McCall Culdoplasty
McCall culdoplasty is a native-tissue apical-support and cul-de-sac-obliteration technique most often performed at vaginal hysterectomy for uterovaginal prolapse. Sutures incorporate the uterosacral support complex, posterior vaginal cuff and cul-de-sac peritoneum; technique descriptions differ in the number and course of internal and external sutures.[15] Uterosacral fixation at abdominal or laparoscopic hysterectomy shares an anatomic goal but is not automatically the same studied operation or outcome population.
For the broader prolapse-repair atlas, see Prolapse Repair. For Moschcowitz / Halban variants targeting cul-de-sac obliteration without USL plication, see Moschcowitz Procedure and Halban Culdoplasty. For high USL suspension as a stand-alone apical operation, see Uterosacral Ligament Suspension.
Indications
- Apical support and enterocele prevention or repair during vaginal hysterectomy for uterovaginal prolapse. This is the setting of the original technique and most McCall outcome series.[8][15][16]
- Advanced uterovaginal prolapse is not an automatic exclusion. In one retrospective cohort, 38 women with exteriorized advanced prolapse and 273 with lesser prolapse had no statistically detected overall-success difference, but the advanced group was small and anterior failure was more frequent.[3]
- Route-adapted prophylactic uterosacral fixation at abdominal or minimally invasive hysterectomy has been described, including a mini-laparoscopic series; do not transfer vaginal McCall outcome rates to a different operation without checking its technique and population.[4][15]
- For established post-hysterectomy vault prolapse, select and counsel among dedicated apical repairs rather than assuming a hysterectomy-adjunct series estimates treatment success; see Uterosacral Ligament Suspension and the Prolapse Repair atlas.
Surgical Technique
Vaginal McCall (original)
- After vaginal hysterectomy, identify the uterosacral support and posterior cuff bilaterally and assess the enterocele/cul-de-sac defect.[15]
- Place internal McCall plication sutures through the pararectal/uterosacral support across the cul-de-sac; a described external suture also incorporates posterior vaginal wall and peritoneum. The cited operative series used one or two internal sutures plus an external suture, rather than a universal fixed count.[15]
- Tie the suspension/cul-de-sac closure without excessive cuff shortening or ureteral traction. Address anterior or posterior wall defects with compartment-specific repair when indicated; many outcome cohorts included these concomitant operations.[8][15]
- Check bilateral ureteral patency with intraoperative cystoscopy after suspension sutures are tied. A compromised efflux pattern warrants assessment and, when suture-related, release or repositioning before completion. Both a published McCall series and the 490-case modified-McCall cohort detected intraoperative ureteral obstruction/kinking.[8][15]
Abdominal McCall (variant)
At abdominal or laparoscopic hysterectomy, the uterosacral/cardinal support can be incorporated into cuff closure or plicated for apical support. Exposure, suture path and outcome evidence differ from vaginal McCall; specify the actual route-adapted operation in an operative record rather than labeling it an identical McCall repair.[4][15]
Modified McCall variants
| Variant | Description | Outcome highlight |
|---|---|---|
| Extraperitoneal high McCall (Zilberlicht 2021) | Sutures placed extraperitoneally, higher and more lateral into the uterosacral / cardinal ligaments; achieves higher cuff suspension[5] | — |
| Modified McCall with extended dissection (Ettore 2024) | Dissection of USLs toward the ischial spines; ligaments shortened and attached to the vaginal apex and to rectovaginal and vesicovaginal fasciae | In a prospective observational comparison, mean vaginal length 8.3 vs 6.4 cm at 12 months; recurrence difference was not established[6] |
| Double ligament suspension (DLS) (Parisi 2020) | Cuff suspended to both USLs and adnexal peduncles | In a retrospective 34-versus-34 comparison, stage ≥II recurrence 2/34 vs 11/34 at mean ~22–23 months; further treatment 1/34 vs 2/34[7] |
Outcomes
McCall techniques have favorable apical outcomes in several observational cohorts, but success definitions, concomitant repairs and follow-up differ; these percentages are study results, not a common predicted rate for every McCall variant.
