Abdominal sacrocolpopexy is the gold-standard treatment for apical compartment prolapse, as it is more effective and durable than the transvaginal approach. In the current era of minimally invasive surgery, laparoscopic sacrocolpopexy techniques have been described, but have not gained popularity due to their complexity and steep learning curves. To overcome this problem, robotic sacrocolpopexy was introduced, and has shown equivalent outcomes and safety compared to open and laparoscopic sacrocolpopexy based on findings that have been accumulated over 15 years.
The incidence of pelvic organ prolapse (POP) has been gradually increasing with the global increase in the aging population, and the lifetime risk of symptomatic vaginal prolapse requiring surgical treatment is estimated to be 12.6% [
abdominal sacrocolpopexy (ASC) remains the gold-standard procedure for apical compartment prolapse, as it offers superior outcomes for a variety of vaginal procedures with few complications [
To address these issues, robotic sacrocolpopexy (RSC) has been explored. After Di Marco et al. [
RSC consists of 3 main steps: vaginal dissection, presacral peritoneal dissection, and mesh fixation. However, as shown in
The shape of the mesh used (Y-shaped mesh, 2 separate meshes, T-shaped mesh, or racket-shaped mesh) varies depending on the surgeon, and the depth dissected is often not mentioned (
Currently, the consensus is to affix the sacral arm of the mesh to the most superior point of the anterior surface of S1. However, although the bleeding risk is lower at the S1 level than at other levels, the promontory is not anatomically familiar, and there is a risk of bleeding due to the close proximity of nerves to the surrounding blood vessels. Therefore, caution is required when performing dissection.
A nonabsorbable suture is used in traditional open sacrocolpopexy to prevent detachment of the mesh from the vagina and sacral promontory and to decrease the risk of mesh exposure and suture erosion. In a series of RSCs with a median of 33 months of follow-up, the use of absorbable sutures for both vaginal and sacral mesh attachment was effective; the 3-year rate of survival without repeat prolapse surgery was 93% [
With regard to the efficacy of RSC, the objective cure rate was reported to be 84%–100% and the subjective cure rate to be 92%–95% in a systematic review that analyzed studies conducted between 2006 and 2013 [
In studies with an average follow-up period of 6 months to 12 months, the cure rate of apical compartment prolapse ranges from 88%–100% [
In studies conducted only on patients with advanced-stage POP, namely Baden-Walker grade 3 or Pelvic Organ Prolapse Quantification System (POP-Q) stage 3 or higher, the anatomical cure rate of apical compartment prolapse is 95%–100%, indicating excellent outcomes [
Because apical compartment prolapse includes not only vault prolapse that occurs in patients who have undergone prior hysterectomy, but also uterine prolapse, many studies are not limited to patients who have undergone hysterectomy. Therefore, when RSC is performed on patients with a uterus, concurrent hysterectomy or supracervical hysterectomy is performed depending on the surgeon, although hysteropexy can be performed with uterus preservation. In addition, supracervical hysterectomy and uterine preservation are performed selectively depending on the patient, even in the same study. However, in most studies, the surgical outcomes of concurrent supracervical hysterectomy or uterine preservation have not been analyzed separately. As shown in
The clinical outcomes of RSC are comparable to those of open sacrocolpopexy (
No difference in efficacy according to surgical method has been observed, even in comparison with LSC (
It is challenging to define the success of POP repair. Is anatomical restoration to the original state a success? Is elimination of bulging symptoms felt by the patient a success? It is important to assess composite outcomes to address this issue. The importance of composite outcomes was clearly demonstrated by the CARE trial, which reported stratified outcomes as subjective, anatomic, or composite failure after POP repair. Anatomic failure after sacrocolpopexy was defined as postoperative POP requiring reoperation or pessary or recurrent prolapse according to the POP-Q system, defined as the vaginal apex descending to below the upper third of the vagina, or anterior or posterior vaginal wall prolapse beyond the hymen. Interestingly, half of the patients with anatomic failure at the 7-year follow-up reported no symptoms and did not require further treatment [
