You Deserve Special Care
To diagnose pelvic organ prolapse, your doctor may ask you for your medical history and may do a vaginal and rectal exam, either while you are laying down, standing, or both. You may be asked to cough during the exam to see if you leak urine and you may be checked to see how completely your bladder empties.3
Robotic Surgery: A Viable Option For Pectopexy
While sacrocolpopexy has been the gold standard for the anatomical correction of pelvic organ prolapse for more than three decades, it is a technically challenging procedure that results in dividing the pelvis by mesh material and often requires extensive bowel manipulation.
Laparoscopic pectopexy was introduced by Banerjee et al in 2011 as a new option in pelvic floor reconstruction, using lateral portions of the iliopectinal ligament for bilateral mesh fixation of descended structures.1 The minimally invasive nature of this procedure makes it an ideal candidate for robotic surgery, although this approach has not been well studied.
A recent retrospective cohort study by Bolovis et al out of Klinikum Nürnberg in Nuremberg, Germany, examined the use of robotic mesh-supported pectopexy in 3 different settings: hysteropectopexy with intact uterus , cervicopectopexy combined with supracervical hysterectomy in the same sessions if uterine pathology was present , and vaginopectopexy in patients presenting after previous total hysterectomy .2
All procedures were performed by the same team of 2 robotic and pelvic floor surgeons using the da Vinci Xi® robotic system. The surgical technique mirrored the method used for laparoscopic pectopexy by Banerjee et al, with adjustments to optimize the technique in the robotic setting.
How Is Vaginal Prolapse Treated
Treatment for vaginal prolapse varies, depending on the severity of the symptoms. Many cases will not require treatment. In mild cases, your physician may recommend pelvic floor exercises to strengthen the muscles. In moderate cases, your doctor may insert a vaginal pessary to support your vaginal wall. In the most severe cases, you may benefit from surgery, such as colposuspension, a minimally invasive surgical procedure, where the vaginal wall is attached to a stable ligament in the pelvis.
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Is One Port Better Than Five
Many patients want procedures that will reduce scarring and effectively treat POP symptoms. The new SP robot by Intuitive allows us to do just that.
With the SP robot, we make one 2.5 cm long incision above the belly button. Through the incision, we place a cannula a slender tube attached to the robot. Through the cannula, we guide four slim robotic arms attached to a tiny surgical camera and delicate instruments, which we maneuver from a control panel to place the mesh in the pelvis.
We use an ultralight mesh that has been proven safe and effective for pelvic organ prolapse. This is not the same astransvaginal mesh, which was banned by the U.S. Food and Drug Administration in 2019.
With the SP approach, the surgeons field of vision is about the size of a grapefruit rather than the whole abdomen, and the robotic arms flex differently than the previous robot. These differences result in less room for the surgeon to operate, which requires expertise.
The differences also mean no incisions in a patients sides, which can result in quicker recovery with less discomfort. Our patients whove had SP surgery have stayed one night in the hospital after surgery most patients who have the current minimally invasive approach also stay one night.
How Da Vinci Works
Surgeons can perform a type of pelvic organ prolapse repair called a sacrocolpopexy using da Vinci technology. With da Vinci, your surgeon sits at a console next to you and operates using tiny, fully wristed instruments.
A camera provides a high-definition, 3D magnified view inside your body. Every hand movement your surgeon makes is translated by the da Vinci system in real time to bend and rotate the instruments with precision.
Its important to remember that Intuitive does not provide medical advice. After discussing all options with your doctor, only you and your doctor can determine whether surgery with da Vinci is appropriate for your situation. You should always ask your surgeon about his or her training, experience, and patient outcomes.
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Disclosures And Important Safety Information
Important Safety Information
Patients should talk to their doctor to decide if da Vinci Surgery is right for them. Patients and doctors should review all available information on non-surgical and surgical options and associated risks in order to make an informed decision.
Serious complications may occur in any surgery, including da Vinci® Surgery, up to and including death. Serious risks include, but are not limited to, injury to tissues and organs and conversion to other surgical techniques which could result in a longer operative time and/or increased complications. For Important Safety Information, including surgical risks, indications, and considerations and contraindications for use, please also refer to www.intuitive.com/safety.
Individuals’ outcomes may depend on a number of factors, including but not limited to patient characteristics, disease characteristics and/or surgeon experience.
