Patient Selection, Risks, and Alternative Surgical Strategies


Aa

Ba

C

GH

PB

TVL

Ap

Bp

D

Stage 0: no prolapse is demonstrated. Aa, Ba, Ap, Bp = −3 and C or D ≤ −(TVL-2) cm

Stage 1: The most distal portion of the prolapse is more than 1 cm above the level of the hymen

Stage 2: The most distal portion of the prolapse is 1 cm or less proximal or distal to the hymenal plane

Stage 3: The most distal portion of the prolapse protrudes more than 1 cm below the hymen but protrudes no farther than 2 cm less than the total vaginal length

Stage 4: Most distal edge of prolapse if ≥ + (TVL-2)cm


Aa point A anterior, Ap point A posterior, Ba point B anterior, Bp point B posterior, C cervix or vaginal cuff, D posterior fornix (if cervix is present), GH genital hiatus, PB perineal body, TVL total vaginal length






Patient Selection



Who Is a Candidate for Robotic Surgery?


Patient selection for RASC has not been well-studied. Selection depends on many factors, including the surgeon’s level of expertise with this surgical technique, resources available at the hospital or surgery center, and patient factors . These include the need for concomitant procedures, age, functional status, body mass index (BMI), previous prolapse or incontinence surgery, and comorbidities that may limit the duration of the anesthesia [14] (Table 2.2). In our opinion, criteria from the Abdominal Colpopexy: Comparison of Endoscopic Surgical Strategies (ACCESS) study should be used for patient selection. Patients must have symptomatic stage II–IV pelvic organ prolapse according to the POP-Q system with significant apical descent, defined as prolapse of the vaginal apex or cervix to at least halfway into the vaginal canal (POP-Q point C ≥ TVL/2) as well as vaginal bulge symptoms [20].


Table 2.2
Consideration for robotic surgery





















Considerations

BMI

Comorbidities

Previous abdominal/pelvic procedures: consider extra-peritoneal

Ability to obtain informed consent for a procedure that involved surgery, mesh, morcellation

Dedicated operating room for robotics

Cost of robotic system

Robotic instrumentation and maintenance


Benefits of Laparoscopy


Benefits of minimally invasive abdominal surgery performed laparoscopically consist of reduced postoperative pain, improved cosmesis due to smaller incisions, shorter hospital stays, faster postoperative recovery, potentially lower costs, and improved patient satisfaction [21] (Table 2.3). Laparoscopic surgery may be beneficial for obese patients compared to an open procedure where the pelvis may be deep and more difficult to visualize. For deep pelvic dissections required during a sacrocolpopexy, laparoscopy allows for a two-dimensional view of the field that can be magnified.


Table 2.3
Benefits of laparoscopic and robotic surgery compared to abdominal surgery





















Benefits of laparoscopic/robotic surgery

Reduced postoperative pain

Improved cosmesis (smaller incisions)

Shorter hospital stays

Faster postoperative recovery

Potentially lower costs (laparoscopic)

Improved patient satisfaction

Improved visualization for deep pelvic dissections


Laparoscopic Versus Robotic Approach in Gynecologic Surgery


In a recent meta-analysis comparing the outcomes of laparoscopic sacrocolpopexy (LSC) and RASC, data on 264 RASC and 267 LSC procedures were collected from seven studies. Pan et al. reported similarities in estimated blood loss (114.4 vs. 160.1 mL; p = 0.36) and incidence of intraoperative/postoperative complications (p = 0.85 vs. p = 0.92). RASC was found to be more costly (p < 0.01) and had a higher mean operative time (245.9 vs. 205.9 min; p < 0.001) [22].

In an effort to compare LSC and RASC for vaginal apex prolapse, a blinded randomized trial included participants with stage 2–4 post-hysterectomy vaginal prolapse. One year after prolapse repair, both groups demonstrated significant improvement in vaginal support and functional outcomes, but RASC had a longer operating time, increased pain postoperatively, and a higher surgical cost [23]. Anger et al. randomized 78 women to laparoscopic (N = 38) and robotic (N = 40) sacrocolpopexies. The initial day of surgery hospital costs for RASC were $2419 higher when robotic costs were included ($13,992 compared with $11,573; p = 0.001), and over 6 weeks, hospital costs were $3104 higher for RASC when robotic costs were included ($15,274 compared with $12,170; p < 0.001). Both the initial and 6-week costs remain significantly higher for robotic sacrocolpopexy when robotic costs were included [24].

