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Obstet Gynecol Sci > Volume 67(2); 2024 > Article
Mozon, Kim, and Lee: Robotic sacrocolpopexy

Abstract

Pelvic organ prolapse (POP) is a common cause of gynecological disease in elderly women. The prevalence of POP has increased with an aging society. Abdominal sacrocolpopexy (ASC) is safer and more effective than the vaginal approach in patients with apical compartment POP because it has a higher anatomical cure rate, a lower recurrence rate, less dyspareunia, and improved sexual function. Laparoscopic sacrocolpopexy (LSC) has replaced ASC. Robotic sacrocolpopexy (RSC) also helps overcome the challenges of LSC by facilitating deep pelvic dissection and multiple intracorporeal suturing. The RSC is technically easy to apply, has a steep learning curve, and offers many advantages over the LSC. However, insufficient data led us to conclude that the LSC is superior overall, especially in terms of cost-effectiveness. The present review provides insights into different aspects of RSC, highlighting the most common benefits and concerns of this procedure. We searched for eligible articles discussing this issue from January 2019 to March 2022 to reveal the outcomes of RSC.

Introduction

Pelvic organ prolapse (POP) is a significant public health concern and a common indication for gynecological surgery [1-3]. POP involves the displacement of pelvic organs such as the bladder, uterus, rectum, and occasionally the small bowel from their normal anatomical position, often descending into the vagina. It is estimated that approximately 20% of women will undergo surgery for POP during their lifetime [1,4,5]. In the United States, the prevalence of symptomatic POP is expected to increase by 46%, affecting approximately 5 million women by 2050 [1,6]. In South Korea, the life time risk of POP is estimated to be 30%, and the prevalence is higher in older women with an estimated 180 cases per 100,000 women aged over 50 [2,7].
The main symptom associated with POP is a sensation of vaginal bulging, often accompanied by various other distressing symptoms including constipation, overflow urinary incontinence, voiding difficulty, urinary retention, and splint behavior during urination or defecation [2,8]. Aging and parity are the primary risk factors for POP [2,9]. For symptomatic patients who experience worsening symptoms despite pelvic floor exercises, the nonsurgical method of pessary insertion is suggested. However, in cases where the patient encounters challenges such as pain, inflammation leading to discharge, bleeding, or even fistula formation communicating with adjacent organs, surgical intervention becomes the primary treatment option [2,4,10]. According to recent study on unsuccessful pessary fitting in Korean women, 40% had the pessary removed within 2 weeks due to discomfort after insertion. Additionally, even among patients with successful pessary fitting, an median of 4 years later, they discontinued pessary use due to discomforts such as vaginal erosion and urinary incontinence [11].
Surgical approaches for the treatment of POP have evolved significantly over the past five decades, from vaginal to abdominal approaches. Abdominal sacrocolpopexy (ASC) and laparoscopic sacrocolpopexy (LSC) have emerged as the gold standard surgical options for apical compartment POP. Robotic sacrocolpopexy (RSC) helps overcome the challenges of LSC by facilitating deep pelvic dissection and multiple intracorporeal suturing. Recently, RSC has become a robust surgical option for the treatment of vaginal apical segment prolapse [12,13]. In this review, we aim to discuss the surgical outcomes of various types of RSC in the treatment of POP, along with a recent literature review.

