Robotic Sacrocolpopexy in Pelvic Organ Prolapse

A Review of Current Literature

Dmitry Y. Pushkar; George R. Kasyan; Alexander A. Popov


Curr Opin Urol. 2021;31(6):531-536. 

In This Article


Efficacy of Robotic Sacrocolpopexy

Long-term results of robotic sacrocolpopexy (RSC) remain unclear. The exploratory multivariate logistic regression performed by Lallemant et al.[2] suggested that the rates of overall reoperation were higher in the robotic group compared with laparoscopic.

At the same time, a recent systematic literature review was published comparing long-term outcomes of open, laparoscopic sacrocolpopexy (LSC), and RSC.[3] A total of 13 studies, including 2115 participants, were involved in the pooled analysis. The pooled results revealed that RSC was associated with a significantly longer operative time (difference of 29.53 min; P = 0.0005), significantly less estimated blood loss (−86.52 ml; P = 0.0001), significantly fewer overall intraoperative complications (OR 0.6; P = 0.01), and significantly lower conversion rate (OR 0.39; P = 0.01) compared with LSC. There were no significant differences between the length of hospital stays, overall postoperative complications, postoperative stress incontinence, mesh erosion, and effectiveness between the two groups. Though RSC was associated with less blood loss and a lower conversion rate, the differences were not clinically significant.

Thomas et al. presented a retrospective cohort study and a cross-sectional, prospective follow-up survey for women who had open, RSC, or LSC.[4] Overall, 1102 participants were found, and 709 satisfied the inclusion criteria. A follow-up survey was used to look into complications, surgeries, and symptoms following the index surgery. In this study, the authors found that POP recurrence and mesh exposure are low for all approaches. Within a year after surgery, the overall POP recurrence was 11.7%, and the prevalence of mesh exposure was 5.3% (open − 7.7%, RSC − 3.6%, LSC − 4.9%). At 6.5 years, the overall patient-reported prevalence of POP recurrence was 9.2% (open − 6.0, RSC − 3.9%, LSC − 8.6%). Authors report a slightly higher objective POP recurrence rate compared with patient-reported prevalence (15 vs. 9.2%, respectively).

Obese Patients

The role of obesity as a predisposing risk factor for POP recurrence after surgical correction has not been well established. A systematic review and meta-analysis[5] demonstrated that the complications and curative effects for obese women are comparable with those of nonobese women, except for a higher conversion rate, higher infection rate, longer operative time, and higher estimated blood loss in obese women. Obesity slightly increases RSC's difficulty, although it does not increase the mesh erosion rate or prolapse recurrence rate.

Ultralight Meshes and Native Tissue Repair

Despite the acceptance of sacrocolpopexy as the most definitive surgery to correct POP, a recent long-term follow-up study reported disappointing rates of success and mesh complications 5–7 years postoperatively.[6] However, the relevance of those findings may be limited by the open abdominal surgical approach and older generation heavier graft materials used for the sacrocolpopexies. Currently, most sacrocolpopexies are performed using very light monofilament polypropylene mesh. For example, one study of robotic-assisted LSC performed with ultra-light Y-mesh demonstrated high surgical success rates and no mesh exposures or mesh-related complications at greater than or equal to 12 months.[7]

Another recently published study showed that ultra-lightweight mesh for minimally invasive sacrocolpopexy was not associated with a higher proportion of composite anatomical prolapse recurrence; however, it was associated with a shorter time to recurrence.[8] These results suggest that a more up-to-date version of sacrocolpopexy with better meshes might demonstrate better rates of long-term success and more acceptable rates of mesh complications.

The goal of the study, published by Culligan et al., was to describe anatomic and symptomatic results after robotic-assisted LSC using very lightweight polypropylene Y-mesh after 5 years or longer. The authors discovered excellent long-term objective and subjective outcomes for robotic-assisted LSC using a very light polypropylene Y-mesh.[9]

Fernando et al. conducted a randomized trial to compare case and mesh placement times for Restorelle Y mesh and flat mesh. The authors also attempted to analyze the two mesh types regarding subjective patient complaints, prolapse recurrence, and mesh erosion. There was no difference in placement time between the two groups, according to the study. There was no difference in subjective recurrence, and there were no objective recurrences or mesh erosions at 6 months for all patients.[10]

Native tissue restoration will eliminate all hazards associated with synthetic meshes but tissue harvesting could increase wound infection and discomfort issues. A RSC with fascia lata was observed in one nonrandomized study. During preoperative counseling, the physician and patient had an informed discussion and made a joint choice about whether to utilize mesh or autologous fascia lata. Despite significant limitations, this study shows that for women with apical prolapse RSC with autologous fascia lata had equivalent short-term anatomic outcomes to mesh. Swelling (10.5%), paresthesia that resolved (5.3%), paresthesia that remained unresolved (5.3%), hematoma (5.3%), and seroma (5.3%) were among the morbidities associated with the harvest site (10.5%). There were no complaints of prolonged discomfort or wound infections, for example. The long-term durability of autologous fascia lata is still unknown.[11]

