The evolution of pelvic organ prolapse repair and incontinence surgeries has been as notable for its failures as its successes. Because of the complexity and variability of pelvic organ prolapse problems a universal best surgical solution has never been found. Traditionally, repairs have been designed either for a vaginal approach or an abdominal approach. Before laparoscopy was developed, the only “minimally invasive” route to pelvic organ repair was vaginal. The unfortunately high failure rate of vaginal repairs led to continued efforts to improve longterm success and achieve satisfying results. The abdominal route had a lower failure rate but was much more invasive and required longer recovery times. Revolutionary improvement in surgery through the development of “minimally invasive” techniques through laparoscopy (surgery done through very small holes in the abdomen) made it possible for the abdominal repairs to be done with better recovery times and excellent longterm success. A high-quality laparoscopic repair of prolapse has excellent longterm success with significantly better recovery times.
Transvaginal mesh repairs (repairs done entirely through the vaginal route) were initially developed because there was hope that this would lead to lower failure rates with the advantage of the vaginal approach, which avoids entry into the abdomen or minimizes it. Unfortunately, the high complication rates and lack of improvement in failure rates has essentially relegated vaginal mesh prolapse repairs to the dustbin of surgical history.
Investigations into laparoscopic repairs of prolapse using the technique of sacrocolpopexy (placing a graft on the vagina which is attached to the sacrum at the top of the tailbone) have demonstrated that it has similar success rates to open abdominal repairs. The use of specially designed meshes in this instance has had much better outcomes than the vaginal mesh repairs, with low mesh-related complications and relatively high longterm success. However, there have been few laparoscopic surgeons available to perform these surgical techniques. The development of the surgical robot was intended to provide an avenue for more surgeons to be able to offer a minimally invasive technique for the abdominal procedure. Like all new surgical techniques and tools, it has had its share of successes, failures, and complications. No surgical tool can be used without risk. When laparoscopic techniques for hysterectomy (removal of the uterus), ovarian cystectomy (removal of growths on the ovary) and treatment for ruptured ectopic pregnancy (a life-threatening emergency due to hemorrhage from a pregnancy developing in the fallopian tube rather than the uterus, resulting in the tube bursting) were first developed, there was great debate regarding its utility and safety. As surgeons gained experience and published data using these techniques, it became clear that they could offer good outcomes with a less invasive approach.
The surgical robot is a tool. It is nothing more nor less. In the proper hands, it can certainly provide the opportunity for excellent outcomes with better recovery times than open procedures. In its current state, it adds some surgical time to traditional laparoscopic time due to positioning and preparation. With the advent of single-incision robotic surgery, popularity is likely to grow. Although there have been reports of significant complications related to the use of the robot, the lesson, I believe, is not that the robot is a bad tool, but that we need to be certain that the surgeons using that tool are well trained and qualified to use it. As the robot becomes more streamlined and less bulky, it is likely to become easier to use and quicker to set up. As our experience grows with this tool, it is likely to provide us with opportunities to see more (due to the 3D vision option) and perform more challenging surgeries with small incisions than even conventional laparoscopy might. Certainly, at this time conventional laparoscopy is more than sufficient for many types of surgeries, and can be a valid option as a minimally invasive approach for gynecologic and urogynecologic surgery. As a surgeon who has performed many procedures both via conventional laparoscopy and robotically-assisted laparoscopy, I feel there is a place in my surgical “toolkit” for both approaches. If one is contemplating a pelvic organ repair, it is appropriate to discuss all options and approaches with the surgeon. If you desire a consultation regarding pelvic organ prolapse repair or surgical approaches, call 561-701-2841.
Linda Kiley, MD
Dr. Kiley is a Board Certified subspecialist in Female Pelvic Medicine and Reconstructive Surgery, and is also Board Certified in general Obstetrics and Gynecology.