Ways to Repair Multicompartment Prolapse: Decision-Making and Surgical Approach

Multicompartment pelvic organ prolapse (POP) occurs when multiple pelvic organs herniate through the pelvic floor, impacting quality of life and daily function. Concomitant POP and rectal prolapse are common but often underrecognized. A multidisciplinary approach involving urology, urogynecology, and colorectal surgery is essential for comprehensive care and improved outcomes. Concurrent surgeries are increasingly performed, allowing patients to address both conditions in a single operation without heightened complication rates. Treatment for rectal and vaginal prolapse can be achieved through robotic, laparoscopic, open abdominal, or vaginal/perineal approaches. Surgical selection is guided by patient comorbidities, treatment goals, the choice of mesh versus native tissue repair, and the surgeon's experience. This article presents five different approaches to illustrate the nuances of combined surgical approaches, offering insights into optimizing the treatment of multicompartment POP.

multicompartment prolapse, rectal prolapse, vaginal prolapse, pelvic organ prolapse, suture rectopexy, ventral rectopexy, sacrocolpopexy, hysteropexy Multicompartment pelvic organ prolapse (POP) is a common occurrence. It is often underdiagnosed and presents a challenge in treatment. 1 Based on the data reported in gynecologic literature, approximately 11% of women will undergo a vaginal prolapse procedure in their lifetime, and of those, a third will experience concomitant rectal prolapse (RP). 2 3 Similarly, for patients with RP, up to 34% have untreated urinary incontinence and POP, and nearly half of patients who undergo RP surgery report symptoms of pelvic organ “bulging” and urinary incontinence. 2 4 5 As continued research demonstrates improved outcomes for patients, we advocate for approaching RP and POP in a multidisciplinary fashion, by routinely evaluating the middle and anterior compartments and addressing concurrent prolapse when indicated. 6 7 Geltzeiler et al reported comparable morbidity when performing rectopexy alone versus combined procedure. 8 Several studies compared recurrence rates and increased recurrence was associated with failure to address all affected compartments. 3 9 10 Patients who undergo combined surgeries report higher satisfaction, improved quality of life, improved defecatory function, and better sexual function. 11 12 13 Concurrent surgery is the recommended treatment for patients with multicompartment POP. Several techniques can be utilized when approaching multicompartment prolapse. There can be variability based on the patient's symptoms, prolapse presentation, and surgeon's expertise. In this article, we will present five cases and highlight different techniques that were utilized to address concurrent prolapse. In our practice, the patients are evaluated in the combined pelvic floor clinic by a urogynecologist and a colorectal surgeon, necessary testing is ordered, and the shared decision is made between two surgeons and the patient on the recommended repair. Case 1: Native Tissue Repair—Suture Rectopexy, Anterior Colporrhaphy Case: A 49-year-old female with a large cystocele and full-thickness RP ( Fig. 1 ). Other considerations: Hypermobile Ehlers–Danlos syndrome (EDS), oxygen-dependent chronic obstructive pulmonary disease (COPD), irritable bowel syndrome (IBS), gastroparesis, chronic pelvic pain, history of sexual abuse with posttraumatic stress disorder (PTSD), 21 miscarriages, lower back multifidus atrophy, poor wound healing at prior procedure, and 4 vaginal deliveries. Urogynecologic symptoms: pelvic pain and pressure, recurrent urinary tract infections (UTIs), and urinary incontinence. Gastrointestinal symptoms: fecal incontinence. Vaginal prolapse description: Anterior vaginal wall prolapse at the level of the hymen, no apical prolapse, and posterior wall prolapse at the level of the hymen. Testing Manometry: Anal hypotension with hypocontractility, abnormal expulsion with poor propulsion, and rectal hypersensitivity. Defecography: Fig. 1 . Treatment Rationale An abdominal approach was recommended for full-thickness RP repair. The patient's pulmonary function and chronic cough were optimized preoperatively with guidance from a pulmonologist. Given the presence of EDS, chronic pain, and poor wound healing, we opted to avoid the use of mesh. Although data on EDS patients are limited, our experience suggests that this group faces an increased risk of recurrence, which we discuss thoroughly