The Negative Impact of Stapled Transanal Rectal Resection Procedure in Patients Who Underwent Surgery for Recurrence of Internal Rectal Prolapse, Rectocele and Obstructed Defecation Syndrome: Results of a Long-Term Single-Center Experience

The Negative Impact of Stapled Transanal Rectal Resection Procedure in Patients Who Underwent Surgery for Recurrence of Internal Rectal Prolapse, Rectocele and Obstructed Defecation Syndrome: Results of a Long-Term Single-Center Experience | 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 Negative Impact of Stapled Transanal Rectal Resection Procedure in Patients Who Underwent Surgery for Recurrence of Internal Rectal Prolapse, Rectocele and Obstructed Defecation Syndrome: Results of a Long-Term Single-Center Experience Angelo Alessandro Marra, Claudia Varrella, Cesare Caruso, Ilaria Simonelli, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8359988/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 Background Although Stapled Trans-Anal Rectal Resection (STARR) was initially met with significant enthusiasm in the treatment of internal rectal prolapse (IRP), rectocele, and obstructed defecation syndrome (ODS), growing evidence has raised concerns about its long-term efficacy and the risk of serious complications. The aim of the study was to analyze patients who underwent surgery for IRP, rectocele, and ODS recurrence following STARR procedure. Methods Patients who underwent abdominal and perineal surgery for IRP with/without rectocele and entero/sigmoidocele between November 1998 and January 2025 were included. Those previously treated with STARR were specifically analyzed. Baseline clinical and radiological characteristics, surgical complexity related to STARR suture, complications, recurrence, ODS and fecal incontinence scores were collected. Results Out of 376 patients, 50 females (13.3%) with previous STARR surgery underwent surgery for IRP, rectocele, and ODS recurrence. At defecography, IRP and rectocele were both detected in 42 of the 50 STARR patients [84.0%, median rectocele size: 40(28–50) mm]. Entero/sigmoidocele was found in 33 cases (66.0%). Forty-five patients had abdominal procedures and five underwent perineal techniques. STARR suture could not be safely overcome in three cases. At a median follow-up of 53(14–115) months, recurrence occurred in 5.9% of cases, with comparable rates in both groups (4.8% vs. 6.1%). One patient experienced persistent chronic pelvic pain due to STARR suture despite anatomical correction. Overall, ODS and fecal incontinence scores significantly improved; however, patients with prior STARR showed higher preoperative and postoperative ODS scores. Conclusions Surgery for IRP, rectocele, and ODS recurrence after STARR is feasible but challenging. Long-term results showed that previous STARR is linked to more severe ODS symptoms and less functional improvement. STARR could be unsuccessful and complicate further surgeries. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 INTRODUCTION The Stapled Trans-Anal Rectal Resection (STARR) procedure is an evolution of the Procedure for Prolapse and Hemorrhoids (PPH) technique, introduced by Longo in 1998 for the treatment of hemorrhoidal prolapse [ 1 , 2 ]. Although these procedures share similar rationale, STARR was conceptually developed as a minimally invasive transanal procedure aimed at correcting not only hemorrhoidal disease, but also anatomical rectal abnormalities such as internal rectal prolapse (IRP) and rectocele, which are associated with symptoms of obstructed defecation syndrome (ODS) [ 3 , 4 ]. Specifically, it involves a double hemi-circumferential transanal resection of the rectal wall using a surgical stapling device designed to remove a greater amount of rectal tissue than the PPH technique, with the goal of restoring anorectal anatomy and improving evacuation. Over time, several modifications have been described in the literature [ 5 , 6 ], including the trans-STARR procedure, which was developed to enable a more extensive, tailored, circumferential correction of IRP under continuous visual control using a Contour stapler [ 7 ]. Although STARR was initially welcomed with considerable enthusiasm for its feasibility and good short-term results in term of reduced pain, shorter length of hospital stays, and a quicker return to work [ 4 , 8 , 9 ], further evidence has increasingly raised concerns about its safety profile, long-term efficacy, and risk of serious complications including bleeding, fecal urgency and incontinence, persistent anorectal pain, stenosis, rectovaginal fistula, pelvic sepsis, and the need for reoperation [ 9 – 15 ]. As a result, several other surgical techniques including abdominal surgery have been explored over time for the management of patients with IRP, rectocele, and ODS. Among these, Ventral Mesh Rectopexy (VMR) has gained growing clinical and scientific interest due to its ability to simultaneously correct other anatomical abnormalities of the posterior compartment, such as enterocele, as well as those of the anterior and middle compartments when combined with other surgical procedures [ 16 – 18 ]. However, when other surgical techniques are performed following any type of the STARR procedure, it is commonly recognized that the operation could be more technically challenging and potentially riskier [ 19 ]. Additionally, the impact of STARR procedures on cases of IRP or rectocele recurrence has rarely been evaluated [ 19 – 21 ]. Therefore, this study aimed to analyze the characteristics and outcomes of patients who underwent surgery for IRP, rectocele, and ODS within our long-term follow-up database, with a particular focus on those who had previously undergone a STARR procedure at other centers. METHODS Study design A prospective single-center observational study was conducted on patients who underwent abdominal and perineal surgery for external rectal prolapse (ERP) and IRP, with or without rectocele and entero/sigmoidocele, at our tertiary academic center from November 1998 to January 2025. Patients who had previously undergone a STARR procedure at other centers and presented with recurrence of IRP, rectocele, and ODS were specifically evaluated. In particular, for this study, exclusion criteria included ERP, malignancies under treatment, inflammatory bowel disease, chronic diarrhea unresponsive to medical treatment, pregnancy, and inability to give written informed consent. The study was approved by the Ethical Committee of our institution (ID 6120), and written informed consent was obtained from each patient. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement for cohort studies was followed [ 22 ]. Data assessment Overall, patients’ baseline characteristics were systematically recorded, including demographic data, comorbidities (described according to the ASA classification), history of abdominal and perineal surgeries (such as hysterectomy, colonic resection, rectal prolapse surgery), vaginal delivery (including episiotomy and obstetric anal sphincter injury), cesarean section, preoperative anxiety and depression, ODS, fecal (FI) and urinary incontinence (UI) symptoms, sexual dysfunction, previous pelvic floor rehabilitation, pelvic trauma/radiotherapy. Clinical and radiological findings were also collected, including evacuation proctography or MRI-defecography imaging, colonic transit time, endoanal ultrasound, anorectal manometry, and colonoscopy when performed. After a comprehensive preoperative evaluation, surgical indications were discussed by a multidisciplinary team comprising proctologists, urogynecologists, gastroenterologists, and radiologists. Over time, several abdominal and perineal techniques were adopted for the treatment of IRP, rectocele, and ODS, depending on the surgeon’s experience and preference. Among the abdominal procedures (performed either through open or minimally invasive approaches) were VMR, in which the mesh is fixed distally to the ventral aspect of the rectum (after anterior rectovaginal dissection) and proximally to the sacral promontory; the Orr-Loygue procedure, involving extensive posterior rectal mobilization with distal mesh fixation to the ventral rectum and proximal anchoring to the sacral promontory; and the Frickman-Goldberg procedure, consisting of sigmoidectomy with suture rectopexy at the sacral promontory. During VMR, two radiopaque clips were placed at the most distal edge of the mesh on the ventral rectal wall, two clips at the level of the mesh’s proximal fixation over the rectum, two additional clips on the mesh at the sacral promontory, one further clip on the sacral periosteum and another on the perineal body. This technical modification was introduced to enable the subsequent radiographic assessment of the mesh position during follow-up, especially in cases of suspected mesh detachment. Conversely, the perineal procedure included the internal Delorme’s technique, involving mucosectomy of the