Outcomes of Laparoscopic Suture Rectopexy Versus Laparoscopic Mesh Rectopexy: A Systematic Review and Meta-Analysis

The contemporary literature provides conflicting evidence regarding the precedence of laparoscopic mesh rectopexy over laparoscopic suture rectopexy for full-thickness rectal prolapse. This study aimed to compare the clinical outcomes of mesh and suture rectopexy to improve the surgical management of complete rectal prolapse. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to extract studies based on mesh versus suture rectopexy and published from 2001 to 2023. The articles of interest were obtained from PubMed Central, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Journal Storage (JSTOR), Web of Science, Embase, Scopus, and the Cochrane Library. The primary outcomes included rectal prolapse recurrence, constipation improvement, and operative time. The secondary endpoints included the Cleveland Clinic Constipation Score, Cleveland Clinic Incontinence Score, intraoperative bleeding, hospital stay duration, mortality, overall postoperative complications, and surgical site infection. A statistically significant low recurrence of rectal prolapse (odds ratio: 0.41, 95% confidence interval (CI) 0.21-0.80; p=0.009) and longer mean operative duration (mean difference: 27.05, 95% CI 18.86-35.24; p<0.00001) were observed in patients with mesh rectopexy versus suture rectopexy. Both study groups, however, had no significant differences in constipation improvement and all secondary endpoints (all p>0.05). The laparoscopic mesh rectopexy was associated with a low postoperative rectal prolapse recurrence and a longer operative duration compared to laparoscopic suture rectopexy. Prospective randomized controlled trials should further evaluate mesh and suture rectopexy approaches for postoperative outcomes to inform the surgical management of complete rectal prolapse.


Introduction And Background
The rectal procidentia, or full-thickness prolapse of the rectum, is the outcome of pelvic floor dysfunction, leading to the complete expulsion of the rectum through the anal sphincters [1].The frequent symptoms of a complete rectal prolapse include fecal incontinence and rectal bleeding [2,3].The anatomic abnormalities associated with a complete rectal prolapse include anterior cul-de-sac extension, diastasis of the levator muscle, and a reduction in anal sphincter tone [4].The sphincter complex injury or chronic straining, resulting in sphincter weakness, increases the risk and incidence of complete rectal prolapse [1,4].The potential risk factors for rectal prolapse include elevated intra-abdominal pressure, chronic constipation, perineal injury, obesity, pregnancy, psychiatric disorders, and connective tissue diseases [1].
The prevalence of complete rectal prolapse in the general population is 0.5% [5].However, a 2.5% annual incidence of rectal prolapse is reported in patients ≥50 years, who often present with tenesmus, pain, rectal bleeding, incomplete evacuation, incontinence, and constipation [5].Of note, the rates of constipation and fecal incontinence in such patients are 25-50% and 50-75%, respectively [5].The progression of rectal prolapse is further aggravated by several potential factors, including pelvic floor weakness, insufficient recto-sacral fixation, redundant sigmoid colon, and a deep Douglas pouch [6].Additionally, the straining chain, constipation, and outlet obstruction are initiated by external sphincter tonus elevation in patients with rectal prolapse [7].The optimization of surgical approaches for rectal prolapse depends on a range of factors including differential diagnosis, patient presentation, and the incidence of clinical complications including fecal incontinence, diarrhea, constipation, mucus discharge, incomplete bowel evacuation, and abdominal discomfort [5].The preoperative scoring systems, such as the Wexner Constipation Score, Rome IV Criteria, Altomare Obstructed Defecation Syndrome (ODS) Score, Pescatori Incontinence Score, Fecal Incontinence Severity Index (FISI), and St. Mark's Incontinence Score (SMIS) facilitate the assessment of rectal prolapse complications [8][9][10].
Suture rectopexy was initially adopted for rectal fixation/redundant bowel plication; however, it has been increasingly replaced with mesh rectopexy to minimize postprocedural morbidity and chronic pain [11].Surgeons utilize a laparotomy or laparoscopic approach to perform a suture rectopexy, which was initially elaborated in 1959 by Cutait [11].The suture rectopexy utilizes a non-absorbable suture for rectal fixation/mobilization [12].This approach facilitates the integration of the presacral fascia with the rectum, by allowing the growth of adhesions and fibrosis, after its mobilization and suturing [13].Literature evidence reveals better clinical outcomes in males, treated with suture rectopexy, than females because of their undiagnosed preoperative occult sphincter defects [14].
Ripstein initially described the treatment of complete rectal prolapse with mesh rectopexy in 1952 [11].Of note, mesh rectopexy fixates the rectum through a non-absorbable/absorbable synthetic material (or anterior sling) following its mobilization [14].The rectal promontory is finally sutured with the mobilized rectum to reinstitute its natural curve [11].The utilization of rectal rectopexy for the repair of rectal prolapse improves the clinical outcomes by reducing the downward abdominal pressure [11].The better anatomic positioning of the rectum via mesh rectopexy is due to its ability to rigidly support the anterior fascia through a non-elastic synthetic graft [15].This is why patients with noticeable pelvic floor descent also benefit from the mesh rectopexy procedure [16].
The current literature provides conflicting evidence about the outcomes of laparoscopic suture versus mesh rectopexy in patients with complete rectal prolapse.For example, the meta-analysis by Lobb et al. defies a significant difference in postprocedural rectal prolapse prevalence between suture rectopexy and mesh rectopexy [11].Alternatively, the observational study by Takahashi et al. reveals reduced occurrences of complete rectal prolapse after laparoscopic suture rectopexy, compared to mesh rectopexy [17].Contrastingly, the meta-analyses by Hajibandeh et al. and Emile et al. indicate prolonged procedure duration and lower rectal prolapse recurrence rates with laparoscopic mesh rectopexy versus suture rectopexy [18,19].Similarly, studies provide conflicting results on several other mesh/suture rectopexy parameters, including mortality, postoperative complications, Wexner scores, constipation/incontinence improvement, intraoperative bleeding, and surgical site infection.
This systematic review and meta-analysis accordingly aimed to address and compare current gaps regarding the clinical outcomes of laparoscopic mesh versus suture rectopexy in patients treated for full-thickness rectal prolapse.

