MULTIMEDIA ARTICLE

Feasibility and Functional Outcome of Laparoscopic Sacrocolporectopexy for Combined Vaginal and Rectal Prolapse P. M. Sagar, M.D., F.R.C.S.1  D. K. Thekkinkattil, M.R.C.S.1 R. M. Heath, M.D., F.R.C.S.1  J. Woodfield, F.R.C.S.A.1  S. Gonsalves, M.R.C.S.1  C. R. Landon, M.D., F.R.C.O.G.2



1 John Goligher Department of Colorectal Surgery, Leeds General Infirmary, Leeds, United Kingdom 2 Department of Urogynecology, Leeds General Infirmary, Leeds, United Kingdom

PURPOSE: Prolapse of multiple pelvic organs causes a variety

of symptoms that impair a patient’s quality of life. A laparoscopic procedure is described that uses a mesh fixation of the mid-compartment vagina to the sacrum with additional rectopexy to correct both the anatomical deformities and the dysfunction of the posterior compartment. METHODS: Patients with significant rectal and vaginal

prolapse with or without rectocele were recruited. A thorough preoperative physiological assessment of each of the compartments of the pelvic floor was carried out. Patients also completed the Pelvic Floor Distress Inventory before and six months after surgery. RESULTS: Ten patients underwent the procedure of

laparoscopic sacrocolporectopexy (median age 47 years, interquartile range 43–53). No mortality or morbidity occurred. Median global distress inventory scores were significantly lower postoperatively (8.3, interquartile range 0–20.8 vs. 37.5, interquartile range 16.6–60.4) P= 0.012. All three median subscales were also significantly lower postoperatively. The procedure corrected associated rectoceles and descent of the perineum on straining. CONCLUSION: The described laparoscopic procedure of

mesh sacrocolpopexy with rectopexy was safe and feasible and conferred good symptomatic improvement in pelvic floor dysfunction. KEY WORDS: Rectal prolapse; Pelvic floor dysfunction;

Laparoscopic repair; Multidisciplinary management.

Electonic supplementary material The online version of this article (doi:10.1007/s10350-008-9371-8) contains supplementary material, which is available to authorized users. Reprints are not available. Address of corrrespondence: P. M. Sagar, M.D., Department of Colon & Rectal Surgery, D160, Clarendon Wing, Leeds General Infirmary, Leeds, United Kingdom LS1 3EX. E-mail: [email protected]

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INTRODUCTION Female pelvic organ prolapse is a distressing and often difficult surgical problem. The prevalence increases with age and parity.1–3 Risk factors include higher BMI, chronic straining, and muscular weakness. The patient’s quality of life can be adversely affected by symptoms including obstructed defecation, rectal discomfort, vaginal discomfort, sensation of bulge, incomplete evacuation, disordered micturition, and sexual dysfunction. A weak pelvic floor with poor structural support can result in prolapse of a single or multiple pelvic organs. The clinical presentation varies according to the type of organ affected and the severity of the prolapse. Patients may suffer from a combination of symptoms from organ prolapse in more than one compartment of the pelvic floor. One or more components of the multiple organ prolapse may remain occult unless each component is looked for specifically.4,5 Mellgren and others reported a high incidence of concomitant rectal intussusception (55 percent) and rectal prolapse (38 percent) in females who presented with urogenital prolapse.4 Likewise, Kuijpers and colleagues observed up to 60 percent of patients with a weak pelvic floor and fecal incontinence had previously undergone treatment for gynecologic, urologic, or rectal prolapse.5 The treatment options for organ prolapse can be conservative or surgical. The former option is usually reserved for patients with extensive comorbidity where surgery is precluded, or as a treatment adjunct until definitive surgery is carried out.6 Various surgical options exist for patients with pelvic organ prolapse. Both perineal and abdominal surgical approaches exist for single compartment (vaginal or rectal) prolapse, each with their own advantages and disadvantages.6 Many abdominal procedures for single organ prolapse are now performed laparoscopically.7 However, the literature on surgical procedures that address multiple organ prolapse, either open or laparoscopic is scarce.8 In cases with prolapse of more than one compartment, a single surgical procedure is needed that corrects all affected compartments including associated rectocele with minimal surgical burden,

