VM75 - Robotic Ventral Mesh Rectopexy for Male Prolapse with Rectocele and Enterocele

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Purpose/Background: Rectal prolapse is generally a female pathology (sex ratio 10:1), associated with age and childbearing. Rectal prolapse in males is rare. Minimally invasive approaches are increasingly used in the treatment of rectal prolapse, the robotic approach is taking the lead over laparoscopy. This video describes a ventral mesh rectopexy for symptomatic rectocele and enterocele in a male patient.

Methods/Interventions: We present the case of a 66-year-old man with severe pelvic floor laxity with moderate anterior rectocele and a large enterocele within 2 cm of the anal skin. The diagnostic work up included high resolution anorectal manometry, showing pelvic floor dysfunction type 1; MRI defecography that showed excessive descent of the anorectal junction 6 cm below the pubococcygeal line, an anterior rectocele of 2.5 cm, and at the end of evacuation a full thickness prolapse of the anterior wall of the rectum within the anal skin with a large enterocele, and trans-enteric motility study, no abnormalities were found. After failing conservative management of bowel regimens and a trial of biofeedback and pelvic floor physical therapy for two months, surgery was offered to the patient. A robotic approach was chosen for the patient having the advantage of facilitating rectum mobilization and the dissection deep at the pelvic floor. The video demonstrates this procedure which is rarely performed in male patients. At inspection, the pelvic peritoneal reflection appeared to be quite low for a male pelvis, resembling that of a female pelvis. Pelvic descent was evident at perineal inspection with a bulging of the perineal body, and the lead point was found above the sphincter complex on rigid sigmoidoscopy. A peritoneal flap was created, allowing for mobilization of the rectum and exposure of the sacral promontory. Dissection proceeded anteriorly to the levator muscle plate to guarantee adequate mesh positioning. A Phasix ST mesh was customized to the width of the rectal wall and secured on the anterior rectal wall with 3 rows of 3 interrupted seromuscular 2-0 PDS sutures. The mesh was secured to the sacral promontory with two interrupted Gore-Tex sutures. An anal operator assisted during the procedure to confirm correct tension of the rectal wall and that sutures were not full thickness after every placement. A Stratafix 3-0 suture was used to recreate the new anterior peritoneal reflection in a pursestring fashion and a peritoneoplasty was performed by imbricating the excess peritoneum to exclude small bowel loops from the pelvis. The peritoneal flap was closed in a running fashion. The peritoneoplasty allowed for reconstruction of a higher peritoneal reflection to improve symptoms related to his large enterocele. Full coverage of the mesh was ensured. The anal operator confirmed good tension of the mesh on the rectal wall.

Results/Outcomes: The postoperative course was uneventful. The patient was discharged on POD1. The patient reported improvement of symptoms at his 1 month postoperative visit and complete resolution of urinary symptoms at 3 months. At one year follow up recovery was sustained with normal anal sphincter tone, good tone upon squeeze, and taut anterior rectal wall.

Conclusion/Discussion: This video demonstrates the effectiveness and feasibility of the robotic approach for ventral mesh rectopexy in a male with symptomatic enterocele.