Modified anterior rectopexy – clinical and radiological outcomes in patients with combined defects in the posterior pelvic compartment

doi:10.21203/rs.3.rs-4984414/v1

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Modified anterior rectopexy – clinical and radiological outcomes in patients with combined defects in the posterior pelvic compartment

https://doi.org/10.21203/rs.3.rs-4984414/v1

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Background

Different types of posterior pelvic organ prolapse (PPOP; rectal prolapse, rectocele or enterocele) often coexist and can be associated with overlapping symptoms. This study introduces a modified laparoscopic anterior rectopexy, laparoscopic vaginorectopexy (LVRP), for the correction of multiple PPOP in a single procedure. The focus is on bowel function, recurrence rates and complications.

Methods

Twenty-five women with symptoms of obstructed defecation (OD) and more than one PPOP were prospectively included and assessed with clinical examination, defecography and a questionnaire for bowel function and quality of life (QoL). During LVRP, a t-shaped mesh was sutured to the pelvic muscles, vagina and sacrouterine ligaments and then stapled to the promontory; the mesorectum was stapled to the mesh. Follow up was scheduled twelve months after the procedure and long term (minimum ten years).

Results

One patient suffered from mesh erosion and another from postoperative bleeding. Outcomes after twelve months were: no recurrence of internal or external rectal prolapse; three rectoceles and one enterocele recurred; bowel function and QoL improved for around half of patients; few patients deteriorated. At long term follow up, the effects on OD and QoL were unchanged, but an increase in incontinence was recorded.

Conclusions

LVRP is a technique for the correction of multiple PPOP in a single procedure. The procedure is safe with low recurrence and complication rates. Bowel function and QoL improve over the short term, while the effect on faecal incontinence deteriorates over the long term.

Trial registration no.:

NCT06330857

Laparoscopy

Pelvic organ prolapse

Prospective studies

Rectal prolapse

Surgical mesh

Treatment Outcome

Posterior Pelvic Organ Prolapse (PPOP) includes rectocele, enterocele and rectal prolapse and is common in patients with symptoms of obstructed defecation (OD) and faecal incontinence (FI). More than one PPOP is observed in 20%-30% of these patients [1, 2]; therefore, patients with PPOP often present with two or more PPOPs. One or more additional PPOPs have been reported in 50% of patients with external rectal prolapse (ERP) [3], in 81%-93% of patients with enterocele (EC) [4, 5] and in 75% of patients with rectocele (RC) [6].

As conservative management of symptomatic PPOP is often insufficient, surgery is frequently considered. Laparoscopic ventral rectopexy (LVR) is widely used to treat rectal prolapse due to reported low recurrence rate and limited morbidity [7-9]. RC and EC have traditionally been corrected using either a vaginal approach or laparoscopic sacrocolpopexy, but attempts have also been made to use rectopexy, with mixed results [10-13].

The optimal surgical intervention for multiple PPOP should correct all PPOPs in a single procedure, which is the aim of the Laparoscopic vaginorectopexy (LVRP). LVRP combines the methods of sacrocolpopexy with anterior mesh rectopexy and has been developed in a collaboration between the Scandinavian Centre for Gynaecological Endoscopy and the Department of Colorectal Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.

The aim of this study is to evaluate LVRP in the treatment of multiple PPOP with bowel function as the primary endpoint. Postoperative complications and recurrence rates were also recorded. Patients were evaluated one year after surgery and at long term follow up (minimum ten years).

Patients

From 2002 to 2008, patients referred with symptoms of OD and diagnosed with multiple POPP (protocol below) were considered for inclusion in the study. More than one defect (internal or external rectal prolapse, EC or RC) was denoted as multiple PPOP. Patients were evaluated with clinical examination, defecography and a questionnaire that evaluated bowel function and bowel-related quality of life (QoL). Patients who did not respond to conservative treatment (dietary advice, oral bulking agents, rectal enemas and/or bio-feedback) were offered inclusion in the study.

Patients with anismus were excluded after evaluation with a combination of defecography (see below) and manometry.

