All right, good evening, everyone, and welcome to the Ogg Fellows webinar series. I'm Jackie Kikuchi, the moderator for today's webinar. So today's webinar is Updates in Uterine Preserving Surgery by Dr. Lucille Ferrando. Dr. Ferrando will present for 35 minutes, and then the last 15 minutes of the webinar will be dedicated to students. So a little bit about Dr. Ferrando, she is a board-certified female pelvic medicine and reconstructive surgery specialist at the Cleveland Clinic. She completed her OBGYN residency at the Combined Brigham and Women's Mass General Hospital Training Program, and then she completed fellowship in female pelvic medicine and reconstructive surgery at Cleveland Clinic. She has been in practice for seven years. She has an academic appointment at the Case Western Reserve University School of Medicine, and she is an active faculty member for the Cleveland Clinic Lerner College of Medicine. Dr. Ferrando is also one of the founders of the Cleveland Clinic Transgender Surgery and Medicine Program, which is housed in their LGBT Center. She is also currently the Director of Surgical Services. Her clinical practice focuses on pelvic reconstruction, including gender affirmation surgery. She has performed over 300 gender affirmation surgeries in the last five years. She is also the Fellowship Program Director for Cleveland Clinic's FPMRS Fellowship, as well as a Program Director for the Transgender Surgery Fellowship. Dr. Ferrando's research is focused on the outcomes of pelvic reconstruction. She has published over 80 peer-reviewed papers and has authored 12 textbooks. She is also the co-founder of the FPMRS FPMRS Foundation, which is a non-profit organization that is committed to expanding research in the area of transgender health and transgender health services in the U.S. Now, before we begin, a few housekeeping items. One, this webinar is being recorded and live streamed. And two, please use the Q&A feature of the Zoom webinar to ask the speaker any questions. And then, if you have any technical issues, please use the chat feature. And our AUG staff will be monitoring the chat and connect us. And next, I'll turn it over to you, Dr. Ferrando. Thank you. Hi, Jackie and everyone. Thanks for that really nice introduction. Everybody can hear me okay? Jackie, can you hear my volume just fine? Okay, great. So, it's so nice to be here. I have no idea how many people are in here. I can't see the number, but I'm presuming it's mostly fellows. So, it's nice to meet those of you I haven't met through this Zoom world. I'm happy to have any questions at the end. I'm also really happy to be here and talking about an FPMRS topic. I often get asked to talk about transgender care and gender-affirming surgery. But my first love, and what I spend more than half of my time doing, is FPMRS. So, thanks for asking me to do this. So, I'm going to talk this evening. I'm going to do some updates on uterine-preserving surgery for uterovaginal prolapse. Review the data that currently exists. And at the end, talk a little bit about the knowledge gaps that we have. And maybe inspire some of you to work on some of the research that is needed in this field. So, I'm going to put us in presenter view. So, here are my disclosures. I do receive some royalties from up-to-date, not related to this topic. But I also wanted to disclose that I will not be discussing the use of transvaginal mesh for hysteropexy. We'll be talking about all of the other modalities. But I'm happy to take questions about that as well. Because the data that do exist do cover the use of transvaginal mesh. But it has become a bit obsolete at this point. Since these meshes have been taken off the market. And aren't to be used for clinical practice currently. So, when it comes to patient selection for hysteropexy. We really have to sort of think about to whom should we be offering these surgeries. And really there is no patient. And I know that people sort of vary in this in terms of their opinion. Not that it's very controversial. But I think when you get a bunch of urogynecologists together. And ask us about to whom we offer hysteropexy. It varies depending upon our different practices. I trained between 2012 and 2015 at Cleveland Clinic. Where I'm currently practicing. And we were really early adopters of hysteropexy. Doing native tissue vaginal hysteropexy. And so, I've been doing a lot of these procedures since the start of my practice in 2015. And really for the fellows and the residents that rotate with me. They know that I pretty much offer hysteropexy to almost any patient. That is either a candidate for or desires native tissue vaginal reconstruction. For utero vaginal prolapse. There are obviously some contraindications. And we're going to talk about that. But for me it has become sort of an equal option. For most of the patients who are undergoing a native tissue surgery. And that includes women even in their late 30s, early 40s. Who are still of reproductive age. Or premenopausal to women who are postmenopausal. And it also sort of spans the gamut when it comes to the stage of uterine prolapse also. I've performed hysteropexies on stage 1 to 2 prolapses. And also stage 3 to 4 prolapses. And again, I'm happy to take questions about that. And speak more on patient selection in a bit. So, these are the considerations. Those of you who are performing hysteropexies in your practices or with your mentors. Probably speak about these considerations all the time when deciding on these surgeries. But the following should be considered in women who are seeking uterine preserving surgery. So, one of the big things. Honestly, what I start with is the patient's goals. And their understanding of the role of their uterus. And their personal views of the organ. You know, it's interesting when you start talking to patients about sort of a lot of their thoughts. About how they feel about having uterus. Or not wanting their uterus anymore. And there are a lot of considerations that go into this. So, this is a big part of the discussion. The two things that are going to come up a lot during the discussion. Are sexual functioning and risk of menopause. Based upon some heterogeneous data. There were some thoughts for a long time. That have now become a little dated and antiquated. That the cervix was really important for sexual functioning. So, sometimes women are very concerned about losing their cervix with a hysterectomy. Especially if they're going to be having a vaginal procedure. And so, there are a few myths to sort of dispel. When it comes to sexual functioning. And intimacy post-operatively. And so, some women have this concern. And share it with you in the office. When they're discussing their options. The other question is really the risk of menopause. And there are studies showing that. You know, concurrent hysterectomy at the time of prolapse repair. May lead, even in the setting of ovarian preservation. To decreased ovarian function. And earlier menopause than anticipated. And so, I think that those discussions are really important with women. Especially when they're in the perimenopausal state of their lives. Or premenopausal state. In terms of what their goals are. Last year at the Society of Gynecologic Surgeons. Livvy Chang, one of our formal fellows. And you'll see she's really been at the forefront of publishing. I don't know if she may be on this webinar. But if she's been at the forefront. And has spoken also in webinar format on hystereopexy. At looking at this. And she and Mark Walters. Really took things in an interesting trajectory. Looking at patients sort of values and thoughts and perspectives. About their uteri. And creating this validated scale looking. Or instrument looking at how women see their uteri. As it relates to pelvic organ prolapse surgery. Which has really sort of been an interesting way to look at this thing. And while this is yet to be published. There really has been a lot of chatter about this. And when you talk to women about sort of their values. A lot of things come up. These are sort of quotes that are representative of what I hear in the office a lot. My mother passed away from advanced ovarian cancer. And I want to eliminate my risk. I don't think I need my uterus anymore. I think there's a lot of information in that statement. But clearly the patient is sort of leading with this understanding. Or thought that removing the uterus