with patients. For primary prolapse cases with a heightened recurrence risk, we prefer tissue repair over mesh. As we were not utilizing mesh, the patient was offered a transvaginal cystocele repair, which was deemed sufficient for addressing the anterior compartment. The patient expressed a desire to preserve her uterus, and as there was no apical prolapse, anterior colporrhaphy was considered appropriate. Pelvic floor physical therapy (PFPT) was recommended to enhance function before and after surgery; however, the patient declined. Ultimately, suture rectopexy and transvaginal cystocele repair (anterior colporrhaphy) were recommended. Surgical Technique Suture rectopexy was performed via robotic abdominal approach, the rectum was fully mobilized to the pelvic floor in the posterior rectal plane, the right lateral stalk was divided, and rectum was pulled on maximum possible tension, lateral peritoneum was pexied to the sacral promontory. The peritoneum and uterosacral ligaments were utilized to close the cul-de-sac providing some additional middle compartment suspension and preventing secondary enterocele formation. Anterior colporrhaphy was then performed: transvaginal mucosa in injected with diluted epinephrine, a midline anterior vagina incision was made, and dissection was carried to the vaginal muscularis, and the bladder was dissected off the cervix. Single-layer plication of the bladder wall was performed and the vaginal epithelium closed. Completion cystoscopy was performed. Case 2: Native Tissue Repair—Modified Suture Rectopexy, Uterosacral Ligament Suspension Case: A 22-year-old female with full-thickness RP and uterovaginal prolapse ( Fig. 2 ). Other considerations: Anxiety, attention deficit hyperactivity disorder (ADHD), constipation, fibromyalgia, nephrolithiasis, recurrent UTI, pelvic inflammatory disease (PID), sexual assault, and chronic pelvic pain. Nulliparous, underwent PFPT, and behavioral GI counseling. Urogynecologic symptoms: pelvic pressure, vaginal bulge, incomplete bladder emptying, and dyspareunia. Gastrointestinal symptoms: constipation, stool urgency, and rectal spasms. Vaginal prolapse description: Anterior vaginal wall prolapse 1 cm proximal to the hymen, significant apical prolapse noted, posterior wall prolapse 1 cm proximal to the hymen Testing Urodynamics: Not indicated as the patient had known and established voiding dysfunction due to hypertonic pelvic floor. Manometry: Anal hypertonicity with hypocontractility, normal balloon expulsion, and rectal hypersensitivity. Defecography: 5 cm rectocele, enterocele, and vaginal shortening. Treatment Rationale Abdominal constipation was optimized preoperatively with assistance from gastroenterology, and the patient was started on a bowel regimen. She underwent a preoperative course of PFPT, which continued 6 weeks postoperatively. Baclofen suppositories were prescribed to alleviate rectal spasms, providing some symptom relief. Counseling was initiated with a gastrointestinal psychologist to address pelvic trauma and the brain–gut connection. Additionally, the patient was referred for genetic testing to rule out connective tissue disorders. Extensive counseling emphasized the importance of a multidisciplinary treatment approach. Robotic-assisted modified suture rectopexy with anterior fixation and hysteropexy was recommended. In young, nulliparous patients with primary prolapse, we prefer an abdominal approach using native tissue to avoid mesh. This approach considers future fertility and the high likelihood of recurrence over a patient's lifetime. Pelvic pain is another factor in avoiding mesh use. A modified suture rectopexy was selected, as the prolapse lead point was high and anterior, with high-tone muscles pushing it out during defecation. Posterior fixation alone would not sufficiently address the anterior rectal wall prolapse and large rectocele, so this approach is ideal when avoiding mesh. Addressing abdominal constipation is critical in these patients, and, when necessary, a sitz marker study is indicated to assess baseline function. Strict adherence to PFPT is advised. While endometriosis was not evident on prior pelvic ultrasound, an endometrial implant was identified on the uterosacral ligament and was completely excised during surgery. The patient was subsequently referred to a gynecologist for postoperative management of endometriosis. Surgical Technique Modified suture rectopexy was performed. Dissection was started by opening the right lateral peritoneum and continuing in a J-fashion into the