Review Study design and data collection
This systematic review and meta-analysis was undertaken in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [20].Retrospective, prospective, and single-/double-blind randomized controlled/comparative studies were evaluated for several postprocedural clinical outcomes in patients with laparoscopic posterior mesh rectopexy versus laparoscopic ventral/posterior mesh rectopexy for full-thickness/complete rectal prolapse.The studies published from 2001 to 2023 were included in this analysis.Of note, articles based on meta-analyses, systematic reviews, review papers, narrative reviews, opinion papers, editorials/correspondences, case studies, and case reports were excluded from this study.All data were initially collected on a Microsoft Excel sheet.Double data checks by two independent reviewers ascertained the avoidance of data entry errors.

Primary and secondary outcomes
The primary outcomes were postoperative rectal prolapse recurrence, constipation improvement, and mean operative time (minutes).The secondary outcomes included Cleveland Clinic Constipation Score (CCCS), Cleveland Clinic Incontinence Score (CCIS), intraoperative bleeding, mean hospital stay duration (postoperative days), mean operative time (minutes), mortality, overall postoperative complications, and surgical site infection.

Literature search
The literature search was conducted on February 29, 2024, by five autonomous reviewers.We explored several databases, including PubMed Central, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Journal Storage (JSTOR), Web of Science, Embase, Scopus, and the Cochrane Library, to identify the published peer-reviewed articles based on the outcomes of laparoscopic mesh versus suture rectopexy for complete rectal prolapse.The following search terms were combined via Boolean operators (OR and NOT) and executed via advanced filters of the selected databases: (1) Rectal prolapse, (2) Full-thickness, (3) Laparoscopic, (4) Mesh rectopexy, and (5) Suture rectopexy.Title and abstract-based searches were undertaken, followed by the assessment of full-text articles.Data were thoroughly evaluated following the eligibility parameters.Discrepancies in literature search and data collection between the two reviewers were resolved with mutual consensus, following the intervention of a third independent reviewer.

