Hi, and welcome to the AUGS urogynecology webinar series. I'm Abby Shackin-Margolis, member of the AUGS Education Committee, urogynecologist at UCSF and moderator for today's webinar. Today's webinar is titled Combined Rectopexy and Psychocopopexy for Multicompartment Pelvic Floor Disorders, Better Outcomes. Our speaker today is Dr. Wolfgang Gertner, and I'm going to start by just going through a couple reminders. The presentation will last approximately 45 minutes, and the last 15 minutes of the webinar will be reserved for Q&A. Before we begin, I'll go through some housekeeping items. AUGS designates this live activity for a maximum of one AMA PRA Category 1 credit. To claim your CME credit, you must log on to the AUGS eLearning portal and complete the evaluation following the completion of this webinar. This webinar is being recorded and live streamed. A recording of the webinar will be made available on the AUGS eLearning portal. Please use the Q&A feature of the Zoom webinar to ask our speaker questions, and we'll answer them at the end of the presentation. You can use the chat feature if you have any technical issues. Our AUGS staff will be monitoring the chat and can assist. So I'd now like to introduce Dr. Gertner. He's a Division Chief of Colon and Rectal Surgery and Associate Professor of Surgery at the University of Minnesota. He also holds the Stanley M. Goldberg Endowed Chair in Colon and Rectal Surgery. He completed General Surgery Residency and Colon and Rectal Surgery Fellowship at the University of Minnesota, and he's actively involved in both clinical and translational research. His research interests include colorectal oncology, minimally invasive surgery, peritoneal carcinomatosis, diverticulitis, pelvic floor disorders, and the human microbiome. We are so happy that you are here with us today. And without further ado, Dr. Gertner, you may begin. Good evening, everyone. Thank you, Dr. Schuch and Margolis, for that generous introduction. Thank you again to the American Urogynecologic Society for the invitation to give this webinar. A special shout out to Dr. Cynthia Falk, who is a colleague, a collaborator, and a good friend here at the University of Minnesota that was intricately involved, I know, in the invitation for me to give this, as we have implemented a great team here at the University of Minnesota over the years. All right, that's working. These are my disclosures. So let's start with prolapse surgery, and I know I'm going to start mainly with the posterior compartment, the rectum, in this instance. But over decades of different implementation of prolapse-related surgery, the keys to the success, or especially posterior compartment prolapse, is to restore the normal anatomy, improve function and quality of life. It was quite obvious to us, and this was highlighted by the FOSPR study, that posterior sutured rectopexy alone, this was highlighted in the United Kingdom, was associated with high recurrence rates, and as well as perineal procedures. If you recall, the Frickman-Goldberg procedure, which is sigmoidectomy in a posterior rectopexy, was widely popularized at the University of Minnesota. And I can tell you that Dr. Goldberg did not perform that operation for many years, if not decades, recently, because of the high risk of recurrence, especially of rectal prolapse. And not to say the widely highlighted data on poor anal rectal function and recurrence rates with perineal procedures, mainly an Altmeier or perineal rectosigmoidectomy. We also learned over decades of doing posterior dissections, is that this was associated with increased rates of constipation. And this is already a complicated population, as many of you know. There was a big debate in colon and rectal surgery, and I don't know if it's so much in urogynecology, but the lateral stocks of the rectum were somewhat of an enigma. When I was growing up, there was half of the room that said that it doesn't make a difference, the other half was, if you divide it this way, it's less severe, the constipation, or people would say, don't touch them at all, as you know that the parasympathetic nerve roots travel along these lateral stocks, and are thought to at least theoretically be associated with increased constipation rates. So already a bad start. I think if I could give one key concept, is to think about the pelvis and compartments. And I think this is highlighted both the way that we approach the disease, and that we understand that as surgeons, we're correcting a functional or functional dysfunction, and we're correcting the anatomy, but the underlying root cause, it relates directly to the compartments that are prolapsing. And many of us as growing up would conceptualize the compartments independently. And we thought that they didn't talk. And so we wouldn't talk with colleagues. And it probably wasn't until the 1980s were at the University of Minnesota where Dr. Rothenberger created a pelvic floor center, literally in a closet, that he emphasized how we should be giving clinic and we should be seeing patients in conjunction with our urogynecology, urology, physical therapy colleagues, and discussing cases with truly a multidisciplinary fashion. This has been long popularized in our specialty with rectal cancer. And I think that concept was extrapolated in pelvic floor disorders, as it is with many disease processes nowadays. But if I could leave you with one slide alone is to conceptualize the pelvis into these compartments and to not think about them as individualized. As you're fixing one, it will impact the other compartment. And the other image is mainly to highlight the dissection that we would typically perform with the posterior rectopexy and highlighting the lateral stock that are somewhat invisible to a certain degree where there's just condensation of fibers low in the pelvis. We're talking about combo and why that makes it better. If anything, the rise of ventral rectopexy, where we dissect the ventral aspect of the distal rectum and support that area compared to the posterior dissection that we would used to do. And how that is highlighted the combo approach. If anything, it made us think more about the anterior plane of the rectum or the ventral aspect of the distal rectum is crucial in treating full thickness rectal prolapse. As all of you know, the great majority of full thickness rectal prolapses start anteriorly and even with intussusception, that's going to be the weakest spot in the pelvis from a posterior standpoint between the posterior compartment and the middle compartment. So as many colorectal surgeons started doing ventral rectopexy, which I'll explain in a minute, have been associated with better outcomes in general, although associated with mesh, obviously, I think it better presented us to think about addressing different