will eliminate the same risk. Her mother underwent or suffered from. And so a lot of this is. Is in the back of this patient's mind when she's chatting about whether or not she wants to use. Have her uterus. Others will say, I'm not using my uterus anymore, right? So what do I need it? That comes up all the time. Well, I'm not using it anymore. But it's true in somebody who is of advanced age, they're no longer using the uterus for childbearing. But then you have to ask them what that really sort of means to them. I don't have prolapse because of my uterus, right? That comes up all the time too. There's, you know, the concept of the uterus being this innocent bystander in prolapse. And it really prolapse resulting from poor supports to the vaginas. Should be at the forefront of the discussion when you're counseling patients about whether or not they need their uterus. There's this also misconception by patients that the uterus is what's causing the prolapse. And so if you don't get rid of the uterus, the prolapse is going to still be there or we'll come back very quickly. And so that education is really important. And a lot of questions. Some patients will say, well, is there anything actually wrong with my uterus, right? In other continents and countries, uterine preservation has been at a standard for many public organ prolapse surgeons. And so the concept that we're removing a uterus that's healthy, that really isn't causing any disease process is seems a little silly or even an extreme and in other parts of the world. And so this is, these are the discussions that come up and I think this instrument that doctors Chang and Walters came up with, or is really interesting because it helps in, it can help in decision-making and really elucidate some of the things that women are thinking about when trying to make their decision. So what are some of the other considerations, right? So in addition to what I just mentioned, the obvious, the big one is the goals for future childbearing. So if you have somebody who's of reproductive age, who has a stage two prolapse and is really uncomfortable, the real question is, is just, she should wait to complete childbearing and then have a prolapse repair. At that point, should she have an interval prolapse repair with a native tissue hystereopexy with counseling about the risk of recurrence following surgery in the near future and weighing the plus pluses and minuses of actually doing, going forward with surgery before finishing her childbearing plans. But then there's also the question of menstrual disorders. Do you, does your patient, if she is premenopausal have a menstrual disorder, does she have heavy menses? Is she bothered by this doing a hystereopexy on a patient who has abnormal menses and is more of a candidate for hysterectomy seems, seems also futile, especially if they're going to be returning for repeat surgery in the near future for hysterectomy. Also understanding whether your patient is of low endometrial cervical cancer risk. So you need to have their pap smear history. You need to understand if they've had any postmenopausal bleeding. Frick et al a while ago, looked at the risk of abnormal uterine pathology and prolapse patients presenting with postmenopausal bleeding, even in the setting of a negative workup. And the risk was found to be up to 13% in those patients. And so, you know, I'm really careful offering hystereopexy to patients who've had experiences with postmenopausal bleeding, even if they've had a negative workup that requires a tremendous amount of counseling, especially in the patient who's very steadfast about having her uterus removed or about, about not having it removed so to speak. So, and then there's also the question of cervical length. Some hystereopexy surgeries aren't appropriate for women who have an extreme long cervix. I was just speaking with my fellows about a case. We just did a trachelectomy for a patient who had had a super cervical hysterectomy and sacrocopalpexy and had an eight centimeter cervix. And so she still had tremendous prolapse of her elongated cervix, even though the rest of her compartments were well suspended. And so in those circumstances, if you can't really truly suspend the apex up to a point where the patient is comfortable, the surgery may not be the right surgery for them. So when I go through my checklist, these are I start first with the patient's goals, their values, what the uterus means to them, what their goals of prolapse surgery are. And then I go into these other risks and sort of make a decision with the patient about what surgery may be best for her. So the real question is what do we know about hystereopexy in general? Is it a good idea? We are very cost conscientious. We've been doing a lot of cost-effectiveness analyses in the field of urogynecology. And so certainly this has been studied in the literature as well. And so this particular study was looking at hysterectomy versus any type of hystereopexy native tissue at the time of prolapse repair and looking at the analysis. And what this analysis focused on was really looking at cost effectiveness. As it relates to the prevention of endometrial cancer. And so this is going back to what we were, what I was just talking about in terms of assessing someone's risk. And certainly when the RIT, when the goal is to reduce risks for endometrial cancer and to achieve cancer prevention, it's more cost-effective to perform a concurrent hysterectomy. So you really have to sort of think about this. So that's like thinking about the patients who are post-menopausal, even though they've had negative workups for abnormal post-menopausal spotting patients who've had abnormal pap smears. And it all depends upon the patient's goals and long-term. And so while this study particularly showed that there was some cost effectiveness for concurrent hysterectomy, it's all depending upon what the actual focus is for that patient. Looking at other outcomes. So the real question is, is hystereopexy safe meaning that do patients do just as well from an adverse event perspective compared to women who are undergoing other types of surgery? The standard for most of these studies being hysterectomy followed by native tissue copepxy. So in this particular study, there were 136 hystereopexy patients. These were patients at our center who were matched to 260 patients who underwent concurrent hysterectomy with vaginal vault suspension, mostly uterus sacral. And what one of our fellows, Angela Yuen found essentially and reported in this paper was that the overall incidence of serious adverse events was low in general. So in the hands of, you know, experienced pelvic reconstructive surgeons adverse events in native tissue repairs are reported to be low. However, hystereopexy itself when compared to concurrent vaginal hysterectomy had a much lower odds of experiencing any adverse event even though the overall incidence was super low had shorter operating times, which wasn't surprising a shorter length of stay. So most the vast majority of patients undergoing hystereopexy are able to go home same day after their procedure. Whereas more patients with concurrent hysterectomy tend to stay overnight. And then patients with hystereopexy also had less, less estimated blood loss. And so I don't think these findings are surprising to everyone, but at least we do have data and there are plenty of other studies that I'm going to discuss in this webinar that, that show this as well. So when we look at intermediate term outcomes, also after transvaginal uterine preserving surgery, we also want to look at, this was another study and I know it sounds like we've sort of have the, the, the monopoly and hystereopexy studies, but our group certainly has been looking at this in the last few years. We wanted to sort of look at all our native tissue cohorts, but we wanted to have patients that were evaluated at two years so that we could have full data. And believe it or not, there's not a lot of intermediate. And when we think intermediate, we think 12 months, 24 months, some people would even say 36 months after surgery. Whereas long-term, you know, is looking at five, seven, 10 years and beyond after surgery. A review of the literature, literature a few years ago showed that there were very few, even intermediate studies looking at hystereopexy. So the goal here was to find a cohort of patients that had followed