Good evening. Welcome to today's webinar. My name is Christina Lewicki-Gaup, and I'll be moderating today's session. Before we begin, I'd like to share that we'll take questions at the end of the webinar, but you can submit them at any time by typing them into the question box on the left-hand side of the event window. So, today's webinar is on hysteropexy, and we have the privilege of having Dr. Barry Ridgway as our speaker. Dr. Ridgway graduated with honors from the University of California, San Diego, with a degree of psychology and minors in chemistry and Spanish literature. She attended medical school at the University of California, San Francisco, and graduated at the top of her class. She completed a four-year residency in OB-GYN at UCSD and became interested in FPMRS at that time. She then went on to complete a three-year fellowship in FPMRS and minimally invasive surgery at the Cleveland Clinic. She's board certified in both obstetrics and gynecology, as well as female pelvic medicine and reconstructive surgery. Dr. Ridgway is an expert in that she's authored more than 55 peer-reviewed articles and seven book chapters, and she has made numerous presentations that I'm sure you've all been privy to at national and international meetings. Her research interests include surgical correction of prolapse, uterine sparing operations to treat prolapse, pelvic floor disorders in young women, mesh-related complications, and surgical outcomes. I just want to thank Dr. Ridgway. She's a very busy individual. She's a friend and a colleague, and I just want to thank you, Dr. Ridgway, for your time this evening to educate us on this very pertinent topic. Well, great. Thank you so much, Christina. I really appreciate it. I'm excited about this opportunity. This is the first time I've done any sort of webinar, so I would love feedback, and I look forward to interacting with questions at the end. I am going to go ahead and get started. My disclosures, I do consulting specifically for education for Coloplast Incorporated, and I also have provided legal expertise consulting for Ethicon. Today, I want to talk about hysterectomy and the role for uterine conservation. But first, we'll start with utilization of hysterectomy at the time of prolapse surgery, review potential reasons to avoid hysterectomy, talk about types of uterine sparing procedures, describe outcomes of hysterectomy, demonstrate laparoscopic sacrohystopexy, and then list the indications and contraindications for uterine sparing procedures. As you know, hysterectomy is a very common surgical procedure in the U.S., and when we look just at hysterectomy for prolapse, approximately 74,000 hysterectomies are performed annually. We know from our own practice that performing hysterectomy alone to treat prolapse is associated with a high recurrence rate. I'm sure everyone here is privy to the case where someone in the community does a hysterectomy for prolapse and they come back within several weeks with malt prolapse. In some countries and ethnic groups, women do not want a hysterectomy if at all possible, and this includes groups in the Middle East and often in South America. When we look historically, before the 1950s, hysterectomy was actually avoided if at all possible, and that was due to the increased morbidity from the procedure itself. Once there were improved antibiotics and surgical technique between the 50s and the 90s, hysterectomy became pretty standard, and it was partly to decrease cancer risk because of our inability to screen and treat cervical cancer. It was also used for other indications like birth control. But since the 90s, we've been rethinking our old habits. There are better cancer screening, and there's more focus on sexuality, autonomy, and quality of life. So when we talk about hysterectomy for prolapse, the need for hysterectomy is not proven. It fails to address the underlying deficiency causing prolapse, and it may disrupt the uterus sacral cardinal ligament complex. So this always must be reattached to the vaginal apex. And interestingly, in the 1930s, Bonnie himself said that the uterus only has a passive role in prolapse. So in the U.S., gynecologists rarely offer uterine preservation for women who desire repair of their uterovaginal prolapse. Well, why is this? And usually I'll ask the group, what would their guess be? But one of the most common things is people will say to me, women want a hysterectomy. And people, especially if you've trained in the South, will come in and say, oh, I'm 40, and my mother had a hysterectomy, my sister had a hysterectomy, and now it's my turn. But when we actually look at and ask our patients, we know that this isn't necessarily true. When we ask our patients about their attitude toward hysterectomy, it's different than what you might assume. And this is a paper that we did. And what we did is we looked for a cohort of women who were referred for uterovaginal prolapse, meaning they had a uterus and complained of prolapse. They were surveyed via postal questionnaire. The POPDI was given a controls preference scale, and then there were questions regarding their perceptions of the impact of hysterectomy on health, social life, and emotional well-being. We interviewed via this postal survey 100 women, and 60% indicated they would decline hysterectomy if presented with an equally efficacious alternative to a hysterectomy-based prolapse repair. And they really valued the doctor's opinion, the risk of surgical complication, and the risk of malignancy. Another multicenter study followed this, and this was done through a network, and it came with very, very similar findings. So I usually don't quote health.com in my academic talks, but I do think that it is something important to understand and see what our patients are reading and what they're evaluating. And what actually we do see is that this, as well as in Reader's Digest, for example, they'll list the top five surgeries to avoid. And the number one surgery listed is often hysterectomy. And they say