LVMR for external rectal prolapse: long-term results
Laparoscopic Ventral Mesh Rectopexy for External Prolapse
J Randall, E Smyth, AR Dixon
North Bristol & SPIRE Hospitals Bristol
Aim: To assess the efficacy of
laparoscopic ventral mesh rectopexy (LVMR) for full thickness external rectal
prolapse, including recurrent rectal prolapse.
Methods: A prospective database was
used to identify all patients who underwent LVMR for external prolapse over the
sixteen year period to December 2013.
Results: 190 patients (87 % female),
median age 69 years (18-93) underwent LVMR; median active follow up was 29
months (1-196) and median time from operation was 73 months (1- 196). 120 patients
were operated on >5 years and 16 >10 years from the end of the study
period. The 60-day mortality was 1%, the recurrence rate was 3% with a current
mesh erosion rate of 3.6%. Cleveland Clinic incontinence scores improved by a
median of 8 points (P<0.0001). 62 patients returned a complete sequence of
QoL scores (Birmingham Bowel and Urinary Symptoms Questionnaire-22), which
improved by 46% at 1 year. This improvement was sustained at a median of 4
years (P<0.001). Mean patient reported satisfaction at final review was 9.1
out of 10. 39 patients underwent a
LVMR for recurrent prolapse post perineal repair(s). Full thickness recurrence
was seen in one and there were no mesh complications. The same improvement in
QoL was seen in this subgroup.
Conclusion: LVMR can be performed for
external rectal prolapse, including those who’ve had previous failed perineal
procedures, with low recurrence rates and morbidity. LVMR produces long term functional
benefits and results in sustained improvements in QoL.
variety of surgical techniques are available for repair of full thickness
external rectal prolapse. The recently reported PROSPER trial found no significant
differences in outcome between those undergoing a perineal or an abdominal
procedure, and those undergoing suture or resection rectopexy. However the
authors noted particular difficulty in recruiting to randomising between
abdominal and perineal approaches and whilst significant improvements in
quality of life were seen in all procedures, a high rate of recurrence was
identified. [Senapati 2013](1).
ventral mesh rectopexy (LVMR) is a well-recognised procedure for treatment of
external prolapse in adults with low morbidity and low rates of morbidity and
early recurrence [D’Hoore 2004, Slavik 2008] (2,3). The procedure is safe in
elderly patients [Wijffels2011] (4). Limiting dissection to the anterior rectum
with an autonomic nerve sparing technique is also believed to limit postoperative
constipation [Boons 2010] (5).
The aim of this
study was to assess the efficacy of LVMR for full thickness external rectal
prolapse. Of particular interest are those patients with longer term follow up
and those with recurrent rectal prolapse, having undergone a previous failed
Delorme’s or Altemeier perineal repair.
underwent LVMR for external rectal prolapse in a single institution were
identified from a prospectively updated database. The study period was sixteen
years from January 1997 to December 2013. The series includes referrals of
challenging or recurrent cases received from other institutions.
symptoms including continence, obstructive defecation and dyspareunia, as well
as any previous procedures were recorded. Patients were asked to complete
Cleveland Clinic faecal incontinence (FI) scores and a quality of life (QoL)
score (Birmingham Bowel and Urinary Symptoms Questionnaire-22). Selected patients
underwent pre-operative investigations including dynamic defaecography, transit
studies and anorectal physiology as appropriate.
were admitted on the day of surgery and length of stay was recorded as the time
to leaving hospital. After an initial examination of the anorectum under
anaesthetic, a laparoscopy was performed using a 10mm 15-degree camera and two
additional ports. Ventral mesh rectopexy was performed as previously described (Badrek
Al-Amoudi 2013) (6).
Posterior dissection was avoided in most cases. During the series there was a
move from polypropelene to polyester meshes and then to titanium coated lightweight
polypropylene mesh. There was also a move to a longer (20cm) mesh.
Active follow up
was at 6, 12 and 26 weeks and annually thereafter. Patients were asked about
new or persistent symptoms and the effect of the operation on their sexual
function. Overall satisfaction with the procedure was established through a
simple scale of 0 (not satisfied) to 10 (very satisfied). Patients were asked
to complete FI and QoL scores post-operatively and at yearly intervals
afterwards. Many patients were
discharged as their symptoms settled but returned if there was a problem. Outcomes
related to complications can therefore be considered to have follow up to the
end of the study. All further operations were recorded, including the need and
timing of re-do surgery. Complications of the primary or re-do surgery
including re-admissions and mesh-related complications were documented. All
full thickness recurrences were recorded. Where this diagnosis was not obvious
from history and examination, dynamic defaecography was repeated and/or
examination under anaesthetic.