up with at least two-year follow-up at our center, which is also very difficult because when patients do well, they tend to not come back if they're not in a randomized trial. But in this study of about 50 patients with two-year outcomes, we did find that about one in four women experienced subjective recurrence. And if you look at the literature, looking at other types of native, native tissue repairs, this isn't actually unusual about 20 to 30% of patients, if not more in some studies report vaginal bald symptoms, even in the setting of absence of objective recurrence. And in this study, less than 5% underwent retreatment with either a pessary or surgery with no differences in outcomes between different types of hystereopexies. And I'll talk a little bit more about different comparing different types of hystereopexies a little bit later in this webinar. But so this, this, in addition to just a couple other studies showed that over the short term, short to intermediate term patients do fairly well when, with regard to recurrence and that also that one in four women experiencing that subjective recurrence is, remains an indicator like all other studies, looking at prolapse that we should remain pretty patient centered when it comes to how we define our outcomes for success. So I'm going to talk a little bit about sacrospinous hystereopexy. I think when I'm going to do the majority of my focus is going to be on native tissue hystereopexy. I will touch a little bit upon sacrohystereopexy. I have a picture of myself and Mark Walters, because he really was the one who taught me how to do sacrospinous suspensions in both uterine preserving cases and post hysterectomy. I know we all have the person that sort of gave us you know, mentorship in particular surgeries. So I'm pretty fortunate to have studied under him and have him teach me a lot of this anatomy. So when we think of the sacrospinous, I think it's important to remind ourselves of the anatomy. And I'm going to do this for the uterus sacral as well. Just so that we are thoughtful about where we're placing our sutures. I know for some, you know, some centers are more prone to be doing uterus sacrals and not so much sacrospinous while others do a lot of sacrospinous and uterus sacrals. So I hope we have a big mix of audience this evening to look at this, but here's a short little video on the actual anatomy to remind us as we get talking about performing the procedure. The sacrospinous ligaments are triangular shaped, dense connective tissues, which contribute to the stability of the bony pelvis. The broader base originates from the sacrum and narrows as it attaches to the ischial spine. In cadaveric studies, the average length of the sacrospinous ligament was 53.7 millimeters. The internal pudendal and inferior gluteal vessels, sciatic and pudendal nerves all pass through the greater sciatic foramen and in close proximity to the ischial spine and sacrospinous ligament. As a result, it is important that surgeons performing sacrospinous ligament suspensions are familiar with the neurovascular structures. Central to or overlying the sacrospinous ligament is the coccygeus muscle because it shares the same origin and insertion points as the sacrospinous ligament. Some call these two structures as the coccygeus sacrospinous ligament complex. The closest nerve structure to the sacrospinous ligament is the third sacral nerve or S3 with a median distance of three millimeters superior to the border of the sacrospinous ligament at the midpoint. The fourth sacral nerve can be found coursing through the medial portion of the coccygeus muscle. The pudendal nerve is formed from the S2, S3 and S4 nerve roots. It courses parallel over the superior border of the coccygeus sacrospinous ligament complex towards the greater sciatic foramen, then wraps medially around the ischial spine as it exits the lesser sciatic foramen. The pudendal nerve is the closest neurovascular structure to the tip of the ischial spine with a median distance of zero millimeters in a range of zero to eight millimeters. Entrapment of the pudendal nerve typically presents with perineal paresthesia or pain. The inferior gluteal artery most commonly originates from the anterior division of the internal iliac artery. It travels between the coccygeus muscle and the piriformis muscle as it exits through the greater sciatic foramen. The internal pudendal artery also originates from the anterior division of the internal iliac artery. Close to 90% of the time, it travels directly behind the ischial spine as it exits the greater sciatic foramen. With the relationship of the neurovascular structures around the ischial spine and the coccygeus sacrospinous ligament complex, we recommend placing the sutures roughly two to three centimeters or one and a half finger breadth medial to the ischial spine to reduce the risk of injuring the pudendal neurovasculature or the S4 nerve. We recommend placement of sutures half a centimeter below the superior edge to reduce the risk of injury, the inferior gluteal artery or S3 nerve. All right. So that's just a little review of anatomy for those of you studying for your boards also. But in terms of the technique, but I think it's really important to be able to picture that anatomy. We don't always get to see it really beautifully unless we're looking at some of these published anatomic papers or we get to see videos like this. But in terms of the approach for a sacrospinous hystereopexy, there's a few things to consider. Some are very similar to what we consider when we're doing a post hysterectomy suspension. So I like that sort of, there's like a direct sort of mirror to me, it's the same procedure. you're just anchoring your sutures in a different place, but the approach and the entry can be really, you know, apical, posterior, or anterior. So you really can approach a sacrospinous even when there's a uterus in place. So it really depends upon the leading compartment, whether you need a concurrent anterior repair, whether there's a large rectocele or enterocele. In some cases, when there's this large sort of big posterior outlet issue, doing a posterior approach is a little bit easier. In some patients where there's no posterior compartment prolapse and no intention to perform a rectocele repair, perineurophy going apically is most convenient. For my approach, I tend to do an apical approach almost always in a hystereopexy. It's very unusual for me to approach it any other way, but there's really so many different ways to do it. When we do an apical approach, we do a semilunar incision in the posterior cervix. So you pretty much make an incision from about nine o'clock to almost four o'clock or four o'clock to nine o'clock, almost like you're going to make a lopsided posterior colpotomy in order to enter beneath the peritoneum and into the pararectal space. So laterality, most of us suspend on the right side mostly because we're right-handed surgeons, but you certainly can suspend on the opposite side. And then you can, in some cases, this was done more commonly when there were mesh suspensions doing a bilateral suspension, but this isn't typically what's done in a hystereopexy. It's usually considered a unilateral procedure. The suture choice, you can use delayed absorbable or permanent or both. Again, that's surgeon dependent. We tend to use delayed absorbable or PDS sutures for this procedure, but certainly I've used permanent suture at some point, and sometimes I revisit that technique. Suture placement can be done with either direct visualization versus palpation. This can be done using either the Deschamps ligature carrier, the Maya hook or the Capio device. In our practice, we tend to use the Capio. I think a lot of people are using that now. And then we consider the repair of concurrent compartmental prolapse. And when we do that during the various steps, and I'll talk about that in a second. So I'm going to show a video of this. I know most of you know how to do sacrospinous, but for those who aren't doing a lot of this, I hope this is informational. To perform the technique, the pointer or middle finger is placed on the sacrospinous ligament just below its superior margin. So that's about three centimeters medial to the ischial spine or in the mid position of the ligament. Showing that anatomy, you really want to make sure that you're not too lateral, too close to the ischial spine, given