Surgical Endoscopy (2023) 37:5215–5225 and Other Interventional Techniques https://doi.org/10.1007/s00464-023-10001-4 Robot‑assisted pelvic floor reconstructive surgery: an international Delphi study of expert users Tommaso Simoncini1 · Andrea Panattoni1 · Mustafa Aktas2 · Jozef Ampe3 · Cornelia Betschart4 · Alexander L. A. Bloemendaal5 · Stephan Buse6 · Giuseppe Campagna7 · Marta Caretto1 · Mauro Cervigni8 · Esther C. J. Consten9 · Hugo H. Davila10 · Jean Dubuisson11 · Eloy Espin‑Basany12 · Bernardina Fabiani13 · Jean‑Luc Faucheron14 · Andrea Giannini1 · Brooke Gurland15 · Dieter Hahnloser16 · Ralf Joukhadar17 · Paolo Mannella1 · Liliana Mereu18 · Jacopo Martellucci19 · Guillaume Meurette20 · Maria Magdalena Montt Guevara1 · Carlo Ratto21 · Barry A. O’Reilly22 · Christl Reisenauer23 · Eleonora Russo1 · Steven Schraffordt Koops24 · Shahab Siddiqi25 · Alessandro Sturiale13 · Gabriele Naldini13 Received: 14 December 2022 / Accepted: 25 February 2023 / Published online: 23 March 2023 © The Author(s) 2023 Abstract Background Robotic surgery has gained popularity for the reconstruction of pelvic floor defects. Nonetheless, there is no evidence that robot-assisted reconstructive surgery is either appropriate or superior to standard laparoscopy for the perfor- mance of pelvic floor reconstructive procedures or that it is sustainable. The aim of this project was to address the proper role of robotic pelvic floor reconstructive procedures using expert opinion. Methods We set up an international, multidisciplinary group of 26 experts to participate in a Delphi process on robotics as applied to pelvic floor reconstructive surgery. The group comprised urogynecologists, urologists, and colorectal surgeons with long-term experience in the performance of pelvic floor reconstructive procedures and with the use of the robot, who were identified primarily based on peer-reviewed publications. Two rounds of the Delphi process were conducted. The first included 63 statements pertaining to surgeons’ characteristics, general questions, indications, surgical technique, and future-oriented questions. A second round including 20 statements was used to reassess those statements where borderline agreement was obtained during the first round. The final step consisted of a face-to-face meeting with all participants to present and discuss the results of the analysis. Results The 26 experts agreed that robotics is a suitable indication for pelvic floor reconstructive surgery because of the significant technical advantages that it confers relative to standard laparoscopy. Experts considered these advantages particu- larly important for the execution of complex reconstructive procedures, although the benefits can be found also during less challenging cases. The experts considered the robot safe and effective for pelvic floor reconstruction and generally thought that the additional costs are offset by the increased surgical efficacy. Conclusion Robotics is a suitable choice for pelvic reconstruction, but this Delphi initiative calls for more research to objec- tively assess the specific settings where robotic surgery would provide the most benefit. Keywords Pelvic floor reconstructive surgery · Robotic surgery · Pelvic organ prolapse · Rectal prolapse · Delphi consensus Pelvic floor reconstructive surgery (PFRS) is an emerg- narrow anatomical areas and facilitated dissection and stitch- ing field of application for robotic platforms, with expert ing in the deep pelvis are often indicated as key reasons why users experiencing advantages from the improved vision surgeons choose a robotic approach to perform abdominal and dexterity, which they assert are particularly useful dur- pelvic organ prolapse (POP) reconstructive procedures. ing abdominal procedures for prolapse. Clarity of vision in Robotic assistance has been used for all the described abdominal techniques, including sacral suspension, lateral suspension, rectal suspension, and para-vaginal repair, as * Tommaso Simoncini tommaso.simoncini@unipi.it well as anti-incontinence procedures [1–6]. Extended author information available on the last page of the article 13 Vol.:(0123456789) 5216 Surgical Endoscopy (2023) 37:5215–5225 Evidence corroborating the perception that robotics Upon invitation of the 37 candidates, 4 declined partici- makes PFRS easier or more effective is so far missing, pation or did not answer and 7 accepted but did not complete including safety, reproducibility, and efficacy in the hands either the first or the second round of questions and were of surgeons with different levels of experience. Nonethe- therefore excluded. Nonresponders were evenly distributed less, studies have suggested that robotic surgery reduces in the different geographic areas and surgical specialties. the conversion rate to laparotomy and shortens the learn- Twenty-six experts completed all Delphi rounds and partici- ing curve for complex procedures, such as colposacropexy pated in the joint discussion during the final teleconference, [7–9]. Expert users of the robot believe that this platform where the results were presented. The number of participants may facilitate the development and spread of PFRS proce- is within the range that is considered appropriate for Delphi dures, with better functional outcomes and long-term suc- studies [15]. cess rates for the treatment of advanced or multicompart- A scientific committee was formed at the beginning of the mental prolapses compared with traditional transvaginal or process and included the 2 organizers plus 5 surgeons who transperineal procedures [4, 10]. were representative of the various specialties, geographic Improving the efficacy of PFRS would have a relevant distributions, and both sexes (Consten, Davila, Meurette, impact because this surgery is performed in high numbers Reisenauer, and Schraffordt Koops). The professional char- and repeat procedures due to relapses increase expendi- acteristics of the experts involved in the Delphi process are tures [11]. In this light, sustainability and cost-effectiveness described in Table 1. of using the robot for POP surgery should be thoroughly assessed [12, 13]. These answers will apply to urologic, The Delphi process gynecologic, and proctologic procedures because of the similarities in terms of anatomical dissection, suspensive The Delphi process was initiated by identifying the research strategies, and technical challenges [6]. statements. This was done by the scientific committee The current study uses a Delphi methodology to report through a series of teleconferences. A total of 64 questions the experience of expert users on the performance of the