It's my pleasure to introduce our first speaker, Dr. Charles Nager, who will be presenting on behalf of the Public Floor Disorders Network his late-breaking abstract, Vaginal Surgery for Uterovaginal Prolapse, a Randomized Trial of Vaginal Hysterectomy with Utero-Sacral Ligament Suspension versus Vaginal Mesh Hysterepexy. All right. Well, thank you. Thank you very much for allowing me to present the results of the Public Floor Disorders Network Super Trial. Okay. This trial received partial support from Boston Scientific Corporation through an investigator-initiated grant by the Data Coordinating Center, but Boston Scientific had no role in study design, interpretation, write-up, or this presentation. I'd like to acknowledge the eight different sites that participated in this study and also my excellent writing group members for this study. So we know that hysterepexy procedures are gaining popularity. We also know that transvaginal mesh procedures are controversial, but all governing bodies agree further research studies are needed. Seven years ago, we designed the Study of Uterine Prolapse Procedures Randomized Trial, so-called Super Trial. The primary aim of this study was to determine whether treatment success differs at time points through a minimum of three years between women undergoing two different treatments. First, vaginal hysterectomy and uterocyclic ligament apical suspension, which I'll refer to as the hysterectomy group, and a transvaginal mesh augmented uphold light hysterepexy I'll refer to as the hysterepexy group. The null hypothesis was that treatment success will not differ in the treatment arms. Our major inclusion criteria included completion of childbearing, amenorrhea for at least one year, symptomatic uterovaginal prolapse beyond the hymen, desire for vaginal surgery, uterine descent into at least the lower half of the vagina, and our major exclusion criteria were uterine abnormalities. The primary outcome of treatment failure was a composite measure. It could be any of three events, either retreatment, pop-Q measure beyond the hymen, or a bulge symptom. Our secondary outcomes included anatomic outcomes, functional outcomes, and safety and adverse event outcomes. We certified surgeons. We standardized the procedures. We allowed concomitant midurethral sling and native tissue procedures. The participants were masked throughout the duration of the study, and our in-person evaluations occurred every six months, and they included anatomic outcomes by non-surgeons, and the study personnel who were administering the questionnaires were kept masked to the study group. With the following assumptions, we assumed an enrollment period of about two years, with participants followed for five years, and the primary outcome was determined when the last participant reaches the three-year follow-up mark. With these assumptions, we needed 180 participants to achieve greater than 89 percent power. This is our consort diagram. At the eight sites, we screened over 1,700 women with uterovaginal prolapse. Many did not meet the eligibility criteria. There were concerns about having a uterus removed or left in place. There were mesh concerns. Others decided on other non-study surgery. We eventually randomized 183 women, pretty much equal in both arms. We later found that eight were ineligible based on baseline POPQ measures, and leaving 87 and 88, and we had over 96 percent complete the 36-month evaluation. There are patients who are continuing to be followed, and more than half of our patients are continuing in this study, and it's ongoing. Our typical patient was in her mid-60s, was typically white, was typically non-Hispanic and not Latina. Our typical patient had predominant anterior prolapse, typically about three centimeters past the hymen, and our typical patient had a uterus that was just past the hymen. Retropubic meteorethral slings were performed in about a third of the patients. Trans-obturator slings were performed in about 15 percent of the patients, and most patients underwent an anterior repair, with more being performed in the hystropexy group. Of note, the hystropexy procedure was 46 minutes quicker, which was highly significant. This graph shows our primary outcome, which was the composite measure I mentioned earlier. In the red hatch line, you see the median value for the hystropexy, and the blue dark line, you see the median value for a hysterectomy, and the shaded graphs represent the 95 percent confidence intervals. Overall, our hysterectomy had a 62.5 percent success rate at 36 months, our hysterepexy 73.8 percent. The confidence intervals overlapped one, and therefore there is no statistically significant difference between groups with up to 48 months follow-up. When we look at our anatomic secondary outcomes, we see that the anterior wall was slightly better in the hysterepexy group, cervical transvaginal, total vaginal length was slightly longer in the hysterepexy group, all other measures were equal. The major differences in adverse events occurred in these categories. We had more suture exposure and granulation tissue in the hysterectomy group. We had two midurethral sling mesh exposures, which were both in the hysterectomy group, and we had an 8 percent hysterepexy mesh exposure rate, none of which