Version July 2025
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. 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) in adults".)
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. 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".)
Rectal procidentia in children is discussed elsewhere. (See "Rectal prolapse in children".)
SELECTING A SURGICAL PROCEDURE —
Surgery is the mainstay for the treatment of full-thickness rectal procidentia and can be performed through the abdomen or the perineum [5]. 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 [4,6-14].
The best surgical approach for a given patient is determined by age, physical condition, and baseline bowel function (constipation or incontinence), as well as any prior surgery and 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 — Traditionally, patients who are candidates (physically fit) for an abdominal procedure should have an abdominal rather than a perineal repair. This is based on historical data that associated abdominal repairs with fewer recurrences and better functional results but greater morbidities than perineal repairs [15,16] (table 2).
However, no significant differences between abdominal and perineal repairs were seen in two newer randomized trials, which noted substantial improvements from baseline in quality of life following all procedures [17,18]. A convincing advantage for transabdominal repair was not reported by a 2015 Cochrane meta-analysis either [4]. Although a 2023 networked meta-analysis reported a lower recurrence rate after posterior mesh rectopexy compared with other procedures (including both perineal procedures), it included a pediatric trial that may have skewed the analysis [19]. Further, there is wide variability in the surgical approach simply based on global location and surgeon preference [20].
Thus, the 2017 American Society of Colon and Rectal Surgeons (ASCRS) guidelines only gave a weak recommendation for transabdominal repair in suitable candidates and called for individualization based on comorbidities and existing bowel functions for all patients [5].
The three most commonly performed transabdominal procedures for full-thickness rectal procidentia are:
●Posterior rectopexy (with sutures or mesh)
●Ventral rectopexy (usually with mesh)
●Resectional rectopexy (with sutures)
The choice of a transabdominal procedure is influenced by the patient's baseline bowel function, as some procedures can worsen existing or induce de novo constipation, and others, fecal incontinence. An experienced surgeon can tailor the procedure to each patient to optimize postoperative bowel function (algorithm 2). (See 'Postoperative bowel function' below.)
Patients with baseline constipation — Patients with chronic, severe constipation and rectal prolapse should avoid posterior rectopexy, as half would develop worsening constipation and 15 percent de novo constipation after that procedure [21]. The etiology is thought to be related to the posterior mobilization of the rectum. A prior history of constipation can be elicited by asking the patient about the frequency of bowel movements and/or other symptoms that may be suggestive of obstructive defecation.
Instead, patients with baseline constipation should be offered resection rectopexy, ventral rectopexy, or a perineal procedure, all of which improve constipation. Furthermore, ventral rectopexy is required when the patient has had a previous perineal rectosigmoidectomy (Altemeier procedure) or concomitant anterior compartment prolapse (eg, enterocele) for anatomical reasons. Although perineal rectosigmoidectomy can be repeated in patients who develop recurrence, a resectional rectopexy should not be performed after a perineal rectosigmoidectomy because of the risk of devascularizing the intervening segment. (See 'Resection rectopexy' below.)
Patients with baseline fecal incontinence — Patients with baseline fecal incontinence should avoid resection rectopexy, which tends to worsen incontinence. Posterior rectopexy or ventral rectopexy is the procedure of choice for such patients. Additionally, the lateral stalks should be divided during rectal mobilization in such patients as it has been shown to benefit incontinence [22]. (See 'Posterior rectopexy' below and 'Ventral mesh rectopexy' below.)
Patients with baseline normal bowel function — Patients with rectal prolapse and normal bowel function do not require a resection rectopexy. Whether they undergo posterior or ventral rectopexy is a matter of surgeon preference. Again, ventral rectopexy is preferred when there is a concomitant anterior compartment prolapse. (See 'Posterior rectopexy' below and 'Ventral mesh rectopexy' 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, fixation of the rectum to the sacral promontory by mesh or nonabsorbable sutures (rectopexy), and sigmoid resection when indicated. 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 [22].
That said, three transabdominal procedures have emerged as the most commonly performed for full-thickness rectal prolapse (table 3). Five older trials (prior to 2000) reported that the rectopexy method did not influence outcomes [4]. Similarly, a 2016 trial that compared laparoscopic posterior suture rectopexy with laparoscopic ventral mesh rectopexy reported no difference in recurrences or functional outcomes [23]. A 2024 systematic review and meta-analysis reported no differences in short- or long-term outcomes between mesh rectopexy and resection rectopexy [24].
