All patients underwent either Ventral Mesh Rectopexy, STARR, Altemeier's procedure, or POPS procedure as a primary one-stage surgical intervention, using the same surgical technique, with or without levatorplasty. This occurred over a 20-month period at EL Kasr Alaini Teaching Hospital from July 2021 to February 2022. Patients presenting with rectal prolapse and eligible for surgery were divided into two groups: one group underwent Rectal Prolapse surgery with levatorplasty (30 patients), while the other underwent Rectal Prolapse surgery without levatorplasty (30 patients).
Risk Factors:
Out of the total patients, 54 (90%) were multiparous, while 2 patients (3.3%) were nulliparous, and 4 patients (6.7%) were male. In the Levatorplasty group, 27 patients (90%) were multiparous, which was consistent with the other group. There were no statistically significant differences between the two groups regarding pre-operative risk factors.
Figure (2) Risk Factor distribution in both groups (RF were distributed equally)
| With Levatorplasty | Without Levatorplasty | Test value | P-value | Sig. |
No. = 30 | No. = 30 |
Risk factor | No | 2 (6.7%) | 2 (6.7%) | 0.000* | 1.000 | NS |
Nulipara | 1 (3.3%) | 1 (3.3%) |
Multipara | 27 (90.0%) | 27 (90.0%) |
Table (5): Risk Factors in both groups |
Change in Wexner Score for Incontinence Over Time:
In all the patients included in our study, there was a notable decrease in the Wexner score over time, specifically comparing pre-operative and post-operative assessments. This decrease was statistically significant, with a p-value of less than 0.001.
| No. = 60 |
Wexner Pre | Median (IQR) | 15 (11–17) |
Range | 3–22 |
Wexner Post | Median (IQR) | 0 (0–3) |
Range | 0–19 |
Willcoxon Rank test | -6.459 |
P-value | < 0.001 (HS) |
Table (6): Wexner score changes over time in all studied patients
In the Levatorplasty group, a significant decrease in the median Wexner score was observed over time, with a pre-operative median of 15 and a post-operative median of 0. This reduction was statistically significant, with a p-value of less than 0.001.
Similarly, in the Without Levatorplasty group, there was a significant decrease in the median Wexner score over time, with a pre-operative median of 15 and a post-operative median of 1. This reduction was also statistically significant, with a p-value of less than 0.001.
Comparing the postoperative median Wexner scores between the Without Levatorplasty group (median of 1) and the Levatorplasty group (median of 0), it's evident that the reduction in the Wexner score was more pronounced in the Levatorplasty group. However, this difference did not reach statistical significance (p-value = 0.07).
| With Levatorplasty | Without Levatorplasty | Test value‡ | P-value | Sig. |
No. = 30 | No. = 30 |
Wexner Pre | Median (IQR) | 15 (12–17) | 15 (10–17) | -0.037 | 0.970 | NS |
Range | 8–20 | 3–22 |
Wexner Post | Median (IQR) | 0 (0–1) | 1 (0–7) | -1.779 | 0.075 | NS |
Range | 0–16 | 0–19 |
Willcoxon Rank test | -4.710 | -4.464 | | | |
P-value | < 0.001 (HS) | < 0.001 (HS) |
Table (7): Comparison between With Levatorplasty and Without Levatorplasty regarding Wexner score pre-operative and post-operative in all patients
Recurrence was observed in 7 out of all studied patients, constituting 11.7% of the total, while a significant majority of 53 patients (88.3%) did not experience recurrence.
In the Levatorplasty group, the rate of postoperative recurrence was notably low, with only 1 case (3.3%) showing recurrence. This was in contrast to the Without Levatorplasty group, where 6 patients (20%) experienced recurrence. The difference in recurrence rates between these two groups was statistically significant, with a p-value of 0.044.
The table clearly illustrates that there was a significant statistical difference between the With Levatorplasty group and the Without Levatorplasty group in terms of recurrence, emphasizing the positive impact of levatorplasty on reducing recurrence rates.
| With Levatorplasty | Without Levatorplasty | Test value | P-value | Sig. |
No. = 30 | No. = 30 |
Recurrence | No | 29 (96.7%) | 24 (80.0%) | 4.043* | 0.044 | S |
Yes | 1 (3.3%) | 6 (20.0%) |
Table (8): Comparison between Levatorplasty group and Without Levatorplasty group regarding post-operative Recurrence in both groups
Post-operative Pain:
After the surgical procedures, post-operative pain was assessed in all the studied patients, with a mean pain score of 4.30 ± 1.18 and a range between 2 and 7 on the pain scale.