required a return to the operating room. Overall, three-quarters of the patients remained massed during the course of this study, and we had very good patient-reported outcomes with no difference in groups. Over 90 percent reported being much better or very much better. We had dramatic reductions in the pelvic floor distress inventory with no difference between groups, and for both groups, sexual function improved with no difference between groups. We looked at pelvic pain and dyspareunia in a number of ways, including the PISQ-IR, our six-month evaluations, and our adverse event log, and no matter how we looked at it, pelvic pain and dyspareunia rates were low with no difference between groups. The strengths of this study, it's an RCT, it's a large N, it's minimum three-year follow-up, multi-center improving generalizability, and three-quarters of women remained massed. Our concern was that there could be potential bias against mesh hysterepexy because it was a newer procedure and surgeons have less experience with it, but we think we mitigated this with training minimum requirements and certification. So our major findings were hysterepexy and hysterectomy have comparable primary outcomes through 36 months. We are following patients for 60 months. Conclusions could change with more extended follow-up. There's a shorter operative time for hysterepexy. There are small differences in anterior prolapse and vaginal length favoring hysterepexy, but the hysterepexy, the clinical significance is unknown. No difference in patient-reported outcomes. Both groups improved sexual function, and pelvic pain and dyspareunia rates are low. Masking subjects to whether they have a uterus or not, or mesh or not, is indeed feasible. Our final conclusion is for women with uterovaginal prolapse, considering vaginal surgery, vaginal hysterectomy with utero-sacral ligament suspension is as durable at 36 months as a mesh-reinforced repair, and for women who want to keep their uterus, the mesh hysterepexy is comparably durable at 36 months and has low complication rates and no difference in pain or sexual function. Thank you very much. Comparing procedural times for two vaginal manipulators during robotic-assisted sacrocopepxy, a randomized controlled trial. Thank you for the opportunity to present our work. Yes. The Copasys device is used in this study. We're part of an investigator-initiated, unrestricted grant from Boston Scientific. The disclosures for Dr. Matthews are listed here, and we have no other disclosures. Sacrocopepxy has been considered the gold standard surgical procedure for the correction of vaginal vault prolapse. Robotic assistance has provided a minimally invasive approach to this procedure, but has been criticized for having longer operative times. Optimizing operative efficiency is one key to minimizing operative times, and one area that may affect operative efficiency is the selection of the vaginal positioning device used during the surgery. There are multiple vaginal positioning devices that are available for robotic sacrocopepxy, including but not limited to those shown here. One commonly used device is the end-to-end anastomosis sizer, which I'll sometimes refer to as EEA Sizer or simply Sizer during this presentation. But these were initially designed for bowel surgery and have often insufficient length for patients with vaginal prolapse. Copasys is an alternative vaginal positioning device. It has several design features intended to improve operative efficiency, including a long curved handle, large and small paddles on either end of the device, and a flat distension surface, which may facilitate suturing mechanics. There is, however, limited data available comparing the operative efficiency of the various vaginal positioning devices. Therefore, the primary objective of this study was to compare operative time for the steps of robotic sacrocopepxy requiring a vaginal positioning device between Copasys and EEA Sizer. Our secondary objective was to compare the satisfaction scores using a visual analog scale for surgeons, fellows, and vaginal surgical assistants between these two devices. We designed a single center, randomized control trial of consecutive patients scheduled for robotic sacrocopepxy between January 2015 and November 2017. Patients presenting to the preoperative holding area for their planned robotic sacrocopepxy were screened on the day of surgery. Inclusion and exclusion criteria are listed here. There were three surgeons included in our study, and allocation was stratified by surgeon in blocks of 10. Randomization was done in a one-to-one fashion between Copasys and Sizer. The study was designed as a superiority trial, and an a priori sample size analysis was performed. The previously published data that reported the mean operative time for the steps of robotic sacrocopepxy requiring a vaginal positioning device was 44 minutes. A 20% difference in operating time was deemed to be clinically significant. Therefore, 25 women were needed in each group to detect a nine-minute difference in operating time. Sixty-one women were screened for eligibility. Nine were excluded for the reasons listed here. Thus, 52 were randomized. Twenty-five were allocated to Copasys, and 27 to the Sizer. Worthwhile to note for consideration in