Surgical approach to rectal procidentia (rectal prolapse)

INTRODUCTION — Rectal procidentia (rectal prolapse) is a disabling condition that mostly affects older adults, particularly women [1-4]. Surgical repair is the treatment of choice for operative candidates who have a full-thickness rectal procidentia. Multiple procedures exist for the repair of rectal procidentia; however, there is no consensus as to which procedure is most effective in regard to recurrence rate, bowel function, and risk [4-13].

Concomitant pelvic organ prolapse can be present in up to one-third of women who present with rectal prolapse. In patients who have a combined rectal/pelvic organ prolapse, an evaluation by a multidisciplinary team (ie, surgeon, gynecologist, urologist) for a combined surgical repair procedure may be required, depending upon the symptoms and patient risk profile.

This topic will discuss various surgical approaches to treating rectal procidentia. The clinical manifestations, diagnostic evaluation, and medical management of rectal procidentia are reviewed separately. (See "Overview of rectal procidentia (rectal prolapse)".)

The repair of other forms of pelvic organ prolapse (eg, rectocele, enterocele, or cystocele) in women is discussed in separate topics:

●(See "Pelvic organ prolapse in women: Choosing a primary surgical procedure".)

●(See "Pelvic organ prolapse in women: Obliterative procedures (including colpocleisis)".)

●(See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment".)

SELECTING A SURGICAL PROCEDURE — Surgery is the mainstay for the treatment of rectal procidentia and can be performed through the abdomen or the perineum [14]. The transabdominal approach is preferred and can be performed with an open or minimally invasive approach. The five most commonly performed procedures for full-thickness rectal procidentia are:

●Transabdominal (anterior) rectopexy with concomitant sigmoid resection

●Transabdominal (anterior) rectopexy without concomitant sigmoid resection

●Ventral mesh rectopexy

●Perineal rectosigmoidectomy (Altemeier procedure)

●Perineal mucosal stripping and muscular plication for rectal procidentia (Delorme procedure)

The best surgical approach for a given patient is determined by age, physical condition, and baseline bowel function (constipation or incontinence), as well as the surgeon's experience and preference (algorithm 1). Patients' physical conditions can be assessed using the American Society of Anesthesiologists (ASA) physical status scale (table 1) or other standard instruments. It is critical for the surgeon to inform the patient about the potential for complications with each approach.

Candidates for abdominal surgery — Patients who are candidates (physically fit) for an abdominal procedure should have an abdominal rather than a perineal repair. This is because recurrence rates after an abdominal repair are generally lower than after a perineal repair (table 2). (See 'Recurrence' below.)

For patients undergoing an abdominal repair, rectopexy (fixation) is superior to no rectopexy (ie, mobilization alone). In a randomized trial, patients who did not undergo a rectopexy had a higher recurrence rate than patients who underwent a rectopexy (8.6 versus 1.5 percent, odds ratio 6.32, 95% CI 1.36-29.47) [4,7]. The technique of rectopexy (suture versus mesh) is determined by surgeon preference as one technique has not been shown to be superior to others [4]. (See 'Rectopexy' below.)

For patients who have preexisting constipation, a sigmoid resection can be performed with rectopexy. Sigmoid resection has been shown to reduce constipation in those who report this symptom preoperatively. Preexisting constipation is elicited by obtaining a thorough patient history, including the frequency of bowel movements and/or other symptoms that may be suggestive of obstructive defecation. Patients without baseline constipation do not benefit from rectopexy with sigmoid resection, and thus, it should not be performed even if the sigmoid colon is redundant.

Abdominal procedures for rectal procidentia can be performed with open or minimally invasive techniques [15]. Although minimally invasive rectal procidentia repair is safe and effective, it has not been shown to be superior to open surgery in patient-centered outcomes such as recurrence or postoperative bowel function. Thus, the operative approach should be determined by the surgeon; minimally invasive surgery is an option when the requisite expertise and equipment are available. (See 'Abdominal procedures' below.)

Patients who are not candidates for abdominal surgery — For patients who are not candidates (physically unfit) for an abdominal procedure, we use one of the perineal procedures to repair their rectal procidentia. In general, the perineal procedures are better tolerated than abdominal procedures because they can be performed without general anesthesia and result in fewer complications and less pain (table 2). (See 'Perineal procedures' below.)

