Cost-analysis and quality of life after laparoscopic and robotic ventral mesh rectopexy for posterior compartment prolapse: a randomized trial

Economic Evaluations of Robotic-Assisted Surgery: Methods, Challenges and Opportunities

BACKGROUND

The use of robotic-assisted surgery (RAS) is growing rapidly. However, economic evaluation of this technology is challenging. This study aims to identify and discuss the different economic evaluation methods which have been used to evaluate RAS.

METHOD

This scoping review systematically searched PubMed and Embase from 2015 to 2023. We included economic evaluation studies comparing RAS versus laparoscopic or open surgery. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used to aid data extraction and was extended to cover additional features relevant to RAS, including learning curve, organisational impact, incremental innovation and dynamic pricing.

RESULTS

A total of 50 economic evaluations of RAS were included. Cost-utility analysis (46%) was the most commonly applied economic evaluation method, followed by cost-consequence analysis (32%). The studies focused on the specialties of urology (42%), hepato-pancreato-biliary (20%), colorectal (14%) and gynaecology (6%). Distinctive features related to the assessment of RAS were under-addressed in economic evaluations. Only 40% of the included studies considered learning curve and organisational impact and less than 12% of the included studies reflected on incremental innovation and dynamic pricing.

CONCLUSIONS

This review found that some studies have incorporated challenges specific to RAS in their evaluations. However, most studies still lack key aspects of importance. In particular, studies rarely considered the ability of RAS platforms to be shared across multiple specialities. Incorporating these distinctive features offers an opportunity for economic evaluation to provide decision-makers with a more realistic assessment of the cost-effectiveness of this technology and to ensure its optimal utilisation in clinical practice.

Comparative study of laparoscopic ventral mesh rectopexy versus perineal stapler resection for external full-thickness rectal prolapse in elderly patients: enhanced outcomes and reduced recurrence rates-a retrospective cohort study

BACKGROUND

In elderly patients with external full-thickness rectal prolapse (EFTRP), the exact differences in postoperative recurrence and functional outcomes between laparoscopic ventral mesh rectopexy (LVMR) and perineal stapler resection (PSR) have not yet been investigated.

METHODS

We conducted a retrospective multicenter study on 330 elderly patients divided into LVMR group (n = 250) and PSR (n = 80) from April 2012 to April 2019. Patients were evaluated before and after surgery by Wexner incontinence scale, Altomare constipation scale, and patient satisfaction questionnaire. The primary outcomes were incidence and risk factors for EFTRP recurrence. Secondary outcomes were postoperative incontinence, constipation, and patient satisfaction.

RESULTS

LVMR was associated with fewer postoperative complications (p < 0.001), lower prolapse recurrence (p < 0.001), lower Wexner incontinence score (p = 0.03), and lower Altomare's score (p = 0.047). Furthermore, LVMR demonstrated a significantly higher surgery-recurrence interval (p < 0.001), incontinence improvement (p = 0.019), and patient satisfaction (p < 0.001) than PSR. Three and 13 patients developed new symptoms in LVMR and PSR, respectively. The predictors for prolapse recurrence were LVMR (associated with 93% risk reduction of recurrence, OR 0.067, 95% CI 0.03-0.347, p = 0.001), symptom duration (prolonged duration was associated with an increased risk of recurrence, OR 1.131, 95% CI 1.036-1.236, p = 0.006), and length of prolapse (increased length was associated with a high recurrence risk (OR = 1.407, 95% CI = 1.197-1.655, p < 0.001).

CONCLUSIONS

LVMR is safe for EFTRP treatment in elderly patients with low recurrence, and improved postoperative functional outcomes.

TRIAL REGISTRATION

Clinical Trial.gov (NCT05915936), retrospectively registered on June 14, 2023.

Outcomes of robotic versus laparoscopic ventral mesh rectopexy for rectal prolapse

INTRODUCTION

Minimally invasive ventral mesh rectopexy is considered the standard of care in the surgical management of rectal prolapse syndromes in fit patients. We aimed to investigate the outcomes after robotic ventral mesh rectopexy (RVR) and compare them with our laparoscopic series (LVR). Additionally, we report the learning curve of RVR. As the financial aspect for the use of a robotic platform remains an important obstacle to allow generalized adoption, cost-effectiveness was also evaluated.

PATIENTS AND METHODS

A prospectively maintained data set including 149 consecutive patients who underwent a minimally invasive ventral rectopexy between December 2015 and April 2021 was reviewed. The results after a median follow-up of 32 months were analyzed. Additionally, a thorough assessment of the economic aspect was performed.