DOI: 10.1007/s10350-008-9371-8  VOLUME 51: 1414–1420 (2008)  ©THE ASCRS 2008  PUBLISHED ONLINE: 3 JULY 2008

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hospital stay, and morbidity. We previously reported the feasibility and functional benefit of open mesh sacrocolporectopexy in a series of 29 patients with combined vaginal and rectal prolapse.9 This study evaluates the feasibility, safety, and functional outcome of laparoscopic sacrocolporectopexy in a consecutive series of patients with concurrent rectal and vaginal prolapse.

METHODS Between October 2005 and December 2006, a consecutive series of ten female patients underwent laparoscopic correction of their pelvic floor and associated multiple pelvic organ prolapses by means of a laparoscopic mesh sacrocolpopexy with rectopexy (Fig. 1) at Leeds General Infirmary, Leeds, United Kingdom. All patients had been referred to a combined pelvic floor surgery clinic where a full clinical assessment was performed. Details of presenting symptoms, past history of urogenital or rectal prolapse, and any previous abdominal, pelvic, or perineal procedures were collected. All patients completed a functional assessment questionnaire, the Pelvic Floor Distress Inventory (see below). A full clinical examination was performed including assessment of the relationships of the pelvic floor to the plane of the ischial tuberosities at rest and when straining. Patients underwent full urodynamic studies, colonic transit studies, and anorectal physiological assessment including anorectal manometry, endoanal ultrasound, and evacuating proctography. Evacuating proctography assessed overt and occult rectal prolapse and the presence and extent of rectoceles. Prolapse of pelvic organs was graded according to the Pelvic Organ Prolapse Quantification (POP-Q) system as described by the International Continence Society.8 Severity of prolapse is graded according to descent of the organ during Valsalva’s maneuver in relation to the level of the hymen from Stage 0, no prolapse, to Stage 4, complete eversion. Patients with confirmed prolapse of both middle (Stage 2 or greater on POP-Q) and posterior compartments (confirmed clinically or radiologically) were recruited for the study. Patients were excluded if their BMI was greater than 35, if they were under 18 years of age, or unfit for surgery. Those patients with delayed colonic transit or a history of multiple previous abdominal operations were also excluded. Patients were extensively counseled. The study was approved by the local research ethics committee. Surgical Procedure: Laparoscopic Mesh Sacrocolpopexy with Rectopexy All patients underwent full mechanical bowel preparation on the day prior to surgery. All procedures were performed by the same two surgeons, a coloproctologist (PMS) and an urogynecologist (CRL). All procedures were performed with the patient in the modified Lloyd-

Davies position under general anesthesia with urethral catheterization and vaginal preparation with povidone iodine solution. Intravenous antibiotic prophylaxis (cefuroxime 750 mg and metronidazole 500 mg) was administered at induction of anesthesia. A pneumoperitoneum was created using a Veress needle and maintained at a pressure of 12 mmHg. A 10/ 12 mm infra-umbilical Optiview port (Ethicon EndoSurgery, Cincinnati, OH) was used to gain access to the abdomen and provide a camera port (0 or 30 degree camera). Three 5 mm working ports were utilized, specifically in the left iliac fossa, suprapubic midline and right iliac fossa. The rectum was mobilized laterally as far down as the lateral ligaments and posteriorly as far as the tip of the coccyx using the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) (Video 1). The dissection continued along the rectovaginal septum deep into the Pouch of Douglas in order to mobilize the vagina anteriorly from the rectum. The nervi erigenti, ureters, and mesenteric vessels were identified and injury avoided. Concomitantly, the urogynecologist performed the pelvic dissection via a 3-cm vertical incision in the lower posterior wall of the vagina. Submucosal dissection was continued in the plane of the rectovaginal septum (Figs. 2 and 3). A suitable length of Gynemesh™ (Ethicon, Livingstone, United Kingdom), a polypropylene mesh support, was modeled into a Y shape such that positioning without tension would return the vagina to its correct anatomical position when the mesh was fixed to the vaginal musculature and the sacral promontory. The vertical limb of the Y-shaped mesh was held at the vaginal introitus while the arms of the Y-shaped mesh were FIGURE 1. Position and attachment of mesh. The insert shows the mesh sutured to the upper half of the vaginal fascia and levator muscle using 2/0 polydioxanone sutures.

