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LVMR for Uterine/Vault & rectal prolapse

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Efficacy of Laparoscopic Ventral Mesh Rectopexy for Co-existent Vaginal Vault and Rectal Prolapse.







Hugh Mackenzie1, Emma J Horrocks2, Kathryn McCarthy3, Anthony R Dixon4


1. Departments of Surgery & Cancer, Imperial College London

2. National Centre for Bowel Research and Surgical Innovation, Queen Mary University, London

3. Department of Coloproctology North Bristol NHS Trust

4. Department of Coloproctology North Bristol NHS Trust, University of Bristol & SPIRE Hospital Bristol.


-       Hugh Mackenzie, BSc MRCS, Clinical Research Fellow

-       Emma J Horrocks, BSc MRCS, Clinical Research Fellow

-       Kathryn McCarthy, MD, FRCS Consultant Colorectal Surgeon

-       Anthony R Dixon DM FRCSEd, FRCS, Consultant Colorectal Surgeon & Reader in Pelvic Floor Surgery




Correspondence to Mr Tony Dixon


Keywords: Laparoscopic ventral mesh rectopexy, rectal prolapse, rectal intussusception, vaginal prolapse, recurrent vault prolapse





 Laparoscopic ventral mesh rectopexy (LVMR) is a well-recognised treatment for rectal prolapse. However, it may be of benefit to co-existing middle compartment prolapse. The objective of this study was to define the efficacy of LVMR for co-existing vaginal and rectal prolapse.


All LVMR cases performed by the senior author for co-existent vaginal and rectal prolapse between January 2002 and December 2013 were included. In addition to the clinical outcomes, quality of life (QOL) outcomes, including the Cleveland Clinic Incontinence Score (CCIS) and Obstructive Defecation Syndrome (ODS) score and patient reported outcome measures (PROMs) were evaluated. The number and efficacy of previous POP procedures was also assessed.


68 LVMRs were performed for co-existent middle and posterior compartment prolapse during the study period. 39 (57.4%) had grade 2 POP-Q, 20 (32%) grade 3 and 9 (13%) grade 4. The mean age was 67.6 (SD - 13.2), mean BMI was 26.5 (SD - 4.01) and median ASA was II (IQR 1-3). 44 had undergone previous POP surgeries; only 9 (20%) were satisfied overall with their care.  The median FU was 24 months (IQR 8-65).  The pre- and post-LVMR QOL of life scores were; CCIS pre - 8 (IQR 4-14), post - 0 (IQR 0-0), BUSSQ-22 Pre - 58 (IQR 51.5-64), at 3 months - 36 (IQR 32 – 41), at 1 year - 34 (IQR 32-38), ODS pre -18 (IQR 14-21), post 7 (IQR 6-9.5). 73.5% rated their outcome as very successful and 20.6% as successful, the remaining 5.8% felt their symptoms were unchanged. Middle compartment prolapse was controlled in all cases, although recurred in one instance.  The operative and mesh-related complication rates were 7.3% and 1.4%.  6 (8.8%) required revision surgery for recurrent rectal prolapse or symptomatic ODS.


LVMR is an effective treatment of co-existing middle and posterior compartment prolapse, providing good symptomatic relief with minimal morbidity. Patients’ with vaginal POP should have their rectal function routinely assessed, ideally in a joint pelvic floor clinic.




















Middle compartment pelvic organ prolapse (POP) is common with a lifetime risk of surgery by 80 years estimated1to be as high as 12 %; unfortunately up to 30% develop a recurrence and undergo repeated surgery. Although vaginal hysterectomy has traditionally been viewed as being the treatment of choice for uterine prolapse, it is associated with an 8 times higher risk of requiring repeat surgery compared with controls2.  This is not surprising since a hysterectomy fails to address the underlying pathophysiology of poor connective tissue support.  The anatomical defect leading to POP3 is a detachment of the pubocervical and rectovaginal fascia from each other and their apical support, the sacro-uterine and cardinal ligaments.  In theory, any apical prolapse can thus be corrected by reconstructing these facial supports with the proximal uterosacral ligaments. Recently, uterine conserving re-suspension surgery has become popular.  Several techniques, including vaginal, open abdominal and laparoscopic approaches, have been described with varying success rates4.  