compartments at the same time, as compared to when we were doing posterior rectopexy, it was a beautiful dissection. We felt good about ourselves, but we knew when we were sewing a little bit of peritoneum to the sacral promontory, that that wasn't something that was going to be durable. And we knew for a fact that when patients present, it's not typically a unique compartment that's prolapsing alone. And we know that addressing these compartments will decrease recurrences. And I'll try to show that during this talk. Dr. DeHore came to Minnesota many times. He's the surgeon in Belgium that has widely popularized this approach or technique as it corrects the middle compartment or the ventral aspect of the distal rectum where the great majority of interceptions and full thickness rectal prolapse has occurred. It avoids deep posterior dissection and lateral dissection with the presumable at least preservation of autonomic nerves at those lateral stocks. It does introduce the big kind of the elephant in the room, right? Because colorectal surgeons, we've never had a great relationship with mesh. And for obvious reasons, you know, it comes from our dental surgery experience, peristomal hernia repairs, the majority of our surgical fields have a higher risk of contamination. And erosions can be more devastating, especially with the formation of fecal fistulas and perforations of hollow viscous organs of a GI content. So we're very, extremely cautious at this. And I think we've been exposed to it through colleagues in urogynecology that has helped us understand the different materials, techniques, fixation methods, and use of different types of sutures. So that's something that we will discuss, especially the synthetic versus biologic mesh. The ventral rectopexy technique has been associated with improvement in constipation. It's not entirely clear why, but probably bullet number two has something to do with it and less posterior dissection and perhaps improved patient selection. And the last thing, which is the main topic of this talk, is that we think about collaboration and multidisciplinary approaches better. So I would argue that maybe not just the technique alone, but addressing multiple compartments at the same time will improve quality of life and constipation. And it opened up a whole new door for us for pelvic floor disorders. And this is mainly patients that had internal rectal intussusception and not full thickness rectal prolapse, but had extreme symptoms of obstructive defecation. So a lot of these patients were getting more evaluated. There was more awareness in the other subspecialties, especially urogynecology, on when to call a colorectal surgeon and how to implement that, as it may help with the correction of obstructive defecation symptoms in patients with exclusive rectal intussusception. So to expand on this, the original data, and I'm talking, this is 30, 40 years ago, that it wasn't completely conclusive to us that all patients with rectal intussusception were going to have a full thickness rectal prolapse. And there was quite good data on this, especially from Sweden. I know Dr. Anders Mellgren was a pivotal researcher in studying the natural history of rectal intussusception towards full thickness rectal prolapse. And it was once believed that it probably doesn't, but there's now emerging data that shows that actually there is a clear association that a lot of these patients will develop rectal prolapse. And so for the patients that have perhaps a higher incidence of symptoms of middle compartment prolapse symptoms that are not so much from a posterior aspect, but do have intussusception, there's another role for the combo approach when patients have, for example, a more advanced internal rectal intussusception, such as three and four, for example. The widespread of medical treatment, you know, when people were having intussusception, I feel like patients were really not finding effective treatment algorithms or strategies for the rectal intussusception. Biofeedback has been around for a very long time. There's obviously a lot we can do with diet, fiber supplement, laxative, stool softeners, evacuation techniques. There's acupuncture. There's a lot of different things that we can do. But I feel like this was especially frustrating for patients with advanced rectal intussusception. And that it showed improved outcomes in constipation and fecal incontinence with ventral rectopexy as compared to the decades of what we were doing, posterior rectopexy, and not even to say the perineal procedures that even though effective in their moment and people feel very passionate about their perineal procedures, the outcomes are undoubtable that the functional outcome will be inferior in those patients. So just to focus on ventral rectopexy for a minute here, we typically use it for full thickness rectal prolapse. The relative indications, and this is a little bit of an older slide, but symptomatic rectal intussusception in the setting of ODS, depending on how symptomatic that is at the time, especially for patients that have a defecography with an Oxford grade three or four, and patients also with solitary rectal ulcer syndrome that obviously will have ODS. It is important to mention that we typically, at least at the University of Minnesota, when patients have a very large ulcer, we do not perform immediate surgery. We try to heal that with a combination of, you name it, non-surgical approaches first to try to heal that ulcer before we're sewing a piece of mesh to exactly where that ulcer is, and I think most institutions would agree with that. Contraindications, obviously number one is somewhat old, and this is falling out of favor, but obviously it's something that needs to be mentioned. Patients with severe endometriosis, a history of pelvic radiation, for example, that at least from a rectal standpoint, we have noticed increased risk of erosions and fistula in these patients, and they probably have nerve injury and muscle injury beyond repair of a rectal prolapse. The relative also for history of sigmoid diverticulitis, as you add more of a clean contaminated case in the setting of placement of a piece of mesh in the pelvis. There are additional patients that have increased risk for rectal cancer, for example, and how that may affect or impact the way we treat them with either chemotherapy, radiation, and obviously surgery. It would be much more difficult to perform an operation for cancer in someone that has one or two pieces of mesh in the pelvis with a higher risk of permanent stoma. And that's something that I still think about every day when I'm performing this operation. And absolutes, obviously you've read them already. The one that I added recently, last night, was severe fecal incontinence, and when patients have injury of the external