Approaching Combined Rectal and Vaginal Prolapse

Abstract

Combined rectal prolapse and pelvic organ prolapse surgery provides significant quality-of-life benefits with improvements in bothersome symptoms of pain, bulge, constipation, urinary retention, as well as bowel and bladder incontinence. Robotic surgery is the ideal tool for a combined surgical repair. It allows enhanced suturing in the deep pelvis, three-dimensional (3D) visualization of the presacral space and easy mobilization of the rectum and dissection of the vagina. Combined procedures can be offered to patients with the advantages of a single operation and concurrent recovery period without increasing complications. In this article, we highlight our approach to combined prolapse repair.

A weakened pelvic floor and attenuated structural support can result in the simultaneous prolapse of both the rectum and adjacent pelvic organs. In patients presenting with rectal prolapse, the concurrent rate of pelvic organ prolapse is between 21 and 34%. ¹ Pelvic floor disorders are associated with parity and increasing age, and by the age of 80 years, 55% of women will have one or more pelvic floor disorders. ² For women with both rectal and pelvic organ prolapse, multidisciplinary evaluation and treatment ³ with combined rectal prolapse and pelvic organ prolapse surgery provide significant quality-of-life benefits by improving feelings of prolapse, pain, bladder, and bowel symptoms. ^{4 5} The advantages of one operation include a reduced risk of anesthesia, a single hospital stay and recovery period, decreased pain medications, and less time off work for the patient.

Rectal and vaginal prolapse can both be treated with an array of surgical procedures. Repair of concurrent prolapse may be abdominal (robotic, laparoscopic, or open) or perineal. Surgical approach is determined by surgeon preference and experience, patient's goals, medical comorbidities, frailty, and presence and type of prior prolapse repairs. ⁶ A perineal approach is recommended for frail patients with perineal proctectomy and colpocleisis. ^{7 8} In younger and healthier patients, a laparoscopic or robotic abdominal approach is often preferred and the rectal and vaginal prolapse is frequently repaired by ventral rectopexy and sacrocolpopexy using a mesh or graft. ⁹

Minimally invasive surgery for both rectal prolapse and pelvic organ prolapse has been shown to have equivalent recurrence rates to open surgery with decreased hospitalization and faster return of bowel function. ¹⁰ Studies comparing laparoscopic rectal prolapse surgery versus open rectal prolapse surgery suggested that patients required less narcotics, had lower pain scores, higher mobility scores, and fewer postoperative complications after laparoscopic surgery. ¹¹ However, these procedures can be challenging for a minimally invasive surgeon as they require significant dissection, possible manipulation of mesh, and extensive suturing. Laparoscopic rectopexy has a steep learning curve and requires advanced suturing skills in the pelvis. ¹² Robotic surgery is the ideal tool for a combined surgical repair as it allows three-dimensional (3D) visualization of the presacral space and easy mobilization of the rectum and dissection of the vagina, access to the deep pelvis, wristed motions, and enhanced suturing. Additionally, robotic surgery has several advantages over laparoscopic surgery including improved dexterity of movement, obliteration of hand tremor, image magnification, and instruments with improved precision. Despite the longer operative time than rectal prolapse surgery or pelvic organ prolapse surgery alone, costs are less as operating room equipment costs are minimized and the total cost of a second operation is avoided. In the following section, we will share our systematic approach to combined prolapse in healthy women who are candidates for abdominal repair.

Benefits to a Multidisciplinary Evaluation and Surgery

In our multidisciplinary pelvic health clinic, we screen patients with urinary complaints, symptomatic prolapse, and defecatory dysfunction for a combined consultation, and evaluation. Guiding principles for all prolapse surgery include attention to anatomic and functional deficits, as well as a focus on what bothers the patient. This framework facilitates setting patient goals and expectations. A thorough pelvic floor history should include questions about bladder and bowel symptoms, urinary and fecal incontinence, feelings of bulge from the vagina or rectum, difficulty emptying the bladder or bowels, sexual function, and pain. Standardized tools such as the Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7) can be used to assess symptom severity and impact on quality of life. ¹³ Patients are discussed as part of a multidisciplinary pelvic floor conference where imaging, anorectal testing, and urodynamic testing are reviewed. Healthy lifestyle and modifiable behaviors, such as dietary choices, exercise, smoking, alcohol consumption, and chronic straining, need to be independently addressed prior to considering surgical intervention. All patients under consideration for abdominal mesh are discussed. The ultimate benefit is a comprehensive patient-centered approach and single-coordinated surgery. Administrative support is the most important component to facilitating a multidisciplinary clinic and to scheduling combined procedures.