Surgical procedure

Pneumoperitoneum was established with Veress needle. Two 12 mm trocars were placed at the umbilicus and two cm above the symphysis. Two 5 mm trocars were placed in the right and left iliac fossa. The procedure started with an incision exposing the promontory, which continued down along the right peritoneal reflection (Fig.1). A limited dissection of the promontory and a shallow unilateral incision were employed to avoid damage to the superior hypogastric plexus and the hypogastric nerves. The rectovaginal space was opened down to the pelvic floor, exposing the pelvic floor muscles. A T-shaped Vypro-mesh was inserted into the rectovaginal space and sutured to the pelvic floor muscles lateral to the vagina and to the distal vagina, using a non-absorbable polyfilament suture (Ethibond^R, Fig.2). Two additional sutures fixated the mesh to the sacrouterine ligaments, closing the rectovaginal space and elevating the pouch of Douglas (Fig.3). Staples were used to anchor the mesh to the promontory and the mesorectum to the mesh, preventing rectal intussusception (Fig.4). The peritoneal defect was closed with a running, absorbable suture (V-loc^R, Fig.5).

Bowel Function Questionnaire

The symptom load was evaluated with the Linkoping Bowel function Questionnaire [14]. It is a quantitative bowel function questionnaire that evaluates four domains: faecal incontinence, constipation, OD and bowel-related quality of life. Symptom load is graded in four levels. Questions considered most relevant for each category of OD, incontinence and QoL were used for the longitudinal analyses.

Defecography

The defecography used plain X-ray and images/video, which were recorded at rest and during straining with the patient situated on a commode. Preparations included oral, rectal and vaginal contrast. Assessment of the investigation was done by two senior radiologists, and the following protocol was used for evaluation:

Rectal prolapse [15]

Oxford grading system 1-5 for rectorectal and rectoanal intususception and external prolapse.

Enterocele [16]

Grade1 EC reaching below cervix, but not distal to half of the vaginal length.

Grade 2 EC reaching below half of the vaginal length, but not below the sphincter plane.

Grade 3 EC protruding below the sphincter plane and out of the anal canal.

Rectocele [16]

A protrusion beyond the imaginary line between the sphincter plane and the rectum over or equal to 2 cm in depth.

Anismus [16, 17]

The inability to open the anal canal during evacuation of rectal contrast without an anatomical reason. The puborectal function is evaluated separately regardless of signs of anismus with assessment of the anorectal angle.

The following protocol was used at follow-up visits:

Three months:

Recording of per -and postoperative complications. Review of medical records and visit at the outpatient clinic.

Twelve months:

1. Clinical examination by one surgeon and one gynaecologist

2. Defecography

3. Bowel function questionnaire (LBQ)

Since defecographic evaluation was not always available due to technical failure and/or patient related factors, the evaluation protocol was adjusted according to the reliability of the clinical examination. Clinical evaluation of EC and internal prolapse (IRP) is difficult and unreliable [18-20]. However, clinical evaluation of RC (> 2cm) is considered reliable [21]. Therefore, clinical evaluation was considered sufficient for evaluation of rectocele, but not for enterocele or internal prolapse.

The following protocol was used:

Rectal prolapse and RC: Clinical evaluation and defecography. If defecography was not evaluable, clinical evaluation was considered sufficient.

IRP and EC: Clinical evaluation and defecography. If defecography was not evaluable, clinical evaluation was considered insufficient.

Long term:

During 2020, the LBQ was sent to all living patients at a minimum 10-year follow-up. Patients who did not respond were contacted via telephone. Median follow-up was 16 years (10-18 years)

Ethical approval

Approval from the regional ethical board:

Dnr 2022-00167-02

Dnr 2021-06921-02

Dnr 2019-02352

Dnr 971-17

Patients

A flow chart of the study is displayed in Fig.6.

Baseline:

25 female patients (34-88 years old) were included. The preoperative PPOP status is displayed below; five defecographies were not evaluable.

*Defecography not evaluable.

Twelve months:

Three patients were lost before the one-year follow up; two died from cancer and one patient developed Alzheimer’s disease, leaving 22 patients one year after surgery. The scheduled defecography was not performed in three patients and was inconclusive in another three. One patient did not attend the clinical examination. This resulted in 16 patients who were evaluable for recurrence according to plan.

The bowel function questionnaire was completed before and after surgery by 17 of the 22 remaining patients.

Long term:

At long-term follow-up, seven patients were deceased, and two patients declined participation (one due to malignant disease and one due to blindness). This resulted in 13 remaining patients for long-term follow-up.

Bowel function and QoL

The results of the questionnaires for symptomatic patients are displayed in figs. 7-11. Two patients in the long-term follow-up had not completed the LBQ before surgery and are not included.

All patients had preoperative symptoms of OD, and around 50% were improved after surgery at short- and long-term follow-up (Fig. 7).

Symptoms of faecal incontinence were improved in 60%-70% of patients at short-term follow-up but were considerably worse at long-term follow-up, especially for patients with loose stools. (Figs. 8-9).

