So I'm going to give it two minutes, Dr. Gillingham, just to let the participants come in, and then I'll mute myself and turn off my video and get the stage to you. Awesome. Sounds good. People are already filtering in. Look at that. Exciting. Yeah, you got a lot of people. No, I'll come to you. Do you want to say hi to Akira? Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. Hi. HI believe this to be stronger than using a Y mesh where there's only a single arm attached to the sacrum because now the load is shared by two sheets of mesh. So that's how I justify using a lighter weight mesh. And then of course patient factors and addressing those, smoking cessation and aggressively treating vaginal atrophy in the postoperative period. So moving on, let's talk about bowel obstruction. Bowel obstruction or ileus is thought to be because adhesion is formed between the bowel and the sacral colpexy mesh. Overall, it's a pretty rare thing to happen with rates anywhere from one to 5%, depending on the study you read. I think it is important to know that despite it happening one to 5% of the time, the rate of a morbid reoperation for a bowel obstruction is actually much, much lower than the rate of bowel obstruction. In most studies and cases, the rate of reoperation is much lower and most cases are actually managed successfully, managed conservatively. But, you know, no one wants to have their patient have a bowel obstruction. So, you know, can we prevent this? So this is where the debate of mesh re-peritonealization comes to the forefront. You know, it makes sense, you know, if you cover the mesh, prevent adhesions from forming between the bowel and the mesh, you know, you could be, you know, theoretically decrease your rates of ileus and small bowel obstruction. However, there's no such thing as a free lunch. There are potential risks to doing a re-peritonealization. One, it, you know, maybe not significantly, but it does increase your operative time. It's a separate dissection. So, you know, it does increase blood loss. Because you are suturing the mesh that normally belongs on the right pelvic sidewall, there is a risk of right ureteral injury. And similarly, injury to the sigmoid colon has also been reported. And then ironically, there are case reports where if you use a barb suture for this portion of re-peritonealization that the barb suture itself can cause a small bowel obstruction. Luckily, this is, you know, case report level stuff, but I just wanted to mention that. So, you know, intuitively it might make sense, but you know, is there evidence for or against mesh re-peritonealization? So, I found there are basically three large retrospective studies, and they're all retrospective because bowel obstruction is a pretty rare event. The first one, it's a retrospective cohort study of 370 women who underwent a minimally invasive robotic sacral colopexy and, you know, were at this time excluding rectopexy. In this study, 100% of cases, so all cases were re-peritonealized. And the rate of small bowel obstruction in ileus was not zero. It was, you know, five cases or 1.3% despite re-peritonealization. So again, there must be other factors that contribute to bowel obstruction. But I just wanted to, for you to keep this number in mind. They did not report on any re-operation for bowel obstruction in this study. So a second retrospective cohort study, a recent one, followed two or examined 209 women who underwent minimally invasive sacral colopexy. And the rates of mesh re-peritonealization were about 50-50. So 55% mesh re-peritonealization performed and then 45% not re-peritonealized. And they actually did not detect any significant difference in the rates of small bowel obstruction or ileus. There was one case of bowel obstruction when the mesh was re-peritonealized. And this case, they did take back for surgery. And then 4.3% when the mesh was not re-peritonealized and none of these cases went back to the OR. There was one case of right and uterine obstruction that was attributed to mesh re-peritonealization. Luckily, this was caught at the time of routine cystoscopy at the end of the case and was easily managed. And finally, I believe this is the largest retrospective cohort reporting on bowel obstruction and bowel complications. This was 458 women who underwent minimally invasive sacral colopexy, where most of the cases actually were not re-peritonealized. So only 14% of cases was re-peritonealization performed and the other 86% mesh was not re-peritonealized. And despite higher numbers of cases without re-peritonealization, there was still no difference in small bowel obstruction or ileus. And just as an aside, excluding things like port site hernia, which I think has very little to do with the mesh. So 1.5% when re-peritonealized, none of them went back for surgery. And then 1.8% when not re-peritonealized with a very, very low reoperation rate. So I think after reviewing these studies, I think, to me, there's really no compelling evidence to re-peritonealize because the rate of small bowel obstruction is essentially the same across all studies. Another unique aspect of re-peritonealization is if you're ever lucky enough, fortunate enough to go back in on your own case to reoperate, say someone has a recurrence of prolapse and you're doing a repeat cerebral colpexy, it's actually, you know, I think very important to know ahead of time