Robotic sacrocolpopexy for the management of pelvic organ prolapse: a review of midterm surgical and quality of life outcomes

Medium-term risk of recurrent pelvic organ prolapse within 2-year follow-up after laparoscopic sacrocolpopexy

Objective

The present study was performed to determine the risk of recurrent pelvic organ prolapse (POP) within 2 years after laparoscopic sacrocolpopexy (LSC) in patients with uterovaginal prolapse.

Materials and Methods

A retrospective comparative study was performed in a population of 204 patients over a 2-year follow-up period following LSC with concomitant supracervical hysterectomy or uterine preservation at a single urological clinic between 2015 and 2019. The primary outcome was surgical failure following LSC in cases of POP, focusing on failures occurring before the 2^ndyear of follow-up. Logistic regression analysis was used to determine the odds ratios (ORs) for surgical failure.

Results

The primary outcome, surgical failure in cases of POP, occurred 2 years after the initial surgery in 19 of the 204 patients (9.3%) (95% confidence interval [CI], 5.7% - 14.2%). Surgical failure was most common in the anterior compartment (n = 10, 4.9%), and further surgery was performed in seven of the patients with surgical failure (3.4%). The poor primary outcome was predicted by lysis of adhesions (OR, 7.5, 95% CI, 1.6-33.8, P = 0.008) and preoperative POP stage IV (OR, 3.5; 95% CI, 1.1-10.8, P = 0.03) on multivariable logistic regression analysis.

Conclusion

The overall rate of surgical failure following LSC in our cohort was 9.3% over the 2-year follow-up period after surgery, and preoperative prolapse stage IV was associated with a higher risk of recurrence.

Incarcerated ventral wall hernia after robotic urogynecologic surgery: A case report

Trocar site hernia is a rare complication of minimally invasive surgery, with incidence estimates varying widely. Studies have demonstrated rates of up to 1.2% in patients undergoing gynecologic surgery. Yet, little is known about hernia risk in the urogynecologic patient population who undergo robotic reconstructive surgery. Risk factors for the development of trocar site hernia include both incisional risk factors (trocar placement location, trocar diameter, intraoperative trocar manipulation) and patient risk factors (obesity, pelvic organ prolapse or other hernia). This report presents a case of large incarcerated small bowel hernia at a trocar site following robotic urogynecologic surgery and the resulting interventions, including repeat surgery, to reduce the hernia. This case should prompt urogynecologic surgeons to check port sites after extensive dissections to assess if large peritoneal or fascial defects need additional closure.

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Complex robotic urogynecologic surgery may increase the risk of trocar site hernia.

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Pelvic organ prolapse is an important risk factor to consider for trocar site hernia.

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Surgeons should inspect robotic port sites for extensions after complex dissection.

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Careful closure of peritoneal and/or fascial extensions may be warranted.

Robotic and laparoscopic sacrocolpopexy for pelvic organ prolapse: a systematic review and meta-analysis

Background

Sacrocolpopexy is the gold standard procedure for treating pelvic organ prolapse (POP) patients with apical defects. Different surgical approaches have emerged and been utilized successively, including traditional laparoscopy, single-hole laparoscopy, robotic laparoscopy, vaginal-assisted laparoscopy, and transvaginal approaches. Robotic sacrocolpopexy (RSC) has attracted increasing attention as an emerging surgical technique and has unique advantages, such as a “simulated wrist” mechanical arm and high-definition three-dimensional (3D) visual field, which has gradually begun to be utilized in the clinical setting.

Methods

We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) reporting checklist, and a systematic literature search was conducted on six databases from their inception to 1st March 2020. We evaluated patients with POP who underwent RSC or laparoscopic sacrocolpopexy (LSC), outcomes (including perioperative outcomes: blood loss, operating times, blood transfusion, and hospital stay), surgery-related complications, as well as cure and recurrence rates.

