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Obut M, Oğlak SC, Akgöl S. Comparison of the Quality of Life and Female Sexual Function Following Laparoscopic Pectopexy and Laparoscopic Sacrohysteropexy in Apical Prolapse Patients. Gynecol Minim Invasive Ther 2021; 10:96-103. [PMID: 34040968 PMCID: PMC8140535 DOI: 10.4103/gmit.gmit_67_20] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/29/2020] [Accepted: 11/23/2020] [Indexed: 11/24/2022] Open
Abstract
Objectives: We sought to compare the surgical outcomes, safety, effectiveness, and mid-term outcomes in patients who had undergone laparoscopic hysterosacropexy and laparoscopic pectopexy due to apical prolapse. Materials and Methods: This prospective randomized study was conducted on a total of 62 women who underwent apical prolapse surgery (32 undergoing a pectopexy and 30 undergoing a sacrohysteropexy) between June 2015 and June 2017. Patients with symptomatic uterine or vaginal vault prolapse with stage 2 or worse were included in the sudy. Before and after the operation, we used the Pelvic Organ Prolapse Quantification System (POP-Q) and questionnaires, which are the Prolapse Quality of Life Questionnaire (P-QOL) and Female Sexual Function Index (FSFI), to evaluated cases. Baseline characteristics, perioperative and postoperative complications, and follow-up results at 12 months were also evaluated. Results: All domains of POP-Q, P-QOL, and FSFI scores improved significantly after surgery both in pectopexy and sacrohysteropexy group. The postoperative complications of both procedures were similar except for constipation after surgery (3.2% in the pectopexy group and 20% in the hysterosacropexy group [P = 0.036]). Conclusion: Both sacrohysteropexy and pectopexy are effective surgical options for apical prolapse patients. The pectopexy is an acceptable alternative to laparoscopic sacrohysteropexy because of its less complexity and not reducing pelvic space for the rectum to exist. We suggest that the laparoscopic pectopexy may be widely used in clinical routine.
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Affiliation(s)
- Mehmet Obut
- Department of Obstetrics and Gynecology, Etlik Zübeyde Hanim Women's Health Training and Research Hospital, Ankara, Turkey
| | - Süleyman Cemil Oğlak
- Department of Obstetrics and Gynecology, Health Sciences University, Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey
| | - Sedat Akgöl
- Department of Obstetrics and Gynecology, Health Sciences University, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
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Abstract
BACKGROUND This is an updated merged review of two originally separate Cochrane reviews: one on robot-assisted surgery (RAS) for benign gynaecological disease, the other on RAS for gynaecological cancer. RAS is a relatively new innovation in laparoscopic surgery that enables the surgeon to conduct the operation from a computer console, situated away from the surgical table. RAS is already widely used in the United States for hysterectomy and has been shown to be feasible for other gynaecological procedures. However, the clinical effectiveness and safety of RAS compared with conventional laparoscopic surgery (CLS) have not been clearly established and require independent review. OBJECTIVES To assess the effectiveness and safety of RAS in the treatment of women with benign and malignant gynaecological disease. SEARCH METHODS For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via Ovid, and EMBASE via Ovid, on 8 January 2018. We searched www.ClinicalTrials.gov. on 16 January 2018. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing RAS versus CLS or open surgery in women requiring surgery for gynaecological disease. