So we'll round it out here with a couple of talks that will hopefully continue to be relevant to your practice. We've touched upon this topic, strengthening your vaginal repairs. We've talked about the apex a lot. This will bring some of it home. I did want to share my email, just because several of you approached me. If there are really difficult or unusual or just ODS patients that you don't want to treat, we are probably going to be running a national trial starting in August, September. And we'll have sites regionally. So if you care to be involved in terms of referring patients that are beyond your scope or just want to keep in touch about that topic I was discussing this morning, feel free to email me. That's my private email. So vaginal prolapse augmentation, is it still a thing? Options do exist. We obviously don't have mesh kits anymore. Rest in peace, Uphold. But it's gone, and we have to move on. And there are now less standardized ways, more DIY ways of doing things as compared to kits. But I want to just share with you, I won't say that it's the ultimate right way to do things, but the way that I've reacted. So I'm going to share with you a few graft and mesh techniques, maybe talk a little bit about the controversies, but we're not going to dwell on that. So why pelvic organ prolapse mesh? Well, the anterior compartment, which yes, it's really the apical anterior compartment, but that whole segment of vaginal prolapse repair is challenging. There's a high rate of recurrence, if not appropriately managed. And the endopelvic fascia in that level two is inherently weak. We know that the presence of a good anterior apical mesh repair has been backed by good level one evidence. Because of the mesh controversies, ironically, that caused us to pour a lot of our RCT time and effort into mesh. Some of it panned out not so well, some of it great, and then in the middle. But I would say the good operations did prove to be very effective, and were studied in the end better than some of our standard run of the mill native tissue repairs. So we have more research on mesh than a lot of other things. Just to remind ourselves, maybe this is unfair, because a lot of these studies were done before we started to really focus properly on the apex. But when we try to treat the anterior segment with coporaphy and rely on it, it simply is inferior to mesh. The big caveat has got to be the right mesh or graft, and we have to incorporate the apex. And there's many factors that we have to tease apart. Was it the mesh? Was it a really good apical repair? Was it the anterior segment being covered with mesh? We can debate all day, and it's probably heterogeneous among patients. This combination or this connection between the anterior and apical supports is really what it's all about. Myles showed that picture's worth a 1,000 words illustration, and I totally agree with that. And Delancey's shown this with his work so beautifully with his cadaver dissections and MRI studies that the loss of apical support is a primary factor contributing to the development of an anterior bulge. And this was duplicated by additional work here, Rooney in 2006. And cystoceles are really a function of this. I don't know if this video can play, if you're able to activate this video. It's one of my favorite. This is my AV guys. Does the video play here? Can you just hover over it or something? There you go. So this is my picture's worth a 1,000 words. I've shown this countless times teaching. And if you see the vagina without a prolapse, here when we pull this hemisected cadaver in the cervix out, you can see that anterior wall buckling down. And it's really more with the suspension here. When we get it roughly near the level of the ischial spine, whether that's sacrospinous, or uterosacral, or sacrocopalpexy, there's the spine. But that anterior segment and posterior segment, the whole envelope is pulled up into position. And you're getting a lot of your work done in the anterior compartment just by correcting the apical defect. And that makes sense. So with grafts, we're striving to create not only that great apical lift, but we're also rebuilding the trapezoidal support of the pubocervical fascia. And the key concept is the graft needs to do both. When I talk to colleagues that were sort of dabbling in grafts when I was in the early 2000s, when I was kind of like in fellowship and coming out of it, there were some failed experiments. And my impression is that's an issue of not incorporating the apex, where there was a feeling you could just put a graft over level two and you'll be fine. And I don't think that those outcomes were good for that very reason. Whereas from the beginning, whether it was luck or not, in our hands, we were always feeling that this was a bilateral sacrospinous suspension. And pretty much every iteration of graft and mesh we've used, I feel, has done a good job, largely because of that. I just think we bet on that horse, and it does pay off getting the apex truly fixed bilaterally. So anterapical prolapse, that's a criteria. I really only do my grafts anter. High risk of recurrence. Patient, maybe she's had a prior repair, still doesn't want an abdominal sacrocolopexy. Maybe she's not a good candidate. Uterine preservation's been a tremendous bucket for me. In Chicago, it's incredibly popular. A woman will be happy to keep her uterus if you offer her that option. And I know that's a very regional issue. So what I've done is, with