A comparative study on the surgical options for male rectal prolapse.

Purpose: Rectal prolapse is known to be a rare condition in males compared to females. This study aimed to analyse the frequency of male rectal prolapse and compare the results of different surgical approaches performed at a single centre. Patients and
Methods: The authors included patients who underwent surgical treatment for rectal prolapse from March 2016 to February 2021. The proportion of males, mean age and recurrence rates were calculated. Patients were divided into two groups, transanal approach and laparoscopic abdominal approach group, to identify the para-operative parameters including functional tests.
Results: A total of 56 males, comprising 23.7% (56/236) of all patients. The mean age was 60.8 years, with a recurrence rate of 7 cases (12.5%) during 7.2 months of follow-up. Forty patients underwent transanal procedures, and fifteen underwent laparoscopic abdominal procedures. The mean operative time was longer in the laparoscopic group (transanal vs. abdominal, 57.5 vs. 70.6 min, P < 0.003), and intra-operative bleeding was greater in the transanal group (12.4 vs. 3.4 ml, P < 0.001). Full-layer prolapse (36.8 vs. 81.2% P = 0.003) and longer length (5.6 vs. 7.8 cm, P = 0.048) were more common in laparoscopic group. Time to feeding resumption was shorter after the transanal group (1.2 vs. 1.7 days, P = 0.028). There was no difference between the groups in terms of post-operative complications and recurrence rates. Both Wexner's constipation and incontinence scores showed significant improvement postoperatively.
Conclusion: The frequency of male rectal prolapse was 23.7%, and perioperative factors differed between transanal and abdominal approaches, but recurrence rates and functional test results did not differ significantly.

INTRODUCTION

Rectal prolapse is a rare condition in males compared to females. Some hypotheses suggest that the prostate acts as a powerful anchorage for pelvic organs. It may also be associated with low frequency of obstructed defecation.[1] However, to date, no specific cause has been identified for the difference in frequency between sexes. As a result, research reports on rectal prolapse in males are also very rare.

Surgical procedures for rectal prolapse can be largely divided into transanal and abdominal approaches. The transanal approach is typical of Delorme's and Altemeier's procedures and stapled transanal rectal resection (STARR), which has recently been implemented. The abdominal approach includes minimally invasive techniques, typically ventral or resection rectopexy.

This study was designed to determine the frequency of males among total patients and to compare various parameters according to the surgical approach by analysing the cases of male rectal prolapse at a teaching hospital.

PATIENTS AND METHODS

This study included patients who were diagnosed with rectal prolapse and underwent surgery at a single institution from March 2016 to February 2021. A total of 56 males were operated on by two experienced surgeons during the specified period. History was taken during the first hospital visit, and the degree of prolapse was initially checked through a digital rectal exam. Before surgery, colonoscopy or sigmoidoscopy was done to exclude intraluminal pathology. Defecography and anal manometry were done for all patients. The Wexner constipation score (WCS)[2] was calculated for constipation, and the Wexner incontinence score (WIS)[3] was calculated for fecal incontinence. These functional tests were re-checked 3 months after surgery. Post-operative complications and recurrences were evaluated in the outpatient clinic after 2 weeks and then re-evaluated about 3 months after surgery.

The authors performed Delorme's procedure, Altemeier's procedure, and STARR transanally. In general, STARR is performed for mucosal prolapse <3 cm from the anus, Delorme's procedure is for larger prolapses, and Altemeier's procedure is performed for full-layered prolapse. The abdominal approach was performed in all patients with laparoscopic ventral rectpexy regardless of the degree of prolapse.

Laparoscopic surgery involved the use of five trocars, one 12-mm trocar for the camera in the umbilicus and four 5-mm trocars for the surgeon and an assistant [Figure 1]. After left lateral traction of the sigmoid colon, an inverted J-shaped peritoneal opening was made from the sacral promontory to the left margin of the peritoneal reflection. A polypropylene mesh (Prolene, Ethicon, USA), incised into 2 cm width and 15 cm length, was sutured to the anterior wall of the rectum 2–3 cm from the anal verge [Figure 2a]. Then, the proximal end of the mesh was pegged to the right side of the periosteum of the sacral promontory with ProTack™(Covidien, USA) [Figure 2b]. The middle part of the mesh was sutured to the right side of the dissected rectum and the most adjacent colonic wall [Figure 2c]. To prevent subsequent exposure of the mesh, the dissected peritoneum was closed from the distal opening with continuous sutures using V-loc™ (Covidien, USA) [Figure 2d].

Figure 1

Port site placement. Laparoscopic surgery involved the use of five trocars, one 12 mm trocar for the camera in the umbilicus and four 5 mm trocars for the surgeon and an assistant

Figure 2

Mesh placement. A mesh, incised into 2 cm width and 15 cm length, was sutured to the anterior wall of the rectum 2–3cm from the anal verge (a). The proximal end of the mesh was pegged to the right side of the periosteum of the sacral promontory (b). The middle part of the mesh was sutured to the right side of the dissected rectum (c). The peritoneum was closed from the distal opening (d)

The recurrence was diagnosed through DRE and/or defecography when the patient visited the hospital following 2 weeks and 3 months after initial discharge, or if the patient had symptoms. In the case of recurrence, the procedures were performed with the opposite approaches; in the case with abdominal access initially, reoperation was carried with a transanal approach.

