Recurrent Rectal Prolapse

Abstract

Surgical correction is the primary treatment of external rectal prolapse. The likelihood that rectal prolapse will return is reported to be between 5 and 40% depending on a combination of technical and patient factors. In this review, we will present patient features as well as technical factors during index repair that have been shown to place patients at higher risk of recurrence. Subsequently, we will present the available data regarding the management of recurrent rectal prolapse and our approach in the care of patients with recurrence.

Rectal prolapse is a rare condition (affects ∼0.5% of the general population) that can occur in both men and women of all ages but is most frequently seen in parous women in the seventh to eighth decade of life. Women above the age of 50 are six times more likely to prolapse compared with men. ¹ In rectal prolapse, the hypothesis is that the anterior wall of the rectum initially intussuscepts and then this progresses to a complete circular infolding that invaginates into the lumen and descends toward the anus. Common causes are weakening of the fascia and pelvic floor muscle, with an enlarged opening on the pelvic floor fascia, which has been described as a pelvic floor hernia. ² Other causal considerations for rectal prolapse are an abnormally redundant colon, or prolapse of the small intestine and other pelvic floor organs between the rectum and uterus. Over time, as the rectum repetitively prolapses through the anal sphincter, it leads to loss of pelvic floor support and suspension. The sphincter muscles stretch and thicken, and pelvic muscle neuropathy develops which impacts bowel control and evacuation. Although rectal prolapse is benign and rarely life-threatening, it frequently becomes severe enough to affect the patient's quality of life. Some of the most common symptoms that patients with rectal prolapse describe include pain, urgency, fecal soiling/mucus seepage, and obstructed defecation. ^{3 4}

Surgical treatments have been shown to provide good short-term relief of symptoms; however, if the prolapse returns bowel function usually deteriorates. Unfortunately, rectal prolapse surgery is associated with variable rates of recurrence with some studies reporting recurrence rates as high as 30 to 50%. ⁵ Prolapse recurrence depends on patient features (tissue quality and straining behaviors), procedure type (perineal vs. abdominal), surgical technique, and features of the index prolapse (e.g., size). The specific cause of recurrence after rectal prolapse surgery is difficult to identify and is frequently multifactorial.

Risk Factors for Recurrent Prolapse

Patient Features

In female patients, increased parity and vaginal deliveries have been recognized as potential risk factors for the development of rectal prolapse. ⁶ In addition to that, elderly patients (age >80) have also been shown to have a higher recurrence rate. ⁷ Regarding male patients, they comprise the minority of rectal prolapse patients, so information is limited. However, it has been hypothesized that the different pelvic anatomy with a more narrow pelvis may be putting male patients at higher risk for recurrence of rectal prolapse. ⁷

Connective tissue disorders have also been identified as risk factors for the development of rectal prolapse. In patients with connective tissue disorders, the incidence of rectal prolapse is usually at a younger age. One of the most common inherited disorders is Ehlers–Danlos syndrome (EDS). In the EDS population, the prolapse is thought to be secondary to defective collagen formation with decreased tensile strength. ⁸ In addition to that, patients with systemic sclerosis have gastrointestinal involvement in up to 90% of cases and anorectal involvement in 50 to 70% of cases with pathogenesis of rectal prolapse closely associated with disordered collagen synthesis and muscle dystrophy. In patients with systemic sclerosis, there may also be a component of neuropathic damage given the observed higher anal sensory thresholds as well as the absent rectal inhibition reflex in this group. These neuromuscular changes with resulting dysmotility put these patients at a higher risk of recurrence as well. However, studies in the literature regarding the care of rectal prolapse in patients with connective tissue disorders are sparse and we do not have data to support one surgical approach over another neither in the initial care of these patients nor during the management of a recurrence. ⁹ Singh et al compared the outcomes of rectal prolapse with concurrent benign joint hypermobility syndrome (BJHS) to patients with rectal prolapse without BJHS and showed that the rates of reintervention were significantly higher in the BJHS group (31% vs. 8%, p -value = 0.03). ¹⁰

