Sacrohysteropexy
Sacrohysteropexy is a uterine-sparing reconstructive operation that suspends the uterus (via the cervix) to the sacral promontory using a synthetic mesh or biologic graft, restoring apical support while preserving the uterus. It can be performed open, laparoscopically, or with robotic assistance — minimally invasive approaches now predominate.[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, recreating the physiologic vaginal axis along the levator plate.[1][4]
Rationale for uterine preservation:
- Shorter operative time and less blood loss than hysterectomy-based mesh repairs.[3][5]
- Lower mesh exposure vs sacrocolpopexy after total hysterectomy.[3][6]
- Preserves fertility and natural menopause timing.[7]
- Patient preference — ~half of patients with prolapse prefer to keep their uterus.[5]
- No significant difference in short-term prolapse outcomes vs hysterectomy.[3]
Indications and Patient Selection
ACOG and AUGS endorse hysteropexy as a viable alternative to hysterectomy in women with uterine prolapse.[1][8]
| Criterion | Detail |
|---|---|
| Stage | Symptomatic POP-Q stage ≥ 2 with apical descent[9][10] |
| Uterine preservation | Patient desires uterine preservation (fertility, personal preference, cultural reasons)[7] |
| Childbearing | Standard indication after childbearing complete; selected cases in fertility-desiring patients[11] |
| Uterine status | No uterine pathology — normal cervical cytology, no abnormal bleeding, no premalignant or malignant disease[7][12] |
Contraindications
- 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 true apical descent — may be better served by Manchester procedure.[12]
Surgical Technique — Laparoscopic / Robotic
The operation is analogous to sacrocolpopexy with uterine preservation.[2][13][14]
- Port placement and exposure. Standard 4-port laparoscopic or robotic configuration; steep Trendelenburg; sigmoid colon retracted to expose the sacral promontory.[2][14]
- Sacral promontory dissection. Incise peritoneum over the promontory; identify and expose the anterior longitudinal ligament (ALL) of S1. Critical structures to preserve: right common iliac vein, middle sacral vessels, left common iliac vein, right ureter crossing the pelvic brim. Presacral venous plexus bleeding is the most feared complication — control with pressure, bone wax, or thumbtacks.[2][14]
- 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]
- Cervical / uterine dissection.
- Standard (wrap) technique: incise anterior and posterior peritoneum overlying cervical stroma; create tunnels through the avascular plane of the broad ligament lateral to the uterine vessels to preserve uterine blood supply; 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 — eliminates risk of bladder perforation and anterior mesh erosion.[15]
- Mesh selection and preparation. See table below.
- Mesh attachment to the cervix.
- Y-shaped mesh (standard): 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]
- Sacral fixation. Secure the sacral end of the mesh to the ALL at S1 with 2–4 interrupted non-absorbable sutures or tackers; place tension-free — uterus elevated to anatomic position without excess tension.[13][4]
- Peritonization. Close peritoneum over the mesh with a running absorbable suture to prevent bowel adhesion and SBO; tunneling technique reduces peritoneal defect size.[2][15]
Mesh selection
| Mesh | Configuration | Notes |
|---|---|---|
| Type-1 polypropylene (macroporous, monofilament) | Y-shaped or flat strip | Most commonly used; diamond weave allows stretch[1][2] |
| PVDF (polyvinylidene fluoride) | Flat strip, square weave | No longitudinal give — wrap not required[3] |
| SERATEX SlimSling | Narrow strip | Designed for isolated apical prolapse[16] |
| Biologic graft | Flat strip | Alternative when synthetic mesh is declined[5] |
Concomitant procedures
- Cervical shortening / amputation — performed in 75% of patients in one series for cervical elongation.[16]
- Anterior colporrhaphy — for concurrent cystocele.[16]
- Posterior colporrhaphy — for concurrent rectocele.
- Midurethral sling — for concurrent or occult SUI (~30% of cases).[16]
Operative metrics
- Mean operative time: ~112 min; laparoscopic sacrohysteropexy is ~60 min longer than vaginal hysteropexy.[9][16][19]
- EBL: minimal; significantly less than hysterectomy-based mesh approaches.[3]
- Hospital stay: 1–2 days.[10]
Outcomes and Efficacy
| Endpoint | Result |
|---|---|
| Objective apical cure | 90–100%[1][2][3] |
| Composite surgical failure at 12 mo | 1.6–16.4%[4][5] |
| Reoperation for apical prolapse | 3.7–6.1% long-term[6][7] |
| Reoperation for any POP | 13.6%[7] |
| Mesh exposure requiring removal | 0.4%[7] |
| Patient satisfaction ("much / very much better") | 79.6–95%[6][7][8] |
| Mean POP-Q point C improvement | −7.4 to −7.6 cm[3][9] |
Comparative Outcomes
vs Vaginal Hysterectomy with Apical Suspension
7-year RCT follow-up (Izett-Kay 2022):[20]
- Trend toward lower apical reoperation (6.1% vs 17.2%, p = 0.17).
- Significantly higher apical suspension (point C −5 vs −4.25, p = 0.02).
