I wanted to thank Augs for putting these webinars on. I think it's a great opportunity for us to be able to look at some things in a way that I think is easier sometimes than looking at a textbook chapter, especially with the pelvic floor where there are so many things that are three-dimensional. And I'd like to share some thoughts about how my practice in the operating room has evolved as we as a group have started to understand a little bit more about the biomechanics of the pelvic floor. And I always think about us as a research team like these pilots during World War II who are trying to understand a little bit more about how parachute works because their lives may depend upon a parachute saving them. And you can see on the left people pulling on individual cables that go to the parachute. You can see the guy kind of leaning back and feeling the force that generates from the wind hitting the inside of the parachute. And it's a very direct way that they have of understanding how this complex mechanism works. And when I thought about where we all started years ago, we basically started or I started this way. I was a practicing gynecologist and that's what I could see. And I think for all of us, many ideas got formed because of the limited view that we have. But over the last couple of decades with the advances in modern imaging, now we can actually see what's going on everywhere. And I think that that's radically changed my understanding of the pelvic floor. And not only can we watch things, but we can also make a mark, for example, on the resting location of the cervix. And then we could make a measurement of exactly how far that moved. We could do that in a woman who has prolapse and we could compare that to a normal asymptomatic woman. And we've studied a lot about what's going on in MRI. And what I'd like to do is talk a little bit about what we found and then how that's changed my surgical practice. I wanted to give thanks to the Pelvic Floor Research Group here at Michigan. Five or six of the individuals in this picture are engineers and it's the dialogue that we've had over the course of time among people from many different specialties. I think that's helped us not only focus on what's the best thing for the patient and making sure that we focus on that first and foremost, but also thinking about the future and how we can understand more about what's going on to be able to change our treatments. These are a couple of my patients. The top pair you can see is a preoperative photograph. And when I saw her one year after her operation, you can see that she still has a bulge. The second pair is a little bit larger prolapse and she's actually had surgery before. And her one year photograph shows a perfect outcome. And I think it troubles all of us that we don't really understand why it is that some patients fail and some patients succeed. Because if we could figure that out, we'd be able to tailor our operations in a more specific way. Now, engineers have a lot of experience with failure analysis. This is the Tacoma Narrows Bridge that failed back in the 1920s, 1930s. And the engineers wanted to know what was wrong. And so they took a look at the structural failures. There are the primary cables that were fraying and the roadbed that was buckling and some of the secondary cables that were failures. But the question is, were those the cause of the failure or the result of the failure? And as many of you know, this was called Galloping Gertie. And it was this oscillation that it had with the high winds and the narrows that was the thing that caused it to fail. And if you look, you can see how thin the roadbed is, that it doesn't have the normal kind of bracing that we're used to now. Because once they figured out that that's what was wrong, they changed the design of bridges afterwards. And those same kinds of failures have never happened again. So if we look on the left here, we can see a patient with a fairly large uterine prolapse here. Here you can see the uterus. Here's the pubic bone. Here's the sacrum. Here's the bladder way down in the front. You can see that this is about 10 centimeters below the hymenal ring. She had a vaginal hysterectomy. We did a Michigan four-wall sacrospinous and an AP repair. And this is her result 12 years later. We're doing a study now where we're looking at long-term follow-up. And even though you can say that her support isn't perfect, it's a whole lot better than it was before. And these kinds of good results long-term are very much achievable with native tissue repairs, as long as the right biomechanical principles are followed in doing these kinds of operations. Now, just to put data behind that, I'd like to compare the Pelvic Floor Disorders Network sacral culpapexi trial with the series that we published a few years ago on a native tissue repair using the Michigan four-wall sacrospinous suspension. In the sacral culpapexi, they had about seven years of follow-up, 126 patients, a 60% response rate, 40% had failed an operation before, 76% were satisfied, and anatomic success was present, 75% with a mesh erosion rate of about 10%. We had eight years of follow-up, about 242 patients, about the same response. We had about 20% more patients that had a previous failure, so you'd expect that we'd probably have a higher failure rate with a native tissue repair because of that. But you can see that 90% were satisfied, and there was an 85% satisfactory anatomical outcome, and the anatomical outcome in ours was at four years on average, which is a little bit shorter than the sacral culpapexi, but certainly, even if you knock 10% off of ours, it's going to be about the same as the abdominal sacral culpapexi. So the point that I'd like to make is native tissue repair can be successful, even in individuals, 57% of whom had failed an operation before, and I think it's the result of understanding the biomechanics of what's going on. So my thought has always been fix what's wrong. When I rebuilt my car engine when I was in medical school, because I didn't have enough money to pay somebody to fix it, if I didn't get it fixed right, I wouldn't be able to drive anymore, and so I've been highly motivated to understand the mechanics, and we've done a lot of 3D imaging to try and understand this. This is just an image of the pelvic bones, the uterus is here, the vagina is here. This is made from an MRI of a