redundant rectal mucosa and plication of the muscular layer; and transvaginal rectocele repair, where the rectal protrusion into the rectovaginal septum is reduced by horizontal plication sutures. No STARR procedures were performed at our center. All surgical procedures were performed by the same experienced colorectal surgeon (C.R.). Among patients who underwent surgery for IRP, rectocele, and ODS following any type of STARR procedures, surgical complexity related to the STARR suture was documented. Postoperative complications and recurrence of IRP and rectocele were recorded at the last patient’s follow-up visit. Validated Patient-Reported Outcome Measures (PROMs) were collected to evaluate ODS and FI symptoms before and after surgery, at the last clinical or telephone follow-up visit. Specifically, ODS severity was assessed with the Altomare ODS score [ 23 ], while FI symptoms were evaluated using the Cleveland Clinic Fecal Incontinence (CCFI) score [ 24 ]. Statistical analysis Categorical data were reported as frequencies and percentages, while continuous variables were shown using mean and standard deviation or median and interquartile range (IQR, 25th -75th percentile). Association between categorical variables was assessed by chi-square test. Due to non-normal distributions, differences in continuous variables among two groups were analyzed performing non-parametric Mann U-Whitney test; parametric T-test was used only for evaluating difference among STARR and no STARR group in age. Differences in pre- and postoperative continuous data were evaluated using the Wilcoxon signed-rank test. Patients with missing data were excluded from the analysis. A p-value < 0.05 was considered statistically significant. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp, Armonk, NY, USA). RESULTS Over the study period, 62 out of 475 (13.1%; 58 females) patients had a history of STARR surgery for ERP and IRP with or without rectocele and entero/sigmoidocele, including 48 who underwent STARR-like procedures, 12 who underwent PPH-like procedures, and 2 who underwent both. Among patients who only had surgery for recurrence of IRP, rectocele, and ODS, 50 (13.3%; all females) patients had a history of 40 with STARR-like procedures, 8 with PPH-like procedures, and notably, 2 with both procedures. Preoperative clinical and radiological assessments Baseline characteristics are summarized in Table 1 . Data regarding preoperative evacuation proctography or MRI defecography are described in Table 2 . Focusing on the STARR group, it is notable that IRP was still detected in 42 out of 50 (84.0%) patients, with 14 (28%) exhibiting intrarectal and 28 (56%) intra-anal intussusceptions. Similarly, rectocele recurrence was found in 42 out of 50 (84.0%) cases, with a median size of 40 (IQR:28–50) mm. Additionally, residual mucosal prolapse was observed in 21 (42.0%) patients who underwent STARR surgery, while entero/sigmoidocele was found in 33 (66.0%) cases, as shown in Fig. 1 . Compared to the rest of the cohort, the STARR group showed a higher prevalence of intra-anal intussusception (non-STARR group 139 cases, 42.6%; chi-square test p < 0.001) and mucosal prolapse (non-STARR group 76 cases, 23.5%; chi-square test p = 0.008), whereas intrarectal intussusception and rectocele were more commonly detected in the non-STARR group. No significant differences were observed across the other variables. Table 1 Baseline characteristics and clinical data of patients with or without previous Stapled Trans-Anal Rectal Resection procedure who underwent surgery for internal rectal prolapse, rectocele, and obstructed defecation syndrome. * Data are shown as mean (standard deviation); § Data are shown as median (25°-75° percentile). P-values are referred to chi-square test. a p-value is referred to T-test; b p-value is referred to non-parametric Mann-Witney test. STARR = Stapled Trans-Anal Rectal Resection; ASA = American Society of Anesthesiologists; OASIs = Obstetric Anal Sphincter Injuries; PF = pelvic floor. Baseline characteristics STARR group n°(%) non-STARR group n°(%) p-value Sex/Females 50 324 Age, years * 57.8 (11.8) 58.4 (10.7) 0.743 a Age < 40 years 5 (10.0%) 19 (5.9%) 0.267 ASA 3 9 (18.0%) 30 (9.3%) 0.107 Anxiety/depression 20 (40.0%) 91 (28.1%) 0.204 Hysterectomy 14 (28.0%) 93 (28.7%) 0.918 Pelvic trauma/radiotherapy 2 (4.0%) 16 (4.9%) 0.773 Vaginal deliveries 31 (62.0%) 248 (76.5%) 0.028 n° vaginal deliveries § 1 (0–2) 2 (1–2) 0.182 b OASIs 9 (18.0%) 83 (25.6%) 0.249 Episiotomy 21 (42.0%) 151 (46.6%) 0.559 Forceps/vacuum 4 (8.0%) 22 (6.8%) 0.747 Cesarean section 9 (18.0%) 68 (21.0%) 0.637 PF rehabilitation 13 (26.0%) 46 (14.2%) 0.073 Slow colonic transit 10 (20.0%) 39 (11.7%) 0.181 Table 2 Data regarding preoperative evacuation proctography or MRI defecography of patients with or without previous Stapled Trans-Anal Rectal Resection who underwent surgery for internal rectal prolapse, rectocele, and obstructed defecation syndrome. * Data are shown as median (25°-75° percentile). P-values are referred to chi-square test. a p value is referred to non-parametric Mann-Witney test. STARR = Stapled Trans-Anal Rectal Resection; MRI = Magnetic Resonance Imaging. Preoperative defecographic data STARR group n°(%) non-STARR group n°(%) p-value Sex, Females 49 (98.0%) 308 (95.1%) 0.353 MRI defecography 8 (16.0%) 32 (9.9%) 0.412 Incomplete rectal empty 23 (46.0%) 153 (47.2%) 0.722 Dyssynergia 11 (22.0%) 52 (16.0%) 0.342 Perineal descendant 31 (62.0%) 197 (60.8%) 0.925 Perineal descendant (mm)* 60 (50–65) 55 (50–60) 0.456 a Rectocele 42 (84.0%) 293 (90.4%) 0.037 Rectocele (mm)* 40 (28–50) 45 (38–50) 0.012 a Rectocele empty 5 (10.0%) 19 (5.9%) 0.296 Intrarectal intussusception 14 (28.0%) 126 (38.9%) < 0.001 Intra-anal intussusception 28 (56.0%) 139 (42.6%) Mucosal prolapse 21 (42.0%) 76 (23.5%) 0.008 Entero/sigmoido/peritoneocele 33 (66.0%) 176 (54.3%) 0.122 Colpohysterocele 21 (42.0%) 133 (41.0%) 0.937 Cystocele 23 (46.0%) 139 (42.9%) 0.864 Surgical details and postoperative outcomes Overall, among abdominal approaches, 265 VMR were performed, along with 26 Orr-Loygue and 4 Frickman-Goldberg procedures. Perineal approaches included 68 transvaginal rectocele repairs and 13 internal Delorme’s procedures over time. Considering the STARR group, 45 patients underwent abdominal surgery (41 VMR, 2 Orr-Loygue, and 2 Frykman-Goldberg procedures), while perineal surgery was performed in 5 patients (4 transvaginal rectocele repairs and 1 internal Delorme’s procedure). Although in most cases the STARR suture was successfully overcome during the rectovaginal dissection (as documented by postoperative X-ray, Fig. 2 ), this was not possible in 3 patients (2 undergoing VMR and one undergoing transvaginal rectocele repair) due to the technical complexity and an increased risk of rectovaginal injury (Fig. 3 ). Overall, 287 out of 475 patients completed the questionnaires at last clinical or telephone follow-up visit, including 42 in the STARR group and 245 in the non-STARR group. Six patients in the non-STARR group had died from unrelated causes. The median follow-up was 53 (IQR:14–115) months; there was no significant difference between the two groups (53, IQR:21.25–90.25 versus 53, IQR:13.75-123.25 months in the STARR group versus non-STARR group, Mann-Whitney p = 0.502). A total of 17 (5.9%) recurrences of IRP and rectocele were documented by postoperative clinical and defecographic evaluation: 2 (4.8%) in patients who previously underwent any type of STARR and 15 (6.1%) in those without previous STARR. Among these, 2 and 11 patients in the STARR and non-STARR groups underwent further surgery for recurrent IRP or rectocele, respectively. In one patient with a history of STARR surgery, chronic pelvic pain due to stapled suture persisted despite surgery having corrected the anatomy of the posterior compartment. Overall, Altomare ODS and CCFI scores showed a statistically significant reduction after surgery (16.4 ± 6.0 versus 9.6 ± 6.7, and 3.8 ± 5.0 versus 1.5 ± 3.9, respectively, Mann-Whitney p < 0.001), even in patients with a history of STARR surgery (18.3 ± 7.0 versus 12.4 ± 8.0, and 3.3 ± 3.8 versus 0.5 ± 2.4, Mann-Whitney p < 0.001 and p = 0.001, respectively, Fig. 4 ). The comparison of PROMs for ODS and FI between the STARR and non-STARR groups is reported in Fig. 5 . As shown, patients who previously underwent any type of STARR showed higher preoperative Altomare ODS score compared to other patients (18.3 ± 7.0 in the STARR group versus 16.0 ± 5.8 in the non-STARR group, Mann-Whitney p = 0.022). Similarly, postoperatively, the Altomare ODS score remained significantly worse in the STARR group (12.4 ± 8.0 in the STARR group versus 9.3 ± 6.5 in the non-STARR group, Mann-Whitney p = 0.041). No differences were observed in overall satisfaction after surgery (6.9 ± 3.3 in the STARR group versus 7.3 ± 2.9 in the non-STARR group, Mann-Whitney p = 0.629). DISCUSSION Following its introduction in 