Female Pelvic Medicine Focused History and Examination

A focused history includes questions about previous prolapse and anti-incontinence surgeries, obstetric history, such as operative deliveries (forceps/vacuum), and perineal lacerations involving the anal sphincter, and any genitourinary disorders. Daytime and nighttime urinary frequency and urinary incontinence, history of urinary tract infections, a sensation of incomplete bladder emptying, hematuria, vaginal pain, and vaginal bulge/pressure should also be assessed. Abnormal vaginal bleeding or discharge should be addressed as these could be a result of poor vaginal tissue quality (atrophy) or uterine pathologies, such as endometrial hyperplasia or cancer. The vaginal examination is performed in the supine or standing position. A pelvic organ prolapse quantification (POP-Q) examination is performed to determine the extent of anterior, apical, or posterior vaginal prolapse with the Valsalva maneuver. ¹⁴ Vaginal prolapse is staged from 1 to 4, with stage 1 being minimal prolapse and stage 4 being complete eversion of the uterovaginal tissue. Urinary leakage with cough or the Valsalva maneuver is also determined. The uterus and adnexa are palpated for any masses, and a Kegel's squeeze is elicited to determine pelvic floor muscle strength.

Colorectal Focused History and Examination

A focused bowel history should include bowel consistency and frequency, use of laxative or bowel stoppers, and digital or positional maneuvers required to defecate. The presence of mucus discharge, fecal soiling or leakage, and urgency or passive incontinence may suggest internal or occult external rectal prolapse, sphincter dysfunction, or dyssynergic defecation. Rectal examination can be performed squatting, standing, on the commode, or in the prone or lateral positions. Patients are encouraged to bring in a picture of the prolapse in situations where it can be painful or difficult to elicit during examination. Visual inspection of the anus is reported as closed, open, or patulous, and visible contractions of the sphincter with squeeze, and movement of the pelvic floor with the Valsalva maneuver is documented. Anoscopy visualizes the hemorrhoid complex and can help to identify internal or full-thickness rectal prolapse. Colonoscopic evaluation is performed in women who are at risk for colon cancer or for those women over the age of 45 years.

Pelvic Floor Testing

Although clinical examination is considered the gold standard when it comes to the diagnosis of prolapse, additional pelvic floor testing can identify occult pathology which can lead to treatment failures. Magnetic resonance imaging (MRI) defecography (MRD) helps identify multicompartment or occult prolapse, enterocele, sigmoidocele, and perineoceles. Anorectal manometry helps determine anorectal sphincter pressures, sensation, and coordination.

Urodynamic testing is a combination of procedures to determine bladder and urethral function and can be performed with reduction of vaginal prolapse using vaginal swabs or pessaries. Of women with vaginal prolapse, 40% suffer from stress urinary incontinence (urinary leakage with activity, lifting, or coughing/sneezing) and 37% have overactive bladder. ¹⁵ In addition, roughly 25% of women who undergo abdominal sacrocolpopexy for vaginal prolapse report bothersome stress urinary incontinence after surgery. ¹⁶ Correction of anterior and apical vaginal prolapse may “unkink” the urethra and bladder neck, unmasking stress urinary incontinence. Preoperative urodynamic testing may help identify patients at higher risk for de novo postoperative stress urinary incontinence who can be offered prophylactic anti-incontinence procedures at the time of prolapse repair.

Surgical Decision-Making

Video 1 A ventral rectopexy and sacrocolpopexy.

Download video file ^{(176.8MB, mp4)}

Factors that need to be considered when offering procedures to women with combined prolapse include health status/frailty, prior abdominal surgeries that could lead to a hostile surgical abdomen, presence of uterus, and patients' feelings about mesh or biological graft. A perineal procedure is recommended for frail individuals at high risk for abdominal surgery or for those women whose abdominal access is known to be treacherous. ⁶

In the following discussion, we will focus on women who are considered fit for abdominal surgery. These are few common scenarios and our approach to these patients is as follows:

• A healthy, posthysterectomy woman with rectal prolapse and anterior or apical vaginal prolapse who is willing to consider mesh: in this situation, our preferred technique is a ventral rectopexy and sacrocolpopexy ( Video 1 [available in the online version]; Fig. 1 ).

