The impact of fellowship surgical training on operative time and patient morbidity during robotics-assisted sacrocolpopexy

Incidence and Risk Factors for Genitourinary Tract Injury Within 1 Year After Surgery for Pelvic Organ Prolapse

IMPORTANCE

The rate of genitourinary tract injury (GUTI) following pelvic organ prolapse (POP) surgery is presently ill-defined and based on relatively small trials with short follow-up time. Given the potential for higher risk of injury with POP, a better understanding of this type of injury is important for patient counseling.

OBJECTIVES

The objective of this study was to identify the incidence and risk factors of GUTI related to POP surgery.

STUDY DESIGN

Women undergoing POP surgery between 2010 and 2019 were identified using Current Procedural Terminology codes in the Premier Healthcare Database. The primary outcome was GUTI, defined as bladder or ureteral injury, and vesicovaginal or ureterovaginal fistula within 1 year of surgery. Genitourinary tract injury was identified using International Classification of Diseases and Current Procedural Terminology codes. Patients were divided into those with and without GUTI. Differences between groups were evaluated using the Student t test, Wilcoxon rank-sum test, and Fisher exact test as appropriate. Multivariable logistic regression was used to evaluate the independent predictors of GUTI.

RESULTS

One hundred thirty-nine thousand one hundred fifty-eight surgical procedures for POP were captured between 2010 and 2019. The rate of GUTI was 1.10%: 0.48% bladder, 0.64% ureteral injuries, and 0.01% fistulas. The most significant variables associated with any GUTI were as follows: adhesiolysis (adjusted odds ratio [aOR], 2.64; 95% confidence interval [CI], 1.07-6.51), blood transfusion (aOR, 3.67; 95% CI, 1.34-10.04), and low-volume surgeons (<12 cases per year) (aOR, 1.68; 95% CI, 1.60-1.77), nonurologic or gynecologic surgeon specialty (aOR, 1.62; 95% CI, 1.49-2.00), and uterosacral suspension (aOR, 1.30; 95% CI, 1.13-1.49).

CONCLUSIONS

The rate of GUTI following POP surgery is lower than has previously been reported. Surgeon experience and specialty and surgical approach may affect GUTI incidence.

Anchor vs suture for the attachment of vaginal mesh in a robotic-assisted sacrocolpopexy: a randomized clinical trial

BACKGROUND

Vaginal mesh attachment can be one of the most time-consuming components of a minimally invasive sacrocolpopexy.

OBJECTIVE

To assess the impact on the duration vaginal mesh attachment of using absorbable anchors compared to interrupted sutures for vaginal mesh attachment in robotic-assisted sacrocolpopexy.

STUDY DESIGN

This was a single-masked, randomized clinical trial of women with pelvic organ prolapse that underwent a robotic-assisted sacrocolpopexy at 2 clinical sites. The participants were randomized to receive either interrupted delayed absorbable anchors or sutures during the vaginal mesh attachment portion of the surgery. The participants completed validated questionnaires at baseline and at 6 weeks, 6 months, and 12 months after the surgery. A certified examiner, masked to the attachment technique that was used, performed a clinical examination using the Pelvic Organ Prolapse Quantification system and also assessed for mesh exposure and the overall appearance of the vaginal walls using a 10-cm visual analog scale at each follow-up visit. The primary outcome was the vaginal mesh attachment time. The categorical variables were compared using chi-square or Fischer's Exact test, whereas the continuous variables were compared using Student's t-test or Mann-Whitney U test where appropriate. An intention-to-treat analysis was performed.

RESULTS

Fifty-three participants were randomized, 26 to mesh attachment with anchor, 27 to mesh attachment with suture, and 81% (21/26) and 93% (25/27) had 12-month follow up respectively. There were no significant differences between the groups with regard to age (P=.12), body mass index (P=.23), stage of prolapse (P=.97), or other preoperative factors. Mesh attachment interval time was faster in the anchor compared to suturing study arm (12.2±7.8 vs 21.2±5.2 minutes; P<.001), while sacrocolpopexy times (107.6±33.2 vs 109.8±21.2 minutes; P=.774) were not different. The ease of placement for the surgeon based on a visual analog scale (P=.16), the appearance of the mesh attachment (P=.07), and the overall satisfaction with the use of the specific attachment type (P=.65) were similar for the arms. There was no difference in perioperative adverse events rates between arms and by 12 months follow-up there were no sacrocolpopexy mesh, anchor, or suture exposures. There was no difference in outcomes at 12 months including composite failure (10% vs 12%; P=.79), patient global impression of improvement (1.06 vs 1.19; P=.27), or patient pelvic pain (9.81 vs 9.67; P=.56).

CONCLUSION

In patients undergoing a robotic-assisted sacrocolpopexy, the anchor vaginal mesh attachment technique required significantly less time than suturing. There was no difference between techniques in complications, failure, surgeon, or patient-reported outcomes through 12 months of follow-up. Mesh attachment during sacrocolpopexy can be performed in less time by using the anchor technique, providing surgeons with an alternative surgical technique for this procedure.

Robotic-assisted repair of pelvic organ prolapse: a scoping review of the literature

The purpose of this article is to perform a scoping review of the medical literature regarding the efficacy, safety, and cost of robotic-assisted procedures for repair of pelvic organ prolapse in females. Sacrocolpopexy is the “gold standard” repair for apical prolapse for those who desire to maintain their sexual function, and minimally-invasive approaches offer similar efficacy with fewer risks than open techniques. The introduction of robotic technology has significantly impacted the field, converting what would have been a large number of open abdominal sacrocolpopexy (ASC) procedures to a minimally-invasive approach in the United States. Newer techniques such as nerve-sparing dissection at the sacral promontory, use of the iliopectineal ligaments and natural orifice vaginal sacrocolpopexy may improve patient outcomes. Prolapse recurrence is consistently noted in at least 10% of patients regardless of route of mesh placement. Ancillary factors including pre-operative prolapse stage, retention of the cervix, type of mesh implant, and genital hiatus (GH) size all adversely affect surgical efficacy, while trainees do not. Minimally-invasive apical repair procedures are suited to early recovery after surgery protocols but may not be appropriate for all patients. Studies evaluating longer-term outcomes of robotic sacrocolpopexies are needed to understand the relative risk/benefit ratio of this technique. With several emerging robotic platforms with improved features and a focus on decreasing costs, the future of robotics seems bright.