After completing this module, the learner should be able to:
Sandip Vasavada, MD
Q-10-1 Glickman Urological Institute
Center for Female Pelvic Medicine and Reconstructive Surgery
Disclosures: Allergan, Medtronic
UROLOGIC ROBOTIC SURGERY COURSE
Robotic Abdominal Sacrocolpopexy
Successful surgical management of pelvic organ prolapse (POP) remains a challenge. It is estimated that more than 500,000 surgeries in the United States are done for POP or associated conditions. Abdominal sacrocolpopexy (ASC) continues to be regarded as the gold standard of surgical treatments for advanced POP. Since robot-assisted laparoscopy was approved by the US Food and Drug Administration for urologic and gynecologic surgeries in 2001 and 2005, respectively, robot abdominal sacrocolpopexy (RASC) has been used to offer a lesser invasive method for surgical management of POP. The early results of RASC indicate comparable results to those of open ASC. Herein, we discuss the indication, selection, methods, and postoperative care for performing RASC.
Female pelvic surgery (FPS) leads to more than 500,000 surgeries in the United States (Subak 2001). As many as 11% of women have surgery for pelvic organ prolapse (POP) or related conditions by age 80. More than half of the women with urinary incontinence have associated POP (Olson 1997). With the expanding portion of population at risk for urinary incontinence or POP, an increasing number of urologists are involved in diagnosis and treatment of FPOP . However,training for the management of FPOP is still missing from a large proportion of urology residency training programs (Daneshgari 2005). The indications for robot abdominal sacrocolpopexy (RASC) in women with POP include: prolapse of the anterior, posterior or apical components with POP-Q Stage III-IV; minimal previous abdominal surgeries; and no contraindications for abdominal laparascopic procedures. As such, it is difficult to decide to do this procedure laparoscopically versus robotically based on some newer literature (Paraiso, et al, 2013). Still, the contraindications to RASC include: extensive previous abdominal or pelvic surgery and general contraindications to laparoscopic surgery.
The aims of POP repair are to restore anatomical anomalies and restore visceral function including bladder, bowel, and sexual function. Therefore, in order to maximize postoperative results, the surgeon should have a full understanding of the preoperative status of anatomical and functional anomalies in the patient. Proper recording of the POP-Q scale would provide the needed information on anatomical status of pelvic organs. Furthermore, review of urinary, sexual, and bowel functions by the preferred method selected by the surgeon should be included in the preoperative assessment.
The need for completion of urodynamic studies remains poorly answered. The current recommendation is performance of urodynamic studies to gain knowledge on the bladder function of the patient or as a tool for assessment of need for a concomitant anti-incontinent procedure. The utility of urodynamic studies as a preoperative requisite for POP has been questioned based on the results of 3 recent randomized clinical trials. Similarly, the need for performance of concomitant anti-incontinence procedure remains unclear. A report of a multicenter randomized clinical trial in the U.S. supported the need for performance of Burch colposuspension at the time of abdominal sacrocolpopexy (Brubaker 2007); however, this was disputed by the results of 2 European randomized clinical trials (Costantini 2008). Thus, the current recommendation for performance of urodynamic should be individualized and based on a physician's preference. In a majority of cases with recurrent POP or urinary incontinence, use of urodynamic studies would provide a more comprehensive understanding of a patient's urinary function. The overall assessment of the patient's medical condition to undergo a major surgery of 3 to 4 hour duration should also be conducted.
The preoperative preparation includes adequate rest and hydration on the day before surgery. The authors no longer recommend formal bowel preparation, but instead use of magnesium citrate on the day before surgery. A shower with general cleansing of the abdomen, perineum, and vaginal douche is also recommended.
A list of all instruments is required including details of manufacturers for specific instruments like locking clips and vascular clamps. Instruments with alternate manufacturers should be included if possible. The instruments should be categorized as non-disposable, disposable, or optional. Furthermore, in an era of cost containment, one should use a minimum of instruments.
Each step must be titled and described separately. The last paragraph in each step should be related to management of anatomical anomalies and troubleshooting. Tips to avoid complications must also be included.
Step 1. Patient positioning and placement of the ports: A patient should be placed in low lithotomy position using Allen Stirrups. A periumbilical port (port 1) is placed with a 12 mm trocar lateral to the umbilicus (Figure 1). Under direct visualization, two 8 mm trocars are placed (ports 2 and 3) for robotic arm instruments approximately midway along a line between the umbilicus and a point 2 cm cephalad to each anterior superior iliac spine (ASIS). An ancillary 12 mm port is then placed laterally from the right 8 mm port for large instrument assistance (port 4), and one or two ancillary 5-mm ports (ports 5 and 6) are placed 2 fingerbreadths superior and medial to the ASIS.
Step 2. Docking of the robot: The da Vinci® system (Intuitive Surgical, Sunnyvale, CA, USA) is then positioned and docked. The robotic system consists of 3 or 4 robotic arms (2 - 3 instrument arms, and 1 camera arm) providing three-dimensional visualization, and 6 degrees of freedom of instrument movement to the surgeon through the computer-modulated remote control. The camera arm is connected to port 1, and the instrument arms connected to ports 2 and 3. A zero or 30° lens is used interchangeably.