one of five operations you don't want to get and what to do instead. And so this is something that our patients are reading, and they value this kind of literature, so I think it's important to to understand it. Interestingly enough, the other four operations were things that you clearly want to avoid and that are very evidence-based, and this would be a episiotomy, a heartburn surgery, and I think the other one is back surgery, but all things that are clearly controversial. But in their mind, the number one one is hysterectomy. This is further supported by ACOG, and this is talking about elective surgery and patient choice. And in cases like prolapse, which is considered elective surgery, it's really critical to uncover and incorporate patients' own priorities and goals in their care, particularly when the preferences are informed and deeply held. So this is supported by ACOG, and it really moves us forward to a shared decision making when it comes to things specifically that are elective. So many people also say, well, it doesn't matter. Hysterectomy has no impact on fat function. You can do the hysterectomy or not. It's not going to affect anything. And there's a developing body of work that I find very interesting, and this is the differences between women who have an intact uterus and those women who have had an ovary sparing hysterectomy. So their uterus is removed, but the ovaries and tubes remain. And in this study here, they looked at prospectively to see what happened after an ovary sparing hysterectomy. And it was 257. They compared with 259 women who had not undergone a hysterectomy. They were followed with annual FSH. Because they could not evaluate bleeding patterns and define menopause in the typical way that we do, they looked at an FSH of greater two or equal than 40. In the hysterectomy group, 21%, well, only 7% in the comparison group reached menopause over the five years of the study. And in fact, when they looked at unilateral oophorectomy, it also had impact. Women in a hysterectomy group with unilateral oophorectomy reached menopause 4.4 years earlier than women with both ovaries intact. So even really removing one ovary has impact. And we also know from other studies that in fact, leaving both ovaries, removing the uterus, we definitely see that impact. This is a second study that was published in obstetrics and gynecology. And it actually has a similar methodology. In this study, they took women who were 30 to 47. And again, going without a bilateral oophorectomy. And they looked at blood samples and questionnaire data. And we saw again, similar definition with ovarian failure of 40 or higher with FSH. And women undergoing hysterectomy were at nearly a twofold increased risk for ovarian failure as compared to women with an intact uteri. So again, this is pretty significant for women, especially in premenopause or perimenopause that their potential to enter menopause is earlier within ovarian sparing hysterectomy than with leaving the uterus intact. And there are additional studies that support this, including a secondary analysis from the same cohort that looked at anti-mullerian hormone, and then longitudinal studies of women that look at vasomotor symptoms. So sexual function, this is one reason that many women cite, they say, I don't want to have my uterus removed because of sexual function. But when we really look at it, it does have conflicting results. Some studies say that leaving the uterus in place maintains and improves sexual function while removing it has consequences. But there's really no consensus. And the interesting thing, of course, is the baseline that we're dealing with has very high levels of sexual dysfunction, both in postmenopausal women and also women with pelvic floor disorders. And that we know from the best available literature that women mostly experience improved sexual function after surgically treating the pelvic floor disorder. And so that's what I really like to focus on. However, I will say if a woman comes to me and says, I think this will affect my sexual function. I think she's probably right. It will affect her sexual function. So really considering what their deeply held beliefs are very important. So the next reason that people often state is that the rate of abnormal uterine pathology is high. Oh, I want to sort of back to this 1950s to 1990s mentality. Oh, I want to remove that uterus so that my patient doesn't get cervical cancer or doesn't get endometrial cancer. And we know from a number of papers that that's not necessarily true. This is one of the first studies that came up that we did out of Cleveland Clinic. And it was 644 women who presented for treatment of prolapse that would include a hysterectomy. So this was divided the cohort into premenopausal and postmenopausal women. And then we also had information on their bleeding on if they had normal menses, obviously no bleeding if they were postmenopausal or if they had abnormal bleeding in each group. And interestingly, the great majority of women, of course, postmenopausal and did not have vaginal bleeding. And in this cohort, the rate of endometrial cancer and or hyperplasia is very low. It's only about 3 percent. However, if you look at postmenopausal women who had bleeding, but had a negative workup, and in this case, cohort, it was either endometrial biopsy, hysteroscopy, DNC, etc. Even with a negative workup, 13 percent ultimately had an endometrial cancer or hyperplasia on pathology. So I think that that's something really important to to evaluate your patient. Ask specifics about this and not consider uterine sparing procedure if they've had any postmenopausal bleeding. So like I said, premenopausal, no one had abnormalities. Postmenopausal, no bleeding, still a very low rate. But if they're bleeding, in my mind, it's unacceptably high. So there are a number of other publications that support this. A retrospective analysis of 1,200 cases found similar levels, as well as a retrospective analysis of over 500 women who had