Robotic surgery: A viable option for pectopexy

While sacrocolpopexy has been the gold standard for the anatomical correction of pelvic organ prolapse for more than three decades, it is a technically challenging procedure that results in dividing the pelvis by mesh material and often requires extensive bowel manipulation.

Laparoscopic pectopexy was introduced by Banerjee et al in 2011 as a new option in pelvic floor reconstruction, using lateral portions of the iliopectinal ligament for bilateral mesh fixation of descended structures.1 The minimally invasive nature of this procedure makes it an ideal candidate for robotic surgery, although this approach has not been well studied.

A recent retrospective cohort study by Bolovis et al out of Klinikum Nürnberg in Nuremberg, Germany, examined the use of robotic mesh-supported pectopexy in 3 different settings: hysteropectopexy with intact uterus (n=18), cervicopectopexy combined with supracervical hysterectomy in the same sessions if uterine pathology was present (n=6), and vaginopectopexy in patients presenting after previous total hysterectomy (n=6).2

All procedures were performed by the same team of 2 robotic and pelvic floor surgeons using the da Vinci Xi® robotic system. The surgical technique mirrored the method used for laparoscopic pectopexy by Banerjee et al, with adjustments to optimize the technique in the robotic setting.

In this study, nearly half of all patients (14/30) needed additional procedures either related to urogenital symptoms or other general gynecologic indications (e.g., supracervical hysterectomy, anterior/posterior colporrhaphy). Mean operation time across all procedures was 111 minutes, with cervicopectopexy taking the longest due to the need for concomitant supracervical hysterectomy. Mean length of hospital stay was 5.4 days, although the authors noted that this could be reduced under optimal circumstances to day-case surgery.

Results showed that there were no conversions among the 30 cases, nor intraoperative complications (specifically, no organ, vessel, or nerve injury, or blood loss >200 ml). Four patients required postoperative medical intervention.

According to the study authors, the problems observed in these 4 cases were not directly related to the robotic procedure. One case of postoperative urinary incontinence was deemed a sequela of correcting the prolapse—a so-called masked stress urinary incontinence—and was treated conservatively with use of a pessary.

“The most important thing about this procedure is that it gives every pelvic floor surgeon an alternative,” said Dimitrios Bolovis, 1 of 2 gynecologic surgeons involved in this study. “When we perform vaginal surgeries, we have options. Every laparoscopic surgeon performs sacrocolpopexies, but what happens if the surgery isn’t successful? What’s the plan B? With our approach that we demonstrated in this study, surgeons who still want to utilize sacrocolpopexies as their first option have a plan B.”

Placement of the uterus, Bolovis said, is the most important component of the surgery. "You need to be able to maintain some elasticity both for bladder and sexual function. It takes some practice to get it precisely right. Working with a consistent team of 2 surgeons in the same procedure as we were helps to improve quality and reliability, but it’s not a highly complex procedure. It’s certainly something that your average gynecologic surgeon could learn,” Bolovis said.

At 3-to-6 month post-procedure evaluation, all 30 patients in the study reported satisfaction with their post-operative result. Anatomical results were assessed using the pelvic organ prolapse (POP)-Q criteria; all patients were deemed stage 0 or 1. There were no indications for repeated surgery. Consequently, according to the primary study endpoint of treatment success (defined as POP-Q stage of ≤1, absence of vaginal bulge syndrome, and no indications for repeat surgery for anterior or apical POP), this study had a 100% success rate.

“The primary goal of any medical treatment is patient satisfaction, which is why we included that as a core measures of this study,” said Cosima Brucker, head of the gynecologic clinic at Klinikum Nürnberg and the second surgeon involved in this study. “The patient comes in with a complaint and they want it solved. The robotic pectopexy allows surgeons to utilize their experience to leave every anatomic marker in the best location for the patient. You can adjust tension at the fixation point of the uterus, you can adjust the height of the pelvic floor. Those are very important factors from a patient satisfaction perspective.”

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References

  1. Banerjee C, Noé KG. Laparoscopic pectopexy: a new technique of prolapse surgery for obese patients. Arch Gynecol Obstet. 2011;284:631-635.
  2. Bolovis D, Hitzl W, Brucker C. Robotic mesh-supported pectopexy for pelvic organ prolapse: expanding the options of pelvic floor repair. J Robot Surg. 2021 Sep 9. Epub ahead of print.