106 Sandeep Gurram & Farzeen Firoozi The Arthur Smith Institute for Urology, Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA Pelvic organ prolapse (POP) remains a common problem for many women. It is estimated that 50% of women will be affected by POP in their lifetime and the risk for them to receive surgery for POP or stress urinary incontinence (SUI) is 11% [1]. This is particularly relevant given the increasing life expectancy rates, the increased rates of POP in the elderly, and the effect that POP has on quality of life [2]. Some have forecast that the incidence of POP will increase from 3.3 million in 2010 to 4.9 million in 2050, an overall increase of 46% [3]. Definitive therapy for POP is surgical and can be approached primarily through a vaginal or an abdominal approach. In general, vaginal correction is done through a uterosacral ligament suspension or sacrospinous ligament fixation, while abdominal surgery relies on sacrocolpopexy with the use of mesh. A Cochrane meta‐analysis demonstrated that the abdominal approach led to decreased rates of recurrent vault prolapse and dyspareunia when compared to the vaginal approach [4]. Even though abdominal sacrocolpopexy has been shown to have greater long‐term success, it remains decidedly more invasive, requires longer recovery time, and has a higher complication rate. The advent of laparoscopy and robotics has led to widespread adoption of these techniques for abdominal sacrocolpopexy (ASC) without evidence demonstrating improved outcomes. Nezhat et al. published the first experience with laparoscopic abdominal sacrocolopopexy in 1994. In this initial technique, the authors advocated using a single piece of Gore‐Tex® mesh attached to the posterior vaginal apex with sutures or staples to the sacral promontory [5]. There have been several modifications to this original technique, to reduce operating time, decrease complications, and improve outcomes. For women wanting a uterine‐sparing procedure, the laparoscopic sacrohysteropexy has been developed. Some techniques use a single arm of posterior mesh or a combination of Y‐shaped anterior mesh with posterior arm of mesh. As volume and experience grew, studies were able to show that although laparoscopic ASC was a longer procedure, it was associated with decreased intraoperative blood loss, shorter hospital stay, and reduced rates of ileus and small bowel obstruction [6]. With the introduction of the da Vinci® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) surgeons were afforded increased ergonomic capability, more degrees of freedom, and 3D vision. The robotic system gave increased ease of surgery with similar outcomes, albeit at a higher cost [7]. In this chapter, we review the laparoscopic and robotic sacrocolpopexy approaches to the management of POP. We will cover evaluation, technique, complications, and outcomes. The primary indication for robotic ASC is the presence of symptomatic apical or uterine POP. The most common symptom is a vaginal bulge or pressure, but this can be accompanied by a considerable number of other urinary, bowel, or sexual complaints [8]. These symptoms can be significantly varied based upon the patient’s degree of underlying prolapse. Patients may experience SUI, obstructive urinary symptoms, or even present without any urinary issues but an occult SUI may be unmasked after a prolapse repair. Similarly, contradictory bowel symptoms may also be encountered. Patients may need to excessively strain or use perineal/vaginal pressure to defecate, while others may experience fecal incontinence. The common indications for robotic ASC include uterine prolapse, post‐hysterectomy vaginal vault prolapse, recurrent apical prolapse, and failed previous vaginal repairs. Some factors to keep in mind during the patient selection process include the patient’s pulmonary status, ability to tolerate steep Trendelenburg, and any previous abdominal or pelvic surgery which would give rise to concern for postsurgical adhesions. Patients should undergo a thorough history and physical examination. They should also complete a preoperative voiding diary, in addition to a quality‐of‐life (QOL) questionnaire. The presence of a uterus should be accounted for and patients should be counseled regarding concomitant hysterectomy or consideration for a sacrohysteropexy. Specific questioning regarding Papanicolaou smear testing history, gynecologic neoplasia, pelvic sonography, and abnormal or postmenopausal uterine bleeding should be pursued. Physical examination should be thorough, with the use of bimanual examination and both bivalve and univalve speculum examination. This will allow for assessment of all compartments and appropriate staging with the pelvic organ prolapse quantification (POP‐Q) system [9]. The estrogen status of the patient should also be noted at this time. The exam should also include a cough stress test to assess for possible SUI though it should be noted that a significant number of patients may have occult SUI that may only be unmasked when the prolapse repair is performed and the urethra is