• A healthy, posthysterectomy woman with rectal prolapse and anterior or apical vaginal prolapse who would like to avoid mesh: in this situation, our preferred technique is a suture rectopexy and native-tissue vaginal suspension procedure (uterosacral ligament suspension or sacrospinous ligament fixation and/or anterior colporrhaphy and/or posterior colporrhaphy).

• A healthy, posthysterectomy woman with constipation poorly controlled with laxatives who is at risk for worsening constipation after rectal dissection or a woman with sigmoid pathology (such as diverticulitis): in this situation, we offer a sigmoid resection and rectopexy. If she has concurrent anterior or apical vaginal prolapse, we offer a native-tissue vaginal suspension procedure (uterosacral ligament suspension or sacrospinous ligament fixation and/or anterior colporrhaphy and/or posterior colporrhaphy). It is our preference to avoid colon resection and mesh placement during the same procedure.

• A healthy woman with rectal and vaginal prolapse who has a uterus: in this situation, we offer a ventral mesh or suture rectopexy with concomitant total hysterectomy and sacrocolpopexy or supracervical hysterectomy and sacrocervicopexy or hysteropexy (suspension surgery without removal of the uterus). To avoid a higher rate of vaginal mesh exposure in total hysterectomy patients, a supracervical hysterectomy can be performed in women with normal Pap smears. ¹⁷ In patients who would prefer to avoid hysterectomy, a vaginal suspension without hysterectomy can be offered. If a hysteropexy is performed with mesh, the mesh is applied to the anterior vagina and cervix with two arms, traveling posteriorly through the broad ligaments to the sacrum.

Fig. 1.

Ventral mesh rectopexy and sacrocolpopexy: mesh is sutured to the anterior rectum and anterior vagina and both mesh are fixed to the anterior longitudinal ligament.

Coordination of Ventral Rectopexy and Sacrocolpopexy

The patient is placed on a gel pad, a bean pad, or thick foam to avoid sliding while in steep Trendelenburg's position during surgery. Following anesthesia induction, she is positioned in the dorsal lithotomy position in Allen or Yellowfins (Allen Medical Systems, Acton, MA) stirrups. Arms are tucked and the chest is secured. Padding is used around all pressure points to avoid nerve or joint injury.

Anal and vaginal examination under anesthesia is performed with both surgeons present to evaluate the extent of prolapse and confirm surgical plan. The lead point of the rectal prolapse, which is the most proximal aspect of the rectal intussusception, is determined since fixation of the mesh to the rectal prolapse lead point is imperative to avoid rectal prolapse recurrence. Anterior, apical, and posterior vaginal walls are examined to confirm repairs for vaginal prolapse.

The abdomen, perineum, vagina, and rectum are prepped and the patient is draped. The XI robot (Intuitive, Sunnyvale, CA) port placement is just above the umbilicus with either a Veress' needle or cut down technique. Alternatively, in patients with suspected adhesions, the preferred entry point is the left upper quadrant (Palmer's point). An orogastric tube and Foley's catheter must be placed prior to trocar insertion.

The camera trocar is placed approximately 1 to 2 finger breadths above the umbilicus and CO ₂ pneumoperitoneum is established. Trocars are placed under direct vision 7 to 8 cm apart in a straight line. Care is taken to avoid the inferior and superficial epigastric vessels during trocar placement. All trocars are 8 mm with four robotic trocars and one 8-mm AirSeal (CONMED, Utica, NY) accessory port, which is placed along the right lateral location. Needles and mesh can be placed through the 8-mm accessory port.

The camera is placed in the umbilical port and targeting of the robot is performed for visualization of the pelvis. A Cadiere or Tips-Up instrument is placed in arm 1 for retraction and a fenestrated bipolar is placed in arm 2. A monopolar scissors or hook is inserted in arm 4. After the rectal and vaginal dissections are done, the fenestrated grasper and scissors are exchanged for a needle driver in arm 2 and Mega Suture Cut in arm 4 ( Table 1 ).

Table 1. Operative steps: describes the operative steps for ventral rectopexy and sacrocolpopexy.

