Evolving Sacrocolpopexy Technique Trends

Sacrocolpopexy (SCP) is widely considered the gold standard procedure for repairing apical and multi-compartment prolapse. Despite its long-standing and widespread use, significant technical variations persist, yet these differences have not been well-characterized or linked to surgical outcomes. Our study aims to describe contemporary variations in surgical techniques, materials, and approaches among SCP surgeons.

We conducted a national cross-sectional survey of members of the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) and the American Urogynecologic Society (AUGS) currently performing SCP. The survey, distributed electronically via REDCap, included sections on demographics, training, practice setting, surgical techniques, and material selection. Case volumes were categorized as low (≤ 20 cases/year) or high (> 20). Descriptive statistics and subgroup comparisons were performed using non-parametric tests with significance defined as p < 0.05.

Of 281 respondents, 66.9% were female, most aged 31-50 years, practicing primarily in academic centers (64.0%). Most completed OB/GYN (64.7%) or urology (33.5%) residency, with 84.8% having fellowship training. A total of 34.3% of surgeons routinely performed total hysterectomy. Posterior dissection to the perineal body was more common among OB/GYN-trained surgeons (55.1% vs. 30%, p < 0.001). Concomitant mid-urethral slings were performed in ≥ 50% of cases by 74.8%, more commonly among OB/GYN-trained surgeons (83.9% vs. 58%, p < 0.001), while staging of slings was higher among urology-trained surgeons. Routine anterior colporrhaphy, posterior colporrhaphy, and perineorrhaphy were still performed concomitantly (> 50% of cases in 6.7%, 18.9%, and 21.7%, respectively). Robotic-assisted SCP was common across both low- and high-volume groups, without a significant difference in routine robotic use. High-volume surgeons (> 20 SCPs/year) (HV) performed fewer open procedures (1.3% vs. 7.6%, OR 0.16, p = 0.018), and were more likely to perform total hysterectomy (84.2% vs. 64.5%, OR 2.94, p < 0.001) and posterior colporrhaphy (22.8% vs. 11.4%, OR 2.27, p = 0.036). They also performed more mid-urethral slings (median 90.0% vs. 70.0%, p < 0.001) and extended anterior dissection more often to the distal vagina or trigone (46.5% vs. 26.9%, p = 0.005). Both groups preferred monofilament absorbable sutures at the apex, though LV providers showed higher rates (68.0% vs. 52.6%, OR 1.91, p = 0.033). HV surgeons also frequently used monofilament permanent sutures (43.6% vs. 25.3%, OR 2.27, p = 0.009).

Robotic-assisted SCP with polypropylene mesh dominates current practice, yet notable variation exists in dissection, suture choice, and concomitant procedures, related to training background and case volume. These systematic differences highlight the importance of reporting surgical techniques, and further research is needed to clarify their impact on outcomes and long-term repair durability.