Sacrospinous Ligament Fixation (SSLF)
Sacrospinous ligament fixation suspends the vaginal apex to one or both sacrospinous ligaments using sutures. This page describes native-tissue SSLF for vaginal vault support. The uterine-preserving sacrospinous procedure is sacrospinous hysteropexy; adding a prolapse graft changes the procedure and its risk profile.[1]
SSLF offers a vaginal operation without a prolapse mesh implant and can usually be performed without entering the peritoneal cavity. The main decisions are the patient's goals, the compartments requiring repair, prior surgery, vaginal length, and the balance between recurrent prolapse and procedure-specific complications. NICE offers vaginal SSLF with sutures or abdominal/laparoscopic sacrocolpopexy with mesh for vault prolapse after discussion of their benefits and risks.[1][2]
Choosing the Operation
- SSLF or uterosacral suspension: both are established vaginal native-tissue options. OPTIMAL did not demonstrate superior composite success for either operation; it did not establish equivalence. Neurologic pain requiring additional treatment was more frequent after SSLF, while intraoperative ureteral obstruction occurred in the uterosacral group.[3][4]
- SSLF or sacrocolpopexy: discuss sacrocolpopexy's greater durability in relevant vault-prolapse evidence alongside its abdominal access, mesh exposure and other procedure-specific risks. Advanced stage alone does not select an operation. The newer ASPIRe trial compared sacrocolpopexy with a native-tissue group that included both SSLF and uterosacral suspension.[2][6]
- Uterine prolapse: decide whether the patient wants uterine preservation and whether uterine/cervical assessment affects that choice. Vault SSLF evidence should not be applied indiscriminately to hysteropexy. See prolapse repair principles for the SAVE U and other uterine-preservation comparisons.[1][2]
- Concomitant procedures: assess anterior/posterior support, stress incontinence, emptying, bowel symptoms and sexual goals. Agree on a continence strategy before surgery; a native-tissue prolapse repair does not itself require a midurethral sling. See the POP evaluation and management page.[2]
Anatomy and Suture Placement
The sacrospinous ligament extends from the ischial spine toward the lateral sacrum and coccyx. It is closely associated with the coccygeus muscle, but fixation through coccygeus alone is not confirmed SSLF: the ligament must be incorporated. The ischial spine is the key palpable lateral landmark.[1][7]
| Structure | Operative implication |
|---|---|
| Pudendal nerve and internal pudendal vessels | Lie close to the ischial spine and lateral ligament; lateral needle passage risks neurovascular injury. |
| Sacral nerve branches supplying coccygeus/levator ani | May cross the region used for fixation, including medial portions of the ligament. Moving medially does not create a nerve-free zone. |
| Superior ligament border and tissues behind it | Sacral nerves and vessels can be very close; control the depth and trajectory of both needle entry and exit. |
| Rectum and pararectal vessels | Identify the operative plane, protect the rectum and maintain exposure during dissection and suture passage. |
Descriptions commonly place sutures approximately 2–3 cm medial to the ischial spine, with variation across techniques. This is a landmark-based description, not a guaranteed safe distance or a substitute for identifying the patient's ligament and controlling the bite. Cadaveric work found substantial variation in ligament thickness and adjacent nerve position; deeply penetrating or superiorly directed bites can capture structures beyond the intended ligament.[1][7][8][10]
For an illustrated procedural orientation, see Figure 5 in the AUGS/IUGA terminology report. Such an illustration does not map every small nerve or define a safe needle trajectory.[1]
Operative Framework
The following describes a conventional posterior vaginal approach; anterior, apical, left-sided and bilateral approaches are recognized variants. The AUGS/IUGA terminology report defines the necessary components rather than prescribing one universal suture pattern.[1]
- Plan exposure and support. Confirm the compartments to repair and the intended vaginal apex. Position for vaginal access, protect pressure points and decompress the bladder. Ensure adequate lighting, retraction, suction and access to cystoscopy.[1][2]
- Develop the posterior plane. Incise the posterior vaginal wall and separate the vaginal wall from the underlying rectovaginal tissue to enter the pararectal space. Identify and protect the rectum while approaching the ischial spine. Exposure should be sufficient to identify the target before passing sutures.[1][7]
- Identify the ligament. Palpate the ischial spine, trace the ligament medially and clear the overlying tissue as needed for controlled visual or palpation-guided placement. Confirm that the fixation incorporates the ligament itself.[1]
- Place suspension sutures. Use a controlled bite in the identified ligament, with attention to adjacent nerves, vessels and penetration depth. The number and material depend on the technique; one to four sutures are described, commonly two. Permanent and delayed-absorbable materials are used. Neither a particular distance nor a suture-capturing device eliminates nerve or vascular risk.[1][7][8]
