Pelvic Floor Disorders: Surgical Approach

14. STARR and TRANSTARR Procedures

Antonio Brescia , Francesco Saverio Mari1, Marcello Gasparrini1 and Giuseppe R. Nigri1


Department of Medical and Surgical Sciences and Translational Medicine, School of Medicine and Psychology, Sapienza University of Rome, Rome, Italy

Antonio Brescia



Obstructed defecation syndrome (ODS) is characterized by a multifactorial etiology, resulting from the interaction of functional and anatomical factors that influence the rectoanal mechanism of evacuation [1]. The most common anatomical changes associated with ODS are rectocele and rectal intussusception [2].

14.1 Introduction

Obstructed defecation syndrome (ODS) is characterized by a multifactorial etiology, resulting from the interaction of functional and anatomical factors that influence the rectoanal mechanism of evacuation [1]. The most common anatomical changes associated with ODS are rectocele and rectal intussusception [2].

The surgical treatment of ODS is directed at resolution of the obstruction (rectorectal or rectoanal intussusception, external rectal prolapse, anterior rectocele, enterocele, and/or sigmoidocele) and to improve mechanical expulsive forces.

Based on the findings that the stapled hemorrhoidopexy could improve rectal evacuation through resection of the internal mucosal prolapse, Antonio Longo proposed stapled transanal rectal resection (STARR) in 2004 [3]. This procedure is a full-thickness resection of the lower rectum, and involves the use of two circular staplers. This gives an increase in the amount of resectable tissue compared with the initial technique for treatment of hemorrhoids.

Despite good functional results in terms of resolution of ODS, STARR has some limitations related to the use of an adapted and nondedicated stapler. The most important limitation is that the amount of resectable tissue is still limited by the capacity of the two-stapler housing that is not adequate to produce good results on larger prolapses.

The natural evolution of STARR is the TRANSTARR procedure, developed around a new stapler with a crescent-shaped profile; the stapler is known as the Contour Transtar (Ethicon EndoSurgery Inc., Cincinnati, Ohio, USA). This procedure is a full-thickness transanal resection of the entire rectal circumference. The new device is able to overcome the limitations of STARR; the length of rectal wall to be resected can be tailored to the patient’s anatomy and the surgeon’s choice, and is not limited by the stapler housing. Initially proposed as an evolution of and substitute for STARR, this technique is now complementary to STARR.

14.2 Surgical Indication and Exclusion Criteria

Patient selection is the key for successful surgical therapy in patients with ODS. Only those patients who have failed prior conservative treatment should be considered as suitable candidates for the transanal stapling techniques. Before considering referral of a patient with ODS to surgery, the anatomical abnormalities that form the basis of patient’s defecatory disorders should always be assessed.

Patients with anterior rectocele and/or rectal prolapse with rectoanal or rectorectal intussusception are the optimal candidates for a transanal stapling procedure. In the absence of rectocele or rectal prolapse, one should never consider a STARR or TRANSTARR procedure.

As outlined in the first consensus conference on STARR [4], and as a result of analysis of the Italian, German, and European STARR registries [57], it is recommended that transanal stapling techniques should never be performed in patients suffering from active anorectal infections or severe anorectal pathologies (i.e., anal stenosis, abscess or fistula, polyps, or incontinence). Also the presence of a concomitant proctitis (i.e., inflammatory bowel disease or radiation proctitis) should discourage the surgeon from performing a STARR or TRANSTARR procedure.

In the presence of inflammatory bowel disease or irritable bowel syndrome there is no agreement on whether or not to perform STARR or TRANSTARR, and many authors suggest that the indication should be considered on a case-by-case basis [47]. Nevertheless, the poor functional results reported for these patients suggest that a transanal stapling technique should not be recommended [56].

In cases of concomitant pelvic floor anatomical disorders, such as genital prolapse, enterocele, or urinary incontinence, the appropriate surgical approach (combined, sequential, or delayed) should be evaluated on a case-by-case basis, preferably by a multidisciplinary team experienced in pelvic floor disorders [47]. A nonsurgical approach, such as pelvic floor rehabilitation or medical therapy, is preferred in the presence of concomitant pelvic floor functional disorders (i.e., pelvic dyssynergy, anismus, anal hypotonia, and minor fecal incontinence), although a surgical approach can be used in patients who have been carefully evaluated [47].