the upcoming slides and analysis is that 16 of the Copasys cases also used the Sizer for some portion of their procedure for the surgeon preference. These 16 were analyzed within their assigned group for the intention to treat analysis, and included in the Sizer group for their actual use analysis. Our sample was primarily Caucasian women in their 60s. Many of the women in each group had had prior prolapse or incontinence surgery, and the majority of women in both groups had stage 2 or 3 pelvic organ prolapse. For our primary outcome, we observed no significant difference in total time using a vaginal positioning device between the groups. Similarly, no difference was seen in the time for the various steps of the procedure, including the anterior and posterior vaginal dissections, as well as the anterior and posterior mesh attachments. As noted earlier, a secondary analysis was performed to control for the impact of crossover in cases where the Copasys was assigned, and additionally, an EEA Sizer was used for some portion of the case. Similar to the intention to treat analysis, there was no significant difference in the median operative time using a vaginal positioning device with this actual use analysis. For our secondary outcomes, both surgeons and fellows in our study were less satisfied with the Copasys compared to the EEA Sizer. In contrast, vaginal surgical assistants were equally satisfied with both devices. Although not powered to evaluate these outcomes, we saw no significant differences in estimated blood loss or rate of cystotomy or vaginotomy between the vaginal positioning devices. The strengths of this study include that it is a randomized control trial, that it used objective outcomes to minimize measurement bias, utilized an intention to treat superiority design methodology, and allowed for small variations of the EEA Sizer. and allowed for small variations in surgical technique and suture type between surgeons, which potentially increases the generalizability of these findings. The limitations of this study include that it was performed at a single academic center and thus may have less generalizability beyond this study. Additionally, surgeons did not receive any pre-study training on optimal techniques for use of the Copasys, while they had been using the Sizer for several years prior to initiation of the study. Thus, a learning curve effect may be present in the data. Finally, surgeons were allowed to use an alternate positioning device for their preference, and this may have impacted the operating time in a manner not fully controlled for in the actual use analysis. In conclusion, we saw no significant difference in operating time using a vaginal positioning device between the cases randomized to Copasys versus Sizer. And regarding satisfaction, surgeons and fellows in our study were generally more satisfied with the Sizer, while the surgical assistants were equally satisfied with both devices. The findings in this study imply that surgical efficiency may not be strongly influenced by the choice of vaginal positioning device. However, surgeons should be aware that the various vaginal positioning devices are available and choose the one with the most desired characteristics. Further research to optimize efficiency in robotic sacral copalpexy may include consideration of other intraoperative variables. Thank you very much, and I welcome your questions. Question of the device, but also, did they feel that it provided improved exposure, ability to suture on, and then did it provide any assistance with dissection? And uniformly, those numbers tended to fall with less satisfaction on the side of the Copasys. So we think those factors probably contributed. Thanks. Can you tell us a little bit more about the circumstances that resulted in crossover and what might have been the most common reasons for that? Certainly. So crossover occurred at the surgeon's discretion, where they felt that they needed an alternative device to be able to complete the dissection. We did not include the time during the crossover with that device. And also, the thing that's important to note here is that we wanted to design the study in a manner that would be consistent with real-life exposure to trying to introduce a new device into your surgical practice. And so potentially a more rigid set of criteria that did not allow the surgeons to transfer over might have shown differences in our final outcomes. But certainly in the real-world situation where you were trying to use a new device, a surgeon would be able to cross over at a time that they felt was appropriate. