EUROPEAN UROLOGY 65 (2014) 1138–1139
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. 1128–1137 of this issue
On the Way Toward Better Evidence for Minimally Invasive Treatment of Pelvic Organ Prolapse Giacomo Novara a,*, Alessandro Volpe b a
Department of Surgery, Oncology, and Gastroenterology – Urology Clinic, University of Padua, Padua, Italy;
b
Division of Urology, University of Eastern
Piedmont, Maggiore della Carita` Hospital, Novara, Italy
Surgical treatment of pelvic organ prolapse (POP) can be performed with several different methods, and more than 40 reconstructive surgical techniques have been described [1]. Surgical repair can be performed vaginally or abdominally with retropubic, conventional laparoscopic, and, more recently, robot-assisted approaches. Sacrospinous vault suspension, iliococcygeus muscle fixation, uterosacral ligament fixation, McCall culdoplasty, and posterior intravaginal slingplasty are the most commonly used vaginal techniques [2], whereas abdominal sacrocolpopexy is the most common abdominal procedure on the market. Theoretically speaking, vaginal surgery might allow several advantages over the abdominal approach, including shorter operative time, lower morbidity, the possible use of local or regional anesthesia, the potential to repair other concomitant pelvic defects, and quicker recovery. In contrast, the presence of orthopedic deformities, concomitant intra-abdominal pathology, and reduced vaginal length might be conditions that could favor an abdominal approach [3]. Surgical experience with the specific approach plays also a major role, with significant differences in clinical practice among gynecologists, urologists, and urogynecologists. Laparoscopic pelvic floor reconstructive surgery aims to maximize the efficacy of the abdominal approach by maintaining its advantages and simultaneously reducing perioperative morbidity and length of hospital stay. Laparoscopic sacrocolpopexy, however, is a complex surgical procedure that requires extensive suturing of the mesh to the pelvic floor structures, making it a difficult surgical procedure for surgeons without advanced laparoscopic skills.
During the past decade, robotic systems have been introduced in an attempt to reduce the difficulty of performing complex laparoscopic procedures, particularly for nonlaparoscopic surgeons. The use of robotic assistance gained massive penetration in urology, especially in urologic oncology, where robotic radical prostatectomy is now considered the gold standard treatment [4–8]. Specifically, three-dimensional imaging systems; magnification up to 12-fold; and the EndoWrist technology, which provides 7 degrees of freedom, increasing the dexterity of the surgeon’s forearm and wrist at the operative site, are all major advantages of the da Vinci platform (Intuitive Surgical, Sunnyvale, CA, USA) that make robotic technology suitable for pelvic floor reconstructive surgery [9]. In the current issue of European Urology, Lee et al. reported an interesting literature review summarizing the available evidence on laparoscopic and robotic surgery for treatment of POP [10]. What are the main conclusions of such an extensive work? First, the study data demonstrated that both pure laparoscopic and robotic sacrocolpopexies are feasible in the hands of experienced minimally invasive surgeons, with good perioperative outcomes, including short operative time (typically 90% in most series). Third, although at present only a few retrospective comparative studies with short follow-up durations have been performed, the available data suggest that laparoscopic and robotic surgery might be
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2013.12.064. * Corresponding author. Department of Surgery, Oncology, and Gastroenterology – Urology Clinic, University of Padua, Via Giustiniani 2, 35100 – Padua, Italy. Tel. +39 049 8211250; Fax: +39 049 8218757. E-mail addresses: [email protected], [email protected] (G. Novara). 0302-2838/$ – see back matter # 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.eururo.2014.02.003
EUROPEAN UROLOGY 65 (2014) 1138–1139
associated with longer operative times, lower blood loss, and similar success rates. On the whole, the quality of the available evidence is quite poor, including mostly retrospective surgical series with relatively short follow-up and nonstandardized indications for sacrocolpopexy. The ideal randomized study comparing open versus laparoscopic or robotic sacrocolpopexy is missing. Similarly, there is a lack of nonrandomized comparative studies adopting validated questionnaires to assess success rates as well as prevalence of lower urinary tract, sexual, or bowel dysfunctions at long-term follow-up after surgery. Moreover, prospective reports comparing laparoscopic or robotic sacrocolpopexy with vaginal procedures, such as sacrospinous fixation, would be desirable. Finally, cost-effectiveness of robotic surgery for sacrocolpopexy has not been evaluated in detail. However, it must be taken into account that the application of robotic surgery to pelvic floor repair is feasible, mainly in high-volume centers, which have already adopted the da Vinci platform for treatment of the most prevalent urologic or gynecologic malignancies.
