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Sacrospinous Ligament Fixation (SSLF)

Sacrospinous ligament fixation (SSLF) is a native-tissue vaginal apical suspension in which the vaginal cuff is anchored to the sacrospinous ligament, usually on the right side. It remains one of the two standard vaginal native-tissue apical repairs: ACOG and AUGS consider SSLF and uterosacral ligament suspension equally effective for apical pelvic organ prolapse, with comparable anatomic, functional, and adverse outcomes.[1]

The operation is attractive when the patient wants a vaginal, mesh-free repair or is a poor candidate for abdominal surgery. Its signature tradeoff is axis: the apex is restored reliably, but posterior vaginal deflection can load the anterior wall and predispose to anterior compartment recurrence.[2][3]

Practice Guideline​

ACOG Practice Bulletin No. 214 recommends SSLF and uterosacral ligament suspension as equivalent native-tissue apical repairs (Level A). In OPTIMAL, 2-year surgical success was 64.5% for uterosacral suspension vs 63.1% for SSLF (adjusted OR 1.1; 95% CI 0.7-1.7), with similar serious adverse event rates (16.5% vs 16.7%).[1][4]

Guideline-relevant operative points:

  • Perform apical suspension at the time of hysterectomy for uterine prolapse to reduce recurrent POP risk (Level B).[1]
  • Use native tissue counseling honestly: abdominal sacrocolpopexy has lower recurrent POP risk but more mesh- and abdominal-route complications than vaginal native-tissue repair (Level B).[1]
  • Hysteropexy, including sacrospinous hysteropexy, is a reasonable uterine-preserving alternative when uterine preservation is desired, although the evidence base is smaller than for hysterectomy-based repair (Level B).[1][5][6]
  • Synthetic mesh and biologic grafts introduce complications not seen with native tissue repair; SSLF is useful when mesh avoidance is a priority.[1][7]

Historical Background​

SSLF was described by Amreich in 1950 and modified by Richter in 1968. Randall and Nichols introduced the operation widely to the English-language literature, and Morley and DeLancey refined the Michigan approach with a 100-patient series showing 90% complete symptomatic relief after repair of vaginal eversion.[2][8]

That history matters technically: modern SSLF is not just a point suspension. It is an apical repair that often needs concurrent anterior, posterior, and perineal reconstruction to counter the posterior axis shift created by fixation to the sacrospinous ligament.[2][3]

Anatomy​

The sacrospinous ligament runs from the ischial spine to the lateral sacrum and coccyx and forms the posterior border of the lesser sciatic foramen. It is closely associated with the coccygeus muscle on its dorsal surface; many authors treat the coccygeus-sacrospinous ligament complex as one operative target.[9][10]

Critical structures around the ligament include the pudendal nerve and internal pudendal vessels near the ischial spine, S3 near the superior ligament border, inferior gluteal neurovascular branches, and S3/S4 branches that may traverse the coccygeus and sacrospinous-sacrotuberous interval.[10][11]

Sacrospinous ligament fixation: the vaginal apex suspended to the sacrospinous ligament with sutures placed 1.5–2 cm medial to the ischial spine, clear of the pudendal bundle

The sacrospinous ligament (with its overlying coccygeus muscle) runs from the ischial spine to the sacrum/coccyx. The pudendal nerve and vessels loop behind the spine and the sciatic nerve passes above it — so suspension sutures are placed into the ligament 1.5–2 cm (two fingerbreadths) medial to the ischial spine, clear of that danger zone. The repair is usually right-sided and unilateral; it shifts the apex posteriorly, which is why concurrent anterior support is often needed and anterior-wall recurrence is higher than after sacrocolpopexy. (Original WARWIKI schematic)

LandmarkOperative implication
Ischial spinePalpable lateral landmark; avoid placing sutures immediately adjacent to it.
2 cm medial to the ischial spineUsual target zone for SSLF sutures to reduce pudendal neurovascular injury.
Superior border of SSLStay controlled; S3 is close to the midpoint superior border.
Coccygeus muscleDissection often exposes the coccygeus-SSL complex rather than a bare ligament.
Right pararectal spaceStandard side in unilateral SSLF to avoid sigmoid colon dissection.

Indications​

SSLF is used for:

  • Posthysterectomy vaginal vault prolapse.
  • Uterovaginal prolapse when performed as sacrospinous hysteropexy.
  • Enterocele repair with required apical suspension.
  • Patients who prefer a vaginal, native-tissue operation.
  • Patients in whom abdominal sacrocolpopexy is undesirable because of surgical risk, adhesions, mesh avoidance, or patient preference.