RESULTS

On a total of 149 consecutive patients 72 underwent a LVR and 77 underwent a RVR. Median operative time was comparable for both groups (98 min (RVR) vs. 89 min (LVR); p = 0.16). Learning curve showed that an experienced colorectal surgeon required approximately 22 cases in stabilizing the operative time for RVR. Overall functional results were similar in both groups. There were no conversions or mortality. There was, however, a significant difference (p < 0.01) in hospital stay in favor of the robotic group (1 day vs. 2 days). The overall cost of RVR was higher than LVR.

CONCLUSIONS

This retrospective study shows that RVR is a safe and feasible alternative for LVR. With specific adjustments in surgical technique and robotic materials, we developed a cost-effective way of performing RVR.

Robot-assisted surgery in thoracic and visceral indications: an updated systematic review

BACKGROUND

In surgical advancements, robot-assisted surgery (RAS) holds several promises like shorter hospital stays, reduced complications, and improved technical capabilities over standard care. Despite extensive evidence, the actual patient benefits of RAS remain unclear. Thus, our systematic review aimed to assess the effectiveness and safety of RAS in visceral and thoracic surgery compared to laparoscopic or open surgery.

METHODS

We performed a systematic literature search in two databases (Medline via Ovid and The Cochrane Library) in April 2023. The search was restricted to 14 predefined thoracic and visceral procedures and randomized controlled trials (RCTs). Synthesis of data on critical outcomes followed the Grading of Recommendations, Assessment, Development, and Evaluation methodology, and the risk of bias was evaluated using the Cochrane Collaboration's Tool Version 1.

RESULTS

For five out of 14 procedures, no evidence could be identified. A total of 20 RCTs and five follow-up publications met the inclusion criteria. Overall, most studies had either not reported or measured patient-relevant endpoints. The majority of outcomes showed comparable results between study groups. However, RAS demonstrated potential advantages in specific endpoints (e.g., blood loss), yet these findings relied on a limited number of low-quality studies. Statistically significant RAS benefits were also noted in some outcomes for certain indications-recurrence, quality of life, transfusions, and hospitalisation. Safety outcomes were improved for patients undergoing robot-assisted gastrectomy, as well as rectal and liver resection. Regarding operation time, results were contradicting.

CONCLUSION

In summary, conclusive assertions on RAS superiority are impeded by inconsistent and insufficient low-quality evidence across various outcomes and procedures. While RAS may offer potential advantages in some surgical areas, healthcare decisions should also take into account the limited quality of evidence, financial implications, and environmental factors. Furthermore, considerations should extend to the ergonomic aspects for maintaining a healthy surgical environment.

Ventral mesh rectopexy. Does a descending perineum impact functional results and quality of life?

PURPOSE

The impact of perineal descent (PD) on functional outcome and quality of life after ventral mesh rectopexy (VMR) is unknown. The purpose of this study was to analyze the effect of PD on the functional outcome and quality of life (QOL) after VMR.

METHODS

A retrospective analysis was performed on fifty-five patients who underwent robotic VMR between 2018 and 2021. Pre and postoperative data along with radiological studies were gathered from a prospectively maintained database. The Cleveland Clinic Constipation score (CCCS), the Rome IV criteria and the 36-Item Short-Form Health Survey (SF-36), were used to measure functional results and QOL.

RESULTS

All 55 patients (mean age 57.8 years) were female. Most patients had radiological findings of severe PD (n = 31) as opposed to mild/moderate PD (n = 24). CCCS significantly improved at 3 months and 1 year post-VMR (mean difference = -4.4 and -5.4 respectively, p < 0.001) with no significant difference between the two groups. The percentage of functional constipation Rome IV criteria only showed an improved outcome at 3 months for severe PD and at 1 year for mild/moderate PD (difference = -58.1% and -54.2% respectively, p < 0.05). Only the SF-36 subscale bodily pain significantly improved in the mild/moderate PD group (mean difference = 16.7, p = 0.002) 3 months post-VMR which subsided after one year (mean difference = 5.5, p = 0.068).

CONCLUSION

Severe PD may impact the functional outcome of constipation without an evident effect on QOL after VMR. The results, however, remain inconclusive and further research is warranted.