The assessment of pain was conducted using the Visual Analog Scale (VAS) score, where a score of 0 indicated no pain, scores from 1 to 3 represented mild pain, scores from 4 to 6 indicated moderate pain, scores from 7 to 9 signified severe pain, and a score of 10 represented the worst pain.
The mean postoperative pain score in the Levatorplasty group was 4.37 ± 1.27, while in the Without Levatorplasty group, it was 4.23 ± 1.10. Importantly, there was no statistically significant difference observed between the two groups in terms of postoperative pain, with a p-value of 0.433. These findings suggest that the presence or absence of levatorplasty did not result in a statistically significant difference in post-operative pain levels among the patients in the study.
| With Levatorplasty | Without Levatorplasty | Test value | P-value | Sig. |
No. = 30 | No. = 30 |
Post-operative pain | Mean ± SD | 4.37 ± 1.27 | 4.23 ± 1.10 | 0.433• | 0.666 | NS |
Range | 2–7 | 2–7 |
Table (9): Comparison between With Levatorplasty and Without Levatorplasty regarding post-operative pain in all patients
Dyspareunia Findings:
Dyspareunia, a condition characterized by pain during sexual intercourse, was reported in 9 out of all the patients, comprising 15% of the total, while a significant majority of 51 patients (85%) did not experience dyspareunia.
Examining the data further, Table 10 illustrates that dyspareunia occurred in 5 patients (16.7%) within the Levatorplasty group. In comparison, dyspareunia was reported in 4 patients (13.3%) in the Without Levatorplasty group. However, it's important to note that this difference in the occurrence of dyspareunia between the two groups was not found to be statistically significant, with a p-value of 0.131.
This suggests that the presence or absence of levatorplasty did not result in a statistically significant difference in the occurrence of dyspareunia among the patients in the study.
| With Levatorplasty | Without Levatorplasty | Test value | P-value |
No. = 30 | No. = 30 |
Dysparunia | No | 25 (83.3%) | 26 (86.7%) | 0.131* | 0.718 |
Yes | 5 (16.7%) | 4 (13.3%) |
Table (10): Comparison between both groups regarding Dyspareunia |
Operative Time:
The mean operative time for both groups combined was 44.05 ± 13.75 minutes, with a range spanning from 18 to 90 minutes.
Looking at the data in more detail, the table indicates that the mean operative time in the Levatorplasty group was 47.33 ± 13.00 minutes. In contrast, the mean operative time in the Without Levatorplasty group was 40.77 ± 13.90 minutes. However, it's important to note that the difference in mean operative time between these two groups did not reach statistical significance, with a p-value of 0.064.
This suggests that there was no statistically significant difference in the mean operative times between the group that underwent levatorplasty and the group that did not.
| With Levatorplasty | Without Levatorplasty | Test value | P-value | Sig. |
No. = 30 | No. = 30 |
Operative time | Mean ± SD | 47.33 ± 13.00 | 40.77 ± 13.90 | 1.890• | 0.064 | NS |
Range | 30–90 | 18–60 |
Table (11): Comparison between With Levatorplasty and Without Levatorplasty regarding post-operative data in all patients
| No. | % |
With Levatorplasty | ALTEMEIER’S operation | 5 | 16.7% |
POPS operation | 5 | 16.7% |
Rectopexy operation | 10 | 33.3% |
STARR operation | 10 | 33.3% |
Without Levatorplasty | ALTEMEIER’S operation | 5 | 16.7% |
POPS operation | 5 | 16.7% |
Rectopexy operation | 10 | 33.3% |
STARR operation | 10 | 33.3% |
Table (12): Operative data in both groups
ALTEMEIER'S Operation:
Five patients from each group underwent the ALTEMEIER'S procedure. Here are the findings:
(A) The mean postoperative pain in both groups was similar, with a value of 4.2 ± 0.84. There was no statistically significant difference in postoperative pain between the two groups (P value 1).
(B) In terms of dyspareunia, 5 patients in the Levatorplasty group and 4 patients in the Without Levatorplasty group reported no dyspareunia. However, the difference in dyspareunia occurrence between these two groups was not statistically significant (P value 0.292).
(C) For the occurrence of recurrence, 5 patients in the Levatorplasty group and 4 patients in the Without Levatorplasty group showed no recurrence. Similarly, there was no statistically significant difference in recurrence rates between these two groups (P value 0.292).
(D) In both groups, all patients had a one-day post-operative hospital stay.