Mesh attached to sacral promontory

Y-shaped mesh attached to and supporting the rectum

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United Kingdom) with avoidance of the presacral veins (Video 2). Correct positioning of the mesh to restore the normal anatomical position of the vagina within the pelvis was determined by the perineal operator with reference to the pelvic floor. The abdominal operator applied tension to the mesh pulling it cephalad while the perineal operator secured the mesh to the vagina to restore it to its normal position and any excess mesh was trimmed. The arms of the Y-shaped mesh were then fixed to the lateral aspect of the cranially drawn, mobilized rectum using either 5 mm clips (Ligaclip Multiple Clip Applier, Ethicon Endo-Surgery, Cincinnati, OH) or 2–0 prolene sutures (Video 3). The mesh was therefore forming a hammock-shaped support to the rectum (Fig. 1). Any potential space for internal herniation was closed and the mesh reperitonealized. The pelvic cavity was irrigated with saline and drainage was not routinely employed. The vagina was packed with gauze soaked in proflavine which was removed on postoperative Day 1 along with the urinary catheter. The position of the mesh is shown in Figure 1.

FIGURE 3. The peritoneum of the Pouch of Douglas is revealed.

FIGURE 2. A vertical incision in the lower third of the posterior vagina gains access for dissection in the plane between the vagina and rectum toward the Pouch of Douglas.

introduced into the pelvic cavity through a 2-cm transverse incision in the peritoneum of the pouch of Douglas at the apex of the vaginal dissection. The 2 arms of the mesh were then grasped laparoscopically and drawn toward the sacrum leaving an adequate segment of the distal portion of the vertical limb of the Y-shaped mesh to be sutured to the vault and posterior aspect of the vagina with No. 1 Polydioxanone (PDS) (Ethicon Endo-Surgery, Cincinnati, OH). The passage of the mesh through the vaginal vault required coordination between the two surgeons to avoid twisting the mesh and trauma to the tissues and to minimize the inevitable escape of the pneumoperitoneum upon breaching the peritoneum (Video 2). With the mesh fixed to the vagina, the urogynecologist performed a posterior levatorplasty and closed the vaginal mucosa such that this suture line was inferior to and remote from the mesh fixation (Fig. 4). The laparoscopic pelvic procedure continued by positioning each of the arms of the mesh around the rectum and then tacking the mesh onto the sacral promontory with a ProTack TM 5-mm device (Autosuture, Edinburgh,

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from 0–100 for the subscales and 0–300 for the cumulative global PFDI score. All scores were recorded for analysis. Statistical Analysis Statistical analysis was performed using SPSS statistical software (SPSS® for Windows, Version 14.0.1, SPSS Inc., Chicago, IL). Wilcoxon’s test was used to compare nonparametric paired data while Mann-Whitney U test was used to compare nonparametric unpaired data. Fisher’s exact test was used to compare categorical data. Statistical significance was set at P<0.05.

RESULTS Ten patients, median age 47 years (interquartile range, 43– 53), underwent a laparoscopic sacrocolpopexy with rectopexy. Details of presenting symptoms for patients are shown in Table 1. Each patient’s combination and severity of organ prolapse is described in Table 2. Five patients had previously undergone surgical procedures to correct pelvic organ prolapse. The procedures included vaginal hysterectomy (n=3), transanal repair of rectocele (n=1) and transanal repair of rectal prolapse (n=2).The median operative time was 85 minutes (range, 70–110). The median length of stay was 3 days (range, 2–5). No postoperative morbidity or Table 1. Presenting symptoms 10 patient series FIGURE 4. A midline fascial placation provides support to the vaginal vault and rectovaginal fascia beneath the mesh.