Rectal prolapse and high-grade intussusception are debilitating conditions, often associated with faecal incontinence, pelvic pain and obstructive defecation. Surgery is a validated treatment and this has evolved from a perineal to an abdominal and now a minimally invasive approach5. Nerve sparing laparoscopic ventral mesh rectopexy (LVMR) is well recognised as a treatment; there is increasing evidence that it not only reduces the prolapse but also improves the associated symptoms6-10. LVMR is also safe in the “super” elderly 11.



The aims of this study were to evaluate the efficacy of LVMR with reference to preservations of lower urinary tract, intestinal and sexual functions in women with significant coexisting middle and posterior compartment prolapse and highlight the role of occult posterior compartment prolapse as a potential mechanism of failure following conventional POP surgery.




















All LVMR cases performed by the senior author for co-existent vaginal POP-Q stages 2-4 and rectal prolapse between January 2002 and December 2013 were included in the study.


Operative Technique

Using the technique previously described6 the pelvic peritoneum is incised from the sacral promontory down to the pouch of Douglas allowing the rectovaginal septum to be then mobilised anteriorly down to the levator ani, deep transverse perineal muscles and the perineal body of the pelvic floor. The pouch of Douglas is then excised to define the anterior rectum.  In patients with a high-grade cystocele the pubocervical fascia is identified ventrally between the vagina and bladder.  A 20 x 4 cm strip of low weight Titanium coated polypropylene mesh (PFM, Nuremberg, Germany) is then sutured to the anterior rectum with 3/0 PDS (Ethicon, Edinburgh, Scotland) for 18cm.  Baggy vaginal prolapse is then sutured to the ventral aspect of the mesh.  In patients with a hysterectomy the vaginal vault and pubocervical fascia are attached to the mesh with the same suture.  If the uterus is in situ the mesh is sutured to the pericervical fascia.  The mesh is then attached to the sacral promontory with “Protacks” (Covidien, Gosport UK).  The uterosacral ligaments are then approximated over and to include the mesh and continued towards the promontory elevating the proximal mesorectum by incorporating it into the repair.  Catheters are removed in theatre. Patients are discharged with a laxative.


Follow up and Outcome Parameters

Patients were followed up at 6, 12 and 26 weeks and annually thereafter. All data was recorded in a prospective database, which was updated after each follow up visit. Patient demographics [age, body mass index (BMI), American Society of Anaesthesiologists (ASA) classification] and case specifications were recorded; including the number and efficacy of previous POP procedures. The clinical outcome parameters studied were operative and mesh-related complications, conversion, 30 day mortality, re-operation rate, re-admission rate, symptomatic recurrence rate and requirement for further treatment (including revision surgery). Objective assessment of pelvic organ prolapse was performed during a Valsalva manoeuvre, in the left lateral position, using a Sims’ speculum and the prolapse staged according to the International Continence Society (ICS) Pelvic Organ Prolapse Quantification  (POP-Q) staging system10.


Quality of life (QOL) was assessed with the validated Birmingham Bowel and Urinary Symptoms Questionnaire (BBUSQ-22) and functional outcomes using the Cleveland Clinic Incontinence Score (CCIS) and Obstructive Defecation Syndrome (ODS) score12-14Patient reported outcome measures (PROMs) and overall satisfaction with the procedure using a simple scale of 0 (not satisfied) to 10 (very satisfied) were also evaluated. Patients were asked to complete these outcome scores post-operatively and at yearly intervals afterwards; the most recent scores were used for the analysis. Patients were asked about new or persistent symptoms and the effect of the operation on their sexual function.

Statistical Analysis

Categorical data was represented as percentages, parametric data as mean and standard deviation and non-parametric (quality of life outcomes) as median and inter-quartile range (IQR). SPSS version 18 was used for statistical analyses and a value of p<0.05 was deemed to be significant. Percentage change was used to assess impact of LVMR on quality of life and functional scores. 




