both graft and mesh, created that trapezoid in different configurations. We're sort of going back before things took an exit ramp onto the uphold phase. That was about 10 years. So the lack of those kits has now brought me back to some of these full-cut trapezoidal mesh options and graft option. This is just a reminder of the mesh timeline. I don't think it's so critical we go through the whole post-mortem on that. But suffice it to say that anything mesh-wise that we use is going to fall into the type one, monofilament, microporous, large weave category. The other categories of mesh, such as the woven multifilament or the stamped or non-woven, non-knitted, simply don't have the wide enough pore size to allow the immune cells to fight off inevitable bacterial colonization or presence in that healing phase. I think one thing that we missed out on in debating mesh, and maybe one of the reasons it didn't end well, is we didn't really differentiate mesh from mesh. And in my mind, I've literally never used a Trocar kit. Some of them were good. And some of you in the room probably had excellent outcomes. But Trocar kits were inherently different from what we were doing from the start with a directly fixed SSL-based with limited perforation into the ligament. And I think that was lost on the public and on the FDA that some were minimal mesh concepts and some were maximal mesh. This is, again, some of you in the room probably are going to say some of your great outcomes were with ProLift. And I completely accept that. But look at what we were doing. The sheer volume of mesh, the sheer perforation points into these gluteal, obturator, these different muscle groups when put in enough hands was just simply is too much. And we know the end of that story. This is ancient history now. But just for point of context where I'm coming from, this was always our approach was sort of a minimal approach. Put the mesh where it's needed, two-point fixation into the sidewall. And I liked that it kind of mirrored, in my mind, sacral copepaxi, apical lift, mesh over the compartment, no lateral perforations needed. And I think that was borne out with the outcomes. Just for, I don't know how many people, age category-wise, I think most of you know what uphold is. I expected maybe a younger SKU. But I just did literally a 90-second quick uphold just to see the principles. And I hadn't looked at this in ages. Too much PTSD. But it was a beautifully simple procedure. But I mainly want to show you kind of the principles of coverage. And it was great for these hystereopexies. I mean, literally, the quickest one I did was 11 minutes. We're not trying to race in the operating room, but there just weren't that many steps. But mainly here, I want to show you the coverage because that zone was anterior apical. You kind of develop these neoligaments. We always just did a little tack of the mesh to the distal. And that was it. And then close, and you're done. And that was uphold just really for point of reference for people who got out of training after that was gone. The super trial, which we don't need to dwell on, but just to show that this concept of mesh repair was borne out by the highest level of evidence, multi-center, nine centers. It survived five years outcome and then some. Actually did really well, and painfully so that the authors were saying that these results suggest it should be now made available again to patients. Debatable whether it'll ever come back, but just for historical reference, I wanted to set that stage. 10-year data coming. Oh, is that right? 10-year data coming? So we'll see what that shows. I'm seeing patients now, gosh, 15-plus years out, and they look amazing. And so it's kind of a weird thing that some of our, at least for me, some of my best outcomes, I can't offer that to the next person. But can we do it with FreeCut? Can we do it with DIY? So admittedly, I have not done this FreeCut mesh repair. This was all pre-uphold. What I've done mostly is biographs since uphold, just again, maybe it's a little PTSD on my end. When we did these FreeCut mesh repairs, this led into the development of uphold, which I frankly think is a lot better just because it involves natural tensioning. But this was the technique we used. You can see it's a crusty old video with the old Capio. But this shows an example of cutting a trapezoidal mesh. And I would do a bilateral. This happened to be a Gore-Tex suture in each ligament. And then we'll pivot to the biograph in a minute. Our exposure rates for this, uphold had incredibly low exposure rates, like 1% to 3% tops once we were good at it. This was more in the kind of low single digits, even up to 10% at the time. And I think it was because we're doing more tensioning in different directions. Maybe some of that isn't necessary. But it was a higher exposure rate back in the day. Manageable, but it was higher than the uphold, which seemed to find its tension more naturally. But this is a trapezoid. I usually go about 10 centimeters across at the apex, about 4 centimeters-ish across at the top. And then this gets laid in using the Gore-Tex sutures to each ligament. I do think it's important to not miss tension. In other words, if there's too much roping of the top edge of that mesh, that's probably not a good thing because it's not going anywhere. And whatever tissue it's lying against, it's going to act like a saw. But you can see here those stitches being tied up. I always tie the apex first. It's