Apical compartment prolapse occurs concomitantly with anterior and posterior compartment prolapse. We previously suggested that identification and correction of apical prolapse is critical to reduce recurrence after POP repair, and clinically significant apical prolapse is virtually always present in cases with both anterior and posterior compartment prolapse [
The reported mean or median operative time of RSC, defined as the time from incision to closure, varies widely, from a minimum of 124.2 minutes to a maximum of 288 minutes. An interesting result is that all 3 RCTs comparing RSC and LSC reported a longer operative time for RSC than for LSC [
When performing RSC, additional time is needed if concurrent vaginal surgery such as anterior or posterior repair and anti-incontinence surgery is required. However, except when antiincontinence surgery such as a sling is simultaneously needed, high-grade cystocele may be satisfactorily corrected by RSC alone, and the time for vaginal surgery can be reduced [
A systematic review of RSC studies reported mesh erosion rates ranging from 0% to 8% [
Mesh materials have also been modified to reduce complications. Type 1 polypropylene mesh is the most commonly used material, although not all type 1 polypropylene materials are the same. In addition to mesh erosion, pain and dyspareunia can also be caused by mesh. To overcome these problems, lightweight or ultra-lightweight mesh products have been launched to reduce “mesh load.” A weight-based classification of mesh materials was introduced by Earle and Mark [
Sacrocolpopexy through an abdominal approach is the current gold standard for the restoration of apical compartment prolapse. RSC is of interest at this time of transition from open surgery to minimally invasive surgery because of the increased risk of morbidity associated with open surgery. Good outcomes have been achieved with RSC even in advanced-stage POP, and there are data that indicate that this technique results in durable outcomes. In terms of postoperative morbidity and complications, RSC can greatly improve patients’ symptoms and quality of life. Particularly for novice surgeons who are not familiar with LSC, RSC is an excellent choice as the first surgical skill to attempt.
The authors have no potential conflicts of interest relevant to this article.
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Supplementary video clip can be found via
Vaginal wall dissection (posthysterectomy vaginal vault prolapse). (A) Surgical anatomy of the vaginal apex and bladder, (B, C) anterior vaginal wall dissection (black arrow: vesicovaginal junction), and (D) posterior vaginal wall dissection.
Fixation of the distal mesh arms to (A, B) the anterior vaginal wall and (C) the posterior vaginal wall using a barbed, delayed-absorbable suture (V-Loc 180; Covidien, Walpole, MA, USA) in a continuous manner. (D) The proximal arm of the mesh passes through the posterior peritoneum (yellow arrow).
Vaginal wall dissection in sacrohysteropexy (uterus-preserving). (A) Surgical anatomy of the vaginal apex and bladder. (B) Anterior vaginal wall dissection. (C) Posterior vaginal wall dissection. (D) The anterior mesh arm is tunneled through the right broad ligament. Fixation of the distal mesh arms to (E) the posterior vaginal wall and (F) the anterior vaginal wall using a barbed, delayed-absorbable suture (V-Loc 180; Covidien, Walpole, MA, USA) in a continuous manner.
Fixation of the proximal arm of the mesh. (A) At this time, the tension of the mesh should be adjusted while the vagina is restored using a vaginal manipulator. (B) The mesh is sutured to the anterior longitudinal ligament overlying the sacrum with 2–3 sutures. (C) Reperitonealization after fixation of the mesh using a barbed, delayed-absorbable suture (V-Loc 180; Covidien, Walpole, MA, USA) in a continuous manner.