Da Vinci Xi® System Precaution Statement
The demonstration of safety and effectiveness for the specific procedure discussed in this material was based on evaluation of the device as a surgical tool and did not include evaluation of outcomes related to the treatment of cancer or treatment of the patients underlying disease/condition. Device usage in all surgical procedures should be guided by the clinical judgment of an adequately trained surgeon.
Medical Advice and Locating a Doctor
Should You Have Surgery
If your symptoms are making your life difficult, surgery may be the answer. You need to think about a few things:
Your age. If youâre young, keep in mind that bladder prolapse can happen again. Even if you have surgery now, you may end up needing another operation down the road. If youâre older, any other health issues you have may affect your decision.
Your plans about having children. If you want more children, itâs best to hold off on surgery until you decide your family is complete.
Your general health. Surgery has some risks, such as infection, blood clots, or problems with the anesthetic. If you have a heart condition, diabetes, or breathing difficulties, any of these things could make an operation riskier. So could smoking or obesity.
Also, talk with your doctor about the chances that surgery could cause new problems. You might develop urinary incontinence — urine leaking out without your control. Sex might become uncomfortable, and you might feel pain in your pelvis.
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What Are The Symptoms
- Pelvic bulge or feeling pressure from pelvic organs pressing against the vaginal wall. This is the most common symptom, seen in 94-100% of patients.
- Feeling very full or pain in your lower belly
- Feeling a pull or stretch in your groin area or pain in your lower back
- Releasing urine without meaning to , or needing to urinate a lot
- Having problems with your bowels, such as constipation
- Difficulty walking or sitting
Ancillary Factors Impacting Efficacy
The surgical efficacy of sacrocolpopexy is impacted by many more important factors than route of procedure including choice of graft material, type of suture for graft attachment, concomitant procedures, pre-operative stage of prolapse, size of the genital hiatus and whether the surgery is for primary or recurrent disease.
Despite robotic-assisted technology enabling the time-intensive suturing portion of the SCP procedure, it is still the portion of the operation that is most amenable to improvements in operative efficiency. Several different studies have examined different methods of graft attachment . One study compared the pull-out force of permanent versus absorbable, as well as barbed versus non-barbed sutures and found that when equivalent caliber suture was used, they all had similar strengths . Another study evaluating the comparative efficacy of barbed sutures reported lower satisfaction scores but greater efficiency of suturing . Transitioning from a permanent to an absorbable suture for vaginal graft attachment has not obviously compromised outcomes. One retrospective study reviewed the use of absorbable suture on both the vaginal and sacral ends of the mesh. They noted only a 7% rate of repeat surgery at 3-year follow-up .
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What Causes Vaginal Prolapse
There are no direct causes of vaginal prolapse. However, women are at an increased risk of developing vaginal prolapse if they:
- Delivered children vaginally, especially repeat deliveries
- Are approaching or experiencing menopause
- Have certain lifestyle factors, including being overweight
- Were born with a rare condition, such as bladder exstrophy
What Causes Pelvic Organ Prolapse
Pelvic organ prolapse can be made worse by anything that puts pressure on your belly.
Pregnancy and childbirth Normally your pelvic organs are kept in place by the muscles and tissues in your lower belly. During childbirth these muscles can get weak or stretched. If they dont recover, they cant support your pelvic organs. The more times you have been pregnant and the larger the babies, the greater the risk for pelvic organ prolapse.
Hysterectomy You may also get pelvic organ prolapse if you have surgery to remove your uterus. Removing the uterus can sometimes leave other organs in the pelvis with less support.
Age – The risk of prolapse increases with age. After menopause, there is less estrogen in the vaginal tissues. This can decrease the strength of the tissues.
Family history – Pelvic organ prolapse tends to run in families.
Being very overweight Having extra weight puts downward pressure on the organs in the lower belly. Smoking or a long-lasting cough Smoking or chronic cough , increases the pressure on the organs in the lower belly.
Frequent constipation Anything that puts pressure on the lower belly can contribute to pelvic organ prolapse over time.
