Örebro University School of Medical Sciences Degree project, 15 ECTS
May 2020/January 2021
Does the symptomatic recurrence rate differ between
robotic-assisted and traditional laparoscopic
sacrocolpopexy?
Version
1
Author: Clara Odén Supervisor: Malin Brunes, (MD)
Abstract
BACKGROUNDApical vaginal prolapse involves descent of the uterus or the vaginal vault post-hysterectomy. Treating apical vaginal prolapse surgically is associated with a high risk of recurrence. To date there is no consensus on how to best surgically treat apical vaginal prolapse.
OBJECTIVE
To compare the surgical outcomes of conventional laparoscopic sacrocolpopexy and robotic-assisted laparoscopic sacrocolpopexy for apical vaginal prolapse.
METHODS
This retrospective cohort study was conducted among 435 women treated for apical vaginal prolapse with laparoscopic or robotic surgery between January 1st, 2015, and December 31st,
2018. Data was obtained from medical files. The primary outcome was a sensation of vaginal bulge up to two years after surgery. Secondary outcomes were operative time, conversion rate, length of stay and reoperations.
RESULTS
A final data set of 104 women were included (robotic n=47; laparoscopic n=57). Total operative time was significantly longer in the robotic group compared to the laparoscopic group (143,2 ± 63,5 vs 58,7 ± 10,6 minutes, P=5e-09). Women in the robotic group also had a significantly higher frequency of length of stay >2 days at the hospital after surgery (27,6 % vs 1,8 %, P=0,02). Finally, it could not be proven to be a significant difference between the groups regarding vaginal bulging symptoms up to two years after surgery, nor regarding reoperations or conversion rate.
CONCLUSION
It was not possible to determine a statistically significant difference in sensation of vaginal bulge up to two years after surgery between robotic-assisted and traditional laparoscopic sacrocolpopexy.
List of abbreviations
ASA American Society of Anesthesiologists BMI Body mass index
FDA United States Food & Drug Administration
GynOp The Swedish National Quality Register of Gynecological Surgery ICS International Continence Society
LASC Laparoscopic sacrocolpopexy POP Pelvic organ prolapse
POP-Q Pelvic organ prolapse quantification system RALSC Robotic-assisted laparoscopic sacrocolpopexy SFOG Swedish Society of Obstetrics and Gynecology TVT Tension free vaginal tape
Index
Abstract ... 2 List of abbreviations ... 3 Introduction ... 5 Aim ... 8 Methods ... 8 Results ... 10 Discussion ... 12 Conclusion ... 15 Acknowledgement ... 15 References ... 15Introduction
Pelvic organ prolapse
Pelvic organ prolapse (POP) is the downward descent of one or more of the female pelvic organs, including the uterus, vagina, bladder and bowel. There are different types of POP depending on organ involvement. Apical vaginal prolapse involves descent of the uterus or the vaginal vault post-hysterectomy. Anterior vaginal wall prolapse, or
cystocele, involves descent of the bladder. Posterior vaginal wall prolapse, also called rectocele, involves descents of the small bowel or rectum [1]. The most specific symptom of POP is seeing or feeling a vaginal bulge [2]. However, women with POP present a variety of symptoms including bowel, bladder and pelvic symptoms. In a cross-sectional study a total of 237 women with symptomatic POP completed a symptom-specific Likert scale questionnaire. Of these, 73 % women reported incontinence, 31 % reported fecal incontinence and 63 % reported lower abdominal pressure [3].
Prevalence
There is no clear consensus about what level of prolapse represents a variation of normal uterovaginal support and what represents a disorder [4]. Therefore, it is difficult to determine the true prevalence of POP in a population. Tegerstedt et al [5] did a cross-sectional study in a Swedish urban female population 30-79 years old, and 8,3 % were classified as having symptomatic POP. Similarity, Samuelsson et al [6] investigated the prevalence of POP in a Swedish population in the age between 20 to 59. The prevalence of any degree of
prolapse in this group was 30,8 %, while 2 % had a prolapse that reached the introitus. The Swedish Society of Obstetrics and Gynecology, SFOG, carefully concluded that between 2-8 % of the female population have a prolapse that reaches the introitus [7].