This study was approved by the Institutional review board of the Chonnam National University Hospital (CNUH-2021-107).

Statistical analysis

Differences between the groups were compared using the Student t-test or the Mann–Whitney U-test for continuous data, and the Chi-square test or Fisher exact test for categorical data. Comparison of perioperative scores was performed with a paired t-test. Statistical analyses were performed using IBM SPSS Statistics ver. 20.0 (IBM Co., Armonk, NY, USA). P ≤ 0.05 were considered statistically significant.

RESULTS

Of the total 56 cases, 40 were performed transanally and 16 laparoscopically. Delorme's procedure was the most common procedure accounting for 55.4% (n = 31) of cases. The proportion of males was 23.7% (56/236) of all patients. The mean age was 60.8 years, and the body mass index (BMI) was 23.5. The median follow-up period was 7.2 months, with seven (12.5%) confirmed recurrences. There were no mesh-related complications or postoperative mortality [Table 1].

Table 1

Patients’ overall information

	n (%)
Total (n)	56
Age (years), mean (range)	60.8 (20-88)
ASA
I	5 (7.7)
II	33 (58.9)
III	18 (32.1)
BMI, mean (SD)	23.5 (3.4)
Past anal surgery	16 (28.6)
Operative methods
Transanal approach
Delorme’s procedure	31 (55.4)
Altemeier’s procedure	5 (8.9)
Stapled transanal rectal resection (STARR)	4 (7.1)
Abdominal approach
Laparoscopic ventral rectopexy	16 (28.6)
Median follow-up period, month (range)	7.2 (1-78)
Recurrence	7 (12.5)

ASA: American Society of anaesthesiologists physical status, BMI: Body mass index, SD: Standard deviation, STARR: Stapled transanal rectal resection

Comparisons between the two groups of surgical approaches showed no difference in age, medical history, past abdominal or anal surgery, American Society of Anaesthesiologists physical status, BMI and smoking or alcohol consumption [Table 2].

Table 2

Pre-operative parameters between transanal and laparoscopic group

	Transanal (n=40), n (%)	LVR (n=16), n (%)	P
Age (years) (SD)	63.9 (2.9)	52.9 (4.5)	0.051
Past medical history	27 (67.5)	7 (43.8)	0.100
Past abdominal surgery	11 (27.5)	3 (18.8)	0.495
Past anal surgery	12 (30)	4 (25)	0.708
ASA
I	3 (7.5)	2 (12.5)	0.380
II	22 (55)	11 (68.8)
III	15 (37.5)	3 (18.8)
BMI, mean (SD)	22.9 (3)	25 (4)	0.070
Smoking	12 (30)	8 (50)	0.158
Alcohol	17 (42.5)	9 (56.2)	0.351

LVR: Laparoscopic ventral rectopexy, ASA: American society of anaesthesiologists physical status, BMI: Body mass index, SD: Standard deviation

Surgery time was longer in the laparoscopic abdominal approach group compared to that in the transanal group (transanal vs. abdominal, 57.5 vs. 70.6 min, P < 0.003). Blood loss during surgery was negligible in both groups. In the laparoscopic abdominal group, the frequency of full-layer prolapse was higher (P = 0.003), and the length of the prolapse was longer (5.6 vs. 7.8 cm, P = 0.048). There was no difference in-hospital stay and the duration of analgesic treatment between the groups [Table 3].

Table 3

Intra-operative parameters between transanal and laparoscopic group

	Transanal, n (%)	LVR, n (%)	P
Operative time (min) (SD)	57.5 (14.1)	70.6 (13.9)	0.003
Extent of prolapse
Full layer	14 (36.8)	13 (81.2)	0.003
Mucosal layer	24 (63.2)	3 (29.6)
Length of prolapse (cm) (SD)	5.6 (1.9)	7.8 (5.8)	0.048
Hospital stay (days) (SD)	2.9 (2.3)	4.4 (2.9)	0.056
Length of analgesia (days) (SD)	3.5 (0.7)	3.3 (0.9)	0.412

LVR: Laparoscopic ventral rectopexy, SD: Standard deviation

Post-operative complications were observed in six cases (15.8%) in the transanal group, in the form of bleeding, voiding difficulty and delirium; two cases with complications (12.5%) were observed in the abdominal group, with voiding difficulty and ileus. There was no difference in the frequency of total complications (P = 0.756). There was no difference in the follow-up period (P = 0.243) and recurrence rate (5 (12.5%) vs. 2 (12.5%), P = 1.000). One case, which recurred after the laparoscopic approach, was diagnosed with prostate cancer after surgery and recurred after radiation treatment [Table 4].

