Robotic assisted surgery for pelvic organ prolapse

There are a number of different operations for prolapse. Your choice of surgery will depend on the type of prolapse you have, but there are other important factors. It is important that you have fully engaged in conservative measures including pelvic floor exercises, support pessaries and other treatments. We recommend that for most women that their family is complete prior to surgery. There are an array of different choices and you should carefully consider the pros and cons of each and if you have any queries, then please discuss with your team.

We might also recommend a particular operation for medical reasons, but it is important you understand the choices and make the final decision.

Many pelvic floor procedures are performed using keyhole surgery through your abdomen. These can also be performed as robotic-assisted surgery:

• Laparoscopic mesh sacrohysteropexy is a keyhole procedure that uses a soft polypropylene permanent mesh to hold the womb up.
• Laparoscopic suture sacrohysteropexy is a keyhole operation that lifts the womb up using permanent stitches.
• Laparoscopic mesh sacrocolpopexy is keyhole operation that lifts the vagina up into a more normal position using a soft polypropylene permanent mesh. This might be required in patients with vaginal vault (the inner end of vagina) prolapse following hysterectomy.
• Laparoscopic suture sacrocolpopexy is keyhole operation that lifts the vagina up into a more normal position using stitches. Depending on your wishes we may avoid the use of mesh and use stitches, some of which are permanent.
• Laparoscopic colposuspension is a keyhole operation where usually permanent stitches are placed to lift up and support the base of the bladder.
• This operation is used in patients with urinary stress incontinence.
• Laparoscopic paravaginal repair is a keyhole operation where usually permanent stitches are placed to lift up and support the front wall of the vagina.

Both traditional laparoscopic surgery and robotic surgery for pelvic organ prolapse are preferred to open surgery as the recovery time is quicker, and the hospital stay is shorter

There is limited data on the outcomes following the above surgeries but in general, robotic-assisted surgery compared to traditional laparoscopic surgery it is associated with:

• Fewer complications.
• Less blood loss.
• Enhanced surgical 3D vision and dexterity of instruments – gives the surgeons high levels of control within the abdomen.
• Lower risk of conversion to open surgery.

All treatments and procedures have risks and we will talk to you about the risks of robotic-assisted surgery for pelvic organ prolapse.

Although the use of the robot is new for our department at UCLH, the actual surgery is identical to that which the surgeons are already expert at performing, and it is only the use of the robotic assistance that is new. Your surgeons will have had extensive training and/or supervision to use the robot, which has been designed to be very intuitive. We therefore do not expect there to be any issues or higher complication rates related to using a new technology.

Problems that may happen straight away
Bleeding, infection, blood clots in legs travelling to lungs.

Problems that may happen later
New or worsening bladder symptoms (stress or urge incontinence, problems with bladder emptying), new or worsening bowel symptoms (gas or faecal incontinence, problems emptying bowel), painful sexual intercourse, long-term problems with pain, problems with implanted mesh used to repair prolapse. Migration of mesh into surrounding areas, including bowel, bladder, vagina. It is usually very difficult to remove mesh once it has been inserted. Migration of permanent stitches into surrounding areas.

Problems that are rare, but serious
Damage to bowel, bladder, ureters, blood vessels and other organs.
More details about the complications of surgery can be found in our information booklets on each surgical procedure.

You should talk to your specialist doctor to decide if robotic surgery is right for you. You should have the opportunity to discuss all the available information on surgical and non-surgical options, and their risks and benefits, to help you make an informed decision. 

Before you consider surgery, you should think about other options:

• Carrying on as you are.
• Pelvic floor physiotherapy.
• The use of a vaginal pessary.

If you decide not to have treatment, you will continue to be troubled by your symptoms. However, you are very unlikely to come to any harm.

Physiotherapy is an effective treatment, especially if your prolapse is not too severe. Around half of women who engage in physiotherapy will find that their symptoms improve. Physiotherapy appears to continue working provided that you do not stop practicing your exercises. If your prolapse is quite severe, we are not sure how well physiotherapy works.

Vaginal pessaries are an alternative treatment. A pessary is a removable device that is placed in your vagina. Most are made of soft plastic or silicone and shaped like a ring. There are different types of pessary and they come in different sizes. Pessaries relieve prolapse symptoms by keeping the womb and vaginal walls in their normal position.

