Success of ASC encompasses a heterogeneous definition of outcomes. Depending on whether success is defined by objective POP-Q postoperative evaluation versus patient satisfaction, effectiveness can range anywhere from 78 % to 100 % for apical prolapse versus 85–100 % for patient satisfaction [21]. In a randomized controlled study evaluating ASC to vaginal sacrospinous colpopexy, subjective success based on prolapse symptoms and satisfaction of ASC based on visual analog scale were 94 % and 85 %, respectively, at an average of 2 years [40]. In one of the longest follow-ups at a mean of 13.7 years, Hilger et al. demonstrated a 74 % success rate with ASC. Success in this study was defined by either no reoperation for POP or a negative answer to question 5 on the Duke Pelvic Floor Distress Inventory (“Do you usually have a bulge or something falling out that you can see or feel in the vaginal area?”) Although significantly long in follow-up, only 12 of the original 47 women included in the study were available for examination. Of those 12 women who were examined, 6 patients had failed by their criteria and none of the 12 had greater than stage II prolapse on examination [41]. At the time of writing this chapter, the latest update from the CARE trial with 7 year follow-up demonstrated an estimated anatomic failure rate of 27 % in the urethropexy arm versus an estimated symptomatic POP failure rate of 29 % in that same group. Anatomic failure was defined as reoperation or pessary for POP where the vaginal apex descends below the upper third of the vagina or the anterior/posterior vaginal wall descends past the hymen. Symptomatic failure was defined as a positive response to one or more questions on the POP distress inventory referring to seeing or feeling a bulge or reoperation or pessary for POP [24].

Attempting to address this obtuse definition of success in ASC patients, Barber et al. evaluated the data from the CARE trial and applied 18 different surgical success definitions. Among their objectives was to describe how using different definitions affect estimates of treatment success and compare different definitions of surgical success by examining their relationship to patient’s subjective assessments of improvement. At 2 years, 94 % of patients achieved surgical success when it was defined by absence of prolapse beyond the hymen. When applying National Institutes of Health definitions of outcomes such as optimal (POP-Q stage 0) or satisfactory (support higher than 1 cm proximal to hymen), the rates of success were lower at 19 % and 57 % [25].

Rates of reoperation for prolapse in the original CARE trial were low at 2.8 % over 2 years which rose to 5.1 % over the course of 7 years [24, 25]. This is comparable to the 4.4 % (0–18.2 %) median reoperation rate observed in summarized published studies. The most common reason for reoperation was for prolapse of the anterior or posterior compartment [21]. The longest follow-up was noted to be 3 years. Hilger et al. evaluating results at a mean of 13.7 years found a 10.5 % rate of reoperation for recurrence [41].

In regard to system specific genitourinary, gastrointestinal, and sexual function after ASC, most studies in the past did not evaluate complaints with standardized validated questionnaires or in prospective fashion thereby making a generalization on outcomes difficult to assess. In a case control study evaluating women who had undergone ASC versus women who had solely undergone hysterectomy, patients were evaluated using a bowel function questionnaire and the Cleveland Clinical Incontinence Score (CCIS). While those undergoing ASC had more significant obstructive defecatory symptoms (splinting, incomplete evacuation, use of enemas), fecal incontinence rates were not different. Incontinence was noted to be higher in patients who had obstetric anal injury. Unfortunately, results from this study are difficult to extrapolate without the context of preoperative symptom scores. On average, time from surgery to questionnaire was 8.1 years for the ASC group [42]. Evaluating 1 year bladder symptoms based on UDI changes in patients who participated in the CARE trial, de novo irritative voiding was reported in 12/131 (9.2 %) women. For those with obstructive voiding symptoms before surgery, improvement was noted in 85.1 %. A statistically significant mean reduction of PVR of 31 mL was observed postoperatively [43]. One year follow-up was also evaluated in regard to sexual function in patients who participated in the CARE trial. Using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Functioning Questionnaire (PISQ-12), patients who had a sexual partner before and after surgery were evaluated at 1 year for effects of surgery on sexual function. There was a statistically significant rise in the amount of women who were sexually active compared to prior to surgery (76.3 % vs. 66.1 %, p < 0.001). Fewer women after ASC avoided sexual activity due to pelvic or vaginal symptoms, fear of incontinence, bulge in the vagina, or being limited by pain. It was noted that 11/148 (7.4 %) women became sexually inactive after surgery. There was a higher proportion limited by pain but this was not statistically significant (26 % vs. 22 %, p = 1.0). The authors did note that there was a higher incidence of infrequent sexual desire amongst those who were inactive after surgery (70 % vs. 22.1 %, p < 0.001) [44].

Although ASC has been recognized as the gold standard surgery for apical POP repair, increased hospital stay, blood loss, and length of recovery have all been listed as drawbacks of open ASC compared to other approaches [45]. Minimally invasive surgery and robot assisted laparoscopic surgery decrease the convalescence associated with transabdominal surgery. Siddiqui et al. evaluated robotic ASC outcomes at 1 year compared to patients in the CARE trial and found no significant difference in surgical failures as defined by bothersome vaginal symptoms or repeat surgery for prolapse (8 % vs. 4 %, p = 0.16). Operative characteristics that were significantly different between robotic vs. open ASC include estimated blood loss (90 mL vs. 228 mL, p < 0.01), concomitant hysterectomy (49 % vs. 28 %, p < 0.01), and posterior repair at time of ASC (8 % vs. 22 %, p < 0.01). Complications that were significantly different included wound disruption (0 % vs. 4.3 %, p = 0.01), febrile morbidity (4.8 % vs. 10.9 %, p = 0.04), and ileus (5.6 % vs. 11.6 %, p = 0.05) [46]. Rozet et al. similarly found laparoscopic sacral colpopexy to be efficacious in treating POP. The retrospective review evaluated 363 patients who underwent a laparoscopic sacral colpopexy. 25 % of patients had undergone a previous hysterectomy and only 4 % had a concomitant hysterectomy. Complications were low with 2 % requiring open conversion. Average hospital stay was noted to be 3.7 days. On average follow-up for 14.6 months, anatomic cure rate, which was not defined on postoperative visit, was noted to be 96 % with a similar 96 % satisfaction rate [47]. These rates are similar to a recent review article regarding laparoscopic sacrocolpopexy [48]. A retrospective cohort study evaluating laparoscopic and ASC found that although mean operating time (269 min vs. 218 min, p < 0.0001) was longer in the laparoscopy cohort, mean hospital stay was significantly shorter (1.8 days vs. 4 days, p < 0.0001). Clinical efficacy was difficult to assess given that not all patients had preoperative and postoperative POP-Q standardized scores [49]. To date no prospective randomized trial have been done to evaluate robotic ASC to open ASC [50].