In the presence of a previous rectal anastomosis (i.e., anterior or intersphincteric rectal resections, Altemeier, STARR, and stapler hemorrhoidopexy) or foreign material adjacent to the rectum, the execution of a transanal stapling technique must be considered carefully because of the high risk of surgical complications [47].

Finally, the presence of concomitant psychiatric disorders should always be excluded before scheduling STARR or TRANSTARR. In fact, psychiatric disorders have been observed in a significant proportion of patients with ODS [89].

14.3 STARR

14.3.1 Surgical Technique

The operation should be performed under general or caudal anesthesia, with the patient placed in the lithotomy position. The anal verge should be gently dilated manually and/or using the lubricated obturator of the circular anal dilator (CAD) in order to facilitate the introduction of the CAD into the anal canal. Finally the dilator should be held against the perineal skin by four knotted sutures.

The prolapse should be evaluated by exposing it through the CAD with a mounted gauze swab (Fig. 14.1a).


Fig 14.1

STARR technique. a Rectal prolapse evaluated by exposing it through the circular anal dilator with a mounted gauze swab. b Three separate one-half (180°) purse-string sutures are made to include the mucosa, submucosa, and rectal muscle wall, 1–2 cm above the apex of the hemorrhoidal ring. c The staple line is carefully inspected and eventually reinforced using reabsorbable 2-0/3-0 stitches at the end of the resection of the anterior rectal wall and subsequently after the resection of the posterior wall

Starting from the anterior rectal wall, the posterior wall must be protected by a retractor inserted in the anal canal through the lower hole of the CAD.

By introducing the purse-string anoscope in the CAD, three separate one-half (180°) purse-string sutures can be made, including the mucosa, submucosa, and rectal muscle wall, 1–2 cm above the apex of hemorrhoidal ring, in order to include both the top of the rectocele and the internal rectal prolapsed tissue (Fig. 14.1b). Polypropylene 2-0 sutures are usually used.

The opened circular stapler should be inserted into the anal canal through the CAD, with the anvil placed above the purse-strings. By using traction on the purse-strings, the prolapsed tissue is brought into the housing when closing the stapler. During this maneuver the posterior vaginal wall should be carefully inspected in order to avoid its entrapment in the staple line. Sometimes a minimal mucosal bridge left between the two edges of the anastomosis and can be removed with scissors.

At the end of the first resection, the staple line should be carefully inspected and eventually reinforced by using reabsorbable 2-0/3-0 stitches (Fig. 14.1c). This also to improve hemostasis.

The same procedure should be repeated for the posterior rectal wall. The retractor should now be inserted into the upper hole of the CAD.

The so-called “dog ear”, a protuberance that remains at the lateral intersections of the staple lines at the end of the procedure, should be oversewn.

14.3.2 Safety and Efficacy

Since its introduction, several studies have been conducted to demonstrate the safety and efficacy of STARR [911].

According to the data reported by the Italian, German, and European STARR registries, STARR is a safe procedure with a morbidity rate of 34% [57]. The most common reported complication is defecatory urgency, which affects 20–25% of patients. Although it is present in more than one-fifth of patients, the defecatory urgency tends to resolve spontaneously within a few weeks, with a very low percentage of patients continuing to have symptoms after 1 year [411].

Postoperative persistent pain is another complication of STARR. This complication has been reported with variable incidence (0.5–7%) in the various series described in the literature [511]. The pain seems to be mainly related to mistakes in surgical technique, such as the inappropriate placement of a low staple line. This is because different surgeons have different levels of familiarity with stapled-aided colonproctology techniques.

Less common, but always present in the various case series, is postoperative bleeding. This is reported in 5% of patients and often requires a reintervention [47].

Other complications include staple line complications (minor bleeding, infection, or partial dehiscence), fecal incontinence, septic events, and postsurgical stenosis; these occur in a small minority of patients [511]. Acute urinary retention reported by some authors seems to be more related to subarachnoid anesthesia rather than surgical technique [511].

Rectovaginal fistula, dyspareunia, and rectal necrosis are extremely uncommon, and only a few single cases have been reported [511].

