The objective of this video is to demonstrate the technique for performing a vaginal utero sacral ligament hystereopexy and to discuss outcomes from a case series of women who underwent the procedure at least 12 months prior. Pelvic organ prolapse is the third most common benign hysterectomy indication. Recently, with growing evidence to support the efficacy of uterine-conserving prolapse repairs and an increased awareness amongst providers regarding patient attitudes towards hysterectomy and desire for uterine preservation, the necessity of a hysterectomy at the time of a prolapse repair has come into question. This has translated into a greater interest in and increasing rates of uterine-conserving prolapse repairs being performed in the United States and abroad. Uterine-sparing procedures for prolapse repair can be approached either vaginally or abdominally and can be performed with or without mesh. A vaginal approach has several clear advantages over an abdominal approach. Shorter operative times, less blood loss, and improved aesthetic outcomes. Of the two vaginal approaches, sacrospinous ligament hystereopexy, which can be performed with or without mesh augmentation, is the best-studied hystereopexy technique in the literature. It has consistently been shown to have similar anatomic outcomes and recurrence rates compared to hysterectomy-based native tissue repairs. In contrast, few studies have assessed the efficacy and outcomes of a vaginal utero-sacral ligament hystereopexy. A retrospective study of 200 women who underwent either a vaginal utero-sacral ligament hystereopexy or a vaginal hysterectomy with utero-sacral ligament suspension found similar rates of durability at a median of 1.5 years follow-up. In another retrospective study, 20 women who had undergone a vaginal utero-sacral ligament hystereopexy were followed for an average of 33.2 months. Anatomic recurrence, defined as greater than or equal to stage 2 prolapse, was observed in 25% of patients, with 15% requiring re-operation. The steps to perform a vaginal utero-sacral ligament hystereopexy include performing a posterior colpotomy and entering the posterior cul-de-sac, visualizing and grasping the utero-sacral ligament at the level of the ischial spine, placing two sutures through each ligament, anchoring the sutures through the distal utero-sacral ligament and through the cervical stroma, closing the colpotomy, and tying down the sutures to suspend the apex. We will now demonstrate our technique for this procedure. After the cervix is brought into view, the posterior cervical surface is grasped with a single-toothed tenaculum and deflected anteriorly to expose the posterior fornix. The colpotomy site is marked, and Alice clamps are placed at the lateral margins of the planned incision site. The area is then injected with a dilute solution of lidocaine with epinephrine. After this, monopolar energy, or a scalpel, can be used to perform the colpotomy. The peritoneal reflection in the pouch of Douglas is palpated and then tented using Alice clamps, permitting intraperitoneal entry to be achieved sharply. The dissection should be extended laterally, if needed, to permit insertion of retractors and improve visualization. The patient is then placed in Trendelenburg position. The cul-de-sac is visually and digitally inspected for adhesions. One or two moissan laparotomy sponges are inserted to displace the bowel cephalad. Breisky Navratil and right-angle retractors are used to visualize the course of the uterosacral ligaments. The distal uterosacral ligament is grasped with two Alice clamps at the level of the colpotomy, and firm upward and outward traction is applied, which helps bring the proximal portion of the ligament into view. The uterosacral ligament is firmly grasped with a long Alice clamp at or proximal to the level of the ischial spine. We prefer to pass two delayed absorbable sutures, such as polyglycinate, immediately beneath the clamp in a lateral to medial fashion to avoid injury to the ureter. The same procedure is then performed on the contralateral side. The sutures are tagged to the drapes and the laparotomy sponges are removed. Next, the sutures are anchored. Starting with the more lateral suture, the needle is utilized to drive the suture through the distal portion of the uterosacral ligament, which can easily be palpated, then through the muscularis and out the vaginal epithelium. The other end of the suture is driven in a similar fashion through the uterosacral ligament using a free needle. Next, the more medial suture is driven through the cervical stroma and the vaginal epithelium. Again, a free needle is utilized to anchor the other end of the suture similarly through the cervical stroma. If permanent suture were placed, the suture should be anchored through the previously mentioned structures, but not the epithelium. Next, the colpotomy is closed. Lastly, the hystereopexy sutures are tied down. The patient is placed in steep Trendelenburg to reduce the risk of bowel entrapment. The sutures are tied down starting with the lateral sutures and then the medial sutures. Measure should be taken to ensure that the suture is in close opposition with the uterosacral ligament and cervical stroma in order to avoid the creation of a suture bridge. At this point, if anterior compartment prolapse is present, an anterior colporaphy can be performed. After an anterior colporaphy, an