, operative, and follow-up details were collected. The latest data were obtained through telephonic conversation. Patients presenting with ERP were assessed with a full colonoscopy to exclude other luminal abnormalities. A computed tomography (CT) scan of the abdomen with intravenous and rectal contrast was performed to look for any redundant sigmoid colon in patients with constipation. Patients with significant pre-operative constipation, if associated with redundant sigmoid colon on CT scan, were offered laparoscopic resection rectopexy (LRR). All other patients underwent laparoscopic posterior mesh rectopexy (LPMR). Patients are advised to take only a liquid diet and mechanical bowel preparation was given to all patients on the pre-operative day. The outcome was analysed in terms of recurrence, post-operative constipation, sexual dysfunction and other complications using descriptive statistics. Ethical approval was obtained from the Institutional Review Board.

Surgical technique

Laparoscopic posterior mesh rectopexy

The patient was placed in a modified lithotomy position with Trendelenburg tilt. Pneumoperitoneum is created by the closed method using Veress needle. Four ports were used, one 10 mm and three 5 mm. The 10 mm umbilical port (placed slightly to the right of umbilicus) is used for the camera with 30° telescope. The 5 mm right lower pararectus is the right hand working port and the 5 mm left lower pararectus is the left hand working port. Another 5 mm port in the suprapubic and/or right upper quadrant is used for traction of the sigmoid colon [Figure 1].

Figure 1

Picture showing port positions for laparoscopic posterior mesh rectopexy and laparoscopic resection rectopexy

Peritoneal incision is made at the level of sacral promontory and extended down up to the recto-vesical pouch. The plane between the visceral layer of pelvic fascia covering the mesorectum anteriorly and the presacral fascia covering presacral nerves posteriorly is entered and posterior mobilisation is done all the way down to the pelvic floor [Figure 2]. The ureters and hypogastric nerves are identified and protected. Lateral mobilisation of rectosigmoid is done after incising the left lateral peritoneal reflection and is extended up to the recto-vesical pouch. The right and left planes of dissection are connected. In the pelvis, minimal right and left side dissection is done close to the rectum to preserve the lateral ligaments. Minimal anterior dissection is done to obliterate the deep recto-vesical space. A 15 cm × 10 cm size polypropylene mesh narrowed at its caudal end is introduced into the pelvis using the metal sleeve or through the trocar after removal of the head. The polypropylene mesh is carefully aligned over the sacrum reaching caudally up to the levator ani. Three or four polypropylene stitches are used to fix the mesh to the presacral fascia along the midline (to avoid the hypogastric nerves), the most proximal one at the sacral promontory [Figure 3]. The excess of the mesh is cut and the proximal corners are trimmed according to individual requirements. The mesh is wrapped to the sidewall of the rectum and fixed with 2 or 3 polypropylene stitches on either side of the rectum [Figure 4]. The mesh is extra-peritonealised by suturing back the divided peritoneal folds [Figure 5].

Figure 2

Nerve preserving posterior rectal mobilisation viewed from the right side

Figure 3

Fixation of the polypropylene mesh to the sacral promontory and sacrum

Figure 4

Half wrap of the rectum done with polypropylene mesh and fixed to the rectum

Figure 5

Peritoneal suturing and extra-peritonealisation of the mesh

Laparoscopic resection rectopexy

The theatre setup, position and port placement are similar to that of LPMR. The mobilisation was carried out up to the splenic flexure. Due to the benign nature of disease, only the sigmoid vessels were ligated and superior rectal vessels were preserved. The bowel was divided with an endoscopic stapler at the rectosigmoid junction [Figure 6] and exteriorised for resection of the sigmoid colon at the descending colon and sigmoid colon junction through a mini-laparotomy by making a Pfannenstiel incision. The anvil of the circular stapler is inserted in the proximal colon and pierced through the sidewall following which the end of the divided colon is closed with a linear stapler. After closure of the wound and re-creation of the pneumoperitoneum, a double-stapled side-to-end anastomosis was performed with a circular stapler [Figure 7]. Sutured rectopexy was performed by anchoring the mesorectum/fascia propria of the rectum to the presacral fascia overlying the sacral promontory using two or three non-absorbable (polypropylene) stitches intracorporeally [Figure 8].

