Welcome back from lunch. I'm really, really excited for our surgical round-robin. We have a few housekeeping items to start with first. Okay, this is the one time where it's okay to get out your phones, so if everyone could take their phones out. We have some instructions on Poll Everywhere. So there's two ways to do this. You can go to PollEv.com slash Augs to join, or just in your phone put in the numbers 22333 and then text Augs. I'll give you guys a second to do that, and then we're going to do a little test question. All right, let's pull up our test question. What is your favorite singing competition? American Idol, text A. X Factor, The Voice, or Sing Off? Got 50 results out of 1,000 of you. 107, 113, 23. All right, can we show the results? The Voice. The Voice wins it. Of course. All right, so we're live. It's working. Okay. I would like to introduce today's host, Tony Sechrest, to the stage, please. Oh, America! I'm your host, Tony Sechrest, coming to you live from the studios of the Hyatt Regency in Chicago. This is Augs Surgical Idol. There's been question of whether the gold standard sacral colopexy, well, maybe it's not so gold. A lot of that is due in part to the CARE trial that published long-term results from sacral colopexy. But because of the modification. Yeah, I'm also just aware that. Yeah. And I'm going to talk about the major modifications. It's generally a decreased use of Gore-Tex material on the vagina, a move from myrceline and other materials to polypropylene mesh, and that just the use of sacral colopexy or some variation of that to actually treat primary uterine prolapse as opposed to only recurrent prolapse. So what we're not going to do today, we are not talking about straight sacral laparoscopy versus robotic surgery. We are not talking about vaginal versus abdominal. We are focused. It's going to be a tight competition. All sacral colopexy variations. Is that okay if I say sacral colopexy variations? And all minimally invasive techniques. What we have in store for you is a great show. We have the best of the best. We have the best techniques, and we have some four of the most skilled surgeon contestants that we could find. So without any further ado, I'm going to introduce the four contestants. No. No. After I bring the contestants up, I'm going to show this slide. So then I'm just going to say that our first contestant comes from San Diego, where the weather is perfect and there's no humidity, and Sean Menefee. He's going to be trying to convince us. And they'll go that way. Oh, actually, they have to go this way. And I'm going to tell them to just stand over there. Yeah, I think so. When they're coming up. Yep. Second is hailing from our nation's capital, Washington, D.C., Rob Gutman, who's going to try to convince us that his way of doing it is the best, a TVH, so total vaginal hysterectomy, sacral colopexy. And from the person who's had to travel the least, from the fun, windy city of Chicago, Kim Kenton, who recently, I'll just say, is going to try to sell us on this concept that total laparoscopic or total robotic hysterectomy, sacral colopexy is the best. And finally, our fourth contestant, coming from British Columbia, Jeff Cundiff, will try to convince us that hysterectomy, sacral colopexy is the way to go. I think we're going to be wowed today. So we're going to start with our case. Our case is simple. It's a 59-year-old female who presents with bothersome bald symptoms after failing a pessary. She has stage 3 anterior prolapse. She still has her uterus. Her uterus is coming out. She has normal pap smears. And she's done her homework. She wants a laparoscopic or robotic repair. And that, as she believes, is the most durable. So the rules of engagement. Each contestant will have seven minutes to present their case, trying to convince us that theirs is the best way to go. There's a trap door behind the podium. If they go over seven minutes, it'll make everybody's voting a little bit easier. Good? No good? Good. Okay. Once the votes are in, in America, you guys will vote. Approaching zero with mesh erosions. And I think that's really what we need to shoot for, a procedure that's very, very low. And even 5% and 8% is not what we're shooting for. We're shooting for a zero. So just to clarify, again, it's easier to perform. We need to eliminate the vaginal incision. And this is the way to go. So I don't have to bring up the morcellation and the Lyme mild sarcoma argument that I had geared up. I guess my big question for Jeff, though, is, with this hysterepxy, which I assume that you're going on, what happens when you have suspected fibroids? Do you actually screen those beforehand? What do you do as far as postoperative screening? Do they then need MRIs and surveillance? And how difficult is it to perform a hysterectomy if somebody has uterine pathology after you've performed your hysterepxy? So that's my question to Jeff. Thanks. Thank you. So I have to be honest with you. I didn't prepare slides for a rebuttal because I didn't really expect to be here. So maybe the fact that I brought forward my conscience and talked about native tissue is why I am. Because I have to tell you, there's not very many patients who I treat with uterine prolapse with a sacrocopalpexy. I used to, and that's why I worked to