Approach to Concomitant Vaginal and Rectal Prolapse: Does Concomitant Surgery Work Best? If Not, Which Compartment Should be Addressed First?

Multi-compartment pelvic floor dysfunction (PFD) is frequently seen by the practicing urogynecologist. Co-existence of urinary incontinence (UI) and vaginal prolapse (VP) is an accepted – and even expected – finding in women who present for care. Fecal incontinence is also frequently present but may require specific questioning in order to be identified – at least during an initial patient-doctor interaction. Rectal prolapse is considered to be a more advanced form of PFD (Gonzalez-Argente et al 2001) It is a less commonly encountered, but very frequently associated with UI and/or VP.

Most experts recommend that concomitant RP and VP should be corrected in one combined surgical procedure to avoid sequential surgeries and their associated increased morbidities. This, of course, unless contraindicated by associated co-morbidities which may limit surgical time, blood loss, etc. (i.e., when a colpocleisis alone is performed under local anesthesia). In my experience, the extended operative time required for a combined procedure is well-tolerated as long as preoperative medical clearance does not warn against it.

Most urogynecologists are not trained in the performance of RP repairs, by either abdominal or perineal route. Thus, a combined team with a colorectal surgeon (CRS) is typically needed for the combined procedure. Preoperative evaluation should be completed by both teams, and preoperative planning is key in order to allow for a smooth combined procedure. Key factors to be discussed include antibiotic prophylaxis, surgical positioning, order of interventions, potential use of mesh vs. suture suspension, and order of procedural dissection and repair. The two commonly used approaches have unique attributes to be considered:

1. Younger, low risk patients undergoing abdominal suspension. This typically involves a sacrocolpopexy (ASC) and a rectopexy. How to “share the sacrum” should be planned preoperatively. In my experience, it is best to allow the CRS to complete the rectal dissection, mobilization, and placement of the lateral rectal sutures first. If a suture suspension will be performed, the lateral suspension sutures can be attached to the lateral sacrum, and tied later in the case after the ASC is completed, as the ASC dissection can further mobilize the rectum limiting the degree of rectal suspension. If the ASC mesh is to be “shared,” then the rectal suspension sutures can be attached to the lateral edges of the mesh once the ASC is completed, before reperitonealization. If a resection RP is needed due to redundant sigmoid, great care must be taken to avoid/limit contamination of the operative field, especially if a mesh ASC is to be performed. In our experience, mesh use is not contraindicated when a resection RP is performed, but meticulous surgical technique, irrigation, and extended antibiotic use is recommended.
2. Older, higher risk patients undergoing vaginal/perineal repair. Positioning becomes important as some CRS prefer the prone position for the perineal resection (requiring “flipping” the patient for the vaginal repair), while others can perform the procedure in lithotomy position. In my experience, if a posterior colporrhaphy is going to be needed, then the perineal resection should be performed first, as the needed dissection could disrupt any previously placed sutures from the posterior vaginal wall repair. The urogynecologist should be careful during the posterior colporrhaphy to avoid cutting any of the resection sutures, or sphincteroplasty sutures if a sphincter repair was also performed by the CRS.

This is the clinical situation where the multi-disciplinary team approach to PFD is most appropriate and has been demonstrated to lead to improved patient outcomes.

REFERENCES

Gonzalez-Argente Fx, Jain A, Nogueras JJ, Davila GW, Weiss EG, Wexner SD. Prevalence and severity of urinary incontinence and pelvic genital prolapse in females with anal incontinence or rectal prolapse. Dis Col Rectum. 2001;44(7):920-6.

SUGGESTED READING

Ghoniem GM, Davila GW. Guide to Pelvic Floor Disorders and Diseases. Martin Dunitz, 2006.

Lim M, Sagar P, Gonsavles S, Thekkinkattil D, Landon C. Surgical Management of Pelvic Organ Prolapse in Females: Functional Outcome of Mesh Sacrocolpoexy and Rectopexy as a Combined Procedure. Dis Colon Rectum. 2007;50:1412-21.

Ossin D, Davila GW. Multidisciplinary approach to pelvic organ prolapse – when and how?’

In: Gomes da Silveira G, Gomes da Silveria G, Arenhart Pessini S. Minimally Invasive Gynecology – An Evidence-based Approach. Springer, 2018.