For technical reasons, a perineal mucosal sleeve resection and muscular plication of the rectal procidentia (Delorme procedure) are typically performed for short-segment (1 to 3 cm) rectal prolapse; a perineal rectosigmoidectomy (Altemeier procedure) is performed for rectal procidentias that are more extensive (>3 cm). (See 'Perineal procedures' below.)

SURGICAL PROCEDURES

Abdominal procedures — Proper transabdominal rectal procidentia repair involves rectal mobilization, sigmoid resection (when indicated), and fixation of the rectum to the sacral promontory by mesh or nonabsorbable sutures (rectopexy). The techniques used for rectal mobilization (anterior versus posterior) and rectopexy (suture versus mesh), as well as the surgical approach (open, laparoscopic, or robotic), are not standardized and depend upon the surgeon's preference and expertise [1].

Rectal mobilization — The first step of any abdominal procedure is to mobilize the rectum. The approaches to rectal mobilization include:

●Posterior mobilization – Mobilize the rectum posteriorly from the pelvic floor to the tip of the coccyx, preserving the lateral stalks. The hypogastric nerves are preserved at the level of the sacral promontory (figure 1).

●Anterior mobilization – In women, mobilize the rectum anteriorly to the level of the mid to upper third of the vagina. In men, mobilize the rectum anteriorly for a few centimeters to allow for straightening of the rectum and additional scarring. However, the efficacy of the anterior mobilization to prevent relapse or improve functional outcome is unknown.

●If ventral mesh rectopexy is performed, the anterior mobilization should be to the pelvic floor in the rectovaginal septum.

Although techniques of rectal mobilization differ (posterior, anterior, or a combination of both), anterior mobilization alone has gained popularity over the years due to improved bowel function outcomes. A 2019 randomized trial comparing ventral rectopexy to posterior suture rectopexy has shown that ventral rectopexy with only anterior mobilization had lower rates of bowel dysfunction with a trend toward a lower recurrence rate and is increasingly preferred over traditional rectopexy [16].

Regardless of whether the posterior or anterior rectum is mobilized, the lateral stalks of the rectum should be preserved during dissection because they contain nerves that innervate the rectum (figure 2). Division of the lateral stalks during rectal mobilization may cause worsening or new-onset constipation postoperatively [4]. However, preservation of the lateral stalks may increase the recurrence rate of rectal procidentia [4].

Rectopexy — A rectopexy is performed by affixing the pararectal tissue to the presacral fascia/sacral periosteum in the sacral promontory using nonabsorbable sutures or mesh. As discussed above, rectopexy has been shown to reduce recurrences when compared with nonrectopexy. (See 'Candidates for abdominal surgery' above.)

Rectopexy is used to treat rectal procidentia in patients who do not have a concomitant pelvic floor abnormality. In such patients, it is assumed that prolapse occurs because the rectum is abnormally straightened from the downward forces of defecation, rather than due to pelvic floor weakness or an enlarged peritoneal sac. Patients who have a concomitant pelvic organ prolapse may require additional surgical repair by a gynecologist or urologist. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'General approach to the choice of procedure'.)

Rectopexy can be performed with sutures or mesh. A 2008 Cochrane review found no detectable differences between the methods used for fixation during rectopexy but cautioned that quality of the evidence is low [17]. Newer single-center studies also reported similar efficacies for mesh and suture rectopexies [18].

Suture rectopexy — Following rectal mobilization as detailed above, the general steps of performing a suture rectopexy include:

●Select a point approximately 1 to 4 cm below the sacral promontory for the inferiormost aspect of suture fixation.

●Place two to three nonabsorbable sutures (eg, 0-Ethibond or silk) in the presacral fascia/sacral periosteum approximately 1 cm apart in a horizontal mattress fashion. To avoid accidental ligation of the blood supply, kinking of the bowel, or damage to the underlying nerves, sutures should be placed only on one side of the rectal mesentery.

Mesh rectopexy — Mesh rectopexy requires affixing a piece of mesh to the sacrum with sutures or tacks and affixing the rectum to the mesh with sutures. Depending upon the technique used, the mesh can be placed posterior or anterior to the rectum.

Anterior mesh rectopexy — An anterior mesh rectopexy (modified Ripstein procedure) incorporates an anteriorly based mesh sling for fixation of the rectum to the sacral hollow (figure 3).

Following rectal mobilization as detailed above, the general steps of an anterior mesh rectopexy include [1,19,20]:

●Select a point approximately 1 to 4 cm below the sacral promontory for the inferiormost aspect of mesh fixation.