normal healthy individual. We've done 3D stress MRI, where we can do models of the pelvic organs both at rest and also at a maximum strain, and then the other thing that we've done are what are called finite element models. Those are biomechanical models that allow you to be able to see what happens when you load the model, and the red layer here is the anterior vaginal wall. The blue layer in the back is the posterior vaginal wall. The purple here are the levator ani muscles. These are the cardinal ligaments. These are the utero sacral ligaments, and once we've built a model like this, we can specifically say what would happen if. What would happen if we made the ligaments longer? What would happen if we made the muscles weaker? We've learned a lot just from looking at those kinds of things. Now, stress 3D MRI is the way that we actually studied the bridge failure. We loaded the pelvic organ system and looked at where it was that the structural failures would occur, so I'd like to kind of lead you through that technique. As I showed before, you can take a pelvic MRI image. Pubic bone's here. Bladder's here. Uterus is here. Sacrum is here. This one, there's a little bit of blurriness from the bowels working, and what we do is just outline all the different organs in a program called Slicer, and then if you do that in a bunch of different slices, and then you hit the magic button, it'll make the models for you. So these are exactly that woman's anterior wall, posterior wall, rectum, bladder, urethra, anal sphincter, and levator plate, and we learned a lot about the spatial relationships, but the problem is that it's not the resting anatomy that we're really interested in. We're interested in this. We're interested in the big cystic seal that's down here. You can see the uterus up here, pelvic bone here, catheter in the bladder, and you can see this big cystic seal protruding outwards. So what we did was come up with some very special MRI sequences that allow us to do sections from one side of the pelvis to the other in the length of time that a woman can hold this maximum valsalva. Then what we needed was a way to be able to compare what we see in normals and compare what we see in women with prolapse. So here I put the pubic bones back in again, and to be able to understand this, we put a reference line that's the arcus tendineus fascia pelvis, so the fascial arch, so that we can be able to look at the distances between different structures and where the bony pelvis would be. So here we've got, again, we've got a blue uterus, pubic bone, sacrum, arcus tendineus, anterior wall, posterior wall, rectum, external sphincter, perineal body, and levator plate. So for the apex, we marked where the top of the greater sciatic foramen is, which is where the cardinal ligament takes origin, and measured the distance to the cervix. For paravaginal defects, we measured the distance from the arcus tendineus to the side of the vagina. We actually, even though I've only shown it in one place on each side, we actually do it on five places at each side. We can then measure the length of the vagina, as well as measuring the width, and here I've shown all five vaginal width sampling locations. And as I said before, the paravaginal, we sample at five places as well. So that gives you a series of measurements in a normal individual, and then you can do that in an individual who has prolapse, so that we'll be able to see how do the women with prolapse differ from the women who don't have prolapse. And I think you can just see very quickly that it's easy to see what's going on. It's not particularly complicated, but we did want to test hypotheses so that we could actually have evidence for some of the theories that we have about what's going on. So what did we find? Well, if you look at the percentage that each of these different measurements predicts the size of a prolapse or the presence of a prolapse, you can see that apical descent is about 78% and paravaginal is about 82%, which adds up to 160%. So the question is, why is it that you have more than 100%? And the answer to that is that these are essentially two different measurements of the same thing. So statistically, that would be called collinearity. It's like if you were looking at how high a person was who was bouncing on a trampoline, how high their shoulders are and how high their arms are, are going to be highly correlated with one another. And I'll show you a little bit more about that now. Pelvic floor closure, the ability of the levator muscles to hold the hiatus closed, came in second at 62%. And this is a very different domain than the attachments of the vagina to the pelvic sidewalls. Now, most of us learned that the vagina was too wide in an individual with cystocele, which turns out not to be true. We also published a paper a number of years ago showing that the vagina was too long in women with cystocele. And I am very embarrassed that I practiced gynecology for about 20 years before realizing that. But we've published that once and then independently confirmed that in a second study that the anterior vaginal wall is responsible for about 28% of cystocele. Now, that's not to say that there aren't some women that have a wider anterior vaginal wall. And there certainly are, especially in the larger prolapses. But it's not nearly as strong a predictor as these other factors. And this is how I'd like to kind of break down the talk about these biomechanically based factors is to talk about apical and paravaginal defects and how those can be repaired. And then what we can do about the hiatus and vaginal length. So, if you think about the bladder as a balloon that's resting on the anterior vaginal wall, which has kind of a trapezoidal shape, you can see that the vaginal wall theoretically is attached to the archus tendineus. Now, if there is descent of the anterior vaginal wall that happens because of apical descent, that opens up the paravaginal defect. So, you can see the descent of the apex and paravaginal defect are just two different assessments of the same kind of thing. And this is why I say they're basically two different factors that are very similar to one another. So, that would presume that if you restore apical support, that you will narrow the paravaginal defect. And although I'm not going to show data for that, I can tell you that we've actually conducted those experiments with