The QoL scores for nearly all patients were affected by bowel function; around half of patients improved and few deteriorated at the one-year follow-up (figs.10-11). At long-term follow-up, a negative impact on social life was reported.

Operative results

There were no conversions to open surgery. Mean operative time was 171 minutes (115-272 minutes) and mean peroperative bleeding was 116 ml (0-1100 ml). Mean length of stay was 2.9 days (2-5 days).

Two postoperative complications were recorded. One patient suffered postoperative bleeding and was treated conservatively with the transfusion of two units of blood. Another patient had an erosion of the mesh to the rectum 16 months after surgery. The patient was treated successfully with local excision of the protruding mesh during a planned cystocele repair.

Recurrence

Evaluable patients and recurrences at 12 months are displayed in Fig. 12. There were no recurrences of ERP or IRP. Four recurrences (three RC and one EC) were recorded in four different patients. Two patients were reoperated due to persistent symptoms of OD, one with posterior colporrhaphy for a RC and one with sacrocolpopexy for an EC. The remaining two patients with RC had minor symptoms and declined further treatment.

With declining recurrence rates after rectal prolapse surgery in recent years, restoration of bowel function is gaining increased attention. Recto-anal bowel function is a complex issue and the posterior pelvic compartment includes three possible sites for defects, each of which can influence function either individually or in combination. We contend that the posterior compartment should be approached as a single entity, necessitating radiological and clinical evaluation followed by tailored surgery. A rational objective is to correct all defects within a single procedure.

The technique of LVRP focuses on combined pelvic defects. Anchoring the mesh to the pelvic floor muscles and distal vagina, as well as to the sacrouterine ligaments, ensures that the mesh is positioned with sufficient depth and width for larger RCs and ECs.

When considering postoperative complications, LVRP seems to be a safe procedure. This outcome was expected since LVRP is essentially a modified, slightly expanded version of LVR. Reported complication rates after LVR are 10%-15%, with a conversion rate of 2%-3%. The average hospital stay is 2-4 days [8, 22-27]. A complication that is specific to anterior mesh rectopexy is mesh erosion. The incidence after transabdominal surgery is low (around 2%), and an incidence rate of one case in the current study seems acceptable. Anchoring the mesh mostly to the mesorectum instead of the anterior rectal wall could reduce the risk for mesh erosion. On the other hand, this technique could result in weaker anchoring of the reduced intussusception. However, at least in the short term, we did not observe recurrent intussusception.

The included patients are heterogeneous with different POPP status and symptom load at baseline. It is well known that the association between (dys)function and the presence and size of the various anatomical defects is weak [6, 20, 28, 29]. Although we did not perform a thorough analysis of baseline functional data, the current study seems to confirm the findings of previous studies in this respect (data not shown).

Functional outcomes after LVR vary and depend on the indication for surgery. A meta-analysis on patients with ERP showed improvement of 3%-72% for constipation and 31%-84% for FI [27]. Similar results have been reported for patients with IRP [8, 30].

Few previous studies have investigated functional outcomes after surgery for multiple PPOP.

Franceschilli et al. [31] reported improvement of FI and constipation in 80%-90% of patients after LVR in patients with IRP and RC, while EC was present in 20% of patients. Slightly inferior results were obtained in a similar study from Tsunoda et al. [32]., where OD was improved in half the patients and FI in 75%. In a retrospective study by van der Esschert et al, [12], 17 patients with EC and RC underwent surgery with LVR for OD. The study included only one patient with ERP and four with IRP. Symptoms of OD did not improve; conversely, 12 of 17 patients deteriorated. In a study by Mellgren et al. [10], 22 patients with EC and either ERP or IRP were operated on with Ripstein rectopexy. OD improved in 30% of patients and deteriorated in 25%, while FI improved in 60% of patients. It is reasonable to assume that preoperative POPP status has an impact on functional outcome. In the current study, 65% of patients had EC and 85% had ERP/IRP and RC, making the cohort study by Mellgren et al. (12) the most similar to the present study. In a comparison, the results here are in accordance for FI (60%-70% vs 62% improvement) and even better for OD (40% vs 29% improved). Furthermore, only 10% of patients in our study deteriorated. The type of surgery may be one explanation for this difference in outcome, as the anterior approach seems to be favourable on postoperative OD compared to a posterior approach [33].