the course of the pudendal nerve. Although I was always taught that what's mostly being entrapped when you're doing a sacrospinous suspension are sort of portions of the sacral nerve roots that are running through the actual ligament itself. But still you want to be in the mid portion of the ligament. And you can use a Breisky retractor for this, pushing the rectum medially or use your actual fingers as you're guiding the suture capturing device, which is slid along the palmar surface right into the area. And with the middle finger, the device notches placed about two to three centimeters medial to the spine, approximately half a centimeter below the superior edge. And I'm going to show you what we mean by those. For those of you not familiar with the CAPIO device, I'll play this one first. This isn't a post hysterectomy patient. It's really hard to get some footage of a sacrospinous hystereopexy or sort of show you. So I wanted to, our footage is best using a post hysterectomy patient, but essentially through the incision that you created, whether it's posterior to the cervix, whether it's along the posterior anterior wall of the vagina, you place your sutures using that device. And again, I'll show you again. So you're bringing it in sort of palmar with your fingers in, sliding the CAPIO device inside, bringing your finger in and then placing either your middle finger, your index, that's palpation of the arcus tendineus, palpation of the sacro, the ischial spine and the sacrospinous ligament, and then placement of the CAPIO device deploying the sutures. And so here you have sort of showing like exactly where they should be in the ligament as it relates to the anatomy. Sometimes we place two stitches, sometimes we place three. It really depends upon the actual prolapse and how broad the ligament is or how long the ligament is and how big our space is to place the stitch. But we never place less than two and we are in our group, we tend to place no more than three. So if an apricot approach is taken, an anterior repair is performed if needed before the suspension sutures are anchored and tied down. So we'll place our stitches, do the anterior repair, close the anterior vaginal wall and then anchor our stitches and tie them down. And then in my practice, a concurrent posterior repair is performed as needed once the apex is actually anchored. So it's the last step of the procedure. If a sling is going to be placed, we'll place the sling right before the posterior repair. In an anterior approach, an anterior repair is often performed and the sutures are then anchored through the anterior apical incision. And then same thing, a concurrent posterior repair is performed as needed once the apex is down. And then in a posterior approach, the posterior repair is performed and then the sutures are anchored after that. And then the incision is closed and everything is tied down. So I always say, make sure to close the vaginal epithelium incision along the posterior wall before tying down the suspension sutures. A lot of new surgeons make this mistake to sort of do your posterior repair, anchor your sutures, and then tie down thinking that you're going to reach all the way down to start your posterior closure. But you're going to be really, really far down. The sacrospinous ligament is pretty far into the pelvis. And so everybody's always surprised. So I say close at least half your incision, if not more, so that you don't get caught struggling when you're doing that part of the case. So complications related specifically to sacrospinous hysteropexy, very similar to post-hysterectomy sacrospinous copepexy. So there are intraoperative complications like vascular injuries that usually resolve with direct pressure or hemostatic agents. Significant bleeding may require embolization. You have to determine in that circumstance, whether it's venous or arterial. Rectal injuries are really rare. I mean, incredibly rare in the surgery, but obviously it's not hard to imagine how that could occur. So they can be closed primarily. And the recommendation in these circumstances anecdotally is to abandon your suspension because you don't want to put all those stitches and cause all that inflammation and fibrosis where you have a rectal injury. And then if you're doing an anterior approach and you get a bladder injury, the plan is also for primary closure and repair and maybe choosing to put your stitches in either posteriorly or apically, but being careful similar to the rectal injury in terms of causing a lot of suture inflammation in that area where you've repaired a cystotomy. Postoperatively, patients can get an infection or abscess in the pararectal space. This has happened before. It often happens as a result of the infected hematoma in this type of clean contaminated case. Nerve entrapment has been reported in sacrospinous cases, both for hysterectomy and posthysterectomy cases. And so the real, it's hard to differentiate sometimes what's regular postoperative gluteal pain and discomfort from having the procedure versus true levator spasm as a result of having, you know, this pain that they're having versus actual neuropathy. So for these patients, physical therapy or trigger point injection can be done conservatively versus consideration to suture removal if there truly is a neurologic component, if there's true nerve entrapment. So again, this can be hard to suss out in the office, but these patients are the types of patients that need to be followed really closely only because you don't want them to have a permanent neuropathy. We've looked at the data and while pain and discomfort reported in the posterior thigh and the gluteus can be up to 55%, true neuropathy and real persistent pain is extremely rare in these patients. So what are our actual outcomes? So this was a study that looked at, this was one of the longest looking, like longest follow-up period for outcomes. This was sacrospinous hysterectomy looking at, again, vaginal hysterectomy with uterus sacral suspension for patients with stage two prolapse or higher. This was an observational follow-up. So this was originally a multi-center randomized trial with a five-year follow-up period for those who were able to follow up. And so it's important to consider attrition rate in this study as well. But what they found that there was significantly less anatomical recurrences of the apical compartment with bothersome bald symptoms or repeat surgery with sacrospinous hystereopexy compared to vaginal hysterectomy with uterus sacral ligament suspension. So at five-year follow-up for those patients who did follow up, hystereopexy actually looked very favorable in this study. And this was one of the first long-term outcome study evaluating these outcomes. So now I'm gonna talk about uterus sacral hystereopexy, look at the data and then look at comparisons as well a little bit later. So uterus sacral hystereopexy, it's interesting. Some centers do these, some centers do these, not at all. So sacrospinous is a little bit more common but I think we're starting to do more and more uterus sacral hystereopexies as well as people are becoming more comfortable with this. I like this surgery a lot also because it's just like replicating uterus sacral suspension with concurrent hysterectomy. So for this patient selection really is about patients who desire and are candidates for uterine preserving surgery, just like sacrospinous patients. I really give a lot of thought to patients who have some degree of cervical elongation. I think in patients who have sort of moderate elongation, sacrospinous suspension might be better just because of the anatomy and how far up you're going to the sacrospinous ligament. I tend to actually consent my patients for native tissue copepexy or vaginal vault suspension. And then I put a tenaculum on the cervix and sort of push the cervix up to where I think it would be if I anchored it to the uterus sacral compared to the sacrospinous. And if they're candidates for either, given their vaginal length and anatomy and history, if they don't have any peritoneal comorbidities or anything I should be worried about, I will then make a decision based upon what anatomically looks better in the operating room. And sometimes I just make the decision ahead of time when I consent the patient. So it just depends upon how the patient's presenting and their anatomy. So this is what I mean by