Obesity has also been identified as a risk factor for pelvic organ prolapse and increased recurrence risk after prolapse repair. ¹¹ The mechanism through which obesity has been hypothesized to lead to higher rates of rectal prolapse recurrence is through chronically increased intra-abdominal pressure and pelvic floor laxity. Although weight loss is not required prior to prolapse repair surgery, encouraging obese patients to lose weight preoperatively can help with the technical features of the operation and can also decrease overall perioperative morbidity. Repetitive heavy lifting and chronic constipation with poor bowel and toilet hygiene and straining also increase the risk of rectal prolapse. ⁶

Data in the literature suggest that there may be an association between preoperative diagnosis of psychiatric diagnosis and prolapse recurrence. A study conducted by Marceau et al found that in a cohort of young patients (<50 years old) that underwent rectal prolapse repair both patients that had a recurrence during follow-up were suffering from chronic severe psychiatric illness. This was hypothesized to be the result of constipation, which is a common side effect of psychiatric medication. ¹² These results, although not conclusively proving the association between psychiatric disorders/medication and rectal prolapse, can be used as adjuncts during preoperative discussions with patients. Chronic smoking as well as resulting chronic obstructive pulmonary disease have also been associated with higher rates of rectal prolapse. ⁶

Lastly, the presence of unilateral or bilateral prolonged pudendal nerve terminal motor latency has also been associated with higher rates of recurrence. This was shown in a study of 231 consecutive patients who underwent laparoscopic ventral rectopexy (reported recurrence rate of 11.7%). This finding, which comes up during preoperative manometry testing, may signify a more inherently weak pelvic floor with poor baseline anal sphincter function that may be making the patient more prone to recurrence. ¹³

Features of Index Operation

More than 100 operations have been described in the literature for the management of rectal prolapse. These are frequently classified into perineal and abdominal approaches. Regarding the perineal approaches, anal encirclement (Thiersch procedure) is rarely used due to high morbidity and failure rates. The Delorme procedure, which is traditionally used in patients with a short segment rectal prolapse (<5 cm), has reported recurrence rates in the literature ranging between 10 and 40%. ¹ Recurrence rates with a perineal rectosigmoidectomy (Altemeier procedure) have also been reported to be in the same range (15–30%). Recurrence after the Altemeier procedure has been shown to be lower with the addition of levatorplasty which can help address concomitant levator diastasis and strengthen the pelvic floor. ^{1 4} Recurrence after an Altemeier procedure may be the result of inadequate mobilization and resection of the redundant colon and/or rectum, whereas recurrence after Delorme's mucosal resection may be the result of incomplete mucosectomy of the prolapsing bowel. ¹⁴

Regarding abdominal approach techniques, available options for minimally invasive prolapse surgery include posterior suture rectopexy, posterior mesh rectopexy, or ventral prosthetic rectopexy. Since the introduction of minimally invasive ventral mesh rectopexy in the early 2000s, it has become the cornerstone for the treatment of rectal prolapse. As shown by Gurland et al, patients with one prior recurrence are at a higher risk for re-recurrence at 5-year follow-up after ventral mesh rectopexy (25% for redo vs. 9.7% in the cohort for primary repair). Furthermore, the time to recurrence is shorter in patients with prior rectal prolapse repairs (8.8 vs. 30.7 months). ¹⁵ These results were contradicted by Pikarsky et al who showed that the re-recurrence rate was not different in patients undergoing de novo repair or redo repair of rectal prolapse (11.1% vs. 14.8%, respectively). ¹⁴ However, physiologically, it makes logical sense that a patient who has already experienced a recurrence is at a higher risk for re-recurrence.

