Clinical Scorecard: Coloproctology Approaches: Addressing the Underutilization of Rectopexy in Treating High-Grade Internal and External Rectal Prolapse

At a Glance

Key Highlights

• Ventral mesh rectopexy (VMR) is the preferred abdominal procedure for full-thickness ERP and selected high-grade IRP patients.
• Resection rectopexy remains a valid option, especially in patients unwilling to undergo mesh surgery or with specific clinical phenotypes.
• Pathophysiology involves mechanical obstruction from rectal wall infolding, internal anal sphincter stretching, and utero-sacral ligament laxity contributing to symptomatology.

Guideline-Based Recommendations

Diagnosis

• Use Oxford grading system to classify internal rectal prolapse severity.
• Assess symptoms of faecal incontinence and obstructed defaecation syndrome.
• Consider imaging such as ultrasound and MR defecography to evaluate anatomy and sphincter status.

Management

• Reserve VMR for full-thickness ERP and selected symptomatic high-grade IRP patients failing conservative treatment.
• Consider resection rectopexy selectively, especially in patients contraindicated for mesh or with redundant sigmoid colon and obstructed defaecation.
• Avoid internal Delorme’s procedure in high-grade IRP due to removal of mucosal mechanoreceptors in functional disorders.

Monitoring & Follow-up

• Monitor functional outcomes post-surgery including continence and defaecation symptoms.
• Be vigilant for mesh-related complications and patient concerns regarding pelvic mesh.
• Evaluate anatomical correction and correlate with symptom improvement.

Risks

• Higher complication rates reported with laparoscopic resection rectopexy compared to VMR.
• Potential mesh-related complications leading to patient reluctance for VMR.
• Risk of litigation and technical errors influencing surgical choice.

Patient & Prescribing Data

Patients with full-thickness external rectal prolapse and symptomatic high-grade internal rectal prolapse unresponsive to non-operative therapy.

VMR is favored for anatomical correction with lower complication rates; resection rectopexy is an alternative in mesh-averse patients or specific clinical phenotypes.

Clinical Best Practices

• Select surgical approach based on patient symptoms, prolapse grade, and patient preference regarding mesh use.
• Consider pathophysiological mechanisms including utero-sacral ligament integrity and colonic motility in surgical planning.
• Use laparoscopic techniques to optimize functional outcomes and minimize complications.
• Educate patients on risks and benefits of mesh versus non-mesh procedures.
• Correlate anatomical correction with functional improvement and adjust management accordingly.

References

• Survey of colorectal surgeons on rectopexy preferences
• Consensus statement on ventral mesh rectopexy
• Oxford grading system for internal rectal prolapse
• Description of resection rectopexy (Frykman–Goldberg procedure)
• Retrospective study comparing laparoscopic resection rectopexy and VMR
• Editorial favoring ventral mesh rectopexy
• NICE guidance restricting VMR use for internal rectal prolapse
• Integral theory and role of utero-sacral ligaments
• Pathophysiology of obstructed defaecation syndrome
• Mechanisms of symptoms in high-grade internal rectal prolapse