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. The objective of our study was to determine the difference of sexual, functional, and objective outcomes in patients undergoing non-TROCARD transvaginal mesh hysterepexy and vaginal hysterectomy with uterus-acral ligament suspension. This was a retrospective cohort study. Study individuals were sexually active women as self-determined on intake questionnaires who underwent mesh hysterepexy or total vaginal hysterectomy with uterus-acral ligament suspension between August 2012 and August 2016. Patients opted for one of the two procedures after going through an informed consent process based on patient preference and surgeon recommendation. As we will see in the demographics of the two cohorts, importance was placed on theoretical risk of recurrence during counseling, and as such, many of the patients in the mesh hysterepexy cohort had anterior compartment as the leading edge, whereas many of those opting for vaginal hysterectomy had the cervix as the leading edge of their prolapse. Patients were included if they were between the ages of 50 and 75 years, currently sexually active, and identified to have stage 2, 3, or 4 prolapse on pelvic organ prolapse quantification examination. Mesh hysterepexies performed on patients with a prior hysterectomy or with trocar-guided mesh hysterepexy, such as ProLift, were not included in this review. Patients were also excluded if they did not complete the preoperative PISQ-12 survey. The primary aim of the study was the change in PISQ-12 validated survey score pre-op to post-op at short-term follow-up. Secondary outcomes included perioperative complications, surgical satisfaction, subjective measures of quality of life, and objective anatomic measures. No a priori power calculation was performed. This is a summary version of our demographic table displaying pertinent demographics. Patients in the mesh hysterepexy group were, on average, four years older, had lower BMI, were more likely to be menopausal, have intrinsic sphincter deficiency, and more likely to have stage 3 prolapse with an anterior leading edge. All other demographics were similar between groups, including baseline PISQ scores, vaginal parity, and vaginal length. Both cohorts had a similar degree of improvement in PISQ-12 scores, 9% for mesh hysterepexy patients and 10% for total vaginal hysterectomy. There was no significant difference between the delta of the two groups. Also included are between-group comparisons of other pertinent validated prolapse-related quality of life outcomes. As with the first abstract presented this morning, total surgical time was shorter with mesh hysterepexy by 60 minutes. The vast majority of hysterepexies were performed under regional anesthesia, while all of the vaginal hysterectomies were performed under general anesthesia. Understanding that this is a short-term follow-up study, there were no mesh exposures. There is no one agreed-upon definition of de novo pelvic pain or dyspareunia in the literature. As such, we used multiple patient-centered measurable outcomes to report our findings. There were no patients in the mesh hysterepexy group who were identified as unsatisfied with their surgery as defined by the Surgical Satisfaction Questionnaire Question 8. There was no statistical difference in short-term composite failure rates between the groups defined by leading edge at or beyond the androidus, sensation of a bulge in the vagina or reoperation for prolapse recurrence. Despite a more severe anterior compartment defect in the hysterepexy arm, the short-term anatomic support was similar in the anterior compartment between the groups. Likewise, despite a greater preoperative degree of apical prolapse in the total vaginal hysterectomy arm, apical outcomes were not statistically different with point C around minus 6 in both groups. The only change that was significant between the groups was a greater degree of vaginal shortening in the total vaginal hysterectomy group. The strengths of this study include this being a novel study prior to this morning, but nonetheless, it adds to the limited existing data on subjective outcomes in these two procedures for sexually active women. Use of validated surveys is increasingly important for our patients and the providers related to pelvic organ prolapse treatment. Given the non-randomized nature of the cohort study being performed at a community hospital, this data may reflect real-world clinical scenarios of many practicing physicians in the United States as opposed to a university-based randomized controlled trial. Weaknesses of the study include a single study site leading to a homogeneous patient population and a single surgeon with high-volume practice who may not have complication rates that apply to the general population. The follow-up period was limited to an average of five months. The groups of patients showed the same degree of improvement in PISQ-12 scores, about 9 to 10%. New onset pelvic pain rates were low for both groups. More importantly, 20% of patients had resolution of pelvic pain with mesh hysterectomy. Intraoperative complication rates were low for both procedures at 0 and 3%. And during short-term follow-up, there were no mesh exposures. In conclusion, sexual health is similarly improved following both mesh hysterectomy and total vaginal hysterectomy. In appropriately selected patients, mesh hysterepexy provides an alternative to vaginal hysterectomy and may be more appropriate for patients unable to tolerate general anesthesia, prolonged operative times, or who have a desire to preserve their uterus while preserving sexual function. Correlation with long-term follow-up is necessary for practice-changing impacts. Thank you. APPLAUSE This paper is now open for questions. One of your exclusion criteria was not having filled out the preoperative PISQ-12. Can you give us an idea of what proportion of otherwise eligible patients might have been excluded because