2004, the STARR technique was enthusiastically adopted, as it was believed to address multiple posterior compartment disorders using a comprehensive, minimally invasive, and painless approach with quick postoperative recovery [ 9 ]. Over time, its initial indications progressively expanded, being initially adopted for hemorrhoidal disease and, then, for more serious conditions such as IRP, rectocele, and ODS. Furthermore, there has been speculation about its use for treating ERP [ 25 ]. However, early enthusiasm was soon dampened by increasing criticism, mainly due to higher rates of severe, sometimes life-threatening complications, along with high recurrence rates, partly caused by inadequate training and limited surgical expertise [11,26–28]. Consequently, some surgeons have gradually phased out the procedure in clinical practice [ 20 ], although it continues to be used in many countries worldwide, including Italy. Moreover, the actual effect of the STARR procedure on rectal function related to defecation has not been clearly determined [ 20 , 21 , 29 ]. The technique has been associated with a significant risk of both anatomical and functional changes in the middle and posterior pelvic regions. These can include rectal deformity, reduced rectal compliance, and the effects of a “full-thickness” excision, which are worsened by scar tissue formation [ 2 , 10 , 30 , 31 ]. Nevertheless, it is important to emphasize that the stapled resection of the rectum was initially described as involving only mucosal and submucosal resection of the rectum. However, subsequent histopathological studies revealed the presence of muscular fibers in more than 90% of surgical specimens, indicating that the actual resection was much more extensive than initially thought and raised significant concerns about its potential impact on rectal function [ 9 , 31 , 32 ]. Similarly, the idea of removing additional rectal tissue, including the muscular layer as performed in STARR-like procedures, to excise redundant tissue in IRP, reduce rectocele, and improve ODS symptoms, has not consistently translated into consistent postoperative outcomes [ 33 , 34 ]. This is particularly relevant when considering both the potential effects of stapled scarring on rectal function and the risk of complications previously discussed, mainly in patients who have undergone both PPH and STARR procedures. Moreover, even in the hands of surgeons experienced in rectal prolapse surgery, operating through a stapled-line scar often entails a considerable intraoperative risk of rectal injury, which may have disastrous consequences and potentially preclude further surgical intervention. Therefore, we strongly recommend that this risk be thoroughly discussed during preoperative counseling. Indeed, as observed in our long-term experience in the surgical management of IRP, rectocele, and ODS, any type of STARR procedure still carries a significant risk of recurrence of posterior compartment abnormalities, which, in some cases, requires additional surgery over time [ 35 , 36 ]. Symptomatic recurrences are often due to inappropriate indications for the STARR procedure, such as the presence of an enterocele [ 26 ]. Notably, in our group of patients who previously underwent STARR surgery, about 66% also showed an enterocele. This poses a substantial risk for surgeons performing STARR in these patients, as intestinal loops of the enterocele may become trapped within the stapled suture, leading to severe consequences, including the entero-vaginal fistula and the need to create a stoma. Some surgeons have recommended using an intraoperative Trendelenburg position or combining the procedure with laparoscopic abdominal assistance to reduce this risk [ 34 , 37 ]. However, a different surgical approach should ideally be used to treat the enterocele itself. In such cases, we suggest reevaluating the indications for surgery, possibly opting primarily for an abdominal approach that can offer more comprehensive treatment, addressing multiple compartments (anterior and middle) simultaneously. Recurrences of IRP, rectocele, and ODS after STARR are often linked to symptoms that are difficult to treat or, in some cases are not treatable at all, such as chronic pain, urgency, tenesmus, fecal incontinence [ 12 , 26 ]. For example, in our series, one patient experienced persistent chronic pelvic pain that could not be resolved even with an additional surgical procedure aimed at restoring rectal anatomy. This aspect should be carefully considered during preoperative counseling of patients with symptom recurrence after STARR procedures. The analysis of symptom severity collected through PROMs revealed that patients who had previous STARR-like procedures experienced greater severity of preoperative and postoperative ODS symptoms compared to the non-STARR group. Likewise, the severity of FI symptoms was also significant. Several factors may account for these findings. First, rectal function and its changes can vary considerably among patients with ODS. A major current limitation in rectal prolapse surgery is the lack of tests that can directly assess rectal function. Some colleagues have used indirect tools such as anorectal and colonic manometry, rectal barostats, rectal scintigraphy, and endorectal capsules capable of tracking intestinal movements during defecation [ 38 , 39 ]. However, to date, we are still unable to assess this function comprehensively and concretely. Once such tests are available, it may be possible to directly evaluate the effects of stapled sutures, mesh implants, or rectal prolapse surgery in general on rectal function. Another possible explanation involves the consequences of any STARR procedure, including the presence of inert scar tissue, anastomoses between discontinuous layers of muscular fibers, metallic clips, nerve disruption, or entrapment within the stapled line, and reduced rectal reservoir capacity [ 10 , 19 , 21 , 26 ]. Additionally, as defecation is a highly complex process, other factors, which are often unknown or underestimated, might influence defecatory mechanics [ 40 ]. However, as our data also indicate, STARR procedures not only fail to resolve symptoms or correct anatomical abnormalities but may also complicate postoperative outcomes in patients with IRP, rectocele, and ODS. This study had some limitations. First, all types of STARR techniques were grouped under the term “STARR surgery". This approach could be justified as, over time, various techniques were proposed that often overlapped or were performed in a very similar manner. Additionally, for some patients, it was not possible to fully understand the surgical procedure due to incomplete or inadequate documentation. However, all patients shared a stapled suture line at the rectal level, which could lead to comparable functional outcomes. Another limitation is that this reflects the long-term experience of a single surgeon (C.R.) in rectal prolapse surgery. Nevertheless, the surgeon is highly experienced and has been thoroughly trained in these procedures. It would be valuable to compare our findings with those from other tertiary referral centers for IRP, rectocele, and ODS, perhaps through the development of a multicenter database with standardized data collection, including previous STARR surgeries. Lastly, as previously mentioned, we cannot determine how many of these outcomes are due to the effects of the STARR procedure itself versus the baseline characteristics of patients with ODS, as we currently lack a test to directly assess this. Nonetheless, we believe that if we cannot be certain that STARR intervention is truly effective or definitive, we should consider discontinuing or replacing it, rather than risking further harm to patients. Declarations Funding Statement: No funding was available for this study. Conflict of Interest: All authors have no conflict of interest to declare. Authors contribution: AAM and CR contributed equally to this manuscript. AAM and CR designed and conducted the study, including data analysis. AAM and IS performed statistical analysis. AAM prepared the manuscript draft with important intellectual input from CR. CV, CC, AP, FL, PC and MP conducted patient recruitment and data collection. All authors revised and approved the final manuscript. Data Availability Statement: All data, analytic methods, and study materials used to conduct this research will be made available to any researcher from the corresponding author (CR), upon reasonable request. ACKNOWLEDGMENTS We would like to thank Marisa Notarianni for the English language review. References Longo A (1998) Treatment of hemorrhoidal disease by reduction of mucosa and hemorrhoidal prolapsed with a circular suturing device: a new procedure. In: Proceedings of the 6th World Congress of Endoscopic Surgery. Monduzzi Editore, Bologna, Italy, pp 777–784. Boccasanta P, Venturi M, Stuto A, et al (2004) Stapled transanal rectal resection for outlet obstruction: a prospective, multicenter trial. 