prolapse as well. When we talk about cervical cancer, we can really extrapolate data from supracervical hysterectomy, because this was something, of course, when supracervical hysterectomy became popular, that people worried about. And in a case control study of over 1,100 women, the incidence of cervical carcinoma was 0.3 percent at 10 years. And a retrospective study of 2,700 women also found an extremely low rate. And now these studies are more than a decade old. And as we really change our screening habits, as well as with HPV vaccine, it's going to be less likely in the future, in my opinion. And then this was something that came out very recently. And this was looking at a much larger cohort at the occult gynecologic cancer in women undergoing hysterectomy or myomectomy for presumed benign indications. And this is using the NISQIP database and included, I believe, 27,000, sorry, 24,000 women who underwent hysterectomy for benign or presumed benign indications. And really, the prevalence of occult uterine cancer was 1.4 percent, cervical 0.6 percent. So I think that it's safe to say that the risk of these things is quite low. So I'm going to switch gears a little bit and talk about approach to hysterepexy, what we're talking about here. So first, contraindications. Again, obviously pregnancy, undiagnosed uterine bleeding. And I would, again, implore you that if they have even a negative workup for postmenopausal bleeding, they're not good candidates. Cervical or uterine pathology, history of familial syndromes that put the patient at risk for additional cancers, tamoxifen use, and then cervical elongation. That can be relative. There are some women who feel very strongly about this. And even with the cervix being elongated, choose to have a uterine sparing procedure, but then have a partial trachelectomy. Again, that's a very specific candidate. So what should we do for evaluation? And this really is expert opinion. There's not anything that's really written in stone, and people triage this very differently. So in my mind, Pap with HPV, if they have aged out of screening or are extremely low risk, I don't make them repeat it. Or if they've had one within a few years and they don't have new partner and there's no concern, I don't really ask that they repeat it. You can just consider an endometrial biopsy or transvaginal ultrasound of postmenopausal. I personally don't do this. I think that the sensitivity and specificity is not good enough. And in fact, when you look at the data for measuring endometrial stripe in women who do not have any abnormal bleeding, the sensitivity and specificity is far, far lower than if someone is symptomatic. And the great majority of data that we have are on women who have bleeding postmenopausally using the ultrasound to triage that. So I don't do any additional workup. And then careful consent with the patient. And again, this postmenopausal bleeding, I do not offer in those cases. So when we're approaching hysteropexy, it can be many different approaches and many different points of attachment. So vaginal or laparoscopic, robotic or open, you can attach it to the uterine sacral ligament, the sacrospinous, the sacrum. And then I've seen others over the year, not that we've done, but that I've had patients who've had hysteropexy who come back and one was attached to the anterior abdominal wall and some other things. They can also be just like our other approaches of native tissue repair or mesh augmented. So when we talk about what's really going on in 2018, the most common ones are uterine sacral ligament shortening or plication, sacrospinous hysteropexy, this could be sutured or mesh augmented, sacrohysteropexy, and that could be approached open, laparoscopic or robotic, and then other types of mesh augmented. So if we're considering sacrospinous ligament, of course, the first step is to know the anatomy. But if you're already performing sacrospinous ligament fixation for the vault, you know this well, and it's practically an identical procedure. So for these cases, I identify the ischial spine, I clean off the sacrospinous ligament, and then I place between two to four permanent and delayed observable sutures through the ligament. Personally, I prefer the Capio. It's something that I have used and been trained with and is available at my institution. But I would imagine that any other device or using the DeChamps or the Miyazaki, if that's what you're comfortable with, will work just as well. Once the sutures are placed, and I tend to go in the medial inferior portion of the ligament pretty close to the sacrum itself, I will tag those off to the side and then I perform a pretty aggressive anterior repair. You'll see as we talk later, that's one of the areas of a hysterectomy that's a little bit different in that in most cases, you can't redefine the vault like you can in a post hysterectomy case. And so I always will do an anterior repair. Then when that's done, I take the suture that's been passed through the sacrospinous ligament, and then I pass it through the posterior cervix and the vaginal apex lateral to the cervix. Typically, I'll use delayed absorbable closest to the sacrum and followed a middle one that's proline and then the most lateral one, again, PDS is what I use, but any delayed absorbable. So that way on each corner of the area where you have your, not technically a colpotomy, but the interruption of the vaginal epithelium, you have the two corners held up by the posterior, by the delayed absorbable. And then with the middle suture that's proline, I pass it through the posterior cervix and just the portion of the vaginal epithelium so it's not exteriorized. And then we'll tie these down and if necessary, do a posterior repair. So again, here's the Capio. Again, I have no relationship with them and any device that you're familiar with using, you can use. And this is what it pretty much turns out. And if you really go medial like I like to do, the vagina itself is not really deviated as much as you would