Redo ventral rectopexy : is it worthwhile?

Background Minimally invasive ventral mesh rectopexy (VMR) is a widely used surgical treatment for posterior pelvic organ prolapse; however, evidence of the utility of revisional surgery is lacking. Our aim was to assess the technical details, safety and outcomes of redo minimally invasive VMR for patients with external rectal prolapse (ERP) recurrence or relapsed symptoms of internal rectal prolapse (IRP). Methods This is a retrospective cohort study of patients with recurrent ERP or symptomatic IRP who underwent redo minimally invasive VMR between 2011 and 2016. The study was conducted at three hospitals in Finland. Data collected retrospectively included patient demographics, in addition to perioperative and short-term postoperative findings. At follow-up, all living patients were sent a questionnaire concerning postoperative disease-related symptoms and quality of life. Results A total of 43 redo minimally invasive VMR were performed during the study period. The indication for reoperation was recurrent ERP in 22 patients and relapsed symptoms of IRP in 21 patients. In most operations (62.8%), the previously used mesh was left in situ and a new one was placed. Ten (23.3%) patients experienced complications, including 2 (4.7%) mesh-related complications. The recurrence rate was 4.5% for ERP. Three patients out of 43 were reoperated on for various reasons. One patient required postoperative laparoscopic hematoma evacuation. Patients operated on for recurrent ERP seemed to benefit more from the reoperation. Conclusions Minimally invasive redo VMR appears to be a safe and effective procedure for treating posterior pelvic floor dysfunction with acceptable recurrence and reoperation rates.Peer reviewe

Robotic-assisted and laparoscopic ventral rectopexy in the treatment of posterior pelvic floor procidentia

Abstract Rectal prolapse and internal rectal prolapse with symptoms of obstructed defecation and/or faecal incontinence are debilitating conditions. Often, symptoms coexist from other pelvic compartments, reducing quality of life. Robot-assisted surgery with its advanced features may offer better conditions in narrow pelvic space to correct rectal prolapses with rectopexy operation. In this thesis, we compared robot-assisted and laparoscopic techniques during the early learning curve in a ‘matched-pairs’ feasibility study (n = 30, follow-up three months) and in a prospective randomized series (n = 33, follow-up 24 months). The long-term functional results were assessed in a retrospective multicenter study with cross-sectional questionnaire assessment (n = 508, median follow-up 44 months). In the randomised series, as demonstrated with MR defecography, ventral rectopexy corrects the posterior compartment defects, external and internal rectal prolapses and recto-enteroceles. The operation restores the posterior and middle compartment anatomy and reduces pelvic organ mobility with a minor impact on the anterior compartment. Pelvic floor dysfunction and symptom-specific quality of life is improved after rectopexy; specifically, the colorectal-anal and the pelvic organ prolapse subscales in the questionnaires showed improvement. We found equality between robot-assisted rectopexy and laparoscopic rectopexy in most relevant outcome measures, which does not justify the added cost of the routine use of robots in rectopexy operations. The health-related quality of life and cost-utility analysis in our cohort indicated, however, that in long-term the technique may be cost-effective. The functional results are retained in the long term. The rate of recurrences (7.1%) and complications (10%) are acceptable and mesh-related complications (1.4%) are rare. Denovo symptoms, such as the urge to defecate or urinary incontinence, may arise, while urinary symptoms may be alleviated. In the long-run, patients with external rectal prolapse benefit more than patients with internal rectal prolapse. In part, the results of this thesis support using a multidisciplinary approach in examining patients with posterior pelvic floor dysfunction. Furthermore, the indications for robotic use in rectopexy operations need to be explored in larger patient samples.Tiivistelmä Rektumprolapsi ja peräsuolen sisäinen tuppeuma eli interni prolapsi aiheuttavat hankalia oireita, kuten ulostusvaikeuksia, ulosteinkontinenssia ja lantion kipua. Elämänlaatua heikentäviä oireita esiintyy usein samanaikaisesti myös muissa lantion osissa. Robottiavusteinen kirurgia tarjoaa paremmat leikkausolosuhteet lantion ahtaassa tilassa tehtävään rektopeksialeikkaukseen ja mahdollisesti edut voivat näkyä leikkaustuloksessa. Tässä väitöskirjassa vertailimme robottiavusteista ja laparoskooppista leikkaustekniikkaa oppimiskäyrän alkuvaiheessa käyttökelpoisuustutkimuksessa kaltaistetussa parivertailuasetelmassa (n = 40, seuranta-aika 3 kk) sekä prospektiivisessa randomoidussa tutkimussarjassa (n = 33, seuranta-aika 24 kk). Monikeskustutkimuksessa (n = 508, seuranta-ajan mediaani 44 kk) selvitimme laajassa aineistossa laparoskooppisen ventraalisen rektopeksian pitkäaikaistuloksia liittämällä aineiston analyysiin poikkileikkauskyselytutkimuksen tulokset. Randomoidussa sarjassa MR-defekografialla todennettiin, että rektopeksialeikkauksen jälkeen peräsuolen sisäinen tuppeuma, rektoseele ja enteroseele korjaantuvat. Rektopeksialeikkaus palauttaa lantion taka- ja keskiosan anatomian, vähentää elinten dynaamista liikkuvuutta ja parantaa lantionpohjan toimintaa sekä oireisiin liittyvää elämänlaatua, erityisesti suolioireiden ja gynekologisten laskeumaoireiden osalta. Robottiavusteinen ja laparoskooppinen tekniikka olivat samanvertaisia perioperatiivisten parametrien, komplikaatioiden, anatomisten ja toiminnallisten tulosten suhteen. Vaikka kustannusvertailussa kalliimpi robottikirurgia voi osoittautua kustannustehokkaaksi pitkäaikaisseurannassa, yhdenvertaiset tulokset eivät oikeuta menetelmää rutiinikäyttöön. Retrospektiivisen tutkimuksen poikkileikkauskyselyn mukaan toiminnalliset tulokset säilyvät pitkäaikaisseurannassa, residiivien (7,1 %) ja komplikaatioiden (10 %) määrä on hyväksyttävä ja verkkoon liittyviä komplikaatioita esiintyy vähän (1,4 %). Leikkauksen jälkeen ilmenee myös uusia oireita, kuten ulostuspakkoa tai virtsankarkailua. Toisaalta virtsankarkailuoire voi korjaantuakin. Pitkäaikaisseurannassa totaalin rektumprolapsin vuoksi leikatut potilaat hyötyvät leikkauksesta enemmän kuin oireisen internin prolapsin vuoksi leikatut. Osa väitöskirjatyön tuloksista tukee moniammatillisen lähestymistavan käyttöä potilaiden arvioinnissa. Jatkossa robottikirurgian käytön indikaatioita rektopeksialeikkauksissa tulisi arvioida isommissa potilasaineistoissa