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Wadhawan H, Shorthouse AJ, Brown SR (2010) Surgery for obstructed defaecation: does the use of the Contour device (Trans-STARR) improve results? Colorectal Dis 12:885–890. https://doi.org/10.1111/j.1463-1318.2009.01876.x . Boccasanta P, Venturi M, Roviaro G (2007) Stapled transanal rectal resection versus stapled anopexy in the cure of hemorrhoids associated with rectal prolapse. A randomized controlled trial. Int J Colorectal Dis 22:245–251. https://doi.org/10.1007/s00384-006-0196-4 . Ommer A, Rolfs TM, Walz MK (2010) Long-term results of stapled transanal rectal resection (STARR) for obstructive defecation syndrome. Int J Colorectal Dis 25:1287–1292. https://doi.org/10.1007/s00384-010-1042-2 . Meurette G, Wong M, Frampas E, Regenet N, Lehur PA (2011) Anatomical and functional results after stapled transanal rectal resection (STARR) for obstructed defaecation syndrome. Colorectal Dis 13:e6-11. https://doi.org/10.1111/j.1463-1318.2010.02415.x . Reibetanz J, Boenicke L, Kim M, Germer CT, Isbert C (2011) Enterocele is not a contraindication to stapled transanal surgery for outlet obstruction: an analysis of 170 patients. Colorectal Dis 13:e131-136. https://doi.org/10.1111/j.1463-1318.2011.02554.x . Carrington EV, Scott SM, Bharucha A, et al (2018) Expert consensus document: Advances in the evaluation of anorectal function. Nat Rev Gastroenterol Hepatol 15:309–323. https://doi.org/10.1038/nrgastro.2018.27 . Fox MR, Kahrilas PJ, Roman S, et al (2018) Clinical measurement of gastrointestinal motility and function: who, when and which test? Nat Rev Gastroenterol Hepatol 15:568–579. https://doi.org/10.1038/s41575-018-0030-9 . Pescatori M, Spyrou M, Pulvirenti d'Urso A (2006) A prospective evaluation of occult disorders in obstructed defecation using the 'iceberg diagram'. Colorectal Dis 8:785–789. https://doi.org/10.1111/j.1463-1318.2006.01138.x . Tables Table 3 is not available with this version. Table 3. Postoperative complications recorded in patients who underwent surgery for internal rectal prolapse, rectocele, and obstructed defecation syndrome at our Unit. P-value is referred to chi-square test. STARR = Stapled Trans-Anal Rectal Resection. 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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07:55:17","extension":"html","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":122895,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8359988/v1/037a0e9182008ed55e2e97c7.html"},{"id":100366988,"identity":"fdb0acf5-2266-44f0-b4e0-31742ae699e0","added_by":"auto","created_at":"2026-01-16 07:56:43","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47506,"visible":true,"origin":"","legend":"\u003cp\u003eDefecographic snapshot showing a large enterocele (E) compressing the rectum (R) and the rectocele (*), which hinders their emptying. An intra-anal intussusception (indicated by the white arrow, likely at the level of the Stapled Trans-Anal Rectal Resection suture) is also present. \u003cem\u003eE = enterocele; R = rectum; A= anal canal; * = rectocele\u003c/em\u003e.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8359988/v1/35cc873384c0d3bdc78ede4f.jpg"},{"id":100365955,"identity":"d0ceaacc-40fe-4081-adad-84789b9b46a6","added_by":"auto","created_at":"2026-01-16 07:55:46","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":126229,"visible":true,"origin":"","legend":"\u003cp\u003eDuring ventral mesh rectopexy, the Stapled Trans-Anal Rectal Resection suture (indicated by the white arrow) was successfully overcome during rectovaginal dissection, as documented by the postoperative X-ray assessment of radiopaque clips. They were intraoperatively positioned at the level of the sacral promontory (1 clip indicated by the green arrow) and on the mesh (2 clips at the sacral promontory level – yellow arrow, 2 clips at the level of the most proximal pair of sutures on the ventral rectum – orange arrow, and 2 clips at the level of the most distal pair of sutures on the ventral rectum – red arrow, beyond the stapled suture) to allow mesh assessment during the follow up.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8359988/v1/b36ab6953c6c92b77391d14d.jpg"},{"id":100366251,"identity":"6c80ffd1-e344-4a69-b543-0e8ebfb050dd","added_by":"auto","created_at":"2026-01-16 07:56:09","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":133523,"visible":true,"origin":"","legend":"\u003cp\u003eDuring robotic ventral rectopexy, the Stapled Transanal Rectal Resection suture increases the technical complexity of the rectovaginal dissection and the risk of rectal and vaginal injury. In this intraoperative image, a clip of the stapled suture (indicated by the white arrow) can be observed beyond the rectal serosa during the rectovaginal dissection. \u003cem\u003eR = ventral rectum; V = posterior vaginal wall.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8359988/v1/b474599b9d517d78ef70a7b2.jpg"},{"id":100122876,"identity":"c8549470-3b2a-47a4-b58f-23ac240a2d21","added_by":"auto","created_at":"2026-01-13 09:07:23","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":64726,"visible":true,"origin":"","legend":"\u003cp\u003eStatistical comparison between preoperative and postoperative\u003cstrong\u003e \u003c/strong\u003eAltomare Obstructed Defecation Syndrome and Cleveland Clinic Fecal Incontinence scores in patients who underwent surgery for internal rectal prolapse, rectocele, and obstructed defecation syndrome at our Unit, even in patients with a history of Stapled Trans-Anal Rectal Resection. \u003cem\u003eP-values are referred to non-parametric Mann-Witney test. STARR = Stapled Trans-Anal Rectal Resection; ODS = Obstructed Defecation Syndrome; FI = Fecal Incontinence.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8359988/v1/a1f825a6b8b775c1d2c290a7.jpg"},{"id":100122883,"identity":"9f3fc1bd-13dc-4245-9689-25e4d20adc87","added_by":"auto","created_at":"2026-01-13 09:07:23","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":69669,"visible":true,"origin":"","legend":"\u003cp\u003eStatistical comparison between Altomare Obstructed Defecation Syndrome and Cleveland Clinic Fecal Incontinence scores in patients with or without previous Stapled Trans-Anal Rectal Resection procedure who underwent surgery for internal rectal prolapse, rectocele, and obstructed defecation syndrome. \u003cem\u003eP-values are referred to non-parametric Mann-Witney test. STARR = Stapled Trans-Anal Rectal Resection; ODS = Obstructed Defecation Syndrome; FI = Fecal Incontinence.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8359988/v1/1fe5844d2ed4c8d7feae3624.jpg"},{"id":101752573,"identity":"1c6cfd8f-9181-4d74-93da-3a2640fe38b2","added_by":"auto","created_at":"2026-02-03 10:28:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1391129,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8359988/v1/3f717383-12b7-48f9-b3ee-3880bcceaff4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Negative Impact of Stapled Transanal Rectal Resection Procedure in Patients Who Underwent Surgery for Recurrence of Internal Rectal Prolapse, Rectocele and Obstructed Defecation Syndrome: Results of a Long-Term Single-Center Experience\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe Stapled Trans-Anal Rectal Resection (STARR) procedure is an evolution of the Procedure for Prolapse and Hemorrhoids (PPH) technique, introduced by Longo in 1998 for the treatment of hemorrhoidal prolapse [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Although these procedures share similar rationale, STARR was conceptually developed as a minimally invasive transanal procedure aimed at correcting not only hemorrhoidal disease, but also anatomical rectal abnormalities such as internal rectal prolapse (IRP) and rectocele, which are associated with symptoms of obstructed defecation syndrome (ODS) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Specifically, it involves a double hemi-circumferential transanal resection of the rectal wall using a surgical stapling device designed to remove a greater amount of rectal tissue than the PPH technique, with the goal of restoring anorectal anatomy and improving evacuation. Over time, several modifications have been described in the literature [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], including the trans-STARR procedure, which was developed to enable a more extensive, tailored, circumferential correction of IRP under continuous visual control using a Contour stapler [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough STARR was initially welcomed with considerable enthusiasm for its feasibility and good short-term results in term of reduced pain, shorter length of hospital stays, and a quicker return to work [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], further evidence has increasingly raised concerns about its safety profile, long-term efficacy, and risk