anal sphincter. When I see somebody that is a candidate for a combo sacrocobalpective enteroectopexy, and they have a patchless anus with very little control, I worry because I feel like these are the failures that I've seen in the past where patients have either exacerbation of their incontinence symptoms, or to the point where their pain does not improve, and they still have quite a bit of atropion and mucosal prolapse that is very symptomatic for these patients. So the M word, that's the main thing, and I think we've learned, I've learned at least a lot from our urogynecology colleagues on mesh in the pelvis and how to treat that, how to think about mesh, how to think about potential of erosions, not only of the mesh, but of suture. When ventroectopexy was popularized in the early 2000s, most people, at least in the United States, were using quite a bit of biologic mesh or biologic prosthesis. And I'll be totally honest that I was using that for quite a while. Obviously, I work at a quaternary healthcare system. There's an increasing amount of immunosuppressed patients. We're an extremely large transplant hospital and community. So there was significant concerns of that. And I started with biologic, and as I've been exposed more to that, obviously, I've made the change, but many patients need that explanation, and they need to know the options of both the synthetic and biologic, and for you to review the literature on what you think is more associated with both recurrences, quality of life, and their thought process as well that could be related to religious beliefs. So that's just something to keep in awareness when you're discussing this with patients. I know that the biologic mesh employment in the UK, if you've read the news over the last five years, that's been related to very large lawsuits. We have not seen or replicated that data here in the United States, but there's some legitimate concerns about the biologic materials that goes beyond this talk. For synthetics, I would say the most common thing is a lightweight polypropylene. There's nothing that's exactly formulated for that. The titanium mesh is mainly from Europe. What I think was clear early on with many consensus from societies both in Europe and the United States to avoid polyester, as it has been associated with more organ erosion. From a biologic standpoint, this is the type of material that you're getting a new one almost every year or two, and there's another person trying to sell you another piece of mesh or a biologic in the operating room. There are crosslink and non-crosslink. For those who know about it, the crosslink are chemically treated, so certain enzymes cannot degrade the actual collagen, as you think about it perhaps as an aortic valve replacement, for example, that are crosslink materials that will not degrade over time. But that has another slew of problems, both from the chemical treatments of it and the fact that you have a rigid piece of collagen in your pelvis. Then the non-crosslink, if you're going to use one of these biologics, I would be extremely comfortable with them. Talk to your partners about their experience with them, because there are biologic prostheses that essentially melt away. This is not with an infection or anything like that, but a lot of these companies are self-promoted, and it's industry-related research where they say, well, it leaves behind a scaffold where your own immune system repopulates that scaffold. And my question to the industry was always, well, if your cells are bad to begin with, if you have a scaffold there and I'm just replacing with my own tissue, how does that differ from just your own tissue being too lax? So there's many questions that are unanswered with regards to the type of biologic you're using. And this is probably slightly more used in adolescents and women in productive age, which is very little literature on this, by the way. These are somewhat arbitrary, but diabetes, smokers, and radiation obviously has a relative contraindication. We typically do not like to use mesh in the pelvis, especially in patients with Crohn's disease, as we know that more than 60-70% of those patients will have reoperations, and especially if they have rectum or perianal involvement of their Crohn's disease, and patients with rectal and vaginal injuries during the operation where they've used a biologic versus a synthetic when the proctotomy was identified, for example, and repaired, and where people have felt more comfortable using a biologic because of that. But I think most people, when they have a significant proctotomy, will not leave a foreign body behind, and that's somewhat debatable, obviously. This is another. The most recent one is permanent and absorbable suture. This has gained a lot more popularity because of publications that, in general, are going away from the permanent sutures. It's been hard for me to do that, and it really depends on your outcomes. I think you have to have awareness of your outcomes and what's happening to you, and what's happening in your societies and your communities, obviously, on how you transition from a permanent to more absorbable suture. But in general, of all the people that I meet that do this or sacrocopal pexi, it's usually the minority that are using more absorbable suture, and I don't know what the right answer is. Complications. You can see them here. These are the most common things we see. Very rare. I've probably had maybe one or two cases of sacrooscopomyelitis. It tends to be a big headache. These patients need antibiotics for a very long time, and sometimes they will have some residual chronic pain related to it. The main thing that people want to talk about is erosion fistula, and it helped me a lot to learn about erosion and fistula in the setting of sacrocopal pexi, as we were extrapolating a lot of these kind of figures of percentages and algorithms of treatment from sacrocopal pexi mesh-related erosions. From a rectal standpoint, it's typically, and this is probably on the generous side, two to three percent. Late and vaginal erosions tend to be more common, and I feel like your gynecologist, at least the collaborators that I work with at the University of Minnesota, have helped me understand how that is treated more than anything else. The true rectal erosions are quite rare and probably closer to one percent, and it's usually in patients that have an unrecognized injury or a full thickness suture that went through the rectal wall. These are just extrapolations of the sacrocopal pexi, that there's been comparisons that are slightly favor the biologic mesh, but with the current literature, you know, when you compare these monocentric experiences that are not perspective and power to answer that question, it's really hard to give a definitive answer between synthetic