V19 - Failure To Incorporate: 3 Cases Of Recurrent Rectal Prolapse Secondary To Lack Of Long-term Incorporation Between Biologic Graft and Rectum

Purpose/Background: The ideal treatment of rectal prolapse remains an enigma, further complicated by concurrent pelvic floor dysfunction, high rates of recurrence, and incomplete understanding of the pathophysiology. As randomized control trials and meta-analyses have been unable to demonstrate a superior approach, current practice tends to offer abdominal procedures such as minimally invasive ventral rectopexy to younger patients due to the presumed durability of the repair and slightly increased morbidity of the procedure (in comparison to perineal approaches). Our institutional standard is to offer a ventral rectopexy with porcine small intestinal submucosa graft to patients as a first line treatment, with or without concurrent pelvic organ prolapse repair.

This video abstract presents 3 cases of full thickness recurrence which appear to have been caused by a technical failure secondary to lack of long-term incorporation of biologic graft to the rectum. In all cases, the graft was well adherent to the sacrum, but the distal graft-rectum connection had failed. All were subsequently repaired with a permanent polypropylene mesh, with satisfactory results to date.

Methods/Interventions: A video case series of 3 patients with rectal prolapse who had previously undergone ventral rectopexy using a porcine small intestine submucosa graft. All cases show failure of the graft to incorporate at the rectum, despite standard distal fixation with >10 polydioxanone sutures.

Results/Outcomes: N/A

Conclusion/Discussion: Rectal prolapse remains a challenging problem to repair surgically, and operative approach for both index and subsequent procedures remains highly individualized to patient and surgeon preference. Several recent reviews suggest a durable repair with ventral rectopexy, especially if completed at the same time as other pelvic organ prolapse repairs. The use of biologic mesh is supported by a recent prospective study, and in theory, the matrix it provides allows for robust native tissue ingrowth. For reasons not entirely clear, these patients here either demonstrated graft failure or tissue in-growth failure. The use of permanent mesh to complete their subsequent repair may expose them to a risk of increased mesh related complications, however after failure of a biologic, we believe this to be a safe and effective choice. This work demonstrates that the repeat ventral rectopexy is feasible and possible for patients with a recurrence of pelvic organ prolapse after the use of a biologic graft.