Factors associated with intraoperative conversion during ... - SciELO

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Brian J. Linder 1, George K. Chow 1, Lindsay L. Hertzig 1, Marisa Clifton 1, Daniel S. Elliott 1 ..... ted to the higher conversion rate reported in the later years of ...
Vol. 41 (2): 319-324, March - April, 2015

ORIGINAL ARTICLE

doi: 10.1590/S1677-5538.IBJU.2015.02.19

Factors associated with intraoperative conversion during robotic sacrocolpopexy _______________________________________________ Brian J. Linder 1, George K. Chow 1, Lindsay L. Hertzig 1, Marisa Clifton 1, Daniel S. Elliott 1 Department of Urology, Mayo Clinic, Rochester, MN, USA

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ABSTRACT ARTICLE INFO ______________________________________________________________

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Objective: To evaluate for potential predictors of intraoperative conversion from robotic sacrocolpopexy (RSC) to open abdominal sacrocolpopexy. Patients and Methods: We identified 83 consecutive patients from 2002-2012 with symptomatic high-grade post-hysterectomy vaginal vault prolapse that underwent RSC. Multiple clinical variables including patient age, comorbidities (body-mass index [BMI], hypertension, diabetes mellitus, tobacco use), prior intra-abdominal surgery and year of surgery were evaluated for potential association with conversion. Results: Overall, 14/83 cases (17%) required conversion to an open sacrocolpopexy. Patients requiring conversion were found to have a significantly higher BMI compared to those who did not (median 30.2kg/m2 versus 25.8kg/m2; p=0.003). Other medical and surgical factors evaluated were similar between the cohorts. When stratified by increasing BMI, conversion remained associated with an increased BMI. That is, conversion occurred in 3.8% (1/26) of patients with BMI ≤25 kg/m2, 14.7% (5/34) with BMI 25-29.9 kg/m2 and 34.7% (8/23) with BMI ≥30 kg/m2 (p=0.004). When evaluated as a continuous variable, BMI was also associated with a significantly increased risk of conversion to an open procedure (OR 1.18, p=0.004). Conclusions: Higher BMI was the only clinical factor associated with a significantly increased risk of intra-operative conversion during robotic sacrocolpopexy. Recognition of this may aid in pre-operative counseling and surgical patient selection.

Key words: Robotics; Pelvic Organ Prolapse; Obesity

INTRODUCTION Abdominal sacrocolpopexy is considered the “gold standard” in the repair of symptomatic high grade vaginal vault prolapse, secondary to high success rates and durable long-term results (1, 2). Recently, multiple series have shown similar excellent long-term outcomes in patients managed with a robotic approach to sacrocolpopexy (35). However, while replicating the anatomic principles of the open sacrocolpopexy and potentially decreasing length of hospitalization and blood

Int Braz J Urol. 2015; 41: 319-24

_____________________ Submitted for publication: February 21, 2014 _____________________ Accepted after revision: July 28, 2014

loss, one issue unique to a minimally invasive approach (whether laparoscopic or robotic) to sacrocolpopexy is that of the potential for requiring conversion to an abdominal sacrocolpopexy (4, 6). Prior series on RSC have demonstrated a conversion rate ranging from 0 to 11% (3, 6-8). Furthermore, in other surgeries performed with robotic assistance, multiple potential risk factors for conversion such as surgeon experience (9), technical difficulty/failure to progress/ injury to adjacent organs (9, 10), patient risk factors (prior abdominal surgery, obesity, etc.)

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ibju | Conversion during robotic sacrocolpopexy

(9-11) and equipment malfunction (12) have been proposed. However, there is a paucity of data regarding potential predictors of conversion specifically for RSC. Notably, compared to other robotic pelvic surgeries, RSC presents unique technical challenges such as dissecting in the retroperitoneal fat and potential for hemorrhage from presacral veins. Thus, recognizing specific factors associated with conversion during RSC may aid in patient selection as well as pre-operative patient counseling. Therefore, in a large cohort of RSC patients we sought to evaluate for clinical predictors of intraoperative conversion from RSC to an open procedure. PATIENTS AND METHODS

National Institutes of Health definitions of normal weight (BMI