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Why Surgery With Da Vinci
A review of published studies suggests that potential benefits of a pelvic organ prolapse repair with da Vinci technology include:
- Patients may experience fewer complications compared to patients who had open surgery4,5 and a comparable complication rate to patients who had laparoscopic surgery.4,5,7,8
- Patients may stay in the hospital for a shorter amount of time compared to patients who had open surgery4 and similar, though sometimes shorter, amount of time compared to patients who had laparoscopic surgery.4,5,8,9
- With da Vinci, you may have a few small incisions compared to an open procedure and, after surgery, a few small scars.
All surgery involves risk. You can read more about associated risks of sacrocolpopexy repair here.
Surgical Risks/complications Of Robotic
The abdominal approach to apical prolapse repairs has an overall low rate of complications. However, it is also associated with some serious risks, including small bowel injury/obstruction, sacral discitis, hemorrhage, and mesh-related complications. Surgeons must be aware of the presenting signs of these complications, as early diagnosis and treatment are critical. This is especially true for elderly patients who may have less medical reserve. Conflicting data regarding the relative risks of robotic sacrocolpopexy in elderly women exists. In one retrospective comparative study of women over 65 undergoing native tissue versus robotic repairs, rates of Clavien-Dindo grade III complications were more common in the robotic group . However, in another similar study of 136 elderly women, there were no differences in outcomes or complications . In older women, the robotic approach should be reserved for those who are interested in preserving penetrative vaginal intercourse .
Systematic reviews comparing laparoscopic and robotic-assisted sacrocolpopexy concluded that there was no difference between the two techniques with regards to complication rates . In a retrospective review of RSC, intra-operative complications were found to be low . RSC has also been associated with lower estimated blood loss and shorter hospitalization, but a higher rate of intra-operative complications as compared to ASC .
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Resources For Learning More
Pelvic organ prolapse brochure
Take away information about pelvic organ prolapse repair surgery using da Vinci technology in our brochure designed for patients and families.
1. Surgery for Pelvic Organ Prolapse. The American College of Obstetricians and Gynecologists. Web. 21 January 2019.
2. Barber, M.D., Maher, C., Int Urogynecol J. 2013 Nov 24:1783-90. doi: 10.1007/s00192-013-2169-9.
3. Pelvic Support Problems. The American College of Obstetricians and Gynecologists. Web. 21 January 2019.
4. Serati, et al . Robot-assisted Sacrocolpopexy for Pelvic Organ Prolapse: A Systematic Review and Meta-Analysis of Comparative Studies. European Urology. 66:202-318.
5. Nosti, Patrick A., Uduak Umoh Andy, Sarah Kane, Dena E. White, Heidi S. Harvie, Lior Lowenstein, and Robert E. Gutman. “Outcomes of Abdominal and Minimally Invasive Sacrocolpopexy.” Female Pelvic Medicine & Reconstructive Surgery 20.1 : 33-37. Print.
6. Siddiqui, Nazema Y., Elizabeth J. Geller, and Anthony G. Visco. “Symptomatic and Anatomic 1-year Outcomes after Robotic and Abdominal Sacrocolpopexy.” American Journal of Obstetrics and Gynecology 206.5 : 435.e1-35.e5. Print.
7. Anger, et al . Robotic Compared with Laparoscopic Sacrocolpopexy. A Randomized Controlled Trial. Obstetrics & Gynecology. 1235-12.
8. Flack, et al . National Trends in the Performance of Robot-Assisted Sacrocolpopexy. J Endourology Jul 29:777-83. doi: 10.1089/end.2014.0710. Epub 2015 Mar 10.
What Is Pelvic Organ Prolapse
Many women will have some kind of pelvic organ prolapse. It can be uncomfortable or painful. But it isnt usually a big health problem. It doesnt always get worse. And in some women, it can get better with time.
More than one pelvic organ can prolapse at the same time. Organs that can be involved when you have pelvic prolapse include the:
- Bladder , this is the most common type of pelvic organ prolapse
- Urethra tube that brings urine from the bladder to the outside of the body
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Robotic Surgery For Pelvic Organ Prolapse
More than 120,000 women have surgery for uterine and vaginal vault prolapse each year in the United States. Prolapse of any pelvic floor organs occurs when the connective tissues or muscles in the body cavity are weak and cannot hold the pelvis in its natural position.The weakening of connective tissues accelerates with age, after childbirth, with weight gain and strenuous physical labor. Women with pelvic organ prolapse typically have problems with pelvic pressure, urinary incontinence, vaginal ulceration, sexual dysfunction and/or having a bowel movement.
