Impact of Combined Sacrocolpopexy and Rectopexy on Long Term Bowel Symptoms

Objectives: Pelvic organ prolapse (POP) is characterized by descent of the bladder, uterus, and/or rectum. Constipation is a risk factor for worsening POP and can lead to distressing bowel symptoms, including decreased bowel frequency and incomplete bowel emptying. Posterior wall prolapse has traditionally been managed with vaginal surgery; however, postoperative bowel symptoms can persist. The objective of this study was to compare long-term postoperative bowel symptoms in individuals who underwent combined sacrocolpopexy and rectopexy (CSR) with those receiving sacrocolpopexy alone (SCP-a).

Methods: This is a retrospective convenience cohort study of women who had preoperative POP Quantification (POP-Q) staging, completed a Pelvic Floor Distress Inventory (PFDI-20), and then underwent sacrocolpopexy (via mini-laparotomy or robotic) between August 2020 and March 2023 at the University of Colorado. Patients were contacted via telephone to complete a PFDI-20 >1 year postoperatively. The primary outcome was the change in Colorectal-Anal Distress Inventory (CRADI-8) scores on the PFDI-20. Secondary outcomes were postoperative PFDI-20 composite scores, bowel movement frequency, and number of bowel medications. Exclusion criteria were individuals with rectal prolapse.

Results: Sixty-five individuals met the inclusion criteria, 52 provided responses, yielding an 80% response rate. Among them, 42 underwent CSR, while 10 underwent SCP-a. Indications for CSR included enterocele, intussusception, or posterior wall prolapse beyond +1. There were no differences between groups regarding average time to follow-up or demographic data; however, a greater percentage of those who underwent CSR had mini-laparotomy compared to those with SCP-a (Table 1). Preoperatively, significantly higher overall prolapse stage was noted in the CSR group, particularly in posterior wall (Ap and Bp) measurements. There were no significant differences in anterior (Aa and Ba) or apical (C) vaginal wall measurements. While preoperative CRADI-8 scores were significantly higher (more distressing) in the CSR group, postoperative scores were not different between groups. The mean difference between pre- and postoperative CRADI-8 composite scores in the CSR group improved compared to worsening scores in the SCP-a group (-7.31±20.42 vs. 4.68±17.87, p=0.04) and similarly for CRADI-8 question 3 addressing fecal incontinence (-0.05±0.31 vs 0.4±1.26, p=0.02) (Table 2). PFDI-20 composite scores, bowel movement frequency, and number of bowel medications were not significantly different between groups pre- or postoperatively.

Conclusions: In this retrospective study, patients with more severe POP and posterior prolapse were more likely to undergo CSR. Additionally, individuals who underwent CSR experienced significant improvement in distressing bowel symptoms compared to SCP-a; this is despite no differences in bowel movement medications and frequency between groups. These results suggest that individuals planning to undergo sacrocolpopexy may benefit from colorectal symptom assessment and diagnostic testing to determine if CSR is indicated to alleviate bowel symptoms, regardless of preoperative posterior wall prolapse severity, bowel movement frequency, or number of bowel medications taken.