kind of eliminating degrees of freedom. Like I'll tie one stitch down, and then I'll just, with a non-surgeon's knot, test the second one. If I don't like it, reposition it. Once my apex is in, I can deal with the level two. You may notice that I'm using the Capio now on level two, which is a mid-arcus bite. So I'll take the Capio or even just a freehand needle. And I'm going to be along that ischiopubic ramus, the descending ramus. And I take a little nip of tissue right where the bone is transitioning into the muscle. So you don't go too far lateral because you could wind up in the obturator canal. But you're essentially going for a white line bite. And it does not need to be deep. It shouldn't be deep because you cause pain. But you just want to show that mesh where to sit laterally. That's the more difficult of the two, the apex and then the mid. And then I'll use a simple vicral tacking distally. Again, I've not really reverted back to this much at all after uphold. What I've done more has been biographed. Biographed is not as strong. It's a little more debatable. But I do think, based on, I think, 20 years of using this, I really do think that you can get some excellent outcomes. I think it's a little more sporadic. Whereas mesh, you can almost bet your house on this patient's never going to recur or probably never will. Biographed, you get these funny outcomes, I think, where some just are amazing, even with huge prolapse. And then you'll have some people, I don't know if it's metabolic, that just don't heal quite as strong. But I love how it looks. It is a little bit more work. I use acellular cadaveric dermis. What is ACD? It's a regenerative human tissue matrix. Most of you have probably used it. But human skin that's decellularized, these are proprietary techniques, it leaves a collagen-free extracellular matrix. Under the microscope, it looks like scaffolding. And this is very inert, very non-immunogenic, repopulated very quickly by autologous cells and revascularized. I've used this for neo-vaginographs, for extending vaginas, constriction. That gives you an opportunity to actually look at how quickly these heal, and it's fascinating. I thought this would be a six-month endeavor. But if you see these women back even after eight weeks, sometimes it gets hard to distinguish it from normal skin, depending on how quickly they heal. So it's pretty interesting to use it as a surface graft. And that made me realize that, yeah, this is not oversold. It really is being revascularized in a real way. Again, very non-immunogenic. I've never seen a problem. I've used this for pretty much the length of my career. Here's just an example of how I've used it for other applications, for the neo-vagina and vaginal foreshortening. When you use it for this application, for a true congenital absence of vagina, it does not allow you to escape that constriction tendency of the vagina, unfortunately. I wish I could say set it and forget it, but it's not the case. These look amazing, but the patient does need to be sexually active or dilate, or they will tend to constrict, just like almost anything else. I don't know if that's less true for peritoneal, some of the other natural products. But this is how it's used. Really elegant, nice procedure. I don't even really need to use stents in these patients. It doesn't tend to constrict in that short-term way. It's just once it's healed, you need the patient to start keeping it patent. Not really the purpose of my talk. I was really talking more about the prolapse indication. So here, I've used this, again, since the early 2000s. This was an example of one of the abstracts from one of my fellows back in 2009, looking at over 100 graft-augmented repairs. And we thought there was about a 60% reduction, 19 versus 43, compared to anterior colporaphy. So the bar is low. 43% objective recurrence after anterior colporaphy leaves a lot of room for improvement. And so we got that down to the teens with the graft. And that really does match my clinical impression. I see some of these patients decades out now, and they've held up amazingly well. And others have failed. The fixation site, this I do think is important, as opposed to mesh. My belief has been you need to give the graft a little bit of stretch. I don't know if this is less true for the current product I'm using, which is different than the previous. But these acellular grafts, unlike mesh, I don't want to leave them loose. I'm not expecting any constriction. So I really want to make it look like the Netter photo of that nice trapezoid attached in all directions. So I'll share with you this video of a graft repair. This I did just a month ago or so. And I wanted to try to get decent enough footage to show the group. Sacrospinous is deep, mid-arcus, and then just a simple tack around the pubic bone to show the graft exactly how to repair. We talked about the acellular dermis. It's a cell-free matrix. And you can see here just a standard vertical incision. I've seen this a few times already this morning. It's getting a little boring, I'm sure. But this is highly edited, so it should move along reasonably well. Oh, this is cool, this is, I learned this from my partner. If you ever don't want to use the Lone Star, just use rubber bands. Did you ever see that? You just take rubber bands and tear your Alice's, that kind of, nice little tip so you can operate without assistance. Sorry about the repeat views of Capio here, but let me just show