preoperative and postoperative MRIs and been able to confirm that if you resuspend the vaginal apex and return it to a normal length in the vast majority of individuals, that normalizes the paravaginal defect. So, let's talk a little bit about apical suspension. Now, high utero sacral is an effective operation for that. Michigan four-wall sacrospinous is an effective operation for that. Abdominal sacral culpapexi is an effective operation for that. And ligament shortening and reattachment is. And I think the first three get a lot of discussion, but I'd like to talk a little bit more about ligament shortening. Now, it's something that I had learned as a resident many years ago and was doing that before everybody said that you had to do a high utero sacral or a Michigan four-wall or a sacral culpapexi. And I wasn't seeing the failures that other people were talking about. And I'd like to explain what it is about this because it's a very safe technique that has a safety advantage over some of the others. Now, you can elevate the apex by shortening the ligaments. Usually, you can shorten the ligaments by a minimum of four to five centimeters and sometimes more than that. We'll also have a surgical goal of returning the vaginal wall to a normal length. And if you have just an example here, somebody with an eight and a half centimeter long pre-op vagina, and if post-operatively, we know that the normal anterior vaginal wall is six and a half centimeters, if you don't return that to normal, you shouldn't be surprised that there may be some sagging. Then we'll make sure that we've got the anterior wall hooked up to the apex and we'll restore the hiatus. So, how does this play out in the operating room? Well, let's just take a type ordinaire cyst to seal, the kind that I think is probably the most characteristic. Anterior wall is two centimeters below the hymen. Uterus is a centimeter above the hymen. So, the first thing that we do during a vaginal hysterectomy that people really don't think about is your first incision is actually above the cervix. And so, that's going to eliminate some of the prolapse and that's even more prominent on the posterior wall where you see here where the cul-de-sac is about three and a half centimeters from the external os of the cervix. And so, you're going to get some of the elevation just by removing the protuberant cervix. But the next thing that we're going to do is use the fact that the ureter is quite a bit higher than the cardinal and the utero sacral ligaments. And here, I'm just showing my finger, palpating the location of the ureter by palpating it against this retractor that's placed in the lateral fornix. And the ureter is a good five or six centimeters up above where the cervix is. So, this is going to give us several centimeters that we can use to be able to elevate things. Now, this is the second clamp, the cardinal ligament clamp. So, we've already taken the utero sacral ligament clamp. And here, I am showing that the clamp has already shortened the prolapse by five and a half centimeters. We're now five and a half centimeters above where the cervix was. So that if the cervix was, I think I said it was a minus two, now you're expecting that you're going to be five or six centimeters above that. So, you're going to be at a minus six or a minus seven, which is where the cuff normally is after a hysterectomy. The other piece of scientific information that we learned from biomechanics is that the ligaments actually are not too stretchy. We had, I think a lot of us had thought that, but in 40 women, we measured the stretchiness of the ligaments in women undergoing surgery with some specialized biomechanics testing equipment and proved that it's the length of the ligament that's the problem, not the stretchiness. So, if you can shorten it, you can really correct what's going on. So then, if we're re-elevating the apex, as you can see with the arrow going upwards here, the question is, does that work? So, I was starting to feel a little bit twitchy because people were saying that what I was doing shouldn't be the right thing. So, we looked at our experience and this is data that my colleague here, Pam Fairchild, published where we looked at 119 of the patients that are managed in the way that I was talking about. And many of my partners will do either a Michigan four wall sacrospinous suspension or a high utero sacral ligaments in the same kind of patients. So, there wasn't really much of a difference in the prolapses. It was just a difference in philosophy. Now, the patients who underwent the vaginal culpapexes were a little bit bigger, just one centimeter, which was statistically significant. But I think, you know, the difference between a plus two and a plus three really isn't that large. And these are the results that if you look at two years at anatomical success, so the percentage of people who have support within the normal range, you see that the two success rates are the same. So, the theory that you need to do a high utero sacral or sacrospinous in patients, those certainly are effective techniques, but they're not really more effective than the people with selective reattachment. Now, the reason that I think that this is important is in the reattachment group, we had fewer abscesses, fewer nerve injuries, and fewer readmissions. So, that's not to say that these are common problems. As all of you know, these are relatively rare, but it is a safety margin that you can get. So, the next question that people say is, well, do you do this on all of your vaginal hysterectomies? And the answer is no. You know, if I have a patient like the one that I showed the MRI of who's got a cervix that's seven centimeters below the hymenal ring, I'll do a Michigan four-wall sacrospinous at the time of that. And I don't think that these were patients, any of whom probably had a cervix that was more than four centimeters below the hymenal ring, but certainly one or two centimeters below, there's plenty of room to be able to shorten the ligaments in those individuals, especially if they have cervical elongation where the high parts of the ligament are up at a normal place. So, I've been saying around here lately that when we've been looking at our scientific studies and what to look at next, that the apex was yesterday's problem because every single one of you has several excellent options that you're probably