Beyond stapled transanal rectal resection vs ventral rectopexy dichotomy: Toward a phenotype-guided surgical paradigm for obstructed defecation syndrome

Table 1 Comparative clinical outcomes between stapled transanal rectal resection and ventral rectopexy[5,6,18,43-48]

Outcome	STARR	VR	Ref.
Symptomatic recurrence (5-10 years)	20%-40% (up to about 40% at 10 years)	< 10% (about 8%-10% at 10 years)	Schiano di Visconte[5]; Mandovra et al[43]; Barra et al[44]
Symptom improvement at 12 months	70%-90% (approximately 85% in one series)	70%-90% (durable relief)	Schiano di Visconte[5]; Mandovra et al[43]; Mäkelä-Kaikkonen et al[45]
Anatomical recurrence	Approximately 20%-38% (rectocele/intussusception)	< 5%-8%	Mandovra et al[43]; Barra et al[44]
Surgical re-intervention rate	Up to about 20%-25%	< 10%	Mäkelä-Kaikkonen et al[45]; Gagliardi et al[46]
Quality-of-life improvement	Improves initially but declines at long-term follow-up	Stable/sustained improvement	Mandovra et al[43]; Mäkelä-Kaikkonen et al[45]
Procedure-specific complications	Urgency, pain/tenesmus (approximately 20%); rare anastomotic dehiscence or fistula	Mesh-related complications about 1%-2% (erosion about 0.9%); rare mesh detachment	Hess et al[47]; Ripamonti et al[18]
Patient satisfaction	About 70%-75% overall long-term satisfaction; about 20%-35% “very satisfied” at 10 years	About 70%-85% “high satisfaction” at 2 years	Mandovra et al[43]; Mäkelä-Kaikkonen et al[45]; Schiano di Visconte et al[6]
Mean operative time	Approximately 40 minutes	Approximately 115 minutes	Mandovra et al[43]; Mandovra et al[48]
Hospital stay (days)	Approximately 2.1 days	Approximately 3.3 days	Mandovra et al[43]; Mandovra et al[48]

Reported ranges reflect variability within cohorts and follow-up periods. VR: Ventral rectopexy; STARR: Stapled transanal rectal resection.