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and risk of bias, and extracted study data and entered them into an Excel spreadsheet. We examined different procedures in separate comparisons and for hysterectomy subgrouped data according to type of disease (non-malignant versus malignant). When more than one study contributed data, we pooled data using random-effects methods in RevMan 5.3. MAIN RESULTS We included 12 RCTs involving 1016 women. Studies were at moderate to high overall risk of bias, and we downgraded evidence mainly due to concerns about risk of bias in the studies contributing data and imprecision of effect estimates. Procedures performed were hysterectomy (eight studies) and sacrocolpopexy (three studies). In addition, one trial examined surgical treatment for endometriosis, which included resection or hysterectomy. Among studies of women undergoing hysterectomy procedures, two studies involved malignant disease (endometrial cancer); the rest involved non-malignant disease.• RAS versus CLS (hysterectomy)Low-certainty evidence suggests there might be little or no difference in any complication rates between RAS and CLS (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.54 to 1.59; participants = 585; studies = 6; I² = 51%), intraoperative complication rates (RR 0.77, 95% CI 0.24 to 2.50; participants = 583; studies = 6; I² = 37%), postoperative complications (RR 0.81, 95% CI 0.48 to 1.34; participants = 629; studies = 6; I² = 44%), and blood transfusions (RR 1.94, 95% CI 0.63 to 5.94; participants = 442; studies = 5; I² = 0%). There was no statistical difference between malignant and non-malignant disease subgroups with regard to complication rates. Only one study reported death within 30 days and no deaths occurred (very low-certainty evidence). Researchers reported no survival outcomes.Mean total operating time was longer on average in the RAS arm than in the CLS arm (mean difference (MD) 41.18 minutes, 95% CI -6.17 to 88.53; participants = 148; studies = 2; I² = 80%; very low-certainty evidence), and the mean length of hospital stay was slightly shorter with RAS than with CLS (MD -0.30 days, 95% CI -0.53 to -0.07; participants = 192; studies = 2; I² = 0%; very low-certainty evidence).• RAS versus CLS (sacrocolpopexy)Very low-certainty evidence suggests little or no difference in rates of any complications between women undergoing sacrocolpopexy by RAS or CLS (RR 0.95, 95% CI 0.21 to 4.24; participants = 186; studies = 3; I² = 78%), nor in intraoperative complications (RR 0.82, 95% CI 0.09 to 7.59; participants = 108; studies = 2; I² = 47%). Low-certainty evidence on postoperative complications suggests these might be higher with RAS (RR 3.54, 95% CI 1.31 to 9.56; studies = 1; participants = 68). Researchers did not report blood transfusions and deaths up to 30 days.Low-certainty evidence suggests that RAS might be associated with increased operating time (MD 40.53 min, 95% CI 12.06 to 68.99; participants = 186; studies = 3; I² = 73%). Very low-certainty evidence suggests little or no difference between the two techniques in terms of duration of stay (MD 0.26 days, 95% CI -0.15 to 0.67; participants = 108; studies = 2; I² = 0%).• RAS versus open abdominal surgery (hysterectomy)A single study with a total sample size of 20 women was included in this comparison. For most outcomes, the sample size was insufficient to show any possible differences between groups.• RAS versus CLS for endometriosisA single study with data for 73 women was included in this comparison; women with endometriosis underwent procedures ranging from relatively minor endometrial resection through hysterectomy; many of the women included in this study had undergone previous surgery for their condition. For most outcomes, event rates were low, and the sample size was insufficient to detect potential differences between groups. AUTHORS' CONCLUSIONS Evidence on the effectiveness and safety of RAS compared with CLS for non-malignant disease (hysterectomy and sacrocolpopexy) is of low certainty but suggests that surgical complication rates might be comparable. Evidence on the effectiveness and safety of RAS compared with CLS or open surgery for malignant disease is more uncertain because survival data are lacking. RAS is an operator-dependent expensive technology; therefore evaluating the safety of this technology independently will present challenges.