anti-incontinence procedure are completed, if indicated. A cystoscopy should be performed as ureteral obstruction due to kinking can occur with approximately 3% of uterosacral ligament colpopexies. After confirming ureteral patency, the hystereopexy sutures are trimmed. Generally with these procedures, a C-point of 5 to 8 centimeters proximal to the hymen can be achieved. A C-point of 7 centimeters proximal to the hymen was achieved in this procedure. At our institution, vaginal uterosacral ligament hystereopexies were performed starting in 2016. To date, 22 surgeries have been completed, with 13 patients having follow-up greater than or equal to 12 months. Appropriate candidates for uterosacral ligament hystereopexy desire uterine preservation and have no significant uterine or cervical pathology, familial cancer syndromes such as BRCA or Lynch or cervical elongation, although this is a relative contraindication. In our series, patients were a mean age of 54 years old and overweight. Several women were parous and the majority were postmenopausal. Nearly two-thirds had preoperative stress urinary incontinence and nearly one-third reported preoperative urgency urinary incontinence. Over three-quarters of women had a pelvic organ prolapse quantification score of 3 on preoperative exam, with a median BA of plus 2, C of minus 1, and BP of minus 1. All but one patient underwent concurrent anterior and posterior colporaphy and over half had a midurethral sling. Total operative time was a mean of 103 minutes. No intraoperative complications were reported. Postoperatively, four women experienced a UTI and one experienced urinary retention requiring Foley catheter reinsertion. As part of an IRB-approved cross-sectional follow-up, all patients were attempted to be reached. Nine women consented to a telephone survey, one woman declined, and three were unable to be contacted. Approximately 90% of women reported that their prolapse is very much or much better compared to their preoperative condition. No patients reported complications related to their surgery. Only one patient reported a sensation of vaginal bulge. No patients reported having reevaluation or undergoing a repeat surgery for vaginal prolapse. The benefits of a vaginally approached uterosacral ligament hystereopexy include a more anatomically correct vaginal axis as compared to the right-sided deviation associated with a sacrospinous ligament hystereopexy. Patients experienced the benefits of a vaginally approached native tissue repair that requires no mesh augmentation. Additionally, the adonexa can be reached for surgical intervention if indicated. In conclusion, a vaginal uterosacral ligament hystereopexy can be performed in a similar fashion to a posthysterectomy copepexy. Anchoring of the hystereopexy sutures should occur through the distal uterosacral ligament and the cervical stroma. Our preliminary data supports previous studies which suggest that uterosacral ligament hystereopexy is a safe and effective procedure. However, we recognize the limitations of a small case series and that additional long-term prospective data on the surgical technique are required. Thank you for the opportunity to present our work. Here are our disclosures. So uterovaginal prolapse is a common condition among women, with up to 11% of women seeking treatment, surgical treatment, in their lifetime. The sacroscervical pexy, sacrosteropexy still remains the gold standard for apical prolapse, but it remains a challenging procedure for many, requiring a significant amount of laparoscopic suturing and knot tying. We describe here a novel technique of laparoscopic sacrohisteropexy, in which endoscopic suturing and knot tying is reduced, as well as our one-year outcomes with the procedure. So, similar to the previous talk, there's more literature looking at the benefits of uterine preservation. Many women prefer to avoid a hysterectomy, as we explain to many of our patients, a hysterectomy doesn't actually cure the prolapse, the uterus isn't causing the prolapse, and avoiding hysterectomy reduces many complications, including the risk of ureteral injury, mesh exposure at the cuff, and vaginal cuff dehiscence. We performed a retrospective chart review of all patients in our practice who underwent a laparoscopic sacrohisteropexy from March 2015 through July 2018. I'll begin with a description of the procedure. We begin laparoscopically, the peritoneum over the sacral promontory is incised to expose the anterior longitudinal ligament. The incision is then carried down along the right pelvic sidewall to the rectovaginal space. At this point, we turn to the vaginal portion of the procedure. So, the vaginal portion of the procedure begins much as a vaginal hysterectomy would. We make an incision from 10 to 2 o'clock along the anterior cervical vaginal junction. The bladder is advanced off the cervix. A second incision is made posteriorly from 4 to 8 o'clock, and the posterior cul-de-sac is actually entered. An Emmet needle is then used to perforate the cervix from posterior to anterior, and a polypropylene mesh is pulled down posteriorly. The care is taken to make sure that the mesh is laying flat around the cervix, and the two tail ends of the mesh are then sutured together to create a wider face. The mesh is then pushed through the posterior cul-de-sac, and the vaginal incisions are then closed. We then return to the laparoscopic portion of the case and attach the mesh to the anterior longitudinal ligament in the usual fashion, and then close the peritoneum over the mesh. So, we identified 71 patients in our practice who underwent a laparoscopic sacroilastic or hysteropexy between March 2015 and July 2018. They had a median age of 59. 