S. Adam Ramin, a urologic surgeon and medical director of Urology Cancer Specialists in Los Angeles, is one of the few surgeons performing robot-assisted sacrocolpopexy for pelvic prolapse in an ambulatory surgery center. Here he discusses the procedure and how ASCs could benefit in the future.
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Q: How does the minimally invasive procedure for pelvic prolapse differ from the traditional open procedure?
Dr. S. Adam Ramin: Traditionally the surgeries were performed via open incisions through the vagina or abdominal cavity. With the advent of robotic surgery, this surgery can be done laparoscopically and in the ambulatory surgery center. It involves great skill and expertise, and when it's done with experienced hands, it's a very safe and effective method of treating patients with pelvic prolapse.
Robotic sacrocolpopexy involves dissection of the anterior vaginal wall and posterior vaginal wall laparoscopically, with the aid of the daVinci surgical robot. The dissection is done through an intracorporeal approach. After the exposure of the vagina, a piece of soft mesh is placed along the posterior and anterior aspects of the vaginal wall and cervix (if present). Both meshes are secured usually with soft Gor-Tex sutures. The tail of each mesh is then secured against the periosteum of the sacrum.
This technique essentially pulls the vaginal wall back inwards into the abdominal cavity.
Q: Are there important considerations surgeons should understand during patient selection for this procedure?
AR: Surgeons should consider the degree of difficulty for each particular patient prior to undertaking the surgery. Factors that can increase the degree of difficulty are previous pelvic surgery, presence of abdominal and pelvic adhesion, prior pelvic radiation, obesity, diabetes, prior history of pelvic radiation, and medical conditions that reduce wound healing. Such factors are important in deciding whether the patient is a good candidate for having the procedure done in an ambulatory surgery center.
Furthermore, surgeons should consider whether a concurrent hysterectomy is necessary at the time of sacrocolpopexy. While many surgeons perform the hysterectomy in order to facilitate the robotic sacrocolpopexy, it is not the case that a hysterectomy is absolutely necessary for a successful robotic sacrocolpopexy. Nor is it true that a robotic sacrocolpopexy cannot be performed without having to remove the uterus.
I generally do not perform a hysterectomy unless there is an additional indication. Many surgeons ask how one attaches the anterior portion of the mesh to the secrum without removing the uterus. The answer is that the anterior mesh can be split into a Y, with each arm of the Y brought through each side of the broad ligament, around the uterus and attached to the sacrum. This technique preserves the uterus in a robotic assisted laparoscopic sacrocolpopexy.
Q: What does it take to perform these procedures in the outpatient surgical center setting?
AR: This minimally invasive procedure uses robotic technology, and like any other robotic procedure, experience is important. Depending on the particular skill set of the surgeon, it may take as low as 20 cases or as high as 100 cases before reaching proficiency. Those who have high levels of robotic surgical experience in complex-type surgeries such as prostate cancer, gynecologic cancers, and pelvic reconstruction surgery are generally able to incorporate this procedure into their practice faster than those with minimal robotic experience.
If the surgery center has in its possession a new generation daVinci robot, then robotic sacrocolpopexy can be done at the surgery center with experienced hands, in selected healthy patients. A center that's looking to purchase a robot for outpatient applications can interest surgeons in doing other procedures with the technology as well. These procedures include robotic prostate cancer surgery in selected patients, hernia repairs, spermatic vein ligation, hysterectomy for benign disease and other gynecology procedures.
Q: Robotic technology is often expensive. Will that be a prohibitive factor for ASCs?
AR: Financially a robotic system can be very expensive and cost-prohibitive. Currently there aren't many centers in the United States with a robot. But some of those that have successfully purchased a robot are doing well financially.
Q: How can surgery centers build a successful robotic surgery program and see a return on investment?
AR: There are a number of factors important to a successful robotic program at any surgery center. These factors include hiring an effective robotic program coordinator, marketing, and following proper safety standards. Furthermore, one of the most important factors is having enough highly trained and experienced surgeons who are able to perform the robotic procedures safely and effectively.
As part of the current changes in our healthcare system, major hospitals are purchasing physician practices and hiring physicians directly. However, many physicians and surgeons do not desire to become employees of large hospitals. The more independent-minded physicians would be more inclined to join surgery centers rather than work for a hospital. Therefore, surgery centers that are well equipped, highly organized, have a history of strong safety standards, and keep current with technological advances are poised to attract the most talented, independent minded surgeons.
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