rectovaginal septum, it is not continued all the way to the pelvic floor but only beyond the lead point of the prolapse, mobilizing the pouch of Douglas to reach previously precleared sacral promontory for fixation. Dissection is also taken in the posterior rectal place, just enough to straighten the rectum when suspended to ensure that there is no kink. The lateral peritoneum and pouch of Douglas tissue (functioning as a native mesh) are pexied to the sacral peritoneum with permanent suture. Next bilateral uterosacral ligaments were suspended to the cervical stroma with a total of four points of fixation with Polydioxanone (PDS) suture. The peritoneum is then closed over the repair. Case 3: Mesh-based Repair—Ventral Rectopexy, Sacro-hysterocolpopexy (Uterus-sparing), Utilization of Two Separate Mesh Case: A 49-year-old female with uterovaginal prolapse, large rectocele, and grade 4 rectal intussusception ( Fig. 3 ). Other considerations: Obesity, anxiety, depression, constipation, nulliparous. Failed pessary treatment. Urogynecologic symptoms: vaginal bulge, incomplete bladder emptying, and dyspareunia. Gastrointestinal symptoms: excessive straining, splinting and disimpaction, and rectal bulge. Vaginal prolapse description: Anterior vaginal wall prolapse 1 cm proximal to the hymen, apical prolapse noted, and posterior wall prolapse at the level of the hymen. Testing Urodynamics: normal bladder sensation, no detrusor overactivity, normal urethral closure. Voiding function normal. No urodynamic stress incontinence. Manometry: anal hypertonicity and normal contractility, failed balloon expulsion without dyssynergia, and hyperacute rectal sensation. Fluoroscopic defecography: Normal initiation of defecation, medium rectocele, grade 4 intussusception, enterocele, and trapping of contrast in the rectocele at completion of defecation. Shortening of vaginal length. Treatment Rationale This patient presented with symptoms of obstructive defecation in the setting of a rectocele and low intussusception. Imaging revealed that intussusception prevented complete emptying in contrast from the rectocele. The primary advantage of using fluoroscopic defecography in such cases is its ability to visualize intussusception and quantify rectocele emptying. Patients with these findings often have a significant history of constipation and straining. In this case, abdominal constipation was managed, and no dyssynergia was identified. Surgery was recommended to address the patient's obstructive defecation symptoms. Given her concurrent anterior and middle compartment prolapse, a combined approach was selected. The patient received counseling on weight loss and nutrition prior to surgery and was advised to continue PFPT postoperatively. As she wished to preserve her uterus, robotic ventral mesh rectopexy (VMR) and hysterocolpopexy were recommended. Hysteropexy is a mesh repair technique that preserves the uterus while addressing both anterior and middle compartment prolapse. Surgical Technique After sacral promontory was identified and precleared dissection continued opening right-sided peritoneum, it was continued into rectovaginal septum all the way to the pelvic floor. Bilateral levator muscles were identified. It was noted that the patient had a very redundant pouch of Douglas which is consistent with long-standing constipation a history of prolapse. As was anticipated, two pieces of mesh were going to be used, the decision was made not to excise the redundant tissue in the pouch of Douglas as it was planned to be incorporated into peritoneal closure to ensure complete coverage of the mesh. In the patient with known dyspareunia levator stitches to secure the mesh are intentionally avoided. Distance between levators was measured and lightweight synthetic mesh was cut in a shovel pattern and secured to the anterior rectum with an absorbable suture through the length of the rectovaginal septum with multiple sutures. This piece of mesh was then fixed to the posterior vagina. A separate piece of mesh was cut as an apron and a wide part of the mesh was sutured to the anterior vagina, tails of the apron were passed through the broad ligament and secured to the anterior mesh with a Prolene suture. This second anterior mesh was necessary to ensure an excellent anterior compartment repair. A combined piece of mesh was then placed on the appropriate amount of tension and secured to the precleared sacral promontory. Rectal sizers as well as specialized vaginal retractors are used to aid dissection and mesh fixation thorough out the