Durable outcomes seen with robotic prolapse surgery

Royal Oak, MI-Robot-assisted prolapse surgery for apical multicompartment vaginal prolapse repair is a safe procedure with durable outcomes, according to a retrospective study undertaken by urologists at Beaumont Hospital, Royal Oak, MI. 

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Co-author Michael Ehlert, MD, presented the findings from the review that included 100 women operated on by three urologists between 2007 and 2012.

“The published literature includes several series reporting on robot-assisted prolapse surgery, but many are small, and the short- and long-term complication rates as well as intraoperative events that might impact the patient’s long-term care are not well characterized,” said Dr. Ehlert, a fellow in female pelvic medicine and reconstructive surgery at Beaumont Hospital.

“The anatomic outcomes for our series compare favorably to previously reported data, as 92% of our patients were experiencing no vaginal bulge-related symptoms at last follow-up. However, we also documented several early and late postoperative complications that occurred at much higher rates than in the published literature. The complications were generally minor, but our data show there is continued risk for vaginal mesh or suture exposure despite abdominal placement of the mesh,” added Dr. Ehlert, who worked on the study with Melissa Fischer, MD, and colleagues.

The women in the series had a mean age of 61 years. About one-fourth of the patients had undergone prior prolapse surgery, 30% had a history of an anti-incontinence procedure, and about 60% had undergone hysterectomy before presenting for prolapse. According to the Pelvic Organ Prolapse Quantification staging system, 56% of women had Grade 3 prolapse and 30% had Grade 4.

Almost all women (94%) had a robotic sacrocolpopexy, while five women had sacrohysteropexy and one patient underwent robotic enterocele repair. Eighty-two women underwent concomitant surgical procedures, including anti-incontinence surgery (usually transobturator sling, 45%), hysterectomy (usually robotic, 37%), and additional vaginal repair (11%).

Mean OR time was about 4 hours, mean length of stay was 1.56 days, and median follow-up was 7.5 months (range, 0 to 50).

Intraoperative complications included three cystotomies, two vaginotomies, and one serosal injury, all of which were repaired primarily without any implications for long-term patient care. In one patient, the procedure was converted to an open procedure after performing the vaginal mesh fixation because of limited visualization. The procedure was aborted in another patient who had adhesions, and she underwent vaginal mesh placement at another time.

Next: Early, long-term complications identified

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Early, long-term complications identified

Early complications (within 30 days) were identified in 34 patients. Clavien II events included single cases of deep venous thrombosis, transfusion, and intensive care unit admission for intraoperative desaturation. There was a single Clavien IIIb event, which was an incarcerated port-site hernia diagnosed on post-op day 2.

Twenty-two patients were identified as having long-term complications. Clavien II complications included five patients with an asymptomatic but palpable or visible mesh or suture material. Complications needing OR intervention (Clavien IIIb) included four cases of symptomatic mesh or suture exposure, one mesh erosion into the bladder, and one patient who was found to have a port-site hernia at 1 year post-op.

“Many of the asymptomatic women with palpable or visible mesh or suture had their procedure early in the series, when surgeons were using braided polyester sutures. Currently, one of the surgeons is using polydioxanone and the other two use expanded polytetrafluoroethylene,” Dr. Ehlert said.

Of the eight women in the series who had a symptomatic bulge, seven had a Grade 3 anterior or posterior compartment on exam, and six of those seven women underwent further vaginal repair at a mean of about 8 months post-op. At last available follow-up in 95 women, 14 women had Grade 2 prolapse and seven patients had Grade 3 prolapse. The rest were Grade 0 or 1.

“None of our collected datapoints was found to independently predict recurrent prolapse in multivariate logistic regression analysis,” Dr. Ehlert said.

He acknowledged that the series suffered from limited follow-up for many women who likely resumed care with their referring physician. However, Dr. Ehlert noted the investigators were trying to address that issue by contacting women and inviting them to return for a visit, and they were also expanding their series to include cases performed from January 2013 onward.

Dr. Ehlert reported the findings at the AUA annual meeting in Orlando, FL.

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