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Affiliation(s)
- Theresa A Lawrie
- Office 305, 3rd floorE‐MBC LtdNorthgate HouseUpper Borough WallsBathUKBA1 1RG
| | - Hongqian Liu
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
| | - DongHao Lu
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
| | - Therese Dowswell
- The University of LiverpoolC/o Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Huan Song
- University of IcelandCenter of Public Health Sciences, Faculty of MedicineReykjavíkIceland
| | - Lei Wang
- West China Second University Hospital, Sichuan UniversityDepartment of OrthopedicsNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Gang Shi
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
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Abstract
OBJECTIVE The primary aim of this study was to report anatomic, symptom, and quality of life outcomes in women with symptomatic stage 2 or greater prolapse 1 year after randomization to robotic and laparoscopic sacrocolpopexy. METHODS This is a planned ancillary analysis of the Abdominal Colpopexy: Comparison of Endoscopic Surgical Strategies trial, a randomized comparative effectiveness trial comparing costs and outcomes of robotic and laparoscopic sacrocolpopexy at 2 academic medical centers. At baseline and 1 year after surgery, women underwent standardized assessment including validated subjective pelvic floor outcomes and physical examination with prolapse assessment. RESULTS Sixty six (85%) of 78 randomized participants completed 1-year follow-up: 33 (87%) of 38 in the laparoscopic arm and 33 (83%) of 40 in the robotic arm (P = 0.59). Ninety-seven percent (32/33) in the laparoscopic group and 100% (33/33) in the robotic arm considered that their prolapse symptoms improved (P = 0.999). The cohort had significant improvement in all pelvic floor symptom and quality of life measures, which did not differ by treatment arm. Of women who were sexually active at 1 year, sexual function improved in both cohorts. No new serious adverse events, including mesh exposure or reoperation for prolapse, were identified between 6 months and 1 year after surgery. No women had a sacrocolpopexy mesh complication or reoperation for mesh exposure. CONCLUSIONS Minimally invasive sacrocolpopexy is associated with significant improvement in pelvic floor symptoms, anatomy, and sexual function. In addition, mesh exposure rates with lightweight polypropylene mesh seem to be lower than those reported with multifilament and heavier polypropylene mesh.
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Cosmetic Appearance of Port-site Scars 1 Year After Laparoscopic Versus Robotic Sacrocolpopexy: A Supplementary Study of the ACCESS Clinical Trial. J Minim Invasive Gynecol 2016; 23:917-21. [PMID: 27180224 DOI: 10.1016/j.jmig.2016.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 04/22/2016] [Accepted: 05/02/2016] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVE To prospectively measure trocar site appearances 1 year after surgery in women participants in the Abdominal Colpopexy: Comparison of Endoscopic Surgical Strategies Trial, a 2-center randomized surgical trial (NCT01124916). DESIGN Supplementary analysis of a surgical trial that randomized women to robotic or laparoscopic sacrocolpopexy (Canadian Task Force classification I). SETTING Operative trial. PATIENTS Women undergoing clinically indicated sacrocolpopexy for symptomatic stage ≥II pelvic organ prolapse were randomized to laparoscopic abdominal sacrocolpopexy (LASC) or robotic abdominal sacrocolpopexy (RASC). Trocar skin incision closure was standardized by using Dermabond (Ethicon, Somerville, NJ). MEASUREMENTS AND MAIN RESULTS Photographs of all incision sites were taken at baseline (immediately), 6 weeks, 6 months, and 1 year after surgery. Study coordinators scored each incision with the validated Stony Brook Evaluation Scale (SBES), a 5-point wound evaluation scale. We calculated the average of all scars scores per case to determine the percent of optimal wound healing (0%-100%) for each case as well as the proportion of cases meeting 100% wound repair scoring. Wound repair scores across groups were tested with the Wilcoxon rank sum test. The overall proportion of cases in each group meeting "optimal" wound recovery (scores of 100%) was tested with the Fisher exact test. Seventy-eight women with a mean age of 59 years (range, 26-79 years) were randomized to LASC (n = 38) or RASC (n = 40). We did not detect significant differences in baseline characteristics or rates of dropout between the 2 study groups (5 in LASC and 7 in RASC, p = .60). Pain in the initial postoperative period was higher in the robotic arm although groups were similar at 2 weeks. Nearly all cases (75/78) contributed wound repair data (36 laparoscopic and 39 robotic). Laparoscopic surgeries require significantly fewer incisions (median = 4; range, 4-6) than robotic surgeries (median = 5; range, 4-6; p < .001). SBES scores at 6 weeks were not different for LASC and RASC (p = .426). By 6 months, the scores were better in the LASC group (84.8% ± 8.8% vs 78.5% ± 7.2%, p = .031), and this finding remained at 1 year (93.4% ± 7.2% vs 85.9% ± 8.8%, p = .001). The proportion of cases with optimal wound repair (score of 100%) was higher in the laparoscopic arm at 1 year after surgery (12/27 vs 4/33, p = .008). INTERVENTIONS Women were randomized to robotic assisted laparoscopy or laparoscopy. CONCLUSION Wound appearance using the SBES was better in the LASC group, suggesting that there may be alterations in the mechanism for wound initiation and/or healing based on the minimally invasive route used for sacrocolpopexy.