Patient Characteristics

Sixty-eight LVMRs were performed for combined recto-urogenital prolapse during the study period. Thirty-nine (57.4%) had grade 2 POP-Q vaginal prolapse, 20 (29.4%) grade 3 and 9 (13.2%) grade 4. The mean age was 67.6 (SD - 13.2), mean BMI was 26.5 (SD - 4.01) and median ASA was 2 (IQR 1-3). (Table 1)  


Fifty patients had undergone a prior hysterectomy (27 abdominal) of which 16 were first line vaginal hysterectomies for POP.  Forty-four women had undergone additional interventions for symptomatic POP including 24 with recurrent POP-Q grades III/IV (Table 2). Ten (15%) had undergone multiple surgeries for re-recurrent POP. There was no difference in multiple surgeries in those with vaginal hysterectomy (4/23 (17.4%) vs. 6/45 (13.3%), p=0.725).  Three patients (2.9%) had been previously been considered too frail for any surgical intervention whilst a further 20 had been managed conservatively. Only 9 (20.5%) were satisfied overall with their care.


Clinical Outcomes

Five patients (7.3%) had operative complications, 4 of which were minor. There was one death from multi organ failure following a delayed perforation at one week from a presumed missed enterotomy; the original surgery having required an early conversion due to dense adhesions. The median length of stay was one day (1-8) and the median follow-up was 27 months (IQR 8-65).


Post-operative clinical outcomes and further treatments are detailed in Table 3.   Middle compartment POP was controlled in all cases, although recurred, together with the associated rectal prolapse in one instance secondary to a mesh detachment from the sacral promontory. There were two cases of partial left lateral rectal prolapse recurrence both responding to a revision of the LVMR. Two patients with recurrent ODS required a “re-do” LVMR and two required local surgery for symptomatic posterior rectal wall intussusception (STARR - stapled trans anal rectal resection) and haemorrhoids (PPH - procedure for prolapsed haemorrhoids).  One (1.4%) developed a mesh erosion requiring per anal removal of the mesh followed by an uneventful repeat LVMR at a later date.  A total of 16 patients’ required further treatments.  Revision surgery was associated with improved function (CCIS/ODS) and restoration of QOL in all cases bar one.  The latter patient failed a trial wire SNS and continues with her ODS and associated incontinence.


Functional Outcomes

The QOL outcomes are detailed in Table 4; there was a greater percentage improvement in the bowel VAS scores (mean – 69.7%) than in bladder VAS scores (mean – 50.8%).  In addition 16.7% of patients had worse bladder VAS scores post-operatively. Six patients (9%) developed post-operative urinary stress incontinence or urgency (3), of which three required Tension-free Vaginal Tapes.  Spontaneous resolution of the urinary urgency occurred within four months. The improvement in bowel function was more dramatic for those patients with faecal incontinence with a mean percentage improvement of 95.2% in CCIS, compared to 53.9% in the ODS score.


Dyspareunia reported in 26 women preoperatively improved in 25 patients; one developed new-onset dyspareunia, which persisted for six months. The patient reported outcome measures (PROMs) are described in Table 5. Sexual function improved in 35.2% and remained unchanged in 16.7%, no patient reported a worsening of their sexual function. 72.3% rated their outcome as very successful and 21.3% as successful; the remaining 6.4% felt their symptoms were unchanged.


















Patient Characteristics

Number of Patients (%)

Total Cases


BMI (S.D.)

26.5 (4.0)

Age (S.D.)

67.6 (13.2)




18 (26.5%)


31 (45.6%)


19 (27.9%)


0 (0.0%)

Bowel Symptoms



48 (70.6%)


51 (75.0%)


48 (70.6%)


17 (25.0%)

Obstructed Defecation

44 (64.7%)


27 (39.7%)

Incomplete Evacuation

54 (79.4%)


51 (75.0%)

Bladder Symptoms


Stress Incontinence

13 (19.1%)

Urge Incontinence


Mixed Incontinence

8 (11.8%

Incomplete voiding

32 (47.1%)

Urinary frequency

8 (11.8%)


26 (38.2%)

Oxford Prolapse Grade


High Grade Intussusception (4-5)

36 (52.9%)

Low Grade Intussusception (2-3)

5 (7.4%)

External Prolapse

27 (39.7%)

POP-Q Grade


Grade 2

39 (57.4%)

Grade 3

20 (29.4%)

Grade 4

9 (13.2%)


Table 1. Description of patient demographics, presenting symptoms and grade of rectal and vaginal prolapse.








