Thank you to AUGS and IUGA for allowing us to present our research. These are our relevant disclosures. There has been an ongoing trend towards the use of lighter weight mesh types for minimally invasive sacrocopalpexy procedures. However, comparative assessment of surgical outcomes with lighter weight mesh has been limited. My co-authors have demonstrated that in a cohort of robotic sacrocopalpexy, ultralight weight mesh was associated with a shorter time to anatomic failure. However, they may have lacked power to determine an overall difference in prolapse recurrence and they also did not assess conventional laparoscopy. Thus, our goal was to compare the proportion of prolapse recurrence between minimally invasive sacrocopalpexy that utilize light weight versus ultralight weight mesh in a broader cohort of women that included both conventional laparoscopy as well as robotic-assisted approaches. We hypothesized that ultralight weight mesh would have a higher proportion of prolapse recurrence and a shorter time to prolapse recurrence. We performed a retrospective cohort study of all minimally invasive sacrocopalpexies which included both straight sick and robotic assistants at two academic institutions from 2009 through 2016 and included a total of 16 surgeons. While all minimally invasive sacrocopalpexies were eligible for inclusion, we excluded those patients who did not have a documented post-operative POPQ examination. We defined light weight mesh as a mesh density of greater than 21 grams per meter squared and we defined ultralight weight mesh as less than or equal to 21 grams per meter squared. The ranges here demonstrate the varying mesh weights of the different mesh types utilized by the surgeons over the study period. Our primary outcome was the proportion of prolapse recurrence by mesh group, which we defined as a composite outcome of any prolapse beyond the hymen and or with retreatment with either pessary or surgery. Our secondary outcomes included times of prolapse recurrence, the proportion of recurrence by surgical approach and mesh complications, which we defined as exposure, erosion or infection. We utilized T-tests, Mann-Whitney U, Chi-square and Fisher's exact as appropriate and we performed Kaplan-Meier and Cox regression for our time to recurrence outcomes. We assessed follow-up within three years for this portion of the statistical analysis to account for differentiating follow-up times between the mesh groups. Our final cohort consisted of 1,272 patients. For mesh type, 59% of the cases utilized light weight mesh and 41% utilized ultralight weight mesh and 42% of the procedures were performed laparoscopically and 59% were performed robotically. There were no major differences in demographic variables between the mesh groups. The average age was 59 years and the average BMI was 27 kilograms per meter squared. The majority of our patients were white, however, there were more African-American patients in the ultralight weight mesh group. The majority of our patients had at least stage 3 pelvic organ prolapse and over 50% in both groups underwent a concomitant hysterectomy. There was a difference in terms of surgical approach between the mesh groups with the ultralight weight mesh group having a higher proportion of robotic-assisted procedures. Stated differently, while there was an even number of both mesh types in the robotic group, the laparoscopic procedures utilized a greater proportion of light weight mesh. For our primary outcome of composite prolapse recurrence, a total of 89 patients or 7% of the total population experienced composite prolapse recurrence and this did not differ between the mesh groups. We also assessed anatomic compartment of recurrence and there was also no difference between mesh groups. There was also no difference in the type of retreatment between the mesh groups. We did find that the light weight mesh group had a significantly longer length of follow-up and we did note that the light weight mesh group had a higher proportion of mesh complications. For our secondary outcome of proportion of prolapse recurrence by surgical modality, we did not find a difference in prolapse recurrence between robotic and straight stick minimally invasive sacral pulpopexy. We then looked at those cases that only utilized ultralight weight mesh and there was still no difference in prolapse recurrence between surgical modality. We then assessed time to prolapse recurrence. Again, as mentioned previously, we did only assess patients with three years of follow-up for this portion of statistical analysis to mitigate the effects of differing follow-up between the mesh groups. Our Kappa-Meier curve demonstrated that ultralight weight mesh had a shorter time to prolapse recurrence and this was statistically significant on the log-rank test. We then performed a multivariable Cox regression to control for other factors to assess time to composite prolapse recurrence. When controlling for the other variables listed in this table, we found that increasing BMI, ultralight weight mesh, greater than or equal to stage 3 pelvic organ prolapse, and robotic surgery were all associated with a shorter time to prolapse recurrence. The benefits of our study include a large cohort and its multi-institutional design. Limitations include the retrospective nature of our study, the differential follow-up between mesh groups. Additionally, mesh weight is not the only mesh property that determines outcomes and the host response and we did not assess other mesh characteristics in this study. In conclusion, it was reassuring that there was no difference in the overall composite prolapse recurrence between lightweight and ultralight weight mesh after minimally invasive sacral copepaxine. We did note that ultralight weight mesh had a shorter time to prolapse recurrence. However, longer follow-up is needed to determine the clinical importance of this finding, particularly with the higher mesh complications in the lightweight mesh group. Lastly, surgical modality, prolapse stage, and increasing BMI may be associated with time to recurrence and these warrant further study. Thank you and I welcome any questions. Hi. Hi. Fiona Reed from England. Can you tell us, did you look at the material that you used to suture the meshes to the vagina? Were they all the same? We did not assess those details of the procedural characteristics and so one of the limitations as well of our study is that there's likely components of the procedures that we were not able to assess. We did not assess those details of the procedural characteristics and so one of the limitations as well of our study is that there's likely components of the procedures that we were not able to assess. We did not assess those details of the procedural characteristics and so one of the limitations as well of our study is that there's likely components of the procedures that we were not able to assess. We did not assess those details of the procedural characteristics and so one of the limitations as well of our study is that there's likely components of the procedures that we were not able to assess. We did not assess those details of the procedural characteristics and so one of the limitations as well of our study is that there's likely components of the procedures that we were not able to assess. We did not assess those details of the procedural characteristics and so one of the limitations as well of our study is that there's likely components of the procedures that we were not able to assess. We did not assess those details of the procedural characteristics and so one of the limitations as well of our study is that there's likely components of the procedures that we were not able to assess. We did not assess those details of the procedural characteristics and so one of the limitations as well of our study is that there's likely components of the procedures that we were not able to assess. 