Surgical procedure and materials used in robotic sacrocolpopexy
Study | Mesh | Depth of vaginal dissection | Type of suture in vagina | Attachment to sacrum | Peritonealization | Concurrent operation | Operative time (min), mean or median (range) |
---|---|---|---|---|---|---|---|
Elliott et al. [ |
Y-shaped PP, IntePro, AMS | As distal as possible | PTFE, interrupted | PTFE, interrupted | NR | Anti-incontinence: 52% | 186 (129–285) |
Benson et al. [ |
Y-shaped PP, IntePro, AMS | NR | 2-0, interrupted | 2-0 polyglactin, interrupted | 3-0 polyglactin, running | NR | 194 (137–280) |
Xylinas et al. [ |
Y-shaped PP, Gynemesh, Ethicon | NR | 2-0 PP, interrupted | 2-0 PP, interrupted | 2-0 polyglactin, running | Anti-incontinence: 50% | 144 (120–180) |
Tan-Kim et al. [ |
Y-shaped PP, Gynemesh, Ethicon | At least 4 cm down | 2-0 PP, interrupted | 2-0 PP, interrupted | 2-0 polyglactin, running | Anti-incontinence: 21% | 281 |
Posterior repair: 7% | |||||||
Paraiso et al. [ |
Two separate PP (unspecified) | NR | NR | Non-absorbable or Tacker | NR | NR | 257 (191–381) |
Seror et al. [ |
Y-shaped PP, Parietex, Tyco | NR | 2-0 PP, interrupted | Mersuture | 2-0 polyglactin, running | Anti-incontinence: 30% | 125 (90–270) |
Siddiqui et al. [ |
Y-shaped PP, Intepro Lite, AMS | NR | NR | NR | NR | Anti-incontinence: 42% | NR |
Posterior colporrhaphy: 8% | |||||||
Belsante et al. [ |
Two separate PP, Marlex, Bard | Anterior: distally to above the level of the trigone (3–5 cm distal to the vaginal apex) | 2-0 polyglactin, interrupted | 2-0 PE | 2-0 polyglactin, running | NR | 288 (210–390) |
Posterior: down as distally as possible | |||||||
Louis-Sylvestre and Herry [ |
Two separate PE, Mersuture, Ethicon | NR | 3-0 polyester | Nonabsorbable (unspecified) | NR | NR | 246 (180–415) |
Salamon et al. [ |
Y-shaped PP, Restorelle Y SmartmeshTM, Coloplast | Anterior: within 1 cm from the bladder neck (4–6 cm anterior coverage) | PTFE, interrupted | PE | Poliglecaprone | Anti-incontinence: 70% | 161 |
Posterior: level of the perineal body (8–10 cm posterior coverage) | Perineorrhaphy: 22% | ||||||
Anger et al. [ |
Two separate PP (unspecified) | NR | PTFE, interrupted | PTFE | Surgeon preference | NR | 202.8 |
Barboglio et al. [ |
Y-shaped PP, IntePro, AMS | NR | PTFE, interrupted | PE | Polyglactin 910 | NR | 124.2 |
Culligan et al. [ |
Y-shaped PP, Alyte, Bard | Anterior: trigone | PTFE, interrupted | PE | Poliglecaprone (Monocryl) | Anti-incontinence: 81.3% | 148 (75–250) |
Posterior: perineum | Perineorrhaphy: 11.3% | ||||||
Sung et al. [ |
Two separate PP, Gynemesh, Ethicon | NR | PE | PE | Absorbable | Anti-incontinence: 50% | 251 |
Vault prolapse: Two separate, Y-fashioned | Cystocele repair (4-arm TO mesh): 6.3% | ||||||
Uterine-preserving: anterior - 4×5 cm rectangular //posterior - T-shaped | |||||||
Jong et al. [ |
Two-separate PP (Y-fashion), Marlex (Bard) or Atrium (Hudson) | NR | Polyglactin | Nonabsorbable (unspecified) | NR | Lysis of adhesion (n = 7), caruncle (n = 1), fulguration of trigone (n = 1) | 234 |
van Zanten et al. [ |
Y-shaped PP, Prolene (Ethicone) or Restorelle (Coloplast) | NR | PE or PTFE | PTFE or Tacker | Polyglycolic barbed, continuous | RSC: anti-incontinence: 2.1%, AC: 3.2%, PC: 1.6% | 145.3 |
RSHS: anti-incontinence: 9.4%, AC: 11.1%, PC: 4.3% | 183.1 | ||||||
Linder et al. [ |
Y-shaped PP, IntePro, AMS | Anterior: immediately proximal to trigone | PTFE | PTFE | Absorbable | Anti-incontinence: 78.6% | 160 |
Posterior: midpoint of posterior vaginal wall | |||||||
Shimko et al. [ |
Y-shaped PP, IntePro, AMS | As distal as possible | PTFE | NR | NR | Anti-incontinence: 60% | 186 |
Illiano et al. [ |
Vault prolapse: two separate PP (rectangular) (unspecified) | As far caudal as possible | Absorbable (unspecified) | PP | Absorbable, running | Never perform | 234.4 |
Uterine preserving: Y-shaped PP (unspecified) | Anterior: down to the bladder neck | ||||||
Posterior: down to level of the levator ani | |||||||
Authors | We use Y-shaped PVDF, DynaMesh-PRS, | Polyglycolic barbed, continuous | PP | Polyglycolic barbed, continuous | |||
FEG Textiltechnik mbH in case of either vault prolapse or uterine-preserving surgery |
AC, anterior colporrhaphy; NR, not reported; PC, posterior colporrhaphy; PE, polyester; PP, polypropylene; PTFE, polytetrafluoroethylene; PVDF, polyvinylidene fluoride; RSC, robotic sacrocolpopexy; RSHS, robotic supracervical hysterectomy with sacrocervicopexy.
