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Sacrospinous Hysteropexy

Sacrospinous hysteropexy is a transvaginal uterus-preserving apical suspension for symptomatic uterine prolapse — the cervix is sutured to the sacrospinous ligament, restoring apical support while retaining the uterus. First described in 1989 as an adaptation of sacrospinous colpopexy, it has emerged as one of the most commonly performed uterus-sparing operations worldwide; in the Netherlands it is the first-choice procedure for ~60% of gynecologists.[1][2][3]

For the post-hysterectomy vault analogue (same anchor, different indication), see Sacrospinous Ligament Fixation (SSLF). For the alternative uterus-preserving operation, see Manchester-Fothergill Procedure. For the broader prolapse decision framework, see Prolapse Repair.

Indications​

  • Symptomatic uterine prolapse (POP-Q stage ≥ 2) in patients who desire uterine preservation.[1]
  • Failed or declined conservative management (PFMT, pessary).[1]
  • Pre- and postmenopausal women; particularly relevant when fertility preservation is desired, although pregnancy data after uterine suspension remain limited.[1]

Relative contraindications​

  • Suspected or known uterine / cervical malignancy
  • Prolapse protruding significantly beyond the hymen — some trials excluded this group.[3]
  • Abnormal uterine bleeding requiring further evaluation
  • Patients who do not desire uterine preservation

Surgical Technique​

The operation is performed in dorsal lithotomy under regional or general anesthesia. Posterior approach is most common; an anterior approach has also been described.[3][4][5][6]

  1. Vaginal incision. Posterior vaginal-wall incision extended to the vaginal apex (posterior approach).[6]
  2. Pararectal-space dissection. Vagina separated from rectovaginal fascia by sharp and blunt dissection until the pararectal space is entered.[5]
  3. Sacrospinous-ligament identification. The sacrospinous ligament (running from ischial spine to sacrum) is palpated and exposed; overlying connective tissue cleared to allow accurate suture placement.[5]
  4. Suture placement. Two nonabsorbable sutures are passed through the sacrospinous ligament at least 2 cm medial to the ischial spine to avoid the pudendal neurovascular bundle. Suture-passing devices commonly used: Capio, Deschamps ligature carrier, Miya hook.[7][8]
  5. Cervical fixation. Sutures passed through the posterior aspect of the cervix and tied — uterus suspended to the sacrospinous ligament. Unilateral right-sided fixation is standard; bilateral techniques (including anterior bilateral) have been described.[3][9]
  6. Concomitant compartment repair. Anterior and / or posterior colporrhaphy as needed; vaginal incision closed.

Outcomes — vs Vaginal Hysterectomy with USL Suspension​

SAVE-U trial (largest RCT, longest follow-up)​

n = 208, stage ≥ 2 uterine prolapse, 5-year follow-up:[10]

EndpointHysteropexyVH + USLSDifference
Apical-compartment failure with bothersome symptoms or reoperation1%7.8%−6.7% (95% CI −12.8 to −0.7)
Composite success (no prolapse beyond hymen, no bulge, no retreatment)87%76%—

SUPeR trial (NIH PFDN, mesh-augmented hysteropexy)​

n = 183 postmenopausal, 5-year follow-up:[11]

EndpointMesh hysteropexyVH + USLSaHR
Composite failure at 5 yr37%54%0.58 (95% CI 0.36–0.94; p = 0.03)

The mesh product used in SUPeR was withdrawn from the US market by the FDA in 2019.[11]

Outcomes — vs Manchester Procedure​

The Enklaar 2023 multicenter RCT (n = 434) compared the two uterus-sparing operations for uterine descent not protruding beyond the hymen:[3]

EndpointSacrospinous HysteropexyManchesterNotes
Composite success at 2 yr77.0%87.3%Sacrospinous hysteropexy did not meet the noninferiority criterion (risk difference −10.3%; 95% CI −17.8 to −2.8; p = 0.63 for noninferiority)
Anterior compartment recurrenceHigherLowerAttributed to unphysiological dorsal deflection of the vaginal axis with sacrospinous fixation
Posterior compartment recurrenceLowerHigher—

Complications​

Buttock / gluteal pain — characteristic complication​

  • 84–90% on postoperative day 1, declining to 16–27% by 6 weeks.[13][14]
  • Attributed to injury / entrapment of S3–S4 nerve branches coursing over the coccygeus-sacrospinous complex (not the inferior gluteal nerve).[12]
  • Intraoperative bupivacaine injection at the sacrospinous ligament does not significantly reduce perceived pain but may reduce NSAID use.[13]

Other complications[5][7][8]​

ComplicationRate / note
Hemorrhage / hematoma~1.7%; risk highest with sutures placed too close to the ischial spine (pudendal vessels) or too lateral
Nerve injury~3.8% across techniques; pudendal nerve lies closest to the ischial spine (median distance 0 mm)[12]
Anterior compartment recurrenceUp to 57% in some series — well-recognized limitation due to posterior vaginal-axis deflection[3]
Mesh exposure (when mesh used)2.9–8%[11][9]
Reoperation for prolapse recurrence~1.2% overall[8]

Risk Factors for Surgical Failure​

A SUPeR secondary analysis identified two independent predictors of composite surgical failure regardless of approach:[15]

  • Obesity — HR 1.7 per 5 kg/m² increase in BMI.
  • Prolonged duration of prolapse symptoms (> 5 years) — 3× higher failure rate.