With regard to functional outcomes, it has been shown that posterior dissection can cause postoperative worsening of preoperative constipation or de novo constipation in patients. ¹ In a randomized controlled trial by Lundby et al comparing laparoscopic posterior suture rectopexy to laparoscopic ventral mesh rectopexy, at the 12-month interval follow-up, functional outcomes (obstructive defecation, constipation, incontinence) as well as recurrence rates were similar between the two groups. ¹⁶ However, at the 6-year interval, laparoscopic ventral mesh rectopexy offered better functional outcomes compared with posterior suture rectopexy. ¹⁷

Numerous retrospective reports in the literature have shown lower recurrence rates in patients undergoing abdominal approach repairs (some with recurrence rates as low as 3–5%) as compared with patients undergoing perineal repairs (unable to fixate the rectum within the pelvis). ^{18 19} This has helped support the practice that in the de novo rectal prolapse patient, the abdominal approach may be a more durable solution and has helped advocate for the abdominal approach as a superior approach when treating patients with rectal prolapse. ^{1 4 5 20} Surgeons caring for patients with rectal prolapse though have raised concerns regarding the unaddressed selection bias in these studies, since the patient population that undergoes a perineal repair is usually older, more comorbid at baseline, and may have poorer tissue quality and a longer prolapse duration. These are all factors that may be putting them at a higher risk of recurrence regardless of the approach. ²¹

The Rectal Prolapse Recurrence Study Group conducted a multicenter pooled analysis of 643 individual patients undergoing abdominal surgery for full-thickness rectal prolapse. The main finding of this study was that surgical technique, means of access, and method of rectopexy (suture vs. mesh) were not independent predictors of rectal prolapse recurrence. ²² A meta-analysis including only randomized controlled trials conducted by the Cochrane Library also failed to show the benefit of any of the described surgical techniques for the management of rectal prolapse over the others. ²³ Another study in which patients were followed up for 21 months after perineal proctectomy, showed that the rates of rectal prolapse recurrence in patients <50 years old were comparable with the rates of recurrence in patients undergoing an abdominal approach. ²⁴ The findings of no significant difference in terms of recurrence after the abdominal versus perineal approach for the index operation were also reinforced by a randomized controlled trial conducted by Senapati et al in the United Kingdom. ²¹

Resection rectopexy, which refers to the addition of a sigmoid colectomy to suture rectopexy, which was the gold standard in the past, is now reserved for patients with refractory constipation or diverticulitis. However, it has fallen out of favor in other patient populations especially if a prosthesis is being used. ¹

Traditionally, rectal prolapse had been considered a problem involving only the posterior compartment (rectum and rectovaginal space). However, the significance of the anterior peritoneum (pouch of Douglas) has gained more enthusiasm after the introduction of ventral mesh rectopexy. In a retrospective cohort study conducted by Bordeianou et al, looking into patients with rectal prolapse undergoing surgery (both de novo procedures and reoperations for recurrence), adding a middle compartment suspension (closure of the pouch of Douglas, mesh colposuspension, or culdoplasty with or without hysteropexy) during abdominal prolapse operations surfaced as a protective factor against short-term recurrence rate (3 months). ²⁵ Therefore, inadequate suspension of the middle compartment during index repair of the prolapse can put patients at a higher risk for recurrence. In addition to that, in patients with pelvic floor laxity, additional stitches may be placed at the levators and pubococcygeus muscles. One additional consideration during ventral mesh rectopexy is the option of suturing the mesh to the posterior vaginal wall (colpopexy) to address the middle pelvic compartment as well. ⁴

It remains controversial whether anterior rectal prolapse repairs (e.g., ventral mesh rectopexy) or posterior rectal prolapse repairs (e.g., suture/mesh rectopexy or resection with suture rectopexy) are superior in terms of recurrences. ¹ However, it is well-known that posterior dissection alone without rectopexy has a higher recurrence risk and is not a durable long-term cure for the management of rectal prolapse. A randomized controlled trial comparing mobilization of rectum only versus rectopexy showed an eight times increase in recurrence rates in the mobilization-only group. ²⁶ Given the above, in the authors' opinion posterior dissection alone should not be used without the addition of rectopexy, and when able ventral rectopexy should be preferred for de novo and recurrent rectal prolapses.