of serious complications including bleeding, fecal urgency and incontinence, persistent anorectal pain, stenosis, rectovaginal fistula, pelvic sepsis, and the need for reoperation [\u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13 CR14\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. As a result, several other surgical techniques including abdominal surgery have been explored over time for the management of patients with IRP, rectocele, and ODS. Among these, Ventral Mesh Rectopexy (VMR) has gained growing clinical and scientific interest due to its ability to simultaneously correct other anatomical abnormalities of the posterior compartment, such as enterocele, as well as those of the anterior and middle compartments when combined with other surgical procedures [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, when other surgical techniques are performed following any type of the STARR procedure, it is commonly recognized that the operation could be more technically challenging and potentially riskier [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Additionally, the impact of STARR procedures on cases of IRP or rectocele recurrence has rarely been evaluated [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Therefore, this study aimed to analyze the characteristics and outcomes of patients who underwent surgery for IRP, rectocele, and ODS within our long-term follow-up database, with a particular focus on those who had previously undergone a STARR procedure at other centers.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eA prospective single-center observational study was conducted on patients who underwent abdominal and perineal surgery for external rectal prolapse (ERP) and IRP, with or without rectocele and entero/sigmoidocele, at our tertiary academic center from November 1998 to January 2025. Patients who had previously undergone a STARR procedure at other centers and presented with recurrence of IRP, rectocele, and ODS were specifically evaluated. In particular, for this study, exclusion criteria included ERP, malignancies under treatment, inflammatory bowel disease, chronic diarrhea unresponsive to medical treatment, pregnancy, and inability to give written informed consent. The study was approved by the Ethical Committee of our institution (ID 6120), and written informed consent was obtained from each patient. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement for cohort studies was followed [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData assessment\u003c/h3\u003e\n\u003cp\u003eOverall, patients\u0026rsquo; baseline characteristics were systematically recorded, including demographic data, comorbidities (described according to the ASA classification), history of abdominal and perineal surgeries (such as hysterectomy, colonic resection, rectal prolapse surgery), vaginal delivery (including episiotomy and obstetric anal sphincter injury), cesarean section, preoperative anxiety and depression, ODS, fecal (FI) and urinary incontinence (UI) symptoms, sexual dysfunction, previous pelvic floor rehabilitation, pelvic trauma/radiotherapy. Clinical and radiological findings were also collected, including evacuation proctography or MRI-defecography imaging, colonic transit time, endoanal ultrasound, anorectal manometry, and colonoscopy when performed.\u003c/p\u003e \u003cp\u003eAfter a comprehensive preoperative evaluation, surgical indications were discussed by a multidisciplinary team comprising proctologists, urogynecologists, gastroenterologists, and radiologists. Over time, several abdominal and perineal techniques were adopted for the treatment of IRP, rectocele, and ODS, depending on the surgeon\u0026rsquo;s experience and preference. Among the abdominal procedures (performed either through open or minimally invasive approaches) were VMR, in which the mesh is fixed distally to the ventral aspect of the rectum (after anterior rectovaginal dissection) and proximally to the sacral promontory; the Orr-Loygue procedure, involving extensive posterior rectal mobilization with distal mesh fixation to the ventral rectum and proximal anchoring to the sacral promontory; and the Frickman-Goldberg procedure, consisting of sigmoidectomy with suture rectopexy at the sacral promontory. During VMR, two radiopaque clips were placed at the most distal edge of the mesh on the ventral rectal wall, two clips at the level of the mesh\u0026rsquo;s proximal fixation over the rectum, two additional clips on the mesh at the sacral promontory, one further clip on the sacral periosteum and another on the perineal body. This technical modification was introduced to enable the subsequent radiographic assessment of the mesh position during follow-up, especially in cases of suspected mesh detachment. Conversely, the perineal procedure included the internal Delorme\u0026rsquo;s technique, involving mucosectomy of the redundant rectal mucosa and plication of the muscular layer; and transvaginal rectocele repair, where the rectal protrusion into the rectovaginal septum is reduced by horizontal plication sutures. No STARR procedures were performed at our center. All surgical procedures were performed by the same experienced colorectal surgeon (C.R.).\u003c/p\u003e \u003cp\u003eAmong patients who underwent surgery for IRP, rectocele, and ODS following any type of STARR procedures, surgical complexity related to the STARR suture was documented. Postoperative complications and recurrence of IRP and rectocele were recorded at the last patient\u0026rsquo;s follow-up visit. Validated Patient-Reported Outcome Measures (PROMs) were collected to evaluate ODS and FI symptoms before and after surgery, at the last clinical or telephone follow-up visit. Specifically, ODS severity was assessed with the Altomare ODS score [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e23\u003c/span\u003e], while FI symptoms were evaluated using the Cleveland Clinic Fecal Incontinence (CCFI) score [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eCategorical data were reported as frequencies and percentages, while continuous variables were shown using mean and standard deviation or median and interquartile range (IQR, 25th -75th percentile). Association between categorical variables was assessed by chi-square test. Due to non-normal distributions, differences in continuous variables among two groups were analyzed performing non-parametric Mann U-Whitney test; parametric T-test was used only for evaluating difference among STARR and no STARR group in age. Differences in pre- and postoperative continuous data were evaluated using the Wilcoxon signed-rank test. Patients with missing data were excluded from the analysis. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp, Armonk, NY, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eOver the study period, 62 out of 475 (13.1%; 58 females) patients had a history of STARR surgery for ERP and IRP with or without rectocele and entero/sigmoidocele, including 48 who underwent STARR-like procedures, 12 who underwent PPH-like procedures, and 2 who underwent both. Among patients who only had surgery for recurrence of IRP, rectocele, and ODS, 50 (13.3%; all females) patients had a history of 40 with STARR-like procedures, 8 with PPH-like procedures, and notably, 2 with both procedures.\u003c/p\u003e\n\u003ch3\u003ePreoperative clinical and radiological assessments\u003c/h3\u003e\n\u003cp\u003eBaseline characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Data regarding preoperative evacuation proctography or MRI defecography are described in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Focusing on the STARR group, it is notable that IRP was still detected in 42 out of 50 (84.0%) patients, with 14 (28%) exhibiting intrarectal and 28 (56%) intra-anal intussusceptions. Similarly, rectocele recurrence was found in 42 out of 50 (84.0%) cases, with a median size of 40 (IQR:28\u0026ndash;50) mm. Additionally, residual mucosal prolapse was observed in 21 (42.0%) patients who underwent STARR surgery, while entero/sigmoidocele was found in 33 (66.0%) cases, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Compared to the rest of the cohort, the STARR group showed a higher prevalence of intra-anal intussusception (non-STARR group 139 cases, 42.6%; chi-square test p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and mucosal prolapse (non-STARR group 76 cases, 23.5%; chi-square test p\u0026thinsp;=\u0026thinsp;0.008), whereas intrarectal intussusception and rectocele were more commonly detected in the non-STARR group. No significant differences were observed across the other variables.\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\u003eBaseline characteristics and clinical data of patients with or without previous Stapled Trans-Anal Rectal Resection procedure who underwent surgery for internal rectal prolapse, rectocele, and obstructed defecation syndrome. \u003csup\u003e*\u003c/sup\u003e\u003cem\u003eData are shown as mean (standard deviation);\u003c/em\u003e \u003csup\u003e\u003cem\u003e\u0026sect;\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eData are shown as median (25\u0026deg;-75\u0026deg; percentile). P-values are referred to chi-square test.