develop the sacrohysterepxy. There's still those ladies who have rectal pelvic floors, and if they've got fibroids, I actually do a supracervical hysterectomy. But approaching zero is not zero. And frankly, if they've got a normal uterus, I leave it in place and do a sacrohysterepxy. But I find that the best sacrocopalpexy, the one that's been around for 50 years and essentially unchanged, is the one in a patient who is post-hysterectomy and has vault prolapse. And so that is who I try to use mesh in. And that's how I do it. America, their fate is in your hands. Don't screw up. Okay? Sean Menefee, why don't you get started? I'd like to thank Dr. Sechrest, Dr. Lane for hosting the debate today, and all the judges in the audience. So I think we can assume that all the teams or techniques have similarities. They have high rates of anatomic success, significant improvement in pelvic floor symptoms, and low rates of adverse events. The obvious best choice should be technically easy, consistent, and reproducible, both for the hysterectomy and the mesh attachment portion, and safe in order to minimize surgical and post-operative AEs. Well, team cervicalpexy has multiple advantages, dissection and coagulation above the ureter, robust and safe anchor points, and uncomplicated mesh placement. The other teams or techniques have additional dissection, a vaginal cough, which can have ischemic changes, multiple positional changes, and mesh gymnastics. What is the main concern for the patients having prolapse surgery today? I'll give you a little musical hint based on what they see in the media. It's mesh complications. Many patients come up and say, am I having that mesh, even when they're not even having a mesh surgery, even with cervicalpexy. But cervicalpexy is not involved in the FDA warning or lawsuits yet. And why? That's the common belief that mesh-replaced abdominally has acceptable mesh exposure rates. Comprehensive review by Dr. Nygaard showed a 3.4% rate. The e-care trial at six years, however, showed this 10.5% mesh erosion. And Dr. Cunduff from the care data showed an odds ratio increase of five with concomitant hysterectomy. Thanks, Jeff. And Dr. Gutman here, in a nice cohort, showed a 5% with total hysterectomy versus a 0.6% with supracervical. So as Tony outlined, there are some advancements that have been made in the last few years that have hopefully kind of decreased our issues with mesh erosion moving forward, but there are certain risk factors. Some of them are modifiable. Type 1 knitted ultra-lightweight polypropylene mesh is the standard now. Suture type, Gore-Tex braided nylon may increase risk. Advanced prolapse, smoking. But I would say the modifiable one is concomitant hysterectomy. And whether that's related to a vaginal incision or a vaginal cuff, I think that's unclear. So many past trials, it's difficult to figure out the mesh exposure and incision, no incision, but I've outlined a few in which we can clearly delineate this. So Dr. Visco and Higgs demonstrated that making a vaginal incision for mesh attachment is probably not a good idea. We see here that overall mesh exposures were more common when the vagina was open, either with hysterectomy or with mesh attachment. And then you look at the no incision group, and obviously it performs better. So this is a debate about uterine prolapse. So these are some numbers with just hysterectomy involved, and I wanted to outline a few. Obviously with total hysterectomy, it exceeds that 3.5% that we always like to use for sacral plexus. When you look at trials in which they use similar mesh and similar techniques, the advantage goes to supracervical. And then I like to highlight the supracervical group, especially two excellent studies by Dr. Kenton, and I just want to highlight that supracervical hysterectomy is from that trial. So the advantage goes clearly to team cervical pexy. So I've been able to perform a lot of these techniques in the past, so much so people thought that I was going to represent another team, which I'm not. And I think it comes down to what works for you and your patients. Total hysterectomy is more time-consuming, dissection close to the ureter. Even with a two-layer closure, a late-absorbable suture, you still have an incision with synthetic mesh above it. And when the incision is open for various reasons, infection, hematomas, and does that increase the risk of mesh exposure, I'd say yes. So vaginal hysterectomy, similar incisional concerns with total hysterectomy, but you have the positional changes. Vaginal, go up abdominally, hook it up, go down below for the sling. You go from a clean contaminated wound to a clean surgical field, plus placing the mesh, attaching it to the mesh that's sitting in the vagina and then into the peritoneal cavity. Not sure if that's a great idea. Hysterectomy, even though the uterus is often small, it obstructs your visual field. Some people aren't comfortable with broad ligament dissection and the edges of mesh against the uterine artery. It lacks standardization. And a recent study showed that overall success rates favor cervical pectus over hysterectomy. Well, even Jeff can't make up his mind as far as what a standardized technique is for hysterectomy. Right, Jeff? And then some people put it anterior, some posterior. I