expect. And it's interesting, I was one of the blinded examiners, so doing PopQ for the optimal trial that compared uterus sacral versus sacrospinous. And I thought like, oh, this isn't going to be blinded. I'll know right away when I look. But really what happened is many, many cases I was like, I wouldn't be able to guess what they had. And that's what I see here in the office when I examine them and they look really nice. So are there data to support sacrospinous ligament hysterepxy? And definitely there are. This is one of the best studied uterine sparing procedures. It was described in 1989. And the outcome and functional data appear to be similar to vag hyst and vault suspension. And sexual function appears to be similar. This is one of the first randomized control trial. And this is one year follow up after sacrospinous hysterepxy. They compared this hysterepxy with vag hyst and uterus sacral. They use their primary outcome as time to return to work. And I'm certain it was powered this way because it allowed them to create a feasible study. But I also think that it is something that even though this was a long time ago, it's we're really returning to this more and more looking at outcomes that are important to our patients. Anatomic failure was defined as stage two in any compartment. And hysterepxy group was in the hospital last returned to work faster. It did have a higher failure in the apical department. No difference in failure in the anterior wall or in reoperations for recurrent prolapse. Interestingly, in that last study, to go back, there was a difference in stage three prolapses in the groups to start with. And most of the failures in the apex and the hysterepxy group were women who presented with stage three prolapse. So this is the, I always want to say a new thing, but now it's actually a couple years old, a well designed randomized control trial that compared sacrospinous hysterepxy versus vaginal hysterectomy and uterine sacral ligament. And these are for women with uterine prolapse stage two or higher. And this is a non-inferiority trial. So this is 208 women at Dutch hospitals. It was an attempt to treat analysis and they were followed for one year. Interestingly, in this study, sacrospinous hysterepxy had no anatomical recurrence, symptom recurrence or repeat surgery with 4% of those in the hysterectomy and uterine sacral group. And then one year postoperatively, really no differences in anatomic recurrence, functional outcome, quality of life, complications, hospital stay, or sexual function. So with those, I think it's pretty safe to say that the data that are available are encouraging. Obviously the amount of data is less than a hysterectomy based repair, but I do think it's important that we accumulate data, continue to study, but that which is available is encouraging. So on to mesh kits. I'm sure mesh kits in itself could be an entire webinar. And as you know, the availability of products is in flux. ProLift, which has the most data on hysterepxy, is no longer available. Our newer kits don't use trocars and there are specific informed consents for FDA website and OGS has a joint statement with ACOG. The one area that does have data and it seems to be accumulating more and more is with Uphold. This is an anatomic and subjective outcome study that looked at 99 women with stage 2 or greater uterovaginal prolapse and at 12 months, almost 98% had a success rate using a very familiar composite outcome. They noted favorable changes on validated questionnaires, though they did have a mesh exposure rate at 6.5% with most patients not requiring surgical intervention. I will just caution that a mesh exposure at one year at 6.5 may be a little higher than most people are comfortable with. I would be very interested in seeing some longer term follow-up on this because I do think it is a great option and I think also we will have some studies from the PFDN coming down that are evaluating Uphold. Okay, so now I'm going to talk about sacrohysterepxy. So this is a diagram of what the sacrohysterepxy will look like when it's done and I'll show you some small video clips that goes over a lot of this. So what this is is mesh that is similar to what you would use for a sacrocopalpexy and where there is traditionally two pieces of material, one for the posterior vagina and posterior cervix and then one that lifts the anterior vaginal wall up and moves around through the broad ligament and attaches all the pieces of material to the anterior longitudinal ligament of the sacrum. So there are a number of ways to do this. This happens to be the way that I do it. There have been some cases I do in someone postmenopausal who's getting a laparoscopy say for rectal prolapse and getting a mesh for that and I will do a hysterepxy just going straight over the top of the uterus because really their uterus is just a few centimeters anyway so it doesn't really provide too much length and cause problems that way. So I'm going to go over a case and this is a 46-year-old G2P2 who presented with a one-year history of bothersome bulge, urinary frequency, urgency and denied stress incontinence. She's a very active woman. She wanted a repair that involved mesh which is a little unusual and people coming asking for that in this day and age but this was just about a year and a half ago and she wanted to be able to have a durable repair and she wanted to be able to really get back to all the activities that she liked. Her POPQ is listed here so again stage two where her cervix came to minus three but anterior wall was at the hymen. She underwent urodynamics and she had neural bladder function and no stress incontinence. She was in our fellows clinic and we talked to her in detail about options and she loved the idea of being able to have her prolapse fixed without having a hysterectomy and as she is 46, she's someone who likely would have perimenopausal symptoms earlier than someone who is younger or already menopausal and I'm sure that many of you have seen this in