Comparison of Robotic-Assisted and Abdominal Hysterectomy with Concomitant Burch Colposuspension

Abstract

Background: Stress urinary incontinence (SUI) affects ∼30% of all women; 4% need surgery; and SUI is most often seen in women ages 25–50. There are >200 surgical treatment methods. Burch colposuspension (BC) and sling operations are used widely today. Objective: Short-term results of robotic-assisted and abdominal approaches were evaluated in patients who had hysterectomies with BC. Materials and Methods: This cross-sectional study involved 40 patients with SUI and benign gynecologic conditions. The patients received either robotic-assisted hysterectomy with BC (Surgery A; 20 patients) or abdominal hysterectomy and BC (Surgery B; 20 patients). All patients were assessed at the Gulhane Military Medical Academy, in Etlik, Ankara, Turkey. The patients' demographics; intraoperative findings; complications; preoperative and postoperative 6th month Urinary Distress Inventory short form (UDI-6), urinary Incontinence Impact Questionnaire short form (IIQ-7) scores; and postoperative 6th month continence situations and values were assessed. Results: The median ages of the patients who received Surgery A and Surgery B procedure were 50 and 48, respectively. Both surgical groups were similar at baseline with respect to age, body mass index, gravidity, parity, operation time, and suturing time. None of these comparisons appeared to be significantly different (p > 0.05). Blood loss and hospitalization periods were statistically different between groups A and B (p < 0.05). No statistical difference was detected in UDI-6 and IIQ-7 scores before and after Surgeries A and B. No incontinence was observed in either group at their postoperative 6th month continence assessments. Conclusions: In this small sample of patients who appeared to be similar at baseline, similar incontinence cures and improvements were made for robotic-assisted and conventional open BC at 6 months. When treating SUI surgically with robotic-assisted hysterectomy, adding robotic BC seems to be a better approach than performing midurethral sling procedures. (J GYNECOL SURG 32:119)

Introduction

Stress urinary incontinence (SUI) is defined as involuntary urinary incontinence, during coughing, laughing, and straining, when inner pressure is increased in the abdomen.¹ Although SUI is observed often in women of any age group, the condition is most often observed in women between ages 25 and 50.² There are >200 surgical methods for treating SUI. However, Burch colposuspension (BC) and sling operations, for which long-term treatment results have been determined, are used widely today.³ SUI affects ∼30% of all women, and 4% of these patients need surgical operations.^4,5

The first operation technique defined by Marshall et al. in 1949, which includes the suspension of periureteral tissues to the pubis,⁶ was modified by Burch in 1961 as suspending paraurethral tissues to the ileopectinate ligaman.⁷ In 1976, Tanogho suggested the stabilization of paraurethral tissues instead of suspending them because of the problems in postoperative urination in BC.⁸ In 1991, Vancaille et al. developed the laparoscopic colposuspension method.⁹ With the widespread use of robotic operations, these operations are now possible to perform with robotic methods.^10–12

With developments in minimally invasive operations; and with the superior visualization, improved ability to move, and increased comfort for surgeons provided by robotic operations, these operations have become more widespread. Robotic operations are used for gynecologic operations, especially oncologic and urogynecologic surgery, and surgery for benign conditions.

The goal of this research was to evaluate the short-term results of robotic-assisted and abdominal approaches in patients who underwent hysterectomies with BC.

Materials and Methods

Approval from the local ethics board was obtained for this study. Written consent from the patients about the procedures to be performed was also obtained. Forty patients, who received simultaneous BC for SUI and hysterectomy between January 2011 and January 2015, were included in the study. The preoperative and postoperative findings of the 20 patients who received robotic-assisted hysterectomy with BC (Surgery A) and both findings of the control group of 20 patients who received abdominal hysterectomy and BC (Surgery B) were compared.

Preliminary case histories were obtained from the patients, and then they had gynecologic examinations. The stress test and standard pad test were performed. All patients were diagnosed clinically with SUI. No urodynamic studies were performed because the patients did not have additional urinary-continence pathology or past incontinence surgery. (Patients who underwent incontinence operations prior to the current operation were not included in the study.) Full urinary tests and urine-culture analyses were performed for all patients, and patients who had urinary-tract infections were treated and then reassessed.

The current authors recommend robotic surgery to all their patients. However, only those patients who agreed to pay the extra fee involved were given robotic surgery. All procedures were performed by an expert single surgeon who had completed a minimum of 50 robotic-assisted surgeries prior to these hysterectomies. In addition, this surgeon has performed 30 laparoscopic BCs.

