There may also be differences between groups in the durability of the two types of repair, an outcome not included in this particular study.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
The laparoscopic approach offers a shorter hospital stay with no increase in intraoperative or postoperative complications, compared with abdominal sacrocolpopexy. However, it entails a significantly longer operative time than the abdominal approach does.
How steep is the learning curve for robotic-assisted sacrocolpopexy?
Akl MN, Long JB, Giles DL, et al. Robotic-assisted sacrocolpopexy: technique and learning curve. Surg Endosc. 2009;23(10):2390–2394.
Akl and coworkers reviewed the medical records of all patients who had undergone robotic-assisted sacrocolpopexy at the Mayo Clinics in Arizona and Florida between 2004 and 2007. All operations were performed by the same four urogynecologists, with an average operative time of 197.9 minutes (standard deviation, ± 66.8 minutes). However, after the first 10 cases, the operative time decreased by 64.3 minutes—a decline of 25.4% (P < .01; 95% confidence interval [CI], 16.1–112.4 minutes).
Details of the trial
Researchers collected baseline information on participants’ age, stage of prolapse, and concomitant procedures. They also gathered data on average operative time, estimated blood loss, intraoperative and postoperative complications, conversion to laparotomy, and length of hospitalization.
Of 80 women who had advanced pelvic organ prolapse (stage III/IV) who underwent robotic-assisted sacrocolpopexy, 88% underwent concomitant robotic and vaginal procedures, including robotic supracervical hysterectomy, Burch procedure, paravaginal repair, lysis of adhesions, bilateral salpingooophorectomy, vaginal cystocele or rectocele repair, and placement of a midurethral sling.
Estimated blood loss for the robotic-assisted approach ranged from 25 mL to 300 mL, with a mean loss of 96.8 mL. Average length of hospitalization was 2.6 days. Four cases (5%) were converted to laparotomy because of limited exposure and one intraoperative bladder injury. Other intraoperative complications included small-bowel injury during trocar placement and one ureteral injury. Postoperative complications included one case of ileus and five (6%) vaginal mesh erosions. Three patients developed recurrent prolapse and underwent subsequent correction.
Learning curve could have been measured more precisely
The authors did not specifically measure the learning curve for robotic-assisted sacrocolpopexy, as they took into account the concomitant procedures. For this reason, the decrease in operative time observed after 10 cases may not accurately reflect an improvement in the performance of sacrocolpopexy.
Akl and colleagues consider this detail to be a strength of the study because most women who undergo prolapse surgery have concomitant procedures. However, recording the length of time it took to perform the sacrocolpopexy portion of the procedure would have been more accurate.
The average length of stay approached that of the abdominal route. Length of stay may decline as a surgeon gains experience with the robotic-assisted approach.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Robotic-assisted sacrocolpopexy has a steep learning curve with respect to technique and surgical time.
Does robotic-assisted sacrocolpopexy provide durable support?
Elliott DS, Krambeck AE, Chow GK. Long-term results of robotic assisted laparoscopic sacrocolpopexy for the treatment of high grade vaginal vault prolapse. J Urol. 2006;176(2):655–659.
Among the few recent series reporting long-term outcomes after robotic-assisted sacrocolpopexy is this observational study from the Mayo Clinic. It involved 30 women who underwent the operation for the treatment of Baden Walker grade 4/4 posthysterectomy vaginal vault prolapse. The authors concluded that advanced prolapse can be treated with robotic-assisted sacrocolpopexy with long-term success and minimal complications.
Details of the trial
Of 30 women in this trial, 52% underwent an anti-incontinence procedure at the time of sacrocolpopexy. Women who had multiple vaginal defects or a history of abdominal surgery were excluded from the study.
Average operative time was 3.1 hours (range, 2.15–4.75 hours) in the early phase of development of operative technique (described in the manuscript) but diminished over time to an average of 2.5 hours.
Twenty-nine patients were discharged from the hospital after an overnight stay. Very few immediate postoperative complications were observed. Two patients experienced mild port-site infections that required outpatient treatment, and one patient had persistent vaginal bleeding from the incision made during the anti-incontinence procedure.
Most patients were followed for at least 1 year
The mean follow-up in this study was 24 months (range, 16–39 months). During this period, 21 women were followed for a full year. Long-term observation revealed that the repair of vault prolapse remained successful in 19 of these women.
One patient experienced recurrent prolapse 7 months after surgery. Another developed a rectocele 9 months after sacrocolpopexy. Vaginal mesh erosions occurred in two patients within 6 months after the procedure; both patients were treated with outpatient resection of the exposed mesh, with no recurrence of the prolapse.