A Survey of Operative Techniques Used by Female Pelvic Medicine and Reconstructive Surgeons Performing Minimally Invasive Sacral Colpopexy

Objective Assess variability of surgical technique for minimally invasive sacral colpopexy (MISC) among Female Pelvic Medicine and Reconstructive Surgery (FPMRS). Methods A voluntary anonymous questionnaire was given to the 2018 American Urogynecologic Society (AUGS) annual meeting attendees. Comparisons were made by age, gender, experience (years), practice setting, and U.S. region. Results There were 59 responses from 671 physician conference attendees. Most were male (64.4%), U.S. physicians (94.6%), completed Obstetrics and Gynecology residencies (91.5%), practicing in University settings (66.1%). The mean age was 47.4±8.6 years, practicing>15 years (47.5%). Predominant routes were 53.8% robotic, 42.2% laparoscopic, and 4.0% open. Surgeons used 3-4 ports (both 50.0%), with 0-degree (46.0%) or 0 and 30 degree laparoscopes (36%). For sacral mesh attachment, 83.1% used suture as opposed to tacking devices, most often Gortex (56.3%). Anterior (48.1%) and posterior (50.0%) vaginal attachment used 5-6 sutures. Concomitant procedures included anterior repair (83.4% “not usually”/“not at all”), posterior repair/perineorrhaphy (77.8% “yes, often”/“yes, sometimes”), midurethral sling (42.6% “yes, often”/51.9% “yes, sometimes”), and hysteropexy (86.5% “not usually”/“not at all”). Post void residual (PVR) was assessed after surgery by 89.8%, 75.5% via retrograde fill voiding trial. Most patients were discharged post-operative day 1 (POD1) (47.6% AM, 29.1% PM) or day of surgery (15.2%). Females more commonly performed hysteropexy (p=0.028) with no other significant differences by age, gender, experience, practice setting or region. Conclusion Most FPMRS surgeons perform MISC, equally robotic and laparoscopic. Concomitant posterior wall procedures and midurethral slings are common. Other than more hysteropexies performed by females, no other variables predicted technique variations, suggesting technique homogeneity.


Introduction
The lifetime risk of a woman undergoing surgical repair of pelvic organ prolapse (POP) is greater than 12% [1]. Sacral colpopexy (SCP) is considered the gold standard procedure for apical prolapse repair. First described in 1962 by Lane, the abdominal SCP uses biological or synthetic material attached to the anterior longitudinal ligament of the sacrum to provide apical support [2]. Over the last several decades, SCP evolved from an open to a minimally invasive technique.
Current literature suggests that minimally invasive approaches decrease morbidity without affecting surgical efficacy. Comparing minimally invasive sacral colpopexy (MISC) to open SCP highlights that the minimally invasive route has lower rates of 30-day complication rates, deep vein thrombosis/pulmonary embolism, surgical site infection, readmission rates, and shorter hospital stay [3]. Another significant milestone in SCP procedure evolution was the shift from inpatient stay to outpatient settings. Previously, patients spent four days in the hospital (interquartile range (IQR) [3][4][5] after open SCP compared to two days after laparoscopic procedures (IQR 2-3) [4]. Despite the rising incidence of obesity causing increased operation time, MISC is still associated with shorter hospital stay [5]. Kisby CK et al. demonstrated that same-day discharge for robotic-assisted SCP is safe. No differences were observed in unplanned clinic visits, emergency department visits or readmissions [6]. Patient satisfaction appears equivalent between those discharged on the day of surgery and those who stayed the night in the hospital [7].
A 2016 review of surgery for POP found that SCP was the preferred method for apical vaginal prolapse, with a predominance of laparoscopic approaches and use of monofilament polypropylene mesh. However, the review concluded that variations exist in a majority of the technical aspects of the procedure [8]. Currently, there are 54 Obstetrics & Gynecology (OBGYN) based Female Pelvic Medicine and Reconstructive Surgery (FPMRS) fellowships and 15 Urology-based FPMRS fellowships [9]. The total number of fellowship-trained urogynecologists in the USA is 1, 378. However, there remains no definitive surgical approach or technique for performing MISC. The aim of this study was to define the tools and techniques used for various MISC steps among American Urogynecologic Society (AUGS) conference attendees and whether there are variations by age, gender, region, training background, practice setting or experience level.

Materials And Methods
A 24-item questionnaire was created about MISC (refer Appendices). We collected basic demographic information: gender, degree, years of practice, practice setting, and geographical location. If the surgeon performed MISC, we asked specific surgical questions: laparoscopic vs robotic approach, number and location of placed ports, degree and size of scope used, type and amount of suture used for vaginal and sacral attachment of the mesh, ureteral identification techniques, concomitant procedures, and timeline for hospital discharge.
This questionnaire was reviewed/revised by the AUGS program committee for content and was approved by our local IRB. The questionnaire was given to attendees at the 2018 AUGS annual meeting in their registration packet. Participants were instructed to return the anonymous survey to the conference registration desk or via email or U.S. mail. Conference attendees were reminded on the first day of the conference to return the survey but were not otherwise contacted to increase the response rate. Survey responses were analyzed with descriptive statistics using Statistical Package for the Social Sciences (SPSS) (IBM Corp, Armonk, NY). Comparisons made between physicians of different ages, genders, years of experience, practice setting, and U.S. region were analyzed using t-tests, Fisher's exact, or Chi-square where appropriate.

