Chapter 4.2.3 100 INTRODUCTION The prevalence of symptomatic pelvic organ prolapse (POP) is on the rise, with an estimated 20% lifetime risk for women to undergo surgery for POP by the age of 80.165 Laparoscopic sacrocolpopexy (LSCP) is the gold standard for apical prolapse repair, yet has a steep learning curve.44 30 This is, at least in part, caused by the need for endoscopic suturing, which may be substituted by using surgical glue. Mesh fixation using synthetic surgical glues has found its way into hernia surgery185 and is also being suggested for LSCP, without adverse impact on anatomical and functional outcomes up to three years post-surgery in different case series.186-192 Unfortunately its use comes with additional and relatively high costs when compared to suture cost, which may be in part offset by a reduction in operation time. In the Belgian healthcare system, procedure specific fees are set (for LSCP this is set at €534.8) yet expenses are variable and have to be paid out of pocket by the hospital. Ideally a comprehensive health economic analysis is done to compare costs and outcomes, yet from the hospital perspective, a cost minimization analysis is very informative. In such study, the effects of the interventions under study are assumed to be equivalent, and one only focuses on identifying and comparing the differences in direct hospital costs.193 Herein, we report on a cost-minimization analysis (CMA), comparing laparoscopic sacrocolpo(recto)pexy using either synthetic surgical glue or sutures only for distal mesh fixation. MATERIALS AND METHODS This is a prospective single-center study on 40 consecutive patients undergoing LSCP by the same experienced surgical team. Until July 2021, only sutures were used (n=20; January to July 2021). Thereafter, synthetic glue (n=20; August to December 2021) was used for fixation of the mesh to the vault and/or rectum, creating two equally sized consecutive cohorts. This was a convenience sample size, yet judged to be representative.188 We have a long standing experience with this procedure and our technique is standardized.153 All patients underwent LSCP using the same standardized technique, by one of two gynecologic surgeons experienced in LSCP (≥50 procedures per year) who were familiar with using glue for LSCP, to discount for the learning curve of the latter in the present study. We have previously reported on the surgical technique throughout its main constituting phases.13 One phase is that of suture fixation of the mesh, which for this study was precisely measured based on the video recordings of the operation. All consumables costs associated to mesh fixation were prospectively recorded by the circulating nurse. Typically we use extracorporeally tied monofilamentary polydioxanone 0 (120cm; PDS, €11.52; EthiconTM; Machelen, Belgium) to fix the mesh on the vagina, and in case of associated rectal intussusception, polyglycolic acid (90 cm; Vicryl, €2.77; EthiconTM; Machelen, Belgium) for fixation on the rectum.194 For fixation with glue we used IFABond® (IfabondTM, Peters Surgical, France, CE label class III; €201.4/vial). A
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