Vaginal mesh exposure is one of the reported complication after colposacropexy (CSP). It is under debate if it is due to the material used or to technical error, in this case strictly connected with surgical expertize.
The primary aim of our study was to evaluate the senior surgeon’s open ,laparoscopic and robot-assisted learning curve, and to assess the trend of the vaginal mesh exposure rate over the years. The secondary objective was to assess how many procedures are needed to reduce the vaginal exposure rate.

This is a retrospective study conducted in a III level urogynecological center. Vaginal mesh exposure rates were analyzed in women with advanced pelvic organ prolapse who underwent colposacropexy with or without uterine preservation. The procedures included also total and subtotal hysterectomy by open, laparoscopic and robot-assisted access from 1995 to 2022. All the procedures were performed by a single surgeon. Vaginal mesh exposure assessment was performed by a different urologist at each postoperative follow-up visit through clinical urogynaecological examination. Follow-up was conducted at 1,3,6,12 months postoperatively and then annually. Mesh exposures were classified with ICS-IUGA complication Classification Calculator. All data were collected in an Excel file. The study was approved by the Ethics Committee of our institution. All patients signed informed

557 procedures were included in the analysis: 267 open, 214 laparoscopic, 76 robotic CSPs. All the procedures were performed using polypropylene or PVDF meshes. The same surgeon began his experience passing from the open approach to the laparoscopic and then robotic one in sequence. The Fig. 1 shows the exposure rate for open, laparoscopic and robotic approaches and Fig 2 shows the exposure rate after 20 procedures for each approach. An in-depth analysis was performed for each approach during the time. The total mesh vaginal exposure rate after open CSP was 4.5%. In the first 8 years (Fig.2), 6 CSPs were performed in women who had already undergone hysteroannexectomy and in 19 case the uterus was preserved (HSP). In this period the vaginal mesh exposure rate tend to increase in the time and this is due to the increasing number of hysteroannexectomy (HY) associated with CSP  (16% in the first  25 HY procedures) After about 20 colposacropexy procedures the rate decrease significantly and from 2006 to 2022 it was 1.9% (3/154). The total mesh vaginal exposure rate for laparoscopic CSP was 5.6%. Laparoscopic approach started in 2003. The introduction in 2014 of concomitant HY increased significantly the mesh exposure rate (15% in the first cases). Again, after 20 procedures the total exposure rate tend to decrease. In 2018 subtotal HY (hysterectomy with uterine cervix preservation) was introduced and no exposure was reported. Robotic assisted CSP started in 2014 and total vaginal exposure rate is 2.6%. All the exposure were in patients who underwent HY. After 12 procedures the exposure rate went to 0. In the 47 sub-total HY (7 open, 25 laparoscopy and 15 robot-assisted) no mesh exposure was reported

The vaginal exposure rate after CSP varied during the learning curve and it is clearly linked to the concomitant hysterectomy. When HY started to be performed preserving the uterine cervix the exposure rate decreased dramatically. The vaginal exposure rate was 4.5% after open approach, slight higher after laparoscopic approach 5.6% and lower for the robotic one (2.6%).The exposure rate is always higher when CSP is associated with hysterectomy and this is particularly evident with the laparoscopic approach. The hypothesis is that the learning curve for the laparoscopic approach is harder with the more difficult steps represented by the vaginal wall preparations and the vaginal cuff closure after HY  against 12 robotic ones.  Particularly interesting is that after 12 robotic assisted procedures the exposure rate goes to zero, from 2018 up to date no exposure was reported even in patients who performed Hy (12/29 cases).

Our study confirmed the decrease of vaginal exposure rate after CSP in experienced surgical hands, independently to the approach: open, laparoscopic or robotic. The robotic learning curve is faster especially if the surgeon is already experienced with the laparoscopic approach. The laparoscopic approach seems to be harder in particular when contemporary HY is performed. Hy is the most important risk factor but the robotic approach seems to decrease this complication after an adequate learning curve. In any case subtotal Hy, when possible, is the best choice to decrease the exposure rate.

Continence 7S1 (2023) 100846
DOI: 10.1016/j.cont.2023.100846