Robotic-Assisted Surgery in Robotic-Assisted Surgery in Urogynecology: Passing Urogynecology: Passing

Fad or Here to StayFad or Here to Stay

Marie Fidela R. Paraiso, M.D.Marie Fidela R. Paraiso, M.D.

Professor of SurgeryProfessor of Surgery

Head, Division of Urogynecology Head, Division of Urogynecology and Reconstructive Pelvic and Reconstructive Pelvic

SurgerySurgery

Cleveland, OHCleveland, OH

DisclosuresDisclosures

Coloplast CorporationColoplast Corporation

ObjectiveObjective

To discuss indications for To discuss indications for robotic-assisted laparoscopic robotic-assisted laparoscopic surgery for pelvic floor disorderssurgery for pelvic floor disorders

To demonstrate various surgical To demonstrate various surgical procedures and techniques that procedures and techniques that are robot-enabledare robot-enabled

My VoteMy Vote

Passing FadPassing FadHere to stayHere to stay

Reasons to Utilize Robotic Reasons to Utilize Robotic Assistance in Gynecologic Assistance in Gynecologic

LaparoscopyLaparoscopy Sacrocolpoperineopexy +/- ventral Sacrocolpoperineopexy +/- ventral

rectopexyrectopexy Also with posterior rectopexy depending on the Also with posterior rectopexy depending on the

indications and surgeon preferenceindications and surgeon preference Sacral HysterocervicocolpoperineopexySacral Hysterocervicocolpoperineopexy

Including other modificationsIncluding other modifications Supracervical hysterectomy and Supracervical hysterectomy and

concomitant sacrocolpopexyconcomitant sacrocolpopexy Especially with lesser skilled assistantsEspecially with lesser skilled assistants

Case #1Case #1 58 year old s/p previous laparoscopic 58 year old s/p previous laparoscopic

enterocele repair with uterosacral enterocele repair with uterosacral vaginal vault suspension and rectocele vaginal vault suspension and rectocele repair with cadaveric fascia lata who repair with cadaveric fascia lata who complains of outlet dysfunction complains of outlet dysfunction constipation. constipation.

She splints perineum to defecateShe splints perineum to defecate Examination shows Stage 2 vaginal Examination shows Stage 2 vaginal

apex prolapse with recurrent anterior apex prolapse with recurrent anterior rectocele and perineal descentrectocele and perineal descent

Defocography confirms exam and Defocography confirms exam and demonstrates no intussusceptiondemonstrates no intussusception

Robotic Robotic SacrocolpoperineopexySacrocolpoperineopexy

Video shown with ventral rectopexy Video shown with ventral rectopexy based on time constraintsbased on time constraints

Surgical techniqueSurgical technique

Difficult to access perineum with laparotomy, perfect for LSC and Robot

Especially with 30 degree up or down scope

Combined Rectal Prolapse Combined Rectal Prolapse SurgerySurgery

VideoVideo Surgical techniqueSurgical technique 24% of women have pelvic floor 24% of women have pelvic floor

disordersdisorders Combined rectal and uterine/vaginal Combined rectal and uterine/vaginal

apex prolapse is uncommonapex prolapse is uncommon Mucosal prolapse/Intussusception Mucosal prolapse/Intussusception

above anus: Ventral rectopexyabove anus: Ventral rectopexy Full thickness prolapse: Posterior Full thickness prolapse: Posterior

dissection and direct attachment of dissection and direct attachment of rectosigmoid mesentary to sacrumrectosigmoid mesentary to sacrum

Side-docking the Robot is Optimal

Case #2Case #2

59 year old female with CREST 59 year old female with CREST syndrome and chronic Stage IV syndrome and chronic Stage IV uterovaginal and full thickness uterovaginal and full thickness rectal prolapse ( 9 cm beyond anal rectal prolapse ( 9 cm beyond anal verge)verge)

Plan Robotic-assisted laparoscopic Plan Robotic-assisted laparoscopic SCH, sacralcolpopexy, and ventral SCH, sacralcolpopexy, and ventral rectopexyrectopexy

Segment shows dissectionSegment shows dissection

HysterosacrocolpopexyHysterosacrocolpopexy

VideoVideo Surgical techniqueSurgical technique Cure rates for open procedure are Cure rates for open procedure are

91-100%91-100% Improved quality of life and sexual Improved quality of life and sexual

functionfunction No data regarding laparoscopic or No data regarding laparoscopic or

robotic sacro-hysterocolpopexyrobotic sacro-hysterocolpopexyE Barranger et al, AJOG 2003

E Constantini et al, European Urol 2005

Dissection of RV and VV spaces, formation of broad ligament windows

Graft measurement and formation

Graft attachment and tunneling

Graft attachment to the sacrum

Hysterosacral Colpopexy Hysterosacral Colpopexy PearlsPearls

Understand the contraindicationsUnderstand the contraindications Negative uterine pathology must be confirmedNegative uterine pathology must be confirmed This particular technique is not recommended in This particular technique is not recommended in

women desiring future childbearingwomen desiring future childbearing Option is biologic graft or tunneling arms underneath Option is biologic graft or tunneling arms underneath

Cardinal ligament and ureterCardinal ligament and ureter Review the risks and benefits thoroughly with the Review the risks and benefits thoroughly with the

patientpatient Future hysterectomy may be more difficultFuture hysterectomy may be more difficult

The procedure leads to improved anatomical The procedure leads to improved anatomical outcomes and resolution of anterior apical outcomes and resolution of anterior apical vaginal wall and uterine prolapsevaginal wall and uterine prolapse

Supracervical Hysterectomy Supracervical Hysterectomy with Sacrocolpopexywith Sacrocolpopexy

Surgical technique and rationaleSurgical technique and rationale A combination of both procedures butA combination of both procedures but

I use bipolar to cauterize the endocervical canalI use bipolar to cauterize the endocervical canal I stitch the canal closed I stitch the canal closed

Combine TVH or TLH with ASC butCombine TVH or TLH with ASC but Recommend 2 layered closure of cuffRecommend 2 layered closure of cuff If mesh is sewn on vaginally to save time, counsel If mesh is sewn on vaginally to save time, counsel

your patients regarding increased risk of mesh your patients regarding increased risk of mesh erosion (Menefee et al, SGS 2010)erosion (Menefee et al, SGS 2010)

Make sure that the patient has negative Paps Make sure that the patient has negative Paps and HPV testingand HPV testing

ConclusionConclusion Robotic-assisted laparoscopic sacrocolpopexy Robotic-assisted laparoscopic sacrocolpopexy

continues with widespread adoption despite lack continues with widespread adoption despite lack of supporting data of supporting data

This technology has enabled many surgeons to This technology has enabled many surgeons to become minimally invasive surgeonsbecome minimally invasive surgeons

Suture labor, difficult dissection, difficult access Suture labor, difficult dissection, difficult access of surgical sites, and ease of manipulation are of surgical sites, and ease of manipulation are reasons to utilize this technology compared to reasons to utilize this technology compared to conventional laparoscopic surgeryconventional laparoscopic surgery

Sacral colpoperineopexy, sacral hysteropexy, Sacral colpoperineopexy, sacral hysteropexy, concomitant rectopexy, and combined SCH and concomitant rectopexy, and combined SCH and ASC are facilitated with robotic assistanceASC are facilitated with robotic assistance

When My Vote No Longer When My Vote No Longer CountsCounts

Here to stayHere to stayPassing FadPassing Fad

Obama HealthcareObama Healthcare