Consider sacrocolpopexy instead when the primary goal is maximal durability for advanced multicompartment prolapse and the patient accepts abdominal-route and mesh-related risks.[1][12][13]

Surgical Technique​

The classic posterior vaginal approach proceeds through the rectovaginal space:[8][9][14]

  1. Make a posterior vaginal wall incision and extend the dissection to the apex.
  2. Mobilize the vaginal epithelium from rectovaginal fascia.
  3. Enter the right pararectal space with sharp and blunt dissection.
  4. Palpate the ischial spine, then trace the sacrospinous ligament medially toward the sacrum.
  5. Clear overlying connective tissue enough to palpate or visualize the coccygeus-SSL complex.
  6. Place two permanent or delayed-absorbable sutures through the ligament approximately 2 cm medial to the ischial spine.
  7. Pass sutures through full-thickness vaginal apex, excluding epithelium.
  8. Complete indicated anterior, posterior, or perineal repairs.
  9. Tie the apical sutures under direct control, drawing the cuff to the ligament without narrowing the vagina.
  10. Close the vaginal incision and confirm hemostasis.

Approach variations include anterior-approach bilateral SSLF, bilateral posterior fixation, and device-assisted suture capture. Unilateral right-sided fixation remains the usual default; bilateral fixation may create more symmetric support but increases dissection.[1][15]

Suture-Passing Devices​

Device choice changes exposure, operative time, and risk profile. In a 2024 systematic review of 125 studies and 10,216 cases, overall complication rates after SSLF were 1.2% reoperation, 3.8% nerve injury, and 1.7% hematoma; complications were higher when suture-capturing rather than suture-passing devices were used.[16]

Device / techniqueOperative note
Deschamps carrierTraditional hook-based passage; associated with higher transfusion rates in pooled device comparisons.
CapioShortens access time but had the highest nerve injury rate in the 2024 pooled analysis.
Capio SlimRefined suture-capturing system with shorter operative time in early series.
Miya hookDeflects rather than penetrates behind thin ligaments in cadaveric comparison.
CaspariCompact shallow bite; favorable vascular safety profile in cadaveric study.
i-StitchPenetrating device; cadaveric data raised concern near thin ligament / coccygeal vascular branches.

A 2025 study comparing double-suture and loop-suture SSLF in 195 patients found shorter operative time with loop suturing while maintaining similar 24-month outcomes. Treat this as technique-refinement evidence, not a reason to compromise the safe medial bite zone.[17]

Outcomes​

OPTIMAL Trial​

OPTIMAL is the key randomized comparison of SSLF and uterosacral ligament suspension. At 2 years, SSLF and uterosacral suspension had similar surgical success and adverse events. At 5 years, composite failure rates were high by strict trial definitions, but symptom improvement persisted and retreatment remained low.[4][18]

OutcomeSSLFUterosacral suspension
2-year surgical success63.1%64.5%
2-year serious adverse events16.7%16.5%
5-year composite failure70.3%61.5%
Estimated median time to failure1.8 years2.6 years

The counseling point is practical: SSLF usually improves bulge symptoms, but anatomic durability depends on compartment, baseline stage, hiatus size, and whether all defects are repaired.

SSLF vs Uterosacral Suspension​

A 2022 meta-analysis of 9 studies and 4,516 patients found no significant difference between SSLF and uterosacral suspension in surgical success, anatomic success, recurrence, or total complications. SSLF had lower vaginal granulation tissue and urethral injury rates, whereas uterosacral suspension avoids buttock pain and better preserves the vaginal axis.[19]

SSLF vs Sacrocolpopexy​

Sacrocolpopexy generally provides greater anatomic durability, especially for advanced or multicompartment prolapse, but at the cost of an abdominal route and mesh-specific risks. A 2022 meta-analysis reported lower success and higher recurrence after SSLF than sacrocolpopexy, but SSLF had shorter operative time, less hemorrhage, fewer wound infections, and fewer gastrointestinal complications.[12]

Long-term registry data sharpen the durability discussion. Shah et al. reported recurrence reoperation rates per 1,000 patient-years of 13.9 for SSLF, 9.0 for uterosacral suspension, 4.8 for sacrocolpopexy, and 1.4 for colpocleisis.[13] A Danish nationwide cohort similarly found higher apical reoperation after SSLF, but lower posterior compartment reoperation, consistent with posterior axis deflection.[3]