you how I tension the graft. Here's the mid-archus stitch. This is the hardest one to teach fellows. You just want your finger to go in about a knuckle's width. It's not really deep. Feel that ischiopubic ramus and then take a nip of the muscle just beyond the bone and don't go too lateral. You can see the head of the device there and that should be nice and strong. There's not a lot of give. PDS. I have used GORE-TEX for the cadaveric dermis on the sacrospinous, figuring that's the strongest, most important, and that this will be healing beyond that, but I don't think I've done that recently. I don't have real strong feelings. I think three months is a good amount of time for it to scar. I'll usually do a little coporphy. This was kind of like uphold-ish where we used to shrink that anterior compartment, kind of like Pat does with the gathering up. You just want to make this a normal-sized anterior compartment and then augment. I don't want a big, stretchy graft going over an unreduced cystoseal. Not sure it really matters, but that's what I do. And here we're cutting the graft. Interestingly, these grafts are cross-hatched. You cannot pull a stitch through it. The stitch will break first, so the tensile strength is excellent. If you overcut your graft, you can go right up to the edge of it. Even by a few millimeters, you won't be able to pull it through. But I usually cut it to about 10 across the bottom, four on top, and it winds up being about five to six centimeters of vertical length. And then I'll bring my sutures in about one centimeter. So I think that corresponds with, I don't know if it's Nas or somebody was saying about eight centimeters across. So it winds up being the same math. And then we'll tie the one corner of the graft up. Now, you can do a sandwich technique, meaning go through graft and take the same stitch and go through your vaginal suspension point. So if it's a hystropexy, that'll be lateral to the cervix. I'm not taking cervical stroma because I can't pull that to two ligaments. So it's gonna be a copepexy bite on the right and left side, but that can be the same suture as the graft. And that really results in a beautiful lift. The apex and the graft are just coming up to the ligament and it should look like really normal anatomy. Again, my sort of tensioning techniques here are really what makes this a great operation rather than just a good one. I tie my first one down and then with a non-surgeon's knot, give your best estimate of the second side. And if it looks too tight or loose, pull it out, replace it with a free needle and do it again. So you really wanna be precise about that second throw, kind of like a single incision sling. The first one doesn't matter. It's the second one that decides the tension. And then same goes for the mid-arcus. I'm gonna tie one down, commit to it. And then that second one, you can be more precise with the tensioning. Really make it look good, flat, not over-tensioned. I wanna give the bladder a little room to descend with voiding. And then the top throws and then we're more or less done. Grafts should look, they should look really good and well-repaired at the time of surgery, as opposed to the mesh where it can be a little loose and you're relying on the constriction. Sorry, I just have no way of speeding this up, but I think it's almost done. And that's the final. So you'll see, I'll just tack that underneath the pubic bone. And these, underneath that little vaginal skin is the continuity with the pubis. So if you pull on that skin, you're gonna feel you're almost moving the patient. So just get a little, I just get a little sub-epithelium. Careful of the ureter right there. There's actually, it's one of the few goofy spots that have gotten a ureter and had to undo it. Not a big deal, but. It's a horizontal incision, right? Actually, no. I just do, you can do whatever you want, but as opposed to the principle of non-overlapping mesh incision, I don't really care about that here. Yeah, so just watch your ureters right there. Obviously, you can take them right out, but then I get in a bad mood, I get grouchy. Anyways, I won't bother with the closure, but you get the sense of what that's doing in the interest of time. So management of these cases. Gluteal pain, at least after the CAPIO, is real. You know, I prepare every patient, I tell them, you're gonna feel some rear end pain, and I would say for me, I don't know if I could be doing it any better, but I'd say 20% of them have like a more significant, where I just say, it's gonna be a couple weeks. You're gonna just feel it there. That's your surgical healing. Stay ahead of it, take your medicine. And that's not any worse or better than non-GRAF cases, but it definitely is something you wanna counsel. Catheter management, I think nothing real specific there. Naz was very nice to send me a reference. I really wasn't able to put in the video, but she had mentioned this yesterday of an additional bio-GRAF concept. They did publish this with a video link using Acell, basically. Using Acell for a graft-augmented sacrospinous. This was sort of interesting, because it hybridizes a few of the things I've shown you, which was the uphold mesh arms that kind of come through with TVT-like arm adjustability, yet they're using a bio-GRAF, so that was a hybrid technique. And I just took a few screen captures, and you can look up that reference from the International Journal. Naz, real quick, how did you get the, did