Da and statements were formulated for the first round, divided Vinci® robotic platform (Intuitive Surgical, Sunnyvale, CA) into 5 categories: 8 questions related to surgeons’ charac- for PFRS. Our results represent the opinions of an interna- teristics and 56 general statements, indications, surgical tional group of high-volume surgeons from various special- technique, and future-oriented statements. The question- ties on the role of robot-assisted PFRS. naire was sent to the participants using Google modules. The participants were asked to vote using a binary Likert scale of 1 through 9 to express their degree of agreement with the statement (with 1 indicating strong disagreement Materials and methods and 9 strong agreement). The participants were also asked to provide a comment explaining their choice. The study is based on the Delphi process, a method of struc- Upon completion of the first round, the scientific com- tured communication applied to reach a consensus on a spe- mittee analyzed the responses. As predefined in the study cific topic with input from a panel of experts. The Delphi setup, those statements for which 70% or more of the group technique uses a multistage, self-completed questionnaire declared disagreement (score of 1–3) or agreement (score of with individual feedback [14, 15]. 7–9) were excluded from the second round. Similarly, state- ments for which the group showed no concordance (scatter Selection of the participants distribution of scores) were considered areas of no consen- sus and were excluded. Those statements for which 60% to Between November 2020 and September 2021, 37 high-vol- 70% of the group either agreed or disagreed were reanalyzed ume robotic surgeons with extensive experience in pelvic by the scientific committee by looking at the explanatory floor reconstruction from all over the World were invited to comments. The committee rephrased these statements for join this project. Urogynecologists, urologists, and colorec- the second round. tal surgeons with an interest in proctology were included. The second questionnaire was composed of 20 state- Candidates were identified primarily based on peer-reviewed ments, and the same procedure was followed for analysis. publications on robotic PFRS procedures or because of The Delphi statements and the level of agreement of round involvement in robotic special interest groups from interna- 1 and round 2 are listed in Table 2 and Table 3. tional scientific societies dedicated to pelvic floor disorders. The scientific committee then adjudicated the areas of Participant selection was performed by the organizers of the consensus and of lack of agreement and performed subanaly- initiative (Tommaso Simoncini and Gabriele Naldini, with ses looking at how the opinions of the group varied based on the aid of collaborators). the specialty of the surgeons, the surgeons’ experience with 13 Surgical Endoscopy (2023) 37:5215–5225 5217 Table 1  Descriptive analysis of the participating experts rounds, as a dichotomized agreement, were performed with Category N = 26 (%) chi-square test (χ2), Fisher’s exact test, and χ2 test for trend. Significance was set at 0.05. All analyses were performed Specialists with SPSS technology v.27 (SPSS Inc., Chicago, IL). Colorectal surgeons 11 (42) Urologists 4 (16) Gynecologists 11 (42) Countries Results Italy 8 (29) The netherlands 4 (15) The first questions in the first Delphi round provided a Germany 3 (12) description of the participants (Table 1). Participants were France 2 (8) representative of the 3 specialties and of different geographic The USA 2 (8) areas and health systems. Most of the participants had been The united kingdom 1 (4) using the robot to perform PFRS for more than 3 years, with Ireland 1 (4) a mean of more than 20 procedures per year. Half of the Spain 1 (4) group performed PFRS via both laparoscopic and robotic Belgium 1 (4) techniques and a majority also performed transvaginal sur- Switzerland 3 (12) gery, with nearly 40% of the group performing transanal No. of robotic pfrs per year (range) procedures. Most of the participants (88%) worked in a mul- 1–20 11 (42) tidisciplinary pelvic floor center. 20–40 8 (31) > 40 7 (27) General aspects of the role of robotic assistance Experience of surgeon (years) for PFRS 1–2 1 (4) 3–4 5 (19) The first set of practice questions explored general aspects >5 20 (77) of the use of robotics for PFRS. The experts strongly agreed Surgeons performing pfrs with other techniques that the use of the robot to perform PFRS is safe. In general, Lps 15 (58) the group believed that the robotic platform allows better No lps 11 (42) vision during PFRS and that the range of motion and articu- Transvaginal 19 (73) lation of the robotic instruments provides a specific advan- No transvaginal 7 (27) tage during this surgery. Transanal 10 (38) The experts agreed that performing PFRS with the robot No transanal 16 (62) causes less physical strain and less fatigue for the surgeon Surgeons employed in a hospital in which there is a multidiscipli- compared with conventional laparoscopic surgery. They also nary team for pf disorders thought that the Da Vinci Xi platform reduces operative time Yes 23 (88) versus standard laparoscopy for reconstructing the pelvic No 3 (12) floor in complex cases. Nonetheless, they did not feel that LPS laparoscopy, PF pelvic floor, PFRS pelvic floor reconstructive using the robot allows the performance of a higher number surgery of procedures within the same day (compared with standard laparoscopy). The experts also agreed that the learning curve of PFRS the use of the robot, surgeons’ annual case load, and on their procedures is shorter for robotic surgery than for laparos- habit of using also standard laparoscopy. copy and that it is easier to transfer surgical competencies The third and concluding step of the Delphi process con- to other surgeons using the robot. To this extent, the experts sisted of a face-to-face virtual meeting with all the partici- subscribed to the idea that having a dedicated center for pants, where the data were reviewed, and several comments robotic surgery with expert staff would facilitate use of the were discussed and agreement with the analysis of the com- robot for non-oncologic applications such as PFRS and that mittee was verified. training sessions for inexperienced surgeon assistants are important to reach proficiency. Data analysis The experts generally agreed that the robot facilitates quicker discharge of patients. In addition, there was a gen- Categorical data are described as absolute frequency. Strat- eralized opinion that collecting patient-reported outcome