The feasibility, safety and short-term clinical efficacy of laparoscopic resection rectopexy with natural orifice specimen extraction surgery for the treatment of complete rectal prolapse

The feasibility, safety and short-term clinical efficacy of laparoscopic resection rectopexy with natural orifice specimen extraction surgery for the treatment of complete rectal prolapse | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The feasibility, safety and short-term clinical efficacy of laparoscopic resection rectopexy with natural orifice specimen extraction surgery for the treatment of complete rectal prolapse Shihan Chen, Yanyang Liang, Ruixue Tang, Jixin Zhang, Shouxin Yuan, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4575462/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose There have been few reports that have focused on the combination of the laparoscopic approach and natural orifice specimen extraction (NOSE) surgery for complete rectal prolapse (CRP). The aim of this study was to compare the feasibility, safety and short-term clinical efficacy of NOSE surgery with those of conventional laparoscopic resection rectopexy in the treatment of CRP. Methods In a group of 45 patients selected between January 2019 and October 2023, 28 patients underwent conventional laparoscopic resection rectopexy (LRR), and 17 patients underwent transanal NOSE laparoscopic resection rectopexy (NOSE-LRR). Preoperative and postoperative clinical variables of the two groups of patients were compared and analyzed. Results The mean operation time was longer in the NOSE-LRR group than in the LRR group (150.29 min versus 134.18 min, p < 0.001). The NOSE-LRR group had less postoperative pain than did the LRR group (median VAS score of 4 versus 5 on the first day after surgery, p = 0.004; median VAS score of 2 versus 3 on the third day after surgery, p = 0.003). The median length of hospital stay was significantly shorter in the NOSE-LRR group (7 days versus 9 days, p < 0.001). A significant reduction in the incontinence score and constipation score was observed in both groups after surgery (p < 0.001). However, there was no significant difference in the postoperative constipation score or incontinence score between the two groups. Conclusion LRR combined with the NOSE technique leads to a shorter length of hospital stay and less postoperative pain in patients with CRP than in patients who undergo traditional LRR but with a longer operation time. The novel NOSE method is feasible and safe for use in patients with CRP. Complete rectal prolapse (CRP) Laparoscopic resection rectopexy (LRR) Natural orifice specimen extraction (NOSE) Clinical efficacy Figures Figure 1 Figure 2 Introduction Complete rectal prolapse (CRP), also known as external rectal prolapse, is defined as a protrusion of the full thickness of the rectum wall through the anal canal. If only the rectal or anal mucosa protrudes, it is called incomplete rectal prolapse or internal rectal prolapse, which should be distinguished from CRP. CRP affects approximately 0.5% of the total population and is accompanied by symptoms of constipation, fecal incontinence, mucous discharge and hemorrhage, thus causing a decline in patient quality of life. The female-to-male ratio in adults is approximately 6:1 [ 1 ]. Although there are several clinical practice guidelines for rectal prolapse, due to the complex etiology and pathogenesis of rectal prolapse, it is difficult to achieve good results with a single treatment strategy for various types of rectal prolapse, thereby creating many challenges for clinicians. Surgery is considered the only effective method for treating CRP. Surgical approaches can be classified into transabdominal approaches and transperineal approaches. The choice of surgical treatment for patients with CRP is mainly determined by the patient's physical condition and the surgeon's preference. Young, fit patients at low surgical risk who undergo transabdominal surgery have lower recurrence rates, and older less fit patients with significant comorbidities who undergo transperineal surgery have lower surgery-related mortality rates. However, there is no evidence showing which surgical method has obvious advantages. All methods appeared to be equally safe. There were no significant differences regarding the incidence of postoperative complications [ 2 ]. Notably, laparoscopic resection rectopexy (LRR) is an effective and popular transabdominal surgical technique for the treatment of CRP that is preferred by colorectal surgeons. Frykman first described the surgical procedure of sigmoid resection and fixing the rectum to the sacral promontory with sutures to prevent telescoping of the redundant bowel in 1955 [ 3 ]; this procedure has also been applied in the treatment of obstructive bowel syndrome [ 4 ]. Patients with symptoms of constipation and/or redundancy of the sigmoid colon were candidates for LRR. LRR has been proven to be a safe and effective procedure with long-lasting effects for CRP patients [ 5 ], and the prolapse recurrence rates are low and the 4% postoperative complication rate is acceptable [ 6 ]. Although LRR has many advantages as a minimally invasive surgery over laparotomy, the removal of sigmoid colon specimens still requires an additional abdominal incision, which may increase the probabilities of postoperative pain, wound infection, and hernia. However, in 1993, Franklin first reported that natural orifice specimen extraction (NOSE) eliminates the need for an extraction site incision [ 7 ]; the procedure has been widely used in the clinic and explored in many studies in colorectal surgery, especially as a surgical treatment of colorectal malignant disease. Many reports on laparoscopic NOSE surgery for colorectal cancer are available [ 8 – 10 ]. The NOSE technique involves the laparoscopic extraction of specimens through natural lumens in the human body, such as the rectum and vagina. This technique has good cosmetic effects, reduces the psychological burden of patients, and is associated with lower postoperative pain scores, decreased consumption of painkillers, and faster recovery [ 11 ]. In 2012, Fuchs et al. [ 12 ] introduced a combination approach involving laparoscopic colorectal surgery and transanal endoscopic microsurgery for treating 15 patients with prolapse, pelvic floor disorders and slow-transit constipation. The results showed that transanal hybrid colon resection seemed to be a feasible and safe procedure. In addition, Can et al. [ 13 ] and Fu et al. [ 14 ] successfully applied the NOSE technique during laparoscopic surgery for rectal prolapse in two patients and introduced it to us via videos. Driouch et al. [ 4 ] suggested that NOSE-LRR is a safe treatment for obstructive defecation syndrome and that patients who undergo this procedure tend to recovery faster. A recent study reported 8 patients with rectal prolapse who underwent robotic sigmoidectomies through transrectal NOSE and demonstrated the practicality and safety of NOSE procedures for sigmoidectomies for treating benign colon diseases [ 15 ]. However, the feasibility and safety of the combination of the NOSE technique and LRR for the treatment of CRP are still unknown. To our knowledge, no study comparing NOSE-LRR and LRR for the treatment of CRP has been published in the literature. The aim of this study was to evaluate the clinical outcomes of these two surgical approaches for treating CRP. Methods Study design and patients This observational cohort study was a retrospective analysis conducted in the Department of General Surgery at the 988th Hospital of Joint Logistics Support Force of the Chinese People's Liberation Army from January 2019 to October 2023. According to the American Clinical Practice Guidelines and Chinese Expert Consensus, sigmoid resection may be added to rectopexy in the treatment of CRP patients only in those with symptoms of significant constipation or with an elongated sigmoid colon [ 6 , 16 ]. For CRP patients diagnosed with colonic slow transit constipation or colonic inertia via the colonic transit test before surgery, rectopexy plus subtotal colectomy is also recommended [ 17 ]. In our study, the inclusion criterion was full-thickness rectal prolapse confirmed by physical examination, barium enema and defecography. All patients had symptoms of constipation and/or a redundant sigmoid colon; in other words, all patients met the sigmoid resection criteria, as determined by the Wexner constipation score (WCS) or by barium enema and computed tomography (CT) (as shown in Fig. 1 ). The exclusion criteria were as follows: (1) patients with acute incarcerated CRP requiring emergency surgery. (2) Elderly or weak patients who cannot tolerate abdominal surgery and who have critical illness, such as severe cardiopulmonary dysfunction, diabetes mellitus, malignant tumors, inflammatory bowel disease, blood disease, a history of mental disease or other surgical contraindications. (3) Pregnant patients. (4) Patients who previously underwent surgery for rectal prolapse. (5) Patients who were lost to follow-up. Forty-five patients were enrolled and divided into two cohorts according to the method of surgical repair for CRP. Seventeen patients underwent NOSE-LRR, and the other 28 patients underwent LRR. All patients were assessed preoperatively by clinical examination, flexible sigmoidoscopy/colonoscopy, defecography, barium enema and CT. Variables, including age, sex distribution, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status (PS) classification, length of rectal prolapse, duration of symptoms, and past abdominal/pelvic surgery, were collected from patient medical records and gathered into a database. A preoperative questionnaire survey was completed to evaluate patients’ incontinence using the Wexner incontinence score (WIS) (0–20) [ 18 ] and constipation using the WCS (0–30) [ 19 ]. These functional tests were readministered during the 6-month postoperative follow-up period. Complications and recurrence were assessed clinically in all patients. Other relevant surgical details and patient outcomes were recorded and analyzed. The VAS scores for pain were recorded twice a day on the first and third days after surgery, and the highest score of the day was used as the degree of pain. All operations were performed by three surgeons from one team who had extensive experience in laparoscopic colorectal surgery. The study was approved by the Institutional Review Boards of the 988th Hospital of Joint Logistics Support Force of the Chinese People's Liberation Army (study number 988YY20230024LLSP). The requirement for informed consent was waived because of the retrospective study design. Preoperative CT scan (a) and barium enema (b) should be performed to confirm a redundant sigmoid colon. Arrow: The long sigmoid colon was located on the right side of the patient's abdominal cavity. Surgical technique NOSE-LRR group (1) Standard preoperative bowel preparation for colorectal surgery was performed. Three boxes of compound polyethylene glycol electrolyte powder were taken orally in the afternoon one day before the operation. The patients fasted from food and water in the early morning of the operation day, and prophylactic antibiotics were administered intravenously. (2) The patient was positioned in a modified lithotomy posture, with the head lowered and feet elevated, and underwent combined intravenous and inhalation anesthesia. Following routine skin disinfection and towel placement, a 1 cm incision was made above the umbilicus to insert a pneumoperitoneum needle. A 10 mm trocar was then inserted to allow CO 2 insufflation at an abdominal pressure of 12 mmHg so as to establish the pneumoperitoneum. Additionally, four other trocars were placed at the left and right McBurney's points (5 mm trocar and 12 mm trocar, respectively), as well as on the outer edge of the left and right rectus abdominis muscles at the level of the umbilicus (10 mm trocar and 5 mm trocar, respectively). Subsequently, laparoscopic instruments were inserted into the abdominal cavity. (3) After entering the abdominal cavity, the sigmoid colon and mesentery were elevated, the junction of the sigmoid colon and posterior peritoneum was incised, and the plane between the Toidts fascia and Gerota fascia was accessed to separate outwardly for penetration through the left peritoneum. The sigmoid colon was completely dissected along the posterior, bilateral, and anterior rectal spaces up to the levator ani muscle plane. The extent of resection of the sigmoid colon was determined based on the criterion of ensuring tension-free anastomosis between the rectum and sigmoid colon at the sacral