familiar with, whether you know sacral occulpopexy or utero sacral or sacrospinous, to be able to solve the apex problem. And that's actually been very consistent. But how many of you were taught during your training to return the length of the vagina to normal? I've not found a single textbook that describes the fact that the vagina is too long in women who have a cysticeal. But take a look at these two MRI scans. The one on the top shows a woman who has an anterior vaginal wall that's seven centimeters in length, and another woman here who has an anterior vaginal wall that's 12 centimeters in length. Now, if you resuspend her apex and if her vaginal wall is still 12 centimeters long, it's going to sag. And on this woman, if you shorten her anterior vaginal wall, it's going to be too short. So part of it is having a technique that returns anterior vaginal wall length to a normal length at the end of the operation so that there isn't this downward sagging. Now, these are data from my partner, Carolyn Swenson, where we looked at a number of individuals. This is preoperative vaginal length that you can see here, and it ranged all the way from about five and a half centimeters, a really short anterior vaginal wall, to most of them were in the 8 to 10 range. And here's one with an anterior vaginal wall of 14 centimeters to start with. This is the length of the anterior vaginal wall at the end of the repair. And you can see that we're pretty good at getting things in the ballpark of about six and a half centimeters, you know, somewhere certainly between five and a half and seven centimeters by using this technique. So how do we do that? It's really pretty simple. So when you're doing an anterior repair, if you place your stitch from side to side, as we see here, then if you take a couple of bites here and you put those together, that's going to bring the left side towards the right side. And so you will get a reduction in the width, but there's nothing about that that's going to make the vagina any shorter. So in an individual who has a, let's say, a seven centimeter vagina that you don't want to make shorter, you're going to take your stitches from side to side. Okay, so what about this? So here is a vertically placed stitch, so a top to bottom stitch. And if you place your stitch top to bottom and then bottom to top and tie that, now you're going to get a reduction in length in addition to getting the side to side. And if you have a 12 centimeter long vagina, you're going to pick an entry point and an exit point that's really far apart. If you have one that's maybe 10 centimeters, they're just not quite as far apart. So just a simple way to be able to think about predictably trying to correct one of the biomechanical abnormalities that people don't normally think about when they're thinking about doing their repairs. Now, once you have shortened the ligaments and done your anterior repair, you need to reattach the ligaments. And I'll show you the biomechanical insights about why I say that. So let's just take a look at a normal situation here. Here is a uterus and a vagina and a cardinal ligament that as you can see, let's just say that there are five strands on each side and most of those go to the cervix, but some of them go to the vagina. And let's say that you've told the patient that you're going to do a hysterectomy. So how much have you decreased the strength of her support? Well, if there were 10 fibers before and now there are only four fibers, that means you've reduced the strength of the apical supports by 60%. And I think it's one of the reasons that vaginal hysterectomy has got a bad rap for being able to elevate the apex because people didn't reattach the ligaments afterwards. And you see that not only will you reattach them, but they're up higher than the other fibers. And so they're going to draw the vagina upwards to those shortened ligaments and give you a substantial amount of elevation. Okay. So this is a Richardson angle stitch and the mnemonic that one of our residents came up with when we were talking about prevention. And she said a cup of prevention is worth a pound of cure. So it's A is for anterior, C is for cardinal, U is for utero-sacral, and P is for posterior. So let's take those steps in an operation and run through them here. Okay. So let's get oriented. You can see that the anterior repair is finished here. This is the cardinal and utero-sacral pedicle over on this side. This is the anterior vaginal wall. Here's the back part of the cuff back here. And you can see that we have a full thickness bite of the anterior wall. We're not skimming superficially up here. We're getting the full thickness of the anterior vaginal wall. And I'll just make a side comment, although I didn't show it, that with the top of our anterior repair, we get that reattached over here so that it's actually attached to this full thickness vaginal wall. So that's A is for anterior. Now, here's the cardinal and utero-sacral pedicles that we're pulling off to the side, I think that you can see over here. And what we're doing is taking a little wimpy tethering bite of just some of the loose tissue here in order to keep the suture in place. And it's always counterintuitive for the residents and the fellows because they say, take a big strong bite. But as you'll see, once we've taken the other stitches, everything that's out here is outside of our stitch and everything in here is inside of the stitch. So you want to have as much inside here as you can. So that's the cardinal and the utero-sacral. And then here's the posterior where we're going through the posterior vaginal wall again, nice full thickness bite. So this is important. Do you see where we're tying here? And do you see that I've got the corner of the vagina over here? I think anybody with any experience has had a patient that had a corner bleed after a vaginal hysterectomy. This virtually eliminates that by ligating those downward descending branches of the uterine artery that come along here. So this is not only reattaching the cardinal and utero-sacral, but at the same time, it is giving you hemostasis. Takes maybe 45 seconds to stitch. Very efficient, low-tech surgical skills that all of you have. So then that's going to allow the apex to retract upwards once you've taken the tension off of it. And here, right afterwards, we release tension. You can see that it's three and