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Sacrohysteropexy

Sacrohysteropexy is a uterine-sparing reconstructive operation that suspends the uterus (via the cervix) to the sacral promontory usually with synthetic mesh, restoring apical support while preserving the uterus. Open, laparoscopic and robotic techniques are described; biologic-graft variants have less supporting evidence.[1][2][3]

For the post-hysterectomy mesh equivalent, see Sacrocolpopexy. For the supracervical hysterectomy variant, see Supracervical Hysterectomy at Sacrocolpopexy. For native-tissue uterus-preserving operations, see Sacrospinous Hysteropexy and Manchester-Fothergill Procedure.

Definition and Rationale​

Sacrohysteropexy attaches the cervix or uterine isthmus to the anterior longitudinal ligament of the sacrum using a synthetic or biologic graft, providing an abdominally placed suspension of the cervix/uterus.[1][4]

Rationale for uterine preservation:

  • Some comparisons report less blood loss or shorter surgery than hysterectomy-based mesh repairs; the comparator and concomitant procedures matter.[3][5]
  • Reviews report lower mesh-exposure risk in some uterine-preserving comparisons, without eliminating mesh complications.[3][6]
  • Retains the uterus; this does not establish fertility, pregnancy safety or a menopause-timing benefit.[7]
  • Patient preference is an independent reason to discuss uterine preservation.[5]
  • Short-term comparative prolapse results vary by procedure and endpoint; absence of a significant difference is not universal equivalence.[3]

Indications and Patient Selection​

ACOG and AUGS endorse hysteropexy as a viable alternative to hysterectomy in women with uterine prolapse.[1][8]

CriterionDetail
StageBothersome apical prolapse; several trials recruited POP-Q stage ≥ 2[9][10]
Uterine preservationPatient desires uterine preservation (fertility, personal preference, cultural reasons)[7]
ChildbearingMost comparative evidence concerns completed childbearing; future pregnancy requires a separate discussion[11]
Uterine statusAppropriate cervical screening and assessment of abnormal bleeding or suspected uterine/cervical disease[7][12]

Findings requiring additional assessment or an alternative plan​

  • Abnormal uterine bleeding requiring evaluation.[7][12]
  • Uterine or cervical premalignancy / malignancy.[12]
  • Significant uterine pathology (fibroids requiring treatment, endometrial hyperplasia).[7]
  • Cervical elongation without comparable descent of the uterine body — consider the anatomy and alternatives, including Manchester repair, rather than using point C alone to select an operation.[12]

Surgical Technique — Laparoscopic / Robotic​

The operation shares the sacral exposure of sacrocolpopexy while retaining the uterus. The sequence below summarizes published laparoscopic/robotic descriptions; port layout, graft configuration and fixation details vary.[2][13][14]

  1. Port placement and exposure. Use the chosen laparoscopic or robotic access and patient positioning; retract the sigmoid as needed to expose the promontory.[2][14]
  2. Sacral promontory dissection. Incise peritoneum over the promontory; identify and expose the anterior longitudinal ligament (ALL) of S1. Identify the iliac vessels, middle sacral vessels, right ureter and nearby autonomic structures before fixation. Presacral vascular injury can cause major hemorrhage; the exposure and fixation site must follow the individual anatomy rather than a fixed distance or blind placement.[2][14]
  3. Peritoneal tunnel. Create a peritoneal tunnel from the promontory to the cervix along the right pelvic sidewall, lateral to the rectum, to house the mesh and allow subsequent peritonization.[2][14]
  4. Cervical / uterine dissection.
    • Standard (wrap) technique: incise anterior and posterior peritoneum overlying cervical stroma; create broad-ligament windows under direct visualization, identifying and protecting the uterine vessels; no region should be assumed avascular from a generic landmark alone; dissect vesicovaginal and rectovaginal spaces to expose cervical stroma.[13][14]
    • Simplified posterior-only technique (Jan 2018): only the posterior aspect of the cervix is dissected — limits anterior dissection; it does not eliminate bladder injury or mesh-related complications.[15]
  5. Mesh selection and preparation. See table below.
  6. Mesh attachment to the cervix.
    • Y-shaped or cervix-encircling configuration: anterior arm sutured to anterior cervical stroma / vaginal wall; posterior arm to posterior cervical stroma — interrupted non-absorbable or delayed-absorbable sutures; arms wrap around cervix and meet at the sacral arm.[13]
    • Flat strip (simplified): single posterior strip with interrupted sutures, extending directly to the promontory.[15]
    • Anterior + posterior extension: in multicompartment prolapse, extend anterior arm along vesicovaginal septum and posterior arm along rectovaginal septum (full sacrocolpopexy-style).[17]
  7. Sacral fixation. Secure the sacral end of the mesh to the ALL at S1 using the fixation method described for the selected technique; avoid fixation into the disc and excessive tension — uterus elevated to anatomic position without excess tension.[13][4]
  8. Peritonization. Close peritoneum over the mesh with a running absorbable suture to separate the graft from bowel; this does not eliminate bowel-obstruction risk; tunneling technique reduces peritoneal defect size.[2][15]