(E) When it comes to operative time, there was a significant difference between the groups. The mean operative time in the Levatorplasty group was 36.00 ± 4.18 minutes, whereas in the Without Levatorplasty group, it was 24.40 ± 4.04 minutes. This difference in operative time between the two groups was statistically significant, with a p-value of 0.002.
These findings provide insights into the outcomes and characteristics associated with the ALTEMEIER'S procedure in both groups, emphasizing the significance of operative time as a differentiating factor.
ALTEMEIER’S operation
|
With Levatorplasty
|
Without Levatorplasty
|
Test value
|
P-value
|
Sig.
|
No. = 5
|
No. = 5
|
Post-operative pain
|
Mean ± SD
|
4.2 ± 0.84
|
4.2 ± 0.84
|
0.000•
|
1.000
|
NS
|
Range
|
3 – 5
|
3 – 5
|
Dyspareunia
|
No
|
5 (100.0%)
|
4 (80.0%)
|
1.111*
|
0.292
|
NS
|
Yes
|
0 (0.0%)
|
1 (20.0%)
|
Recurrence
|
No
|
5 (100.0%)
|
4 (80.0%)
|
1.111*
|
0.292
|
NS
|
Yes
|
0 (0.0%)
|
1 (20.0%)
|
Hospital Stay
|
1 Day
|
5 (100.0%)
|
5 (100.0%)
|
NA
|
NA
|
NA
|
Operative time
|
Mean ± SD
|
36.00 ± 4.18
|
24.40 ± 4.04
|
4.462•
|
0.002
|
HS
|
Range
|
30 – 40
|
20 – 30
|
Table (13): Comparison between With Levatorplasty and Without Levatorplasty regarding postoperative data in ALTEMEIER’S operation
Table shows Postoperative, median Wexner score in Without Levatorplasty (1) was less that in Levatorplasty group (0) so Wexner score reduction in Levatorplasty group is more than in Without Levatorplasty but with no statistically significant difference (P value 0.4).
ALTEMEIER’S operation
|
With Levatorplasty
|
Without Levatorplasty
|
Test value‡
|
P-value
|
Sig.
|
No. = 5
|
No. = 5
|
Wexner Pre
|
Median (IQR)
|
12 (10 - 12)
|
12 (10 - 12)
|
-0.108
|
0.914
|
NS
|
Range
|
8 – 13
|
8 – 15
|
Wexner Post
|
Median (IQR)
|
0 (0 - 1)
|
1 (0 - 1)
|
-0.808
|
0.419
|
NS
|
Range
|
0 – 1
|
0 – 10
|
Willcoxon Rank test
|
-2.032
|
-2.032
|
|
|
|
P-value
|
0.042 (S)
|
0.042 (S)
|
Table (14): Comparison between With Levatorplasty and Without Levatorplasty regarding Wexner score pre-operative and post-operative in ALTEMEIER’S operation
POPS Operation:
In both groups, five patients each underwent the POPS procedure. Here are the findings:
(A) The mean postoperative pain was comparable between the Levatorplasty group (4.4 ± 1.52) and the Without Levatorplasty group (4.4 ± 1.14). There was no statistically significant difference in postoperative pain scores between these two groups (P value 1).
(B) In terms of dyspareunia, four patients in both the Levatorplasty group and the Without Levatorplasty group reported no dyspareunia. The occurrence of dyspareunia was not statistically significantly different between these two groups (P value 1).
(C) Regarding recurrence, one patient in the Without Levatorplasty group experienced recurrence, while there were no cases of recurrence in the Levatorplasty group. The difference in recurrence rates between the two groups was not statistically significant (P value 0.292).
(D) All patients in both groups had a one-day post-operative hospital stay.
(E) In terms of operative time, there was a significant difference between the groups. The mean operative time in the Levatorplasty group was 31.00 ± 2.24 minutes, while in the Without Levatorplasty group, it was 20.20 ± 1.92 minutes. This difference in operative time between the two groups was statistically significant, with a p-value of 0.00.
These findings provide insights into the outcomes and characteristics associated with the POPS procedure in both groups, highlighting the significant difference in operative time.
