1. Pelvic Floor Disorders-Rectal Prolapse
Dr. Brij B. Agarwal
MBBS, MS (Gold Medalist) FIMSA
Dip Yoga (Gold Medalist) FCLS
Vice Chairman
Professor & Senior Consultant, Department of Laparoscopic & General Surgery,
GRIPMER  & Sir Ganga Ram Hospital, Dilli, Bharat
International Advisor, SLS America
Secretary, Association of Surgeons of India, Dilli
Associate Editor, Indian Journal of Surgery
Vice President, International Society of Colo-Proctology
Chairman, Delhi State, International Medical Sciences Academy (IMSA)
Brij B.Agarwal , 60thFoundation Day, KGMU

2. Presenter Disclosure Slide
Thank you Prof. Kul Ranjan Singh & Prof. Arshad Ahmad for the support
Dr. Brij B. Agarwal
Vice Chairman
Department of Laparoscopic & General Surgery,
GRIPMER  & Sir Ganga Ram Hospital, Dilli, Bharat
Nothing To Disclose
(My interest in Pelvic Floor Dysfunction is a spill over of compliments I received for STARR, husbands telling me “Dr. you have given me a new wife)

3. Understanding Pelvic Floor Dysfunction -From Bathroom to Bed room

4. Introduction
MR Pelvicography has improved our understanding of dynamic anatomy of pelvic floor hitherto gained from non-functional cadaveric teaching.
Constipation, so far an index presentation of pelvic floor dysfunction (PFD), is usually accompanied by urogenital manifestations.
Internal Rectal Prolapse with ODS can be successfully managed by STARR
Trans Anal resection of rectum has thrown exciting possibilities for the management of rectal prolapse
Agarwal BB et al. Stapled trans-anal rectal resection (starr) for obstructed defecation syndrome-early results of a prospective study. Surg Endosc (2010) 24:S1–S61
Agarwal BB, Chintamani, Mahajan KC. Pelvic Floor Dysfunction: Reinventing the Spokes of the Wheel. JIMSA 2012; 25(1) :7
Agarwal B.B et al. Stapled transanal rectal resection (STARR): Results of the first Asian experience. The Ganga Ram Journal 2011;1(3);
Brij B.Agarwal , 60thFoundation Day, KGMU

5. Pelvic Floor – Introduction
Pelvic floor is a dome-shaped striated muscular enclosure
It has two important functions that are distinct and unrelated
Physical support to pelvic viscera - Pubo-ileo-ischiococcygeus
Constrictor mechanism to anal canal, vagina and urethra – Puborectalis
Agarwal S (2012) JIMSA.25 (1):19-21
Brij B.Agarwal , 60thFoundation Day, KGMU

6. Pelvic Floor Constrictors
Urethra
Internal (Bladder Neck) sphincter + External sphincter
Anal Canal
Internal anal sphincter + External anal sphincter
Vagina
Puborectalis
Brij B.Agarwal , 60thFoundation Day, KGMU

7. Pelvic Floor Constrictors
Puborectalis is an important third sphincter to urethra and anal canal.
 Hence puborectalis has a constrictor role in all the three tubes. “The levator ani is one of those muscles which has been studied the most and the one about which we know the least.” Thompson
Raizada Vet.al.(2008) Gastroenterol Clin N Am.37:
Brij B.Agarwal , 60thFoundation Day, KGMU

8. Three spokes of the pelvic wheel
Anterior compartment i.e. urethra
Middle compartment i.e. genitalia/vagina
Posterior compartment i.e. anal canal
Unfortunately, we surgeons are fixed at the anal canal because constipation has become an index of pelvic floor dysfunction (PFD).
Lower urinary tract symptoms (LUTS) have long been known 
Agarwal BB (2012) JIMSA:25(1):13
Brij B.Agarwal , 60thFoundation Day, KGMU

9. Pelvic floor dysfunction- Current paradigms
PFD affects both genders but early identification in females has led to much scientific research in their role in quality of life.
Posterior compartment failure
Rectal Prolapse/ODS/incontinence
Anterior compartment failure
LUTS
Middle compartment failure
Sexual dysfunction
Agarwal BB (2012) JIMSA.25(1):13
Brij B.Agarwal , 60thFoundation Day, KGMU