1. Clear the pelvis

2. Dissect presacral fat to visualize anterior longitudinal ligament of the sacrum

3. Create peritoneal flaps

4. Dissect the rectal vaginal septum

5. Dissect and excise the pouch of Douglas

6. Dissect bladder off of the vagina

7. Place and suture fixation of mesh to the rectum

8. Place and suture mesh to the vagina

9. Tension and fix both meshes proximally, to the anterior ligament along the sacrum

10. Check for fixation of the prolapse and finger sweep into the vagina and rectum for sutures

11. Close the peritoneum to cover the mesh

12. Cystoscopy

• Step 1. Clearing the pelvis: if the patient has a uterus, a uterine manipulator is inserted and an assistant located between the legs elevates the uterus up toward the pubic bone. The patient is placed in steep Trendelenburg's position and gravity helps move the small bowel out of the pelvis into the upper quadrants. Redundant sigmoid is retracted out of the pelvis. The right ureter is usually visible coursing along the side wall. If the sigmoid colon obscures visualization, an Endoloop can be placed on an epiploicae to retract redundant sigmoid colon out of the pelvis.

• Step 2. Dissecting the anterior longitudinal ligament on the sacrum: this will be the single fixation point for both vaginal and rectal mesh along the anterior longitudinal ligament at the level of the sacral promontory. The camera is positioned in a 30-degree down position to visualize the sacrum. Using robotic arm 1, the sigmoid colon mesentery is gently grasped and moved to the left. The fenestrated grasper in arm 2 is used to elevate the peritoneum midway between the right ureter and the rectal mesentery and the peritoneum is opened at the sacral promontory. With the scissor tips positioned perpendicular to the sacrum, dissection is taken directly down onto the anterior longitudinal ligament along the sacrum taking care to avoid the presacral veins or the left common iliac vein ( Fig. 2 ). There is a loss of tactile dexterity using robotic technology and the assistant can help to identify the sacrum by pushing on the sacrum with a laparoscopic instrument.

• Step 3. Create peritoneal flaps: the opening in the peritoneum is extended caudal midway between the rectum and pelvic side wall. The peritoneum is elevated-off of the rectal mesentery as flaps that will later be used to cover the mesh. The lateral rectal ligaments are left intact. Dissection is taken caudal to the uterosacral ligaments and in a J -shape between the rectum and vagina ( Fig. 3 ).

• Step 4. Dissect rectovaginal dissection: the rectovaginal septum is dissected by retracting the pouch of Douglas up and out of the pelvis and scoring the peritoneum in the midline. The robotic camera is rotated to a 30-degree up position and sharp and blunt dissection is used to develop a plane down to the perineal body. The levator ani muscles can be visualized laterally. An assistant sits between the legs and places sizer in the vagina. The sizer is pushed up and toward the pubic bone to elevate the vagina.

• Step 5. Dissect and excise the pouch of Douglas: the pouch of Douglas is excised-off of the anterior rectum, so that the lead point of the prolapse is exposed. The excess pouch of Douglas is excised making sure to leave enough peritoneum to completely cover the mesh. If concurrent anterior repair or hysteropexy is being performed, the excess pouch of Douglas is left to facilitate covering of the mesh.

• Step 6. Anterior dissection: if the patient has a uterus, a total or supracervical hysterectomy is then performed. If the patient has had a prior hysterectomy, then a transverse incision of the peritoneum is made at the vaginal cuff. The bladder is then dissected off the anterior vagina until the bladder neck is reached for a distance of at least 5 cm. Backfilling the bladder may help delineate the plane between the vagina and bladder if there is scarring in the area.

• Step 7. Place and suture fixation of mesh or biological graft to the anterior rectum: after dissection is complete, the fenestrated bipolar (arm 2) and scissors (arm 4) are exchanged for a needle driver on the left and a Mega Suture Cut on the right. A polypropylene mesh or biological graft is cut in a hockey stick fashion approximately 5 cm × 5 cm tapered up to 2 cm. Taking seromuscular bites, the mesh is sutured to the anterior rectum using 2–0 polydioxanone (PDS) sutures. Approximately 12 sutures are placed. A sizer in the rectum helps delineate the anatomy and moving the sizer to the left or right helps to ensure adequate coverage of mesh over the distal rectum.