Sacrocervicopexy vs. sacrocolpopexy

In the case of hysterectomy for benign gynecological conditions, the choice between total hysterectomy (TH) and supracervical hysterectomy (SCH) continues to be debated, with varying opinions. A Cochrane review concluded that there were no significant differences in urinary, bowel, or sexual function outcomes between the two surgical procedures. SCH demonstrated a significantly reduced operation time (11 minutes difference) and blood loss (57 mL difference) [14], but it is important for patients to conitnue regular cervical monitoring due to the risk of cervical cancer [15]. According to a recent multicenter study, abnormal vaginal discharge and bleeding occured in up to 40% of patients after SCH, and cervical cancer occured in 7.5% of patients [16]. However, studies comparing the efficacy of TH and SCH during RSC are limited. Consequently, this review aims to provide a comprehensive summary of recent studies focusing on robotic SCH with sacrocervicopexy and robotic TH with sacrocolpopexy.
In the most recent prospective observational cohort study (sacrocervicopexy, 67.5%; sacrocolpopexy, 32.5%), both surgical approaches showed substantial effectiveness in the treatment of POP over a 50-month follow up period, and 96% patients showed no apical recurrence [17]. The symptoms of bulging and pelvic organ prolapse quantification system (POP-Q) stages at all landmarks improved significantly postoperatively. The most common recurrence symptom was cystocele (20%), with higher incidence observed in sacrocervicopexy than in sacrocolpopexy (P=0.002). There was one surgical reintervention for recurrent POP (1.6%); however, specific details regarding the type of surgery performed were not provided. As this study was not designed as a comparative study, comprehensive information regarding each surgical procedure was unavailable. In another study by van Zanten et al. [18] which included the largest prospective cohort of 305 patients, the anatomical success rates in all compartments were 67% for sacrocolpopexy and 65% for sacrocervicopexy over 12 months of follow up period (P=0.680). Recurrence rates of apical compartment were only 0.7% and 0.0% for sacrocolpopexy and sacrocervicopexy, respectively (P>0.999). Intraoperative complications were low in both procedures but were significantly higher in sacrocolpopexy (5.3% vs. 0.0%; P=0.008), including bladder injury, ureteric injury, and conversion for bleeding. Therefore, this study concluded that both procedures were safe and provided sustainable results.
Several studies have suggested that TH during RSC is associated with increased vaginal cuff cellulitis, mesh exposure, and ureteral injury. In contrast, SCH during RSC (sacrocervicopexy) revealed better results with an extremely low risk of blood transfusion, prolonged hospital stay, and intensive care unit admission [19]. According to the American National Surgical Quality Improvement Program database, urogynecologists are more likely to perform SCH than gynecologists are. SCHs are increasing by approximately 2% annually. This was attributed to concerns regarding mesh exposure [20]. However, recent studies have reported mixed mesh exposure results. In the largest observational cohort study by van Zanten et al. [18], mesh exposure rates were similar for both robotic procedures (2.1% for TH vs. 0.9% for SCH; P>0.999). A most recent systemic analysis review of 19 studies for rate of mesh erosion demonstrated that SCH had a lower rate of mesh erosion than that in TH (combined odds ratio [OR], 0.26; 95% confidence interval [CI], 0.18-0.38; I2, 0%) [21]. This review suggested that this may be due to the opening of the vaginal cuff weakening the tissue because of vaginal bacteria, tissue devascularization, or loss of structural support of the cervix for mesh or suture attachment. The majority of studies (98%) included in this review analysis focused on minimally invasive surgery (MIS). Among the MIS approaches, LSC was the most common method (57%), followed by RSC (30%). To the best of our knowledge, there is currently a lack of systematic reviews on TH and SCH during RSC. Consequently, the comparative risk of mesh exposure between the two procedures during RSC remains unclear. Further studies are needed to investigate this aspect and provide more comprehensive insights into the safety and efficacy of these procedures.

Surgical success and recurrence

Surgical success is defined as no recurrent prolapse on short-or long-term follow-ups, measured subjectively by a survey and/or objectively by the POP-Q. According to Culligan et al. [22], the success rate was 89.3%. However, of the remaining percentage of cases classified as surgical failure, 4.4% met the objective and subjective recurrence. Of these, 2.4% were found to have anterior compartment POP-Q points (Aa or Ba) greater than 0, while the other 2% were found to have posterior compartment POP-Q points (Ap or Bp) greater than 0, and subsequently having native tissue anterior colporrhaphies and posterior colporrhaphies, respectively. In contrast, RSC has been shown to have a higher anatomical success rate when compared with the vaginal approach, as well as five-fold less postoperative urinary retention than those undergoing native-tissue apical vaginal repair, such as the uterosacral and sacrospinous ligaments [22].
In terms of vaginal vault prolapse, the need for additional operations for mesh removal increases owing to partial or complete mesh exposure. Sassani et al. [23] conducted a retrospective study of patients who underwent mesh removal after sacrocolpopexy between 2010 and 2019; these patients were time matched with women who underwent sacrocolpopexy but did not undergo mesh removal. A total of 26 cases of mesh removal were identified [23]. The most common indications were exposure (69%) and pain (58%). Recurrence of POP occurred in 46% of women who had mesh removal compared to 8% in those without. Further studies are required to determine the efficacy of concomitant prolapse repair during mesh excision.

