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Meta-Analysis
. 2015 Nov 24;2015(11):CD001758.
doi: 10.1002/14651858.CD001758.pub3.

Surgery for complete (full-thickness) rectal prolapse in adults

Samson Tou  1 , Steven R Brown, Richard L Nelson
Affiliations
Meta-Analysis

Surgery for complete (full-thickness) rectal prolapse in adults

Samson Tou et al. Cochrane Database Syst Rev. .

Abstract

Background: Complete (full-thickness) rectal prolapse is a lifestyle-altering disability that commonly affects older people. The range of surgical methods available to correct the underlying pelvic floor defects in full-thickness rectal prolapse reflects the lack of consensus regarding the best operation.

Objectives: To assess the effects of different surgical repairs for complete (full-thickness) rectal prolapse.

Search methods: We searched the Cochrane Incontinence Group Specialised Register up to 3 February 2015; it contains trials from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) as well as trials identified through handsearches of journals and conference proceedings. We also searched EMBASE and EMBASE Classic (1947 to February 2015) and PubMed (January 1950 to December 2014), and we specifically handsearched theBritish Journal of Surgery (January 1995 to June 2014), Diseases of the Colon and Rectum (January 1995 to June 2014) and Colorectal Diseases (January 2000 to June 2014), as well as the proceedings of the Association of Coloproctology meetings (January 2000 to December 2014). Finally, we handsearched reference lists of all relevant articles to identify additional trials.

Selection criteria: All randomised controlled trials (RCTs) of surgery for managing full-thickness rectal prolapse in adults.

Data collection and analysis: Two reviewers independently selected studies from the literature searches, assessed the methodological quality of eligible trials and extracted data. The four primary outcome measures were the number of patients with recurrent rectal prolapse, number of patients with residual mucosal prolapse, number of patients with faecal incontinence and number of patients with constipation.

Main results: We included 15 RCTs involving 1007 participants in this third review update. One trial compared abdominal with perineal approaches to surgery, three trials compared fixation methods, three trials looked at the effects of lateral ligament division, one trial compared techniques of rectosigmoidectomy, two trials compared laparoscopic with open surgery, and two trials compared resection with no resection rectopexy. One new trial compared rectopexy versus rectal mobilisation only (no rectopexy), performed with either open or laparoscopic surgery. One new trial compared different techniques used in perineal surgery, and another included three comparisons: abdominal versus perineal surgery, resection versus no resection rectopexy in abdominal surgery and different techniques used in perineal surgery.The heterogeneity of the trial objectives, interventions and outcomes made analysis difficult. Many review objectives were covered by only one or two studies with small numbers of participants. Given these caveats, there is insufficient data to say which of the abdominal and perineal approaches are most effective. There were no detectable differences between the methods used for fixation during rectopexy. Division, rather than preservation, of the lateral ligaments was associated with less recurrent prolapse but more postoperative constipation. Laparoscopic rectopexy was associated with fewer postoperative complications and shorter hospital stay than open rectopexy. Bowel resection during rectopexy was associated with lower rates of constipation. Recurrence of full-thickness prolapse was greater for mobilisation of the rectum only compared with rectopexy. There were no differences in quality of life for patients who underwent the different kinds of prolapse surgery.

Authors' conclusions: The lack of high quality evidence on different techniques, together with the small sample size of included trials and their methodological weaknesses, severely limit the usefulness of this review for guiding practice. It is impossible to identify or refute clinically important differences between the alternative surgical operations. Longer follow-up with current studies and larger rigorous trials are needed to improve the evidence base and to define the optimum surgical treatment for full-thickness rectal prolapse.

PubMed Disclaimer

Conflict of interest statement

Samson Tou: none known. Steven Brown: none known. Rick Nelson: none known.