of that and how that might have impacted your study? I believe there were about 20% of patients who did not fill out the preoperative PISQ evaluation completely enough to be able to evaluate it. After the surgery, if someone didn't have urgency incontinence, the protocol still had the interventionists discuss the training with them, but if they weren't doing it because they didn't have urgency incontinence, then they didn't focus on that, if that makes sense. Thank you. This paper was awarded the Best Clinical Paper, so please join me in congratulating Dr. Sung and her office. APPLAUSE MUSIC Congratulations. Alright, so we'd like to invite up Dr. Jigali, who will be presenting their work on Outcomes of a Staged Mid-Urital Sling Strategy in Women with Symptomatic SUI Undergoing Pelvic Organ Prolapse Repair. Good morning. I'll be presenting for Dr. Jigali. Good morning. Thank you for the opportunity to present our research. We have no disclosures. Stress urinary incontinence affects about 30-80% of women undergoing surgery for pelvic organ prolapse. This has led many surgeons to perform concomitant mid-urethral slings at the time of prolapse repair. Small studies have shown that vaginal prolapse repairs result in resolution of stress urinary incontinence in approximately 30-60% of patients. In addition, small studies have shown that with a staged approach to sling placement, 66% of patients did not undergo a preoperative and mid-urethral sling procedure. While data exist on vaginal prolapse procedures and resolution of stress urinary incontinence, data on outcomes of a staged mid-urethral sling approach for preoperative stress urinary incontinence after minimally invasive sacrocolpopexy are limited. Thus, our objective was to determine the proportion of women who experienced resolution of preoperative stress urinary incontinence after minimally invasive apical suspension procedures without a concomitant sling procedure. This study was a retrospective observational cohort study from 2009 to 2015, which included minimally invasive sacrocolpopexies and uterus sacral ligament suspensions. Procedures were performed by seven SPRS surgeons. We included women in this study who had preoperative, subjective, and objective stress urinary incontinence. Subjective stress incontinence was defined as patient-reported symptoms. In objective stress incontinence, patients had to demonstrate leakage with coffer-Vasalva, unsimple systemetrics, or multichannel urodynamics. Women were excluded if they had The primary outcome was subjective resolution of stress incontinence after prolapse repair, and we defined this as the absence of patient-reported symptoms at any point during follow-up. For our secondary outcomes, we assessed the proportion and timing of the staged midurethral sling procedures, and we assessed clinical characteristics associated with resolution of stress incontinence and a staged sling approach. We used exploratory multivariable regression to assess clinical characteristics associated with the resolution of stress incontinence and the staged sling. In total, we had 93 women with preoperative stress incontinence who met study inclusion criteria. Mean age was 60. The majority of women were white. Average BMI was 29, and the majority of patients had stage 3 pelvic organ prolapse. The most common procedure performed was a minimally invasive sacroculpopexy followed by uterus-sacral ligament suspension. The diagnosis of stress incontinence was made mostly by simple system metrics followed by multichannel urodynamics, and our median follow-up was 8.3 months. At baseline, our women had significant bother from stress-generating incontinence. 67% reported moderate or quite a bit of bother. For our primary outcome, resolution of stress incontinence, we found 30% of women had symptoms that resolved. Of those 28 women, 26 reported resolution by 12 months, and an additional 2 women had resolution between 12 and 24 months. Approximately 50% of our patients did not require treatment for stress incontinence after their prolapse repair surgery. For those who required treatment, 37% had a sling placed, 12% had physical therapy, and 2 had a periurethral balking procedure. Of the 34 women who underwent a staged sling, 80% were placed at less than 12 months after the initial prolapse surgery, 15% were placed between 12 and 24 months, and 6% were placed at greater than 24 months after surgery with a median time to sling placement of 5.5 months. When we performed adjusted multivariable regression controlling for the baseline UDI stress symptoms, we found that obese women were 70% less likely to have resolution of their stress incontinence with an adjusted odds ratio of .28. On univariable analysis, we found that there was no associated clinical factors with a staged midurethral sling procedure. Strengths of this study include our cohort, which is mostly made up of minimally invasive sacral colpopexy, which is lacking in the literature. In addition, our retrospective design enabled extended follow-up. Most studies of SUI resolution only report up to 12 months. About a third of our cohort had follow-up greater than two years. In terms of limitations, our sample size was small. In addition, there was concern for preoperative surgeon bias for the decision to place a concomitant sling or not. We did not use validated measures or objective data for our postoperative SUI outcome. And lastly, this is mostly a descriptive study of women without a concomitant sling and is lacking a comparison group. In conclusion, we found that one in three women reported resolution of preoperative stress incontinence after minimally invasive sacral colpopexy or utero-sacral ligament suspension. In addition, obese women were less likely to experience stress incontinence resolution. 