Pelvic organ prolapse (POP) consists of the fall of the anterior vaginal wall (also known as cystocele) or posterior vaginal wall (or rectocele), uterus, or the apex of the vagina if a hysterectomy has been previously performed [1]. POP is common in 40%–60% of parous women; the most common sites for repair are the anterior compartment, followed by the posterior compartment [2].

The risk of surgery for POP by age 80 is estimated to be around 12.2% [3, 4]. Therapies for symptomatic POP consist of surgical and conservative options. Non-surgical options for POP include pelvic floor physical therapy (including Kegel exercises) and pessary placement [5]. According to a Cochrane review, there is no rigorous evidence from randomized controlled trials on the use of conservative options in the management of POP [6].

Surgical interventions for pelvic organ prolapse include apical abdominal reconstructive repairs (mainly sacrocolpopexy) through open, laparoscopic, or robotic approaches; apical vaginal reconstructive repairs (sacrospinous hysteropexy, uterosacral hysteropexy, iliococcygeal hysteropexy, hysteropexy); and vaginal obliterative procedures [7].

Most patients with symptomatic POP can be managed properly with the vaginal approach, while correction of apical descent or multicompartmental prolapse is usually treated abdominally [8].

In sacrocolpopexy (SC), the surgeon fixes the vaginal vault and/or cervix by grafting into the sacrum. Sacrocolpopexy with laparotomic access achieves a 90% success rate. However, this procedure involves longer operation time, higher morbidity and higher hospital costs. These downsides can be avoided by performing SC with a less invasive, laparoscopic access (LASC) or its robotic equivalent (RASC) [9, 10].

The da Vinci Surgical System® (Intuitive Surgical Inc., Sunnyvale, CA, USA) is a surgical robot that increases magnification, enables 3-dimensional vision, eliminates physiological tremor, and has 7 degrees of freedom in order to simplify complex laparoscopic tasks such as suturing and knot tying, key techniques in SC [9].

Two randomized control trial (RCT) studies compared RASC with LASC without finding any difference in functional outcomes between the robotic and laparoscopic approaches at 1 year. In the RASC group, however, there were significantly longer operative times, greater pain reported by patients up to 5 weeks after surgery, and higher surgical costs [10, 11]. After these studies, three reviews state that it seems reasonable to conclude that SCs of any type RASC or LASC are equally effective [12, 13, 14]. Therefore, the choice of surgical method should be determined by evaluating complication rates, postoperative recovery, surgeon preference, and surgical factors such as uterine size or adnexal pathology [15].

Vaginal approach to the peritoneal cavity may decrease the rate of intraoperative complications by avoiding bowel manipulation and extreme Trendelenburg positioning, as well as by shortening the need for general anesthesia. However, this approach can implicate higher mesh exposure rates and poorer functional outcomes [12, 16, 17].

The aim of this study was to review the literature about vaginal and robotic surgical approaches in POP.

We conducted a comprehensive literature review, focusing on a particular research area or topic, in order to provide an opportunity to identify key concepts, research gaps, when the topic has not been extensively examined or is complex or heterogeneous in nature. The steps to perform this review were: identifying the research question, identifying relevant studies, making a selection of studies, tracking data, collecting, summarizing, and reporting results [18, 19, 20]. The sixth step (stakeholder consultation) was not performed in this review because it is optional [18, 19, 20, 21].

We follow the Preferred Reporting Items for Systematic reviews and Meta-Analyzes extension for Scoping Reviews (PRISMA-ScR) Checklist [22].

Electronic database search yielded a total of 577 results. After exclusion of duplicates, 243 citations remained. Of these, 233 were not relevant for review based on title and abstract screening. 10 studies were considered for full-text evaluation. No articles were added by searching the reference lists. Therefore, 10 studies met the inclusion criteria and were added to the review [17, 25, 26, 27, 28, 29, 30, 31, 32, 33]. All included studies were prospective and retrospective studies published from 2013 to 2021 and described a total of 1424 patients. A total of 547 women underwent robotic surgery and 877 underwent vaginal surgery. The main characteristics of these studies are listed in Table 1.