In a retrospective cohort study comparing abdominal sacrocolpopexy with RASC, there was similar short-term vaginal vault support but the latter had a longer operative time, less blood loss, and a shorter length of stay [18]. A cost minimization study was performed comparing open with RASC and found the robotic approach to be equal or less costly than the open approach depending on the institutional robotic case volume [25]. Although laparoscopic sacrocolpopexy has been shown to be equivalent or better in some aspects mentioned, the skills required are not easily acquired and the learning curve is long. It is technically challenging to place the large number of sutures necessary without wristed instruments, and the physical cost to the surgeon has not yet been studied in wear and tear on the neuromuscular skeletal system. Interestingly, the learning curve for RASC is shorter than LSC even though it is considered a complex robotic surgery.


Anesthetic Concerns


Despite the advantages of laparoscopic or robotic gynecologic surgery, there are concerns from the other side of the surgical curtain. Concerns from anesthesia providers range from positioning of the patient to physiologic changes. From the beginning of the surgical procedure, the anesthesiology team has restricted access to the patient due to the mass of the equipment set over the patient (Fig. 2.1). During robotic surgery, access is even further restricted by docking the robot, as the patient cannot be moved after this point. Furthermore, the arms are completely tucked and often wrapped or padded, limiting access for intraoperative blood draws or placement of an arterial catheter or additional venous access during the procedure (Table 2.4).

A370477_1_En_2_Fig1_HTML.jpg


Fig. 2.1
Access to the patient is limited for the anesthesiology team during robotic surgery (© 2016, Intuitive Surgical, Inc)



Table 2.4
Concerns from the anesthesiology providers













Physiological effects of pneumoperitoneum in the Trendelenburg position

Restricted access to the patient due to the mass of the equipment set over the patient, tucked arms, docked robot

Patient obesity (see Table 2.5)

Prolonged lithotomy position


Pneumoperitoneum and Trendelenburg Position


Prevention and treatment of complications due to induced pneumoperitoneum , prolonged lithotomy position, and steep Trendelenburg positions have been explored. Although apparently well-tolerated by most patients, the combined effect of the steep Trendelenburg position, which is about 40°, and carbon dioxide pneumoperitoneum during these long procedures, has not been completely defined. In one observational study of robotic endoscopic radical prostatectomy, Trendelenburg position combined with a carbon dioxide pneumoperitoneum significantly influenced cardiovascular, cerebrovascular, and respiratory homeostasis, but variables remained within a clinically acceptable range.

Mean arterial pressure is increased by increased cardiac output, systemic vascular resistance, or both. These changes have been demonstrated by an increased intra-abdominal pressure compressing the aorta and increasing the afterload, possibly further enhanced by humoral factors during laparoscopic surgery [26]. Also, transesophageal Doppler measurements have shown a significant increase in stroke volume when patients are placed in steep Trendelenburg position [27]. Furthermore, regional cerebral oxygenation was well-preserved and the cerebral perfusion pressure remained above the lower limit of the cerebral autoregulation [28, 29].


Cardiovascular Considerations


The assessment of a patient’s cardiac risk in the perioperative period is made during the history, physical examination , and electrocardiogram. Depending on a patient’s cardiac risk, the surgeon should decide if surgery should proceed without further cardiovascular testing, or be postponed for further testing such as stress testing, echocardiography, or 24 h ambulatory monitoring. The planned surgery may have to be changed to a lesser risk surgery, or conservative management may be chosen instead of surgical treatment. In patients assessed to be at increased cardiovascular risk, a referral to a cardiologist for further evaluation may be indicated preoperatively [30].

A history of ischemic heart disease, congestive heart failure, cerebral vascular disease, renal dysfunction, and preoperative insulin treatment all increase the risk of cardiac complications. Studies have shown a 10–30% reduction in cardiac output in Trendelenburg. Parameters including heart rate, arterial pressure, stroke volume, carbon dioxide elimination, and total respiratory compliance have been measured. Using these values, mean arterial pressure, total peripheral resistance, stroke index, and cardiac index were calculated. At maximum hemodynamic strain, stroke index and cardiac index were reduced by 42%, without significant changes in heart rate and mean arterial pressure. Total peripheral resistance was increased by 50–100% [31].

The Trendelenburg position in awake and anesthetized patients increases pulmonary arterial pressures, central venous pressure, and pulmonary capillary wedge pressure. The cardiac index, a parameter that relates the cardiac output from left ventricle in 1 min to body surface, decreased with anesthesia induction and then again further during laparoscopy. Soon after deflation after laparoscopy, the cardiac index returns to pre-insufflation values [32].