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And then we used the VAS again at hours 4, 8, 16, and 24. Vaginal pain was defined by the nurses as pain between the anus and the top of the vaginal opening. Total inpatient morphine equivalents per hour of stay from the time the patient arrived in PACU until they discharged home were then calculated. Everybody knows the VAS here. So we had standardized post-operative orders for everybody barring no contraindications for like IV Toradol or IV Tylenol. They got it around the clock every six hours with a Toradol and then they had the NSAIDs if they were longer than 24 hours they could have oral NSAIDs. Everybody got IV Tylenol and then every eight hours as well for oral. Other medications were available so they could get IV morphine, they had oxycodone, etc. And then all participants underwent a standardized voiding trial. So if you were discharged home on post-operative day zero, you underwent a trial that day and then obviously if you stayed one day, then you got it right the morning that you went home. So on post-operative day seven plus or minus three days and post-operative days 14 plus or minus three days, patients were contacted via telephone and asked to rate their vaginal pain using the VAS. We also asked about bowel movements and whether or not they had passed their second void trial if they had failed. Our statistical analysis was used using SPSS and Excel. We used a T-test, Chi-square, and ANOVAs for our analysis. So basically a total of 130 women were randomly assigned between May of 2017 and December 2018. 68 had bupivacaine and 62 had placebo. The median patient age was 61, mean BMI was 29.3, median parity was 3. Five of these actually were null-ups of the 130. One hundred and twenty-five were Caucasian and there were no statistical difference noted demographically. So this is our table of demographic variables and you can see on the right there that all the P-values are not statistically significant between age, weight, height, etc. Stage two was actually our most prevalent stage of prolapse at 84.6%. This is a really busy slide, sorry, but this is just our summary of categorical demographic variables. This is really the most important slide. So the first line is the pain score at hour 0 and then going down 4, 8, 16, 24, as well as post-operative weeks 1 and 2, and then average morphine equivalent use per hour and post-operative days to BM, and then you can see on the right that none of the statistics were significant. So this is our pain score. This has standard error bars. You can see placebo is blue and the treatment is orange. And you can see really at hour 0 to 8 is probably the most important part, the half-life of bupivacaine being 2.7 hours, and really you probably get about 8 to 12 hours depending on metabolism. And so there was a slight difference at hour 8 where placebo actually had a higher pain score, but it was not statistically significant. So no difference was seen between the groups and the pain scores, and this is average morphine equivalent per hour. So actually the treatment group actually used more morphine equivalents per hour of stay. And then here's void trials. So on the left is the people who passed the void trial. Placebo is blue. So more people actually passed their voiding trial if they had placebo, and more people failed their voiding trial if they had the study drug. So no difference was seen there. So we were kind of scratching our heads wondering why is this happening. So we did a post hoc analysis using an ANOVA to see if having a hysterectomy or not made any difference, and it did not. So our study did not find sufficient evidence to support injections of 0.5% bupivacaine into the levator muscles after posterior pulporaphy. We didn't use liposomal bupivacaine in our study. There's a really high direct cost, and there was a lot of paucity of data showing whether or not it worked, so we just decided to look at something inexpensive. There was also a Cochrane review by Hamilton that said that it did significantly reduce pain, but it really wasn't shown to be superior to pain, plain bupivacaine, sorry. And possibly liposomes don't diffuse through the tissue well and may require multiple needle tracks to better spread out to the affected nerves. So current data says that this doesn't really work. Our study was attempting to isolate the nerve to levator ani as well as the terminus of the pedendal nerve to reduce pain, and perhaps maybe in the future maybe someone could use transvaginal ultrasounds, kind of like when you do a tap block that could aid in the identification of where these nerves are. And maybe further studies should look at investigating just an isolated posterior repair without taking concomitant procedures at the same time to eliminate confounders. Future studies also could consider just using regular bupivacaine, I think, instead of using liposome bupivacaine until we find some positive results and maybe then repeat it again. So strengths of this study was it was double-blinded, randomized, placebo-controlled. The randomization allocation concealment decreased possibility of selection bias. There was a second and third geographic location, so hopefully that increases our generalizability. This was done by four board-certified fellowship-trained FPMRS surgeons as well as the FPMRS fellows, so hopefully that helped a little bit as well. And all blinding was preserved with syringes of clear liquid, so there was never any wonder of what this was. And standardized post-operative orders were always used for every patient. So limitations, so possibility of information bias is pretty big in this study, I think, and not all nursing documentation said when the pain score was done exactly, and I think that they weren't always done at post-operative hours zero and four. Also location of pain was not always specified. I think this is rare, this happened rarely, but it did happen, so maybe they had a headache