Chapter 5 124 subtotal hysterectomy or a comparison to hysteropexy has not been clearly established and require further assessment. The next research question therefore may well be whether sacropexy should be done with uterine preservation or subtotal hysterectomy, which has been our practice in most patients. In terms of subjective and objective outcomes, we found that the vast majority of our patients who underwent laparoscopic sacrocolpopexy were (much) improved (PGIC-score ≥4), regardless of the type of implant used. Anatomically, recurrence rates at the vault were low and not different between groups. In the uncommon case of recurrent apical prolapse, one may consider a redo laparoscopic sacrocolpopexy. Previous data on the safety and efficacy of redo sacrocolpopexy was scarce, so we reviewed our own experience. Therefore we performed a matched case-control (1:4) study and found that complication rates and outcomes that fell within the range of what is reported on primary laparoscopic sacrocolpopexy, at a higher risk for conversion. Our data suggest that a redo sacrocolpopexy is feasible and effective in experienced hands and is therefore a reasonable option when counseling patients with post-sacrocolpopexy apical prolapse. Although laparoscopic sacrocolpopexy in our unit is well standardised, its steep learning curve and long operating times hinder its wider implementation in clinical practice.30 This is, at least in part, caused by the need for advanced endoscopic suturing skills, which may be overcome by using surgical glue. Unfortunately use of the latter comes with additional and relatively high costs when compared to suturing costs. We performed a cost-minimization analysis, comparing laparoscopic sacrocolpo(recto)pexy using either synthetic surgical glue or sutures only for distal mesh fixation, and calculated that the initially higher procedural costs are offset by reduced operation time, yielding an overall cost saving favoring glue-based mesh fixation. This is in line with contemporary studies demonstrating reduced operation times with the use of glue.187,190,192 Additional expected benefits include a shorter learning curve and lower risk of vaginal exposures due to the absence of sutures perforating the vagina. However, solid evidence on these points is currently lacking. Another promoted strategy to overcome the aforementioned bottlenecks of this surgical procedure is the robotic approach. However, recent trials have shown that the learning curve associated with robotic sacrocolpopexy remains as steep as that of the laparoscopic approach217,218. In addition, the 2023 Cochrane review found that robotic sacrocolpopexy was associated with longer operating times and more postoperative pain.215 Thus, although laparoscopic and robotic approaches yield comparable anatomical and functional outcomes, the latter obviously comes at a higher cost.215 This warrants further exploration of the potential benefits and specific indications of this newer approach, such as a reduction in musculoskeletal demands and cognitive load for surgeons, possibly improving surgical performance.219 Achieving “perfect” patient outcomes necessitates continuous implementation of, and simultaneous evaluation of improvements. Sacrocolpopexy is no exception to this. Studying surgical skills and complications, and different approaches to this procedure requires an analysis at the level
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