Outlet Constipation 1 Year After Robotic Sacrocolpopexy
Outlet Constipation 1 Year After Robotic Sacrocolpopexy
One year after RSCP, women reported improved overall pelvic floor function and quality of life. Although the overall rate of postoperative outlet constipation improved from 60% to 40%, with a corresponding significant improvement in quality of life, 44% of the women who were symptomatic preoperatively had persistent symptoms and 13.6% developed de novo outlet constipation. The addition of a concomitant PR did not affect this outcome.
The high rate of persistent outlet constipation supports the finding that apical prolapse repair is more effective for bulge control than for restoring normal defecation function. The concomitant PR yielded less favorable results than RSCP alone. Several other studies corroborate this finding that neither a concomitant PR nor an extension of mesh to the perineal body improves obstructed defecation symptoms. Women with a chief complaint of outlet constipation who are being considered for SCP should be advised carefully about poor symptom resolution and the very real potential for worsening of symptoms.
Our 40% rate of postoperative outlet constipation following RSCP is similar to rates of 22% to 38% that have been reported after laparoscopic and abdominal SCP. In a prospective study of 33 women undergoing ASCP with or without a concomitant colpoperineorrhaphy based on the presence of a persistent distal defect following abdominal repair, outlet constipation persisted in 38% and rectoceles recurred in 57%. The authors noted that splinting of the vagina no longer facilitated evacuation and that patients considered this to be a deterioration compared with their preoperative status. Similarly, Fox and Stanton reported an increase from 24% to 36% in outlet constipation symptoms in a series of 29 women undergoing vault prolapse and rectocele repair with SCP. The method of sacral mesh attachment in both of these series was below the sacral promontory.
In contrast, 80% of women enrolled in the CARE study, a randomized trial of 322 women who underwent SCP with or without a concomitant PR, experienced resolution of the need for digital assistance to defecate. Although subjects undergoing a concomitant PR were the more likely group to have obstructed defecation symptoms preoperatively, there was no difference in postoperative questionnaire scores between groups. New bothersome bowel symptoms, including fecal incontinence and pain ahead of defecation occurred more frequently in those who underwent a PR.
Our study has some similarities and differences to the study of Kaser et al, in which 258 women underwent 76% laparoscopic SCP and 24% ASCP. At 1 year after SCP, 48.4% followed up, with 68 (54.4%) having SCP alone and 57 (45.6%) having SCP + concomitant PR. The SCP + PR group had worse posterior descent and bowel function preoperatively compared with the SCP-only group, but there was no significant difference in postoperative anatomic support or symptoms by CRADI scores. The specific bowel symptoms pertaining to outlet constipation (straining, splinting, and incomplete emptying) were much lower in the Kaser et al study. Incomplete emptying was significantly improved in the SCP + PR group versus the SCP-only group (100% vs 68.1%; P = 0.04); however, straining and splinting were not significantly improved between groups.
These conflicting reports on the impact of SCP with or without a PR on outlet constipation are difficult to explain but theoretically could be to the result of denervation during posterior rectovaginal dissection or disruption of the hypogastic nerve and presacral plexus during sacral graft fixation. The superior hypogastric plexus branches into two hypogastric nerves at or just below the sacral promontory. In the presacral space, the parasympathetic pelvic splanchnic nerves from the ventral rami of the sacral spinal nerves (S2–S3) join the hypogastric nerves, forming the inferior hypogastric plexus on both sides. If the mesh is attached too low on the sacral promontory, the autonomic innervation of the pelvic organs could be disrupted. Although our technique of sacral mesh attachment did not change when we converted from an open to a robotic approach, it is possible that nerve disruption is occurring more frequently.
Overall, 11.7% underwent a subsequent PR within 1 year of initial surgery. None of the women who underwent reoperation had concomitant PR at initial surgery. Our findings corroborate the results of Dallenbach et al, who reported that the absence of PR at initial surgery increased the risk of reoperation (odds ratio 1.7, 95% confidence interval 1.0–2.8; P = 0.04). This may, however, represent selection bias because there was no significant difference in the rate of symptomatic rectoceles in the two groups. Women who had already undergone a concomitant distal PR may have been dissuaded from returning to surgery for a procedure that had already been attempted.
The principal limitations of this study are the retrospective design, relatively small sample size, and lack of strict criteria and protocol regarding when a concomitant PR/perineoplasty was performed. Selection and reporting bias may have affected the observed rates of outlet constipation; however, the use of a standardized questionnaire that was collected prospectively may help decrease any reporting bias. The sample size was additionally limited because only 73% of the subjects completed preoperative validated questionnaires. The decision of whether to perform a concomitant PR was based on the surgeon's discretion and for this, there was no standardization. Although the surgeons stated that reasons for concomitant PR include the presence of obstructed defecatory symptoms and/or a predominant posterior prolapse in addition to the apical prolapse at baseline, our analysis revealed that outlet constipation was less common and posterior wall support was better at baseline in the group that underwent a concomitant PR. The strengths of the study include the use of validated questionnaires that were collected prospectively, the use of a strict definition for outlet constipation, and the use of 1-year follow-up. These strengths increase the generalizability of the results.