Statistical analysis
The authors of this study utilized RevMan (Web version) to statistically evaluate the primary and secondary clinical outcomes [21].Odds ratios (ORs), within 95% confidence intervals (CIs), were calculated to determine the occurrence of intraoperative bleeding, mortality, overall operative complications, postoperative constipation improvement, rectal prolapse recurrence, and surgical site infections [22].Alternatively, mean differences (MDs) with standard deviations (SDs) were calculated for CCCS, CCIS, hospital stay duration, and operative time in both study groups [23].The heterogeneity among the included studies was determined by tau-squared, chi-squared, and I-squared statistics [24,25].The minimal, moderate, and high heterogeneity levels were indicated by 0-30%, 31-60%, and 61-100% I-squared values, respectively.The statistical analyses of the dichotomous data type were undertaken via the Mantel-Haenszel random-effects approach [26].However, continuous data were examined via the inverse variance randomeffects model [27].The statistical significance of outcomes was evaluated via the probability value reference (p≤0.05)[28].

Risk of bias (ROB)
The Cochrane risk of bias in non-randomized studies of interventions (ROBINS-I) tool was used to evaluate the ROB for non-randomized/observational studies [29].Alternatively, the risk-of-bias visualization (ROBVIS) ROB-2 tool was used to evaluate ROB in randomized controlled studies [30].Accordingly, the traffic light plots and summary plots were obtained for observational and randomized studies, respectively.ROBs were calculated based on a multitude of parameters, including confounding, participant selection, intervention classification, intervention deviation, missing data, outcome measurement, result selection, and randomization.ROBs were further classified/scaled as low risk, moderate risk, critical risk, no information, and some concerns, respectively.

Results
The literature search resulted in the selection of 456 studies from PubMed/Medline and CINAHL and 289 studies from Web of Science, JSTOR, and Scopus (Figure 1).One hundred forty-five records were subsequently retrieved after removing the duplicate entries.Of them, 111 records were excluded due to duplicate data.Finally, 34 full-text articles were screened for eligibility, and 11 of them were included for systematic review and meta-analysis after excluding 23 studies based on dubious results, missing data, inconsistent findings, and incorrect interpretation.

FIGURE 1: Study flow diagram
Table 1 describes the baseline and preoperative characteristics of participants in each study group.A total of 2362 patients with mesh rectopexy and 2172 patients with suture rectopexy were evaluated for the operative/intraoperative/postoperative outcomes.The mean age of the participants was 55±11 years, and the mean female-to-male ratio was 25/5±0.5.However, most of the included studies did not provide data on preprocedural characteristics, including comorbidities and medication use.
Preoperative rectal pain
The low rectal prolapse recurrence finding in the mesh rectopexy group in this study contradicted the finding from a recent prospective study by Schabl et al. indicating a high recurrence of rectal prolapse with mesh rectopexy, specifically in patients with a prior history of multiple surgeries.Notably, a recurrence rate of 3.7-15.4% is reported after mesh rectopexy, in patients without a past history of surgery for rectal prolapse [42].However, following the abdominal approach, an 8% risk of a second recurrence is reported in the medical literature [43].Contrastingly, outcomes of a systematic review by when compared with ventral mesh rectopexy (7-15% vs. 5-8.8%)[11,17].A recent meta-analysis by van der Schans et al. reveals a comparatively lower risk of rectal prolapse recurrence with biologic versus synthetic mesh rectopexy [44].However, the associated risk factors of recurrence include CCCS (≧9), FISI score (>34), sacral fixation (tacks), length of external rectal prolapse (>4 cm), past rectal prolapse surgery, ASA physical status 3, body mass index (≧22), and age (>80 years) [45].
The finding of the current study regarding the longer operative time with mesh rectopexy, compared to suture rectopexy, concords with the outcome of the systematic review by Hajibandeh et al. [18].Contrarily, the meta-analysis results of Emile et al. defy statistically significant differences in operative time between suture and mesh rectopexy [19].However, findings from a retrospective study by Sahoo et al. also specify that mesh rectopexy requires 120±10.8minutes, compared to 100.8±12.4minutes for suture rectopexy [38].
The increased procedural time in mesh rectopexy is due to the additional workup warranted for circumferential rectal mobilization and additional dissection [46].Our results, however, matched the metaanalysis outcomes of Hajibandeh et al. that indicated similarities in hospital stay duration, surgical site infection, CCCS, and CCIS between suture rectopexy and mesh rectopexy [18].
The laparoscopic ventral mesh rectopexy specifically aims to restore the function as well as the anatomy of the prolapsed rectum [47].However, postoperative hemorrhoid development, fistula due to intrarectal mesh migration, and mesh-related erosion are the potential complications contributing to the recurrence of rectal prolapse after mesh rectopexy [48,49].It is therefore important to periodically evaluate the functional outcomes of mesh rectopexy to determine its impact on the health-related quality of life and recovery paradigm.Of note, most patients treated with mesh rectopexy experience a noticeable improvement in Birmingham Bowel and Urinary Symptom (BBUS) score, ODS score, Wexner Fecal Incontinence (WFI) score, bladder dysfunction, and incontinence [47].That is why despite a low response rate, mesh rectopexy remains a gold standard for treating complete rectal prolapse.
The laparoscopic suture rectopexy is a conservative approach for attaching the sacrum to the mesorectum via sutures [50,51].However, the fragility of the mesorectum leads to poor rectal fixation that increases the risk of rectal prolapse recurrence in the treated patients.The suturing of the sacrum with the rectal wall's seromuscular layer is performed due to tension-related lengthening of the mesorectum [17].While the mucosal layer's penetration of rectal sutures increases the risk of infection, the erosion of the rectal wall at the suture location triggers the onset of perirectal abscess.Additionally, postoperative spondylitis and intraabdominal abscess are the potential complications of suture rectopexy, requiring long-term management [17,52].Consequentially, the inflammation of the appendix after mesh rectopexy warrants management with ileostomy covering, appendectomy, and mesh excision [53].Similarly, ileostomy covering and anterior resection are the required treatment approaches for patients who develop rectal mesh fistulation, after mesh rectopexy [17].Future randomized controlled studies should specifically evaluate and compare these mesh versus suture rectopexy complications to improve the personalized management of complete rectal prolapse.