whether or not the mesh was re-peritonealized because the anatomy becomes very different. So on the cases that I've gone back to operate on and the mesh was re-peritonealized, what you find is that the mesh gets sucked towards the right pelvic sidewall. It's actually retracted against the right pelvic sidewall. And because of this, the right ureter is also not in its normal anatomic spot. It actually gets drawn immediately towards the mesh. So, you know, if you have to, you know, cut the mesh or dissect it out, there's a really high degree of difficulty and risk of ureteral injury in these cases where surgical mesh re-peritonealization was performed. I'd be interested to hear other people's thoughts and experiences on this because I don't think this is, you know, reported at least in the literature that I was looking at. So here's my own case, not too long ago where I had to go back in on a patient because of a prolapse recurrence. I did not surgically re-peritonealize the mesh at the time of index surgery and I got in and this is what I saw. If you don't surgically re-peritonealize the mesh, you actually, you know, get this mesh bridge that forms between the vagina and the sacrum. And because you never opened up the right pelvic sidewall, the right ureter remains in its normal anatomic location. So it's, you know, in my opinion, much easier to deal with than if the mesh was re-peritonealized. And as you can see, you know, your own body, the host cells do a pretty good job of growing into the mesh through a process I've just made up called auto-peritonealization. And then surprisingly, in this case, I think I may have just gotten lucky, but surprisingly little adhesions between bowel and the mesh, despite, you know, despite not surgically re-peritonealizing during the index surgery. Again, I think this is, this is purely just my speculation. I couldn't find any data on this, but I have a feeling that, you know, the lighter mesh you use, the less chance of adhesions. But again, I just wanted to point out that this, that's not a data-driven statement at all. That's something just, a pattern I started to notice in my own cases. Okay. So let's talk about the last topic of osteomyelitis. I'll start with a case presentation. So this was during fellowship. We had a 79-year-old patient with stage three vaginal prolapse, elected to undergo robotic cerebral colopexy, which was completely uncomplicated. She was discharged home, but came back on post-operative day 13 to the emergency room with symptoms of abdominal pain, back pain, and fever. She had a white blood cell count of 12.5, her C-reactive protein was elevated, blood cultures grew streptococcus, and a CT on the submission didn't really show anything specific, perhaps some inflammatory changes around the sigmoid colon, you know, the idea of diverticulitis was brought up. And just to be safe, we obtained an MRI, which you can see on the right, and we're looking at the level of L5 and S1 with the disc face in between. And essentially, this was read as a completely normal MRI. So she was treated with IV antibiotics, her fevers and pain improved, and was discharged home, but then eventually came back about a month later with worsening back pain. At this time, she didn't have an elevated white count, but her C-reactive protein was still elevated, and a repeat MRI was performed. So here's her initial MRI on the left, and her most recent MRI on the right. It doesn't take a radiologist to tell you that there's something abnormal going on. You can see a loss of the architecture of the intervertebral disc, as well as edema and infectious changes of the bony sacrum. So the diagnosis of vertebral osteomyelitis and discitis was made. There's actually a very good systematic review, recent systematic review, that outlines diagnostic pearls and treatment pearls, but getting an IR or surgically obtained biopsy and culture is important. In this case, the patient's biopsy grew out pseudomonas, her IV antibiotics were appropriately adjusted, and we tried to treat her with IV antibiotics. However, she did not make any significant improvement. So the next step in management, we did a laparoscopic excision of her sacral mesh. But unfortunately, this was not enough to treat the infection. Eventually, with the help of orthopedic spine surgery, she went back for a debridement and L5S1 anterior interbody fusion using this titanium spacer. Fortunately, she improved, and as far as I know, has not been seen since then. So yeah, osteomyelitis, it's a scary complication. But it's important to know how this disease process presents. So in terms of symptoms, back pain is actually the most common initial symptom present in 86% of cases, not just after your gynecologic surgery, but also after orthopedic surgery as well. Fevers aren't the most reliable indicator with fever being present only in 35 to 60% of patients. Neurologic impairments such as leg weakness only in 33% of cases, and spine tenderness only in about 20% of cases. The workup, the C-reactive protein is actually elevated in all reported cases in this one study, followed closely by the ESR at 98%. So definitely if you think a patient might have osteomyelitis, definitely get these two labs. Leukocytosis is only present in 64% of cases and neutrophilia in 39% of cases. Imaging is interesting. MRI is definitely more sensitive than CT for detecting early spinal