Figure 6

Division with linear cutting stapler at the rectosigmoid junction

Figure 7

Colorectal anastomosis after sigmoid colonic resection

Figure 8

Anchoring the mesorectum/fascia propria of the rectum to the presacral fascia overlying the sacral promontory

Follow-up

Patients were discharged once they were started on a soft diet and had a satisfactory bowel movement. Patients were followed up at 2 weeks, 2 months and 1 year after surgery and then as necessary. Regular laxatives were prescribed for 2 months after surgery. All patients were advised not to strain in the toilet. Patients were specifically asked for any symptoms of constipation and incontinence in comparison to their symptoms before surgery. They were also asked for any symptoms of urinary dysfunction (urinary incontinence, incomplete bladder emptying and urinary obstruction) and sexual dysfunction (erectile impotence and retrograde ejaculation). At each visit, patients were examined to look for any evidence of recurrence of rectal prolapse or mucosal prolapse.

RESULTS

A total of 118 male patients were included in the study. While 106 patients underwent LPMR, 12 patients had LRR. The mean age was 46.2 years (standard deviation [SD]: 11.8, range: 21–88 years). The mean operating time was 108 min (SD: 24). The average blood loss during surgery was 43 ml. The mean length of hospital stay was 4.8 days (SD: 1.4, range: 3–11 days). There was no anastomotic leak in the LRR group. There was no mortality in both the study groups. Patients’ characteristics and operative data for both LPMR and LRR groups are summarised in Table 1.

Table 1

Summary of patients’ characteristics and operative details

Details	LPMR	LRR	Total
Total patients	106	12	118
Mean age (SD), years	45.6 (12.1)	48.1 (10.2)	46.2 (11.8)
Mean operating time (SD), min	102 (22)	121 (26)	108 (24)
Length of stay (SD), days	4.6 (1.4)	6.3 (1.2)	4.8 (1.4)
Average blood loss (SD), ml	40	59	43
Conversion to open	Nil	Nil	Nil

LPMR: Laparoscopic posterior mesh rectopexy, LRR: Laparoscopic resection rectopexy, SD: Standard deviation

There was suprapubic wound infection in two patients who underwent LRR. There was no incidence of port-site infection or port-site hernia. There was one patient with mesh infection along with sigmoid colon perforation 6 months after surgery. This patient underwent laparoscopic mesh removal along with sigmoid colectomy and suture rectopexy. A total of 10 patients experienced mucus soiling up to 6 months after surgery and then settled. One patient had a high drain output without any clinical evidence of mesh infection in the post-operative period and was removed only on the 9th post-operative day after a prolonged course of antibiotics. Complications are summarised in Table 2.

Table 2

Summary of complications

Complication	LPMR	LRR	Total
Recurrent ERP	1	0	1
Mucosal prolapse	3	0	3
Wound infection	0	2	2
Urinary infection	2	1	3
Pelvic sepsis	1*	0	1
Urinary urgency	2	1	3
Retention of urine	3	1	4
Anastomotic leak	NA	0	0
Worsening constipation	2	2	4**

*Mesh erosion with sigmoid colon perforation, **Resolved with laxatives. NA: Not available, LPMR: Laparoscopic posterior mesh rectopexy, LRR: Laparoscopic resection rectopexy, ERP: External rectal prolapse

Among the 12 patients in the LRR group, 2 patients had persistent constipation, while the remaining patients had improved. These two patients however responded to prolonged laxative therapy for 6 months. Among the 106 patients who underwent LPMR, 18 patients had pre-operative constipation needing laxatives. Among those 18 patients, constipation symptoms were unchanged in 6 patients and a worsening of constipation was reported in 2 patients. Pre-operative faecal incontinence was reported by 22 patients. While the continence had improved in 19 patients, incontinence remained unchanged in 3 patients who were advised sphincter strengthening exercises.