Limitations
Findings from this systematic review and meta-analysis cannot be generalized for all patients with complete rectal prolapse due to several limitations, including high heterogeneity, a small sample size, and a smaller number of randomized controlled studies.Additionally, we could not perform a subgroup analysis of the primary and secondary endpoints based on the demographic characteristics, including prior surgeries, comorbidities, body mass index, ASA grade, age, gender, preoperative complications, and previous treatments.This limitation could further impact the reliability of our results.

Conclusions
This study revealed a longer operative duration due to the different levels of skills of surgeons in various studies and the low postoperative rectal prolapse recurrence in patients with laparoscopic mesh rectopexy versus those with laparoscopic suture rectopexy.However, no differences between the groups were reported for constipation improvement and secondary endpoints.Future studies should further examine the potential causes and outcomes of rectal/mesh rectopexy to improve the decision-making for the surgical management of full-thickness rectal prolapse.

TABLE 1 : Baseline and preoperative characteristics
ASA: American Society of Anesthesiologists scoring

Table 2
synthesizes details of the authors, publication year, study type, patient classification, study methods, and outcomes.At the follow-up of 6.1 years, the Patient Assessment of Constipation Quality of Life was significantly higher in laparoscopic posterior sutured rectopexy patients compared to those with laparoscopic ventral mesh rectopexy.The No mortality was reported in patients with ventral mesh rectopexy.The recurrence rates for ventral mesh rectopexy and posterior suture rectopexy 2024 Kumari et al.Cureus 16(6): e61631.DOI 10.7759/cureus.constipationandcontinence were observed with suture rectopexy versus mesh rectopexy.No statistically significant differences in all other parameters were observed between the study groups 2024 Kumari et al.Cureus 16(6): e61631.DOI 10.7759/cureus.Compared to mesh rectopexy, suture rectopexy was associated with postoperative improvements in hospital stay duration, bowel activity, and operative times.Mesh rectopexy was associated with wound-related complications; however, suture rectopexy was devoid of intraoperative bleeding.Mesh rectopexy had higher recurrence rates, compared to suture rectopexy (9.8% vs.