Known risk factors
The cause of POP is likely to be multifactorial. A systemic review showed that parity, vaginal childbirth, obesity and advancing age seemed to be important risk factors for developing POP [8]. In the Oxford Family Planning Study, increasing vaginal parity was the strongest risk factor for symptomatic POP amongst women younger than 60 years old [9]. Other potential risk factors for symptomatic POP are constipation and irritable bowel syndrome [10]. Regarding POP recurrence the preoperative stage seems to be the only confirmed risk factor [8].
Diagnosing and grading the severity of POP
Since 1996 a pelvic organ prolapse quantification (POP-Q) is used when diagnosing and grading POP. POP-Q is developed and validated by the International
Continence Society (ICS). It is an objective site-specific system were hymen is the fixed point of reference in relation to six defined anatomic landmarks. This system provides five stages of pelvic organ support. Stage 0 is when no prolapse is demonstrated, while stage IV is a
complete eversion of the lower female genital tract [11].
Functional pelvic floor anatomy
The support of the pelvic organs is primarily provided by the pelvic diaphragm and connective-tissue attachments called the endopelvic fascia. The pelvic diaphragm is composed of the levator ani and the coccygeus muscle. The levator ani is a muscle complex that consists of the pubococcygeus, the puborectalis and iliococcygeus muscles. The urethra and vagina pass through an opening within the levator ani called the urogenital hiatus. At rest, the levator ani tonically contracts and closes the urogenital hiatus. The pubococcygeus muscle is also termed the pubovisceral muscle and is subdivided based on points of insertion and function in to pubovaginalis, puboperinealis and puboanalis muscle [12]. The pelvic diaphragm is innervated by the pudendal nerve formed from the anterior rami of S2-4 spinal
nerves. It courses between the piriformis and coccygeus muscle and exits through the greater sciatic foramen [13]. Muscle atrophy of the levator ani and loss of structural integrity are most likely playing a part in female pelvic floor dysfunction [14].
Levels of support – 1992 DeLancy three levels of vaginal support
In 1992 DeLancy [15] divided the vaginal support in three levels. Level I suspends the upper third of the vagina and consists of the uterosacral and cardinal ligaments. Level II is supported by the endopelvic fascia. The pubocervical fascia supports the bladder and anterior vagina while the rectovaginal fascia supports the rectum and posterior vagina. Level III is supported by the levator ani muscles and the perineal body. The perineal body acts as junction for several structures and serves an important mechanism to provide perineal support [16].
Surgical treatment of apical pelvic organ prolapse
The aim of surgical treatment of POP is to restore vaginal function and support. Barber et al [17] concluded that the absence of vaginal bulging symptoms had the strongest
correlation with the patient’s satisfaction regarding the surgical outcome. There are several surgical methods available to treat apical vaginal prolapse. However, treating POP surgically is associated with a high risk of recurrence. It is estimated that the overall reoperation rate is about 11,5% [18]. According to a Cochrane review about how to best treat apical vaginal prolapse, sacrocolpopexy is recommended primarily [19]. Sacrocolpopexy is a method were a Y-formed mesh is sutured against the anterior and posterior vaginal wall and suspended to the promontory, sacrum. The aim is to re-suspend the upper vagina. When this includes the uterus, it is called sacrohysteropexy. When this includes the vaginal vault post hysterectomy, it is called sacrocolpopexy. Sacrocolpopexy can be done open abdominal, laparoscopic or robotic-assisted laparoscopic.