A systematic review of full economic evaluations of robotic-assisted surgery in thoracic and abdominopelvic procedures

This study aims to conduct a systematic review of full economic analyses of robotic-assisted surgery (RAS) in adults' thoracic and abdominopelvic indications. Authors used Medline, EMBASE, and PubMed to conduct a systematic review following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 guidelines. Fully published economic articles in English were included. Methodology and reporting quality were assessed using standardized tools. Majority of studies (28/33) were on oncology procedures. Radical prostatectomy was the most reported procedure (16/33). Twenty-eight studies used quality-adjusted life years, and five used complication rates as outcomes. Nine used primary and 24 studies used secondary data. All studies used modeling. In 81% of studies (27/33), RAS was cost-effective or potentially cost-effective compared to comparator procedures, including radical prostatectomy, nephrectomy, and cystectomy. Societal perspective, longer-term time-horizon, and larger volumes favored RAS. Cost-drivers were length of stay and equipment cost. From societal and payer perspectives, robotic-assisted surgery is a cost-effective strategy for thoracic and abdominopelvic procedures.Clinical trial registration This study is a systematic review with no intervention, not a clinical trial.

A network meta-analysis of surgical treatments of complete rectal prolapse

PURPOSE

Surgical treatment of complete rectal prolapse can be undertaken via an abdominal or a perineal approach. The present network meta-analysis aimed to compare the outcomes of different abdominal and perineal procedures for rectal prolapse in terms of recurrence, complications, and improvement in fecal incontinence (FI).

METHODS

A PRISMA-compliant systematic review of PubMed, Scopus, and Web of Science was conducted. Randomized clinical trials comparing two or more procedures for the treatment of complete rectal prolapse were included. The risk of bias was assessed using the ROB-2 tool. The main outcomes were recurrence of full-thickness rectal prolapse, complications, operation time, and improvement in FI.

RESULTS

Nine randomized controlled trials with 728 patients were included. The follow-up ranged between 12 and 47 months. Posterior mesh rectopexy had significantly lower odds of recurrence than did the Altemeier procedure (logOR, - 12.75;  95% credible intervals, - 40.91, - 1.75), Delorme procedure (- 13.10; - 41.26, - 2.09), resection rectopexy (- 11.98; - 41.36, - 0.19), sponge rectopexy (- 13.19; - 42.87, - 0.54), and sutured rectopexy (- 13.12; - 42.58, - 1.50), but similar odds to ventral mesh rectopexy (- 12.09; - 41.7, 0.03). Differences among the procedures in complications, operation time, and improvement in FI were not significant.

CONCLUSIONS

Posterior mesh rectopexy ranked best with the lowest recurrence while perineal procedures ranked worst with the highest recurrence rates.

Is robotic ventral mesh rectopexy for pelvic floor disorders better than laparoscopic approach at the beginning of the experience? A retrospective single-center study

PURPOSE

To compare perioperative results of laparoscopic and robotic ventral mesh rectopexy for pelvic floor disorders at the beginning of the surgical experience.

METHODS

Between 2017 and 2022, the first 30 laparoscopic ventral mesh rectopexies and the first 30 robotic ventral mesh rectopexies at the beginning of the experience of 2 surgeons were retrospectively analyzed. Perioperative (demographic characteristics, surgical indication, conversion rate, operative time), and postoperative (complications, length of stay, unplanned reintervention) data were compared between groups.

RESULTS

Demographic characteristics were similar between groups. Conversion rate was lower (0 vs 17%, p = 0.05), but the operative time was significantly longer (182 [146-290] vs 150 [75-240] minutes, p < 0.0001) during robotic procedure when compared with laparoscopic approach. In terms of learning curve, the number of procedures to obtain the same operative time between the 2 approaches was 15. Postoperative results were similar between groups, in terms of pain (visual analogic scale = 2 [0-8] vs 4 [0-9], p = 0.07), morbidity (17 vs 3%, p = 0.2), and unplanned reintervention (1 vs 0%, p = 0.99). Mean length of stay was significantly reduced after robotic approach when compared with laparoscopic approach (3 [2-10] vs 5 [2-11] days, p < 0.01). Functional results were better after robotic than laparoscopic ventral mesh rectopexy, with higher satisfaction rate (93 vs 75%, p = 0.05), and reduced recurrence rate (0 vs 14%, p = 0.048).

CONCLUSION

Despite longer operative time at the beginning of the learning curve, robotic ventral mesh rectopexy was associated with similar or better perioperative results than laparoscopic ventral mesh rectopexy.

