Ventral mesh rectopexy (VMR) is gaining popularity for the repair of full-thickness rectal prolapse. Its abdominal approach and nerve-sparing technique provide a lower recurrence rate and better functional outcomes. However, management of recurrent cases continues to be a challenge.  Biofeedback therapy has shown to improve bowel function and quality of life for postoperative colorectal patients. Perioperative biofeedback training has shown to improve symptoms associated with rectal prolapse. However, the role of biofeedback in the peri-operative management of rectal prolapse, especially in conjunction with VMR, has yet to be studied. Thus, this study aims to bridge this gap in the literature by potentially identifying a non-invasive adjunct therapy to further improve patient outcomes. We aim to investigate whether the use of perioperative biofeedback sessions could result in lower recurrence rates after VMR.

Patients who underwent VMR for a full-thickness rectal prolapse between 2012-2022 were included in the study. Data included baseline characteristics such as age, gender, ethnicity, and socioeconomic status, body mass index (BMI), smoking status, ASA grade, previous pelvic floor or rectal prolapse surgery, preoperative investigations, type of rectal prolapse (low versus high take-off), biofeedback clinics attended before and after surgery, surgical approach (robotic versus laparoscopic), postoperative complications and recurrence.

VMR was performed in 83 patients with female dominance (90.4%). The median age of the patients was 64 years and the mean BMI was 25. Diagnosis of rectal prolapse was made clinically in 32.5% patients and a defaecating proctogram was performed in 59%. Previous rectal prolapse surgery had been performed on 29 (35%) patients. Joint Urogynaecological and Colorectal procedures were performed in 5 patients. Further details are mentioned in Table 1.  

VMR was performed robotically in 28 patients, while laparoscopic repair was performed in 55. Biological mesh was used in all patients. The median length of follow-up was 495 days. 61% of patients attended the bowel retraining program for biofeedback pre-operatively and 52% after the surgery. Biofeedback was attended both pre- and post-operatively by 27.7% of patients, and 21.7% did not attend any biofeedback peri-operatively. Post-operative complications were recorded for 8 patients. 
Recurrence of rectal prolapse occurred in 20 (26.3%) patients at a median duration of 370 days. The diagnosis of recurrence was made clinically in 80% patients while a defaecating proctogram was performed in 4 (20%). Table 2 provides peri-operative details.  

Recurrence of rectal prolapse was more likely to be seen in patients who underwent bowel function retraining after surgery when compared to those who did not have any bowel function retraining preoperatively (35.7% versus 14.7%, p-value 0.039). However, there was no difference in recurrence of the prolapse when patients who underwent biofeedback both before and after surgery were compared to those who did not undergo any biofeedback peri-operatively. 
No association was established between recurrence of rectal prolapse and gender, age, ethnicity, socioeconomic status, smoking status, ASA grade, previous pelvic floor or rectal prolapse surgery, joint procedure with Urogynaecologists, surgical approach (robotic versus laparoscopic) and high versus low take-off rectal prolapse. Table 3 shows predictors of recurrence of rectal prolapse post ventral mesh rectopexy.

-	Ventral mesh rectopexy for the repair of rectal prolapse has acceptable morbidity, however, recurrence rates are high. 
-	Recurrence is independent of previous rectal prolapse repairs. 
-	In this study, peri-operative biofeedback did not show a reduction in recurrence.

Future prospective studies are needed to explore risk factors for recurrence and to ascertain if correction of pelvic floor function via bowel retraining is crucial to good anatomic and functional outcomes after VMR.

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