a half centimeters above the hymenal ring. And I happen to know from her post-operative visit that her cuff was at a minus seven centimeters after the full recovery had taken place. So very effective operation. And I showed you the long-term data at two years about the fact that this is an effective technique. So the hiatus is the Rodney Danger field of the pelvic floor. All of us love to believe that it's ligaments and connections and fascias that are what causes prolapse. Because if you think that it's a broken ligament, you can put stitches and deal with that kind of thing. If you think that it is a break in the fascia, you can put stitches in. Surgeons love to think in terms of fascia. But, are these two women have the same prolapse? They both have a point BP of plus one. And what's different between those two? Is it the rectocele? Or is it the fact that the woman on the right has a gigantic hiatus? And I can tell you that if you were to pull that posterior vaginal wall back up and not fix the hiatus, an assistive seal would fill that gap. That this is one of the things about the closure of the pelvic floor, is that when the pelvic floor is closed, the vaginal walls are in contact with one another. And the pressure on one is counterbalanced by the pressure on the other. They're equal and opposite. And for those of you that have done urodynamics, you know that if you have a catheter in the bladder and a catheter in the rectum and have somebody valsalva, they both go up equally. So this is the importance of the hiatus in terms of closing things. And yet it hasn't gotten the same degree of attention that the ligaments and the fascias and other things have gotten. 62% of what's going on with prolapse is related to the hiatus. Now, one of the reasons that the hiatus hasn't been something that we think about is that as soon as you see somebody with prolapse, this is what you see. This is what happens when you push the prolapse back in. And if this was a woman coming in for an annual examination, you'd say, that's not normal. Look at that gaping introitus. And that's an indication of hiatal failure. And hiatal failure actually is becoming more widely recognized as one of the primary factors in recurrence. And if you wanna have a high success rate, you need to be able to have a strategy for trying to address what's going on with the hiatus. These are some drawings from an absolutely fabulous book from the turn of the century by Hall, Ben and Tandler, where they did dissections of about 60 cadavers that had prolapse. And there are these beautiful lithographic reproductions of the original drawings that show the real anatomy in real individuals. And the one that's on your left here has a nice normal sized vaginal introitus because the levator ani muscles and the perineal membrane and the perineal body are all intact and holding this in a normal position. This is a dissection of a woman who has prolapse. And you can see that the perineal membranes are detached from one another. And the levators are splayed way out on the outside so that they're not underneath the pelvic floor, but there's this large diastasis that occurs between the muscles. And if you have a large diastasis of the rectus muscles and you try and sit up, you get a bulge in between. So in the same way, you can imagine that somebody with a large diastasis here is gonna have a bulge when they strain. That the more open the hiatus is, the more the vaginal walls lie between intra-abdominal pressure inside and atmospheric pressure outside. And that pressure differential drives the vaginal walls downwards and makes them protrude through this enlarged and open hiatus. So back in 1998, I published a study. I was still doing general obstetrics and gynecology at that point. And I had quite a variety of patients. And so I just made measurements of the width of the urogenital hiatus, the AP diameter of the urogenital hiatus, and then the thickness of the perineal body on the patients that I was seeing. And this is what I found. And I left this kind of as a faded original graph just to kind of show you that this is not something that was done yesterday. So I had 198 women who were normal and this was the size of the hiatus. What we did is use the formula for an oval, multiplied the AP and the transverse diameters with the equation of an oval to get the area. You see that in women with prolapse, this area is substantially larger than it is in normal women. In women who are cured of their prolapse, it's better than with the unrepaired prolapses, but it's still statistically significant, about 30% larger than a normal individual is. People who failed one operation are about the same as people who are cured. And the people who failed multiple operations had huge hiatuses. Now, what does this tell us? Well, these are resting hiatus measurements. So this is not straining. This is not the effect of the prolapse itself. It's how big the hiatus is at rest. And it says that prolapse is associated with an enlarged hiatus and operative failure is associated with an even larger increase that we can see there. Now, these are data from the group at Duke who were looking at hiatus and failure in their patients who had abdominal sacral culpapexes. And they classified the individuals who had prolapse into three groups. One was stably normal. And that meant that the prolapse was less than four, the hiatus was less than four centimeters with Valsalva. They did Valsalva values. 