\u003c/em\u003e \u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003cem\u003ep-value is referred to T-test;\u003c/em\u003e \u003csup\u003e\u003cem\u003eb\u003c/em\u003e\u003c/sup\u003e\u003cem\u003ep-value is referred to non-parametric Mann-Witney test. STARR\u0026thinsp;=\u0026thinsp;Stapled Trans-Anal Rectal Resection; ASA\u0026thinsp;=\u0026thinsp;American Society of Anesthesiologists; OASIs\u0026thinsp;=\u0026thinsp;Obstetric Anal Sphincter Injuries; PF\u0026thinsp;=\u0026thinsp;pelvic floor.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSTARR group\u003c/p\u003e \u003cp\u003en\u0026deg;(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003enon-STARR group\u003c/p\u003e \u003cp\u003en\u0026deg;(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\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\u003e\u003cb\u003eSex/Females\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, years\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.8 (11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.4 (10.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.743\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u0026thinsp;\u0026lt;\u0026thinsp;40 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (5.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.267\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA 3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (18.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (9.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.107\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnxiety/depression\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 (28.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.204\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHysterectomy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (28.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93 (28.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.918\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePelvic trauma/radiotherapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (4.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.773\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVaginal deliveries\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (62.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e248 (76.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003en\u0026deg; vaginal deliveries\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026sect;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.182\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOASIs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (18.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83 (25.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.249\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEpisiotomy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (42.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e151 (46.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.559\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eForceps/vacuum\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (8.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (6.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.747\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCesarean section\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (18.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68 (21.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.637\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePF rehabilitation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (26.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (14.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSlow colonic transit\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (11.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.181\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\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\u003eData regarding preoperative evacuation proctography or MRI defecography of patients with or without previous Stapled Trans-Anal Rectal Resection who underwent surgery for internal rectal prolapse, rectocele, and obstructed defecation syndrome. \u003csup\u003e*\u003c/sup\u003e\u003cem\u003eData are shown as median (25\u0026deg;-75\u0026deg; percentile). P-values are referred to chi-square test.\u003c/em\u003e \u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003cem\u003ep value is referred to non-parametric Mann-Witney test. STARR\u0026thinsp;=\u0026thinsp;Stapled Trans-Anal Rectal Resection; MRI\u0026thinsp;=\u0026thinsp;Magnetic Resonance Imaging.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative defecographic data\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSTARR group\u003c/p\u003e \u003cp\u003en\u0026deg;(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003enon-STARR group\u003c/p\u003e \u003cp\u003en\u0026deg;(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\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\u003e\u003cb\u003eSex, Females\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (98.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e308 (95.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.353\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMRI defecography\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (16.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (9.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.412\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIncomplete rectal empty\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (46.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e153 (47.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.722\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDyssynergia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (22.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (16.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.342\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerineal descendant\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (62.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e197 (60.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.925\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerineal descendant (mm)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (50\u0026ndash;65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (50\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.456\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRectocele\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (84.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e293 (90.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRectocele (mm)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (28\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (38\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.012\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRectocele empty\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (5.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.296\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntrarectal intussusception\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (28.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e126 (38.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\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\u003e\u003cb\u003eIntra-anal intussusception\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (56.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e139 (42.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMucosal prolapse\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (42.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76 (23.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEntero/sigmoido/peritoneocele\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (66.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e176 (54.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.122\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eColpohysterocele\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (42.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e133 (41.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.937\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCystocele\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (46.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e139 (42.