Controversy in the treatment of symptomatic internal rectal prolapse: suspension or resection?

Abstract

Internal rectal prolapse (IRP) is a full-thickness intussusception of the rectum during defecation. Radiologically, different grades have been proposed: from low-grade (rectorectal intussusception) to high-grade (rectoanal intussusception) prolapse. This prolapse may lead to an outlet obstruction and/or fecal incontinence. IRP plays an important role in the pathophysiology of obstructed defecation (OD), which is the inability to empty the rectum satisfactorily during defecation and is more specifically defined in the Rome III criteria. There has been debate for decades about the clinical significance of IRP. However, there appears to be a renewed interest in the clinical relevance and treatment of IRP. The long disputed progression into ERP has been made more plausible by recent data published by Wijffels et al. [1] on the natural history of IRP. Moreover, various recent publications on new surgical techniques have shown improved functional outcome after prolapse correction compared with historical surgical series. Patient selection however remains critical [2–4]. Surgical correction for IRP is possible via a transabdominal or transanal approach. Currently the most common procedures are laparoscopic ventral rectopexy (LVR) and stapled transanal rectal resection (STARR). LVR corrects the intussusceptions of the rectum and reinforces the rectovaginal septum by the use of a mesh, which suspends the rectum and vaginal vault to the sacral promontory, whereas in the STARR procedure a stapled resection of the redundant rectal wall is performed. Most of the recent publications on IRP and OD are divided between proponents of these two techniques. There are, however, no comparative studies, making it difficult to select the optimal treatment for each individual patient. Therefore, our purpose was to give an overview of the existing data and controversies on these techniques.