●Suture a 5 cm wide mesh (eg, Marlex, Teflon, Prolene) to the anterior wall of the rectum.

●Retract the rectum cephalad and posteriorly toward the sacrum to reduce redundancy of the bowel. Suture the mesh in place to the presacral fascia/sacral periosteum of the sacral promontory. Do not completely encircle the rectum with the mesh wrap; the posterior aspect of the rectum should simply rest against the sacrum.

●The original Ripstein procedure was associated with a high complication rate because the mesh completely encircled the rectum anteriorly, causing obstruction or mesh erosion. A modified Ripstein procedure uses posterior fixation of the mesh to the sacrum with attachment of the ends of the mesh to the rectum laterally (figure 4).

Posterior mesh rectopexy — The posterior mesh rectopexy (Wells procedure) is similar to the anterior mesh rectopexy, except that the mesh is secured to the sacrum between the posterior rectum and sacral promontory (figure 5).

Following rectal mobilization as detailed above, the general steps for performing a posterior mesh repair include [10,21-24]:

●Secure the mesh with staples or nonabsorbable sutures to the periosteum of the sacral promontory.

●Retract the rectum cephalad and posteriorly toward the sacral hollow to reduce redundancy of the bowel. Wrap the sling from the posterior to anterior surface of the rectum, and suture the mesh in place to the serosal surface of the rectum. Do not completely encircle the rectum with the mesh wrap; leave an anterior gap of approximately 1 cm.

●Sufficient tension is applied to the mesh sling to prevent a recurrence of the prolapse, but not enough to result in an obstruction.

Ventral mesh rectopexy — In a ventral rectopexy, the rectum is mobilized anteriorly but not posterolaterally [25,26]. Following mobilization, the anterior wall of the rectum is sutured to a mesh that is affixed to the sacral promontory or Cooper's ligament (figure 6). Ventral mesh rectopexy is typically performed without a concomitant sigmoid resection. Both biologic and nonabsorbable meshes have been used [27].

Anterior mobilization of the distal rectum and mesh suspension performed during ventral mesh rectopexy can correct not only rectal procidentia but also rectoceles and internal rectal prolapse (rectal intussusception) and can be combined with vaginal prolapse procedures, such as sacrocolpopexy, in patients with multicompartment pelvic floor defects [28]. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure".)

A ventral mesh rectopexy can be carried out laparoscopically or robotically and has a low rate of postoperative constipation because of its avoidance of posterolateral rectal mobilization [29]. In a meta-analysis of 789 patients in 12 nonrandomized studies of laparoscopic ventral mesh rectopexy, the pooled recurrence rate was 3.4 percent [30]. Complications occurred in 14 to 47 percent of patients. In all 12 studies, the fecal incontinence rate was lower after than before surgery with an overall weighed mean decrease of 45 percent (95% CI 35.6-54.1). Constipation rates were reported by 10 studies, in which 8 showed a decrease after surgery with an overall weighed mean decrease in constipation rate after surgery of 24 percent (95% CI 6.8-40.9). Two studies reported a modest increase in constipation rate after surgery.

In a case-control study of close to 300 laparoscopic ventral mesh rectopexy procedures, the use of absorbable sutures was associated with fewer mesh erosions than nonabsorbable sutures (0 versus 3.3 percent) after a median follow-up of six months [31]. There were four erosions into the rectum and two into the vagina in patients who underwent rectopexy with nonabsorbable sutures.

Sigmoid resection — If the sigmoid colon is redundant in a patient with preexisting constipation and a rectal procidentia, a sigmoid resection is typically performed with the rectopexy (figure 7).

The general steps of a transabdominal rectopexy with concomitant sigmoid resection include:

●The rectum is mobilized as previously described. (See 'Rectal mobilization' above.)

●The distal transection is at the level of the splayed taeniae coli, distal to the transition to the intraperitoneal rectum. The superior rectal artery may be sacrificed or preserved, depending upon the level of transection (figure 8).

●The proximal transection level is identified by selecting the location where there is no tension on the anastomosis and no residual redundant descending/sigmoid colon (figure 7).

●In patients who undergo a sigmoid resection, rectopexy is typically performed after the sigmoid anastomosis for technical reasons; scarring assists in adherence of the rectum and mesorectum to the presacral fascia (figure 9 and figure 10). (See 'Rectopexy' above.)

