The aim of this study is to evaluate effects, safety, and any changes in lower bowel tract function (LBTF) after multicompartment prolapse surgery in patients using two different surgical approaches, transvaginal mesh surgery with levatorplasty (TVMLP) and robot-assisted sacrocolpopexy (RSC) with anterior and posterior mesh.

This was a randomized prospective study. The exclusion criteria were age over 75 years old, BMI ≥ 35 kg/m2, neurogenic voiding and bowel symptoms, previous pelvic surgery and any medical condition or psychiatric illness.
Inclusion criteria were female patients with symptomatic multicompartment prolapse stage III-IV. All patients were studied preoperatively at time 0 (baseline) and postoperatively at 6 and 12 months with a pelvic and rectal examination to assess the severity of POP (POP-Q staging system) and to evaluate anal sphincter tone, a urodynamic study, and a pelvic MR defecography. All the patients completed Wexner’s questionnaire at time 0, 6 and at 12 months.

From March 2018 to November 2021, 73 patients were enrolled and classified into two group: RSC group (36 cases) and TVMLP (37 cases). After surgery, the main POP-Q stage in both groups was stage I (RCS 80.5% vs TVMLP 82%). There was a significant difference (p<0.05) according to post-operative anal sphincter tone: 35% of TVMLP patients experienced hypertonic anal sphincter. The operation time in the TVMLP group was significantly shorter than the RSC group (mean: 76.62 vs. 109.35; SD: 0.92 vs. 8.73; p<0.005), while the bleeding was significantly higher (mean: 20.89 vs. 4.94; SD: 4.44 vs.1.06; p<0.005). There were no significant differences regarding hospital stay, complications rate, recurrence of POP and mesh exposure between two groups (p>0.005). According to LBTF, at the baseline were not significant differences between two groups.  At 12 months of follow-up after surgery, both groups exhibited a significant improvement. The main postoperative differences between the two groups were observed in favor of RSC, especially regarding the domain of pain (RSC mean: 0.50 vs. TVMLP mean: 2.00; SD: 0.50 vs 0.97; p<0.05) and the total Wexner Score (RSC mean: 6.88 vs TVMLP mean: 8.56; SD 1.63 vs 1.76; p<0.05).

RSC and TVMLP successfully correct multicompartment POP. RSC causes an improvement in total Wexner score: the mesh and relative peritoneum fibrosis obliterate the deep Pouch of Douglas and eliminate the potential space of enterocele, rectocele and sigmoidocele; this surgery can straighten the angle of the rectosigmoid junction, so defecation will be complete. TVMLP is associated with increased pain during defecation, maybe because stiches suture could aliterate the physiological distensibility of the rectum during stool passage and could determinate a painful hypertonic status of external anal sphincter, as confirmed to follow-up digital rectal examination.

RSC and TVMLP successfully corrected multicompartment POP. RSC showed a greater improvement in the total Agachan-Wexner score and lower bowel symptoms.

Karjalainen, P.K.; Mattsson, N.K.; Nieminen, K.; Tolppanen, A.-M.; Jalkanen, J.T. The relationship of defecation symptoms and posterior vaginal wall prolapse in women undergoing pelvic organ prolapse surgery. Am. J. Obstet. Gynecol. 2019, 221, 480.e1–480.e10.
Gustilo-Ashby, A.M.; Paraiso, M.F.R.; Jelovsek, J.E.; Walters, M.D.; Barber, M.D. Bowel symptoms 1 year after surgery for prolapse: Further analysis of a randomized trial of rectocele repair. Am. J. Obstet. Gynecol. 2007, 197, 76.e1–76.e5.

Continence 12S (2024) 101673
DOI: 10.1016/j.cont.2024.101673