Assessment of feasibility of abdominal mesh vaginorectopexy in the repair of multiple pelvic organ prolapse

ABSTRACT Introduction Pelvic organ prolapse (POP) is the descent of one or more aspects of the vagina and uterus, while rectal prolapse (RP) is the protrusion of the rectum through the anal canal. Multiple POP is combined prolapse of more than one pelvic organ and it is ideally surgically treated. Vaginorectopexy is a modification of the classical ventral mesh rectopexy which may be used in case of combined prolapse of multiple pelvic organs where a polypropylene mesh is used to support pelvic tissues and repair prolapse. Aim To assess the feasibility of open abdominal mesh vaginorectopexy in the repair of multiple POP. Patients and methods This study was carried out on 20 female patients who underwent open abdominal mesh vaginorectopexy for the repair of multiple POP. Results All the cases who complained of complete RP and 90% of cases who complained of uterine prolapse were cured, while symptoms of obstructed defecation were significantly improved in 95% of cases, of which 35% were completely cured. Fecal incontinence was significantly improved in 100% and significantly cured in 80% of cases, urinary incontinence was significantly cured in 75% of cases, and 94.4% of the cases who presented with urinary symptoms (dysuria and urgency), were treated at 12 months post surgery. There was no statistically significant postoperative complications. Conclusion Abdominal mesh vaginorectopexy for the repair of multiple pelvic organ is feasible and can result in significant improvement of function and quality of life.


Introduction
Pelvic organ prolapse (POP) is the descent of one or more aspects of the vagina and uterus; there are different types of POP depending on which organ is bulging into the vagina such as cystocele, rectocele, uterine prolapse, and vault prolapse.It is common to have more than one type of organ prolapse at the same time [1,2].Rectal prolapse (RP) is the protrusion of the rectum through the anal canal, while multiple POP is combined prolapse of more than one pelvic organ [3,4].
POP and RP may occur together.A gynecological series reports a 6.1% incidence of RP among women with genital prolapse, while a coloproctological series reports that 48% of patients with RP suffer from genital prolapse [5,6].
The main cause of POP is weakness of the ligaments and muscles which support the pelvic organs [7].The treatment of prolapse of multiple pelvic organs is ideally surgical [8].
Vaginorectopexyis a modification of the classical ventral mesh rectopexy used in cases of RP.It may be done in case of combined prolapse of multiple pelvic organs where a polypropylene mesh is used to provide permanent support to the weakened organs and to repair prolapse [4,9].
Aim: The aim of this work was to assess the feasibility of open abdominal mesh vaginorectopexy in the repair of multiple POP.

Patients
This study was carried out on 20 female patients who underwent open abdominal mesh vaginorectopexy for the repair of multiple POP at our unit between September 2019 and January 2021.
Thorough history taking including personal data, age, complaints, past medical and surgical history, menstrual history, gynecological history, and drug history of all patients were recorded.Patients presented with obstructed defecation were classified into mild, moderate, and severe according to Renzi obstructed defecation score (Table 1) [10].While patients presented with fecal incontinence were classified into mild, moderate, and severe according to the Jorge-Wexner incontinence score.(Table 2) [11].
All patients were subjected to general systemic examination, digital rectal examination and pervaginal examination.They also underwent investigations in the form of routine laboratory tests, dynamic pelvic MRI, and pudendal nerve conduction test.Informed consent was taken from all patients.

Preoperative preparation
Colon preparation included specific diet, with reduced fiber content for 3 days before surgery, as well as purgative medication.Antibiotic and thromboembolic complications prophylaxis were achieved according to usual protocols.

