High versus low take-off rectal prolapse: Outcomes of tailored surgery

Full-thickness rectal prolapse (FTRP) is heterogeneous, with outcomes varying despite similar anatomy. Cooper et al. proposed a radiological classification based on prolapse 'take-off' level on defecating proctography (DPG), hypothesising that high take-off (HTO) and low take-off (LTO) phenotypes may respond differently to abdominal versus perineal repair. This hypothesis has not previously been tested in a clinical cohort.

A retrospective observational cohort study was performed across three hospitals over 12 years (2012-2024). Patients undergoing laparoscopic ventral mesh rectopexy (VMR), as first standardised by D'Hoore et al. [3] or Delorme's procedure with DPG-defined take-off were included. Outcomes were compared between procedures, matched versus unmatched surgery, and HTO versus LTO. The primary end-point was anatomical recurrence. Secondary end-points included radiological findings and symptom profiles by phenotype.

Of 108 patients, 71 (52 VMR, 19 Delorme's) had evaluable DPG and were included in phenotype analysis (HTO, n = 28; LTO, n = 43). Overall recurrence was 15.5%. Recurrence was lower after VMR than Delorme's (13.5% vs. 21.1%, p = 0.47) and in matched versus unmatched surgery (12.8% vs. 20.8%, p = 0.53), though not statistically significant. Within VMR, recurrence was lower in HTO than LTO (8.3% vs. 17.9%). HTO was significantly associated with enterocele (71.4% vs. 44.2%, p = 0.030) and greater perineal discomfort (85.7% vs. 55.8%, p = 0.010), whereas LTO more frequently presented with incontinence/urgency.

This first clinical validation of the high/low take-off concept demonstrates phenotype-specific differences in radiology, symptoms, and surgical outcomes. Tailoring surgery to prolapse phenotype may reduce recurrence and guide personalised operative planning. Prospective, multicentre studies with quality-of-life outcomes are warranted.