Rectal prolapse in search of the holy Grail
The treatment of (internal and external) rectal prolapse (IRP/ERP), and its affiliated rectocele and enterocele, has become an increasingly important part of health care over the years. Although benign, rectal prolapse is associated with a myriad of debilitating symptoms including fecal incontinence, obstructed defecation syndrome and pelvic discomfort. Considering the increasing prevalence, the high costs and the major impact on the quality of life, prolapse of the posterior compartment of the pelvic floor constitutes a significant health issue.
A proper pre-operative assessment is crucial. Physical examination has its limitations and therefore dynamic imaging plays an important role. The two most commonly used techniques, conventional dynamic defecography (CD) and dynamic magnetic resonance imaging (D-MRI), were compared but no superiority was found of either technique. Based on our study and the literature it appears that CD and D-MRI are complementary imaging modalities in the evaluation of patients with symptoms of prolapse of the posterior compartment.
The difficulty in treating rectal prolapse is shown by the astounding number of surgical procedures—more than 300—that have been developed. The Dutch prolapse guideline, incorporated in this thesis, concluded high-quality evidence on rectal prolapse surgery is lacking. Based on observational series and expert opinion Laparoscopic Ventral Mesh Rectopexy (LVMR) is recommended as the first choice to treat high-grade symptomatic IRP and ERP in the Netherlands. In this thesis, the literature and our studies show that both LVMR as Robot-Assisted Ventral Mesh Rectopexy are safe and effective on the long term in large cohorts of patients.
Rectal prolapse frequently occurs with prolapses of other compartments. A multi-compartment assessment of the pelvic floor before planning surgical repair in every patient with a prolapse is essential to avoid possible under-treatment. To date no standardised multi-compartment procedure exists. In this thesis we show a significant improvement of quality of life, functional and sexual outcomes following Robot-Assisted Sacrocolporectopexy (RSCR) for multi-compartment prolapse.
In recent years the public opinion has turned against synthetic grafts based on high mesh erosion rates following transvaginal repair. We show, however, that synthetic meshes for abdominal pelvic reconstructive surgery are safe in the long-term.