your day-to-day work where you'll have someone who's 48 or 49 with no menopausal symptoms and you do a hysterectomy, spare the ovaries and they come back and they're having hot flashes and oh I didn't know this was going to happen which I'm very careful about counseling but this is something that for this patient was particularly important. So she had no history of abnormal bleeding. She had a recent negative PAP and HPV. She had a normal examination, was slim, again offered all options and she elected a dual mesh sacrohystorpexy. Again her interest was durable repair, natural menopause timing and her desire to be very active. So this here is the patient and the setup that I use as you can see slim and a normal exam. I tuck the arms for all cases, make sure that I have good access and to set up this is what I like to do. I put a Holka uterine manipulator so that I can manipulate the uterus. I don't like to use anything that has a colpotomy cup because I have tried that and it's a little bit hard to dissect on that and then also especially if it's a v-care, the curve of the v-care becomes problematic on the posterior dissection and it's hard to kind of turn it around without altering the anatomy. So I end up using a Holka and then I use a malleable and I switch it sort of between the, in front of the Holka and behind it so that I can really delineate where that cul-de-sac is from above. You can do an EEA sizer for that. I also tend to put, if necessary, an EEA sizer into the rectum. And then you can use a three-way Foley if you're anticipating a difficult dissection anteriorly. So I tend to do conventional laparoscopy. These can also be done robotic. And I use a five millimeter ports that I place. I usually, I will do a direct entry through the umbilicus if they don't have a vertical incision. If they do, I'll usually do a left upper quadrant. So I'll do five in the umbilicus and then I do ports two centimeters superior and medial to the anterior superior iliac spine. On the left side, I use a 10-12 so I can pass suture. On the right, it's a five. And then I do one in the mid-clavicular line, more or less at the level of the belly button. Again, it depends on how their body is and if they're short or long-waisted. Again, just back to that, you can always add a fourth port if you need to, depending on who your assistants are and if you're encountering any abnormal pathology. I would say 95% of the time, I don't use that additional port. So here we are, I have my port set up ready here. As you can tell, I got into bleeding just from making a skin incision, which is never a good omen for a case, but that's what it looks like. So I'm gonna show just some short video clips here. And this is one of the cases that, this is the same case I looked in. And actually she had a little bit of a fibroid uterus and it was more than I had expected. And it surprised me because she's very slim, I got a very good exam in the office and then immediately pre-op. But it wasn't enough that made it where I would not wanna do the case. So this is just doing a evaluation of her anatomy. I hope this is gonna transmit okay. So I look there, she's nice and thin again, good sacral anatomy. You can see the ureter on the right side. So take a look, identify everything, make sure there's no significant abnormalities and identify everything, the vessels and the ureter on that right side. So for hysteropexy, I think angled scopes are critical. I can't really emphasize enough how important that is because you have a little bit less visibility with the uterus in place cause you're wanting to still go down low enough. And especially for posterior, you'll need to look up. So here I'm gonna start with just standard. I open using a little bit of electrocautery. And then I do a dissection down, keeping the vessel and the ureter in view. This is jumping ahead a little bit, but try to find that avascular plane. Once I get near the uterus sacral, I notice it's a little more fibrous, get through that. And continue dissection down towards the periorectal area. As you can see, it's getting a little fattier. I know I'm closer to the rectum, but I really want to free up this peritoneum. And the reason I care so much about freeing it up is that I wanna cover the mesh at the end. And it's easiest to free it up right now as opposed to later in the case. And so I just, even up higher, where I know I'm gonna be trying to cover the mesh, I like to have, and I just test to make sure that on each side I have some mobility so that at the end of the case, the peritoneum can be pulled over pretty easily. So then I clear off the sacral promontory like I would in a sacrocopal pexi. I like to clear it off pretty significantly. I'll use some kitteners to make sure that I can really see that anterior longitudinal ligament. Then I'll go posterior. So for this case, I have an EASizer in the rectum here so that I can see exactly where the rectum is. My assistant, as you'll see, is a little aggressive pushing it in, but I can see where it is, get down low enough that I want to here. And again, I'm using the 30 degree looking down. So then I look anteriorly and it often is easier than say a difficult bladder dissection in sacrocopal pexi. And so the Foley bulb, you can see at the top there, the vesicouterum peritoneum, and either you can, if you have any struggle, you can retrograde fill, or you can just jostle the Foley bulb and see the borders of the bladder here. So looking anteriorly, I'll then elevate that peritoneum and you want to go so that you can get into that space. And so here, it is going to be a dissection that I go right along, pushing that bladder down. And you want to do, okay, so that's a key point right there. So to keep in mind, I have the Holka in and I ask my assistant to place the EEA between the cervix, so right in that anterior cul-de-sac. I want to just show that link. And then it really tells you where your vagina is. And once you know that is you can decide really how low to go. And I try to get to the