What is the best treatment for rectal prolapse?

From the Guidelines

Surgical intervention is the most effective treatment for rectal prolapse, with the choice between abdominal and perineal approaches depending on the patient's age, health status, and extent of prolapse. The decision between these two approaches should be individualized, taking into account the patient's specific characteristics and the surgeon's skills and expertise 1. For patients with complicated rectal prolapse and no signs of peritonitis or hemodynamic instability, the choice between abdominal and perineal procedures should be based on the patient's characteristics and the surgeon's skills and expertise 1.

Some key points to consider when deciding on the best treatment approach for rectal prolapse include:

• The severity of the prolapse: mild or partial prolapse may be managed with conservative measures, while complete rectal prolapse typically requires surgery 1.
• The patient's age and health status: abdominal approaches are generally preferred for younger, healthier patients, while perineal procedures are better suited for elderly or medically compromised patients 1.
• The presence of complications such as peritonitis or hemodynamic instability: in these cases, an abdominal approach is recommended 1.
• The surgeon's skills and expertise: the choice of approach should take into account the surgeon's experience and proficiency with different procedures 1.

In terms of specific surgical approaches, options include:

• Abdominal procedures such as rectopexy, with or without mesh, and resection rectopexy 1.
• Perineal procedures such as Altemeier's procedure, Delorme's procedure, and perineal stapled prolapse resection 1.
• Laparoscopic-assisted perineal sigmoid resection with colo-anal anastomosis, which may be considered for patients with complicated rectal prolapse 1.

Overall, the goal of treatment for rectal prolapse is to restore the rectum to its normal position, reinforce the weakened pelvic floor muscles, and improve the patient's quality of life 1. The most recent and highest quality study, the PROSPER study, found that there were no significant differences in outcomes between abdominal and perineal approaches, but that substantial improvements in quality of life were noted following all procedures 1.

From the Research

Treatment Options for Rectal Prolapse

The treatment for rectal prolapse depends on various factors, including the patient's age, overall health, and the severity of the condition. The following are some of the treatment options available:

• Abdominal procedures: These are ideal for young, fit patients and offer lower recurrence rates and greater chance for functional improvements 2.
• Perineal procedures: These are generally reserved for older, frail patients with significant comorbidity and are better suited for patients who are not fit for abdominal procedures 2, 3.
• Laparoscopic procedures: These have emerged as an effective tool for the treatment of rectal prolapse, offering advantages such as less pain, early recovery, and lower morbidity 4, 2.

Comparison of Surgical Techniques

Studies have compared the outcomes of different surgical techniques for rectal prolapse, including:

• Laparoscopic resection rectopexy and laparoscopic ventral mesh rectopexy: These procedures have been shown to have a small advantage in improving constipation or preventing new-onset constipation compared to other laparoscopic procedures 4.
• Suture and mesh rectopexy: These procedures produce equivalent results, although the polyvinyl alcohol (Ivalon) sponge rectopexy has been largely abandoned due to an increased risk of infectious complications 2.
• Abdominal and perineal approaches: There were no detectable differences in recurrent prolapse between abdominal and perineal approaches, although abdominal surgery may be associated with less residual faecal incontinence 5.

Individualized Approach

Due to the significant heterogeneity of available studies, an individualized approach is recommended for every patient, considering age, comorbidity, and underlying anatomical and functional disorders 4. The decision between different surgical techniques should be based on the patient's specific needs and the surgeon's experience and preference 2, 6.