and it wasn't actual vaginal pain and they said it was a 10 out of 10. Patient's perceptions of location pain is also very variable. We did put vaginal packing in, and maybe that's putting pressure that may not have been present otherwise. Pain scores were not always discharged less than 24 hours after surgery, and we didn't always reach them on the telephone. And so conclusions, use of local anesthetics for targeted muscle blocks following posterior corporeal does not reduce post-operative pain, nor does it impact the need for narcotic supplementation, time needed to pass post-operative void trial, or time to first bowel movement. So further studies are needed. Thank you. Okay, thank you. This paper is open for one question. I have a question. Yes. Thanks for a very nice presentation. Thank you. It's really challenging to study post-operative pain, particularly acutely, but we're all aware with the desire to limit narcotics, and I applaud you for this effort. I recognize that you don't have any differences in those who passed or failed their post-operative void trial, but particularly posterior corporeal patients are occasionally quite susceptible to failure. That's correct. Did you notice any differences in those who passed or failed at post-op day two since Foley catheters are such a high satisfaction issue for our patients? So you're saying was there a difference between posterior repair patients if they passed on post-operative day two? How about any of your patients who passed on post-op day one or post-op day two? No, we didn't look at that. That's a good question. We looked specifically whether or not they failed on either the day of discharge or post-operative day one, but I think looking back to see if, because not many people were there on day two. I would say probably 99% of the patients went home after one day. So yeah, but that would be something to look at in the future. Thank you very much. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. 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Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you to the Society for allowing us to present our work. The impact of postoperative urinary retention following pelvic reconstructive surgery is substantial, with reported incidence rates as high as 43%. We lack a standardized definition, however, generally speaking, poor can be characterized by any impairment in bladder emptying following surgery. The management of poor varies widely in regards to type of catheterization, duration of catheter use, and bladder function evaluation. Despite the varied treatment algorithms, what remains a constant is that the evaluation and management of poor requires additional patient encounters and resources in the immediate postoperative period. This can be cumbersome to patients, providers, and the healthcare system at large. Therefore, our objective was to evaluate if self-discontinuation of a transresal catheter is non-inferior to office discontinuation in patients requiring catheterization for poor following pelvic reconstructive surgery. Said more simply, we wanted to see if having patients remove their catheters at home was just as good as having them return to the office. This randomized non-inferiority trial was approved by the Tri-Health Institutional Review Board and subsequently registered with the National Clinical Trials Registry. Eligible participants were women who underwent a vaginal vault suspension or robotic sacrocopal pexy for the treatment of pelvic organ prolapse and who required catheterization for the management of poor following surgery. Enrolled participants were randomized to either self-discontinuation or office discontinuation upon discharge. Self-discontinuation participants were given verbal and diagrammatic instruction regarding how to remove their catheter at home. They were instructed to remove their catheter on post-op day seven and to call our office if they were unable to avoid within five hours or if they had any symptoms of urinary retention. Office discontinuation participants had their catheters removed in the office in conjunction with a standard retrograde failed voiding trial on post-op day six, seven, or eight. Our primary outcome was a non-inferiority comparison between self-discontinuation and office discontinuation on the incidence of POR at one week post-op. POR at one week was defined as a failed voiding trial and continued catheterization following removal on post-op day six, seven, or eight. Our secondary outcomes included the incidence of urinary tract infection, recurrent retention, duration of catheter use, post-void residual at two weeks, the number of patient encounters, and patient experience. Patient experience was measured using a visual analog scale completed at the two-week post-op visit. Participants were asked to rate the illustrated prompts on a continuous scale from zero to 100 millimeters. Please note that lower scores correspond with a more positive experience. Based on a known incidence of POR at one week in this population and a pre-specified non-inferiority margin of 15%, a sample size of 74 per group was planned to detect non-inferiority. One hundred and fifty-seven participants were included in our analysis, 78 in the self-discontinuation group and 79 in the office discontinuation group. The mean age was 61 years and most participants had stage two or three pelvic organ prolapse. Approximately 78% of participants underwent a vaginal valve suspension and approximately 18% underwent robotic psychocopalpexy in each group. An equal number of participants in each group had a concomitant hysterectomy and or a concomitant incontinence procedure. Pre-existing comorbidities and post-operative complications did not differ between groups either. Eleven subjects in each group experienced POR at one week. The upper bound of our 95% confidence interval was less than our predetermined non-inferiority margin of 15% which concluded that self-discontinuation was non-inferior to office discontinuation. Regarding our secondary outcomes, we found the incidence of recurrent retention to be 7.8% with self-discontinuation and 14.5% with office discontinuation. This difference did not reach significance. As for UTIs, 59% of self-discontinuation participants and 67% of office discontinuation participants had UTIs within six weeks of surgery. Despite an overall high rate of UTI, no difference was detected between groups. The average PVR at two weeks and average duration of catheter use did not differ between groups either. There were significantly fewer patient encounters with self-discontinuation. When broken down by type of encounter, self-discontinuation resulted in more telephone calls but fewer office visits. The number of pages the staff and emergency department visits did not differ between groups. Additionally, self-discontinuation participants demonstrated significantly better VAS scores with regards to pain, ease, how