10. Is Middle Pelvic compartment stand alone unit? No
The three compartments of pelvic wheel have perfect synergy + harmony.
Neglecting any compartmental symptoms leads to unsatisfactory outcomes.
Erectile dysfunction is a known component of symptomatic hemorrhoids.
LUTS are known to cause sexual dysfunction.
Female cyclist have FSD due to altered pelvic floor dynamics .
Pilkington SA etal (2000) Ann R Coll Surg Eng
Agarwal BB, Chintamani. (20212) JIMSA.25(10):13
Keller JJ, Lin HC (2012) Int. J Androl.doi:
Zyczynski H Metal (2012) Am J Gynecol.(Ahead of Publication)
Voorham-van Zalm PJ et al.(2008) J Sex Med. 5(4):
Brij B.Agarwal , 60thFoundation Day, KGMU

11. Role of vaginal connective tissue in bladder and anorectal dysfunction
The circles indicate the intimate relationship between the fascia and ligaments ensheathing bladder, vagina and anorectum
Red circles: attachment points of ligaments and fascia to vagina and bladder; blue circles, to vagina and rectum.
The circles pictorially explain the relationship between birth, urinary and feces dysfunction.
CL = cardinal ligament; PB = perineal body
Brij B.Agarwal , 60thFoundation Day, KGMU

12. Muscles and ligaments of the pelvic floor 3D schematic sagittal view, ano-rectum closed
Organs
B = bladder; R = rectum; V = vagina; U = uterus;
Ligaments and fascia: pubourethral ligament (PUL); uterosacral ligament (USL); PB = perineal body;
RVF = rectovaginal fascia; Cardinal ligament (not shown) attached to anterior part of cervical ring (CX). Muscles upper layer: PCM = anterior portion of m.puboccygeus; LP = levator plate; middle layer
LMA = longitudinal muscle of the anus; PRM = m. puborectalis; lower (anchoring) layer: EAS = external anal sphincter; PM = muscles of the perineal membrane.
Brij B.Agarwal , 60thFoundation Day, KGMU

13. Levator Ani/Pubovisceralis Muscle ?? Innervation Mystery
“The doctrine of continuity of muscles of independent actions has been applied to levator ani, and this ancient error renewed time and again has complicated its study.” Sappey
 Functionally/neurologically 16 distinct portions of pubovisceralis are inserted into the urethra, genitalia, perineal body and anal canal i.e. pubourethralis, pubovaginalis, puboperinealis and puboanalis etc.
 MR – Pelvicography has outlined the anatomy of pelvic floor much more clearly than was known from cadaver dissections
Lawsen IO (1974) Ann R Coll Surg Engl.54:244-52
Kearny R et al. Obstet Gynecol Jul; 104(1): 168–173
Brij B.Agarwal , 60thFoundation Day, KGMU

14. “There is no considerable muscle in the body whose form and function are more difficult to understand than those of the levator ani, and about which such nebulous impressions prevail.”
Despite a century of medical progress since Dickinson offered this observation, the details of levator ani muscle anatomy remain poorly understood.
Dickinson RL. Studies of the levator ani muscle. Am J Obstet 1889;9:898–917

15. Terminology of PFD
> 250 symptoms complexes identified in six presentations
Urinary incontinence symptoms
Bladder storage symptoms
Pelvic organ prolapse symptoms
Sexual dysfunction symptoms
Anorectal dysfunction symptoms
Pelvic pain syndromes
Haylen BT et al (2010) Neurology and Urodynamics.29:4-20
Brij B.Agarwal , 60thFoundation Day, KGMU

16. Urinary Incontinence Symptoms
Urinary incontinence: Involuntary loss of urine
 Stress incontinence
Urge incontinence
Postural incontinence
Nocturnal Enuresis
Insensible incontinence
Coital incontinence
Haylen BT et al (2010) Neurology and Urodynamics.29:4-20
Brij B.Agarwal , 60thFoundation Day, KGMU

17. Bladder Storage Symptoms
Day time frequency
Nocturia
Urgency
Overactive bladder syndrome
Hesitancy, Intermittency, Straining
Incomplete evacuation
Voiding / postmicturition leakage
Haylen BT et al (2010) Neurology and Urodynamics.29:4-20
Brij B.Agarwal , 60thFoundation Day, KGMU