Obese Patients


Concerns have been raised about the applicability of robotic and laparoscopic surgery in the obese patient (Table 2.5). Arterial oxygenation and alveolar-arterial difference in oxygen tension are significantly impaired in obese patients. One study looking at the issues of obesity in a surgical population compared 15 overweight and 15 nonobese patients undergoing robot-assisted radical prostatectomy under general anesthesia. This procedure is similar to a RASC in length and in Trendelenburg positioning of the patient. The alveolar-arterial difference in oxygen tension is a measure of the difference between the alveolar concentration of oxygen and the arterial concentration of oxygen and is used in diagnosing the source of hypoxemia. This small study demonstrated that overweight (BMI of 25–29.9 kg m2) patients had impaired arterial oxygenation with a higher alveolar-arterial difference in oxygen tension levels after induction of anesthesia and Trendelenburg positioning. In these overweight patients, pneumoperitoneum reduced the impairment of arterial oxygenation as well [33].


Table 2.5
Considerations in obese patients

















Arterial oxygenation and A(a) DO2 are significantly impaired in overweight patients under general anesthesia in Trendelenburg position

Pneumoperitoneum may transiently reduce impairment in arterial oxygenation and decrease A(a) DO2

Higher expiratory airway pressures

Increased open conversion rates

Increased airway pressures after placing a morbidly obese patient in the lithotomy and steep Trendelenburg positions, possibility of aborting or converting to an open procedure

Hemodynamic parameters are not affected by BMI

In a study to determine the impact of BMI on perioperative functional and oncological outcomes in patients undergoing robotic laparoscopic radical prostatectomy, 945 patients were stratified by BMI: normal weight (BMI < 25 kg/m2), overweight (BMI = 25 to <30 kg/m2), and obese (BMI ≥ 30 kg/m2). Obese patients experienced increased open conversion rates (2.3%) compared with nonobese patients (0.9%), with over 80% of these open conversion cases due to higher expiratory airway pressures while in Trendelenburg [34].

Hemodynamic parameters have not been shown to be affected by BMI in laparoscopic or robotic surgeries [33, 35]. A recent retrospective study on obese patients (BMI of 30 kg/m2) followed 1032 patients who underwent robotic gynecological surgery at two institutions between 2006 and 2012 and found that 14% had any complication, but only 3% of patients had a pulmonary complication. The degree of obesity did not predict complications or success of robotic surgery. Age was significantly associated with a higher risk of pulmonary complications (p = 0.01). Older age (p = 0.0001), higher estimated blood loss (p < 0.0001), and longer case length (p = 0.004) were associated with a higher rate of all-cause complications. The authors concluded that the vast majority of obese patients can tolerate robotic gynecological surgery with low complication rates and even lower rates of pulmonary complications [36]. In a subgroup analysis, there was no clinical difference between patients who underwent robotic gynecologic surgery for oncologic versus benign indications [37].


Alternative Surgical Strategies


When considering candidacy for RASC, it is important to understand the other surgical options available for apical POP repair, as there are several good options for surgical correction of apical prolapse with relatively high success rates.


Transvaginal Approaches



Sacrospinous Ligament Fixation


Sacrospinous ligament fixation (SSLF) is one of the most frequently performed and well-studied of the hysteropexy/colpopexy techniques. This procedure involves performing an extra-peritoneal dissection until the sacrospinous ligament is identified and exposed. The right sacrospinous ligament is often used due to the left side’s proximity to the rectum. With the use of a reusable ligature carrier or a suture delivery device, the sacrospinous ligament is attached to the posterior cervix, vagina, or possibly the uterosacral ligament using a permanent monofilament suture, delayed absorbable sutures, or a combination of both (Fig. 2.2).

A370477_1_En_2_Fig2_HTML.gif


Fig. 2.2
Placement of suture with a suture delivery device through the sacrospinous ligament (Image used with permission from Boston Scientific, 2017)

The safety profile, as well as the success of this procedure, has been extensively studied and described in detail in the literature. Generally, there is a low recurrence rate [38], shorter recovery times, less morbidity, shorter operating times, less pain, and a shorter hospital stay when a SSLF is performed without a hysterectomy [39]. In one randomized controlled trial, 71 women either underwent a SSLF without a hysterectomy or vaginal hysterectomy and uterosacral ligament suspension (USLS). There were no differences in quality of life, prolapse or incontinence symptoms, or reoperation rates at 1 year. Although subjectively, prolapse symptoms were the same 1 year postoperatively, 27% of the SSLF group had stage II or greater prolapse on the POP-Q (Table 2.6) compared to only 11% in the vaginal hysterectomy with USLS group. SSLF was associated with shorter hospitalization, shorter recovery with more rapid return to work, and a significantly longer mean total vaginal length of 8.8 versus 7.3 cm than the hysterectomy with apical suspension group (p < 0.01) [40]. Most recently, SSLF was reported to be non-inferior to vaginal hysterectomy with suspension of the uterosacral ligaments for symptomatic recurrent prolapse of the apical compartment. Although the main outcome was POP recurrence at Stage II or higher of the apical compartment, this study also reported no significant differences between anatomical recurrences, functional outcomes, or quality of life [41].