Advantages and Disadvantages​

DomainAdvantageDisadvantage
Uterine statusUterine preservation; potential fertilityOngoing cervical-cancer screening and endometrial surveillance; small future-malignancy risk (0.0–1.1%) and possible later need for hysterectomy[3]
OperativeShorter operative time vs hysterectomy[1]Buttock pain in vast majority on POD1
MeshLower mesh erosion than mesh-augmented hysterectomy[1]Mesh exposure 2.9–8% when mesh used
Apical durabilityExcellent; SAVE-U 1% apical failure at 5 yr[10]—
Compartment-specificProtects against posterior recurrence vs Manchester[3]Higher anterior recurrence due to posterior vaginal-axis deflection[3]

Guideline Position​

  • ACOG PB 214 (2019): hysteropexy is a viable alternative to hysterectomy for uterine prolapse (Level B); uterosacral and sacrospinous ligament suspension for apical POP with native tissue are equally effective (Level A).[1]
  • AUGS (Pelvic Organ Prolapse, 2019): hysteropexy is endorsed as a viable option.[16]

Key Principles​

  • Sacrospinous hysteropexy is a uterus-preserving native-tissue apical operation — sutures from the sacrospinous ligament to the cervix.[1][2]
  • Place sutures ≥ 2 cm medial to the ischial spine — the pudendal neurovascular bundle lies closest to the spine (median 0 mm).[7][12]
  • Apical durability is excellent — 1% apical failure at 5 yr (SAVE-U) and superior composite success vs vaginal hysterectomy with USL suspension.[10][11]
  • Anterior compartment recurrence is the dominant failure mode — caused by posterior deflection of the vaginal axis; counsel patients accordingly.[3]
  • Buttock / gluteal pain is near-universal on POD1 (84–90%) and resolves to 16–27% by 6 weeks; mediated by S3–S4 branches over the coccygeus-sacrospinous complex.[12][13]
  • Manchester procedure may outperform hysteropexy for uterine descent not protruding beyond the hymen (Enklaar 2023 — 87.3% vs 77.0%).[3]
  • Obesity and prolonged symptom duration > 5 yr are independent risk factors for failure regardless of approach.[15]
  • Patients require ongoing cervical and endometrial surveillance and should be counseled about possible future hysterectomy.[3]

Videos​

Sacrospinous Hysteropexy (Sacrospinous Ligament Fixation)
geogyn1 (2013)

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. Kapoor S, Sivanesan K, Robertson JA, Veerasingham M, Kapoor V. Sacrospinous hysteropexy: review and meta-analysis of outcomes. Int Urogynecol J. 2017;28(9):1285-1294. doi:10.1007/s00192-017-3291-x.

3. 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.

4. 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.

5. Goh JTW, Ganyaglo GYK. Sacrospinous fixation: review of relevant anatomy and surgical technique. Int J Gynaecol Obstet. 2023;162(3):842-846. doi:10.1002/ijgo.14751.

6. Plair A, Matthews C. Native tissue sacrospinous hysteropexy from an anterior approach. Int Urogynecol J. 2021;32(6):1591-1593. doi:10.1007/s00192-020-04601-0.

7. Giraudet G, Ruffolo AF, Lallemant M, Cosson M. The anatomy of the sacrospinous ligament: how to avoid complications related to the sacrospinous fixation procedure for treatment of pelvic organ prolapse. Int Urogynecol J. 2023;34(9):2329-2332. doi:10.1007/s00192-023-05496-3.

8. Amiri E, Bastani P, Mallah F, Mostafaei H, Salehi-Pourmehr H. Comparison of the complications rate of different suture-passing techniques at the time of sacrospinous ligament fixation: a systematic review and meta-analysis. Arch Gynecol Obstet. 2024;310(6):2791-2809. doi:10.1007/s00404-024-07788-5.

9. Naumann G, Börner C, Naumann LJ, Schröder S, Hüsch T. A novel bilateral anterior sacrospinous hysteropexy technique for apical pelvic organ prolapse repair via the vaginal route: a cohort study. Arch Gynecol Obstet. 2022;306(1):141-149. doi:10.1007/s00404-022-06486-4.

10. Schulten SFM, Detollenaere RJ, Stekelenburg J, et al. Sacrospinous hysteropexy versus vaginal hysterectomy with uterosacral ligament suspension in women with uterine prolapse stage 2 or higher: observational follow-up of a multicentre randomised trial. BMJ. 2019;366:l5149. doi:10.1136/bmj.l5149.

11. Nager CW, Visco AG, Richter HE, et al. Effect of sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral ligament suspension on treatment failure in women with uterovaginal prolapse: 5-year results of a randomized clinical trial. Am J Obstet Gynecol. 2021;225(2):153.e1-153.e31. doi:10.1016/j.ajog.2021.03.012.

12. Florian-Rodriguez ME, Hare A, Chin K, et al. Inferior gluteal and other nerves associated with sacrospinous ligament: a cadaver study. Am J Obstet Gynecol. 2016;215(5):646.e1-646.e6. doi:10.1016/j.ajog.2016.06.025.

13. Ferrando CA, Walters MD. A randomized double-blind placebo-controlled trial on the effect of local analgesia on postoperative gluteal pain in patients undergoing sacrospinous ligament colpopexy. Am J Obstet Gynecol. 2018;218(6):599.e1-599.e8. doi:10.1016/j.ajog.2018.03.033.

14. Mowat A, Wong V, Goh J, et al. A descriptive study on the efficacy and complications of the Capio (Boston Scientific) suturing device for sacrospinous ligament fixation. Aust N Z J Obstet Gynaecol. 2018;58(1):119-124. doi:10.1111/ajo.12720.

15. Richter HE, Sridhar A, Nager CW, et al. Characteristics associated with composite surgical failure over 5 years of women in a randomized trial of sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral ligament suspension. Am J Obstet Gynecol. 2023;228(1):63.e1-63.e16. doi:10.1016/j.ajog.2022.07.048.

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