With aging populations and advances of healthcare, patients with complex medical histories are more likely to present to our practices. Similarly, robotic-assisted surgery is gaining momentum with view to improving patient outcomes, including in such patients. 

Traditionally, post renal-transplant pelvic organ prolapse (POP) has been surgically treated using vaginal approach, likely to avoid potential damage of the transplanted kidney (1). Patients with collagen abnormalities, like Ehlers-Danlos syndrome (EDS) are particularly at risk of developing POP, including recurrence.  In cases of recurrent apical prolapse, an abdominal approach may present a more appropriate option, if feasibility and safety could be demonstrated. In 2017, Rouffilange and colleagues, described an uncomplicated laparoscopic sacrocervicopexy in a post renal-transplant patient (2). 

Here, we present the first robotic-assisted sacrocolpopexy (RASC) in a renal transplant patient with EDS, and review the literature for perioperative considerations.

This was a retrospective review of patient records. Quality of life was assessed using the Pelvic Floor Impact Questionnaire (PFIQ-7) and clinical examination performed using the Simplified Pelvic Organ Prolapse Quantification (sPOPQ) (3). The patient was followed up at 6 weeks, 6 months and 1 year post-operatively. 

We also reviewed the literature for risks associated with these cases and how to mitigate them. We summarise them in this submission (table 1).

Our 51 year old patient presented with obstructed micturition (indwelling catheter in-situ), stage 4 vault prolapse (following previous vaginal hysterectomy, anterior and posterior colporrhaphies), stage 4 cystocele and stage 4 rectocele. There was no urinary incontinence on prolapse reduction and filling the bladder with 300ml of saline. 

The patient had suffered from adult polycystic kidney disease, renal insufficiency, had had peritoneal dialysis then renal transplantation in the right iliac fossa, and was currently on anti-rejection therapy. She also suffered of severe visual impairment following cerebral haemorrhage and was wheelchair bound. Both shoulder joints were supported by braces to prevent recurrent dislocations.

Pre-operative work-up included assessment of renal function, performing dynamic pelvic MRI to exclude asymptomatic rectal intussusception and diagnostic laparoscopy to assess abdomino-pelvic accessibility and aid surgical decision making.

Uncomplicated RASC was performed with uneventful recovery. Patient was discharged on day 1 postoperatively after catheter removal and absence of postvoid residual on ultrasound. 

Six weeks, 6 months and 1 year follow-up demonstrated no POP recurrence or urinary symptoms, with improved quality of life on her PFIQ-7.

Risks associated with EDS and prior renal transplant and how to mitigate them are summarised in table 1.

Patients such as the above, are high risk for perioperative complications, both from the anaesthetic and the surgical perspectives. This is due to both EDS and renal transplant. In addition, safety and feasibility of robotic-assisted surgery in such patients have not been explored. 

Management of these patients needs to be conducted via multidisciplinary team including anaesthetic and renal function assessments pre-operatively.

Pre-operative laparoscopic assessment can be performed at the beginning of the robotic procedure and should be focused on: localisation of the transplanted kidney (in relation to the planned robotic ports) to avoid its injury and assess whether enough peritoneum would be available in the right iliac fossa to re-peritonealise the mesh. Also quantifying intra-peritoneal adhesions (due to previous peritoneal dialysis) in addition to standard pelvic assessments for sacrocolpopexy e.g. level of aortic bifurcation and access to sacral promontory. Other surgical and anaesthetic precautions are summarised in table 1.

The use of the robot in these cases may also be beneficial due to operating at lower intra-abdominal pressures (compared to laparoscopy), in addition to other benefits e.g. wristed instruments and 3D magnified operative views which are aimed at enhancing surgical safety.

We demonstrated the feasibility and safety of the first-reported RASC in a renal transplant patient. Our patient also had Ehlers-Danlos Syndrome which increased her peri-operative surgical and anaesthetic risks. Hence, we also reviewed the literature for potential risks and mitigations and summarised them in this submission. 

With the rise of uptake of robotic surgery in Urogynaecology, more evidence is needed in this regard particularly managing complex patients. This is to ensure patient safety and enable appropriate patient counselling for making their informed decision. We call upon specialist societies to utilize surgical databases to support such cause, particularly for rare cases such as the one presented here.

Raschid H, Wagner S, Greco F, Heynemann H, Fornara P. Pelvic organ prolapse management in female kidney transplant recipients. J Urol. 2010;184:1064-8.
Rouffilange J, Deslandes M, Lopez L. Laparoscopic Management of Pelvic Organ Prolapse in a Kidney Transplant Recipient. Urol Case Rep. 2017;13:145-146.
Swift S, Morris S, McKinnie V et al. Validation of a simplified technique for using the POPQ pelvic organ prolapse classification system. Int Urogynecol J Pelvic Floor Dysfunct. 2006;6:615-20.