Table 2.6
Relative contraindications to laparoscopic or robotic surgery

























Relative contraindications

BMI

Patient preference for Pfannenstiel/previous Pfannenstiel

Pelvic/abdominal radiation therapy

Immunosuppression: chemotherapy, chronic steroid use, immunosuppressive medications

Connective tissue disorders causing poor wound healing

Severe intra-abdominal adhesions

Compromised pulmonary status

Inability to tolerate positioning

Prior upper limb neural injury during surgery

Because this procedure is short in duration, has minimal blood loss, and does not require entering the posterior cul de sac, patients with comorbidities that do not allow for long procedures or patients who have scarring in the cul de sac due to previous surgeries, endometriosis, or pelvic inflammatory disease, may be good candidates.


Uterosacral Ligament Suspension

This technique involves entering the peritoneal cavity through the vagina at the location of the vaginal cuff in a post-hysterectomy patient , through a posterior colpotomy in a uterine-sparing procedure, or through the open cuff at the time of a vaginal hysterectomy. One to three delayed absorbable sutures and/or permanent sutures are placed through each uterosacral ligament at or above the ischial spine. The sutures are then attached either extra-peritoneally or intra-peritoneally to the cervix or vaginal apex. This procedure is done extra-peritoneally when the surgeon choses to avoid the posterior cul de sac due to a previous history of pelvic surgery, endometriosis, pelvic inflammatory disease, or other known pelvic scarring.

One retrospective study compared 100 cases of USLS to 100 cases of USLS at the time of a vaginal hysterectomy and found similar objective results at the postoperative mark of 1.5 years. Objective apical support was 96.4%, with no difference between hysteropexy and cuff suspension (96.0% vs. 96.8%, p = 0.90), cystocele (86.8% vs. 93.8%, p = 0.31), or rectocele (97.8% vs. 100%, p = 0.16) at 2 years after surgery [42].

Using the POP-Q D point, which is the point of the posterior fornix, has been shown to correlate with postoperative apical support, and a clinically meaningful relationship exists between the preoperative D point and anatomic apical success. D points are only present in patients who have a uterus. Richter et al. found that a more negative preoperative D point was significantly related to improved postoperative apical support (p = 0.0005). This study excluded women who had a previous hysterectomy, as they did not have a preoperative D point [43]. In our experience, the outcomes are similar except when there is cervical elongation (more than 4 cm) and/or when there is a very large anterior compartment defect, in which case it is difficult to adequately elevate and support the anterior wall with the cervix in place, or even with sufficient elevation of the apex or anterior wall, the elongated cervix may cause the patient bulge symptoms.


Manchester Procedure

Originally described in 1888, the Manchester procedure involved amputation of the cervix, colporrhaphy , and attachment of the cervical stump to the transposed contralateral uterosacral-cardinal ligament complex [44]. Since then, modifications have been made, involving plication of the uterosacral ligaments instead of cutting and transposing the ligaments [45].

In a study comparing the modified Manchester to vaginal hysterectomy with uterosacral ligament suspension outcomes, 98 patients returned for a 1 year follow-up (51 in modified Manchester group and 48 in TVH with USLS group) and were included in this comparison. There were similar anterior and posterior compartment prolapse recurrences (POP stage greater than or equal to stage II) of about 50%, but no apical recurrence for the modified Manchester group. In the modified Manchester group, there was no apical recurrence versus two patients with objective apical recurrence in the vaginal hysterectomy group. Despite more apical recurrence objectively, there was no difference in the pre- and postoperative subjective scores between groups [46]. This procedure is less commonly performed because cervical amputation has been associated with hematometra, which is retention of blood in the uterine cavity caused by obstruction to uterine flow at the level of the uterus , cervix, or vagina, infection in the uterus, infertility, miscarriage, and preterm delivery [47].

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Jan 29, 2018 | Posted by in UROLOGY | Comments Off on Patient Selection, Risks, and Alternative Surgical Strategies

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