Considering the above-mentioned studies on patients with multiple POPP, the two studies that included patients with higher proportions of EC [10, 12] show inferior functional results compared to the other two studies [31, 32]. This may reflect the technical challenge of correcting EC. LVRP seems to be a technique with reasonable effects on both FI and OD, including when EC is present.

Some studies have reported good functional outcome five years after LVR for ERP and IRP [33, 34]. For longer follow-up, we are only aware of three studies, mostly on suture rectopexy and resection rectopexy, that show a major deterioration of recurrence rate and functional outcome ten years after surgery compared to five years after surgery [35-37]. The current study shows a worsening of incontinence at long-term follow-up; however, the effect on OD seems more sustained. This outcome is expected since it is well known that the prevalence of incontinence increases with age [38].

Short-term bowel related QoL improved in accordance with outcomes for OD and incontinence. This effect has been shown previously after LVR [32, 34, 39]. Interestingly, QoL at long-term follow-up was seemingly more related to OD than to incontinence, revealing a slight deterioration over time.

There are several large series on LVR demonstrating a low recurrence rate (3%-5%) for ERP at short-term follow-up [7, 9, 23, 25, 27]. The optimal approach for repair of RC is still unclear. Makela-Kaikonnen et al. reported a recurrence rate of 18% three months after laparoscopic and robotic LVR [13]. Results seem similar after transvaginal repair (with and without mesh) [40-42]. Correction of an EC can be done transvaginally and transabdominally, though the evidence is scarce for both techniques. Recurrence rates vary between 0%-18% [10, 11, 43, 44]. Considering previous reported outcomes for repair of the different anatomical defects, the results after LVPR are comparable with the advantage of a single procedure.

In summary, LVRP seems to be a safe alternative to the conventional anterior mesh rectopexy for patients with multiple PPOP. Functional outcomes and recurrence rates are in accordance with previous results.

LVRP is a modified anterior mesh rectopexy that aims to correct multiple PPOP in a single procedure. Functional outcomes and recurrence rates are in accordance with previous studies, and the complication rate seems low. The method offers an option to use a more tailored procedure in patients with multiple PPOP. Recurrence rates and effectiveness at long-term need to be studied further.

Author Contribution

BM and LB wrote and reviewed the entire manuscriptGraphs were made by BMPictures of operative technique were made by dr Leif Nelvin who were otherwise not involved in the manuscriptGK participated in writing and reviewing the part in the article concerning operative technique and short term follow-up.

Acknowledgments:

Dr Leif Nelvin: illustrations of the surgical procedure.

Grants from:

Region Västra Götaland, Södra Älvsborgs Hospital, Department of Research, Education and Innovation, Borås, Sweden

The Gothenburg Society of Medicine; Vera and Hans Albrechtsson Foundation.

Swedish state, under the agreement between the Swedish government and the county councils, the ALF-agreement ALFGBG-73950

Data Availability

CRF of questionnaires and reported results from medical journals are available unidentified but not extracts from medical journals.

