The Paradigm Shift from Laparoscopy to Robotics for Pelvic Floor Reconstruction

The surgical trend from transvaginal to transabdominal approach for pelvic floor reconstruction. After the warning letters for transvaginal mesh (TVM) from U. S. Food and Drug Administration, pelvic reconstructive surgery for pelvic organ prolapse (POP) has been shifted from transvaginal route to transabdominal route, thereafter. Abdominal sacrocolpopexy (ASC) is regarded as a traditional abdominal approach, in which vaginal apex (vaginal stump) was anchored to the sacral promontory in a manner that recreates the natural anatomic support. A graft is used to support the vaginal apex to the sacral promontory, including autologous (patient’s own tissue), allograft (tissue from the same species), xenograft (biologic material from other species), and synthetic materials (e.g., polypropylene). Laparoscopic-assisted sacrocolpopexy (LASC) is a feasible abdominal approach for POP, however, it needs more meticulous and challenging suture techniques. Therefore, laparoscopic-assisted pectopexy (LAPP), by Banerjee and Noé in 2011,[1] has been proposed as a safer alternative. With the emergence of robotic system, sacrocolpopexy, as well as pectopexy, can be done either by robotics, in addition to laparoscopy, in the minimal invasive surgery era. To compare robotic-assisted sacrocolpopexy (RASC) versus ASC, both Elliott and Li studies found decreased lengths of stay for RASC compared with ASC. Elliot et al., over 4 years, observed an overall 10% cost savings for RASC versus ASC, largely due to decreased costs per hospitalization day in the postoperative period.[2] Li et al. observed lower postoperative wound, genitourinary, and vascular complications with RASC compared with ASC.[3] The adoption of RASC has the advantages of better instrument dexterity and range of motion due to features of wristed instruments with multiple degrees of freedom, and improved suturing and reconstruction, especially beneficial in complex procedures such as meticulous and laborious suture and knot-typing pelvic reconstructive surgeries, which are the limitations of LASC.[4] To compare RASC versus LASC, in the American College of Obstetricians and Gynecologists ACOG Committee Opinion, there were no significant differences between the different approaches in anatomic outcomes at the 1-month, 3-month, and 6-month intervals, and no significant differences in recurrence rates at 1 year. In addition, there were no differences in mortality, length of hospital stay, and postoperative quality of life (QoL).[4] In the two RCTs, Paraiso et al. and Anger et al., that compared RASC with LASC, operating time, postoperative pain, and cost were found to be significantly greater in RASC, but anatomical and functional outcomes 6 months to 1 year after surgery were similar.[5-7] The higher cost of RASC was from purchase and maintenance of robotic machines and disposable instruments. Ultimately, the surgical approach should take into account individual patient characteristics and surgical expertise of the physician. As for QoL, all QoL score domains improved significantly in both LASC versus RAS. There were no questionnaire parameters that worsened in both groups. RASC, in addition to LASC, improves prolpase QoL (P-QoL) with a low incidence of surgical complications for POP patients may be a prospective new procedure for POP.[8] LAPP, first initiated by Banerjee and Noé in 2011,[1] is a novel surgical method for correcting apical prolapse. The descended cervix or vaginal vault is suspended with a synthetic mesh by fixing the bilateral mesh ends to the pectineal ligaments, instead of anterior longitudinal ligament at presacral area.[1] Chuang et al. found the operation time of LAPP group was significantly shorter,