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Uterosacral Ligament Suspension (USLS)

Uterosacral ligament suspension (USLS) is a bilateral native-tissue apical suspension that restores the vaginal apex toward the uterosacral-cardinal support axis. It is the main vaginal alternative to sacrospinous ligament fixation: similar efficacy in randomized data, different anatomy, and a different complication signature. USLS avoids the buttock pain and posterior axis shift of SSLF, but its defining risk is ureteral obstruction, so intraoperative cystoscopy is mandatory.[1][2][3]

Practice Guideline​

ACOG and AUGS recommend USLS and SSLF as equally effective native-tissue apical repairs (Level A). In OPTIMAL, the 2-year surgical success rate was 64.5% for USLS vs 63.1% for SSLF (adjusted OR 1.1; 95% CI 0.7-1.7), and serious adverse events were similar (16.5% vs 16.7%).[1][2]

Guideline-relevant points:

  • Perform vaginal apex suspension at the time of hysterectomy for uterine prolapse to reduce recurrent POP (Level B).[1]
  • USLS can attach the apex bilaterally to the ipsilateral uterosacral ligaments or to a midline-plicated uterosacral complex; durable repair requires securing an adequate segment of ligament near the midportion, close to the ischial spine.[1][4]
  • Hysteropexy, including uterosacral shortening, is a viable uterine-preserving alternative in selected patients, although long-term evidence is less extensive than for hysterectomy-based repairs.[1][5]
  • Abdominal sacrocolpopexy has lower recurrent POP risk but more abdominal-route and mesh-related complications than vaginal native-tissue repair.[1][6]
  • Intraoperative cystoscopy is recommended after USLS because the ureter courses close to the uterosacral ligaments.[1][7]

Anatomy​

Uterosacral ligament suspension: the vault suspended to the intermediate uterosacral ligaments toward the sacrum, with the ureter running 1-2 cm lateral and cystoscopy mandatory

Bird's-eye view. The vault is suspended bilaterally to the intermediate uterosacral ligament at the ischial-spine level and drawn back toward the sacrum, restoring a near-midline vaginal axis. The ureter runs ~1–2 cm lateral to the ligament (mean ~14 mm, as close as 0 mm in cadaver work) — so ureteral kinking is the signature complication and intraoperative cystoscopy confirming bilateral jets is mandatory. Equally effective to SSLF in the OPTIMAL trial. (Original WARWIKI schematic)

The uterosacral ligament extends from the S2-S4 region to the cervix and upper posterior vagina. It is not a clean fibrous cord; it is a visceral ligament containing connective tissue, vessels, autonomic nerves, and adipose tissue. The deep component is especially nerve-rich.[8]

For USLS, the ligament is best thought of in three portions:[4]

USL portionMean distance to ureterOperative implication
Cervical0.9 cmHighest ureteral-risk zone; avoid low cervical bites as the primary suspension point.
Intermediate2.3 cmPreferred fixation zone; strong tissue with fewer subjacent vital structures.
Sacral4.1 cmFarthest from ureter but harder to access vaginally and closer to sacral nerves.

The intermediate portion, with the ligament on tension and the bite placed about 1 cm posterior to the anterior palpable margin, is the safest balance between strength and ureteral distance. The ischial spine is a reliable landmark because the ureter lies roughly 4.9 cm from it in cadaveric studies.[4]

Even with correct technique, the ureter may be close. In unembalmed cadavers, USLS sutures lay 0-33 mm from the ureter, with a mean distance of about 14 mm.[9] The distal pelvic ureter is closest to the uterine isthmus and lateral vaginal apex, which explains why cystoscopy is not optional after apical sutures are tied.[10]

Indications​

USLS is used for:

  • Posthysterectomy vaginal vault prolapse.
  • Uterovaginal prolapse at the time of vaginal hysterectomy.
  • Apical support prophylaxis when hysterectomy is performed for uterine prolapse.
  • Uterine preservation as uterosacral hysteropexy or laparoscopic uterosacral shortening in selected patients.
  • Patients who want a native-tissue, mesh-free repair and have anatomy suitable for safe high uterosacral fixation.

USLS is especially appealing when maintaining the physiologic vaginal axis is important or when sacrospinous buttock pain risk is a major concern. For stage III or advanced multicompartment prolapse, counsel that sacrocolpopexy may be more durable.[11][12]

Surgical Technique​

USLS can be performed transvaginally, extraperitoneally, laparoscopically, robotically, or with vNOTES assistance. The classic vaginal high uterosacral suspension is the Shull-type intraperitoneal repair.[13][14]

Transvaginal Intraperitoneal USLS​

  1. Perform vaginal hysterectomy if the uterus is present.
  2. Open the posterior cul-de-sac peritoneum for intraperitoneal access.
  3. Identify the uterosacral ligaments by palpation and visualization; use the ischial spines as lateral landmarks.
  4. Palpate or visualize the ureters before suspension suture placement.
  5. Place 2-3 sutures per side through the intermediate USL, commonly about 2 cm medial to the ischial spine.
  6. Pass each suture through the full-thickness vaginal cuff, incorporating pubocervical and rectovaginal fascia while excluding epithelium.
  7. Close the cul-de-sac / peritoneum as needed to prevent enterocele.
  8. Tie the USL sutures bilaterally to elevate the apex.
  9. Perform cystoscopy under tension and confirm bilateral ureteral efflux.
  10. Complete indicated anterior, posterior, or perineal repairs.