taking their surgical history into account. Clearly, if they have had a lot sigmoid surgery or anything that would make you not, if they have a history of bad endometriosis and you're worried about even getting into the posterior cul-de-sac, I think that doing a uterus sacral is probably not a great idea and you could utilize your extra peritoneal dissection skills and do a sacrospinous. And then my personal experience, and not everybody agrees with me on this, but isolated, for me, an isolated apical prolapse without concurrent anterior posterior prolapse is the ideal patient for uterus sacral just based upon the restoration of anatomy. When I have to do an anterior repair, I sort of often will do a sacrospinous only because I think I can get the apex a little bit higher with sacrospinous, but that is not based on any data, that is purely anecdotal. So again, for uterus sacral, reminding yourself of the anatomy in terms of where the ureter runs and where the rectum is. You're making, usually when you do uterus sacral hystropexy, we'll show you, you are essentially doing it very similar to when you do a high uterus sacral post hysterectomy, but your visualization is a little bit more, a wee bit more challenging just because the cervix and uterus is in the way and you have to lift them. And so it's really important to know your anatomy and to try to avoid the ureter when you're placing your uterus sacrals. And so what we're gonna show you, I mean, we know the anatomy of the uterus sacral, so I'm actually in the interest of time so that there's time for questions. Gonna skip this sort of beautiful video that Lauren Siff made and published years ago, but I'm going to show you, again, this is reminding you, the take-home point of the anatomic video is that the sacral nerve roots also run very closely to the uterus sacral ligament. And so when you're taking your bites and placing this, it's really important to consider this because you can get postoperative neuropathy in a uterus sacral patient as well, though it's less common than the sacrospinous patient. But I'm gonna show you the video of how we do uterus sacral suspension in a second. So the technique, approach and entry, unlike a sacrospinous ligament hystereopexy, we need to do a posterior colpotomy and you need to do it just like you would if you were doing a vaginal hysterectomy. So you do your posterior colpotomy. Laterality is bilateral, unlike sacrospinous. Suture choice remains the same. Some people like delayed absorbable, others like permanent. And then there's the consideration for repair of concurrent compartmental prolapse. So in these cases, the anterior repair can be done after the suspension sutures are placed before they're tied down. And then the posterior repair is usually done once the apex is suspended. So that's similar to a sacrospinous. And here, Lisa Hickman put together a really beautiful video for us looking at this technique. And so we're gonna show you what we mean for performing this procedure. And I think this is one that less people have seen compared to sacrospinous. The steps to perform a vaginal utero-sacral ligament hystereopexy include performing a posterior colpotomy and entering the posterior cul-de-sac, visualizing and grasping the utero-sacral ligament at the level of the ischial spine, placing two sutures through each ligament, anchoring the sutures through the distal utero-sacral ligament and through the cervical stroma, closing the colpotomy and tying down the sutures to suspend the apex. We will now demonstrate our technique for this procedure. After the cervix is brought into view, the posterior cervical surface is grasped with a single-toothed tenaculum and deflected anteriorly to expose the posterior fornix. The colpotomy site is marked and Alice clamps are placed at the lateral margins of the planned incision site. The area is then injected with a dilute solution of lidocaine with epinephrine. After this, monopolar energy or a scalpel can be used to perform the colpotomy. The peritoneal reflection in the pouch of Douglas is palpated and then tented using Alice clamps, permitting intraperitoneal entry to be achieved sharply. The dissection should be extended laterally if needed to permit insertion of retractors and improve visualization. The patient is then placed in Trendelenburg position. The cul-de-sac is visually and digitally inspected for adhesions. One or two moistened laparotomy sponges are inserted to the patient's left ventricle and the patient is then placed in the right ventricle and the patient is inserted to displace the bowel cephalad. Breisky-Navratil and right angle retractors are used to visualize the course of utero-sacral ligaments. The distal utero-sacral ligament is grasped with two Alice clamps at the level of the colpotomy and firm upward and outward traction is applied, which helps bring the proximal portion of the ligament into view. The utero-sacral ligament is firmly grasped with a long Alice clamp at or proximal to the level of the ischial spine. We prefer to pass two delayed absorbable sutures such as polyglycinate immediately beneath the clamp in a lateral to medial fashion to avoid injury to the ureter. The same procedure is then performed on the contralateral side. The sutures are tagged to the drapes and the laparotomy sponges are removed. Next, the sutures are anchored. Starting with the more lateral suture, the needle is utilized to drive the suture through the distal portion of the utero-sacral ligament, which can easily be palpated, then through the muscularis and out the vaginal epithelium. The other end of the suture is driven in a similar fashion through the utero-sacral ligament using a free needle. The needle is then inserted into the ventricle and then through the ventricle-sacral ligament using a free needle. Next, the more medial suture is driven through the cervical stroma and the vaginal epithelium. Again, a free needle is utilized to anchor the other end of the suture similarly through the cervical stroma. If permanent suture were placed, the suture should be anchored through the previously mentioned structures, but not the epithelium. Next, the colpotomy is closed. Lastly, the hystereopexy sutures are tied down. The patient is placed in steep Trendelenburg to reduce the risk of bowel entrapment. The sutures are tied down starting with the lateral and then the medial sutures. Care should be taken to ensure that the suture is in close opposition with the utero-sacral ligament and cervical stroma in order to avoid the creation of a suture bridge. At this point, if anterior compartment prolapse is present, an anterior colporaphy can be performed. After an anterior colporaphy, an anti-incontinence procedure are completed, if indicated. A cystoscopy should be performed as ureteral obstruction due to kinking can occur with approximately 3% of utero-sacral ligament colpopexies. After confirming ureteral patency, the hystereopexy sutures are trimmed. Generally with these procedures, a C point of five to eight centimeters proximal to the hymen can be achieved. A C point of seven centimeters proximal to the hymen was achieved in this procedure. So in this case, the authors of the video decided to do the anterior repair secondly, but I would recommend doing that and then tying down your suspension sutures. For me, that's always sort of worked better, but you can do it either way. So that's how the procedure is performed. It's really quite easy if you know your anatomy well, if you've got a good assistant to sort of lift up the cervix and uterus with the valves packed. And we've had really sort of great results performing this procedure. So what are the actual outcomes? So transvaginal utero-sacral ligament hystereopexy, in this study, this was a retrospective feasibility study. It was one of the first studies that was published looking at this. This was a small series of 20 patients with a median follow-up of almost three years. They reported that their case time was about an hour and 20 minutes with an EBL. Sorry, that's a typo. That was the max, their EBL of up to 228 mLs and recurrence with 25%, meaning one in four patients had some degree, in this study specifically, of subjective recurrence with 15% of patients undergoing reoperation. So with this small series, again, I think this is why people started shying away from utero-sacral. This seemed sort of not as ideal. It obviously is a feasible