Abdominal Colpopexy: Comparison of Endoscopic Surgical Strategies (ACCESS)

• Measure total cost of care between women who undergo laparoscopic and robotic assisted laparoscopic Abdominal Sacrocolpopexy [ Time Frame: 1 month ] [ Designated as safety issue: No ]
  To measure the total cost of care and relate the difference in cost of care between the women undergoing laparoscopic and robotic assisted laparoscopic Abdominal Sacrocolpopexy (ASC)to differences in health utilities and health-related quality of life, which will allow us to examine the cost-effectiveness of robotic assistance.
  
  

• To compare short-term recovery and the time to return to normal activities between women undergoing laparoscopic and robotic assisted laparoscopic ASC. [ Time Frame: 1 year ] [ Designated as safety issue: No ]

  1) Quality of Life

  1. Global: compare SF-36 scores and sub-scales , EQ-5D amongst groups.
  2. Disease-specific: compare urinary, bowel and prolapse scales of validated conditions specific Pelvic Floor Impact Questionnaire amongst groups.
  
  

Approximately one in ten women undergoes surgery for prolapse or incontinence in her lifetime. Of these, up to thirty percent require a re-operation for recurrence of their prolapse or incontinence symptoms. It has been estimated one in nine women will undergo a hysterectomy in her lifetime, and up to 10% of these women will require surgery for symptomatic vaginal vault prolapse. The search for the ideal repair for pelvic organ prolapse has led to the invention of several approaches to this problem.

Abdominal sacrocolpopexy (ASC) with synthetic mesh is considered the gold standard in the surgical management of pelvic organ prolapse with anatomic success rates ranging from 90 to 100% (Brubaker L, Guiahi M). Randomized comparative effectiveness trials and systematic literature reviews demonstrated the anatomic superiority of open ASC compared to vaginal sacrospinous ligament suspension.

Although ASC has the highest anatomic success rates for correcting apical prolapse, it is traditionally done via a laparotomy requiring an abdominal incision. Open technique is associated with more frequent short-term complications, including gastrointestinal (Benson JT, Whitehead W).

Minimally invasive approaches to ASC using laparoscopy or robotic assisted laparoscopy demonstrate shorter hospital stays, decreased blood loss, and similar short-term anatomic outcomes when compared to open ASC (Geller E, Tarr M, Paiso M). Increasing numbers of surgeons and patients choose minimally invasive ASC to maximize the benefits of abdominally placed mesh and the shorter-recovery associated with minimally invasive surgery. Few studies have compared laparoscopy to robotic assisted-laparoscopy in pelvic reconstructive surgery.

Like many techniques in pelvic surgery, trends in the management of pelvic organ prolapse continue to evolve. Unfortunately, such trends are not supported by level I data, specifically that provided by randomized clinical trials. Although robotic technology is new and rapidly spreading throughout the urologic and gynecologic communities, there are no randomized trials comparing outcomes of robotic to more traditional laparoscopic techniques for reconstructive pelvic surgery. Retrospective series indicate comparable efficacy with respect to cure of prolapse. However, to date is it unknown how robotic surgery compares to laparoscopic techniques with respect to cost, patient safety, pain, and ability to return to normal activities.

The use of the robot in laparoscopic surgery is costly. The costs of purchasing a robot has been estimated at $1.5 million dollars with annual maintenance costs of $112,0007. In addition, additional costs exist for the robotic equipment utilized with each case. It is arguable that the maintenance and operative equipment costs may overshadow any potential savings in length of hospital stay and patient convalescence. However, if robotic sacrocolpopexy can provide better immediate quality of life, less pain, and faster recovery compared to laparoscopic techniques, the investment in robotic techniques may very well be cost effective when a societal perspective is taken.