Robotic-assisted laparoscopic treatment in conducted with a surgical robot system composed of a patient-side robot, a vision chart and the robotic master console. The surgeon operates from a remote master console using both hand controls and foot pedals. Surgeon hand movements are transmitted to laparoscopic surgical instruments which
reproduce surgeon hand activity [20]. The development of this method was based on concept of telepresence, which US military saw as a potential to reduce the mortality from service personnel positioned in fields of conflicts [21]. In 2005, the United States Food & Drug Administration (FDA) approved the daVinci surgical system in gynecologic surgery. One advantage of the robotic system is the increased degree of freedom when performing procedures in the confined space of the female pelvis. The robotic camera also provides a closer visualization. This enables better preservation of blood vessels and therefore potentially reducing blood loss. Some of the disadvantages of robotic-assisted surgery are the costs, lack of tactile feedback or haptics, and the need to train surgeons and operating teams [20].
A systemic review from 2015 compared the results of laparoscopic
sacrocolpopexy (LASC) and robotic-assisted laparoscopic sacrocolpopexy (RALSC) and came to conclusion that the clinical outcomes were similar, but RALSC was less efficient in terms of cost and time [22]. In three randomized controlled trials comparing LASC and RALSC, both groups demonstrated significant improvement in vaginal support. RALSC provided anatomic correction of the apical vaginal prolapse comparable to LASC in all three studies [23, 24, 25]. However, Paraiso et al [24] found a longer suturing time in the robotic group compared to the laparoscopic group (98 min vs 68 min, P<0,0001). Anger et al [25] found that the overall operation time was 24,4 minutes longer in the robotic group but meant that the longer time in the robotic group was attributable to both docking time and console
time. The robotic group presented increased pain one week post operation respectively three to five weeks post operation in both Anger et al [25] and Paraiso et al [24] studies.
To date there is no consensus on how to best surgically treat apical vaginal prolapse. Different surgical techniques are used by different surgeons, but usually surgery is performed by fixation of wire or mesh to pelvic ligaments. The introduction of robotic
surgery in the benign gynecologic field has been controversial. The method is associated with greater costs and no clear evidence of better cure rate [26, 22]. More research is needed. The purpose of this study is to gain knowledge about how RALSC and LASC differs in terms of symptom relief and surgical outcomes.
Aim
The aim of this study was to compare the symptomatic recurrence rate between robotic-assisted sacrocolpopexy and traditional laparoscopic sacrocolpopexy when treating patients with apical vaginal prolapse.
Methods
This is a retrospective cohort study based on clinical data retrieved from medical files from hospitals in Stockholm which perform laparoscopic and robotic-assisted surgery to treat apical vaginal prolapse. Hospitals included were Södersjukhuset, Danderydssjukhus and Sophiahemmet (Stockholm). Social security numbers of patients undergoing laparoscopic or robotic-assisted sacrocolpopexy between January 1st, 2015, and December 31st, 2018, were
obtained from the hospitals. Women who still had their uterus at the time, women who did not have a vaginal vault prolapse according to the POP-Q classification, women not planned for sacrocolpopexy with mesh and women who were loss in follow up were excluded from the data set. Additional to sensation of vaginal bulge, the dataset included the age of the patients, body mass index (BMI), parity, menopausal status, smoking habits, previous hysterectomy, American Society of Anesthesiologists (ASA) physical status classification (1-5), POP-Q classification (I-IV), previous prolapse surgery, previous tension free vaginal tape (TVT), hospital, surgent, surgery, operative time, perioperative bleeding, risk of conversion to another procedure, length of stay, revisit time (months), and reoperation with anterior- or posterior colporrhaphy after surgery. Data from the medical files were collected up to two years after surgery to be able to identify any POP relapses.
The primary outcome was sensation of bulging or protrusion from the vagina after surgery. This was identified in the medical files during the return visits after surgery or if the hospitals were contacted by the patients due to relapse up to two years after surgery.
