A Survey of Operative Techniques Used by Female Pelvic Medicine and Reconstructive Surgeons Performing Minimally Invasive Sacral Colpopexy

Abstract

Objective: To assess the variability of surgical technique for minimally invasive sacral colpopexy among Female Pelvic Medicine and Reconstructive Surgeons (FPMRS). Methods: Avoluntary and anonymous questionnaire was given to attendees at the 2018 AUGS annual meeting in their registration packet. Results were analyzed using descriptive statistic and t-tests, Fisher's Exact, or Chi-Square for comparisons made between physicians of different ages, genders, years of experience, practice setting, and U.S. region. Results: There were 59 responses from 671 physician conference attendees (8.8%) from all 4 U.S regions (32.1% Northeast, 30.2%South, 20.8%Midwest, 17.0% West). The majority were US physicians (94.6%), who were ObGyntrained FPMRS (91.5%), in a University-based setting (66.1%), and male (64.4%). Mean age was 47.4±8.6 years, most commonly with >15 years in practice (47.5%). Minimally invasive sacral colpopexy was performed by 84.7%. Overall, surgical routes were 53.8% robotic, 42.2% laparoscopic, and 4.0% open. However, individual surgeons predominantly operated via either a robotic or laparoscopic route. Surgeons used 3 or 4 ports (both 50%), with a 0-degree scope (46%) or combination of 0 and 30 degree scopes (36%). 83.1% used suture as opposed to tacking devices to attach mesh to the sacrum, most often Gortex (56.3%), prolene (18.8%), or Ethibond (16.7%). Both anterior and posterior vaginal attachment used 5-6 sutures (48.1% and 50.0%) or 7-8 sutures (35.3% and 31.5%). Large bowel retraction was performed by 55.2%, most commonly with suture (38%). Anterior repair was either “not usually” or “not at all” performed (83.4%). Conversely, posterior repair and perineorrhaphy were performed either “yes, often” or “yes, sometimes” by 70.4% and 77.8%. Midurethal sling was performed by 42.6% “yes, often” and 51.9% “yes, sometimes”. Hysteropexy is rare with 86.5% performing either “not usually” or “not at all”. Most commonly surgeons did not use additional means to identify ureteral efflux at time of confirmatory cystoscopy (31.5%) followed by pyridium/uribel(27.8%) and fluorescein (24.1%). PVR was assessed after surgery by 89.8%, predominantly with a retrograde fill and voiding trial (75.5%). The majority discharge patients on POD1 (47.6% in AM and 29.1% in PM) with 15.2% discharged day of surgery. Females were more likely to perform hysteropexy (p=0.028). For all other comparisons, we did not see statistically significant differences in age, gender, experience, practice setting or region (all p>0.05). Conclusions: The vast majority of AUGS attendee survey respondents perform minimally invasive sacral colpopexy, with similar distribution of robotic and laparoscopic cases. Concomitant surgeries of the posterior wall are commonly performed. Other than more hysteropexies performed by females there were no other identified demographic variables to predict technique variations. While this potentially suggests homogeneity of technique, results should be interpreted with caution given the low response rate.