Results

A total of 49 articles were available, including 3,014 patients, among which 18 were comparative studies on LSC vs. RSC, and 31 were non-comparative single-arm studies on RSC. For RSC, median operative time was 226 [90–604] minutes, estimated blood loss was 56 [5–1,500] mL, and hospital stay was 1.55 [1–16] days. Intraoperative complications and postoperative complications occurred in 74 (2.7%) and 360 (13.0%) patients, respectively. Of 2,768 RSC patients, 40 had been converted from a robot-assisted approach to other approaches, and 134 of 1,852 patients (7.2%) have recurrent prolapses of any compartment. Compared to LSC, RSC was associated with significantly lower blood loss and lower conversion rate. However, more operative time was observed in RSC. No significant differences were observed in perioperative transfusion, intraoperative and postoperative complications, or objective recurrence between RSC and LSC.

Conclusions

RSC’s application seems to contribute some advantages compared to conventional laparoscopic surgery, although both approaches appear to promote equivalent clinical outcomes. Notably, heterogeneity among studies might have affected the outcome of the study. Consequently, high-quality and large-sample randomized trials comparing both techniques are necessitated.

Robotic Sacrocolpopexy for Treatment of Apical Compartment Prolapse

Abdominal sacrocolpopexy is the gold-standard treatment for apical compartment prolapse, as it is more effective and durable than the transvaginal approach. In the current era of minimally invasive surgery, laparoscopic sacrocolpopexy techniques have been described, but have not gained popularity due to their complexity and steep learning curves. To overcome this problem, robotic sacrocolpopexy was introduced, and has shown equivalent outcomes and safety compared to open and laparoscopic sacrocolpopexy based on findings that have been accumulated over 15 years.

Robotic sacrocolpopexy for the management of pelvic organ prolapse: quality of life outcomes

Background:

Our aim was to investigate longer-term surgical and quality of life (QOL) outcomes in a cohort of women undergoing robotic-assisted laparoscopic sacrocolpopexy (RALS) for pelvic organ prolapse (POP).

Methods:

We performed a retrospective cohort study at a single institution of female patients undergoing RALS with and without concomitant robotic-assisted laparoscopic hysterectomy, urethral sling, and rectocele repair. Scores from the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) surveys were used to evaluate QOL outcomes. Clinical improvement was defined by a decrease in a patient’s PFDI and PFIQ postoperative score by ⩾70%.

Results:

Clinical improvement was seen in 62.6% by the PFIQ and in 64% by the PFDI survey. Younger patient age (OR 0.92, p = 0.011) and worse preoperative American Urological Association (AUA) Quality of Life score (OR 1.42, p = 0.046) were associated with clinical improvement. Within the PFIQ, 35.6% of patients saw clinical improvement with their bowel symptoms, compared with bladder (54.1%, p < 0.001) and prolapse (45.6%, p = 0.053) symptoms. Within the PFDI, 45.5% of patients reached clinical improvement with their bowel symptoms, compared with bladder (56.7%, p = 0.035) and prolapse (62.6%, p < 0.001) symptoms. Of the patients who had a rectocele repair, 46.3% reached clinical improvement in their CRADI-8 score, and 51% saw clinical improvement in the bowel portion of the PDFI.

Conclusions:

Significantly fewer patients reached clinical improvement within the portions of the surveys that focus on bowel symptoms, compared with symptoms related to urination and POP. Of those that had a concomitant rectocele repair, approximately half reached clinical improvement with their bowel symptoms.

Long-term mesh erosion rate following abdominal robotic reconstructive pelvic floor surgery: a prospective study and overview of the literature

Introduction and hypothesis

The use of synthetic mesh in transvaginal pelvic floor surgery has been subject to debate internationally. Although mesh erosion appears to be less associated with an abdominal approach, the long-term outcome has not been studied intensively. This study was set up to determine the long-term mesh erosion rate following abdominal pelvic reconstructive surgery.

Methods

A prospective, observational cohort study was conducted in a tertiary care setting. All consecutive female patients who underwent robot-assisted laparoscopic sacrocolpopexy and sacrocolporectopexy in 2011 and 2012 were included. Primary outcome was mesh erosion. Preoperative and postoperative evaluation (6 weeks, 1 year, 5 years) with a clinical examination and questionnaire regarding pelvic floor symptoms was performed. Mesh-related complications were assessed using a transparent vaginal speculum, proctoscopy, and digital vaginal and rectal examination. Kaplan–Meier estimates were calculated for mesh erosion. A review of the literature on mesh exposure after minimally invasive sacrocolpopexy was performed (≥12 months’ follow-up).