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Laparoscopic versus robotic-assisted sacrocolpopexy for pelvic organ prolapse: a systematic review. ACTA ACUST UNITED AC 2016; 13:115-123. [PMID: 27226787 PMCID: PMC4854942 DOI: 10.1007/s10397-016-0930-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 01/11/2016] [Indexed: 12/23/2022]
Abstract
The use of robot-assisted surgery (RAS) has gained popularity in the field of gynaecology, including pelvic floor surgery. To assess the benefits of RAS, we conducted a systematic review of randomized controlled trials comparing laparoscopic and robotic-assisted sacrocolpopexy. The Cochrane Library (1970–January 2015), MEDLINE (1966 to January 2015), and EMBASE (1974 to January 2015) were searched, as well as ClinicalTrials.gov and the International Clinical Trials Registry Platform. We identified two randomized trials (n = 78) comparing laparoscopic with robotic sacrocolpopexy. The Paraiso 2011 study showed that laparoscopic was faster than robotic sacrocolpopexy (199 ± 46 vs. 265 ± 50 min; p < .001), yet in the ACCESS trial, no difference was present (225 ± 62.3 vs. 246.5 ± 51.3 min; p = .110). Costs for using the robot were significantly higher in both studies, however, in the ACCESS trial, only when purchase and maintenance of the robot was included (LSC US$11,573 ± 3191 vs. RASC US$19,616 ± 3135; p < .001). In the Paraiso study, RASC was more expensive even without considering those costs (LSC US$ 14,342 ± 2941 vs. RASC 16,278 ± 3326; p = 0.008). Pain was reportedly higher after RASC, although at different time points after the operation. There were no differences in anatomical outcomes, pelvic floor function, and quality of life. The experience with RASC was tenfold lower than that with LSC in both studies. The heterogeneity between the two studies precluded a meta-analysis. Based on small randomized studies, with surgeons less experienced in RAS than in laparoscopic surgery, robotic surgery significantly increases the cost of a laparoscopic sacrocolpopexy. RASC would be more sustainable if its costs would be lower. Though RASC may have other benefits, such as reduction of the learning curve and increased ergonomics or dexterity, these remain to be demonstrated.
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Robotic-Assisted Laparoscopy vs Conventional Laparoscopy for the Treatment of Advanced Stage Endometriosis. J Minim Invasive Gynecol 2015; 22:40-4. [DOI: 10.1016/j.jmig.2014.06.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 06/03/2014] [Accepted: 06/04/2014] [Indexed: 11/21/2022]
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Abstract
BACKGROUND This is an updated merged review of two originally separate Cochrane reviews: one on robot-assisted surgery (RAS) for benign gynaecological disease, the other on RAS for gynaecological cancer. RAS is a relatively new innovation in laparoscopic surgery that enables the surgeon to conduct the operation from a computer console, situated away from the surgical table. RAS is already widely used in the United States for hysterectomy and has been shown to be feasible for other gynaecological procedures. However, the clinical effectiveness and safety of RAS compared with conventional laparoscopic surgery (CLS) have not been clearly established and require independent review. OBJECTIVES To assess the effectiveness and safety of RAS in the treatment of women with benign and malignant gynaecological disease. SEARCH METHODS For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 5) and the Cochrane Gynaecological Cancer Review Group Trials Register. We also searched MEDLINE and EMBASE databases, to complement the searches of the original malignant and benign disease reviews (conducted up to July 2010 and November 2011, respectively), from July 2010 to June 2014. SELECTION CRITERIA Randomised controlled trials (RCTs) of RAS compared with CLS or open surgery in women requiring surgery for gynaecological disease. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion and risk of bias, and extracted study data and entered them into an Excel spreadsheet. We subgrouped data according to type of procedure and pooled data using random-effects methods in RevMan 5.3. We performed sensitivity analyses by excluding studies at high risk of bias. MAIN RESULTS We included six RCTs involving 517 women. Most were at low to moderate overall risk of bias; one was at high risk of bias. Four studies evaluated RAS for hysterectomy (371 women), and two studies evaluated RAS for sacrocolpopexy (146 women). All studies compared RAS with CLS, except for one study, which compared RAS with CLS or a vaginal surgical approach for hysterectomy. Confidence intervals for the risk of intraoperative and postoperative complications