EP874 - Rectal Prolapse Surgery In Elderly Patients: Characteristics And Outcomes Of A Long-Term Experience, Highlighting Differences Between Abdominal And Perineal Approaches

Purpose/Background: The management of rectal prolapse (RP) in elderly patients represents a surgical challenge. Although several techniques have been described, the optimal approach is still debated, especially in older patients with multiple comorbidities. This study aimed to evaluate our long-term experience with RP surgery in elderly patients, comparing outcomes between abdominal and perineal approaches.

Methods/Interventions: A prospective single-center observational study was conducted on patients aged ≥70 years who underwent surgery for external or internal RP, with or without associated rectocele and/or entero/sigmoidocele, at a tertiary referral center between November 1998 and January 2025. Demographic, clinical, and radiological data were prospectively collected, including comorbidities (ASA classification), previous pelvic surgery, and preoperative functional symptoms. Surgical procedures were categorized as abdominal (Ventral Mesh Rectopexy - VMR, Orr-Loygue, and Frykman-Goldberg) or perineal (Delorme's and Altemeier's procedures, transvaginal rectocele repair) depending on patient selection and surgeon preference. All operations were performed by a single experienced colorectal surgeon (C.R.). Postoperative complications, RP recurrence, and functional outcomes (using Altomare ODS, Cleveland Clinic FI, and ICIQ-SF scores) were recorded.

Results/Outcomes: Out of 497 patients who underwent RP surgery, 91 patients aged ≥70 years were analyzed (88 females, 96.7%, with a mean age of 76.24 ± 5.2 years). Patient characteristics among older and younger groups are shown in Figure 1. External RP was more common in elderly patients (p < 0.001), while intrarectal and intra-anal intussusception were more frequent in younger ones (p=0.101). Among the elderly, 74 (81.3%) received an abdominal procedure (65 VMR, 8 Orr-Loygue, 1 Frykman-Goldberg), and 17 (18.7%) underwent perineal repair (2 transvaginal rectocele repairs, 12 Delorme's and 3 Altemeier's procedures). Figure 2 summarizes the time trend in adopting perineal vs. abdominal approaches in patients older and younger than 70 years. Perineal procedures were more frequently performed in elderly patients with external RP (76.5% vs. 27.0%, p< 0.001), while abdominal approaches were preferred for internal RP associated with other posterior compartment abnormalities (78.4% vs. 23.5%, p< 0.001).

Seventy-three older patients completed a mean follow-up of 54.6 ± 50.6 months. Twelve patients died from unrelated causes [6 (35.3%) in the perineal group vs. 6 (8.1%) in the abdominal group, p=0.003], and 6 patients were lost to follow-up. Postoperative complications occurred in 15 patients, with no significant difference between groups [4 (40.0%) perineal vs. 11 (17.5%) abdominal, p=0.101]. RP recurrence was recorded in 5 elderly patients, with no differences between the perineal and abdominal groups [1 (10.0%) vs. 4 (6.3%), p=0.671].

Although an overall improvement in functional outcome was documented, only the abdominal approach group showed significant reductions in ODS and FI scores (p < 0.001).

Conclusion/Discussion: RP surgery is safe and effective in elderly patients. Both abdominal and perineal procedures can be safely performed in older patients. However, in the present series, abdominal approaches (particularly VMR) showed significantly better functional outcomes and similar complication and recurrence rates when compared with perineal procedures.

Figure 1
Baseline characteristics among patients older or younger than 70 years old who underwent rectal prolapse surgery. *These data are presented as mean ± standard deviation. F= female; M= male; ASA= American Society of Anesthesiologists; OASIs= Obstetric Anal Sphincter Injuries; PF= Pelvic Floor; ERP= external rectal prolapse; ODS= Obstructed Defecation Syndrome; FI= Fecal Incontinence; UI= Urinary Incontinence
Figure 2
Time trend in adopting perineal and abdominal approaches in patients older and younger than 70 years.