procedure, but more data was necessary looking at this. So I will say that when you look at these kinds of data, it's not super convincing that this is any better, but the question is, is it really non-inferior to what we currently have, right? So I think that's what we don't know until you sort of study it in a different way. This was a slightly bigger study looking at also utero-sacral ligament hystereopexy. And what this series showed in 40 patients showed a median operative time of 116 minutes with a mean EBL of 150, follow-up of one year with all patients having symptomatic improvement and no recurrence of bulge symptoms. So this looked a little bit more favorable. Again, shorter term outcomes still, and only about 40 patients with no comparison group. And so clearly data is still lacking on how patients are doing. This study was a bit larger looking at 104 patients. So this was looking at transvaginal utero-sacral ligament hystereopexy, now comparing to what is considered the standard hysterectomy with utero-sacral suspension. This was a matched cohort study. And so 52 patients were in each group, follow-up of three years. So these sort of intermediate to longer term follow-up. And the authors of this study found that hystereopexy was associated with shorter operative time, less blood loss, but there were no differences in complications. And overall anatomic and subjective recurrence and patient satisfaction were no different between the groups. But hystereopexy was associated with higher reoperation for apical recurrence, thought to be due to cervical elongation. So still here are some considerations. And I think in this paper, what the authors took away from this was that it's safe. There's no more complications, which is not surprising compared to concurrent hysterectomy, but very high satisfaction, but maybe there should be consideration to the actual anatomy of the patient as it relates to cervical elongation. And that perhaps, quote, recurrence is higher in that particular patient group. So the complications going back to utero-sacral ligament suspension, the data are really sparse, but when it looks at AE's specific to utero-sacral hystereopexy, but we can extrapolate that the kinds of adverse events are similar to that with transvaginal hysterectomy. If you remove the component of the actual risks associated with hysterectomy, but there's significantly less morbidity with hystereopexy as has been demonstrated by the data that we do have. And so I think, as I mentioned earlier, familiarity with the aforementioned anatomy helps keep you out of trouble. So if you know where the ureter is, you know where the rectum is in that small space that you're operating in, you should keep the surgery as safe as possible. But the real question is, when it relates to adverse events, what are the comparisons to sacrospinous hysteropexy? In here, so we looked at these data. This is from a published paper, just a simplified version of it, looking at AEs, and found that when you compare directly utero-sacral and sacrospinous hysteropexy, so we had 40 utero-sacral patients and 89 sacrospinous, we found no difference in actual complications. Sacrospinous suspension did take a little bit less time. I attribute this to probably learning curve bias. We were doing far more sacrospinous when we did this study than utero-sacral. But if you also look at the ranges of the time, there really wasn't that. The trend and the statistical significance show that sacrospinous was a bit shorter, but in general, the times were about the same between the groups. So I'm going to briefly talk about MIS hysteropexy. There are two approaches. One is doing laparoscopic utero-sacral. There have been plenty of data published in that in the last decade, a little bit less in the last few years since we've been focusing a lot on native tissue hysteropexy. And then laparoscopic sacrohysteropexy. What's really interesting is there haven't been a tremendous amount of data recently on this, because again, I think we've been moving more towards doing native tissue surgery. The concept of the sacrohysteropexy is placement of a mesh on the anterior uterus and cervix, lower uterine segment and cervix, bringing the arms to the broad ligament and suturing them onto a posterior mesh, and then suturing that to the sacrum. So that's sort of the actual goal of the surgery. I have a video that I'm going to show just parts of, and I might actually just actually bring the sound off so that we don't, so I can narrate a little bit. So a bladder flap has to be created on the uterus. And now in this particular patient, she had, a different surgeon had placed just a posterior mesh. My partner, Dr. Marie Perezo performed the surgery with one of our fellows, and she's really sort of the expert in sacrohysteropexy in our group. But essentially this patient had already had a posterior mesh, but had complete sort of recurrence of her apical and anterior prolapse. And so the thought was that she really could have benefited. So there's a sizer inside of the vagina here. So you perform this similar to a sacrocopalpexy, and then you create your mesh so that it has two arms that are going to be passed through the broad ligament, and one that's placed on the vagina and the cervix and the very, very lower uterine segment, if you're to put it at all on a portion of the uterus. And so the mesh is sewed on just like you would in a sacrocopalpexy, and it's brought out laterally. And you have to know your landmarks here so that you avoid the ureter, but also the uterine vessels. But if you go a little bit lateral into the broad and above the cervicovaginal junction, you will avoid this, but the mesh arms essentially pass through these sort of windows in the broad ligament. The same thing is performed on the other side. I'm just going to advance this. The arms are pulled through, excuse me. And then the mesh is sutured down. Again, this is like, just like performing a sacrocopalpexy. So you do a posterior flap where the posterior mesh is placed. You can see in this case, this patient had already had a posterior mesh. And so the arms are going to be brought to the old mesh. And instead of sewing everything down on the sacrum, you can sew it right down on the mesh, which is similar to what you would do if you were doing a revision sacrocopalpexy. You don't have to sew right on the sacrum. If you've got mesh still stuck to the sacrum, you can avoid that dissection and causing a lot of bleeding. But here, the mesh arms are passed through and then sutured, and I'll show you sort of the end result. But that's the principle of doing a sacrohistoropexy, and they're sutured to the mesh here, brought down to the mesh that's on the sacrum. You can see when you tie everything down, everything's anchored, and then everything's re-peritonealized at the very end, just closing over the peritoneum. And then you would close over the peritoneum anteriorly, too, to hide that mesh using your bladder flap. So this is what a sacrohistoropexy. And I think the important take-home message here is it's important to do an anterior and posterior mesh. Some people will just do posterior, but I think that the results are better with both meshes. Okay, so in terms of the data that exists on sacrohistoropexy, when it's been compared to vaginal hysterectomy with uterine sacrals, this is one of the largest series that's been published looking at this comparison. They found that both types of surgeries were effective options for uterovaginal prolapse. Again, intermediate follow-up at two years showed that they had similar improvement in symptoms, overall scores, adverse events, and recurrent prolapse, and new onset SUIs. So all the outcomes we tend to look at after prolapse surgery. So in general, this procedure has been shown to be sort of equivalent to what's been considered the native tissue gold standard. And this study, this is the LAVA trial that looked at sacrohistoropexy compared to sacrospinous hysteropexy. This was a randomized controlled trial across several centers. This study looked at 126 women with prolapse and basically found that hysteropexy was non-inferior to sacrospinous hysteropexy. And so in general, for some patients, this is considered a good procedure. I think you have to be sort of thoughtful. It's a little bit more of an involved procedure. It certainly makes it more difficult if somebody is still planning to