1139
Theobald P, Zimmerman CW, Davila GW, editors. New Techniques in Genital Prolapse Surgery. London, UK: Springer London; 2011. p. 163–70. [2] Biller DH, Davila GW. Vaginal vault prolapse: identification and surgical options. Cleve Clin J Med 2005;72(Suppl 4):S12–9. [3] Alarab M, Drutyz HP. Vaginal approach to fixation of the vaginal apex. In: Cardozo L, Staskin D, editors. Textbook of Female Urology and Urogynecology. London, UK: Informa Healthcare; 2006. p. 1055–66. [4] Novara G, Ficarra V, Rosen RC, et al. Systematic review and metaanalysis of perioperative outcomes and complications after robotassisted radical prostatectomy. Eur Urol 2012;62:431–52. [5] Ficarra V, Novara G, Rosen RC, et al. Systematic review and metaanalysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol 2012;62:405–17. [6] Novara G, Ficarra V, Mocellin S, et al. Systematic review and metaanalysis of studies reporting oncologic outcome after robot-assisted radical prostatectomy. Eur Urol 2012;62:382–404. [7] Ficarra V, Novara G, Ahlering TE, et al. Systematic review and metaanalysis of studies reporting potency rates after robot-assisted radical prostatectomy. Eur Urol 2012;62:418–30. [8] Montorsi F, Wilson TG, Rosen RC, et al., Pasadena Consensus Panel. Best practices in robot-assisted radical prostatectomy: recommendations of the Pasadena Consensus Panel. Eur Urol 2012;62: 368–81.
Conflicts of interest: The authors have nothing to disclose.
[9] Merseburger AS, Herrmann TR, Shariat SF, et al. EAU guidelines on robotic and single-site surgery in urology. Eur Urol 2013;64:
References [1] Novara G, Artibani W, Secco S, Neuman M. Surgical mesh reconstruction for post-hysterectomy vaginal vault prolapse. In: von
277–91. [10] Lee RK, Mottrie A, Payne CK, Waltregny D. A review of the current status of laparoscopic and robot-assisted sacrocolpopexy for pelvic organ prolapse. Eur Urol 2014;65:1128–37.
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. 1128–1137 of this issue
On the Way Toward Better Evidence for Minimally Invasive Treatment of Pelvic Organ Prolapse Giacomo Novara a,*, Alessandro Volpe b a
Department of Surgery, Oncology, and Gastroenterology – Urology Clinic, University of Padua, Padua, Italy;
b
Division of Urology, University of Eastern
Piedmont, Maggiore della Carita` Hospital, Novara, Italy
Surgical treatment of pelvic organ prolapse (POP) can be performed with several different methods, and more than 40 reconstructive surgical techniques have been described [1]. Surgical repair can be performed vaginally or abdominally with retropubic, conventional laparoscopic, and, more recently, robot-assisted approaches. Sacrospinous vault suspension, iliococcygeus muscle fixation, uterosacral ligament fixation, McCall culdoplasty, and posterior intravaginal slingplasty are the most commonly used vaginal techniques [2], whereas abdominal sacrocolpopexy is the most common abdominal procedure on the market. Theoretically speaking, vaginal surgery might allow several advantages over the abdominal approach, including shorter operative time, lower morbidity, the possible use of local or regional anesthesia, the potential to repair other concomitant pelvic defects, and quicker recovery. In contrast, the presence of orthopedic deformities, concomitant intra-abdominal pathology, and reduced vaginal length might be conditions that could favor an abdominal approach [3]. Surgical experience with the specific approach plays also a major role, with significant differences in clinical practice among gynecologists, urologists, and urogynecologists. Laparoscopic pelvic floor reconstructive surgery aims to maximize the efficacy of the abdominal approach by maintaining its advantages and simultaneously reducing perioperative morbidity and length of hospital stay. Laparoscopic sacrocolpopexy, however, is a complex surgical procedure that requires extensive suturing of the mesh to the pelvic floor structures, making it a difficult surgical procedure for surgeons without advanced laparoscopic skills.