Complications

Robotic surgery used for dissecting and suturing the mesh has a big advantage over the laparoscopic approach, with a greater range of motion and a three-dimensional, high-resolution view of the surgical area. However, there is still risk of the absence of haptic feedback on robotic platforms [24].
Mesh exposure is a serious adverse event after sacrocolpopexy. At a median 6.5 years after surgery, mesh and/or suture exposure was lowest in RSC, but there was no significant difference among the three groups (ASC, 7.7% vs. LSC, 4.9% vs. RSC, 3.6%; P=0.20) [25]. In addition, the most recent systematic review of MIS sacrocolpopexy analyzed that there were no significant differences between LSC and RSC (OR, 0.87; 95% CI, 0.47-1.63; P=0.67) [26]. The mesh exposure in MIS estimated to date is very low at 3.5%, and most exposures occurred in the vaginal wall [27]. Although conservative management or simple procedures, such as trimming or excision, can be considered in asymptomatic or minimally symptomatic patients, complete mesh removal and vaginal revision may be needed for patients with severe mesh-related infections [28]. Therefore, care should be taken during the procedure; more experience with MIS sacrocolpopexy is required.
American National Inpatient Sample database analysis results reported that the conversion rate was much lower for RSC (1.33%) than for LSC (7.14%), and the adjusted OR was 0.32 (95% CI, 0.19-0.54) [29]. The most common causes of conversion were obesity and extensive adhesions leading to bladder injury or unclear anatomical structures [29]. Considering that the rate of obesity was similar between the two surgeries (6.4% vs. 7.0%; P=0.65), RSC may provide surgery with a low risk of conversion, even in obese patients. In terms of blood loss, the most recent meta-analysis found that RSC showed significantly lower blood loss than LSC (weighted mean difference, −86.52 mL; 95% CI, −130 to −42.79; P=0.0001) [26]. In addition, overall intraoperative complications were significantly lesser in RSC than in LSC (OR, 0.5; 95% CI, 0.40-0.91; P=0.01). There was no significant difference between the two groups in terms of postoperative complications.
In conclusion, RSC showed efficacy comparable to that of LSC in terms of mesh-related complications; however, RSC was associated with a lower conversion rate, reduced blood loss, and fewer intraoperative complications.

Concurrent operation for stress urinary incontinence

Defects in the pelvic floor support may result in stress urinary incontinence (SUI) and vaginal apical prolapse, which mandate simultaneous correction. In our recent literature review, we did not find any controversies regarding the combination of RSC with a sling operation for SUI. The main concern in concurrent surgery for SUI was post-operative urine retention, and there was no difference in voiding trials regardless of combined surgery for SUI [30]. However, this study result was for minimally invasive surgeries using both RSC and LSC [30]. It might be acceptable postponing the midurethral sling and performing a delayed (two-stage) operation for SUI, if required.

Concurrent posterior colporrhaphy (PR)

In most cases, apical vaginal prolapse is associated with anterior- or posterior-compartment prolapse. Although compartment prolapse may not be symptomatic, it can affect the success rate of RSC. Concurrent PR can reduce the odds of composite patient-centered failure without increasing the rate of defecatory dysfunction or dyspareunia [22]. However, there are currently no standardized guidelines for performing concurrent PR at the time of RSC. In addition, research on concurrent PR is limited and has shown conflicting results. A study on ASC found that the majority of women had restored posterior vaginal topography 1 year after sacrocolpopexy without PR [31]. In contrast, Chang et al. [32] concluded that concurrent PR for asymptomatic rectocele reduced the surgical failure rate (OR, 2.79; 95% CI, 1.25-6.23; P=0.01) without an increased rate of dyspareunia of defecatory dysfunction. However, in this study, RSC was performed in 22% of cases, with the remainder being LSC and ASC [32]. Recently, a retrospective study of RSC compared postoperative anatomical failure categorized by the genital hiatus size [33]. The study suggested that patients with an enlarged genital hiatus may benefit from concomitant PR for the anatomical success of posterior compartment prolapse.

Conclusion

In patients with advanced-stage POP, RSC enables the successful anatomical correction of the apical compartment with careful dissection and reconstruction. In addition, RSC has a low recurrence rate and minimal complications of mesh erosion and dyspareunia, making it a safe and beneficial surgical option. However, a few concerns remain regarding this technique, one of which is the high cost of the procedure, which is considered more expensive than other surgical methods. This may be an obstacle preventing patients from accessing this operation. Another concern is the long-term safety and efficacy of RSC. Despite some studies advocating lower complication rates associated with the procedures, further research is needed to fully evaluate the long-term outcomes of the procedure in the long run.

Notes

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Ethical approval

Institutional Review Board (IRB) approval is not applicable for this study.

Patient consent

Patient consent was not required for this review article.

Funding information

None.

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