case. Care is then taken to close the peritoneum. We close it in what we call a lollipop fashion with waxed Vicryl suture by starting on the right side of the distal peritoneum, taking care to visualize the ureter and continuing anterior in a circle to the left, incorporating bladder peritoneum into closure as a purse string which is the carefully tied sinching the peritoneum down tightly over the mesh, the remainder is closed in a straight line thus creating a circle and a stick a “lollipop” closure. We take great care to close the cul-de-sac to ensure proper enterocele repair. Case 4: Mesh-based Repair—Ventral Mesh Rectopexy, Posthysterectomy Sacrocolpopexy, Utilization of Two Separate Mesh Case: A 73-year-old female with recurrent vaginal vault prolapse and large rectocele ( Fig. 4 ). Other considerations: Prior total vaginal hysterectomy for uterine prolapse and two vaginal deliveries. Urogynecologic symptoms: pelvic pressure, vaginal bulge, urinary urgency and frequency. Gastrointestinal symptoms: Incomplete evacuation, fecal urgency with occasional incontinence. Vaginal prolapse description: Anterior vaginal wall prolapse 3 cm distal to the hymen, apical prolapse 2 cm distal to the hymen, and posterior wall prolapse at the level of the hymen. Testing Urodynamics: Normal bladder sensation, no detrusor overactivity, bladder capacity is normal. There is incompetent urethral closure and evidence of urodynamic stress incontinence at maximum capacity (685 mL). Overall voiding function is normal. Slightly elevated postvoid residual (135 mL). Anorectal manometry: Anal normotension with hypocontractility, normal balloon expulsion without dyssynergia, and hyperacute rectal sensation. Fluoroscopic defecography: normal initiation of defecation, large rectocele with complete emptying, and prolonged descent with partial recoil. Treatment Rationale This postmenopausal woman with recurrent middle compartment prolapse and a large rectocele was evaluated in a multidisciplinary clinic and offered a combined abdominal repair. She is active, high-functioning, and in overall good health, making her an ideal candidate for an abdominal approach, which is generally superior for addressing middle compartment prolapse and large rectocele. Her primary defecatory complaints included fragmented bowel movements and urgency. For postmenopausal patients, we recommend vaginal estrogen supplementation for at least 6 weeks prior to surgery to strengthen the vaginal epithelium when mesh use is planned. Surgical Technique Robotic VMR was performed as described in case 3. In this case, the mesh was fixed to the levator muscles bilaterally with an absorbable suture and then secured to the anterior rectum in several rows to the level of a pouch of Douglas. Significant scarring is usually noted in the rectovaginal septum in the patient who previously underwent a transvaginal hysterectomy. Utilization of rectal and vaginal retractors by bedside assistant is helpful to identify the plane of dissection. Next, the bladder was dissected off the anterior vagina. The rectal mesh was lifted, placed on appropriate tension, and secured to the posterior vagina. It was noted that the posterior vaginal wall was significantly elongated and there was not enough mesh (standard 20 cm used) to adequately flip it over to secure to the cervix and anterior vagina as we usually do in our practice. The decision was made to use a separate mesh to fix to the anterior vagina and cervix. Both meshes were then layered one on top of the other and secured at the sacral promontory. Vaginal and rectal exams were performed to ensure that the mesh was on appropriate tension and was fixating the prolapse appropriately. The decision to use the same mesh for both compartments versus two pieces is made intraoperatively and depends on the patient's anatomy, organ redundancy, size of rectocele, vaginal length, and the shape of the pelvis. As in the previous case, it is imperative to cover the mesh completely with peritoneum to prevent a bowel obstruction and mesh-related complications. In the cases when a patient had prior repair or vaginal hysterectomy there can be limited peritoneum, in such cases extra care is taken to make sufficient flaps in the lateral and rectovaginal septum dissection. Culdoplasty, bladder mobilization, and coverage of the mesh can be performed when there is insufficient peritoneum to fully cover the mesh. Case 5: Mesh-based Repair—Ventral Mesh Rectopexy, Sacrocolpopexy, Utilization of Single Mesh, Bladder Sling Revision Case: A 67-year-old with full-thickness