There is a variety of methods performed by surgeons for POP repair, each technique has its own success and complication rates, and surgeons should arrange individualized plans for each patient, considering risks and benefits. McCall Culdoplasty is the surgical correction of enterocele during vaginal hysterectomy [38]. In a larger retrospective study (n = 693), the McCall Culdoplasty technique demonstrated 82% patient satisfaction and a reintervention rate of 5.2% [39]. No recent RCTs evaluating McCall culdoplasty have been performed. A 2011 prospective study evaluating this technique at the time of vaginal hysterectomy found that the only risk factor for failure at 2 years, defined as Pelvic Organ Prolapse Quantification (POPQ) $\ge$stage 3, was a history of fetal macrosomia (44.4 vs 6.9%, p = 0.000) [40]. The satisfaction rate of uterosacral ligament suspension was estimated to be around 89%, with only 5.5% requiring reoperation [41]. A meta-analysis of 32 studies reported 81.2%, 98.3%, and 87.4% success for the anterior, apical, and posterior compartments, but with a high ureteral injury rate of 1–11% [42]. Minimally invasive surgery for abdominal sacrocolpopexy is designed to promote rapid postoperative recovery, reducing 30-day complication rates, blood transfusion, long hospital stay, and hospital readmission compared with abdominal sacrocolpopexy [43, 44]. In 2014, a retrospective study compared abdominal sacrocolpopexy (ASC) (n = 58) with a minimally invasive abdominal surgical approach, including robotic-assisted sacrocolpopexy (RS) n = 262 and laparoscopic-assisted sacrocolpopexy (LS) n = 273. No differences in anatomical failures were observed, but complications such as postoperative ileus or small bowel obstruction were greater in the ASC group (20 vs 12.7%, p = 0.001). Women undergoing the robotic procedure had similar surgical success rates compared to the vaginal route or laparoscopic approach. Once the feasibility of undergoing minimally invasive surgery is established, robotic surgery could be considered an alternative to classic laparoscopic surgery, with equal efficacy [45, 46, 47, 48]. Robotic sacrocolpopexy has longer operative times, while vaginal procedures have been associated with higher estimated blood loss [45, 49].

The literature has considered many heterogeneous procedures, often enrolling women with significant differences in baseline characteristics [50]. In Vanspauwen et al. [51], it is clear that vaginal vault prolapse repair post hysterectomy is preferred in older patients. Jha and Moran [52] report that 11% of physicians surveyed in the United Kingdom would change the procedure of choice for posthysterectomy vaginal vault prolapse if the patient was not sexually active [25]. When asked what factors influence the choice of type of surgery for primary or recurrent correction of a pelvic organ prolapse, Montoya et al. [50] found that for primary correction the vaginal route was preferred, while in case of prolapse recurrence the abdominal route was preferred. In the study, factors considered by surgeons for primary or recurrent POP were age, desire to maintain vaginal function, comorbid conditions, and stage of POP. In choosing the type of laparoscopic technique (laparoscopic SC or robotic SC), the relevant decision factors were the degree of prolapse and the surgeon’s experience [50]. POP is a public health problem and affects the lives of millions of adult women. Surgery can offer effective treatment. The problem of pelvic prolapse will become larger and larger, requiring more and more surgeries each year [53, 54, 55]. It is estimated that the demand for pelvic prolapse treatment will increase by 35% from 2010 to 2030, and surgical intervention rates for pelvic organ prolapse will increase by 42.7% by 2050 [4, 56, 57]. Therefore, it will be increasingly necessary to provide subspecialty medical care.

To date, this appears to be the first paper to examine the state of the art of robotic and vaginal surgery for pelvic organ prolapse. Surprisingly, very few papers met the inclusion criteria, although we tried to include any study design, type of surgery, and clinical outcome. Despite these limitations, the general conclusion can be drawn that RS and VS have comparable efficacy in terms of prolapse correction. The choice of robotic or vaginal approach is based on the patient’s characteristics and preferences. This review suggests that robotic apical suspension may be associated with less pain and narcotic use than vaginal suspension and that robotic surgery has lower rates of postoperative urinary complications, such as urinary tract infections, urinary retention, and prolonged urethral catheterization. For repeated surgical prolapse procedures, the most commonly reported route is the robotic approach. When possible, choosing the robotic approach appears to provide more favorable functional outcomes and lower infection rates.

NA conceived the topic; NA, GG and ST retrieved the literature; NA, ST and MA wrote the paper; AMM provided relevant methodological support and supervision. All authors read and approved the final manuscript.

Not applicable.

Not applicable.

This research received no external funding.

The authors declare no conflict of interest. Giorgia Gaia is serving as one of the Guest editors of this journal. Anna Maria Marconi is serving as one of the Editorial Board members and Guest editors of this journal.We declare that Giorgia Gaia and Anna Maria Marconi had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to Christos Iavazzo.