SALTO-2 showed that at 12 months, laparoscopic sacrocolpopexy and vaginal sacrospinous fixation had similar disease-specific quality of life and apical composite success, reminding surgeons that short-term patient-centered outcomes may be closer than long-term reoperation curves suggest.[20]

Sacrospinous Hysteropexy​

SSLF can be adapted for uterine preservation. In SAVE U, 5-year apical failure with bothersome symptoms or reoperation was 1% after sacrospinous hysteropexy vs 7.8% after vaginal hysterectomy with uterosacral suspension, with better composite success after hysteropexy and similar functional outcomes.[5]

The procedure is not interchangeable with every uterine-preserving operation. In the 2023 randomized comparison of Manchester procedure vs sacrospinous hysteropexy for uterine descent not beyond the hymen, sacrospinous hysteropexy was inferior, driven largely by anterior recurrence. That result fits the axis-deflection mechanism and supports selecting hysteropexy route based on leading compartment and cervical elongation.[6]

Complications​

ComplicationPattern
Gluteal / buttock painCommon early; usually improves by 4-6 weeks. Likely related to S3/S4 branches rather than inferior gluteal nerve alone.
Pudendal nerve entrapmentRare but disabling; SSL suture removal can be effective even years later.
Hemorrhage / hematomaUsually pararectal or pudendal-vessel related; risk varies by exposure and device.
Anterior recurrenceCharacteristic late failure pattern from posterior axis shift.
DyspareuniaHigher than sacrocolpopexy in some comparative series.
Ureteral injuryLess characteristic than in uterosacral suspension.

Pudendal nerve entrapment after SSLF deserves a low threshold for recognition when pain is severe, neuropathic, and procedure-linked. In a 21-patient series, surgical SSL suture removal produced pain reduction in 95% and complete relief in 57%, with recurrent symptomatic POP in 10%.[21]

Operative Pearls​

  • Palpate the ischial spine first, then deliberately move medial before placing sutures.
  • Keep the bite on the ligament / coccygeus-SSL complex, not blindly high above the superior border.
  • Avoid overtensioning the cuff; the goal is apical support, not vaginal narrowing.
  • Repair the anterior compartment when it is clinically deficient; SSLF alone does not neutralize anterior wall forces.
  • Counsel about temporary buttock pain before surgery so the common early symptom does not feel like an unexpected complication.
  • Use sacrocolpopexy rather than SSLF when advanced multicompartment durability is the dominant priority and mesh is acceptable.

Summary​

FeatureSSLF
RouteVaginal native tissue
Usual sideRight unilateral; bilateral in selected cases
2-year OPTIMAL success63.1%
Key advantageVaginal, mesh-free, shorter operative time than sacrocolpopexy
Key limitationPosterior axis deflection with anterior recurrence risk
Signature complicationButtock / gluteal pain, rarely pudendal entrapment
Best candidatesVault prolapse or uterine prolapse patients desiring vaginal native-tissue repair

SSLF is a core native-tissue apical operation. It is not "lesser" surgery than uterosacral suspension; it is a different vector with a different complication signature. The best SSLF is deliberate about anatomy, medial suture placement, anterior compartment support, and patient counseling about the durability tradeoff versus sacrocolpopexy.

Videos​

Sacrospinous Ligament Fixation for Vault Prolapse
Urogynecology for Beginners (2024)
Sacrospinous Ligament Suspension
Louisville FPMRS (2022)

References​

1. Committee on Practice Bulletins--Gynecology and American Urogynecologic Society. "Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214." Obstetrics & Gynecology. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519

2. Morley GW, DeLancey JOL. "Sacrospinous Ligament Fixation for Eversion of the Vagina." American Journal of Obstetrics and Gynecology. 1988;158(4):872-881. doi:10.1016/0002-9378(88)90088-9

3. Teilmann-Jorgensen D, Gommesen D, Wu C, Klarskov N, Rudnicki M. "Long-Term Risk of Reoperation After Vaginal Vault Suspension by Surgical Technique: A Nationwide Cohort Study." BJOG. 2026;133(5):1046-1055. doi:10.1111/1471-0528.70138

4. Barber MD, Brubaker L, Burgio KL, et al. "Comparison of 2 Transvaginal Surgical Approaches and Perioperative Behavioral Therapy for Apical Vaginal Prolapse: The OPTIMAL Randomized Trial." JAMA. 2014;311(10):1023-1034. doi:10.1001/jama.2014.1719