trigone, but you can see it going in and you can see your border of the bladder there. So again, your anterior cul-de-sac, you can see where your dissection is and your bladder is. So once you know that, I do more dissection. I want to create an area that's big enough. And I want to go lateral on each side because I want to be able to know where those uterine vessels are. Because you're going to see that we will need to go through the broad. And if you know where the uterine vessels are, you can avoid it as opposed to blindly doing that. So I'm pretty sure you can see my pointer. All right here is the vagina. And that whole area is being cleared off. And you can go pretty laterally. And then this side, you also get into some avascular space. So I make sure that my peritoneum is open this entire way so that I can identify the uterine vessels right here. And once I identify them, I know that I can go lateral to that to pass the mesh arms and that part comes in a little bit. So I just make sure this is nice and cleared off and it's lateral enough. So as you can see, I have opened it all the way here and my uterines are here and over here. And then my vagina, and if I were to lift that up more towards the pubic bone, you would see that it's dissected off quite a bit. So I use a lightweight polypropylene mesh and I use eight by 24. I cut it into two different strips. One I use for the posterior vagina and cervix and that I just cut into a long rectangle. And the other I do sort of what I call a boomerang shape. And I used to do a square with two little arms, but I found that the boomerang shape really sort of cradles that lower uterine segment and lifts it up as opposed to having two very thin mesh arms that are hard to pass and hard to work with. And then I make a mark in the middle so that it helps me orient during surgery. So I'm gonna be putting some stitches here. These are gonna be my lower posterior. And again, you have to keep in mind, you're going very low and you're having to look underneath the whole uterus. And so definitely the 30 degree scope is critical here. Oops, I thought that was a, there we go, video. Okay, so I know it's away from the rectum, I put it in there and then I pass my mesh through the actual suture and then I'm gonna do extra corporeal knot tying. So there's with the 30, still you can see that the optics can be a little bit challenging. So I'm gonna anchor that as low as possible. And then a key point is to take this mesh, I like to put it just as I would do for sacrocopalpexy and pin it against the anterior abdominal wall. So it's sitting there and it's not flopping in where you're trying to work. So I end up using on the vagina, a combination of monofilament permanent and delayed observable. So the vaginal, it's mostly the delayed observable. And then I'm gonna put two additional sutures in the posterior lower uterine segment. And I almost always use permanent for this. And so it's attaching the mesh to that as well. And then just tying that down. So there are a total of six sutures, a combination of delayed absorbable and permanent. So then I'm gonna look anteriorly. And as you can see, I've introduced the mesh here, I've lifted up the bladder and I have my black mark in the middle so that I know where the midline is. Because it gets as you're moving and trying to get through the broad, it can get a little bit tricky if you don't have that done. So here I am putting it down. And again, I'm using the 30 degree looking down now. And I use a total of four sutures. I always use delayed absorbable by the bladder. We've had a few cases over the years where people come back with the proline tips poking through the bladder. And so I always use delayed absorbable towards the bladder. And then I usually will use two of the permanent sutures on the uterus. So here's the four sutures. One, two, distal again are delayed absorbable and these are permanent. Now this is the part that I've tried a number of different ways. I used to make sort of bigger holes or defects in the broad ligament and then try to then later in the case, fish it through that. But this is sort of the most cumbersome part in my mind. And so what I like to do is I like to sew the mesh on, make the defect and pull the mesh arm through all in one step and it saves a lot of time. So the first thing I do is I really grasp that round ligament because that really can help you define where you're gonna want to place it. So here I'm grasping the round and you see you can really move things up and see where you're gonna go. Now I'm gonna make my defect on this side and I showed two slightly different techniques either are fine, but again, I've pulled my peritoneum laterally. I know where my uterines are medially and so the broad ligament usually is gonna be just fine. Go ahead and just use a little bit of electrocautery here. I know that I'm in a safe zone. Now I'm gonna look behind and my assistant is right here and then she's gonna use, see that defect? She's gonna go through again, grab the round and then hand her the mesh arm and then she pulls it through. So that prevents a lot of the back and forth in an area that's a little hard to see and to do sometimes. Then I just make sure that it's not curled. Here's the other side and again, you can use a blunt dissection and helpful again, just having that come through, grasp the edge and then pull it through. So similar on each side there and just make sure that it's flat and it's not curled. So now comes the part of actually attaching it to the sacrum and sometimes this can be a little bit tricky as you're dealing with multiple arms and so the pattern always goes the right arm, the posterior mesh, the sacrum, the posterior mesh and then the left arm and I will do two different sutures here. So the first one, you kind of get through that. You get the posterior mesh and then really get a good bite of that anterior longitudinal ligament and you can see it just really rotates on the bone nicely. And then go posteriorly. Grab that