8.4% had had a prior prolapse repair. The stage of prolapse was 2, with a range of 2 to 4. And the pre-op point C was at positive 0.5, with a range of minus 3 to 10. Looking at our intraoperative data, we had three intraoperative complications. One gastric perforation at the placement of the initial trocar, one uterine perforation with placement of the uterine manipulator, and one possible testotomy with placement of the suprapubic trocar. Operative time median was 138 minutes. 45% of patients had a concomitant vaginal procedure, with 9.8% with an anterior repair, 94.2% posterior repair, 40.8% with a perineurophy, and 63.3% with an incontinence procedure. We had no significant postoperative complications and no mesh exposures noted. Three patients had a re-operation during the time period. One had a sling for new-onset SUI, one had a perineurophy, and one had a revision of a perineurophy. So far, we've had 94.3% of our patients present for a six-week post-op visit, with a prolapse stage of one with a range of zero to two, and point C at minus six. Six-month post-op visit, we've had 59% of patients present, with similar outcomes to a six-week post-op visit. At 12 months, we've had 29.5% of our patients present so far, with a prolapse stage of one, range of one to two, and point Cs at minus six. In conclusion, laparoscopic sacralar sacrohistoropexy is a novel variation of the traditional sacrohistoropexy, which minimizes the amount of laparoscopic dissection and suturing, and however, does not appear to compromise long-term outcomes or complications. Thank you. Thank you for the opportunity to present our work. These are our disclosures. Uterine preserving surgery, as we've seen today, continues to be a trend in the treatment of uterovaginal prolapse. And historopexy can be performed transvaginally, abdominally through an open technique, or through laparoscopy. It can be performed with or without the use of mesh augmentation. And while there have been previous studies describing and comparing various historopexy modalities, there has yet to be a direct comparison of two minimally invasive abdominal options, mesh-augmented sacrohistoropexy and utero-sacral ligament historopexy. Thus, the aim of our study was to describe and compare these procedures. Our primary objective was to describe and compare prolapse recurrence after these two surgeries. And our secondary objective was to compare long-term patient-centered outcomes. Our study design was a retrospective cohort study with an addition of a cross-sectional survey component. The two cohorts were women undergoing mesh-augmented sacrohistoropexy and utero-sacral ligament historopexy as their first surgery for uterovaginal prolapse between 2004 and 2016. The electronic medical record was queried for perioperative data, including patient characteristics and adverse events, post-operative outcomes, I'm sorry, outcomes including recurrent bulge symptoms, mesh exposure, and retreatments were also collected. Our definition of recurrence was a patient-centered outcome. Documentation in the medical record of bulge symptoms and or retreatment with a pessary and or surgery. To capture long-term differences in patient-reported outcomes between the groups, the cross-sectional survey also assessed for outcomes. This survey utilized components of validated assessments, including the patient global impression of improvement scale, the pelvic floor distress inventory, the incontinence severity index, and the prolapse and incontinence sexual questionnaire. We also inquired about the presence of pelvic floor symptoms, including vaginal bulge, and history of retreatment and complications like mesh exposure. This table shows the preoperative characteristics of all the subjects. There were statistically significant differences between the cohorts. The sacrohistoropexy group was older and more likely to be menopausal, and this group also had more advanced prolapse than the women who underwent utero-sacral historopexy. In terms of perioperative data, there were no differences in postoperative complications, including readmission and reoperation within one month, and there was no difference in length of postoperative hospital stay. However, the mesh group was more likely to be performed with robotic assistance and had a longer operative time. In addition, the mesh sacrohistoropexy group was less likely to undergo a concurrent prolapse procedure, including cloporapy. Based on the retrospective data, there was a 23% incidence of recurrent prolapse in all patients. And again, recurrence was defined as subjective bulge symptoms and or retreatment that was documented in the electronic medical record. 11% of all patients underwent retreatment for recurrence, 8% with a repeat surgery. And of the women who underwent surgical retreatment, the anterior and apical compartments were the most common sites of retreatment. While the mesh group appeared to have a greater incidence of recurrence on univariate analysis, this finding was no longer significant when controlling for the preoperative differences between the groups in age, menopausal status, and preoperative prolapse stage. For the cross-sectional survey, 61% of all patients responded. The median time from surgery to survey was 104 months. 