Iliococcygeus Fascia Suspension
Iliococcygeus fascia suspension (ICG fixation, "prespinous fixation") is a transvaginal native-tissue apical operation in which the vaginal vault (or cervix) is sutured bilaterally to the fascia overlying the iliococcygeus muscle to restore apical support. The iliococcygeus fascia is targeted anterior (ventral) and medial to the ischial spine, distinguishing it from sacrospinous-ligament fixation, which engages tissue at or posterior to the spine. The prespinous location keeps suture placement away from the pudendal neurovascular bundle.[1][2][3][4]
For the more commonly performed sacrospinous variant, see Sacrospinous Ligament Fixation (SSLF). For the uterosacral alternative, see Uterosacral Ligament Suspension (USLS). For the broader prolapse decision framework, see Prolapse Repair.
History and Definition
First described by Inmon (1963), popularized by Meeks et al. (1994) and Shull et al. (1993). Peters and Christenson (1995) described a related technique using "coccygeus fascia" (the fascia overlying the coccygeus-sacrospinous complex).[2][3]
Despite being technically simple and low-morbidity, the procedure is not commonly performed compared with sacrospinous or uterosacral ligament suspension.[1]
Relevant Anatomy
The iliococcygeus is the most posterior and lateral component of the levator ani complex (alongside pubococcygeus and puborectalis):[5][6]
- Origin: arcus tendineus levatoris ani (a fascial thickening on the obturator-internus fascia)
- Insertion: coccyx and anococcygeal raphe
- Geometry: forms a horizontal levator plate supporting the pelvic viscera
- The fascia overlying the iliococcygeus is the suture target — located 1–2 cm anterior and medial to the ischial spine ("prespinous" area), and further from the pudendal neurovascular bundle than the sacrospinous ligament[2][7]
Indications
- Posthysterectomy vaginal vault prolapse (POP-Q stage ≥ 2) — primary and best-studied indication.[8][9]
- Mild uterine prolapse as a hysteropexy — outcomes acceptable; less favorable for advanced uterine prolapse.[10]
- Patients in whom an abdominal approach or synthetic mesh is not desired or contraindicated.[1]
- Both primary and recurrent prolapse.[3]
Relative contraindications
- Severe levator-ani defects or atrophy — fascia may be too thin to hold sutures.[12]
- Stage IV vault prolapse — strongest independent predictor of failure.[8][9]
Surgical Technique
The operation is performed in dorsal lithotomy under regional or general anesthesia.[1][3]
- Vaginal incision. Midline posterior vaginal-wall incision extended to the apex; identify and address any enterocele.
- Pararectal-space dissection. Enter the rectovaginal space and develop the pararectal space bilaterally by sharp and blunt dissection, sweeping the rectum medially. Carry dissection laterally and superiorly until the iliococcygeus muscle is exposed and palpable.[1]
- Fascia identification. Identify the iliococcygeus fascia in the prespinous area — 1–2 cm anterior and medial to the ischial spine, using the spine as a palpable landmark.[2][3]
- Bilateral suture placement. Place two delayed-absorbable or permanent sutures on each side (4 total) through the iliococcygeus fascia in figure-of-eight or mattress fashion, incorporating a generous bite of fascia and underlying muscle.[3]
- Vaginal-vault fixation. Pass the sutures through the full thickness of the vaginal vault (or cervix in hysteropexy) and tie, suspending the vault bilaterally to the iliococcygeus fascia.
- Concomitant compartment repair. Anterior colporrhaphy, posterior colporrhaphy, and / or perineorrhaphy as needed; adequate repair of all fascial defects and the perineal body is considered critical to durability.[3]
- Vaginal closure.
Technical points
- Bilateral fixation restores a more midline, physiological vaginal axis vs the unilateral posterior deflection of sacrospinous fixation.[2]
- Adequate pararectal-space exposure is the key technical step.[1]
- Suture placement remains away from the pudendal neurovascular bundle.[2]
Outcomes — Long-Term Efficacy
| Series | Follow-up | n | Subjective cure | Objective cure |
|---|---|---|---|---|
| Serati 2021 (10-year follow-up)[8] | Median 120 mo | 39 | 82% | 74.4% |
| Serati 2015 (5-year follow-up)[9] | 5 yr | — | 88.6% | 84.1% |
Across both series, only preoperative stage IV vault descensus independently predicted failure (OR 7.66–8.78).[8][9]
Meeks 1994 (founding series)[3]
- 110 patients; success in 96.4%; only 4 recurrences — all anterior compartment.