Results

Ninety-six of the 130 patients included (73.8%) were clinically examined. Median follow-up time was 48.1 months (range 36.0–62.1). Three mesh erosions were diagnosed (3.1%; Kaplan–Meier 4.9%, 95% confidence interval 0–11.0): one bladder erosion for which mesh resection and an omental patch interposition were performed, and two asymptomatic vaginal erosions (at 42.7 and 42.3 months) treated with estrogen cream in one. Additionally, 22 patients responded solely by questionnaire and/or telephone; none reported mesh-related complaints. The literature, mostly based on retrospective studies, described a median mesh erosion rate of 1.9% (range 0–13.3%).

Conclusions

The long-term rate of mesh erosion following an abdominally placed synthetic graft is low.

Electronic supplementary material

The online version of this article (10.1007/s00192-019-03990-1) contains supplementary material, which is available to authorized users

Single-port versus multi-port robotic sacrocervicopexy: Establishment of a learning curve and short-term outcomes

OBJECTIVES

The purpose of this study was to compare the learning curves, surgical outcomes and complications of multi-port access robotic-assisted laparoscopic sacrocervicopexy (MP-RSC) to single-port robotic access (SP-RSC) for vaginal apex prolapse.

METHODS

A retrospective study of the first 52 MP-RSC procedures compared with the first 52 SP-RSC procedures performed at one medical center. Primary outcomes were intraoperative bleeding, operative time, and hospitalization. Secondary outcomes were surgical complications.

RESULTS

There was a statistically significant difference in mean operative times between the MP-RSC and SP-RSC procedures: 206.5 ± 39.4 and 187.8 ± 46.2, respectively, P = 0.028. The mean estimated intraoperative blood loss was 35 [20-87.5] ml and 20 [10-47.5] ml, respectively, P = 0.008. Respective mean operative times decreased from the first 15 to the subsequent 15 cases: in the MP-RSC group from 224.2 ± 43.2 to 198.4 ± 36.3 min, P = 0.088, and in the SP-RSC group from 222.4 ± 53.1 to 161.3 ± 28.2 min, P < 0.001. The subsequent 22 cases showed different trends. Hospitalization (days) and level of pain at 24 h postoperative, according to a 1-10 point visual analogue scale, did not differ. Adverse events were rare in both groups.

CONCLUSIONS

MP-RSC and SP-RSC are feasible and the short term outcomes and learning curves for both procedures are comparable.

Long-term outcomes of robotic mesh sacrocolpopexy

The aim of the study is to evaluate anatomic and functional late-term outcomes of robotic mesh sacrocolpopexy (RMS) at a single tertiary-care institution. Following IRB approval, a retrospective chart review of a prospectively collected database on consecutive patients who underwent RMS for symptomatic pelvic organ prolapse and had 3 year minimum follow-up was performed. Data collected included physical examination, validated questionnaires including Urogenital Distress Inventory, Incontinence Impact Questionnaire, and global Quality of Life (QOL). The primary outcome was failure defined as the need for re-operation and/or prolapse recurrence by examination. Those with office follow-up < 36 months underwent structured phone interviews. Between 12/2007 and 2/2012, 56 women underwent RMS. Thirty women had follow-up ≥ 3 years (median 64 (IQR 48-85) months). Mean C-point went from - 2.33 (range 0 to - 5) to - 9.00 (0 to - 12) (p < 0.01), and mean QOL score from 3.93 (0-10) to 1.93 (0-8) (p < 0.01). Two developed recurrent vault prolapse later on at 26 and 34 months, respectively. Four women (13%) required surgery for secondary prolapses, with three for anterior compartment and one for posterior compartment. Sixteen of twenty six were contacted via structured phone interviews, with 14 doing well, one deceased, and one who underwent a secondary posterior compartment prolapse 6 years later at an outside facility. This long-term study indicates durability for RMS in the management of symptomatic pelvic organ prolapse.

Bowel injury in robotic gynecologic surgery: risk factors and management options. A systematic review

OBJECTIVE

We sought to analyze the published literature on bowel injuries in patients undergoing gynecologic robotic surgery with the aim to determine its incidence, predisposing factors, and treatment options.