Data was analysed as
intention to treat on a last observation carried forward basis. This was
necessary to allow meaningful comparisons between the patient groups. Only
those who returned a complete set of baseline and follow up QoL scores were
included in the final analysis. After analysis of the entire group, a further
analysis was performed on those with longer term follow up (>5 years) and
those operated on for recurrent prolapse.
The quality of life data
was deemed to be non parametric and analysed accordingly. SPSS version 18 was
used for statistical analyses. A Wilcoxon signed rank test was used for
comparison of the groups and a value of p<0.05 was deemed to be consistent
with a statistically significant result. A separate sub group analysis was
performed for those patients who presented with recurrent rectal prolapsed. This
data was analysed using a Kruskal Wallis test, again a value of p<0.05 was
deemed to be consistent with a statistically significant result.
1997 to December 2013 190 patients underwent LVMR in a single institution for
external rectal prolapse. The median patient age was 69 years (18-93) with a
median active follow up of 29 months (1-196) and a median time of 73 months (1-
196) from the operation. The demographics of the group are shown in table 1.
underwent examination under anaesthetic at the start and end of the procedure.
As shown in table 2, 22 patients had an additional element to their procedure
combined with LVMR, including a limited posterior rectal dissection
(Orr-Loygue), anterior colporraphy, a posterior stapled transanal rectal
resection procedure (STARR) or procedure for prolapsed haemorrhoids (PPH).
Conversion from a totally laparoscopic case occurred in 5 cases, due to
adhesions and difficult access. Median length of stay was 2.2 days (0-45); 51%
had a 24 hour stay (table 2).
There were 12
re-admissions; medical and surgical complications are listed in table 2. Laparotomy
was required for surgical-related complications in three patients: adhesional
small bowel obstruction, perforated diverticular disease and a delayed enterotomy.
The latter two patients died on days 6 and 8 respectively.
The current mesh
erosion rate is 3.6%. Over half the mesh erosions seen were into the vagina,
the remainder involving the rectum or a recto-vaginal fistula. Table 3 records
the further procedures that patients in this series underwent. Of the mesh
erosions, 3 went on to have local mesh excision and 3 laparoscopic removal.
Redo LVMR was performed after mesh removal. 1 patient eventually required a
proctectomy for recurrent prolapse (LVMR performed for prolapsed rectal stump).
developed full thickness recurrence during the follow up period, giving an
overall recurrence rate of 3%. Redo LVMR was performed for recurrence (table
3). Four further patients developed symptomatic posterior lateral
intussusception, which was managed by the addition of a posterior STARR.
reported outcomes, Faecal Incontinence (FI) and QoL scores
Mean patient reported
satisfaction at last follow up, obtained from 119 patients, was 9.1 out of 10
(1-10). FI scores improved from baseline by a median of 8 points (0-16)
(P<0.0001) at last follow up. This was a 93% improvement rendering subjects
continent. As shown in table 3 only 14 patients (7%) needed further biofeedback
after LVMR. QoL scores (BBUSQ-22) were assessed at baseline, 1 year and up to 5
years. 62 patients returned a complete sequence of QoL scores, which improved
by 46% at 1 year. This improvement was sustained at last follow up, median 4
patients described dyspareunia as a significant symptom. Whilst this resolved
in all cases, two patients (1%) developed new onset dyspareunia. There were no
cases of hyspareunia and none of the male patients developed new-onset
impotence or retrograde ejaculation. 44% of 169 patients who responded to questions
addressed at their sexuality were not sexually active post-operatively. 37%
felt that their sex life was improved, 16% felt there had been no change,
whilst 2% described a worsening of their sex lives.
term follow up group
were operated on more than 5 years from the end of the study period and 16 over
10 years. 4 patients (3.3%) returned with recurrence in this group at 25, 30,
31 and 60 months. Nine patients died from other causes, without their prolapse
recurring, at a median of 6 years post- surgery (0.5-8).