| Endpoint | Result | Source |
|---|---|---|
| Posterior enterocele after vaginal hysterectomy | 2/32 McCall-type, 10/33 vaginal Moschcowitz-type, 13/33 peritoneal closure only at three years | Cruikshank/Kovac 1999 randomized comparison of these three prophylactic closures; not a modern post-hysterectomy vault-repair trial[16] |
| Objective vault support / subjective success | 97.1% / 94.1% at mean 2.8 years | Bushra 2021; single-surgeon, retrospective modified-McCall cohort, n = 490[8] |
| Reoperation for vault recurrence | 1.0% | Same Bushra cohort; distinct from anatomic or composite recurrence[8] |
| Vault prolapse after hysterectomy | 2/200 at median 8.9 years | Schiavi 2018 retrospective modified-McCall group; Shull group also 2/214[9] |
| Overall success in advanced versus lesser prolapse | 76.3% of 38 vs 68.5% of 273, p = 0.3553 | Alas 2018 retrospective cohort; no detected difference does not prove equivalence[3] |
| Anterior-compartment failure in advanced versus lesser prolapse | 18.4% vs 6.2% | Same Alas cohort; this is not a pooled McCall recurrence range[3] |
A 2025 systematic review discussed McCall among preventive approaches, but its four included studies (497 women) were heterogeneous and summarized qualitatively; it cannot establish a McCall-specific rank or a head-to-head recurrence advantage.[14]
Comparison With Other Apical Techniques
| Comparison | What the cited study observed | Counseling limit |
|---|---|---|
| Modified McCall vs Shull suspension | Schiavi's retrospective groups had 2/200 vs 2/214 vault prolapses at median 8.9 years; vaginal length shortened more with McCall, while sexual-function scores improved more with Shull.[9] | Not a randomized equivalence result; concomitant repairs and selection matter. |
| Modified McCall vs Shull suspension | Spelzini's retrospective comparison reported roughly 8 mm longer total vaginal length with Shull and no statistically detected anatomic-outcome difference.[12] | Surgeon selection by age/sexual activity limits causal inference. |
| McCall vs high USLS (Shull) | Novara's retrospective 155 McCall / 69 Shull cohort recorded objective cuff recurrence 4/155 vs 1/69 at median 15 vs 13 months.[10] | Surgeon familiarity determined technique; short follow-up and no statistically detected difference do not establish equivalence. |
| Traditional McCall vs double-ligament modification | Parisi found stage ≥II recurrence 11/34 vs 2/34 and longer vaginal length with DLS.[7] | Small, nonrandomized, ~2-year comparison; recurrence is not the same as retreatment. |
| Vaginal McCall vs vNOTES high USLS | Arkan reported 6/46 vs 1/46 cuff prolapses at 12 months and mean length 8.2 vs 9.0 cm.[11] | Small prospective cohort; access, visualization and apical technique differ together. |
For a post-hysterectomy vault comparison, the ASPIRe trial studied native-tissue repair (mostly sacrospinous fixation, some USLS) against sacrocolpopexy and transvaginal mesh; it did not test McCall culdoplasty. Its modeled 36-month composite failure was 43% with native repair and 28% with sacrocolpopexy. That endpoint includes anatomy and symptoms/retreatment, not simply recurrent vault prolapse, and cannot be substituted for any McCall row above.[13] The Cochrane reviews provide wider prolapse context, not McCall-specific operative instructions.[1][2]
Complications
| Complication | Rate / note |
|---|---|
| Ureteral kinking/obstruction | 2.9% in Bushra's 490 modified-McCall operations; one intraoperative suture release after cystoscopic obstruction in a separate 70-case McCall series. Check patency after suspension sutures.[8][15] |
| Ureteral or bladder injury | Arkan's 46-patient McCall arm had one of each at 12 months; this is a small selected cohort, not a general 0–1% McCall risk estimate.[11] |
| Vaginal shortening / sexual function | Greater length reduction with modified McCall than Shull in Schiavi's retrospective comparison; procedure selection and concomitant repairs limit attribution.[9][12] |
| Other-compartment recurrence | Alas found more anterior failure in the advanced subgroup; posterior and anterior defects warrant separate assessment rather than assuming cuff support corrects them.[3] |
Key Principles
- The best-described McCall use is apical support and cul-de-sac closure at vaginal hysterectomy. Describe abdominal/laparoscopic adaptations by their actual suture path and do not import vaginal-series outcomes.[4][15]
- Check bilateral ureteral patency after suspension sutures; published series document suture-related obstruction detected intraoperatively.[8][15]
- Favorable vault results in modified-McCall cohorts do not eliminate anterior or posterior compartment failure, and the small advanced-prolapse subgroup does not establish equivalent durability.[3][8]
- Extended-dissection and double-ligament variants may preserve more vaginal length or improve anatomy in their cohorts, but the studies differ in design and do not prove a single superior modification.[6][7]
- ASPIRe is a post-hysterectomy vault trial, not a McCall or SUPeR trial. Use its composite endpoint only when counseling about the procedures and population it actually studied.[13]
Videos
References
1. Baessler K, Christmann-Schmid C, Haya N, et al. Surgery for women with pelvic organ prolapse with or without stress urinary incontinence. Cochrane Database Syst Rev. 2026;2:CD013108. doi:10.1002/14651858.CD013108.pub2.