During a mean follow-up of 5.2 years, recurrent ERP was noted in one patient and partial mucosal prolapse was seen in three patients. The recurrent ERP was a patient who had LPMR and had a very lax pelvic floor and a Thiersch wiring was done subsequently. Among the 118 patients, 11 patients had reported sexual dysfunction (erectile dysfunction) prior to surgery. Among these 11 patients, 3 patients reported improvement in sexual function after surgery. Two patients reported new-onset erectile dysfunction. Both the patients were over the age of 65 years and one of them improved to pre-operative status after 1 year. Three patients reported urinary urgency which improved in all patients over 6 months. Four patients developed obstructive urinary symptoms in the post-operative period which responded well to alpha-blocker therapy.

DISCUSSION

In the adult population, women are more commonly affected, representing 80%–90% of patients with rectal prolapse.[1819] However, the Indian scenario is different as we have a male predominance in the incidence of rectal prolapse which was noted also in the PROSPER trial.[2] The mean age of our study group was 46.2 years, indicating that it is predominantly affecting the young- and middle-aged groups. While the exact reason for this is not known, it is probably due to lack of normal fixation of the rectum, with a mobile mesorectum and lax lateral ligaments.[202122]

The most dreaded consequences of rectal prolapse surgery are worsening constipation, sexual dysfunction and recurrence. Recently, anterior rectopexy has gained more importance because of assumed lower risk of nerve damage and post-operative constipation.[23] The definition of constipation and the operating techniques (e.g., division of lateral ligaments) have varied in different studies, making comparison of the results difficult. Autonomic nerve damage, functional obstruction caused by kinking of the redundant sigmoid colon above the fixed rectum and fibrosis related to the use of mesh are all regarded as aetiological factors for post-operative constipation after rectopexy alone. Injury to the hypogastric nerves can be prevented by dissecting in the plane between the visceral layer of pelvic fascia covering the mesorectum anteriorly and the presacral fascia covering presacral nerves posteriorly. Experience in performing total mesorectal excision has contributed largely to the development of expertise in posterior dissection with nerve preservation. The lateral ligament is the meeting point of the sympathetic and parasympathetic nerve fibres forming the inferior hypogastric plexus. Hence, we aimed at preserving the lateral ligaments in all patients. To reduce the risk of mesh-related fibrosis, we modified the two-third wrap of the rectum to half wrap of the rectum. In patients who had chronic constipation with a redundant sigmoid colon, we preferred to do the sigmoid resection rectopexy to avoid worsening of constipation. In this study, worsening of constipation was seen only in two patients.

With the mean age at presentation in our series being 46.2 years, majority of the patients can be considered as sexually active. In our study, 11 patients had reported sexual dysfunction preoperatively, which likely included patients with not only age-related dysfunction but also patients who were psychologically affected due to the presence of prolapsing mass on straining. In this group, we are unwilling to offer laparoscopic ventral mesh rectopexy (LVMR) due to the risk of damage to the cavernous nerves resulting in sexual dysfunction. While some authors have reported LVMR as safe in men in terms of reduced recurrence rates and post-operative sexual dysfunction,[24] others have not been able to replicate the results.[1011] Although many studies included men, their numbers were so small that a subgroup analysis was not possible.[3] To reduce the risk of injury to cavernous nerves in the plane anterior to the rectum, the tendency is to make a very narrow window of dissection in an already narrow and difficult male pelvis. The nerves are vulnerable to injury at the posterolateral border of the apex and base of the prostate, closely related to the anterior wall of the rectum. This results in placing a narrow strip of mesh which may not be adequate and lead to recurrence. On the contrary, female patients with a wider pelvis and absence of nerve injury risk are benefitted with LVMR as the wider mesh can be placed which provides support for both middle and posterior compartments.