ified analyses of responses to questions of the 2 Delphi measures and/or patient-reported experience measures will 13 5218 Surgical Endoscopy (2023) 37:5215–5225 Table 2  First round of the Delphi process Level of agreement (N = 26) General questions RS allows you to reduce operative times for the reconstruction of PF (meaning whole surgical time including docking and undocking 31% as compared with open or standard LPS) RS allows better vision during PF reconstructive surgery (independent of the scope used) 96% The range of motion and articulation of robotic instruments offer an advantage for PF reconstructive surgery 96% The learning curve for reconstructive PF procedures is shorter with robot-assisted surgery than with traditional laparoscopic surgery 76% It is not necessary to have expertise in traditional laparoscopy to perform robotic reconstructive PF surgery 27% The use of the robot helps in transferring skills in PF reconstruction to other surgeons 85% The use of the robot for PF reconstruction is safe 92% RS facilitates a quick discharge of patients undergoing PF reconstruction 85% Use of robot-assisted surgery could help increase the uptake of transabdominal PF reconstructive procedures 65% RS could decrease the rates of intra- and postoperative complications associated with PF reconstruction 54% The robot is less of a physical strain for my body in comparison to traditional LPS 85% The use of RS makes the surgery easier so I can concentrate longer 65% After a day of RS, I feel less tired than after a day of conventional surgery 73% The robot allows me to perform more PF reconstructive procedures in the same day than with standard LPS 38% A more widespread use of the robot would allow an increase in the number of PF reconstructive procedures and would decrease the 46% waiting time to access surgery The organizational ‘fit’ into existing pathways and frameworks is a barrier to the widespread use of the robot 35% Lack of acceptance and resistance to change from colleagues are still able to affect the widespread use of RS 50% The collection of PROM/PREM data can facilitate the widespread use of robotics and highlight its multidimensional benefits (e.g., 92% socioeconomic) Covid-19 is negatively affecting the widespread use of the robot for PF reconstruction 58% I would recommend the use of robot-assisted surgery for PF reconstruction to other colleagues 88% Training sessions and opportunities for inexperienced surgeon assistants are easily available in my center/hospital 65% I feel close to the current real-world evidence literature, as it gives a realistic picture of benefits and limits of RS 50% Indications I choose robotic surgery over standard LPS to perform PFRS in obese patients 85% I choose robotic surgery over standard LPS to perform PFRS in patients with previous abdominal surgery 73% I choose robotic surgery over standard LPS to perform PFRS in patients with advanced prolapse 77% I choose robotic surgery over standard LPS to perform PFRS in patients with multicompartmental prolapse 81% I choose robotic surgery over standard LPS to perform PFRS in patients with relapsed/recurrent prolapse 73% I choose robotic surgery over standard LPS to perform PFRS in patients who underwent previous reconstructive surgeries with meshes 77% I choose robotic surgery over standard LPS to manage patients with late complications associated with previous PFRS (erosions, 62% abscesses, fistulas) I choose robotic surgery over standard LPS to perform PFRS in patients with previous ureteral injury 46% I choose robotic surgery over standard LPS to perform PFRS due to near-infrared fluorescence (NIRF) imaging using indocyanine 19% green dye (ICG) Surgical technique It is mandatory to use 4 robotic arms (1 optic arm + 3 assistant arms) to perform PF reconstructive procedures 27% The use of advanced energy devices is needed for robot-assisted pelvic floor surgery 27% The last generation of robotic tools (Da Vinci Xi, integrated table motion) has improved reconstructive PF surgery over the previous 46% platforms Robotic single-port technology is potentially useful for PF robotic reconstruction 31% The isolation of the sacral promontory is more precise and safer with the aid of the robot 70% The robot allows the management of major vascular damage at the level of the sacral promontory 42% The robot decreases the risk of nerve injuries at the level of the sacral promontory 54% The robot decreases the risk of injuries of the pelvic ureters 38% The robot simplifies the performance of hysterectomy in the context of PFRS 46% The robot simplifies deep dissection between the rectum and the vagina 77% Robot surgery simplifies deep dissection between the vagina and the bladder 69% 13 Surgical Endoscopy (2023) 37:5215–5225 5219 Table 2  (continued) Level of agreement (N = 26) Robotic surgery simplifies dissection of the Retzius space 73% The robot simplifies and increases the accuracy of suturing on the sacral promontory 92% The robot simplifies and increases the accuracy of suturing on the posterior wall of the vagina 92% The robot simplifies and increases the accuracy of suturing on the anterior wall of the vagina 73% The robot simplifies and increases the accuracy of suturing in the Retzius space 73% The robot simplifies and increases the accuracy of suturing on the anterior rectal wall 77% The robot allows better positioning of meshes 62% The modality of robot-assisted suturing and mesh positioning could decrease complications related to synthetic non-resorbable meshes 50% Future-oriented questions Taking into consideration the costs and benefits of RS, PF reconstruction is a suitable indication for robotics for every patient 58% Taking into consideration the costs and benefits of RS, PF reconstruction is a suitable indication for robotics only for selected patients 50% If I were the manager of a hospital, I would approve a robotic program for PF reconstruction 77% If I were a patient with a pelvic floor disorder, I would preferentially select a hospital with a robotic program 81% The spread of the use of the robot for PF reconstruction may in future become a socioeconomic advantage (e.g., because of increased 62% performance of transabdominal reconstructive procedures or possible decreases in relapses) Where do you see the future main developments of robotic technology for PFRS? (open question) ▪Preoperative anatomical planning and surgical navigation applications to perform pelvic floor reconstruction (66%) ▪The development of tactile feedback (66%) ▪Availability of new energies applied to the robotic platform (17%) ▪Development of new tools for pelvic floor reconstruction with