Secondary outcomes were operative time, rate of conversion to another procedure, length of stay and reoperation due to recurrence of POP. Operative time was either mentioned in the surgery report in the medical files, or obtained from Orbit, a planning system for surgeries.
The baseline demographic and descriptive data included age, BMI, ASA
Physical Status classification (grouped as ASA class 1-2 or 3-5), parity (grouped as 0, 1-2 and >3 children), previous TVT, previous POP surgery, and POP-Q classification (grouped as I, II, III and IV). Missing values is presented in the tables. Smoking and estimated blood loss were excluded from the study because of a high frequency of missing data.
Statistical analysis
Data was compiled in Excel (Microsoft, Redmond, USA) and was processed in the computer program R (© The R Foundation, version 4.0.3). Demographic data and perioperative descriptive data were presented as frequencies and proportions for categoric variable. Continuous data were listed as mean values with their standard deviations. Differences in group proportions regarding categorical variables were calculated with Pearson’s Chi2-test. Differences in group means were tested by a Welch two sample t-test. All p-values <0,05 were considered significant. All analyses were performed using R (© The R Foundation, version 4.0.3).
Ethical considerations
The study “A register study regarding evaluation of robotic-assisted benign gynecological surgery, such as removal of the uterus (hysterectomy) and surgery of apical vaginal prolapse” was approved by the Swedish Ethical Review Authority in Stockholm 2018-03-21. An application for amendment was approved 2020-05-18 by the Swedish Review Authority in Uppsala. The diary number of the ethical review is 2018/18-31. Approval of the review of the medical files has been obtained from the head of the Women´s health clinics at Danderyds sjukhus, Södersjukhuset and Sophiahemmet (Stockholm). To ensure the integrity of the patients, every patient was deidentified. All patients were given an ID-number instead of the social security number when collecting data in excel. Because of the number of patients in this study, it was not considered necessary to obtain consent. It is not possible to identify a single patient when presenting the study. The benefit of the study is to increase knowledge about sacrocolpopexy which will be useful for future patients. This benefit is considered to outweigh the risks.
Figure 1. Diagram showing flow of patients.
Results
The initial dataset consisted of 435 women undergoing robotic-assisted or laparoscopic surgical treatment for apical vaginal prolapse between January 1st, 2015 and
December 31st, 2018, at Södersjukhuset, Danderydssjukus and Sophiahemmet (Stockholm).
The dataset where then divided into two groups: women who had undergone previous hysterectomy and women who still had their uterus at the time. Women with no previous hysterectomy were excluded from the study. The study population was women with vaginal vault prolapse undergoing sacrocolpopexy. Women not having an apical vaginal prolaps according to the POP-Q (n=3), women not planned for sacrocolpopexy with mesh (n=2) and women with missing data on vaginal bulge symptoms after surgery (n=5) were excluded from the study. The study population, 104 women, was divided into two groups: robotic
sacrocolpopexy (n=47) and laparoscopic sacrocolpopexy (n=57) (Fig. 1).
Table 1 demonstrates the baseline characteristics and surgical data of the study population. Women in the robotic group were an average 3,2 years older and had a higher prevalence of ASA-classification 3-5 compared to women in the laparoscopic group. Women undergoing RALSC also had a higher frequency of previous TVT and previous POP surgery. Missing data is presented for every variable.
Patients with medical files which incorporated surgery codes for robotic or laparoscopic sacrocolpopexy, or sacrohysteropexy, from 1st of January 2015 to 31st of December 2018.
n= 435 Uterus n= 321 Excluded No uterus (previous hysterectomy) n= 114 Laparoscopic sacrocolpopexy n= 57 Robotic sacrocolpopexy n= 47 Excluded n= 10 No apical prolaps n= 3 No planned sacrocolpopexy n= 2 Missing data on vaginal bulging symptoms n=5
Converted n= 3
Converted n= 6
Table 1. Baseline characteristic.
