Robotic-Assisted Laparoscopic Sacrocolpopexy

Pelvic organ prolapse (POP) is a medical condition in which female pelvic organs, including the bladder, uterus, vagina, and/or rectum, descend from their normal positions within the pelvis. ^[1] These organs can sometimes protrude through the opening of the vagina. This condition is common, being symptomatic in approximately 30% of women 50-89 years of age and requiring a corrective procedure in 11% of women by 80 years of age. ^{[2, 3]}

POP occurs frequently with normal aging in women who have had vaginal delivery or deliveries or prior hysterectomy, and in those who have increasing body mass index, which predispose these women to weakening of the supporting ligaments and muscles in the pelvic floor. ^[1]

The prevalence of POP increases with age. ^[4] Researchers estimate that up to 250,000 surgical procedures to correct POP are performed each year in the United States, ^[5] and, as the proportion of older women continues to rise, the requirement for these procedures is expected to increase by approximately 50%. ^[6]

Sacrocolpopexy is a surgical technique used to treat vaginal vault or uterine prolapse, 2 types of POP. The objectives of the procedure are to reduce prolapse and to restore the anatomy and function of the vagina. During the procedure, the apex of the vagina/fundus of the uterus or stump of the cervix is lifted back up to its natural position by attaching a synthetic mesh from the top and back of the vagina to the sacral promontory. The mesh provides the vagina with the right amount of support to keep it in the correct position (see the image below).

Diagram of the surgical mesh repair

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No particular criterion standard for POP repair exists, yet the open abdominal mesh sacrocolpopexy has been revered as the main abdominal approach ^{[7, 8]} for correction given its cure rates of 85-100% in recent studies. ^{[9, 10]} However, when performed via a robotic-assisted laparoscopic (RAL) approach, the procedure is comparable in its clinical results, providing the same long-term durability of open sacrocolpopexy with the added benefits of a minimally invasive surgery, greater precision and control during the procedure, less pain, less blood loss, better cosmesis, and shorter hospitalization. ^{[11, 12, 13, 14, 15, 16]} Many surgeons are unfortunately limited in their knowledge of how to skillfully perform sacrocolpopexies laparoscopically, but the assistance from a robotic system can significantly reduce the learning curve associated with laparoscopic sacrocolpopexy. ^[11]

Indications for robotic-assisted laparoscopic sacrocolpopexy (RALS) are similar to those for the open procedure and include mainly symptomatic pelvic organ prolapse, graded according to the Baden Walker grading system (grade 3-4 genitourinary prolapse, or symptomatic grade 2) ^[17] or the International Classification of Standards (ICS) classification (stage II-IV). ^[18] Symptoms include urinary incontinence or difficulty urinating, the latter due to urethral obstruction; difficulty passing stool; and pelvic pressure or the sensation of pulling on the vagina or the lower back. Most patients seek surgical correction when they experience bulging and protrusion of organs with or without voiding symptoms.

An absolute contraindication to robotic procedures, including the RALS, is increased intracranial pressure because of the steep Trendelenburg necessary in positioning. ^[19]

Some of the general contraindications are the same as those for any other surgical procedure, including bleeding diathesis or a requirement for anticoagulation; anemia; active infection such as cystitis, bacterial or fungal vaginal infection, pelvic inflammatory disease, or active sexually transmitted disease; uncontrolled hyperglycemia; and active venous thromboembolism.

Some relative contraindications, because an exaggerated Trendelenburg position is required, include severe cardiac disease, severe emphysema or other chronic respiratory/pulmonary disease, glaucoma, history of stroke or aneurysm, and pregnancy. ^[19]

Some contraindications specific to sacrocolpopexy include cancer of the cervix, vagina, or uterus that is untreated or that cannot be treated due to advanced stage; vesico-vaginal, vesico-uretero, urethral, or recto-vaginal fistulas; and prior POP repairs with infected or exposed foreign material and erosions.