- Longer total vaginal length (9 cm vs 6 cm, p < 0.05).
The Brennand 2025 prospective cohort (n = 321) found uterine-preserving surgery was associated with lower composite recurrence (adjusted RR 0.47, 95% CI 0.32–0.69) and fewer procedural complications (adjusted RR 0.19).[5]
vs Sacrospinous Hysteropexy — LAVA trial
Non-inferior for surgical failure at 12 months (1.6% sacrohysteropexy vs 3.3% sacrospinous hysteropexy). However, more bothersome OAB and fecal incontinence after laparoscopic sacrohysteropexy; dyspareunia less frequent.[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).[24]
Cochrane 2023
Little to no difference between vaginal and sacral hysteropexy in awareness of prolapse, repeat surgery, recurrent prolapse, bladder / bowel injuries, or dyspareunia. Vaginal hysteropexy operative time may be ~60 min shorter.[19]
Complications
| Complication | Rate / note |
|---|---|
| Intraoperative complications | 2.7% overall (bladder injury, conversion to laparotomy)[22] |
| Mesh exposure requiring removal | 0.4% — significantly lower than after sacrocolpopexy with total hysterectomy[21][6] |
| Chronic pain service use | 1.8%[21] |
| Small bowel obstruction | Rare; adequate peritonization is critical[22] |
| Presacral hemorrhage | Rare; related to promontory dissection[14] |
| De novo SUI requiring surgery | 14.5% in one long-term series[17] |
| De novo OAB | More frequent after laparoscopic sacrohysteropexy than vaginal approaches[9] |
| Newly diagnosed systemic autoimmune disorders | 5.8% in one large cross-sectional study; causality uncertain[21] |
Long-Term Durability
A 270-patient series with follow-up up to 14.5 years showed surgical success gradually decreasing with time but remaining durable in most women. 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.
- Only 4% developed recurrent uterine prolapse postpartum.
- 8% developed de novo anterior compartment prolapse.
- Procedure does not appear to negatively impact fetal growth.
A meta-analysis found that sacrohysteropexy was associated with higher obstetric adverse outcomes vs native-tissue procedures (p = 0.04) — native-tissue hysteropexy (sacrospinous or uterosacral) may be safer for women planning pregnancy.[25]
A simplified PVDF posterior-only technique may allow vaginal delivery by not restricting cervical dilation.[15]
Mesh-Free Alternative — Suture Hysteropexy
Laparoscopic / robotic suture-based hysteropexy (uterosacral ligament plication) offers a mesh-free option. A retrospective comparison found similar composite success rates between suture hysteropexy and mesh sacrohysteropexy (84.5% vs 81.7%), although mesh provided better uterine elevation (point C change −7.38 vs −6.99 cm, p < 0.05).[26]
Counseling Points
- Sacrohysteropexy preserves the uterus but requires ongoing gynecologic surveillance (cervical screening, evaluation of abnormal bleeding).[7][1]
- Risk of unanticipated uterine pathology is low in appropriately screened patients.[7]
- Mesh exposure rate is very low (0.4%); counsel about mesh-related risks.[21]
- Future pregnancy is possible but delivery is typically cesarean section; women planning pregnancy may be better served by native-tissue hysteropexy (sacrospinous or uterosacral).[11][25]
- Offers longer vaginal length and stronger apical support than vaginal hysterectomy with suspension.[20]
- Sexual function is preserved or improved; lower dyspareunia rates than some vaginal approaches.[9]
Key Principles
- Sacrohysteropexy is a uterine-preserving mesh-augmented apical operation — the abdominal-mesh analogue of sacrocolpopexy.[1][2]
- Lower mesh exposure (~0.4%) than sacrocolpopexy after total hysterectomy.[21][6]
- Preserve the broad ligament's avascular plane lateral to the uterine vessels to avoid compromising uterine blood supply.[13]
- LAVA RCT non-inferiority vs sacrospinous hysteropexy at 12 months; better dyspareunia profile but worse OAB / fecal incontinence.[9]
- Longer vaginal length and superior apical support vs VH+USLS at 7 years (Izett-Kay 2022).[20]
- Adequate peritonization is critical to prevent SBO.[2][15]
- For pregnancy-desiring patients, native-tissue hysteropexy is generally safer than mesh-augmented sacrohysteropexy.[25]
- Suture-only hysteropexy is a viable mesh-free alternative with comparable composite success.[26]
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. Haliloglu Peker B, Ilter E, Peker H, et al. Laparoscopic sacrohysteropexy in a woman at 12 weeks' gestation. J Minim Invasive Gynecol. 2018;25(7):1146-1147. doi:10.1016/j.jmig.2018.01.035.
19. 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.
20. 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.
21. 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.
22. 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.
23. Daniels S, Robson D, Palacz M, et al. Success rates and outcomes of laparoscopic mesh sacrohysteropexy. Aust N Z J Obstet Gynaecol. 2020;60(2):244-249. doi:10.1111/ajo.13104.
24. 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.
25. 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.
26. 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.