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436 Robotic Versus Laparoscopic Rectopexy for Complex Rectocele: A Prospective Comparison of Short-Term Outcomes 2011-11-12 2222
1Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, University Hospital of Nantes Hotel Dieu, Nantes, France

PURPOSE: The role of robotic assistance in pelvic floor prolapse surgery is debatable. This study aims to report our early experience of robotic-assisted ventral mesh rectopexy in the treatment of complex rectocele and to compare this with the laparoscopic approach in terms of safety and short-term postoperative outcomes.

METHODS: We analyzed a cohort of 63 consecutive patients operated on for complex rectocele from March 2008 to December 2009. A complex rectocele was defined as a rectocele that had one or more of the following features: larger than 3 cm in diameter, associated with an enterocele or internal rectal prolapse. The patients underwent either the robotic procedure or laparoscopic procedure, based only on the availability of the robotic system. Procedures involved either a single-mesh fixation for posterior-compartment prolapse (concurrent rectocele and enterocele) or a double-mesh fixation for a concurrent anterior compartment prolapse (with cystocele). A transvaginal tape was inserted at the same surgery in patients with urinary incontinence.

RESULTS: All patients were female; 40 underwent the laparoscopic procedure and 23 underwent the robotic procedure. Both groups were similar in age (mean, 59 ± 13 vs 61 ± 11; P = .440), ASA status, and previous abdominal surgery, respectively. Patients undergoing the robotic procedure had a significantly higher body mass index (mean, 27 ± 4 vs 24 ± 4; P = .03), more frequent double-mesh implantation (17/23 vs 14/40; P = .003), and longer operative time (mean, 221 ± 39 min vs 162 ± 60 min; P = .0001). Patients undergoing a laparoscopic procedure had slightly more blood loss (mean, 45 ± 91mL vs 6 ± 23 mL, P = .05). The number of transvaginal-tape procedures performed (6/40 vs 3/23, P > .999), conversion rate (10% vs 5%; P = .747), and duration of hospitalization were similar (mean, 5 ± 2 d vs 5 ± 1.6 d; P = .872). There were no mortalities or recurrences at the 6-month postoperative review.

CONCLUSION: In our experience, the robotic approach for the treatment of complex rectocele is as safe as the laparoscopic approach, with favorable short-term results

A primary motivation in the development of surgical robots is rooted in the desire to overcome the current limitations of laparoscopic surgery and to expand the benefits of minimally invasive surgery. Surgical robotics has revolutionized the field of minimally invasive surgery since its introduction in the late 1990s, when Cadiere and colleagues1 performed the first cholecystectomy with use of a robotic system. With the increasing acceptance and recognition of the advantages of robotics, this technique has now been applied to the fields of cardiothoracic surgery, gynecology, urology, and neurosurgery.
In colorectal surgery, the use of surgical robotics has also been gaining momentum. The improved 3-dimensional magnification and intuitive tremor-filtrated movements have greatly facilitated pelvic dissection, intracorporeal suturing, and visualization of vital pelvic structures, with several centers reporting favorable outcomes.2–6 A recent randomized controlled trial has now shown that the approach is safe and comparable to the laparoscopic approach for rectal cancer surgery.7 Similarly, because the laparoscopic approach has been shown to be a feasible technique with favorable long-term functional outcomes in the treatment of rectal prolapse and, recently, internal rectal prolapse,8–10 it seems natural to extend the technique to the treatment of complex rectoceles. Rectocele is defined as any hernial protrusion of the anterior rectal wall into the vagina, and we defined a complex rectocele as having one or more of the following features: larger than 3 cm in diameter, associated with an enterocele or internal rectal prolapse. Although the role of robotic assistance in pelvic floor prolapse surgery is debatable, the inherent advantages of stereoscopic magnification and tremor-filtrated movements makes it an attractive surgical option. In fact, a few reports have now shown that the robotic approach is safe and feasible for pelvic organ prolapse, but these are small series with heterogeneous patient populations, focusing primarily on complete rectal prolapse.11–14
The aim of this article was thus to assess the safety and feasibility of using the Da Vinci-S robotic system to treat a consecutive series of female patients with complex rectocele. The secondary aim was to compare the short-term outcomes of these patients with those who underwent a laparoscopic procedure during the same period.