included benefits with either approach when they were analysed together (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.46 to 1.99; participants = 513; studies = 6; I(2) = 74%) and separately (low-quality evidence). Moderate-quality evidence was found for the effects of RAS on intraoperative injury when compared with CLS (RR 1.23, 95% CI 0.44 to 3.46; participants = 415; studies = 5; I(2) = 0%), along with low-quality evidence for bleeding and infection complications.Mean total operating time was consistent across procedures and on average was about 42 minutes longer in the RAS arm compared with the CLS arm (95% CI 17 to 66 minutes; participants = 294; studies = 4; I(2) = 82%; moderate-quality evidence). Mean hospital stay for hysterectomy procedures was on average about seven hours shorter in the RAS arm than in the CLS arm (mean difference (MD) -0.30 days, 95% CI -0.54 to -0.06; participants = 217; studies = 2; I(2) = 0%; low-quality evidence). The estimated effect of conversion with RAS compared with CLS was imprecise (RR 1.28, 95% CI 0.40 to 4.12; participants = 337; studies = 4; I(2) = 0%; moderate-quality evidence). Limited data from two studies suggest that RAS for sacrocolpopexy may be associated with increased postoperative pain compared with CLS; this needs further investigation. We identified five ongoing trials-four of cancer surgery. AUTHORS' CONCLUSIONS We are uncertain as to whether RAS or CLS has lower intraoperative and postoperative complication rates because of the imprecision of the effect and inconsistency among studies when they are used for hysterectomy and sacrocolpopexy. Moderate-quality evidence suggests that these procedures take longer with RAS but may be associated with a shorter hospital stay following hysterectomy. We found limited evidence on the effectiveness and safety of RAS compared with CLS or open surgery for surgical procedures performed for gynaecological cancer; therefore its use should be limited to clinical trials. Ongoing trials are likely to have an important impact on evidence related to the use of RAS in gynaecology.
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Affiliation(s)
- Hongqian Liu
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduChina610041
| | - Theresa A Lawrie
- Royal United HospitalCochrane Gynaecological, Neuro‐oncology and Orphan Cancer GroupEducation CentreBathUKBA1 3NG
| | - DongHao Lu
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and Gynaecology20, 3rd Section, Ren Min Nan RdChengduChina610041
| | - Huan Song
- Karolinska InstitutetDepartment of Medical Epidemiology and BiostatisticsBox 281StockholmSwedenSE‐17177
| | - Lei Wang
- West China Hospital, Sichuan UniversityDepartment of OrthopedicsNo. 37, Guo Xue XiangChengduChina610041
| | - Gang Shi
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduChina610041
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Update on Robotic Versus Laparoscopic Sacrocolpopexy: Outcomes and Costs. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2014. [DOI: 10.1007/s13669-014-0099-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Unger CA, Paraiso MFR, Jelovsek JE, Barber MD, Ridgeway B. Perioperative adverse events after minimally invasive abdominal sacrocolpopexy. Am J Obstet Gynecol 2014; 211:547.e1-8. [PMID: 25088866 DOI: 10.1016/j.ajog.2014.07.054] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 04/26/2014] [Accepted: 07/30/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Our first objective was to compare peri- and postoperative adverse events between robotic-assisted laparoscopic sacrocolpopexy (RSC) and conventional laparoscopic sacrocolpopexy (LSC) in a cohort of women who underwent these procedures at a tertiary care center. Our second objective was to explore whether hysterectomy and rectopexy at the time of sacrocolpopexy were associated with these adverse events. STUDY DESIGN This was a retrospective cohort study of women who underwent either RSC or LSC with or without concomitant hysterectomy and/or rectopexy from 2006-2012. Once patients were identified as either having undergone RSC or LSC, the electronic medical record was queried for demographic, peri-, and postoperative data. RESULTS Four hundred six women met study inclusion criteria. Mean age and body mass index of all the women were 58 ± 10 years and 27.9 ± 4.9 kg/m(2). The women who underwent RSC were older (60 ± 9 vs 57 ± 10 years, respectively; P = .009) and more likely to be postmenopausal (90.9% vs 79.1%, respectively; P = .05). RSC cases were associated with a higher intraoperative bladder injury rate (3.3% vs 0.4%, respectively; P = .04), a higher rate of estimated blood loss of ≥500 mL (2.5% vs 0, respectively; P = .01), and reoperation rate for pelvic organ prolapse (4.9% vs 