Mesh selection​

MeshConfigurationNotes
Type-1 polypropylene (macroporous, monofilament)Y-shaped or flat stripCommon in published techniques; weight, pore structure and handling differ by product[1][2]
PVDF (polyvinylidene fluoride)Flat strip, square weaveUsed in some described techniques; graft geometry and handling are product-specific[3]
SERATEX SlimSlingNarrow stripReported in a named retrospective sacrohysteropexy series[16]
Biologic graftFlat stripDescribed alternative with limited comparative durability evidence; not interchangeable with synthetic mesh[5]

Concomitant procedures​

Assess anterior and posterior compartment defects separately; colporrhaphy, cervical shortening or treatment for stress incontinence may be added when indicated. Published series report differing combinations. Their procedure percentages are not a rule to perform a sling or cervical amputation in an individual patient.[9][16][17]

Operative planning​

Operating time, blood loss and length of stay vary with surgical route, concomitant repairs, surgeon experience and local recovery pathways. Comparison with vaginal hysteropexy includes the additional abdominal access and mesh-dissection burden; use trial-specific results when counseling rather than a universal operating-time estimate.[9][18]

Outcomes: retain the endpoint and denominator​

SourceReported resultHow to interpret it
Izett-Kay cross-sectional cohort1,121/1,766 women responded (63.5%), median 46-month follow-up; 4/1,121 (0.4%) reported a mesh complication requiring removal, confirmed from recordsMesh-removal surgery, not all mesh exposure or all mesh complications. Nonresponse and unequal follow-up limit interpretation.[20]
Same cohortReoperation for apical POP 3.7%; any POP 13.6%; 81.4% reported being much/very much betterSeparate apical retreatment, any-compartment retreatment and patient-reported improvement; none is a universal anatomical cure rate.[20]
Izett-Kay randomized-trial follow-up62 of 101 randomized women attended long-term review, mean 100 monthsSmall surviving sample and attrition constrain the comparison; see below.[19]

Comparative Outcomes​

vs Vaginal Hysterectomy with Apical Suspension​

7-year RCT follow-up (Izett-Kay 2022; 62 of 101 randomized participants attended long-term review):[19]

  • Apical reoperation was 6.1% vs 17.2% (p = 0.17); the study did not establish a significant between-group difference.
  • Significantly higher apical suspension (point C −5 vs −4.25, p = 0.02).
  • Longer total vaginal length among those assessed (9 cm vs 6 cm, p < 0.001).

The Brennand 2025 prospective cohort (n = 321) compared uterine-preserving with hysterectomy-based surgery more broadly. It found associations with lower composite recurrence (adjusted RR 0.47, 95% CI 0.32–0.69) and fewer procedural complications (adjusted RR 0.19). This is not a randomized, isolated test of one sacrohysteropexy technique.[5]

vs Sacrospinous Hysteropexy — LAVA trial​

LAVA reported noninferiority of laparoscopic mesh sacrohysteropexy to vaginal native-tissue sacrospinous hysteropexy for its 12-month composite surgical-failure endpoint. The specific population, procedures, short follow-up and differing symptom outcomes matter; this does not establish long-term equivalence or a universal preference for either approach.[9]

vs Sacrocolpopexy with Subtotal Hysterectomy​

A propensity-matched study found comparable objective cure rates, but subjective success (PGI-I) was higher after sacrocolpopexy with subtotal hysterectomy (97.8% vs 81.8%, p = 0.034).[22]

Cochrane 2023​

The review found differences in awareness of prolapse, repeat surgery, recurrent prolapse and several adverse outcomes uncertain or small for vaginal versus sacral hysteropexy. Operations and outcome definitions vary; it does not establish a universal best uterine-preserving repair.[18]

Complications​

IssueRelevant assessment and counseling
Mesh exposure, erosion or painPossible even with uterine preservation; a mesh-removal rate does not measure every exposure or symptom.
Bladder, ureter or bowel injuryRelated to the dissection, anatomy and associated procedures; a posterior-only graft does not remove all injury risk.
Presacral hemorrhageA potentially serious hazard during promontory exposure and fixation.
Bowel obstructionMay result from adhesions or exposed material despite peritoneal coverage.
Urinary, bowel or sexual symptomsMay persist, improve or arise after repair; assess them separately from apical support.
Recurrent prolapse / reoperationMay involve the apex or another compartment, with risk accumulating during follow-up.

