IUJ VIDEO

Robot-assisted rectopexy and colpopexy for rectal prolapse

Kristie A. Greene & Jaime E. Sanchez &

Michael L. Campbell & Jorge E. Marcet

Received: 27 June 2013 /Accepted: 22 August 2013# The International Urogynecological Association 2013

AbstractAim This video demonstrates a technique for robot-assistedcombined rectopexy with colpopexy, but without the use ofmesh for rectal prolapse.Methods This case features a 61-year-old woman who pre-sents with complaints of tissue protruding through her rectumand fecal incontinence. On examination, she was found tohave circumferential, full-thickness rectal prolapse and peri-neal descent. We present a technique that combines rectopexywith colpopexy without the use of mesh for repair of rectalprolapse. Postoperative examination revealed resolution ofrectal prolapse and good perineal support. This video illus-trates a technique that may serve as a useful adjunct to have in

one’s surgical armamentarium in circumstances when meshshould not or cannot be used, such as in cases that requireresection of the sigmoid colon or for patients who simplyprefer to avoid the use of mesh.Conclusion Given that rectal prolapse and posthysterecomyvaginal vault prolapse often occur together, our institutionroutinely performs colpopexy with rectopexy for rectal pro-lapse to provide additional support to the pelvic floor asdemonstrated in this video.

Keywords Rectal prolapse . Rectopexy . Colpopexy . Pelvicorgan prolapse . Robotic

Aim

This video demonstrates a technique for robot-assisted com-bined rectopexy with colpopexy without the use of mesh forrectal prolapse. This case features a 61-year-old woman whopresented with complaints of tissue protruding through herrectum and fecal incontinence. On examination, she wasfound to have circumferential, full-thickness rectal prolapseand perineal descent. We present a technique that combinesrectopexy with colpopexy for repair of rectal prolapse.

Methods

After patient positioning in low lithotomy, laparoscopic accessis achieved via port placement at the umbilicus, midclavicularand anterior axillary lines bilaterally in the typical “W” con-figuration. The procedure is commenced with elevation of therectum out of the pelvis to expose the sacral promontory andprovide visualization of the right ureter. The peritoneum isincised over the rectosigmoid mesentery at the level of thesacral promontory. Right lateral dissection is continued within

The abstract to this paper was presented at the InternationalUrogynecological Association (IUGA), Brisbane, Australia, September2012.

Electronic supplementary material The online version of this article(doi:10.1007/s00192-013-2217-5) contains supplementary material,which is available to authorized users. This video is also available towatch on http://videos.springer.com/. Please search for the video by thearticle title.

K. A. GreeneDivision of Female Pelvic Medicine and Reconstructive Surgery,Department of Obstetrics and Gynecology, University of SouthFlorida, Tampa, FL, USA

J. E. Sanchez : J. E. MarcetDivision of Colon and Rectal Surgery, Department of Surgery,University of South Florida, Tampa, FL, USA

M. L. CampbellDepartment of Surgery, University of South Florida, Tampa, FL,USA

K. A. Greene (*)Division of Female Pelvic Medicine and Reconstructive Surgery,College of Medicine, University of South Florida, 2 Tampa GeneralCircle, 6th Floor, Tampa, FL 33606, USAe-mail: kgreene2@health.usf.edu

Int Urogynecol JDOI 10.1007/s00192-013-2217-5

the presacral space taking care to preserve the right ureter andhypogastric nerve.

At this level, the hypogastric nerves originate from thenervous tissue overlying the bifurcation of the aorta. Theythen condense into 2- to 3-mm bundles bilaterally as theyreceive further innervation from S2 and S3. They travel withinand posterior to the presacral fascia toward the genitourinarystructures. Preservation of the hypogastric nerves is key toavoiding urinary and sexual dysfunction.

The incision is then carried anteriorly toward therectovaginal fold, and the dissection is performed from rightto left across the rectovaginal fold. The rectovaginal space isfurther developed with the assistance of a sponge stick in thevagina. Additionally, a rectal examination is performed toensure complete dissection to the pelvic floor. Dissection isthen continued along the left side of the rectum in a similarfashion. The dissection is carried down to the pelvic floor inthe presacral space to the level of the levator ani muscles. Thisdistal dissection ensures full mobilization of the rectum.

A 2-0 Tycron suture is placed through the anterior longitu-dinal ligament at the level of S2. This suture is then used topexy the right rectal stalk. The left side is then pexied in asimilar fashion. In addition, the retained rectopexy suture onthe left is used to begin the colpopexy. After appropriatetensioning of the rectopexy, the sutures are then used toincorporate the apex of the vagina to complete the colpopexyportion of the procedure. The vagina is suspended so that itlies over, but does not compress the rectum. Appropriatetensioning is paramount to avoid obstruction of the rectumwith the colpopexy sutures. The peritoneum is thenreapproximated to obliterate the cul de sac.

Postoperative examination revealed resolution of rectalprolapse and good perineal support. The patient’s postopera-tive course was uncomplicated. She was discharged home onpostoperative day # 1, doing well and tolerating a regular diet.At 6-month follow-up, the patient had no recurrence of rectalprolapse and good perineal support.

Discussion

Rectal prolapse frequently coexists with other pelvic floordefects. In fact, rectal prolapse as an isolated diagnosis isunusual, with 55 % of cases documented in women withconcomitant urogenital prolapse [1]. The etiology of rectalprolapse is similar to that of pelvic organ prolapse with afemale:male ratio of greater than 10:1, suggesting birth injuryas a contributing factor [2]. Other contributing factors to rectalprolapse include neurological conditions, connective tissuedisorders, weakness of the internal and external anal sphinc-ters, and a deep pouch of Douglas [3]. Both rectal prolapseand pelvic organ prolapse can be repaired using a variety oftechniques either with or without the use of mesh [1, 2, 4–10].

However, limited publications exist describing clinical out-comes when a combined surgical approach is utilized [1, 2,10]. Most studies appear within the colorectal literature andmany include the use of mesh [4, 5].

In our clinical practice, we typically perform a combinedsuture rectocolpopexy without the use of mesh for rectalprolapse as demonstrated in this video. We feel that by addingthe colpopexy to this procedure, we provide additional sup-port to the pelvic floor and help prevent pelvic organ prolapsefrom occurring in the future. We typically do not use meshunless vaginal prolapse is present along with rectal prolapseand is advanced (POPQ stage 3 or 4). We believe that thisvideo illustrates a technique that may serve as a useful adjunctto have in one’s surgical armamentarium in circumstanceswhen mesh should not or cannot be used, such as in casesthat require resection of the sigmoid colon or for patients whosimply prefer to avoid the use of mesh.

This video demonstrates one technique among many foraddressing defects of the pelvic floor. Regardless of whattechnique is used, we feel that it is important to recognize thatthese disorders often coexist and require an interdisciplinaryeffort between the urogynecologist and colorectal surgeon.Future work will be aimed at reporting patient outcomes fromthis combined procedure.

Conclusion

Given that rectal prolapse and posthysterecomy vaginal vaultprolapse often occur together, our institution routinely per-forms colpopexy with rectopexy for rectal prolapse to provideadditional support to the pelvic floor, as demonstrated in thisvideo.

Acknowledgements Written informed consent was obtained from thepatient for publication of this video article and any accompanying images.No financial support was received for this study.

Conflicts of interest None.

References

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