1.1%, respectively; P = .02) compared with LSC. Concomitant rectopexy was associated with a higher risk of transfusion (2.8% vs 0.3%, respectively; P = .04), pelvic/abdominal abscess formation (11.1% vs 0.8%, respectively; P < .001), and osteomyelitis (5.6% vs 0, respectively; P < .001). The mesh erosion rate for all the women was 2.7% and was not statistically different between LSC and RSC and for patients who underwent concomitant hysterectomy and those who did not. CONCLUSION Peri- and postoperative outcomes after RSC and LSC are favorable, with few adverse outcomes. RSC is associated with a higher rate of bladder injury, estimated blood loss ≥500 mL, and reoperation for recurrent pelvic organ prolapse; otherwise, the rate of adverse events is similar between the 2 modalities. Concomitant rectopexy is associated with a higher rate of postoperative abscess and osteomyelitis complications.
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Affiliation(s)
- Cecile A Unger
- Center for Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, OH.
| | - Marie Fidela R Paraiso
- Center for Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - John E Jelovsek
- Center for Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Matthew D Barber
- Center for Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Beri Ridgeway
- Center for Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, OH
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Abstract
Pelvic organ prolapse (POP) is a prevalent condition with 1 in 9 women seeking surgical treatment by the age of 80 years. Goals of treatment are relief and prevention of symptoms, and restoration of pelvic floor support. The gold standard for surgical treatment of POP has been abdominal sacrocolpopexy (ASC). However, emerging technologies have allowed for more minimally invasive approach including the use of laparoscopic assisted sacrocolpopexy and robotic assisted sacrocolpopexy (RASC). We performed a PubMed literature search for sacrocolpopexy, “robotic sacrocolpopexy” and “RASC” and reviewed all retrospective, prospective and randomized controlled trials. The techniques, objective and subjective outcomes and complications are discussed. The most frequent technique involves a polypropylene Y mesh attached to the anterior and posterior walls of the vagina with the single arm attached to the sacrum. Multiple concomitant procedures have been described including hysterectomy, anti-incontinence procedures and concomitant vaginal prolapse repairs. There are few studies comparing RASC to ASC, with the longest follow-up data showing no difference in subjective and objective outcomes. Anatomic success rates have been reported at 79-100% with up to 9% of patients requiring successive surgery for recurrence. Subjective success is poorly defined, but has been reported at 88-97%. Most common complications are urinary retention, urinary tract infection, bladder injury and vaginal mucosal injury. Mesh exposure is reported in up to 10% of patients. RASC allows for a minimally invasive approach to treatment of POP with comparable outcomes and low complication rates.
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Affiliation(s)
- Teresa L Danforth
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Monish Aron
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - David A Ginsberg
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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The challenge of implementing laparoscopic sacrocolpopexy. Int Urogynecol J 2014; 25:1153-60. [PMID: 24846152 DOI: 10.1007/s00192-014-2398-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 04/07/2014] [Indexed: 10/25/2022]
Abstract
Vaginal-vault prolapse is effectively treated using sacrocolpopexy (SCP). A randomized trial demonstrated that it can be performed as effectively via laparoscopy (LSCP) as via laparotomy and with less morbidity. This evidence begs the question of how units offering abdominal sacrocolpopexy will implement LSCP. Several limitations need to be overcome. LSCP initially requires longer operating time; however, that decreases with surgeon experience. To decrease operation time, suture training can be implemented ahead. Following a 15-h suturing lab, trainees achieved comparable operation times after 30 cases. Dissection is another critical time-consuming step and is difficult to model. Proficiency is more dependent on patient characteristics, though this component is poorly studied. One experience showed it takes 60 procedures to effectively limit complications. The large number of patients required for surgeon training for this relative infrequent operation creates a problem, thus limiting the number of centers available for training surgeons within a reasonable period.
