EP384 - Recurrence After Abdominal Rectal Prolapse Repair: Insights from MR Defecography and Anorectal Manometry

Purpose/Background: Recurrence of rectal prolapse after surgical repair remains a major limitation. Prior research of recurrence risk has yielded inconsistent results and assessed a limited range of factors, many of which are not modifiable. The aim of this study was to evaluate whether pre-operative MR defecography and anorectal manometry measurements could identify biomarkers associated with recurrence in patients undergoing abdominal rectopexy procedures for rectal prolapse.

Methods/Interventions: A prospectively maintained rectal prolapse database was reviewed to identify patients undergoing abdominal rectopexy for rectal prolapse between 2017 and 2025, who also underwent pre-operative MR defecography or anorectal manometry. Clinical, technical, and imaging parameters were compared between patients with and without prolapse recurrence. MR defecography parameters evaluated included the levator hiatus length, levator hiatus descent and anorectal angle during rest and defecation; presence of cul-de-sac hernias; descent of pelvic organs (bladder, uterus and/or vagina) during defecation; rectal axis, estimated levator ani subtended volume; and measures of muscle mass or sarcopenia including the puborectalis thickness, mean cross-sectional area of the psoas muscle, psoas muscle index and psoas muscle mean fat fraction.

Results/Outcomes: A total of 155 patients (10 male, 145 female) with a median age of 63.0 years were included, with a recurrence rate of 10.3% (n=16) over a median follow up of 1295 days. All procedures were performed robotically and included robotic ventral rectopexy (n=126, 75%), suture rectopexy (n=21, 12.5%), and resection rectopexy (n=8, 4.8%). 26% (n=32) of patients had undergone a prior rectal prolapse repair. The only clinical factor associated with recurrence was diabetes mellitus, which was more common among those with recurrence than those without recurrence (31.3% versus 5.8%, p < 0.001). Body mass index was not significantly associated with recurrence (recurrence mean 26.0kg/m2 (SD 6.4) versus no recurrence mean 23.7kg/m2 (SD 4.1), p=0.17). Technical factors and findings on anorectal manometry were comparable between groups. On MR defecography in female patients (Table 1), those with recurrence were more likely to have an enterocele (43.8% versus 16.7%, p=0.018) or cul-de-sac hernia (75.0% versus 42.9%, p = 0.015) and had reduced cross-sectional area of the psoas muscle (median 12.3cm2 (IQR 10.5 - 13.7) versus median 14.3cm2 (IQR 11.8 - 15.8), p = 0.04) compared to those without recurrence.

Conclusion/Discussion: Recurrence after robotic rectopexy is associated with patient, prolapse and imaging factors. This study is the first and only study to integrate MRI findings with clinical factors to comprehensively evaluate risk for recurrence. Our results suggest that some measures of low muscle mass (sarcopenia) and an enterocele or cul-de-sac hernia on defecography, along with diabetes mellitus, may be associated with recurrence risk. Diabetic control and sarcopenia are potentially modifiable through lifestyle interventions, highlighting opportunities for preoperative optimization. Larger-scale studies are warranted to further investigate these risk factors and guide risk-stratified management.

Table 1. Comparison of MRI defecography results in female patients with or without prolapse recurrence
Continuous normally distributed variables reported as mean ± standard deviation. Continuous variables that do not conform to a normal distribution reported as median (IQR Q1 - Q3). * For no recurrence group n=56, recurrence group n=14. eLASV: estimated levator ani subtended volume. PMI: psoas muscle index.