A specialist nurse or doctor will fit your pessary for the first time. After this, you can be taught to insert and remove your pessary yourself. Pessaries can be used as a long-term treatment or as a temporary measure. A small number of women might experience some bleeding or discharge when they use a pessary. Rarely, a minor infection might develop. These problems are usually easy to treat.

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with robotic surgery, we will ask you to sign a consent form. This confirms that you would like to have the procedure and understand what it involves.

The medical team will explain all the risks, benefits, and alternatives, and invite you to ask any questions, before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment, please do not hesitate to speak with a senior member of the medical or nursing team again.

Preparing your body for surgery

• Some changes can have a really big impact on your recovery, for example:
• Increasing your exercise: try to do 30 minutes of activity which makes you feel out of breath, at least three times each week.
• Eating a healthy, balanced diet before surgery and planning easy to cook meals for your recovery.
• Stopping smoking and alcohol can be hard, but quitting or cutting down before surgery can reduce your hospital stay and improve wound healing.

More information is available in our “Gynaecology Enhanced Recovery Pathway” leaflet. 

Preoperative Assessment Clinic
A few weeks before your surgery you will be asked to attend a preoperative assessment appointment. This can be by telephone, or in person in the hospital. You will be asked questions about your health, medical history and home circumstances. Some tests may also be required, for example blood tests, or an ECG (a tracing of your heart rhythm). You will be given information about the morning of your surgery: when to stop eating and drinking, and if you need to stop taking any of your regular medications.

The day of your surgery
You will receive instructions about the time of your admission, and where to go. If you do not receive these, please contact your team using the contact details below. More information about what to bring to hospital, and what to expect once you arrive, can be found in the “Gynaecology Enhanced Recovery Pathway” leaflet. 

During robotic-assisted surgery for pelvic organ prolapse, your surgeon makes several small incisions (usually four to five), then uses a 3D high-definition camera for a crystal clear, magnified view of your uterus and pelvis.

The surgeon then sits at a console next to you and operates through the incisions using tiny instruments and the camera. Every hand movement your surgeon makes, is translated in real time by the robotic system, which bends and rotates the instruments so your surgeon can lift up the uterus.
 
The skin incisions (cuts) are then closed with stitches or special glue as for any other surgery.

Detailed information about what to expect in hospital after an operation, and about your longer-term recovery, can be found in our “Gynaecology Enhanced Recovery Pathway” leaflet.

When you wake up from the operation, you will have a drip in your arm and a catheter in your bladder. These will usually stay in for about 24 hours.

You may feel drowsy and nauseous from the anaesthesia. Your abdomen may feel painful and bloated. You may also have pain around the shoulders from the gas that is used within the abdomen for the procedure. This will settle within a few days, and can be improved by moving around and taking pain killers.

You will be discharged once you are eating, drinking, passing urine and moving around safely, and when your pain is well-controlled with tablets. This is usually after one to three nights. Occasionally your surgeon may recommend that you stay in hospital a little longer, especially if your surgery was difficult, or if there were complications.

It is important that someone is available to help you get home when you are discharged (e.g., to help carry your bag). You will need to plan in advance for the fact that you won’t immediately be able to do things you usually would do at home, including driving. Our leaflet “Gynaecology Enhanced Recovery Pathway” explains in more detail about what to expect, and what plans you may need to make.

We would suggest that you plan to be off work for six weeks. You may feel able to go back sooner, or you may need longer if your job is very active, or if there were complications.

If you develop the following symptoms once you get home, you should go to your nearest Accident and Emergency Department. They can be signs of complications, for which you may need urgent treatment.

• High fever.
• Pain in the abdomen that is getting worse.
• Swelling of the abdomen that is getting worse.
• Being unable to pass urine, or passing very little.
• Swelling, redness, or tenderness in the lower legs.
• Difficulty breathing, or chest pain.

The urogynaecology team will return telephone calls and messages the same day, or the next working day. You should ring them first if you have problems. If you call them on Friday and do not hear back the same day, you should see a GP. At the weekend, you should see a GP or go to Accident and Emergency if there is no other help available.