Posterior rectopexy
Rectal mobilization — In preparation for a posterior rectopexy, the rectum can be mobilized posteriorly or both posteriorly and anteriorly:
●Posterior mobilization – Mobilize the rectum posteriorly from the sacral promontory to the levators, in the plane between mesorectum and presacral fascia. 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.
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, but preservation of the lateral stalks may increase the recurrence rate of rectal procidentia [25-27]. The lateral stalks are intentionally divided when treating rectal prolapse in patients with pre-existing fecal incontinence [22]. (See 'Patients with baseline fecal incontinence' above.)
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.
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'.)
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) [8].
Rectopexy can be performed with sutures or mesh. A 2015 Cochrane review of five trials found no detectable differences between the methods used for fixation during rectopexy but cautioned that quality of the evidence is low [4]. A subsequent trial comparing laparoscopic posterior suture rectopexy with laparoscopic ventral mesh rectopexy did not find any difference in recurrence rate or functional outcomes either [23].
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.
Anterior mesh rectopexy (modified Ripstein procedure) — 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 [1,28,29]:
●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 (Wells procedure) — 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 [11,30-33]:
●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 [34,35]. If ventral mesh rectopexy is performed, the anterior mobilization should be to the perineal body.
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). Both biologic and nonabsorbable meshes have been used [36]. Ventral mesh rectopexy is typically performed without a concomitant sigmoid resection.
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 [37]. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure".)
A ventral mesh rectopexy has a low rate of postoperative constipation because of its avoidance of posterolateral rectal mobilization [29,38,39]. As a result, some authors have favored ventral mesh rectopexy for patients with rectal prolapse and chronic severe constipation and/or concomitant anterior compartment prolapse. (See 'Patients with baseline constipation' above.)
Some studies also suggest ventral rectopexy may improve associated fecal incontinence in significant number of patients [35,40]. Fecal incontinence is very common among older and frail patients and loss of rectal reservoir can significantly worsen symptoms of fecal incontinence and urgency. There has been an increasing trend towards offering laparoscopic ventral rectopexy in older patients who may be candidate for an abdominal procedure. (See 'Patients with baseline fecal incontinence' above.)
Resection rectopexy — For patients who have pre-existing constipation, another option is to perform a sigmoid resection with rectopexy. This is referred to as resection rectopexy (figure 7).
Sigmoid resection has been shown to reduce constipation in those who report this symptom preoperatively [11,17,41]. 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.
The general steps of a transabdominal rectopexy with concomitant sigmoid resection include:
●The rectum is mobilized as previously described. (See 'Posterior rectopexy' 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, a suture 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). Resection alone does not ensure long-lasting rectal prolapse repair [42,43]. (See 'Suture rectopexy' above.)
Sigmoid resection is contraindicated after a failed perineal rectosigmoidectomy (Altemeier procedure) due to the risk of devascularizing the intervening bowel segment. Patients with existing fecal incontinence or markedly weakened anal sphincter tone are not candidates for resection rectopexy due to poor functional outcomes. (See 'Patients with baseline fecal incontinence' above.)
Open versus minimally invasive surgery — Abdominal procedures for rectal procidentia can be performed with open or minimally invasive techniques [44]. 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, and selective patient eligibility (eg, lack of extensive intra-abdominal adhesions, tolerance of pneumoperitoneum) [4,45]. 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 [46,47].
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.
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) [15].
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 [48]. (See 'Selecting a surgical procedure' above.)
Additionally, perineal procedures may be preferred to abdominal procedures to minimize morbidity in the following clinical settings [49]:
●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. However, the morbidity of removing the rectal reservoir outweighs the benefits of minimizing an already small risk of nerve injury, especially with the use of robotic approaches, although large-scale data remain lacking.
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 two randomized trials, the two perineal procedures achieved similar functional outcomes and recurrence rates [17,50].
Altemeier perineal rectosigmoidectomy — Altemeier perineal rectosigmoidectomy is the most frequently performed perineal procedure in North America (figure 11) [13,51,52]. For technical reasons, it is typically performed for rectal procidentia with a length of ≥3 to 4 cm.
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.
●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 [15].
The Delorme procedure, which is more commonly performed in Europe [13], is performed by dissecting within the submucosal layer of the rectum (figure 12) [12,51,53,54]. 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 [55]. 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.
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 [8,15,31,45,54,56-59].