93% of patients reported improvements in surgery, with 88% reporting that they would choose to have the surgery again. And this is not different between groups. However, 41% of all respondents reported some bothersome, persistent, or de novo pelvic floor symptoms. There was a difference in the report of the feeling of a vaginal bulge between the groups on the survey, 41% after sacrohistoropexy compared to 10% in the utero-sacral group. There was also a difference in those reporting seeking care for vaginal bulge, 33% versus 10%. In conclusion, we found that there was no significant difference in documented subjective prolapse recurrence after mesh-augmented sacrohystoropexy and utero-sacral-licorate hystoropexy. However, there did appear to be a greater incidence of bulge symptoms after mesh-sacrohystoropexy on cross-sectional survey. In addition, 40% of all respondents reported bothersome pelvic floor symptoms. Despite this, both types of hystoropexy were associated with high patient-reported satisfaction and impression of improvement, with no difference seen between groups. And as such, both types of minimally invasive abdominal hystoropexy remain good options for patients desiring uterine-preserving prolapse surgery. Thank you. We're going to take a few minutes for questions for these two short oral presentations, if both presenters could come on up. Hi, thank you for that presentation. Toya Pratt from Kaiser UCSF. Of the patients who reported bulge symptoms, what compartment was the recurrence noted? Which presenter are you directing that to? There, with the hystoropexy comparing to your sacro. Sure. For the cross-sectional survey component, because this was a phone survey, we couldn't say what bulge or what compartment they felt. However, on the retrospective portion, for people who had a documented recurrence, it was actually a tie. I think it was 88% had anterior and 88% had apical recurrence. Thank you. Yeah, thank you. Question for each of you, sorry. So Dr. Armstrong, am I understanding you right that there is no mesh on the anterior compartment at all except around the anterior cervix, where you've passed it sort of up and back? Yes, the mesh goes just around the cervix. There's no mesh sort of lining the posterior or anterior vaginal wall. So all anterior repair is sort of native tissue from below, like an anterior? If needed. If needed. The patients are sort of screened in office by sort of pushing up on the cervix with a scopette, and if that reduces anterior-posterior prolapse, then we are more likely to use this procedure. Gotcha. Thank you. Dr. Davidson, my question for you is, am I understanding right that the mesh cohort here was a heterogeneous cohort of both robotic and transvaginal mesh surgery? No, these were all, it was a mix of robotic and laparoscopic, but these were all abdominal sacrohystoropexy. They were all sacrohystoropexy? Yes. Okay. Thank you for clarifying. If there's no other questions, since we're actually behind schedule, I'm going to move on. I'm Dr. Evan Goldman. I run a gross anatomy lab, and I teach anatomy. So I'm well aware of what students and residents and attending physicians and fellows have to do in order to understand their gross anatomy when they don't have access to the lab, and they don't have access to cadavers. So they often supplement with whatever they can. They sometimes draw. They will sometimes use pictures and atlases. The problem with using atlases and drawing is these are two-dimensional representations of something that is in three dimensions. So what we've done is we've created some software. It's virtual reality software that allows us to create anatomy from a cadaver. We actually have real cadaveric specimens that we've converted into virtual reality models, and we can take these specimens in our program. This is a controller that we would be using, and I can grab that specimen. I can rotate it in space, or I can take another controller and grab it, and I can make it larger and smaller. I can look inside of it. I can even draw on this anatomical specimen, and I can trace a path of an artery through there. And we've even created a module where we can have multiple people in the VR world at the same time. This is Dr. Shefali Sharma. She's going to help me demonstrate the virtual reality. So she's wearing a virtual reality headset. So what she sees in there is a virtual reality world. So as she's looking around, it seems as though, to her, she's truly in this world. So if there are objects in there, they seem extremely real to her. So if there was a person standing next to her and she turned, she would be surprised by that person. In her hands are the controllers. I showed you those before. So she's going to grab different objects, and then she's going to paint on them. So, Shefali, if you could reach forward, and then when that model of the pelvis turns color, pull the side button and pull that towards you. You can now move that around, just swing it in the air. Move it around however you want to look at it. So this is a three-dimensional model. On the screen, it obviously just looks two-dimensional. But in her world, she could put her face in there. She could turn it around and look from behind. So, in fact, why don't you look around posteriorly? I