Current diagnostic tools and treatment modalities for rectal prolapse

Rectal prolapse is a circumferential, full-thickness protrusion of the rectum through the anus. It is a rare condition, and only affects 0.5% of the general population. Multiple treatment modalities have been described, which have changed significantly over time. Particularly in the last decade, laparoscopic and robotic surgical approaches with different mobilization techniques, combined with medical therapies, have been widely implemented. Because patients have presented with a wide range of complaints (ranging from abdominal discomfort to incomplete bowel evacuation, mucus discharge, constipation, diarrhea, and fecal incontinence), understanding the extent of complaints and ruling out differential diagnoses are essential for choosing a tailored surgical procedure. It is crucial to assess these additional symptoms and their severities using preoperative scoring systems. Additionally, radiological and physiological evaluations may explain some vague symptoms and reveal concomitant pelvic disorders. However, there is no consensus on or standardization of the optimal extent of dissection, type of procedure, and materials used for rectal fixation; this makes providing maximum benefits to patients with minimal complications difficult. Even recent publications and systematic reviews have not recommended the most appropriate treatment options. This review explains the appropriate diagnostic tools for different conditions and summarizes the current treatment approaches based on existing literature and expert opinions.

Innovating for Value-Based Surgical Care in Canada: A Post-Pandemic Necessity

Providing high-quality, efficient and cost-effective surgical care to Canadians has become increasingly challenging since the pandemic, resulting in long waitlists due to limited staff and resources. The pandemic has facilitated some areas of innovation in surgical care, notably in virtual care and expedited discharge, although many challenges remain. Key policy recommendations for reform include investing in infrastructure to collect and report on value-based metrics beyond volume, devising strategies to improve health equity, enhancing out-of-hospital support for surgical patients by using remote monitoring and digital technology, increasing patient segmentation into low- and high-complexity pathways, centralizing surgical triage and initiating careful financial incentivization of integrated groups of clinicians.

Robot-assisted pelvic floor reconstructive surgery: an international Delphi study of expert users

BACKGROUND

Robotic surgery has gained popularity for the reconstruction of pelvic floor defects. Nonetheless, there is no evidence that robot-assisted reconstructive surgery is either appropriate or superior to standard laparoscopy for the performance of pelvic floor reconstructive procedures or that it is sustainable. The aim of this project was to address the proper role of robotic pelvic floor reconstructive procedures using expert opinion.

METHODS

We set up an international, multidisciplinary group of 26 experts to participate in a Delphi process on robotics as applied to pelvic floor reconstructive surgery. The group comprised urogynecologists, urologists, and colorectal surgeons with long-term experience in the performance of pelvic floor reconstructive procedures and with the use of the robot, who were identified primarily based on peer-reviewed publications. Two rounds of the Delphi process were conducted. The first included 63 statements pertaining to surgeons' characteristics, general questions, indications, surgical technique, and future-oriented questions. A second round including 20 statements was used to reassess those statements where borderline agreement was obtained during the first round. The final step consisted of a face-to-face meeting with all participants to present and discuss the results of the analysis.

RESULTS

The 26 experts agreed that robotics is a suitable indication for pelvic floor reconstructive surgery because of the significant technical advantages that it confers relative to standard laparoscopy. Experts considered these advantages particularly important for the execution of complex reconstructive procedures, although the benefits can be found also during less challenging cases. The experts considered the robot safe and effective for pelvic floor reconstruction and generally thought that the additional costs are offset by the increased surgical efficacy.

CONCLUSION

Robotics is a suitable choice for pelvic reconstruction, but this Delphi initiative calls for more research to objectively assess the specific settings where robotic surgery would provide the most benefit.

Technical modifications for cost optimization in robot-assisted ventral mesh rectopexy: an initial experience

BACKGROUND

Robot-assisted ventral mesh rectopexy is considered a valid option in the treatment of rectal prolapse. However, it involves higher costs than the laparoscopic approach. The aim of this study is to determine if less expensive robotic surgery for rectal prolapse can be safely performed.

METHODS

This study was conducted on consecutive patients who underwent robot-assisted ventral mesh rectopexy at Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, from 7 November 2020 to 22 November 2021. The cost of hospitalization, surgical procedure, robotic materials, and operating room resources in patients undergoing robot-assisted ventral mesh rectopexy with the da Vinci Xi Surgical Systems was analyzed before and after technical modifications, including the reduction of robotic arms and instruments, and the execution of a double minimal peritoneal incision at the pouch of Douglas and sacral promontory (instead of the traditional inverted J incision).

