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Sacrocolpopexy – How Low Can You Go? Lessons Learned from the Dead Poets Society

2021; Elsevier BV; Volume: 28; Issue: 4 Linguagem: Inglês

10.1016/j.jmig.2021.01.019

1553-4669

David Shveiky,

Anorectal Disease Treatments and Outcomes

The famous chorus line “How low can you go?” from the “Born to Hand Jive” song from the prom scene of the 1978 musical film Grease is a frequently asked question by pelvic reconstructive surgeons when performing minimally invasive sacrocolpopexy. Decisions regarding specific surgical steps in sacrocolpopexy are complex: How low should we dissect and place the mesh on the anterior and posterior vagina? Should we suture it only to the apex? Midvagina? Or should we dissect down to the bladder neck anteriorly or posteriorly at the levator ani muscles? Proponents of low mesh placement may argue that the anterior wall placement of mesh improves anatomic surgical success [1Wong V Guzman Rojas R Shek KL Chou D Moore KH Dietz HP Laparoscopic sacrocolpopexy: how low does the mesh go?.Ultrasound Obstet Gynecol. 2017; 49: 404-408Crossref PubMed Scopus (24) Google Scholar], whereas mesh placement covering the entire posterior wall may improve defecatory symptoms. Although this may be true, such deep dissection may increase the risk of bladder or rectal injuries, as well as vaginal mesh exposure. Many more questions remain unanswered with regard to variations in surgical technique in sacrocolpopexy. What suture material should we choose—permanent or absorbable [2Matthews CA Geller EJ Henley BR et al.Permanent compared with absorbable suture for vaginal mesh fixation during total hysterectomy and sacrocolpopexy: a randomized controlled trial.Obstet Gynecol. 2020; 136: 355-364Crossref PubMed Scopus (5) Google Scholar]? Should we use sutures or tackers to attach the mesh to the anterior longitudinal ligament at the sacral promontory? What, if any, concomitant vaginal procedures should we add? In a previous article from 2014, we reviewed the current evidence on several procedural steps in laparoscopic or robotic sacrocolpopexy and developed an evidence-based guide for surgeons [3Parkes IL Shveiky D. Sacrocolpopexy for treatment of vaginal apical prolapse: evidence-based surgery.J Minim Invasive Gynecol. 2014; 21: 546-557Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar]. Nevertheless, the variability of surgical technique for the procedure is so wide among surgeons, necessitating the collection of data in a structured fashion for the development of a robust database of procedures. In this issue of Journal of Minimally Invasive Gynecology, Ulrich et al [4Ulrich D Preyer O Bjelic-Radisic V et al.The Austrian Sacrocolpopexy Registry: surgical techniques, perioperative safety, and complications.J Minim Invasive Gynecol. 2021; 28: 909-912Abstract Full Text Full Text PDF Scopus (1) Google Scholar] published their results from the Austrian Sacrocolpopexy Registry. This national registry reported surgical techniques, as well as perioperative safety and complications, in 13 Austrian and 1 Swiss medical centers. They included 401 patients, describing patient characteristics as well as surgical approaches; rates of hysterectomy vs vault prolapse repair; and many key surgical details including mesh type, suture materials, and fixation techniques. In addition, complications and their association with some surgical variables were also reported. National registries may be a great tool for quality assurance at the national level. Surgeons who share medical education and philosophy and speak the same language are thus encouraged to share their experience with colleagues. Surgeons should feel free to share their complications, not for grading purposes or criticism, but rather truly to improve patient care. I congratulate the Austrian Society of Urogynecology for creating such a registry and encourage other national societies to follow. Clear advantages aside, this report has several limitations. Participation in this registry is voluntary, as such data are vulnerable to reporting bias. In addition, data regarding anatomic success and long-term outcome are missing from this registry. Despite these limitations, this is an excellent example of a national effort resulting in invaluable data for the pelvic reconstructive surgeon. So, how low can you get? This registry taught me that the depth of dissection did not seem to correlate with bladder or rectal injuries. You can go as deep as you want, but the question remains, should you? I have also learned that the use of tackers at the promontory cuts 48 minutes off operating room time. Are there any explanatory variables for this difference? In his memorable act as Professor Keating in the 1989 film “Dead Poets Society,” Robin Williams quoted the Roman poet Horace, “Carpe diem”—Seize the day. We, too, must seize the day. Such an opportunity to collect such valuable data should not be missed. National registries should serve as large and uniform databases, continuously collecting additional information such as anatomic outcome and long-term follow-up, thereby allowing researchers to explore the association between each surgical step and patient outcome.