Surgery A

Eight patients underwent total robotic hysterectomy, bilateral salpingo-oophorectomy, and BC; and 4 patients underwent total robotic hysterectomy and BC in the Surgery A group. During the Surgery A procedures, general anesthesia, endotracheal intubation, bladder catheterization, and uterine manipulator were applied routinely. The da Vinci^® Si was used for the operations. During the robotic operation, the right lateral side was approached in all patients for docking. During installation of the ports, a 12-mm port was used for an optical telescope with a supraumbilical location; two 8-mm ports with bilateral infraumbilical locations were approached for the robotic operator arms; and a 10-mm port with a left lateral supraumbilical location was approached for an assistant port.

During entry to the abdomen, the skin was elevated with manual traction, and direct trocar insertion was performed without veress needle insufflation. Then, other ports were inserted. The hysterectomy procedure was completed to patients as planned. The excised hysterectomy material was removed from the vagina. Intraperitonerally, the peritoneal-fold between the lateral umbilical ligaments, which are 2 cm over the bladder, was incised with bipolar scissors and the retzius space was dissected via sharp dissections. The bladder neck and ileopectinate ligaments were exposed in the retzius space on both sides.

One assistant operator entered the vagina with 2 fingers and lifted the periurethral area and located the ureterovesical component. Two sutures were placed bilaterally 2 cm lateral to the urethra, at midurethral level 2 cm over it, without going through the vaginal wall mucosa. For suturing, 2/0 Prolene™ (Polypropylene Suture, Ethicon Co.) nonabsorbable sutures were used. Suturing was performed without elevation; only stabilization was achieved by inserting the ileopectinate ligaments ipsilaterally. The same procedure was repeated on the other side (Video 1; see Supplementary Data available online at: www.liebertpub.com/gyn). During these procedures, special care was taken not to cause excessive tension in the vagina wall and not to suspend it more than was necessary. Cystoscopy was applied after the BC.

Surgery B

During abdominal hysterectomy and BC (Surgery B) procedures, general anesthesia, endotracheal intubation, and Foley catheterization were performed for all patients. After the hysterectomy was completed, the parietal peritoneum was sutured with 3/0 Vicryl™ (Polyglactin 910 Suture, Ethicon Co.). The retzius area was opened with sharp dissections at the symphysis pubis insertion area of the rectus abdominis muscles. Ileopectinate ligaments and the bladder neck were exposed on both sides and in the retzius space. An assistant surgeon entered with 2 fingers, and lifted the periurethral area and located the ureterovesical component. Two sutures were placed bilaterally 2 cm lateral to the urethra (midurethral level), 2 cm over first sutures without passing the vaginal-wall mucosa. As suture material, 2/0 Prolene™ (Polypropylene Suture, Ethicon Co.) nonabsorbable sutures were used. Then suturing was performed through the ileopectinate ligaments ipsilaterally. The same procedure was repeated for the other side. During these procedures, special care was taken not to cause excessive tension in the vagina wall and not to make it suspended more than necessary. Cystoscopy was applied after the BC was performed.

All patients

Intraoperative antibiotic prophylaxis was provided to all patients. No additional antibiotics were given in postoperative period. Foley catheters were taken from the patients' bladders in the 24th postoperative hour.

The Urogenital Distress Inventory (UDI) is one of the most commonly used tests in pelvic-based diseases. The UDI is composed of 19 questions about irritation, and stress and obstructive symptoms in the urinary tract. The UDI has also a short form with 6 questions (UDI-6), which correlate well. The Incontinence Impact Questionnaire (IIQ) is a quality-of-life (QoL) test used together with the UDI in patients with urinary incontinence. The IIQ is composed of 30 questions and determines components of suburinary system symptoms affect patients' daily activities and emotions. The IIQ has 4 scales: (1) travel; (2) social; (3) emotional; and (4) physical. The IIQ has a short form (IIQ-7), which consists of 7 questions. The UDI-6 and IIQ-7 have been translated into Turkish and validated.^13,14 These tests are used preoperatively and postoperatively to assess the effectiveness of treatment for conditions, such as urinary incontinence, for which treatment success is multifactorial. These scales capture the last 4-week period of the QoL perceived by the individual.