osteomyelitis. However, as we found out in our case, there's a two to four week delay between the onset of a patient's symptoms and any changes that are detectable by MRI. So even though you may have one normal MRI, you're still not out of the woods. Therefore, MRI is not considered to be useful for monitoring any sort of clinical response. So why does this happen? There are multiple proposed mechanisms such as hematogenous spread. This is I think more seen in orthopedic patients where any hardware gets infected through more like a systemic infection. For the sacral colopexy, some proposed mechanisms include bacterial seeding of the mesh. So bacteria from the vagina travels up the mesh in a sense of the sacrum. This is why things like mesh exposures are potentially of concern in a sacral colopexy. But probably one of the most modifiable things is direct inoculation of the L5S1 disc by the sacral suture. And so this is one thing that we can really look into and change our technique if it's not something we're already paying attention to. So how do we avoid this? Well, I think it's important to review the anatomy of the sacral promontory. A really, really great study did a retrospective review of spinal MRIs of healthy female subjects. And the goal of the study was to identify what exists at the most prominent point of the sacrum before the promontory drops off. And so what do I mean by this? So we have L5 and S1. And then this point here, the study aimed to identify what is directly at the promontory. And so after looking at these MRIs, only 27% of the time was it the superior aspect of the S1 bone. And in these cases, the distance to the base of the disc was within millimeters. Most of the time, the green arrow corresponds to the L5S1 intervertebral disc. So to reiterate, most of the time, the promontory is still the disc. And so I think the biggest take-home is that if the goal is to suture over the S1 vertebral body, you should always aim to be at least five millimeters inferior to the promontory because in this MRI study, the S1 vertebral body was within five millimeters in all cases that they reviewed. So you want to place your sacral suture past the promontory, but this can sometimes be challenging depending on the patient's anatomy. So if you're looking at your sacral dissection and it looks kind of like this or a really challenging black diamond ski hill, don't hesitate to call for the 30 degree scope. And as you can see, just by switching the scope, you get a much better view of the drop-off of the sacrum past the promontory and it makes placing the stitches much, much easier. So how do we avoid the intervertebral disc? As we discussed, don't hesitate to use a 30 degree down scope, especially if you're on that black diamond sacral promontory place the suture five millimeters below the promontory and then realize that the anterior longitudinal ligament is really thin. It's really thin, but it's really strong. So you don't have to go too deep because it's only one to two millimeters in thickness. You can really just skim the surface to really try to decrease the depth of your needle placement. And then other tips that I employ to reduce the infection risk, use a monofilament suture when you're suturing mesh onto the sacrum. The thought is that a multifilament or braided suture can trap bacteria or infection within the braided suture. I always irrigate my mesh. After the procedure, that's some advice that I got from a general surgery, general surgery colleague. I think it's important to always use a clean needle for your sacral stitch. And what I mean by this is that I really don't think you want to use a needle or suture that's already been used on the vagina to use onto the sacrum. I think it just makes sense to use a fresh needle for your sacral suture. I didn't really get into this, but there are studies that show that performing a concomitant rectopexy increases your risk of osteomyelitis and dysgitis. So if at all possible, try to avoid that. And then I think I mentioned that, most of the time I don't reperitinalize mesh, but I do do it selectively if I'm worried that maybe the mesh would be involved in some future intra-abdominal process, such as maybe diverticulitis. So, you know, never say never, I do selectively reperitinalize mesh, but of course I don't have any data to support that. So thank you for listening. These are my main references, and I'd like to open up this time for any questions. Thanks, Akira. That was awesome. So there's actually some questions. One is what patient characteristics would make you do a supra-cervical hyst over a total hyst? Sure. I think, you know, obvious ones would be like smoking. If a patient was a smoker, we know that that increases tissue, that, you know, affects tissue healing and also increases the rate of mesh exposure. So, you know, that's someone who I'd consider or at least bring up a supra-cervical hysterectomy. You were talking earlier in the talk about using two separate sheets of mesh. Are there any studies that have compared the approaches of two sheets versus like Y versus that you're aware of? I'm actually not aware of that. I could be totally wrong, but, you know, basically I think I've had many, several recurrences where a Y mesh breaks at the sacral arm. And so basically distributing the load of, you know, the forces on the vagina over two sheets of mesh, I think makes a lot of