disruptive and how likely they were to use the same method of catheter removal again. There were more patient comments received from the self-discontinuation group and the vast majority of them described a positive experience whereas only a few office group participants provided comments and most of them were negative. We describe an alternative management strategy for post-operative urinary retention following pelvic reconstructive surgery. In this randomized trial, we found that self-discontinuation of a transresal catheter is equally reliable in identifying those patients in need of aided bladder drainage at one week. Furthermore, self-discontinuation was not associated with any additional risk, reduced the number of patient encounters and improved the patient experience. In addition to these important findings, I'd like to highlight a few more key points. All participants in the self-discontinuation group were successful in removing their catheters at home. No one required an office visit or ER visit to aid with catheter removal. Secondly, participants were able to identify adequate bladder emptying. Fourteen self-discontinuation participants contacted our staff with symptoms of incomplete bladder emptying and were subsequently seen in the office. Eleven of those were found to have elevated residuals and three had normal residuals. This is consistent with prior work illustrating that patients are capable of assessing their urinary force of stream to determine if they are voiding adequately. And lastly, half as many participants in the self-discontinuation group had recurrent poor compared to that of the office group. While this finding did not meet statistical significance, the clinical significance may be notable. One possible explanation for this finding is that the comforts of one's home and passive method voiding trial may allow for a more accurate evaluation of bladder function. In conclusion, self-discontinuation of a transreusal catheter following pelvic reconstructive surgery proved to be non-inferior to office discontinuation. Self-discontinuation is an innovative method of postoperative urinary retention management that reduced the number of patient encounters, improved patient satisfaction, and offered no additional identifiable risk. Thank you and I welcome your questions. Thank you. Any questions? My name is Harvey from Canada. This is a very nice city, very helpful for our patients. Thank you very much. Can you elaborate on what was your criteria with a patient for the group that were randomized to come back to the office for a trial of void? What was your criteria to determine that they had a recurrent retention? Yes, thank you for that excellent question. Patients who were randomized to the office discontinuation group had a retrograde fill voiding trial in the office, which consisted of backfilling the bladder with approximately 300 milliliters and allowing the patient to void. If they voided greater than 200 or had a post-void residual less than 100, then they were deemed passed. The outcome of recurrent poor was defined as somebody who passed that void trial at one week, and then subsequently in the following five weeks had to come back in for retention. Okay, thank you. Yeah, Elena Tanitsky from Hartford. So UTI rate was high at 60%. We recently did a randomized control trial similar to this and found also surprisingly very high UTI rate. And I just want to comment that I think we underestimate the biofilm and everything that forms with the catheter. So I think it's basically confounder that it's because the patients have catheters we identify as UTI, but it's really just colonization. Yeah. Yeah, thank you for that great point. I agree. Dr. Toglea. Good morning, Mark Toglea. My disclosure for this question is I'm the prior chair of the coding committee. So when I see things like this, it gives me a little bit of agita. Can I ask you, so how many times do you see the patient in total after surgery in the office? Patients with a catheter, our standard would be they'd come back at one week, two weeks, six weeks, 12 weeks, one year. And then obviously if there was any additional unusual postoperative symptoms, they'd come in as well. So while I appreciate the fact that you're looking to minimize inconvenience to the patients, we all need to be mindful that our reimbursement is a global package, and included in that global package are two prepaid post-op visits within the first 90 days. If you're going to start to do something routinely where you're not going to get two visits in, then in theory you're supposed to give some of that money back by using reduced services modifier. More importantly, I think, is that as CMS looks at data like this, they're just going to reduce our reimbursement because they're saying we're not providing that thing. What is foremost in CMS right now is they're taking a very hard look at the global surgical package, and they are trying very hard to eliminate it. If you eliminate the global surgical package, the roughly 20% of what we currently get paid is for what we do in the first 90 days. That goes away. We're all familiar that laparoscopic hysterectomy has been reduced by about 26%, and it's precisely for that reason. So we just have to be very careful, I think, as if we're going to say that this is going to be the new routine, it is going to negatively affect our reimbursement, which may be fine if in our hearts we think I'll take less money if it means less convenience to the patients. I just think that we just need to be aware of the future effects of what we're doing. Sure. I think that's an excellent point. I think that we do still see patients multiple times in their global period for postoperative evaluation. I also think what's important to notice is that this reduced healthcare utilization by minimizing the number of office visits, which not only improved these patients' satisfaction, but also allowed for opportunities for us to see other patients who are waiting to be seen. So I think overall there are opportunities for reimbursement in other avenues as well. Sure. Thank you. Dr. Siddiqui, I'll apologize. We have time for just one more question, and the gentleman will end with... So connected... Hi, Bruce Kahn from Scripps in San Diego. So connected possibly to your pretty high level of urinary tract infection, why do you keep the catheter in for seven days? I've never heard of that, honestly. Yes, thank you for that excellent point. It is our standard practice to keep catheters in for seven days. Our patient population spans a wide tri-state area. Some of our patients are traveling multiple hours to come into the office, and the retention rates are lower at seven days compared to five days, for instance. But yes, that is obviously contributing to our high TI rate, and it is something that we're evaluating in our standards. One day at the most for our patients, and they get intermittent cell cath at that, and