Urogynecology is a relatively new subspecialty of obstetrics and gynecology. It has grown out of need. Urogynecologists focus on the care of women with bladder issues and symptomatic pelvic floor relaxation.
For time immortal, there has been a need for therapies to treat the problems women face that are related to childbirth, aging, and the forces of gravity. When women go through pregnancy and vaginal delivery, the organs of the pelvis are stretched and rarely return to their pre-baby state. These effects are amplified by age, a genetic predisposition, and other medical conditions such as diabetes. When the uterus and vagina lose their normal support, they begin to fall. They can even fall outside of the vaginal opening. This phenomenon is called pelvic floor relaxation or prolapse. There are several different types of prolapse. [link to types of prolapse] For years, the best treatments doctors had to offer for these issues were exercises, open abdominal surgeries with large incisions and difficult recoveries, or the use of pessaries. Pessaries are devices that must be worn constantly to physically push the organs back up into the vagina and hold them in place.
Surgical robots were originally developed by the military with the idea that a surgeon could operate on a wounded soldier from a remote location, sort of like flying a drone. What has evolved is totally different. The robots are now used by surgeons sitting at a console in the same operating room where the patient is. The advantage the robots offer is that surgeons can do very delicate surgeries inside the abdomen through very small poke holes rather than through large incisions. The result of all that is that the patients can have less blood loss, less post-operative pain, and require fewer days in the hospital. In fact, the surgical robot actually makes some surgeries much more practical than their open counterparts have always been. Specifically speaking, the gold-standard surgery for uterine prolapse is the sacrocolpopexy, which has traditionally been performed through a large incision in the abdomen.
The Robotic Sacrocolpopexy is performed mostly by urogynecologists. It is done in conjunction with a robotic hysterectomy in women with utero-vaginal prolapse. It is also done alone in women who have previously had a hysterectomy and now have vaginal vault prolapse. [link to types of prolapse] In a Robotic Sacrocolpopexy, from inside the abdomen, a Y-shaped piece of flat surgical mesh is used. The arms of the “Y” are sewn to the front and back of the vagina respectively and the stem of the “Y” is sewn to a ligament on the inside of the sacrum (lower part of the spine attached to the pelvic bones.) This procedure lifts the vagina back into the pelvis and securely holds it there. This surgery has a high success rate, higher than most other prolapse surgeries, making it the gold standard surgery for the treatment of uterovaginal or vaginal vault prolapse. When indicated, a procedure for urinary incontinence can be done at the time of a sacrocolpopexy. [link to types of urinary incontinence]
The primary benefit of this surgery is obvious. It is that the patient’s pelvic organs are no longer falling out of the vaginal opening.
The women who have had these procedures report that they are more comfortable both mentally and physically when not having to deal with the constant vaginal pressure and discomfort.
This obviously goes with the above topic, but women are happier after these surgeries, because they no longer have the anguish that goes along with constant worry about feeling less feminine, poor sexual performance, and embarrassment.
Another less obvious benefit is improvement in urination. By pulling the vagina back into the pelvis, the urethra (the tube from the bladder to the outside) is pulled back into a more normal alignment allowing more normal urine flow, without obstruction. This can improve the bladder’s ability to empty and reduce the risk of urinary tract infection.
Improved sexual intercourse is not guaranteed, but is often reported by patients. It only makes sense that if the vagina is held firmly back inside the pelvis instead of falling out, vaginal intercourse would be easier and more gratifying for all parties involved. Many patients report this sort of result. However, in a small percentage of cases, the implanted mesh can erode through the vaginal wall making intercourse uncomfortable for male sex partners. Also, any prolapse repair procedure, not just sacrocolpopexies, can lead to discomfort with intercourse, but fortunately, these problems are the exception rather than the rule.
Another surgical option for uterovaginal prolapse that can be done robotically is a uterosacral ligament suspension. In this surgery, the surgeon ties the upper part of the vagina to a pair of ligaments in the pelvis called the uterosacral ligaments. These ligaments lie on either side of the lower part of the sacrum and are in part responsible for suspension of the top of the vagina. This is done with suture. No surgical mesh is used. It has the same goals and benefits as the Sacrocolpopexy. The main difference is that many studies have found the Uterosacral Ligament Suspension has a slightly lower long-term success rate when compared to the sacrocolpopexy. One of the benefits of this procedure is that since there is no mesh used, mesh erosion is never an issue.
Other surgeries are often performed together with one of the above procedures. If the patient has a weak front vaginal wall and her bladder is bulging into her vagina, this is called a Cystocele. The surgery for this is called an Anterior Colporrhaphy (commonly known as an Anterior Repair). If her back/posterior vaginal wall is weak and the rectum is bulging into her vagina, this is called a rectocele. For this, the patient might need a Posterior Colporrhaphy (Posterior Repair). If the woman leaks urine when she coughs or laughs, it is called Stress Urinary Incontinence. The most common surgery for that is a Urethral Sling procedure to help prevent urine leakage.
The sub-specialty of Urogynecology has grown rapidly since the introduction of the surgical robot, but not all Urogynecologists are firm believers in robotic surgery. Some of these doctors still prefer open procedures because that is what they have experience doing.