just don't know what a hysterectomy is. So I know all of you want to do supracervical hysterectomy, but what about power morcellation? I'm sure you're going to hear more. 2014, all medical centers have different rules. Many taken power morcellators off the shelf altogether. The November 17, we thought there would be more data and clarification. Basically, you can't perform a power morcellation in a postmenopausal patient with suspected fibroids. But this case and most cases do not require power morcellation. I happen to have some slides of this case. We actually put a stay stitch in the cervix. We elevate it up through our accessory port. We then remove the port. We actually extend the fascia or the skin, grab it with a Leahy, and then we just have the uterus coming on out. You can turn up the volume. So we found that this does not increase our length of stay or postoperative pain. So concerns with morcellation. A large portion of our patients are postmenopausal. I get it. The older the patient with presumed fibroids, the greater the risk of malignancy. Be smart. Screening should be performed when indicated. A bimanual exam or something to assess the uterus. Postmenopausal bleeding should be worked up and cervical screening when appropriate. So, vote Team Cervical Pexi. Where's my music? Take the wrong one. Anyway, I guess I'm finished. Vote for Team Cervical Pexi. Slides. Well, thanks, Felicia. Thanks, Tony. Thanks to the Augs and everybody. Make sure you vote. But I'm going to tell you a little bit of why vaginal hysterectomy is the way to go. And I know it's the exception. It's not the way everybody's doing it. But it's important to look at, be open to this. So these are my disclosures. They're not relevant to this. And I also have other disclosures. I do a lot of vaginal native tissue. I've done every combination of these. I currently actually perform three out of the four. I believe Sacral Colpexi is the most durable. And I favor more extensive mesh attachment. And I typically do a concomitant posterior repair. But my technique has evolved. So I didn't just all of a sudden start throwing on mesh vaginally and doing this technique. And so I think it's important to understand that I started by training with my esteemed colleague and mentor, Dr. Cundiff, who taught me how to do total abdominal hysterectomy and super cervical and then attach the grafts abdominally and do a Sacral Colpexi. And that was great until we converted to laparoscopic. And then we started doing more super cervical Sacral Colpexi. If there were no contraindications to keeping the cervix, good technique. And then for those patients that you didn't want to keep the cervix, we started doing a vaginal hysterectomy. And the nice thing about the vaginal hysterectomy is you actually have a vaginal hysterectomy for the residents to do. So instead of teaching them one more laparoscopic, we could do a vaginal hysterectomy. Great. But I'd close the cuff. I'd go up laparoscopically. And it is really hard to do that anterior dissection. And you know why? Because you put that malleable or that easizer or that briskey in, and the posterior wall is longer. So you're in the posterior fornix, and you're pushing real hard, and you can't get the anterior wall distended. Or it goes in the lateral fornix, which is usually a lot longer, wider. And it's never where you want it to be. The anterior wall is long. And then you can't get it right at the cuff, and you're close to the bladder when you get in. It's a pain. So then I thought, well, how can I improve this? So I said, well, I can open up the anterior space vaginally, and then I can go back and do the rest because the posterior dissection is actually really easy on the sacral colpex. It's somehow easier than even open or sometimes even the vaginal. So I could do that and do the rest of the case. So I started doing this. And this is my technique. And these are some of our slides from our video that if you want to see later, you're going to vote me forward. But this shows grasping the cuff, identifying the bladder, and then we're getting in the vesicovaginal space. And I typically go about one to two centimeters from the cuff because I want attention-free closure. And I enter the space, and I start dissecting the bladder off. And you can see you can identify the Foley balloon. You were in the true vesicovaginal space. And we're getting it down, and we can get down all the way to the urethra-vesicle junction. And you can see it's pretty easy to do that anterior dissection. So I'd close the cuff. I'd go up above, and I'd finish it laparoscopically. And that was seeming to work very well for me. But then my partner suggested, well, maybe why don't you just attach the grass while you're down there? And I said, well, that seems a little out there. But there was someone in Virginia who was doing it and showed decent outcomes, very preliminary. And I said, well, maybe I'll develop my own technique. And independently we did, and we published on it. But I basically said, if I'm going to go to the bother of doing this, I actually want to attach the grafts both anterior and posterior to save time because, you know, why bother doing the one and not the other? And then we're going to go up laparoscopically, and we're going to attach them. So we started