V262: Robotic-assisted Sacrocolpopexy with Uterus Preservation: Trans-broad ligament anterior and posterior fixation

Video

Introduction and Objectives
In this video we describe a technique for robotic sacrocolpopexy with uterus preservation offered to women who do not require nor wish to have a hysterectomy, but who have high grade, symptomatic pelvic organ prolapse (POP). Reasons for uterus preservation include sexuality, female identity, confidence, self-esteem, and body image. Other patients refuse hysterectomy based upon religious concerns or they simply do not wish to have unnecessary removal of an otherwise normal uterus with normal PAP smears and normal pelvic ultrasounds.



Transvaginal procedures for repair of POP have come under legal scrutiny due to numerous severe complications of mesh erosion. Isolated anterior and posterior repairs performed transvaginally have high recurrence rates. Comprehensive repair of POP through open sacrocolpopexy has a high success rate, but has a prolonged recovery from surgical morbidity. Robotic sacrocolpopexy offers women a comprehensive repair of POP with precision, durability and less morbidity.

Methods
This patient had a Grade 4 Baden/Walker POP and a desire for uterus preservation. A da-Vinci S robot was used with side port docking, one right arm and two left arms and one assistant port. Robotic instruments included monopolar cutting scissors (right arm), plasma kinetic dissecting forceps (left arm) and prograsp instrument (left arm).

Results
Eight patients underwent uterus sparing robotic-assisted sacrocolpopexy with a mean age 65.9 years and mean BMI 26.7. All patients had complete reduction of prolapse.

Surgery steps:

1) Identify the sacral promontory. Dissect the anterior longitudinal ligament (ALL).

2) Placement of two Gore-tex sutures in ALL.

3) Creation of a posterior peritoneal tunnel from ALL to vaginal apex.

4) Preparation and cutting of the 23 x 4 cm mesh into two pieces.

5) Dissection of the anterior vaginal wall, fixation of the anterior Y-shaped mesh, and passage through the broad ligament bilaterally.

6) Dissection of the posterior wall and fixation of the rectangular mesh.

7) All 3 segments of the mesh are pulled through the posterior peritoneal tunnel with the help of an assistant grasper.

8) Anchor the 3 segments of mesh to the ALL.

9) Closure of the peritoneum so that no mesh is left exposed.

Conclusions
There is an increasing trend for women to request or demand uterus preservation at the time of POP repair. For women who have no medical necessity for hysterectomy and desire uterus preservation, this procedure allows for a durable, anatomically sound repair comparable to standard sacrocolpopexy without concomitant hysterectomy.

Funding: None