Step 3. Intracorporal dissections: The sigmoid colon is retracted using the 3rd instrument arm to keep the bowel retracted into a lateral position. The remaining sigmoid colon and small bowel are carefully retracted using small bowel graspers (Figure 2). Exposure of the sacral promontory and presacral space could be further facilitated using a paddle (Snowden Pencer, Tucker, GA, USA) or fan retractor (Origin Medsystems, Menlo Park, CA, USA) placed through the ancillary 12 mm port. A vaginal sizer is also positioned to facilitate the dissection and return the vagina and uterus to the normal anatomical position in preparation for mesh placement (Figure 3). For sacrocolpopexy, the peritoneum overlying the vaginal apex is incised longitudinally, including the planes between the bladder and the vaginal anteriorly, and between the colon and vagina posteriorly. This incision is extended cephalad towards the sacral promontory (Figure 4). For sacrouteropexy, the peritoneum is incised over the posterior vaginal cuff and posterior cervix and carried to the promontory (Figure 5). Blood vessels encountered during dissection are coagulated, clipped, or suture-ligated for hemostasis.
Step 4. Placement of the mesh: For sacrocolpopexy, a Y-shaped wide pore and preferably light weight polypropylene mesh is introduced and sutured to the vaginal apex anteriorly and posteriorly with number 0 nonabsorbable sutures (Figure 6). Sutures placed near the bladder can be exchanged for 0 delayed absorbable long acting sutures (polydiaxone). The sutures are placed through the entire thickness of the vaginal wall, excluding the vaginal epithelium. Use of a metal vaginal sizer often assists the surgeon in suture placement. For sacrouteropexy, a straight mesh is sutured to the posterior vaginal cuff and posterior surface of the cervix. The cephalic end of the mesh is sutured to the longitudinal ligament of the sacrum using two rows of number 0 nonabsorbable sutures (Ethibond, Ethicon, New Brunswick, NJ, USA).
Step 5. Closure of peritoneum over mesh and reconstruction of the pelvic floor: Care is taken to avoid undue tension on the mesh, and therefore is placed tension free with care below to assure mobility to the bladder neck and avoid hypersuspension. Subsequently, the redundant portion of mesh is excised. After posterior mesh placement, a Halban procedure or Moschcowitz culdoplasty is performed based on surgeon preference when a deep cul-de-sac is noted. The peritoneum is then reapproximated over the mesh with 2/0 polyglactin suture. If exposed mesh remains, sigmoid epiploic fat can be sutured over it. In all patients, the upper half of the vagina is verified as being under no tension and in an anatomically correct position with mobility to the bladder neck and urethra (Figure 7).
Step 6. Disengagement of the robot and removal of ports: After completion of the repairs the robotic arms are disengaged, the robot is undocked and all ports are removed under direct visualization. The fascial layer of all 12 mm port sites is closed in two layers, including the fascia.
Postoperative care consists of progression of patient ambulation, start and progression of oral intake and wound care. The general precautions for post abdominal laparoscopic surgeries apply. In the authors' experience, a majority of the patients regain normal function within 24 hours and are discharged on postoperative day 1. In general, there is minimal need for pain control. Patients are followed up at 2 weeks, 3 and 6 months, when a POP-Q-based pelvic examination is done. The preoperative values and the latest available postoperative values of the 5-points of the POP-Q scale from the anterior, posterior, and apex of the vaginal wall are shown in Figure 6.
Bleeding: In general, laparoscopic/robotic surgery results in significantly less blood loss than open sacrocolpopexy. A difficult bleeding complication specific to sacrocolpopexy is bleeding from the presacral veins. When injured, these can, on occasion, retract into the bone and become difficult to suture. In open surgery, thumbtacks can be used to stop bleeding. We have found that, with the robotic system, suturing into bone/periosteum is fairly easy and that the visual magnification and pneumoperitoneum permit accurate placement of figure of eight sutures to control bleeding. To save time, Lapar-Ty™ (Ethicon Inc., San Angelo, Texas) clips can be used to anchor the hemostatic suture.
Bladder injury: When dissecting the vagina off the bladder, inadvertent bladder injury can occur. Recognition of the injury can be assisted by intra-operative cystoscopy. The cystotomy can be closed in two layers using absorbable suture of the surgeon's choice. Sometimes, in cases of an extremely short vagina, the cuff of the vagina can be completely covered by bladder. It is extremely difficult to identify and develop the plane between the two organs in this case and open conversion may be necessary.
Extrusion/erosion: As with any vaginal procedure in which mesh is utilized, vaginal extrusion is a potential complication. Usually if an extrusion occurs it will occur with the first six months to one year postoperatively. However, the treating physician must be vigilant in examining any patient that presents with vaginal discharge following this procedure regardless of duration from surgery. Extrusion can usually be managed successfully and easily as an outpatient with transvaginal excision of the mesh and primary closure. In an effort to reduce postoperative extrusion it would be recommended to continue most patients on postoperative vaginal estrogen until healing is complete and to avoid overly aggressive dissection of the bladder off the vagina at the time of surgery.
A summary of relevant manuscripts are provided in Table 1. We thank Kerry O. Grimberg, PhD, for her medical editorial assistance.
Figure 6. A T-shaped polypropylene mesh is introduced and sutured to the vaginal apex anteriorly and posteriorly with absorbable sutures. The cephalic end is sutured to the sacral longitudinal ligament using nonabsorbable suture.