Control checks of all the patients were performed and the results were assessed in the postoperative 6th month. Age, body mass index (BMI), bleeding amount (preoperative and postoperative hemoglobin and hematocrit values), total operation time, duration of BC sutures, docking time in the robotic group, preoperative and postoperative 6th month status, results of the UDI-6 and IIQ-7 scales, continence states, and complications were assessed. For the statistical analysis, SPSS for Windows (15.0) was used. For continuous variables, the Mann-Whitney–U and Wilcoxon signed rank were used. Statistically, p < 0.05 was accepted as meaningful. Patient data were given as average (± standard deviation [SD]), %, median (minimum–maximum [Min–Max]).

Results

The median ages of the patients who underwent Surgery A and Surgery B were 50 (35–52) and 48 (40–60), respectively. The median body mass indexes were 29 (28–30) and 32 (28–34), respectively. The robotic operation docking median time was 27 (24–30) minutes. In both groups, the median operation time was 180 (160–200) and 180 (150–200) minutes, respectively. BC suturing median time was 30 (20–30) and 30 (30–35) minutes respectively. Blood loss median was 80 (50–110) and 150 (120–200) mL, respectively. The preoperative total UDI-6 score medians were 9 (6–11) and 11 (6–12), respectively. The postoperative total UDI-6 scores 3 (0–4) and 4 (0–5), respectively. The preoperative IIQ-7 score medians were 14 (12–18) and 13 (10–18), respectively. The postoperative IIQ-7 scores were 5 (1–8), 6 (4–9), respectively. Hospitalization time was an average of 2.2 (2–3) and 4 (3–5) days, respectively. (The current authors do not have any limitations for patients who undergo gynecologic laparotomies to stay in the hospital.)

In the postoperative 6th month continence assessment, it was observed that both groups had full continence. No complications were seen in both groups in the intraoperative and postoperative periods. Tables 1 and 2 summarize these findings.

Table 1.

Demographic Information

Factors	Robotic group (n = 20) median (Min–Max)	Abdominal group (n = 20) median (Min–Max)	p-Value
Age	50 (35–52)	48(40–60)	0.841
BMI	28 (28–30)	32 (28–34)	0.056
Gravida	4 (4–5)	3 (3–4)	0.095
Parity	3 (2–4)	2 (2–4)	0.690
Operation time (in minutes)	180 (160–200)	120 (100–130)	0.841
Amount of bleeding (in mL)	80 (50–110)	150 (120–200)	0.008^*
Burch suturing period (in minutes)	30 (20–30)	30 (30–35)	0.095
Hospitalization period (in days)	2 (2–3)	4 (3–5)	0.008^*

Mann-Whitney–U test was used for statistical analysis.

Min, minimum; Max, maximum; BMI, body mass index.

p < 0.05 means statistically significant.

Table 2.

Comparison of UDI-6 and IIQ-7 Scores of Both Groups

Scores	Robotic group (n = 20) median (Min–Max)	Abdominal group (n = 20) median (Min–Max)	p-Value
UDI-6 Preop 1–2	3 (1–3)	3 (2–4)	0.222
UDI-6 Preop 3–4	5 (3–6)	5 (4–6)	0.690
UDI-6 Preop Total	9 (6–11)	11(6–12)	0.421
IIQ-7 Preop	14 (12–18)	13 (10–18)	0.548
UDI-6 Postop 1–2	1 (0–2)	2 (1–2)	0.095
UDI-6 Postop 3–4	1 (1–2)	1 (1–2)	0.690
UDI-6 Postop total	3 (0–4)	4 (0–5)	0.310
IIQ-7 Postop	5 (1–8)	6 (4–9)	0.690

The Mann-Whitney–U test was used for statistical analysis.

UDI-6, Urogenital Distress Inventory, short form; IIQ-7, Incontinence Impact Questionnaire, short form; Min, minimum; Max, maximum; preop, preoperative; postop, postoperative.

In 9 patients who received Surgery A, there was myoma uteri, and 11 patients had abnormal uterine bleeding and stress incontinence. In the Surgery A group, only 1 patient had a previous abdominal operation. In the Surgery B group, 9 patients had myoma uteri, 9 patients had abnormal uterine bleeding, and 2 patients had descensus uteri. According to the operative histories of the patients in this group, 8 had undergone Cesarean delivery and 12 patients had no operative history. All patients had SUI.

Blood transfusions were performed in 2 patients who received Surgery A. The intraoperative transfusions were not given because of any inoperative bleeding but rather because of the anemia that these two patients already had. No blood transfusions were performed in the Surgery B group.