Rautio et al. showed that while LVMR was safe in male patients, it was associated with a high reoperation rate due to recurrent prolapse.[10] It is clear that VMR achieves adequate anterior rectal fixation but fails to adequately address the circumferential elements and posterior components of the ERP. Hence, modifications to LVMR have been described which include limited posterior dissection.[25] More recently, Siddika et al. have developed a robotic modified Orr–Loygue rectopexy in an attempt to deal with the persistent components of posterior rectal prolapse.[26] However, it is possible that the presence of mesh both anteriorly and posteriorly may reduce the compliance of the rectum. We limit the wrapping of the mesh to 50% of the circumference of the rectum to limit the reduction in compliance which may lead to worsening of constipation and faecal urgency in some patients. However, this proves to be beneficial in patients who had pre-operative incontinence. In our series, of 22 patients who reported pre-operative incontinence, 19 of them improved after surgery. The other three patients were advised sphincter strengthening exercises and would also benefit from biofeedback therapy.

In our study, two patients reported new-onset sexual dysfunction (erectile impotence) after surgery. Both of them were over the age of 65 years and one of them reported a return of pre-operative function status after 1 year. Hence, it could be considered that it was more age-related and psychological disturbance rather than a direct complication of surgery. Of the 11 patients who had pre-operative sexual dysfunction, 3 improved after surgery likely due to the psychological impact of the absence of prolapsing mass. While some of the patients in our study had urinary disturbances, all of them were short term and responded well to medical therapy.

We had one patient who had mesh causing erosion and perforation of the sigmoid colon necessitating reoperation and removal of the mesh. However, there was no instance of mesh causing erosion of the rectum or other pelvic organs. A recent review had reported that after LVMR (using synthetic mesh), the mesh erosion rate was 1.87% with the involvement of either the rectum or vagina or both resulting in rectovaginal fistula.[27] This is a complication that is unlikely to happen with posterior mesh placement, as there is a thick layer of the mesorectum between the rectum and mesh.

LVMR for ERP has been shown to have high rates of recurrence[11] rates varying from 1.5% to 15.4%.[28] In our series, full-thickness recurrence rate was 0.8% (n = 1), which is among the lowest reported in literature. Even though anterior rectopexy has gained wide interest because of the assumed lower risk of nerve damage and post-operative constipation, it could not be established as the ideal procedure in men. With the modifications we have adopted – preservation of the lateral ligaments, wrapping of half the circumference of rectum instead of two-third has largely reduced the problem of post-operative constipation. In elderly patients, a unilateral (right) division of the lateral stalk was performed if the mesh fixation was not satisfactory without division of the lateral stalk. In addition, with improved technology such as ultra-HD and Robotic three-dimensionalvisualisation, it has been possible to dissect in the appropriate posterior mesorectal plane with the preservation of hypogastric nerves. The avoidance of deep dissection of the extraperitoneal rectum in the anterior aspect also eliminates the chance of cavernous nerve injury that can result in erectile dysfunction. Hence on the balance, we feel that with our results, the posterior mesh rectopexy with our modifications could be termed as a safe and effective procedure in men who are predominantly young and middle age.

A nerve preserving posterior dissection needs a high level of expertise. We are a tertiary centre with a huge volume of experience in rectal surgery. Hence, these results may not be easily reproducible in a low-volume centre. While we have shown a significantly low rate of post-operative constipation, we may need further modifications to reduce it even further. As this was a retrospective study, objective measurement of symptoms such as constipation, incontinence and sexual function was not possible. Through this study, a comparison with LVMR was not possible as we did not perform any LVMR for males.

CONCLUSION

LPMR is a safe and effective treatment for ERP in men with very low recurrence rates. The modifications in mesh wrap and preservation of lateral stalk and hypogastric nerves have made it a very effective procedure with reduced post-operative constipation rates. It also appears to be safe with respect to sexual dysfunction which is vital in the younger population. Randomised trials comparing modified LPMR with LVMR are needed to establish the better procedure in males.

Financial support and sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of interest

There are no conflicts of interest.