The prevalence of pelvic organ prolapse is increasing as the population ages, with an estimated 43.8 million women affected by at least one pelvic floor disorder by 2050 (1). The abdominal sacral colpopexy with mesh for management of pelvic organ prolapse is considered the gold standard. Prior studies have demonstrated a lower rate of vaginal vault prolapse recurrence and dyspareunia when compared to vaginal sacrospinous colpopexy (2). Traditionally, mesh is secured using non-absorbable monofilament suture in an interrupted fashion during sacral colpopexy, however one of the major complications of this procedure is mesh and suture erosion. We depict in this video our experience with running 2-0 Polydioxanone delayed absorbable suture during robotic sacral colpopexy and predict that absorbable suture will lead to decreased suture erosion with comparable failure rates.

We demonstrate a robotic approach to sacral colpopexy using mesh and 2-0 Polydioxanone delayed absorbable suture in a running fashion and compare the results in a same-institution cohort of interrupted 2-0 non-absorbable monofilament. Outcome measures included Pelvic Organ Prolapse Quantification (POP-Q) exams, quality of life indices, and complications such as suture erosion and need for surgical revision.

Robotic sacral colpopexy was performed in 119 women with 15.5 mo follow up.  70 patients underwent fixation with running polydioxanone while 49 underwent fixation with interrupted non-absorbable monofilament. The technique is summarized in the video attached. Two sutures of 2-0 Polydioxanone absorbable monofilament were run in a parallel fashion on the posterior aspect of the vagina and an additional two 2-0 Polydioxanone sutures were run parallel on the anterior aspect of the vagina to secure the mesh in place. POP-Q exam and quality of life indices improved significantly in both groups, and neither was shown to be inferior.  There were significantly less repair failures at the anterior compartment (p=0.012) with the use of Polydioxanone suture and no differences in repair failures at the apex or posterior compartment. There were significantly less suture erosions associated with Polydioxanone suture compared to non-absorbable monofilament (p <0.05) with no Polydioxanone erosions requiring excision.

Our video demonstrates the feasibility of robotic sacrocolopexy with a running 2-0 Polydioxanone suture.  Anatomic outcomes for delayed absorbable suture for fixation were not inferior to interrupted non-absorbable monofilament at intermediate-term follow up. Delayed absorbable suture led to significantly less suture erosion.  As the viewer can see from the video, running the suture provides some obvious efficiency over interrupted knot tying. We conclude that running Polydioxanone suture during robotic sacral colpopexy is preferable to interrupted non-absorbable suture.

Wu J.M., Hundley A.F., Fulton R.G., Myers E.R. (2009) Forecasting the prevalence of pelvic floor disorders in U.S. Women: 2010 to 2050. Obstet Gynecol 114: 1278–1283
Maher C, Baessler K, Glazener CMA, Adams EJ, Hagen S. Surgical management of pelvic organ prolapse in women: a short version Cochrane review. Neurourol Urodyn 2008; 27: 3–12