Pelvic organ prolapse is common, as women have an 11% lifetime risk of undergoing surgery for prolapse or urinary incontinence, and the reoperation rate is estimated at 30%. Surgery is but one approach to pelvic organ prolapse treatment, with alternative treatment options including observation without intervention, or a pessary. When surgery is pursued, the surgeon should choose a repair that addresses all support deficits, as anatomical studies of vaginal support demonstrate different levels of support within the vagina. Support of the vaginal apex derives from the uterosacral and cardinal ligaments, while the lateral attachments of endopelvic fascia provide the support of the anterior and posterior vaginal walls. In any given patient, pelvic organ prolapse is a combination of support defects, and surgical repair should address all support defects. Unfortunately, studies show that many gynecologists do not follow this surgical principle, and the most neglected level of support is the apical support, provided by attachment of the uterosacral and cardinal ligaments to the cervix.

Choosing the appropriate surgery requires identification of the anatomical defects present, whether at the vaginal apex, rectovaginal fascia, or pubocervical fascia, and then combining repairs to address all identified support defects. Consequently, proper identification of all support defects is essential, and correction of apical support is frequently the cornerstone of many prolapse surgeries. This chapter is focused on the uterosacral suspension, an anatomical, vaginal approach to repairing apical support. We prefer the uterosacral suspension to other vaginal repairs, such as the sacrospinous suspension, McCall culdoplasty, or iliococcygeal suspension, because it provides more anatomical vaginal support. The major distinction between the McCall culdoplasty technique and uterosacral ligament suspension described here is that the latter does not plicate the uterosacral ligaments, instead attaching the vaginal apices to the ipsilateral uterosacral ligament bilaterally. The vaginal approach decreases postoperative pain and shortens recovery. It also provides flexibility, as it can be utilized at the time of vaginal hysterectomy or for post-hysterectomy prolapse.

The primary goal of prolapse surgery is to alleviate symptoms related to compromised pelvic support, while restoring normal bladder, bowel, and coital function. The patient’s symptoms that can be attributed to prolapse must, therefore, be the primary basis of surgical planning, although choosing the best procedure should also consider other factors as well as the patients’ preferences and expectations. Factors that potentially increase the risk of recurrent prolapse are an important consideration, and include the severity of prolapse, prior failed prolapse surgery, young age, wide genital hiatus, weakness of the levator ani muscles, and chronically increased intra-abdominal pressures associated with heavy lifting, chronic cough, tobacco use, obesity, and chronic constipation. In the presence of these risk factors, the sacral colpopexy (Chapter 36) may be a preferred approach to repairing apical prolapse due to the added support provided by the surgical mesh. However,
in discussions with patients, the increased durability offered by the graft should be balanced by the potential complications associated with a foreign body, and the longer recovery associated with laparotomy.

The uterosacral suspension has been shown to provide excellent relief of prolapse symptoms as well as consistent anatomical outcomes that are durable over time. Intraoperative complications are similar to or better than alternative vaginal apical repairs. The possible exception is ureteral obstruction, which has been reported in up to 11% of patients undergoing the uterosacral suspension. However, this high rate is limited to one case series, and subsequent anatomical studies have provided preferential locations for anchoring sutures that decrease the risk of kinking the ureters. The surgical approach described in this chapter incorporates these surgical landmarks to minimize ureteral obstruction, yet perioperative cystoscopy should be used to insure ureteral patency at the conclusion. Studies also suggest that the uterosacral suspension tends to shorten vaginal length by 0.5 to 0.75 centimeters, although this is not physiologically important as the majority of women have normal vaginal length postoperatively.

Some surgeons advocate preoperative estrogen cream to promote a healthier mucosal epithelium in atrophic postmenopausal patients, although histological studies do not support this hypothesis. A bowel prep is not generally indicated preoperatively. Antibiotic prophylaxis with a second generation cephalosporin or metronidazole is recommended, although there is minimal data to show its efficacy. A risk assessment for deep venous thromboembolism prophylaxis is also indicated. Given the lithotomy position and average length of surgery, most patients have at least a moderate risk of venous thromboembolism, and consequently, we routinely use prophylaxis. Either pharmacologic or mechanical prophylaxis is appropriate.

The patient should be positioned in lithotomy or modified lithotomy position. Either regional anesthesia or general anesthesia can be used. Submucosal infiltration with injectable lidocaine with epinephrine simplifies postoperative pain and assists dissection and hemostasis. A Foley catheter should be placed during the surgery to drain the bladder. Following is a brief description of the surgical procedure used (see also video: Uterosacral Suspension).

The uterosacral suspension can be performed at the time of vaginal hysterectomy in patients with uterine prolapse or independently in a patient with post-hysterectomy apical prolapse. In the latter case, the surgery begins with a posterior colpotomy. In most cases of post-hysterectomy prolapse, there is an apical enterocele caused by a discontinuity between the superior portion of the pubocervical fascia and the rectovaginal fascia. This results when the surgeon performing the hysterectomy neglects to close the cuff and support it at the conclusion of the hysterectomy (see Chapter 3 for discussion of apical support at the time of vaginal hysterectomy). In this circumstance, the reconstructive surgeon wants to incise the vaginal cuff and open the enterocele sac in a manner that will allow easy identification of the superior margin of the pubocervical fascia and rectovaginal fascia. If the enterocele sac is large, this may be best accomplished by removing some of the vaginal mucosa and enterocele sac at the time of colpotomy. We will usually try to identify the stumps of the uterosacral ligaments at the superior margins of the pubocervical fascia and rectovaginal fascia before making an incision as we use these landmarks in deciding how to make the colpotomy. Frequently, an elliptical or diamond shaped incision just proximal to the superior margins of the pubocervical fascia and rectovaginal fascia provide the easiest approach (Figure 35.1).

Following vaginal hysterectomy or post-hysterectomy cuff colpotomy, the patient is placed in Trendelenburg position and the small bowel is packed away using a moistened 6-inch Kerlix sponge (Figure 35.2). Because the Kerlix does not have a radiopaque tag, we attach a suture to the sponge and hold it outside the field. Breisky-Navratil retractors help deflect the rectum medially and the bowel and surgical pack cephalad. The remnants of the distal uterosacral ligaments are identified and grasped. When we perform this surgery with concurrent vaginal hysterectomy, we hold the sutures used to ligate the uterosacral ligaments and use them for traction. Otherwise, we place sutures through the distal ligaments and hold them. Caudal traction on the distal uterosacral ligament along with the use of a head-lamp facilitates visualization of the uterosacral ligament.