- All recurrences underscore the dominant late failure mode of any posterior-axis suspension.
Comparative Outcomes
vs Sacrospinous Ligament Fixation (Maher 2001 matched case-control, 36 pairs)[4]
| Outcome | ICG fixation | Sacrospinous fixation | p |
|---|---|---|---|
| Subjective success | 91% | 94% | 0.73 |
| Objective success | 53% | 67% | 0.36 |
| Patient satisfaction (VAS) | 78/100 | 91/100 | 0.01 |
| Recovery time (days) | 54 | 39 | 0.04 |
| Postoperative cystocele | No difference | No difference | NS |
| Buttock pain | No difference | No difference | NS |
| Hemorrhage requiring transfusion | No difference | No difference | NS |
Conclusion: equally effective; sacrospinous fixation should not be discarded in favor of ICG.[4]
vs Coccygeus Fascial Suspension vs Sacrospinous (Peters 1995)[2]
Projected 2-yr cure: 96% coccygeus-fascial suspension vs 80% sacrospinous fixation.
vs Abdominal Sacrocolpopexy (Milani 2014, n = 36 vs 41)[11]
- Operative time: significantly shorter (78 vs 140 min, p < 0.001).
- Comparable outcomes; ICG offers a faster, mesh-free vaginal alternative.
As hysteropexy (Suh & Jeon 2018, n = 144)[10]
| Subgroup | 4-yr success |
|---|---|
| ICG with hysterectomy, mild prolapse (stage II, point C ≤ 0) | 100% |
| ICG with hysterectomy, advanced prolapse | 91.2% |
| ICG as hysteropexy, mild prolapse | 75.3% |
| ICG as hysteropexy, advanced prolapse | 48.0% |
Independent failure predictors: advanced prolapse (stage > II, point C > 0) and uterus-saving technique. Acceptable as hysteropexy only for mild uterine prolapse.
Complications
The procedure has a notably low complication profile:[1][3][4]
| Complication | Rate / note |
|---|---|
| Hemorrhage | 3/110 (2.7%) had EBL > 750 mL in Meeks; 2 required transfusion[3] |
| Bladder injury | Rare (1/110 in Meeks)[3] |
| Bowel injury | Rare (1/110 in Meeks)[3] |
| Buttock / gluteal pain | Similar to sacrospinous fixation in comparative data; theoretically lower because suture placement is anterior to the spine and away from the pudendal nerve[4] |
| Postoperative urinary retention | Mean catheterization 6.1 days (Meeks)[3] |
| Anterior compartment recurrence | The dominant late failure mode — 4 of 4 recurrences in Meeks[3] |
| Mesh-related complications | None (native tissue) |
Risk Factors for Failure
- Preoperative stage IV vault prolapse — strongest predictor (OR 7.66–8.78).[8][9]
- Advanced prolapse (stage > II, point C > 0).[10]
- Uterus-preserving technique (hysteropexy), particularly for advanced prolapse.[10]
Advantages and Disadvantages
| Advantage | Disadvantage |
|---|---|
| Technically simpler than SSLF — no specialized suture-passing devices required[1] | Less commonly performed; surgeon familiarity limited[1] |
| Bilateral fixation → more physiological midline vaginal axis[2] | Anterior compartment recurrence is the dominant late failure[3] |
| Prespinous suture placement → lower theoretical pudendal NV-bundle risk[2] | Lower success as hysteropexy, particularly for advanced prolapse[10] |
| Native tissue — no mesh[1] | Limited high-quality comparative data — no large RCTs vs SSLF / USLS |
| Shorter operative time than abdominal sacrocolpopexy[11] | Dependent on levator-ani muscle quality — limited in significant levator defects / atrophy[12] |
| Comparable apical efficacy to sacrospinous fixation[4] | Patient satisfaction and recovery may be slightly inferior to SSLF[4] |
Guideline Position
ACOG PB 214 (2019) lists iliococcygeus ligament fixation as one of the transvaginal apical suspension procedures available for POP repair, alongside sacrospinous and uterosacral ligament suspension. ACOG/AUGS guidelines focus primarily on sacrospinous and uterosacral suspension as the two best-studied native-tissue vaginal apical operations (Level A evidence for equivalence). ICG is not separately rated, reflecting its more limited comparative evidence base.[13][14]
Key Principles
- ICG fixation is a prespinous, bilateral, native-tissue apical operation — sutures into iliococcygeus fascia 1–2 cm anterior and medial to the ischial spine.[2][3]
- The prespinous position keeps suture placement away from the pudendal neurovascular bundle.[2][7]
- Best-studied indication is post-hysterectomy vault prolapse — 5- and 10-year cure 74–88%.[8][9]
- Acceptable as hysteropexy only for mild uterine prolapse — failure rises sharply with advanced prolapse and uterus preservation (Suh 2018: 48% success in advanced hysteropexy).[10]
- Stage IV vault descensus is the strongest independent failure predictor.[8][9]
- Comparable apical efficacy to SSLF (Maher 2001 matched case-control); SSLF gives better patient satisfaction and faster recovery.[4]
- Dominant late failure mode is anterior compartment recurrence — assess and address anterior support concurrently.[3]
- Underutilized despite simplicity and safety — surgeon familiarity is the primary barrier.[1]
References
1. Milani R, Frigerio M, Spelzini F, Manodoro S. Transvaginal iliococcygeus fixation for posthysterectomy vaginal vault prolapse repair. Int Urogynecol J. 2017;28(10):1599-1601. doi:10.1007/s00192-017-3315-6.