you just pull the arms through with a suture through the ligament? Got it. Got it. Does that make sense? Yeah. It's exactly. You're not folding. You're not folding. You're sewing it too. You're sewing it. Right. Yeah, yeah, yeah. Yeah, the arm does not traverse the ligament. OK. Got it. OK. I got you. So this is the shape of your graft, and you're sewing it on, and the cutout is to leave room for the central anatomy. You mean even for the biograph you're asking? Well, the acellular cadaveric dermis is fairly flexible. So I've never found that I needed to do that as opposed to uphold where I probably if I did it today with mesh, I would do more of a cutout to let it relax in the middle. But I've never done that with my biographs. I'm not saying it's maybe it would be best to leave a little give in the middle. But the dermis, I just haven't. I can't really comment on whether it would be a nicer fit without it. Did you have a comment, Stephanie? I was just going to say I do the same thing. So I recreated uphold, the shape, and tied it down just like she's mentioning, attach it to the cervix. You get that apical suspension with it. So I was just very interested. I was going to ask the same thing. Why are you doing a trapezoid when we all love the shape of uphold, right? And I was thinking that probably is bunching up at the apex, especially if they have a cervix. So that's a really great point. The truth is I had come up with these shapes before uphold. Uphold, I think, came to fruition around 2005. Everything that you're seeing here were the shapes that led up to that. Then when we developed that mesh, I was like, let's give it a little breathing room. I don't have a rational reason why I haven't gone in your direction. I should probably reshape the meshes and graphs I'm using now based on that success. The one thing I would say is that when we were doing uphold, sometimes you would not have full coverage of that anterior wall. It would be up by the cervix, and it would stop partway down if you had a long vagina. And so when you're doing the graphs, you can actually pull it all the way down to the bladder. Like, you can leave it long enough that you can get it all the way down to the bladder neck, which is the one slight difference where the middle part, it might be a little longer than the uphold. That is true. And with uphold, I'd always make a big point of shrinking that anterior compartment down, even if it's like, quote unquote, a vertical coporaphy, just to kind of shape the compartment to the mesh. But you're right. It didn't always provide that really comfortable coverage. So in the interest of keeping on time, because people have planes to catch and we have a schedule, I hope this was a little bit helpful. You can probably sense this is a real nuanced thing, as opposed to the mesh kits. If you do it, I think you have to start tailoring to different individual patients. It can definitely broaden your surgical range. I think as a field, I would like to see us not just doing sacrocopalpexy, which I do as well, but I think this whole domain of vaginal surgery is super interesting. It's creative. It does allow you to talk to patients with just a broader range of options. And I personally like that. It's just, to me, satisfying. Tensioning and sizing nuances, we talked about, but they really are important. And they differ for the graft and the mesh. And again, full disclosure, the mesh that you've seen there, the cutout mesh, I really haven't gone back to, but I've also seen quite a few recurrent cystocele. So unless I'm going to start doing a lot more sacrocopalpexy, we do have to make some adjustments to make this DIY successful. And finally, I think if you're going to do this like anything, it's important, just learning our lessons from the mesh, negative mesh events, is to manage your own complications and feel comfortable in that lane. Do enough of them to see the patterns. So thanks for your attention. Any quick questions are fine. We have about a minute. Yeah. Sorry, real quick. I know you weren't able to say, but do you use Acell for the BioGraft or Axis? I use the latter, yeah, the Coloplast product. Yeah, we're not supposed to be talking, but there's only really one on the market. And Acell, we did mention as well. So full disclosure, we have no connections to those companies, but yes. Just to order, Acell is with, are they their own company? Oh, they're both Coloplast. Yeah, Acell is not Coloplast as a sole company. Acell, if you're going to buy them, you're just going to get the chips, which is on our shelves for our general surgeons. But Acell makes different sizes. Yeah, and I will say, just to be squeaky clean for Oggs, there are different acellular cadaveric dermal products. None of these are really FDA. They're not using marketing language to target urogynecologists or this particular indication. You can feel free to look at the full scope of what's out there. There are a few companies. And I think we've all talked about this. We're pretty transparent with patients. When I say, this is not FDA approved for this indication, I'm using it as a tool to help with this problem. I'm going off label. I'll tell patients that, and I think they've been fine with it. So access is FDA approved for use in the pelvis. That's all they say. So if that makes any difference to you.

vaginal prolapse repair

mesh kits

DIY approaches

grafts and mesh

apical suspension

acellular cadaveric dermis

patient-specific factors