We hypothesize that octogenarian patients with rectal prolapse can be safely treated with abdominal approaches and that perineal approaches should be used only in patients with a non-permissible risk of abdominal surgery and general anesthesia. Our study's main aim was to evaluate the outcomes of rectal prolapse surgery by comparing morbidity and mortality rates following abdominal and perineal approaches in a large octogenarian population. The secondary aim was to evaluate the recurrence rate.

We conducted an IRB-approved retrospective single-center cohort study of patients who underwent surgery to treat full-thickness rectal prolapse, between 2010 and 2023, at our tertiary referral center. We included patients who were ≥ 80 years old at the time of surgery. A total of 164 patients met our inclusion criteria. Data was retrospectively obtained by reviewing clinical and operative charts. Patients were stratified into two groups according to the approach of surgical repair for rectal prolapse. Outcomes were compared between the two groups.

Of the 164 patients included, abdominal approaches were performed in 58 (35.4%), and perineal approaches were performed in 106 (64.4%). Comparing the two approaches, no differences were observed in the female sex (96.6% vs 93.4% p=0.49), mean Body Mass Index (22.7 vs 23.8 kg/m2 p=0.14), ASA class or comorbidities (table 1), history of prior rectal prolapse surgery (34.5% vs 30.2% p= 0.73) and surgery performed under general anesthesia (100% vs 93.4% p=0.052). Patients who underwent abdominal procedures had a significantly longer mean length of stay (4.4 vs 3.7 days p=0.014). With a mean follow-up period of 6.8 months, patients who underwent perineal approaches recurred significantly more than those who underwent abdominal approaches (18.9% vs 8.6% p=0.045). No differences were found in intrahospital complications rate, 30-day complications rate, and 30-day mortality rate among the two groups (table 2).

In our study, no differences were observed between the two groups in ASA scores or comorbidities. In our cohort of patients general anesthesia was extensively used to perform perineal procedures, even though the perineal procedure can be performed under spinal anesthesia. The interpretation of these findings suggests that surgeons' choice of perineal approach for elderly patients was not motivated by the patient’s anesthesia intolerance, comorbidities or ASA. 
We did not observe differences in the morbidity or mortality rate at 30 days. Our findings suggest that abdominal approaches can be a safe surgical option for octogenarian patients.  Our study demonstrates that perineal approaches have a higher risk of recurrence than compared to abdominal approaches.

We recommend that when treating octogenarian patients, surgeons consider abdominal approaches whenever possible and limit perineal approaches to patients who are too frail for general anesthesia or have a complex history of prior abdominal surgery. Age alone should not be a guiding factor for the choice of procedure for rectal prolapse repair. Abdominal procedure should be considered in the appropriate patient who can tolerate general anesthesia and the degree of frailty should help guide this multifactorial decision on the choice of operation.

Continence 12S (2024) 101679
DOI: 10.1016/j.cont.2024.101679