that'd be helpful. Yes, thank you. Okay, thank you. Good morning. Thank you to AUGS and IUGA for the opportunity to present our work regarding suture choice for uterus sacral ligament suspensions. Thank you especially to IUGA for generous funding of this study. The contemporary approach to the high uterus sacral ligament suspension was first described by Scholl et al. in 2000. This procedure has since become widely adopted by pelvic reconstructive surgeons, and its efficacy demonstrated in high-quality randomized trials. Briefly, the procedure was originally described using six permanent braided sutures, three through each ligament. Dr. Scholl's group subsequently published a retrospective cohort study in 2011 comparing permanent to delay-absorbable suture. They found that prolapse recurrence was higher in the absorbable suture group. In the same year, Castori et al. published a similarly designed retrospective cohort study showing that there was no difference in recurrence rates between permanent and delayed-absorbable suture. They also reported a high rate of suture erosion in the permanent suture group. Given these conflicting results, we decided to do an RCT. So our primary aim was to compare absorbable suture to permanent suture as measured by point C 12 months postoperatively with a non-inferiority limit of 2 centimeters. We chose this non-inferiority limit of 2 centimeters as this is likely to be clinically meaningful and is also a large enough value to avoid the possibility of a difference detected due to the inherent error in POPQ measurement. We hypothesized that absorbable suture is non-inferior to permanent suture. We also evaluated a composite outcome that defined surgical success at 12 months as no apical prolapse greater than or equal to half of TVL, no prolapse beyond the hymen, no bald symptoms as measured by the PFDI question number 3, and no retreatment of prolapse. Additional secondary aims included comparing subjective outcomes and suture-related complications. Patients were randomized one-to-one to absorbable zero polydioxinone, or PDS, or permanent CB2 PTFE, or Gore-Tex. Randomization was in blocks of four and stratified by surgeon. Patients planning to undergo uterus-sacral hystereopexy were excluded. Only patients undergoing post-hysterectomy uterus-sacral ligament suspension or having a concomitant hysterectomy were included. Uterus-sacral suspension was performed as originally described, with the exception that two sutures were placed on each side instead of three. All subjects, outcome assessors, and statisticians were blinded, and follow-up exams occurred at six weeks and 12 months post-operatively. Appropriate statistical tests were used. Fifty-eight patients were assessed for eligibility. Forty-four were randomized, 22 to each group. Two subjects in each group were lost to follow-up, leaving 20 patients available for analysis in each group. I neglected to put it in here, but our power analysis was for 18 patients in each group to meet 80% power at an alpha of 0.05. Group characteristics were similar, with a mean age of about 63 years and BMI of 29. Notably, you'll see also that largely this group of patients did not have prior prolapse surgery, and only two patients had prior hysterectomy. Most patients had stage 3 prolapse. There were no differences in baseline POPQ measurements between groups. Specifically, point C was a median of 0 in the permanent group and minus 1.5 in the absorbable group at baseline. Almost all patients had a concomitant hysterectomy. Most had anterior repairs, and some had posterior repairs and slings. At 12 months of follow-up, the median POPQ point C was minus 7 in each group, giving a p-value for non-inferiority of 0.0002. There was no difference in bold symptoms or a response of 1 or 2 on the PGII between groups. There was no difference in composite success or failure between groups, and no patients had retreatment for prolapse within 12 months. While not statistically different, there were slightly more failures in the permanent suture group. Adverse outcomes related to suture were relatively common at 6 weeks after surgery. These mostly included suture exposure and spotting. However, the frequency of complications were not different between groups at any time point, and also suture-related complications were infrequent by 12 months post-op. Importantly, our results should not be extrapolated to include other types of suture that were not studied, or other procedures such as sacrospinous ligament suspensions or uterosacral hystereopexy. This was a rigorously performed RCT comparing PDS and Gore-Tex suture for uterosacral ligament suspensions. In this study, we conclude that absorbable suture was not inferior to permanent suture for apical anatomic outcomes 12 months following vaginal approach uterosacral ligament suspension. There were no differences in adverse outcomes related to suture material. Again, thank you to AUGS and IUCAA, and especially IUCAA again for funding this study. Charbel Salomon from Morristown. Great study, Joe. This is very nice work. Quick question. I noted that most of your patients were stage 2 prolapse. Do you think you would have found the same results if they were stage 3 or stage 4? Actually, the majority, about 60 to 65 percent, were stage 3. For point C, it was 0 and minus 1.5. Sure. You know, I mean, honestly, I think based on our patient population, it's really impossible to say. I mean, I don't think I can really answer that question. And are you planning to do a longer-term follow-up? We are not. You know, our logic for that was that, in theory, the polydioxinone, you know, should be gone by about six months. So if you were going to see a recurrence related to the suture type, we would expect us to see that. Hi. What was the rationale for using Gore-Tex sutures instead of... Honestly, that was just the kind of historical suture that we had used most commonly at our institution prior to adopting PDS. Perhaps I can ask you one question? Of course. Does this change your practice? Are you now using only absorbable... Yep. So, actually, myself and my two partners following this only use PDS now. Okay. Thank you. Okay. Thank you. Thank you. Good morning. My name is Matthew Isett. I'm a research fellow at University College London Hospital in the UK. Thank you very much to the Scientific Committee for allowing us to present our study today that we undertook in conjunction with our colleagues based in Oxford, looking at the safety and efficacy of laparoscopic mesh sacrohistropexy. These are our relevant disclosures. We received ethical approval for this study in May of last year, and we had some funding from local charities for consumables. So the lifetime incidence of surgery for prolapse, as we all know, is relatively common. And in the UK, for utero vaginal prolapse, the vaginal hysterectomy remains the preferred procedure, and this figure of 75% was taken from a relatively recent