These categories are reported in clinical series and reviews; use source-specific denominators when quoting rates.[3][17][19][20][21]

Long-Term Durability​

A 270-patient series followed some patients for as long as 14.5 years; that maximum is not the follow-up of the entire cohort. Its success estimates varied over time. PFDI-20 and PFIQ-7 scores remained significantly improved across follow-up. Anal incontinence and constipation rates decreased significantly after surgery.[17]

Fertility and Pregnancy​

A 2025 systematic review of pregnancy after laparoscopic sacrohysteropexy:[11]

  • All 26 reported patients delivered by cesarean section at mean 38 weeks.
  • The small published case literature included recurrent uterine prolapse postpartum; the reported percentage is not a reliable population risk estimate.
  • Anterior-compartment prolapse was also described after birth.
  • The small and selectively published literature cannot exclude fetal, obstetric or pelvic-floor risks.

A meta-analysis compared reported pregnancies after different uterus-preserving operations, but small, heterogeneous observational data cannot establish that one repair is safest for a future pregnancy. The fact that all 26 pregnancies in the cited laparoscopic-hysteropexy review ended by cesarean section describes the reports, not a universal delivery mandate. Discuss repair choice and delivery planning with urogynecology and obstetrics.[11][23]

Posterior-only configurations have been described with the intention of avoiding cervical encirclement; this technical rationale is not proof of safe vaginal birth after a specific implant.[15]

Mesh-Free Alternative — Suture Hysteropexy​

Laparoscopic / robotic suture-based hysteropexy (uterosacral ligament plication) is a distinct mesh-free option. A retrospective comparison reported composite success rates between suture hysteropexy and mesh sacrohysteropexy (84.5% vs 81.7%); this was not a randomized equivalence trial. Mesh was associated with greater uterine elevation (point C change −7.38 vs −6.99 cm, p < 0.05).[24]

Counseling and follow-up​

  • Clarify whether the goal is uterine preservation, future pregnancy, avoidance of vaginal surgery, or a combination; these are different decisions.
  • Explain the permanent graft, operative route, native-tissue alternatives, and the possibility of mesh-related or prolapse retreatment.
  • Continue appropriate cervical screening and evaluate new abnormal bleeding rather than imposing routine endometrial surveillance on every asymptomatic patient.
  • Assess recurrent bulge, pain, urinary, bowel and sexual symptoms separately.
  • Keep SUPeR (vaginal mesh sacrospinous hysteropexy) and SAVE-U (native-tissue sacrospinous hysteropexy) separate from direct sacrohysteropexy evidence; their procedures and harms are not interchangeable.[1][3][9][18]

References​

1. 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.

2. Labanca L, Centini G, Lazzeri L, et al. Sacrohysteropexy: a way to spare the uterus. J Minim Invasive Gynecol. 2020;27(6):1254-1255. doi:10.1016/j.jmig.2019.12.006.

3. Meriwether KV, Antosh DD, Olivera CK, et al. Uterine preservation vs hysterectomy in pelvic organ prolapse surgery: a systematic review with meta-analysis and clinical practice guidelines. Am J Obstet Gynecol. 2018;219(2):129-146.e2. doi:10.1016/j.ajog.2018.01.018.

4. Leron E, Stanton SL. Sacrohysteropexy with synthetic mesh for the management of uterovaginal prolapse. BJOG. 2001;108(6):629-33. doi:10.1111/j.1471-0528.2001.00138.x.

5. Brennand EA, Scime NV, Huang B, et al. Hysterectomy versus uterine preservation for pelvic organ prolapse surgery: a prospective cohort study. Am J Obstet Gynecol. 2025;232(5):461.e1-461.e20. doi:10.1016/j.ajog.2024.10.021.

6. Rosati M, Bramante S, Conti F. A review on the role of laparoscopic sacrocervicopexy. Curr Opin Obstet Gynecol. 2014;26(4):281-9. doi:10.1097/GCO.0000000000000079.

7. Ridgeway BM. Does prolapse equal hysterectomy? The role of uterine conservation in women with uterovaginal prolapse. Am J Obstet Gynecol. 2015;213(6):802-9. doi:10.1016/j.ajog.2015.07.035.