POPS operation
|
With Levatorplasty
|
Without Levatorplasty
|
Test value
|
P-value
|
Sig.
|
No. = 5
|
No. = 5
|
Post-operative pain
|
Mean ± SD
|
4.4 ± 1.52
|
4.4 ± 1.14
|
0.000•
|
1.000
|
NS
|
Range
|
3 – 7
|
3 – 6
|
Dyspareunia
|
No
|
4 (80.0%)
|
4 (80.0%)
|
0.000*
|
1.000
|
NS
|
Yes
|
1 (20.0%)
|
1 (20.0%)
|
Recurrence
|
No
|
5 (100.0%)
|
4 (80.0%)
|
1.111*
|
0.292
|
NS
|
Yes
|
0 (0.0%)
|
1 (20.0%)
|
Hospital Stay
|
1 Day
|
5 (100.0%)
|
5 (100.0%)
|
NA
|
NA
|
NA
|
Operative time
|
Mean ± SD
|
31.00 ± 2.24
|
20.20 ± 1.92
|
8.187•
|
0.000
|
HS
|
Range
|
30 – 35
|
18 – 23
|
Table (15): Comparison between With Levatorplasty and Without Levatorplasty regarding postoperative data in POPS operation
Table shows Postoperative, median Wexner score in Without Levatorplasty (3) was less that in Levatorplasty group (0) so Wexner score reduction in Levatorplasty group is more than in Without Levatorplasty but with no statistically significant difference (P value 0.5).
POPS operation
|
With Levatorplasty
|
Without Levatorplasty
|
Test value‡
|
P-value
|
Sig.
|
No. = 5
|
No. = 5
|
Wexner Pre
|
Median (IQR)
|
17 (16 - 18)
|
19 (15 - 20)
|
-0.629
|
0.530
|
NS
|
Range
|
12 – 20
|
13 – 22
|
Wexner Post
|
Median (IQR)
|
0 (0 - 3)
|
3 (0 - 4)
|
-0.671
|
0.502
|
NS
|
Range
|
0 – 10
|
0 – 15
|
Willcoxon Rank test
|
-2.023
|
-1.841
|
|
|
|
P-value
|
0.043 (S)
|
0.066 (NS)
|
Table (16): Comparison between With Levatorplasty and Without Levatorplasty regarding Wexner score pre-operative and post-operative in POPS operation
Ventral Mesh Rectopexy Operation:
Ten patients from each group underwent the Ventral Mesh Rectopexy procedure. Here are the findings:
(A) Dyspareunia was reported in 2 patients in the Levatorplasty group, while 1 patient reported Dyspareunia in the Without Levatorplasty group. However, there was no statistically significant difference in the occurrence of Dyspareunia between these two groups (P value 0.5).
(B) The mean postoperative pain score was 4.2 ± 1.55 in the Levatorplasty group and 4.3 ± 1.49 in the Without Levatorplasty group. There was no statistically significant difference in postoperative pain scores between these two groups (P value 0.8).
(C) Regarding recurrence, one patient in the Levatorplasty group experienced recurrence, while 2 patients in the Without Levatorplasty group had recurrence. However, there was no statistically significant difference in recurrence rates between the two groups (P value 0.5).
(D) All patients in both groups had a one-day post-operative hospital stay.
(E) The mean operative time in the Levatorplasty group was 58.0 ± 12.29 minutes, while in the Without Levatorplasty group, it was 52.3 ± 5.1 minutes. There was no statistically significant difference in operative times between these two groups (P value 0.19).
These findings provide insights into the outcomes and characteristics associated with the Ventral Mesh Rectopexy procedure in both groups, highlighting the absence of statistically significant differences in Dyspareunia, postoperative pain, recurrence rates, and operative times.
Rectopexy operation
|
With Levatorplasty
|
Without Levatorplasty
|
Test value
|
P-value
|
Sig.
|
No. = 10
|
No. = 10
|
Dyspareunia
|
No
|
8 (80.0%)
|
9 (90.0%)
|
0.392*
|
0.531
|
NS
|
Yes
|
2 (20.0%)
|
1 (10.0%)
|
Post-operative pain
|
Mean ± SD
|
4.2 ± 1.55
|
4.3 ± 1.49
|
-0.147•
|
0.885
|
NS
|
Range
|
2 – 7
|
2 – 7
|
Recurrence
|
No
|
9 (90.0%)
|
8 (80.0%)
|
0.392*
|
0.531
|
NS
|
Yes
|
1 (10.0%)
|
2 (20.0%)
|
Hospital Stay
|
1 Day
|
10 (100.0%)
|
10 (100.0%)
|
NA
|
NA
|
NA
|
Operative time
|
Mean ± SD
|
58 ± 12.29
|
52.3 ± 5.1
|
1.354•
|
0.192
|
NS
|
Range
|
45 – 90
|
45 – 60
|
Table (17): Comparison between With Levatorplasty and Without Levatorplasty regarding postoperative data in Rectopexy operation.
Table shows Postoperative, median Wexner score in Without Levatorplasty (3) was less that in Levatorplasty group (0) so Wexner score reduction in Levatorplasty group is more than in Without Levatorplasty but with no statistically significant difference (P value 0.27).
