The Effect of Body Mass Index (BMI) in Peri-operative Outcomes in
Patients undergoing Davincci® Assisted Sacrocolpopexy for Pelvic
Organ Prolapse
Ali Azadi, MD, Kira C. Taylor, PhD, Susan B. Muldoon, PhD, Donald
R. Ostergard, MD
Introduction:
Pelvic floor dysfunction is a major health issue for older women, as shown by the 11.1%
lifetime risk of undergoing a single operation for pelvic organ prolapse and urinary
incontinence, as well as a large proportion of re-operations(1). Reconstructive pelvic
surgery for correction of significant pelvic support defects has been shown to be more
effective with an abdominal approach(2). Sacrocolpopexy is a reliable procedure that
effectively and consistently resolves vaginal vault prolapse(3). The introduction of
minimally invasive surgery has made the laparoscopic approach for sacrocolpopexy a
feasible option for surgical treatment of pelvic organ prolapse. It has been shown that
laparoscopic and open sacral colpopexies have comparable clinical outcomes(4). In recent
years, the introduction of robot-assisted laparoscopy surgery has caused many surgeons
to choose robot-assisted sacrocolpopexy for treatment of pelvic organ prolapse. It is a
feasible procedure which has acceptable complication rates and short learning curve(5).
Even though robotic sacrocolpopexy is more expensive compared to the laparoscopic or
abdominal routes under baseline assumptions, robot-assisted laparoscopic surgery allows
suturing and dexterity skills to be performed quicker than does manual laparoscopy (6,7).
The robot-assisted laparoscopic sacrocolpopexy combines the advantage of an open
sacrocolpopexy with the decreased morbidity of laparoscopy. Decreased hospital stay,
low complication rates, and high patient satisfaction are among the advantages of this
surgical approach for treatment of pelvic organ prolapse(8).
The objective of this study was to evaluate the impact of obesity in peri-operative
outcomes and success of robot-assisted sacrocolpopexy. According to the center for
disease control, about one-third of American adults are obese(9). Previous studies have
shown that most outcomes and complication rates after sacrocolpopexy are similar in
obese and healthy-weight women(10). Increase in the amount of presacral fat in obese
women can be challenging for surgeons to perform sacrocolpopexy. We hypothesize that
better visualization including magnification and 3-D image may aid the surgeon to
overcome this challenge. In addition, having control over more than 2 instruments at a
time and the ability to perform more complex movements may aid the surgeon to be more
comfortable in this critical part of the procedure.
Material and Methods:
After approval by the Institutional Review Board at the University of Louisville,
Kentucky, we conducted a retrospective chart review study. This is a retrospective casecontrol study of patients who underwent Davinci® assisted sacrocolpopexy for treatment
of pelvic organ prolapse by a single surgeon from January 1st 2010 to March 14th 2012.
Patients were scheduled to undergo surgery for symptomatic uterovaginal prolapse,
vaginal vault prolapse, cystocele and rectocele. The indication for concomitant midurethral sling was if they had symptomatic stress urinary incontinence at presentation or
stress urinary incontinence was found during urodynamic testing upon reduction of
prolapse. Patients underwent concomitant rectopexy if they had symptomatic rectal
prolapse after evaluation by colorectal surgeon. Rectopexy was done at the same time of
prolapse surgery by a colorectal surgeon using the Davinci system. Each robotic case was
performed using Davinci surgical system in a similar fashion as laparoscopy. Entry to
the abdomen was obtained through a left upper quadrant port using optiview trocar®.
After obtaining the pneumoperitoneum, the other trocars were entered with direct
visualization. A 12 mm trocar was entered at or above the umbilicus for the video
camera. Two robotic trocars were entered on patient’s left side with adequate distance
and with care to avoid abdominal wall vessels. The third robotic arm was entered on the
patients right side in a similar fashion. A 12 mm assistant port was entered in the
patient’s right side in a similar fashion. Two pieces of soft polypropolene mesh were
used for sacrocolpopexy by attaching them to the vagina after completion of the
vesicovaginal and rectovaginal dissection and the procedure was completed by attaching
the pieces of mesh to the anterior longitudinal ligament of sacrum with 3 sutures of
Ethibond®.
All the cases were performed at the University Hospital and Norton Hospital in
Louisville, KY. All the information was obtained from patients’ charts that were kept in
our Urogynecology office. Cases included patients with BMI>30 [body mass index
calculated as weight (kg)/height (m2)] and controls were patients with BMI of less than
30 who underwent Davinci® assisted sacrocolpopexy.
Demographics and hospital data, complications, and follow up visits were reviewed.
Patients’ age, race, parity, weight, height, date of surgery, previous pelvic surgeries, any
concomitant surgeries, complications, estimated blood loss, length of hospital stay, past
medical history, prolapse stage, POP-Q exam (pelvic organ prolapse quantification)
preoperatively and postoperatively at 3 months were reviewed.
Estimated blood loss was defined as the amount of blood in the suction container and
surgical sponges. Length of hospital stay was defined as the duration of hospitalization
from admission to discharge. Peri-operative complications were defined as any major
complication occurring from skin incision in the operating room to the date of discharge
from the hospital. Mesh erosion was considered if there was any exposure of the mesh
found during postoperative examinations.
Statistical analysis was done using SAS software (SAS Institute, Cary, NC, USA). For
categorical variables Chi-square test or Fisher’s exact test was used to compare the 2
groups with different BMI’s. A P-value of less than 0.05 was considered statistically
significant. Continuous/ordinal variables were compared using the student t-test.
Results:
Seventy one eligible patients were identified from January 1st 2010 to March 14th 2012.
Forty eight patients had a BMI under 30 and 23 had a BMI of 30 or more (BMI range
from 18.5 to 40.8). The mean age of patients in the obese group was 53.6 years old and
in the non-obese group was 60.6 (P -value 0.0022). The mean prolapse ICS stage at the
time of surgery in the obese group was 2.81 and in the non-obese group was 2.95 (Pvalue 0.17). Individual points of the POP-Q measurements were compared. For
preoperative measurements refer to Table 1.
BMI <30
(N=44)
BMI≥ 30
(N=27)
2-sided
P-value
60.6
53.6
0.0022
(Mann-Whitney)
1.93
1.70
0.71