survey of urogynaecologists practising in the UK. But vaginal hysterectomy is not without some limitations. We know that the risk of post-hysterectomy vault prolapse procedures is at least 8%, if not higher, and there is some data suggesting that a significant proportion of women, if given an equivalent alternative, would choose for a uterine sparing procedure. To that effect, in the UK, we've seen over the last decade increasing trend towards uterine sparing alternatives to vaginal hysterectomy. And this data is taken from the National Health Service Hospital Episode Statistics data published by Zakatel, showing this increasing trend over the last 10 years. When we're talking about uterine sparing procedures, one option that we offer in our unit is a laparoscopic mesh sacrohistropexy. It's minimally invasive, women can keep their uterus. It's also a surgical option that's been included in the latest national guidelines in terms of treatment to offer women for pelvic organ prolapse. But it's not without its own limitations. Indeed, a recent systematic review found that a lot of the data in support of laparoscopic mesh sacrohistropexy comes from single-centre studies with very short-term follow-up. And, of course, we can't talk about any mesh-augmented procedure in pelvic floor surgery without considering the huge controversy that has developed internationally over the last 5 to 10 years. So, given that we offer this procedure relatively routinely to women that attend to both these units, we wanted to determine the incidence of mesh-associated complications in women who'd undergone laparoscopic mesh sacrohistropexy. We decided to undertake a postal questionnaire study and gave women the options of responding via the post, online, or telephone. And we piloted the questionnaire at one site for face validity prior to rolling out the study. In terms of our potential participants, we obtained them from five databases of surgeons who were based in two tertiary gynaecology centres using the two codes shown there. And, just to clarify, we use a wraparound hystropexy technique where we make windows in the broad ligaments bilaterally and secure the mesh both anteriorly and posteriorly with minimal dissection down into the vagina. We previously published that technique for hystropexy. Women came from a 10-year period of operating. And we sent two rounds of questionnaires to non-responders. After eight weeks, we sent a second questionnaire just to increase our response rate. Our primary outcome that we chose was a patient-reported mesh complication requiring removal of the hystropexy mesh to give us an objective as measurable as possible. Secondary outcomes included patient-reported referral to chronic pain services, a new diagnosis of autoimmune disease, subsequent re-operation for either prolapse or stress incontinence, the validated patient global impression of improvement in prolapse symptoms, and the friends and family test. Would you recommend this procedure to friends or family with an equivalent condition? So, from our databases, we identified 1,766 potential participants. Following two rounds of questionnaires, we had 1,121 respondents, giving us a response proportion of 63.5%. I think helped somewhat by the controversy surrounding mesh in the media in the UK. Looking at length of follow-up, our median follow-up was nearly four years from index hystropexy to return of the questionnaires with a range of two to 141 months. So what did we find? Well, nine women, 0.8%, reported a mesh complication requiring removal of their hystropexy mesh. 1.78% reported the use of chronic pain services. And 5.8% of women reported a new diagnosis of autoimmune conditions subsequent to their hystropexy. We asked for consent of all the women that reported a mesh excision surgery to contact a clinician who'd removed their mesh or, indeed, to let us look through their medical notes. And actually, of those nine, two had undergone a re-operation for prolapse and had their hystropexy mesh removed without actually having a complication due to the mesh, other than recurrent prolapse. One woman had had a concurrently inserted mid-rethal sling, and she underwent a partial excision of this for vaginal erosion, and actually her hystropexy mesh was left in situ. And a fourth lady developed a post-operative hematometria. And she underwent a subtotal laparoscopic hysterectomy for this, but we actually left the hystropexy mesh in situ, and it was used for her cervicopexy. So we excluded these four ladies from our analysis. So if we do a Kaplan-Meyer survival using this removal of mesh, excluding those four ladies with just the persisting five ladies, that's shown here. Reasons for mesh removal. Appreciably, the numbers are very small, so it's difficult to draw any strong conclusions, but in keeping with other reports into mesh complications, three of the five ladies reported pain of some description, two reported bladder symptoms. They developed prior to diagnosis of their mesh complication. And again, in keeping with the published literature, the vast majority of these five ladies reported a presentation of their symptoms within the first 12 months. Subsequent re-operation. 13% had a further prolapse operation in our four years, and 2.3% a subsequent operation for stress urinary incontinence. We were quite reassured to see that even at four years, over 80% of our patients reported their prolapse symptoms as very much better or much better, and equally reassured to see that given all the controversy in media coverage of mesh in the UK, still over 80% of women would recommend the procedure to friends or family. If we look at what sort of re-operation these women had for their recurrent prolapse, 3.8% reported a subsequent apical procedure, which compares favourably to the risk of post-hysterectomy vault prolapse procedure following a vaginal hysterectomy. So what can we conclude from this study? Well, we report here a large cohort with long-term follow-up following mesh-augmented prolapse surgery, and found a low incidence of re-operation for mesh complications, as well as recurrent prolapse or stress incontinence. We feel the incidence of chronic pain and autoimmune disease is comparable to that reported in the literature for other comparable elective gynecological procedures. And importantly, we don't report any vaginal mesh erosions within this cohort, something seen with other cohorts of hysterepexy patients. Strengths include patient-reported data, and I think that can't be overstated in light of the controversies, and certainly in the UK there's been commentary about breakdown in trust between clinicians and the women that we look after, and I think patient-reported data can provide some reassurance. This is the largest available cohort of long-term follow-up following this sort of procedure. We recognise there are significant limitations to this sort of study. We used a non-validated questionnaire because of