Coloproctology Approaches: Underutilization of Rectopexy in High-Grade Rectal Prolapse

Overview

Ventral mesh rectopexy (VMR) is widely preferred for treating full-thickness external rectal prolapse (ERP) and selected high-grade internal rectal prolapse (IRP). However, concerns about mesh complications and regulatory restrictions have led to increased interest in resection rectopexy, which may be underutilized despite evidence supporting its role in specific patient phenotypes.

Background

Full-thickness external rectal prolapse (ERP) and high-grade internal rectal prolapse (IRP) cause significant symptoms including obstructed defaecation syndrome (ODS) and faecal incontinence. VMR is currently the favored abdominal surgical approach, supported by consensus and surgeon surveys. Nonetheless, the role of rectopexy in IRP remains controversial, with some surgeons reserving surgery until ERP develops due to concerns about mesh complications. Resection rectopexy, combining sigmoid resection and rectal fixation, has shown efficacy but is less commonly performed.

Data Highlights

A recent survey indicated approximately 5% of surgeons would perform resection rectopexy for a typical ERP patient, reflecting its limited use despite evidence of effectiveness. Comparative studies show both laparoscopic resection rectopexy (LRR) and VMR yield favorable functional outcomes in ERP, though LRR has a higher complication rate. National guidelines such as NICE have restricted VMR use for IRP due to mesh-related safety concerns, influencing surgical practice patterns.

Key Findings

• VMR is the preferred abdominal procedure for full-thickness ERP and selected high-grade IRP patients with symptoms refractory to conservative therapy.
• Resection rectopexy combines sigmoid colon resection with posterior rectal mobilisation and suture rectopexy, potentially addressing colonic motility and redundant sigmoid contributing to symptoms.
• Concerns about mesh complications and regulatory restrictions have increased the use of resection rectopexy in some centers.
• Pathophysiology of IRP involves circular infolding causing outlet obstruction and sphincter stretching leading to incontinence, mechanisms potentially improved by rectopexy.
• Damage or laxity of utero-sacral ligaments contributes to IRP development and associated symptoms, especially post-hysterectomy.
• Progressive prolapse likely begins as mucosal prolapse with tissue degeneration and mechanical trauma, emphasizing the importance of early intervention.

Clinical Implications

Clinicians should consider resection rectopexy as a viable surgical option for patients with full-thickness ERP and symptomatic high-grade IRP, especially when mesh use is contraindicated or declined. Understanding the underlying pelvic support defects and colonic motility issues can guide patient selection and optimize outcomes. Conservative management remains first-line, but timely surgical intervention tailored to clinical phenotype may prevent progression and improve quality of life.

Conclusion

While VMR remains the standard for many patients with rectal prolapse, resection rectopexy offers an important alternative, particularly in the context of mesh-related concerns. A nuanced approach considering individual patient anatomy, symptomatology, and preferences is essential to optimize treatment outcomes in high-grade internal and external rectal prolapse.

References

1. Survey of colorectal surgeons on rectopexy preferences [1]
2. Consensus statement on ventral mesh rectopexy [2]
3. Observations on internal rectal prolapse in normal subjects [3]
4. Description of resection rectopexy (Frykman–Goldberg procedure) [4]
5. Denervation concerns in posterior rectal mobilisation [5]
6. Comparative study of laparoscopic resection rectopexy vs VMR [6]
7. Editorial favoring VMR over sigmoid resection [7]
8. Publications supporting resection rectopexy efficacy [8,9,10,11]
9. Mechanisms of obstructed defaecation syndrome in IRP [12]
10. Studies on internal anal sphincter changes and incontinence [13,14,15]
11. Improvement of symptoms with laparoscopic ventral mesh rectopexy [16,17]
12. Limitations of anatomical correction in symptom relief [18]
13. Integral theory and role of utero-sacral ligaments [19]
14. Impact of hysterectomy on utero-sacral ligament integrity [20]
15. Pathophysiology of progressive rectal prolapse [21,22]