Fully Extraperitoneal Robotic Sacrohysteropexy Compared With Transperitoneal Robotic Sacrocervicopexy for Anterior and Apical Pelvic Organ Prolapse

OBJECTIVES: To evaluate the feasibility, safety, and short‑term outcomes of fully extraperitoneal robotic sacrohysteropexy (EP‑RSH) compared with transperitoneal robotic sacrocolpopexy (RSC) for anterior and apical pelvic organ prolapse. METHODS: This retrospective comparative study included women who underwent EP‑RSH or RSC for symptomatic pelvic organ prolapse between January 2023 and October 2025 at a high‑volume referral center. EP‑RSH was performed entirely within the extraperitoneal space without peritoneal entry or Trendelenburg positioning. Eight early EP‑RSH cases requiring intraoperative conversion to a transperitoneal approach were excluded from the primary per‑protocol analysis. Perioperative, anatomical, recurrence, and functional outcomes were compared. A learning curve analysis was performed using surgeon‑specific sequential console time plots with LOESS smoothing. RESULTS: A total of 231 patients were analyzed (EP‑RSH, n = 84; RSC, n = 147). EP‑RSH was associated with longer operative and console times (approximately 30 min), whereas blood loss, hospital stay, and major complication rates were comparable. At 12 months, both groups demonstrated significant anatomical improvement with similar subjective, objective, and composite recurrence rates and comparable patient‑reported and functional outcomes. No clear time‑dependent reduction in console time was observed, and early EP‑RSH‑to‑transperitoneal conversions were confined to the initial surgeon learning phase and excluded from the comparative analysis. CONCLUSIONS: EP‑RSH may represent a feasible and safe expert‑level alternative to RSC in carefully selected patients. When performed by experienced robotic surgeons, EP‑RSH achieved comparable short‑term outcomes while avoiding peritoneal entry and Trendelenburg positioning. Further multicenter validation and structured training are warranted.