the rare outcome nature. Research setting, we don't know how transferable this is to other units using different approaches. And as with all questionnaire studies, there's quite significant inherent recall and response bias, and it's difficult to know how that would affect our reporting. Further comparative trials are obviously needed, and we're working on some of that at the moment. And data from national databases also provides high-volume data, although the quality can be questionable. We've just published in the UK data from a national database of women who've had hysterepexy, and the follow-up of that is limited to 12 months. Thank you very much for your time, and I'd be happy to take any questions. Questions? Professor Dwyer. Did you notice any difference between the operators in their complications and their results? We haven't undertaken analysis looking at the different operators within this data set. It's obviously experience and surgical skill is very important, so I think it's probably worth looking at. It may well do for the recurrence of prolapse. I don't know with the numbers of mesh complications whether you'd find anything significant, but yes, we should look at it for prolapse distress. Thank you. Matthew from North Carolina. I was really struck not by your zero rate of mesh exposure, but by your 13% risk of re-operation. It seems that if you're going to justify the use of mesh for an index procedure, we should be looking for a re-operation rate that is lower than that for native tissue repair. Could you comment on that? I think that's a very valid point. There's sort of two aspects to that. One is what sort of ladies we operate on and how invasive we are, and I think culturally in both of the units that were involved in this study, there is a tendency to avoiding concurrent anterior-posterior colporaphy at the time, with a view to avoiding, albeit a theoretical and not necessarily evidence-based concern about dyspareunia from over-operation of the anterior-posterior compartments. So the general clinical practice is to undertake a hystereopexy, and provided there's no anterior-posterior perhaps beyond the hymen to leave it at that, unless there's a sort of patient-specific discussion about that prior to operating. And that probably then reflects our reasonably high rate of anterior-posterior repair. I think the flip side of that is that if we look at apical procedures, our apical rate would appear lower than that quoted elsewhere. And I think comparing, for example, sacrospinous fixation or subsequent sacral colpopexy compared to an anterior-posterior repair in isolation as a subsequent procedure, the risk profiles are probably different. So I think there is some still validity, even if the headline re-operation rate is the same. Okay, thank you very much for your presentation. Thank you. Thank you. Okay, thank you. I am delighted to present our one-year outcomes from our study recoup. So we all know that one in five women will undergo surgery for a pelvic floor disorder in their lifetime. As quality-of-life surgeons, we strive to restore women's quality of life. However, many women value an active lifestyle, and this very well might factor into the quality that they expect. With stringent post-operative restrictions, we've wondered if we're inadvertently adversely affecting the very quality of life that we're trying to improve. Post-operative activity restrictions have been imposed on women recovering from gynecologic surgery for many years. With the advent of more minimally invasive surgery, leading to decreased hospital stays and quicker recovery, surgeons have really begun to question this practice. As eloquently proposed by Dr. Becky Rogers yesterday, should we really be keeping women from lifting a gallon of milk in the post-operative period? Several questionnaires have actually demonstrated gynecologic surgeons' recommendations for post-operative activity and the role for rest after gynecologic surgery, and they vary widely. Moreover, there's really no evidence to support any of these post-operative activity recommendations. Gone are the days of convalescence in the hospital for recovery following major surgery. Major strides have been made both in gynecologic and urogynecology surgeries to enhance recovery and expedite discharge. Both ARIS and same-day discharge following prolapse and incontinence surgery, with and without hysterectomy, have demonstrated safety and efficacy. Now that we've established that getting women home sooner can actually enhance recovery, can resuming activity sooner enhance recovery? We fought to evaluate this at three months in our previously published study, Restricted Convalescence, Outcomes Following Urogynecologic Procedures, where women undergoing prolapse surgery were randomized to either liberal activity recommendations or restricted activity recommendations. Our primary outcome at three months was satisfaction with their prolapse surgery. We found that women who liberally resumed activities following their reconstructive pelvic surgery reported fewer prolapse and urinary symptoms three months post-op compared to those who restricted lifting and activity, despite similar levels of satisfaction and anatomic outcomes. Now the next question coming, I know, from everyone is, what about longer-term outcomes? With our planned secondary analysis of our primary study, we thought to compare anatomic and functional outcomes in women one year following prolapse surgery given liberal and restricted activity recommendations. As a reminder, we defined liberal activity recommendations as resuming lifting, running, high-impact exercise and aerobics, as well as sit-ups, as the women saw fit. On the other hand, women in the restricted group were told to abstain from lifting, high-impact aerobic exercise, and sit-ups for about 12 weeks following surgery. At one year, satisfaction again was assessed by asking women, how satisfied are you with your prolapse surgery? Responses were graded on a five-point Likert scale, and those of completely and mostly satisfied were documented as satisfied. Symptom severity was also assessed by the PFDI, PFIQ, and anatomic outcomes were assessed at one year using the POPQ stage. This is our study flowchart from our initial study at the three-month primary outcome. There were initially 108 women randomized to receive either the restricted activity recommendation intervention or the liberal, and included in our three-month analysis were 50 and 45 in each group. Looking at our one-year secondary analysis, there were 45 women in the restricted intervention and 38 in the liberal intervention who followed up and were included in our primary or our secondary analysis. It's interesting to note that follow-up did not differ between these two groups, and ultimately 34 in the liberal and 43 in the restricted groups had complete functional and anatomic data at this time point. This table represents the baseline