1. Transvaginal Apical Repair (non-mesh)
Bob L. Shull, M.D.
Professor of Obstetrics and Gynecology
Scott & White Clinic and Hospital
Texas A&M University Health Sciences Center
Temple, Texas

2. Learning Objectives
At the end of the discussion the participant will be able to:
To describe the key steps of uterosacral ligament suspension
To describe how to minimize the risk of ureteral injury

3. Choice of Operative Procedure
Vaginal repair
Abdominal suspension
Combined abdomino-vaginal repair

4. Sacrospinous Ligament Suspension
Zweifel - Sacrotuberous ligament
White - Tendinous arch
Amreich - Sacrotuberous ligament
Sederl - Sacrospinous ligament
Randall & Nichols - Sacrospinous ligament

5. % of Recurrences Vagina Author No. Pts Apex Other sites too small S.U.I.
Richter % 22% 12% 4%
Nichols % ? 2% 6%
Morley % 20% 6% 6%
Kettel % ? ? ?
? - Information not reported

6. Pre- and Post-Operative Analysis of Site-Specific Pelvic Support Defects in 81 Women Treated by Sacrospinous Ligament Suspension and Pelvic Reconstruction
Conclusion: The principal support loss during the follow-up period was the bladder.
Shull BL, Capen CV, Riggs MW, Kuehl TJ
Amer J Obstet Gynecol, 1992: 166(6-1):

7. “RETROVERSION of the vagina… a step towards prolapse of the anterior vaginal wall” Victor Bonney, 1934

8. Bilateral Attachment of the Vaginal Cuff to Iliococcygeus Fascia: An Effective Method of Cuff Suspension
Shull BL, Capen CV, Riggs MW, Kuehl TJ
American J Obstets Gynecol, 1993, 168:

9. Conclusion
Ninety-five percent of women experienced no persistence or recurrence of cuff prolapse in follow-up from six weeks to five years.

10. Repair of Vaginal Vault Prolapse by Suspension of the Vagina to Iliococcygeus (Prespinous) Fascia
110 patients
Minimum follow-up 3 years
4 patients with recurrent defects - all anterior segment
Meeks GR, Washburne JF, McGehee RP, Wiser WL. Am J Obstet Gynecol 1994; 171:444-54

11. Fixation of the Vaginal Apex to the Coccygeus Fascia during Repair of Vaginal Vault Eversion with Enterocele
121 patients with posthysterectomy vault eversion
81 coccygeus fascia, 30 sacrospinous ligament fixation
Projected cure at 2 years
Coccygeus 96%
Sacrospinous 80%
Peters III WA. Christenson NL. Am J Obstet Gynecol 1995; 172:

12. Posthysterectomy Vaginal Vault Prolapse: Primary Repair in 693 Patients
Study Period
693 underwent primary repair of posthysterectomy vaginal vault prolapse. 95% of procedures were performed with Mayo culdoplasty.
Webb MJ, Aronson MP, Ferguson LK, Lee RA.
Obstet Gynecol 1998;92:281-5.

13. Posthysterectomy Vaginal Vault Prolapse: Primary Repair in 693 Patients
Complications
Visceral injury 2.3%
Vault hematoma 1.3%
Cuff infection 0.6%
Ureteral complication 0.6%
Webb MJ, Aronson MP, Ferguson LK, Lee RA.
Obstet Gynecol 1998;92:281-5.

14. Posthysterectomy Vaginal Vault Prolapse: Primary Repair in 693 Patients
Outcomes
504 patients available for follow-up examination or survey
Satisfied 85%
Bulge or Protrusion 16%
Reoperated 7%
Webb MJ, Aronson MP, Ferguson LK, Lee RA.
Obstet Gynecol 1998;92:281-5.

15. A Transvaginal Approach to Repair of Apical and Other Associated Sites of Pelvic Organ Prolapse Using Uterosacral Ligaments
Shull BL, Bachofen C, Coates KW, Kuehl TJ
Am J Obstet Gynecol, 2000: 183;

16. Study Design Jan 1, 1994 - Dec 31, 1998 302 consecutive patients
289 returned for follow-up
Morbidity: transfusion, visceral injury, death
Durability: life table analysis

17. Objective
To describe a group of women with pelvic organ prolapse associated with apical loss of support using the Baden-Walker halfway system preoperatively, intraoperatively, and postoperatively
To describe the operative repair of the support defects
To report the morbidity associated with the operative repair
To access the durability of the repair at each site

18. Uterosacral Ligament: Description of Anatomic Relationships to Optimize Surgical Safety
Fifteen female cadavers were evaluated between December 1998 and September Eleven hemisected pelves were dissected to better define the urterosacral ligament and identify adjacent anatomy. Ureteral pressure profiles with and without relaxing incisions were done on four fresh specimens. Suture pullout strengths also were assessed in the uterosacral ligament.
Buller JL, Thompson JR, Cundiff GW, et. al. Obstet Gynecol 2001; 97:873-9.

19. Results
The uterosacral ligament was attached broadly to the first, second, and third sacral vertebrae, and variably to the fourth sacral vertebrae. The intermediate portion of the uterosacral ligament had fewer vital, subjacent structures. The mean ± standard deviation distance from ureter to uterosacral ligament was 0.9±0.4, 2.3±0.9, and 4.1±0.6 cm in the cervical, intermediate, and sacral portions of the uterosacral ligament, respectively. The distance from the ischial spine to the ureter was 4.9±2.0 cm. The ischial spine was consistently beneath the intermediate portion but variable in location beneath the breadth of the ligament. Uterosacral ligament tension was transmitted to the ureter, most notably near the cervix. The cervical and intermediate portions of the uterosacral ligament supported more than 17 kg of weight before failure.
Buller JL, Thompson JR, Cundiff GW, et. al. Obstet Gynecol 2001; 97:873-9.

20. Conclusion
Our findings suggest that optimal site for fixation is the intermediate portion of the uterosacral ligament 1 cm posterior to its most anterior palpable margin, with the ligament on tension
Buller JL, Thompson JR, Cundiff GW, et. al. Obstet Gynecol 2001; 97:873-9.

22. Bilateral Uterosacral Ligament Vaginal Vault Suspension With Site-specific Endopelvic Fascia Defect Repair for Treatment of Pelvic Organ Prolapse
Objective: The anatomic and functional success of suspension of the vaginal cuff to the proximal uterosacral ligaments is described.
Barber MD, Visco AG, Weidner AC, Amundsen CL, Bump RC.Am J Obstet Gynecol 2000; 183:

23. Conclusion: Suspension of the vaginal vault to the proximal uterosacral ligaments combined with site-specific repair of endopelvic fascia defects provides excellent anatomic and functional correction of pelvic organ prolapse in most women. The risk of ureteral injury with this technique makes intraoperative cystoscopy essential.
Barber MD, Visco AG, Weidner AC, Amundsen CL, Bump RC. Am J Obstet Gynecol 2000; 183:

24. The underlying concepts for this repair are based on the anatomy of the support defects. The repair can be performed vaginally, abdominally, or laparoscopically