Robot-Assisted Laparoscopic Sacrocolpopexy

Abstract

The gold standard for repair of symptomatic high-grade, posthysterectomy vaginal vault prolapse is the sacrocolpopexy. Surgical routes to perform the sacrocolpopexy have included the transabdominal, transvaginal, laparoscopic, and more recently the robot-assisted laparoscopic sacrocolpopexy (RALS). The Urology Department at our institution has recently described the long-term results from the RALS. This technique has demonstrated a greater than 90% durability in repair, as defined by no recurrent pelvic organ prolapse (Elliott DS, Krambeck AE, Chow GK, J Urol 176:655–659, 2006). In addition, it has been shown that the RALS is an excellent technique for posthysterectomy vaginal vault prolapse repair with decreased hospital stays, less postoperative pain control, and similar postoperative morbidity when compared to the open transabdominal route (Elliott DS, Siddiqui SA, Chow GK, J Robotic Surg 1:163–168, 2007; McGee SM, Chow GK, Elliott DS, World Congress of Endourology, Shanghai, China, 2008; Daneshgari F, Kefer JC, Moore C, Kaouk J, BJU Int 100:875–879, 2007). The success of the sacrocolpopexy is largely due to correctly identifying the appropriate patient for the RALS. The diagnosis of vaginal vault prolapse is broad and includes female patients with or without a uterus presenting with a cystocele, rectocele, enterocele, or a combination of these. The sacrocolpopexy has traditionally been used for patients with posthysterectomy apical vaginal vault prolapse which may include a concomitant posterior or anterior vaginal vault defect (Fig. 8.1). The female patient may be a candidate for sacrocolpopexy if she suffers from high-grade apical vaginal prolapse as classified by a standardized grading system such the Baden Walker scale or Pelvic Organ Prolapse Quantification system. This chapter focuses on RALS, a technique that has evolved since our first description in patients with posthysterectomy, high-grade vaginal vault prolapse (Elliott DS, Frank I, DiMarco DS, Chow GK, Am J Surg 188:52S–56S, 2004). Urologic surgeon familiarity is noted due to the set-up of the robotic system and surgical suite, which are similar when compared to the robotic-assisted laparoscopic prostatectomy described in other chapters. As the reader will see, specific steps of the RALS have evolved, but still simulate the open repair with respect to the female anatomy and sacral mesh fixation.