• Step 8. Suture mesh to the vagina: a light-weight polypropylene mesh is trimmed to the length and width of the anterior vagina. Biologic graft is typically not used for the sacrocolpopexy due to variable results in the literature. The mesh strip is then sutured to the anterior vagina with PDS or GoreTex sutures. A minimum of five sutures are placed with at least two of those sutures placed at the vaginal apex. A separate strip of mesh can be sutured to the posterior vagina at the discretion of both surgeons.

• Step 9. Tension both meshes and fix the mesh proximally, to the sacrum: the camera is repositioned to a 30-degree down angle. The mesentery is retracted laterally to expose the spot on the sacrum that was previously dissected. When the prolapse is reduced and in anatomic position, the posterior rectal mesh should lay flat up to the sacrum. No additional tension is placed on the rectal mesh. The vaginal mesh is tensioned so that the anterior, apical, and posterior vaginal prolapse are reduced, elevated, and without significant stretching. Before attaching the mesh to the sacrum, the vaginal mesh is held against the sacrum and a vaginal examination is performed to ensure adequate prolapse reduction.

  Once the vaginal mesh is tensioned, a suture is placed through the anterior mesh, posterior rectal mesh, the sacrum, and then back through the mesh. The needle is placed, so that it skives the ligament to avoid suture placement that is too deep or within the disc space between L5–S1 and S1–2. The assistant places gently pressure on the mesh to keep it flat as the operator is tying so that the mesh lies flush with the anterior longitudinal ligament. Sliding the knot helps that tighten the knot along the longitudinal ligament. At least two sutures are placed along the longitudinal ligament.

• Step10. Examination of the prolapse: rectal and vaginal finger sweep is performed to assess that the lead point has been adequately incorporated on the repair and that there are no inadvertent sutures in the rectum or vagina. If sutures were visualized, these would be removed.

• Step 11. Closing the peritoneum: the peritoneum is closed over the mesh ( Fig. 4 ). Care is taken to only suture the lateral edge of the peritoneum since the right lateral peritoneum can retract and aggressive bites may cause kinking or injury to the right ureter. Creating adequate flaps of peritoneum in the beginning of the case facilitates peritoneal closure.

• Step 12. Cystoscopy: cystoscopy is performed to evaluate for foreign body, injury, or suture in the bladder and to ensure the ureters, particularly the right ureter, are not kinked or occluded. Preoperative phenazopyridine or intraoperative indigo or methylene blue is recommended to assist in the evaluation of ureteral efflux.

Fig. 2.

Exposure of the anterior longitudinal ligament.

Fig. 3.

Creation of peritoneal flaps.

Fig. 4.

Close of the peritoneal flaps over the mesh.

Outcomes of Combined Repairs

Published data on combined rectal prolapse and pelvic organ prolapse surgical outcomes are limited. Most studies that report outcome data have small cohort sizes, short follow-up periods, and primarily describe results of mixed abdominal repairs, including open, laparoscopic, and robotic approaches. Data focusing specifically on combined robotic repair is less robust and long-term outcome data on the surgical treatment of concurrent prolapse is scarce.

Recently, large national databases have been utilized to analyze the trends in combined prolapse surgery and to better understand postoperative complications and recurrence rates. Data from the Optum database, a national administrative database, showed that, among patients who underwent combined surgeries between 2003 and 2017, 8.3% of patients had a failed surgery that resulted in a repeat surgical repair. ¹⁸ Clinical application of this data are limited as the study included patients who underwent both abdominal and perineal procedures and did not specifically track those patients who received combined robotic repairs.

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) is a prospective surgical registry which hospitals use to track their risk-adjusted outcomes after surgery. Data from the NSQIP between 2005 and 2014 identified 3,600 women who underwent rectopexy of which 206 women underwent a combined procedure with a sacrocolpopexy. ¹⁹ Overall morbidity was similar between rectopexy only and combined procedure groups (14.8 vs. 13.6%, p  = 0.65). After controlling for the addition of a resection to a rectopexy procedure, elevated body mass index (BMI), smoking, wound class, American Society of Anesthesiologists' (ASA) class and other patient factors, the addition of sacrocolpopexy to rectopexy did not increase overall morbidity (odds ratio = 1.00, p  = 0.98). A later NSQIP study of vaginal and rectal prolapse surgeries from 2013 to 2016 found 123 concurrent laparoscopic sacrocolpopexy and rectopexy cases. ²⁰ Complication rates between colpopexy, rectopexy, and concurrent procedures were not significantly different (6.2, 7.6, and 8.9%; p  = 0.058), although concurrent procedures had the highest surgical site and urinary tract infection rates (all p  < 0.05). The NSQIP database is also limited as it neither provides long-term morbidity data nor long-term recurrence rates or reoperations.