Study design, demographics, and objective outcomes
Study | Year | Preoperative POP grade | Cases | Previous hysterect omy (%) | Concurrent hysterectomy, supracervical hysterectomy, or uterine preservation: % | Mean or median follow-up (mo) | Mean age (yr) | Cure rate (%) |
Recurrence (%) | Reoperati on rate (%) | ||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Overall | Apical | Anterior | Posterior | |||||||||||
RCTs | ||||||||||||||
Paraiso et al. [ |
2011 | POP-Q stage 2–4 | 40 RSCs/38 LSCs | 100/100 | - | 12 | 61/60 | 88/91 | NR | NR | NR | 0 | 0 | |
Anger et al. [ |
2014 | POP-Q stage 2–4 | 40 RSCs/38 LSCs | 35/50 | Supracervical hysterectomy: 63 | 6 | 58.5/60.6 | NR | Point C: -7.97/ | Point Ba: -2.48/ | Point Bp: -2.33/ | NR | NR | |
Supracervicalhysterectomy:53 | Point C: -7.30 | Point Ba: -2.43 | Point Bp: -2.63 | |||||||||||
Kenton et al. [ |
2016 | POP-Q stage 2–4 | 40 RSCs/38 LSCs | 35/50 | Supracervical hysterectomy: 63 | 12 | 58.5/60.6 | NR | Point C: -7.6/ | Point Ba: -2.2/ | Point Bp: -2.2/ | 0 | 0 | |
Supracervical hysterectomy: 53 | Point C: -8.7 | Point Ba: -2.5 | Point Bp: -2.4 | |||||||||||
Illiano et al. [ |
2019 | POP-Q stage 3–4 | 49 RSCs/51 LSCs | 71.4/70.6 | All uterine preservation cases | 25.7/25.1 | 60.2/60.3 | NR | 100/100 | 90/85 | 98/90 | 0 | 0 | |
Prospective studies | ||||||||||||||
Moreno et al. [ |
2011 | Vault prolapse, grade 3–4 cystocele | 31 RSCs | 41.9 | NR | 24.5 | 65.2 | NR | NR | NR | NR | 0 | 0 | |
Seror et al. [ |
2012 | Baden-Walker grade 2–4 | 20 RSC/47 LSC | 9.0 | NR | 15/18 | 60.0/66.7 | NR | 98.5 | NR | NR | 5.0/0 | 0 | |
Salamon et al. [ |
2013 | POP-Q stage 2–4 | 120 RSCs | 26.7 | All supracervical hysterectomy | 12 | 56.6 | NR | 89 | NR | NR | 0.8 | 0 | |
Culligan et al. [ |
2014 | Mean POP-Q 2.7 | 143 RSCs | 22 | All supracervical hysterectomy | 12 | 58.6 | 84 | 99.3 | 89.5 | 95.1 | NR | NR | |
van Zanten F et al. [ |
2019 | POP-Q stage 2-4 | 188 RSC/117 RSHS | 100/0 | - | 12.6/14.8 | 63.1/59.9 | 67.1/64.8 | 91.4/99 | 84.3/77.1 | 95.7/92.4 | Apical: 0.7/0.0 | 22.9/3.7 | |
All supracervical hysterectomy | Anterior: 15.7/22.9 | |||||||||||||
Posterior: 4.3 /7.6 | ||||||||||||||
Multiple: 7.9 /1.0 | ||||||||||||||
Retrospective studies | ||||||||||||||
Elliott et al. [ |
