(Video Poster 16) Intraoperative Strategies and Alternatives in Robotic Sacrocolpopexy

Objectives: To describe anatomical and disease-related factors encountered during robotic SCP that necessitated intraoperative deviation from the standard technique, and to illustrate how tailored minimally invasive alternatives were selected to achieve successful outcomes. Additionally, we aim to demonstrate the accessibility of the presacral space in selected cases of renal pelvis.

Methods: We conducted a retrospective review of over 1,569 robotic SCP cases performed by a single surgeon from 2012 to 2024. We identified cases where intraoperative findings—such as aberrant anatomy, prior surgeries, pelvic adhesions, or inflammatory disease—necessitated deviation from SCP to an alternative minimally invasive apical suspension. Data sources included operative reports, imaging, and intraoperative video. Each case was evaluated for anatomical limitation, decision-making rationale, alternative technique used, and surgical outcomes.

Clinical Relevance: Conversion from sacrocolpopexy (SCP) to an alternative minimally invasive prolapse repair was required in fewer than 1% of cases. All conversions resulted in favorable outcomes and remained minimally invasive. Key reasons for conversion included:
• Right pelvic kidney (n=1): The sacrum was inaccessible due to renal position; conversion to sacrospinous ligament fixation (SSLF) was performed. Preoperative CT imaging confirmed the obstructive anatomy.
• Left pelvic kidney (n=1): Despite renal ectopia, the sacrum remained accessible, and SCP was successfully completed. CT and intraoperative video demonstrated that left-sided renal anomalies may still permit safe sacral dissection.
• Prior sacral surgery/scarring (n=1): Distorted anatomy necessitated conversion to laparoscopic pectopexy.
• Frozen pelvis secondary to inflammatory bowel disease/diverticulitis (n=1): Dense adhesions led to conversion to sacrospinous hysteropexy.
• Anomalous sacral vasculature (n=1): To avoid vascular injury, pectopexy was performed.
• Renal transplant (n=1): Initially presumed a contraindication due to graft location over iliac vessels; conversion to uterosacral ligament suspension (USLS) was performed. However, intraoperative findings revealed adequate sacral access and safe distance from the graft, suggesting that renal transplant should not be considered an absolute contraindication to SCP in appropriately selected patients.
These findings support SCP as feasible even in select anatomically complex cases, with alternative minimally invasive techniques providing safe and effective backup options when conversion is necessary.

SCP remains highly feasible in the vast majority of cases. Intraoperative deviations, though rare, are best guided by an understanding of pelvic anatomy and a flexible surgical approach. Preoperative imaging is invaluable, but surgical judgment is paramount. Importantly, renal transplant should not be considered an absolute contraindication to SCP. This series offers a framework for anticipating challenges and adapting effectively to optimize patient outcomes.