unkinked [8]. Urodynamics may be used in complex cases, but determination of the need for urodynamics should be made on an individual case basis. In 2006, the Colpopexy and Urinary Reduction (CARE) trial demonstrated that the addition of a Burch colposuspension in women without preoperative SUI who underwent an ASC had significantly lower rates of postoperative SUI (23.8% vs. 44% in the control group) [10]. The long‐term outcomes from the CARE trial were published in 2013 and showed that at 7 years, women who underwent concomitant Burch colposuspension at the time of ASC had a longer time to recurrence of SUI compared to those women who did not have an anti‐incontinence procedure [11]. Inevitably, there have been those who have used these data to justify prophylactic anti‐incontinence procedures to be done concomitantly with prolapse surgery. A more contemporary trial that has echoed this stance has been the Outcomes Following Vaginal Prolapse Repair and Midurethral Sling (OPUS) trial. The OPUS trial concluded that a prophylactic midurethral sling placed during vaginal prolapse surgery resulted in a lower rate of SUI at 12 months postoperatively, albeit at the cost of a higher rate of adverse events [12]. Even though these results seemingly reinforced the CARE trial findings, these were vaginal procedures and cannot be used to directly extrapolate to similar outcomes in ASC, laparoscopic sacrocolpopexy (LSC), or robotic ASC. Our practice is to counsel patients regarding this risk and generally recommend the placement of a midurethral sling concomitantly with the ASC if SUI is experienced clinically or demonstrated during the workup. After induction of general endotracheal anesthesia, the patient is placed in low lithotomy position with the use of Yellowfin stirrups. The patient needs to be secured in order to allow for steep Trendelenburg position and the arms should be tucked in. All pressure points are padded. Both the abdomen and the vagina/perineum should be prepped and a split drape should be employed to allow one assistant to manipulate the vagina while the other assists in the abdomen. A Foley catheter is placed in a sterile manner after draping to allow for further manipulation. A nasogastric tube may also be inserted at this time per surgeon preference. The abdomen is insufflated with either a Veress needle or Hassan trocar in the periumbilical or supraumbilical region. At our institution, we prefer the use of a periumbilical Veress needle, unless there is concern for significant adhesions or chance of bowel injury. If that is the case, Veress needle access can be attempted two fingerbreadths below the costal margin at the level of the midclavicular line. Abdominal pressures should be monitored closely. If the intra‐abdominal pressure exceeds 8 mmHg, the needle should be repositioned to ensure it is not in any abdominal structures, adherent to bowel or omentum, or outside the peritoneal cavity. After adequate insufflation, the trocar sites are marked out appropriately (Figure 106.1). Based on surgeon preference, 4 or 5 ports may be used in total. Local anesthesia is administered at each trocar site for preemptive analgesia. A 10–12 mm camera port is then placed at the umbilical edge or slightly cranial to the umbilicus. Two additional 10–12 mm ports are placed lateral to the rectus muscle. One or two additional ports are placed 2–3 cm cephalad and 2–3 mm medial to the anterior superior iliac spines. The sigmoid is retracted to the left and cephalad by using the left lower port. Figure 106.1 The trocar sites. Typically anywhere from 4 to 5 ports are used, based on surgeon preference. Source: Wesley White. Reproduced with permission of Wesley White. Once the sigmoid colon is retracted, attention is drawn to the sacral promontory. Of note, this left lower port may be obviated by the use of suture retraction. A 1‐0 nonabsorbable suture on a large needle (CT‐X) can be passed through the left lower quadrant under visualization, placed through an epiploic appendage of the sigmoid colon, and back through the left lower abdomen and clamped to the skin where retraction is desired. Once the retraction of the sigmoid colon is achieved, the sacral promontory, right iliac vessels, and right ureter are identified. The posterior peritoneum over the sacral promontory is incised longitudinally to the level of the vaginal apex (Figure 106.2). Figure 106.2 The posterior peritoneum over the sacral promontory has been incised longitudinally to the level of the vaginal apex. Source: Wesley White. Reproduced with permission of Wesley White. The assistant seated at the perineum will place the vaginal manipulator, such as the EEA Reusable Sizer (Medtronic, Inc, Minneapolis, MN, USA), inside the vaginal vault (Figure 106.3
Laparoscopic and Robotic Techniques for Management of Pelvic Organ Prolapse
Introduction
Evaluation and workup
Surgical approach
Laparoscopic sacrocolpopexy
Step 1: Preparation
Step 2: Abdominal access
Step 3: Posterior peritoneal dissection
Step 4: Anterior vaginal dissection
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