characteristics of the women who followed up at one year. The cohort had a mean age of 63, a BMI of 26.5, and the majority had stage three or four prolapse. The preoperative characteristics were very similar between the two groups, but I should note that there were differences in the PFIQ, the urinary subscale and the vaginal subscale between the two groups. Most women in our cohort underwent a minimally invasive copepaxi with a concomitant hysterectomy and incontinence procedure, but there are no difference in between the groups with respect to these variables. At one year, I'm happy to report that satisfaction remained high in these women with no difference between the two groups. Other functional outcomes including PFDI, PFIQ scores did not differ, but women in the restricted activity group did report higher PFIQ bowel symptoms. Anatomic outcomes also did not vary between the two groups. I should note that three women, two from the restricted group and one in the liberal group, had recurrent prolapse for which they planned intervention. We also qualitatively and quantitatively assessed women's activity at one year using questions derived from the activity assessment scale. When asked how many days per week did you engage in strenuous or very hard exercise that caused you to work up a sweat or made your heart beat fast, such as jogging or exercise, women in our study reported on average two days per week and qualified this as about 51 minutes per session. There was, again, no difference between the two groups, but this did signify that we had a relatively active group of women. One of the limitations of our study certainly is the lack of an objective activity measure during the postoperative period such as the use of an accelerometer. However, we suggest that this potential limitation can actually lend some generalizability of our study to clinical practice. The strengths included a robust study design and one-year follow-up with low attrition rate. So in conclusion, postoperative activity restriction do not impact anatomic or functional outcomes as well as satisfaction one year following reconstructive surgery for prolapse. Given the positive impact of liberal recommendations on urinary and prolapse symptoms seen at three months following surgery, women should be allowed to resume physical activity at their own pace following prolapse surgery. And finally, reconstructive pelvic surgeons should consider their implicit biases when counseling women about postoperative activity. Thank you, and I welcome any questions you might have. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. 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Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. That's Shelly. I'm a physiotherapist just out of Chicago. And I was having a conversation with some Uruguayans on our first night here expressing their upset about the large amount of pelvic physical therapists who are in cash-based practices and the difficulties of accessing with patients who don't have those means. But I will tell you this is exactly why physical therapists are cash-based is because when you are outside of those restrictions that are imposed on people inside of hospitals, we can make our own decisions about productivity. We can make our own decisions about what we are recording or EMRs or any of that. It really is very liberating. And I'm so sorry that that is the case for people who are not able to pay. But please don't come down on us because we have chosen to have a reasonable work life. Just a comment. Hi, Linda. Thank you for a very thought-provoking talk. And as you know, I've had problems of my own, so it resonates with me. And doctors can be very cruel to each other. But that was not what I wanted to say. What I wanted to say was the 48-hour working time directive doesn't work. It doesn't work for anyone because all of the senior doctors take the time that it takes to do all the tasks they have to do, so they never obey to 48 hours. It just doesn't happen. All it does is compromise the trainees because they have restricted time in which to learn and they have no continuity of care, and it's a disaster for everyone. So your system in that regard is better. Linda, thank you. Thank you. Thank you. I appreciate that valuable perspective. Tony Visco-Duke. Linda, thanks again for another great lecture. So it's easy to say that it's everyone's problem, and I agree with that. Do you have any advice on whether you should start, let's say, at a division level and fix some things internally at a small level? Because there's stuff that's coming down from the top to improve work life balance and wellness, but it seems so far removed. And what can we do at a division level, at multiple divisions to push up and sort of manage up and sort of change some of the culture that is really problematic? Like the IT things are so higher level, you won't fix those things at a divisional level. Tony, you're so right, and you're very insightful, as always. So I do think there first has to be an awareness, and I think the awareness is growing, and it can't be a stigmatizing thing because people may not want to endorse the term burnout, but you can see that they're beginning to disengage and disconnect and they're losing the joy that they should have from being a physician, which is a very joyful line of work, joyful profession. So I think finding out what it is that stimulates that passion again for that individual, what they really want to resonate with so that they're just not into the mundane is really, really important. I don't have a simple structural fix. I think it has to be more individualized, and I don't think just simply establishing a physician wellness program magically solves the problem. As a matter of fact, for many people, that's just like one more thing. Yeah. Can we take just one more question or comment? Hello. My name is Victoria. I'm from the UK, so I work the 48-hour week, and I've got two children, and that's fine. I think it's a... It works for me. Thank you for your fantastic presentation, and I think you have touched on some very important issues. And I think it's really important that we don't confuse women at work with the overall culture that you described of the IT systems and the organizational problems and sort of blame it on women, you know, being doctors or something like this. It's not been a long time that women have even been allowed to study medicine, so it's a privilege that we have worked really hard for to get this far. And sure, yes, there is lots of things that we still need to work out, and that's why this is a really important topic, so I just wanted to say that. Thank you. Thank you, ladies and gentlemen. This concludes this session.

study

lightweight mesh

ultralightweight mesh

sacrocolpopexy procedures

prolapse recurrence

time to recurrence

research

work-life balance

burnout

physicians

women

working hours

administrative burdens