promontory. Initially, the bowel wall at the rectosigmoid junction was skeletonized, and the proximal end was tied with a band. The doctor subsequently sterilized the distal rectum lumen with dilute iodophor through the anus. Then, skeletonization of the proximal colon was carried out in a similar manner to proceed to subsequent steps. The sterile plastic sleeve and iodophor gauze were inserted into the abdominal cavity through the right 12-mm trocar. The redundant sigmoid colon and rectum were transected (as shown in Fig. 2 a), the distal rectum was opened, the area was sterilized with iodophor gauze, and the gauze was removed through the rectum to prevent abdominal contamination. One end of the sterile plastic sleeve was removed from the anus, and the anvil was inserted into the abdominal cavity through a sterile plastic sleeve (Fig. 2 b). The bowel wall at the skeletonized proximal sigmoid segment region was cut, the intestinal cavity was sterilized with iodophor gauze, and the anvil was placed. A linear stapler was used to transect the proximal sigmoid colon, and the central rod of the anvil holder protruded from the proximal stump (as shown in Fig. 2 c). Then, the sigmoid colon specimens were successively removed through the anus (as shown in Fig. 2 d and e). (4) Next, the broken end of the rectum was closed with a linear stapler through a 12-mm trocar, and a circular stapler was inserted transanally to complete the end-to-end anastomosis between the rectum and sigmoid colon by joining to the anvil (as shown in Fig. 2 f). Once completed, the anastomosis was tested under a water bath or air insufflation for evidence of leakage. (5) The rectum below the anastomosis was straightened, and the posterior rectum was fixed at the sacral promontory with absorbable sutures (as shown in Fig. 2 g). (6) The pelvic floor peritoneum was closed with continuous barbed sutures for reconstruction (Fig. 2 h). It is important to ensure that the anastomotic site is located below the pelvic floor peritoneum. After the abdominal cavity was flushed, a drainage tube was inserted at the completion of surgery (Fig. 2 i). LRR group All patients underwent preoperative bowel preparation in the same way. Following the same established trocar layout and adhering to sterility principles, the sigmoid bowel and mesentery were dissected, and the bowel wall at the rectosigmoid junction was skeletonized. The sigmoid colon was then transected using a linear stapler, and the sigmoid mesangium was excised. Then, a 5 cm incision was made in the rectus abdominis muscle of the left lower abdomen to facilitate extraction of the proximal intestine. After deflation of the pneumoperitoneum, the bowel was carefully severed at the predetermined location for specimen retrieval. The proximal end of the bowel was inserted into an anvil, a purse-string suture was used for tightening, and then 4 to 5 knots were made for reinforcement. After the proximal bowel was returned to the abdominal cavity, the pneumoperitoneum was reinflated, the circular stapler was inserted through the anus and the bowel protruding very close to the middle of the stapler line was anastomosed end-to-end with the tubular stapler and anvil. The anastomosis was subjected to a water bath and air insufflation to check for hemostasis and integrity. The distal rectum of the anastomosis was straightened, and the mesentery was fixed at the sacral promontory with absorbable sutures. The pelvic floor was reconstructed, the abdominal cavity was rinsed, and a drain was placed. Statistical analysis Statistical analysis was performed using IBM SPSS Version 22.0 (IBM Corp, Armonk, NY, USA). Continuous data are presented as the means and standard deviations if normally distributed or medians and ranges if not normally distributed. Categorical data are presented as frequencies and percentages. Student’s t test or the Mann-Whitney U test for continuous data and the chi‒squared test or Fisher's exact test for categorical data were used to compare the differences between the groups. P values < 0.05 were considered to indicate statistical significance. Results Patient characteristics Seventeen patients were included in the NOSE-LRR cohort, and 28 patients were included in the LRR cohort. The patients’ baseline characteristics are listed in Table 1 . In the NOSE-LRR group, 10 (58.82%) patients were male, 7 (41.18%) were female; in the LRR group, 12 (42.86%) were male, and 16 (57.14%) were female (p = 0.299). The mean age was 47.53 years in the NOSE-LRR group and 48.43 years in the LRR group (p = 0.591). The mean BMIs in the NOSE-LRR and LRR groups were 23.38 and 23.68 kg/m 2 , respectively (p = 0.592). There were no significant differences regarding the ASA PS classification. Nine (52.94%) patients in the NOSE-LRR group and 17 (60.71%) in the LRR group were classified as ASA 1. Six (35.29%) patients in the NOSE-LRR group and 8 (28.57%) in the LRR group were classified as ASA 2. Two (11.76%) patients in the NOSE-LRR group and 3 in the LRR group (10.71%) were classified as ASA 3 (p = 0.730). There were also no differences between the two groups in terms of the mean length of rectal prolapse or the mean duration of symptoms (11.65 cm versus 12.46 cm, p = 0.966; 11.29 years versus 11.68 years, p = 0.209). Two (11.76%) patients in the NOSE-LRR group and 2 (7.14%) in the NOSE-LRR group had a history of previous abdominal or pelvic surgery (p = 0.602). Specifically, one male patient in the NOSE-LRR group previously suffered from acute appendicitis, and another male patient in the NOSE-LRR group had an umbilical hernia. Additionally, one female patient in the LRR group had acute appendicitis, and another male patient in the LRR group had an indirect inguinal hernia. All four patients underwent successful abdominal surgical treatment and recovered well before suffering CRP. Before surgery, 7 (41.18%) patients in the NOSE-LRR group and 12 (42.86%) patients in the LRR group had some degree of fecal incontinence (WIS > 4). Ten (58.82%) patients in the NOSE-LRR group reported symptoms of constipation (WCS > 8). The incidence of these symptoms was comparable to that preoperatively in the LRR group (18 patients, 57.14%). Table 1 Demographic and Clinical Data of the Patients in Both Study Groups NOSE-LRR(n = 17) LRR(n = 28) X 2 /t/Z p value Age(Years) 47.53 ± 13.12 48.43 ± 14.62 0.293 0.591 Sex 1.079 0.299 Male 10(58.82%) 12(42.86%) Female 7(41.18%) 16(57.14%) BMI(kg/m2) 23.38 ± 2.40 23.68 ± 2.67 0.292 0.592 ASA PS classification 0.449 0.904 I 9(52.94%) 17(60.71%) II 6(35.29%) 8(28.57%) III 2(11.76%) 3(10.71%) Length of rectal prolapse (cm) 11.65 ± 5.42 12.46 ± 5.37 0.002 0.966 Duration of symptoms (Years) 11.29 ± 7.00 11.68 ± 4.94 1.629 0.209 Past abdominal/ pelvic surgery 2(11.76%) 2(7.14%) 0.271 0.602 Fecal incontinence (WIS > 4) 7(41.18%) 12(42.86%) 0.012 0.912 Constipation (WCS > 8) 10(58.82%) 18(57.14%) 0.134 0.714 Surgical results The mean operative time was 150.29 minutes in the NOSE-LRR group and 134.18 minutes in the LRR group (p < 0.001). The mean amount of intraoperative bleeding was 46.75 ml in the NOSE-LRR group and 47.76 ml in the LRR group (p = 0.739). The difference between the mean resection length was not statistically significant between the two groups (16.71 cm versus 17.39 cm, p = 0.840). The median length of hospital stay was 7 days in the NOSE-LRR group, which was significantly shorter than that in the LRR group (9 days) (p < 0.001). The postoperative pain score in the NOSE-LRR group was lower than that in the LRR group (median VAS score of 4 in the NOSE-LRR group compared to 5 in the LRR group on the first postoperative day, p = 0.004; median VAS score of 2 in the NOSE-LRR group compared to 3 in the LRR group on the third postoperative day, p = 0.003). Two patients in the LRR group developed a postoperative wound infection, which did not occur in the NOSE-LRR group (p = 0.519). Urinary retention was observed in 1 (5.88%) patient in the NOSE-LRR group and in 2 (7.14%) patients in the LRR group (p = 0.868). In our study, urinary catheters were routinely removed on postoperative day 1 for patients who underwent surgery. When patients developed urinary retention, they were treated with tamsulosin and a urinary catheter was reinserted and remained in place for at least 24 hours. Additionally, only 1 patient in the LRR group was readmitted due to surgical complications of incisional hernia after 6 months. There were no cases of postoperative mortality, pulmonary/intra-abdominal infection, ileus or anastomotic leakage/stenosis in either group (Table 2 ). Table 2 Outcomes of the Study NOSE-LRR(n = 17) LRR(n = 28) X 2 /t/Z p value Operative Time (min) 150.29 ± 11.51 134.18 ± 8.82 -4.947 < 0.001 Blood loss (mL) 46.75 ± 5.61 47.76 ± 6.51 0.113 0.739 Postoperative VAS score for pain Day 1 Day 3 Day 1 Day 3 Day 1 Day 3 Day 1 Day 3 4(3–7) 2(1–3) 5(4–7) 3(2–5) -2.858 -2.990 0.004 0.003 Days of hospital stay 7(6–10) 9(7–13) 24.366 < 0.001 Resection length 16.71 ± 5.34 17.39 ± 5.47 0.041 0.840 Urinary retention 1(5.88%) 2(7.14%) 0.027 0.868 Wound infection 0 2(7.14%) 1.243 0.519 Incisional hernia 0 1(3.57%) 0.607 0.622 The preoperative and postoperative median WCSs decreased from 9 (2–22) to 3 (1–10) (p < 0.001) in the NOSE-LRR group and from 11.5 (2–25) to 2 (1–10) in the LRR group (p < 0.001). The preoperative and postoperative median WISs decreased from 4 (1–11) to 2 (0–5) in the NOSE-LRR group (p < 0.001) and from 4 (1–13) to 1 (0–6) in the LRR group (p < 0.001). None of the patients in either group showed increasing constipation and fecal incontinence or new-onset constipation and fecal incontinence postoperatively. Prolapse disappeared in all patients after surgery (Tables 3 and 4 ). Table 3 Preoperative and Postoperative Wexner Incontinence Score (WIS) NOSE-LRR(n = 17) LRR(n = 28) Z P Preoperative WCS 9(2–22) 11.5(2–25) -0.023 0.981 Postoperative WCS 3(1–10) 2(1–10) -0.489 0.625 Z -3.626 -4.630 P < 0.001 < 0.001 Table 4 Preoperative and Postoperative Wexner Constipation Score (WCS) NOSE-LRR(n = 17) LRR(n = 28) Z P Preoperative WIS 4(1–11) 4(1–13) -0.142 0.887 Postoperative WIS 2(0–5) 1(0–6) -0.347 0.728 Z -3.636 -4.648 P < 0.001 < 0.001 Discussion According to adequate clinical evaluation and examination, there are various surgical methods for the treatment of CRP. Unfortunately, there is no generally accepted standard technique that can mitigate all clinical concerns, and the curative effect is affected by many factors, such as the patient's age, weight, medical history, and rectal prolapse stage. With the continuous progress and popularity of laparoscopic technology, minimally invasive surgery has become the main surgical treatment for colorectal diseases. LRR is a common and effective treatment option for CRP in the USA [ 20 , 21 ]. However, LRR requires an auxiliary incision measuring 4–8 cm in length to be made on the lower abdominal wall to remove specimens and to place the anvil into the proximal end of the sigmoid colon lumen outside the abdominal cavity. Regrettably, the presence of this abdominal incision offsets some of the minimally invasive effects. With the aim of reducing access trauma, as a new method, the NOSE technique allows removal of the specimen through the natural lumen and complete reconstruction of the digestive tract in the abdominal cavity, thereby reducing surgical trauma and emphasizing its advantages over conventional laparoscopic surgery [ 22 ]. In the present study, we described a novel LRR procedure for CRP, which was combined with the transrectal NOSE method, and we aimed to evaluate the outcomes of the NOSE-LRR and LRR surgical approaches for the treatment of CRP. To our knowledge, this series is the first retrospective comparison of patients who underwent NOSE-LRR and LRR in China. In our study, most patients were middle-aged, with 12 (26.67%) patients over age 60. The high proportion of male patients in the present study is most likely related to the high prevalence of colorectal diseases in male patients in China [ 23 , 24 ]. The incidence of these diseases has gradually increased in recent years [ 25 ]. Additionally, a review of the literature suggested that NOSE has a longer operative time and causes less intraoperative bleeding [ 26 , 27 ], mostly due to the cumbersome steps and complex nature of the NOSE method and its minimal invasiveness. However, our results presented here show that there was no significant difference between the two groups of patients in terms of intraoperative bleeding volume, but a significant difference in the operation time was indeed observed. The NOSE procedure tends to be more time consuming than the conventional method. Compared with LRR, the NOSE