| Objective: The main aim of this study is to explore the efficacy of robot-assisted sacrocolpopexy(RASC)and summarize its related surgical complications.Conventional abdominal sacrocolpopexy(ASC)was compared with RASC and minimally-invasive sacrocolpopexy(MSC= RASC+LSC)to evaluate RASC’s indications and intraoperative technics in order to promote its domestic application.Biological promotors in the postoperative mesh exposure were tested preliminarily to reduce the incidence of sacrocolpopexy complications,and improve the life quality of patients.Methods: The patients with advanced symptomatic POP who recieved ASC,LSC or RASC in Chinese PLA General Hospital from January 2013 to December 2020 were enrolled.Their general information was colleted,including age,times of pregnancy/delivery,body mass index,operation duration time,intraoperative bleeding,preoperative and postoperative anatomical POP level and life quality scores(including Pelvic Floor Distress Inventory-20,Patient’s Global Impression-I,Pelvic Floor Impact Questionnaire-7),postoperative hospital stay,mesh exposure,etc.These cases were catigarited into 3 groups: RASC group,ASC group and MSC group(RASC+LSC).Their data were analyzed statistically.Neural network and random-forest model were employed to find the relationship between preoperative and postoperative cause-effect influence.In mesh exposure removal surgey,the exposed tissues and surrounding normal tissues were collected during the operation.Immunohistochemistry and gene sequencing were used to detect the transcription and expression level of inflammatory factors and show the biological signal pathways that may play roles in mesh exposure,to explore the mechanism of mesh exposure and reduce the occurrence.Results: From January 2013 to December 2020,24 patients recieved RASC due to high-stage POP in the Department of Obstetrics and Gynecology,First Medical Center of Chinese PLA General Hospital.The average intraoperative bleeding was 62.91 ± 77.54ml(20-300ml),the operation time was 148.96 ± 43.64(60-240)minutes,and the postoperative hospital stay duration was 8.54 ± 2.90 days(8-16)days.These cases were clinically followed up for 58.9 ± 22.5 months(6-72 months).The subjective/objective success rate was 100%.The PGI-I score was very good in 10(41.7%),very good in 11(45.8%),and good in 3(12.5%).Mesh exposure was found in 4 patients(30.8%).Based on the standard published by IUGA and ICS,the exposure was claasified as follows:exposure diameter < 1 cm and asymptomatic(2A),exposure time 2-12 months after operation(T3),3 cases located at the suture of vaginal mesh(S1)(2A / T3 / S1,3 cases);exposure diameter more than 1 cm(3B),occurred in 2-12 months after operation,and located in the suture area(3B/T3/S1,1 case).In the selected period,69 patients received ASC,LSC or RASC,including 24 in RASC,35 in ASC and 34 in MSC(24 RASC + 10 LSC).There was no significant difference between the three groups in the pregnancy/delivery times,maximal birth weight,body mass index,postmenopausal time,hypertension / diabetes complications(P>0.05).The age of patients in ASC group(56.26±7.21)was obviously lower than that of MSC group(63.68±9.66)and RASC group(64.29±10.35)(P<0.05).Intraoperative bleeding in ASC group(244.86 ± 216.56ml)was significantly greater than that in MSC(81.56 ± 83.68ml)and RASC(62.92 ± 77.54 ml)(P < 0.05).As for the operation time,RASC(148.95 ± 43.64min)and MSC(159.70 ± 46.38 min)was significantly shorter than ASC(188.86 ± 55.82 min)(P < 0.05).During POP-Q follow-up,we found that Aa,Ba,Ap,Bp,Cx,GH,Pb and TVL in three groups significantly improved compared with the baseline(P < 0.05),and the subjective / objective cure rate was 100%.The PGI-I score was satisfactory(1-2).PFDI-20 and PFIQ-7 decreased dramatically in the three groups,indicating that the three operations can improve the quality of life of POP patients efficiently(P < 0.05).At 2-12 months,10 cases(5 cases of ASC,1 case of LSC,4 cases of RASC,P > 0.05)had mesh exposure.7 cases(2A / T3 / S1)were treated with estrogen ointment and metronidazole suppository locally,and 3 cases(3B / T3 / S1)were treated with local resection of exposed mesh,which were all healed after treatment.Gene sequencing showed that the expression of many genes in mesh exposure tissues changed compared with normal tissues.Clustering analysis showed that there were many abnormally expressed genes in the extracellular matrix collagen(ECMP)and the extracellular matrix(ECM)pathways.HE and immunohistochemical staining of matrix metalloproteinase-9(MMP-9)in mesh exposure tissues showed that inflammatory cells gathered around the exposed mesh,resulting in interstitial edema and immune response.There was increased MMP-9 protein expression locally,indicating that MMP-9 may play a role in the mesh exposure.Conclusions:1.RASC is effective in patients with high-stage POP.They can restore the anatomical position of uterus / vagina effectively and significantly improve the life quality.2.RASC,ASC and LSC can treat severe pelvic floor prolapse effectively.In comparison,ASC has better improvement in postoperative anatomical reconstruction(Cx,Gh and TVL).RASC bears the advantage of shorter operation time,less intraoperative bleeding and shorter place urinary catheter-placing time/hospital stay.3.The implantion of polypropylene mesh may result in local gene translational change in the implantation tissure.Mesh exposure may be related with MMP-9overexpression.This requires further exploration. |
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