Hypothesis / aims of study
Robot-assisted ventral mesh rectopexy (RVMR) is a well-established surgical procedure for rectal prolapse (RP) and obstructed defecation syndrome (ODS). However, this approach could also be effective in case of concomitant fecal incontinence (FI). Aim of this study was to assess the impact of RVMR in patients suffering from RP/ODS and FI, and identify factors associated to postoperative persistence of FI.
Study design, materials and methods
This is a prospective single-center observational study on consecutive patients with external or internal RP, rectocele with/-out entero/sigmoidocele who underwent RVMR using Xi Da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). Patients’ baseline characteristics, intra- and postoperative data were collected. Symptoms of FI were assessed using the CCFI score. Uni- and multivariate analysis of factors affecting postoperative persistence of severe FI with a significant impairment of quality of life (CCFI score >9) was performed using SPSS for Windows (version 25.0).
Results
From November 2020 to January 2024, 73 patients (70 females, 95.9%, mean age 58.7±13.0 years) who underwent RVMR were included. Thirty-two patients (43.8%) suffered from concomitant FI, 18 of whom (56.3%) reported severe FI. Mean postoperative follow up was 21.0±11.2 months. At last follow up, an overall statistically significant reduction in CCFI score (4.2±5.8 vs 1.6±3.4, p<0.0001) was reported. Specifically in the 32 patients with preoperative FI, CCFI score decreased from 9.5±4.9 to 3.7±4.4 (p<0.0001). Sixteen of them (50%) reported no FI symptoms after RVMR, while 16 patients (50%) showed persistent FI (it was severe in 6 of them – 37.5%). New-onset FI was found in one case after the procedure (reporting a CCFI score <9). In the overall sample, although age >65 years, external RP, presence of internal and external anal sphincter lesions at preoperative endoanal ultrasound, reduced resting, squeeze and endurance squeeze (ES) pressures at preoperative anorectal manometry were associated to postoperative severe FI, none of these factors showed to be significant at multivariate analysis. Analyzing only patients with preoperative FI, age >65 years, reduced resting and ES pressures, and rectocele recurrence were correlated with severity of FI after RVMR, but only reduced ES pressure resulted statistically significant at multivariate analysis (p=0.034).
Interpretation of results
RVMR allowed a significant reduction of FI severity in patients with RP/ODS and FI. A decreased preoperative anal sphincter function could be a predictive factor of severe persistent FI after RVMR. Further multicentric studies on patients with RP and FI are needed to confirm these findings.