There are numerous surgical procedures available for the treatment of full-thickness rectal prolapse. All surgical approaches share the common objective of correcting the underlying morphological changes, preventing recurrent prolapse, and addressing functional issues such as incontinence and constipation. The various techniques are based on different operative principles, which are often combined: rectal mobilization, resection or plication of the elongated bowel segment, and/or rectopexy to the presacral fascia.
A fundamental distinction is made between transabdominal and transanal/perineal approaches. Furthermore, several access routes exist, including open surgery, conventional laparoscopy, robot-assisted laparoscopy, and other methods such as SILS.
Among the perineal techniques, the Rehn-Delorme and Altemeier procedures are most prominent. Transabdominal approaches differ in terms of whether rectopexy is performed with or without mesh and whether resection is included. Given the current state of evidence, it is difficult to issue a clear recommendation for any single technique. In addition to patient-specific factors such as previous surgeries, comorbidities, mobility, and life expectancy, the surgeon’s expertise is a key determinant in the selection of the operative method.
The literature often suggests that transabdominal procedures are associated with lower recurrence rates, whereas perineal operations are associated with lower perioperative morbidity. As such, perineal approaches are typically favored in older or high-risk patients. However, this assumption has not been sufficiently substantiated by clinical studies [1, 2], due to heterogeneity in patient cohorts, small sample sizes, short follow-up periods, and lack of resources for large randomized controlled trials.
Perineal procedures
The most common perineal or transanal techniques include:
– the Rehn-Delorme procedure
– the Altemeier procedure
– stapler-assisted techniques
These procedures are described in detail at webop.de, where the relevant teaching modules are referenced.
Comparison of Rehn-Delorme and Altemeier procedures
A retrospective controlled cohort study compared outcomes in 22 patients treated using the Altemeier procedure and 53 patients with the Rehn-Delorme technique. Both procedures had the same recurrence rate at 13 months; however, the complication rate was significantly higher in the Altemeier cohort, primarily due to a relatively high rate of anastomotic leakage [3]. Due to limited evidence, there is no clear preference between the two techniques.
Transabdominal surgical procedures
Laparoscopic access has become the standard for transabdominal techniques. Patients benefit from the widely recognized advantages of laparoscopic surgery, such as shorter hospital stays and faster recovery. In a Cochrane review by Tou et al., laparoscopic surgery for prolapse was found to have fewer complications compared to open techniques, with similar functional outcomes [2]. Robotic rectopexy has also been shown to be feasible with comparable complication and recurrence rates.
The transabdominal procedures vary based on the use of suture versus mesh, with or without resection, as summarized below [4, 5]:
Procedure | Recurrence rate | Pexy type | Mesh | Resection | Technique |
|---|---|---|---|---|---|
Suture rectopexy (Sudeck) | 0–41% | dorsal | no | no | full rectal mobilization, sutured to presacral fascia |
Anterior sling rectopexy (Ripstein) | 0–12% | dorsal | yes | no | same as Sudeck, with circular mesh wrap around rectum, mesh fixation to rectum and presacral fascia |
Posterior mesh rectopexy (Wells) | 0–11% | dorsal | yes | no | similar to Sudeck, mesh placed around posterior two-thirds of rectum (ventral third left free) |
Resection rectopexy (Frykman-Goldberg) | 0–18% | dorsal | no | yes | complete mobilization, resection of sigmoid, anterior suture to obliterate cul-de-sac |
Lateral mesh rectopexy (Orr-Loygue) | 0–6% | ventral | yes | no | complete anterior and posterior mobilization, fixation of two mesh strips anterolaterally to rectum and promontory, peritoneal closure over mesh |
Ventral mesh rectopexy (d’Hoore) | 0–15% | ventral | yes | no | ventral mobilization only, mesh fixed ventrally to distal rectum and laterally to the promontory, peritoneal closure over mesh |
Key differences among techniques:
Suture rectopexy (Sudeck) involves full rectal mobilization to the pelvic floor and suture fixation to the presacral fascia, with or without resection. Recurrence rates may be as high as 40% [6]. Functional outcomes, especially regarding constipation, vary across studies, with some even reporting worsening of constipation [7].
Resection rectopexy includes sigmoid resection and pelvic floor elevation via anterior and lateral sutures. Dorsal dissection in the total mesorectal excision (TME) plane down to the upper anal sphincter, with preservation of autonomic nerves, is a key component of traditional pexy techniques. Recurrence rates range from 0 to over 10%. Compared to pexy alone, constipation tends to improve.