have children given the fact that you now have mesh involved in the actual repair. We tend at Cleveland Clinic to do these for patients who have significant prolapse and concurrent rectal prolapse and are young, and who want to keep their uteri. So we'll sometimes do a mesh sacrohistoropexy at the same time as a ventral rectopexy. I think that's, for us, the main indication for these procedures, but there are certainly outlier cases in which it could be performed. So the only thing, there haven't been a ton of studies looking at patient-centered outcomes. So our group did take a look at about 100 patients and compared mesh sacrohystoropexy to laparoscopic uterostacral hysteropexy. We were interested in knowing if you go minimally invasive and you add mesh, do things get better? And what we found was that about 20% of patients experienced subjective pelvic organ prolapse recurrence, which is very similar to what we mentioned earlier in this talk. And I think we've been seeing that over several, many studies over the last five to 10 years, looking at patient-centered outcomes like subjective bulge postoperatively shows that even in the setting of good objective results, patients still do tend to feel some sort of bulge symptom, but still in the study, less than 10% underwent repeat surgery for recurrence, which is consistent with the data for other types of surgery. And we didn't show that there was a significant difference in recurrence between the two types of hysteropexies. Some would argue that this means that laparoscopic uterostacral is probably just as good, but on the flip side, looking at this, some people would argue that it means that mesh hysteropexies are effective surgeries too, and maybe worth the extra surgical risks that it takes to perform the surgery. Again, it requires a specific skillset. They can be done with conventional laparoscopy as well, but certainly a lot of providers who perform them do them robotically. So then how do we put sort of all these data together? So I really sort of updated, what was interesting to me was that when I was putting this talk together, I really saw less, not as much data in the last couple of years, there was this huge push to do a lot of hysteropexy data. So I hope that there's currently some trials on, I didn't look at clinicaltrials.gov, so I don't know what's actually going on right now, but looking at the aggregate data. So Kate Merriweather and this systematic review group did a really nice job looking at what data, aggregate data we have for hysteropexy for uterovaginal prolapse, and this was presented at SGS a couple of years ago. And essentially the take-home message was that uterine preserving prolapse surgeries improve OR time, blood loss, and in the case of sacrohysteropexy, risk of mesh exposure compared to its equivalent, like sacrocopepxy. So this is when we're comparing different types of hysteropexies with similar surgical routes with concomitant hysteropexy, and they also do not change short-term prolapse outcomes. So the systematic review group essentially concluded that surgeons can offer uterine preservation, that this is an appropriate for women who want to keep their uteri, and that outcomes seem to be very similar with some advantages in the hysteropexy groups. So to summarize with a few minutes for questions, uterine preserving surgery is a good option for people who want to keep their uterus, as long as there's no contraindications. All routes seem to be associated with good short-term efficacy, and some benefits compared to concurrent hysterectomy. But we're really missing long-term efficacy data, and what we're really missing is comparisons among the hysteropexy types, like head-to-head perspective comparisons. We really don't know whether or not one hysteropexy type is better than the other, and so that would be very interesting to study as well. So there's a lot more that can be said about this, but I had 50 minutes, so I hope that I was able to provide everyone who's on this webinar and whoever's going to be watching this recording with some data updates and then also review of technique and offering some ideas and hopefully some inspiration specific to uterine preserving surgery. So I'm going to stop my share. Thank you very much, Dr. Ferrando, for that very insightful and wonderful talk. So for our audience members, you can feel free to type in your questions into the Q&A box, and we actually already have a handful of questions, so we can get started. So one of the questions, Dr. Ferrando asks if there are any outcomes looking at sexual satisfaction before and after hysteropexy, and are there any outcomes looking at dyspareunia before and after hysteropexy? Yeah, so that's a great question, and that's one of the, along when it comes to patient-centered outcomes we should be focusing on. So sexual functioning hasn't been looked at, I believe, and I just looked at all the literature as a primary outcome. As a secondary outcome, it's been shown to have no difference with other standards of surgery like concurrent hysterectomy or sacral suspension, and dyspareunia specific to hysteropexy hasn't looked at. Dyspareunia is still looked at sort of as an aim when looking at patients undergoing posterior repair or genital hiatus narrowing, but specific to hysteropexy hasn't been looked at. So that's one way to look into sort of overall sexual functioning, post-op sexual functioning. That makes sense. Thank you. And then another audience member asked, do we have any studies looking at outcomes with different degrees of prolapse and different hysteropexy approaches? For example, grade one to two versus grade three to four on recurrence of bulge symptoms. Can we expect recurrence to be lower with grades one to two versus grade or stage three to four? It's a great question. I was just talking about this with my fellows today during their didactic. So there are some data that show that the risk of recurrence is a bit higher in advanced stage prolapse, but it doesn't specify whether it's advanced stage apical versus anterior. And so, and there's no studies comparing recurrence between hysteropexy types in terms of the stages. But it's a very good question. I will tell you from my experience, and again, this is all anecdotal. It's not so much about how the degree of prolapse for the apex. So to me, a stage three or four predominantly apical prolapse is no different in this reconstruction with a stage one or two in terms of suspending the apex. What I get concerned about is somebody who has a large interior compartment prolapse, so a large, large cyst to seal. I worry about needing additional support for that prolapse and tend to not offer a hysteropexy in those circumstances. Or I counsel them more about the risk of anterior compartment recurrence, certainly with a sacrospinous hysteropexy. So I think these are the data that we need though, and we're not going to have them until we do a large, large prospective trial where we measure the leading edge and comment on the different stages and make that one of the outcomes of the study. And then another question asks what your views are on laparoscopic lateral suspension fixing to the undersurface of the suprapubic abdominal wall. Does it preserve the natural access of the vagina better? You know, I have no actual significant experience with that, but I've spoken to surgeons who do it and think that it's a good idea and, and that anatomically it actually makes sense or these so-called like ventral suspensions. I don't think, I think they're not being done commonly anatomically like from where you're placing the uterus, it seems to make sense, but I just don't have a lot of experience. So I can't even sort of speak on it and in a way that that would be convincing to anybody on this webinar, but it's a, it's a good question. And there are some surgeons who have modified that technique and still perform it for some of their patients. And then another question asks, if we know any, if we have any data about hystereopexy in Ehlers-Danlos patients, will they tend to have more recurrence compared to non-EDS patients? And is one hystereopexy approach better than another for these patients? That's also a great question. So the answer is, we don't know. We suspect that it's similar to any native tissue repair. Most surgeons perform, you know, mesh augmented procedures on a lot of those patients with the expectation that