the robot (52%) ▪Development of new types of robots for pelvic floor reconstruction (34%) ▪Applications of artificial intelligence or deep learning for pelvic floor reconstruction with the robotic platform (66%) ▪Less or no need for an assistant surgeon (59%) ▪Others: -Ultrasound-assisted robotic surgery -Ultra mini-invasive approach LPS laparoscopy, PF pelvic floor, PFRS pelvic floor reconstructive surgery, PROM/PREM patient-reported outcomes/patient-reported experi- ence measure, RS robotic surgery be a useful tool to show the multidimensional (e.g., socio- Surgical technique in robot‑assisted PFRS economic) benefits of this technology. Overall, the experts strongly concurred that they would The third set of practice items addressed the technicalities recommend the use of robot-assisted surgery for PFRS to of using the robot to perform PFRS. other colleagues. The experts agreed that the robotic platform provides specific technical advantages over standard laparoscopy Indications of robotics for PFRS for performing all the key steps of abdominal PFRS. Spe- cifically, experts perceived an advantage for dissection of The second set of practice questions tested the opinions the sacral promontory, the vesicovaginal space, the rec- of the experts on the correct indications for the use of the tovaginal space, and the Retzius space. In contrast, the robotic platform for PFRS procedures. experts did not feel that the use of robotics decreases the The panel agreed that robotic surgery is preferable to risk of nerve injury at the level of the promontory com- standard laparoscopy for obese patients and for patients pared with standard laparoscopy. with previous abdominal surgeries. Cases of advanced or Experts considered suturing in all the districts that are multicompartmental prolapse, relapsed/recurrent prolapse, relevant for PFRS procedures to be significantly easier or previous reconstructive surgery with meshes were also using the robot, including the anterior and posterior vagi- considered indications for preferring use of the robot over nal wall, the Retzius space, and the sacral promontory. standard laparoscopy. Although the experts concurred that Suturing on the anterior rectal wall was considered both the use of robotics is preferable in more complex cases, they easier and safer with the robotic technique compared with did not believe that robotics should be limited to selected laparoscopy. Further, mesh placement was thought to be indications. 13 5220 Surgical Endoscopy (2023) 37:5215–5225 Table 3  Second round of the Delphi Process Level of agreement (N = 26) General questions RS performed with the Da Vinci Xi platform may allow for reducing operative times versus standard LPS for the reconstruction of PF 88% in complex surgical cases (please consider only the console time, without including docking and undocking) It is mandatory to have expertise in traditional LPS before starting to perform PFRS 19% Gaining access to a robot in a practice where this was not available before would likely increase the number of transabdominal PFRS 54% procedures (without considering the costs) RS could decrease the rates of complications associated with PF reconstruction in complex cases 62% The presence of a dedicated center for RS with expert staff facilitates the use of the robot for non-oncologic applications such as PFRS 92% There are still a lack of acceptance of RS for PF reconstruction within the surgical community 46% Training sessions and opportunities for inexperienced surgeon-assistant trainees are important to perform PFRS 91% The current literature does not yet correctly depict the advantages of robotics for PF reconstruction 62% Surgical technique The use of the fourth robotic arm is not always mandatory to perform PF reconstructive procedures in simple cases 81% The standard robotic monopolar and bipolar instruments of the intuitive Da Vinci Xi system are sufficient to perform PFRS 96% The development of an effective single-port robotic platform is of interest for PFRS 73% In case of major vascular damage at the level of the sacral promontory, surgical management with the robot is less effective than with 8% standard LPS The identification of nerve bundles during PF reconstructive surgery is facilitated by the robot as compared with standard LPS 50% RS decreases the time needed to perform supracervical hysterectomy during PFRS compared with standard LPS 31% Suturing mesh on the anterior rectal wall is easier with the robot than with standard LPS 77% Suturing mesh on the anterior rectal wall is safe with the robot 77% Mesh placement is more precise with the use of robotic instruments as compared with standard LPS 73% Future-oriented questions Taking into consideration the costs and benefits of PFRS, PF reconstruction with robotics is a suitable indication for patients requiring 81% abdominal correction of POP Taking into consideration the costs of RS, PFRS should be limited to selected indications 50% If a more widespread use of the robot in future will lead to more abdominal PF reconstructive procedures, this is likely to turn into 58% socioeconomic advantages (e.g., because of decreased relapses and/or reoperations) LPS laparoscopy, PF pelvic floor, PFRS pelvic floor reconstructive surgery, POP pelvic organ prolapse, RS robotic surgery more precise with the use of robotic instruments compared program for the management of these disorders. The group with standard laparoscopy. also deemed it important from the patient’s perspective Related to safety, the experts did not feel that major vas- that a hospital managing pelvic floor diseases is equipped cular damage at the level of the sacral promontory would be with a robotic platform. any more difficult to manage with robotics than with stand- From a health economics point of view, considering ard laparoscopy. both the costs and benefits, the experts agreed that robotic On a more technical note, the group agreed that use of the surgery should be considered a suitable technology for fourth robotic arm is not necessary to perform PFRS in sim- patients requiring abdominal correction of POP. The ple cases and that standard robotic monopolar and bipolar experts also thought that the expanding use of the robot for instruments are sufficient. The experts expressed interest in PFRS may offer socioeconomic advantages (e.g., increased the development of a single-port robotic platform for PFRS. performance of transabdominal reconstructive procedures or possible decreases in relapses). When asked to select possible refinements of the robotic Future perspectives on robot‑assisted PFRS platform that could improve the performance of PFRS, most experts indicated the development of tactile feed- When the experts were asked about the future role of back, artificial intelligence or deep learning dedicated to robotics in the management of pelvic floor defects, they PFRS, and tools for preoperative anatomical planning and agreed that they would recommend activation of a robotic surgical navigation. 