Recent publications, as well as decreased complication rates, reflect the rapid adoption of the robotic approach worldwide. In 2011, Reddy et al reported on their initial technique of robotic sacrocolpoperineopexy with ventral rectopexy in 10 patients. ²¹ Their average follow-up time was 3 months and their major complication rate was 30% with one patient presenting with a small bowel obstruction, one patient with lumbar osteomyelitis, and one patient with appendicitis treated with an appendectomy. While serious complications were numerous in this small study, later published data on the robotic approach for combined surgery reported significantly less morbidity. van Iersel et al reported on 51 patients who underwent robot-assisted sacrocolporectopexy with a median follow-up time of 12.5 months. ²² One patient (2.0%) was converted to an open procedure and seven patients (13.7%) had <30-day complications including constipation, hematoma, abscess, hypokalemia, and fecal obstruction. One patient (2.0%) had a mesh complication requiring surgery and one (2.0%) patient had a vaginotomy. No full-thickness rectal prolapse recurrence was noted, although seven (13.7%) patients underwent hemorrhoid treatment (staple hemorrhoidectomy or rubber banding). Two (3.9%) patients had recurrence of vaginal prolapse and one (2.0%) required reoperation for rectocele repair.

Most recently, van Zanten et al have published long-term outcomes of their prospective cohort of 53 patients who underwent robot-assisted sacrocolporectopexy. ⁵ In this cohort, the median follow-up time was 48.2 months and 10 patients had prolapse recurrence: 2 (3.8%) had vaginal apical prolapse and 8 (15.1%) had internal rectal prolapse. Two (3.8%) patients underwent rectal prolapse reoperation and one (2.0%) patient had a vaginal mesh erosion which was managed conservatively.

Data appears to show that increased case volume improves outcomes regarding both complications and prolapse recurrence. An early study by Unger et al in 2014 reviewed 36 women who underwent laparoscopic or robot-assisted concomitant rectopexy and sacrocolpopexy at a tertiary care center. ²³ Their results suggested that the addition of rectopexy to sacrocolpopexy adds significant morbidity with respect to cardiac, bleeding, and infectious complications. Concomitant rectopexy was associated with high morbidity when compared with patients who underwent sacrocolpopexy only, including a higher risk of transfusion (2.8 vs. 0.3%, p  = 0.04), cardiac-related complications (5.6 vs. 0.8% p  = 0.01), and pelvic/abdominal abscess formation (11.1 vs. 0.8%; p  < 0.001). Rectopexy was also associated with a higher risk of osteomyelitis (5.6 vs. 0; p  = 0.001).

The same group then published their long-term data on 59 patients who underwent laparoscopic or robot-assisted laparoscopic combined rectopexy and sacrocolpo or hysteropexy between 2009 and 2015. ⁹ Of the patients, 15 (25.4%) experienced a perioperative adverse event and five patients (8.5%) required readmission for sepsis, ileus, small bowel obstruction, pulmonary embolism, and pelvic abscess. The median follow-up for all patients was 17 months (range, 1–76 months) and 91% of patients reported significant improvement after surgery. The composite success rates for rectal prolapse alone, pelvic organ prolapse alone, and both pelvic organ prolapse and rectal prolapse were 86.4% (51/59), 91.5% (54/59), and 79.6% (47/59), respectively.

As surgeons have become more experienced with combined prolapse surgery technique, complication rates and reoperation for recurrent prolapse have decreased. In 2020, Campagna et al published on their prospective cohort of 98 patients who underwent laparoscopic sacrocolopexy plus ventral rectopexy for concurrent prolapse. ²⁴ No patients had intraoperative complications or required conversion to open. Postoperatively, one (1.0%) patient developed a urinary tract infection which was treated with antibiotics and one (1.0%) patient developed a fever which resolved with paracetamol. Patients were followed for a median length of 12 months (range, 12–36 months). No patients had recurrent rectal prolapse and one (1.0%) patient had recurrent posterior vaginal wall prolapse which did not require reoperation.

