Does Concomitant Pelvic Organ Prolapse Repair at the Time of Rectopexy Impact Rectal Prolapse Recurrence Rates? A Retrospective Review of the Prospectively Collected Pelvic Floor Disorders Consortium Quality Improvement Database Pilot

Abstract

BACKGROUND: Pelvic organ prolapse is reported in 30% of women presenting with rectal prolapse. Combined repair is a viable option to avoid the need for future pelvic floor interventions. However, the added impact of adding a modicum of middle compartment suspension by closing the pouch of Douglas during a rectal prolapse repair has not been studied. OBJECTIVE: The study aimed to assess the impact of middle compartment suspension on the durability of rectal prolapse repair. We also aimed to determine whether adding some form of pouch of Douglas closure to achieve middle compartment suspension leads to any improvements in the rates or severity of postoperative constipation or in the rates or severity of postoperative fecal incontinence. DESIGN: This study was a retrospective analysis of a multicenter prospective database. SETTING: Data were analyzed from the Pelvic Floor Disorders Consortium Quality Improvement in Rectal Prolapse Surgery database. Deidentified surgeons at more than 20 sites (75% academic, 81% high volume) self-reported patient demographics, previous repairs, symptoms of fecal incontinence and obstructed defecation, and operative details, including addition of concomitant gynecologic repairs, use of mesh, posterior or ventral dissection, and sigmoidectomy. PATIENTS: Patients were included who underwent abdominal repair for rectal prolapse. INTERVENTIONS: Abdominal rectopexy procedures with and without middle compartment suspension were compared. Middle compartment suspension was defined as excision and closure of the pouch of Douglas with some degree of colpopexy or culdoplasty. MAIN OUTCOME MEASURES: The primary outcome of prolapse recurrence and secondary outcomes of incontinence and constipation were calculated via univariate and multivariable regression by comparing those who underwent rectopexy with and without middle compartment suspension. RESULTS: Of the 198 patients (98% female, age 60.2 ± 15.6 years) who underwent abdominal repairs (59% robotic), 138 patients (70%) underwent some concomitant middle compartment suspension. Patients who had an added middle compartment suspension seemed to have lower early rectal prolapse recurrences. On multivariable regression to control for age, previous repairs, and the use of mesh, addition of some form of pouch of Douglas repair was associated with a decrease in short-term recurrences. LIMITATIONS: Our data need to be interpreted cautiously. Future studies are critically needed to further explore this observation, with an a priori, prospective definition of middle compartment suspension, validated measurement of concomitant pathology, and longer follow-up. CONCLUSION: Our results suggest that some middle compartment suspension at the time of rectal prolapse repair may improve short-term durability of rectal prolapse repair. See Video Abstract at http://links.lww.com/DCR/C30. ¿LA REPARACIÓN CONCOMITANTE DEL PROLAPSO DE ÓRGANOS PÉLVICOS EN EL MOMENTO DE LA RECTOPEXIA AFECTA LAS TASAS DE RECURRENCIA DEL PROLAPSO RECTAL? UNA REVISIÓN RE...

Durable Approaches to Recurrent Rectal Prolapse Repair May Require Avoidance of Index Procedure

“…First, these findings were presented at the annual meeting of the ASCRS. 14 After this, 57 colorectal surgeons with a significant clinical interest in pelvic floor disorders convened to offer their opinions on how these data, combined with their prior expertise, could inform future decision-making when faced with the need to offer a redo rectal prolapse repair. Their opinions are summarized in Figure 3.…”

The Middle Compartment: Keystone or Cul De Sac?

“…The article by Bordeianou et al 25 on concomitant pelvic organ prolapse repair at the time of rectopexy, published in this edition, highlights many of the difficulties in finding better treatments for rectal prolapse and questions whether Middle ComPartment Suspension (MCPS) should be performed at the time of rectal prolapse repair. The authors interrogated a multicenter database created by the newly established Pelvic Floor Disorders Consortium to retrospectively determine the impact of MCPS during abdominal rectal prolapse repair on short-term prolapse recurrence rates and bowel function.…”