- Attach the vaginal apex. Incorporate its fibromuscular layer. For permanent sutures, keep the material covered and avoid exposed vaginal epithelial bites; techniques that tie sutures within the vaginal lumen use absorbable material. Assess the suspension before final tying to avoid unnecessary tension, shortening or narrowing.[1][7]
- Complete the planned repair. Coordinate anterior, posterior and perineal repairs with apical suspension according to the defects and goals. Confirm hemostasis and exclude rectal penetration, including a digital rectal examination. Close the vaginal incision with the suspension under control.[1][7]
- Check the urinary tract. Perform cystoscopy with inspection of the bladder/urethra and confirmation of bilateral ureteral efflux after reconstructive prolapse surgery. Normal efflux does not exclude every injury, including a delayed injury. The AUGS exception for an isolated posterior repair does not apply to SSLF.[9]
- Assess recovery. Evaluate pain pattern, bleeding and bladder emptying before discharge, with a documented voiding/catheter plan. Severe focal buttock, perineal or leg pain, sensory change or weakness warrants prompt assessment rather than reassurance based only on the expectation of temporary postoperative pain.[3][10]
Suture Devices and Technical Variants
A suture-passing or suture-capturing device can facilitate access in a deep operative field. It does not replace knowledge of the ligament, its surrounding anatomy or the device's needle path. Comparative device evidence is heterogeneous and does not justify a universal ranking of brands as safest. Similarly, the available comparisons of unilateral versus bilateral fixation and anterior versus posterior access do not establish one approach as best for all patients.[1][7]
Outcomes: Use the Trial's Endpoint
OPTIMAL: SSLF Versus Uterosacral Suspension
OPTIMAL randomized 374 women with stage II–IV apical prolapse and demonstrable, symptomatic stress incontinence to uterosacral suspension or SSLF. All were scheduled for a retropubic midurethral sling; 371 actually received one. Women retaining their uterus were not included. Thus, its safety results reflect the combined surgical setting, including concomitant procedures.[3][4]
The corrected two-year composite success endpoint required adequate apical/anterior/posterior support, no bothersome vaginal bulge and no prolapse retreatment. The anatomical criteria included no apical descent greater than one-third of vaginal length and no anterior or posterior wall beyond the hymen.[3][4]
| Corrected two-year outcome | SSLF | Uterosacral suspension |
|---|---|---|
| Composite surgical success | 94/149 (63.1%) | 100/155 (64.5%) |
| Anterior wall beyond the hymen | 20/153 (13.1%) | 20/155 (12.9%) |
| Prolapse retreatment with surgery or pessary | 8/155 (5.2%) | 8/161 (5.0%) |
| Serious adverse event | 31/186 (16.7%) | 31/188 (16.5%) |
| Neurologic pain requiring additional treatment | 23/186 (12.4%) | 13/188 (6.9%) |
| Intraoperative ureteral obstruction | 0/186 | 6/188 (3.2%) |
The adjusted odds ratio for success was 1.1 (95% CI 0.7–1.7) for uterosacral suspension versus SSLF. A nonsignificant superiority test is not proof of equal efficacy or safety. Outcome-specific denominators vary because of missing assessments; the ureteral count above comes from the corrected supplement's adverse-event table. One additional delayed ureteral injury occurred in the uterosacral group.[3][4]
Anterior recurrence remains an important counseling and follow-up issue, but these randomized results do not support claiming that SSLF's posterior axis change necessarily causes more anterior recurrence than uterosacral suspension.[3][4]
E-OPTIMAL: Five-Year Follow-up
Of the original 374 participants, 285 enrolled in the extension and 244 completed it. Modeled five-year first composite failure was 70.3% after SSLF and 61.5% after uterosacral suspension; the adjusted difference for uterosacral suspension minus SSLF was −8.8 percentage points (95% CI −24.2 to 6.6). This did not demonstrate superiority of either repair.[5]
The trial counted the first qualifying anatomical finding, bothersome bulge or retreatment as failure and retained that classification thereafter. It does not mean that 70% had persistent symptomatic recurrent prolapse or needed another operation. Prolapse symptom scores remained substantially improved. Discuss anatomical recurrence, current symptoms and retreatment separately.[5]
Comparison With Sacrocolpopexy
ASPIRe (2024) is the higher-yield contemporary vault-prolapse trial: 376 women were randomized, 360 underwent surgery and 358 contributed to the primary analysis. Three-year modeled composite failure was 28% with sacrocolpopexy versus 43% with vaginal native-tissue repair (adjusted HR 0.57, 99% CI 0.33–0.98; P=.008). The native-tissue group was 82% SSLF and 18% uterosacral suspension. The result supports counseling about durability after total-hysterectomy vault prolapse; it is not an isolated randomized estimate for SSLF or for uterine-preserving surgery.[6]
The smaller SALTO-2 study randomized 64 women and also followed a separate, self-selected cohort of 115. At 12 months, it detected no difference in its primary disease-specific quality-of-life outcome. Apical composite success in the randomized comparison was 89.3% after laparoscopic sacrocolpopexy versus 86.2% after vaginal SSLF. Its small randomized sample and short follow-up do not establish equivalence or refute longer-term durability differences.[11]
