EP151 - The Impact of Selective Versus Routine Pre-Operative Urogynecologic Evaluation on Rectopexy Outcomes

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Purpose/Background: Women with full thickness rectal prolapse (FTRP) frequently present with symptoms of concurrent middle and anterior pelvic organ prolapse (POP). Studies suggest that 20-35% of women with FTRP report urinary incontinence and 15-30% have significant vaginal vault prolapse. Overlooking this association during FTRP treatment can result in exacerbation of symptoms related to concurrent POP after FTRP repair. A multidisciplinary approach may help avoid sequential surgeries and decrease the rate of recurrence. The American Society of Colon and Rectal Surgeons’ Clinical Practice Guidelines for the Treatment of Rectal Prolapse strongly recommends multidisciplinary assessment of patients with multivisceral POP but does not elaborate on best practices. Our aim was to evaluate the impact of selective versus routine pre-operative urogynecologic evaluation on the rate of rectal prolapse recurrence among women undergoing rectopexy.

Methods/Interventions: We conducted a retrospective chart review of all female patients who underwent rectopexy for FTRP between 2013 and 2024. Exclusion criteria included previous rectopexy by the same surgeon and duration of clinical follow-up less than 3 months. Two eras of practice were compared: the first defined by selective referral to urogynecology for evaluation of symptoms of anterior and middle compartment POP elicited on survey at the time of colorectal surgical evaluation (2013-18), the second defined by routine urogynecologic evaluation in a multidisciplinary clinic (2019-24). The primary outcome was the frequency of clinically significant recurrence evidenced by the need for further surgery to correct FTRP. Pre- and post-operative symptom and quality-of-life scores, frequency and grade of diagnosed multivisceral POP, additional pelvic surgical history, and time to recurrence were also compared. Frequencies, continuous variables, and ordinal variables were compared using the chi-squared test, Student’s t test, and Mann-Whitney test, respectively.

Results/Outcomes: A total of 52 and 44 women underwent rectopexy following selective and routine urogynecologic evaluation, respectively. Among the former, 14 (27%) were referred to urogynecology. Women in the selective referral era had significantly higher rates of recurrent disease at index evaluation with 21% having undergone previous rectopexy compared to 7% in the later era. Rates of diagnosed cystocele, rectocele, and enterocele between groups were 10% vs 77%, 14% vs 84%, and 10% vs 64%; there was no difference in the stage of POP between eras. Ventral rectopexy was the most common type of repair with a trend from laparoscopic to robotic platforms between eras. Rates of concurrent sacral colpopexy, hysterectomy, and posterior colporrhaphy increased significantly. Repeat FTRP repair was necessary in 15 (29%) patients under the selective referral paradigm compared to 3 (7%) seen in routine multidisciplinary clinic (p=0.006). Time to recurrence was similar between groups at 24.5 months and 22.8 months, respectively.

Conclusion/Discussion: In this retrospective comparison of referral paradigms across eras, routine evaluation by urogynecology was associated with a lower rate of FTRP recurrence among women undergoing rectopexy when compared with selective referral. These findings suggest a possible benefit to the detection of multivisceral POP with concurrent repair and warrant future multicenter prospective evaluation.