2. Yeung E, Baessler K, Christmann-Schmid C, et al. Transvaginal mesh or grafts or native tissue repair for vaginal prolapse. Cochrane Database Syst Rev. 2024;3:CD012079. doi:10.1002/14651858.CD012079.pub2.
3. Alas A, Chandrasekaran N, Devakumar H, et al. Advanced uterovaginal prolapse: is vaginal hysterectomy with McCall culdoplasty as effective as in lesser degrees of prolapse? Int Urogynecol J. 2018;29(1):139-144. doi:10.1007/s00192-017-3436-y.
4. Gencdal S, Demirel E, Soyman Z, Kelekci S. Prophylactic McCall culdoplasty by a vaginal approach during mini-laparoscopic hysterectomy. Biomed Res Int. 2019;2019:8047924. doi:10.1155/2019/8047924.
5. Zilberlicht A, Dwyer PL, Karmakar D, Carswell F, Schierlitz L. Extraperitoneal high vaginal cuff suspension at the time of vaginal hysterectomy for advanced uterovaginal prolapse: results of a modified McCall technique from a longitudinal clinical study. Aust N Z J Obstet Gynaecol. 2021;61(2):258-262. doi:10.1111/ajo.13288.
6. Ettore G, Torrisi G, Grimaldi RL, Ettore C. A modified McCall culdoplasty in pelvic organ prolapse surgery: anatomical and functional outcomes. Int Urogynecol J. 2024;35(12):2341-2348. doi:10.1007/s00192-024-05886-1.
7. Parisi S, Novelli A, Olearo E, Basile A, Puppo A. Traditional McCall culdoplasty compared to a modified McCall technique with double ligament suspension: anatomical and clinical outcomes. Int Urogynecol J. 2020;31(10):2147-2153. doi:10.1007/s00192-020-04403-4.
8. Bushra M, Anglim B, Al-Janabi A, Lovatsis D, Alarab M. Long-term experience with modified McCall culdoplasty in women undergoing vaginal hysterectomy for pelvic organ prolapse. J Obstet Gynaecol Can. 2021;43(10):1129-1135. doi:10.1016/j.jogc.2021.04.012.
9. Schiavi MC, Savone D, Di Mascio D, et al. Long-term experience of vaginal vault prolapse prevention at hysterectomy time by modified McCall culdoplasty or Shull suspension: clinical, sexual and quality of life assessment after surgical intervention. Eur J Obstet Gynecol Reprod Biol. 2018;223:113-118. doi:10.1016/j.ejogrb.2018.02.025.
10. Novara L, Sgro LG, Pecchio S, et al. Transvaginal high uterosacral ligament suspension: an alternative to McCall culdoplasty in the treatment of pelvic organ prolapse. Eur J Obstet Gynecol Reprod Biol. 2019;240:278-281. doi:10.1016/j.ejogrb.2019.07.007.
11. Arkan K, Cavusoglu Colak G, Bırol Ilter P, Akdenız E, Akgol S. Effectiveness and comparison of vNOTES-assisted uterosacral ligament suspension and vaginal McCall culdoplasty in apical prolapse. Eur J Obstet Gynecol Reprod Biol. 2026;317:114861. Epub 2025 Nov 28. doi:10.1016/j.ejogrb.2025.114861.
12. Spelzini F, Frigerio M, Manodoro S, et al. Modified McCall culdoplasty versus Shull suspension in pelvic prolapse primary repair: a retrospective study. Int Urogynecol J. 2017;28(1):65-71. doi:10.1007/s00192-016-3016-6.
13. Menefee SA, Richter HE, Myers D, et al. Apical suspension repair for vaginal vault prolapse: a randomized clinical trial. JAMA Surg. 2024;159(8):845-855. doi:10.1001/jamasurg.2024.1206.
14. Silva AKS, Bonfim MB, Ferreira LL, Miguel L, Hermes TA. Surgical approaches to prevent vaginal vault prolapse after hysterectomy, and risk factors for vaginal vault prolapse. Eur J Obstet Gynecol Reprod Biol. 2025;314:114684. doi:10.1016/j.ejogrb.2025.114684.
15. Niblock K, Bailie E, McCracken G, Johnston K. Vaginal McCall culdoplasty versus laparoscopic uterosacral plication to prophylactically address vaginal vault prolapse. Gynecol Surg. 2017;14:3. doi:10.1186/s10397-017-1006-4.
16. Cruikshank SH, Kovac SR. Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele. Am J Obstet Gynecol. 1999;180:859-865. doi:10.1016/S0002-9378(99)70656-3.