Rectopexy operation
|
With Levatorplasty
|
Without Levatorplasty
|
Test value‡
|
P-value
|
Sig.
|
No. = 10
|
No. = 10
|
Wexner Pre
|
Median (IQR)
|
16 (14 - 18)
|
16 (8 - 17)
|
-0.499
|
0.618
|
NS
|
Range
|
8 – 20
|
3 – 20
|
Wexner Post
|
Median (IQR)
|
0 (0 - 3)
|
3 (0 - 8)
|
-1.096
|
0.273
|
NS
|
Range
|
0 – 16
|
0 – 19
|
Willcoxon Rank test
|
-2.673
|
-2.375
|
|
|
|
P-value
|
0.008 (HS)
|
0.018 (S)
|
Table (18): Comparison between With Levatorplasty and Without Levatorplasty regarding Wexner score pre-operative and post-operative in Rectopexy operation.
STARR Operation:
Ten patients from each group underwent the STARR procedure. Here are the findings:
(F) Dyspareunia was reported in 2 patients in the Levatorplasty group, while 1 patient reported Dyspareunia in the Without Levatorplasty group. However, there was no statistically significant difference in the occurrence of Dyspareunia between these two groups (P value 0.5).
(G) The mean postoperative pain score was 4.6 ± 1.17 in the Levatorplasty group and 4.1 ± 0.88 in the Without Levatorplasty group. There was no statistically significant difference in postoperative pain scores between these two groups (P value 0.295).
(H) In terms of recurrence, there were no cases of recurrence in the Levatorplasty group, while 2 patients in the Without Levatorplasty group experienced recurrence. The difference in recurrence rates between the two groups was not statistically significant (P value 0.136).
(I) All patients in both groups had a one-day post-operative hospital stay.
(J) The mean operative time in the Levatorplasty group was 50.5 ± 5.1 minutes, while in the Without Levatorplasty group, it was 47.7 ± 1.64 minutes. However, there was no statistically significant difference in operative times between these two groups (P value 0.1).
These findings provide insights into the outcomes and characteristics associated with the STARR procedure in both groups, emphasizing the absence of statistically significant differences in Dyspareunia, postoperative pain, recurrence rates, and operative times.
STARR operation
|
With Levatorplasty
|
Without Levatorplasty
|
Test value
|
P-value
|
Sig.
|
No. = 10
|
No. = 10
|
Dyspareunia
|
No
|
8 (80.0%)
|
9 (90.0%)
|
0.392*
|
0.531
|
NS
|
Yes
|
2 (20.0%)
|
1 (10.0%)
|
Post-operative pain
|
Mean ± SD
|
4.6 ± 1.17
|
4.1 ± 0.88
|
1.080•
|
0.295
|
NS
|
Range
|
3 – 7
|
3 – 6
|
Recurrence
|
No
|
10 (100.0%)
|
8 (80.0%)
|
2.222*
|
0.136
|
NS
|
Yes
|
0 (0.0%)
|
2 (20.0%)
|
Hospital Stay
|
1 Day
|
10 (100.0%)
|
10 (100.0%)
|
NA
|
NA
|
NA
|
Operative time
|
Mean ± SD
|
50.5 ± 5.1
|
47.7 ± 1.64
|
1.652•
|
0.116
|
NS
|
Range
|
47 – 60
|
45 – 50
|
Table (19): Comparison between With Levatorplasty and Without Levatorplasty regarding postoperative data in STARR operation.
Table shows Postoperative, median Wexner score in Without Levatorplasty (0.5) was less that in Levatorplasty group (0) so Wexner score reduction in Levatorplasty group is more than in Without Levatorplasty but with no statistically significant difference (P value 0.3).
STARR operation
|
With Levatorplasty
|
Without Levatorplasty
|
Test value‡
|
P-value
|
Sig.
|
No. = 10
|
No. = 10
|
Wexner Pre
|
Median (IQR)
|
13 (10 - 17)
|
15 (10 - 17)
|
-0.266
|
0.790
|
NS
|
Range
|
8 – 20
|
8 – 20
|
Wexner Post
|
Median (IQR)
|
0 (0 - 1)
|
0.5 (0 - 1)
|
0.991
|
0.322
|
NS
|
Range
|
0 – 3
|
0 – 10
|
Willcoxon Rank test
|
-2.805
|
-2.805
|
|
|
|
P-value
|
0.005 (HS)
|
0.005 (HS)
|
Table (20): Comparison between With Levatorplasty and Without Levatorplasty regarding Wexner score pre-operative and post-operative in STARR operation