All patients were prescribed laxatives for 2 to 4 weeks after surgery (movicol 1 sachet twice daily or, fybogel 1 sachet twice daily) and encouraged to consume a high-fiber diet in order to avoid straining upon defecation. Length of hospital stay and morbidity were recorded. Patients were advised to avoid sexual intercourse for 6 weeks. All patients were followed in the outpatient department with visits at 2 weeks, 6 weeks, and 6 months. Patients were required to complete the Pelvic Floor Distress Inventory questionnaire at each visit. Functional Assessment All patients were required to complete a Cleveland Clinic Short Form-20 Pelvic Floor Distress Inventory (SF-20 PFDI) questionnaire before and after surgery.8 The PFDI questionnaire has 3 subscales. The Urinary Distress Inventory (UDI) subscale assesses the anterior compartment, the Pelvic Organ Prolapse Distress Inventory (POPDI) subscale assesses the middle compartment and, the Colorectal Anal Distress Inventory (CRADI) subscale assesses the posterior compartment. The scores range

Symptom Pressure in the lower abdomen Heaviness or dullness in the pelvic area Pain or discomfort in the lower abdomen or genital region Feeling of a bulge or something coming out of vagina Reduction of vaginal prolapse to aid micturition Straining at stool Urgency for bowel movement Incomplete bowel emptying Digitation of vagina or rectum to aid defaecation Pain on defaecation Incontinence of flatus Incontinence for loose or liquid stool Incontinence of well-formed stool Overt rectal prolapse Bleeding per rectally Incomplete bladder emptying Difficulty in emptying bladder Frequency of micturition Urge incontinence for urine Stress incontinence of urine Passive incontinence of urine Pain or discomfort on sexual intercourse

Number of patients 6 6 8 5 1 7 6 8 6 4 9 4 1 6 2 4 3 7 1 4 3 5

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Table 2. Pelvic organ prolapse quantification in patients undergoing laparoscopic sacrocolporectopexy

Pelvic organic prolapse grade Patient 1

Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8

Patient 9

Patient 10

Cystocele Grade 1 Uterine descent Grade 2 Enterocoele Grade 2 Rectocele with overt prolapse Grade 3 Enterocele Grade 2 Overt prolapse Rectocele Grade 3/4 Enterocele Grade 3 Overt rectal prolapse Cystocele Grade 2 Vaginal vault laxity Rectoanal prolapse on DP Rectocele Grade 3 Enterocele Grade 3 Overt prolapse Enterocele Grade 2/3 Rectocele Grade 2/3 Rectoanal prolapse on DP Enterocele Grade 2 Overt prolapse CystoceleGrade 2/3 Rectocele Grade 2 Vault prolapse Grade 2 Rectoanal prolapse on DP Enterocele Grade 3 Rectocele Grade 3 Vault prolapse Grade 3 Overt prolapse Cystocele Grade 1 Enterocele Grade 3 Overt rectal prolapse

DP = Defecating proctogram

mortality occurred; no infections related to the mesh and no reports of dyspareunia occurred. Global and subscale pelvic floor symptom scores improved significantly after the procedure, P≤0.01 (Table 3). The position of the pelvic floor changed after operation. Before surgery, with reference to the plane of the ischial tuberosities, the anal verge was sited 2 cm (0–4) below at rest and 5 cm (3–7) below when straining, as assessed by a perineometer. After surgery, the anal verge was found to be 4 cm (3–7) above this plane at rest and 2 cm (0–4) above when straining, P<0.05 for both measurements. All of the patients were opening their bowels at least once every other day by 6 months, although three patients were still taking movicol.

DISCUSSION Laparoscopic mesh sacrocolpopexy with rectopexy by means of a combined abdominal and transvaginal approach is safe and feasible. The patients gained significant improvement in symptoms and the pelvic floor no longer descended below the plane of the ischial tuberosities on straining.

