Laparoscopic vs. Robotic Sacrocolpopexy

Interview with John Crane, MD, Director of Robotic Surgery, Banner Health; and Kim Kenton, MD, Chief of Urogynecology, Department of Obstetrics and Gynecology, Northwestern Medicine

Introduction

Though only 3-6 percent of women report symptoms of pelvic organ prolapse (POP), prevalence is as high as 50 percent when based upon vaginal examination.1 Conservative approaches are often the first line of treatment, but women in the U.S. still have an estimated 13 percent lifetime risk of undergoing surgery for POP.2

Abdominal sacrocolpopexy (SCP) has been identified as a proven and effective surgery for the treatment of POP, according to the American College of Obstetricians and Gynecologists and the American Urogynecologic Society.2

In this article, two leaders in the field of SCP – Drs. John Crane and Kim Kenton – share their perspectives on the procedure itself, as well as laparoscopic vs. robotic approaches.

Is SCP the gold standard for POP repair?

Dr. Kenton: SCP is the gold standard for optimizing anatomic outcomes of POP repair.3 However, I don’t think every woman should get SCP; surgeons should understand each woman’s goals for POP treatment and determine the appropriate surgical approach.

Do you perform a hysterectomy prior to completing a SCP?

Dr. Kenton: I offer SCP in women with or without prior hysterectomy; I will perform a hysterectomy in women who do not desire uterine preservation. I offer total and supracervical hysterectomy depending on the patient’s risks and desires.

Are you currently performing robotic or laparoscopic SCPs?

Dr. Crane: I prefer robotic approach, which allows me the ability to see and access the anatomy better. I have done over 550 robotic SCPs with and without hysterectomies.

Dr. Kenton: I perform both laparoscopic and robotic SCP and have done many of each. I reserve robotics for complex cases that benefit from the wristed motion associated with robotics.

What are the benefits of robotic SCP?

Dr. Crane: The benefits of a robotic approach include better visualization and access to the anatomy; and the ability to manage complications and continue in a minimally invasive fashion.

What are the benefits of laparoscopic SCP?

Dr. Kenton: Laparoscopic SCP has been shown in two randomized clinical trials to be slightly faster and less expensive than robotic SCP, and the data are consistent with hysterectomy procedures too. Laparoscopic SCP may also result in slightly less port site pain in the immediate post-op period.4,5

Are there additional procedure time and costs associated with robotic SCP?

Dr. Crane: Robotically, I can achieve surgical times I could never reach laparoscopically, and time is the most costly item within an OR. If I can get in and out of each case faster, and get the patient out of the hospital faster, it saves money.

Dr. Kenton: With all things being equal, the literature suggests that laparoscopic SCP can be done faster and cheaper than robotic.

What is the learning curve for becoming proficient in robotic or laparoscopic SCP?

Dr. Kenton: Learning curves are steep with both, since many wrist motions robotically are more similar to open and vaginal surgery. There are many strategies learned during laparoscopic surgery that benefit the robotic surgeon, including patient positioning, retraction and adhesiolysis.

A recent study comparing robotic to laparoscopic sacrocolpopexy found that for experienced surgeons, the learning curve for robotic was shorter.6 This echoes an earlier study which found that the estimated learning curve for robotic is 10-20 procedures.7 To me, robotic surgery is much more intuitive.

Can you offer any technique suggestions for a robotic SCP?

Dr. Crane: Always manage your operative field as you are operating. Robotically, you can do this because you alone are in charge of finding your anatomy.

Can you offer any technique suggestions for a robotic SCP?

Dr. Kenton: Similar to robotics and surgery in general, optimizing exposure is essential. Patient positioning is steep Trendelenberg, with exposure to the vagina for manipulation with stent, etc.

For anterior/posterior dissection, is there any difference between completing laparoscopically versus robotically?

Dr. Kenton: I think it is much easier to get depth needed to reach perineal body in the posterior dissection with the robot. These dissections are easily done with both approaches, so I have no preference.

What types of sutures do you use for the vaginal wall/sacral promontory for your SCPs?

Dr. Kenton: Traditionally, permanent sutures have been used on both the vagina and sacrum for SCP. 

Dr. Crane: I use 2-0 vicryl on anterior and posterior vagina. It’s inexpensive and absorbs in six weeks, giving plenty of time for full integration. I use 0 Ethibond on the anterior longitudinal ligament.

Are there particular mesh properties that you prefer for your SCP mesh?

Dr. Kenton: I prefer soft, lightweight polypropylene mesh, such as Boston Scientific’s Upsylon™ Y-Mesh.

How do you handle the peritoneum following the mesh attachment?

Dr. Kenton: I do not typically reperitonealize the mesh. In our study evaluating adverse events in approximately 450 women who had SCP with and without reperitonealization, we did not find differences in bowel complications.8

Dr. Crane: I close the peritoneum starting at the left cuff by grabbing the peritoneum from my vesicovaginal space incision, going over the cuff, grabbing the peritoneum from my rectovaginal incision and running that to the right cuff.

What types of training would you recommend for any physicians interested in improving their SCP skills?

Dr. Crane: If you have never done an SCP in any fashion, you need to go to a course, watch as the bedside assistant in 8-10 cases and then be proctored on at least three cases before conducting on your own patients.

Dr. Kenton: Practice, practice, practice. Observe skilled surgeons, then establish a team at your own institution. Spend time practicing in simulation labs. If you know how to do a SCP and are just learning new “route of access,” you may consider teaming up with a minimally invasive surgeon for a few cases.

Conclusion

Given the aging population in the U.S., it is anticipated that the number of women experiencing POP will increase by approximately 50 percent by 2050.2  While each woman’s course of treatment is based on the assessment of the type and degree of POP, as well as the severity of symptoms, sacrocolpopexy – both laparoscopic and robotic – is a proven and effective surgery2 that can improve quality of life for women suffering from POP.
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