attaching the anterior graft. And I usually use about six sutures or, you know, somewhere between five or six. And I attack distal and proximal. We're using Gore-Tex here, but we've switched to PDS a long time ago. And we leave it two centimeters from the cuff incision. And then we go posteriorly, and we dissect it, and we get down pretty far. And it's pretty easy to get down there. And I typically stop about two-thirds, three-quarters along the posterior wall because I want to leave room for a perineoraphy without the mesh overlapping that area. And then I attach the grafts. And you can see I leave it two centimeters from the cuff, and I've got good support on the posterior wall. And then we irrigate a lot, like a liter. Some use biobiotic or, you know, antibiotic solution. I don't. Put the mesh back in. Close the cuff. I try to keep the grafts spread out by doing interruptives or figure of eights. And then before I go up laparoscopically, I do a perineoraphy just because it's easy, and I don't have to do a lot of vaginal manipulation. The only thing I have to do is for tensioning. So in our cohort, retrospectively, we actually compared it to supracervical, Dr. Menefee's technique. And short-term outcomes, nine months, but we saw very low mesh exposure rates in each group, a lot lower than what we've seen in those studies. And we saw a shorter operating time. I actually cut an hour off the surgery. An hour. Okay? And there's no difference in all the other outcomes. So why do other potential advantages? Did I mention an hour? Shorter operating time. Who wouldn't like an hour shorter operating time? Longer anterior graft attachment. This has the potential for fewer recurrence. It's hard to prove, but long-term it may. Less time in steep Trendelenburg, and we all know the effects of that steep Trendelenburg. Better surgeon ergonomics if you do straight stick. You're not going to have to worry about those C-spine issues. And lower cost if you use the robot, because I really don't think you need the robot for this. And if you have those really severe advanced stage 4 prolapse where, you know, it's really stretched out 12, 13 centimeters, you can actually shorten the vagina, get a really wide, long mesh attachment, and those are like the perfect patients for this procedure. So what are the disadvantages? Well, as Dr. Menefee pointed out and my colleagues will point out, there's a higher potential risk for mesh. And that's the biggest thing. So this is my ICI data, which you saw already. But basically the International Consultation of Conducts, and we looked at all these studies, but when you break it down, a lot of those were the abdominal approach using older meshes that were not as lightweight, not the ultra-lightweight, and they showed that 9%. And some of those studies showed all sorts of grafts in them. And the laparoscopic were some of the lighter weight meshes. They're down to 6%, but there's still about a threefold increased mesh risk compared to if you have a post-hist patient, if you keep the uterus, if you keep the cervix. So when we break down that data and you look at it a little further, because what my colleague from San Diego didn't tell you is that they actually did some of these totals versus supra-cervicals. They had a 23% rate if you do remove the hole versus 5% in a supra-cervical. That's really high, 5% with a supra-cervical. And those patients, they have both vaginal attachment and abdominal in that group. And then the colleagues in Virginia, they actually had 5%, which is zero. So it's definitely higher, but it's not very high. And we showed 1.6% versus 1.7%. So why do I think that our mesh exposure rate is so much lower? Well, we're using ultra-lightweight mesh, tension-free attachments. And then this is short-term. I do expect it to go up a little bit long-term, but I certainly do not see, and I've been doing this for 10 years, I don't see that rate going up above 3%. So when you look at the vaginal versus the laparoscopic attachment, which Dr. Kenton is going to talk about, 14% versus 32%, 3% versus 11%. The 3% is using a technique similar to ours, but they're using a heavier mesh, and we're using ultra-lightweight. So the evidence support that if you're going to do this, attach the grafts vaginally, don't attach them laparoscopically. And the bottom line is why do I think this is higher? I think you do a lot of manipulation, you disrupt the cuff, thermal energy, overlapping suture lines, and I think you get a better, longer anterior attachment. So in summary, Dr. Kenton is going to come up and talk to you about her laparoscopic hiss, and what I'm going to say is say no to TLH because you really don't want to increase that mesh risk, and you will. That increases the risk. Thank you. So here are my disclosures, but perhaps my most important disclosure of the morning is I was at the first break discussing strategy with Dr. Gutman when I learned that I actually was debating the wrong thing. So my first slide, which was going to be really easy to defend why one shouldn't do a vag hiss at the time of sacral colopexia against Dr. Menefee, we're just going to sort of pass over. And then I was wondering why did I think Dr. Gutman was doing hysteropexy? So I rushed back up to my room and I did a quick PubMed search, and three