Uterosacral Ligament Suspension

Reattaching the uterosacral ligaments to the vaginal vault represents a very attractive means of normalizing vaginal vault support and anatomy - similarly to a McCall culdoplasty at the time of vaginal hysterectomy. In the hysterectomized patient, it can be challenging to identify the actual uterosacral ligaments. In addition, there is a reported risk of ureteral trauma of 10% to 15% in published series.2 As such,we do not favor this procedure to restore vaginal vault support in a hysterectomized patient. However, the popularity of this procedure is growing, as is the number of published series.

Normalization of vaginal axis is the most attractive feature of this procedure. To identify the uterosacral ligaments, most surgeons recommend palpation of the cul-de-sac peritoneum overlying the ischial spine. This should be inferior to the location of the ureters. In a patient with a large, bulbous prolapse, this may be somewhat difficult because of redundancy of peritoneum. Typically, 1-3 monofilament permanent sutures are used to perform this procedure. Long-term results are not yet available.

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