DATA SOURCES

Studies included in this analysis were identified by searching PubMed Central, OVID Medline, EMBASE, Cochrane, and ClinicalTrials.gov databases. References for all studies were also reviewed. Time frame for data analysis spanned from November 2001 through December 2014.

STUDY ELIGIBILITY CRITERIA

All English-language studies reporting the incidence of bowel injury or complications during robotic gynecologic surgery were included. Studies with data duplication, not in English, case reports, or studies that did not explicitly define bowel injury incidence were excluded.

STUDY APPRAISAL AND SYNTHESIS METHODS

The Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies were used to complete the systematic review with the exception of scoring study quality and a single primary reviewer.

RESULTS

In all, 370 full-text articles were reviewed and 144 met the inclusion criteria. There were 84 bowel injuries recorded in 13,444 patients for an incidence of 1 in 160 (0.62%; 95% confidence interval, 0.50-0.76%). There were no significant differences in incidence of bowel injury by procedure type. The anatomic location of injury, etiology, and management were rarely reported. Of the bowel injuries, 87% were recognized intraoperatively and the majority (58%) managed via a minimally invasive approach. Of 13,444 patients, 3 (0.02%) (95% confidence interval, 0.01-0.07%) died in the immediate postoperative period and no deaths were a result of a bowel injury.

CONCLUSION

The overall incidence of bowel injury in robotic-assisted gynecologic surgery is 1 in 160. When the location of bowel injuries were specified, they most commonly occurred in the colon and rectum and most were managed via a minimally invasive approach.

Latency to vaginal mesh exposure with mesh placed abdominally versus vaginally in pelvic floor surgery: A retrospective comparative study. J OBSTET GYNAECOL 2016;37:238-242. [PMID: 27966387 DOI: 10.1080/01443615.2016.1245716]

The primary aim was to compare the difference in time to mesh exposure between mesh placed abdominally versus vaginally. This is a retrospective comparative study of patients presented with vaginal mesh exposure between January 2001 and July 2012. This study compares patients who had undergone vaginally placed mesh procedures to those who had had abdominally placed mesh. Kaplan-Meier survival analysis was used to measure the time to mesh exposure. There were 68 patients with mesh exposure in our cohort. Thirty eight patients had undergone vaginal placement of mesh and 30 patients had abdominal mesh. There was a statistically significant difference in time to mesh exposure between abdominal and vaginal meshes (p≤.0001). Mean time to vaginal mesh exposure with abdominal mesh was 59.8 months (95%CI 46.2-73.3) compared to 23 months (95%CI 15.9-30.2) for vaginal mesh. When controlling for age, BMI and surgeon at index surgery, the Hazard Ratio for mesh exposure in our Cox Regression model was 0.53 (95%CI 0.39-0.71) (p ≤.0001). The mean time to vaginal mesh exposure after abdominal mesh was longer compared to the time to exposure with vaginally placed mesh (60 versus 23 months, p ≤.0001). These results support the evolving evidence that mesh exposures can occur many years distant from the procedure and warrant some level of surveillance or provision of warning signs by the providers who perform procedures with mesh.

Robotic Single-Site® Sacrocolpopexy: First Report and Technique Using the Single-Site® Wristed Needle Driver

The recently introduced da Vinci Single-Site® platform offers cosmetic benefits when compared with standard Multi-Site® robotic surgery. The innovative endowristed technology has increased the use of the da Vinci Single-Site® platform. The newly introduced Single-Site® Wristed Needle Driver has made it feasible to perform various surgeries that require multiple laparoscopic sutures and knot tying. Laparoscopic sacrocolpopexy is also a type of technically difficult surgery requiring multiple sutures, and there have been no reports of it being performed using the da Vinci Single-Site® platform. Thus, to the best of our knowledge, this is the first report of robotic single-site (RSS) sacrocolpopexy, and I found this procedure to be feasible and safe. All RSS procedures were completed successfully. The mean operative time was 122.17±22.54 minutes, and the mean blood loss was 66.67±45.02 mL. No operative or major postoperative complications occurred. Additional studies should be performed to assess the benefits of RSS sacrocolpopexy. I present the first six cases of da Vinci Single-Site® surgery in urogynecology and provide a detailed description of the technique.