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Many patients who complain of prolapse of a single pelvic compartment may have prolapse of multiple compartments.9 Identification and surgical correction of all compartment prolapses in a single procedure should be the aim of treatment given the improved functional results of the pelvic floor and resolution of symptoms postoperatively. Addressing all compartment prolapses in a single procedure should obviate the need for further surgical procedures to correct the “missed” prolapse. We have reported previously that open mesh sacrocolporectopexy is a feasible surgical procedure for the management of patients with multiple pelvic organ prolapses that resulted in good outcomes.9 The current study demonstrates that a laparoscopic variation of the procedure can be used and results in similar improved functional outcomes in patients with prolapse of multiple pelvic organs. The development and adoption of a laparoscopic procedure from an open technique has potential benefits such as decreased use of pain relief, shorter hospital stay, and better cosmesis. Within the field of colon and rectal surgery, experience with laparoscopic surgery has gradually increased since 1991 and the demand for laparoscopic procedures by patients has increased as well as the enthusiasm of surgeons. The patients in this study had a shorter hospital stay, less analgesic use, less morbidity, improved cosmesis, and reduced wound sizes compared with our series of patients who underwent an open sacrocolporectopexy procedure.9 The operating times for this laparoscopic procedure were comparable to that of the open procedure. The procedure required the same amount of time as a standard laparoscopic mesh rectopexy since the perineal (vaginal) part of the operation is carried out concurrent with the laparoscopic part of the procedure. Despite reports that the laparoscopic approach may be difficult in patients who have had previous open hysterectomy because of a higher likelihood of small bowel adhesions in the pelvis,10 we did not select against patients who had undergone previous pelvic surgery. However, 4 of 10 patients in our series had recurrence after open organ

Table 3. Pelvic floor distress inventory scores before and after laproscopic sacrocolporectopexy

Distress Inventory Scale† Pelvic organ prolapse Colorectal anal Urinary Pelvic floor global

Presurgery median(IQR)

Postsurgery, median (IQR)

37.5 (16.6–60.42) 50 (46.88–71.89) 37.5 (18.75–47.90) 110.42 (98.39–172.39)

8.3 (0–20.83) 17.86 (12.5–20.32) 8.3 (0–14.59) 34.38 (16.65–49.97)

P-Value* 0.012 0.008 0.008 0.008

*Wilcoxon’s test  † Subscale scores range from 0 to 100, Pelvic Floor Global scores range from 0 to 300.

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prolapse surgery and no additional difficulties or complications were noted during any laparoscopic repairs. Adhesions within the pelvis were easily dealt with. However, although previous pelvic surgery appears not to be a contraindication for laparoscopic sacrocolporectopexy, the surgeon should be aware of the potential need for a careful and meticulous adhesiolysis procedure. Morbidity was nonexistent, but it should be emphasized that care was taken to ensure that suturing of the mesh to the vaginal muscle was kept remote from that vaginal mucosal repair. Patients were aware of a sensation of sutures within the vagina but this did not persist in any patient beyond 6 weeks. Constipation was apparent if patients neglected to take their laxatives but was soon corrected by the appropriate dose of medication. Whenever introducing a new laparoscopic procedure, cost analysis is important. Although not formally analyzed in this study, major determinants of the cost of laparoscopic surgery are operative time, length of hospital stay, and readmission rates.7,11,12 As previously mentioned, operative times were not long. The technique of simultaneous operating surgeons and the use of tacking devices kept operating times down. However, the length of hospital stay was significantly shorter in those undergoing laparoscopic sacrocolporectopexy and no readmissions occurred. As with other laparoscopic colorectal procedures, this reduction in length of stay is not unexpected and would contribute significantly to offsetting the extra equipment cost for the procedure. Recent publications have also suggested new laparoscopic techniques to treat rectal prolapse. D’Hoore and Penninckx reported a technique that avoided any posterolateral dissection of the rectum.13 They argued that extensive rectosigmoid mobilization may lead to injury of the autonomic nerves and consequently dysmotility and impaired evacuation. Their technique used anterior placement of the mesh sutured onto the anterior aspect of the rectum and the posterior wall of the vagina (without opening the vault) and fixation of the mesh to the sacral promontory. Slawik et al. reported a similar technique that also attached the mesh to the ventral aspect of the rectum and then to the posterior wall of the vagina.14 While these two techniques permit fixation of the vaginal vault and restore the normal anatomical position of the anterior rectal wall, they do not offer support to the posterior aspect of the rectum in contrast to our technique that supports the rectum by means of the two arms of the Y-shaped mesh positioned behind the rectum. Furthermore, the vaginal aspect of our procedure permits a posterior levatorplasty to be performed and this offers further reinforcement of the pelvic floor. Technically, a number of issues regarding laparoscopic sacrocolporectopexy specifically are worthy of discussion. First, the surgeons must be able to determine extracorporeal, the correct length of mesh so as to be able to suspend the vagina from the sacral promontory with the correct

