Evolution of male rectal prolapse surgery and initial experience of robotic rectopexy in men

Laparoscopic ventral mesh rectopexy (LVMR) has proven benefit in the treatment of external rectal prolapse and symptomatic internal rectal prolapse in women. However, there is a recurrence rate of 4-50% depending on indication. Some of this recurrence is attributable to persistent lateral and posterior prolapses. Modifications of LVMR (modified Orr-Loygue rectopexies) describe an additional narrow posterior rectal mesh fixed to the mesorectal fat, which is inherently insecure. Additional complications in men include sexual dysfunction caused by nerve damage from the ventral rectal dissection. There is one case series in men, published by a surgeon with an unusually large practice, showing LVMR to have a good success rate with low rates of sexual dysfunction. Other series have contained small numbers of men, but subgroup analysis to determine success and complication rates is not possible. Robotic surgery is more precise than laparoscopic surgery, allows stereotactic vision, and has a stable platform. We have developed a robotic modified Orr-Loygue rectopexy in an attempt to deal with the persistent components of posterior rectal prolapse by placing a mesh posteriorly through a narrow dissection and securing the mesh to the distal rectal muscle tube. Mesh-to-muscle fixation is more secure than mesh-to-mesorectal fat fixation. The robotic platform also improves the accuracy of ventral dissection and reduces the risk of sexual dysfunction in men. Our initial results indicate that robotic modified Orr-Loygue rectopexy is a safe and feasible option for rectal prolapse in men, with no more complications or recurrences than the best published outcomes for LVMR.