technique combined with LRR does have increased intraoperative risks and is a difficult procedure, especially when the anvil is inserted through the sigmoid transanally. After adequate training, our colorectal surgeons continued to become experienced in sigmoidectomy with transanal specimen removal. We speculated that the operative time of the NOSE procedure may be further shortened and that the intraoperative bleeding volume may be further reduced. The median postoperative hospital stay is an important measure for assessing and comparing patient recovery and was significantly shorter in the NOSE-LRR group. The studies by Stevenson et al. [ 28 ] and Sezai et al. [ 29 ] reported that the median length of hospital stay of patients with rectal prolapse was approximately 5 or 6 days after LRR surgery, which was 7 days in our study. Many previous studies also reported that patients who underwent the NOSE procedure had shorter hospital stays than did those who underwent conventional laparoscopy [ 11 , 30 ], which is similar to our study's findings. In contrast, several other studies have shown no difference in the length of postoperative hospital stay between laparoscopic surgery and conventional surgery [ 31 – 33 ]. This discrepancy may be related to different types of colorectal diseases, heterogeneity in operative technique and similar recovery pathways in different hospitals. Thus, whether the NOSE technique can significantly shorten the hospitalization time of patients who undergo colorectal surgery requires further confirmation in higher-quality randomized controlled trials. Moreover, the median degree of pain on the first and third postoperative days was lower in the NOSE-LRR group than in the LRR group. This outcome is in line with earlier studies in which less pain was reported and/or fewer analgesics were needed in patients with benign or malignant colorectal diseases who underwent NOSE surgery than in patients who underwent conventional specimen extraction [ 11 , 32 , 34 ]. The reasons for this result were that there was no auxiliary incision on the abdominal wall and only a few small trocar punctures remained. Enterotomy and bowel reconstruction were completed intraperitoneally, and the interference of the pelvic organs and nerves was minimized. Given that pain relief effectively reduces the psychological burden of patients and promotes adequate sleep and early ambulation, consequently, the NOSE method is beneficial for promoting patients' early recovery. In previous research, Karagul et al. [ 35 ] emphasized that the length of the specimen contributes to the feasibility of NOSE. They evaluated the factors affecting failure in patients who were scheduled for NOSE in laparoscopic colorectal resections. The results of this study demonstrated that the length of the resected bowel in the failed NOSE group (36.5 ± 27.6 cm) was significantly greater than that in the successful NOSE group (21.2 ± 19.4 cm). Therefore, they inferred that the use of specimens with smaller diameters increased the success rate of NOSE. However, in this study, we measured the resection length of the rectal prolapse, and there were no statistically significant differences between the two groups (16.71 ± 5.34 cm in the NOSE-LRR group, 17.39 ± 5.47 cm in the LRR group), and there were no instances of NOSE failure. In contrast to that in large-scale colectomy surgery, the length of the resected bowel in NOSE-LRR is relatively shorter, and the specimen is easier to remove transanally; thus, we believe that this technique will not affect the NOSE success rate in our study. As rectal prolapse is considered a benign colorectal disease, the NOSE success rate is not influenced by factors such as tumor size, shape, or location. Nevertheless, specimen width also appears to be an important factor in the feasibility of NOSE, which was not analyzed in the present study, and whether specimen width affects the feasibility of the NOSE for CRP must be assessed in future research. This experience may aid in the selection of suitable CRP patients for NOSE. Regarding postoperative complications, in the conventional laparoscopic surgery group, 2 patients had an incision infection, and 1 patient had an incision hernia, while, in the NOSE group, no patients had surgical complications. This is because the NOSE method does not require an auxiliary incision for the removal of abdominal wall specimens, which decreases the risks of postoperative abdominal incision infection and incision hernia. Perhaps due to the small sample size in our study, there was no significant difference in the incidence of postoperative complications between the two groups. Previous long-term outcome studies, however, revealed that patients in the NOSE group had a significantly lower rate of postoperative complications than did those in the conventional laparoscopic colorectal surgery group, which aligns with the trend of our research findings [ 36 , 37 ]. In addition, there was 1 case of urinary retention in the NOSE group and 2 cases of urinary retention in the conventional laparoscopic surgery group, but no catheter-associated urinary tract infection existed in either group. These 3 patients were elderly males with a history of benign prostatic hyperplasia. After treatment with tamsulosin and retention of a urinary catheter for at least 24 hours, the symptoms of urinary retention were significantly relieved. Interestingly, Kin et al. [ 38 ] have proposed that the practice of earlier urinary catheter removal must be balanced with fluid volume and operative time to avoid high urinary retention rates, while age, sex, and preoperative prostatism are not related to an increased rate of postoperative urinary retention. In our study, there were 2 other patients with preoperative prostatism in the NOSE-LRR group and 2 patients in the LRR group, but no postoperative urinary retention was observed in these patients. Therefore, we speculated that preoperative prostatism may not be a key factor leading to postoperative urinary retention. However, these 3 patients who survived surgery all received an average of 2.5 L of intravenous fluid during the operation and 2.4 L on the first postoperative day, which was significantly greater than that of the other patients. Consequently, we believe that a large volume of fluid is associated with urinary retention, which should be avoided in subsequent perioperative patient management, while operative time is also a factor that needs to be considered, although no significant difference in operative time was observed between urinary retention patients and others in the present study due to the small number of retention cases. Notably, the potential for bacterial contamination during NOSE surgery has always been a concern. Leroy et al. [ 39 ] reported that the NOSE method increased the risk of intraperitoneal bacterial contamination in patients because of the breach of peritoneal sterility in some procedures, which was confirmed by both routine bacterial culture and direct bacteriological examination. In contrast, some experts believe that the postoperative intra-abdominal abscess rate after NOSE surgery is not significantly higher than that after conventional laparoscopic colorectal resection [ 40 , 41 ]. In our study, there were no cases of pulmonary or intra-abdominal infection reported in either group. According to the recommendations of the international consensus on NOSE surgery for colorectal cancer and combined with our experience, we believe that preoperative bowel preparation, reasonable administration of prophylactic antibiotics, correct use of sterile plastic sleeve and iodophor gauze, intraoperative transanal lavage with a large amount of dilute iodophor, and proper placement of abdominal or pelvic drainage tubes are all effective measures that can reduce the risk of postoperative intra-abdominal infection [ 42 ]. Furthermore, anastomotic leakage or stenosis represents serious postoperative complications. Previous studies on LRR have reported a low incidence of anastomotic leakage [ 43 , 44 ]. However, in our study, no instances of anastomotic leakage or stenosis were observed in either group. Another study conducted by Kellokumpu et al. [ 45 ] reported the same functional outcomes for both LRR and laparoscopic sutured rectopexy. Moreover, Formijne et al. [ 46 ] also found the same benefit in terms of postoperative improvement of constipation and continence with LRR and laparoscopic ventral rectopexy. For this reason, Panis [ 20 ] suggested that there is no need for anastomotic leakage to occur during rectosigmoid resection and colorectal anastomosis and that there is no need to make an auxiliary abdominal incision. However, the current appropriate use of staplers by proficient surgeons has the potential to significantly mitigate the occurrence of postoperative anastomotic leakage and stenosis and substantially provide good surgical results, thus alleviating concerns regarding this issue. Complete resolution of prolapse following surgical intervention was also found in all patients, as well as significant improvements in fecal incontinence and constipation after surgery for CRP within both groups. The results of a prospective study including 154 patients who underwent LRR suggested the benefits of LRR for rectal prolapse both in younger and elderly patients, of whom the symptoms of incontinence (64.6%) and constipation (77.8%) were also significantly improved after the operation [ 43 ]. Compared to other surgical strategies, we speculated that reasons why LRR effectively relieves symptoms of CRP are as follows: first, compared with laparoscopic rectopexy, LRR can significantly relieve constipation symptoms in patients because part of the rectum and/or the lengthy sigmoid colon is removed so that there is no redundant intestinal canal, thereby avoiding intestinal obstruction. Second, compared with sigmoidectomy, LRR restores the physiological curvature because the rectum is fixed to the presacral fascia with sutures, thus reducing the possibility of postoperative recurrence and intussusception. Third, LRR can cure defects in the intestine without the need for mesh implantation, reducing the incidences of postoperative infection, recurrence, mesh erosion and rejection reactions and eliminating potential intestinal symptoms such as constipation and even obstruction caused by folding and mesh implantation. In our study, there were no statistically significant differences observed in terms of symptoms of fecal incontinence or constipation between the LRR and NOSE-LRR groups before and after surgery, respectively. This finding suggests that the NOSE method has no negative impact on the favorable outcome of LRR treatment for CRP and is accompanied by a low incidence of postoperative complications; therefore, both methods appear to be equally safe and effective. Limitations This study has several limitations. First, considering that CRP is a rare disease, this was a single-center retrospective study with a small sample size. More reliable conclusions must be drawn from large multicenter case series and randomized controlled trials to avoid possible selection bias. Second, in our study, there were no recurrences in either group, which was probably due to the short follow-up time; hence, longer follow-up is required in further research. Third, some other auxiliary measurements were not used in our study, such as anal manometry, electromyography, urodynamic, and colonic transit time, which can be used to assess anal sphincter structure and function and identify other possible pathologies associated with CRP. These tests should be performed selectively in future research to refine the diagnosis and provide patients with a more comprehensive assessment before surgery because this may change the surgical plan. Conclusion In conclusion, our study demonstrated that LRR with NOSE is a feasible and safe procedure for treating CRP and is therefore worthy of clinical implementation. The procedure has a low rate of complications and good cosmetic effect and may be superior to conventional LRR in terms of postoperative pain and length of hospital stay. Declarations Funding This work was supported by the Henan Medical Science and Technology Research Project (No. SB201903034). Competing interests The authors have no competing interests to declare that are relevant to the content of this article. Consent to participate The requirement for informed consent was waived because of the retrospective study design. Consent for publication Not applicable. Data availability The datasets generated or analyzed during the study are available from the corresponding author on reasonable request. Author contributions Chunxu Zhang conceived and designed the study. Shihan Chen collected the data and wrote the manuscript. Yanyang Liang, Ruixue Tang, Jixin Zhang and Shouxin Yuan analyzed and interpreted the data. Shuang Xie critically read the manuscript. Quanhui Wang and Chunxu Zhang supervised the study and revised the paper. All authors approved the final version of the article to be published. Ethics declarations This study was approved by the Institutional Review Boards of the 988th Hospital of Joint Logistics Support Force of the Chinese People's Liberation Army (study number 988YY20230024LLSP). Corresponding authors Please forward correspondence to Quanhui Wang or Chunxu Zhang. Author information Shihan Chen and Yanyang Liang contributed equally to this work and should be considered co-first authors. References Hotouras A, Murphy J, Boyle DJ, Allison M, Williams NS, Chan CL (2013) Assessment of female patients with rectal intussusception and prolapse: is this a progressive spectrum of disease? Dis Colon Rectum 56:780–785. https://doi.org/10.1097/DCR.0b013e31827ba32c Smedberg J, Graf W, Pekkari K, Hjern F (2022) Comparison of four surgical approaches for rectal prolapse: multicentre randomized clinical trial. 