Management of Pelvic Organ Prolapse with or without Hysterectomy Via Transvaginal Robotic Notes High Uterosacral Ligament

Abstract

<h3>Study Objective</h3> To demonstrate stepwise techniques for the successful use of the robotic-assisted transvaginal natural orifice transluminal endoscopy surgery high uterosacral ligament suspension (RvNOTES-HUS) technique for pelvic organ prolapse with and without uterine preservation. <h3>Design</h3> Stepwise demonstration with narrated video footage (Canadian Task Force classification III). <h3>Setting</h3> An academic tertiary care hospital. <h3>Patients or Participants</h3> Case 1: 62-year-old G0P0 with a symptomatic stage Ⅱ anterior vaginal prolapse and Stage Ⅱ uterine prolapse. Preoperative vaginal length was measured at 9cm. Case 2: 42-year-old G3P2 with a symptomatic fibroid uterus with stage Ⅱ anterior vaginal prolapse and Stage Ⅱ uterine prolapse. Preoperative vaginal length was measured at 8cm. <h3>Interventions</h3> Since the approval of the robotic platforms in gynecologic surgery by the Food and Drug Administration in 2005¹, robotic assisted surgery has been proliferating in the treatment of benign gynecological diseases including sacrocolpopexy, hysterectomy, myomectomy and endometriosis resection^2-5. In recent years, publications have demonstrated the feasibility and safety of traditional laparoscopic assisted high uterosacral ligament suspension for pelvic organ prolapse with long term follow up^6-8. However, robotic assisted RvNOTES-HUS has yet to be investigated in a publication. Utilizing the RvNOTES-HUS technique with or without uterine preservation operations greatly reduces the difficulty of intraperitoneal suture for the surgeon and postoperative pain for the patient. <h3>Measurements and Main Results</h3> Case 1: Procedure was successfully performed with a postoperative vaginal length of 8cm. Pain level was 4/10 in the first week, 2/10 in the second, 0/10 in the third. POP was stage 0. Case 2: Procedure was successfully performed with a postoperative vaginal length of 7cm. She had one day of post-operative pain. POP was stage 0. <h3>Conclusion</h3> RvNOTES-HUS is a practical technique in women with uterine prolapse while choosing whether to preserve the uterus. This technique allows for the better exposure of the ureter, while the articulating robotic joints allow for increased precision of dissection and suturing.