can see Padendal really easily. In fact, why don't you draw on the Padendal just to show that you know where it is. Very good. What I would like to do now is show a different program, one in which we're both in a virtual reality world together. We could actually be in different buildings, we could be in different states, we could be in different countries and be viewing this exact same pelvis model together. So as we're working in here, I can take a pointer and I can point out different structures and I just want to turn around for a moment and point out that we've got other types of models that we've built for different types or levels of instruction. So I might use this with my medical student that has different structures labeled and here's another group who's working on the back and I can go inside there and I can recognize different arteries. I'm going to hand the reins over to her and have her give me a little bit of an anatomy lesson. So now we're in our pelvic cadaveric dissection and I'm just going to point out some common structures that we often try to teach within the operating room but don't have this kind of tool available to give our medical learners a good appreciation of. So here we see the bifurcation of the aorta into the common iliacs and you can see the external iliac artery and vein and the internal iliac artery and vein and it's a great tool to be able to go through the divisions of the internal iliac and to be able to move this model and really appreciate where those divisions are. So we can look at something that is what some would call the most difficult nerve to understand especially in our field, the pudendal dissection. So you can see the pudendal branching out coming out through Alcock's canal. So I'd like to know what you thought about this and what suggestions you might have because we're obviously still building this and we're going to be making more modules for our students and more simulators for you guys. What would you like to see in there? So I really like the functionality of being able to be in there with another user and kind of use that in a way for residents and for medical students to be able to test their knowledge of anatomy and also for fellows to work with attendings and better understand the steps that we take during some of our surgical procedures. That's great. Okay, so I'd love to take this out and show the world and so hopefully people will see this video and get excited about this virtual reality. Yeah, definitely. Thank you. You did a very good job with printing that out. So, I don't know, I'm looking at that whether you should... Well, thank you for allowing us to present our work. This study was supported by the North Carolina Translational and Clinical Sciences Institute. The authors have no relevant financial relationships to disclose. Short-term voiding dysfunction is common after surgery. Voiding trials are performed to identify post-operative voiding dysfunction with protocols varying amongst institutions. A backfill-assisted void trial consists of filling the bladder with water, removing the Foley catheter, and then allowing the patient to void. Backfill-assisted voiding trials have been shown to be an efficient assessment of voiding with a quicker time to discharge. This method should provide a close estimate of the post-void residual, or PBR. But is checking a PBR necessary? Proponents of checking a PBR do so in order to ensure sufficient emptying as the bladder is not always adequately drained prior to backfilling, or too much time is allowed to pass before prompting the patient to void. Reasons not to check a PBR include discomfort to patient and increased risk of urinary tract infections, especially if a PBR is checked with an in-and-out catheter. The authors believe that checking a PBR is more likely to result in a failed void trial, resulting in excessive and unnecessary post-operative catheterization. Therefore, our primary outcome of this study was to compare the rate of void trial failure at discharge in women undergoing a backfill-assisted voiding trial with and without a PBR. Our secondary outcomes included days of catheterization, urinary tract infection, and voiding dysfunction. This was a non-blinded, randomized controlled trial at the University of North Carolina at Chapel Hill from March through October 2017. We assessed women undergoing prolapse and or stress incontinence surgeries. We included English-speaking women 18 years and older with a preoperative PBR of less than 100 mLs. We excluded women who were pregnant, dependent on catheterization to void preoperatively, patients undergoing illicit procedures, as well as those who needed prolonged catheterization following surgery. All participants underwent a backfill-assisted voiding trial under the following protocol, and avoided volume was measured. Participants were randomized to either a PBR void trial or a PBR-free void trial. For the PBR void trial group, a PBR was checked via bladder scan or catheterization. Void trial failure was defined as a PBR of greater than 100 mLs or greater than 50% of the voided volume if the voided volume was greater than 200 mLs. In the PBR-free group, a PBR was not checked, and void trial failure was defined as a voided volume of less than 50% of the backfilled volume. We aimed to detect a 25% reduction in void trial failure in the PBR-free group. We needed to randomize 126 participants and sought to enroll 150 participants in order to account for voiding trials performed incorrectly. And now for the results. 