Recurrent prolapse group
patients had a LVMR performed for recurrent prolapse after a previous perineal
repair, including repeated perineal procedures as shown (table 1). Length of
stay in this group was a median of 2 days (1-5) and active follow up a median
of 27 months (1- 184). Complications included the mortality occurring at day
eight following re-operation for a delayed presentation of an enterotomy on day
seven described above. There were no re-admissions or mesh complications.
patient (2.5%) developed a full thickness external recurrence whilst another a
partial thickness posterior prolapse during follow up. These were successfully
managed by revision surgery- the former patient’s mesh was reattached to the
sacral promontory and a posterior suture Orr-Loygue rectopexy performed for
correction of the posterior prolapse. The only other additional treatment required
by this group was one patient requiring a period of biofeedback.
patient reported satisfaction was 8.9/10. . Comparison of quality of life data
(BBUSQ-22) between those patients undergoing revision procedures and those
undergoing primary VMR showed no statistical difference between the two groups
(p=0.459), highlighting that there is no significant impairment in outcomes.
still exists over the optimum surgical approach to rectal prolapse. Many
procedures are associated with potentially high recurrence rates. The recently
reported PROSPER trial randomised more patients between perineal approaches
than to abdominal rectopexy but described 3-year recurrence rates of 24% for
Altemeier’s and 31% for Delorme’s [Senapati 2013](1). In our series the overall
medium term recurrence rate post LVMR was 3%, a figure comparable to the 5%
reported by D’Hoore in 42 patients with a median follow up of 61 months (2004)(2) and 3-4% reported in several
other series [Smart 2013](7). The initial series reported
by this unit reported a zero recurrence rate  highlighting the need for
medium to long term follow-up. Importantly, our current series also reports a
group with longer term follow up. Results are demonstrated to be sustainable with
a recurrence rate of 3.3% in this group and no recurrences seen after 5 years.
LVMR has been
demonstrated to be safe in the elderly population with rectal prolapse
[Wijffels 2010](4). Our series reports a low
rate of readmission and medical complications in a pre-dominantly elderly
group. However the two mortalities reported highlight potential hazards and the
need to consider early re-intervention.
this series has demonstrated a significant improvement in quality of life for
patients undergoing LVMR that is maintained at a median last follow up of 4
years. The PROSPER trial also noted sustained improvements in quality of life
from baseline to the early post-operative period, and over the 3 years of
follow up, for all methods of prolapse repair [Senapati 2013](1). However, they also found
that having a recurrence was found to have an adverse impact on quality of
life. This series has demonstrated that patients with a recurrence can achieve
the same sustained improvements in QoL after redo surgery by LVMR as those
undergoing primary repair.
improvement in faecal incontinence was also seen at last follow up as judged by
Cleveland Clinic incontinence scores. Several studies have documented
improvements in the numbers of patients suffering incontinence [Lechoux 2005,
D’Hoore 2004](2, 8)
and others have used objective scores after the operation to demonstrate this
[Formijne Jonkers 2013](9).
Our series is important in quantifying a change in objective scores after the
operation compared to before. Restricting dissection anterior to the rectum in
LVMR also reduces post-operative constipation [Boons 2010](5)
and is associated with good functional results [Lechoux 2005] (8). Relief of
symptoms of sexual dysfunction, with a general improvement in respondent’s sex
lives, was observed in this study in keeping with other studies .
approaches have been associated with lower morbidity and earlier discharge than
other methods of prolapse repair [Tou 2008, Purkayastha 2005](11,12)
Daycase surgery is possible in selected patients [Powar 2013](13).
A previous report from this institution has suggested that most complications,
including recurrence, after LVMR are amenable to correctional surgery. Re-do
LVMR or sometimes just re-attaching a detached mesh, is associated with
improvement in overall function [Badrek Al-Amoudi 2013](6). This current series also
provides evidence that LVMR is a useful technique after failed perineal repair,
with results comparable to primary repair.
mesh erosions highlight the need for long term follow up. A mesh erosion rate
of 3.6% is reported here, mostly through the vagina. Some changes were made
across this series, including the type of mesh used, to try to limit the
potential for complications and in line with suggestions made at a national
level [Mercer-Jones 2014](14). However, the optimal mesh
for LVMR has not been established [Smart 2013](7). National reporting of
outcomes and complication rates will help decision-making about techniques for
mesh rectopexy, and aid informed consent for patients.
described in this paper reflect those of an experienced surgical team in a
tertiary referral centre. Whilst this paper benefits from large numbers and
follow up, only a third of patients returned sufficient data to analyse quality
of life changes over a sustained period of time. Other large studies have also
suffered with limits in response rate [Senapati 2013, Formijne Jonkers 2013](1, 9).
