Beyond stapled transanal rectal resection vs ventral rectopexy dichotomy: Toward a phenotype-guided surgical paradigm...

Obstructed defecation syndrome (ODS) is a heterogeneous pelvic floor disorder in which a persistent focus on "stapled transanal rectal resection (STARR) vs ventral rectopexy (VR)" has encouraged procedure-driven rather than phenotype-guided care. This opinion review synthesizes contemporary evidence on STARR and VR and proposes a phenotype-guided algorithm for surgical decision-making in ODS. We first summarize comparative outcome data, highlighting higher rates of late recurrence and urgency after STARR in contrast to more durable functional relief but greater invasiveness and mesh-related concerns after VR. We then outline a structured preoperative workup that integrates symptom scores, fluoroscopic or magnetic resonance defecography, and high-resolution anorectal manometry to discriminate between isolated structural disease, complex multilevel prolapse, functional defecatory disorders, mixed phenotypes, and ODS with impaired continence or excessive perineal descent. For each phenotype, we discuss the optimal role of STARR, VR, perineal resections, pelvic organ prolapse suspension, neuromodulation, and transverse perineal support within staged, multimodal pathways. Finally, we identified research priorities, including stratified randomized trials and phenotype-indexed multicenter registries, to validate this algorithm and refine the indications. Reframing ODS management around phenotyping, rather than procedural dichotomies, may improve patient selection, reduce functional failure, and align pelvic floor surgery with a broader movement toward precision medicine.