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World J Surg Oncol 18:215. https://doi.org/10.1186/s12957-020-01982-w Ma B, Huang XZ, Gao P, Zhao JH, Song YX, Sun JX, Chen XW, Wang ZN (2015) Laparoscopic resection with natural orifice specimen extraction versus conventional laparoscopy for colorectal disease: a meta-analysis. Int J Colorectal Dis 30:1479–1488. https://doi.org/10.1007/s00384-015-2337-0 Stevenson AR, Stitz RW, Lumley JW (1998) Laparoscopic-assisted resection-rectopexy for rectal prolapse: early and medium follow-up. Dis Colon Rectum 41:46–54. https://doi.org/10.1007/bf02236895 Sezai D, Demirbas S, Akin L, Kurt Y, Ogün I, Celenk T (2005) The impact of laparoscopic resection rectopexy in patients with total rectal prolapse. Mil Med 170:743–747. https://doi.org/10.7205/milmed.170.9.743 Zhou Z, Chen L, Liu J, Ji F, Shang Y, Yang X, Yang Y, Fu C (2022) Laparoscopic natural orifice specimen extraction surgery versus conventional surgery in colorectal cancer: a meta-analysis of randomized controlled trials. Gastroenterol Res Pract 2022:6661651. https://doi.org/10.1155/2022/6661651 Hisada M, Katsumata K, Ishizaki T, Enomoto M, Matsudo T, Kasuya K, Tsuchida A (2014) Complete laparoscopic resection of the rectum using natural orifice specimen extraction. World J Gastroenterol 20:16707–16713. https://doi.org/10.3748/wjg.v20.i44.16707 Wolthuis AM, Fieuws S, Van Den Bosch A, Van Overstraeten ADB, D'Hoore A (2015) Randomized clinical trial of laparoscopic colectomy with or without natural-orifice specimen extraction. Br J Surg 102:630–637. https://doi.org/10.1002/bjs.9757 Awad ZT, Griffin R (2014) Laparoscopic right hemicolectomy: a comparison of natural orifice versus transabdominal specimen extraction. Surg Endosc 28:2871–2876. https://doi.org/10.1007/s00464-014-3540-8 Costantino FA, Diana M, Wall J, Leroy J, Mutter D, Marescaux J (2012) Prospective evaluation of peritoneal fluid contamination following transabdominal vs. transanal specimen extraction in laparoscopic left-sided colorectal resections. Surg Endosc 26:1495–1500. https://doi.org/10.1007/s00464-011-2066-6 Karagul S, Kayaalp C, Sumer F, Ertugrul I, Kirmizi S, Tardu A, Yagci MA (2017) Success rate of natural orifice specimen extraction after laparoscopic colorectal resections. Tech Coloproctol 21:295–300. https://doi.org/10.1007/s10151-017-1611-2 Zhang J, Li W, Li Y, Amin B, Zhang N, Sun Z, Zhu B (2022) Short- and long-term outcomes as well as anal function of transanal natural orifice specimen extraction surgery versus conventional laparoscopic surgery for sigmoid colon or rectal cancer resection: a retrospective study with over 5-year follow-up. Wideochir Inne Tech Maloinwazyjne 17:344–351. https://doi.org/10.5114/wiitm.2022.113567 Li Z, Xiong H, Qiao T, Jiao S, Zhu Y, Wang G, Wang X, Tang Q (2022) Long-term oncologic outcomes of natural orifice specimen extraction surgery versus conventional laparoscopic-assisted resection in the treatment of rectal cancer: a propensity-score matching study. BMC Surg 22:286. https://doi.org/10.1186/s12893-022-01737-2 Kin C, Rhoads KF, Jalali M, Shelton AA, Welton ML (2013) Predictors of postoperative urinary retention after colorectal surgery. Dis Colon Rectum 56:738–746. https://doi.org/10.1097/DCR.0b013e318280aad5 Leroy J, Costantino F, Cahill RA, D'Agostino J, Morales A, Mutter D, Marescaux J (2011) Laparoscopic resection with transanal specimen extraction for sigmoid diverticulitis. Br J Surg 98:1327–1334. https://doi.org/10.1002/bjs.7517 Liu RJ, Zhang CD, Fan YC, Pei JP, Zhang C, Dai DQ (2019) Safety and oncological outcomes of laparoscopic NOSE surgery compared with conventional laparoscopic surgery for colorectal diseases: a meta-analysis. Front Oncol 9:597. https://doi.org/10.3389/fonc.2019.00597 Park JS, Kang H, Park SY, Kim HJ, Lee IT, Choi GS (2018) Long-term outcomes after natural orifice specimen extraction versus conventional laparoscopy-assisted surgery for rectal cancer: a matched case-control study. Ann Surg Treat Res 94:26–35. https://doi.org/10.4174/astr.2018.94.1.26 Guan X, Liu Z, Longo A, et al (2019) International consensus on natural orifice specimen extraction surgery (NOSES) for colorectal cancer. Gastroenterol Rep (Oxf) 7:24–31. https://doi.org/10.1093/gastro/goy055 Laubert T, Bader FG, Kleemann M, Esnaashari H, Bouchard R, Hildebrand P, Schlöricke E, Bruch HP, Roblick UJ (2012) Outcome analysis of elderly patients undergoing laparoscopic resection rectopexy for rectal prolapse. Int J Colorectal Dis 27:789–795. https://doi.org/10.1007/s00384-011-1395-1 Ashari LH, Lumley JW, Stevenson AR, Stitz RW (2005) Laparoscopically-assisted resection rectopexy for rectal prolapse: ten years' experience. Dis Colon Rectum 48:982–987. https://doi.org/10.1007/s10350-004-0886-3 Kellokumpu IH, Vironen J, Scheinin T (2000) Laparoscopic repair of rectal prolapse: a prospective study evaluating surgical outcome and changes in symptoms and bowel function. Surg Endosc 14:634–640. https://doi.org/10.1007/s004640000017 Jonkers HAF, Maya A, Draaisma WA, Bemelman WA, Broeders IA, Consten EC, Wexner SD (2014) Laparoscopic resection rectopexy versus laparoscopic ventral rectopexy for complete rectal prolapse. Tech Coloproctol 18:641–646. https://doi.org/10.1007/s10151-014-1122-3 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4575462","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":317638715,"identity":"84068e76-2a1b-4623-8722-a8fd23cf637b","order_by":0,"name":"Shihan Chen","email":"","orcid":"","institution":"the No. 988th Hospital of Joint Logistic Support Force of PLA","correspondingAuthor":false,"prefix":"","firstName":"Shihan","middleName":"","lastName":"Chen","suffix":""},{"id":317638716,"identity":"df78d705-6856-4418-9e85-5968c38c12b0","order_by":1,"name":"Yanyang Liang","email":"","orcid":"","institution":"the No. 988th Hospital of Joint Logistic Support Force of PLA","correspondingAuthor":false,"prefix":"","firstName":"Yanyang","middleName":"","lastName":"Liang","suffix":""},{"id":317638717,"identity":"2d5277f3-8274-4c84-b7ff-154e8b14cdb1","order_by":2,"name":"Ruixue Tang","email":"","orcid":"","institution":"Xinxiang Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ruixue","middleName":"","lastName":"Tang","suffix":""},{"id":317638718,"identity":"f831bb9e-131f-42f2-9e50-7c8cd38707ae","order_by":3,"name":"Jixin Zhang","email":"","orcid":"","institution":"the No. 988th Hospital of Joint Logistic Support Force of PLA","correspondingAuthor":false,"prefix":"","firstName":"Jixin","middleName":"","lastName":"Zhang","suffix":""},{"id":317638719,"identity":"791e43e5-51c2-4488-970d-76b6b47c3f38","order_by":4,"name":"Shouxin Yuan","email":"","orcid":"","institution":"the No. 988th Hospital of Joint Logistic Support Force of PLA","correspondingAuthor":false,"prefix":"","firstName":"Shouxin","middleName":"","lastName":"Yuan","suffix":""},{"id":317638720,"identity":"01028e9e-d8d3-4857-b150-7c01a2cdec7f","order_by":5,"name":"Shuang Xie","email":"","orcid":"","institution":"the No. 988th Hospital of Joint Logistic Support Force of PLA","correspondingAuthor":false,"prefix":"","firstName":"Shuang","middleName":"","lastName":"Xie","suffix":""},{"id":317638721,"identity":"f30c66e6-1f48-4291-a557-0ffec92e95bf","order_by":6,"name":"Quanhui Wang","email":"","orcid":"","institution":"the No. 988th Hospital of Joint Logistic Support Force of PLA","correspondingAuthor":false,"prefix":"","firstName":"Quanhui","middleName":"","lastName":"Wang","suffix":""},{"id":317638722,"identity":"4be8eb72-781a-49c2-b18e-eca3c046b903","order_by":7,"name":"Chunxu Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYDACCcYGECXHz9584MCHHyRoMZbsOZZ4cGYPUVogVOKGGznGhznYiNDBP7u5+cPHHbWJM3vOfDjMwMMgzy92gIAldw62Sc48c9y4n713w+ECCwbDmbMT8GsxkEhsY+ZtOyY7s+fshsMzeBgSDG4T1tL8+W/bMUagXx4c5mEjTkuDNGNbjSJQCwNxWiRuJLZJ9rYdAAWyATCQJQj7hX9G+uMPP9vqQFH5+MOHHzby/NIEtEDBYbitRCkHgTqiVY6CUTAKRsEIBADVsk5wjrD+SQAAAABJRU5ErkJggg==","orcid":"","institution":"the No. 988th Hospital of Joint Logistic Support Force of PLA","correspondingAuthor":true,"prefix":"","firstName":"Chunxu","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-06-13 10:23:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4575462/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4575462/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60184704,"identity":"8d63fc8e-4e6a-4c87-bfd8-c3a214fe1fb9","added_by":"auto","created_at":"2024-07-12 18:38:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":945392,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative workup\u003c/p\u003e\n\u003cp\u003ePreoperative CT scan (a) and barium enema (b) should be performed to confirm a redundant sigmoid colon. Arrow: The long sigmoid colon was located on the right side of the patient's abdominal cavity.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4575462/v1/12c5cf3c3a5e78e4d55bc55a.png"},{"id":60184703,"identity":"83c3813b-98c3-482f-b45b-806fb9a85093","added_by":"auto","created_at":"2024-07-12 18:38:28","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1165751,"visible":true,"origin":"","legend":"\u003cp\u003eLRR with the NOSE method for CRP\u003c/p\u003e\n\u003cp\u003ea. Theredundant sigmoid colon and rectum were transected. b. The anvil was placed into the abdominal cavity through a sterile plastic sleeve. c. The anvil head was placed into the proximal intestinal cavity and protruded from the stump through a small opening. d. Placement of the specimen into the sterile plastic sleeve. e. The specimen was removed through the distal rectum and anus. f. End-to-end anastomosis and closure were performed. g. The posterior wall of the distal rectum was fixed at the sacral promontory. h. Pelvic floor reconstruction. i. Appearance of the abdomen after LRR with NOSE.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4575462/v1/ded9a16ec0ca5e10efd92142.png"},{"id":73111178,"identity":"df032ef3-3928-48d4-bfb7-a49802ac4a34","added_by":"auto","created_at":"2025-01-06 22:16:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3688115,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4575462/v1/5dac2b9e-a518-4146-809e-d70218698222.