When considering the type of mesh available for a rectopexy, studies in the literature have identified certain pitfalls that can lead to higher recurrences. Interestingly, while the studies that used only synthetic mesh in the literature have lower recurrence rates than those using either biologic or synthetic, or synthetic mesh exclusively, Fu et al identified the use of synthetic mesh as a risk factor for higher recurrence rates. ^{7 13} The authors explained that this may have been in part due to other concurrent modifications in their surgical technique that could have confounded the outcomes. These results were also contradicted by the meta-analysis conducted by Emile et al, where the type of mesh used did not appear to affect recurrence. However, in their analysis, the length of the mesh used in ventral mesh rectopexy surfaced as a predictor of recurrence, with shorter mesh leading to higher recurrence rates. ⁷ This highlights the importance of appropriate mesh length selection that has to be long enough to accommodate for fixation in the pelvis without increased tension that puts it at high risk for detachment (the most common cause of early failure as discussed above) but also not too long leading to loose fixation of the rectum and prolapse with defecation or straining.

Lastly, a long debate exists regarding the division of the lateral stalks. It has been shown that it can decrease the risk of recurrence but it is strongly associated with worsening of preoperative or de novo constipation, making it particularly useful in patients with rectal prolapse that present with preoperative fecal incontinence. ²⁷ Therefore, the surgeon needs to take into consideration the presenting symptoms of the patient and balance the need for adequate dissection to decrease the risk of recurrence while keeping in mind that too much mobilization has been associated with worse functional outcomes.

Classification of Recurrence

For patients undergoing ventral rectopexy, the most common findings on repeat prolapse repair include mesh detachment from the sacrum or inadequate/loose adherence of the mesh to the ventral rectum. ¹³ Additionally, van der Schans et al looked into 90-day minimally invasive redo interventions after ventral mesh rectopexy and identified suboptimal distal mesh position (71% of recurrences) with the mesh not positioned deep enough in the rectovaginal septum (instead positioned too laterally on the rectum or too loosely without providing enough tension) as the leading cause of failure. ²⁸ Hool et al reviewed their 30-year experience at a single institution with the management of recurrent rectal prolapse (24 patients). ²⁹ In this patient population, the median time to recurrence was 2 years (34% had experienced a recurrence within 7 months from the index operation). The reason for the recurrence was identified in less than half of the patients (41%) and the dominant etiology was related to mesh use in rectopexy (e.g., pulled off rectum or sacrum, placed too high). ²⁹

Looking in more detail into the most common reasons for recurrence, a study conducted in the United Kingdom by Brown et al evaluated 24 patients who underwent repeat operation for full-thickness recurrent rectal prolapse after index laparoscopic ventral mesh rectopexy. The reasons for recurrence were identified in the majority of patients (21 [87.5%]) and they were classified into seven different categories ³⁰ :

• Type I: The mesh had become detached from the sacral promontory

• Type II: The mesh had become detached from the rectal wall

• Type III: There was inadequate mid-rectal support

• Type IV: The mesh was not sutured distally enough onto the rectal wall

• Type V: Mesh was sutured too loose

• Type VI: Posterior rectal prolapse

• Type VII: No mesh identified on laparoscopy—usually occurs after placement of a biologic mesh during index operation ³⁰

Management of Recurrent External Rectal Prolapse

Preoperative Planning

Anorectal examination with straining confirms the diagnosis of recurrent rectal prolapse which can be mucosal, partial, or complete with visible circumferential folds. The most proximal aspect of the prolapse also known as the take-off or lead point is noted. Mucosal prolapse can be treated with rubber band ligation or perineal surgery. A low take-off may allow for a perineal approach for the repair of the recurrence, whereas a high take-off makes an abdominal approach necessary. ³⁰ Similar to an evaluation of patients with de novo rectal prolapse, we recommend careful history obtaining for the presence of associated symptoms (constipation, incontinence, and concurrent vaginal and/or uterine prolapse).

Most colorectal surgeons with a focus on pelvic floor disease have shifted toward an abdominal approach for the management of recurrent disease regardless of the index operation. A recently published landmark study by the Committee for the Pelvic Floor Disorders Consortium Quality Improvement in Rectal Prolapse Surgery Database Pilot prospectively reviewed 461 patients across the United States who underwent surgery for full-thickness external rectal prolapse. Of these patients, 89 (19.3%) were undergoing redo rectal prolapse repair. The rates of failed abdominal and perineal prior repairs were 48.3% and 51.6%, respectively. Interestingly, looking into the patients with a prior failed abdominal approach, the vast majority (79.1%) were offered a repeat abdominal surgery whereas the rest were converted to a perineal approach. In contrast to that, 50% of the patients with a prior failed perineal approach were converted to an abdominal approach for their redo operation. The authors also compared the rates of recurrence between the patients undergoing de novo rectal prolapse repair to the recurrence rates in the redo repair group and there were no statistically significant differences (15.6% vs. 11.7%, respectively). ⁵