Longer-term observational data add context. A 9,681-patient US cohort found fewer reoperations for recurrent prolapse after sacrocolpopexy, but more reoperations for complications; all-cause reoperation was not significantly different between the reconstructive procedures. A 2026 Danish cohort of 1,374 women with prior hysterectomy also found higher long-term reoperation after SSLF, with different results by compartment. These are adjusted observational associations, influenced by selection, technique and follow-up, not individual predictions or proof that every patient should receive sacrocolpopexy.[12][13]
Older pooled comparisons mixed open and laparoscopic sacrocolpopexy, uterine and vault populations, concomitant procedures and varying success definitions. Avoid using their aggregate cure, dyspareunia or complication percentages as a direct prediction for a modern isolated native-tissue SSLF.[14]
Complications and Follow-up
| Problem | Assessment and counseling |
|---|---|
| Buttock, groin or leg pain | Often improves during recovery, but severe, focal, persistent or neurologic symptoms need examination. In OPTIMAL, additional-treatment pain occurred after both procedures, more often after SSLF; 8/186 SSLF participants still had this pain at 4–6 weeks and three underwent suture removal. |
| Suspected nerve entrapment | Consider the timing, distribution, examination and other causes of pain. Specialist assessment and possible suture removal may be needed. Absorbable suture does not guarantee that severe pain will resolve acceptably without intervention. |
| Hemorrhage or hematoma | Maintain exposure and recognize significant pararectal/neurovascular bleeding promptly. Avoid blind attempts at deep hemostasis; escalate according to the bleeding source and local surgical resources. |
| Urinary tract injury or emptying difficulty | Use the intraoperative cystoscopy and postoperative emptying checks above; assess new urinary symptoms rather than attributing them automatically to the repair. |
| Suture exposure, granulation or dyspareunia | Examine for exposed material, focal tenderness, scarring or excessive narrowing; distinguish these findings from recurrent prolapse and other causes of pelvic pain. |
| Recurrent prolapse | Record the affected compartment, bulge bother, urinary/bowel function and treatment preference. An anatomical finding alone is not an automatic indication for repeat surgery. |
These risks and checks are supported by the randomized surgical data, operative consensus and complication literature.[1][2][3][4][7][9][10]
For severe or persistent pain, a selected retrospective referral series of 21 women reported complete relief after suture removal in 12/21 and partial improvement in 8/21. Assessment occurred at about 6–8 weeks, not long-term follow-up. Two women developed new symptomatic prolapse for which further surgery was indicated; one removal caused 520 mL blood loss. These findings support discussing specialist removal when appropriate, while avoiding a promised 95% cure rate or an assumption of negligible recurrent-prolapse risk.[10]
Videos
References
1. Developed by the Joint Writing Group of the American Urogynecologic Society and the International Urogynecological Association. "Joint report on terminology for surgical procedures to treat pelvic organ prolapse." International Urogynecology Journal. 2020;31:429–463. doi:10.1007/s00192-020-04236-1.
2. NICE. "Urinary incontinence and pelvic organ prolapse in women: management." NG123. Recommendations, sections 1.6–1.9.
3. 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;311:1023–1034. doi:10.1001/jama.2014.1719. Corrected article and supplement, June 25, 2015.
4. "Incorrect Outcomes Data." Correction to the OPTIMAL trial. JAMA. 2015. doi:10.1001/jama.2015.4817.
5. 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;319:1554–1565. doi:10.1001/jama.2018.2827.
6. Menefee SA, Richter HE, Myers D, et al. "Apical Suspension Repair for Vaginal Vault Prolapse: A Randomized Clinical Trial." JAMA Surgery. 2024;159:845–855. doi:10.1001/jamasurg.2024.1206.
7. Athanasiou S, Prodromidou A, Zacharakis D, et al. "Technical Challenges and Surgical Considerations in Sacrospinous Ligament Fixation for Apical Prolapse Repair." Journal of Clinical Medicine. 2026;15:4209. doi:10.3390/jcm15114209.
8. 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;215:646.e1–646.e6. doi:10.1016/j.ajog.2016.06.025.
9. American Urogynecologic Society. "Consensus Statement: Cystoscopy at the Time of Prolapse Repair." Female Pelvic Medicine & Reconstructive Surgery. 2018;24:258–259. doi:10.1097/SPV.0000000000000529.
10. Vodegel EV, van Delft KWM, Nuboer CHC, et al. "Surgical Management of Pudendal Nerve Entrapment After Sacrospinous Ligament Fixation." BJOG. 2022;129:1908–1915. doi:10.1111/1471-0528.17145.
11. 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;130:1542–1551. doi:10.1111/1471-0528.17525.
12. Shah NM, Berger AA, Zhuang Z, et al. "Long-Term Reoperation Risk After Apical Prolapse Repair in Female Pelvic Reconstructive Surgery." American Journal of Obstetrics and Gynecology. 2022;227:306.e1–306.e16. doi:10.1016/j.ajog.2022.05.046.
13. Teilmann-Jørgensen D, Gommesen D, Wu C, et al. "Long-Term Risk of Reoperation After Vaginal Vault Suspension by Surgical Technique: A Nationwide Cohort Study." BJOG. 2026;133:1046–1055. doi:10.1111/1471-0528.70138.
14. 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;33:3–13. doi:10.1007/s00192-021-04823-w.