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The feasibility, safety and short-term clinical efficacy of laparoscopic resection rectopexy with natural orifice specimen extraction surgery for the treatment of complete rectal prolapse","fulltext":[{"header":"Introduction","content":"\u003cp\u003eComplete rectal prolapse (CRP), also known as external rectal prolapse, is defined as a protrusion of the full thickness of the rectum wall through the anal canal. If only the rectal or anal mucosa protrudes, it is called incomplete rectal prolapse or internal rectal prolapse, which should be distinguished from CRP. CRP affects approximately 0.5% of the total population and is accompanied by symptoms of constipation, fecal incontinence, mucous discharge and hemorrhage, thus causing a decline in patient quality of life. The female-to-male ratio in adults is approximately 6:1 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although there are several clinical practice guidelines for rectal prolapse, due to the complex etiology and pathogenesis of rectal prolapse, it is difficult to achieve good results with a single treatment strategy for various types of rectal prolapse, thereby creating many challenges for clinicians. Surgery is considered the only effective method for treating CRP. Surgical approaches can be classified into transabdominal approaches and transperineal approaches. The choice of surgical treatment for patients with CRP is mainly determined by the patient's physical condition and the surgeon's preference. Young, fit patients at low surgical risk who undergo transabdominal surgery have lower recurrence rates, and older less fit patients with significant comorbidities who undergo transperineal surgery have lower surgery-related mortality rates. However, there is no evidence showing which surgical method has obvious advantages. All methods appeared to be equally safe. There were no significant differences regarding the incidence of postoperative complications [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Notably, laparoscopic resection rectopexy (LRR) is an effective and popular transabdominal surgical technique for the treatment of CRP that is preferred by colorectal surgeons. Frykman first described the surgical procedure of sigmoid resection and fixing the rectum to the sacral promontory with sutures to prevent telescoping of the redundant bowel in 1955 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]; this procedure has also been applied in the treatment of obstructive bowel syndrome [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Patients with symptoms of constipation and/or redundancy of the sigmoid colon were candidates for LRR. LRR has been proven to be a safe and effective procedure with long-lasting effects for CRP patients [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], and the prolapse recurrence rates are low and the 4% postoperative complication rate is acceptable [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough LRR has many advantages as a minimally invasive surgery over laparotomy, the removal of sigmoid colon specimens still requires an additional abdominal incision, which may increase the probabilities of postoperative pain, wound infection, and hernia. However, in 1993, Franklin first reported that natural orifice specimen extraction (NOSE) eliminates the need for an extraction site incision [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]; the procedure has been widely used in the clinic and explored in many studies in colorectal surgery, especially as a surgical treatment of colorectal malignant disease. Many reports on laparoscopic NOSE surgery for colorectal cancer are available [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The NOSE technique involves the laparoscopic extraction of specimens through natural lumens in the human body, such as the rectum and vagina. This technique has good cosmetic effects, reduces the psychological burden of patients, and is associated with lower postoperative pain scores, decreased consumption of painkillers, and faster recovery [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In 2012, Fuchs et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] introduced a combination approach involving laparoscopic colorectal surgery and transanal endoscopic microsurgery for treating 15 patients with prolapse, pelvic floor disorders and slow-transit constipation. The results showed that transanal hybrid colon resection seemed to be a feasible and safe procedure. In addition, Can et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and Fu et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] successfully applied the NOSE technique during laparoscopic surgery for rectal prolapse in two patients and introduced it to us via videos. Driouch et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] suggested that NOSE-LRR is a safe treatment for obstructive defecation syndrome and that patients who undergo this procedure tend to recovery faster. A recent study reported 8 patients with rectal prolapse who underwent robotic sigmoidectomies through transrectal NOSE and demonstrated the practicality and safety of NOSE procedures for sigmoidectomies for treating benign colon diseases [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, the feasibility and safety of the combination of the NOSE technique and LRR for the treatment of CRP are still unknown. To our knowledge, no study comparing NOSE-LRR and LRR for the treatment of CRP has been published in the literature. The aim of this study was to evaluate the clinical outcomes of these two surgical approaches for treating CRP.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and patients\u003c/h2\u003e \u003cp\u003eThis observational cohort study was a retrospective analysis conducted in the Department of General Surgery at the 988th Hospital of Joint Logistics Support Force of the Chinese People's Liberation Army from January 2019 to October 2023. According to the American Clinical Practice Guidelines and Chinese Expert Consensus, sigmoid resection may be added to rectopexy in the treatment of CRP patients only in those with symptoms of significant constipation or with an elongated sigmoid colon [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. For CRP patients diagnosed with colonic slow transit constipation or colonic inertia via the colonic transit test before surgery, rectopexy plus subtotal colectomy is also recommended [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In our study, the inclusion criterion was full-thickness rectal prolapse confirmed by physical examination, barium enema and defecography. All patients had symptoms of constipation and/or a redundant sigmoid colon; in other words, all patients met the sigmoid resection criteria, as determined by the Wexner constipation score (WCS) or by barium enema and computed tomography (CT) (as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The exclusion criteria were as follows: (1) patients with acute incarcerated CRP requiring emergency surgery. (2) Elderly or weak patients who cannot tolerate abdominal surgery and who have critical illness, such as severe cardiopulmonary dysfunction, diabetes mellitus, malignant tumors, inflammatory bowel disease, blood disease, a history of mental disease or other surgical contraindications. (3) Pregnant patients. (4) Patients who previously underwent surgery for rectal prolapse. (5) Patients who were lost to follow-up. Forty-five patients were enrolled and divided into two cohorts according to the method of surgical repair for CRP. Seventeen patients underwent NOSE-LRR, and the other 28 patients underwent LRR. All patients were assessed preoperatively by clinical examination, flexible sigmoidoscopy/colonoscopy, defecography, barium enema and CT. Variables, including age, sex distribution, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status (PS) classification, length of rectal prolapse, duration of symptoms, and past abdominal/pelvic surgery, were collected from patient medical records and gathered into a database. A preoperative questionnaire survey was completed to evaluate patients\u0026rsquo; incontinence using the Wexner incontinence score (WIS) (0\u0026ndash;20) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and constipation using the WCS (0\u0026ndash;30) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These functional tests were readministered during the 6-month postoperative follow-up period. Complications and recurrence were assessed clinically in all patients. Other relevant surgical details and patient outcomes were recorded and analyzed. The VAS scores for pain were recorded twice a day on the first and third days after surgery, and the highest score of the day was used as the degree of pain. All operations were performed by three surgeons from one team who had extensive experience in laparoscopic colorectal surgery. The study was approved by the Institutional Review Boards of the 988th Hospital of Joint Logistics Support Force of the Chinese People's Liberation Army (study number 988YY20230024LLSP). The requirement for informed consent was waived because of the retrospective study design.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePreoperative CT scan (a) and barium enema (b) should be performed to confirm a redundant sigmoid colon. Arrow: The long sigmoid colon was located on the right side of the patient's abdominal cavity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical technique\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eNOSE-LRR group\u003c/h2\u003e \u003cp\u003e(1) Standard preoperative bowel preparation for colorectal surgery was performed. Three boxes of compound polyethylene glycol electrolyte powder were taken orally in the afternoon one day before the operation. The patients fasted from food and water in the early morning of the operation day, and prophylactic antibiotics were administered intravenously.\u003c/p\u003e \u003cp\u003e(2) The patient was positioned in a modified lithotomy posture, with the head lowered and feet elevated, and underwent combined intravenous and inhalation anesthesia. Following routine skin disinfection and towel placement, a 1 cm incision was made above the umbilicus to insert a pneumoperitoneum needle. A 10 mm trocar was then inserted to allow CO\u003csub\u003e2\u003c/sub\u003e insufflation at an abdominal pressure of 12 mmHg so as to establish the pneumoperitoneum. Additionally, four other trocars were placed at the left and right McBurney's points (5 mm trocar and 12 mm trocar, respectively), as well as on the outer edge of the left and right rectus abdominis muscles at the level of the umbilicus (10 mm trocar and 5 mm trocar, respectively). Subsequently, laparoscopic instruments were inserted into the abdominal cavity.\u003c/p\u003e \u003cp\u003e(3) After entering the abdominal cavity, the sigmoid colon and mesentery were elevated, the junction of the sigmoid colon and posterior peritoneum was incised, and the plane between the Toidts fascia and Gerota fascia was accessed to separate outwardly for penetration through the left peritoneum. The sigmoid colon was completely dissected along the posterior, bilateral, and anterior rectal spaces up to the levator ani muscle plane. The extent of resection of the sigmoid colon was determined based on the criterion of ensuring tension-free anastomosis between the rectum and sigmoid colon at the sacral promontory. Initially, the bowel wall at the rectosigmoid junction was skeletonized, and the proximal end was tied with a band. The doctor subsequently sterilized the distal rectum lumen with dilute iodophor through the anus. Then, skeletonization of the proximal colon was carried out in a similar manner to proceed to subsequent steps. The sterile plastic sleeve and iodophor gauze were inserted into the abdominal cavity through the right 12-mm trocar. The redundant sigmoid colon and rectum were transected (as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea), the distal rectum was opened, the area was sterilized with iodophor gauze, and the gauze was removed through the rectum to prevent abdominal contamination. One end of the sterile plastic sleeve was removed from the anus, and the anvil was inserted into the abdominal cavity through a sterile plastic sleeve (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb). The bowel wall at the skeletonized proximal sigmoid segment region was cut, the intestinal cavity was sterilized with iodophor gauze, and the anvil was placed. A linear stapler was used to transect the proximal sigmoid colon, and the central rod of the anvil holder protruded from the proximal stump (as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec). Then, the sigmoid colon specimens were successively removed through the anus (as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ed and e).\u003c/p\u003e \u003cp\u003e(4) Next, the broken end of the rectum was closed with a linear stapler through a 12-mm trocar, and a circular stapler was inserted transanally to complete the end-to-end anastomosis between the rectum and sigmoid colon by joining to the anvil (as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ef). Once completed, the anastomosis was tested under a water bath or air insufflation for evidence of leakage.\u003c/p\u003e \u003cp\u003e(5) The rectum below the anastomosis was straightened, and the posterior rectum was fixed at the sacral promontory with absorbable sutures (as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eg).\u003c/p\u003e \u003cp\u003e(6) The pelvic floor peritoneum was closed with continuous barbed sutures for reconstruction (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eh). It is important to ensure that the anastomotic site is located below the pelvic floor peritoneum. After the abdominal cavity was flushed, a drainage tube was inserted at the completion of surgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ei).