Savitha Krishnan, MD, discusses patient selection for robotic sacrocolpopexy

Robotic sacrocolpopexy has emerged as a leading surgical option for apical pelvic organ prolapse, particularly for patients with advanced-stage disease or those seeking a more durable reconstructive repair. However, patient selection and counseling—especially regarding mesh use—remain central to surgical decision-making, according to Savitha Krishnan, MD.

Krishnan, a urogynecologist with El Camino Health, said her approach to prolapse surgery is highly individualized and largely guided by prolapse stage, patient activity level, and long-term goals.

“I tailor my approach to the individual patient,” Krishnan said. “There’s pretty clear evidence that stage 1 and stage 2 prolapse—meaning just beyond the hymen—do almost as well with traditional repair as they do with robotic repair.”

For patients with less advanced prolapse, Krishnan said she discusses both native tissue vaginal repair and robotic sacrocolpopexy as viable options. However, she noted that stage 3 and 4 prolapse are generally “better served by a graft-augmented repair like a robotic sacrocolpopexy.”

In counseling patients, Krishnan said she carefully reviews the specific compartments involved, including the anterior compartment, apex, and posterior compartment, and explains how robotic sacrocolpopexy can provide broader support across all areas.

“Not only are you supporting the apex, but if done correctly, you’re supporting that entire anterior compartment to prevent a recurrent cystocele,” she said. “You’re supporting the entire posterior compartment to prevent a recurrent rectocele.”

Durability is another major consideration, particularly among younger and more physically active patients. Krishnan said marathon runners and avid exercisers often favor sacrocolpopexy because of its long-term support profile.

“Our shared goal in the appointment is really to prevent that patient from returning to the operating room for a second procedure,” she said. Krishnan also emphasized how advances in minimally invasive surgery have reshaped the risk-benefit discussion surrounding sacrocolpopexy. Early in her career, sacrocolpopexy was performed as an open operation associated with longer hospitalization, greater pain, and prolonged recovery.

“Patients were in the hospital for 3 days,” she said. “They had significant activity restrictions and pain for almost 4 to 6 weeks.” Today, however, she said robotic sacrocolpopexy offers a markedly different recovery experience. “In my hands, the sacrocolpopexy is almost as short as a vaginal native tissue repair, and all of our patients go home the same day,” Krishnan said. “If you look at pain scores, patients with a sacrocolpopexy actually have less pain than a vaginal native tissue repair.”

Counseling patients about mesh

Mesh counseling remains a critical component of preoperative discussions, particularly in the wake of FDA safety communications and litigation involving transvaginal mesh kits. Krishnan said many patients react immediately when they hear the word “mesh.”

“As soon as I present the word 'mesh,' I can kind of see the alarming eye opening of my patients,” she said. She stressed that the mesh used in robotic sacrocolpopexy differs substantially from transvaginal mesh in both placement and complication profile.

According to Krishnan, transvaginal mesh complications were often related to placement within an incorrect tissue plane, increasing the risk of dyspareunia and exposure.

“With laparoscopic sacrocolpopexy, you’re in a completely different plane,” she said. “You have a full-thickness vaginal wall on the anterior wall and the posterior wall.”

Krishnan estimated that mesh exposure in her own practice is “probably less than 0.2%,” which she attributed in part to meticulous surgical technique and limited cautery use to preserve tissue vascularity.

She also discussed the role of supracervical hysterectomy in reducing mesh exposure risk.

“Published data show that the mesh exposure rate is 0.3% if we preserve the cervix,” she said. “If you take out the cervix, that can go upward to 3.6% to 3.7%. Although 3.6% to 3.7% is low, it’s a tenfold difference.”

Ultimately, Krishnan said transparent counseling and individualized decision-making are essential to helping patients navigate reconstructive options and understand the distinct evidence base supporting robotic sacrocolpopexy.