SUFU 2018: Vaginal: Sacrospinous Ligament Fixation and Uterosacral Ligament Suspension

Austin, TX (  Dr. Noblet presented the anatomy of the sacrospinous ligament and uterosacral ligament and highlighted the following bullets notes:

  • Delancey et al and Lowder et al studies, showed the relationship between the anterior and apical compartment support, she showed a nice video for simulated restoration of apical support corrected cystoceles in 55 5 of cases and rectoceles in 30 % of cases.
  • The sacrospinous ligament anatomy: closed proximity if too lateral pudendal branch bundles, if to medial we will get the the S3/S4 nerves. We need to palpate the ischial spine then 2 or 1 finger breadth medial to the ischial spine; these should be the green spot for the fixation.
  • Surgical steps for SSL fixation:
1. Performed vaginally ( with or without hysterectomy, and in post- hysterectomy  women)
2. Bilateral or unilateral
3. Native tissue or graft augmented 
4. Generally a minimum of 2 sutures on each side
5. Mark the apex of vagina
6. Dissection can be via anterior or posterior approach
7. Place sutures through the SSL
8. Place sutures through the vaginal apex and tie down

• There is some clinical relevance of complications: hemorrhage, pain ( gluteal, perineal, or lower extremity), and injury to pelvic floor nerves
• Surgical steps of Uterosacral ligament fixation:

1. Performed vaginally or laparoscopically
2. Bilateral
3. Native tissue
4. Generally a minimum of 2 sutures on each side
5. Mark the apex of vagina
6. Place sutures through the USL bilaterally
7. Place suture through the apex and tie down

Anatomy of USL:

  • Fibro-elastic tissue and smooth muscle, contain autonomic nerves( frankenhausen’s plexus)
  • Fan like structure at the sacrum originating S1-S3, inserting on the lateral cervix and upper 1/3.
  • USL(12-14 cm) can be divided into 3 section( distal 2-3 cm, intermediate 5 sm, proximal 5-6 cm), intermediate section is relatively unattached , wide, thick and more than 2 cm from the ureter. It can withstand >37.5 IBs of pull out force before failing
The USLS fixates the anterior and posterior walls of the vaginal apex to the uterosacral ligaments at or above the level of the ischial spines, it aligns the vagina in its normal axis believed to yield more anatomic results.

USLS complications: uretral compromise in up to 11 %, nerve entrapment 7/182( 3.8%) women s/p USVS with sensory neuropathy/pain in S2-S3 dermatoms postoperatively, 3 women had immediate reduction of pain s/p suture removal. Nerve entrapment can be decreased using a tenting technique. 

Optimal trial, between USLS vs SSLF:

  • 1:1 randomization
  • Primary outcome was anatomical success (apex < 1/3 of vaginal length, anterior and posterior prolapse beyond the hymen.
  • Result at 2 years- no significant difference with the success rates( 59.2%- USLS, 60.5%- SSLF)
  • No difference in serious adverse events
  • Conclusion: neither USL nor SSLF was significantly superior to the other for anatomical functional and or adverse events.

Presented by: Karen Noblett, MD. MAS, University of California, Irvine.

Written by: Bilal Farhan, MD, Female Urology Fellow and Voiding Dysfunction, Department of Urology, University of California, Irvine at the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Winter Meeting (SUFU 2018), February 27-March 3, 2018, Austin, Texas