Lee et al. suggest a new 'wrinkle approach', claiming that it can reduce anterior compartment recurrence and vaginal mesh erosion following RSC. To the anterior vaginal wall, two or three rows of purse-string sutures using delayed absorbable monofilament suture material are created, and the mesh is then anchored on the wrinkle. RSC was performed on 57 individuals using the wrinkle approach and 66 patients using the nonwrinkle method. The nonwrinkle group had a follow-up period of 24.03 months, whereas the wrinkle group had a follow-up period of 9.13 months. Because of the short follow-up time, the authors could not demonstrate that the wrinkle approach reduced POP recurrence and vaginal wall mesh erosion following RSC. Still, preliminary findings were positive in terms of safety. More long-term, well designed randomized controlled trials are needed to fully understand the benefits of the wrinkle method.[12]

Alternative Robotic Approaches

One case report described a robotic transvaginal sacrocolpopexy by Natural Orifice Transluminal Endoscopic Surgery (NOTES) as a variant of the NOTES pelvic surgery. Two patients underwent successful operations, with the results documented in a case report. The advantages of intraabdominal suturing and knot-tying may make robotic transvaginal NOTES sacrocolpopexy a viable and feasible alternative to standard laparoscopic NOTES sacrocolpopexy. At the same time, even with robotic technology, NOTES with mesh may not eliminate the dangers of mesh problems seen with traditional vaginal repair and may have questionable cost and time efficacy.[13]

Single-site and Single-port Approach

In the realm of pelvic surgery, the robotic laparoendoscopic single-site (R-LESS) has emerged as a practical, feasible, and broadly applicable minimally invasive method. Even though R-LESS surgery has been widely adopted, few comparative prospective randomized controlled studies compare R-LESS to the multiport robotic (MPR) approach, and only a few studies have reported on initial experiences with R-LESS sacrocolpopexy. Matanes et al. published a randomized controlled trial that compared the R-LESS to the MPR approach for women with POP. The mean total operative times for R-LESS and MPR sacrocolpopexy were 181 and 157 min, respectively; the difference was 23.8 min (P = 0.018). The mean differences in duration between the procedures were: 29.8 min for anesthesia (P = 0.005); 33.1 min for console time (P < 0.0001); 8.6 min for supracervical hysterectomy (P = 0.025); 8.3 min for mesh suturing and fixation to the promontory (P = 0.03); and 4.7 min for peritoneum suturing (P = 0.004). Estimated blood loss, intraoperative problems, and the need for analgesics throughout the hospital stay did not show statistically significant differences between the groups. In R-LESS group, patients had a more favorable opinion of their scars. The study found that R-LESS surgery took longer to perform than multiport robotic surgery but had similar short-term outcomes. Both techniques are feasible, with comparable short-term results, quality-of-life measures, and anatomic repair.[14]

R-LESS utilizing the da Vinci Xi or Si system, or single-port system, is now available for single-incision robotic surgery. Suturing in R-LESS is made more accessible by the wristed needle driver; nonetheless, multiple suturing remains difficult because of the 45° movement angle of the single-site wristed needle driver, which necessitates a longer surgical time than multiport robotic surgery. The da Vinci single-port system, which was recently released, provides a more aesthetically pleasing finish and more versatility. A flexible three-dimensional camera and three fully wristed, 6-mm double-jointed articulating robotic instruments are introduced in a specifically developed single trocar. Surgeons can use a single trocar to control all three robotic devices, making suturing and tying easier than with R-LESS. For sacrocolpopexy, the transition from multiport to single-port robotic surgery has become increasingly popular.[15]

Lee et al. published the first comparative study of the Da Vinci Xi or Si system on a single site (SS-RSC) with the da Vinci single-port system on a single port (SP-RSC). The SS-RSC and SP-RSC groups had comparable mean operational and console times (135 vs. 141 min; 94 vs. 89 min, respectively). The SP-RSC group had a faster docking time and a faster cervix suturing time (P = 0.05). However, in an examination of the first eight patients in each group, all surgical times were quicker in the SP-RSC group (P = 0.05), except for the cervix suturing time. RSC can be performed using any approach with good cosmetic effects.[16]

Concomitant Urinary Incontinence

Simultaneous treatment of stress urinary incontinence (SUI) and POP is still a controversial topic. In retrospective study, Stewart et al. reviewed patients who had a RSC and a mid-urethral sling. Patients were divided into three groups: those who received a MUS symptomatic SUI, those who received a prophylactic MUS, and those who did not receive a MUS. A total of four patients (7%) who had a MUS implanted for SUI experienced persistent SUI after the procedure. Two patients (5%) who had a prophylactic MUS had SUI, whereas 12% of patients who did not have a MUS developed de novo SUI. The rate of postoperative SUI did not differ across the three groups (P = 0.459). When comparing all patients who received a sling with those who did not, the rate of postoperative SUI was 6% (6/101) for those who received a sling and 12% (4/33) for those who did not receive a sling. This distinction, however, was not statistically significant (P = 0.208).[17]