Complication Prevention

Rare but serious perioperative complications include urine leak, bowel obstruction, and peritonitis ^{[20, 21]} from failed detection of injury to the bladder, bowel, dehiscence, or infection during the procedure. Being mindful of the potential for these rare complications is important. In addition, although rare, delayed bleeding must be high on the differential in a patient who develops hemodynamic instability.

Postoperative complications can be prevented by awareness and understanding of the risks of surgery, including the risks of bleeding, infection, and injury to adjacent organs, as well as the risks of anesthesia, mesh and other implants, and positioning. For example, appropriate positioning and adequate cushioning of pressure points can prevent neurapraxia. Peroneal nerve injury can occur from compression if a stirrup is not appropriately padded and positioned. In the modified lithotomy position used for sacrocolpopexy, a position that permits simultaneous operative exposure to the abdomen and the perineum, femoral nerve injury can occur by hyperextension at the hip.

In addition, calf compression in this position increases the risk of venous thromboembolism (VTE) and compartment syndrome. The duration of a procedure was found to be the most consistent factor contributing to the development of compartment syndrome. ^[22] VTE results from alterations in blood flow caused by general anesthesia, positioning, and surgical manipulation, including retractor compression of great vessels.

Prevention of VTE may be achieved with use of modified Krauss arm supports as stirrups during the procedure; ^[23] in addition to pneumatic compression devices; prophylactic doses of Lovenox, heparin, or low-molecular weight heparin in patients at increased risk for VTE; and early postoperative ambulation. Overall, a reduced operative time will likely reduce the amount of time a patient is in a particular position that can increase injuries to the nerves and other structures.

Mesh erosion, in which the bladder or vagina are exposed to synthetic material, is a late postoperative complication with a reported rate of 3-7.6%. ^{[24, 25, 26]} Erosion is reported to occur within the first 5-14 months post-procedure. ^{[24, 27]} Symptoms include vaginal discharge, often malodorous, vaginal bleeding, and dyspareunia. ^{[24, 27]} Concurrent hysterectomy ^[24] and smoking are modifiable risks associated with mesh erosion. ^{[24, 25]} Monofilament polypropylene mesh has been found to have lower rates of erosion. ^[24] Conservative management of mesh erosion, including use of vaginal estrogen cream, antibiotics, and mesh trimming, often fails. ^[28] However, treatment is often not necessary because these will granulate well. Partial or complete removal of the graft via transvaginal excision is known to be more successful. ^[25]

In one study, Akl et al described the technique and learning curve for RALS, ^[29] which was performed in 80 patients with stage III-IV prolapse. They found that the mean operative time for RALS was decreased from 179.9 minutes in the first 30 cases in the study, to about 167 minutes in the last 30 cases.

Elliot et al ^[30] evaluated 30 patients with posthysterectomy vaginal vault prolapse who underwent RALS. The mean follow-up was 24 months, with 21 out of 30 patients having had a minimum of 12-months of follow-up. The success rate was 95% (19 out of 20) based on physical examination, with 1 recurrent vault prolapse and 2 vaginal extrusions of mesh. Ninety-five percent of patients were satisfied with the outcome, assessed with asking the patients whether they would recommend the procedure to others.

Geller et al compared RALS with open abdominal sacrocolpopexy via review of 73 patients who underwent RALS and 105 patients who underwent open abdominal sacrocolpopexy. ^[20] They demonstrated that the operative time was significantly longer for RALS, although the estimated blood loss and length of hospital stay were significantly less. The 2 techniques had similar short-term vaginal support, in addition to comparable overall complication rates: 17.8% for RALS and 11.4% for open abdominal sacrocolpopexy.

Barboglio et al reviewed RALS complications in 127 patients and found that mesh extrusion occurred in 3 (2.4%) patients. Other complications reported were bowel injury (2.4%), readmission rate (2.4%), wound infection (1.6%), and postoperative hernia at port site (1.6%). ^[31]