5. 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

6. 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

7. Yeung E, Baessler K, Christmann-Schmid C, et al. "Transvaginal Mesh or Grafts or Native Tissue Repair for Vaginal Prolapse." Cochrane Database of Systematic Reviews. 2024;3:CD012079. doi:10.1002/14651858.CD012079.pub2

8. Declas E, Giraudet G, Delplanque S, Rubod C, Cosson M. "How We Perform a Posterior Sacrospinous Ligament Fixation by the Vaginal Route." International Urogynecology Journal. 2020;31(7):1479-1481. doi:10.1007/s00192-019-04149-8

9. Goh JTW, Ganyaglo GYK. "Sacrospinous Fixation: Review of Relevant Anatomy and Surgical Technique." International Journal of Gynecology & Obstetrics. 2023;162(3):842-846. doi:10.1002/ijgo.14751

10. 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." International Urogynecology Journal. 2023;34(9):2329-2332. doi:10.1007/s00192-023-05496-3

11. Florian-Rodriguez ME, Hare A, Chin K, et al. "Inferior Gluteal and Other Nerves Associated With Sacrospinous Ligament: A Cadaver Study." American Journal of Obstetrics and Gynecology. 2016;215(5):646.e1-646.e6. doi:10.1016/j.ajog.2016.06.025

12. Zhang W, Cheon WC, Zhang L, et al. "Comparison of the Effectiveness of Sacrospinous Ligament Fixation and Sacrocolpopexy: A Meta-Analysis." International Urogynecology Journal. 2022;33(1):3-13. doi:10.1007/s00192-021-04823-w

13. Shah NM, Berger AA, Zhuang Z, Tan-Kim J, Menefee SA. "Long-Term Reoperation Risk After Apical Prolapse Repair in Female Pelvic Reconstructive Surgery." American Journal of Obstetrics and Gynecology. 2022;227(2):306.e1-306.e16. doi:10.1016/j.ajog.2022.05.046

14. Milani R, Frigerio M, Manodoro S. "Transvaginal Sacrospinous Ligament Fixation for Posthysterectomy Vaginal Vault Prolapse Repair." International Urogynecology Journal. 2017;28(7):1103-1105. doi:10.1007/s00192-016-3255-6

15. Cespedes RD. "Anterior Approach Bilateral Sacrospinous Ligament Fixation for Vaginal Vault Prolapse." Urology. 2000;56(6 Suppl 1):70-75. doi:10.1016/S0090-4295(00)00919-5

16. 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." Archives of Gynecology and Obstetrics. 2024;310(6):2791-2809. doi:10.1007/s00404-024-07788-5

17. Albayrak Denizli AB, Bulutlar E, Uluutku Bulutlar GB, Boz Izceyhan G, Sahin S. "A Comparative Evaluation of Double Versus Loop Suture Techniques in Sacrospinous Ligament Fixation Over Two Years." International Urogynecology Journal. 2025. doi:10.1007/s00192-025-06341-5

18. Jelovsek JE, Barber MD, Brubaker L, et al. "Effect of Uterosacral Ligament Suspension vs Sacrospinous Ligament Fixation With or Without Perioperative Behavioral Therapy for Pelvic Organ Vaginal Prolapse on Surgical Outcomes and Prolapse Symptoms at 5 Years in the OPTIMAL Randomized Clinical Trial." JAMA. 2018;319(15):1554-1565. doi:10.1001/jama.2018.2827

19. Chen Y, Peng L, Zhang J, Shen H, Luo D. "Sacrospinous Ligament Fixation vs Uterosacral Ligaments Suspension for Pelvic Organ Prolapse: A Systematic Review and Meta-Analysis." Urology. 2022;166:133-139. doi:10.1016/j.urology.2022.04.012

20. van Oudheusden AMJ, van IJsselmuiden MN, Menge LF, et al. "Laparoscopic Sacrocolpopexy Versus Vaginal Sacrospinous Fixation for Vaginal Vault Prolapse: A Randomised Controlled Trial and Prospective Cohort (SALTO-2 Trial)." BJOG. 2023;130(12):1542-1551. doi:10.1111/1471-0528.17525

21. Vodegel EV, van Delft KWM, Nuboer CHC, Kowalik CR, Roovers JWR. "Surgical Management of Pudendal Nerve Entrapment After Sacrospinous Ligament Fixation." BJOG. 2022;129(11):1908-1915. doi:10.1111/1471-0528.17145