185 preoperative patients were assessed for eligibility. 150 patients were randomized with 75 women in each group. 72 participants in the PBR void trial group received the intended protocol, while 74 in the PBR-free group received the proper intervention. Intensity analysis was utilized to interpret the data. This chart illustrates preoperative demographics, and as you can see, there were no differences between the two groups. In looking at operative demographics, most of the patients had general anesthesia. The surgeries are representative of our practice, with the majority being vaginal cases. Most of the sacrocopal pexies were done laparoscopically, and over half of the participants had a mid-urethral sling placed. Again, there were no differences between the two groups. For our primary outcome of failed void trial, there was no difference between the PBR and PBR-free groups, with a 53% rate of failure in both. In looking at our secondary outcomes, there were also no differences in duration of catheterization, urinary tract infection, and voiding dysfunction. The strengths of this study are that it is a randomized controlled trial. The groups are balanced with no significant differences in demographics and perioperative characteristics, and we have a large sample size that is representative of our urogynecologic patient population. Our limitations include that this study was done at one academic center, which limits generalizability. We have strict preoperative PBR criteria, and our study was unblinded, which could lead to potential bias. In conclusion, when performing a backfill-assisted voiding trial, eliminating a PBR does not affect void trial failure. Although our study was not powered to look for our secondary outcomes, we did not see a difference in post-operative duration of catheterization, urinary tract infection, or prolonged voiding dysfunction. Checking a PBR is not necessary to assess voiding dysfunction following pelvic reconstructive surgery. I'd like to thank my co-authors and our clinical staff for helping me with this study. Thank you. Using data from the OPUS trial in 2014, the OGSNOW Risk Calculator for de novo urinary incontinence after prolapse surgery was developed to predict post-operative de novo stress incontinence risk following pelvic organ prolapse surgery. The calculator gives a percentage score for risk of stress incontinence with and without concomitant continence procedure. Prior studies have demonstrated limited outcome data on the calculator's ability to accurately discriminate between women with and without post-operative stress incontinence, and that there is no increase in patient satisfaction in decision making when it is utilized in preoperative counseling. The primary objective of this study was to evaluate the distribution and variance of calculator scores in a large urban hospital setting. The secondary objective was to compare calculator scores with actual incidents of stress incontinence during the first post-operative year. This was a retrospective review of consecutive women who underwent vaginal prolapse surgery in an academic hospital between 2010 and 2017. Women were identified who had no subjective or objective stress incontinence preoperatively. Demographics, type of prolapse repair, risk of stress incontinence, and post-operative stress incontinence were reported. Group comparisons of calculator scores were accomplished using the student's t-test. Of the 404 cases of vaginal prolapse repair identified, 148 women without preoperative stress incontinence were analyzed. Demographic data is as listed with a mean age of 58 years, BMI of 30, and parity of 4. Of note, 69% of women were Hispanic. The breakdown of surgical procedure type included 118 utero-sacral ligament suspensions, 9 sacro-spinous ligament fixations, 13 copal chleesis, and 8 women received an isolated anterior repair. This graph represents an estimated normal distribution curve of the frequency of calculated scores for risk of de novo stress incontinence. The solid purple line represents the frequency of calculated scores for risk of stress incontinence with a continence procedure, and the green line represents a risk without. The values between the corresponding dashed lines represent an estimated 68% confidence interval, or one standard deviation for each score. Confidence intervals were used to demonstrate where a majority of the calculators fell. These values ranged between 6 and 16% for with, and 35 to 55% for without a continence procedure. For our secondary objective, we asked whether there was a difference in calculated risk for those that did and did not ultimately develop stress incontinence. The table compares the calculated risk values between the 20 women that actually developed stress incontinence and the 128 women that did not. The first row demonstrates there was no significant difference in calculator scores for risk with a continence procedure in women who did and did not ultimately develop stress incontinence, with an average calculator score of 12% in both groups. The second row shows the calculated scores for risk without a continence procedure, which also demonstrated no difference and was 45% in both groups. Although the predicted risk was 45%, the actual rate of stress incontinence in our population