Discussion 125 of each of its individual phases, which for sacrocolpopexy typically have large durations and variability. Indeed, going through large volumes of lengthy surgical videos to annotate the duration of each phase, is time-consuming, and subjective and requires clinically trained staff. Automating this task, by surgical workflow segmentation, therefore would greatly assist in expediting this research. We started this process in collaboration with the engineers of UCL, demonstrating its feasibility with more advanced AI-tools.220,221 Implications for clinical practice: The use of lightweight polypropylene mesh, alongside absorbable sutures or mesh fixation at the time of sacrocolpopexy, seems recommendable as it significantly reduces the risk of long-term graft related morbidity without compromising subjective and objective outcomes. In the uncommon case of recurrence of apical prolapse, a redo sacrocolpopexy is feasible and effective in experienced hands and is therefore an option when counseling patients with post-sacropexy apical prolapse. However, since the infrequent need of this procedure, and paucity of data, this should remain confined to high volume centers. Using synthetic glue for mesh fixation in laparoscopic sacrocolpo(recto)pexy significantly reduces operating times, eventually reducing hospital costs. Implications for further research: The main issue with current studies on graft related complications is the short follow-up period, certainly for a complication such as mesh exposure, which is expected to increase over time. Therefore, further comparative and long-term cohort studies are required to better inform patients, surgeons and policy makers on the actual risk of using durable mesh for sacrocolpopexy and what materials may be better suitable. The rise in reluctance to have mesh inserted during the past decade prompts the need for exploration of the potential benefit of “mesh-less” and “mesh-free” surgical alternatives. The efficacy and safety of sacrocolpopexy for uterine prolapse, with subtotal hysterectomy or hysteropexy, have not been clearly established and require further assessment through well designed trials. Longer term follow-up studies would be needed to assess whether the use of synthetic glue for mesh fixation in sacrocolpopexy also reduces the risk of vaginal mesh exposures, and/or increases recurrence rates on the long term. A reduction in negative cognitive and musculoskeletal impact on surgeons, and subsequently an improvement in surgical performance when performing longer and more complex procedures such as sacrocolpopexy, is a possible added value of the robotic approach worth exploring. Therefore, the future for clinical research looks bright.
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