Short and long-term results of managing 386 mucohemorrhoidal prolapse cases with mucopexy-recto anal lifting (Mural), a minimally invasive and standardized treatment

Purpose/Background: managing grade iii/iV hemor- rhoidal disease with traditional excisional surgery or stapled hemorrhoidopexy have been challenging undertak- ings considering the risks of non-negligible complications associated with invasive techniques. the aim of this study was to assess the safety and efficacy of mucopexy-recto Anal Lifting (murAL) in treating patients affected by grade iii and iV hemorrhoidal disease. Methods/Interventions: three hundred eighty-six patients affected by grade iii and iV hemorrhoidal diseasehave been enrolled in our study and underwent mucopexy- recto Anal Lifting (murAL) between may 2013 and November 2018. the method has already been described in detail by Pagano et al. [minerva chirurgica 2018 october; 73(5):469-74]. Arterial ligation and mucopexy involving progressive lifting have been performed at 6 positions, by following a standardized sequence (as outlined in the attached image). six longitudinal scars anchor perma- nently the mucosa and sub-mucosa to the muscular wall beneath. the follow-up examinations have been carried out by independent observers as follows: a digital explora- tion 3 weeks after the intervention, digital exploration and proctoscopy at 3 and 12 months, repeated at a 12-month interval. Patients not following strictly the postoperative clinical examination calendar have been excluded from the study. Primary outcome measure was the recurrence rate observed in patients who completed at least 12 months of follow-up. secondary outcome measures were: operative time, postoperative hospital stay, postoperative pain, post- operative symptoms and patient satisfaction score.Results/Outcome(s): murAL has been performed on 386 patients (59.6 % male, mean age 53.9, range 26-87); 297 (76.9%) with grade iii and 89 with grade iV hemor- rhoids. thirty-three (8.5%) patients had murAL as a revisional procedure of a previous intervention (17 stapled anopexy, 6 milligan-morgan, 5 murAL, 3 stArr, 2 tHd). mean duration of follow-up was 814 days (range 15-2007). the mean duration of the procedure was 23 minutes (range 13-45); 195 patients (53.0%) were discharged on the day of surgery and 163 (44.3%) had a one-day hospitalization; 10 patients treated with murAL required hospitalization > 1 day due to comorbidity. Pain Nrs score (0-10) on the first, second and third postoperative day was 3.8, 2.5 and 2.2 respectively. No major complications were observed. thirty-eight (10.3%) patients, all submitted to spinal anesthesia, had postop- erative acute urinary retention. transient fecal urgency was observed in 13 (3.4%) patients at the first follow-up. mean time to return to normal activity was 7 days (range 2-10). At one-year follow-up 89.5% of patients reported an excellent/good satisfaction score. operating time wassignificantly shorter, postoperative pain lower and tran- sient fecal urgency less frequent in patients with grade iii than in those with grade iV hemorrhoids. one-year recur- rence rate was evaluated in 279/386 patients (214 with grade iii and 65 with grade iV disease). recurrence was observed in 12 patients (4.3%): 7/214 (3.3%) with grade iii and 5/65 (7.7%) with grade iV hemorrhoids (P=0.12). two patients out of 28 (7.1%) had a second recurrence after murAL (1 previous mm, and 1 previous murAL). Conclusions/Discussion: in our experience, mucopexy- recto Anal Lifting (murAL) with its standardized proce- dure management approach, offers a safe and effective treatment solution of managing grade iii and iV symp- tomatic hemorrhoids with minimal invasivity, lowering the patient’s risk of developing severe complications. the method does not cause tissue trauma, which permits to easily perform a redo-murAL in the event of recurrence.