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Li H, Sammon J, Roghmann F, Sood A, Ehlert M, Sun M, Menon M, Atiemo H, Trinh QD. Utilization and perioperative outcomes of robotic vaginal vault suspension compared to abdominal or vaginal approaches for pelvic organ prolapse. Can Urol Assoc J 2014; 8:100-6. [PMID: 24839477 DOI: 10.5489/cuaj.1858] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Robot-assisted vaginal vault suspension (RAVVS) for pelvic organ prolapse (POP) represents a minimally-invasive alternative to abdominal sacrocolpopexy. We measured perioperative outcomes and utilization rates of RAVVS. METHODS RAVVS (n = 2381) and open VVS (OVVS, n = 11080) data were extracted from the 2009-2010 Nationwide Inpatient Sample. Propensity score-matched analysis compared patients undergoing RAVVS or OVVS for complications, mortality, prolonged length-of-stay, and elevated hospital charges. RESULTS Use of RAVVS for POP increased from 2009 to 2010 (16.3% to 19.2%). Patients undergoing RAVVS were more likely to be white (77.2% vs. 69.6%), to carry private insurance (52.8% vs. 46.0%) and to have fewer comorbidities (Charlson Comorbidity Index [CCI] ≥1 = 17.5% vs. 26.6%). They were more likely to undergo surgery at urban (98.2% vs. 93.7%) and academic centres (75.7% vs. 56.7%). Patients undergoing RAVVS were less likely to receive a blood-transfusion (0.7% vs. 1.8%, p < 0.001) or experience prolonged length-of-stay (9.3% vs. 25.1%, p < 0.001). They had more intraoperative complications (6.0% vs. 4.2%, p < 0.001), and higher median hospital charges ($32 402 vs. $24 136, p < 0.001). Overall postoperative complications were equivalent (17.9%, p = 1.0), though there were differences in wound (0.4% vs. 1.3%, p < 0.001), genitourinary (4.9% vs. 6.5%, p = 0.009), and surgical (6.6% vs. 4.9%, p = 0.007) complications. CONCLUSIONS The increasing use of RAVVS from 2009 to 2010 suggests a growth in the adoption of robotics to manage POP. We show that RAVVS is associated with decreased length of stay, fewer blood transfusions, as well as lower postoperative wound, genitourinary and vascular complications. The benefits of RAVVS are mitigated by higher hospital charges and higher rates of intra-operative complications.
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Affiliation(s)
- Hanhan Li
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI
| | - Jesse Sammon
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI
| | - Florian Roghmann
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC
| | - Akshay Sood
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI
| | - Michael Ehlert
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI
| | - Maxine Sun
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC
| | - Mani Menon
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI
| | - Humphrey Atiemo
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI
| | - Quoc-Dien Trinh
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI; ; Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC
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Abstract
OBJECTIVE Laparoscopic and robotic sacrocolpopexy are widely used for pelvic organ prolapse (POP) treatment. Evidence comparing outcomes and costs is lacking. We compared costs and clinically relevant outcomes in women randomized to laparoscopic sacrocolpopexy compared with robotic sacrocolpopexy. METHODS Participants with symptomatic stage POP II or greater, including significant apical support loss, were randomized to either laparoscopic or robotic sacrocolpopexy. We compared surgical costs (including costs for robot, initial hospitalization) and rehospitalization within 6 weeks. Secondary outcomes included postoperative pain, POP quantification, symptom severity and quality of life, and adverse events. RESULTS We randomized 78 women (mean age 59 years): laparoscopic (n=38) and robotic (n=40). The robotic sacrocolpopexy group had higher initial hospital costs ($19,616 compared with $11,573, P<.001) and over 6 weeks, hospital costs remained higher for robotic sacrocolpopexy ($20,898 compared with $12,170, P<.001). When we excluded costs of robot purchase and maintenance, we did not detect a statistical difference in initial day of surgery costs of robotic compared with laparoscopic ($12,586 compared with $11,573; P=.160) or hospital costs over 6 weeks ($13,867 compared with $12,170; P=.060). The robotic group had longer operating room times (202.8 minutes compared with 178.4 minutes, P=.030) and higher pain scores 1 week after surgery (3.5±2.1 compared with 2.6±2.2; P=.044). There were no group differences in symptom bother by Pelvic Floor Distress Inventory, POP stage, or rate of adverse events. CONCLUSION Costs of robotic sacrocolpopexy are higher than laparoscopic, whereas short-term outcomes and complications are similar. Primary cost differences resulted from robot maintenance and purchase costs. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov, www.clinicaltrials.gov, NCT01124916. LEVEL OF EVIDENCE I.