65% had improvement, which means they started abnormal, but they became normal. And 13% were persistently wide. And when you looked at the risk of operative failure, those who had a normal hiatus had a 4% failure rate. Those in whom the hiatus approved was a 6% failure rate. And those with a persistently wide hiatus was about 14%. When they did multivariable regression analysis, so they could look at the individual factors, the odds ratio is five for the individuals who had a persistently wide hiatus. They did posterior repairs only in about 18% of those individuals because they were doing sacral culpapexes. Although I'm not showing it, they also published a couple years before their native tissue vaginal repairs where their posterior repair rate was quite a bit higher, but the same findings occurred. So enlarged hiatus associated with operative failure. Now, what is it that we do to fix this? Now, many of you have heard people talk about denonveliase fascia or the posterior fascia on the vagina as if there was a layer that had ruptured and that you had to do a repair of that layer. I don't know how many dissections I've done. It's probably about 400 or 500. I've looked at histologic sections of the pelvis in about 15 specimens. I've done lots of operations. There is no magical layer that's between the vagina and the rectum. Yes, there is a thin layer of areolar tissue that's there that you can dissect off of it, but that doesn't have any surgical strength. The real thing is whether or not you get the bottom part of this put back into a normal situation. Just imagine what would happen if you tied that suture. See how that would pull the levators back into alignment? See how it would get the perineal membranes connected in the perineal body as it would do? This is a cornerstone of our approach to restoring the hiatus to normal. Now, we obviously don't take a stitch on the outside like this. What we do is to remove a V-shaped wedge of the vaginal wall, and underneath the surface here, we make sure that we get the tissues laterally here and here, and in a small, mildly abnormal hiatus, we may have three PDS sutures, and I've had hiatuses like that really big one that I showed you before that was huge that I had 15 stitches to reconstruct that. But the thing is that this is not leaving it up to chance. This is getting things to come back to normal. Now, that doesn't fix all of erectocele because you have to get the posterior vaginal wall resuspended, but most of the time, we're getting that resuspended with the apical suspension. So, if this is the situation, this is what it looks like at the end of, you can see the anterior repair there. See that? These are the tails of the sacrospinous stitches. So you can see that the anterior wall is up where it is, but that doesn't look normal. So what we do is to put an Alice clamp on either end of where we believe those tissues are, and we get a deep bite of the Alice so that we don't have just the mucosa, but we've got the deep tissue underneath. And then we test that in order to be able to have a size of the introitus that we believe will allow for comfortable intercourse. Now, then what we'll do is just excise this triangle of full thickness vaginal wall. We'll anchor a running vicral stitch up here just because it's easiest at the beginning, and then we'll put a series of PDS stitches to bring the left side to the right side. And once we've done that, that's what the repair looks like afterwards. It's a very predictable repair that once you know what this is gonna be, you know that it's gonna be like this once you finish the repair. Now, in the interest of full disclosure, we've done MRI scans before and afterwards, and there's no question that we improve the hiatus quite a bit, but we don't get the hiatus into the normal range in everybody. And that's, I think, one of the things that we have to think about. And part of that is that in younger women who have a very small hiatus, the reason that you can have that smaller hiatus is simply because the tissues are so elastic. And in an elderly individual where there isn't that same elasticity, you have to use some judgment in terms of not over-correcting that. Our pain with intercourse rate with this is very low because we're not actually sewing the muscles, we're sewing the tissue that attach to the muscles. And this is a very smooth repair when you look at it afterwards. So let's kind of repeat now and take a look at what we've looked at so far. So native tissue repair can result in high success. And I've shown you several large series with good follow-up, but that comes from understanding what failed and how to correct it. You can't just do a series of steps thoughtlessly without knowing how to make your anterior repair, for example, get the anterior vaginal wall to a normal length again. So you want to normalize anterior vaginal wall length. You want to resuspend the apex by whichever of the techniques you feel the most comfortable with. You want to address the enlarged hiatus as best you can. And especially for those of you who do abdominal sacral culpapexes, I know that at the end of a long and difficult operation where there've been adhesions and it's been difficult, when people look below, everybody says, oh, that looks okay. I don't think we need to do a rectocele repair. It's one of the reasons that I like operating vaginally is that I'm already there and I'm less likely. And I've done probably two or 300 abdominal sacral culpapexes. And I have to admit that there were times that I kind of said, well, we've been here a long time. And if I was operating vaginally, I would have done the posterior repair, but I hadn't, so I'd encourage people to do that. Now, the advantages of native tissue repairs, the first thing is that the mesh erosion in the future is just not an issue if you're not having to use mesh. That's not to say that mesh shouldn't be used. And certainly for abdominal sacral culpapexy, it would have to be used, but everybody who does mesh repairs has to accept the fact that there are gonna be some erosions. Some of those can be pretty significant. It's also a shorter operating time and there are no disposables. A Capio, for example, is $400. And so there are little things like that that we haven't paid attention to, but if there's gonna be bundled payments in the future where you just get X amount of money, this is gonna be a very cost-effective way to be able to do it. Now, if I told you that I never had complications and that I never had failures, you'd all kind of ring off the webinar right now and know that I was lying to you. But I think we've looked at it carefully and I think we can say that our approaches get good success. And the other thing for the future that we're working on is rules that you can depend upon, that if the cervix in the clinic is here and if it's here in the operating room, this technique has an 85% chance of success. We need those kinds of guidelines. None of us would diagnose gestational diabetes without knowing what the cutoff is. And I think that that's a lot of what we're working towards and some of the stuff that we're doing now with our biomechanical modeling where we're looking at those finite element models is Lujan Chen in our group actually has a model that you can customize so that it reflects a specific patient's