Results
Of the 671 physician conference attendees, there were 59 responses (8.8%). Respondents were distributed across the four regions of the US: Northeast 32.1%, South 30.2%, Midwest 20.8%, and West 17%. The vast majority (94.6%) of the responders were U.S. based, with two participants from Canada and one from China. Most of the respondents were males (64.4%). Training, practice settings, and years in practice of participants are presented in Table 1.   Surgeons commonly perform concomitant procedures at the time of SCP ( Table 3). Midurethral sling placement was frequently performed defined as responses of "yes, often" (42.6%) or "sometimes" (51.9%).
Posterior repair and perineorrhaphy were performed either "yes, often" or "sometimes" by 70.3% and 77.7%, respectively. Conversely, concomitant anterior repair was rarely performed with responses of "not usually" or "not at all" in 83.4%. Hysteropexy is rare, with 86.6% performing "not usually" or "not at all".  There was more variation in physician assessment of the bladder ( Table 2). All responders performed cystoscopy during MISC but used different additional means to enhance the visibility of ureteral jets. The most common responses were "no additional intervention used to identify the ureters" (31.5%), "urine discoloring medications such as Azo, Uribel, Pyridium" (27.8%), and "fluorescein" (24.1%). Post-operatively 89.8% of the surgeons assessed post void residual (PVR), most commonly via "retrograde fill followed by active voiding trial" (75.5%).
A majority of patients were discharged on post-operative day 1 (POD1) with 47.6% of patients discharged in the morning of POD1 and 29.1% discharged in the afternoon of POD1 ( Table 2). Only 15.2% of patients were discharged on the day of the procedure. One participant from China reported typical discharge on POD5.
For comparisons between physicians of different ages, genders, years of experience, practice setting, and U.S. region, we only found a difference in the frequency of hysteropexy by gender. Men performed hysteropexy with SCP either "not usually" or "not at all" 97% of the time. On the contrary, women performed hysteropexy with SCP "yes, all the time", "yes, often", or "yes, sometimes" 33.4% of the time (p=0.03). For all other comparisons of technique there were no differences by these comparative factors.

Discussion
The majority of AUGS attendee survey respondents perform MISC, with an equal distribution of both laparoscopic and robotic surgeons. Concomitant posterior colporrhaphy was far more common than anterior colporrhaphy. Hystereopexy was performed more commonly by female surgeons. Beyond this variation, there is relative homogeneity of surgical technique across regions, practice settings, gender, age, and years of experience.
We found that 84.7% of responders perform sacrocolpopexy via a minimally invasive approach, and techniques are mostly homogeneous across survey respondents. We hypothesized prior to completing this research that older physicians further out from training may be less likely to use minimally invasive routes. We did not find this result, which shows that minimally invasive techniques have been relatively well adopted across AUGS.
One of the interesting findings of this study was that while hysteropexy is less commonly performed overall, it is more commonly performed by female surgeons. Hysteropexy is an evolving technique with increasing popularity in practice. Meriwether et al. showed that laparoscopic sacral hysteropexy improves point C and vaginal length while reducing mesh exposure, without increasing blood loss or pain [10]. Currently, there is largely only short-term data on prolapse outcomes for minimally invasive hysteropexy, but with increasing use of hysteropexy there is opportunity for future research.
Notably, this study highlights current discharge practices amongst respondents. Historically, abdominal sacrocolpopexy was associated with longer hospital stay [11]. Since the majority of the surgeons have moved towards minimally invasive approaches, time spent in the hospital after surgery has decreased. In addition, concurrently evolving Enhanced Recovery After Surgery (ERAS) protocols have further changed discharge practices. Carter-Brooks et al. demonstrated that ERAS in urogynecological populations resulted in a greater percentage of same-day discharges. Their study also showed a 93.5% patient satisfaction rate for overall surgical experience, but the authors note a slightly increased 30-day hospital readmission rate [12]. Our survey suggest that the majority of patients are discharged POD1 (76.9%), but with continued integration of minimally invasive techniques and ERAS protocols, there is potential for same-day discharge to become more routine.

Conclusions
In summary, our survey showed that the majority of survey respondents perform MISC split equally between robotic and laparoscopic routes. Among concomitant procedures, posterior colporrhaphy/perineorrhaphy and midurethral sling are the most common. Hysteropexies are more often performed by female surgeons. The vast majority of patients are discharged on POD1.

Additional Information Disclosures
Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.