Prospective assessment of robotic pelvic floor surgery

The word ‘prolapse’ is derived from the Latin word prolabi meaning ‘to fall out’. It can include protruding of the bladder, uterus, vaginal cuff in post-hysterectomy patients, and the small or large bowel. This can lead to very severe symptoms. Sacrocolpopexy is one of the treatment options for apical prolapse (i.e. vaginal vault and uterine prolapse). This procedure has been performed more often with robotic assistance due to improvement freedom of movement, optimal ergonomics and 3D. Perioperative and one year anatomic and functional outcomes after robot-assisted sacrocolpopexy (RASC) and supracervical hysterectomy with sacrocervicopexy (RSHS) were examined. Anatomical success of the apical compartment was high (RASC 91%; RSHS 99%). A symptomatic recurrent cystocele occurred in 12% after RASC and 5% after RSHS. Symptoms of bulge (97.4 vs 17.4%; p<0.0005), quality of life (QoL) and sexual function improved after surgery. Intraoperative/severe postoperative complications and conversion rates were low. In this age of rapidly changing surgical techniques, determination of learning curves is essential to improve safety and efficiency. Cumulative sum (CUSUM) analysis can mark phases in which complications arise, thereby warning the surgeon to add additional training. A CUSUM analysis for two surgeons showed proficiency to be obtained after 78 cases. After 24-29 cases surgery time stabilized. Robotic sacrocolporectopexy (RSCR) for multi-compartment prolapse showed 90% of patients to be recurrence free 48 months postoperatively. Symptoms of bulge, QoL, obstructive defecation and faecal incontinence improved. A subgroup of patients showed persistent bowel complaints. After RASC, 96% of patients had no apical recurrence 50 months postoperatively (N=77). One in nine patients had a symptomatic cystocele. The American Food and Drug Administration published a safety report regarding the safety of mesh usage in pelvic floor surgery in 2011. This report was based on the high incidence of mesh-related complications found after transvaginal mesh implants (10.3%). In this study, with transabdominal mesh usage, a low number of mesh exposure was found (1.2% after 16 months [RASC/RSHS], 3.1% after 48 months [RASC/RSHS/RSCR]). Based on these findings, mesh-related complications seem to be lower in transabdominal mesh surgery than in transvaginal mesh surgery.