anatomy. And then at the present time, we're starting to be able to actually simulate different operations. And I believe that that's gonna be the way forward for us in being able to actually say, here's this individual's specific anatomy and we've looked at three different operative approaches and this operative approach has the highest success rate. And so that's what we would check. So I think, as we kind of gaze in the crystal ball about where we're gonna be in a decade or so, I think that's kind of where we're gonna be heading. Well, again, I wanted to thank you all for listening in. It's something that we've got a lot of passion for here is trying to figure out how things work. And then on Tuesdays, when I'm in the operating room all day, I get to be able to try some of these ideas out. And over the course of time, I've realized that there are certain problems that I used to have that now aren't problems anymore. But I sure know that it's not a complete success. And I think that understanding the hiatus is the next area that we're gonna be making the biggest strides in. And hopefully in a couple of years when we have another webinar like this, we'll be able to have some specific strategies for getting that fixed. Well, Jennifer, that's what I had to present. And I'd be happy at this point to answer any questions that people have. Dr. Delancey, thank you so much for that fantastic presentation. So for all of our listeners, we do have some time for questions. You can submit a question for Dr. Delancey in the questions box on the left-hand side of the window. We do have a couple that have come in already. So first, would you mind addressing how you feel about getting an MRI for your patients and who you think should or shouldn't have one and where you start from there? Yeah. Yeah, we don't do MRIs as part of our clinical care. It's a research tool that we've used that we found very effective. And I think all of these things are things that you can do with a relatively simple, like a ring forceps and a ruler. I mean, you can measure how long the anterior vaginal wall is if you just take a standard obstetrical tape, put a little ring forceps on the cervix and just straighten out the anterior vaginal wall and then figure out how long that is. It's pretty easy. So I think it's the conceptual insights that have really been the driver for us. And Marie-Andrée, let's see, I've used to measure total vaginal, oh, was there one before that? Jennifer, is that Marie-Andrée's? So the one was, I'm actually gonna skip that one question because the next one sort of links to what you just said. So in regards to measuring the anterior vaginal wall length and other things that you do preoperatively for some of your patients, are you measuring anterior vaginal length both pre and post-op or intra-op? Can you sort of press that? Yep, yeah, that's a really good question. Yes, anterior vaginal wall length can be very, very different to total vaginal length. And so what we do, and I have to admit that I don't actually use a ruler anymore in the operating room, although I did for many years, just because after you get the hang of it, you kind of know how much you have to shorten things. But what we would do is to put a long Alice or a Leahy or whatever you use to grab a hold of the cervix and straighten out the anterior vaginal wall and then take a metal ruler that they have on most of the surgical sets and just put the tip of the ruler at the cervical vaginal junction and then look at where it is relative to the external urethral meatus. And that gives you what the anterior vaginal wall length is. And then if you measure it at the end, you have instant feedback on what you've done. And with that, I think you'll find that you get quite a bit better very quickly. You give any of us obsessive compulsive former premeds two measurements to be able to get and we can get that right. So yes, it's an easy thing to take and you can either do it in clinic or in the operating room. We usually do that right at the beginning of the case to see what it is that we're dealing with. And then the next couple of questions are in regards to the surgical approach. Have you had a difference in post-operative MRI measurements of apical prolapse in patients who underwent a sacrospinous ligament fixation with peroneoplasty the way you described compared to those who did not require or have an intraoperative peroneoplasty? So specifically in apical prolapse after, yeah. So with the sacrospinous, we're usually eight to nine centimeters above the hymenal ring with the stitch that we put in the sacrospinous ligament. So that pretty much determines where that's gonna be. And in this long-term follow-up study where we're now looking at people that are between 11 and 20 years after their surgery, they're coming back for MRIs now, you can see the vagina directly attached to the ligament. That just doesn't fail. With, when there's less prolapse and you don't need to have as much of that, I would say that our average point C post-operative is probably about points, is about six centimeters to seven centimeters above the hymenal ring, which is where the cervix is in the normal population. So it's not quite as high, but patients really don't know where their apex is. What they're interested in is whether the vaginal walls are attached. And both of them in the properly selected patients seem to do pretty well. And then we have two questions that are focusing on reattachment of the ligaments. So when you're reattaching the ligaments to the vagina, how often are you noticing ureters have been compromised intraoperatively? Very rare because we palpate the ureter. And so we know exactly where it is. And there's not a single resident in our program that finishes without feeling confident and palpating where the ureter is. It's one of the things that we teach on every vaginal hysterectomy. And so, you know, even the residents have a lot of confidence. And so I suspect the people that are on the call can learn it. And you pull the uterus down. Once you've gotten into the anterior cul-de-sac, you pull the uterus down, you pull the anterior vaginal wall down, you put a retractor in lateral fornix, and then just stick your finger into the peritoneum and then rub the tissue stroking towards yourself against the retractor and you'll feel a pop of the ureter. And then what we do is put a clamp two