Figures

1
1
PRISMA study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Conventional diathermy and handsewn rectosigmoidectomy versus harmonic scalpel and stapled technique, Outcome 1 Number of patients with recurrent full‐thickness prolapse.
1.2
1.2. Analysis
Comparison 1 Conventional diathermy and handsewn rectosigmoidectomy versus harmonic scalpel and stapled technique, Outcome 2 Incontinence score.
1.3
1.3. Analysis
Comparison 1 Conventional diathermy and handsewn rectosigmoidectomy versus harmonic scalpel and stapled technique, Outcome 3 Hospital stay.
1.4
1.4. Analysis
Comparison 1 Conventional diathermy and handsewn rectosigmoidectomy versus harmonic scalpel and stapled technique, Outcome 4 Recovery time.
1.5
1.5. Analysis
Comparison 1 Conventional diathermy and handsewn rectosigmoidectomy versus harmonic scalpel and stapled technique, Outcome 5 Number of patients with defecatory problems.
1.6
1.6. Analysis
Comparison 1 Conventional diathermy and handsewn rectosigmoidectomy versus harmonic scalpel and stapled technique, Outcome 6 Resting anal pressure (mmHg).
1.7
1.7. Analysis
Comparison 1 Conventional diathermy and handsewn rectosigmoidectomy versus harmonic scalpel and stapled technique, Outcome 7 Squeeze pressure (mmHg).
1.8
1.8. Analysis
Comparison 1 Conventional diathermy and handsewn rectosigmoidectomy versus harmonic scalpel and stapled technique, Outcome 8 Threshold volume (ml).
2.1
2.1. Analysis
Comparison 2 Comparisons of different perineal approaches, Outcome 1 Number of patients with recurrent full‐thickness prolapse.
2.2
2.2. Analysis
Comparison 2 Comparisons of different perineal approaches, Outcome 2 Number of patients with residual faecal incontinence.
2.3
2.3. Analysis
Comparison 2 Comparisons of different perineal approaches, Outcome 3 Number of patients with constipation after surgery.
2.4
2.4. Analysis
Comparison 2 Comparisons of different perineal approaches, Outcome 4 Operating time (min).
2.5
2.5. Analysis
Comparison 2 Comparisons of different perineal approaches, Outcome 5 Number of patients with postoperative complications.
2.6
2.6. Analysis
Comparison 2 Comparisons of different perineal approaches, Outcome 6 Length of hospital stay (days).
2.7
2.7. Analysis
Comparison 2 Comparisons of different perineal approaches, Outcome 7 Postoperative maximum resting pressure.
2.8
2.8. Analysis
Comparison 2 Comparisons of different perineal approaches, Outcome 8 Postoperative maximum squeeze pressure.
2.9
2.9. Analysis
Comparison 2 Comparisons of different perineal approaches, Outcome 9 Postoperative rectal sensation.
2.10
2.10. Analysis
Comparison 2 Comparisons of different perineal approaches, Outcome 10 Patient's postoperative satisfaction score.
2.11
2.11. Analysis
Comparison 2 Comparisons of different perineal approaches, Outcome 11 Number of patients with recurrent full‐thickness prolapse.
2.12
2.12. Analysis
Comparison 2 Comparisons of different perineal approaches, Outcome 12 Vaizey incontinence score 3 years post‐op.
2.13
2.13. Analysis
Comparison 2 Comparisons of different perineal approaches, Outcome 13 Bowel function (bowel thermometer) 3 years post‐op.
2.14
2.14. Analysis
Comparison 2 Comparisons of different perineal approaches, Outcome 14 Quality of life score (EQ‐5D) at 3 years.
3.1
3.1. Analysis
Comparison 3 Open abdominal Ivalon sponge rectopexy versus open abdominal suture rectopexy, Outcome 1 Number of patients with recurrent full‐thickness prolapse.
3.2
3.2. Analysis
Comparison 3 Open abdominal Ivalon sponge rectopexy versus open abdominal suture rectopexy, Outcome 2 Number of patients with postoperative faecal incontinence.
3.3
3.3. Analysis
Comparison 3 Open abdominal Ivalon sponge rectopexy versus open abdominal suture rectopexy, Outcome 3 Number of patients with constipation after surgery.
3.4
3.4. Analysis
Comparison 3 Open abdominal Ivalon sponge rectopexy versus open abdominal suture rectopexy, Outcome 4 Number of patients with postoperative complications.