and biologic mesh, and I would assume, at least unless the patient requests it or the surgeon has a very particular technique, that the great majority of patients getting a sacrocopal pexi will have synthetic mesh. Also, less reoperations with biologic mesh, but that was only one report. This is just a summary of studies looking at erosion depending on mesh type, the number of patients, obviously, and if where they were located. As you can see, there's quite a bit of rectal, but a lot more vaginal erosions in these patients. And this is probably the money slide on this one or the table on this one, but you can see that the percentages in systematic reviews are close to one to two percent. From a sexual function, I think this is an important discussion to have in clinic with patients, and it's hard to compare as many patients either do not mention or we don't ask enough about sexual function in a colorectal clinic. I'm not saying in a urogynecologic clinic, and that's another importance of having a combined approach to this, but in general, colorectal surgeons don't ask the right questions for sexual function and what your baseline sexual function is and how a ventral rectal pexi may be associated with a higher risk of dyspareunia, for example. It has shown a higher risk of sexual dysfunction when it's compared to posterior rectal pexi. This is obviously where this because of the site of the mesh and obviously the site of dissection, but the great majority, if you actually, if you summarize all of the studies, I usually quote patients in the higher teens that can be sexual dysfunction or dyspareunia mainly that can be long-term, and it tends to improve over time, and it's probably in the low teens to high single digits of the patients that have some sexual dysfunction, mainly dyspareunia long-term. Other sequelae, urinary incontinence, this is difficult to assess. These populations are difficult to assess, and there's usually not good baseline data on how that changes. I feel like these are getting better and better as we have more of a collaborative effort in treating pelvic organ dysfunction and obviously the dyspareunia. When we look at outcomes, the laparoscopic and robotic approaches seem to be equivalent. This is not well studied in the literature. As with everything we do nowadays, as our kind of natural evolution from MIS, from laparoscopy to robotic has evolved over time, we, a lot of us feel very strongly about the robotic approach, mainly because of the ergonomics, the clarity of vision, and one of my disclosures is that I have a relationship with the intuitive company for proctoring, so take that with a grain of salt, obviously, but it's very hard for me to conceptualize doing very low dissections and sewing in mesh in the ventral discal aspect of the rectum without the robot, and this is probably more accentuated. I think my urogynecologic colleagues at the University of Minnesota truly appreciated that when we dissected all the way down to the anus, essentially, anteriorly, and we have such a limited area to sew in the mesh, which may be different to sewing in a sacrocopalpexy mesh. There's definitely longer operative times with a robotic approach, and this is definitely associated with your experience and your training and what type of team you have in the operating room. From a ventral rectopexy alone, biologic mesh has been associated with the lower risk of erosion, but when you're comparing 0.2 to 1.8 percent and various techniques and approaches, it's really hard to have homogeneous data to give a conclusive answer to that. There's also been a higher erosion risk with non-absorbable sutures. Again, these are low percentages, but many patients, when they come to my clinic, will ask me this as they come in and they know that they're having a ventral rectopexy, they go straight to the question of what type of mesh do you use, are you going to use a robot, and what type of suture do you use? So expect this more and more from patients as the pelvic floor population is definitely more savvy in asking this. With COVID, I think the ambulatory approach was becoming definitely more popular. We are pushing this quite a bit at the University of Minnesota. Because of our already very comorbid population, it's hard to sometimes discharge the patient the same day, but we are definitely doing this for both combo and ventral rectopexies alone. We were discharging those patients same day. We have learned that, at least I can tell you honestly, after almost 420 ventral rectopexies, that the recurrence rates at the University of Minnesota are in the 12 to 13 percent rate. And we do see a lot of patients that have had ventral rectopexies from other institutions that have recurrences that are either a recurrence of the full thickness rectal prolapse or a conversion of what was once rectal intussusception and now are presenting with a full thickness rectal prolapse. A lot of those patients did not have a combo approach, and in my own experience, the patients that I've done a primary ventral rectopexy on, I can tell you that the most common reason for failure is that it was failed to address the middle compartment. I apologize for that. All right, I think that went back up. So, a redo ventral rectopexy in the right experience hands is effective and safe. Outcomes. There's a lot of retrospective single institution studies on this. This is one where almost 123 patients lap versus robotic. You can see the years, and this was mainly in full thickness rectal prolapse patients and obstructive defecation patients. Majority were minor complications, bleeding, seroma, hematoma, urinary retention, readmissions, no mesh related complications. You can see the reintervention rate is low and similar outcomes between lap and robotic. As ventral rectopexy started, it was popularized by European institutions that were very developed with regards to MIS laparoscopy, and the technique was slightly different. As we learn more about the robotic approach, I would say that the majority of institutions doing this frequently in the United States will use a robotic approach, but I can't tell you that there's significant differences that have been published on that. I do it mainly, and I tell people, number one, number two, and number three is going to be ergonomics and the freedom of suturing in the distal aspect of the rectum, and that I can function the next day and actually as a human being, not just as a surgeon. Improvement in general of obstructive defecation. When they compared six versus 12 months, there was a difference in the recurrence rates. Only one of these were statistically significant, so a lot of comparisons in the early on experience between lap and robotic with slightly favoring the robotic approach. When they looked at obstructive defecation scores with the