Lantionpohjan toimintahäiriöt ovat yleisiä

Tiivistelmä Lantionpohjan toimintahäiriöitä ovat lantion laskeumat, virtsaamiseen, ulostamiseen ja seksuaalitoimintoihin liittyvät rakenteelliset ja toiminnalliset häiriöt sekä kiputilat. Vaivat ovat yleisiä, mutta vaiettuja. Virtsaamisen ja ulostamisen ongelmista tulee aktiivisesti kysyä. Tutkimisessa ja hoidossa tulee huomioida kaikki lantionpohjan osa-alueet. Konservatiivinen hoito ja fysioterapia perusterveydenhuollossa ovat hoidon kulmakivi. Kirurgialla, botuliinitoksiini- ja sakraalineuromodulaatiohoidolla voidaan parantaa elämänlaatua.Summary One in three women experience at least one pelvic floor disorder (PFD). PFDs include pelvic organ prolapse, urinary and fecal incontinence, bladder and bowel storage and evacuation problems, as well as pelvic pain and sexual dysfunction. Although benign conditions, their symptoms can greatly impair the quality of life and body image and cause restrictive behaviour. Symptoms are underreported owing to embarrassment and social stigma; therefore, they should be actively sought. Patients usually present with a variety of co-existing PFDs. The pathophysiology is multifactorial and complex, often a combination of genetic, anatomic, physiological, environmental, reproductive and life-style factors accumulating during the life-span. The most important risk factors are female gender, vaginal delivery, age and obesity. The evaluation should cover all pelvic floor compartments. Validated questionnaires facilitate symptom screening. In referral centres, management of complex cases by multidisciplinary teams is beneficial. Pelvic floor imaging and functional tests (e.g. defecography) are used to detect those structural and functional abnormalities that are not easily recognized during clinical examination (e.g. rectal intussusception). The management addresses all affected compartments and follows a step-wise approach. A selection of conservative measures including lifestyle and dietary modifications, bladder and bowel training programmes, medication and pelvic floor muscle training form the cornerstone of treatment. Pelvic floor surgery aims to restore anatomy and function and improve quality of life. Surgery for pelvic organ prolapse and stress urinary incontinence provides a high level of cure and patient satisfaction. However, recurrent pelvic organ prolapse remains a challenge for clinicians. Sacral neuromodulation and botulinum toxin injections are used to treat fecal incontinence and overactive bladder symptoms

Does ventral rectopexy improve pelvic floor function in the long term?