RESULTS

Twenty-two robot-assisted ventral mesh rectopexies were performed [21 females, 95.5%, median age 62.0 (54.8-70.0) years]. After an initial experience performing traditional robot-assisted ventral mesh rectopexy in four patients, we adopted technical modifications in other cases. No major complication or conversion to open surgery occurred. In total, mean cost of hospitalization, surgical procedure, robotic materials, and operating room resources was €6995.5 ± 1058.0, €5912.7 ± 877.0, €2797.6 ± 545.6, and €2608.3 ± 351.5, respectively. Technical modifications allowed a significant reduction in the overall cost of hospitalization (€6604.5 ± 589.5 versus €8755.0 ± 906.4, p = 0.001), number of robotic instruments (3.1 ± 0.2 versus 4.0 ± 0.8 units, p = 0.026), and operating room time (201 ± 26 versus 253 ± 16 min, p = 0.003).

CONCLUSIONS

Considering our preliminary results, robot-assisted ventral mesh rectopexy with appropriate technical modifications can be cost-effective and safe.

Quality of Life Following Pelvic Organ Prolapse Treatments in Women: A Systematic Review and Meta-Analysis

Introduction: Quality of life (QoL) improvement is one of the main outcomes in the management of pelvic organ prolapse as a chronic illness in women. This systematic review aimed to investigate the impact of surgical or pessary treatment for pelvic organ prolapse (POP) on quality of life. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was applied. Electronic databases, including PubMed, Scopus, and Web of Science, were searched for original articles that evaluated the QoL before and after surgical interventions or pessary in pelvic organ prolapse from 1 January 2012 until 30 June 2022 with a combination of proper keywords. Included studies were categorized based on interventions, and they were tabulated to summarize the results. Results: Overall, 587 citations were retrieved. Of these, 76 articles were found eligible for final review. Overall, three categories of intervention were identified: vaginal surgeries (47 studies), abdominal surgeries (18 studies), and pessary intervention (11 studies). Almost all interventions were associated with improved quality of life. The results of the meta-analysis showed a significant association between the employment of surgical approach techniques (including vaginal and abdominal surgeries) and the quality of life (Pelvic Floor Distress Inventory (PFDI) (MD: −48.08, 95% CI: −62.34 to −33.77, p-value < 0.01), Pelvic Floor Impact Questionnaire (PFIQ) (MD: −33.41, 95% CI: −43.48 to −23.34, p < 0.01)) and sexual activity of patients with pelvic organ prolapse (Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ) (MD: 4.84, 95% CI: 1.75 to 7.92, p < 0.01)). Furthermore, narrative synthesis for studies investigating the effect of the pessary approach showed a positive association between the use of this instrument and improvement in the quality of life and sexual activity. Conclusions: The results of our study revealed a significant improvement in the women’s quality of life following abdominal and vaginal reconstructive surgery. The use of pessary was also associated with increased patient quality of life.

More work is needed on cost-utility analyses of robotic-assisted surgery

OBJECTIVE

To comprehensively analyze the cost-utility of robotic surgery in clinical practice and to investigate the reporting and methodological quality of the related evidence.

METHODS

Data on cost-utility analyses (CUAs) of robotic surgery were collected in seven electronic databases from the inception to July 2021. The quality of the included studies was assessed using the CHEERs and QHES checklists. A systematic review was performed with the incremental cost-effectiveness ratio as the outcome of interest.

RESULTS

Thirty-one CUAs of robotic surgery were eligible. Overall, the identified CUAs were fair to high quality, and 63% of the CUAs ranked the cost-utility of robotic surgery as "favored," 32% categorized as "reject," and the remaining 5% ranked as "unclear." Although a high heterogeneity was present in terms of the study design among the included CUAs, most studies (81.25%) consistently found that robotic surgery was more cost-utility than open surgery for prostatectomy (ICER: $6905.31/QALY to $26240.75/QALY; time horizon: 10 years or lifetime), colectomy (dominated by robotic surgery; time horizon: 1 year), knee arthroplasty (ICER: $1134.22/QALY to $1232.27/QALY; time horizon: lifetime), gastrectomy (dominated by robotic surgery; time horizon: 1 year), spine surgery (ICER: $17707.27/QALY; time horizon: 1 year), and cystectomy (ICER: $3154.46/QALY; time horizon: 3 months). However, inconsistent evidence was found for the cost-utility of robotic surgery versus laparoscopic surgery and (chemo)radiotherapy.