The effectiveness of STARR in the treatment of ODS has been demonstrated by several studies [511]. The European STARR registry showed that symptoms of ODS were reduced after 12 months in 2,224 (78%) of 2,838 patients treated by STARR [6].

Also, the National Institute for Health and Care Excellence (NICE) recently recognized the efficacy of STARR, but stressed that, although there are limited data on this procedure, there are particularly good-quality comparative data and studies reporting on long-term outcomes [12].

Only a few trials with a median follow-up of more than 1 year have been reported. These, despite the small number of enrolled patients, appear to confirm good results for STARR in the correction of rectocele and rectal prolapse, with only a small percentage of patients reporting a worsening of symptoms [1315].

Of note is a recently published randomized controlled trial that showed an advantage in terms of reduced intraoperative bleeding and operative time with the use of PPH03 instead of PPH01 (Ethicon EndoSurgery) [16].

Recently, the introduction of newly circular staplers with a more spacious housing, also called “high-volume circular staplers”, may be able improve the results of STARR, but no good-quality data or comparative studies are yet available on the use of these devices [17].


14.4.1 Surgical Technique

Bowel-rectum preparation and antibiotic prophylaxis are recommended before this procedure. The patient should be in the lithotomy position and under general or spinal anesthesia.

The first step is the introduction of a CAD after careful dilatation of the anal verge with the obturator provided in the TRANSTARR kit. The surgeon must check that the dentate line is protected directly below the anal dilator. The CAD must be secured to the perianal skin with four stitches at 2, 4, 8 and 10 o’clock (Fig. 14.2a).


Fig. 14.2

TRANSTARR technique. a A circular anal dilator is introduced and secured to perianal skin with four stitches at 2, 4, 8 and 10 o’clock. b 4–5 polypropylene 2-0 sutures are placed in the form of parachute cords to control the prolapse during the resection. c Longitudinal opening of the prolapse with one firing of the Transtar CCS-30, with a linear stapler or between two Kocher clamps. d Rectal prolapse opened longitudinally. e Circumferential rectal resection with the Contour Transtar. f The posterior vaginal wall is inspected with a finger during the resection of the anterior rectal wall to prevent its entrapment in the staple line, as this can result in formation of a rectovaginal fistula

The prolapsed tissue should be pulled gently out through the CAD using a gauze pad and Allis forceps to evaluate the extent of the prolapse and assess the amount of tissue to be resected.

With the aid of the Allis forceps, the rectal wall should be unfolded to expose the apex of the prolapse in order to place 4–5 polypropylene 2-0 stitches, resembling parachute cords (Fig. 14.2b). The sutures must be positioned with two or three full-thickness bites to gain a solid traction on the prolapse. This maneuver must be performed with the use of the access suture anoscope provided with theTRANSTARR kit, being careful not to inadvertently catch some tissue from the opposite rectal wall or the vagina. These stitches allow the surgeon to achieve symmetrical traction of the prolapse around its circumference and to obtain good tissue control during resection.

The initial step provides a longitudinal opening of the prolapse with one firing of the CCS-30 Transtar (Fig. 14.2c). However, in presence of a large prolapse, this is not always easy and it often makes the loading of the prolapsed tissue between stapler jaws more difficult because of the presence of an irregular staple line or bundled tissue. To overcome this, it has been proposed that the prolapse be opened longitudinally with a linear stapler (but this increases the cost of the procedure), or by using two Kocher clamps placed at 2 and 4 o’clock to grab the prolapsed tissue, and then opening the prolapse with a cautery between the clamps (Fig. 14.2c, d) [1819].

Another one or two polypropylene 2-0 stitches should be placed on both sides of the deep vertex of the prolapse opening, to handle the prolapse during its insertion between the CCS-30 jaws for the first transverse firing. These stitches also act as a reference for the start and end-points of the circumferential resection, allowing the surgeon to prevent spiraling of the staple line. In fact, if the stapler is not well positioned at the bottom of the prolapse opening or it is not perpendicular to the rectum, an irregular or spiraling resection will result, thereby increasing the risk of complications. Using traction on the parachute stitches, it is then possible to start the circumferential rectal resection (Fig. 14.2e).

