Rectal prolapse is uncommon in men, representing 10% of rectal prolapse cases. Surgical options for repair include abdominal and perineal approaches. Abdominal approaches have gained favor for appropriate patients as they may provide more durable results. Minimally invasive abdominal approaches, such as robotic ventral mesh rectopexy, have gained acceptance as safe and effective procedures to treat pelvic organ prolapse. 

Rectal prolapse repair in male patients requires additional consideration of pelvic nerve anatomy to reduce the risk of injury to hypogastric or parasympathetic nerves during rectal mobilization. Existing data suggests that minimally invasive ventral mesh rectopexy can be completed safely in male patients with minimal risk of postoperative sexual dysfunction [1-3]. We review the relevant anatomy and techniques necessary to complete robotic ventral mesh rectopexy safely in male patients.

In this video, we discuss the technique for robotic ventral mesh rectopexy using a sample case in a male patient. We demonstrate potential nerve injuries that can occur during male abdominal rectal prolapse procedures and how to avoid them.

We present the case of a healthy 77-year-old man with full thickness rectal prolapse, whose progressive symptoms led to obstructed defecation. Preoperative workup included anorectal manometry and MRI defecography. Robotic ventral rectopexy was planned. Following standard port placement and docking, the peritoneum overlying the sacrum was opened and cleared until the anterior longitudinal ligament was visualized. Anterior dissection was performed by dividing the anterior peritoneum overlying Denonvilliers’ fascia, mobilizing the peritoneum off of the rectum. Dissection proceeded inferiorly towards the rectovesical pouch, staying close to the rectum. Wide lateral dissection was avoided to prevent disruption of the pelvic neural plexus. A Biodesign (Cook) rectopexy graft was cut to a hockey-stick configuration and sutured to the anterior rectum at the prolapse lead point using 2-0 PDS sutures. The graft was attached to the sacral promontory using 2-0 Prolene sutures. The entrance and exit point of the needle was visualized to confirm that the hypogastric nerve was not been inadvertently involved. Repeat rectal examination elicited no further prolapse, confirming the integrity of the repair. Peritoneal flaps were closed using 2-0 Monocryl to cover the graft. The patient recovered uneventfully and was discharged to home on POD1 with improved quality of life reported at one month postoperatively.

We support the use of minimally invasive ventral mesh rectopexy for males with rectal prolapse. Critical technical points include maintaining a plane close to the rectum and avoiding wide lateral dissection to minimize pelvic nerve plexus disruption. Mesh placement should fixate the prolapse lead point distally and avoid involving the hypogastric nerve proximally during fixation on the sacral promontory. Unnecessary mesh tension should be avoided and peritoneum overlying the mesh should be closed.

Owais AE, Sumrien H, Mabey K, McCarthy K, Greenslade GL, Dixon AR. Laparoscopic ventral mesh rectopexy in male patients with internal or external rectal prolapse. Colorectal Dis. 2014;16(12):995-1000.
Siddika A, Saha S, Siddiqi S. Evolution of male rectal prolapse surgery and initial experience of robotic rectopexy in men. J Robot Surg. 2017;11(3):311-316.
Rautio T, Makela-Kaikkonen J, Vaarala M, et al. Laparoscopic ventral rectopexy in male patients with external rectal prolapse is associated with a high reoperation rate. Tech Coloproctol. 2016;20(10):715-720.