centimeters below that so that we've got a two centimeter margin. And I would guess, we haven't looked at the numbers. We do a cystoscopy on everybody at the end of the operation. And it's been about five years since I had to take a stitch out. It's much less than with high uterus sacrals, just because in high uterus sacrals, you've gotta be pretty close to where the ureter is to get a high enough bite. Mm-hmm. And then a comment about repairing the cystocele with a side-to-side placation. Have you noticed that it seems to exaggerate a paravaginal defect or is addressing the apex usually enough to help that? Yeah. Addressing the apex is usually enough to address that. And I've done 400 paravaginal repairs. I got started with my interest in this through Colin Richardson, who invented the paravaginal defect repair. And I was a zealot early in my career for that operation. But I started to realize that there were some problems with it and that it wasn't all about paravaginal defects. And if you think about it, there are thousands of sacral culpapexes done every year. And it's a tiny minority that have paravaginal repair done at the same time, and yet the cystocele is gone. And so even though there is a paravaginal separation there, it's my opinion that in most individuals, that separation is a result of the apical descent rather than a cause of the apical descent. And in this small study that we did where we did preoperative and postoperative MRIs, we actually measured the paravaginal gap at five different locations in all 10 of those individuals. And in 95% of those individuals, the paravaginal distances were returned to normal. And none of them had a paravaginal repair. So if you get the apex lifted up, then the gap between the side of the vagina and the pelvic sidewall normalizes itself. The one thing to be careful about is if you've got a 12 centimeter long vagina, the problem is can you really get enough elevation without returning it to a normal size in order to get that? We have another question that focuses on your selective reattachment technique. And it reads, could you clarify how the reattachment of the anterior and posterior wall to the upper cardinal ligament resulting in C at minus three and a half results in a postoperative minus seven C without any additional apical suspension? Right. I'm assuming that everybody on the call has done a DNC. And at the end of the DNC, frequently the cervix is a couple centimeters or three centimeters above the hymenal ring. There's a lot of recoil in the cardinal and utero sacral ligaments. And a lot of the descent is because of a failure of closure. And the data are the data. You know, when we look at that and they come back for their postoperative checkups, their apex is at six or seven centimeters above because we've corrected the malalignment, which then avoids pulling down on the cardinal ligaments and gets them back into a normal place. So I think that, you know, that's the biomechanical explanation of why it is. Great. And then a question regarding your suture selection, considering delayed absorbable suture with PDS better than Vicryl for the anterior plication or what is your thought about that? Yeah, we use 3O-PDS for the plication. I don't know whether that makes a difference. I feel a little bit better, but I know that using PDS for the sacrospinous suspension makes a real difference. That back when we were using Vicryl for the Michigan four wall, our apical failure rate was about three or 4%. And once we shifted over to PDS, our apical failure rate is now one in 200. So I think that the PDS for the apex really does make a difference. And I personally use a delayed absorbable, I mean, the PDS for the anterior plication stitches. It means for the women that would like to be sexually active early, every once in a while, there's one where you have to trim one or two of those. But I just feel a little bit better with that, having a longer life to be able to hold things together. Mm-hmm. And then there was a comment about, I don't know if you're able to pull up the slide where you drew out the archic tendinous fascia pelvis, but there was a comment on its relationship to the pubosacral line. Right, it's parallel to the pubosacral line, but it's obviously off to the side. I think that's the one people are talking about. Mm-hmm, mm-hmm. So that is the line of the archus tendinous fascia pelvis, and it tends to be empirically, if you looked at the sagittal section, about parallel to the pubosacral line, although the pubo, going to the sacrococcygeal junction is obviously in the midline there. Mm-hmm. And as you can see, the vagina isn't really a trapezoid parallel to the archus tendinous. Mm-hmm. You know, I did that drawing years ago before we started to do MRI, and I think conceptually it shows the relationship between apical descent and paravaginal defect, but it's not quite as true as maybe I thought 20 years ago. Sure. So my last question for you is, the work you're doing is really amazing, and it's fantastic to see the MRI-based simulation. Do you think that we'll be able to find a nomogram as far as, you know, plugging your patient's measurements in and what the best surgery would be? Absolutely. Absolutely. There's no doubt in my, just most of you are probably not old enough to remember before echocardiography, but I remember that you treated everybody with congestive heart failure the same. And now that you can tell what's wrong, you target treatment for that. So it's, we're going to get there, and it's not going to be 20 years from now. It's going to be 10 years from now. It's just a matter of getting first the data, and then the clinical trials afterwards that demonstrates selecting the right operation for the right patient is really going to be the key. Thank you so much for that. I think we're just about out of time. On behalf of the Oggs Education Committee, I'd really love to thank Dr. DeLancey and everyone for joining us today. Our next webinar is titled Aproscopic Sacrocobalpexy Tips and Tricks, and will be presented by Dr. Peter Rosenblatt on March 11th. Thank you all for joining, and thanks, Dr. DeLancey. Yep, and thanks, Jennifer. Thank you all.

practice in the operating room

biomechanics of the pelvic floor

surgical practices

modern imaging techniques

MRI studies

mechanics of the pelvic floor

native tissue repairs

surgical techniques

personalized treatment