The British Society of Urogynaecology
Website: www.bsug.org.uk
Email: bsug@rcog.org.uk
Telephone: 020 7772 6211
Fax: 020 7772 6410

The International Urogynaecology Association
Website: http://www.iuga.org
Email: office@iuga.org
https://biargs.org.uk/patient-education
https://www.intuitive.com/en-us/patients/da-vinci-robotic-surgery

Pan, Ke et al. “A systematic review and meta-analysis of conventional laparoscopic sacrocolpopexy versus robot-assisted laparoscopic sacrocolpopexy.” International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics vol. 132,3 (2016): 284-91.
Nobbenhuis, Marielle A E et al. “Robotic surgery in gynaecology: Scientific Impact Paper No. 71 (July 2022).” BJOG : an international journal of obstetrics and gynaecology vol. 130,1 (2023)
Bugge, C., et al. (2013). "Pessaries (mechanical devices) for pelvic organ prolapse in women." Cochrane Database Syst Rev(2): CD004010.
Hagen, S., D. Stark, C. Glazener, S. Dickson, S. Barry, A. Elders, H. Frawley, M.
P. Galea, J. Logan, A. McDonald, G. McPherson, K. H. Moore, J. Norrie, A. Walker, D. Wilson and P. T. Collaborators (2014). "Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial." Lancet 383(9919): 796-806.
Jefferis, H., N. Price and S. Jackson (2017). "Laparoscopic hysteropexy: 10 years' experience." Int Urogynecol J. Epub: DOI 10.1007/s00192-016-3257-4.
Krause, H. G., J. T. Goh, K. Sloane, P. Higgs and M. P. Carey (2006). "Laparoscopic sacral suture hysteropexy for uterine prolapse." Int Urogynecol J Pelvic Floor Dysfunct 17(4): 378-381.
Kupelian, A. S., A. Vashisht, N. Sambandan and A. Cutner (2016). "Laparoscopic wrap round mesh sacrohysteropexy for the management of apical prolapse." Int Urogynecol J.
Maher, C. F., B.; Baessler, K.; Schmid, C. (2013). Surgical management of pelvic organ prolapse in women. The Cochrane Library, The Cochrane Collaboration.
Maher, C. F., M. P. Carey and C. J. Murray (2001). "Laparoscopic suture hysteropexy for uterine prolapse." Obstet Gynecol 97(6): 1010-1014.
Maher, C. F., A. M. Qatawneh, P. L. Dwyer, M. P. Carey, A. Cornish and P. J. Schluter (2004). "Abdominal sacral colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective randomized study." Am J Obstet Gynecol 190(1): 20-26.
Marchionni, M., G. L. Bracco, V. Checcucci, A. Carabaneanu, E. M. Coccia, F. Mecacci and G. Scarselli (1999). "True incidence of vaginal vault prolapse.
Thirteen years of experience." J Reprod Med 44(8): 679-684.9
Prodigalidad, L. T., Y. Peled, S. L. Stanton and H. Krissi (2013). "Long-term results of prolapse recurrence and functional outcome after vaginal hysterectomy." Int J Gynaecol Obstet 120(1): 57-60.
Rahmanou, P., B. White, N. Price and S. Jackson (2014). "Laparoscopic hysteropexy: 1- to 4-year follow-up of women postoperatively." Int Urogynecol J 25(1): 131-138.
Symmonds, R. E. and J. H. Pratt (1960). "Vaginal prolapse following hysterectomy." Am J Obstet Gynecol 79: 899-909

Urogynaecology nursing team
Direct line: 020 3447 6547
Mobile: 07951 674140
Fax: 020 3447 6590
Email: urogynaecology@uclh.nhs.uk

Women’s Health Physiotherapy
Direct line: 020 3447 6546
Fax: 020 3447 6590
Email: uclh.whphysio@nhs.net

Urogynaecology secretary
Direct line: 020 3447 2516
Fax: 020 3447 9775
Email: uclh.whphysio@nhs.net

Urogynaecology secretary
Direct line: 020 3447 2516
Fax: 020 3447 9775

University College Hospital
Switchboard: 020 3456 7890 
Website: www.uclh.nhs.uk

Pre-operative assessment clinic (PAC) (if you have questions about how to prepare for the operation)
Tel: 020 3347 2504

Surgical reception (if you are running late on the day of your operation)
Tel: 020 3447 3184 or 07939 135323

The Urogynaecology and Pelvic Floor Unit Clinic 2, Lower Ground Floor
Elizabeth Garrett Anderson (EGA) Wing University College Hospital
25 Grafton Way London, WC1E 6DB