Characteristic Study population
(n=104) Robotic (n=47) Laparoscopic (n=57) Age 67,5 ± 8,8 69,3 ± 9,0 66,1 ± 8,3 median 69 72 67 missing data 0 0 0 BMI 25,6 ± 3,8 25,3± 3,8 25,9± 3,8 median 25 24 25 missing data 7 0 7 ASA 1-2 92 (92,0) 38 (86,4) 54 (96,4) 3-5 8 (8,0) 6 (13,6) 2 (3,6) missing data 4 3 1 Parity 0 0 0 0 1-2 67 (70,5) 35 (81,4) 32 (61,5) > 3 28 (29,5) 8 (18,2) 20 (38,5) missing data 9 4 5 Previous TVT 7 (6,7) 6 (12,7) 1 (1,8) missing data 0 0 0 Previous POP surgery 48 (46,2) 25 (53,2) 23 (40,4) missing data 0 0 0 POP-Q I 33 (31,7) 6 (12,8) 27 (47,4) II 32 (30,8) 17 (36,2) 15 (26,3) III 28 (26,9) 16 (34,0) 12 (21,1) IV 11 (10,6) 8 (17,0) 3 (5,3) missing data 0 0 0
Data are mean ± standard deviation or n (%) unless otherwise specified.
Table 2. Surgical outcomes.
Data are mean ± standard deviation or n (%) unless otherwise specified.
Surgical outcomes Robotic n=47 Laparoscopic n=57 P-value
Operative time (min) 143,2 ± 63,5 58,7 ± 10,5 5e-09
missing data 6 5
Conversion rate 3 (6,4) 6 (10,5) 0,50
missing data 0 0
Length of stay (days) 0,024
<2 33 (70,2) 56 (98,2)
2-3 12 (25,5) 0 (0)
>3 1 (2,1) 1 (1,8)
Table 2 shows intraoperative data and postoperative outcomes with regard to LASC or RALSC. Total surgery time was an average of 84,5 minutes longer in the robotic group (143,2 ± 63,5 vs 58,7 ± 10,5 minutes, P=5e-09). Women undergoing robotic surgery more often had a hospital stay > 2 days in comparison to women undergoing laparoscopic surgery (27,6 % vs 1,8 %, P=0,024). The laparoscopic surgeries were converted more frequently compared to the robotic surgeries in this study, but it was not statically significant (10,5% and 6,4% respectively, P=0,5). One robotic-assisted sacrocolpopexy was converted do abdominal sacrocolpopexy due to carbon dioxide retention, and two robotic-assisted
sacrocolpopexies were called off due to abdominal adherents. In the laparoscopic group six surgeries were converted to vaginal surgery methods due to adherents in the abdomen or anatomic abnormalities making it difficult to attach the mesh to the promontory. The converted surgeries (n=9) will be excluded in further analysis.
Table 3. Clinical outcomes.
Clinical outcome Robotic (n=44) Laparoscopic (n=51) P-value
Vaginal bulge 12 (27,3) 8 (15,7) 0,17
missing data 0 0
Reoperations 5 (11,6) 11 (21,6) 0,27
missing data 1 0
Data are n (%) unless otherwise specified.
The clinical outcomes are presented in table 3. In the dataset, the fraction of women experiencing vaginal bulging symptoms was higher for women undergoing robotic surgery compared to laparoscopic surgery (27,3% and 15,7% respectively, P=0,17) and it was not possible to discard the null-hypothesis that there is no difference in symptoms of vaginal bulging between the two types of surgeries. The frequency of undergoing a reoperation was higher in the laparoscopic group compared to the robotic group, but it was not statically significant (11,6% and 21,6% respectively, P=0,27).