ventral rectopexy, and it was hard to know how many of these were combo procedures, as it wasn't detailed in this paper, but significant improvement in obstructive defecation scores. So, just bringing back ventral versus posterior, this is the only randomized controlled trial. I believe there's one more in Europe and Australia right now of 75 patients, which is obviously underpowered comparing full thickness and full thickness rectal prolapse ventral versus posterior. When they looked at their obstructive defecation, you can see that there was a significant difference in the scores for ODS, similar complications, and recurrence at 12 months, which all of you will agree is quite early to know for these. This is usually a technical failure or somebody that probably wouldn't have benefited in the first place because of other reasons, and it's hard to know, and these patients did not undergo any combo operations, but obviously you can see that it was underpowered to the point where this was not statistically significant. When they compared obstructive defecation scores and constipation, there was largely only for colon transit times, there was a slight approach to something being statistically significant, but they did not see a significant difference compared to the previous trial that favored ventral rectopexy. So, why combo ventral rectopexy and sacrocopalpexy? So, this is how it started. We've been doing multidisciplinary pelvic floor since the 90s, but it was probably with Dr. Sarah Bowler published this with Dr. Watadani back in 2013 of our early 2000 experience at the University of Minnesota where, and these are posterior rectopexy patients, but when we started noticing that we were doing posterior rectopexy with the sacrocopalpexy compared to posterior rectopexy alone, there were differences in outcomes, mainly constipation, quality of life, obstructive defecation. You can see the patient population there on your left. Almost a third of patients had previous repairs. This is a very good follow-up, especially for a pelvic floor group. Many patients obviously reported resolution improvement in the constipation. Most of these patients obviously had a rectal prolapse, so you'll see a drastic improvement in those patients, and it's going to be the late recurrences or late recurrences of symptoms that is probably going to level out your groups. There was a statistically significant and fecal incontinence severity scores in these, in patients that underwent the combo approach. There was also a quality of life improvement. When this was published, there was no recurrences, but I can tell you that it's probably for posterior rectopexy. What was first alone, what was first noticed that we have recurrences rate that could go up to 35-40%. If you follow those patients long enough, when they were offered a combo approach with the same amount of outcome, we did see a decrease in the recurrences, although this was not a comparative study, obviously. When we looked at constipation and fecal incontinence, there were statistically significant differences, so this is kind of the seed that started everything, right? As this launched out and we developed more ventral rectopexy, doing it with sacral culpopexy of everything that I've mentioned so far, we're seeing more and more outcomes, and these are going to be more recent studies, obviously. So this is a retrospective trial of almost 350 patients. There's four groups of the laparoscopic or it can be laparoscopic or robotic sacral culpopexy with or without ventral rectopexy or hysteroscopexy. A decent follow-up of two years, that's kind of the bare minimum in pelvic floor patients, and you can see recurrences when it was combined with the ventral rectopexy still in that percentage of low teens to high single digits. Not a statistically significant difference. It's hard to know from this study because there wasn't, there were not details with regards to the studying of the posterior compartment and how these patients had full thickness rectal prolapse or rectal intussusception, but this initial study from the urogynecologic literature showed no difference in perioperative complications, and this is the main reason why I put that because I feel like there's going to be a lot of people that say, well, why can't I just do this now? It doesn't make a difference. It's not that it make, it's not going to make a difference. I think that's a legitimate concern and argument, to be very honest. The fact that we're not studying these patients in combination with the different disciplines to see if they actually have a posterior compartment prolapse is that it may lead to differences in quality of life and obviously ODS scores and constipation. So I'm not saying that you're going to have more or less complications. What we're really focusing on here is that we need to study these patients correctly and think about the other compartments, and I think it's safe to say, at least from this study, even though there was no differences in recurrences, that it doesn't offer increased risk of perioperative or late complications. This is an experience from the Cleveland Clinic, also retrospective, smaller group of patients, ventral rectopexy with or without, or with sacrocopalpexy or uteropexy. The great majority obviously was sacrocopalpexy. Shorter follow-up, as you can see there. 25% experienced some perioperative adverse events. These were usually minor, as you can see from the top right there. Conversion to open, there was one bladder injury. Obviously, these are a lot of single digits because it's a very small group, but in general, safe for what you would see. What they saw from the Cleveland Clinic report is that the use of a biologic graft was associated with a higher risk of adverse event, which has been noticed as well in the UK. And this is a drastic difference, as you can see here, 40% versus 10. When you look at the bottom right figure, and this is a recurrence essentially, that there was a significant difference in recurrence, at least from the rectal prolapse standpoint, in patients that had a combo operation and more so with the sacrocopalpexy. Well, it's not just for full thickness rectal prolapse. I think probably at least a third, if not 40% of my patient population is rectal intussusception. Patients with ODS that are highly selective for this, that have improvement in their symptoms, and we think about a combo approach all of the time. This is another study that goes from the 90s to the early 2000s from one of the major centers for ventral rectopexy and pelvic floor disorders in Europe as a whole. Not a terribly large group, half patients with full thickness and the other half with rectal intussusception. Almost more than half the patients had previous prolapse surgery. This is rectal prolapse surgery, a combination