Bp
0.60
0.81
0.63

C
0.05
-1.33
0.18

TVL
8.00
8.22
0.40
Age- t test
Baseline
 Ba –
Prolapse Stage –(Mann2.95
2.81
Whitney)
Table 1: The Effect of BMI on Preoperative Variables
0.17
Postoperative POP-Q measurements at about 3 months were compared. There was no
significant difference in point Ba, Bp, C and total vaginal length (TVL) in each group
(Table 2). There were 5 mesh erosions within 3 months after surgery in the obese group
compared to 3 cases in the patients with BMI less than 30 (P-value 0.13). The mean
estimated blood loss for the obese group was 104.8 ml as opposed to 127.4 ml in the nonobese group (P-value 0.23). The length of hospital stay was 1.74 days in the obese group
as opposed to 1.5 days in the non-obese group (P-value 0.28). For postoperative
measurerments refer to Table 2.
3 months post-op
 Ba
 Bp
 C
 TVL
BMI <30
(N=44)
BMI≥ 30
(N=27)
2-sided
P-value
-2.76
-2.64
-9.21
-2.78
-2.59
-9.23
0.88
0.56
0.62
9.33
9.59
0.94
Mesh erosion rate
3 (6.8%)
5 (18.5%)
proportions
Estimated blood loss
127.4
104.8
t-test
Hospital stay (d)
1.50
1.74
t-test
Table 2: The Effect of BMI on Peri-operative Outcomes
0.13
0.23
0.28
There were 19 concomitant hysterectomies in patients with BMI of less than 30
compared to 14 in the group with BMI of 30 or higher (P-value 0.53). Four patients had
rectopexy at the same time in the non-obese group compared to two cases in the obese
counterpart (P-value 0.80). Twenty nine patients had a mid-urethral sling in the nonobese group as compared to 15 patients in the obese group (P-value 0.32). Posterior
repair or perineoplasty was done for 18 patients in the non-obese group compared to 10
patients in the obese group (P-value 0.78). For concomitant surgeries refer to Table 3.
BMI <30
(N=44)
Hysterectomy 19 (44.2%)
proportions
Rectopexy
4 (10.3%)
Sling
29 (67.4%)
Posterior repair/
18 (41.9%)
perineoplasty
Table 3: BMI versus Concomitant Surgery
BMI≥ 30
(N=27)
P-value
14 (51.9%)
0.53
2 (8.3%)
15 (55.6%)
0.80
0.32
10 (38.5%)
0.78
Discussion:
Both women with a BMI of 30 or higher compared to those with a BMI under 30 showed
comparable pelvic support 3 months after robotic sacrocolpopexy with no differences
between the two groups. As it has been shown in previous studies(10), patients in our
study population also have symptomatic pelvic organ prolapse at an earlier age if they are
obese. The mesh erosion rate was higher among the obese group; however, there was no
statistical difference between the two groups. The limitations of our study include the
retrospective nature of the study, short term follow up as well as the low number of
patients. However, this study shows that robotic sacrocolpopexy is feasible and safe in
obese patients. Potential advantages of robotic surgery especially in this group of
patients include the 3-D magnified visualization as well as better dexterity in the
performance of the surgical procedure. The availability of the third arm will potentially
improve the traction and exposure required for difficult cases. Prospective data and long
term follow up are needed to investigate the outcome of robotic sacrocolpopexy in obese
patients for surgical treatment of pelvic organ prolapse.
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