13 Surgical Endoscopy (2023) 37:5215–5225 5221 Subanalyses While all the experts were skilled laparoscopic surgeons with experience in laparoscopic PFRS, a subgroup reported The results were reanalyzed to explore whether surgeons currently using only the robot to perform these procedures. of different specialties, experience, caseloads, and patterns We then ran a subanalysis comparing the opinions of sur- of surgical practice may differ in opinion on selected ques- geons who perform PFRS only with the robot compared tions. Items for which statistically significant differences with surgeons who perform both robotics and conventional were found are reported. laparoscopic procedures (Table 5). Experts performing only Gynecologists strongly believed that pelvic floor recon- robotic surgery felt that the robot offers several advantages struction is a suitable indication for robotics only for over laparoscopy: decreased rates of complications, more selected patients, whereas colorectal surgeons and urolo- precise and safer isolation of the sacral promontory, easier gists did not (Table 4). deep dissection between the rectum and the vagina, better When the opinions of surgeons were analyzed by years positioning of meshes, easier suturing of meshes on the ante- of experience (< 5 vs ≥ 5 years), only the more-experi- rior rectal wall, lower risk of injuries to the pelvic ureters, enced surgeons agreed that after a day of robotic surgery and easier performance of hysterectomy in the context of they felt less tired than after a day of conventional surgery PFRS. Experts performing both robotic and laparoscopic (Table 4). surgeries did not agree on the previous points. Only surgeons The opinions of experts were also compared by case- who exclusively use the robot felt that PFRS is a suitable load of robotic PFRS procedures (< 20, 20–40, or > 40 per indication for robotics for every patient. year) (Table 4). Surgeons performing fewer than 20 robotic cases per year did not feel that the robot facilitates manag- ing major vascular damage at the level of the sacral prom- Discussion ontory. Surgeons with a high case-load had an opposite opinion. Surgeons performing more than 40 procedures Robots are expensive tools that facilitate the performance per year disagreed with the view that it is not necessary of surgical maneuvers through better vision and more effec- to have expertise in traditional laparoscopy to perform tive instruments. These technologically advanced platforms robotic pelvic floor surgery. Only the surgeons with the ease the execution of minimally invasive procedures by less- higher case-load agreed that they felt less tired after a day experienced surgeons or make the performance of a techni- of robot-assisted PFRS than after conventional surgery. cally challenging procedure more effective in the hands of an Table 4  Subanalysis by Specialty, Case-Load (Number of Procedures per Year), and Years of Experience (N = 26) Agree Specialty Colorectal (n = 11) Gynecologist (n = 11) Urologist (n = 4) P value Taking into consideration the costs and benefits of RS, PF reconstruction is a suitable indication for robotics only for selected patients No 8 (73%) 2 (18%) 3 (75%) 0.030 Yes 3 (27%) 9 (82%) 1 (25%) Procedures per year < 20 (n = 11) 20–40 (n = 8) > 40 (n = 7) The robot allows management of major vascular damage at the level of the sacral promontory No 9 (82%) 5 (62%) 1 (14%) 0.006 Yes 2 (18%) 3 (38%) 6 (86%) It is not necessary to have expertise in traditional laparoscopy to perform robotic PFRS No 6 (55%) 6 (75%) 7 (100%) 0.034 Yes 5 (45%) 2 (25%) 0 (0%) After a day of RS, I feel less tired than after a day of conventional surgery No 5 (45%) 2 (25%) 0 (0%) 0.034 Yes 6 (55%) 6 (75%) 7 (100%) Years of Experience ≥ 5 (n = 20) 1–4 (n = 6) After a day of RS, I feel less tired than after a day of conventional surgery No 3 (15%) 4 (67%) 0.028 Yes 17 (85%) 2 (33%) Data are expressed as frequencies and percentages. Data analysis was done with Fisher’s exact test. Procedures by year analysis was done with chi-square test for trend. Values of P < 0.05 were considered significant PF pelvic floor, PFRS pelvic floor reconstructive surgery, RS robotic surgery 13 5222 Surgical Endoscopy (2023) 37:5215–5225 Table 5  Subanalysis by patterns of surgical practice added cost of such instruments is considered good clinical Agreement No LPS (n = 11) LPS (n = 15) P value practice. Applying the same metric to the complexity of robotic RS could decrease the rates of intra- and postoperative complica- platforms is not easy because multiple parameters influence tions associated with PF reconstruction decision-making. For instance, patients may be attracted No 2 (18%) 10 (67%) 0.021 toward robotic centers because they consider them more Yes 9 (82%) 5 (33%) modern [17, 18], which may lead to an economic advan- Isolation of the sacral promontory is more precise and safer with the aid of the robot tage for the organizations that are equipped with these No 0 (0%) 8 (53%) 0.036 instruments. Yes 11 (100%) 7 (47%) One of the ways to assess the value of robotics in a spe- The robot simplifies deep dissection between the rectum and the cific surgical setting is to assess the opinions of expert users vagina who can express through personal experience the technical No 0 (0%) 6 (40%) 0.024 and nontechnical strengths and weaknesses in comparison Yes 11 (100%) 9 (60%) with other approaches. We followed this approach to explore The robot allows for better positioning of meshes the value of robotics in PFRS with the use of a Delphi meth- No 1 (9%) 9 (53%) 0.014 odology. This approach has recently become popular to Yes 10 (91%) 6 (47%) assess robotic surgery [19, 20], including training [21], and Suturing mesh on the anterior rectal wall is easier with the robot the role of innovations related to this surgical approach [22]. than with standard LPS Our study confirms that surgeons who use the robot No 0 (0%) 6 (40%) 0.024 extensively consider this approach safe and generally more Yes 11 (100%) 9 (60%) effective than standard laparoscopy for PFRS. The experts The robot decreases the risk of injuries of the pelvic ureters involved in the Delphi process agreed that the technical No 4 (36%) 12 (80%) 0.043 advantages of the Da Vinci® robotic platform are