Elderly Patients

The feasibility of robotic technologies for older patients is being debated, with the long operating time, steep Trendelenburg posture, and other factors all being taken into account. Sanci et al. looked at the safety and effectiveness of RSC in patients with symptomatic apical pelvic organ prolapse who were over 65 years old. A total of 74 patients were assessed retrospectively. The operations' success rates, surgical outcomes, and perioperative adverse events were compared in both groups. The open abdominal technique was used on 44 patients, whereas the robotic approach was used on 30 others. The open abdominal surgery group had a mean age of 68 years, whereas the robotic surgery group had a mean age of 69 years. Although the mean analgesics' intake and length of hospital stay for the RSC group were much lower and shorter, the mean operation duration was significantly greater (141.2 min). Open abdominal sacrocolpopexy had a 16% rate of grade 2 or above complications, whereas RSC had a 17% rate by Clavien-Dindo. The authors concluded that anatomical outcomes and adverse events in elderly patients receiving open vs. RSC are identical.[18]

Concomitant Hysterectomy

When compared with operations without concomitant hysterectomy, a hysterectomy at the time of RSC may increase the risk of infection and mesh exposure. Residents' experience with vaginal hysterectomy has decreased since the implementation of sacrocolpopexy. To give sufficient training, some hospitals implemented a switch to perform vaginal hysterectomy before RSC. Jones et al. published a retrospective study in which SCP and the vesicovaginal followed vaginal hysterectomies and rectovaginal planes were created transvaginally after vaginal hysterectomies. With a median follow-up time of 49 weeks, 1.4% of patients in a cohort of 209 women had repeat prolapse surgery. A pelvic abscess was treated in 1.9% of those with postoperative fever. Within 6 weeks after surgery, 18 patients (8.6%) were treated for urinary tract infection. Mesh exposure was found in 7.7% of patients, with 6.2% requiring reoperation. As a result, the authors concluded that vaginal hysterectomy before RSC increases mesh-related problems and infection rates.[19]

Additional Instruments/Tools to Facilitate the Procedure

The effect of vaginal instrumentation on RSC operational time is little understood. The vaginal cuff is traditionally presented using an end-to-end anastomosis sizer (EEAS) during dissection and mesh fixation. In one randomized trial, surgeon satisfaction with the Colpassist (Boston Scientific, Quincy, Massachusetts, USA) vaginal positioning device was compared with that of the EEAS. The median operating time to complete the RSC phases did not differ significantly between groups. Although the Colpassist has design elements that improve operative efficiency, it is possible that the patient-oriented concepts of the Colpassist (e.g. curved handle, different sized paddles) are not the primary effectors of operative time, and that factors, such as patient anatomy and a surgeon's technique have a greater impact.[20]

Proper sigmoid removal from the operating field is hard with a single port technique and additional tools are needed obviously. At this stage, the Levita ragnetic retractor could be good supplement to complete single port RSC. Three patients with pelvic organ prolapse underwent SP-RSC in one case report research. The external magnet was utilized for bowel and bladder retraction and attached to the bed's left side. The RSC took between 198 and 247 min to complete, with an estimated blood loss of 10–50 ml and no problems.[21]

Mesh Fixations

Laparoscopic incisional and ventral hernia repair have both benefited from mesh attachment using absorbable anchors. This study aimed to see how absorbable anchors compared with interrupted sutures affected the time it took to connect a vaginal mesh in RSC. This is a prospective, randomized, single-blinded, two-arms-parallel clinical investigation at two clinical sites to compare the length of vaginal mesh attachment in women undergoing SCP with anchor vs. interrupted suture. It was discovered that it decreased suturing time in half, with an average savings of 9 min. Additionally, surgeon satisfaction, simplicity of placement, and vaginal appearance were comparable between arms, and there was no difference in surgical failure, overall patient improvement, or pelvic pain at 12 months.[22]

Traditional nonabsorbable monofilament sutures are used to anchor vaginal mesh for RSC but they can become exposed after surgery, necessitating vaginal removal. A prospective registry was used to conduct a cohort study with a mean follow-up of 16 months following RSC. The nonabsorbable monofilament cohort had a substantially higher rate of anterior compartment failures (Polydiaxone delayed absorbable suture). There were no significant differences in failures in the apical and posterior compartments across groups.[23]

In a separate trial, 189 women were randomized to receive permanent or absorbable sutures for mesh fixation, with a 1-year follow-up. The total rate of mesh or permanent suture exposure was 12 of 198 (6.1%), with permanent sutures accounting for 5.1% and delayed absorbable sutures accounting for 7%. The authors concluded that the type of suture used to attach vaginal mesh did not affect mesh or permanent suture exposure rates.[24]