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tension, thus restoring the normal pelvic anatomical position of the vagina in relation to the pelvic floor and the bladder. We would not advocate the removal of the mesh once introduced into the pelvis so as to correct its length as this may increase the potential risk of bacterial contamination. Intuitively, there is a perceived risk of perineal contamination of the mesh. No infective complication occurred presumably because of the strict aseptic measures taken with regard to the handling of the mesh and generous vaginal preparation with antiseptic. Reassuringly, the incidence of infection related to the transvaginal placement of mesh is very low (0 of 248 cases from a multicenter Swedish study).15 Introduction of the mesh via the perineal wound, through the posterior wall of the vagina allows for the escape of the pneumoperitoneum. In our experience, although a potential nuisance, it did not cause significant intraoperative problems or delay. To minimize loss of gas and therefore laparoscopic vision, the passage of the mesh from the vagina to the abdomen needs to be swift. The quick placement of a damp swab in the vaginal vault controlled further loss of gas while the arms of the Y-shaped mesh were positioned. Once attachment to the sacral promontory had been effected, the stem of the Y-shaped mesh could be fixed by the perineal operator at leisure and then the vaginal wound closed before the pneumoperitoneum was reestablished. Third, PDS sutures which provide an extended wound support (approximately 60 days) were used for mesh - vaginal attachment so as to permit sufficient time to elapse for fixation before the integrity of the sutures was lost and yet prevent erosion through the vaginal mucosa that could have occurred with a permanent suture. Mesh erosion was avoided by opening the vaginal dissection below the final position of mesh fixation. The closure of the vaginal mucosa was such that this wound was remote from the mesh. We specifically chose a type I loose weave mesh to reduce the incidence of infection. Erosion by the mesh is uncommon. A retrospective analysis of 109 patients reported 11 patients with mesh erosion; 10 required office excision and one required outpatient surgical excision.16 The procedure addressed not only the problem of prolapse of rectum and vagina but also the symptoms caused by a rectocele. After operation, none of the patients needed to self-digitate or provide counter pressure to the vaginal wall or perineum to expel stool. Subjectively, patients believe that they evacuated much better after operation than before operation. Vaginal examination showed correction of the rectocele. Rather than attaching the mesh to the vaginal vault, this procedure takes the mesh much farther down and the mesh is secured to the vaginal and pelvic floor musculature. We believe that it is this aspect of the repair that permits the elevation of the pelvic floor. Furthermore, while a levatorplasty alone may have dealt with some of the symptoms in patients with a rectocele, the support is diminished relative to the currently described mesh repair.

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A standard validated questionnaire (SF-20 PFDI) assessed different compartments of the pelvic floor separately both preoperatively and postoperatively and hence provided an objective measurement of functional outcome to support these findings. The current study demonstrates significant functional improvement after laparoscopic mesh sacrocolpopexy with rectopexy with a significant reduction between preoperative and postoperative global PFDI scores. Subset scores for each compartment were also significantly reduced following laparoscopic repair. As with the open procedures, restoration of the pelvic organs with respect to their position with the pelvic floor and with each other by fixation with the mesh is paramount to functional improvement. Perhaps the return of the pelvic floor to its correct position above the plane of the ischial tuberosities, at rest and when straining, was central to this good functional outcome. Of note, increases in urinary incontinence and voiding difficulties has been reported after sacrocolposuspension for vaginal prolapse,17,18 while others have failed to confirm this.19 In our series, no worsening of existing urinary symptoms occurred and a significant improvement in the symptoms from all compartments was reported. Of note, the anterior compartment symptoms were improved without any additional procedure for urinary distress. Again, we propose that this results from the restoration of normal pelvic anatomy of the vagina and rectum with respect to each other, the pelvic floor and the bladder complex. However, if there is evidence of significant anterior vaginal weakness, additional support or repair should be considered.

