Pelvic organs prolapse, including rectal prolapse (RP), is a condition that mainly affects women in middle and advanced age and can involve both the anterior and posterior compartments. A multidisciplinary approach is traditionally required, involving urologists, gynecologists, and colorectal surgeons [1]. Depending on the anatomy and the type of prolapse, symptoms may vary from urinary or fecal incontinence to obstructed defecation, pelvic pain, and sexual dysfunction. This condition may significantly worsen the quality of life (QoL) and represent an important social and economic burden in the setting of an aging population.

Surgery is the mainstay of treating this complex disease, and several abdominal and perineal approaches have been described to date. However, since multiple options are available, treatment may be surgeon-dependent and is influenced by many factors. Therefore, a tailored, multidisciplinary approach is recommended, with abdominal procedures usually performed in younger, healthier patients and perineal procedures offered to higher-risk individuals.

External rectal prolapse or symptomatic internal rectal prolapse with rectocele or enterocele are commonly treated with ventral rectopexy in fit patients.

The abdominal approach aims to reduce rectal mobility by fixation with or without excision of the redundant colon. Rectopexy is associated with lower recurrence risk than simple rectal mobilization, with a similar rate of overall complications [2]. Fixation of the prolapsed rectum to the sacral promontory is the key to restore the physiological anatomy of the pelvic floor. This goal can be achieved by simple suturing, as first described by D. Cutait in 1959 [3], or using a mesh fixed anteriorly, posteriorly, laterally, or all over the rectum. Many techniques have been described, such as the Ripstein rectopexy, based on the anterior fixation of a mesh below the sacral promontory, or the Wells procedure, with the detachment of the lateral ligaments of the rectum.

Both these approaches are associated with a significant complication rates and are currently abandoned [4,5].

There is no evidence as to whether associated sigmoidectomy results in better functional outcomes compared to a simple rectopexy. Resection rectopexy is thought to improve complaints of constipation, reducing the possible kinking of the redundant colon. However, it is a matter of fact that the creation of an anastomosis may increase the risk of severe complications [6,7,8]. Ventral rectopexy is typically performed laparoscopically and involves the anterior placement of a mesh to the sacral promontory, as described by D’Hoore [9]. It is favored over posterior mesh rectopexy since it reduces autonomic nerve injuries by avoiding postero-lateral dissection of the rectum. This approach thus reduces impairment of rectal motility that could potentially and ultimately lead to ongoing functional disfunction and impaired quality of life [10,11].

Since the introduction of the minimally invasive treatment for rectal prolapse in the early 90 s [12], the uptake of laparoscopy has been progressively growing to treat this condition. The benefits of the minimally invasive approach are well known in terms of faster recovery and normal return to daily activities, lower morbidity, decreased postoperative pain, shorter length of stay, and lower blood loss and the laparoscopic approach as the preferred technique has been recommended by several authors [13,14,15,16]. Laparoscopy has shown similar outcomes compared to the open technique for the surgical treatment of rectal prolapse [14,17]. A meta-analysis by Sajid et al. in 2010 reported no statistically significant difference between 688 patients treated with an open or laparoscopic approach in terms of recurrence, functional outcomes, and complication rate. Moreover, they reported a shorter length of hospital stay in the laparoscopic group [18]. However, the laparoscopic approach can be challenging, especially in the deep and narrow pelvis or in the setting of morbid obesity.

Since its introduction, the uptake of robotic surgery in several fields of general surgery has constantly grown. Robotic assistance is rapidly increasing in pelvic floor surgery because of its advantages in complex maneuvers such as dissection and intracorporeal suturing in the deep narrow pelvis. The technical features of the available robotic platforms may potentially overcome the limitations of conventional laparoscopy, thanks to enhanced dexterity, a stable optical platform, and exposure (third arm) that allows for a “precision” surgery to be performed. Adequate traction and counter traction allow for optimal surgical field exposure following embryological planes with minimal tissue trauma and blood loss [19]. Moreover, it has the potential of shortening the learning curve even regarding rectal mesh rectopexy, as demonstrated in other surgical procedures [20,21].

1. Introduction