Abstract Background: Information is needed on long-term functional results, sequelas, and outcome predictors for laparoscopic ventral mesh rectopexy. Objective: The purpose of this study was to evaluate long-term function postventral rectopexy in patients with external rectal prolapse or internal rectal prolapse in a large cohort and to identify the possible effects of patient-related factors and operative technical details on patient-reported outcomes. Design: This was a retrospective review with a cross-sectional questionnaire study. Settings: Data were collated from prospectively collected registries in 2 university and 2 central hospitals in Finland. Patients: All 508 consecutive patients treated with ventral rectopexy for external rectal prolapse or symptomatic internal rectal prolapse in 2005 to 2013 were included. Interventions: A questionnaire concerning disease-related symptoms and effect on quality of life was used. Main outcome measures: Defecatory function measured by the Wexner score, the obstructive defecation score, and subjective symptom and quality-of-life evaluation using the visual analog scale were included. The effects of patient-related factors and operative technical details were assessed using multivariate analysis. Results: The questionnaire response rate was 70.7% (330/467 living patients) with a median follow-up time of 44 months. The mean Wexner scores were 7.0 (SD = 6.1) and 6.9 (SD = 5.6), and the mean obstructive defecation scores were 9.7 (SD = 7.6) and 12.3 (SD = 8.0) for patients presenting with external rectal prolapse and internal rectal prolapse. Subjective symptom relief was experienced by 76% and reported more often by patients with external rectal prolapse than with internal rectal prolapse (86% vs 68%; p < 0.001). Complications occurred in 11.4% of patients, and the recurrence rate for rectal prolapse was 7.1%. Limitations: This study was limited by its lack of preoperative functional data and suboptimal questionnaire response rate. Conclusions: Ventral mesh rectopexy effectively treats posterior pelvic floor dysfunction with a low complication rate and an acceptable recurrence rate. Patients with external rectal prolapse benefit more from the operation than those with symptomatic internal rectal prolapse. See Video Abstract at http://links.lww.com/DCR/A479

Restored pelvic anatomy is preserved after laparoscopic and robot‐assisted ventral rectopexy:MRI‐based 5‐year follow‐up of a randomized controlled trial

Abstract Aim: Our aim was to compare the long‐term anatomical outcomes between robot‐assisted ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR) for external or internal rectal prolapse. Method: This study is a follow‐up of a single‐centre randomized controlled trial (RCT). Thirty patients were randomly allocated to RVMR (n = 16) or LVMR (n = 14). The primary end‐point was maintenance of the restored pelvic anatomy 5 years after the operation, as assessed by magnetic resonance (MR) defaecography. Secondary outcome measures included the Pelvic Organ Prolapse Quantification (POP‐Q) measures and functional results assessed using symptom questionnaires. Results: Twenty‐six patients (14 RVMR and 12 LVMR) completed the 5‐year follow‐up and were included in the study. The MRI results, POP‐Q measurements and symptom‐specific quality of life measures did not differ between the RVMR and LVMR groups. The MRI measurements of the total study population remained unchanged between 3 months and 5 years. In the Pelvic Floor Distress Inventory (PFDI‐20), the RVMR group had lower symptom scores (mean 96.0, SD 70.7) than the LVMR group (mean 160.6, SD 58.9; P = 0.004). In the subscales of pelvic organ prolapse (POPDI‐6) (mean 23.2, SD 24.3 vs mean 52.4, SD 22.4; P = 0.001) and the Colorectal–Anal Distress Inventory (CRADI‐8) (mean 38.4, SD 23.3 vs mean 58.6, SD 25.4; P = 0.009), the patients in the RVMR group had significantly better outcomes. Conclusions: After VMR, the corrected anatomy was preserved. There were no clinically significant differences in anatomical results between the RVMR and LVMR procedures 5 years after surgery based on MR defaecography. However, functional outcomes were better after RMVR