In our practice, in patients who present with recurrent rectal prolapse, we obtain an MRI defecography to assess the integrity of the mesh and look for concomitant middle or anterior compartment prolapse ( Figs. 1 and 2 ). Additional testing, such as colonoscopy, fluoroscopic enema, anal manometry studies, or urodynamic studies can be utilized on a case-by-case basis.

Fig. 1.

Coronal T2-weighted with Valsalva maneuver showing intact mesh as T2 hypointense band (orange arrows) from sacral promontory to rectum.

Fig. 2.

Coronal oblique image (in-phase T1-weighted gradient echo) shows mesh (orange arrows) ending with a gap (yellow double arrow) to sacral promontory (blue arrow).

When evaluating a patient with recurrent rectal prolapse preoperatively, if the patient is a good candidate for an operation and willing to undergo surgery for repair, the recommendation should be to perform the procedure as early as convenient for the patient and surgeon. Significant delays have been shown to increase the risk of complications secondary to the prolapse (e.g., incarcerated rectum) but have also been shown to be associated with higher recurrence rates after surgical repair, likely in the setting of secondary weakening of the pelvic floor. This has been described in long delays that exceed 4 years. ¹

Regarding the functional outcomes of patients undergoing surgery for recurrent rectal prolapse, Pikarsky et al compared a group of patients who had surgery for recurrent rectal prolapse to patients who had undergone an initial operation for rectal prolapse. The authors showed that the outcomes of patients undergoing surgery for recurrent rectal prolapse (including anastomotic complications, wound infection, and postoperative incontinence scores) were similar to those undergoing the initial operation, including overall re-recurrence rates (14.8% in the recurrent rectal prolapse group vs. 11.1% in the primary rectal prolapse repair group). ¹⁴

In our practice, we prefer abdominal approaches over perineal approaches for the repair of the recurrent rectal prolapse. We counsel all our patients that the final operative plan will depend on intraoperative findings. We consent our patients for “Laparoscopic or Robotic Ventral or Posterior Rectopexy with Biologic or Synthetic Mesh or Perineal Procedure.” If there are significant adhesions in the pelvis that make this procedure unsafe and not feasible, or if the prolapse is identified to be very distal or mucosal (instead of full thickness), we opt for a perineal procedure. We also offer perineal repairs in patients who are more frail unless the take-off is noted to be very proximal. In patients with prior abdominal surgeries that we anticipate challenging pelvic dissections, we frequently place preoperative ureteral stents that are removed at the end of the case or inject indocyanine green to allow for intraoperative identification of the ureters.

Intraoperative Management

Studies focused on how to improve the care of patients with recurrent rectal prolapse have been limited primarily due to the heterogeneity of the patient population, the impact of surgeon preferences and experience with a particular approach, as well as the long-term follow-up needed to capture re-recurrences. Decisions on how to manage recurrent rectal prolapse are challenging and the available quality of evidence is not sufficient to create a treatment algorithm. ³¹

The results of the landmark study by the Committee for the Pelvic Floor Disorders Consortium Quality Improvement in Rectal Prolapse Surgery Database Pilot were reviewed in a consensus meeting among 57 colorectal surgeons significantly interested in pelvic floor disease. A strong consensus was defined as >70% agreement. From that meeting, the expert recommendations summarized in Table 1 were drawn for the management of recurrent rectal prolapse. ⁵

Table 1. Expert recommendations from the “Committee for the Pelvic Floor Disorders Consortium Quality Improvement in Rectal Prolapse Surgery” in managing recurrent rectal prolapse.

If a patient is a good surgical candidate for abdominal surgery, a redo abdominal procedure should be considered.

The redo abdominal procedure should be modified so as not to simply repeat the prior failed index repair.

Ventral mesh rectopexy for patients who have failed other repairs is a suitable option for most redo rectal prolapse patients.

