(Poster 181) Survey of Peritoneal Closure Practices During Minimally-Invasive Sacrocolpopexy

Objectives: Minimally-invasive sacrocolpopexy (MISC) is a commonly performed surgery for pelvic organ prolapse with demonstrated success. While serious adverse events are uncommon, approximately 2% of patients experience bowel complications after MISC, such as ileus or small bowel obstruction. Post-surgical adhesions and use of intra-abdominal mesh can contribute to the etiology of bowel complications. To mitigate this risk, some surgeons approximate the peritoneum over the mesh. The primary objective of our study is to assess national practice patterns regarding reperitonealization during sacrocolpopexy among urogynecologists who perform MISC. We also aim to assess specific practice patterns regarding suture choice and technique.

Methods: A survey was designed to assess peritoneal closure practices during MISC. Questions were developed based on practice patterns in the literature and from a sample of practicing urogynecologists. Participants were surveyed whether they reperitonealize mesh during MISC with and without concomitant hysterectomy and during minimally-invasive sacrohysteropexy. Answers included ‘Always,’ ‘Most of the time,’ ‘About half the time,’ ‘Rarely,’ and ‘Never.’ Questions also included suture material, technique (i.e. figure-of-8, running), and portion/location of the mesh involved in reperitonealizaiton. The survey was reviewed by multiple board-certified urogynecologists for face validity with an iterative process to improve content and readability. The survey was distributed by the American Urogynecologic Society (AUGS) to their members.

Results: There were 291 survey respondents. The majority held primary certification in obstetrics and gynecology (282, 96.9%) and completed fellowship in urogynecology (238, 82.1%). Half of respondents identified their practice as academic (136, 46.7%), while half reported a non-academic employer (155, 53.3%). Most were moderate to high volume surgeons with 37.1% (n=108) performing 5-25 MISC yearly and 29.9% (n=87) reporting more than 50 yearly. Most participants reported “always” reperitonealizing in cases with and without concomitant hysterectomy (84.9% n=247, 85.6% n=249, respectively). Only 10 (2.8%) reported never reperitonealizing at the time of MISC with concomitant hysterectomy. Fewer respondents performed sacrohysteropexy but of those who did, most “always” reperitonealize mesh (100/120, 83.3%). Most providers use a running suture (249, 88.9%) and there is a near-even mix between short-acting and delayed absorbable suture. Desire to avoid bowel complications was the most cited reason for mesh reperitonealization (263, 91.3%) followed by available peritoneum (91, 31.6%).

Conclusions: Most urogynecologic providers participating in this survey report always reperitonealizing the majority of the mesh during MISC. Desire to avoid bowel complications was the most cited reason for mesh reperitonealization, followed by availability of peritoneum and other anatomic factors. A minority of surgeons do not reperitonealize the mesh, and a similar number cite lack of data to support the practice as impacting their decision. As future evidence is available on best surgical practices, this survey may contribute to research on standardizing the surgical steps of MISC.