Transabdominal rectopexy with or without sigmoid resection can be accomplished with open or minimally invasive techniques. Minimally invasive surgery (eg, laparoscopic, laparoscopic assisted, or robotic assisted) has the advantages of reduced postoperative pain, early return of bowel function, and shortened length of hospital stay but the disadvantages of longer operating times, more specialized technical skills and costly equipment, higher rate of intraoperative complications (eg, bowel injury), and selective patient eligibility (eg, lack of extensive intra-abdominal adhesions, tolerance of pneumoperitoneum) [4,32]. Robotic-assisted surgery combines the advantages of laparoscopic surgery (eg, less postoperative pain, faster recovery) with those of open surgery (eg, high-quality three-dimensional vision, restoration of the eye-hand-target axis) but has the disadvantages of high cost, long intraoperative setup times, and long procedure times [33-35].

Perineal procedures — The perineal procedures have the theoretical advantage of sparing the pelvic nerves and do not require an abdominal incision, but the disadvantages of a higher recurrence rate and potential bowel dysfunction from a reduction in the rectal reservoir need to be taken into consideration (table 2) [36]. In general, the perineal procedures are reserved for patients who are not candidates for any abdominal procedures, generally old and frail individuals, or individuals with significant comorbid illnesses [37]. (See 'Selecting a surgical procedure' above.)

Additionally, perineal procedures may be preferred to abdominal procedures to minimize morbidity in the following clinical settings [38]:

●Failed previous transabdominal repair or prior pelvic surgery – To avoid repeat pelvic dissection and potential for injury to adjacent organs, vessels, or nerves.

●Prior pelvic radiation therapy – To avoid potential radiation-related fibrosis.

●Young males – to minimize the risk of erectile dysfunction related to the mobilization of the rectum by dissecting within the mesorectum. There is minimal risk of damage to the hypogastric nerves with the perineal procedures.

The two most commonly used perineal procedures are perineal rectosigmoidectomy (Altemeier procedure) and perineal mucosal stripping and muscle plication for rectal prolapse (Delorme procedure). In a randomized comparison involving 213 patients, the two perineal procedures achieved similar functional outcomes and recurrence rates [39].

Altemeier perineal rectosigmoidectomy — Altemeier perineal rectosigmoidectomy is the most frequently performed perineal procedure in North America (figure 11) [12,40,41]. For technical reasons, it is typically performed for rectal procidentia with a length of ≥3 to 4 cm.

The principle components of this procedure include:

●The redundant rectum is prolapsed through the anal canal using Allis clamps.

●The dentate line is identified, and epinephrine-based solution is injected into the submucosa to aid in hemostasis.

●A full-thickness circumferential incision is performed in the rectum, approximately 1 to 2 cm proximal to the dentate line.

●The dissection continues proximally along the rectum, detaching the rectum from the mesorectum and surrounding ligamentous attachments, typically until the peritoneal cavity is entered.

●After ensuring that there is no longer any redundancy in the rectum, the bowel is transected at the level of the rectosigmoid junction or the sigmoid colon, where there will be no tension on the anastomosis.

●A hand-sewn coloanal anastomosis is performed in a single layer with nonabsorbable sutures.

●A levatorplasty (ie, suture approximation of the levator muscles) is performed anteriorly to lengthen the anal canal and provide additional support.

Delorme procedure — For patients with a rectal procidentia <3 to 4 cm, a perineal rectosigmoidectomy is technically difficult, and instead, the Delorme procedure can be performed [36].

The Delorme procedure, which is more commonly performed in Europe [12], is performed by dissecting within the submucosal layer of the rectum (figure 12) [11,40,42,43]. The principal components of this procedure include:

●The redundant rectum is prolapsed through the anal canal using Allis clamps.

●The dentate line is identified, and epinephrine-based solution is injected into the submucosa to aid in hemostasis.

●The mucosa is incised circumferentially to the submucosal layer at a level of approximately 1 to 2 cm proximal to the dentate line. A sleeve resection of the mucosa is continued proximally until the tube of redundant mucosa is resected.

●The exposed muscularis propria is plicated using a series of interrupted nonabsorbable sutures.

●A hand-sewn anastomosis is performed in a single layer with absorbable sutures between the proximal mucosa at the level of transection and the incision proximal to the dentate line.