of perineal and rectopexy, posterior rectopexy. They saw no recurrent full thickness prolapse at a median follow-up of 54 months, which is a very long follow-up. And it's surprising to see this. It's almost not believable, but I can say that I know a couple of the surgeons in that group, and they have had some recurrences, and it's not as drastic of a difference of none versus like in the single digits, for example, even if it was up to 10%, which is a significant difference when you compare to patients that have a non-combo operation or when you're not addressing the other compartments. Overall improvement in fecal incontinence in the great majority of patients and resolvement in 80% of obstructive defecation, which is also hard to believe. Not only, when you conceptualize combo operations, I think the question I get most commonly is like the surgeon that I, colorectal surgeon that I work with does not do ventral rectopexy. And I, you know, it's hard for me to say, well, you need to refer the patient somewhere else. That's, I don't think that's a legitimate answer, especially the way climate of healthcare is going nowadays. You will probably have a combination of surgeons that you'll work with that will do perineal procedures for rectal prolapse or abdominal. It would probably be my preference that if, if somebody is not doing ventral rectopexy, at least doing MIS posterior suture rectopexy at the time of the sacrocopalpexy. And as the last option, a perineal procedure with a sacrocopalpexy, which I, I don't need, I don't, I can't believe I'm even saying that, but that's something that in general, I think I would probably avoid much if you're offering that to a patient and Altmeier with the sacrocopalpexy, because I'd be worried about the function and long-term durability of an operation like that. But that's, that's not the main topic of what, you know, what we're discussing today. This is a NISQIP trial. Obviously there's a lot of, you know, when I read NISQIP trials nowadays, I, I, I, I don't know if I roll my eyes more or if I stutter more, but it's hard. But I think NISCP is getting better. Obviously this is data from, you know, into the 2000 teens, almost 300 patients, majority abdominal approach. So it's hard to, you know, represent that perineal approach very well. When they looked at perioperative complications, obviously this is abdominal versus perineal with that confidence interval, which was not statistically significant in that situation. Does the robot help? Well, you saw that trial from the UK that there was no difference. I think there's been an evolution of pelvic floor surgery and we're on this path that it's hard to go back. I, again, one of my disclosures is that I do education and proctor for intuitive. And it's hard for me to believe or even conceptualize doing a ventral rectopexy laparoscopic anymore. I'll be completely honest. It has improved the way that I teach fellows and residents. It makes me show anatomy better for patients. I can function the same the next day. I can visualize things much better. If there is a learning curve, there's a cost difference, obviously, for your team to become effective with this. And a lot of that has not been completely elucidated from the literature. All of this is single center experiences. There's definitely more prolapse than intussusception if that makes a difference at all. Opt times for a combo of 266 minutes. This can take longer. Obviously, ORs have, you may be in a hospital where you have very little robotic time and you have to optimize your functionality as much as you can, especially if you're doing a combo operation. But I'll tell you from my personal experience when I'm doing combo operations at the university, in general nowadays, I can probably do two max three, but I'm hesitant to even say that. But I would say in general, two combos per day. And Dr. Cynthia Falk can attest to that as well as turnover times and getting patients in and you name it, right? The things we think about every day. Most of our patients will stay overnight. If it's a long transplant patient or whatever complicated situation, obviously, keep a closer eye on those patients. But a lot of patients wanna leave the same day. That's not typically the case nowadays with how difficult it is to get in though. No increase in complications in general from those two publications that are from this year comparing lap versus robotic. What I did find interesting after reviewing the literature recently on this that in general, when I'm doing combos, I felt, and I didn't influence this, but I felt like there was a lot more urogynecologists that because of the nature of the procedure being more with fecal incontinence and so forth that there was less slings in general. And they thought that that may increase the risk of SSI. But if anything, what has been reported more recently is there are more slings being performed during eventual rectopexy, sacrocopopexy procedure. Many of these patients have undergone previous repairs. So that's something you have to study well. And recurrence rates have been associated, like I said, between the single digits to low teen digits in this. I do have a technique video and I'll share this. So you guys have this available to go through the steps and there's some narration like that, but I believe I'm a little bit short on time and it's 6.44. So I don't wanna go past that, but this is just a way, in general, I use the same thing for colectomies or pelvic work that I use for this. This is somewhat of a different depiction of this, but so typically it's straight across. I've used that. I've used every configuration you can imagine for the robots. And what typically works best for me is going more in a diagonal. This picture in particular, especially in the left upper quadrant, I have to stagger these so there's less collision, both externally or internally. If we're doing a hysterectomy at the time of the operation, this supraumbilical port will typically be a gel port mini, as you can say there. And we just use an additional assistant port to take that out. We use an air seal on all of our patients, not that you need it. It can help with smoke evacuation and stabilizing pneumoperitoneum. I will emphasize on your right side with the sewing, especially for ventral rectopexies, to not put this one too lateral as you're gonna massage the lateral pelvic sidewall during the entire operation. And that can be devastating from a venous standpoint and stasis and venous DVTs in these patients. So do not put this too lateral. It's because you're gonna get all the way down to the anus. It's very difficult to sew right above the anus when these ports are too lateral. The video will be available for everyone that's on and I think they're gonna post this. So this is for you to go through and my email