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Lee RK, Mottrie A, Payne CK, Waltregny D. A review of the current status of laparoscopic and robot-assisted sacrocolpopexy for pelvic organ prolapse. Eur Urol 2014; 65:1128-37. [PMID: 24433811 DOI: 10.1016/j.eururo.2013.12.064] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 12/27/2013] [Indexed: 11/25/2022]
Abstract
CONTEXT Abdominal sacrocolpopexy (ASC) represents the superior treatment for apical pelvic organ prolapse (POP) but is associated with increased length of stay, analgesic requirement, and cost compared with transvaginal procedures. Laparoscopic sacrocolpopexy (LSC) and robot-assisted sacrocolpopexy (RSC) may offer shorter postoperative recovery while maintaining equivalent rates of cure. OBJECTIVE This review evaluates the literature on LSC and RSC for clinical outcomes and complications. EVIDENCE ACQUISITION A PubMed search of the available literature from 1966 to 2013 on LSC and RSC with a follow-up of at least 12 mo was performed. A total of 256 articles were screened, 69 articles selected, and outcomes from 26 presented. A review, not meta-analysis, was conducted due to the quality of the articles. EVIDENCE SYNTHESIS LSC has become a mature technique with results from 11 patient series encompassing 1221 patients with a mean follow-up of 26 mo. Mean operative time was 124 min (range: 55-185) with a 3% (range: 0-11%) conversion rate. Objective cure was achieved in 91% of patients, with similar satisfaction rates (92%). Six patient series encompassing 363 patients treated with RSC with a mean follow-up of 28 mo have been reported. Mean operative time was 202 min (range: 161-288) with a 1% (range: 0-4%) conversion rate. Objective cure rate was 94%, with a 95% subjective success rate. Overall, early outcomes and complication rates for both LSC and RSC appeared comparable with open ASC. CONCLUSIONS LSC and RSC provide excellent short- to medium-term reconstructive outcomes for patients with POP. RSC is more expensive than LSC. Further studies are required to better understand the clinical performance of RSC versus LSC and confirm long-term efficacy. PATIENT SUMMARY Laparoscopic and robot-assisted sacrocolpopexy represent attractive minimally invasive alternatives to abdominal sacrocolpopexy. They may offer reduced patient morbidity but are associated with higher costs.
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Affiliation(s)
- Richard K Lee
- Department of Urology, Weill Medical College of Cornell University, New York, NY, USA.
| | - Alexandre Mottrie
- Department of Urology, O.L.V. Clinic, Aalst, Belgium; O.L.V. Vattikuti Robotic Surgery Institute, Melle, Belgium
| | | | - David Waltregny
- Department of Urology, University Hospital of Liège, Liège, Belgium
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Segal D, Awad N, Nasir H, Mustafa S, Lowenstein L. Combined spinal and general anesthesia vs general anesthesia for robotic sacrocervicopexy: a randomized controlled trial. Int Urogynecol J 2013; 25:369-74. [DOI: 10.1007/s00192-013-2194-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 07/14/2013] [Indexed: 10/26/2022]
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Takase-Sanchez MM, Hale DS. Minimally Invasive Pelvic Reconstructive Surgery: A Literature Review of Laparoscopic Surgery for Pelvic Organ Prolapse. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2013. [DOI: 10.1007/s13669-013-0050-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Where Do We Place the Sacrocolpopexy Stitch?—A Magnetic Resonance Imaging Investigation. Female Pelvic Med Reconstr Surg 2013; 19:31-3. [DOI: 10.1097/spv.0b013e31827d87ae] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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