Some surgeons perform a postanal repair and levatorplasty with the Delorme procedure. In one trial, this addition improved functional outcomes and decreased recurrences compared with performing a Delorme procedure alone [44]. The technique of levatorplasty is discussed elsewhere. (See "Delayed surgical management of the disrupted anal sphincter", section on 'Surgery'.)

POSTOPERATIVE MANAGEMENT — The typical postoperative course includes early ambulation and initiation of enteral feeding after both perineal and abdominal repairs. Enhanced recovery protocols in colorectal surgery should be utilized to optimize postoperative care. (See "Enhanced recovery after colorectal surgery", section on 'Postoperative strategies'.)

For patients with a history of constipation, an aggressive bowel regimen is maintained for the first one to two weeks following surgery to avoid constipation and excessive straining that may lead to recurrence of rectal procidentia. There can be issues of anorectal spasm, urgency, and tenesmus in the early postoperative period.

Most patients will be able to return to normal activities, including work, in four to six weeks after surgery. Heavy lifting or straining of the abdominal and perineal muscles is to be avoided until the muscles are fully healed in approximately a few months.

SURGICAL OUTCOMES

Mortality and morbidity — In general, abdominal procedures have higher mortality and morbidity rates than perineal procedures due to the requirement for abdominal incision(s) (table 2). Because of that, patients who are not candidates (physically unfit) for an abdominal procedure may be able to tolerate perineal repairs. (See 'Selecting a surgical procedure' above.)

Abdominal procedures — For patients undergoing an abdominal procedure (open or laparoscopic), the mortality rates ranged from 0 to 7 percent and morbidity rates ranged from 0 to 52 percent [7,22,36,43,45-49].

The most common major complications following abdominal repairs include pelvic sepsis, hematomas, fistulas, stenosis, and obstructed defecation. Sigmoid colon resections are associated with anastomotic leaks and, when performed with a mesh repair, slightly higher rates of surgical site infections and fistulas [43]. Rectopexy by sutures alone avoids the complications associated with mesh repair (eg, infections, fistulas, stenosis) but otherwise has comparable morbidity [43,45]. Rates of reoperation and 30-day readmission were similar between open and laparoscopic repairs [46].

Perineal procedures — The perineal procedures generally have fewer operative risks and complications than abdominal procedures. Most series report low mortality (0 to 4 percent) and morbidity rates (typically less than 20 percent). Potential complications after a perineal repair include bleeding, pelvic sepsis, and fecal leakage [36,43,48].

Recurrence — Based upon prospective studies and retrospective reviews, the abdominal procedures generally have lower recurrence rates compared with perineal procedures (table 2) [5,6,22,36,43,45,46,49-52].

Rectopexy is the step of abdominal repair that is credited with reducing recurrences. In a randomized, multicenter trial that included 252 patients with rectal procidentia, patients undergoing a rectal mobilization procedure with rectopexy had a significantly lower five-year recurrence rate compared with patients undergoing rectal mobilization without a rectopexy (1.5 versus 8.6 percent) [7].

Similar recurrence rates can be achieved with suture or mesh rectopexy [43], as well as with open or laparoscopic approaches [43,46]. Risk factors associated with recurrence following ventral rectopexy include use of synthetic mesh (as opposed to biologic mesh) and prolonged pudendal nerve terminal motor latency, as well as technical failures associated with mesh fixation [53].

By contrast, the higher recurrence rate following perineal repairs is attributed to the lack of a rectopexy [43]. (See 'Rectopexy' above.)

Postoperative bowel function — Patients with rectal procidentia may present with symptoms of constipation or fecal incontinence. While it is possible for patients to have preserved "normal" bowel function, the majority of patients present with either constipation or incontinence as a result of rectal prolapse. The incidences vary widely; the same patient may even present with either constipation or fecal incontinence at different time points.

After surgery, symptoms of fecal incontinence generally improve with all procedures; symptoms of constipation generally improve with perineal procedures but may improve or be exacerbated with abdominal procedures [5,22,43,45,46]. (See 'Constipation' below.)

For patients with preexisting problems with bowel function, symptoms may persist after surgery due to either prolonged preoperative anal sphincter trauma or due to the negative effects of long-term constipation on colon motility. While postoperative satisfaction with rectal procidentia repair was rated as excellent or good in 72 to 80 percent of patients, incontinence and persistent constipation were the two most common reasons for dissatisfaction [50]. Before surgery, patients should receive counseling regarding setting realistic expectations for their bowel function postoperatively.