Table 4

Postoperative and functional parameters between transanal and laparoscopic group

	Transanal, n (%)	LVR, n (%)	P
Complications	6 (15.8)	2 (12.5)	0.756
Op site bleeding	3
Voiding difficulty	2	1
Delirium		1
Ileus		1
Followup period (months) (SD)	8.6 (2.4)	3.9 (1.2)	0.243
Recurrence	5 (12.5)	2 (12.5)	1.000
Mortality (n)	0	0
Pre-operative WCS (SD)	7.1 (3.6)	6.2 (2.8)	0.367
Post-operative WCS (SD)	5.3 (3.7)	4.5 (2.8)	0.447
Pre-operative WIS (SD)	6.6 (4.1)	7.4 (3.8)	0.497
Post-operative WIS (SD)	4.6 (4)	4.9 (2.2)	0.736

WCS: Wexner constipation score, WIS: Wexner incontinence score, LVR: Laparoscopic ventral rectopexy, SD: Standard deviation

WCS and WIS showed no statistically significant differences between the groups [Table 4], and comparisons between pre-operative and post-operative scores in each group showed improvement after surgery [Table 5].

Table 5

Functional score difference between pre- and post (3 month after)-operation

	Transanal	P	LVR	P
Pre-post WCS (SD)	1.8 (1.5)	<0.001	1.7 (0.6)	0.010
Pre-post WIS (SD)	2 (2.5)	<0.001	2.5 (2.6)	0.003

WCS: Wexner constipation score, WIS: Wexner incontinence score, LVR: Laparoscopic ventral rectopexy, SD: Standard deviation

DISCUSSION

The proportion of males in our study was 56 out of 236, which is 23.7% during 5 years. The surgical approach was determined by the patient's choice after sufficient explanation of the pros and cons of each surgical method and considering age and underlying diseases. Recurrence occurred in both groups at the same rate.

Rectal prolapse is known to be a rare condition in males,[4] but reports from some countries, such as Egypt and India, show that it is no less common in males than in females.[5678] The aetiology in males is not clear, but some reports attribute it to pelvic floor myopathy caused by schistosomiasis.[5] However, other researchers disagree with this theory.[6] To date, no clear clinical practice guidelines have been published for males. Therefore, rectal prolapse in males is managed by the same surgical methods used in female patients. A comparison of pre-operative patients showed that males were younger, healthier and had better anorectal function than females.[9] However, surgery, especially with the laparoscopic abdominal approach, is technically difficult in males due to various anatomical factors. Surgical dissection should be carried out with care to avoid complications of urinary and sexual dysfunction.[10] The narrow android pelvis limits the range of activity of laparoscopic instruments, which can result in unexpected injuries to the seminal vesicles and prostate and cause sexual dysfunction such as retrograde ejaculation or impotence due to autonomic nerve damage. Therefore, several studies have reported that laparoscopic ventral mesh rectopexy (LVMR) should be used only by surgeons who have passed the learning curve.[1112]

According to a recent systemic review and meta-analysis, male sex was identified as an independent predictor of recurrence after LVMR.[13] However, after one study reported that both males and females could consider laparoscopic ventral rectopexy.[14] Other trials, such as PROSPER, a randomised trial for surgical procedures with abdominal and perineal approaches, compared the details of suture versus resection rectopexy, and Altemeier's versus Delorme's procedures.[15] According to the study, there were pros and cons for each operation, but there was no statistically significant difference in recurrence rates and function test results. A systematic review of transanal approaches showed that recurrence occurred in 16.6% and complications occurred in 13.2% of patients, concluding that there was a high incidence of recurrence and a low complication rate.[16] A meta-analysis of abdominal rectopexy showed recurrence in 5.8% of cases and complications in 15% of cases.[17] According to another review of abdominal anterior rectopexy in 574 patients, recurrence occurred in 4.7% of patients and major complications occurred in 4.8% of patients.[18] Emile et al., who analysed systematic reviews only for an individual group, published a prospective randomised study to compare LVMR and Delorme's operation. A total of 50 patients were assigned to two groups with 25 patients each. The LVMR group had low recurrence, and the Delorme's procedure group had long hospital stay. Both groups showed low and acceptable rates of complications.[19]

This study is limited by its short follow-up duration, which is a major weakness, and retrospective nature and the comparison of two nonrandomised groups. In particular, there may be selection bias in the choice of surgery. Perineal approaches were generally considered for frail and/or elderly patients, and abdominal procedures were opted for healthy and young patients.[20] However, studies have shown that abdominal access, especially laparoscopic ventral rectopexy, can be performed safely even at an advanced age.[21] Our study also shows that the number of patients in the laparoscopic group was smaller than that in the transanal group. However, with a recent increase in the proportion of laparoscopic abdominal surgeries, further studies may include a larger number of patients.

CONCLUSION

The frequency of male rectal prolapse was 23.9% of total cases, and perioperative factors differed between transanal and laparoscopic abdominal approaches, but recurrence rates and functional test results showed no significant difference.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.