2006 | Baden-Walker grade 4 | 30 RSCs | 100 | - | 24 | 67 | NR | 95 | NR | NR | Apical: 3.3 | 6.7 | |
Posterior: 3.3 | ||||||||||||||
Benson et al. [ |
2010 | Baden-Walker grade 3-4 | 33 RSCs | 63.6 | All supracervical hysterectomy | 32 | 62 | NR | 97 | NR | NR | Apical: 3.0 | 3.0 | |
Xylinas et al. [ |
2010 | POP-Q stage 3-4 | 12 RSCs | 8 | NR | 19.1 | 57.1 | NR | 100 | NR | NR | 0 | 0 | |
Tan-Kim et al. [ |
2011 | Mean C point 0 | 43 RSCs/61 LSCs | 100 | - | 6 | 60/65 | NR | 100/100 | 97.5/89 | 92.5/91 | Anterior: 2.5/11.0 | NR | |
Posterior: 7.5/9.0 | ||||||||||||||
Shimko et al. [ |
2011 | Baden-Walker grade 3-4 | 40 RSCs | 100 | - | 62 | 67 | NR | 100 | NR | NR | Anterior: 2.5 | 5 | |
Posterior: 5.0 | ||||||||||||||
Siddiqui et al. [ |
2012 | POP-Q stage 2-4 | 125 RSCs/322 ASCs | NR | Supracervical hysterectomy: 46.4 | 18.3/11.7 | 59.5/60.9 | 92.0/96.0 | 94.0/94.0 | NR | NR | Posterior: 2.4 | 2.4/1.6 | |
Supracervical hysterectomy: 1.0 | Anterior or posterior: 1.6 | |||||||||||||
Belsante et al. [ |
2013 | Mean C point -1.1 | 35 RSCs | 97 | Supracervical hysterectomy: 17 | 28 | 65 | NR | 100 | NR | NR | Anterior: 5.7 | 0 | |
Posterior: 2.9 | ||||||||||||||
Louis-Sylvestre et al. [ |
2013 | POP-Q stage 3-4 | 90 RSCs | 7.8 | Supracervical hysterectomy: 59 | 16.5 | 60.9 | NR | 100 | 94.4 | 98.9 | 0 | 0 | |
Uterine preservation: 41 | ||||||||||||||
Barboglio et al. [ |
2014 | Baden-Walker grade 2-4 | 127 RSCs | 42 | Supracervical hysterectomy: 53 | 12 | 59 | 92 | 100 | 92.2 | 88 | Anterior: 1.6 | 1.6 | |
Sung et al. [ |
2017 | POP-Q stage 2-4 | 16 RSCs | 31.3 | All uterine preservation | 25.3 | 65 | NR | 100 | NR | NR | NR | NR | |
Linder et al. [ |
2017 | Median POPstage3 | 132 RSCs | 100 | - | 33 | 61.1 | NR | 98.5 | NR | NR | Anterior: 3.0 | 7.6 | |
Apical: 3.0 | ||||||||||||||
Posterior: 1.5 | ||||||||||||||
Unknown: 1.5 | ||||||||||||||
Jong et al. [ |
2018 | NR | 30 RSCs | 93 | All supracervical hysterectomy | 64 | 64.3 | NR | 93.3 | 90 | 96.7 | Anterior: 10.0 | 13.0 | |
Apical: 6.7 | ||||||||||||||
Posterior: 3.3 |
RCT, randomized controlled trial; ASC, open abdominal sacrocolpopexy; LSC, laparoscopic sacrocolpopexy; NR, not reported; POP, pelvic organ prolapse; POP-Q, Pelvic Organ Prolapse Quantification System; RSC, robotic sacrocolpopexy; RSHS, robotic supracervical hysterectomy with sacrocervicopexy.