Cost-analysis and quality of life after laparoscopic and robotic ventral mesh rectopexy for posterior compartment prolapse:a randomized trial

Abstract Background: The aim of this study was to assess, whether robotic-assistance in ventral mesh rectopexy adds benefit to laparoscopy in terms of health-related quality of life (HRQoL), cost-effectiveness and anatomical and functional outcome. Methods: A prospective randomized study was conducted on patients who underwent robot-assisted ventral mesh rectopexy (RVMR) or laparoscopic ventral mesh rectopexy (LVMR) for internal or external rectal prolapse at Oulu University Hospital, Finland, recruited in February–May 2012. The primary outcomes were health care costs from the hospital perspective and HRQoL measured by the 15D-instrument. Secondary outcomes included anatomical outcome assessed by pelvic organ prolapse quantification method and functional outcome by symptom questionnaires at 24 months follow-up. Results: There were 30 females (mean age 62.5 years, SD 11.2), 16 in the RVMR group and 14 in the LVMR group. The surgery-related costs of the RVMR were 1.5 times higher than the cost of the LVMR. At 3 months the changes in HRQoL were ‘much better’ (RVMR) and ‘slightly better’ (LVMR) but declined in both groups at 2 years (RVMR vs. LVMR, p > 0.05). The cost-effectiveness was poor at 2 years for both techniques, but if the outcomes were assumed to last for 5 years, it improved significantly. The incremental cost-effectiveness ratio for the RVMR compared to LVMR was €39,982/quality-adjusted life years (QALYs) at 2 years and improved to €16,707/QALYs at 5 years. Posterior wall anatomy was restored similarly in both groups. The subjective satisfaction rate was 87% in the RVMR group and 69% in the LVMR group (p = 0.83). Conclusions: Although more expensive than LVMR in the short term, RVMR is cost-effective in long-term. The minimally invasive VMR improves pelvic floor function, sexual function and restores posterior compartment anatomy. The effect on HRQoL is minor, with no differences between techniques

A prospective pilot study on MRI visibility of iron oxide-impregnated polyvinylidene fluoride mesh after ventral rectopexy

Abstract Background: Magnetic resonance imaging (MRI) provides excellent information about pelvic anatomy after ventral rectopexy, but the position of the conventional mesh is not seen constantly. Iron oxide-impregnated polyvinylidene fluoride (PVDF) meshes are proven to have MRI visibility in hernia or vaginal reconstructive surgery. This prospective pilot study was designed to assess the visualization, position, and shape of the magnetic resonance (MR)–visible synthetic pelvic mesh used in minimally invasive ventral rectopexy. Methods: Eight patients with pelvic organ prolapse were recruited for laparoscopic (LVMR) or robotic-assisted ventral mesh rectopexy (RVMR) with a synthetic MR–visible PVDF mesh. A follow-up visit was scheduled at 3 months after surgery. MR imaging was performed to evaluate the position and dimensions of the mesh and anatomical result. The visibility of the mesh in each sequence was assessed subjectively. Results: The visibility of the mesh was best on T1-weighted flash images. The mesh was also well visualized on T2-weighted sagittal images. T2-weighted images, in general, provided best visualization of the surrounding anatomical structures and enabled assessment of the mesh fixation. Conclusions: T2 sagittal and T1-weighted flash images provide the best information about the position and integrity of the iron oxide-impregnated PVDF mesh after LVMR or RVMR with a short examination time

X-ray video defaecography is superior to magnetic resonance defaecography in the imaging of defaecation disorders

Abstract Aim: The aim of this work was to study the technical success and diagnostic capability of magnetic resonance defaecography (MRD) compared with video defaecography (VD). Method: Sixty four women with defaecation disorders underwent both MRD and x-ray VD over 1 year. The assessment by two radiologists in consensus was retrospective and blinded. The technical success of straining and evacuation was evaluated subjectively. The presence of enterocele, intussusception, rectocele and dyssynergic defaecation was analysed according to established criteria, with VD as the standard of reference. Results: It was found that 62/64 (96.9%) VD studies were technically fully diagnostic compared with 29/64 (45.3%) for MRD. The number of partially diagnostic studies was 1/64 (1.6%) for VD versus 21/64 (32.8%) for MRD, with 1/64 (1.6%) (VD) and 14/64 (21.9%) (MRD) being nondiagnostic. Thirty enteroceles were observed by VD compared with seven in MRD with moderate agreement (κ = 0.41). Altogether 53 intussusceptions were observed by VD compared with 27 by MRD with poor agreement (κ = −0.10 and κ = 0.02 in recto-rectal and recto-anal intussusception, respectively). Moderate agreement (κ = 0.47) was observed in diagnosing rectocele, with 47 cases by VD and 29 by MRD. Dyssynergic defaecation was observed in three patients by VD and in 11 patients by MRD, with slight agreement (κ = 0.14). Conclusions: The technical success and diagnostic capabilities of VD are better than those of MRD. VD remains the method of choice in the imaging of defaecation disorders