of the four last papers that Dr. Gutman has published on prolapse all have to do with hysteropexy. Things that he said about hysteropexy were there's high satisfaction and low reoperation rates over and over and over again. Well, I know this probably seems like I'm helping Dr. Condis' argument. It's more to disclose why I'm so confused that Dr. Gutman is now moving on to like inserting mesh through the vagina. So let's talk about his one paper, a retrospective chart review looking at vaginal versus abdominal mesh placement. Short-term follow-up, nine months, and I'll totally give him at nine months he has very low complication rates in either arm, 1.6%. So to me, the only advantages would be the ones that he pointed out were a one hour shorter OR time in the laparoscopic group, 344 minutes versus 256 minutes. I would say if you compare that 344 minutes, that may be on the higher side compared to other published laparoscopics. So perhaps it's because he can't do a very quick laparoscopic hysterectomy. And there was a higher posterior repair rate or more just pyrunia in the vaginal arm. So really, I think this argument gets down to like Dr. Menefee and Dr. Gutman fighting it out. In San Diego, they have a 10% mesh exposure rate with this technique. In D.C., they have a 1.6 mesh erosion rate. Who do we believe? So the survey, when we surveyed the audience about this repair. So let's go on to the next one. So now let's talk about uterine preservation. Excellent systematic review recently published by a bunch of members of our organization. Compelling conclusions were basically a hystereopexy is associated with a decrease in OR time, bleeding, and mesh exposure rates. So basically, what that boiled down to was the OR time decreased by about 20 minutes. I'm not going to make big surgical changes over 20 minutes. A decrease in bleeding of 64 mils. That's about what you have in these four test tubes. If you read Dr. Guinnessman's recent publication in the Gold Journal, it's about the equivalent blood loss of all the excess labs that get drawn routinely on our patients. So then what did they say about the mesh complications? This review further underscores that hysterectomy is an increased risk of mesh exposure and reoperation for mesh. So really, the other side of that argument is how does it weigh up against the risks of uterine pathology and keeping the uterus in situ? Well, this is what the systematic review concluded. There's a dearth of information in the literature, and they're unable to make evidence-based recommendations about how to counsel patients regarding the risk and need for later hysterectomy. So basically, we're promoting hystereopexy, but we're fully conceding that we have no idea how to counsel patients in our area of shared decision-making about their uterus. So let's talk about mesh exposure. They only included three studies. The first one is this very well-done study of 29 patients who underwent, quote-unquote, pelvic reconstruction with mesh. Unclear what they did. Published in 2005 in the very prestigious Jönsson Medical Journal. So let's just move on. The second one that they included in their mesh exposure rates was one in the very prestigious European Urology Journal. Also in 2005, all the copeplexies were done with the MARLEX. So we're going to skip that one. But perhaps the most compelling of these three studies was by our very own Dr. Kundis. This one had a whopping 27 patients included. Most of them had polypropylene, but he had read Dr. Visco's earlier work from the 90s about sacrocopepine and aropaxi, and he put in porcine in those. Probably they should have been excluded. But in his nine patients who had an open hysterectomy and laparoscopic sacrocopopexy, how many people are doing open copepexies? He had an alarmingly high 33% mesh erosion rate. So I'm really not quite sure what to do. We've heard Dr. Menefee publish tons of studies about that high mesh erosion, low mesh erosion rates, and this is an outlier. So the survey said no to hystereopexy. So our patient wanted a durable repair. Here's the definition of durable. One study actually looks at this head-on, looking at supracervical hysterectomy versus total. UNC looked at about 80 women. Their primary outcome was greater than or equal to stage 2 prolapse. Anatomic failures were three times more likely with supracervical hysterectomy. Symptoms were more likely with supracervical hysterectomy, and mesh exposures were no different. So tons of data about the cervix and how mostly it doesn't matter. However, there is about a 20% reoperation rate for this retained cervical stump. I have to go back to 1976 to talk about this. Basically, complications are about 46%, and none of those patients had their apex supported to the sacrum with mesh. So no to that. So what is the best way to surgically manage prolapse? Survey says laparoscopic hysterectomy and sacroculpopexy. Bring it on. I have a debate with Kim Kenton where Kevlar. Okay. Jeff, you're up. Talk to us about hysterectomy. Well, good afternoon. We've heard from my esteemed colleagues, and they've provided excellent arguments for sacrohystereopexy. Thank you very much for making such a good case. I've been tasked with arguing for laparoscopic sacrohystereopexy. I think they've actually made most of my arguments