Abdominal procedures usually considered to have a lower recurrence rate than perineal procedures, but this is not demonstrated in RCTs. There are two RCTs assessing the abdominal vs. perineal approach. The PROSPER trial [1] randomized 23 patients to abdominal procedures (suture posterior rectopexy and posterior rectopexy with resection) and 26 patients to perineal procedures (Altemeier and Delorme). The group allocation was controlled for age, ASA status and preoperative bowel function, with a median length of follow up of 36 months. Although underpowered, there was no statistical significance between abdominal (26 %) and perineal (20 %) operations regarding the incidence of recurrence (p = 0.8). In addition, PROSPER performed a non–randomized comparison between abdominal and perineal procedures, with reported recurrence rates of 13/68 (19 %) vs. 56/202 (28 %) respectively (p = 0.2). This is a higher abdominal recurrence rate (19-26 %) than previously quoted in the literature (~10 %). In another RCT, Deen et al. [4] allocated ten patients to each arm and median follow-up was 17 months. They reported no recurrence in the abdominal group and one recurrence in the perineal procedure group (NS). A third RCT from Germany comparing posterior rectopexy with resection and Delorme is ongoing and results are pending [5].

The University of Minnesota group reported their experience in one of the largest retrospective reviews in the literature [6]. They compared abdominal procedures (posterior rectopexy with and without resection) and perineal procedures (Altemeier or Delorme). Patients in the perineal group were significantly older and sicker (p = 0.001) and had shorter recurrence free survival than the abdominal group (p = 0.0001). The authors reported significantly lower recurrence rates after abdominal vs. perineal procedures (5 % vs. 16 %), despite longer follow up in the abdominal group (98 vs. 47 months respectively; p = 0.002; Table 31.2). Recurrences were usually seen within 3 years, regardless of the type of procedure.

Lee et al. [7] reported similar results in a retrospective review of 104 patients, noting more recurrences after perineal (15 %) than abdominal (6.3 %) procedures (p = 0.14). Yakut et al. [8] retrospectively looked at 94 patients and reported no recurrences after abdominal procedures (0/67) and four recurrences in 27 patients undergoing Delorme procedures (p < 0.01; Table 31.2). A smaller 10 year retrospective review from Ochsner Clinic [9] reported a higher incidence of recurrences after perineal procedures (16 %) compared to abdominal approach (8 %). However, this was not significant, possibly because of the small sample size.

The PROSPER trial [1] reported significant improvements from baseline for incontinence (Vaizey score), bowel function and quality of life (EQ-5D) after abdominal and perineal procedures, without significant differences between the groups. However, it is noteworthy that patients with a recurrence of their prolapse had significantly worse quality of life (p = 0.0009). In the abdominal arm, patients reported significantly increased ‘straining’, possibly related with constipation.

Deen et al. [4] reported that the perineal group had greater residual fecal incontinence (OR 13.50) and significantly lower maximal resting and squeeze pressures on manometry (p = 0.003; Table 31.3).

Mirroring PROSPER’s findings, Madoff and coworkers [6] large retrospective series noted improvement in continence, constipation, and overall satisfaction following both abdominal and perineal procedures, without significant differences between the two groups. However, Lee et al. [7] reported higher rates of persistent constipation following abdominal procedures (20.3 %) than after perineal procedures (15 %; p = 0.49), while perineal procedure patients struggled more often with persistent fecal incontinence (p = 0.054).

Yakut et al. [8] noted that both the abdominal (posterior rectopexy with and without resection) and perineal (Delorme) were effective treatments for rectal prolapse. They reported, however, a significant risk for sexual dysfunction in males (retrograde ejaculation and/or impotence) after posterior rectopexy, likely secondary to the pelvic dissection [8, 10].

Sexual dysfunction and persistent constipation may be more frequently encountered after abdominal procedures, while persistent incontinence may be more frequently encountered after perineal procedures.

There has been no significant difference in mortality in RCT or large retrospective reviews comparing abdominal and perineal procedures [1, 6, 7, 11, 12]. Morbidity is more frequent after abdominal procedures with longer length of stay, especially after open procedures. Morbidity reported in the PROSPER trial included four anastomotic leaks after Altemeier procedures, three of which were reported by one center. Deen et al. [4] reported prolonged ileus (n = 2), wound infection (n = 1), and anastomotic stricture (n = 1) following posterior rectopexy with resection [11]. Madoff and coworkers [6] reported bowel obstruction (n = 21) and anastomotic complications, such as leak, bleeding, and stricture (n = 7). Lee et al. [7] reported more frequent morbidity in the abdominal group, although not statistically significant, when compared to perineal resections (p = 0.40). Young et al. [12] evaluated 30 day NSQIP morbidity data after abdominal vs. perineal procedures in 3,254 patients of abdominal and found an increased morbidity after open posterior rectopexy with resection when compared to perineal procedures (OR: 1.89, p = 0.03; Table 31.3). Length of postoperative stay has been consistently shown to be significantly shorter after perineal procedure than after abdominal procedures [6, 7, 9, 11, 12].

Recurrence rates after Altemeier and Delorme procedures range vastly in the literature. In retrospective reviews with at least 40 patients, the recurrence rates range between 3–18 % after Altemeier procedures and 6–26 % after Delorme procedures [6, 13–17]. Follow-up in different series varied, up to 60 months, and recurrence rates tended to be higher with longer follow-up.

The only RCT to compare recurrence rates between the two perineal approaches is the PROSPER trial [1]. With 36 month follow up data and controlling for age and ASA status, there were fewer recurrences after Altemeier procedures (24/102; 24 %) than after Delorme procedures (31/99; 31 %; p = 0.4; Table 31.4).

Elagali et al. [18] recently compared recurrence rates between these two procedures and reported a significantly higher recurrence rate after Delorme procedures (16 % vs. 9 %; p = 0.07) with 13 months of follow-up in a retrospective study. Agachan et al. [19] reported no significant difference in recurrence rates between Delorme procedures and Altemeier procedures without levatorplasty. Patients with a concurrent levatorplasty at time of Altemeier procedure had a lower recurrence rate (p < 0.05). Concurrent levatorplasty has been shown to improve continence as well. Chun et al. [20] supported this finding in a retrospective review, noting significantly reduced recurrence rates (p = 0.05) and improved continence (p = 0.002) with the addition of levatorplasty with perineal proctectomy, when compared to perineal proctectomy only. Of historic interest, Dr. Altemeier originally described a concurrent levator plication with the proctectomy [13], but this has not always been used after the procedure was ‘re-introduced’ in the 1980s and 1990s by Gopal, Eftaiha et al. and Prasad et al. [21–23]. With respect to hand sewn vs. stapled anastomosis when performing the Altemeier technique, Boccasanta et al. [24], randomized 20 patients in each arm and found no significant difference in recurrence between the two techniques.