Table 2 Stratified treatment recommendations by phenotype

Phenotype	Key clinical features	Diagnostic findings (defecography/HRAM)	Recommended primary intervention	Rationale/clinical notes
Isolated structural ODS	Single anatomical defect (large rectocele or low-grade internal intussusception); preserved sphincter function and no major dyssynergia	Defecography: Solitary rectocele or low-grade internal prolapse without multi-compartment involvement; HRAM: Normal relaxation pattern and adequate rectal propulsive pressure	STARR or targeted local repair (e.g., site-specific rectocele repair)	Minimally invasive and directly addresses the mechanical obstruction; high symptom relief and satisfaction (> 80%) in appropriately selected “simple” ODS when continence and coordination are preserved
Complex structural ODS (multi-compartment)	Combined defects (e.g., rectocele with intussusception and/or enterocele and/or perineal descent) or high-grade internal prolapse approaching external prolapse	Defecography: Multi-compartment pelvic organ prolapse (anterior, apical, and posterior compartments) or high-grade internal prolapse; HRAM: Generally preserved coordination but anatomical obstruction predominates	Ventral rectopexy (LVMR/RVMR) and/or adjunct pelvic repairs; in selected women with multi-organ pelvic support defects, POPS with or without concomitant transanal repair	Provides comprehensive anatomical correction and pelvic support with long-term recurrence < 10%; VR addresses combined rectocele with intussusception and reduces perineal descent; in multi-compartment female prolapse, POPS offers comparable ODS relief while avoiding extensive sacral dissection, preserving sexual function, and remaining fully compatible with transanal procedures
Functional ODS with dyssynergia (types I-III FDD)	Outlet obstruction without structural lesion; paradoxical contraction or incomplete relaxation of the pelvic floor during attempted defecation	Defecography: Minimal or absent mechanical obstruction; HRAM: Types I-III coordination failure (paradoxical contraction, inadequate relaxation, or mixed pattern); Balloon expulsion test: Prolonged or failed	First-line: Pelvic-floor biofeedback and retraining; Second-line adjunct in refractory cases: Targeted botulinum toxin injection to puborectalis and/or internal anal sphincter	Corrects functional dyssynergia and avoids unnecessary surgery; success in up to 70% of patients; adjunctive botulinum toxin can transiently reduce hypertonicity, facilitate pelvic floor relaxation, and enhance the effectiveness of biofeedback in selected refractory cases within a multimodal rehabilitation strategy
Rectal inertia (type IV FDD)	Severe outlet obstruction with marked straining, sense of incomplete evacuation, often associated with slow-transit constipation; anal relaxation preserved but expulsive force inadequate	Defecography: Little or no fixed mechanical obstruction despite persistent incomplete emptying; HRAM: Type IV pattern with normal or adequate anal relaxation but markedly reduced rectal propulsive pressure (< 40 mmHg); Balloon expulsion: Markedly prolonged or failed	Motility-targeted therapies (intensified conservative measures, laxative optimization, and neuromodulation); in carefully selected severe cases with combined colonic/rectal inertia, consideration of resectional procedures; avoid suspensive operations such as STARR or ventral mesh rectopexy	Represents a distinct rectal inertia phenotype in which the primary defect is propulsion failure rather than obstruction; suspensive procedures may “anchor” a non-propulsive rectum and worsen symptoms without correcting motility; management should prioritize restoration of motility (including neuromodulation) and reserve resectional surgery for selected refractory patients, rather than applying standard suspensive ODS operations
Mixed ODS (structural with dyssynergia)	Coexistence of structural lesion (e.g., rectocele or internal intussusception) and functional defecatory disorder (paradoxical pelvic floor contraction)	Defecography: Demonstrable rectocele and/or internal prolapse; HRAM: Dyssynergic pattern (types I-III)	Stepwise multimodal therapy: Initial pelvic-floor physical therapy and biofeedback to correct dyssynergia, followed by anatomical correction (STARR, VR, or local repair as indicated by the dominant mechanical defect)	Surgery alone may only partially relieve symptoms when dyssynergia is ignored; treating the functional deficit first, then addressing the anatomical obstruction, reduces the risk of persistent ODS, postoperative urgency, and recurrence; staged, phenotype-guided management improves overall outcomes
ODS with compromised continence	ODS associated with weak sphincter, obstetric injury, or low anal pressures	HRAM: Low resting and/or squeeze pressures; Endoanal ultrasound or MRI may show sphincter defects; Clinical history of urge or passive incontinence	Avoid STARR; prefer VR, local rectocele repair; consider sacral neuromodulation when incontinence predominates and the structural component is minor	Preference for VR or local repairs mitigates the risk of continence deterioration and prevents iatrogenic anal sphincter injury
ODS with excessive perineal descent	Long-standing straining; perineal sagging or descent > 3 cm, often coexisting with rectocele or internal prolapse	Defecography or dynamic MRI: Perineal descent > 3 cm and pelvic floor laxity; Associated rectocele/intussusception may be present but does not fully explain outlet obstruction	Combined surgery: STARR with TPS or VR with TPS	Reinforces perineal body and prevents recurrence; emerging phenotype-guided strategy with improved long-term functional outcomes

ODS: Obstructed defecation syndrome; HRAM: High-resolution anorectal manometry; FDD: Functional defecatory disorder; MRI: Magnetic resonance imaging; STARR: Stapled transanal rectal resection; LVMR: Laparoscopic ventral mesh rectopexy; RVMR: Robotic ventral mesh rectopexy; POPS: Pelvic organ prolapse suspension; VR: Ventral rectopexy; TPS: Transverse perineal support.