Ask Anything

Where do you place the sutures on the uterosacral ligament in uterosacral ligament suspension and what is the success rate and complications profile associated with the level of suture taken in uterosacral ligament?

Uterosacral ligament suspension is a common procedure performed for restoration of apical prolapse. Various techniques and modifications have been described regarding the levels at which sutures on the ligament should be taken. The technique described by Bob L. Shull uses three sutures with the first suture on the sacral side of ischial spine and two sutures distal to the first suture (Shull et al 2000). Several modifications describe the use of sutures at or above the level of the ischial spine (Lee & Unlu 2020), while some authors describe the use of two sutures at or below the level of the ischial spine (Alas & Anger 2015). I would like to ask where would you recommend placing the suture on the uterosacral ligament? And what is the success rate and complications profile associated with the level of suture taken on the uterosacral ligament?    

REFERENCES

Alas AN, Anger JT. Management of apical pelvic organ prolapse. Curr Urol Rep. 2015;16(5):33. doi:10.1007/s11934-015-0498-6

Lee TG, Unlu BS. Sacrospinous ligament suspension and uterosacral ligament suspension in the treatment of apical prolapse. Gynecol Pelvic Med 2020; 3:39.

Shull BL, Bachofen C, Coates KW, Kuehl TJ. A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments. Am J Obstet Gynecol. 2000;183(6):1365-1374. doi:10.1067/mob.2000.110910

Expert Responses

In our practice, we usually identify the trajectory of the uterosacral ligaments after hysterectomy by placing traction on the previously placed vaginal vault sutures, while the ischial spine is palpated with index finger. Once the intermediate portion of the uterosacral ligament is determined, we seize the ligaments with an Allis clamp approximately 1 cm medial and cephalad to the ischial spine on the sacral side of the spine. We place two polyglactin 0 sutures on the uterosacral ligament bilaterally at that spot passing the needle driver in the lateral to medial direction. Cystoscopy is performed routinely to assess ureteral integrity. After that, the sutures of the uterosacral ligament are passed through the vaginal apex. Traditional side-to-side anterior and posterior vaginal wall plication with native tissues is performed if needed for POP repair.

Considering descent below the hymen as failure for the three vaginal compartments (Ba, Bp, C points po ≥ 0), our success rate is around 93% after 12 months (success rate of 88%, 88% and 100% for Ba, Bp, and C points respectively). If descent less than -1 point above the hymen is considered as success, then the success rate remains the same for the C point but drops for anterior compartment to 35%. The most frequent complication we observed was bleeding (around 10%), followed by site infection (9%), thigh paresthesia and dyspareunia (4% each). Ureteral injury occured in less than 2% of our cases.

This technique has been used for years in the Federal University of São Paulo with good results. It respects the known anatomic landmarks for a safe procedure.

When placing the sutures for the uterosacral ligament suspension (USLS), it is important to palpate the previously tagged ligament and the ischial spine. Retracting the rectum medially, using the ischial spine as a landmark, place your first suture just above or at the level of the ischial spine on the medial aspect. This first suture at the ischial spine marks the depth of vagina. Proceed with placing an additional 1-2 sutures cephalad 1 cm-1.5 cm apart and slightly medially from the last one. In addition, suture away from the side wall which would require loading the needle left-handed for the right side. This helps to ensure avoidance of the ureter that runs lateral to the ligament in the retroperitoneum. The placement of 3 sutures bilaterally offers redundancy to ensure durability to the repair. If ureteral obstruction is identified on cystoscopy and the sutures need to be released, starting with the most distal of the affected side, having 3 sutures bilaterally in place ensures that the entire repair is not disrupted.

The success rate of USLS has been found to be up to 89% (Barber et al 2014). A recent RCT showed that there was no difference in anatomical success between delayed absorbable suture and permanent suture after 2-year follow up (Kowalski et al 2021). The higher the ligament is secured above the level of spine, there is increased risk of nerve entrapment of the sacral nerves up to 1.6% (Chung et al 2012). The depth of suture placement also needs to be considered. Sutures that are placed too deep may compromise branches of the sacral plexus and pelvic autonomic nerves.  Patients will have significant buttock pain on the side of the entrapment. This can be resolved by releasing the uterosacral sutures on the affected side, with almost immediate relief. Ureteral obstruction has been reported to be 3.4% (1). This is more likely to occur with sutures secured below the level of the ischial spine. Utilizing above listed techniques will decrease the risk of ureteral obstruction.

REFERENCES

Barber MD, et al., Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA. 2014;311(10):1023–34.

Chung CP, Kuehl TJ, Larsen WI, Yandell PM, & Shull, BL. Recognition and Management of Nerve Entrapment Pain After Uterosacral Ligament Suspension. Obstetrics & Gynecology. 2012;120: 292–295.

Kowalski JT, Genadry R, Ten Eyck P, Bradley CS. A randomized controlled trial of permanent vs absorbable suture for uterosacral ligament suspension. Int Urogynecol J. 2021;32(4):785-790. Doi:10.1007/s00192-020-04244-1