DISCUSSION
The most appropriate surgical approach to treating symptomatic complex rectocele remains controversial. Methods range from the transabdominal rectopexy to perineal approaches, including transvaginal repairs and transanal stapling techniques, or a combination of approaches.15 In the era of minimally invasive surgery, laparoscopic rectopexy has been reported as a feasible technique for treating external rectal prolapse, with sustainable long-term outcomes.8 Several reports have also shown that the robotic approach is safe and feasible for pelvic organ prolapse, but these were small case series with heterogeneous patient populations, focusing primarily on complete rectal prolapse.11–14 Thus, a paucity of data remains regarding the use of laparoscopic or robotic approaches for the treatment of complex rectocele, that is, patients with concurrent rectocele, enterocele, and/or cystocele. This report is the first in the literature to focus on the comparison of the robotic and laparoscopic approaches in dealing with complex pelvic organ prolapse in a consecutive series of patients from a tertiary referral center.
The minimally invasive approach to the surgical management of pelvic organ prolapse is a technically challenging exercise, requiring meticulous dissection and preservation of vital nerve structures and suturing within the confines of a deep pelvis. Robotic assistance in such a procedure thus seems like a natural extension of its applications, facilitated by the high-definition stereoscopic vision, intuitive tremor-filtrated movements of instruments, and improved ergonomics for the surgeon. We thus embarked on the use of the Da Vinci-S system for the treatment of complex rectocele in early 2008, and this study reports on the feasibility and short-term outcomes of the robotic approach, with a prospective follow-up study on functional outcomes in progress.
We applied similar selection criteria for both RP and LP, with the only indication for the robotic approach based on the availability of the Da Vinci-S system. Both groups (LP and RP) were similar for age, ASA status, and previous abdominal surgery. The mean operative time was significantly longer in the RP compared with the LP group (mean, 221 ± 39 min vs 162 ± 60 min; P = .0001), similar to findings in other comparative series.13,14 Apart from the learning curve for the RP approach, we postulate that the significantly higher BMI (mean, 27 ± 4 vs 24 ± 4; P = .03) and more frequent double-mesh implantation (17/23 vs 14/40; P = .003) in this group could have contributed to the longer duration of surgery as well. However, the mean robotic set-up time was a respectable 17 ± 6 min (range, 9–28 min) compared with reported durations of between 10 and 60 min.11,12
Patients undergoing LP had marginally greater intraoperative blood loss (mean, 45 ± 91 mL vs 6 ± 23 mL; P = .05), although this finding remains of doubtful clinical significance and the patients did not experience a worse outcome. Although the LP group also had more postoperative complications, these were minor events that responded well to conservative management. Conversely, all patients in the RP group recovered uneventfully, and we believe that the longer duration for the RP is possibly offset by the improved visualization and dexterity afforded by its inherent features, allowing for more precise tissue handling and hemostasis, which is vital for deep pelvic work. Furthermore, despite the learning curve, RP allowed us to safely perform more double-mesh implantations in a group with a greater mean BMI, both findings being purely due to chance and not to deliberate study design. We feel that here lies the main advantage of the robotic technique, because a trained laparoscopist attempting the RP should not find the learning curve very daunting, which is particularly encouraging when dealing with complex pelvic procedures. Furthermore, when operating within the narrow confines of the pelvis, the superior stereoscopic views, intuitive tremor-filtrated movements, and improved ergonomics certainly add to the overall confidence of the surgeon. It is reassuring that the conversion rate of LP vs RP was not statistically significant (10% vs 5%; P = .747) and the durations of hospitalization were similar.
At the present time, cost-effectiveness remains a significantly limiting factor to the broader implementation of surgical robotics. Functional outcomes are of paramount importance in these patients, but were not included in this report because the duration of follow-up was short, and we believed that it would be premature and misrepresentative to report the results at this time. However, we are in the process of evaluating long-term results and are monitoring all patients in a strict follow-up protocol comprising systematic evaluations of continence scores, obstructed defecation scores, and quality-of-life scores during each visit. If prospective randomized studies can eventually show that the functional results of the robotic approach are better than of the laparoscopic approach and ensure a lower recurrence rate in the long term, the cost-effectiveness of the robotic approach could be confirmed. Despite the doubts that exist regarding surgical robotics, we strongly feel that surgical robotics is an important modality in the surgical armamentarium of the colorectal surgeon and that functional pelvic floor surgery is an ideal training model to develop the use of this surgical platform in digestive surgery, because one does not have to fear any compromise of oncological principles.
We acknowledge that this study is limited by the small number of patients and that it was nonrandomized. However, in the context of a feasibility study, our results show that the robotic technique is as safe as the laparoscopic approach for the treatment of complex rectocele. It represents the largest comparative report of consecutive patients undergoing robotic and laparoscopic rectopexy for complex rectocele in the literature. In our experience as a tertiary referral center for pelvic floor prolapse, we therefore conclude that robotic rectopexy for complex rectocele is safe and feasible and has favorable short-term results.