Previous Treatments for POP

 Number of Patients

No of Patients Satisfied with Previous Treatment





50 (73.5%)



23 (33.8%)



27 (39.7%)


Type of POP Treatment




44 (64.7%)

9 (20.5%)

Birch Colposuspension

4 (5.9%)

2 (50%)

Ring Pessary

20 (29.4%)

2 (10%)

Manchester Repair

2 (2.9%)

1 (50%

Open Vaginal Sacrocolpopexy

14 (20.6%)

1 (7.1%)

Sacrospinous Fixation

9 (13.2%)

3 (33.3%)

Farnsworth Mesh

1 (1.5%)

0 (0%)

Turned down for surgery

3 (2.9%)




Table 2. Table detailing previous treatments for middle compartment POP and patient satisfaction














Overall Number of Cases (%)

Further Treatment required

Overall Number of Cases (%)

Mesh Related Complications

1 (1.5%)


16 (23.5%)

Mesh Erosion

1 (1.5%)

Repeat LVMR

5 (7.3%)


12 (17.6%)

Removal of Mesh


Rectal Prolapse

2 (2.9%)

Re-attach LVMR

1 (1.5%)

Combined vault and rectal prolapse

1 (1.5%)




7 (10.5%)

1 (1.5%)

1 (1.5%)

Urinary stress Incontinence

3 (4.4%)


1 (1.5%)

Urinary Urgency

3 (4.4%)


3 (4.4%)


4 (5.9%)




1 (1.5%)



Operative Complication

5 (9.9%)



30 Day Mortality

1 (1.5%)




1 (1.5%)




Table 3. Post-operative clinical outcomes and further treaments required.















Outcome measure (N)

Pre (mean and IQR)

Post (mean and IQR)

Mean Percentage Improvement

De Novo or worse Symptoms

Bladder Visual Analogue Scale (48)

  65 (32.5-65)



8 (16.7%)

Bowel Visual Analogue Scale (48)

130 (110-130)

32.5 (65-75)


1 (2.0%)

CCIS (58)

  8 (4-14)

0 (0-0)


1 (1.0%)

ODS Score (45)

18 (14-21)

7 (6-9.5)


0 (0%)

BUSSQ-22  (48)

58 (51.5-64)

36 (32 – 41)


0 (0%)



Table 4. Pre and post-LVMR quality of life outcomes.

































Number (%)


Is your sexual function?


Somewhat better


Somewhat worse

A lot worse


15 (27.8%)

4 (7.4%)

9 (16.7%)

0 (0%)

0 (0%)

26 (48.1%)


How would you rate the outcome?


Very successful

Somewhat successful


Somewhat unsuccessful

Very unsuccessful

34 (72.3%)

10 (21.3%)

3 (6.4%)

0 (0%)

0 (0%)


Was your decision to have surgery?

The right decision


The wrong decision

42 (89.4%)

5 (10.6%)

0 (0%)


Has the result been?


Better than expected

Different - not better or worse

As expected

Worse than expected

32 (47.1%)

13 (19.1%)

0 (0%)

2 (4.3%)


Would you recommend this surgery?


Yes definitely



Probably not

Definitely not

45 (81.8%)

9 (16.4%)

0 (0%)

1 (1.8%)

0 (0%)


Are you glad you had this surgery?


A lot

A bit

Not sure

Not really

Not at all

47 (85.4%)

6 (10.9%)

1 (1.8%)

1 (1.8%)

0 (0%)


If in same situation, would you still have the same treatment?





Not sure

Probably not

Definitely not

44 (86.3%)

4 (7.8%)

2 (3.9%)

1 (1.9%)

0 (0%)


Overall how satisfied were you?


Very Satisfied                   10                                                                                                                                                                     










 Not Satisfied                      0

24 (35.3%)

12 (17.6%)

8 (11.8%)

4 (5.9%)

0 (0%)

2 (2.9%)

0 (0%)

0 (0%)

0 (0%)

1 (1.5%)

0 (0%)





Table 5. Patient reported outcome measures (PROMs) recorded at the last follow-up appointment










This is the first study to report the efficacy of LVMR for symptomatic rectal prolapse (internal and external) and co-existent uterine or vault prolapse. The study cohort was a heavily pre-treated group; the majority had undergone hysterectomy and previous POP surgeries. Vault prolapse is a common complication following vaginal hysterectomy with negative impact on women's quality of life due to associated urinary, anorectal and sexual dysfunction; however the method to correct this remains debated. In this study middle compartment POP was controlled in all cases, with a low recurrence rate. This correction of the anatomical defect was associated with significant improvements in bowel and bladder function and QOL at 3 months with the “normalised” scores maintained at one year and at last follow-up. In addition sexual function improved in one third of patients and none reported deterioration post-operatively. In conjunction with these improvements over 90% of the patients rated their outcome from LVMR as successful.