\u003c/p\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eLRR group\u003c/h2\u003e \u003cp\u003eAll patients underwent preoperative bowel preparation in the same way. Following the same established trocar layout and adhering to sterility principles, the sigmoid bowel and mesentery were dissected, and the bowel wall at the rectosigmoid junction was skeletonized. The sigmoid colon was then transected using a linear stapler, and the sigmoid mesangium was excised. Then, a 5 cm incision was made in the rectus abdominis muscle of the left lower abdomen to facilitate extraction of the proximal intestine. After deflation of the pneumoperitoneum, the bowel was carefully severed at the predetermined location for specimen retrieval. The proximal end of the bowel was inserted into an anvil, a purse-string suture was used for tightening, and then 4 to 5 knots were made for reinforcement. After the proximal bowel was returned to the abdominal cavity, the pneumoperitoneum was reinflated, the circular stapler was inserted through the anus and the bowel protruding very close to the middle of the stapler line was anastomosed end-to-end with the tubular stapler and anvil. The anastomosis was subjected to a water bath and air insufflation to check for hemostasis and integrity. The distal rectum of the anastomosis was straightened, and the mesentery was fixed at the sacral promontory with absorbable sutures. The pelvic floor was reconstructed, the abdominal cavity was rinsed, and a drain was placed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using IBM SPSS Version 22.0 (IBM Corp, Armonk, NY, USA). Continuous data are presented as the means and standard deviations if normally distributed or medians and ranges if not normally distributed. Categorical data are presented as frequencies and percentages. Student\u0026rsquo;s t test or the Mann-Whitney U test for continuous data and the chi‒squared test or Fisher's exact test for categorical data were used to compare the differences between the groups. P values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered to indicate statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eSeventeen patients were included in the NOSE-LRR cohort, and 28 patients were included in the LRR cohort. The patients\u0026rsquo; baseline characteristics are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. In the NOSE-LRR group, 10 (58.82%) patients were male, 7 (41.18%) were female; in the LRR group, 12 (42.86%) were male, and 16 (57.14%) were female (p\u0026thinsp;=\u0026thinsp;0.299). The mean age was 47.53 years in the NOSE-LRR group and 48.43 years in the LRR group (p\u0026thinsp;=\u0026thinsp;0.591). The mean BMIs in the NOSE-LRR and LRR groups were 23.38 and 23.68 kg/m\u003csup\u003e2\u003c/sup\u003e, respectively (p\u0026thinsp;=\u0026thinsp;0.592). There were no significant differences regarding the ASA PS classification. Nine (52.94%) patients in the NOSE-LRR group and 17 (60.71%) in the LRR group were classified as ASA 1. Six (35.29%) patients in the NOSE-LRR group and 8 (28.57%) in the LRR group were classified as ASA 2. Two (11.76%) patients in the NOSE-LRR group and 3 in the LRR group (10.71%) were classified as ASA 3 (p\u0026thinsp;=\u0026thinsp;0.730). There were also no differences between the two groups in terms of the mean length of rectal prolapse or the mean duration of symptoms (11.65 cm versus 12.46 cm, p\u0026thinsp;=\u0026thinsp;0.966; 11.29 years versus 11.68 years, p\u0026thinsp;=\u0026thinsp;0.209). Two (11.76%) patients in the NOSE-LRR group and 2 (7.14%) in the NOSE-LRR group had a history of previous abdominal or pelvic surgery (p\u0026thinsp;=\u0026thinsp;0.602). Specifically, one male patient in the NOSE-LRR group previously suffered from acute appendicitis, and another male patient in the NOSE-LRR group had an umbilical hernia. Additionally, one female patient in the LRR group had acute appendicitis, and another male patient in the LRR group had an indirect inguinal hernia. All four patients underwent successful abdominal surgical treatment and recovered well before suffering CRP. Before surgery, 7 (41.18%) patients in the NOSE-LRR group and 12 (42.86%) patients in the LRR group had some degree of fecal incontinence (WIS\u0026thinsp;\u0026gt;\u0026thinsp;4). Ten (58.82%) patients in the NOSE-LRR group reported symptoms of constipation (WCS\u0026thinsp;\u0026gt;\u0026thinsp;8). The incidence of these symptoms was comparable to that preoperatively in the LRR group (18 patients, 57.14%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and Clinical Data of the Patients in Both Study Groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNOSE-LRR(n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLRR(n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e/t/Z\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge(Years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47.53\u0026thinsp;\u0026plusmn;\u0026thinsp;13.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.43\u0026thinsp;\u0026plusmn;\u0026thinsp;14.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.293\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.591\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.299\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(58.82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(42.86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(41.18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(57.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI(kg/m2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.38\u0026thinsp;\u0026plusmn;\u0026thinsp;2.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.68\u0026thinsp;\u0026plusmn;\u0026thinsp;2.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.292\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.592\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA PS classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.449\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.904\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(52.94%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17(60.71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(35.29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(28.57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(11.76%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(10.71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of rectal prolapse (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.65\u0026thinsp;\u0026plusmn;\u0026thinsp;5.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.46\u0026thinsp;\u0026plusmn;\u0026thinsp;5.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.966\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of symptoms (Years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.29\u0026thinsp;\u0026plusmn;\u0026thinsp;7.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.68\u0026thinsp;\u0026plusmn;\u0026thinsp;4.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.629\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.209\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePast abdominal/\u003c/p\u003e \u003cp\u003epelvic surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(11.76%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(7.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.602\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFecal incontinence (WIS\u0026thinsp;\u0026gt;\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(41.18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(42.86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.912\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstipation (WCS\u0026thinsp;\u0026gt;\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(58.82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(57.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.714\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSurgical results\u003c/h2\u003e \u003cp\u003eThe mean operative time was 150.29 minutes in the NOSE-LRR group and 134.18 minutes in the LRR group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mean amount of intraoperative bleeding was 46.75 ml in the NOSE-LRR group and 47.76 ml in the LRR group (p\u0026thinsp;=\u0026thinsp;0.739). The difference between the mean resection length was not statistically significant between the two groups (16.71 cm versus 17.39 cm, p\u0026thinsp;=\u0026thinsp;0.840). The median length of hospital stay was 7 days in the NOSE-LRR group, which was significantly shorter than that in the LRR group (9 days) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The postoperative pain score in the NOSE-LRR group was lower than that in the LRR group (median VAS score of 4 in the NOSE-LRR group compared to 5 in the LRR group on the first postoperative day, p\u0026thinsp;=\u0026thinsp;0.004; median VAS score of 2 in the NOSE-LRR group compared to 3 in the LRR group on the third postoperative day, p\u0026thinsp;=\u0026thinsp;0.003). Two patients in the LRR group developed a postoperative wound infection, which did not occur in the NOSE-LRR group (p\u0026thinsp;=\u0026thinsp;0.519). Urinary retention was observed in 1 (5.88%) patient in the NOSE-LRR group and in 2 (7.14%) patients in the LRR group (p\u0026thinsp;=\u0026thinsp;0.868). In our study, urinary catheters were routinely removed on postoperative day 1 for patients who underwent surgery. When patients developed urinary retention, they were treated with tamsulosin and a urinary catheter was reinserted and remained in place for at least 24 hours. Additionally, only 1 patient in the LRR group was readmitted due to surgical complications of incisional hernia after 6 months. There were no cases of postoperative mortality, pulmonary/intra-abdominal infection, ileus or anastomotic leakage/stenosis in either group (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutcomes of the Study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eNOSE-LRR(n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eLRR(n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e/t/Z\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative Time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e150.29\u0026thinsp;\u0026plusmn;\u0026thinsp;11.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e134.18\u0026thinsp;\u0026plusmn;\u0026thinsp;8.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e-4.947\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e46.75\u0026thinsp;\u0026plusmn;\u0026thinsp;5.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e47.76\u0026thinsp;\u0026plusmn;\u0026thinsp;6.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.739\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePostoperative VAS score for pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDay 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDay 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDay 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDay 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDay 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDay 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDay 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDay 3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(3\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5(4\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3(2\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.858\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-2.990\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDays of hospital stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e7(6\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e9(7\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e24.366\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResection length\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e16.71\u0026thinsp;\u0026plusmn;\u0026thinsp;5.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e17.39\u0026thinsp;\u0026plusmn;\u0026thinsp;5.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.041\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.840\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary retention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1(5.88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e2(7.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.868\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e2(7.