Thank you for this opportunity to present our work, Enterocele-Induced Rectal Prolapse, a Novel Form of Pelvic Organ Prolapse. Rectal prolapse is a full thickness aversion of the rectum through the anus. It affects approximately 0.5% of the population and occurs most frequently in older individuals of female gender. There is little in the way of non-operative management for rectal prolapse. Surgeries include both perineal and abdominal approaches. The Delorme procedure is a perineal mucosal stripping and placation of sphincter muscles, while the Altmeyer procedure involves a full thickness resection of the rectum with a colorectal anastomosis. Recurrence rates are as high as 30% for the perineal approaches. Abdominal approaches include a suture rectopexy with a recurrence rates of three to nine percent. If a sigmoid colectomy is added, recurrence rates decrease to two to five percent. Mesh rectopexy was initially performed by Ripstein, who used a circumferential mesh on the rectum and attached it to the sacrum. Morbidity with this procedure was high, however, and the mesh rectopexy has since been modified to fix either the posterior or the anterior wall only to the sacrum. An anterior resection of the rectum itself is not considered first-line surgery for rectal prolapse as recurrence rates are as high as 12% over six years, and such a low anastomosis in those who already have borderline continence may worsen symptoms. To our knowledge, rectal prolapse in the form of an enduraceal in the pouch of Douglas is a novel problem. Concomitant sacrocopalpexy with rectopexy is advocated as treatment for combined vaginal and rectal prolapse. There are no reports of sacrocopalpexy alone as surgical treatment for enduraceal-induced rectal prolapse. We will report on two cases of recurrent rectal prolapse caused by prolapse in small bowel and treated with sacrocopalpexy. Patient one is a 59-year-old woman who underwent laparoscopic sigmoid colectomy and suture rectopexy in 2006, and then a laparoscopic modified Ripstein mesh rectopexy in April 2012 for recurrent prolapse. The patient presented to the colorectal service in June 2013, complaining of constipation, fecal soiling, perianal burning, rectal bleeding, and rectal bulge. Patient two is a 59-year-old woman who underwent laparoscopic sigmoid colectomy and treated with sacrocopalpexy in April 2012 for recurrent rectal prolapse. She was noted to have a large anterior full-thickness prolapse on rectal exam. Here, she is bearing down while on a commode to demonstrate her rectal prolapse. This does not appear as a classic rectal prolapse showed with folded mucosa. Instead, its smooth, full appearance suggests another pelvic organ-inducing rectal prolapse. A dynamic MRI is seen in sagittal view here. The rectum is outlined in green. Here with strain, you can see the enterocele outlined in red in the pouch of Douglas. Again, mid-strain. And with maximum strain, prolapsing rectally in this final image. Her vaginal exam revealed asymptomatic stage two anterior and posterior wall prolapse. The planned operation to correct the enterocele included a supracervical hysterectomy, sacrocopalpexy with perineal body mesh attachment, and Moskowitz caldoplasty with mesh reinforcement. Here, overlaid on an MRI image, you can see a depiction in pink of where we placed the posterior mesh. And here, a depiction of the caldoplasty in green with the mesh reinforcement in purple. In this intraoperative image, you can see the mesh on the posterior vaginal wall reaching to the perineal body along with the sutures of the caldoplasty. The rectum was not prolapsing, and a repeat rectopexy was not necessary. Seven months postoperatively, the patient continues to report that all of her bowel symptoms have entirely resolved. Patient two is a 73-year-old woman with scleroderma who underwent an open sigmoid colectomy and suture rectopexy in 2006, and a laparoscopic modified Ripstein mesh rectopexy in January 2013 for recurrent prolapse. She began complaining of recurrent prolapse one month after her mesh rectopexy, and an anterior bulge was noted on rectal exam. In August 2013, she underwent a Delorme procedure. Postoperatively, the patient complained of continued prolapse, pain, mucus drainage, and fecal incontinence. A dynamic MRI was performed. She had previously undergone a vaginal hysterectomy, and the vaginal cuff can be seen here outlined in pink in the pre-strained sagittal view. The rectum is outlined in green. Here with strain, you can see the entrance seal outlined in red between the vaginal cuff and the rectum. Maximum strain is seen here. Her vaginal exam revealed asymptomatic anterior wall prolapse to the hymenal ring without apical or posterior prolapse. The patient underwent an open sacral copepxy with perineal body mesh attachment and mesh-reinforced Moskowitz cultiplasty. Here you can see the posterior vaginal mesh reaching to the perineal body along with the cultiplasty. In this image, you can see the mesh reinforcement of the cultiplasty outlined in green and the posterior vaginal mesh outlined in pink. Intraoperatively, her mesh rectopexy was noted to be intact. Seven months postoperatively, she reports that she is 99% improved. As pelvic reconstructive surgeons, we might dismiss recurrent rectal prolapses outside the scope of our practice. This new problem with entrance seal-induced rectal prolapse should be on our differential in the setting of recurrent rectal prolapse, especially if the prolapse is primarily anterior. Oftentimes, these patients see multiple specialists and undergo multiple unnecessary operations without improvement of symptoms. MRI can be obtained to confirm presence of the entrance seal preoperatively, and consultation of our colorectal colleagues is also essential in preoperative planning. In conclusion, we would recommend obliteration and reinforcement of the posterior cul-de-sac with sacral copepxy and cultiplasty as treatment for this previously undescribed phenomenon of an entrance seal-induced rectal prolapse. Thank you.

pelvic organ prolapse

enterocele-induced rectal prolapse

rectal prolapse

sacrocopalpexy

recurrent prolapse