evident Yes 7 (64%) 3 (20%) in all the surgical steps required to perform urogynecology The robot simplifies the performance of hysterectomy in the context and colorectal PFRS procedures. Specifically, dissection of of PFRS relevant anatomical planes, mesh placement, suture place- No 3 (36%) 11 (73%) 0.045 ment, and knot tying are easier and more effective using Yes 8 (64%) 4 (27%) the robot than with standard laparoscopy. The participating Taking into consideration the costs and benefits of RS, PF recon- experts believe that these features allow easier and more struction is a suitable indication for robotics for every patient effective learning of complex prolapse procedures, particu- No 1 (9%) 10 (67%) 0.005 larly in the presence of a robotic center, consistent with pre- Yes 10 (91%) 5 (33%) vious observations [23–25]. The experts generally agreed Surgeons performing robotics only (no LPS) vs surgeons performing that robotics is particularly useful for the treatment of more robotics and laparoscopy (LPS) (N = 26). Data are expressed as fre- complex prolapse cases. quencies and percentages. Data analysis was done with Fisher’s exact Enhanced efficacy and safety were also perceived by the test. Values of P < 0.05 were considered significant experts; hence they considered the robotic platform as a LPS laparoscopy, PF pelvic floor, PFRS pelvic floor reconstructive surgery, RS robotic surgery means to facilitate early discharge of patients. Consistent with this view, recent research has investigated the possibil- ity of enhanced recovery after surgery protocols combined expert laparoscopic surgeon, thus extending the indications with early, same day, and even ambulatory surgery for PFRS of minimally invasive surgery beyond the boundaries set procedures performed with the robot [26–30]. by the limitations of standard laparoscopic instruments [3]. Some interesting differences were identified in the group Whether a robotic approach is of significant advantage subanalyses. Gynecologists felt that robotic POP surgery for a specific procedure depends on the procedure itself, the should be limited to selected and more complex cases, patient’s characteristics, and the surgeon’s skills; hence it is whereas urologists and colorectal surgeons did not. This difficult to measure objectively. If one adds the economic difference could be due to the different case mixes of proce- impact of the use of a robot, some procedures, including dures and selection algorithms for robotics in the 3 special- PFRS, are more debatable as indications because they are ties; however, since urologists were less numerous in the associated with lower reimbursements [12, 13]. expert groups, this finding might be biased. Nonetheless, the advantage of a surgical tool should be A number of experts over time had chosen to perform measured based on the degree of technical advantage that PFRS only with the robot. This group showed a stronger it confers during a specific procedure rather than on its cost appreciation for the technical advantages of this platform [16]. The selection of procedures that benefit most from the compared to those who used both robotics and standard 13 Surgical Endoscopy (2023) 37:5215–5225 5223 laparoscopy. They indeed believed that robotics should not Funding Open access funding provided by Università di Pisa within be limited to selected cases but that it is instead useful also the CRUI-CARE Agreement. The project was funded with research funds from the University of Pisa to Tommaso Simoncini. for less complex procedures. This finding shows how within an expert group of pelvic floor surgeons, a significant pro- Declarations portion elected using only the robot to perform PFRS due to perceived technical advantages. We did not explore whether Disclosures Alexander L.A. Bloemendaal is proctor and speaker for those using both laparoscopy and robotics did so for a strate- Intuitive Surgical, TelaBio, and FascioTens. Stephan Buse is proctor for Intuitive Surgical. Ralf Joukhadar is proctor and speaker for Intuitive gic surgical choice or because of other factors (e.g., limited Surgical. Christl Reisenauer received speaker’s honoraria from Intuitive access to the robotic platform). Surgical, Contura/Axonics, and Boston Scientific. Tommaso Simoncini Another interesting difference was that the more-expe- has received consulting fees from Abbott, Astellas, Gedeon Richter, rienced surgeons were more likely to emphasize the ergo- Mitsubishi Tanabe, Sojournix, Estetra, Mithra, Actavis, Medtronic, Shionogi, and Applied Medical and has received speakers’ honoraria nomic advantages of the robotic platform and were con- from Shionogi, Gedeon Richter, Intuitive Surgical, Applied Medical, vinced that it decreased the duration of PFRS procedures, and Theramex. Steven Schraffordt Koops is proctor for Intuitive Surgi- possibly indicating that continued use leads to better exploi- cal. Andrea Panattoni, Mustafa Aktas, Jozef Ampe, Cornelia Betschart, tation of the benefits of the robot. This may suggest that cen- Alexander L.A. Bloemendaal, Giuseppe Campagna, Marta Caretto, Mauro Cervigni, Esther C.J. Consten, Hugo H. Davila, Jean Dubuisson, tralization of robotic procedures in the hands of high-volume Eloy Espin-Basany, Bernardina Fabiani, Jean-Luc Faucheron, Andrea surgeons could have advantages. Giannini, Brooke Gurland, Dieter Hahnloser, Paolo Mannella, Liliana Overall, the general feeling of the group of gynecologists, Mereu, Jacopo Martellucci, Guillaume Meurette, Maria Magdalena urologists, and colorectal surgeons’ expert in the use of the Montt Guevara, Carlo Ratto, Barry A. O'Reilly, Eleonora Russo, Sha- hab Siddiqi, Alessandro Sturiale, and Gabriele Naldini have no con- robotic platform for PFRS was that robotics is appropriate flicts of interest or financial ties to disclose. for this type of surgery given the significant technical advan- tages and the overall cost–benefit balance. This Delphi initi- Open Access This article is licensed under a Creative Commons Attri- ative calls for more research to objectively assess the specific bution 4.0 International License, which permits use, sharing, adapta- settings where robotic surgery might be more wisely chosen tion, distribution and reproduction in any medium or format, as long over standard laparoscopy, with the overarching objective of as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes improving patient care and sustainability. were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in Study limitations the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a This study has some limitations. The study population is copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. a self-selected group of expert pelvic floor surgeons who may have more positive feelings and confidence with robot- assisted surgery than those who did not participate. Also, while the sample size of the total group is within the recom- References mended range for a Delphi analysis, groups in the subanaly- ses are smaller, which is an obvious limitation. 