they're going to feel native tissue. Some people go in a different direction and say it's worth at least trying one native tissue surgery. And then if that feels doing a sacrocopexy on those patients, I think I would treat it the same and have the same expectation as you would for a native tissue prolapse repair with hysterectomy. Since you can extrapolate from the data that efficacy seems to be the same between those two procedures, the overall efficacy should be no different in an Ehlers-Danlos patient, but it doesn't mean that the efficacy would be better than a mesh augmented repair in those patients. And then going along different lines now, someone had asked if there's a specific uterine size over which you would not recommend uterine preservation. There's no size, but I think that this is where judgment is necessary. So I think if somebody has bulky fibroids and they're of reproductive or premenopausal age, the question is, are they going to get bigger? Are they going to have abnormal bleeding? So there's no real cutoff or size. I think that if somebody has an enlarged uterus, certainly you need to sort of consider why that uterus is enlarged and whether they're at risk for anything down the road, like significant perimenopausal bleeding, do they have adenomyosis? And so that's where patient, informing the patient well at the time of preoperative counseling is really important. So the thought process is if they have enlarged bulky fibroids, you should probably counsel them against a uterine preserving surgery. And then if you have, or when you have patients who are postmenopausal and they are asymptomatic with no vaginal bleeding, and they're considering hystereopoxy, would a transvaginal ultrasound or pelvic ultrasound be sufficient in evaluating the uterus? The can sort of, this is, again, there's no guideline for this. It's almost like also like copal claises. There's no guideline, although that seems a little bit more obvious, right? For these patients, if the, if there's no, in a postmenopausal bleeding, if they're in a postmenopausal patient, if there's no bleeding or clinical risk, there's no consensus about what to do. I will tell you that in our practice, we do not regularly screen postmenopausal patients who are asymptomatic only because, you know, if it weren't for their prolapse, you wouldn't be screening them anyway. And we don't screen them for pest replacement, right? And that's also an option that doesn't involve removing their uterus. I think you sort of have to think through that one. You also can have incidental findings on ultrasound and then you're, you know, chasing these, you know, quote unquote incidental lomas. And I think that's an important consideration. So there is no hard recommendation to screen hystereopoxy patients who are postmenopausal. You certainly have access to the uterus and cervix if you need it, if they start to have any symptoms. Mm-hmm. That makes sense. And then someone had asked, I believe this is in reference to sacrospinous hystereopoxy, but they said, do we know it's true that in the U.S. it is done primarily unilaterally? Admitting my bias of long-term use of bilateral with better personal outcomes in my original unilateral training, I do wonder what the concerns are for bilateral. Yeah, I think part of it is for those of us, I mean, I've done some bilateral procedures, but mostly when there was like significant sort of prolapse and such that the lateral, the parts of the vagina that need to sort of reach the sacrospinous can, in a hystereopexy or anchoring, and somebody asked this question too, to the stroma of the cervix, the sacrospinous is very similar to the uterus sacral video I showed you anchor through this sort of copotomy that you've created. And so oftentimes it won't reach bilaterally anyway, and you have to choose a side, which is a little bit different than uterus sacral because you're going very lateral. But I think that, again, I know some people who still do bilateral if they think it can reach, and I don't think there's anything wrong with that. It's the way that vaginal meshes were designed to be anchored and placed. And then along sacrospinous, one audience member said that Dr. Catherine Matthews recent study found no difference in gluteal pain between suture and anchorship placement in the sacrospinous ligament. Any comments on your thoughts as to the cause of gluteal pain? Yeah, I think, I think the cause of gluteal pain is related to sort of levator spasm just from having, I think it is a little uncomfortable to have tension. If you've ever felt like most surgeons, when you placate, feel rectally, you can feel the tension on the suture, like pulling the apex of the vagina or the cervix up. And I think there's that, it's more of a pulling sensation. In some patients, the reaction probably is to spasm a bit in their pelvic floor, which can have nerve entrapment in itself. If we looked, we did a study here at Cleveland Clinic where we tracked pain, that kind of pain. And it really, I think we overstate that amount of pain. What we found in us and our cohort of 60 patients where we tracked their pain daily for the first week and then weekly up to six weeks is that the median pain report was about a three out of 10 within the first few days of surgery. And by one or two weeks, it was all the way down to a one out of 10. So in my personal opinion, I think we've overstated how much pain patients have. They do have some, but I think we've overstated the actual severity of it. But I think it's a multi, it's a component of levator spasm and just the mechanics of the suspension in itself. But if you track patients, they get better very quickly and neuropathy itself or pain that requires actual intervention is not that common in sacrospinous. And yes, Dr. Matthew's study was a nice study comparing the two. And I wasn't surprised to see that there was no difference, I think. And I, which means that there's now more options to play sacrospinous sutures. And another member, audience member asked what your experience is with biologic graft sacrospinous hystereopexy. I have no experience with that. I know that some people again, think about doing that. Certainly for sacrocopalpexy, there's been you know, fascial grafting and biologic grafting. I've sort of taken the experience from that. I think some people want to use biologic grafts as a bridge if like the either vagina can't reach or, but I don't have any personal experience with it. So can't speak to it. And then someone else asks, where do you think Manchester fits in when selecting uterine preserving surgery? Yeah, I didn't. That's a great question. I didn't bring that up. I think the Manchester procedure is still a good option. I think if you've learned how to do it, it's not, it's not super difficult of a procedure. It's just more of a more, I don't want to be offensive and say antiquated, but it's more of one of the traditional procedures. And there's still sort of a room for that procedure. And perhaps I should have included in this presentation. So thank you for mentioning that. And then just a couple more. Any experience on the end place procedure and data? No, but I'm going to look it up. And then I think this is more of a technical housekeeping item, but someone asked for the sacro-spinous hystereopexy. What CPT codes you're using for that procedure? Extraperitoneal copepexy. Okay. Yep. So I used to know them all because I did so many studies, but like looking patients up, but my, my fellows would know, but it's the, it's the CPT code for extraperitoneal copepexy for uterine sacro. I do intraperitoneal copepexy and then for for everything else for MIS, we do abdominal copepexy. And my favorite is 57282. It used to roll off the... Thank you, Dennis. He used to roll off the tongue so well. Wonderful. We made it through all of our questions. We had 12 of them, so I think we hit them all. Thank you very much again for Dr. Ferrando for taking time out of your busy schedule to give us this talk and for all of our audience members and for AUGS for hosting this talk. This was super fun. Thank you so much for having me. Thank you. Have a good rest of the night, everyone. Bye. Bye. Bye.

uterine preserving surgery

uterovaginal prolapse

sacrospinous hysteropexy

uterosacral hysteropexy

patient selection

surgical techniques

outcomes

complications

pelvic organ prolapse

sutures placement

anatomical recurrence