CONCLUSIONS

Fair or high-quality evidence indicated that robotic surgery is more cost-utility than open surgery, while it remains inconclusive whether robotic surgery is more cost-utility than laparoscopic surgery and (chemo)radiotherapy. Thus, an additional evaluation is required.

Trends in the surgical management of rectal prolapse: An Asian experience

BACKGROUND

Posterior compartment pelvic floor prolapse (PCPFP) leads to anatomical distortion and functional impairment. Definitive management involves surgery. Ventral mesh rectopexy (VMR) has gained increasing popularity in the West as it emerges as a durable approach. Existing literature and evidence on safety and efficacy of PCPFP surgery in the Asian population remains sparse. Our study aims to review our institution's experience in surgery for PCPFP.

METHODS

All cases of PCPFP surgery in Singapore General Hospital between 2014 to 2019 were studied.

RESULTS

Eighty-three patients had surgery performed for PCPFP, with the majority (83%) in the last 3 years. Median age was 63 years and 92% were female. Most patients (64%) had obstructive defecation symptoms, while the remaining had fecal incontinence, rectal bleeding, or anal discomfort. Main anatomical indication for surgery was external rectal prolapse (48%). Other indications were rectocele and/or rectal intussusception. The majority (66%) had abdominal rectopexy, while 28 underwent Delorme's procedure. Forty-five of the 50 VMRs were minimally invasive. Patients undergoing rectopexy were observed to be younger. Median length of stay was 3 days. Nine patients had early operative complications of which ileus was most common. Median length of follow-up was 12 months. The majority (93%) had initial symptom satisfaction. Eleven patients had anatomical recurrence with a median length of 9 months to development. There was no significant difference in outcomes between abdominal vs perineal approach, or laparoscopic vs robotic VMR.

CONCLUSION

Surgery for PCPFP has gained acceptance in our Asian institution with good symptom improvement, alongside low morbidity and recurrence.

Mid-term functional and quality of life outcomes of robotic and laparoscopic ventral mesh rectopexy: multicenter comparative matched-pair analyses

Background

The aim of this study was to compare patients’ mid-term functional and quality of life (QoL) outcomes following robotic ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR).

Methods

The data of consecutive female patients who underwent minimally invasive ventral mesh rectopexy for external or symptomatic internal rectal prolapse at 3 hospitals in Finland between January 2011 and December 2016 were retrospectively collected. Patients were matched by age and diagnosis at a 1:1 ratio. A disease-related symptom questionnaire was sent to all living patients at follow-up in July 2018.

Results

After a total of 401 patients (RVMR, n = 187; LVMR, n = 214) were matched, 152 patients in each group were included in the final analyses. The median follow-up times were 3.3 (range 1.6–7.4) years and 3.0 (range 1.6–7.6) years for the RVMR and LVMR groups, respectively. The postoperative QoL measures did not differ between the groups. Compared with the LVMR group, the RVMR group had lower postoperative Wexner Incontinence Score (median 5 vs. median 8; p < 0.001), experienced significant ongoing incontinence symptoms less often (30.6% vs. 49.0%; p < 0.001) and reported less postoperative faecal incontinence discomfort evaluated with the visual analogue scale (median 11 vs. median 39; p = 0.005). RVMR patients had a shorter hospital stay (2.2 days vs. 3.8 days; p < 0.001) but experienced more frequent de novo pelvic pain (31.8% vs. 11.8%; p < 0.001).

Conclusion

RVMR and LVMR patients had equal functional and QoL outcomes. Those who underwent RVMR had lower mid-term anal incontinence symptom scores but suffered more frequent de novo pelvic pain.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-021-02563-z.

Robotic versus laparoscopic ventral mesh rectopexy: a systematic review and meta-analysis

INTRODUCTION

Ventral mesh rectopexy is frequently performed as a means of improving the quality of life for sufferers of rectal prolapse. The minimally invasive approach is highly desirable but can be technically difficult to achieve in the narrow confines of the pelvis. The robotic platform is becoming a more common means of overcoming these difficulties, but evidence of an objective benefit over standard laparoscopy is scarce. This study seeks to review and analyse the data comparing outcomes after robotic and laparoscopic ventral mesh rectopexy.

METHOD

We searched MEDLINE, EMBASE and the Cochrane database for papers comparing robotic to laparoscopic ventral mesh rectopexy. Comparable data was pooled for meta-analysis.

