Chapter 4.2.3 104 DISCUSSION Herein we calculated what the difference in direct hospital costs were for a sacrocolpo(recto)pexy using either suture only, as compared to an operation using glue for most of the mesh fixation. Although the synthetic glue introduced an increase in consumables cost, it significantly decreased procedure time, thereby in our system reducing the total direct surgery cost. Therefore, the initially higher procedural costs are offset by reduced operation time, yielding an overall cost savings favoring glue-based mesh fixation. This is in line with earlier studies demonstrating reduced operation times with the use of glue187,190,192. Our study is the first study formally assessing and comparing costs of both techniques. Synthetic tissue glue fixation in laparoscopic sacrocolpopexy has been shown to be simple, safe and effective up to 3 years after surgery.186,187,189-191 Additional expected benefits include decreased procedure time, a shorter learning curve and lowering the risk of vaginal exposures due to the absence of transfixing sutures. However, solid evidence on these points is currently lacking. Findings on operating time vary. Lamblin et al. and Panel et al. found a significant reduction in operating time favoring glue, while Willecocq et al. reported no difference.186,189,191 However, overall they looked at total operation times, to which several factors such as anatomy of the patient and associated procedures contribute. Therefore it is more correct to compare the fixation time for each patient rather than overall procedure time, which for this study was accurately measured based on the video recordings of the operation. Although conventional fixation methods were used, the simultaneous application of glue allowed us, nevertheless, to reduce the total number of sutures, thus facilitating the intervention and decreasing the operating time. Complete replacement of sutures by glue only on the other hand, remains counterintuitive. Providing solid anchor points for the suspension intuitively creates a feeling of safety; though it is uncertain what the effects would be of fixation with glue only. Previous studies on sacrocolpopexy allowed a variable numbers of additional sutures (ranging from 1 to 6) although these were not always specified. 186,187,189-191 None of these studies included concomitant ventral mesh rectopexy procedures. In the present study, we limited the allowed additional sutures according to the procedure: 4 in case of sacrocolpopexy, and 6 in case a concomitant rectopexy was performed. Of note is that in one study on VMR, no sutures but glue only was used.192 We think our findings are widely generalizable. To calculate the actual difference, one can use the “proportional” difference we report, and replace consumables and OR costs with local data, to calculate the local impact. Conversely, the above cannot be applied to robotic sacrocolpopexy, as the time spent to suturing and operating room maintenance cost would be very different. Finally, longer term studies on glue mesh fixation would be welcomed to ensure its longevity hence persistence of the initial cost savings on the long term.
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