is gonna be on there. If there's any follow-up questions after this, I'm very happy to answer any of those. I'm gonna move forward through that. This is just something that I think for everyone to know and it's more from a colorectal literature standpoint, but this is the position statement from the Pelvic Floor Society and of the European Association of Coloproctology, oh, sorry, of Great Britain and Ireland on their controversy with mesh and ventral, mesh rectopexy. But there was a lot of people doing these operations. So I think training is key for this and feeling comfortable and proctoring with your partners or having a group or a team to do this. I can't tell you how important it has been for us and painful at the same time because it's not easy to do this, having a multidisciplinary team to see these patients. There has to be buy-in from the system to help you with this type of process. It's mandatory to discuss all these patients or at least the complex patients in a multidisciplinary meeting. All of the complications and outcomes should be recorded typically. And this is something that we do intuitively anyway for research perspective. There's a move towards accreditation in UK units, just FYI for ventral mesh rectopexy. And they feel like that will improve performance and outcomes. It really depends on the situation or the community that you're in and your type of institution and what type of support you have, obviously. Enhanced consent forms and patient information booklets. I feel like if anything, this made me more aware of my consenting process and we've changed the way we consent patients at the University of Minnesota to include specific things that we felt that were not being addressed on the regular consents. And it's the way that you talk to the patient as well. But the available evidence is insufficient to support the use of one mesh or another. So they couldn't decide or give you a strong recommendation or one or another of versus especially biologic and synthetic. So ventral rectopexy is safe and effective operation in patients with full thickness rectal prolapse with less recurrence rates and postoperative constipation and is being increasingly used in ODS patients with interception. Although the follow-up is more limited than in those full thickness rectal prolapse patients. Multicompartment pelvic organ prolapse is common but frequently under-reported and under-recognized in general. And I think it's up to us to improve that. The multidisciplinary evaluation treatment as well as patient selection are crucial and discussing these patients obviously goes above everything. Both abdominal and perineal combined procedures can be offered to patients. It depends on what type of approach you're using in a single operation. And I hope I've showed you enough for you to feel that that's a strong conclusion. And concurrent recovery period without increasing especially complications. And the one that we are scared of the most is mesh erosion, especially for the rectal patients. I welcome you to our course in Minneapolis where we are gonna talk about pelvic floor as well as many other colorectal disorders. Thank you so much for inviting me and I'm happy to answer any questions. Thank you so much, Dr. Gairtner. That was fantastic. And we have some questions here in the chat that I'll share with you. What options are there for patients who've had prior radiation or may have inflammatory bowel disease like Crohn's? I'll attack the IBD one first. I feel like selectively, I have not seen a lot of literature or results on the use of mesh in especially Crohn's patients because I think what you're gonna see most often are not the UC patients, but the Crohn's patients. There's some anecdotal literature just looking at hernia repair mesh from abdominal walls in IBD patients with known increased risk for infections. And as these patients will have a lot of abdominal re-operations, they'll be immunosuppressed on biologics. I have not felt comfortable using mesh in Crohn's patients, especially if they have proctitis or perianal fistulizing disease, but I do feel comfortable performing an MIS posterior sutured rectopexy with or without the sacral copepexy. I would say most of your gynecologists do not feel comfortable with that. If I'm not putting in mesh, it's not like somebody can say, well, I'll put in mesh. That's never gonna happen, right? So that's just the premise that I would say with that. For radiation, it depends on the type of radiation and the dose. My most common thing that I'll see is prostate and rectal and for anal cancer. I think the anal cancer patients are a higher dose. It's a slightly different location. They do have more soft tissue injury of the anus. With those patients, I feel like it's probably the minority that I've used a combo approach. And when I say minority, because everybody I do nowadays is a combo, is probably gonna be in the realm of about 20%. The other patients I'll probably address more with a posterior sutured rectopexy. But if they have relatively good function, I think the public or study there is going to be crucial. And that discussion you're gonna have, multidisciplinary discussion, is gonna be crucial of what you're gonna use. But I feel like in general, over the last five years at our institution, we're seeing an increased rate of using ventral rectopexy and sacral colopexy, even in radiated patients. Great, thank you for that. Another question from an attendee pointed out that most of the studies you shared today had supra-cervical hysterectomies. Is there any data on total hysterectomy at the time of a combo procedure? Well, I've been thoroughly educated by my colleagues that the erosion risk is higher in, or less, I guess, with the supra-cervical hysterectomy. But, and they're totally right on that. I would say the majority of patients do have that. But I do feel like we are seeing an increased representation of total hysterectomies in pelvic floor studies, as that's what's happening. A lot of the patients, if you think about, well, how many patients already have a hysterectomy? In my practice, probably closer to a third or less of patients require hysterectomy during that index operation because the majority of patients have had a hysterectomy before that. There's a lot of differences between provider comfort level. Most urogynecologists that I work with will do a supra-cervical hysterectomy. There are different ways of training in urogynecology, obviously. And it really depends on training, expertise, and comfort level. But I do work with providers that prefer to not perform the supra-cervical hysterectomy. But in general, when I'm doing this, I'll say the people that I work with will have a supra-cervical hysterectomy. Okay, another question regarding what you recommend for urogynecologists to