Fecal incontinence — Fecal incontinence generally improves with the repair of rectal procidentia, regardless of which operative procedure (eg, rectopexy, anterior resection) or surgical approach (abdominal or perineal) is chosen:

●Simple suture rectopexy alone improved incontinence in 15 to 82 percent of patients, with most studies demonstrating success rates of over 50 percent [49,52,54,55]. (See 'Suture rectopexy' above.)

●Rectopexy with a mesh sling improves incontinence in 3 to 92 percent, with a mean improvement of 20 to 60 percent of patients [18,21,56]. Incontinence is improved in 15 to 80 percent of patients undergoing an anterior rectopexy (Ripstein repair) [57]. (See 'Mesh rectopexy' above.)

●A sigmoid resection improves incontinence in 11 to 90 percent of patients [9,49,50]. (See 'Sigmoid resection' above.)

●Perineal procedures (ie, Altemeier or Delorme) resulted in a complete resolution of fecal incontinence in 20 to 50 percent of patients, with varying improvements identified in 20 to 90 percent of patients and worsening of symptoms in 22 percent [43,48,50,58,59]. (See 'Perineal procedures' above.)

Constipation — Preexisting constipation generally improves with the repair of rectal procidentia, the magnitude of which depends upon the procedures. New-onset or worsening constipation may develop in some patients after abdominal procedures but rarely after perineal procedures. Both preservation of the lateral stalks during rectal mobilization and adding a sigmoid resection to transabdominal rectopexy seem to reduce the rate of constipation postoperatively.

Abdominal procedures — Most series reported improvement in constipation for patients undergoing abdominal procedures (range 14 to 83 percent) [5,7,8,22,49], but new-onset or worsening constipation occurred in 14 to 50 percent of patients after abdominal procedures [21,22,54,56]. Possible etiologies include neuropathy from division of the lateral stalks or redundant sigmoid colon kinking at the proximal rectum resulting in increased outlet resistance [13].

Limiting mobilization to the anterior rectal wall as is done for ventral mesh rectopexy has also been shown to have excellent results with improvement in bowel function without significant rates of de novo constipation or fecal incontinence [60,61]. (See 'Ventral mesh rectopexy' above.)

Preservation of the lateral stalks during rectal mobilization may prevent worsening constipation postoperatively. In one small trial, 4 out of 21 patients (19 percent) developed delayed colonic transit after rectopexy with preservation of the lateral ligaments compared with 10 out of 23 patients (43 percent) after division of the ligaments (odds ratio 0.32, 95% CI 0.08-1.23) [13]. A similar conclusion was reached by two earlier small trials [10,62]. (See 'Abdominal procedures' above.)

Adding a sigmoid resection to the rectopexy seems to improve constipation in patients who have this symptom preoperatively. In a 2015 Cochrane review of three randomized trials, postoperative constipation in 82 randomized patients was significantly less common in patients who had a sigmoid resection with rectopexy compared with those who had rectopexy alone (12 versus 48 percent, odds ratio 0.14, 95% CI 0.04-0.44) [4]. (See 'Sigmoid resection' above.)

Perineal procedures — Patients undergoing perineal repair procedures have also shown an improvement in constipation following surgery (range 13 to 100 percent) [36,63-65], as well as a very low rate of new-onset constipation (1 to 15 percent) [38]. The low rate of new-onset constipation may be a result of loss of capacitance of the rectum and relief of the intussusception and functional obstruction following rectal resection.

The low rate of new-onset constipation may be a result of loss of capacitance of the rectum and relief of the intussusception and functional obstruction following rectal resection.

MANAGEMENT OF RECURRENT RECTAL PROCIDENTIA — Most recurrent rectal procidentias present within three years after surgery, with a mean time to recurrence ranging from 7 to 33 months [66-69]. Recurrence rates after an abdominal repair were approximately three times higher in men than women, possibly due to the technical challenges of performing a rectopexy in a narrow male pelvis [43].

Management of recurrent rectal prolapse is guided by the type of recurrence (mucosal prolapse versus full-thickness prolapse), the severity of symptoms, the patient's operative risk profile, current pelvic floor function with particular attention to obstructive defection and pelvic floor dyssynergia, and the surgical approach of the failed repair.

For patients with asymptomatic or minimally symptomatic rectal prolapse, initial medical management, including observation, pelvic floor retraining/biofeedback, and bowel regimen, may suffice. (See "Overview of rectal procidentia (rectal prolapse)", section on 'Medical management'.)