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e1.243\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.519\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisional hernia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e1(3.57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.607\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.622\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe preoperative and postoperative median WCSs decreased from 9 (2\u0026ndash;22) to 3 (1\u0026ndash;10) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in the NOSE-LRR group and from 11.5 (2\u0026ndash;25) to 2 (1\u0026ndash;10) in the LRR group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The preoperative and postoperative median WISs decreased from 4 (1\u0026ndash;11) to 2 (0\u0026ndash;5) in the NOSE-LRR group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and from 4 (1\u0026ndash;13) to 1 (0\u0026ndash;6) in the LRR group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). None of the patients in either group showed increasing constipation and fecal incontinence or new-onset constipation and fecal incontinence postoperatively. Prolapse disappeared in all patients after surgery (Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative and Postoperative Wexner Incontinence Score (WIS)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNOSE-LRR(n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLRR(n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eZ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative WCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(2\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.5(2\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.981\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative WCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(1\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(1\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.489\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.625\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-3.626\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-4.630\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative and Postoperative Wexner Constipation Score (WCS)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNOSE-LRR(n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLRR(n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eZ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative WIS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(1\u0026ndash;11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(1\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.887\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative WIS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.347\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.728\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-3.636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-4.648\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAccording to adequate clinical evaluation and examination, there are various surgical methods for the treatment of CRP. Unfortunately, there is no generally accepted standard technique that can mitigate all clinical concerns, and the curative effect is affected by many factors, such as the patient's age, weight, medical history, and rectal prolapse stage. With the continuous progress and popularity of laparoscopic technology, minimally invasive surgery has become the main surgical treatment for colorectal diseases. LRR is a common and effective treatment option for CRP in the USA [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, LRR requires an auxiliary incision measuring 4\u0026ndash;8 cm in length to be made on the lower abdominal wall to remove specimens and to place the anvil into the proximal end of the sigmoid colon lumen outside the abdominal cavity. Regrettably, the presence of this abdominal incision offsets some of the minimally invasive effects. With the aim of reducing access trauma, as a new method, the NOSE technique allows removal of the specimen through the natural lumen and complete reconstruction of the digestive tract in the abdominal cavity, thereby reducing surgical trauma and emphasizing its advantages over conventional laparoscopic surgery [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In the present study, we described a novel LRR procedure for CRP, which was combined with the transrectal NOSE method, and we aimed to evaluate the outcomes of the NOSE-LRR and LRR surgical approaches for the treatment of CRP. To our knowledge, this series is the first retrospective comparison of patients who underwent NOSE-LRR and LRR in China.\u003c/p\u003e \u003cp\u003eIn our study, most patients were middle-aged, with 12 (26.67%) patients over age 60. The high proportion of male patients in the present study is most likely related to the high prevalence of colorectal diseases in male patients in China [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The incidence of these diseases has gradually increased in recent years [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Additionally, a review of the literature suggested that NOSE has a longer operative time and causes less intraoperative bleeding [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], mostly due to the cumbersome steps and complex nature of the NOSE method and its minimal invasiveness. However, our results presented here show that there was no significant difference between the two groups of patients in terms of intraoperative bleeding volume, but a significant difference in the operation time was indeed observed. The NOSE procedure tends to be more time consuming than the conventional method. Compared with LRR, the NOSE technique combined with LRR does have increased intraoperative risks and is a difficult procedure, especially when the anvil is inserted through the sigmoid transanally. After adequate training, our colorectal surgeons continued to become experienced in sigmoidectomy with transanal specimen removal. We speculated that the operative time of the NOSE procedure may be further shortened and that the intraoperative bleeding volume may be further reduced.\u003c/p\u003e \u003cp\u003eThe median postoperative hospital stay is an important measure for assessing and comparing patient recovery and was significantly shorter in the NOSE-LRR group. The studies by Stevenson et al. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and Sezai et al. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] reported that the median length of hospital stay of patients with rectal prolapse was approximately 5 or 6 days after LRR surgery, which was 7 days in our study. Many previous studies also reported that patients who underwent the NOSE procedure had shorter hospital stays than did those who underwent conventional laparoscopy [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], which is similar to our study's findings. In contrast, several other studies have shown no difference in the length of postoperative hospital stay between laparoscopic surgery and conventional surgery [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. This discrepancy may be related to different types of colorectal diseases, heterogeneity in operative technique and similar recovery pathways in different hospitals. Thus, whether the NOSE technique can significantly shorten the hospitalization time of patients who undergo colorectal surgery requires further confirmation in higher-quality randomized controlled trials. Moreover, the median degree of pain on the first and third postoperative days was lower in the NOSE-LRR group than in the LRR group. This outcome is in line with earlier studies in which less pain was reported and/or fewer analgesics were needed in patients with benign or malignant colorectal diseases who underwent NOSE surgery than in patients who underwent conventional specimen extraction [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The reasons for this result were that there was no auxiliary incision on the abdominal wall and only a few small trocar punctures remained. Enterotomy and bowel reconstruction were completed intraperitoneally, and the interference of the pelvic organs and nerves was minimized. Given that pain relief effectively reduces the psychological burden of patients and promotes adequate sleep and early ambulation, consequently, the NOSE method is beneficial for promoting patients' early recovery.\u003c/p\u003e \u003cp\u003eIn previous research, Karagul et al. [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] emphasized that the length of the specimen contributes to the feasibility of NOSE. They evaluated the factors affecting failure in patients who were scheduled for NOSE in laparoscopic colorectal resections. The results of this study demonstrated that the length of the resected bowel in the failed NOSE group (36.5\u0026thinsp;\u0026plusmn;\u0026thinsp;27.6 cm) was significantly greater than that in the successful NOSE group (21.2\u0026thinsp;\u0026plusmn;\u0026thinsp;19.4 cm). Therefore, they inferred that the use of specimens with smaller diameters increased the success rate of NOSE. However, in this study, we measured the resection length of the rectal prolapse, and there were no statistically significant differences between the two groups (16.71\u0026thinsp;\u0026plusmn;\u0026thinsp;5.34 cm in the NOSE-LRR group, 17.39\u0026thinsp;\u0026plusmn;\u0026thinsp;5.47 cm in the LRR group), and there were no instances of NOSE failure. In contrast to that in large-scale colectomy surgery, the length of the resected bowel in NOSE-LRR is relatively shorter, and the specimen is easier to remove transanally; thus, we believe that this technique will not affect the NOSE success rate in our study. As rectal prolapse is considered a benign colorectal disease, the NOSE success rate is not influenced by factors such as tumor size, shape, or location. Nevertheless, specimen width also appears to be an important factor in the feasibility of NOSE, which was not analyzed in the present study, and whether specimen width affects the feasibility of the NOSE for CRP must be assessed in future research. This experience may aid in the selection of suitable CRP patients for NOSE.\u003c/p\u003e \u003cp\u003eRegarding postoperative complications, in the conventional laparoscopic surgery group, 2 patients had an incision infection, and 1 patient had an incision hernia, while, in the NOSE group, no patients had surgical complications. This is because the NOSE method does not require an auxiliary incision for the removal of abdominal wall specimens, which decreases the risks of postoperative abdominal incision infection and incision hernia. Perhaps due to the small sample size in our study, there was no significant difference in the incidence of postoperative complications between the two groups. Previous long-term outcome studies, however, revealed that patients in the NOSE group had a significantly lower rate of postoperative complications than did those in the conventional laparoscopic colorectal surgery group, which aligns with the trend of our research findings [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition, there was 1 case of urinary retention in the NOSE group and 2 cases of urinary retention in the conventional laparoscopic surgery group, but no catheter-associated urinary tract infection existed in either group. These 3 patients were elderly males with a history of benign prostatic hyperplasia. After treatment with tamsulosin and retention of a urinary catheter for at least 24 hours, the symptoms of urinary retention were significantly relieved. Interestingly, Kin et al. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] have proposed that the practice of earlier urinary catheter removal must be balanced with fluid volume and operative time to avoid high urinary retention rates, while age, sex, and preoperative prostatism are not related to an increased rate of postoperative urinary retention. In our study, there were 2 other patients with preoperative prostatism in the NOSE-LRR group and 2 patients in the LRR group, but no postoperative urinary retention was observed in these patients. Therefore, we speculated that preoperative prostatism may not be a key factor leading to postoperative urinary retention. However, these 3 patients who survived surgery all received an average of 2.5 L of intravenous fluid during the operation and 2.4 L on the first postoperative day, which was significantly greater than that of the other patients. Consequently, we believe that a large volume of fluid is associated with urinary retention, which should be avoided in subsequent perioperative patient management, while operative time is also a factor that needs to be considered, although no significant difference in operative time was observed between urinary retention patients and others in the present study due to the small number of retention cases.