Discussion
The main findings were that a robotic-assisted approach to sacrocolpopexy results in a longer operating time and a higher frequency of length of stay > 2 days with no clear advantage in symptomatic relief up to two years after surgery. Furthermore, it could not be proven to be a significant difference between the groups regarding vaginal bulging
This study found a longer operative time in the robotic group, which is in line with the studies of Paraiso [24] et al and Anger [25] et al. Operative time were presented in suturing time, docking time, additional procedure time, anaesthesia time, operating room time and sacrocolpopexy time in the study of Paraiso [24) et al. They showed that the robotic approach took a significantly longer time in all of the categories mentioned above except for additional procedure time. This study does not present data showing time specifics for
different moments during surgery, partly due to its observational design. Systemic bias cannot be ruled out when different health care professionals at different hospitals take time. Specific time management during surgery would have been helpful information to better compare LASC and RALSC regarding the operative time in this study. The subject requires further research.
Three hospitals were included in this study: Sohpiahemmet where two surgeons performed solely laparoscopic sacrocolpopexy (n=60), Södersjukhuset where one surgeon performed only robotic-assisted sacrocolpopexy (n=15), and Danderyds sjukhus where two surgeons performed both approaches (n=37). One could speculate how surgeon volume affects the operating time. It is possible that surgeons at Sophiahemmet were faster as a result of the volume of sacrocolpopexies per year. However, the skills of the doctors are out of this study’s reach. This is a limit of this study partly due to its observational design.
In this study the symptomatic recurrence rate was based on the sensation of vaginal bulge after surgery. Women undergoing RALSC had a higher frequency of vaginal bulging symptoms after surgery compared to women undergoing LASC. However, the group difference did not prove to be significant. In three previous randomized controlled trials comparing LASC and RALSC, the robotic approach provided anatomic correction of the apical vaginal prolapse comparable to LASC in all three studies [23, 24, 25]. In one of the studies, the objective cure rate of the apical compartment was 100 % with both approaches at a mean follow-up of 24 months, and the patients were satisfied with both procedures. Its single-centre, single-surgeon design was discussed by Illiano et al as a possible explanation for the high objective success rate [23]. This study did not include the objective success rate. An addition to this study would have been to also include postoperative POP-Q classification. This to analyse if remaining symptoms of vaginal bulge correlate with postoperative anatomic correction.
Longer operative times and longer length of stays means increased costs. In a cost-minimization analysis of robotic, laparoscopic and abdominal sacrocolpopexy made by Judd [27] et al, the robotic approach was more expensive. Parameters in their analysis were
operative time, conversion risk, transfusion risk and length of stay. The increased costs when performing RALSC were a result of longer operative time and higher disposable equipment costs. One could speculate how the results in this study affect the costs of both RALSC and LASC. Longer operative time and longer length of stay probably makes RALSC the more expensive method. However, the conversion risk and the reoperation risk are also possible parameters to take into account. Further studies are needed in Sweden to compare the two methods in terms of cost efficiency.
The strength of this study is the inclusion of all hospitals and surgeons in Stockholm performing sacrocolpopexy. The Swedish National Quality Register of
Gynecological Surgery, GynOp, shows that the main part of sacrocolpopexy performed in Sweden, is performed in Stockholm [28]. Another strength is the long study period stretching over four years. Furthermore, the study collected data about symptomatic recurrence, as well as, reoperations up to two years after surgery.
A limitation of this investigation is the systemic bias which might occur when reviewing medical files. There were three partakers evaluating the medical files in this study. First, it can be a subjective question of interpretation when reading medical files. Second, there is risk for typo when transferring data to excel. Even though the information from the medical files were retrieved in a structured excel-sheets with majority binary questions, the human error cannot be eliminated. Also, when reviewing medical files, there is a loss
regarding follow up after surgery if the patient moves to another city and thereby seek further care elsewhere.
Another limitation was the absence of a regression analysis. Women in the robotic group were an average 3,2 years older and had a higher prevalence of
ASA-classification 3-5 compared to women in the laparoscopic group, which are factors that might affect the surgery. Women undergoing RALSC also presented a higher stage of POP-Q preoperatively. As mentioned in the introduction, the preoperative stage of POP seems to be the only confirmed risk factor regarding the POP recurrence [8]. Due to the non-randomized study design, these factors have not been eliminated and could be a source of bias.
