BALTIMORE – Robotic procedures compare favorably with vaginal apical prolapse repair in elderly women, for whom pelvic organ prolapse repair is the most common gynecologic procedure.

In a retrospective study of 136 patients, estimated blood loss and need for postoperative transfusion were significantly lower in the robotic surgery group. Estimated blood loss was 91 mL in the robotic surgery group, compared with 172 mL in the vaginal surgery group. No patients needed postoperative transfusion in the robotic group, compared with 10 patients in the vaginal group, reported Dr. Barbara L. Robinson at the annual meeting of the Society of Gynecologic Surgeons.

"We demonstrate low rates of perioperative morbidity in elderly women undergoing both robotic and vaginal reconstructive procedures for apical prolapse repair."

Total operative and total anesthesia times were significantly lower in the vaginal surgery group. Total operative time was 139 minutes for the vaginal surgery group, compared with 201 minutes in the robotic surgery group; total anesthesia time was 168 and 237 minutes in the vaginal and robotic groups, respectively.

"We demonstrate low rates of perioperative morbidity in elderly women undergoing both robotic and vaginal reconstructive procedures for apical prolapse repair," said Dr. Robinson of the department of obstetrics and gynecology, University of North Carolina at Chapel Hill.

The researchers conducted a chart review of women aged 65 years and older who underwent robotic or vaginal apical support surgery (including colpocleisis) between March 2006 and April 2011. Patients were excluded if they had undergone a primary abdominal or laparoscopic apical support procedure for malignancy.

Preoperative risks were assessed using the American Society of Anesthesiologists (ASA) physical classification system and the Charlson Comorbidity Index (CCI). The CCI predicts 10-year mortality risk based on age and comorbidities. The ASA physical classification system is used to assess patient fitness prior to surgery. The researchers sought to determine if these measures of preoperative risk can predict risk in this population, and to characterize complications during apical support procedures using the Dindo classification of surgical complications. The Dindo system is used to grade and define perioperative complications. This system has five grades; a greater grade is associated with more severe complications. Cases were reviewed for surgical complications up to 12 months after surgery, and a Dindo grade was assigned accordingly.

Dr. Robinson and her colleagues identified a total of 136 patients – 70 had robotic surgery and 66 had vaginal surgery. The average age was 72 years, although patients in the vaginal surgery group were significantly older (74 vs. 70 years). The two groups did not significantly differ by body mass index, parity, or smoking status. The average apical prolapse stage was significantly lower in women who had vaginal surgery compared with robotic surgery – 1.6 vs. 2.1.

In the robotic surgery group, sacrocolpopexy was the most common procedure. In the vaginal group, uterine sacral ligament suspension and colpocleisis were the two most common procedures. Length of hospital stay was significantly longer for the vaginal surgery group than the robotic group – 2.2 vs. 2.0 days, respectively.

The most common preoperative comorbidities were hypertension, coronary artery disease, and diabetes. These morbidities were not significantly different between the two groups. However, history of a myocardial infarction was significantly lower in patients who had robotic surgery than in the vaginal surgery group (9% vs. 21%), as was the presence of dementia (0% vs. 9%).

"The [overall] study population was generally healthy, with a low mean CCI of 0.97. However, the vaginal surgery group had more severe comorbidities than the robotic surgery group based on the CCI," said Dr. Robinson. In contrast, based on ASA class, comorbidity was similar for the two groups. The most commonly assigned ASA classes were 2 and 3. No patients were assigned as class 5 or 6.

There were no significant differences in overall intraoperative complications, including cystotomy, trocar injury to the bladder, ureteral injury, bowel injury, or intraoperative transfusion. However, there were significantly fewer urinary tract infections – 6% vs. 18% – in the robotic surgery group following the procedure, she said at the meeting, which was jointly sponsored by the American College of Surgeons.

Overall, the majority of procedures – both robotic (67%) and vaginal (56%) – were associated with no complications based on Dindo class, she said. No patients were classified as grade IV or V. The Dindo classification was similar between the two groups.

"Neither the ASA or CCI correlated significantly with the Dindo grade," he said. Given the lack of correlation with the Dindo classification, ASA and CCI may have limited utility in elderly women undergoing pelvic floor reconstruction.

The authors reported that they had no relevant financial disclosures.

Robotic Surgery Safe for Vaginal Apical Prolapse