Agachan F, Pfeifer J, Wexner SD. Defecography and proctography. Results of 744 patients. Dis Colon Rectum. 1996;39(8):899-905.
Mellgren A, Bremmer S, Johansson C, Dolk A, Uden R, Ahlback SO, et al. Defecography. Results of investigations in 2,816 patients. Dis Colon Rectum. 1994;37(11):1133-41.
Tsunoda A, Takahashi T, Sato K, Kusanagi H. Factors Predicting the Presence of Concomitant Enterocele and Rectocele in Female Patients With External Rectal Prolapse. Ann Coloproctol. 2021;37(4):218-24.
Lapalus MG, Henry L, Barth X, Mellier G, Gautier G, Mion F, et al. [Enterocele: clinical risk factors and association with others pelvic floor disorders (about 544 defecographies)]. Gynecol Obstet Fertil. 2004;32(7-8):595-600.
Mellgren A, Johansson C, Dolk A, Anzen B, Bremmer S, Nilsson BY, et al. Enterocele demonstrated by defaecography is associated with other pelvic floor disorders. Int J Colorectal Dis. 1994;9(3):121-4.
Savoye-Collet C, Savoye G, Koning E, Leroi AM, Dacher JN. Defecography in symptomatic older women living at home. Age Ageing. 2003;32(3):347-50.
D'Hoore A, Penninckx F. Laparoscopic ventral recto(colpo)pexy for rectal prolapse: surgical technique and outcome for 109 patients. Surg Endosc. 2006;20(12):1919-23.
van Geluwe B, Wolthuis A, Penninckx F, D'Hoore A. Lessons learned after more than 400 laparoscopic ventral rectopexies. Acta Chir Belg. 2013;113(2):103-6.
Samaranayake CB, Luo C, Plank AW, Merrie AE, Plank LD, Bissett IP. Systematic review on ventral rectopexy for rectal prolapse and intussusception. Colorectal Dis. 2010;12(6):504-12.
Mellgren A, Dolk A, Johansson C, Bremmer S, Anzen B, Holmstrom B. Enterocele is correctable using the Ripstein rectopexy. Dis Colon Rectum. 1994;37(8):800-4.
Cook JR, Seman EI, O'Shea RT. Laparoscopic treatment of enterocele: a 3-year evaluation. Aust N Z J Obstet Gynaecol. 2004;44(2):107-10.
van den Esschert JW, van Geloven AA, Vermulst N, Groenedijk AG, de Wit LT, Gerhards MF. Laparoscopic ventral rectopexy for obstructed defecation syndrome. Surg Endosc. 2008;22(12):2728-32.
Makela-Kaikkonen J, Rautio T, Paakko E, Biancari F, Ohtonen P, Makela J. Robot-assisted vs laparoscopic ventral rectopexy for external or internal rectal prolapse and enterocele: a randomized controlled trial. Colorectal Dis. 2016;18(10):1010-5.
Hallbook O, Sjodahl R. Surgical approaches to obtaining optimal bowel function. Semin Surg Oncol. 2000;18(3):249-58.
Collinson R, Cunningham C, D'Costa H, Lindsey I. Rectal intussusception and unexplained faecal incontinence: findings of a proctographic study. Colorectal Dis. 2009;11(1):77-83.
Stoker J, Rociu E, Wiersma TG, Lameris JS. Imaging of anorectal disease. Br J Surg. 2000;87(1):10-27.
Halligan S, Malouf A, Bartram CI, Marshall M, Hollings N, Kamm MA. Predictive value of impaired evacuation at proctography in diagnosing anismus. AJR Am J Roentgenol. 2001;177(3):633-6.
Hock D, Lombard R, Jehaes C, Markiewicz S, Penders L, Fontaine F, et al. Colpocystodefecography. Dis Colon Rectum. 1993;36(11):1015-21.
Kaufman HS, Buller JL, Thompson JR, Pannu HK, DeMeester SL, Genadry RR, et al. Dynamic pelvic magnetic resonance imaging and cystocolpoproctography alter surgical management of pelvic floor disorders. Dis Colon Rectum. 2001;44(11):1575-83; discussion 83-4.
Kelvin FM, Maglinte DD, Hornback JA, Benson JT. Pelvic prolapse: assessment with evacuation proctography (defecography). Radiology. 1992;184(2):547-51.
Delemarre JB, Kruyt RH, Doornbos J, Buyze-Westerweel M, Trimbos JB, Hermans J, et al. Anterior rectocele: assessment with radiographic defecography, dynamic magnetic resonance imaging, and physical examination. Dis Colon Rectum. 1994;37(3):249-59.
Formijne Jonkers HA, Poierrie N, Draaisma WA, Broeders IA, Consten EC. Laparoscopic ventral rectopexy for rectal prolapse and symptomatic rectocele: an analysis of 245 consecutive patients. Colorectal Dis. 2013;15(6):695-9.
Wijffels N, Cunningham C, Dixon A, Greenslade G, Lindsey I. Laparoscopic ventral rectopexy for external rectal prolapse is safe and effective in the elderly. Does this make perineal procedures obsolete? Colorectal Dis. 2011;13(5):561-6.
Slawik S, Soulsby R, Carter H, Payne H, Dixon AR. Laparoscopic ventral rectopexy, posterior colporrhaphy and vaginal sacrocolpopexy for the treatment of recto-genital prolapse and mechanical outlet obstruction. Colorectal Dis. 2008;10(2):138-43.
Boons P, Collinson R, Cunningham C, Lindsey I. Laparoscopic ventral rectopexy for external rectal prolapse improves constipation and avoids de novo constipation. Colorectal Dis. 2010;12(6):526-32.