8. American Urogynecologic Society. Pelvic organ prolapse. Female Pelvic Med Reconstr Surg. 2019;25(6):397-408. doi:10.1097/SPV.0000000000000794.

9. van IJsselmuiden MN, van Oudheusden A, Veen J, et al. Hysteropexy in the treatment of uterine prolapse stage 2 or higher: laparoscopic sacrohysteropexy versus sacrospinous hysteropexy — a multicentre randomised controlled trial (LAVA Trial). BJOG. 2020;127(10):1284-1293. doi:10.1111/1471-0528.16242.

10. Hwang WY, Jeon MJ, Suh DH. Minimally invasive sacrohysteropexy versus vaginal hysterectomy with uterosacral ligament suspension for pelvic organ prolapse: a prospective randomized non-inferiority trial. J Minim Invasive Gynecol. 2024;31(5):406-413. doi:10.1016/j.jmig.2024.01.018.

11. Pitsillidi A, Vona L, Bettocchi S, Schiermeier S, Noé GK. Pregnancy after laparoscopic hysteropexy: a systematic review. J Clin Med. 2025;14(8):2777. doi:10.3390/jcm14082777.

12. Enklaar RA, Schulten SFM, van Eijndhoven HWF, et al. Manchester procedure vs sacrospinous hysteropexy for treatment of uterine descent: a randomized clinical trial. JAMA. 2023;330(7):626-635. doi:10.1001/jama.2023.13140.

13. Warehime J, Cope Z, Feroz R, et al. Robotic sacrohysteropexy: an instructional video for uterovaginal prolapse repair in patients with desired uterine preservation. Int Urogynecol J. 2022;33(12):3585-3586. doi:10.1007/s00192-022-05260-z.

14. Acsinte OM, Rabischong B, Bourdel N, Canis M, Botchorishvili R. Laparoscopic promontofixation in 10 steps. J Minim Invasive Gynecol. 2018;25(5):767. doi:10.1016/j.jmig.2017.10.020.

15. Jan H, Ghai V, Thakar R. Simplified laparoscopic sacrohysteropexy. J Minim Invasive Gynecol. 2018;25(7):1134. doi:10.1016/j.jmig.2018.01.014.

16. Rotem R, Alkeesh Y, Hirsch A, Ben-Shachar I, Marcus N. Long-term outcomes of laparoscopic sacrohysteropexy with SERATEX SlimSling mesh: a retrospective case series. Int Urogynecol J. 2025;36(3):655-661. doi:10.1007/s00192-024-06037-2.

17. Rusavy Z, Grinstein E, Gluck O, Abdelkhalek Y, Deval B. Long-term development of surgical outcome of laparoscopic sacrohysteropexy with anterior and posterior mesh extension. Int Urogynecol J. 2023;34(1):191-200. doi:10.1007/s00192-022-05102-y.

18. Maher C, Yeung E, Haya N, et al. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev. 2023;7:CD012376. doi:10.1002/14651858.CD012376.pub2.

19. Izett-Kay ML, Rahmanou P, Cartwright RJ, Price N, Jackson SR. Laparoscopic sacrohysteropexy versus vaginal hysterectomy and apical suspension: 7-year follow-up of a randomized controlled trial. Int Urogynecol J. 2022;33(7):1957-1965. doi:10.1007/s00192-021-04932-6.

20. Izett-Kay ML, Aldabeeb D, Kupelian AS, et al. Long-term mesh complications and reoperation after laparoscopic mesh sacrohysteropexy: a cross-sectional study. Int Urogynecol J. 2020;31(12):2595-2602. doi:10.1007/s00192-020-04396-0.

21. Nightingale G, Phillips C. Long-term safety and efficacy of laparoscopically placed mesh for apical prolapse. Int Urogynecol J. 2021;32(4):871-877. doi:10.1007/s00192-020-04374-6.

22. Arcieri M, Morlacco A, Montebelli F, et al. Sacrocolpopexy after sub-total hysterectomy vs sacral hysteropexy for advanced urogenital prolapse: a propensity-matched study. Int J Gynaecol Obstet. 2023;163(3):847-853. doi:10.1002/ijgo.14959.

23. Barba M, Schivardi G, Manodoro S, Frigerio M. Obstetric outcomes after uterus-sparing surgery for uterine prolapse: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2021;256:333-338. doi:10.1016/j.ejogrb.2020.11.054.

24. Gopinath D, Yong C, Harding-Forrester S, et al. Laparoscopic and robot-assisted suture versus mesh hysteropexy: a retrospective comparison. Int Urogynecol J. 2023;34(1):105-113. doi:10.1007/s00192-022-05283-6.