Counseling patients regarding outcomes after combined rectal prolapse and pelvic organ prolapse surgery can be challenging due to the heterogeneity of surgical approaches, as well as the wide range of complication and recurrence rates. Follow-up times vary as do the definitions of prolapse recurrence. Researchers may choose to define prolapse recurrence by symptoms, physical examination, or need for reoperation and these definitions are inconsistent in the literature. The risk of complications also differs based on surgical approach, surgeon experience, and patient frailty and health status.

Future Investigations

As multidisciplinary approaches to prolapse and combined surgical repairs gain traction among colorectal surgeons and urogynecologists/female urologists, more questions arise about the optimal technique for this surgery.

Biologic grafts for ventral rectopexy are more commonly used than biologic grafts for sacrocolpopexy. Due to histologic similarities with native tissues, biologic grafts are more likely to undergo tissue remodeling and less likely to cause erosion. However, several prospective trials have compared synthetic and biologic meshes for sacrocolpopexy and found that pelvic organ prolapse failure rates are higher with biologic mesh. ^{25 26 27} In the rectal prolapse literature, the long-term durability of biological mesh has yet to be determined. However, mesh complications are reported at 1.87 and 0.22% for synthetic and biological mesh, respectively, suggesting that biological mesh may be safer. ²⁸ Currently, there is no data comparing synthetic mesh and biologic mesh for ventral rectopexy or sacrocolpopexy during combined surgery. Most surgeons choose the graft material based on surgeon preference and their prior experience with rectal prolapse only surgery or pelvic organ prolapse only surgery.

Similarly, there is no data comparing the use of single or multiple pieces of mesh during combined surgery. Some colorectal surgeons and urogynecologists/female urologists choose to use the same piece of mesh for both rectal prolapse and pelvic organ prolapse repair. A single piece of mesh is sutured to the anterior rectum and possibly the levator ani muscles, and then attached to the posterior vagina and finally to the sacrum. If a Y-mesh is used, the other arm may be sutured to the anterior vagina. Other surgeons prefer an additional piece of mesh for the anterior vagina or a Y-mesh that is only used for the anterior and posterior vagina and remains unattached to the rectum. Again, these variations in technique are based on surgeon preference and surgeon “gestalt.” Some surgeons believe that less mesh in the pelvis reduces the risks of erosion or extrusion, while others believe that multiple pieces of mesh allow for accuracy and precision in tensioning of the vagina and rectum.

Optimal tensioning of the rectum and vagina is usually based on surgeon's experience when performing these procedures separately, as there are no in vivo studies which describe the optimal mesh tensioning during combined surgery. During tensioning of the mesh arms, we ensure that the rectal prolapse and pelvic organ prolapse are reduced and the pieces of mesh lay as flat as possible along the peritoneum and the sacrum. We also ensure that the anterior rectum has been sufficiently dissected and the mesh is attached to the rectal prolapse lead point. The rectal mesh should lay without tension while the anterior rectum is in its anatomical position. The vagina is usually suspended with gentle tension without undue traction while deviated toward the sacral promontory. Balancing the tension between the rectum and vagina may be more challenging with a single piece of mesh, but there are currently no outcome data guiding differences in tensioning techniques.

Techniques for mesh fixation on the anterior longitudinal ligament along S1 and S2 can also vary. Some surgeons prefer to place separate sutures to attach the rectal mesh and vaginal mesh in different locations on the sacrum. There is concern about relying on two or three sutures for multiple pieces of tensioned mesh, as well as increasing the risk of possible mesh erosion with the mesh pieces affixed on top of each other. Other surgeons choose to place the sutures through the same pieces of mesh to reduce the risk of osteomyelitis and reduce the need for a larger dissection at the sacral promontory. However, there is no published data on the optimal technique for suture placement at the sacrum during combined surgery.

Conclusion

Combined rectal and vaginal prolapse causes significant patient distress, and a multidisciplinary approach is safe and effective. Surgical decision for combined repair includes the patient, surgeon, and prolapse variables. In the healthy, posthysterectomy patient who is agreeable to mesh implantation, an abdominal approach with robotic ventral rectopexy and sacrocolpopexy is our first choice.