\u003c/p\u003e \u003cp\u003eNotably, the potential for bacterial contamination during NOSE surgery has always been a concern. Leroy et al. [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] reported that the NOSE method increased the risk of intraperitoneal bacterial contamination in patients because of the breach of peritoneal sterility in some procedures, which was confirmed by both routine bacterial culture and direct bacteriological examination. In contrast, some experts believe that the postoperative intra-abdominal abscess rate after NOSE surgery is not significantly higher than that after conventional laparoscopic colorectal resection [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. In our study, there were no cases of pulmonary or intra-abdominal infection reported in either group. According to the recommendations of the international consensus on NOSE surgery for colorectal cancer and combined with our experience, we believe that preoperative bowel preparation, reasonable administration of prophylactic antibiotics, correct use of sterile plastic sleeve and iodophor gauze, intraoperative transanal lavage with a large amount of dilute iodophor, and proper placement of abdominal or pelvic drainage tubes are all effective measures that can reduce the risk of postoperative intra-abdominal infection [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, anastomotic leakage or stenosis represents serious postoperative complications. Previous studies on LRR have reported a low incidence of anastomotic leakage [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. However, in our study, no instances of anastomotic leakage or stenosis were observed in either group. Another study conducted by Kellokumpu et al. [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] reported the same functional outcomes for both LRR and laparoscopic sutured rectopexy. Moreover, Formijne et al. [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] also found the same benefit in terms of postoperative improvement of constipation and continence with LRR and laparoscopic ventral rectopexy. For this reason, Panis [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] suggested that there is no need for anastomotic leakage to occur during rectosigmoid resection and colorectal anastomosis and that there is no need to make an auxiliary abdominal incision. However, the current appropriate use of staplers by proficient surgeons has the potential to significantly mitigate the occurrence of postoperative anastomotic leakage and stenosis and substantially provide good surgical results, thus alleviating concerns regarding this issue.\u003c/p\u003e \u003cp\u003eComplete resolution of prolapse following surgical intervention was also found in all patients, as well as significant improvements in fecal incontinence and constipation after surgery for CRP within both groups. The results of a prospective study including 154 patients who underwent LRR suggested the benefits of LRR for rectal prolapse both in younger and elderly patients, of whom the symptoms of incontinence (64.6%) and constipation (77.8%) were also significantly improved after the operation [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Compared to other surgical strategies, we speculated that reasons why LRR effectively relieves symptoms of CRP are as follows: first, compared with laparoscopic rectopexy, LRR can significantly relieve constipation symptoms in patients because part of the rectum and/or the lengthy sigmoid colon is removed so that there is no redundant intestinal canal, thereby avoiding intestinal obstruction. Second, compared with sigmoidectomy, LRR restores the physiological curvature because the rectum is fixed to the presacral fascia with sutures, thus reducing the possibility of postoperative recurrence and intussusception. Third, LRR can cure defects in the intestine without the need for mesh implantation, reducing the incidences of postoperative infection, recurrence, mesh erosion and rejection reactions and eliminating potential intestinal symptoms such as constipation and even obstruction caused by folding and mesh implantation. In our study, there were no statistically significant differences observed in terms of symptoms of fecal incontinence or constipation between the LRR and NOSE-LRR groups before and after surgery, respectively. This finding suggests that the NOSE method has no negative impact on the favorable outcome of LRR treatment for CRP and is accompanied by a low incidence of postoperative complications; therefore, both methods appear to be equally safe and effective.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, considering that CRP is a rare disease, this was a single-center retrospective study with a small sample size. More reliable conclusions must be drawn from large multicenter case series and randomized controlled trials to avoid possible selection bias. Second, in our study, there were no recurrences in either group, which was probably due to the short follow-up time; hence, longer follow-up is required in further research. Third, some other auxiliary measurements were not used in our study, such as anal manometry, electromyography, urodynamic, and colonic transit time, which can be used to assess anal sphincter structure and function and identify other possible pathologies associated with CRP. These tests should be performed selectively in future research to refine the diagnosis and provide patients with a more comprehensive assessment before surgery because this may change the surgical plan.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, our study demonstrated that LRR with NOSE is a feasible and safe procedure for treating CRP and is therefore worthy of clinical implementation. The procedure has a low rate of complications and good cosmetic effect and may be superior to conventional LRR in terms of postoperative pain and length of hospital stay.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by\u0026nbsp;the Henan Medical Science and Technology Research Project (No. SB201903034).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe requirement for informed consent was waived because of the retrospective study design.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData availability\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated or analyzed during the study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthor contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChunxu Zhang conceived and designed the study. Shihan Chen collected the data and wrote the manuscript. Yanyang Liang, Ruixue Tang, Jixin Zhang and Shouxin Yuan analyzed and interpreted the data. Shuang Xie critically read the manuscript. Quanhui Wang and Chunxu Zhang supervised the study and revised the paper. All authors approved the final version of the article to be published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Boards of the 988th Hospital of Joint Logistics Support Force of the Chinese People's Liberation Army (study number 988YY20230024LLSP).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding authors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePlease forward correspondence to Quanhui Wang or\u0026nbsp;Chunxu Zhang.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eShihan Chen and Yanyang Liang contributed equally to this work and should be considered co-first authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHotouras A, Murphy J, Boyle DJ, Allison M, Williams NS, Chan CL (2013) Assessment of female patients with rectal intussusception and prolapse: is this a progressive spectrum of disease? 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Front Oncol 9:597. https://doi.org/10.3389/fonc.2019.00597\u003c/li\u003e\n\u003cli\u003ePark JS, Kang H, Park SY, Kim HJ, Lee IT, Choi GS (2018) Long-term outcomes after natural orifice specimen extraction versus conventional laparoscopy-assisted surgery for rectal cancer: a matched case-control study. Ann Surg Treat Res 94:26\u0026ndash;35. https://doi.org/10.4174/astr.2018.94.1.26\u003c/li\u003e\n\u003cli\u003eGuan X, Liu Z, Longo A, et al (2019) International consensus on natural orifice specimen extraction surgery (NOSES) for colorectal cancer. Gastroenterol Rep (Oxf) 7:24\u0026ndash;31. https://doi.org/10.1093/gastro/goy055\u003c/li\u003e\n\u003cli\u003eLaubert T, Bader FG, Kleemann M, Esnaashari H, Bouchard R, Hildebrand P, Schl\u0026ouml;ricke E, Bruch HP, Roblick UJ (2012) Outcome analysis of elderly patients undergoing laparoscopic resection rectopexy for rectal prolapse. Int J Colorectal Dis 27:789\u0026ndash;795. https://doi.org/10.1007/s00384-011-1395-1\u003c/li\u003e\n\u003cli\u003eAshari LH, Lumley JW, Stevenson AR, Stitz RW (2005) Laparoscopically-assisted resection rectopexy for rectal prolapse: ten years\u0026apos; experience. Dis Colon Rectum 48:982\u0026ndash;987. https://doi.org/10.1007/s10350-004-0886-3\u003c/li\u003e\n\u003cli\u003eKellokumpu IH, Vironen J, Scheinin T (2000) Laparoscopic repair of rectal prolapse: a prospective study evaluating surgical outcome and changes in symptoms and bowel function. Surg Endosc 14:634\u0026ndash;640. https://doi.org/10.1007/s004640000017\u003c/li\u003e\n\u003cli\u003eJonkers HAF, Maya A, Draaisma WA, Bemelman WA, Broeders IA, Consten EC, Wexner SD (2014) Laparoscopic resection rectopexy versus laparoscopic ventral rectopexy for complete rectal prolapse. Tech Coloproctol 18:641\u0026ndash;646. https://doi.org/10.1007/s10151-014-1122-3\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Complete rectal prolapse (CRP), Laparoscopic resection rectopexy (LRR), Natural orifice specimen extraction (NOSE), Clinical efficacy","lastPublishedDoi":"10.21203/rs.3.rs-4575462/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4575462/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003ePurpose\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThere have been few reports that have focused on the combination of the laparoscopic approach and natural orifice specimen extraction (NOSE) surgery for complete rectal prolapse (CRP). The aim of this study was to compare the feasibility, safety and short-term clinical efficacy of NOSE surgery with those of conventional laparoscopic resection rectopexy in the treatment of CRP.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn a group of 45 patients selected between January 2019 and October 2023, 28 patients underwent conventional laparoscopic resection rectopexy (LRR), and 17 patients underwent transanal NOSE laparoscopic resection rectopexy (NOSE-LRR). Preoperative and postoperative clinical variables of the two groups of patients were compared and analyzed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe mean operation time was longer in the NOSE-LRR group than in the LRR group (150.29 min versus 134.18 min, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The NOSE-LRR group had less postoperative pain than did the LRR group (median VAS score of 4 versus 5 on the first day after surgery, p\u0026thinsp;=\u0026thinsp;0.004; median VAS score of 2 versus 3 on the third day after surgery, p\u0026thinsp;=\u0026thinsp;0.003). The median length of hospital stay was significantly shorter in the NOSE-LRR group (7 days versus 9 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A significant reduction in the incontinence score and constipation score was observed in both groups after surgery (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, there was no significant difference in the postoperative constipation score or incontinence score between the two groups.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eLRR combined with the NOSE technique leads to a shorter length of hospital stay and less postoperative pain in patients with CRP than in patients who undergo traditional LRR but with a longer operation time. The novel NOSE method is feasible and safe for use in patients with CRP.\u003c/p\u003e","manuscriptTitle":"The feasibility, safety and short-term clinical efficacy of laparoscopic resection rectopexy with natural orifice specimen extraction surgery for the treatment of complete rectal prolapse","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-12 18:38:23","doi":"10.21203/rs.3.rs-4575462/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4fb9c420-1ddd-4948-b4c2-933690982be7","owner":[],"postedDate":"July 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-13T05:08:22+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-12 18:38:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4575462","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4575462","identity":"rs-4575462","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}