In this retrospective cohort study, RALSC was associated with a longer
operative time and a higher frequency of length of stay > 2 days, without increased symptom relief up to two years after surgery compared with the conventional laparoscopic approach. Although robotic surgical systems are a development of laparoscopic minimally invasive surgery, this study could not show a clear advantage for the patient, nor the health care. For the patient living with POP related symptoms, it can reduce quality of life [29]. Almost half of
of the women in the robotic group and 21,6 % of the women in the laparoscopic group had a reoperation after the sacrocolpopexy. One can imagine how several reoperations might affect the individual both emotionally and physically. It is important both for the affected individual and for the health care to find the best surgical method regarding symptomatic cure rate and sustainable use of health care resources. Future research is warranted discern the best method to surgically correct apical vaginal prolapse.
Conclusion
It was not possible to determine a statistically significant difference in sensation of vaginal bulge up to two years after surgery between robotic-assisted and traditional
laparoscopic sacrocolpopexy.
Acknowledgement
A special thanks to my supervisor Malin Brunes and her colleagues at
Södersjukhuset, Stockholm. They all made me feel welcomed at their work space. Thanks for giving me the opportunity to look into this subject that really interests me.
References
1. Milsom I, Altman D, Cartwright MC, Nelson R, Sillén U, Tikkinen K et al. Epidemiology of Urinary Incontinence (UI) and other Lower Urinary Tract Symptoms (LUTS), Pelvic Organ Prolapse (POP) and Anal Incontinence (AI). I Abrams P, Cardozo L, Khoury S, Wein AJ, editors. Incontinence: 5th International Consultation on Incontinence, Paris, February 2012. 5th ed. Paris: ICUD-EAU; 2013. p. 15–107.
2. Swift SE, Tate SB, Nicholas J. Correlation of symptoms with degree of pelvic organ support in a general population of women: what is pelvic organ prolapse? Am J Obstet Gynecol. 2003 Aug;189(2):372–7.
3. Ellerkmann RM, Cundiff GW, Clifford FM, Nihira MA, Leffler K, Bent EA. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol. 2001 Dec;185(6):1332-8.
4. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. The Lancet. 2007 Mar;369(9566):1027–38.
5. Tegerstedt G, Maehle-Schmidt M, Nyrén O, Hammarström M. Prevalence of symptomatic pelvic organ prolapse in a Swedish population. Int Urogynecol J Pelvic Floor Dysfunct. 2005 Nov-Dec;16(6):497–503.
6. Samuelsson EC, Victor FT, Tibblin G, Svärdsudd KF. Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors. Am J Obstet Gynecol. 1999 Feb;180(2 pt 1):299–305.
7. Svensk förening för obstetrik och gynekologi arbets-och referensgrupp för urogynekologi och vaginal kirurgi. Prolaps. Stockholm: Svensk förening för Obstetrik och Gynekologi; 2008. Rapport nr 60 [cited 2020 Sep 24]. Available from:
https://www.sfog.se/natupplaga/nr60392513ba-27b9-47b0-ba8d-2b8940608d94.pdf 8. Vergeldt TF, Weemhoff M, IntHout J, Kluivers KB. Risk factors for pelvic organ prolapse and its recurrence: a systematic review. Int Urogynecol J. 2015
May;26(11):1559–73.
9. Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol. 1997
May;104(5):579–85.
10. Rortveit G, Brown JS, Thom DH, Van Den Eeden SK, Creasman JM, Subak LL. Symptomatic Pelvic Organ Prolapse: prevalence and risk factors in a population-based, racially diverse cohort. Obstet Gynecol. 2007 Jun;109(6):1396–403.
