da Vinci® Sacrocolpopexy for Vaginal Vault or Uterine Prolapse: Lessons Learned Oz Harmanli, MD Chief, Urogynecology and Pelvic Surgery Baystate Medical Center Professor of OB/GYN Tufts University School of Medicine Massachusetts 1

Apical Prolapse Vaginal apex is the keystone Any surgical correction of the anterior and posterior walls will fail if the apex is not adequately supported

Procedures for Apical Support Sacral colpopexy Sacrospinous ligament fixation Utero-sacral ligament suspension Ilio-coccygeus suspension Vaginal mesh systems such as Prolift, Avaulta, Perigee/Apogee and etc.

Apical Prolapse Surgery Cochrane Database Analysis for abdominal sacral colpopexy versus vaginal sacrospinous colpopexy 3 trials (Benson 1996; Lo 1998; Maher 2004) Abdominal sacral colpopexy was better than vaginal colpopexy in terms of Lower rate of apical recurrence (3/84 vs 13/85; RR 0.23, 95% CI 0.07 to 0.77) Higher success rate (The number of women failing to improve to Stage 2 or better) (3/52 vs 13/66; RR 0.29, 95% CI 0.09 to 0.97) Lower postoperative dyspareunia (7/45 vs 22/61; RR 0.39, 95% CI 0.18 to 0.86) No significant difference in reoperation rate for prolapse (6/84 vs 14/85, RR 1.46, 95% CI 0.19 to 1.11) Sacrospinous colpopexy was Quicker Cheaper Faster return to normal activities The data were too few to assess other clinical outcomes and complications Maher et al. Neurourology and Urodynamics 2008

Sacral Colpopexy

Abdominal Sacral Colpopexy Elevation of vaginal vault to Sacral 2 utilizing a mesh bridge Abdominal, laparoscopic, or robotic approach May change the vaginal axis (if sacral promontory is used) 85-90% success rate May be done with cervical preservation as a cervicopexy Mesh erosion around 3-5 %, higher with concomitant hysterectomy Nygaard, Obstet Gynecol 2004, Kohli , Obstet Gynecol 1998

da Vinci Robotic Surgery Benefits All the benefits of standard laparoscopy Tremor filtration Motion scaling 3D vision EndoWrist® instruments with 7 degrees of freedom 4th arm to perform traction and retraction tasks Net result: Improved technical capabilities 5 cm 1 cm 7

Patient Benefits Same as Standard Laparoscopy Less post-operative pain Less blood loss Fewer transfusions Less risk of infection Less scarring Improved cosmesis Shorter hospital stay Faster recovery time Equivalent urogynecologic outcomes 8

Surgeon Benefits Improved access to the pelvis Easier, more precise dissections Improved handling of suture and mesh Easier, quicker and more precise intracorporeal suturing Control of camera and 3rd instrument arm adds precision, autonomy and efficiency No short cuts just because it is minimally invasive surgery Easier to learn, perform and teach 9

Surgeon Benefits Precise dissection Intracorporeal suturing Mesh handling Graft attachment 10

da Vinci Sacrocolpopexy: Proven Results When compared with open techniques, robotic abdominal sacrocolpopexy is associated with less blood loss, shorter lengths of stay, and longer operative times Geller Obstet Gynecol 2008 McDermott Obstet Gynecol Clin North Am 2009

da Vinci Sacrocolpopexy: Proven Results E.J. Geller et al. Short-Term Outcomes of Robotic Sacrocolpopexy Compared With Abdominal Sacrocolpopexy. Obstetrics & Gynecology. 2008;112:1201–6 Robotic Sacrocolpopexy N=73 Open (Abdominal) Sacrocolpopexy N=105 P Value Pre-op POP-Q Exam: C point* +3 +1 0.002 Concomitant Hysterectomy 47.9% 29.5% 0.02 Total Operative Time (min) 328 225 <0.001 Post-op POP-Q Exam: C point* -9 -8 0.008 EBL (ml) 103 255 <0.001 Length of Stay (days) 1.3 2.7 <0.001 73 v 105 patients Higher POPQ values and more concomitant hysterectomies in the robotic group  Blood loss and length of stay in the robotic group C point suspension superior to open cohort results 12

Obstet Gynecol 2014 Costs of robotic sacrocolpopexy are higher than laparoscopic Short-term outcomes and complications are similar Primary cost differences resulted from robot maintenance and purchase costs.

Robotic vs Standard Laparoscopic Sacrocolpopexy Anger et al.

Systematic Review of Robotic Sacrocolpopexy Hudson et al FPMRS 2014 13 studies were selected for the systematic review. Meta-analysis yielded a combined estimated success rate of 98.6% (95%CI 97.0–100%) The combined estimated rate of mesh exposure/erosion was 4.1% (95%CI 1.4–6.9%) The rate of reoperation for mesh revision was 1.7%

Systematic Review of Robotic Sacrocolpopexy Hudson et al FPMRS 2014 The rates of reoperation for recurrent apical and non-apical prolapse were 0.8% and 2.5% The most common surgical complication (excluding mesh erosion) was cystotomy (2.8%), followed by wound infection (2.4%).

Optimizing Operating Room Efficiency in Robotic Surgery Baystate Medical Center Tufts University School of Medicine Massachusetts Oz Harmanli, MD Keisha Jones, MD Beril Yuksel, MD Faisal ElJehani, MD University of Massachusetts Isenberg School of Management Massachusetts Senay Solak, PhD Armagan Bayram, PhD This research was funded by an unrestricted educational grant from Intuitive Surgical Inc.

Optimizing Operating Room Efficiency in Robotic Surgery Objectives To assess the critical threshold to optimize operating room time for each surgical team member in robotic sacrocolpopexy. Evaluate the peak and plateau of the performances for each surgical team member Determine the most optimal team configurations

Optimizing Operating Room Efficiency in Robotic Surgery Optimal Experience Level Doctor 44 First Assistant 13 Anesthesia Provider 46 Scrub Technician 66 Circulating Nurse 56

Console Time for Surgeon by Experience The Console Time of an inexperienced surgeon can be up to 1 hour longer

First Assistant’s Experience Level and Console Time While some difference (up to around 25 minutes) in average Console Times exists for FA with different experience levels, these time differences are not sufficient to claim a statistically significant distinction

Does the Time of the Robotic Procedure Matter? Specifically, the impact of the shift change in the afternoon Cases which start before 11am were significantly shorter than those that start after 11am The average difference was 12 minutes

The Role of a Dedicated Anesthesia Provider Effect of a highly experienced Anesthesia Provider on OR time and specifically surgery prep time was studied No significant difference in total OR times (which may be due to the effects of other factors) However, prep times was significantly different

The Most Optimal Team Configurations Based on the Stochastic Model The optimization tool can be used at a hospital to determine the `best’ surgical team assignments for any set of available team members with known experience levels

Practical Implications of the Stochastic Model If a Surgeon has low experience, it is better to match him with more experienced First Assistant If a Surgeon has high experience, it is fine to match him with less experienced First Assistant and Scrub Technician If both the Surgeon and First Assistant are not as experienced it is better to match them with an experienced Scrub Technician

Practical Implications of the Stochastic Model A low-experienced Scrub Tech should be matched with either a more-experienced Surgeon or First Assistant We do not recommend to team up a low-experienced Surgeon, First Assistant, and Scrub Tech If the anesthesia provider has more experience, it is fine to have a less experienced Circulating Nurse, however if anesthesia provider has less experience, it is best to match with a more experienced Circulating Nurse Low-experienced Circulating Nurse should be teamed with an experienced Surgeon or vice versa