for me already. I'd like to start with this survey, which came out of the Cleveland Clinic 2013, and they noted that all things being equal, this is a survey of women undergoing prolapse surgery, all things being equal, they just assumed keep their uterus unless hysterectomy improves the outcomes. And what they didn't actually ask is what if hysterectomy increased the complications. So after this, there became really a huge increase in the literature on sacrohystereopexy, and these studies largely show that you get the same symptomatic relief as sacrocopopexy with hysterectomy. Actually, one of these is by one of my contestants up here, Dr. Gutman. As we already know, he's a big advocate of the sacrohystereopexy. So you could say that all of these papers came out because they were actually trying to fulfill the patient's wishes for keeping their uterus. But I would actually suggest that that's not the case. I would say that the primary motivator for developing the sacrohystereopexy was this. You see, concurrent hysterectomy is a well-established risk factor for mesh exposure. And we've heard some efforts to actually poo-poo the data as being too old and not relevant. But it's not just the care data. It's also prospective data and systematic review that make it very clear that hysterectomy is a risk factor for mesh exposure. So we might ask ourselves, how morbid is mesh exposure after a sacrocopopexy? And the answer to that question is provided by this surgical series. It showed that vaginal excision with partial coprochliasis resolved symptoms in half of patients who had mesh exposure. But excision by laparotomy was indicated if this failed. And in total, 80 percent, not quite 80 percent of the patients had complete resolution. But it took a mean of 1.4 surgeries, and a third of them suffered major complications. So a concurrent hysterectomy significantly increases the risk of a complication that has significant morbidity. And as we look at our choices here, I have to note that three out of four actually include a hysterectomy. So I think right there, that is the argument for a laparoscopic sacral hystereopexy. But before I finish, I want to take a little bit closer look at our patient. So I thought she was 59. Actually, it turns out she's 49. So it seems that she is asking for a mesh procedure. But I have to ask, does she really need mesh? I mean, our duty as surgeons is to provide our patients with informed consent, which should include discussion of alternative procedures and related benefits and risk of each procedure. And my opponents have focused on the discussion of technique for hysterectomy, neglecting the issue of mesh, and really focusing on what's easiest for the surgeon, you know, whether you have to change fields. But what about the patient? We all know that a mesh repair is more durable. But does this patient need that durability and the associated risk? To answer that question, we need to think about what are her risks for developing recurrent prolapse. So what are the risks for recurrent prolapse? Well, there's good data to show that if you fail a prior prolapse procedure, you're at risk. And this same study actually showed that many of the other risk factors that have been bandied about really don't meet significance. And that's been confirmed by systematic review and a more recent meta-analysis that showed that really the only significant risk factor besides a prior failure is an avulsion of the pelvic floor. So when we're trying to identify those patients who will benefit from a mesh-based repair, really it's a prior failure and a wrecked pelvic floor are what we should be looking for. And I don't think this patient has those. So how do we proceed in discussing the benefits and risks and alternatives with this patient? Well, the Cleveland Clinic has developed an evidence-based risk calculator to make that easier for us. And so I plugged in our patient to that. And you can see that she actually has a very low risk of having recurrent bulge because she went the sacrocopalpexy route. But she only has a 6 percent risk of recurrent bulge from an apical vaginal procedure, native tissue repair. And if we look at the risk of any serious adverse events, that's also equally low for the native tissue apical repair, whereas it's 20 percent, one in five, for sacrocopalpexy. So when I'm going to counsel this patient, I'm going to tell her that she should really look to a native tissue repair with a vaginal hysterectomy. And if she happens to be in that 6 percent, which the EVALT study tells us is what percentage of patients who've had that repair actually seek another surgical treatment, then she will actually have a good risk factor for a sacrocopalpexy because she will have failed and she also won't have a uterus. So the obvious choice is a sacrocopalpexy. So I think that this comes down to informed consent. She has no clear factors for recurrence. The risk calculator says she needs a native tissue repair. Only if she insists on mesh should we then consider a laparoscopic sacrohistropexy because it's the only reasonable procedure that maximizes symptom relief without maximizing complications. Thank you.

surgeons

surgical approach

pelvic prolapse

hysterectomy

mesh exposure rates

postoperative complications

patient preferences