Discussion
One year after RSCP, women reported improved overall pelvic floor function and quality of life. Although the overall rate of postoperative outlet constipation improved from 60% to 40%, with a corresponding significant improvement in quality of life, 44% of the women who were symptomatic preoperatively had persistent symptoms and 13.6% developed de novo outlet constipation. The addition of a concomitant PR did not affect this outcome.
The high rate of persistent outlet constipation supports the finding that apical prolapse repair is more effective for bulge control than for restoring normal defecation function. The concomitant PR yielded less favorable results than RSCP alone. Several other studies corroborate this finding that neither a concomitant PR nor an extension of mesh to the perineal body improves obstructed defecation symptoms. Women with a chief complaint of outlet constipation who are being considered for SCP should be advised carefully about poor symptom resolution and the very real potential for worsening of symptoms.
Our 40% rate of postoperative outlet constipation following RSCP is similar to rates of 22% to 38% that have been reported after laparoscopic and abdominal SCP. In a prospective study of 33 women undergoing ASCP with or without a concomitant colpoperineorrhaphy based on the presence of a persistent distal defect following abdominal repair, outlet constipation persisted in 38% and rectoceles recurred in 57%. The authors noted that splinting of the vagina no longer facilitated evacuation and that patients considered this to be a deterioration compared with their preoperative status. Similarly, Fox and Stanton reported an increase from 24% to 36% in outlet constipation symptoms in a series of 29 women undergoing vault prolapse and rectocele repair with SCP. The method of sacral mesh attachment in both of these series was below the sacral promontory.
In contrast, 80% of women enrolled in the CARE study, a randomized trial of 322 women who underwent SCP with or without a concomitant PR, experienced resolution of the need for digital assistance to defecate. Although subjects undergoing a concomitant PR were the more likely group to have obstructed defecation symptoms preoperatively, there was no difference in postoperative questionnaire scores between groups. New bothersome bowel symptoms, including fecal incontinence and pain ahead of defecation occurred more frequently in those who underwent a PR.
Our study has some similarities and differences to the study of Kaser et al, in which 258 women underwent 76% laparoscopic SCP and 24% ASCP. At 1 year after SCP, 48.4% followed up, with 68 (54.4%) having SCP alone and 57 (45.6%) having SCP + concomitant PR. The SCP + PR group had worse posterior descent and bowel function preoperatively compared with the SCP-only group, but there was no significant difference in postoperative anatomic support or symptoms by CRADI scores. The specific bowel symptoms pertaining to outlet constipation (straining, splinting, and incomplete emptying) were much lower in the Kaser et al study. Incomplete emptying was significantly improved in the SCP + PR group versus the SCP-only group (100% vs 68.1%; P = 0.04); however, straining and splinting were not significantly improved between groups.
These conflicting reports on the impact of SCP with or without a PR on outlet constipation are difficult to explain but theoretically could be to the result of denervation during posterior rectovaginal dissection or disruption of the hypogastic nerve and presacral plexus during sacral graft fixation. The superior hypogastric plexus branches into two hypogastric nerves at or just below the sacral promontory. In the presacral space, the parasympathetic pelvic splanchnic nerves from the ventral rami of the sacral spinal nerves (S2–S3) join the hypogastric nerves, forming the inferior hypogastric plexus on both sides. If the mesh is attached too low on the sacral promontory, the autonomic innervation of the pelvic organs could be disrupted. Although our technique of sacral mesh attachment did not change when we converted from an open to a robotic approach, it is possible that nerve disruption is occurring more frequently.
Overall, 11.7% underwent a subsequent PR within 1 year of initial surgery. None of the women who underwent reoperation had concomitant PR at initial surgery. Our findings corroborate the results of Dallenbach et al, who reported that the absence of PR at initial surgery increased the risk of reoperation (odds ratio 1.7, 95% confidence interval 1.0–2.8; P = 0.04). This may, however, represent selection bias because there was no significant difference in the rate of symptomatic rectoceles in the two groups. Women who had already undergone a concomitant distal PR may have been dissuaded from returning to surgery for a procedure that had already been attempted.
The principal limitations of this study are the retrospective design, relatively small sample size, and lack of strict criteria and protocol regarding when a concomitant PR/perineoplasty was performed. Selection and reporting bias may have affected the observed rates of outlet constipation; however, the use of a standardized questionnaire that was collected prospectively may help decrease any reporting bias. The sample size was additionally limited because only 73% of the subjects completed preoperative validated questionnaires. The decision of whether to perform a concomitant PR was based on the surgeon's discretion and for this, there was no standardization. Although the surgeons stated that reasons for concomitant PR include the presence of obstructed defecatory symptoms and/or a predominant posterior prolapse in addition to the apical prolapse at baseline, our analysis revealed that outlet constipation was less common and posterior wall support was better at baseline in the group that underwent a concomitant PR. The strengths of the study include the use of validated questionnaires that were collected prospectively, the use of a strict definition for outlet constipation, and the use of 1-year follow-up. These strengths increase the generalizability of the results.