Comparison of Trendelenburg Angles in Vaginal, Laparoscopic, and Robotic Uterovaginal Apical Prolapse Repairs

Published:April 11, 2021DOI:


      Study Objective

      To compare the Trendelenburg angle used in laparoscopic uterovaginal apical prolapse repairs with the angles used in vaginal and robotic uterovaginal apical prolapse repairs.


      Prospective, multicenter cohort study from May 2015 to December 2016.


      Two academic teaching hospitals.


      Sixty patients who underwent vaginal high uterosacral ligament suspension, laparoscopic sacrocolpopexy, or robotic sacrocolpopexy performed by 6 surgeons board-certified in female pelvic medicine and reconstructive surgery.


      Measurement of Trendelenburg angle and time spent in Trendelenburg during surgery.

      Measurements and Main Results

      Twenty patients were enrolled in each procedure group. The median maximum angle of Trendelenburg was significantly greater in the laparoscopic group (22° [20–25]) than in the vaginal group (15° [6–19]; p <.001) and the robotic group (19° [16–21]; p = .02). The participants in the laparoscopic group spent significantly more time overall in Trendelenburg (176 minutes [143–221]) than those in the robotic group (150 minutes [127–161]; p = .01) and those in the vaginal group (120 minutes [86–128]; p <.001). The participants in the laparoscopic and robotic groups spent similar amounts of time in maximum Trendelenburg (116 minutes [52–164] and 117 minutes [61–134], respectively; p = .56), whereas the participants in the vaginal group spent significantly less time in maximum Trendelenburg (10 minutes [7–38]) than those in the laparoscopic group (p <.001). The total median operative time was highest for the laparoscopic approach (211 minutes [173–270]), followed by the robotic approach (181 minutes [165–201]) and the vaginal approach (162 minutes [128–186]; p = .008).


      The median maximum angle of Trendelenburg was highest in laparoscopic sacrocolpopexy—followed by robotic sacrocolpopexy—and lowest in vaginal high uterosacral ligament suspension. Patients who underwent robotic sacrocolpopexy spent less time in Trendelenburg than those who underwent the laparoscopic approach. Prolonged, steep Trendelenburg is often not required for any of the 3 surgical procedures, but a vaginal approach should be considered for those at high risk of complications from Trendelenburg position.


      To read this article in full you will need to make a payment
      AAGL Member Login
      AAGL Member, full access to the journal is a member benefit. Use your society credentials to access all journal content and features.
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Wu JM
        • Matthews CA
        • Conover MM
        • Pate V
        • Jonsson Funk M
        Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery.
        Obstet Gynecol. 2014; 123: 1201-1206
        • Olsen AL
        • Smith VJ
        • Bergstrom JO
        • Colling JC
        • Clark AL
        Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence.
        Obstet Gynecol. 1997; 89: 501-506
        • Siddiqui NY
        • Grimes CL
        • Casiano ER
        • et al.
        Mesh sacrocolpopexy compared with native tissue vaginal repair: a systematic review and meta-analysis.
        Obstet Gynecol. 2015; 125: 44-55
        • Maher C
        • Feiner B
        • Baessler K
        • et al.
        Surgical management of pelvic organ prolapse in women.
        Cochrane Database Syst Rev. 2010; 4CD004014
        • Jonsson Funk M
        • Edenfield AL
        • Pate V
        • Visco AG
        • Weidner AC
        • Wu JM
        Trends in use of surgical mesh for pelvic organ prolapse.
        Am J Obstet Gynecol. 2013; 208: 79.e1-79.e7
        • Wang LC
        • Al Hussein Al Awamlh B
        • Hu JC
        • et al.
        Trends in mesh use for pelvic organ prolapse repair from the Medicare database.
        Urology. 2015; 86: 885-891
        • Paraiso MF
        Robotic-assisted laparoscopic surgery for hysterectomy and pelvic organ prolapse repair.
        Fertil Steril. 2014; 102: 933-938
        • Danic MJ
        • Chow M
        • Alexander G
        • Bhandari A
        • Menon M
        • Brown M
        Anesthesia considerations for robotic-assisted laparoscopic prostatectomy: a review of 1,500 cases.
        J Robot Surg. 2007; 1: 119-123
        • Kadono Y
        • Yaegashi H
        • Machioka K
        • et al.
        Cardiovascular and respiratory effects of the degree of head-down angle during robot-assisted laparoscopic radical prostatectomy.
        Int J Med Robot. 2013; 9: 17-22
        • Souki FG
        • Rodriguez-Blanco YF
        • Polu SR
        • Eber S
        • Candiotti KA
        Survey of anesthesiologists’ practices related to steep Trendelenburg positioning in the USA.
        BMC Anesthesiol. 2018; 18: 117
        • Maerz DA
        • Beck LN
        • Sim AJ
        • Gainsburg DM
        Complications of robotic-assisted laparoscopic surgery distant from the surgical site.
        Br J Anaesth. 2017; 118: 492-503
        • Aggarwal D
        • Bora GS
        • Mavuduru RS
        • et al.
        Robot-assisted pelvic urologic surgeries: is it feasible to perform under reduced tilt?.
        J Robot Surg. 2021; 15: 553-559
        • Ghomi A
        • Kramer C
        • Askari R
        • Chavan NR
        • Einarsson JI
        Trendelenburg position in gynecologic robotic-assisted surgery.
        J Minim Invasive Gynecol. 2012; 19: 485-489
        • Gould C
        • Cull T
        • Wu YX
        • Osmundsen B
        Blinded measure of Trendelenburg angle in pelvic robotic surgery.
        J Minim Invasive Gynecol. 2012; 19: 465-468