18. Pelvic Organ Prolapse (POP) Symptoms
Departure from normal sensation, structure or function experienced by woman in relation to her pelvic organs especially at times of activity of required activity
Vaginal bulging; felt or seen by mirror
Pelvic pressure / drag
Bleeding / Discharge / Irritation
Splintting / Digitation for voiding / Defecation
Low backache
Haylen BT et al (2010) Neurology and Urodynamics.29:4-20
Brij B.Agarwal , 60thFoundation Day, KGMU

19. Symptoms of Anorectal Dysfunction
Incontinence
ODS
Haylen BT et al (2010) Neurology and Urodynamics.29:4-20
Brij B.Agarwal , 60thFoundation Day, KGMU

20. Pelvic Pain Syndrome Pudendal Neuralgia (Nantes Criteria)
Pain in anatomical region of pudendal innervation
Pain that is worse in sitting
No waking at night with pain
No sensory deficit on examination
Relief of symptoms with a pudendal block
Recurrence with demonstrated PFD
Haylen BT et al (2010) Neurology and Urodynamics.29:4-20
Labat JJ et al (2008) Neurourol Urodyn.27:
Brij B.Agarwal , 60thFoundation Day, KGMU

21. Mechanical Basis for RP (No Consensus)
“Sliding Hiatus Hernia” theory:
Moschcowitz 1912
Intussusception led theory
Hunter 1811
Pudendal neuropraxia theory
Park 1977
Musculo-ligamentous laxity based theory
Lack of rectal fixation / mobile mesorectum: Small gut pushes the rectum X
Moschcowitz AV (1912) The pathogenesis, anatomy and cure of prolapse of the rectum. Surg Gynecol Obstet 15:7–21
Monro A (1811) The morbid anatomy of the human gullet, stomach, and intestines. Archibald Constable & Co, Edinburgh, pp 363
Porter N (1961) A physiological study of the pelvic floor in rectal prolapse. Ann R Coll Surg Engl 31:379–404
Broden B, Snellman B (1968) Procidentia of the rectum studied with cineradiography. Dis Colon Rectum 11:330–347 
Kuijpers HC (1992) Treatment of complete rectal prolapse: to narrow, to wrap, to suspend, to fix, to encircle, to plicate or to resect? World J Surg 16:826–830 
Parks AG, Swash M, Urich H (1977) Sphincter denervation in anorectal incontinence and rectal prolapse. Gut 18:656–665 
Brij B.Agarwal , 60thFoundation Day, KGMU

22. Surgical Approach to Rectal prolapse
Abdominal- conventional, Laparoscopic, Robotic
- Resection, Mesh/Sponge Rectopexy/ Suture Rectopexy
Perineal - Delorme/ Altemeier
TransAnal STARR. Trans-Starr
Pelvic Prolapse-- POPSTARR
Brij B.Agarwal , 60thFoundation Day, KGMU

23. Internal rectal Prolapse Mucosal Prolapse/ Intussusception Syndrome
SRUS Solitary Rectal Ulcer Syndrome
ODS Obstructed Defecation Syndrome
SRUS + ODS = Mucosal prolapse/ Intussusception syndromes
Brij B.Agarwal , 60thFoundation Day, KGMU

24. What is Mucosal Prolapse Syndrome?
1830-First described by Cruveilhier,
1969-Recognized as a clinical entity by Madigan and Morson.
About 80% of patients are < 50 > 40 Years (Mean 49?)
There is a female preponderance
The condition is associated with an evacuation disorder/ ODS
Defecography has shown that an intussusception is usually present
Ulceration results during forceful straining against failed outlet.
Presents with rectal bleeding, mucus, pain, tenesmus usually with ODS.
GastroenterolClin North Am Sep;37(3):645-68, Felt-Bersma RJ, Tiersma ES, Cuesta MA.
Brij B.Agarwal , 60thFoundation Day, KGMU