use as a symptom threshold for ordering dynamic MRI or referring to colorectal when working up a patient for pelvic organ prolapse surgery. When is it okay to order X-ray versus MRI deficography? The easy answer there is everyone, right? Because we do multidisciplinary kind of rounds and I'm always in clinic with a urogynecologist that's just down the hall. And it's very easy for us, and it's easy for me to say this. MRI deficography in general, when you're laying down to, we don't lay down to stool or have a bowel movement. We're not laying on a side. So having a standing or sitting, excuse me, sitting X-ray deficography with an experienced person reading it is probably the most crucial thing that I use to think about support in the pelvis. And if somebody has vaginal support or what degree of intussusception. By and large, we do not use MRI deficographies. I'll selectively use it and maybe redo, patients that were done at institutions that I don't know what's going on, or if patients have very atypical symptoms, mainly a pain, and I'm worried about the outcomes and the expectations of that patient. I'll order an MRI deficography or when they've been fired by the pelvic floor center, which is not completely uncommon. But for us, the sitting deficography with somebody experienced reading it, and it's a colorectal surgeon, Amy Thorson reads all of our deficographies at the University of Minnesota, and is just a basket of wisdom for our entire division. And she's amazing at communicating this to you. So that little nugget of gold that she puts in there is absolutely crucial for me. Great, and then we have a couple of questions on a similar theme. How much vaginal prolapse or what degree or stage uterovaginal prolapse in the setting of rectal prolapse requires a combo procedure, in your opinion? That is something that we're trying to investigate currently. I feel like that's not something that has been well-addressed in the literature on, well, how much is enough for me to think about a combo operation? It's usually the other way around when a urogynecologist is referring to the patient and I don't have to have that thought process unless we're in the multidisciplinary sessions about like, you know, how much support. So when I, the way, the result that I have from this as a surgeon is when I'm looking at the deficography and I'm seeing the posterior vagina coming down with an enterocele, that automatically sets off the red flag for me, particularly when they're straining and they develop a non-evacuating rectocele after that. And that is at least a grade, at least a grade three rectal interception with poor vaginal support. And if I will, how do you categorize that if it's like a true, but when they have their posterior vagina coming down into the interception with or without a rectocele, that is setting off all the flags for me. Now we can get into like the grades and stages of that. And I feel like that was probably a question that you guys can answer better than I can. But for me is when I'm looking at that deficography and I see the posterior vagina coming down significantly into that interception, there's a large enterocele behind it. That's what makes me think about combo. Great. And one attendee asked, what mesh do you use in your practice? And another asked in the setting of a rectal mesh exposure, how do you manage that? Yeah, great questions. I used Permacol for a long time because I was a chicken and I was operating on a lot of heart transplant patients and you name it, it was all the sick patients that come to the university. And as I've done this more and I have more elective procedures and patients that are not as comorbid, I have switched to a lightweight polypropylene mesh. And that's been more of a unified vision, I think throughout our division to do that. But a lot of us started with biologics and we slowly transitioned. I did not see, at least my experience, I probably have 50-50 now. I did not see the complications that other centers saw with the biologic. So I was less in tune to change rapidly. I did it mainly to have more of a unified kind of, of way that we were doing things. So now I just use polypropylene unless the patient specifically requests it for one reason or another. And that's still up to debate depending on why they're requesting it. The other thing about rectal erosions, I can tell you without having full follow-up of all of my patients, because they come from all over the Midwest, that I've never had a patient come back with a rectal erosion, but I have had my sutures and my mesh erode into the sacral colpopexy or into the vagina. It's more frequent, obviously, in a non-supercervical, a total abdominal hysterectomy patient. We have excellent urogynecologic colleagues here that take care of that. And it's usually between cutting a suture, trimming a piece of mesh, hyperbaric oxygen occasionally, vaginal estrogen, but probably a combination of all those above, depending on the magnitude and degree. Just from a general standpoint, for people to conceptualize this, rectal erosions with fecal discharge are obviously a problem. When you have an erosion that is not a full-blown perforation, those patients do not equal immediate dismantlation of the entire operation. If you have feces coming out of an abscess cavity, yes. But if you have a localized infection with perhaps an erosion where you can trim something or release a suture and treat with antibiotics, and sometimes I even hate to say this, a drain, but we rarely try to put in IR drains in these patients because they typically form a lot of fluid in the pelvis and we try to avoid contaminating those fluid collections with IR drains. But many of the rectal erosions, depending on the magnitude of them, can be managed without surgery. Great. Well, in the interest in time, I will wrap things up. We have some awesome questions that didn't get answered and we'll do our best to send those on to you so attendees can get their answer. On behalf of AUGS, I'd really like to thank you, Dr. Gairtner, today for this excellent webinar. And to our attendees, be sure to register for our upcoming webinars. On November 15th, Dr. Peter Rosenblatt will discuss non-mesh surgery for stress incontinence. And on December 20th, there'll be a complex case panel discussion with Drs. Sherelle Iglesias, Sean Menefee, and Catherine Matthews. And lastly, follow on AUGS Twitter and Instagram or check our website for information on all upcoming webinars. Thank you all so much for joining and a special thank you to Dr. Gairtner for being here today and have a great evening. My pleasure. Thank you.

combined rectopexy

sacro-copoplexy

pelvic floor disorders

prolapse surgery

mesh options

recurrence rates

anal rectal function

multidisciplinary approach

laparoscopic approach

ventral mesh rectopexy