Concomitant repair of uterine and vaginal prolapse should be offered when stage II or higher pelvic organ prolapse is clinically identified.

Concomitant levatorplasty if Altemeier's approach is chosen should be offered.

Index Procedure

Prior Perineal Approach

Redo perineal rectosigmoidectomy is a feasible and safe procedure that can be repeated many times. However, it has been shown to have significantly higher recurrence rates and this should be carefully considered and thoroughly discussed with the patient, potentially leaving the redo perineal approach as a viable option only for the elderly and frail patients, or patients in whom the abdominal approach would be very high risk or not feasible. Ding et al evaluated 23 patients that had initially undergone a perineal rectosigmoidectomy with a subsequent recurrence that was treated again with a redo perineal resection. Comparing the outcomes of the recurrent patients to patients undergoing perineal rectosigmoidectomy for the first time, no significant differences were identified (including operating time, length of bowel resection, and postoperative complications including anastomotic failure). However, recurrence rates were significantly higher in the redo group compared with the primary repair group (39% vs. 18%). ³² Two important technical considerations when a redo perineal approach is performed in a patient with a prior perineal rectosigmoidectomy include (i) making sure that the prior anastomosis is included in the redo resection to avoid leaving behind a devascularized segment of the rectum that increases the likelihood of an anastomotic leak, and (ii) making sure that the new anastomosis is tension-free. ³²

Resection rectopexy when performed in patients with recurrent rectal prolapse that have had a perineal approach repair in the past (and vice versa) has a high risk of creating a piece ischemic bowel between the two anastomoses, so it is important to perform a close colonic dissection to minimize this risk and if needed resect the prior anastomosis. In addition to that, in patients that have concurrent fecal incontinence from the rectal prolapse, the rate of resolution of the fecal incontinence postoperatively appears to be lower in patients undergoing a sigmoid colectomy. Some surgeons also advocate against performing a sigmoid colectomy in patients with low rectal tone and preoperative hypotensive anal pressure on manometry as well given the risk of postoperative incontinence. ¹

Prior Rectopexy with and without Sigmoid Resection

Based on the results of the study by Brown et al, which evaluated 24 patients who underwent repeat operation for recurrent rectal prolapse after index laparoscopic ventral mesh rectopexy and classified the seven types of recurrences, the following treatment algorithm was generated by the authors. ³⁰ In more detail based on the recurrence type:

• Type I: Mobilize the proximal end of the mesh and reattach it to the sacral promontory with sutures. The authors recommended two non-absorbable sutures for the sacral fascia.

• Type II and III: Unclear whether the main reason for this is the inadequate superficial placement of the sutures on the rectum or proper suture placement with detachment from pressure but regardless of the cause the authors suggested leaving the mesh from the index operation intact and placing a second mesh over it with repeat rectopexy. In our opinion, if the prior mesh does not allow for a good landing zone on the rectum, we recommend complete or partial mesh excision.

• Type IV: Given that most commonly these patients have a low take-off (below the level of the mesh) a perineal approach may be offered. Otherwise, redo laparoscopic ventral mesh rectopexy with a second mesh is recommended. The repeat abdominal approach can be challenging as the plane for mobilization of the rectum distal to the entry point of the first mesh may be distorted. Care should be given to not enter the vagina during this dissection.

• Type V: Repeat ventral mesh rectopexy with second mesh placement.

• Type VI: In this type of recurrence if there is a low take-off, Brown et al suggested considering a perineal approach. ³⁰ If this approach is chosen, then Delorme's procedure was preferred over a resection procedure (Altemeier's) to minimize the risk of encountering the mesh. If an abdominal procedure is chosen, posterior dissection with suturing of the lateral pedicle of the mesorectal tissue to the sacral promontory and preexisting mesh is performed.

• Type VII: Although the data are conflicted regarding the use of synthetic mesh as compared with biologic mesh and the differences in recurrence, if a patient has failed with the use of the biologic mesh, the authors of this study suggested the use of a synthetic mesh during the redo ventral mesh rectopexy.