25. J Clin Pathol Nov;36(11):1264-8
Mucosal prolapse syndrome--a unifying concept for solitary ulcer syndrome, ODS and related disorders
duBoulay CE, Fairbrother J, Isaacson PG.
Histological and histo-chemical features of SURS and rectal prolapse are characteristically identical.
Hence the term "mucosal prolapse syndrome" be used.
As mucosal prolapse--overt or occult is the underlying mechanism.
Changes due to traction ischaemia on submucosal vasculature
Brij B.Agarwal , 60thFoundation Day, KGMU

26. Br J Surg Mar;76(3):290-5.
A common pathophysiology for full thickness rectal prolapse, anterior mucosal prolapse and solitary rectal ulcer.
Sun WM, Read NW, Donnelly TC, Bannister JJ, Shorthouse AJ. University of Sheffield, UK.
Study- based upon High Resolution Manometry
Similar manometry in rectal prolapse, anterior mucosal prolapse, ODS & SRUS
They share a common pathophysiology.
Brij B.Agarwal , 60thFoundation Day, KGMU

27. Natural history of anterior mucosal prolapse-Evolution of ODS?
Br J Surg Aug;74(8):
Natural history of anterior mucosal prolapse-Evolution of ODS?
Allen-Mersh TG, Henry MM, Nicholls RJ. St. Mark's Hospital, London.
From patients (M:F, 1:2.7; age / years)
Mucosal prolapse cases at one hospital
Symptoms described were those of what we call ODS now
Brij B.Agarwal , 60thFoundation Day, KGMU

28. Trans Anal Procedures (NOTES)
What is the evidence?

29. GERMAN EXPERIENCE
Langenbecks Arch Surg. 2010 Jun;395(5): Epub 2010 Jun 13.
Assessing the safety, effectiveness, and quality of life after the STARR procedure for obstructed defecation: results of the German STARR registry.
Schwandner O. et al.
CONCLUSION:
Correction of internal rectal prolapse & Intussusception is the basis for efficacy of STARR in ODS
Brij B.Agarwal (2012) Innovations in Coloproctology, Berlin
Brij B.Agarwal , 60thFoundation Day, KGMU

30. Italian Experience Surg Innov. 2011 Sep;18(3):248-53. Epub 2011 Feb 8.
Stapled trans-anal rectal resection (STARR) in the surgical treatment of the obstructed defecation syndrome: results of STARR Italian Registry.
Stuto A, et al.
CONCLUSION:
The analysis of data seems to confirm that STARR is a safe and effective procedure in the treatment of ODS.
Correction of internal rectal prolapse & Intussusception is the basis for efficacy of STARR in ODS
Brij B.Agarwal (2012) Innovations in Coloproctology, Berlin
Brij B.Agarwal , 60thFoundation Day, KGMU

31. European Experience
Dis Colon Rectum. 2009 Jul;52(7): ; discussion
Stapled transanal rectal resection for obstructed defecation syndrome: one-year results of the European STARR Registry.
Jayne DG, Schwandner O, Stuto A.
CONCLUSION:
STARR produces improved function and better HrQoL in patients of ODS, that is maintained at 12 months of follow-up.
Correction of internal rectal prolapse & Intussusception is the basis for efficacy of STARR in ODS
Brij B.Agarwal (2012) Innovations in Coloproctology, Berlin
Brij B.Agarwal , 60thFoundation Day, KGMU

32. What is STARR? STARR -Stapled Trans-anal Resection Rectopexy
Usually reserved for surgically treatable ODS
Brij B.Agarwal , 60thFoundation Day, KGMU

33. Why do Resection Rectopexy for ODS?
ODS is manifestation of rectal intussusception
Can be Recto-Rectal or Recto-Anal Intussusception (RRI-RAI)
Rectal prolapse identified as end point of RRI by Hunter 1811
Confirmed on cineradiography by Broden and Snellman
Usually intussusception starts 6-8 cm from anal verge
Rectopexy wth / without resection is the surgical strategy for RP
Monro A (1811) The morbid anatomy of the human gullet, stomach, and intestines. Archibald Constable & Co, Edinburgh, pp 363
Broden B, Snellman B (1968) Procidentia of the rectum studied with cineradiography. Dis Colon Rectum 11:330–347 
Devadhar DSC (1965) A new concept of mechanism and treatment of rectal procidentia. Dis Colon Rectum 8:75–81
Pantowitz D, Levine E (1975) The mechanism of rectal prolapse. S Afr J Surg 13:53–56
Brij B.Agarwal , 60thFoundation Day, KGMU

