Comparison of Rectal Prolapse Repair via Perineal versus Laparoscopic Approach

Objectives: Perineal approach (resection surgery) for rectal prolapse, when compared to laparoscopic approach (rectopexy), is associated with a higher recurrence but lower peri-operative morbidity, decreased pain, and relatively faster recovery. The objective of this study was to evaluate if adjusted post-operative complication rates for perineal approach is indeed lower than laparoscopic approach.

Methods: A secondary analysis of National Surgical Quality Improvement Program database for patients who underwent surgery for rectal prolapse from 2014 to 2022. Demographics, perioperative variables and postoperative complications data were extracted. Identified patients were divided into two cohorts: perineal resection (PR) and laparoscopic rectopexy (LR) cohorts. These two cohorts were compared using univariable analysis techniques. Multivariable logistic regression was then performed to compare covariates-adjusted post-operative complications between the two cohorts.

Results: Among 9,410 patients who were captured, laparoscopic approach was employed in 4,152 (44.12%) and perineal approach in 5,258 (55.88%) of patients. More patients undergoing perineal approach, compared to laparoscopic approach, had the following characteristics: Older (mean 56.14 ± 13.10 vs 43.25 ± 16.56 years-old), White race, Hispanic ethnicity (4.98% vs 3.76%), lower BMI (mean 25.38 ± 5.95 vs 25.73 ± 5.52 kg/m2), lower pre-operative hematocrit (mean 37.41 ± 4.71 vs 39.22 ± 4.17 %), higher prevalence of comorbidities including tobacco smoking, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, bleeding disorder and American Society of Anesthesiologist Class 3 or 4 (p < 0.001). Total operative time was shorter for perineal approach than laparoscopic approach (88.76 ± 49.09 vs 170.18 ± 80.45 minutes, p< 0.001). Multivariable logistic regression adjusted for these covariates showed that laparoscopic approach was not associated with an increased risk of composite postoperative complication when compared to perineal approach (adjusted odds ratio 0.86, 95% CI 0.74-1.00) (Table 1). While laparoscopic approach was associated with a higher risk of superficial surgical site infection (aOR 3.36, 95%CI 1.47-7.67), it was associated with a lower risk of organ level surgical site infection (0.24, 0.15-0.39). Further, laparoscopic approach was associated with lower odds or readmission and return to the operating room.

Conclusions: Laparoscopic approach for rectal prolapse surgery has no increased odds of composite post-operative complications than compared to perineal approach. Thus, if feasible, laparoscopic approach that is associated with a lower recurrence risk may warrant being offered as the first-line surgical intervention for rectal prolapse.