Presented by: Genesis G. Dolgetta BS
Sarasota Memorial Health Care System Research Institute

Introduction

Robotic sacrocolpopexy (RASCP) is a transabdominal approach for repair of pelvic organ prolapse (POP) that reliably provides durable repair of high grade prolapse. Although reoperation for recurrent prolapse after RASCP should be a rare event, the techniques and problems associated with robotic salvage in these cases is under reported. 

Materials

Data was collected from an IRB-approved prospectively maintained database of robotic POP repair in a tertiary care hospital. The surgery was performed with a da Vinci Si or Xi system with 4 robotic ports and 1 assistant port by a single surgeon. Commercially available 4 x 24 cm Y-shaped wide pore polypropylene mesh was modified to accommodate the anterior and posterior dissections of the vaginal walls, and these were attached with running barbed suture with 16-20 sites of fixation. The long Y-arm of the mesh was trimmed to size for attachment to the anterior longitudinal ligament with GoreTex sutures. Posterior peritoneal flaps were created, and the entirety of the mesh and repair was completely covered by the peritoneum. No mesh or suture was left exposed. Mid-urethral slings were placed at the time of salvage RASCP (sRASCP) to prevent de novo stress incontinence. All repairs restored maximal vaginal length and desired vaginal axis. All patients for RASCP had stage 4 prolapse. There were no conversions from robotic to open. 

Results

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Between 2010 and 2022, a total of 450 patients underwent RASCP at the same institution. 8 (1.8%) were done in the salvage setting with a previous attempt at open or RASCP performed and pre-existing mesh inside the abdomen. On reoperation for these RASCP patients for the purpose of salvage, 8/8 (100%) were found to have no connectivity of the mesh to the anterior longitudinal ligament (ALL). 4/8 (50%) had no connectivity to either the anterior or posterior vaginal vault. Mean age at salvage operation was 69.5 years and mean BMI was 28.5. Cases were completed with robotic console time between 105 and 123 minutes.  

Conclusion

sRASCP is a safe and durable surgery for repair of prolapse in the setting of a failed first attempt of RASCP with pre-existing mesh. Every case achieved excellent repair of prolapse.  The most common finding in these cases was non-attachment of the mesh to the ALL.  All patients required dissection of the ALL for appropriate mesh attachment. Pre-existing mesh can be used to help in repair as long as there is an appropriate attachment to the vaginal vault.  Pre-existing mesh should be excised if there is no useful vaginal or ALL attachment.   

Funding

None. 

Lead Authors

Tonya S. King, PhD
Sarasota Memorial Health Care System Research Institute

Robert I. Carey, MD, PhD
Sarasota Memorial Health Care System

Co-Authors

Benjamin J. Behers, MD
Florida State University School of Medicine

Maximilian S. Carey,
Sarasota Memorial Health Care System Research Institute

Karim Ghazli,
Sarasota Memorial Health Care System

Victoria Y. Bird, MD
Urologic Integrated Care