without a continence procedure was 15%. Also of note, only a single patient underwent subsequent continence procedure during the study period. In conclusion, the distribution of scores for risk of de novo stress incontinence does not vary considerably from our traditional prediction and counseling method. In our patient population, the average calculator assessed risk for de novo stress incontinence without a continence procedure was 45%, while the actual rate was only 15%. This discrepancy may lead to higher rates of continence surgery selection, which may not be indicated. Thank you. Thank you for the opportunity to present our work. We have no relevant financial disclosures. The objective of this study is to compare complication rates between intraperitoneal and extraperitoneal vaginocopalpexy using the American College of Surgeons National Surgical Quality Improvement Program Database. We performed a cross-sectional study of this large database. We identified subjects using CPT codes for vaginocopalpexy, both intraperitoneal and extraperitoneal. We further identified those patients who underwent a concurrent hysterectomy. All surgeries were for benign indications between 2014 and 2016. We evaluated 30-day postoperative complications as well as readmissions and reoperations. Patient demographics, preoperative comorbidities, ASA scores and operating times were also obtained. 10,271 patients underwent vaginocopalpexy during our study period, with 44% undergoing intraperitoneal copalpexy and 56% undergoing extraperitoneal copalpexy. In terms of concurrent hysterectomy, 37% of patients underwent intraperitoneal copalpexy with a concurrent hysterectomy, while only 7% underwent an intraperitoneal copalpexy alone. 36% underwent an extraperitoneal copalpexy with concurrent hysterectomy, while 20% underwent extraperitoneal copalpexy alone. Mean age was 44 years, the mean BMI was 29, and the majority of our patients were white with an ASA class of 2. For our primary outcome, the rate of postoperative complications was 2.1%. Readmission rate was 2.6%, and reoperation rate was 1.6%. 213 postoperative complications were identified, 56% of which were postoperative transfusion. While transfusions were the most common complication, this was only experienced by 1.2 of all patients undergoing vaginocopalpexy. No difference was appreciated in rates of complications across different types of copalpexy with or without hysterectomy. On multivariable logistic regression model, controlling for age, BMI, race, ASA class, operative time, preoperative hematocrit, and type of surgery, ASA class 3 and 4 remained significantly associated with postoperative complications. Intraperitoneal copalpexy without hysterectomy also remained associated with an increased odds of experiencing a postoperative complication compared with intraperitoneal copalpexy with a concurrent hysterectomy. Increasing preoperative hematocrit was associated with a lower odds of experiencing a postoperative complication. The major strength of this study is that the cohort was identified using the NISQIP database, which is a large national database whose data is collected in a standardized and audited manner. In terms of limitations, all studies based on retrospective databases are subject to information and data collection biases. Also, CPT codes were used to determine the types of surgery performed. Thus, we were unable to determine if vaginocopalpexy performed without concurrent hysterectomy or posthysterectomy of all suspensions or hysterepexies. In conclusion, the overall rate of complications following vaginocopalpexy for pelvic organ prolapse is low. The odds of experiencing a complication following intraperitoneal copalpexy without hysterectomy were approximately two-folds greater than intraperitoneal copalpexy with a concurrent hysterectomy. The findings of this study can be useful in informing discussions regarding post-operative risks following common surgeries for pelvic organ prolapse. More studies are needed to elucidate factors that increase patients' risk of experiencing post-operative complications following vaginal surgery for pelvic organ prolapse. Thank you. We thank the committee for allowing us to present our work titled Perioperative Outcomes for Combined Ventral Rectopexy with Cigar Copalpexy Compared to Perineal Rectopexy with Vaginal Apical Suspension. The authors have no relevant financial relationships to disclose. Pelvic floor disorders can result in prolapse of any vaginal compartment as well as prolapse of the rectum, and oftentimes these disorders coincide. In fact, rectal prolapse has been reported in 38% of women with interstitial defects noted on defecography. Combined surgical approaches can be accomplished via an abdominal route, either laparoscopic or open, or a perineal route. Currently, there is a lack of population-based data on perioperative outcomes comparing these two approaches. Utilizing a national database, our aim was to describe and compare perioperative complications in women undergoing combined ventral rectopexy with cigar copalpexy compared to perineal rectopexy with vaginal apical suspension. The National Surgical Quality Improvement Program database was utilized to identify non-pregnant women 18 and older undergoing ventral rectopexy with cigar copalpexy or perineal rectopexy with vaginal apical suspension from the years 2006 to 2015. Women diagnosed with preoperative sepsis or undergoing emergent or oncologic procedures were excluded. Our primary outcome was perioperative complication within 30 days of surgery, and this was defined as any of the following, death, surgical site infection, pneumonia, venous thromboembolism, ICU admission, stroke, sepsis, MI, return to the operating room, or transfusion. Secondary outcomes included length of hospital stay, operative time, estimated blood loss, 30-day readmission, and rate of urinary tract infections. Modified regression analysis was used to estimate adjusted relative risks of complication associated with these two approaches. As you can see from the top line, a total of 273 women met eligibility criteria. 