Sling placement during robotic sacrocolpopexy efficacious

May 15, 2011

Of the many questions raised by the advent of robot-assisted surgery, two are germane to robotic sacrocolpopexy: Does the technology increase the risk of stress urinary incontinence in women undergoing the robotic procedure, and if it does, should an anti-incontinence procedure accompany the primary procedure as prophylaxis against incontinence?

Phoenix-Of the many questions raised by the advent of robot-assisted surgery, two are germane to robotic sacrocolpopexy: Does the technology increase the risk of stress urinary incontinence in women undergoing the robotic procedure, and if it does, should an anti-incontinence procedure accompany the primary procedure as prophylaxis against incontinence?

The answers appear to be "no" and "perhaps," according to a study presented at the 2011 Society for Urodynamics and Female Urology winter meeting in Phoenix.

"The CARE [Colpopexy and Urinary Reduction Efforts] study is a major trial that has influenced our practice," first author Andrea Crane, MD, told Urology Times.

"All the patients in the CARE trial underwent an abdominal sacrocolpopexy. The findings of that study did not address the outcomes of patients undergoing the same procedure done robotically. We wanted to compare those findings to the rates of postoperative SUI in women undergoing robotic sacrocolpopexy with and without a concomitant sling," said Dr. Crane, a fellow in female pelvic medicine and reconstructive surgery at the University of North Carolina, Chapel Hill, working with Catherine Matthews, MD, and co-authors.

The retrospective study looked at outcomes in 82 patients undergoing robotic sacrocolpopexy, 43 (52.4%) of whom received a concomitant mesh sling for documented urodynamic stress incontinence (USI) and 39 (47.6%) who did not have USI and underwent the robotic sacrocolpopexy but without sling placement. The patients were evaluated by a series of validated questionnaires administered preoperatively and at 3 or 6 months post-surgery.

Better results seen in sling patients

The results were unequivocal. The overall rate of postoperative SUI was 31.7%. Nearly one-fifth (18.6%) of the patients receiving the sling as treatment developed subsequent SUI compared to 46.2% of those who did not get a sling (p=.007). Severe SUI was far less common in sling patients (2.4%) than in those without prophylaxis (15.8%, p=.049). These findings translate to 3.6 slings that need to be placed to prevent one case of de novo SUI.

"The number needed to treat data is practical information for surgeons considering a potential prophylactic sling and can help in patient counseling. We counsel our patients on both the abdominal procedure and a minimally invasive procedure, which at our institution is mainly robotic," said Dr. Crane.

She noted that while robotic procedures present a different set of challenges compared to abdominal procedures, there has not been any significant difference in anatomic and functional outcomes at her institution. In the CARE trial, 32% of women receiving concomitant suspension evidenced stress incontinence at 2-year follow-up compared to 45.2% of those undergoing a sacrocolpopexy alone.

Both the University of North Carolina study and the CARE study avoided defining an optimal procedure, but both also noted that doing a concomitant anti-incontinence procedure significantly reduced the risks of postoperative stress incontinence.