11. Bump RC, Mattiasson A, Bø K, Brubaker LP, DeLancy JO, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor
dysfunction. Am J Obstet Gynecol. 1996 Jul;175(1):10–7.
12. Kearney R, Sawhney R, DeLancey JO. Levator ani muscle anatomy evaluated by origin-insertion pairs. Obstet Gynecol. 2004 Jul;104(1):168–73.
13. Barber MD, Bremer RE, Thor KB, Dolber PC, Kuehl TJ, Coates KW.
Innervation of the female levator ani muscles. Am J Obstet Gynecol. 2002 Jul 1;187(1):64– 71.
14. Hoyte L, Schierlitz L, Zou K, Flesh G, Fielding JR. Two- and 3-dimensional MRI comparison of levator ani structure, volume, and integrity in women with stress incontinence and prolapse. Am J Obstet Gynecol. 2001 Jul;185(1):11–9.
15. DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992 Jun;166(6 pt 1):1717–28.
16. Woodman PJ, Graney DO. Anatomy and physiology of the female perineal body with relevance to obstetrical injury and repair. Clin Anat. 2002 Aug;15(5):321–34. 17. Barber MD, Brubaker L, Nygaard I, Wheeler TL 2nd, Schaffer J, Chen Z, et al. Defining success after surgery for pelvic organ prolapse: Obstet Gynecol. 2009
Sep;114(3):600–9.
prolapse: a Danish cohort study with 15–20 years’ follow-up. Int Urogynecol J. 2018 Jan;29(1):119–24.
19. Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Brown J. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev. 2016 Oct; 2016(10): CD012376.
20. Visco AG, Advincula AP. Robotic gynecologic surgery. Obstet Gynecol. 2008 Dec;112(6):1369–84.
21. Lane T. A short history of robotic surgery. Ann R Coll Surg Engl. 2018 May;100(6_sup):5–7.
22. Pan K, Zhang Y, Wang Y, Wang Y, Xu H. A systematic review and meta-analysis of conventional laparoscopic sacrocolpopexy versus robot-assisted laparoscopic sacrocolpopexy. Int J Gynaecol Obstet. 2016 Mar;132(3):284–91.
23. Illiano E, Ditonno P, Giannitsas K, De Rienzo G, Bini V, Costantini E. Robot-assisted vs laparoscopic sacrocolpopexy for high-stage pelvic organ prolapse: a prospective, randomized, single-center study. Urology. 2019 Dec;134:116–23.
24. Paraiso MF, Jelovsek JE, Frick A, Chen CC, Barber MD. Laparoscopic Compared with robotic sacrocolpopexy for vaginal prolapse: a randomized controlled trial. Obstet Gynecol. 2011 Nov;118(5):1005–13.
25. Anger JT, Mueller ER, Tarnay C, Smith B, Stroupe K, Rosenman A, et al. Robotic compared with laparoscopic sacrocolpopexy: a randomized controlled trial. Obstet Gynecol. 2014 Jan;123(1):5–12.
26. Carlsson P, Sjödahl R, Theodorsson E. Robotassisterad kirurgi ökar – trots osäker kostnadseffektivitet. Läkartidningen. 2016;113;D7CM.
27. Judd JP, Siddiqui NY, Barnett JC, Visco AG, Havrilesky LJ, Wu JM. Cost-minimization analysis of robotic-assisted, laparoscopic, and abdominal sacrocolpopexy. J Minim Invasive Gynecol. 2010 Jul-Aug;17(4):493–9.
28. Bergman, Ida. Årsrapport för operationer utförda år 2019 – prolapskirurgi [Internet]. The Swedish national quality register of gynecological surgery; 2020 [cited 2021 Jan 3]. Available from:
http://www.gynop.se/wpcontent/uploads/2020/06/Prolapsrapport2019.pdf
29. Jelovsek JE, Barber MD. Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life. Am J Obstet Gynecol. 2006