34. Why to do a full thickness resection when intussusception in ODS is thought to be mucosal?
Aim is complete amputation of the Intussusceptum.
MR imaging has revealed that intussusception is full thickness.
Sero-serosal anastomosis , ensures perirectal inflammatory fibrosis which ensures fixation of rectum by perirectal fibrosis to preempt recurrence.
Brij B.Agarwal , 60thFoundation Day, KGMU

35. Why then do A Rectal Resection that is Blind and not Uniform in extent of resection from Mucosa to Serosa?
An enterocele considered contraindication for STARR
But we can do Laparoscopy guided STARR in eneterocele
The end point is complete intussusceptum excision + full thickness rectal procedure with serosal transection & anastomosis
Brij B.Agarwal , 60thFoundation Day, KGMU

36. Why not Routine Rectopexy Procedures?
> 100 procedures described
>suture pexy; mesh (ant/post)pexy ; resection+/- pexy.
Approaches for all Abdominal/ laparoscopic/ Perineal
Rectum approached centripetally from lateral to medial
Centripetal approach trangresses the pararectal structures
It is potential insult to many structures specially nerves
Violation of peritoneal virginity for an extra-peritoneal issue
STARR approach is centrifugal; unwanted insult avoided.
Brij B.Agarwal , 60thFoundation Day, KGMU

37. Is there any procedure that was a Bench Mark For Evaluating STARR?
There is no ‘gold standard’ for comparison
No technique incorporates the extensive rectal resection of STARR.
Hence, a good randomized clinical trial is probably not achievable.
So RCT not recommended for Level 1 evidence for evaluating STARR
Jayne DG, Finan PJ. Stapled transanal rectal resection for obstructed defaecation and evidence-based practice. Br J Surg 2005; 92: 793–794.
Brij B.Agarwal , 60thFoundation Day, KGMU

38. STARR Efficacy Good or excellent clinical outcome parameters
< 2 episodes per month or symptoms free
> 50% fall in ODS score at 1 year
Improvement in quality of life
Systemic Review by NICE
STARR – Biofeedback 82% v/s 33% P <0.0001
STARR – Mean ODS reduction from 17.8 to 5.8
STARR- Significant HrQoL improvement
NICE guideline
Brij B.Agarwal , 60thFoundation Day, KGMU

39. Safety of STARR Adverse Outcome (Excluding Routine i. e
Safety of STARR Adverse Outcome (Excluding Routine i.e. Urine Retention like issues)
Rectal Bleeding: 2.7 to 11% (4% in European Registry)
Rectal Stricture: 1.2 to 3.6% (Managed by dilatation)
Rectal Obliteration: One case reported
De Novo Pelvic Pain: %
(Piriformis syndrome: Staple related- Agraphectomy)
Rectal Diverticulum: Technical issue
Pescatori M, Gagliardi G (2008) Tech Coloproctal 12:7-19
NICE guideline
Ratnatunga K et al (2010) Tech Coloproctol, 14:
Brij B.Agarwal , 60thFoundation Day, KGMU

40. Safety of STARR Adverse Outcome
Urgency: 22-23% at one year: commonest cause of dissatisfaction
De Novo Incontinence: 3-19%
Rectovaginal Fistula
3 cases reported, attributed to ischemia/hematoma
Rectal Perforation/Pelvic Sepsis: 3.2% , a fatal case reported; hence antibiotics.
Pescatori M, Gagliardi G (2008) Tech Coloproctal 12:7-19
NICE guideline
Ratnatunga K et al (2010) Tech Coloproctol, 14:
Brij B.Agarwal , 60thFoundation Day, KGMU

41. Adverse Outcomes in Our Experience April 2008-Feb 2013 n=317
Staple line Dehiscence = 2 (PPH03)
Rectal Perforation = 1 ? Retractor
Vaginal Injury = 1 Hubris
Retention of Urine has come down-Lessons Learnt
Bleeding not seen = Learnt from PPH Experience
Non-responders = 7 (2%+)
Chronic Pain = 3
Unsatisfied Patients = (2 in last 3 years)
Anal Canal Stenosis = ( one symptomatic, one happy)
Brij B.Agarwal , 60thFoundation Day, KGMU