4.1
4.1. Analysis
Comparison 4 Open abdominal polyglycolic acid mesh versus open polyglactin or polypropylene mesh rectopexy, Outcome 1 Number of patients with recurrent full‐thickness prolapse.
4.2
4.2. Analysis
Comparison 4 Open abdominal polyglycolic acid mesh versus open polyglactin or polypropylene mesh rectopexy, Outcome 2 Number of patients with residual mucosal prolapse.
4.3
4.3. Analysis
Comparison 4 Open abdominal polyglycolic acid mesh versus open polyglactin or polypropylene mesh rectopexy, Outcome 3 Number of patients with residual faecal incontinence.
4.4
4.4. Analysis
Comparison 4 Open abdominal polyglycolic acid mesh versus open polyglactin or polypropylene mesh rectopexy, Outcome 4 Incontinence score.
4.5
4.5. Analysis
Comparison 4 Open abdominal polyglycolic acid mesh versus open polyglactin or polypropylene mesh rectopexy, Outcome 5 Number of patients with constipation after surgery.
4.6
4.6. Analysis
Comparison 4 Open abdominal polyglycolic acid mesh versus open polyglactin or polypropylene mesh rectopexy, Outcome 6 Number of patients with postoperative complications.
5.1
5.1. Analysis
Comparison 5 Preservation versus division of the lateral ligaments during open mesh rectopexy, Outcome 1 Number of patients with recurrent full‐thickness rectal prolapse.
5.2
5.2. Analysis
Comparison 5 Preservation versus division of the lateral ligaments during open mesh rectopexy, Outcome 2 Number of patients with residual mucosal prolapse only.
5.3
5.3. Analysis
Comparison 5 Preservation versus division of the lateral ligaments during open mesh rectopexy, Outcome 3 Number of patients with constipation.
5.4
5.4. Analysis
Comparison 5 Preservation versus division of the lateral ligaments during open mesh rectopexy, Outcome 4 Constipation score.
5.5
5.5. Analysis
Comparison 5 Preservation versus division of the lateral ligaments during open mesh rectopexy, Outcome 5 Number of patients with postoperative complications.
5.6
5.6. Analysis
Comparison 5 Preservation versus division of the lateral ligaments during open mesh rectopexy, Outcome 6 Defecation frequency (per day).
5.7
5.7. Analysis
Comparison 5 Preservation versus division of the lateral ligaments during open mesh rectopexy, Outcome 7 Resting anal pressure (mmHg).
5.8
5.8. Analysis
Comparison 5 Preservation versus division of the lateral ligaments during open mesh rectopexy, Outcome 8 Anal squeeze pressures (mmHg).
5.9
5.9. Analysis
Comparison 5 Preservation versus division of the lateral ligaments during open mesh rectopexy, Outcome 9 Compliance (ml/mmHg).
6.1
6.1. Analysis
Comparison 6 Laparoscopic versus open procedure, Outcome 1 Number of patients with recurrent full‐thickness prolapse.
6.2
6.2. Analysis
Comparison 6 Laparoscopic versus open procedure, Outcome 2 Number of patients with residual mucosal prolapse only.
6.3
6.3. Analysis
Comparison 6 Laparoscopic versus open procedure, Outcome 3 Incontinence score.
6.4
6.4. Analysis
Comparison 6 Laparoscopic versus open procedure, Outcome 4 Number of patients with constipation after surgery.
6.5
6.5. Analysis
Comparison 6 Laparoscopic versus open procedure, Outcome 5 Operating time (min).
6.6
6.6. Analysis
Comparison 6 Laparoscopic versus open procedure, Outcome 6 Number of patients with postoperative complications.
6.7
6.7. Analysis
Comparison 6 Laparoscopic versus open procedure, Outcome 7 Length of hospital stay (days).
6.8
6.8. Analysis
Comparison 6 Laparoscopic versus open procedure, Outcome 8 Maximum resting anal pressure (cmH2O).
6.9
6.9. Analysis
Comparison 6 Laparoscopic versus open procedure, Outcome 9 Maximum squeeze pressure.
6.10
6.10. Analysis
Comparison 6 Laparoscopic versus open procedure, Outcome 10 Maximum rectal volume (ml).
6.11
6.11. Analysis
Comparison 6 Laparoscopic versus open procedure, Outcome 11 Rectal capacity (ml).
6.12
6.12. Analysis
