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PhD Defence Femke van Zanten | PROSPECTIVE ASSESSMENT OF ROBOTIC PELVIC FLOOR SURGERY

prospective assessment of robotic pelvic floor surgery

Femke van Zanten is a PhD student in the research group Robotics and Mechatronics (RAM). Her supervisor is prof.dr. I.A.M.J. Broeders from the Faculty of Electrical Engineering, Mathematics and Computer Science.

The word ‘prolapse’ is derived from the Latin word prolabi meaning ‘to fall out’. It can include protruding of the bladder, uterus, vaginal cuff in post-hysterectomy patients, and the small or large bowel. This can lead to very severe symptoms and has a profoundly negative impact on the quality of life (QoL). About 11-19% of all women will undergo a surgical repair because of pelvic floor prolapse (POP) and/or urine incontinence. Economic costs of POP care are substantial and rising. Recurrence rates after a primary prolapse surgery are high. Sacrocolpopexy has been increasingly used to treat apical prolapse (i.e. vaginal vault and uterine prolapse) as it has been associated with reduced recurrence rates compared to vaginal sacrospinous colpopexy. Sacrocolpopexy has been performed more often with robotic assistance. The optimal ergonomics, freedom of movement and 3D vision aid surgeons in their performance.

Perioperative and one year anatomic and functional outcomes after robot-assisted sacrocolpopexy (RASC) and supracervical hysterectomy with sacrocervicopexy (RSHS) were examined. Anatomical success of the apical compartment was high (RASC 91%; RSHS 99%). A symptomatic anterior vaginal wall recurrence (cystocele) occurred in 12% after RASC and 5% after RSHS. Symptoms of bulge (97.4 vs 17.4%; p<0.0005) and QoL improved after surgery (Pelvic Floor Impact Questionnaire 76.7 ± 62.3 vs 13.5 ± 31.1; p<0.0005). Intraoperative/severe postoperative complications and conversion rates were low. An improvement in sexual function was seen one year after RASC.

In this age of rapidly changing surgical techniques, determination of learning curves is essential to improve safety and efficiency. Cumulative sum (CUSUM) analysis can mark phases in which complications arise, thereby warning the surgeon to add additional training. We performed a CUSUM analysis for two surgeons. After 78 cases proficiency was obtained and after 24-29 cases surgery time stabilized.

Robotic sacrocolporectopexy (RSCR) for multi-compartment prolapse showed 90% of patients to be recurrence free 48 months postoperatively. Symptoms of bulge, QoL, obstructive defecation and faecal incontinence improved. A subgroup of patients showed persistent bowel complaints. After RASC, 96% of patients had no apical recurrence 50 months postoperatively (N=77). One in nine patients had a symptomatic cystocele. A re-intervention because of recurrent prolapse or ‘de novo’ stress urinary incontinence can be expected to be 5 and 5% respectively. Symptoms of bulge, urinary symptoms and QoL improved substantially.

The American Food and Drug Administration published a safety report regarding the safety of mesh usage in pelvic floor surgery in 2011. This report was based on the high incidence of mesh-related complications found after transvaginal mesh implants (10.3%). In this study, with transabdominal mesh usage, a low number of mesh exposure was found (1.2% after 16 months [RASC/RSHS], and 3.1% after and 48 months [RASC/RSHS/RSCR]). The median mesh exposure rate found in the literature was 1.9% (range 0-13.3%; follow-up ≥ 12 months). Based on these findings, mesh-related complications seem to be lower in transabdominal mesh surgery than in transvaginal mesh surgery.