sense in terms of making that aspect of repair stronger. Yeah, I agree. I had one recurrence like in the OR when I was using a Y mesh. Like at the end of the case, we put the legs down and the fellow, I think was like, her prolapse is back. And it had fractured at the sacral arm. So I'm a convert too with the two separate sheets. So another question regarding the slight increase in sacral colopexy failures with ultralight mesh, is there a trend of where the failure occurs regarding the mesh, i.e. the sacral attachment anterior, posterior? Yeah, I don't actually know of any studies that report on the specific location of the recurrence because, I mean, that'll be a great study to do, but it would involve everyone having to reoperate on recurrences abominably, which might not be in the patient's best interest when they have a recurrence. Yeah. Another question, what was the time interval between the index surgery and your repeat surgery for colopexy? This is in reference to the picture without the peritonealization. Yeah. She actually, I diagnosed her with an objective recurrence on exam at her six-week visit. It was pretty early. And so I mentioned it to her. And then, of course, a few weeks, few months after that, she came back with symptomatic prolapse. She doesn't have any diagnosis of a connective tissue disorder, but it was one of those patients where you can tell that her tissues were super stretchy. Totally. Yeah, basically, I used the same lightweight mesh, but I reattached a much wider mesh with more rows of suture for her. I didn't want to use a heavier mesh because of her, I guess, poor tissue quality. I was really worried about a mesh exposure in her. Yeah. For antibiotic prophylaxis, I'm actually not aware of this. Maybe you are. My question is, is there any evidence to support the use of ANSIF with FLAGYL to reduce sacrocolopexy infection versus ANSIF alone? I don't believe there is. Yeah, I think we just use antibiotic prophylaxis for the same thing we use for hysterectomies. Totally. But I've thought about this too, because I wonder what the ortholiterature shows with implants and if there's a little bit. Yeah, there's also this whole other rabbit hole of, do you use an antibiotic irrigation? I think maybe this was performed- Did you say you irrigate your mesh? What do you irrigate it with? Just saline. I just irrigated dilution is the, what is it? The solution to pollution. So, but I don't use an antibiotic irrigation. I know some of my partners back in the days of transvaginal mesh would irrigate their transvaginal meshes with antibiotic irrigation. But again, I don't know where the literature stands on that. Yeah. Have you come across any cases of osteomyelitis after using bone tacks at the sacrum? Ah, I've never used bone tacks, but that would be- Neither have I. That would be a fear of mine. It's probably the biggest reason I would probably never use a bone tack, because I think I have more control with a suture rather than a tack. But I know plenty of people who do use bone tacks. Yeah. One of the attendees said, have you seen infected sacrocopalpexy mesh causing vaginal discharge without the presence of a mesh exposure? This attendee said that they have seen this three times in patients without a history of diverticulitis after a supracervical has sacrocopalpexy, all were re-peritonealized. And I can tell you, I can recall one of my patients had this too. And she had created a tract between the infected mesh and her cervix. And so she was just draining transcervically. Yeah. What are your experiences? Never had that. Definitely heard about sinus tracts and things like that forming. Yeah, it would be interesting. I think, like all things, I think the type of mesh and the mesh weight would play into this. So I'd wonder what type of mesh was used. Yeah. I think that's everything, Akira. And there's another, oh, hold on. There's some stuff in the chat. Okay. Oh, any reports regarding differences in outcomes using ethabond to secure the mesh? I can tell you my anecdotal stuff, which is, as you know, ethabond is not good and definitely erodes. What do you think? I think, yeah, I prefer not to use ethabond. You know, I think if you're looking at purely suture types, I think, and I'm talking about vaginal attachment, I think Gore-Tex is very soft and forgiving, in my experience. Yeah, and monofilament, so it's- Monofilament, it doesn't tend to poke through tissues. And even if you have a Gore-Tex mesh, Gore-Tex suture exposure, it's pretty easy to take out because it just slides out. Okay, let's do a couple more. You have not mentioned the sacral sutures, how many, and what kind of a pattern on the sacrum? I use two. What kind of pattern? I guess one above the other. I do suture, I try to suture horizontally because I was told- You go around those. Yeah, because that's the direction of the anterior longitudinal ligament fibers, I guess you can call it. Yeah. Go ahead. Regarding the most common presenting symptoms, you mentioned leg weakness. Leg weakness is not a common presenting symptom. It's back pain, first and foremost, followed by fevers. And so it could be pretty nonspecific, which is the tricky part. Do you dissect the peritoneum off of the posterior vaginal wall if you're not going to reperitonealize the mesh? Yes, I do. And that's basically so that I can dissect the rectum off of the distal vagina. We didn't, yeah, we