RESULTS

Six studies compared outcomes between robotic and laparoscopic ventral mesh rectopexy. Sample sizes were relatively small, and only two of the studies were randomised. Pooled analysis was possible for data on operating time, complication rates, conversion rates and length of stay in hospital. This showed a non-significant trend towards longer operating times and a statistically significant reduction in length of stay after robotic procedures. There was no significant difference in complication and conversion rates.

CONCLUSION

The frequent finding of longer operating time for robotic surgery was not confirmed in this study. Shorter length of stay in hospital was seen, with other post-operative outcomes showing no significant difference. More data is needed with cost-benefit analyses to show whether the robotic platform is justified.

Meta-analysis on current status, efficacy, and safety of laparoscopic and robotic ventral mesh rectopexy for rectal prolapse treatment: can robotic surgery become the gold standard?

PURPOSE

Robotic-assisted surgery and robotic-assisted ventral mesh rectopexy are gaining attention in the treatment of rectal prolapse and increased positive findings are proposed. The objective of this meta-analysis was to investigate whether robotic-assisted ventral mesh rectopexy is comparable with the conventional laparoscopic approach surgery.

METHODS

Five major databases (PubMed, Sciencedirect, Web of Science, Embase, and Cochrane Library) were searched for eligible studies. Observational studies of the effect and safety of robotic-assisted and laparoscopic approaches on ventral mesh rectopexy were included. Odd ratios (OR) and weight mean difference (WMD) were used for dichotomous data and continuous data analysis. Clinical outcomes, functional outcomes, and cost-effectiveness data were extracted for meta-analysis.

RESULTS

Compared to the laparoscopic approach, a significant shorter length of hospital stay (LOS), lesser intraoperative blood loss, and lower post-operative complication rate of RVMR group were observed. However, operation time of RVMR was significant increased. The expense of RVMR was higher than LVMR; mean Wexner scores and fecal incontinence were lower in RVMR group while there were no statistical differences.

CONCLUSION

The result of the current analysis revealed that the robotic-assisted ventral mesh rectopexy is effective and feasible in the treatment of rectal prolapse. However, long-term follow-up and results are needed for the promotion of this approach. There is a long way for robotic-assisted surgery to become a gold standard in rectal surgery.

Update on Robotic Rectal Prolapse Treatment

Rectal prolapse is a condition that can cause significant social impairment and negatively affects quality of life. Surgery is the mainstay of treatment, with the aim of restoring the anatomy and correcting the associated functional disorders. During recent decades, laparoscopic abdominal procedures have emerged as effective tools for the treatment of rectal prolapse, with the advantages of faster recovery, lower morbidity, and shorter length of stay. Robotic surgery represents the latest evolution in the field of minimally invasive surgery, with the benefits of enhanced dexterity in deep narrow fields such as the pelvis, and may potentially overcome the technical limitations of conventional laparoscopy. Robotic surgery for the treatment of rectal prolapse is feasible and safe. It could reduce complication rates and length of hospital stay, as well as shorten the learning curve, when compared to conventional laparoscopy. Further prospectively maintained or randomized data are still required on long-term functional outcomes and recurrence rates.

Outsourcing robotic-assisted operations to private hospitals: Cost analysis of a retrospective cohort

BACKGROUND

The Lyell McEwin Hospital entered into a public-private collaborative agreement in 2019 in order to access Da Vinci® Xi Surgical Systems (Intuitive Surgical, Sunnyvale, CA, USA) in private hospitals. This study aimed to examine the costs associated with usage of robot surgical systems under the agreement, and the potential for acquisition in the public hospital.

METHODS

Retrospective data on robotic-assisted and equivalent operations performed between 1 May 2019 and 30 April 2020 were collected and formed subsequent model inputs. Cost data were from hospital records and the local Da Vinci® Xi distributor. Clinical workflow of operations was simulated with a decision-analytic model, with output being costs incurred. The model's base case scenario assumed 5% of cases were robotically assisted.

RESULTS

A total of 35 robotic-assisted, 101 laparoscopic and 34 open operations were performed. Patients were predominantly male and overweight with multiple comorbidities. Length of stay and duration of operation were associated with increased costs (p < 0.001, r² 0.72). In the base case scenario, there was a cost of AU$26 424 per patient, with an open conversion rate of 11%. Increasing robotic-assisted case percentage resulted in reduced cost, open conversion rates and length of stay. Extrapolation of cost model data indicated if 50% were robotic-assisted cases, then the initial capital investment (assumed at AU$4 000 000) could be recovered in 10 years.