arm. And so then you can see really with this first suture here, there's the two mesh arms and the posterior mesh all incorporated and pretty similar to what a sacrocopal pex is. So this is the second suture and this is where it gets a little bit tricky depending on the uterus itself because the area is tight and you're really operating between not just the vagina and that, but there's a uterus above you. So again, the angled scope is critical. You can see the uterus is kind of bobbing in the view at the top there. Just get that out of the way. Good, and you can see the needle. And then for the sake of time, it goes through the other arm and ultimately will tie down as well. So you can see the two sutures here, suspending that and I use for the sacrum, I always use O-proline or an O-permanent monofilament. And then a key point is really closing this peritoneum because in addition to just having mesh in the area, there are different arms and other things. So it's a little bit easier for the bowel to get trapped there. And in some of the series, there's a much higher likelihood of SBO. And so I think it's really critical. I use O-vicryl or a polysorb depending on which hospital and I just do box sutures. And the key point is that I go as low as I can go, like here, and then I actually will lift that up cephalad and you can go even lower. So really leveraging that because you really want the space to be closed properly. And as you can see, I look and even lifting it up, you can see that area has to be obliterated and just takes a few extra sutures and then it usually will work out just fine. And so when it's done, it should look like that. And then anteriorly, I also close and I just typically will use box sutures. We used to use the V-lock quite a bit and knock on wood, I have not had any issues with it, but in some of the colorectal literature and with my colorectal colleagues, they've had a number of issues with small bowel obstruction or the barbs on the suture snagging bowel. And so I just have gone back to O-vicryl. So this is what it looks like here with the sutures closed there. So outcomes for this are pretty favorable, similar to sacrocopalpexy. And there are a number of studies that do support this. And when it's been compared prospectively to uphold, we know that there are no differences between groups at one year and most people being extremely happy. So I'm gonna conclude with the next few slides. We have been fortunate that this year a systematic review was published and it looked at uterine preservation versus hysterectomy in prolapse surgery. And this really ended up finding 53 studies which compared preservation to hysterectomy in patients with prolapse. The evidence quality overall was moderate. When we look at hysterectomy plus mesh sacrocopalpexy, sacrohysterepexy reduces mesh exposure, operative time, blood loss, surgical cost. When we compare it with bad chest and uterus sacral, we see improved C-point and vaginal length. And really you can see going on here, we have a number of different things that they've compared it to. But I think it's key that data are accumulating and what is there is in fact encouraging. So what we know is a reduction in surgical time and blood loss, maintenance of fertility, natural menopause timing, avoidance of an unnecessary procedure, less invasive, associated with a quicker recovery, a decreased risk of mesh exposure, similar short-term meaning a year outcomes and patient preference. Disadvantages, we do have fewer data. For some maintenance of fertility is actually a disadvantage. There is this very small and ongoing risk for cervical or endometrial cancer. Subsequent hysterectomy may be difficult. Continuation of menses, ongoing surveillance and copalpexy may be easier for the surgeon after hysterectomy. There are limited pregnancy outcome data and it is interesting in that we have most after sacrospinous hysterectomy. I don't like to do dual mesh if someone's planning a pregnancy. So how I use this is young active women who desire uterine sparing procedure. They can have dual mesh hysterectomy plus usually a BTL or self-inject me. A young active woman who desires future fertility, sacrospinous hysterectomy or a posterior mesh only. I've before added an SIS graft anteriorly. And postmenopausal woman, usually dual mesh sacrohysterectomy. They really have all the options. So I wanted to just go over briefly pearls from my clinical experience and who are not good hysterectomy candidates. Stage four prolapse, especially if they have an elongated vagina plus uterus are not an ideal candidate. And that's because as you lift things up, it's actually longer than your target and you can't shorten the vagina like you can for sacropalpopexy if you wanted to. And then for vaginal hysterepexy, I will rarely offer it if you have a late stage three or stage four prolapse, because in those studies, they did have higher failure rates for advanced stage three and four prolapse with vaginal hysterepexy. And then those women with severe anterior wall prolapse or recurrent anterior wall prolapse, they may not be ideal. And though the hysterepexy pretty reliably suspends the apex well, it doesn't always lift the anterior apex quite as much. And I think I spoke a little bit about how you can't redefine the apex like you can so much in a hysterectomy-based approach. So again, I usually do that anterior repair. And I think it's just something to be aware of. There are ways in which you can shorten the anterior wall and cut out, either wedge out a portion of the epithelium to shorten it, and that can be helpful if necessary. So there are a lot of future questions. Will the durability of the prolapse repair be as good or better than vault suspension? Will these repairs reliably hold up to the strains related to pregnancy, labor, and delivery? How often will reoperations be required? And who's the ideal candidate? So it's safe and feasible, comparable outcomes. The best study does sacrospinous hysterepexy. And in my practice, that's