Robot-assisted surgery with the body's own tendon for genital prolapse

The world's first robot-assisted cervical lift using the body's own tendon has been performed at the Department of Gynecology and Gynecologic Oncology at the University Hospital Bonn (UKB). In an interview with MEDICA-tradefair.com, Prof. Dominique Könsgen-Mustea assesses the initial results of the new minimally invasive surgical method.

Prof. Könsgen-Mustea, how do you experience the further development of surgery for uterine prolapse?

Prof. Dominique Könsgen-Mustea: For many years, we have had an internationally established standard for the treatment of uterine and vaginal prolapse: laparoscopic sacrocolpopexy, in which the uterus is lifted using a plastic mesh.

Minimally invasive procedures using robot-assisted surgical systems make it possible to operate more precisely and with less tissue damage. This method has significant advantages for the patient, such as generally less blood loss, fewer intraoperative complications, less postoperative pain and a shorter stay in hospital.

We were looking for an alternative to plastic mesh and came across the use of autologous tissue from the abdominal wall or thigh in the USA. In Germany, laparoscopic sacrocolpopexy using a tendon from the leg was first described a few years ago.

At the UKB, we performed these tendon operations with the Da Vinci surgical robot for the first time in 2022. The surgical method was further developed for the robot-assisted procedure. With the robot-assisted surgical system, we have a 10x magnification with high-resolution 3D optics of the surgical area. The instruments are used very ergonomically, and 360-degree rotations are also possible. The procedure enables precise and tissue-conserving surgery in narrow and low-lying spaces. Compared to classic laparoscopy, we only use access points at the level of the navel and can dispense with a further incision above the pubic bone.

What is the long-term outcome of the new method? Is there a comparison with conventional procedures?

Könsgen-Mustea: The one-year follow-up of the first ten patients showed that it is a very effective procedure. There were no recurrences of prolapse and no complications during the operation. The fixation with the tendon is very stable. There was no pain or mobility restrictions in the leg.

After the first 10 operations, we initiated an international register study with five other centers in Germany, Austria and Switzerland under the leadership of the UKB, in which the outcome of patients treated with this surgical method is analyzed consecutively. The other centers perform the procedure in the classic laparoscopic way, only we work robot assisted. But it would be premature to compare the results at this stage.

Can the procedure replace the traditional surgical method?

Könsgen-Mustea: It is an alternative for a special group of patients. In the case of a defect that extends over several compartments or is very pronounced, the tendon is not sufficient for a reconstruction. If the prolapse is only moderate, and especially if the middle compartment is affected, the procedure is a very good alternative. The decisive factor is therefore a defect- and symptom-oriented indication.

Is robot-assisted surgery possible for other pelvic floor disorders or organ prolapse?

Könsgen-Mustea: I think that minimally invasive surgery with robot-assisted surgical systems is very suitable for pelvic floor surgery in general and will become established in the future. It is designed for operations in the lesser pelvis, as it enables precise surgery in confined spaces and at depth. There are training courses for this, exercises on the robot, and it is also possible to observe operations in other surgical centers. In my opinion, the learning curve is rather quick, especially if surgeons have already performed a lot of open surgery. The handling is very intuitive. Various robot-assisted surgical systems are now available to us and demand is very high.

Around half of all women are affected by pelvic floor dysfunction at some point in their lives. This can be prolapse or associated dysfunction. The majority of women are over 65 years old, but we also have many younger patients. At our clinic alone, we perform around 200 operations for prolapse every year.

Does the tendon used show signs of wear and tear?

Könsgen-Mustea: We assume that the tendon remains stable and does not disintegrate. We don't yet have any data over several years. But orthopedic surgeons have been using this tendon for many years as an established procedure for replacing the cruciate ligament in the knee. Their experience makes us optimistic. Another positive aspect is that tendon-like tissue grows back on the leg where the tendon was removed.