The intraoperative and 90-day complication rates, as well as the complication profile, have been shown to be similar in patients undergoing redo ventral mesh rectopexy when compared with patients undergoing primary ventral mesh rectopexy, making this a safe procedure in the management of patients with recurrent rectal prolapse. ^{15 28} In terms of management of the prior mesh, in a study conducted in Finland by Laitakari et al, the authors performed 43 redo minimally invasive ventral mesh rectopexy. In the majority of the patients, the previous mesh was left intact, whereas in one patient refixation of the proximal part of the mesh was employed. ³³ In terms of functional quality of life improvement and symptomatic control, patients with an external rectal prolapse recurrence benefited more from the redo operation when compared with patients with internal recurrence. In our opinion, a redo abdominal rectopexy, although it can sometimes be technically challenging, is a safe and feasible operation in the hands of an experienced surgeon in the management of rectal prolapse and the prior mesh can be left intact as long as it does not hinder exposure and good fixation of the rectum. In a patient with prior ventral mesh rectopexy, if an early recurrence is observed, separation of the mesh at the sacral promontory should be suspected and reoperation for repeat fixation should be considered. This signifies a true technical failure and an early return to the operating room to reassess and refixate the mesh should be offered. ²⁹

In patients who have had resection rectopexy for the index operation, as noted above, if a perineal approach is chosen, we recommend the Delorme procedure. If an abdominal approach is chosen, we recommend a ventral mesh rectopexy. An Altemeier's procedure in patients with prior sigmoid resection carries the risk of creating a segment of ischemic bowel between the two anastomoses at risk of stricture or leak. Also, a perineal resection in this patient population may make mobilization and creation of a tension-free anastomosis challenging. Another consideration would be a redo resection rectopexy with complete rectal mobilization. This allows for the repeat resection of the redundant colon; when colon resection is performed, we recommend against the use of mesh and instead suture rectopexy. A modified Wells procedure with a posterior dissection (added benefit of dissection and scarring fixing the rectum in place) with a concurrent posterior mesh rectopexy can also be considered. If a modified Wells procedure is chosen, care must be given in patients with preoperative constipation, as it has been shown to worsen after posterior dissection. ¹ Table 2 summarizes the available options for the management of recurrent disease based on the index operation.

Table 2. Surgical options and considerations for recurrent prolapse based on index operation.

Index operation	Options and considerations for recurrent prolapse
Perineal approach (Delorme's or Altemeier's)	1) Repeat perineal procedure: frail/elderly. If index Altemeier's → care to resect prior anastomosis and create a new tension-free anastomosis 2) Mesh rectopexy 3) Resection rectopexy: If index Altemeier's → care to perform close colonic dissection to not disrupt blood supply to neorectum. If needed, resect prior anastomosis
Resection rectopexy	1) Perineal approach: prefer Delorme's over Altemeier's to minimize the risk of ischemic segment. If Altemeier's procedure is performed, care to excise above prior colorectal anastomosis. 2) Redo resection rectopexy with complete rectal mobilization. 3) Mesh rectopexy
Mesh rectopexy	1) Perineal approach for elderly/frail patients or patients with low take-off. Prefer Delorme's to avoid encountering mesh. 2) Repeat mesh rectopexy: Three options exist regarding mesh handling from index operation: (a) leave mesh from index operation (if present) intact, (b) bolster the mesh to retighten, or (c) excise or partially excise prior mesh to allow for good landing zone on the rectum.

Conclusion

Overall, reviewing the existing literature for the management of patients with recurrent rectal prolapse has demonstrated a clear paucity of high-quality data. The lack of large-volume prospective randomized controlled trials with sufficient long-term follow-up looking into the management of recurrent rectal prolapse urges caution in the adoption of techniques or interpretation of studies in the literature, the vast majority of which are retrospective institutional studies. No strong data-driven conclusions can be drawn. Despite all the above, we believe it is important to identify high-risk patients prior to the index operation. Performing a good index operation and avoiding the above pitfalls, can help decrease the risk of recurrence. Based on expert recommendations, in patients with recurrent prolapse surgeons should modify the procedure to avoid performing the exact operation and when feasible, a redo abdominal procedure should be preferred over the perineal approach.