Gultekin FA, Wong MT, Podevin J, Barussaud ML, Boutami M, Lehur PA, et al. Safety of laparoscopic ventral rectopexy in the elderly: results from a nationwide database. Dis Colon Rectum. 2015;58(3):339-43.
Faucheron JL, Trilling B, Girard E, Sage PY, Barbois S, Reche F. Anterior rectopexy for full-thickness rectal prolapse: Technical and functional results. World J Gastroenterol. 2015;21(16):5049-55.
Tsunoda A, Takahashi T, Kusanagi H. Reappraising the Role of Enterocele in the Obstructed Defecation Syndrome: Is Radiological Impaired Rectal Emptying Significant in Enterocele? J Anus Rectum Colon. 2022;6(2):113-20.
Shorvon PJ, McHugh S, Diamant NE, Somers S, Stevenson GW. Defecography in normal volunteers: results and implications. Gut. 1989;30(12):1737-49.
Gosselink MP, Joshi H, Adusumilli S, van Onkelen RS, Fourie S, Hompes R, et al. Laparoscopic ventral rectopexy for faecal incontinence: equivalent benefit is seen in internal and external rectal prolapse. J Gastrointest Surg. 2015;19(3):558-63.
Franceschilli L, Varvaras D, Capuano I, Ciangola CI, Giorgi F, Boehm G, et al. Laparoscopic ventral rectopexy using biologic mesh for the treatment of obstructed defaecation syndrome and/or faecal incontinence in patients with internal rectal prolapse: a critical appraisal of the first 100 cases. Tech Coloproctol. 2015;19(4):209-19.
Tsunoda A, Takahashi T, Matsuda S, Kusanagi H. Long-term annual functional outcome after laparoscopic ventral rectopexy for rectoanal intussusception and/or rectocele: evaluation of sustained improvement. Tech Coloproctol. 2021;25(12):1281-9.
Hidaka J, Elfeki H, Duelund-Jakobsen J, Laurberg S, Lundby L. Functional Outcome after Laparoscopic Posterior Sutured Rectopexy Versus Ventral Mesh Rectopexy for Rectal Prolapse: Six-year Follow-up of a Double-blind, Randomized Single-center Study. EClinicalMedicine. 2019;16:18-22.
McLean R, Kipling M, Musgrave E, Mercer-Jones M. Short- and long-term clinical and patient-reported outcomes following laparoscopic ventral mesh rectopexy using biological mesh for pelvic organ prolapse: a prospective cohort study of 224 consecutive patients. Colorectal Dis. 2018;20(5):424-36.
Durbeck A, Johannessen HO, Drolsum A, Johnson E. Very long-term outcome after resection rectopexy for internal rectal intussusception. Scand J Gastroenterol. 2021;56(1):122-7.
Foppa C, Martinek L, Arnaud JP, Bergamaschi R. Ten-year follow up after laparoscopic suture rectopexy for full-thickness rectal prolapse. Colorectal Dis. 2014;16(10):809-14.
Raftopoulos Y, Senagore AJ, Di Giuro G, Bergamaschi R, Rectal Prolapse Recurrence Study G. Recurrence rates after abdominal surgery for complete rectal prolapse: a multicenter pooled analysis of 643 individual patient data. Dis Colon Rectum. 2005;48(6):1200-6.
Rey E, Choung RS, Schleck CD, Zinsmeister AR, Locke GR, 3rd, Talley NJ. Onset and risk factors for fecal incontinence in a US community. Am J Gastroenterol. 2010;105(2):412-9.
Tsunoda A, Takahashi T, Matsuda S, Oka N, Kusanagi H. Midterm functional outcome after laparoscopic ventral rectopexy for external rectal prolapse. Asian J Endosc Surg. 2020;13(1):25-32.
Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Marjoribanks J. Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse. Cochrane Database Syst Rev. 2016;2:CD012079.
El Haddad R, Martan A, Masata J, Svabik K, Koleska T. [Long-term review on posterior colporrhaphy with levator ani muscles plication and incorporating a Vypro II mesh]. Ceska Gynekol. 2009;74(4):282-5.
Lim YN, Muller R, Corstiaans A, Hitchins S, Barry C, Rane A. A long-term review of posterior colporrhaphy with Vypro 2 mesh. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(9):1053-7.
Gosselink MJ, van Dam JH, Huisman WM, Ginai AZ, Schouten WR. Treatment of enterocele by obliteration of the pelvic inlet. Dis Colon Rectum. 1999;42(7):940-4.
Raz S, Nitti VW, Bregg KJ. Transvaginal repair of enterocele. J Urol. 1993;149(4):724-30.

No competing interests reported.

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You are reading this latest preprint version

Modified anterior rectopexy – clinical and radiological outcomes in patients with combined defects in the posterior pelvic compartment

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Abstract

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Introduction

Patients and Methods

Results

Discussion

Conclusions

Declarations

Author Contribution

Data Availability

References

Additional Declarations

Status:

Version 1