RP and uterovaginal prolapse ( Fig. 5 ). Other considerations: Fecal incontinence, sacral nerve stimulator implant with limited improvement in fecal urgency symptoms postimplantation, IBS, retropubic midurethral sling for stress incontinence, and four vaginal deliveries. Urogynecologic symptoms: pelvic pressure, vaginal bulge, and urge urinary incontinence. Gastrointestinal symptoms: nausea, FI, urgency, mucous leakage, and diarrhea on Imodium. Vaginal prolapse description: Anterior vaginal wall prolapse at the level of the hymen, some apical prolapse noted, and posterior wall prolapse at the level of the hymen. Testing Urodynamics: Normal bladder sensation, no detrusor overactivity, normal urethral closure. Voiding function normal. Positive for urodynamic stress incontinence. Cystoscopy: Preoperative cystoscopy showed normal bladder and urethra with no evidence of mesh exposure or erosion. Anorectal manometry: Anal normotension, mild hypocontractility, failure of balloon expulsion dyssynergia, and hyperacute rectal sensation. Fluoroscopic defecography: incontinent of contrast, rectoanal intussusception progressing to full thickness RP, vaginal length/support: Shortening of vaginal length with preserved anterior support. Treatment Rationale This postmenopausal woman, who leads an active lifestyle and wishes to preserve sexual function, presented with mixed fecal and urinary incontinence as well as chronic diarrhea, with a negative gastrointestinal workup. She expressed a desire for a hysterectomy to be performed during surgery, with ovarian preservation. Despite a prior sling procedure, her urinary incontinence persisted, so a sling revision was also recommended. Given her suitability for abdominal repair, her agreement to mesh, and her preference for complete pelvic floor reconstruction, we recommended robotic VMR, supracervical hysterectomy, bilateral salpingectomy, sacrocolpopexy, and midurethral sling revision. In our experience, mesh repair provides superior durability and function for patients with active lifestyles. Most patients in our practice are discharged the same day following a trial of voiding in the recovery area. Patients are advised to avoid heavy lifting, strenuous exercise, and sexual activity for 3 months postoperatively. Surgical Technique We usually start the operation by performing the hysterectomy and then proceeding to the VMR part followed by sacrocolpopexy. In our practice, we find that this flow works best, however, the order can be changed depending on case flow and patient anatomy. For example, in a patient with a very large uterus, it is helpful to the colorectal surgeon if a hysterectomy is done first but if a uterus is small, the colorectal surgeon and urogynecologist/urologist can work in tandem minimizing back and forth alternation. In this patient, VMR was performed as described in the case 3. Next, urogynecologist performed vaginal and bladder flap dissection. The rectal mesh was lifted with appropriate tension (usually 2 cm between the last row of rectal stitches and the vagina) but can be variable and needs to be adjusted to each specific patient and their anatomy. Mesh is then secured to the posterior vaginal wall and cervix with several rows of PDS stitches. The mesh was then folded and secured to the anterior vaginal wall. It was then secured to the sacral promontory. It takes teamwork and shared experience between colorectal and urogynecological surgeons to ensure proper tension of the mesh to properly fix tricompartment prolapse. Care is taken to secure the mesh with seromuscular bites on the rectum, we do not perform flexible sigmoidoscopy routinely in our cases. However, in a patient with a large rectocele and thinned rectal wall, prior Altemeier procedure when mesh is secured to the sigmoid colon flexible sigmoidoscopy can be done before completion of the case to ensure that there are no full-thickness stitches which would increase the risk of mesh erosion and infection. A bladder sling is performed last followed by a completion cystoscopy.

Multicompartment prolapse leads to bothersome symptoms and a decreased quality of life, requiring a multidisciplinary approach to achieve optimal outcomes. Treating these patients involves coordinated efforts between both urogynecology/urology and colorectal surgical teams, making this collaboration both rewarding and educational for patients, trainees, and surgeons alike. Footnotes Conflict of Interest A.R.S. Serves On The Advisory Board For Medtronic.

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