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.864\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\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSurgical details and postoperative outcomes\u003c/h2\u003e \u003cp\u003eOverall, among abdominal approaches, 265 VMR were performed, along with 26 Orr-Loygue and 4 Frickman-Goldberg procedures. Perineal approaches included 68 transvaginal rectocele repairs and 13 internal Delorme\u0026rsquo;s procedures over time. Considering the STARR group, 45 patients underwent abdominal surgery (41 VMR, 2 Orr-Loygue, and 2 Frykman-Goldberg procedures), while perineal surgery was performed in 5 patients (4 transvaginal rectocele repairs and 1 internal Delorme\u0026rsquo;s procedure). Although in most cases the STARR suture was successfully overcome during the rectovaginal dissection (as documented by postoperative X-ray, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), this was not possible in 3 patients (2 undergoing VMR and one undergoing transvaginal rectocele repair) due to the technical complexity and an increased risk of rectovaginal injury (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOverall, 287 out of 475 patients completed the questionnaires at last clinical or telephone follow-up visit, including 42 in the STARR group and 245 in the non-STARR group. Six patients in the non-STARR group had died from unrelated causes. The median follow-up was 53 (IQR:14\u0026ndash;115) months; there was no significant difference between the two groups (53, IQR:21.25\u0026ndash;90.25 versus 53, IQR:13.75-123.25 months in the STARR group versus non-STARR group, Mann-Whitney p\u0026thinsp;=\u0026thinsp;0.502). A total of 17 (5.9%) recurrences of IRP and rectocele were documented by postoperative clinical and defecographic evaluation: 2 (4.8%) in patients who previously underwent any type of STARR and 15 (6.1%) in those without previous STARR. Among these, 2 and 11 patients in the STARR and non-STARR groups underwent further surgery for recurrent IRP or rectocele, respectively. In one patient with a history of STARR surgery, chronic pelvic pain due to stapled suture persisted despite surgery having corrected the anatomy of the posterior compartment.\u003c/p\u003e \u003cp\u003eOverall, Altomare ODS and CCFI scores showed a statistically significant reduction after surgery (16.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0 versus 9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7, and 3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0 versus 1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9, respectively, Mann-Whitney p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), even in patients with a history of STARR surgery (18.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0 versus 12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0, and 3.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8 versus 0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4, Mann-Whitney p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and p\u0026thinsp;=\u0026thinsp;0.001, respectively, Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The comparison of PROMs for ODS and FI between the STARR and non-STARR groups is reported in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. As shown, patients who previously underwent any type of STARR showed higher preoperative Altomare ODS score compared to other patients (18.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0 in the STARR group versus 16.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8 in the non-STARR group, Mann-Whitney p\u0026thinsp;=\u0026thinsp;0.022). Similarly, postoperatively, the Altomare ODS score remained significantly worse in the STARR group (12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0 in the STARR group versus 9.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5 in the non-STARR group, Mann-Whitney p\u0026thinsp;=\u0026thinsp;0.041). No differences were observed in overall satisfaction after surgery (6.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3 in the STARR group versus 7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 in the non-STARR group, Mann-Whitney p\u0026thinsp;=\u0026thinsp;0.629).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eFollowing its introduction in 2004, the STARR technique was enthusiastically adopted, as it was believed to address multiple posterior compartment disorders using a comprehensive, minimally invasive, and painless approach with quick postoperative recovery [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Over time, its initial indications progressively expanded, being initially adopted for hemorrhoidal disease and, then, for more serious conditions such as IRP, rectocele, and ODS. Furthermore, there has been speculation about its use for treating ERP [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, early enthusiasm was soon dampened by increasing criticism, mainly due to higher rates of severe, sometimes life-threatening complications, along with high recurrence rates, partly caused by inadequate training and limited surgical expertise [11,26\u0026ndash;28]. Consequently, some surgeons have gradually phased out the procedure in clinical practice [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e20\u003c/span\u003e], although it continues to be used in many countries worldwide, including Italy.\u003c/p\u003e \u003cp\u003eMoreover, the actual effect of the STARR procedure on rectal function related to defecation has not been clearly determined [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The technique has been associated with a significant risk of both anatomical and functional changes in the middle and posterior pelvic regions. These can include rectal deformity, reduced rectal compliance, and the effects of a \u0026ldquo;full-thickness\u0026rdquo; excision, which are worsened by scar tissue formation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNevertheless, it is important to emphasize that the stapled resection of the rectum was initially described as involving only mucosal and submucosal resection of the rectum. However, subsequent histopathological studies revealed the presence of muscular fibers in more than 90% of surgical specimens, indicating that the actual resection was much more extensive than initially thought and raised significant concerns about its potential impact on rectal function [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Similarly, the idea of removing additional rectal tissue, including the muscular layer as performed in STARR-like procedures, to excise redundant tissue in IRP, reduce rectocele, and improve ODS symptoms, has not consistently translated into consistent postoperative outcomes [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. This is particularly relevant when considering both the potential effects of stapled scarring on rectal function and the risk of complications previously discussed, mainly in patients who have undergone both PPH and STARR procedures. Moreover, even in the hands of surgeons experienced in rectal prolapse surgery, operating through a stapled-line scar often entails a considerable intraoperative risk of rectal injury, which may have disastrous consequences and potentially preclude further surgical intervention. Therefore, we strongly recommend that this risk be thoroughly discussed during preoperative counseling.\u003c/p\u003e \u003cp\u003eIndeed, as observed in our long-term experience in the surgical management of IRP, rectocele, and ODS, any type of STARR procedure still carries a significant risk of recurrence of posterior compartment abnormalities, which, in some cases, requires additional surgery over time [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Symptomatic recurrences are often due to inappropriate indications for the STARR procedure, such as the presence of an enterocele [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Notably, in our group of patients who previously underwent STARR surgery, about 66% also showed an enterocele. This poses a substantial risk for surgeons performing STARR in these patients, as intestinal loops of the enterocele may become trapped within the stapled suture, leading to severe consequences, including the entero-vaginal fistula and the need to create a stoma. Some surgeons have recommended using an intraoperative Trendelenburg position or combining the procedure with laparoscopic abdominal assistance to reduce this risk [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. However, a different surgical approach should ideally be used to treat the enterocele itself. In such cases, we suggest reevaluating the indications for surgery, possibly opting primarily for an abdominal approach that can offer more comprehensive treatment, addressing multiple compartments (anterior and middle) simultaneously.\u003c/p\u003e \u003cp\u003eRecurrences of IRP, rectocele, and ODS after STARR are often linked to symptoms that are difficult to treat or, in some cases are not treatable at all, such as chronic pain, urgency, tenesmus, fecal incontinence [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. For example, in our series, one patient experienced persistent chronic pelvic pain that could not be resolved even with an additional surgical procedure aimed at restoring rectal anatomy. This aspect should be carefully considered during preoperative counseling of patients with symptom recurrence after STARR procedures.