2. Peters WA, Christenson ML. Fixation of the vaginal apex to the coccygeus fascia during repair of vaginal vault eversion with enterocele. Am J Obstet Gynecol. 1995;172(6):1894-900; discussion 1900-2. doi:10.1016/0002-9378(95)91429-3.
3. Meeks GR, Washburne JF, McGehee RP, Wiser WL. Repair of vaginal vault prolapse by suspension of the vagina to iliococcygeus (prespinous) fascia. Am J Obstet Gynecol. 1994;171(6):1444-52; discussion 1452-4. doi:10.1016/0002-9378(94)90386-7.
4. Maher CF, Murray CJ, Carey MP, Dwyer PL, Ugoni AM. Iliococcygeus or sacrospinous fixation for vaginal vault prolapse. Obstet Gynecol. 2001;98(1):40-4. doi:10.1016/s0029-7844(01)01378-3.
5. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet. 2007;369(9566):1027-38. doi:10.1016/S0140-6736(07)60462-0.
6. DeLancey JO, Mastrovito S, Masteling M, et al. A unified pelvic floor conceptual model for studying morphological changes with prolapse, age, and parity. Am J Obstet Gynecol. 2024;230(5):476-484.e2. doi:10.1016/j.ajog.2023.11.1247.
7. Roshanravan SM, Wieslander CK, Schaffer JI, Corton MM. Neurovascular anatomy of the sacrospinous ligament region in female cadavers: implications in sacrospinous ligament fixation. Am J Obstet Gynecol. 2007;197(6):660.e1-6. doi:10.1016/j.ajog.2007.08.061.
8. Serati M, Salvatore S, Athanasiou S, et al. Ten years' follow-up after iliococcygeus fixation for the treatment of apical vaginal prolapse. Int Urogynecol J. 2021;32(6):1533-1538. doi:10.1007/s00192-020-04598-6.
9. Serati M, Braga A, Bogani G, et al. Iliococcygeus fixation for the treatment of apical vaginal prolapse: efficacy and safety at 5 years of follow-up. Int Urogynecol J. 2015;26(7):1007-12. doi:10.1007/s00192-015-2629-5.
10. Suh DH, Jeon MJ. Risk factors for the failure of iliococcygeus suspension for uterine prolapse. Eur J Obstet Gynecol Reprod Biol. 2018;225:210-213. doi:10.1016/j.ejogrb.2018.05.001.
11. Milani R, Cesana MC, Spelzini F, et al. Iliococcygeus fixation or abdominal sacral colpopexy for the treatment of vaginal vault prolapse: a retrospective cohort study. Int Urogynecol J. 2014;25(2):279-84. doi:10.1007/s00192-013-2216-6.
12. de Alba Alvarez I, Noort FVD, Simonis FFJ, Grob ATM. Upright and supine assessment of pelvic floor muscle defects in women with and without prolapse. Sci Rep. 2026. doi:10.1038/s41598-026-35598-z.
13. Committee on Practice Bulletins—Gynecology and American Urogynecologic Society. Pelvic organ prolapse: ACOG Practice Bulletin, Number 214. Obstet Gynecol. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519.
14. American Urogynecologic Society. Pelvic organ prolapse. Female Pelvic Med Reconstr Surg. 2019;25(6):397-408. doi:10.1097/SPV.0000000000000794.