what I usually do the most. Decreased OR time, blood loss, and recovery. And then patient consent and really shared decision-making are the key, in my mind, to approaching any patient, but specifically when it comes to this. And I know we still at least have a couple minutes because we started a few minutes late. Christina, are you available? Absolutely. So thank you, Barry, so much for your presentation. We do have some questions from the peanut gallery. So let me start with the first question that came in, which is how do you deal with an obliterated posterior cul-de-sac? So, well, usually, an obliterated posterior cul-de-sac would be someone who has endo. And I really don't know if a uterine sparing procedure is the best for that patient. But in general, let's say they're for sacrocopepxy or they've had scarring or something else, I'll definitely put either an EEA or malleable so that I can define that, and then an EEA sizer in the rectum. And then make sure that I have a really good assistant in that area. It's usually, unfortunately, the least trained person who ends up manipulating the vagina and the rectum, but this is really critical. And then dissect that. Often, I'll try to approach it going lateral to medial because you can often get into an avascular plane, find that, and then cut, find where those adhesions are and the obliteration, and open that. And then I always have a low threshold to do the bubble test if it's a truly obliterated cul-de-sac, just to make sure that I haven't created a defect in the sigmoid or the rectum. Great, we have a couple more questions. Do you do an anterior repair with sacrohystorpexy like you do with your sacrospinous hystorpexy? And if not, why not? Okay, so not typically. I will look at the end and make sure that I'm happy with how things look because I don't like it to, some people say, oh, it can have a nice little flexibility on there. I like it to look pretty straight immediately post-op. And so I will look, and if necessary, I will do one. And usually I would then shorten the anterior wall a little bit. But for my average mesh hystorpexy, I don't. For sacrospinous, I almost always do. Just partly for sacrospinous, the angle's a little bit different. So that would be why. Okay, how do you manage prolapsed recurrence in post-sacrohystorpexy patients, especially if they have abnormal uterine or cervical pathology that requires a hysterectomy? I think that's a great question, and that's something that people often worry about. And so what I would do is I would put in a uterine manipulator, and I would go in laparoscopically. I'd cut the anterior mesh arms, and I would leave the posterior there, or at least that patch on the sacrum. It kind of depends on what that looks like, but I would leave that there. And I would do the hysterectomy, and as part of that, removing a lot of that anterior mesh. Then I would, again, pull the specimen vaginally. I would close the vagina, and then put on an anterior mesh, and attach it to the area on the mesh that's on the sacrum. If you left the whole posterior one in, which sometimes you can do, you can just attach it to that posterior mesh. But if it's just a patch, and you have to redo the posterior and anteriorly, then you can attach it to the patch of mesh that's already on the sacrum. Great. How long does robotic or laparoscopic hysterepexy take you to do? I think the ultimate question is, is it shorter than your time for hyst plus a sacroculpal pexy? It's a great question. So it is, there are some steps that are definitely cumbersome, but when you get faster as you do more, I would say it takes me longer than sacroculpal pexy, but shorter than hyst sacroculpal pexy. And so with a small uterus especially, the one I showed you was a little bit of a challenging case, to be honest. But for a smaller uterus, gosh, I don't know, three hours, two and a half hours, depends if you're counting the sling and the rectocele and everything. But I would definitely put it in the middle of sacroculpal pexy's fastest, this is next, and then hyst sacroculpal pexy. Okay, since we're pretty much out of time, I'm gonna give you one more question, Barry, and that's for a sacrospinous hysterepexy, do you approach the ligament anteriorly or posteriorly? Is it based on the patient's anatomy? And are you able to approximate the uterus to the ligament if you do opt for an anterior approach? So I make my incision almost as if I'm gonna be doing a posterior colpotomy, but I don't make a full thickness. And then I dissect the epithelium from the peritoneum. And so I guess it's an apical approach. It's hard when the uterus is in place and you're going posteriorly to call it anterior, but go into that. I personally don't like to do a posterior wall approach to the sacrospinous ligament. With this approach, you can feel where the uterus sacral is, and I go just medial to that, and then dissect down, and you can pop right into the space pretty easily. Great, well, since we are basically running over at this point, on behalf of the Augs Education Committee, I wanna thank you so much, Barry, and everyone for joining us today. Remember, these webinars are on the website, and so if your friends or colleagues weren't able to join us tonight, these do live on the website permanently. And our next webinar is entitled The Sacrospinous Ligament Fixation Classical Apical Support with a Great Future, which will be on October 17th. So thank you again, everybody. And again, on behalf of the Augs Education Committee, Barry, thank you so much for your time tonight. My pleasure, and I really appreciate everyone listening to this, and you can definitely contact me offline, by phone, or anything if I didn't have time to answer your question. And I really appreciate the opportunity. Thank you, Christina, and thank you, Augs.

Dr. Barry Ridgeway

hysteropexy

prolapse treatment

sacrospinous hysteropexy

uterine sacral ligament hysteropexy

sacrohysteropexy

advantages

disadvantages

patient consent

shared decision-making