Anatomic Outcomes of Robotic Assisted Supracervical Hysterectomy and Concurrent Sacrocolpopexy at a Tertiary Care Institution at Initial Adaptation of the Procedure

OBJECTIVE

The aim of the study was to review anatomic and surgical outcomes of robotic-assisted supracervical hysterectomy (RASCH) with concurrent sacrocolpopexy in the treatment of primary pelvic organ prolapse (POP) on initial adaption of this procedure.

STUDY DESIGN

A retrospective chart review of patients undergoing RASCH with concurrent sacrocolpopexy between 2009 and 2012 was performed at a tertiary care academic institution, after initial adaption of this procedure. The primary outcome was change in vaginal support (assessed with the pelvic organ prolapse quantification [POP-Q]) at 3 months and 1 year postoperatively. Secondary measures assessed included estimated blood loss, operative times, hospital length of stay, and operative complications.

RESULTS

Forty patients (N = 40) underwent RASCH with concurrent sacrocolpopexy. Twenty-six patients (65%) had preoperative stage II POP, and 35% had stage III POP. Three months after undergoing the procedure, 55% had achieved stage 0 POP. An additional 35% were categorized as stage I POP. At 1 year, 72.7% were stage I POP or lower. The mean (SD) operating time was 275 (82.3) minutes. Estimated blood loss and mean (SD) length of hospital stay were 163 (114.9) mL and 1.3 (0.8) days, respectively. There were no intensive care unit admissions. The most common postoperative complication was immediate urinary retention in 10% of patients; all cases resolved with time-limited intermittent self-catheterization.

CONCLUSIONS

Even with initial adaptation of the procedure, RASCH with concurrent sacrocolpopexy for the repair of primary POP is effective in restoring anatomic support in the short term. Operative complications are minimal.

Long-term quality of life outcomes and retreatment rates after robotic sacrocolpopexy

OBJECTIVE

To evaluate the long-term outcomes and potential predictors of treatment failure after robotic sacrocolpopexy.

METHODS

We identified 70 consecutive patients from 2002 to 2012 with symptomatic post-hysterectomy vaginal vault prolapse that underwent robotic sacrocolpopexy. Multiple clinical and surgical variables were evaluated for potential association with treatment failure, which was defined as any repeat operation for recurrent prolapse or mesh-related complications.

RESULTS

The median age at surgery was 67 years (interquartile range 59-74 years) and median follow up was 72 months (interquartile range 39-114 months). Overall, six out of 70 patients (8.6%) underwent a total of six secondary surgeries, including four for recurrent prolapse (two anterior repairs, one posterior repair, one apical) and two mesh complications. No patient-related factors were associated with the risk of repeat surgery: age (P = 0.45), diabetes mellitus (P = 0.24), tobacco use (P = 0.61) or prior prolapse surgery (P = 0.1) on univariate analysis. Freedom from repeat prolapse surgery or surgery for mesh complication was 98% at 1 year, 95% at 3 years and 90% at 6 years. At last follow up, 80% of patients reported that they would or probably would recommend robotic sacrocolpopexy to a family member or friend.

CONCLUSIONS

Robotic sacrocolpopexy is associated with excellent long-term outcomes. Recognition of long-term success is important for preoperative patient counseling.

Robotic pelvic organ prolapse surgery

Robotic sacrocolpopexy (RSC) has rapidly gained popularity over the past 10 years, owing to claims that it is associated with a reduced learning curve compared with standard laparoscopic sacrocolpopexy (LSC) and that it has equal efficacy to the gold-standard treatment, abdominal sacrocolpopexy (ASC). The specifics of the surgical technique used for RSC vary widely, but the basic steps and principles are largely the same. Although complication rates are low, specific complications can be minimized by meticulous attention to surgical technique at several important points in the procedure. Multiple levels of evidence support the efficacy of RSC, and show that it is associated with a shorter hospital stay and convalescence than ASC. The learning curve for RSC usually comprises 10-20 procedures but for those with extensive experience of laparoscopy it is likely to be even shorter. RSC is more expensive than LSC but cheaper than ASC. As RSC has only been used for about a decade, we await long-term outcomes of more than a few years.