Robotic versus laparoscopic surgery for severe deep endometriosis:protocol for a randomised controlled trial (ROBEndo trial)

Abstract Introduction: Endometriosis is a common gynaecological disease affecting around 10% of fertile-aged women, causing severe pain symptoms. Deep endometriosis is defined as endometriotic implants that infiltrate the underlying organs more than 5 mm in depth. Surgery for deep endometriosis requires advanced multidisciplinary surgical technique, often in very difficult surgical conditions, with increased risks of complications. Robotic surgery offers a high-definition three-dimensional view and articulating instruments that may allow more precise dissection than conventional laparoscopy in the pelvic area. The superiority of robotic surgery has not, however, been provedin randomised controlled studies, and there is a lack of long-term outcome data. Advanced endometriosis surgery offers an excellent platform to study the feasibility and long-term outcomes of robotic surgery compared with conventional laparoscopy. Methods and analysis: ROBEndo is a prospective, randomised, controlled clinical trial in a single-centre setting. Patients with deep endometriosis verified by MRI needing surgery at Oulu University Hospital (Oulu, Finland) will be considered eligible. 70 patients will be allocated 1:1 to receive either robotic-assisted or conventional laparoscopic surgery in two strata: radical surgery (with the removal of the uterus and adnexae) and gynaecological organ-sparing surgery. The primary outcome will be the surgical outcome as regards to pain symptoms measured on numeric rating scale (NRS) questionnaires at 24 hours and 6, 12 and 24 months postoperatively. As secondary outcomes, intraoperative measures, enhanced recovery after surgery factors, complications, cost and long-term quality of life measured with Endometriosis Health Profile-30 (EHP-30), Female Sexual Function Index (FSFI) and 15-dimensional (15D) questionnaires will be compared. Ethics and dissemination: This study has been approved by the Northern Ostrobothnian Hospital District Ethical Committee at Oulu University Hospital (212/2021). Informed consent will be obtained during the preoperative check-up by the operating gynaecologist. The results will be published in peer-reviewed international journals. Trial registration number: NCT05179109

Mid-term functional and quality of life outcomes of robotic and laparoscopic ventral mesh rectopexy:multicenter comparative matched-pair analyses

Abstract Background: The aim of this study was to compare patients’ mid-term functional and quality of life (QoL) outcomes following robotic ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR). Methods: The data of consecutive female patients who underwent minimally invasive ventral mesh rectopexy for external or symptomatic internal rectal prolapse at 3 hospitals in Finland between January 2011 and December 2016 were retrospectively collected. Patients were matched by age and diagnosis at a 1:1 ratio. A disease-related symptom questionnaire was sent to all living patients at follow-up in July 2018. Results: After a total of 401 patients (RVMR, n = 187; LVMR, n = 214) were matched, 152 patients in each group were included in the final analyses. The median follow-up times were 3.3 (range 1.6–7.4) years and 3.0 (range 1.6–7.6) years for the RVMR and LVMR groups, respectively. The postoperative QoL measures did not differ between the groups. Compared with the LVMR group, the RVMR group had lower postoperative Wexner Incontinence Score (median 5 vs. median 8; p < 0.001), experienced significant ongoing incontinence symptoms less often (30.6% vs. 49.0%; p < 0.001) and reported less postoperative faecal incontinence discomfort evaluated with the visual analogue scale (median 11 vs. median 39; p = 0.005). RVMR patients had a shorter hospital stay (2.2 days vs. 3.8 days; p < 0.001) but experienced more frequent de novo pelvic pain (31.8% vs. 11.8%; p < 0.001). Conclusion: RVMR and LVMR patients had equal functional and QoL outcomes. Those who underwent RVMR had lower mid-term anal incontinence symptom scores but suffered more frequent de novo pelvic pain