Guidelines for Privileging and Credentialing Physicians for Sacrocolpopexy for Pelvic Organ Prolapse

摘要

EXECUTIVE SUMMARY The adoption of new technology or procedures into a clinician’s surgical armamentarium is driven by multiple factors. Patient safety and anticipated long-term improvement in outcomes should be the primary objective that guides a surgeon’s decision to deliver care involving new procedures. Surgically complex procedures require a balance of knowledge, surgical skill, and experience as well as an appropriate ongoing surgical volume, an adequately trained and equipped surgical team, and the ability to monitor outcomes and adverse events. Sacrocolpopexy is a complex procedure used to treat apical vaginal prolapse. Clinical outcome studies support its effectiveness in managing apical prolapse. Serious adverse events have been noted in several of these studies (hemorrhage, sacral infection, mesh erosion, bowel obstruction, and injury to the urinary tract).1,2 This document provides guidelines for the privileging and credentialing of physicians planning to implement or continue the use of sacrocolpopexy in clinical practice. KEY POINTS Sacrocolpopexy should only be performed by surgeons with board certification or active candidacy for board certification in obstetrics and gynecology or urology who also have requisite knowledge, surgical skills, and experience in reconstructive pelvic surgery. Outcomes and complications of sacrocolpopexy and other prolapse procedures should be monitored by annual internal audit or other mechanism at the local institution. Informed consent should highlight the following: Potential benefits and complications of sacrocolpopexy. Alternatives including nonsurgical options (eg, pessary) and other surgical treatments. Potential complications of mesh used in sacrocolpopexy including but not limited to mesh exposure/extrusion through vaginal epithelium or erosion into viscera, possibly requiring repeat surgery, and other known complications. BACKGROUND Sacrocolpopexy is a procedure used to treat apical pelvic organ prolapse (POP) including uterine prolapse and posthysterectomy vaginal vault prolapse. It involves placement of a graft or mesh from the anterior and posterior walls of the vagina to the anterior longitudinal ligament of the sacrum. Sacrocolpopexy can be performed via laparotomy, or endoscopically with or without robotic assistance. This procedure is considered a highly effective and durable treatment for POP.3 However, major complications such as intraoperative hemorrhage, bowel and bladder injury, postoperative bowel obstruction, sacral discitis and osteomyelitis, and other serious mesh-related complications can occur.1,4 Training to perform sacrocolpopexy is not included in the currently published goals of general urology or obstetrics and gynecology residency programs. Many practitioners learn sacrocolpopexy as part of a fellowship in Female Pelvic Medicine and Reconstructive Surgery (FPMRS). This fellowship training includes didactic and clinical training in the sacrocolpopexy procedure. Some clinicians who have not completed an FPMRS fellowship may request privileges for sacrocolpopexy. The purpose of this guideline is to provide recommendations to assist health care institutions when considering granting privileges to perform sacrocolpopexy. Sacrocolpopexy for POP should be performed by surgeons with board certification or active candidacy for board certification in obstetrics and gynecology or urology who also have requisite knowledge, surgical skills, and experience in reconstructive pelvic surgery. Minimally invasive sacrocolpopexy refers to sacrocolpopexy performed endoscopically with or without robotic assistance. Additional training will be required to perform sacrocolpopexy via a minimally invasive approach in addition to the aforementioned requisite knowledge, surgical skills, and experience in reconstructive pelvic surgery. A surgeon should possess the skills and privileges to perform sacrocolpopexy via laparotomy before requesting minimally invasive privileges for s