Since the introduction of robotic surgery, over 14 million robotic surgeries have been performed, and over 76,000 surgeons worldwide have been trained to perform robotic surgery.¹ The specialty of urogynecology and reconstructive pelvic surgery contributes to these numbers, and our panel discussed the application of robotic surgery in urogenital reconstruction. While there are advantages of robotic surgery, including the ability to perform concomitant abdominal procedures, decreased pain, and shorter hospital stays, these advantages must be weighed against surgeon preference and outcomes.

Vesicovaginal Fistula

The management of vesicovaginal fistula (VVF) can vary considerably; however, a few surgical principles are very important. These include (1) the surgeon using the approach they feel most comfortable with, (2) the clinician realizing that the first attempt is the best attempt, and (3) maximizing postoperative healing by encouraging smoking cessation and providing adequate postoperative drainage of the bladder with prevention of significant bladder spasms.^2,3 One can approach a VVF either vaginally, open abdominally, or using minimally invasive techniques. Each approach has its pros and cons, and the majority of VVFs are approached vaginally or robotically (multiport).⁴ An abdominal or robotic approach can be advantageous for nulliparous patients as most VVFs are at the vaginal apex following hysterectomy and accessing the apex can be challenging in this patient population due to lack of vaginal laxity. Regardless of approach, the majority of these surgeries entail a 2- or more-layer primary repair with tissue interposition between the bladder and vagina. Intraoperative ureteral stents can help prevent inadvertent ureteral injury (Figure 1). A catheter is left indwelling for 1 to 2 weeks before a postoperative cystogram is performed to confirm resolution of the fistula. Alternatively, an extravesical repair of a VVF can be performed by identifying the fistula tract endoscopically with wire placement (Figure 2). The fistula tract can be dissected with exposure of both the bladder and vaginal lumens. After closure of each lumen, tissue interposition with either omentum or peritoneum can be placed. A unique option with single-port robotic technology entails direct access into the bladder in order to correct the fistula from within the bladder. This approach is ideal in the difficult to access vaginal fistula, those with hostile abdomens, and those with solitary fistulas that do not need any concomitant ureteral reimplantation. The single-port surgical technique uses standard principles of nonoverlapping sutures to correct the fistula in both bladder and vaginal sides.⁴ A limitation of this approach is the lack of ability to interpose any pedicle or vascularized flap.

Ureteral Reimplant

For adult patients, ureteroneocystostomy (ureteral reimplantation) is generally performed for an injury or stricture of the distal ureter. Robotic approaches to ureteral reimplant are increasingly common. When performing this surgery robotically, port placement is generally consistent with other robotic pelvic surgery, and a transperitoneal extravesical approach is used with a refluxing anastomosis. Similar to open reimplant, a tension-free, watertight repair is critical, and a ureteral stent and catheter aid in urinary tract decompression postoperatively. Robotic approaches also allow for concomitant psoas hitch and/or Boari flap reconstruction as needed to span longer defects. In fact, a well-executed Boari flap in a patient with adequate bladder capacity can easily reach the midureter, spanning 10- to 15-cm defects. While the surgical approach should be dictated by the comfort of the surgeon, robotic ureteral reimplant generally has high success rates reported upward of 95% with no increase in postoperative complications as well as the added benefits of shorter hospital stay and decreased narcotic usage as compared with open surgery.^5-9 Similar to open approaches, a period of ureteral rest is recommended prior to robotic ureteral reimplant, which has been associated with higher rates of surgical success.⁵ In conclusion, a robotic approach to distal ureteral reconstruction is becoming increasingly common, offering the benefit of a minimally invasive surgical approach without compromising surgical outcomes.

Sacrocolpopexy, Mesh Complications, and Beyond

Sacrocolpopexy (SCP) has become the gold standard treatment of apical prolapse. A recent randomized trial of surgical approaches to pelvic organ prolapse compared SCP, native tissue suspension (sacrospinous ligament fixation and uterosacral vault suspension), and transvaginal mesh repair. Three hundred seventy-six patients were randomly assigned with 360 patients receiving surgery. SCP was performed in 113 patients total: robotically (61%), laparoscopically (23%), and abdominally (16%). Composite subjective and objective failure rates at 36 months were lowest for the SCP group at 28% compared with 29% for the transvaginal mesh repair group and 43% for the native tissue repair group. All treatments demonstrated no decisional regret and sustained improvement was noted. Adverse events were rare with only 3% of patients in the SCP group experiencing mesh exposure.^10,11 Whether performed as an open or minimally invasive procedure, the surgical principles of SCP have been stable over the last 20 years. These surgical principles include anterior dissection of the vaginal cuff with care to avoid a cystotomy, posterior dissection of the vaginal cuff, and dissection of the sacral promontory to expose the anterior longitudinal ligament (Figure 3). Type I polypropylene “Y” mesh is the preferred mesh type with the lowest complication rates and superior outcomes compared with cadaveric fascia or porcine dermis allografts.¹² Advances in robotic surgical techniques have allowed this procedure to be performed as an outpatient or same-day surgery procedure.^12,13 Unfortunately, complications associated with the use of mesh for the treatment of urinary incontinence or pelvic organ prolapse are not uncommon. Transvaginal mesh extrusions from midurethral sling procedures or SCP can often be treated conservatively with topical estrogen cream, especially if they are small. Fortunately, removal of malpositioned mesh either in the retropubic space or an apical mesh exposure after SCP can be accomplished through minimally invasive approaches with high success rates and low complication rates.^14,15

As with other urologic subspecialties, robotic surgery plays an important role in urogynecology and reconstructive pelvic surgery and is arguably the preferred approach for procedures such as SCP, ureteral reimplant, and select VVF repairs. Our panel encourages surgeons to continue performing whatever surgical approach results in their best outcomes.