Timing of Concomitant Midurethral Sling Placement During Minimally Invasive Sacrocolpopexy

INTRODUCTION: Surgeons typically place the synthetic midurethral sling (MUS) after completing the apical suspension procedure when performing minimally invasive surgeries (MIS) for combined pelvic organ prolapse (POP) and stress urinary incontinence (SUI). We hypothesize that it may be more efficient to place the MUS at beginning of the case while ports are being placed without compromising MUS success for treating SUI. OBJECTIVE: To determine if timing of MUS placement (before or after sacrocolpopexy) impacts SUI treatment outcomes 3 months after surgery. METHODS: A retrospective cohort study was performed of consecutive patients who had MIS sacrocolpopexy (SCP) and MUS for POP and SUI at a single tertiary care center between June 2023 and June 2024. Surgeries were performed by eight board-certified urogynecology and reconstructive pelvic surgeons. Four surgeons place MUS prior to and 4 place MUS after completion of the SCP. Surgical cases were categorized into “MUS pre-SCP” and “MUS post-SCP” based on surgeon and confirmed in operative notes. Standardized postoperative in-person or telehealth follow-up based on patient preference occurred 3 months after surgery; patients completed the Pelvic Floor Distress Inventory (PFDI) items related to SUI and vaginal bulge symptoms. If a patient reported bothersome persistent SUI, a cough stress test was performed to confirm SUI. SUI treatment failure was defined as: (1) patient report of persistent or de novo SUI, (2) positive cough stress test, and/or (3) retreatment for SUI (including pelvic floor physical therapy, pessary, or surgery). Standard group comparisons were performed as appropriate. RESULTS: One hundred seventy-seven women had minimally invasive SCP with MUS for POP and SUI during the study period. Sixty-six subjects (37.3%) had MUS done before SCP (MUS pre-SCP), and 111 (62.7%) had MUS after completing SCP (MUS post-SCP). Demographic and perioperative characteristics are in Table 1. The majority had stage III POP (60.5%) at baseline. Indications for MUS placement were SUI only, SUI predominant mixed incontinence, and occult SUI in 37.3%, 34.5%, and 28.2% of participants, respectively. Baseline and operative characteristics differed between groups. The MUS pre-SCP group was more likely to have advanced stage III/IV POP (81.8% vs 52.2%, p<0.001), while the MUS post-SCP group was more likely to be current smokers (0% vs. 6.3%, p=0.04). Similarly, the MUS pre-SCP group was more likely to have had a concomitant hysterectomy (p=0.01), total hysterectomy (p<0.001), single port (SP) robotic procedure (p<0.001), and shorter operative times (240 vs. 289 minutes, p<0.001). Overall, SUI treatment failure was similar between MUS pre-SCP and post-SCP cohorts (10.6% vs 10.0%, p=0.54); this was true for both subjective and objective SUI treatment failures as well as need for retreatment (Table 2). CONCLUSIONS: Placing a MUS prior to MIS SCP was associated with shorter operative times and did not affect SUI treatment outcomes at 3 months, despite this group having a more advanced baseline POP stage and being more likely to have a concomitant hysterectomy. Surgeons can consider placing MUS prior to SCP to maximize efficiency during these cases without compromising treatment success for SUI.