\u003c/p\u003e \u003cp\u003eThe analysis of symptom severity collected through PROMs revealed that patients who had previous STARR-like procedures experienced greater severity of preoperative and postoperative ODS symptoms compared to the non-STARR group. Likewise, the severity of FI symptoms was also significant. Several factors may account for these findings. First, rectal function and its changes can vary considerably among patients with ODS. A major current limitation in rectal prolapse surgery is the lack of tests that can directly assess rectal function. Some colleagues have used indirect tools such as anorectal and colonic manometry, rectal barostats, rectal scintigraphy, and endorectal capsules capable of tracking intestinal movements during defecation [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. However, to date, we are still unable to assess this function comprehensively and concretely. Once such tests are available, it may be possible to directly evaluate the effects of stapled sutures, mesh implants, or rectal prolapse surgery in general on rectal function. Another possible explanation involves the consequences of any STARR procedure, including the presence of inert scar tissue, anastomoses between discontinuous layers of muscular fibers, metallic clips, nerve disruption, or entrapment within the stapled line, and reduced rectal reservoir capacity [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Additionally, as defecation is a highly complex process, other factors, which are often unknown or underestimated, might influence defecatory mechanics [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. However, as our data also indicate, STARR procedures not only fail to resolve symptoms or correct anatomical abnormalities but may also complicate postoperative outcomes in patients with IRP, rectocele, and ODS.\u003c/p\u003e \u003cp\u003eThis study had some limitations. First, all types of STARR techniques were grouped under the term \u0026ldquo;STARR surgery\". This approach could be justified as, over time, various techniques were proposed that often overlapped or were performed in a very similar manner. Additionally, for some patients, it was not possible to fully understand the surgical procedure due to incomplete or inadequate documentation. However, all patients shared a stapled suture line at the rectal level, which could lead to comparable functional outcomes. Another limitation is that this reflects the long-term experience of a single surgeon (C.R.) in rectal prolapse surgery. Nevertheless, the surgeon is highly experienced and has been thoroughly trained in these procedures. It would be valuable to compare our findings with those from other tertiary referral centers for IRP, rectocele, and ODS, perhaps through the development of a multicenter database with standardized data collection, including previous STARR surgeries. Lastly, as previously mentioned, we cannot determine how many of these outcomes are due to the effects of the STARR procedure itself versus the baseline characteristics of patients with ODS, as we currently lack a test to directly assess this. Nonetheless, we believe that if we cannot be certain that STARR intervention is truly effective or definitive, we should consider discontinuing or replacing it, rather than risking further harm to patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Statement:\u0026nbsp;\u003c/strong\u003eNo funding was available for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003eAll authors have no conflict of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contribution:\u0026nbsp;\u003c/strong\u003eAAM and CR contributed equally to this manuscript. AAM and CR designed and conducted the study, including data analysis. AAM and IS performed statistical analysis. AAM prepared the manuscript draft with important intellectual input from CR. CV, CC, AP, FL, PC and MP conducted patient recruitment and data collection. All authors revised and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e All data, analytic methods, and study materials used to conduct this research will be made available to any researcher from the corresponding author (CR), upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACKNOWLEDGMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Marisa Notarianni for the English language review.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eLongo A (1998) Treatment of hemorrhoidal disease by reduction of mucosa and hemorrhoidal prolapsed with a circular suturing device: a new procedure. In: Proceedings of the 6th World Congress of Endoscopic Surgery. 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Nat Rev Gastroenterol Hepatol 15:568\u0026ndash;579. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s41575-018-0030-9\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePescatori M, Spyrou M, Pulvirenti d\u0026apos;Urso A (2006) A prospective evaluation of occult disorders in obstructed defecation using the \u0026apos;iceberg diagram\u0026apos;. Colorectal Dis 8:785\u0026ndash;789. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1463-1318.2006.01138.x\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 3 is not available with this version.\u003c/p\u003e\u003cp\u003eTable 3. Postoperative complications recorded in patients who underwent surgery for internal rectal prolapse, rectocele, and obstructed defecation syndrome at our Unit. P-value is referred to chi-square test. STARR = Stapled Trans-Anal Rectal Resection.\u003c/p\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":"","lastPublishedDoi":"10.21203/rs.3.rs-8359988/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8359988/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAlthough Stapled Trans-Anal Rectal Resection (STARR) was initially met with significant enthusiasm in the treatment of internal rectal prolapse (IRP), rectocele, and obstructed defecation syndrome (ODS), growing evidence has raised concerns about its long-term efficacy and the risk of serious complications. The aim of the study was to analyze patients who underwent surgery for IRP, rectocele, and ODS recurrence following STARR procedure.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients who underwent abdominal and perineal surgery for IRP with/without rectocele and entero/sigmoidocele between November 1998 and January 2025 were included. Those previously treated with STARR were specifically analyzed. Baseline clinical and radiological characteristics, surgical complexity related to STARR suture, complications, recurrence, ODS and fecal incontinence scores were collected.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOut of 376 patients, 50 females (13.3%) with previous STARR surgery underwent surgery for IRP, rectocele, and ODS recurrence. At defecography, IRP and rectocele were both detected in 42 of the 50 STARR patients [84.0%, median rectocele size: 40(28\u0026ndash;50) mm]. Entero/sigmoidocele was found in 33 cases (66.0%). Forty-five patients had abdominal procedures and five underwent perineal techniques. STARR suture could not be safely overcome in three cases. At a median follow-up of 53(14\u0026ndash;115) months, recurrence occurred in 5.9% of cases, with comparable rates in both groups (4.8% vs. 6.1%). One patient experienced persistent chronic pelvic pain due to STARR suture despite anatomical correction. Overall, ODS and fecal incontinence scores significantly improved; however, patients with prior STARR showed higher preoperative and postoperative ODS scores.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSurgery for IRP, rectocele, and ODS recurrence after STARR is feasible but challenging. Long-term results showed that previous STARR is linked to more severe ODS symptoms and less functional improvement. STARR could be unsuccessful and complicate further surgeries.\u003c/p\u003e","manuscriptTitle":"The Negative Impact of Stapled Transanal Rectal Resection Procedure in Patients Who Underwent Surgery for Recurrence of Internal Rectal Prolapse, Rectocele and Obstructed Defecation Syndrome: Results of a Long-Term Single-Center Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-13 09:07:18","doi":"10.21203/rs.3.rs-8359988/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":"ad0291cf-7b5c-46c3-972a-0ac0e0a51ee6","owner":[],"postedDate":"January 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-01T08:54:49+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-13 09:07:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8359988","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8359988","identity":"rs-8359988","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}