It is important that surgeons encourage patient reporting of outcomes and
prospective registries may again help collate this information.
In conclusion this
series demonstrates that LVMR can be safely used to manage full thickness
rectal prolapse and that this technique produces long term functional
improvements. Outcome data for redo surgery in those with previous failed
perineal procedures was similarly good.
Table 1 Demographics and pre-operative findings
Median Age (years)
Previous surgery for rectal prolapse
Pre-operative Wexner Score
Pre-operative ODS score
3 posterior rectopexy- 1 with resection
Table 2 Details of operative procedure and outcome
Additional procedure performed
LVMR and anterior colporraphy
LVMR and posterior STARR
LVMR and PPH
Median length of stay (range)
24 hour stay
60 day mortality
Re-operation- diverticular perforation
Re-operation- small bowel obstruction
Port site hernia
2.2 days (0-45)
Table 3 Further procedures required
Local mesh excision
Laparoscopic mesh removal
Port site hernia
Rectovaginal fistula repair
A, Gray RG, Middleton LJ, Harding J, Hills RK, Armitage NC, et al. PROSPER: a
randomised comparison of surgical treatments for rectal prolapse. Colorectal
Dis. 2013 Jul;15(7):858-68.
A, Cadoni R, Penninckx F. Long-term outcome of laparoscopic ventral rectopexy
for total rectal prolapse. Br J Surg. 2004 Nov;91(11):1500-5.
S, Soulsby R, Carter H, Payne H, Dixon AR. Laparoscopic ventral rectopexy,
posterior colporrhaphy and vaginal sacrocolpopexy for the treatment of
recto-genital prolapse and mechanical outlet obstruction. Colorectal Dis. 2008
N, Cunningham C, Dixon A, Greenslade G, Lindsey I. Laparoscopic ventral
rectopexy for external rectal prolapse is safe and effective in the elderly.
Does this make perineal procedures obsolete? Colorectal Dis. 2011
P, Collinson R, Cunningham C, Lindsey I. Laparoscopic ventral rectopexy for
external rectal prolapse improves constipation and avoids de novo constipation.
Colorectal Dis. 2010 Jun;12(6):526-32.
Amoudi AH, Greenslade GL, Dixon AR. How to deal with complications after
laparoscopic ventral mesh rectopexy: lessons learnt from a tertiary referral
centre. Colorectal Dis. 2013 Jun;15(6):707-12.
NJ, Pathak S, Boorman P, Daniels IR. Synthetic or biological mesh use in
laparoscopic ventral mesh rectopexy--a systematic review. Colorectal Dis. 2013
8. Lechaux D, Trebuchet G, Siproudhis L, Campion J.
Laparoscopic rectopexy for full-thickness rectal prolapse: a single institution
retrospective study evaluating surgical outcome. Surg Endosc. 2005 Apr; 19 (4):
Jonkers HA, Poierrie N, Draaisma WA, Broeders IA, Consten EC. Laparoscopic
ventral rectopexy for rectal prolapse and symptomatic rectocele: an analysis of
245 consecutive patients. Colorectal Dis. 2013 Jun;15(6):695-9.
M, Abet E, Rigaud J, Frampas E, Lehur P, Meurette G. Minimally invasive ventral
mesh rectopexy for complex rectocele: impact on anorectal and sexual function.
Colorectal Dis. 2011 June; 13: e320-e326
S, Tekkis P, Athanasiou T, Aziz O, Paraskevas P, Ziprin P, et al. A comparison
of open vs. laparoscopic abdominal rectopexy for full-thickness rectal
prolapse: a meta-analysis. Dis Colon Rectum. 2005 Oct;48(10):1930-40.
S, Brown SR, Malik AI, Nelson RL. Surgery for complete rectal prolapse in
adults. Cochrane Database Syst Rev. 2008(4):CD001758.
MP, Ogilvie JW, Jr., Stevenson AR. Day-case laparoscopic ventral rectopexy: an
achievable reality. Colorectal Dis. 2013 Jun;15(6):700-6.
MA, D'Hoore A, Dixon AR, Lehur P, Lindsey I, Mellgren A, et al. Consensus on
ventral rectopexy: report of a panel of experts. Colorectal Dis. 2014