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 [54]. Rectopexy by sutures alone avoids the complications associated with mesh repair (eg, infections, fistulas, stenosis) but otherwise has comparable morbidity [54,56]. Rates of reoperation and 30-day readmission were similar between open and laparoscopic repairs [45]. Rates of mesh erosion are very low, especially with minimally invasive procedures [60].
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 [15,54,58].
Recurrences — Based upon prospective studies and retrospective reviews, the abdominal procedures generally have lower recurrence rates compared with perineal procedures (table 2) [6,7,15,31,45,54,56,59,61-63]. (See 'Candidates for abdominal surgery' above.)
Rectopexy is the step of abdominal repair that is credited with reducing recurrences [8]. Similar recurrence rates can be achieved with suture or mesh rectopexy [54], as well as with open or laparoscopic approaches [45,54]. By contrast, the higher recurrence rate following perineal repairs is attributed to the lack of a rectopexy [54]. (See 'Patients who are not candidates for abdominal surgery' 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 some procedures but may improve or be exacerbated with other procedures [6,31,45,54,56]. (See 'Candidates for abdominal surgery' above.)
For patients with pre-existing 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 [61]. Before surgery, patients should receive counseling regarding setting realistic expectations for their bowel function postoperatively.
In particular, 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 [64-67]. (See 'Ventral mesh rectopexy' above.)
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 [68-71]. 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 [54].
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) in adults", 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 [72].
Symptomatic patients with full-thickness rectal procidentia require a reoperative repair with the surgical options as for primary rectal procidentia [68]. 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 [73]. 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 [9,68-71,74,75].
MALE PATIENTS —
Rectal procidentia is predominantly seen in older female patients. In a database study of 12,000 patients who underwent rectal prolapse repair, only 8 percent were males. Compared with females, male patients are younger (56 versus 71 years) and less likely to be White [76]. In that study, male patients were more likely to undergo transabdominal repair than female patients, but the outcomes were not different. Multiple small retrospective studies reported that both transabdominal and perineal rectal prolapse repair are as safe and effective for males as for females [77,78].
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. (See 'Introduction' above and "Overview of rectal procidentia (rectal prolapse) in adults".)
●Selecting a surgical procedure – 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 (Grade 2C) for patients with rectal prolapse who are candidates for an abdominal procedure (algorithm 1). Recurrence rates are generally lower for patients undergoing an abdominal procedure compared with perineal procedures (table 2).
The choice of a transabdominal procedure is influenced by the patient's baseline bowel function (algorithm 2) (see 'Candidates for abdominal surgery' above):
•For patients with baseline constipation, we suggest either ventral mesh rectopexy or resection rectopexy rather than posterior rectopexy (Grade 2C). Posterior rectopexy can exacerbate pre-existing constipation or induce de novo constipation. Those who have either a concomitant anterior compartment prolapse or prior failed perineal rectosigmoidectomy should undergo ventral mesh rectopexy.
•For patients with baseline fecal incontinence, we suggest either posterior rectopexy or ventral mesh rectopexy rather than resection rectopexy (Grade 2C). Resection rectopexy could exacerbate fecal incontinence.
•Patients with normal baseline function may choose from ventral mesh rectopexy and posterior rectopexy. Resection rectopexy is only performed in patients with pre-existing constipation.
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 the repair of rectal procidentia (algorithm 1). (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.)
●Abdominal procedures – Proper transabdominal rectal procidentia repair involves rectal mobilization, fixation of the rectum to the sacral promontory by mesh or nonabsorbable sutures (rectopexy), and sigmoid resection when indicated (table 3). (See 'Abdominal procedures' above.)
•Rectal mobilization – 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. (See 'Rectal mobilization' above.)
•Rectopexy – A rectopexy is to affix the pararectal tissue to the presacral fascia/sacral periosteum in the sacral promontory using nonabsorbable sutures or mesh. For all transabdominal rectal prolapse repairs, performing a rectopexy is superior to mobilization alone. The choice between a suture and mesh rectopexy, and that between a posterior and ventral rectopexy, is dependent upon the surgeon's preference, as the outcomes are not different. (See 'Rectopexy' above.)
•Sigmoid resection – For patients with constipation and rectal procidentia, one option is to perform a sigmoid resection with the rectopexy (resection rectopexy). Sigmoid resection has been shown to improve postoperative bowel function in such patients. (See 'Resection rectopexy' above.)
•Open versus minimally invasive – 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.)
●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 'Recurrent rectal procidentia' above.)