CONCLUSION As with laparoscopic rectopexy,20 laparoscopic mesh sacrocolpopexy with rectopexy is a feasible procedure for prolapse of multiple pelvic organs. The operation was safe at least up to six months. Short-term (six month) results show good functional outcomes were achieved with improvement in pelvic floor function of all three compartments. Long-term follow-up is needed to see if improvements are maintained and to confirm long-term safety.

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3. Versi E, Harvey MA, Cardozo L, et al. Urogenital prolapse and atrophy at menopause: a prevalence study. Int Urogynecol J 2001;12:107–10. 4. Mellgren A, Johansson C, Dolk A, et al. Enterocoele demonstrated by defecography is associated with other pelvic floor disorders. Int J Colorectal Dis 1994;9:121–4. 5. Kuijpers HC, Scheuer M. Disorders of impaired fecal control: a clinical and manometric study. Dis Colon Rectum 1990;33:207–11. 6. Onwude JL. Genital prolapse in women. Clin Evid 2006;15:1–2. 7. Salkeld G, Bagia M, Solomon M. Economic impact of laparoscopic versus open abdominal rectopexy. Br J Surg 2004;91:1188–91. 8. Barber MD, Walters MD, Bump RC. Short forms of two condition-specific quality of life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol 2005;93:103–13. 9. Lim M, Sagar PM, Gonsalves S, Thekkinkattil D, Landon C. Surgical management of pelvic organ prolapse in females: functional outcome of mesh sacrocolpopexy and rectopexy as a combined procedure. Dis Colon Rectum 2007;50:1412–21. 10. Collopy BT, Barham KA. Abdominal colporectopexy with pelvic cul-de-sac closure. Dis Colon Rectum 2002;45:522–29. 11. Solomon MJ, Young CJ, Eyers AA, Roberts RA. Randomized clinical trial of laparoscopic versus open abdominal rectopexy for rectal prolapse. Br J Surg 2002;89:35–9. 12. Paraiso MF, Walters MD, Rackley RR, Melek S, Hugney C. Laparoscopic and abdominal sacral colpopexies: a comparative cohort study. Am J Obstet Gynecol 2005;192:1752–8. 13. D’Hoore, Penninckx F. Laparoscopic ventral recto(colpo) pexy for rectal prolapse: surgical technique and outcome for 109 patients. Surg Endosc 2006;20:1919–23. 14. Slawik S, Soulsby R, Carter H, Payne H, Dixon AR. Laparoscopic ventral rectopexy, posterior colporrhaphy and vaginal scarocolpopexy for the treatment of recto-genital prolapse and mechanical outlet obstruction. Colorectal Dis 2008;10:138–43. 15. Altman D, Falconer C. Perioperative morbidity using transvaginal mesh in pelvic organ prolapse repair. Obstet Gynecol 2007;109:303–08. 16. Su KC, Mutone MF, Terry CL, Hale DS. Abdominovaginal sacral colpoperineopexy: patient perceptions, anatomical outcomes, and graft erosions. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:503–11. 17. Snyder TE, Krantz KE. Abdomino-retroperitoneal sacral colpopexy for correction of vaginal prolapse. Obstet Gynecol 1991;77:944–9. 18. Hardiman PJ, Drutz HP. Sacrospinous vault suspension and abdominal colposacropexy: success rates and complications. Am J Obstet Gynecol 1996;175:612–6. 19. Varner RE, Plessala KJ, Richter H. Effects of sacrocolposuspension on the lower urinary tract. Am J Obstet Gynecol 1995;173:1684–9. 20. Purkayastha S, Tekkis P, Athanasiou T, Aziz O, Paraskevas P, Ziprin P, Darzi A. A comparison of open vs. laparoscopic abdominal rectopexy for full-thickness rectal prolapse: a meta-analysis. Dis Colon Rectum 2005;48:1930–40.