88% underwent an abdominal approach, and 12% underwent a perineal approach. The median age of patients was about 62 years old. Nearly half of the cohort was overweight and obese. The majority of our subjects were Caucasian at 95%, followed by African American at 4.6%. The two groups were similar in terms of BMI, smoking status, medical comorbidities, and ASA physical status class. Age was the only patient characteristic that was found to be significant, significantly different among these two groups. Perioperative complications defined in our primary outcome occurred in a total of 24 patients, 8% in the abdominal group and 15% in the perineal group. The age-adjusted risk of perioperative complications was nearly twice that in patients undergoing a perineal approach compared to those undergoing an abdominal approach at 1.84. Although suggestive of an association, these results were not statistically significant. The most common complication was return to the operating room at 2 and 6% in the abdominal and perineal group respectively, followed by occurrences of bleeding and sepsis in the abdominal group alone. The following table describes associations between surgical approach and secondary outcomes. Readmission within 30 days was not found to be statistically significant between the two groups. In terms of rate of urinary tract infections, there was none reported in the perineal group and about 5% in the abdominal group. Total operative time was on average 18 minutes shorter once adjusting for age in the perineal group compared to the abdominal group, although these results were not found to be significant. And patients in the perineal group were less likely to stay in the hospital, although once again these results were not significant. In conclusion, perioperative complications in combined prolapse procedures is approximately 10%. Although there was a suggestion of an association towards more complications in the perineal group, after adjusting for age these results were not significant. Larger studies are needed to determine the impact of potential effect modifiers such as minimally invasive approaches and concurrent procedures such as hysterectomy or sigmoid resection. Thank you. So we're now open for questions. I have a question regarding the vaginococcal pepsi intra versus extra perineal. Just for clarity, intra perineal would be things like uterus refilling and fixation and extra would be sacro-spinal stigma fixation? Yes, correct. Okay, thanks. I actually have a question for the two database studies. It seemed to me that both studies would suggest that the ostensibly less invasive approach had actual more complications, and I was wondering if each of you could comment on why you think that is in your data sets. Yeah, so what we think is that for many, even though it wasn't found to be statistically significant at the end, what we think is that it's possible that the providers chose patients who are older and more frail for the vaginal approach, and that their comorbidities, which maybe may not be entirely captured within our database, are affecting the outcome where it could potentially increase the rate of complications. I was just saying that the database studies both seem to suggest that the complication rates were higher in the group that is ostensibly less invasive. So the vaginal hystereopexy group, for instance, had a higher complication rate compared to a concomitant hysterectomy. I got you. For the risk calculator study, we didn't really look at complications. Directly in the study, we were just looking at outcomes and like actual evidence of stress incontinence afterwards. So we were. I think intraperitoneal copepexy for vaginal valve suspension is actually rather difficult and can incur more risk in terms of, say, bowel injury and whatnot, and potentially just because it is a post-hysterectomy procedure, getting into intraperitoneal cavity can be more challenging. So I don't know if it is necessarily more or less complicated, but it is an interesting association that needs to be examined further. For Dr. Brettschneider, did you look at hysterectomy as an independent risk factor in the sacrospinous group? I think you mentioned it in the uterus sacral group. Both extraperitoneal and intraperitoneal groups were then further categorized into those who underwent hysterectomy and those who did not. Was there more risk with the hysterectomy in that group? No, there was no association with increased risk. All right. Well, that concludes the session because it is lunch.

surgical techniques

pelvic organ prolapse

laparoscopic sacrohysteropexy

voiding dysfunction

risk calculator scores

virtual reality system

complication rates

perioperative outcomes