30% of women in this study underwent a staged midurethral sling approach. And in conclusion, we found a staged approach to treatment of stress incontinence may result in a marked reduction in midurethral sling placement. Thank you. Hi, this is Ronnie Adam. I'm hiding behind the pillar. Hello. From Vanderbilt. Can we move that mic? Hi. So, thank you very much. That's very good information to have because this happens, I think, to a lot of us. Could you further break down those 27 that you had with less than a year? I'm just interested to see how soon did you get to it on average? In less than a year? We do not have that data, but it's something we can definitely look at. I think on average we said time to sling placement was 5.5 months after the initial prolapse repair surgery. Yeah, it would just be nice to have the breakdown within the, just saying less than one year. For every patient? Well, maybe in three-month increments or something, just to have an idea. Thank you. I'm not sure who's next. Hi, Miles Murphy, Philadelphia. Thank you very much for that presentation. So, if you had a procedure that had a, for instance, 37% mesh erosion rate that the patient had to come back to the OR for a second procedure, I would think that most people would think that was probably not a great procedure. So, my question to you is, do you think that doing a staged procedure or offering a staged procedure for this type of clinical situation where a patient has preoperative stress incontinence is a good way to proceed based on your study, or do you think it's a bad thing to do? So, I will leave that to the discretion of the surgeon, but I think it's information that we can share with our patients that maybe you have a one-in-three chance of needing a sling after surgery. We could do one now. We don't actually have data in this study on outcomes after a sling placement and what the risk of postoperative stress incontinence is, and so I think it might be nice to have a comparison group to say, okay, we know 37% or 50% will have stress incontinence symptoms without the sling. This many will have stress incontinence symptoms with a sling. That would be a great comparison to have, but really I would leave it up to the surgeon and the patient. I think in my practice I'm going to present it to the patient and help them make the best decision for themselves with regard to postoperative mesh placement. Great. Thank you very much. Chuck Asher Walsh from New York. So, a third of the patients wound up being symptomatic afterwards but not getting treatment. So, did you look to see why they didn't get treatment? Because, you know, surgery is somewhat disruptive to people's lives. So, in fact, a third of the patients who sounded like had symptoms didn't wind up getting treated. Potentially because they didn't have the time for it. Did you look for that? And then, did you also look for the recurrence of prolapse in the patients who resolved their symptoms to see if that was different from the patients who didn't resolve? Both great questions. So, the first question, unfortunately due to the retrospective nature of this study, we did not have documentation as to the reason the patient chose what type of therapy to have with their stress incontinence. So, that's a great point. It could be because of patient time, FMLA, job, income loss of salary. So, that's a very valid point. In terms of your second question, I'm sorry, what was your second question again? About the recurrence of prolapse. So, we did in the manuscript, we do have resolution, no resolution, no sling placement, looking at post-operative BA, and there was no difference between the two groups, which is not necessarily, you can define recurrent prolapse in a number of ways. We chose to look at BA. One last question. Kate Merriweather, Louisville. Thanks for a great presentation. I'm very interested in the clinical practice around this study. Is this a population of folks who you universally offer them stress incontinence surgery, and this represents a population that declined to that? Or is this a population that you don't routinely offer them the stress incontinence surgery concurrently, and this is everybody, pretty much? That's a great question. So, the practice pattern at our institution during the timeframe of this study was to not offer a concomitant sling at the time of prolapse repair surgery, and to offer a staged approach. About 5% of our patients do have a concomitant midurethral sling, which does potentially introduce some bias into our results. Helps put it in context. Thanks. Thank you. So, this ends this morning's first scientific session.

Dr. Charles Nager

vaginal surgery options

uterovaginal prolapse

vaginal hysterectomy

mesh hysterepexy group

complication rates

patient-reported outcomes