Symptomatic patients with recurrent mucosal prolapse can be treated with longitudinal multiple rubber band ligation of the prolapsing mucosa. In one study, 14 of 17 patients experienced complete remission of symptoms at a median follow-up of 12 months after double or triple ligation of mucosa on the anterior rectal wall [70].

Symptomatic patients with full-thickness rectal procidentia require a reoperative repair with the surgical options as for primary rectal procidentia [66]. However, one should consider the vascular supply of the rectum in the setting of a previous resection as a second operation with any further resection (eg, using a perineal approach after an initial abdominal approach with bowel resection) could result in devascularization of the intervening and remaining segment of rectum.

There are no prospective data to determine the optimal surgical management for recurrent rectal procidentia. In a meta-analysis of nonrandomized studies of recurrent rectal prolapse repair, 158 and 144 patients underwent abdominal and perineal repairs, respectively [71]. The morbidity, mortality, and recurrence rates associated with abdominal and perineal repairs were 0 to 32, 4, and 0 to 15 percent and 0 to 17, 0, and 0 to 50 percent, respectively. These rates varied significantly because most of the studies were heterogeneous, of low quality, and involved small numbers of patients.

Multiple retrospective studies also showed that, although reoperation can be safely performed with comparable complication rates to a primary repair, the re-recurrence rates were generally expected to be higher [8,58,63,66-69].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Rectal prolapse".)

SUMMARY AND RECOMMENDATIONS

●Rectal procidentia (prolapse) – Rectal procidentia (prolapse) is a disabling condition that typically affects older adults, particularly women. Surgical management is the treatment of choice for patients who are operative candidates.

●Transabdominal approach – There is no consensus on the optimal procedure or approach for repair of rectal procidentia. We suggest an abdominal approach rather than a perineal approach for patients with rectal prolapse who are candidates for an abdominal procedure (Grade 2C). Recurrence rates are generally lower for patients undergoing an abdominal procedure compared with perineal procedures (table 2). (See 'Candidates for abdominal surgery' above.)

•The rectum may be mobilized anteriorly, posteriorly, or both; the lateral stalks are not dissected, to preserve nerves that innervate the rectum. Anterior mobilization alone has gained popularity due to improved bowel function outcomes. Anterior mobilization for ventral mesh rectopexy should be performed to the pelvic floor in the rectovaginal septum. (See 'Rectal mobilization' above.)

•The use of a suture or mesh rectopexy is dependent upon the surgeon's preference. For most patients with rectal procidentia without constipation, we perform a suture rectopexy without a sigmoid colon resection. Mesh repairs have the potential for more complications, including infection, fistulas, or stenosis. However, ventral mesh rectopexy is gaining popularity due to the reduced complications of bowel dysfunction. (See 'Rectopexy' above.)

•For patients with constipation and rectal procidentia, we suggest that a sigmoid resection be included with the rectopexy to improve postoperative bowel function (Grade 2C). (See 'Sigmoid resection' above.)

•Abdominal procedures for repair of rectal procidentia can be performed with open, laparoscopic, or robotic-assisted approaches. Minimally invasive surgery should only be performed when the requisite expertise and equipment are available. (See 'Abdominal procedures' above.)

●Perineal approach – For patients with comorbid illnesses that would preclude an abdominal repair, those with a history of pelvic surgery or radiation, and young males who are concerned about erectile dysfunction, we perform a perineal procedure for repair of rectal procidentia. (See 'Perineal procedures' above.)

•For patients with a rectal prolapse shorter than 3 to 4 cm, we perform a Delorme procedure based on the technical challenges of performing a perineal rectosigmoidectomy. (See 'Delorme procedure' above.)

•For patients with a rectal prolapse longer than 3 to 4 cm, we perform a perineal rectosigmoidectomy (Altemeier procedure). (See 'Altemeier perineal rectosigmoidectomy' above.)

●Recurrent rectal procidentia – Recurrent rectal procidentia can be repaired by the same procedures as for primary rectal procidentia. Although reoperative repairs can be performed safely with comparable complication rates to those of primary repairs, the re-recurrence rates are generally expected to be higher. The surgeon should consider the vascular supply to the rectum if any bowel resection was performed with the previous rectopexy. (See 'Management of recurrent rectal procidentia' above.)