Surgery for complete rectal prolapse in adults (Cochrane Review)

A substantive amendment to this systematic review was last made on 30 June 1999. Cochrane reviews are regularly checked and updated if necessary.

Background: Complete rectal prolapse is a debilitating condition, which affects both the very young and the elderly and can cause faecal incontinence.The range of surgical methods available to correct the underlying anal sphincter or pelvic floor defects in complete rectal prolapse poses the question about the choice of the best operation.

Objectives: To determine the effects of surgery on the treatment of rectal prolapse in adults.The following specific issues have been addressed:whether surgical intervention is better than no treatment;whether an abdominal approach to surgery is better then a perineal approach;whether one method for performing rectopexy is better than another;whether laparoscopic access is better than open access for surgery;whether resection should be included in the procedure.

Search strategy: Electronic searches of the Cochrane Incontinence Group trials register (February 2003), the Cochrane Colorectal Cancer Group trials register (March 1999), the Cochrane Controlled Trials Register (Issue 2, 1999), EMBASE (January 1998 to January 1999), SIGLE (January 1980 to December 1996), BIOSIS (January 1998 to March 1999), Science Citation Index (January 1998 to March 1999), Index to Scientific and Technical Proceedings (January 1982 to March 1999) were undertaken. The British Journal of Surgery (January 1995 to December 1998) and the Diseases of the Colon and Rectum (January 1995 to December 1998) were specifically hand searched. The proceedings of the Association of Coloproctology meeting held in 1999 were perused. Reference lists of all relevant articles were searched for further trials. Date of the most recent searches: February 2003.

Selection criteria: All randomised or quasi-randomised trials of surgery in the management of rectal prolapse.

Data collection and analysis: Two reviewers independently selected studies from the literature, assessed the methodological quality of eligible trials and extracted data.The three primary outcome measures were: number of patients with recurrent rectal prolapse, number of patients with residual mucosal prolapse, and number of patients with faecal incontinence.

Main results: Ten trials were included with a total of 324 participants. No trial included a group receiving no treatment, or anal encirclement, or Delormes procedure, or laparoscopic suture rectopexy, or laparoscopic resection rectopexy. One trial (20 participants) compared both perineal and abdominal resection rectopexy with pelvic floor repair; five trials (195 participants) compared different types of open rectopexy techniques; two trials (61 participants) compared laparoscopic with open mesh rectopexy; and two trials included comparisons between open resection rectopexy and rectopexy alone.In all comparisons data were few. There were no detectable differences in recurrent prolapse between abdominal and perineal approaches, although there was a suggestion that residual faecal incontinence was less common after abdominal surgery. There were no detectable differences between the methods used for fixation during rectopexy. Division, rather than preservation, of the lateral ligaments was associated with less recurrent prolapse but more post-operative constipation, although these findings were found in small numbers. Laparoscopic rectopexy was associated with fewer post-operative complications and shorter hospital stay than open rectopexy in a small trial. Bowel resection during rectopexy was associated with lower rates of constipation, but again numbers were small.

Reviewers' conclusions: The small sample size of included trials together with their methodological weaknesses severely limit the usefulness of this review for guiding practice. It is impossible to identify or refute clinically important differences between the alternative surgical operations. Larger rigorous trials are needed to improve the evidence with which to define optimum surgical treatment for rectal prolapse.

Citation: Brazzelli M, Bachoo P, Grant A.. Surgery for complete rectal prolapse in adults (Cochrane Review). In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software.

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This is an abstract of a regularly updated, systematic review prepared and maintained by the Cochrane Collaboration. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).

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