This maneuver is performed counterclockwise by ensuring that the stapler is placed at the base of the prolapse and perpendicular to the CAD. It is important not to bundle the tissue between the stapler jaws and to maintain the stapler at the same depth, using the CAD as a reference, to reduce the risk of spiraling and the formation of dog ears at the beginning and end of the mechanical suture. During the resection of the anterior rectal wall, the surgeon must be careful not to entrap the posterior vaginal wall in the suture, which can result in formation of a rectovaginal fistula (Fig. 14.2f). This can be achieved by pulling the posterior vaginal wall upward, and inspecting the vagina before firing the stapler.

Usually between four and six recharges are needed to complete resection of the rectum. If a number greater than six cartridges is needed, spiraling should be suspected.

At the end of the procedure, it is possible to place some reabsorbable stitches along the staple line to reinforce the suture and improve hemostasis, especially at the beginning and end-points of the metallic staples.

The resected specimen should always be inspected before the end of the procedure to exclude the presence of tissue not belonging to the rectum (enterocele, sigmoidocele). Before removing the CAD, some surgeons prefer to leave a hemostatic cylindrical sponge of regenerative oxidized cellulose in the rectum to further improve hemostasis.

14.4.2 Safety and Efficacy

Since the introduction of TRANSTARR in 2006, there have been only a few studies conducted to demonstrate the safety and efficacy of the procedure [1925].

As a result of its recent introduction, there are contrasting data on morbidity of the TRANSTARR procedure, with figures ranging from 7–16% to 60–62% [1926]. The case series with the higher morbidity are probably subject to complications related to the learning curve for the procedure. The data reported by colorectal surgeons who are experienced in transanal stapling techniques show a lower morbidity rate [19212326].

Following TRANSTARR, as well as STARR, the most common postoperative complication is fecal urgency, which affects 14–28% of patients [1925]. The incidence of this complication seems to be lower for TRANSTARR than STARR. This is probably related to the fact that the CCS-30 allows uniform rectal resection without reducing the size of the rectal ampulla. The fecal urgency usually resolves spontaneously within a few weeks of surgery, as reported for the STARR procedure.

Postoperative pain and bleeding are less frequent for TRANSTARR than STARR, with an incidence of 0.6% and 1.5%, respectively [2426].

Gas or fecal incontinence are rare after TRANSTARR (2–3%), but this can be a serious complication because of psychological implications [1923]. To reduce the risk of postoperative incontinence, it is important to assess the anal sphincter contractile deficit with an anorectal manometry and endorectal ultrasound before scheduling the patient for TRANSTARR. The role of preoperative pelvic floor rehabilitation is paramount to improve the anal sphincter contractile function and help previously incontinent or hypocontinent patients to become suitable for TRANSTARR [19].

Staple line complications, such as spiraling, dehiscence, infection, or retained staple granuloma, have been reported for TRANSTARR; these were mainly reported at the beginning of the learning curve for the procedure [1926].

Other rare, but feared, complications, such as rectovaginal fistula, dyspareunia, rectal wall necrosis, retroperitoneal sepsis, and retroperitoneal or endoabdominal bleeding, have been reported following TRANSTARR [1926]. These complications are typically related to technical errors such as entrapment of the vaginal posterior wall in the suture line, or excessive resection of the rectal wall.

The results confirm the statements made by some authors that the TRANSTARR is a safe procedure, but it should be carried out by surgeons with appropriate training and experience in transanal stapled surgery [1926]. Therefore TRANSTARR, in experienced hands, has shown good results in ODS treatment. This is mainly due to its capacity to ensure a real tailored therapy, allowing the surgeon to decide the amount of prolapsed tissue to be resected on a case-by-case basis.

The three larger studies reported in the literature show an improvement of ODS symptoms in 88%, 83% and 77% of patients [192126]. These results appear to be stable after 1 year of follow-up.

Despite all the studies reported in the literature agreeing that TRANSTARR allows the surgeon to resect a greater amount of prolapsed tissue than STARR, none is able to state whether transanal resection of more tissue improves the functional outcome [222527]. This has prompted most surgeons not to consider TRANSTARR as a replacement for STARR, but rather as a complementary procedure [222527]. Therefore, the decision on which technique to use should be assessed case by case, on the basis of the extent of prolapsed tissue in each patient, using STARR for the treatment of small internal rectal prolapses or male patients, and reserving TRANSTARR for treatment major or external rectal prolapses.



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