Laparoendoscopic Single-Site (LESS) Sacral Colpopexy

Abstract

As the general population has aged yet remained active, the demand for correction of pelvic organ prolapse (POP) has progressively increased (Maher et al., Cochrane Database Syst Rev (3):CD004014, 2007; Nygaard et al., Obstet Gynecol 104:805–823, 2004). Traditionally, management of POP has come in the form of cautious observation, pessary fitting and use, myriad vaginal repairs, and/or abdominal sacral colpopexy (ASC). The ideal treatment approach and/or type of operation should be based not only on the objective outcomes of the myriad procedures but also on the expectancies, desires, and risk factors of the individual and the proficiency and purview of the surgeon.

Among patients that desire, and are considered good candidates for, definitive surgical reconstruction, ASC is considered the “gold standard” technique owing to superior anatomical support of the vaginal apex (Geller et al., Obstet Gynecol 112: 1201–1206, 2008; McDermott et al., Obstet Gynecol Clin North Am 36:585–614, 2009; Pollard et al., Curr Opin Urol 23:306–311, 2013). Historically, open ASC was considered a disproportionately invasive procedure associated with prolonged convalescence and increased pain as compared to native-tissue and/or mesh-augmented vaginal repair. The application of laparoscopy and robotics during ASC has dramatically improved morbidity associated with the procedure while continuing to offer durable and satisfactory outcomes (Pollard et al., Curr Opin Urol 23: 306–311, 2013). Coupled with the current climate of fear surrounding mesh-augmented vaginal repair, ASC has become the preferred corrective procedure for pelvic organ prolapse for many patients and providers.

Sacral Colpopexy would appear to be an ideal indication for LESS. Prior studies examining patient-driven factors for pursuing LESS include a benign surgical indication and female gender (Autorino et al., Urology 80:495–502, 2012). Moreover, from a purely technical standpoint, access to the vagina externally for manipulation alleviates some element of triangulation loss, a major criticism and impediment of LESS in general (White et al., Urology 74:1008–1012, 2009). Results from a retrospective, matched cohort study demonstrated equivalent results between laparoscopic, robotic, and LESS ASC with improved cosmesis and high patient satisfaction in the LESS group (White et al., Urology 74:1008–1012, 2009).

Despite these seemingly ideal circumstances and promising early results, the major impediment to LESS ASC remains the significant amount of reconstruction required during the procedure. Freehand intracorporeal suturing and knot-tying using an in-line approach are extraordinarily challenging even among laparoscopic experts. ASC demands precise mesh placement and suture fixation, and the ability to reproducibly place and secure sutures using LESS is demanding. As has been repeatedly demonstrated with other reconstructive indications, the da Vinci® platform greatly facilitates intracorporeal suturing and may likewise alleviate many of the limitations of conventional LESS ASC (Kaouk et al., Eur Urol 60:998–1005, 2011). However, the existing robotic platform is not purpose-built for LESS and newer configurations are not yet FDA approved for ASC. This textbook chapter will describe our group’s technique for reduced port robotic and LESS ASC using the existing da Vinci Si® platform and offer pearls of wisdom for patient selection, technical nuances, and troubleshooting.