1. Pushkar DY, Kasyan GR, Popov AA (2021) Robotic sacrocol- popexy in pelvic organ prolapse: a review of current literature. Acknowledgements The authors thank Laura J. Ninger, ELS (Ninger Curr Opin Urol 31:531–536. https://d​ oi.o​ rg/1​ 0.1​ 097/M ​ OU.0​ 0000​ Medical Communications, LLC) for professional English language 00000​000932 revision. Tommaso Simoncini had full access to all the data in the study 2. Pan K, Zhang Y, Wang Y, Wang Y, Xu H (2016) A systematic and takes responsibility for the integrity of the data and the accuracy review and meta-analysis of conventional laparoscopic sacrocol- of the data analysis. popexy versus robot-assisted laparoscopic sacrocolpopexy. Int J Gynecol Obstet 132:284–291. https://d​ oi.o​ rg/1​ 0.1​ 016/j.i​ jgo.2​ 015.​ Author contributions TS and AP: wrote the manuscript. TS and GN: 08.​008 organized the project, chaired the organizing committee and the sci- 3. Schachar JS, Matthews CA (2020) Robotic-assisted repair of entific committee, and participated in the Delphi process. ECJC, HD, pelvic organ prolapse: a scoping review of the literature. Transl GM, CR, and SSK: formed the scientific committee and participated Androl Urol 9:959–970. https://​doi.​org/​10.​21037/​tau.​2019.​10.​02 in the Delphi process. MA, JA, CB, ALAB, SB, GC, MC, JD, EE-B, 4. Flynn J, Larach JT, Kong JCH, Warrier SK, Heriot A (2021) J-LF, BG, DH, RJ, PM, LM, JM, CR, BAO, and SS: participated in Robotic versus laparoscopic ventral mesh rectopexy: a system- the Delphi process. AP and MMMG: set up and managed the Google atic review and meta-analysis. Int J Colorectal Dis 36:1621–1631. module system to perform the electronic Delphi process and analyzed https://​doi.​org/​10.​1007/​s00384-​021-​03904-y the results. MC, BF, AG, ER, and AS: assisted with selection of par- 5. Albayati S, Chen P, Morgan MJ, Toh JWT (2019) Robotic vs. ticipants, creation of the statements, and final elaboration of the results. laparoscopic ventral mesh rectopexy for external rectal prolapse and rectal intussusception: a systematic review. Tech Coloproctol 23:529–535. https://​doi.​org/​10.​1007/​s10151-​019-​02014-w 13 5224 Surgical Endoscopy (2023) 37:5215–5225 6. Naldini G, Fabiani B, Sturiale A, Russo E, Simoncini T (2021) esophagectomy: an international expert Delphi consensus. Dis Advantages of robotic surgery in the treatment of complex pelvic Esophagus. https://​doi.​org/​10.​1093/​dote/​doaa1​01 organs prolapse. Updates Surg 73:1115–1124. https://​doi.​org/​10.​ 20. Fuchs HF, Collins JW, Babic B, DuCoin C, Meireles OR, Grim- 1007/​s13304-​020-​00913-4 minger PP, Read M, Abbas A, Sallum R, Müller-Stich BP, Perez 7. Capmas P, Suarthana E, Larouche M (2021) Conversion rate of D, Biebl M, Egberts J-H, van Hillegersberg R, Bruns CJ (2021) laparoscopic or robotic to open sacrocolpopexy: are there associ- Robotic-assisted minimally invasive esophagectomy (RAMIE) ated factors and complications? Int Urogynecol J 32:2249–2256. for esophageal cancer training curriculum-a worldwide Delphi https://​doi.​org/​10.​1007/​s00192-​020-​04570-4 consensus study. Dis Esophagus 35:doab055 8. Callewaert G, Bosteels J, Housmans S, Verguts J, van Cleynen- 21. Dell’Oglio P, Turri F, Larcher A, D’Hondt F, Sanchez-Salas R, breugel B, van der Aa F, de Ridder D, Vergote I, Deprest J (2016) Bochner B, Palou J, Weston R, Hosseini A, Canda AE, Bjerggaard Laparoscopic versus robotic-assisted sacrocolpopexy for pelvic J, Cacciamani G, Olsen KØ, Gill I, Piechaud T, Artibani W, van organ prolapse: a systematic review. Gynecol Surg 13:115–123. Leeuwen PJ, Stenzl A, Kelly J, Dasgupta P, Wijburg C, Collins https://​doi.​org/​10.​1007/​s10397-​016-​0930-z JW, Desai M, van der Poel HG, Montorsi F, Wiklund P, Mottrie 9. Mäkelä-Kaikkonen J, Rautio T, Klintrup K, Takala H, Vierimaa A (2022) Definition of a structured training curriculum for robot- M, Ohtonen P, Mäkelä J (2014) Robotic-assisted and laparoscopic assisted radical cystectomy with intracorporeal ileal conduit in ventral rectopexy in the treatment of rectal prolapse: a matched- male patients: a Delphi consensus study led by the erus educa- pairs study of operative details and complications. Tech Coloproc- tional board. Eur Urol Focus 8:160–164. https://d​ oi.o​ rg/1​ 0.1​ 016/j.​ tol 18:151–155. https://​doi.​org/​10.​1007/​s10151-​013-​1042-7 euf.​2020.​12.​015 10. Giannini A, Caretto M, Russo E, Mannella P, Simoncini T (2019) 22. Collins JW, Marcus HJ, Ghazi A, Sridhar A, Hashimoto D, Advances in surgical strategies for prolapse. Climacteric. https://​ Hager G, Arezzo A, Jannin P, Maier-Hein L, Marz K, Valdastri doi.​org/​10.​1080/​13697​137.​2018.​15432​66 P, Mori K, Elson D, Giannarou S, Slack M, Hares L, Beaulieu Y, 11. Giannini A, Russo E, Cano A, Chedraui P, Goulis DG, Lambrin- Levy J, Laplante G, Ramadorai A, Jarc A, Andrews B, Garcia P, oudaki I, Lopes P, Mishra G, Mueck A, Rees M, Senturk LM, Neemuchwala H, Andrusaite A, Kimpe T, Hawkes D, Kelly JD, Stevenson JC, Stute P, Tuomikoski P, Simoncini T (2018) Current Stoyanov D (2021) Ethical implications of AI in robotic surgical management of pelvic organ prolapse in aging women: EMAS training: a Delphi consensus statement. Eur Urol Focus. https://​ clinical guide. Maturitas. https://d​ oi.o​ rg/1​ 0.1​ 016/j.m ​ aturi​ tas.2​ 018.​ doi.​org/​10.​1016/j.​euf.​2021.​04.​006 02.​004 23. van der Schans EM, Verheijen PM, el Moumni M, Broeders 12. Mäkelä-Kaikkonen J, Rautio T, Ohinmaa A, Koivurova S, IAMJ, Consten ECJ (2022) Evaluation of the learning curve of Ohtonen P, Sintonen H, Mäkelä J (2019) Cost-analysis and quality robot-assisted laparoscopic ventral mesh rectopexy. Surg Endosc of life after laparoscopic and robotic ventral mesh rectopexy for 36:2096–2104. https://​doi.​org/​10.​1007/​s00464-​021-​08496-w posterior compartment prolapse: a randomized trial. Tech Colo- 24. Carter-Brooks CM, Du AL, Bonidie MJ, Shepherd JP (2018) The proctol 23:461–470. https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 10151-0​ 19-0​ 1991-2 impact of a dedicated robotic team on robotic-assisted sacrocol- 13. Wang R, Hacker MR, Richardson M (2021) Cost-effectiveness popexy outcomes. Female Pelvic Med Reconstr Surg 24:13–16. of surgical treatment pathways for prolapse. Female Pelvic Med https://​doi.​org/​10.