1. Uterosacral Suspension

2. Educational Objectives This lecture will enable the participant to list and discuss the indications and complications of uterosacral suspension for apical defects. This lecture will enable the physician to describe the surgical technique for uterosacral suspension

3. Techniques There are many techniques for reestablishing support of the vaginal apex Sacrospinous ligament suspension Iliococcygeus fascia suspension Abdominal sacral colpopexy Uterosacral ligament suspension

4. Historical Perspective Miller (1927) –bilateral suspension of the vaginal vault to the uterosacral ligaments McCall (1957) –combined uterosacral suspension with an extensive culdeplasty Jenkins (1997) –vaginal approach Miklos (1998) –laparoscopic approach

6. Anatomy The uterosacral ligament is a fanlike structure originating at the sacrum and narrowing just proximal to its insertion at the cervix.

12. Divisions of the Uterosacral Ligament (Campbell 1950) Cervical –made up of smooth muscle with abundant blood vessels and nerve fibers Intermediate—predominantly connective tissue, fewer nerves and vessels Sacral—almost entirely composed of loose strands of connective tissue intermingled with fat

15. Vascular structures adjacent to the Uterosacral Ligament Sacral portion— the superior gluteal vein lies medial to the superior gluteal artery (post. branch of Hypogastric) Inferior gluteal vein and artery (anterior branch of Hypogastric) Intermediate portion— the middle rectal artery is near the inferior margin ( hypogastric and Inferior mesenteric) Cervical portion— the coccygeal and accessory coccygeal artery (Branch of inferior gluteal)

20. Proximity of the Ureter Sacral portion---4.1 +- 0.6 cm Intermediate portion—2.3 +- 0.9 cm Cervical portion—0.9 +- 0.4 cm Ischial spine—4.9 +- 2 cm

21. Effect of Sutures Sutures placed at the cervical portion exerted greater pressure on the ureter Sutures placed in the sacral portion pulled out easiest

22. The Intermediate portion Provides strong suture fixation Little pressure on the ureter Greater distance from vascular structures

23. Location is everything !! Level of the ischial spine One centimeter posterior to the anterior most palpable margin of the uterosacral ligament while held on tension

27. Uterosacral Plication ? We do not plicate the uterosacral ligaments Narrowing of the upper vagina Increased risk of ureteral obstruction?

29. Abdominal and Laparoscopic Approach Permits uterine preservation Better for patients with shortened vagina? Those with lifestyles involving heavy work Prior prolapse surgery or procedures in the cul de sac Suspicion of endometriosis Severe uterine prolapse?

37. Steps for Vaginal Uterosacral Suspension Dissect cuff-enter peritoneum Develop anterior and posterior endopelvic fascia Three permanent double armed sutures on each side 1.5 cm posterior to the ischial spine and1-2 cm apart toward the sacrum Distal sutures placed laterally and proximal sutures medially through the fascia of the cuff (Shull 2000)

42. Results 82% had good support at two years The anterior segment was more likely to fail Anterior enterocele (Barber 2000)

43. Complications Ureteral obstruction—11% (Barber, 2000) Cystoscopy with indigo carmine is indicated Significant vascular involvement ? Have a plan to handle it

44. Conclusion Uterosacral suspension is a safe and effective technique for the treatment of apical prolapse. The gynecologic surgeon should be familiar with the vascular structures adjacent to the uterosacral ligaments and their proximity to the ureters at all levels.

45. Suggested reading McCall ML; Posterior culdeplasty, Obstet Gynecol 10;595, 1957 Shull BL, Capen CV:preoperative analysis of site specific pelvis support defects in 81 women treated with sacrospinous ligament suspension, Am J Obstetric Gynecol 166:1764. 1992 Shull BL, Bachofen C, Coates KW. A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments. Am J Obstet Gynecol. 183:1346, 2000