The traditional approach to uterine prolapse requires an apical suspension carried out vaginally or abdominally, with or without hysterectomy. These operations only perform a level 1 repair and more importantly from the colorectal perspective, ignore any occult or symptomatic intussusception within the posterior compartment. If they are performed laparoscopically they require a high level of skill and experienceCurrently there is no widely accepted definitive procedure, most of the data for subjective and objective outcomes coming from uncontrolled retrospective case series with short-term follow up and selection bias. The most commonly used techniques are sacrospinous hysteropexy (vaginal or abdominal), uterosacral ligament suspension and sacrocolpopexy. The success rates and satisfaction scores produced by LVMR in this study compare favorably with these techniques.


The vaginal technique for uterine preservation most extensively reported is sacrospinous hysteropexy.  In the largest study16 of 99 women followed up for a median of 2 years, 84% reported a high satisfaction rate with recurrent POP in 2%; cystocoele recurrence was reported in up to a third of cases.  The largest study of laparoscopic hysteropexy (LH)17 in 182 patients, median FU 2 years reported 89% patient satisfaction with a significant improvement in POP-Q scoring and a 4% apical recurrence.  The patient group had a high rate of concurrent surgical interventions to include: posterior colpoperineorraphy 86%, anterior colporraphy 19% and TVT 12%.  No comment was made on the 13% of patients who developed evacuatory problems.  There were no reported cases of mesh erosion although the same group reported a rate of 6% for mesh erosion in laparoscopic sacro-colpopexy (LSC)18


Seman et al reported19 a 2-year success rate in 73 women post laparoscopic uterosacral ligament suspension (with additional sub-total hysterectomy in patients with uterine prolapse) of 90%. This high level of control was maintained in a larger series20 of 133 patients followed-up for between 2 and 7.3 years; major complications seen in 2%.


Abdominal sacrocolpopexy (ASC) has a higher success rate in controlling POP than sacrospinous colpopexy, uterosacral colpopexy and transvaginal mesh with less stress urinary incontinence (SUI) and postoperative dyspareunia.  However, ASC had greater morbidity including a longer operating time, inpatient stay, and a slower return to activities of daily living and higher overall cost21, 22. In single case series studies, sacral colpopexy had a higher clinical success and a lower reoperation rate than high vaginal uterosacral suspension or transvaginal polypropylene mesh22In their review of 1000 LSC repairs from 11 case series, Ganatra et al23 reported at a mean follow-up of two years: 94% satisfaction, 6% re-operation rate for recurrent POP, 3% mesh erosion with sexual dysfunction reported in a further 8%.  These results are similar to the outcomes following ASC22.


We found a significant improvement in urinary urge and stress incontinence (SUI) in women undergoing LVMR without concomitant continence surgery.  This contradicts previous reports of urinary symptom deterioration post POP surgery. Although this study was not designed to assess the effect of LVMR on urinary continence an improvement in urinary incontinence was detected on patient reported VAS scores. De novo urinary incontinence (4.4%) was identified on direct questioning and required TVT placement, however urinary urgency (4.4%) resolved spontaneously. This favourable outcome has changed our practice whereby we advise patients presenting with concurrent symptoms arising from posterior compartment and urinary incontinence, that anatomical defects are corrected initially and if lower urinary tract symptoms persist or develop we investigate and treat them subsequently.  This stance of avoiding unnecessary intervention is supported by the 2007 Cochrane review of ASC24.


