Pre-operative surgical planning for minimally-invasive sacral colpopexy: integrating patient choice into surgical approach

Abstract

Pelvic organ prolapse (POP) occurs when organs in the female pelvis herniate into the vaginal canal. Moderate to severe cases of POP can cause sexual, urinary, and defecatory dysfunction and often require surgical intervention. Sacral colpopexy (SCP) is a safe, durable procedure widely used to treat apical POP. It is typically performed in a minimally-invasive manner via laparoscopic or robot-assisted surgery, but can be converted to an open abdominal approach intraoperatively if unforeseen challenges arise. There is ample literature describing patient risk factors for intraoperative conversion, but little to describe patient preference in surgical approach. The purpose of this study was to examine factors that may influence a patient’s decision to choose to undergo laparotomy vs. opting for a native-tissue vaginal repair. 128 patients between the ages of 32-82 who underwent SCP to treat apical POP were included in the study. Each patient participated in a pre-operative conversation with the operating surgeon during which the patient indicated their preference of surgical approach if intraoperative conversion was deemed necessary. Each patient chose one of two options: to convert the procedure to an open SCP or to convert the procedure to a different, less durable vaginal repair. The data of interest, including demographic information, medical history, and POP severity were collected pre-operatively and were entered into a secure database. Of the 128 patients who underwent SCP, 74% (n=95) elected to undergo laparotomy if intraoperative conversion were to become necessary and 26% (n=33) opted for a native-tissue vaginal repair. The average age of patients who chose laparotomy was 60 years old, which was significantly younger than patients who chose vaginal repair (m=64y, p=0.03). Patients who chose laparotomy were also significantly more likely to have a higher BMI than their counterparts who chose vaginal repair (p=0.03). There was no statistically significant association between groups regarding race, education, marital status, severity of POP, or symptomatology. When given the opportunity to indicate their preference, most patients chose to undergo a more invasive surgery with higher rates of complication to receive SCP, which likely reflects the prolapse patient’s desire for the most durable and effective procedure for treating POP. The group opting for native-tissue vaginal repair was significantly older, which is likely due to a greater risk of complication and longer recovery with open abdominal surgery. Patients with a higher BMI were more likely to choose laparotomy, which could reflect the increased risk of POP recurrence with high BMI, especially after vaginal repair. More research is needed to further examine what influences patient preference of surgical approach in elective surgery.