Comparison 6 Laparoscopic versus open procedure, Outcome 12 Total cost (USD).
7.1
7.1. Analysis
Comparison 7 Abdominal versus perineal approach, Outcome 1 Number of patients with recurrent full‐thickness prolapse.
7.2
7.2. Analysis
Comparison 7 Abdominal versus perineal approach, Outcome 2 Number of patients with recurrent full‐thickness prolapse.
7.3
7.3. Analysis
Comparison 7 Abdominal versus perineal approach, Outcome 3 Number of patients with residual mucosal prolapse only.
7.4
7.4. Analysis
Comparison 7 Abdominal versus perineal approach, Outcome 4 Vaizey incontinence score 3 years post‐op.
7.5
7.5. Analysis
Comparison 7 Abdominal versus perineal approach, Outcome 5 Number of patients with residual faecal incontinence.
7.6
7.6. Analysis
Comparison 7 Abdominal versus perineal approach, Outcome 6 Complications requiring surgical interventions.
7.7
7.7. Analysis
Comparison 7 Abdominal versus perineal approach, Outcome 7 Number of patients with postoperative complications.
7.8
7.8. Analysis
Comparison 7 Abdominal versus perineal approach, Outcome 8 Bowel function (bowel thermometer) 3 years post‐op.
7.9
7.9. Analysis
Comparison 7 Abdominal versus perineal approach, Outcome 9 Straining at 3 years post‐op.
7.10
7.10. Analysis
Comparison 7 Abdominal versus perineal approach, Outcome 10 Maximum resting pressure (cmH2O).
7.11
7.11. Analysis
Comparison 7 Abdominal versus perineal approach, Outcome 11 Maximum squeeze pressure (cmH2O).
7.12
7.12. Analysis
Comparison 7 Abdominal versus perineal approach, Outcome 12 Rectal compliance (ml/cmH2O).
7.13
7.13. Analysis
Comparison 7 Abdominal versus perineal approach, Outcome 13 Quality of life score (EQ‐5D) at 3 years.
8.1
8.1. Analysis
Comparison 8 Resection versus no resection rectopexy, Outcome 1 Number of patients with recurrent full‐thickness prolapse.
8.2
8.2. Analysis
Comparison 8 Resection versus no resection rectopexy, Outcome 2 Number of patients with residual faecal incontinence.
8.3
8.3. Analysis
Comparison 8 Resection versus no resection rectopexy, Outcome 3 Vaizey incontinence score 3 years post‐op.
8.4
8.4. Analysis
Comparison 8 Resection versus no resection rectopexy, Outcome 4 Number of patients with constipation due to surgery.
8.5
8.5. Analysis
Comparison 8 Resection versus no resection rectopexy, Outcome 5 Number of patients with postoperative complications.
8.6
8.6. Analysis
Comparison 8 Resection versus no resection rectopexy, Outcome 6 Bowel function (bowel thermometer) 3 years post‐op.
8.7
8.7. Analysis
Comparison 8 Resection versus no resection rectopexy, Outcome 7 Maximum resting anal pressure (mmHg).
8.8
8.8. Analysis
Comparison 8 Resection versus no resection rectopexy, Outcome 8 Maximum rectal volumes (ml).
8.9
8.9. Analysis
Comparison 8 Resection versus no resection rectopexy, Outcome 9 Volume to first sensation (ml).
8.10
8.10. Analysis
Comparison 8 Resection versus no resection rectopexy, Outcome 10 Anorectal angle (postoperative).
8.11
8.11. Analysis
Comparison 8 Resection versus no resection rectopexy, Outcome 11 Rectal compliance (mmHg/ml).
8.12
8.12. Analysis
Comparison 8 Resection versus no resection rectopexy, Outcome 12 Postoperative transit time (days).
8.13
8.13. Analysis
Comparison 8 Resection versus no resection rectopexy, Outcome 13 Quality of life score (EQ‐5D) at 3 years.
9.1
9.1. Analysis
Comparison 9 Rectopexy versus no rectopexy, Outcome 1 Number of patients with recurrent full‐thickness prolapse.
9.2
9.2. Analysis
Comparison 9 Rectopexy versus no rectopexy, Outcome 2 Mortality.
9.3
9.3. Analysis
Comparison 9 Rectopexy versus no rectopexy, Outcome 3 Number of patients with complications.
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Update of

References

References to studies included in this review

Boccasanta 1998 {published data only}
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Gupta 2006 {published data only}
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