didn't touch on this, but I think getting a nice large dissection to really maximize the amount of mesh you can suture onto the vagina is important in terms of prolapse repair durability. All right. I think I've covered, give me one second, because we had questions and oh, there's more in here now. You're a popular dude, Akira, tonight. Yeah, this is great. We have 45 people on, this is great. That will generate some discussion. Okay, what type of post-op instructions are you providing? Do you typically place a midurethral sling at the time of sacrocopalpexy? Yes, I do. I think more often than not perform a midurethral sling at the time of the sacrocopalpexy. Interestingly, I do it at the beginning of the case because I just find trying to place a sling in a post-sacrocopalpexy vagina is just much too difficult. You really have to like get up there. Too well-supported. Again, you don't want to over-tension the mesh because I've seen cases where if you over-tension the mesh the sling stops working. What was the other question? No, that was it. Post-op instructions, oh. Oh yeah, post-op instructions. I'm pretty near- I hope you're following our study here at Northwestern that you were a part of. Yes. Activity restriction. I guess I'm pretty liberal. I kind of leave it up to the patient. Just nothing inside the vagina and don't attempt to lift a couch, just common sense things because a study we did showed that even if you restrict a patient, half the time they don't listen. And in our study, liberal versus restrictions had no difference on post-op outcomes. And do you have any concern about increased infection rates for people? You know how some people do a vag-hyst and vaginal dissection at the time of sacrocopalpexy? Yeah. Any thoughts on that versus doing everything laparoscopically? Yeah, that's an interesting thing. I mean, one of my partners does that, do a vag-hyst and then go robotically to- I think a lot of people were doing that, especially to like help resident numbers. Sure, yeah. Just falling out of style, if you will. Yeah, again, it doesn't seem to cause any increase. This is obviously anecdotally. I think the main mechanism, therefore, is inoculation of the sacral disc by a suture. So it's not necessarily that ascending infection from the vagina that we're always worried about. I think it probably has more to do with the sacral stitch. Yeah. Do you offer site-specific repair at the time if indicated after sacrocopalpexy? What suture do you use? I'm assuming this means like if someone had like a- An anterior. A current anterior prolapse, would you potentially just do an anterior repair? Yeah, so I always, after I, you know, I'm not the one positioning the vagina because I'm the one securing to the sacrum where I practice. I think before I undock the robot, I would go back down and look at the repair. And if something still seems to be prolapsing, instead of creating more incisions inside the vagina, I would prefer to try to re-tension one of the mesh arms. And that's a useful part about using, you know, two separate pieces of mesh. You can always abdominally kind of pull back on, say, the anterior portion if there's still some prolapse to re-tension. Bunch up that vagina. Bunch it up and just kind of, you know, pleat the, am I using the right term? Basically suture some of that anterior mesh more proximal to bring it up. Yeah. Any changes to your approach if you're doing straight stick versus robotic? No, I think all the, I use all the same material. I, of course, I'm not intracorporeally tying. I'm using an extracorporeal knot pusher, but I still use the same type of mesh and the same sutures. Yep. And then let's do one more. When you operate for recurrence, do you typically do something different with your technique? You sort of alluded to that one case where you used kind of like a broader piece of that. Yeah. You and I, back in the day, we, you know, tried to change things up a little bit, but. I think if you can think of something that's, you know, within reason, I think, yeah, doing something different probably makes sense. You know, you don't want to do the same procedure over and over again and expect a different result. So yeah, so for that one patient who I showed the picture for, I used basically a wider, larger piece of mesh, you know, width-wise, because that more suited her anatomy and used more sutures to secure the posterior mesh onto the vagina. For a different case, I distinctly remember using a heavier mesh, actually, because that was the patient who actually snapped, snapped her Y mesh. She was, you know, BMI was bigger. You know, she lived a very active lifestyle. So I actually used a heavier weight mesh in that case. All right. Well, I think we've covered all the questions. So we'll give people 10 minutes back. So Akira, on behalf of AUGS, I want to thank you so much for taking the time tonight. I can tell you, this was one of the most highly attended webinars of the year. So for the audience, thank you for coming tonight. Our next webinar is on March 15th, and it's all about accidental bowel leakage with Candice Parker Autry. So again, Akira, on behalf of AUGS, thank you so much. Thank you. Thanks, everyone. Okay, everybody, have a good night.

sacrocolpopexy

mesh selection

complications

surgical techniques

lighter weight mesh

repair

mesh re-peritonealization

avoiding sacral sutures

infection