Operative technique [9]
Proper exposure of the pelvis was achieved by anterior retraction of the uterus, exposing the pelvic excavation, thus facilitating peritoneal incision which was performed in this place.The rectum was mobilized down to the tip of the coccyx.The first step of the intervention was the opening of the presacral space, then posterior dissection was advanced through an avascular plane caudally to the pelvic floor, while the lateral rectal stalks were preserved.
Further, the dissection was realized anterior to the rectum, starting from the peritoneal incision, in the rectovaginal space, as close as possible to the vagina.It was important that anterior dissection of the rectum descended as caudal as possible, being known that RP affects especially the anteror wall and less the posterior wall.After the dissection of the anterior and posterior rectal wall, the excessive peritoneum that constituted the pouch of Douglas, which is very deep in these cases, was excised.
For suspension, Ethicon monofilament polypropylene mesh 15 × 15 cm was used, tailored with two arms, measuring about 13 cm each and attached first to the promontory, using stitches passed through the sacral ligament.The rectum was tractioned cranially, and the posterior arm of the mesh was lowered to be fixed to the anterior rectal wall with 3 or 4 nonabsorbable sutures.Vaginopexy was performed with the anterior arm of the mesh, which was fixed to the posterior wall of the vagina, using 2 or 3 nonabsorbable sutures as well.
The mesh should be covered entirely with peritoneum to prevent formation of visceral adhesions and eventual erosive complications.Also, the approximation of the peritoneal edges should be perfect to avoid peritoneal breaches which could present an occlusive potential by engagement of intestinal loops.Drainage was achieved using a tube drain placed in the pelvic cavity.
Postoperatively, it was recommended to avoid physical efforts for 3 months, to have a liquid-rich diet to combat constipation, to have sexual rest for 6 weeks, and Kegel exercises were also indicated.All patients were evaluated at 2nd week, 1st, 3rd, 6th and 12th month after surgery.At each visit, improvement of symptoms, complications, and recurrence were evaluated.

Statistical analysis of the data
Data were analyzed using IBM SPSS software package version 20.0.(Armonk, NY: IBM Corp).Qualitative data were described using number and percent.Shapiro-Wilk test was used to verify the normality of distribution.Quantitative data were described using range (minimum and maximum), mean, standard deviation, median, and interquartile range.Significance of the obtained results was judged at the 5% level.
McNemar and Marginal homogeneity test was used to analyze the significance between the different stages, while Chi-square test was used for categorical variables, to compare between different groups.
The patients underwent open abdominal mesh vaginorectopexy with an operative time which ranged from 90 to 110 mins with a mean of 100.50 ± 6.67 min, and a post-operative hospital stay which ranged from 2 to 3 days with a mean of 2.30 ± 0.47 min.
All the cases who complained of complete RP were cured with no clinical recurrence occurred, 90% of cases who complained of uterine prolapse were cured, and only 10% of cases had relapsed uterine prolapse after initial improvement which was not significant.The symptoms of obstructed defecation were significantly improved in 95% of cases, of which 35% were completely cured, while only 5% (1 case) had worse symptoms after initial improvement with no statistical significance.Cases with residual obstructed defecation symptoms were referred to the physical medicine department for biofeedback.
Fecal incontinence was significantly improved (100%) and a statistically significant cure (80%) was reached by the end of the follow-up period, 94.4% of the cases who presented with urinary symptoms (dysuria and urgency), were treated at 12 months post surgery; which was statistically significant, and urinary incontinence was significantly cured in 75% of cases at the end of follow-up period (Table 4).
There was no statistically significant post-operative complications, as none of the cases experienced mesh erosion, while only three cases had lower abdominal pain (15%), two cases had dyspareunia (10%), and one case had wound infection (5%) during the follow-up period and all of them were treated consevatively (Table 5).