Mesh fixation may be dorsal (Ripstein, Wells) or ventral (d’Hoore). The Ripstein procedure is no longer performed due to complications like mesh erosion and stricture caused by circumferential mesh placement. The Wells technique, which avoids complete circumferential fixation, is still associated with higher complication rates [8]. Orr-Loygue technique involves full rectal mobilization with bilateral lateral mesh fixation.
In the d’Hoore technique, only the ventral rectum is mobilized to the level of the levator ani. The mesh is placed deep between the rectum and vagina. One of the largest multicenter studies on this approach included 919 patients with rectal prolapse, 242 of whom had external prolapse. After 10 years, the recurrence rate was 8%, and 5% experienced mesh-related complications. Both incontinence and obstructed defecation improved significantly (incontinence reduced from 41% to 15%, obstruction from 34% to 13%) [9].
Mesh erosion is a rare but serious complication of synthetic implants. Use of absorbable biosynthetic mesh has been proposed as a preventive strategy. However, a recent meta-analysis from the Netherlands found no significant differences in recurrence or mesh-related complications between mesh types [10].
Due to limited evidence, direct comparisons among transabdominal procedures are challenging. In some centers, the surgical approach depends on whether constipation is a primary symptom (favoring resection rectopexy) or whether the ventral compartment is the focus (favoring ventral mesh rectopexy).
Comparison of perineal and transabdominal techniques for external rectal prolapse
The Cochrane review by Tou et al. could not determine superiority of either approach due to insufficient quality evidence [2]. However, it highlighted the benefits of resection for constipation and laparoscopic access in transabdominal techniques.
Neither the international multicenter randomized controlled PROSPER trial nor the Swedish study by Smedberg et al. provided conclusive guidance on whether perineal or transabdominal procedures should be preferred [1, 11].
The DeloRes study addressed the design flaws of previous trials [12]. In a multicenter comparison of the most common perineal (Rehn-Delorme) and transabdominal (resection rectopexy) procedures, the resection rectopexy group had significantly better outcomes at 24 months, without increased morbidity.
A prospective evaluation within the largest DeloRes center, including randomized patients and additional non-study cases, found a significant difference in recurrence rates: 44% in the Rehn-Delorme group versus 4% after resection rectopexy. None of the patients experienced complications requiring intervention. At 24 months, incontinence improved more markedly after resection rectopexy than after the Rehn-Delorme procedure [13].
The findings from the DeloRes study and two other RCTs support the expert consensus that perineal techniques are associated with significantly higher recurrence rates and do not show the presumed lower morbidity. This conclusion was also confirmed by a recent Italian meta-analysis [14], raising doubt as to whether elderly and comorbid patients should routinely be treated with perineal procedures.
Only a few comparative studies on ventral mesh rectopexy are available, and most have significant methodological limitations. Recent analyses have not shown a substantial difference in recurrence when compared with the Rehn-Delorme or resection rectopexy procedures [15, 16]. Ventral rectopexy according to d’Hoore is widely performed across Europe and demonstrates outcomes comparable to resection rectopexy [17]. Overall, the data support the use of transabdominal techniques even in elderly patients, due to significantly lower recurrence rates with similar perioperative morbidity.
A prospective randomized study demonstrated significantly better functional outcomes—including continence and constipation scores—for laparoscopic ventral rectopexy compared to suture rectopexy [18].
Another randomized trial from Egypt also showed better functional results and a lower recurrence rate for laparoscopic ventral rectopexy than for perineal stapled procedures [19].
Conclusion
The available evidence for surgical treatment of full-thickness rectal prolapse is primarily based on retrospective cohort studies and a few small RCTs. Conducting meta-analyses and comparing outcomes is difficult due to heterogeneous study designs and endpoint definitions.
Current evidence can be summarized as follows:
No definitive superiority of transabdominal versus transanal/perineal procedures
No clear advantage of biological versus synthetic mesh
Lower morbidity and faster recovery with similar recurrence rates in laparoscopic versus open surgery
No demonstrated superiority of the Delorme procedure over the Altemeier procedure
Thus, no single procedure can currently be recommended based solely on evidence; treatment must continue to be guided by clinical experience and individual patient factors.