There were no difficulties in urinating after Foley catheter withdrawal from the bladders of the patients in both groups. Both groups did not have any complications in intraoperative or postoperative periods.

Discussion

Incontinence cures and reductions were seen in patients who underwent either robotic-assisted or conventional open BC at 6 months. There were no differences in adverse-event frequency, but the robotic-assisted group had less estimated blood loss and shorter postoperative hospitalization periods.

BC is widely used in many centers to treat SUI.

The short- and long-term results of BC have been determined with meta-analyses. After the operation, the efficacy in the first year is 90%; however, it became only 70% after 5 years. In this case, it was obvious that the long-term success of BC is sufficient.¹⁵

Although it has been proven that BC being used in laparoscopic procedures ensures less hospitalization time and less analgesic use, and is as effective as open procedure, there are not sufficient studies showing long-term patient satisfaction and effectiveness of robotic-assisted hysterectomy with BC.¹⁵ In a study by Meltomaa et al., long-term success rates for patients who underwent abdominal hysterectomy and simultaneous BC were similar to those patients who only underwent BC (81%, 77%, respectively).¹⁶

BC has been made easier to perform because of the superior three-dimensional visual ability and flexible movement of the robotic system. Moreover, the robot arms make placing sutures easier, faster, and more effective, compared conventional laparoscopic instruments. With respect to postoperative hospitalization times, the patients in the Surgery A group were discharged earlier than the patients in Surgery B group. After operations, early mobilization and early return of patients to their social lives is important. When both groups were compared in the current study, there were shorter hospitalization times and less bleeding in the patients in the Surgery A group (Table 1).

When BC is added to robotic surgery, there is no need for additional surgical costs or for changing the places of docking or ports. According to the current authors' experience, Surgery A seems applicable. However, with an increase in the experience of the surgeon, the operation time will decrease.

In the literature, there are fewer robotic-assisted BC studies. In a study by Patel et al., which was similar to the current study, there were few cases like the ones in the current study.¹⁷ This is because: (1) robotic operations are new and have begun to be used in many centers recently, and (2) surgeons usually prefer sling operations mostly. Moreover, early study results can pave the way for wider studies.

When the UDI-6 and IIQ-7 scores of the patients' preoperative and 6th postoperative month were compared in the current study, an obvious decrease in the scores was noted (Tables 2 and 3). It was noted that urinary continence was ensured in the 6th postoperative month. However, although continence is ensured with BC robotic operation, more studies are needed to evaluate long-term results.

Table 3.

Assessment of Preoperative and Postoperative Period Scores of the Robotic and Abdominal Group Patients in Terms of QoL

	Robotic group (n = 20) p-value	Abdominal group (n = 20) p-value
UDI-6 preop 1–2 and UDI-6 postop 1–2	0.063	0.059
UDI-6 preop 3–4 and UDI-6 postop 3–4	0.042^*	0.038^*
UDI-6 preop total and UDI-6 postop total	0.043^*	0.043^*
IIQ-7 preop and IIQ-7 postop	0.042^*	0.042^*

The Wilcoxon signed-rank test was used for statistical analysis.

QoL, quality of life; UDI-6, Urogenital Distress Inventory, short form; preop, preoperative; postop, postoperative; IIQ-7, Incontinence Impact Questionnaire, short form.

p < 0.05 means statistically significant.

With the increase in average lifetime, it is not possible to anticipate the future complications of a foreign material being put into the body at an early age. In order to avoid mesh operations in middle-age patients, BC may still be the preferred method because BC avoids surgery that requires mesh.

The shortcomings of the current study included: (1) a small sample size that limited the ability to comment on the lack of differences identified in efficacy; and (2) only short-term outcomes were included. The strengths of this study included: (1) provision of a helpful report on efficacy and safety for a surgical approach that is not otherwise well-described in the literature and for an approach (BC) that is not outmoded but perhaps making a resurgence, given the current controversy regarding mesh; and (2) use of validated measures of efficacy and a condition-specific QoL tool for pre- and postoperative assessments.

Conclusions

For patients with SUI, who undergo robotic-assisted hysterectomy, adding robotic BC seems to be a proper approach instead of midurethral sling procedures. This is relevant also because the long-term complications involved with mesh implants remains unknown.

Footnotes

Disclosure Statement

The authors declare that they have no conflict of interest.

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