Discussion
POP is a common problem which affects almost half of all women over 50 years of age, with a lifetime prevalence of 30-50% [2].Most surgical techniques are usually used to repair a single POP, while the majority of female patients usually suffer from simultaneous prolapse of more than one pelvic organ.
Complete RP in our study was completely cured with no clinical recurrence occurred.Lim et al. obtained the same results, as no recurrence of RP took place after mesh sacrocolporectopexy for the repair of combined RP and POP [4].Comparable results were also reported in a systemic review by Samaranayake et al, where the estimated recurrence rate of RP after ventral rectopexy was 3-5% and this was consistent with the results observed by Consten et al. in an observational study for long-term outcome after laparoscopic ventral mesh rectopexy [12,13].In our study, 90% of cases who complained of uterine prolapse were cured and only 10% of cases had relapsed uterine prolapse after initial improvement; a result consistent with results reported by many studies such as those conducted by Lim et al. [4], Zhioua et al. [14], and and Ayav et al. [15].
Obstructed defecation is a complex and multifactorial problem, and it is essential to differentiate between impaired colonic transit and pelvic floor dysfunction as shown in a review by D'Hoore, where it was pointed out that different mechanisms can eventually lead to obstructed defecation: defective rectal filling sensation, functional outlet obstruction, mechanical outlet obstruction, and finally the dissipation of force vector at straining [16,17].
Obstructed defecation symptoms in our study were improved in 95% and completely cured in 35% of cases, while only 5% (1 case) had worse symptoms after initial improvement.Shi-Jun et al. obtained comparable results where symptoms of obstructed defecation were resolved in 5 of 7 patients following laparoscopic vaginal suspension and rectopexy [18].Same results were recorded after laparoscopic ventral rectocolpopexy where symptoms of obstructed defecation resolved in 16 of 19 patients [19].
On the other hand, contradictory results were recorded by van den Esschert as during short-term follow-up, all patients had improvement of their defecation problems, but on long-term follow-up; the obstructed defecation score (Longo's ODS) deteriorated in 12 patients (75%) 2-5 years after the laparoscopic ventral rectopexy for obstructed defecation syndrome (mean follow-up 38 months) [16].This is confirmed by findings in an earlier study by Orrom et al., in which they concluded that rectopexy, can result in a significant amelioration of symptoms of obstructed defecation during initial follow-up, but during the time many patients reported even worsening of complaints as reflected by an increase in tenesmus, stool frequency, and incomplete emptying [20].
One can argue that worsening of complaints may be due to the possible innervation damage, kinking of the sigmoid above the stretched rectum, local inflammation due to the mesh resulting in scar tissue and stenosis, and finally the disappearance of the physiological enterocele, which can be helpful in emptying the rectum and rectocele, may be the cause for [16].So longer follow-up period is needed to confirm our results concerning the persistence of improvement in obstructed defecation manifestations.
Fecal incontinence is a common clinical finding in patients with total RP (especially in the aged patients).In our study, we recorded a statistically significant improvement (100%) and a statistically significant cure (80%).These results were consistent with those obtained by D'Hoore et al., where a significant improvement occurred in 90% of patients after laparoscopic ventral rectopexy.This finding is in agreement with the results of classic rectopexy and reflects the importance of preserving the rectal ampulla [19].
In a study by Lim et al., patients with constipation or mixed symptoms of both constipation and fecal incontinence seemed to gain significant benefit from mesh sacrocolpopexy and rectopexy as a combined procedure [4].Van den Esschert et al. also reported that all of the three patients who suffered from fecal incontinence stopped complaining after laparoscopic ventral rectopexy [16].
Both urinary and bowel symptoms are common in patients with POP as shown by Gallentine and Cespedes, who found that 50% of patients with POP had occult urinary stress incontinence [21], and likewise, a 50% incidence of detrusor instability was noted in a series of 24 patients with POP [22].
In our study, 94.4% of the cases who presented with urinary symptoms (dysuria and urgency), and 75% of cases who complained of urinary incontinence were treated by the end of the follow-up period.Data collected by Lim et al. suggested that patients with mixed urinary incontinence or urodynamic stress incontinence did gain significant benefit from combined repair using mesh sacrocolporectopexy [4].
On the contrary, in a retrospective study which included patients who underwent laparoscopic ventral rectopexy for obstructed defecation syndrome; stress urine incontinence was experienced in 7 and urge urine incontinence in 1 of the 16 patients after the operation, while only 5 patients complained of urine incontinence at the time of admission [16].Post-operative complications in our study were in the form of lower abdominal pain (15%), dyspareunia (10%), and wound infection (5%) during the follow-up period and all of them were consevatively treated, but none of the cases experienced mesh erosion.
These results were comparable to those obtained by Vizeteu et al., where there was no dyspareunia problem, nor mesh-related complications: infections, erosions during the first follow-up year following rectovaginopexy to the sacral promontory [9].Series by Lim et al., Consten et al., and D'Hoore and Penninckx reported consistent findings; so they concluded that the use of polypropylene mesh on the anterior aspect of the rectum is safe [4,13,19].
Finally, Literature regarding the combined surgical treatment of POP and RP is scarce and contains mainly case reports and a few small series of patients, and clinical studies on larger groups of patients with POP and RP are required in order to achieve a clear conclusion on the best therapeutic option.

Conclusion
Abdominal mesh vaginorectopexy for the repair of multiple pelvic organ is feasible and can result in significant improvement of function and quality of life.The procedure resulted in significant improvement in POP, anorectal, and urinary symptoms, although more studies on larger groups of patients with longer follow-up periods is needed to confirm these results.

Disclosure statement
No potential conflict of interest was reported by the authors.