For most women, da Vinci sacrocolpopexy offers numerous potential benefits over a traditional open approach that involves larger incisions to the lower abdomen. These benefits include:
Less blood loss and need for transfusions
Less risk of infection
Quicker return to normal activities
While clinical studies support the effectiveness of the da Vinci Surgical System when used in minimally invasive surgery, individual results may vary. Surgery with the da Vinci Surgical System may not be appropriate for every individual and you may be counseled that an alternative surgical approach is a better options for individual condition. Always ask your doctor about all treatment options, as well as their risks and benefits.
Minimally Invasive And Robotic Treatments
Laparoscopic pelvic floor repair is a surgical option for prolapse. In this procedure, surgeons insert a tiny telescope through a small incision. The laparoscope is attached to a camera-television setup, giving the surgeons a magnified view of the pelvic floor. After making several “keyhole” incisions in the abdomen, the surgeons use specially designed instruments to lift and attach the prolapsed organs back in their normal positions with permanent sutures.
By using the da Vinci robot, surgeons are able to perform the procedure through several small incisions instead of a large single incision. That can result in:
- Shorter hospital stays
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Questions You Can Ask Your Doctor
- What options are available to address my pelvic organ prolapse?
- What happens if I dont get surgery?
- What are the differences between open, vaginal, laparoscopic, and robotic-assisted surgery?
- Can you tell me about your training, experience, and patient outcomes with da Vinci?
- How will I feel after surgery?
Why Might I Need Robotic
Robotic-assisted sacrocolpopexy can help relieve the symptoms of pelvic organ prolapse, such as:
- Leaking urine when you cough, sneeze, or laugh
- Sudden urges to urinate
- Pain with sexual intercourse
If you decide to have surgery, you may have certain options. For example, some women choose to have their uterus removed as part of their surgery. The best type of surgery for you may vary depending on the severity and location of your prolapse. Your provider can help you decide which type of surgery may be best for you.
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Whats The Future Of Sp Surgery For Pop
Today, we offer SP sacrocolpopexy for patients who meet these criteria. Patients must have:
- Already had a hysterectomy
- A body mass index of 30 or less
- Had limited abdominal surgeries
These criteria offer surgeons maximum visibility and maneuverability in the abdomen. The next step is to offer the SP approach to women who have not had a hysterectomy .
As we perform more SP sacrocolpopexy procedures, we will report anonymized data to the FDA. The ultimate goal will be FDA approval of the procedure for pelvic organ prolapse.
In the meantime, we are offering the procedure on a case-by-case basis.
One of the many reasons I enjoy working at UT Southwestern is that we are always pushing the envelope always striving to bring our patients the best care with the latest medical technology.
If you are tired of living with pelvic organ prolapse symptoms, ask your doctor if you might be eligible. Call or request an appointment online.
Minimally Invasive Robotic Surgery Offers Quick Recovery From Prolapsed Bladder
|Andy Vu, DO, MHA, FACOG|
Those who spend their working day on their feet know a little something about discomfort. Now, imagine adding pelvic pain and incontinence to that discomfort.
Just ask Deborah Boyce, who is a nurse. A quick trip to her doctor led to a referral to Andy Vu, DO, MHA, FACOG, a specialist in urogynecology, female pelvic medicine and reconstructive surgery for UNT Health. His diagnosis? Prolapsed bladder, an uncomfortable but often treatable malady.
Prolapsed bladders are commonly associated with aging. The biggest risk factors for prolapse are age and pregnancy . Other common risk factors are chronic coughing, constipation and obesity.
|Symptoms of a Prolapsed Bladder
Other symptoms of a prolapsed bladder include the following:
Vu and Boyce decided that an abdominal prolapse repair called a sacrocolpopexy was the best option for her because it is a more durable surgery and arguably the gold standard for vaginal prolapse. This surgery is performed with small incisions and robotic arms controlled by the surgeon sitting in a console on the other side of the operating room. This minimally invasive surgery allows patients to recover quickly while enjoying the long term success of the traditional surgery. In the past, this same surgery used to require a large incision on the abdomen.
To schedule an appointment with Dr. Vu, call 817-735-DOCS . Visit UNTHealth.org for more information.
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