42. Our Results > 60 months Follow Up
Improved ODS scores statistically stable from 3 months onwards
The long-term concern- perineal discomfort and pain
(reported by 2 females till now in the reported group)
This may be the pyriformis syndrome or staple line issue
Granuloma/ Abscess
Ratnatunga K et al (2010) Tech Coloproctol 14:197-98
Levin A, Lysy J (2011) Int J Colorectal Dis 26:955
Brij B.Agarwal , 60thFoundation Day, KGMU

43. ODS improvement vs IRIL
Difference in Preop and Postop Scores = * IAIRP (p = 0.000)
Brij B.Agarwal (2012) Innovations in Coloproctology, Berlin
Brij B.Agarwal , 60thFoundation Day, KGMU

44. Predictive IRIL for Outcome Positivity
AUC = (p = 0.000, 95% CI – 1.00)
Best Cut off IRIL to predict = 2.75 cm (Sensitivity = 100%, Specificity = 79.2%)
Brij B.Agarwal (2012) Innovations in Coloproctology, Berlin
Brij B.Agarwal , 60thFoundation Day, KGMU

45. Pelvic Floor Reconstructive Surgery
Ideally, the goal of pelvic reconstructive surgery is to address each pelvic compartment separately and provide adequate repair to restore the normal anatomy and functionality of the pelvic floor as a whole.
Barber MD. et al.  Cleve. Clin. J. Med.72(3), (2005).
Brij B.Agarwal , 60thFoundation Day, KGMU

46. PFD Road Ahead
Adequately powered and well-planned randomized, controlled trials are urgently needed to reliably assess sexual function after pelvic surgery.
This can happen only with surgeons looking at the pelvic floor as a unit, a wheel with many spokes
Brij B.Agarwal , 60thFoundation Day, KGMU

47. Brij B.Agarwal , 60thFoundation Day, KGMU

48. POPSTARR

49. ODS Journey Our ODS-STARR Related Publications (2008-2013)
Agarwal BB.et al. Stapled trans-anal rectal resection for obstructed defecation syndrome: three year results of the first asian experience. Surg Endosc (2013) ahead of publication
Agarwal BB. STARR procedure for obstructed defecation syndrome. How I do it? JIMSA (2013) ahead of publication.
Agarwal N. et al.effect of continuing yoga practice on the adverse patient reported outcomes following stapled trans-anal resection of the rectum (STARR) for obstructed defecation syndrome(ODS). Surg Endosc (2013) ahead of publication
Agarwal BB et al. Pelvic Floor Dysfunction: Reinventing the Spokes of the Wheel. JIMSA 2012; 25(1) :7
Agarwal BB et al. Can Yoga Improve the Outcomes of Surgery for Haemorrhoids? A Prospective Randomized Controlled Study. JIMSA 2012; 25(1) :37-40
Agarwal BB et al. Scoring systemsin evaluation of constipation and obstructed defecation syndrome (ODS). JIMSA 2012;25(1);57-59
Agarwal BB et al. Stapled transanal rectal resection (STARR): Results of the first Asian experience. The Ganga Ram Journal 2011;1(3);
Agarwal BB. Do dietary spices impair the patient-reported outcomes for stapled hemorrhoidopexy? A randomized controlled study. Surg Endosc May;25(5):
Agarwal BB et al. Stapled trans-anal rectal resection (STARR) for obstructed defecation syndrome: Early results of a prospective study. Surg Endosc 2010; 24: O094–S29.
Agarwal BB et al. Stapled transanal rectal resection (STARR) for obstructive defecation syndrome: A prospective study with 6 months follow up. Surg Endosc 2010; 24: P123–S384.
Agarwal BB et al. Effect of yoga exercises on outcome of stapled hemorrhoidectomy: results of a prospective randomized controlled study , Surg Endosc (2008) 22:S150
Brij B.Agarwal , 60thFoundation Day, KGMU

50. Thank You Acknowledgement:
Pooja, Ramneek, Krisna Adit Agarwal & Nayan Agarwal
Brij B.Agarwal , 60thFoundation Day, KGMU