Early safety and efficiency outcomes of a novel interdisciplinary laparoscopic resection rectopexy combined with sacrocolpopexy for women with obstructive defecation syndrome and pelvic organ prolapse: a single center study

Abstract

Background: Obstructive defecation syndrome (ODS) defines a disturbed defecation process frequently associated with pelvic organ prolapse (POP) in women that substantially compromises quality of life. Conservative management offers limited relief and a surgical intervention may be required. This is characterized by individual approaches. AIM OF THE STUDY: This retrospective single center study evaluated the surgical and clinical short-term outcome of a novel interdisciplinary laparoscopic resection rectopexy (L-RRP) with mesh- sacrocolpopexy (L-SCP) for women suffering from ODS and POP.

Methods: The study participants underwent surgery in an interdisciplinary laparoscopic approach. Safety was the primary endpoint, assessed via postoperative morbidity classified by Clavien-Dindo scale. Secondary outcomes included evaluation of bowel function, fecal and urinary incontinence and pelvic organ prolapse status at 12 months follow-up. Additionally, a biological mesh (BM) was offered to women, who asked for an alternative to synthetic mesh material (SM).

Results: Of the 44 consecutive patients requiring surgery for ODS and POP, 36 patients underwent the interdisciplinary surgical approach; 28 patients with SM and 8 patients with BM. In total 5 complications occurred, four of them were classified as minor. One minor complication was observed in the BM group. One anastomotic leakage occurred in the SM group. The two ODS scores, the bowel dysfunction score, and the incontinence score improved significantly (p = 0.006, p = 0.003, p < 0.001, and p = 0.0035, respectively). Pelvic floor anatomy was fully restored (POP-Q 0) for 29 (80%) patients after surgery. 17 patients (47%) suffered from urinary incontinence before surgery, which was restored in 13 patients (76.5%).

Conclusions: The interdisciplinary approach with L-RRP and L-SCP and the use of a BM in a small subgroup were technically feasible, safe, and effective in this single center setting. The study's retrospective design, the small sample size and the lack of comparators limit the generalizability of the findings requiring future randomized trials.

Trial registration: Retrospectively registered at clinicaltrials.gov, trial number NCT05910021, date of registration 06/10/2023.

Keywords: Biological mesh; Obstructed defecation syndrome; Pelvic organ prolapse; Resection rectopexy; Sacrocolpopexy; Synthetic mesh.

Fig. 1

Flowchart of the study. 44 women suffering from obstructed defecation syndrome (ODS) and pelvic organ prolapse (POP) presented to the tertiary pelvic floor center after failure of conservative treatment. All 36 patients, who received laparoscopic resection rectopexy (L-RRP) and sacropexy (L-SCP) were enrolled in the study. 28 patients received a synthetic mesh (SM) for the L-SCP; in 8 patients a biological mesh (BM) was used

Fig. 2

Magnetic resonance image defecography (MRI-D) in sagittal view of a female pelvis with obstructed defecation syndrome (ODS) and pelvic organ prolapse (POP) before surgery. The red dotted arrow marks the pubo-coccygeal line. The white asterisk marks the uterus, the black star marks the filled rectum (ultrasound gel), and the white star marks the excreted ultrasound gel. Figure 2A shows the position at rest, 2B shows the defecation process and descending of the rectum and uterus, and 2C shows the excreted ultrasound gel

Fig. 3

Sagittal view of the female pelvis with obstructed defecation syndrome (ODS) and pelvic organ prolapse (POP) before and after the combined laparoscopic resection rectopexy (L-RRP) and sacrocolpopexy (L-SCP) as well as intraoperative laparoscopic pictures. A. The black dotted arrow marks the elongated and descending sigma, and the black star marks the descending uterus before the combined surgical procedure. The right picture shows the elongated sigma completely filling the small pelvis. B. The black arrow marks the sigma anastomosis after resection, but before rectopexy. The black star marks the descending uterus. C. The black arrow marks the sigma after L-RRP. The black asterisk marks the synthetic mesh for L-SCP, in the depict case a hysteropexy. On the laparoscopic picture a white asterisk marks the synthetic mesh. The mesh is placed unilaterally on the right side of the small pelvis, fixed at the posterior cervix and the sacrum at the level of promontory / S1. The black star marks the elevated uterus after apical fixation

Fig. 4

The summarized results of the clinical bowel symptoms of the 36 patients with respect to the obstructed defecation syndrome (ODS), the functional bowel symptoms, and fecal incontinence are visualized below. The y-axis represents the numeric value of the score in 5-point steps. The boxplots are showing the median score values of the questionnaires for the Altomare score, the modified Longo ODS score, rectal toxicity score, and Wexner incontinence score depicted as boxplots pre- and postoperative (at 12 months

Fig. 5

The distribution of each individual score result for the Altomare score, the modified Longo ODS score, rectal toxicity score, and Wexner incontinence score before surgery and after 12 months follow up are shown in a linear diagram. The y-axis represents the value of the score in 5-point-steps. Each line represents one patient to give an impression of the individual outcome after the interdisciplinary surgical approach addressed in the study

Fig. 6

The value of the POP-Q score result before surgery and after 12 months follow up are shown in a linear diagram to give an impression of the outcome after the interdisciplinary surgical approach addressed in the study. The y-axis represents the value of the POP-Q score reaching from 0 to 4. The three patients with no change in the POP-Q score (horizontal lines) are not shown. The dotted line from POP-Q 3 drops to POP-Q 0 after 12 months represents one patient. Three patients in the SM group were improved, but not totally restored with respect to their POP (POP-Q 2 before surgery to POP-Q 1 after 12 months). No surgical re-intervention was wished for. The line POP-Q 1 to POP-Q 0 represents 12 Patients and the line POP-Q 2 to POP-Q 0 16 patients, who were all totally restored with respect to their POP at 12 months follow up.

Fig. 7

The clinical outcome for pelvic organ prolapse quantification system (POP-Q) stages (0 – IV) and urinary incontinence of the 36 patients are illustrated in a block diagram. The results are depicted pre- and postoperatively at 12 months follow-up after surgery