Postoperative complications
Study | Year | Design | No. | Mesh extrusion/erosion (%) | Bladder injury (%) | Bowel injury | Vascular injury/bleeding (%) | Bowel obstruction/ileus (%) | Others (%) | ||
---|---|---|---|---|---|---|---|---|---|---|---|
Elliott et al. [ |
2006 | R | 30 | 6.7 | 0 | 0 | 0 | 0 | 0 | 0 | Mild port site infection (6.7) |
Benson et al.[ |
2010 | R | 33 | 0 | 0 | 0 | 0 | 3 | 0 | 0 | None |
Xylinas et al. [ |
2010 | R | 12 | 0 | 0 | 0 | 0 | 0 | NR | NR | None |
Tan-Kim et al. [ |
2011 | R | 43 | 5 | 2.3 | 2.3 | 2.3 | 0 | NR | NR | Electrolyte imbalance (2.3), trocar site cellulitis (2.3) |
Paraiso et al. [ |
2011 | RCT | 40 | NR | 6 | 6 | 0 | 6 | NR | NR | Corneal abrasion (3), UTI (14), wound infection (6), abdominal pain (9), abscess (3) |
Shimko et al. [ |
2011 | R | 40 | 5 | 0 | 0 | 0 | 0 | 16 | NR | Mild port site infection (5), vaginal bleeding (5), port site hernia (5) |
Moreno et al. [ |
2011 | P | 31 | 0 | 3.2 | 3.2 | 0 | 0 | NR | NR | Vaginal injury (3.2), port infection (3.2), AMI (3.2) |
Seror et al. [ |
2012 | P | 20 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | Constipation (5), UTI (5) |
Siddiqui et al. [ |
2012 | R | 125 | 2.4 | 1.6 | 1.6 | 0 | 5.6 | NR | NR | Febrile morbidity (4.8%), wound infection (4.9), deep vein thrombosis (0.8), pneumonia (1.6) |
Belsante et al. [ |
2013 | R | 35 | 3 | 0 | 0 | 0 | 0 | 2 | 0 | Vaginal injury (14) |
Louis-Sylvestre et al. [ |
2013 | R | 90 | 1 | 2.9 | 1.1 | 0 | 0 | 0 | 0 | Vaginal injury (1.1), trocar site herniation (2.2) |
Salamon et al. [ |
2013 | P | 120 | 0 | 0 | 0 | 0 | 0.8 | 4.1 | 2.6 | None |
Anger et al. [ |
2014 | RCT | 40 | 0 | 0 | 0 | 0 | 2.5 | NR | NR | Pulmonary embolism (2.5) |
Barboglio et al. [ |
2014 | R | 127 | 2.4 | 0 | 2.4 | 0.8 | 1.6 | NR | NR | Port site wound infection (1.6), voiding dysfunction (7.0) |
Culligan et al. [ |
2014 | P | 143 | 0 | 0 | 0 | 0 | 0 | 0 | 4.7 | None |
Kenton et al. [ |
2016 | RCT | 40 | 0 | 0 | 0 | 0 | 5 | NR | NR | Port site hernia (2.5) |
Sung et al. [ |
2017 | R | 16 | 0 | 0 | 0 | 6.3 | 0 | 40 | NR | Headache (6.3), nausea (6.3), transient nerve palsy (6.3) |
Linder et al. [ |
2017 | R | 132 | 6.1 | NR | NR | NR | NR | NR | NR | None |
Jong et al. [ |
2018 | R | 56 | 3 | 0 | 0 | 0 | 0 | 1.8 | NR | Vaginal injury (5.4) |
van Zanten et al. [ |
2019 | P | 305 | 2.1 | 3.2 | 0.3 | 1.1 | 0 | NR | NR | Vaginal injury (0.5), ureteric injury (0.5), incisional hernia (0.3), CVA (0.3) |
Illiano et al. [ |
2019 | RCT | 49 | 4.1 | 0 | 0 | 0 | 0 | 4.1 | NR | Fever (2.0), nausea and vomiting (16.3), |
AMI, acute myocardial infarction; CVA, cerebrovascular accident; NR, not reported; R, retrospective; RCT, randomized controlled trial; P, prospective; SUI, stress urinary incontinence; UTI, urinary tract infection.