CONCLUSION

Our model highlights potential advantages of performing greater numbers of robotic-assisted operations in a collaborative environment. Cost-effective analysis with prospective data could evaluate if these results are translatable and potentially support acquisition of robotic systems in the public sector.

The health-related quality of life of patients with a benign gynecological condition: a 2-year follow-up

Aim: To assess health-related quality of life (HRQoL) of patients with benign gynecological disorders. Materials & methods: Prospective 2-year follow-up with the 15D HRQoL-instrument of 311 women treated in Helsinki-area hospitals in 2012-2013. Results: The initially impaired HRQoL regarding excretion, discomfort and symptoms, and vitality and sexual activity improved after treatment. However, only sexual activity reached similar levels as in the general population. Treatment of endometriosis, fibroids and polyps resulted in best and that of unspecific pelvic pain and bleeding disorders in worst HRQoL scores. Results were independent of hospital size. Conclusion: The impaired HRQoL dimensions were improved by treatment but HRQoL still remained poorer than in the general female population. Treatment of unspecific pelvic pain and bleeding disorders needs further evaluation.

Advantages of robotic surgery in the treatment of complex pelvic organs prolapse

Robot-assisted surgery is safe and effective to treat the complex pelvic organs prolapse (C-POP). The present study analyzes all the robotic procedures and their advantages in the treatment of C-POP performed in a Proctologic and Pelvic Floor Clinical Centre. All the patients affected by C-POP who had robot-assisted surgery were retrospective analyzed. The anatomical and functional outcomes were respectively evaluated through POP-Q grading system and Wexner score about constipation and incontinence. The satisfaction rate was investigated using a five-point scale. From September 2014 to December 2018, 229 women underwent robotic surgery. The follow-up was 12 months. There were no robot-related complications. One hematoma (4.5%) of the recto-vaginal space occurred after Robotic Ventral Rectopexy with Folded Mesh (R-VRP-FM). In the robotic assisted lateral suspension (R-ALS) group there was one case of anterior vaginal wall mesh exposure (0.9%). After the robotic ventral rectopexy (R-VRP) the recurrence rate of external rectal prolapse, internal rectal prolapse, rectocele and enterocele was respectively 6.6, 9.5, 7.4 and 9.5%. After R-VRP-FM only one cystocele (14%) and one partial rectal prolapse (25%) recurred. Vaginal bulge symptoms resolution rate was 95.4%. The mean Wexner constipation score significantly decreased after R-VRP and R-VRP-FM. Vaginal bulge symptoms improved in 98.3% of cases with any apical prolapse recurrence after robotic abdominal colposacropexy. Success rate after R-ALS was 99.1% and 96.4% for apical and anterior prolapse respectively. Robotic assistance makes some surgical steps easier and more precise and this may result in less morbidity and better results.

Research quality and transparency, outcome measurement and evidence for safety and effectiveness in robot-assisted surgery: systematic review

BACKGROUND

Robot-assisted surgery (RAS) has potential panspecialty surgical benefits. High-quality evidence for widespread implementation is lacking. This systematic review aimed to assess the RAS evidence base for the quality of randomized evidence on safety and effectiveness, specialty 'clustering', and outcomes for RAS research.

METHODS

A systematic review was undertaken according to PRISMA guidelines. All pathologies and procedures utilizing RAS were included. Studies were limited to RCTs, the English language and publication within the last decade. The main outcomes selected for the review design were safety and efficacy, and study purpose. Secondary outcomes were study characteristics, funding and governance.

RESULTS

Searches identified 7142 titles, from which 183 RCTs were identified for data extraction. The commonest specialty was urology (35·0 per cent). There were just 76 unique study populations, indicating significant overlap of publications; 103 principal studies were assessed further. Only 64·1 per cent of studies reported a primary outcome measure, with 29·1 per cent matching their registration/protocol. Safety was assessed in 68·9 per cent of trials; operative complications were the commonest measure. Forty-eight per cent of trials reported no significant difference in safety between RAS and comparator, and 11 per cent reported RAS to be superior. Efficacy or effectiveness was assessed in 80·6 per cent of trials; 43 per cent of trials showed no difference between RAS and comparator, and 24 per cent reported that RAS was superior. Funding was declared in 47·6 per cent of trials.

CONCLUSION

The evidence base for RAS is of limited quality and variable transparency in reporting. No patterns of harm to patients were identified. RAS has potential to be beneficial, but requires continued high-quality evaluation.