During the past decade, robotic systems have been introduced in an attempt to reduce the difficulty of performing complex laparoscopic procedures, particularly for nonlaparoscopic surgeons. The use of robotic assistance gained massive penetration in urology, especially in urologic oncology, where robotic radical prostatectomy is now considered the gold standard treatment [4–8]. Specifically, three-dimensional imaging systems; magnification up to 12-fold; and the EndoWrist technology, which provides 7 degrees of freedom, increasing the dexterity of the surgeon’s forearm and wrist at the operative site, are all major advantages of the da Vinci platform (Intuitive Surgical, Sunnyvale, CA, USA) that make robotic technology suitable for pelvic floor reconstructive surgery [9]. In the current issue of European Urology, Lee et al. reported an interesting literature review summarizing the available evidence on laparoscopic and robotic surgery for treatment of POP [10]. What are the main conclusions of such an extensive work? First, the study data demonstrated that both pure laparoscopic and robotic sacrocolpopexies are feasible in the hands of experienced minimally invasive surgeons, with good perioperative outcomes, including short operative time (typically 90% in most series). Third, although at present only a few retrospective comparative studies with short follow-up durations have been performed, the available data suggest that laparoscopic and robotic surgery might be
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2013.12.064. * Corresponding author. Department of Surgery, Oncology, and Gastroenterology – Urology Clinic, University of Padua, Via Giustiniani 2, 35100 – Padua, Italy. Tel. +39 049 8211250; Fax: +39 049 8218757. E-mail addresses: [email protected], [email protected] (G. Novara). 0302-2838/$ – see back matter # 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.eururo.2014.02.003
EUROPEAN UROLOGY 65 (2014) 1138–1139
associated with longer operative times, lower blood loss, and similar success rates. On the whole, the quality of the available evidence is quite poor, including mostly retrospective surgical series with relatively short follow-up and nonstandardized indications for sacrocolpopexy. The ideal randomized study comparing open versus laparoscopic or robotic sacrocolpopexy is missing. Similarly, there is a lack of nonrandomized comparative studies adopting validated questionnaires to assess success rates as well as prevalence of lower urinary tract, sexual, or bowel dysfunctions at long-term follow-up after surgery. Moreover, prospective reports comparing laparoscopic or robotic sacrocolpopexy with vaginal procedures, such as sacrospinous fixation, would be desirable. Finally, cost-effectiveness of robotic surgery for sacrocolpopexy has not been evaluated in detail. However, it must be taken into account that the application of robotic surgery to pelvic floor repair is feasible, mainly in high-volume centers, which have already adopted the da Vinci platform for treatment of the most prevalent urologic or gynecologic malignancies.
1139
Theobald P, Zimmerman CW, Davila GW, editors. New Techniques in Genital Prolapse Surgery. London, UK: Springer London; 2011. p. 163–70. [2] Biller DH, Davila GW. Vaginal vault prolapse: identification and surgical options. Cleve Clin J Med 2005;72(Suppl 4):S12–9. [3] Alarab M, Drutyz HP. Vaginal approach to fixation of the vaginal apex. In: Cardozo L, Staskin D, editors. Textbook of Female Urology and Urogynecology. London, UK: Informa Healthcare; 2006. p. 1055–66. [4] Novara G, Ficarra V, Rosen RC, et al. Systematic review and metaanalysis of perioperative outcomes and complications after robotassisted radical prostatectomy. Eur Urol 2012;62:431–52. [5] Ficarra V, Novara G, Rosen RC, et al. Systematic review and metaanalysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol 2012;62:405–17. [6] Novara G, Ficarra V, Mocellin S, et al. Systematic review and metaanalysis of studies reporting oncologic outcome after robot-assisted radical prostatectomy. Eur Urol 2012;62:382–404. [7] Ficarra V, Novara G, Ahlering TE, et al. Systematic review and metaanalysis of studies reporting potency rates after robot-assisted radical prostatectomy. Eur Urol 2012;62:418–30. [8] Montorsi F, Wilson TG, Rosen RC, et al., Pasadena Consensus Panel. Best practices in robot-assisted radical prostatectomy: recommendations of the Pasadena Consensus Panel. Eur Urol 2012;62: 368–81.
Conflicts of interest: The authors have nothing to disclose.
[9] Merseburger AS, Herrmann TR, Shariat SF, et al. EAU guidelines on robotic and single-site surgery in urology. Eur Urol 2013;64:
References [1] Novara G, Artibani W, Secco S, Neuman M. Surgical mesh reconstruction for post-hysterectomy vaginal vault prolapse. In: von
277–91. [10] Lee RK, Mottrie A, Payne CK, Waltregny D. A review of the current status of laparoscopic and robot-assisted sacrocolpopexy for pelvic organ prolapse. Eur Urol 2014;65:1128–37.