​1097/​SPV.​00000​00000​000413 Reconstr Surg 27:E408–E413. https://d​ oi.o​ rg/1​ 0.1​ 097/S ​ PV.0​ 0000​ 25. van Zanten F, Schraffordt Koops SE, Pasker-De Jong PCM, Lent- 00000​000948 ers E, Schreuder HWR (2019) Learning curve of robot-assisted 14. Humphrey-Murto S, Varpio L, Wood TJ, Gonsalves C, Ufholz LA, laparoscopic sacrocolpo(recto)pexy: a cumulative sum analysis. Mascioli K, Wang C, Foth T (2017) The use of the Delphi and Am J Obstet Gynecol 221:483.e1-483.e11. https://​doi.​org/​10.​ other consensus group methods in medical education research: a 1016/j.​ajog.​2019.​05.​037 review. Acad Med 92:1491–1498. https://​doi.​org/​10.​1097/​ACM.​ 26. Evans S, McCarter M, Abimbola O, Myers EM (2021) Enhanced 00000​00000​001812 recovery and same-day discharge after minimally invasive sacro- 15. Boulkedid R, Abdoul H, Loustau M, Sibony O, Alberti C (2011) colpopexy. Female Pelvic Med Reconstr Surg 27:740–745. https://​ Using and reporting the Delphi method for selecting healthcare doi.​org/​10.​1097/​SPV.​00000​00000​001043 quality indicators: a systematic review. PLoS ONE. https://​doi.​ 27. Kisby CK, Polin MR, Visco AG, Siddiqui NY (2019) Same-day org/​10.​1371/​journ​al.​pone.​00204​76 discharge after robotic-assisted sacrocolpopexy. Female Pelvic 16. Lyons SD, Law KSK (2013) Laparoscopic vessel sealing tech- Med Reconstr Surg 25:337–341. https://​doi.​org/​10.​1097/​SPV.​ nologies. J Minim Invasive Gynecol 20:301–307. https://​doi.​org/​ 00000​00000​000573 10.​1016/j.​jmig.​2013.​02.​012 28. Lloyd JC, Guzman-Negron J, Goldman HB (2018) Feasibility of 17. Chu CM, Agrawal A, Mazloomdoost D, Barenberg B, Dune TJ, same day discharge after robotic assisted pelvic floor reconstruc- Pilkinton ML, Chan RC, Weber Lebrun EE, Arya LA (2019) tion. Can J Urol 25:9307–9312 Patients’ knowledge of and attitude toward robotic surgery for 29. Faucheron JL, Trilling B, Barbois S, Sage PY, Waroquet PA, pelvic organ prolapse. Female Pelvic Med Reconstr Surg 25:279– Reche F (2016) Day case robotic ventral rectopexy compared 283. https://​doi.​org/​10.​1097/​SPV.​00000​00000​000556 with day case laparoscopic ventral rectopexy: a prospective 18. Thomas D, Medoff B, Anger J, Chughtai B (2020) Direct-to-con- study. Tech Coloproctol 20:695–700. https://​doi.​org/​10.​1007/​ sumer advertising for robotic surgery. J Robot Surg 14:17–20. s10151-​016-​1518-3 https://​doi.​org/​10.​1007/​s11701-​019-​00989-0 30. Trilling B, Sage PY, Reche F, Barbois S, Waroquet PA, Faucheron 19. Müller PC, Kapp JR, Vetter D, Bonavina L, Brown W, Castro S, JL (2018) Early experience with ambulatory robotic ventral rec- Cheong E, Darling GE, Egberts J, Ferri L, Gisbertz SS, Gockel topexy. J Visc Surg 155:5–9. https://​doi.​org/​10.​1016/j.​jvisc​surg.​ I, Grimminger PP, Hofstetter WL, Hölscher AH, Low DE, Luyer 2017.​05.​005 M, Markar SR, Mönig SP, Moorthy K, Morse CR, Müller-Stich BP, Nafteux P, Nieponice A, Nieuwenhuijzen GAP, Nilsson M, Publisher's Note Springer Nature remains neutral with regard to Palanivelu C, Pattyn P, Pera M, Räsänen J, Ribeiro U, Rosman jurisdictional claims in published maps and institutional affiliations. C, Schröder W, Sgromo B, van Berge Henegouwen MI, van Hillegersberg R, van Veer H, van Workum F, Watson DI, Wijn- hoven BPL, Gutschow CA (2021) Fit-for-discharge criteria after 13 Surgical Endoscopy (2023) 37:5215–5225 5225 Authors and Affiliations Tommaso Simoncini1 · Andrea Panattoni1 · Mustafa Aktas2 · Jozef Ampe3 · Cornelia Betschart4 · Alexander L. A. Bloemendaal5 · Stephan Buse6 · Giuseppe Campagna7 · Marta Caretto1 · Mauro Cervigni8 · Esther C. J. Consten9 · Hugo H. Davila10 · Jean Dubuisson11 · Eloy Espin‑Basany12 · Bernardina Fabiani13 · Jean‑Luc Faucheron14 · Andrea Giannini1 · Brooke Gurland15 · Dieter Hahnloser16 · Ralf Joukhadar17 · Paolo Mannella1 · Liliana Mereu18 · Jacopo Martellucci19 · Guillaume Meurette20 · Maria Magdalena Montt Guevara1 · Carlo Ratto21 · Barry A. O’Reilly22 · Christl Reisenauer23 · Eleonora Russo1 · Steven Schraffordt Koops24 · Shahab Siddiqi25 · Alessandro Sturiale13 · Gabriele Naldini13 1 13 Division of Obstetrics and Gynecology, Department Proctology and Pelvic Floor Clinical Center, Cisanello of Clinical and Experimental Medicine, University of Pisa, University Hospital, Pisa, Italy Pisa, Italy 14 Colorectal Surgery Unit, Visceral Surgery and Acute Care 2 Division of Obstetrics and Gynecology, Maasstad Hospital, Surgery Department, Grenoble Alps University Hospital, Rotterdam, The Netherlands Grenoble, France 3 15 Department of Urology, AZ Sint-Jan Bruges Hospitals, Division of Colorectal Surgery, Department of Surgery, Brugge, Belgium Stanford University School of Medicine, Stanford, CA, USA 4 16 Department of Gynecology, University Hospital of Zurich, Department of Visceral Surgery, University Hospital University of Zurich, Zurich, Switzerland Lausanne, Lausanne, Switzerland 5 17 Department of Surgery, Reinier de Graaf Hospital, Delft, Department of Obstetrics and Gynecology, University The Netherlands of Wuerzburg, Würzburg, Germany 6 18 Department of Urology and Urologic Oncology, Alfried Department of Obstetrics and Gynecology, Cannizzaro Krupp Hospital, Essen, Germany Hospital, Catania, Italy 7 19 Division of Urogynecology and Pelvic Floor Reconstructive Department of General, Emergency and Minimally Invasive Surgery, Department of Women and Child Health, Surgery, Careggi University Hospital, Florence, Italy University Hospital A. Gemelli IRCCS, Catholic University 20 Digestive and Endocrine Surgery Clinic, IMAD, CHU de of the Sacred Heart, Rome, Italy Nantes, Hôtel Dieu, Nantes Cedex, France 8 Department of Urology, La Sapienza University-Polo Pontino 21 Proctology Unit, Fondazione Policlinico Universitario ICOT, Latina, Italy Agostino Gemelli IRCCS, Università Cattolica del Sacro 9 Department of Surgery, Meander Medical Center, Cuore, Rome, Italy Amersfoort and Department of Surgery, University Medical 22 Department of Obstetrics and Gynecology, Cork University Center Groningen, Groningen, The Netherlands Maternity Hospital, Cork, Ireland 10 Cleveland Clinic Indian River Hospital, Florida State 23 Department of Obstetrics and Gynecology, University University, College of Medicine, Tallahassee, FL, USA Hospital Tuebingen, Tuebingen, Germany 11 Department of Pediatrics, Gynecology, and Obstetrics, 24 Department of Gynecology, Meander Medical Center, Geneva University Hospitals and University of Geneva, Amersfoort, The Netherlands Geneva, Switzerland 25 12 Broomfield Hospital, Court Road, Chelmsford, UK Unidad de Cirugía Colorrectal, Servicio de Cirugía General, Hospital Valle de Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain 13