Even with pre-operative urodynamic testing, 9-42% of patients develop de novo SUI after sacrocolpopexy24. Brubaker et al showed25 a significant decrease in SUI development by performing a concomitant Burch colposuspension, an operative addition not supported by other studies26 (Costantini).  Anti-incontinence procedures however, are not without risk and in themselves can cause de novo urinary dysfunction; 1 in 11 develop complications during trans vaginal tape (TVT) placement, the most common of which is bladder perforation27 and 11–27% developing urgency27, 28.  In the largest LSC series to date29, Rozet et al placed sub-urethra slings in 163 women with SUI; 19 (12%) developed urge incontinence and two (1.2%) developed urinary retention that resolved after TVT section.  Of the 162 patients who had LSC without TVT, 19 (12%) developed de novo SUI and of these 13 were cured with simple conservative measures and six (3.7%) required a TVT, a figure similar to that seen post LVMR.


Data are mixed regarding the impact of POP repair, specifically rectocele repair on faecal incontinence30-33. A prospective study30 of 101 women undergoing rectocele repair reported that 63% of those who had incontinence preoperatively reported symptom resolution or improvement at one year.  In contrast, in a retrospective series of 231 women who underwent posterior colporrhaphy31, the prevalence of fecal incontinence increased postoperatively from 4 to 11%.  There are very few reported data about the effects of ASC on bowel function, although some retrospective series do suggest a high rate of postoperative bowel dysfunction34, 35. Using data from nine studies Ganatra et al reported23 that 10% (range: 0-25%) developed dysfunction to include constipation, anal pain. faecal incontinence and ODS.  In one large series [Sullivan] 28% of 236 patients undergoing LSC (follow-up 3-5 yrs) required re-operation for recurrent rectal prolapse36.


There are limitations to our study in that it was a highly treated cohort for previously failed POP surgeries, urodynamic and anorectal physiology testing was only performed preoperatively and only when indicated and we did not measure objective changes in POP-Q scoring other than point C (the most distal/dependent edge of the cervix or vaginal cuff) - a measure of uterine/vault descent.  In addition BBUSQ-22 and PROM returns at one year or more were not completed by 7 - 8% of patients.


With an ageing, informed and active female population there is a growing need for a high quality, cost effective solution to POP, particularly in those patients with an occult posterior compartment prolapse. The long-term challenges of ASC/LSC are to reduce de novo storage and voiding symptoms, avoid erosion and to preserve both vaginal and posterior compartment function allowing the pelvic anatomy to remain as close as possible to the normal physiologic status.  


Whilst works such as this are rarely the final solution. It does contain much to think about and will we hope stimulate a huge amount of further study, we believe that LVMR represents a natural progression and improvement upon LSC and laparoscopic hysteropexy.   Like the latter it avoids the need for the more traditional vaginal hysterectomy and unlike other interventions, posterior colporraphy.  Patients’ with significant vaginal prolapse should have their rectal function routinely assessed, particularly when one intervention for POP has already failed, ideally within a joint pelvic floor clinic.  Failure to appreciate occult prolapse of the posterior compartment and dismissing ODS as “irritable bowel” leads to early failure of conventional POP surgery or when it succeeds the development of an external rectal prolapse.  POP is a complex condition requiring individualised patient care. The pelvic surgeon needs to be proficient in a number of different techniques so that surgical treatment can be tailored to need. 


We believe that laparoscopy in offering a superior visualisation of the pelvic floor anatomy allows a more exact identification of the individual patients’ defects and their underlying cause allowing for a more effective anatomical correction.  LVMR in correcting external or internal (high-grade intussusception) rectal prolapse, which invariably presents with a coexisting rectocele and enterocele also corrects primary or recurrent middle compartment POP and more importantly, restores function.  The optimal procedure depends on the specific defects that are present, as well as considerations such as age, co morbidities, activity level, desire for future fertility, history of prior prolapse surgery in other compartments, patient preference, as well as the skill of the surgeon.  Do we need to re-evaluate our pre-treatment investigations in patients with prolapse? Is sphincter physiology really valid? What does pudendal nerve conduction really tell us? Should urodynamics be part of anorectal investigation? Should all patients with pelvic floor dysfunction of any kind undergo proctography? Which are the important ligaments for each disorder?


A prospective randomized clinical trial with long-term follow up is needed to further evaluate and compare the outcomes of laparoscopic hysteropexy, sacrocolpopexy and ventral mesh rectopexy in terms of functional outcome, symptomatic and anatomical cure



















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