Suture strategies vary. Standardized trial protocols commonly use one permanent and one delayed-absorbable suture per side. Other surgeons place two sutures per side, with a superior permanent suture and an inferior delayed-absorbable suture 0.5-1 cm apart.[15][16] Cadaveric data suggest three sutures may reduce apex migration under load, although the most cranial suture approaches S1-S3 nerves and must be placed thoughtfully.[17]

Transvaginal Extraperitoneal USLS​

Extraperitoneal USLS reaches the uterosacral ligaments through the pararectal space without entering the peritoneal cavity.[18][19] It is useful when intraperitoneal adhesions are expected or when avoiding peritoneal entry is desirable.

In a 472-patient longitudinal series, extraperitoneal USLS produced 89% objective vault support success at approximately 5 years, with 4% revision surgery for vault recurrence and 1% ureteral injury.[18] A comparative study found similar short-term success to intraperitoneal USLS, with shorter operative time, less blood loss, and shorter hospitalization.[20]

Laparoscopic / Robotic USLS​

Laparoscopic USLS allows direct visualization of the ureter and high uterosacral ligament. A 2023 systematic review found pooled anatomic success of about 90%, subjective cure of about 90.5%, and a major complication rate of 1%.[21] Laparoscopic series report few ureteral complications across large pooled cohorts, but the approach still requires deliberate ureteral identification and final cystoscopic or visual confirmation of patency.[22][23]

Relationship to McCall Culdoplasty​

McCall culdoplasty plicates the uterosacral ligaments at the vaginal cuff to obliterate the cul-de-sac and add apical support during vaginal hysterectomy. High USLS places sutures more cephalad on the intermediate uterosacral ligaments near the ischial spines, producing a more formal apical suspension.[24]

Comparative studies suggest both are effective, but high USLS may preserve slightly more vaginal length. Modified McCall techniques that dissect toward the ischial spines can narrow the gap between the procedures.[24][25] Early vNOTES-assisted high USLS data also suggest longer total vaginal length and less cuff prolapse than McCall culdoplasty at 12 months, but these data should be treated as evolving rather than definitive.[26]

Outcomes​

StudyFollow-upKey result
OPTIMAL2 yearsUSLS success 64.5%; equivalent to SSLF.
OPTIMAL extension5 yearsComposite failure 61.5%, but symptom improvement sustained.
Barba et al.Variable87.6% any-compartment success in a >1000-patient single-center series.
Cola et al.10 years80.9% objective success; 2.1% retreatment.
Karmakar extraperitoneal series~5 years89% vault support success; 4% revision.
Laparoscopic meta-analysis~22 months90% pooled anatomic success; 1% major complications.

The OPTIMAL 5-year data are the best warning against overpromising perfect anatomy: composite failure was 61.5% for USLS vs 70.3% for SSLF, not statistically different, while prolapse symptom scores remained substantially improved and retreatment stayed low.[3]

Long-term high-USLS data are more encouraging when recurrence is defined clinically rather than by strict trial composite criteria. Cola et al. reported 80.9% objective success at 10 years, subjective recurrence of 6.3%, and retreatment of 2.1%; premenopausal status increased recurrence risk, whereas concurrent anterior and posterior repair were protective against reoperation.[27]

Comparative Evidence​

USLS vs SSLF​

USLS and SSLF are equivalent native-tissue apical repairs in guideline framing and pooled comparative evidence. A 2022 meta-analysis of 9 studies and 4,516 patients found no significant differences in surgical success, anatomic success, recurrence, or total complications.[28]

Key differences:

  • Vaginal axis: USLS maintains a more physiologic axis toward the sacrum; SSLF deflects posteriorly and may increase anterior recurrence.[29]
  • Ureteral risk: USLS has higher ureteral obstruction / kinking risk, making cystoscopy mandatory.[7][30]
  • Buttock pain: Not characteristic of USLS; common early after SSLF.[18]
  • Long-term compartment pattern: Danish registry data suggest lower anterior reoperation after intraperitoneal USLS than SSLF.[29]

USLS vs Sacrocolpopexy​

Durability differences depend heavily on baseline prolapse stage. Lavelle et al. found similar recurrence for stage II prolapse after sacrocolpopexy and USLS (6.0% vs 5.0%), but significantly higher recurrence after USLS in stage III prolapse (25.7% vs 7.8%).[11]

For laparoscopic procedures, Campagna et al. reported higher objective cure after laparoscopic sacrocolpopexy than laparoscopic high USLS (93.7% vs 68%), while USLS had shorter operative time. Their practical conclusion fits most reconstructive counseling: sacrocolpopexy is best for advanced multicompartment prolapse when mesh is acceptable; laparoscopic USLS is reasonable for moderate or isolated apical prolapse.[12]

Long-term reoperation data place USLS between SSLF and sacrocolpopexy: recurrence reoperation per 1,000 patient-years was 9.0 for USLS, 13.9 for SSLF, 4.8 for sacrocolpopexy, and 1.4 for colpocleisis.[31]

USLS vs Vaginal Mesh Hysteropexy​

In SUPeR, vaginal mesh hysteropexy had a lower 36-month adjusted failure incidence than vaginal hysterectomy with USLS (24% vs 36%), but the difference did not meet the prespecified statistical threshold (adjusted HR 0.61; 95% CI 0.37-1.02; P=.06).[15] Because transvaginal mesh hysteropexy devices have a different regulatory and complication context, this evidence should inform counseling rather than shift a native-tissue USLS page into mesh technique detail.

Complications​

Ureteral Obstruction​

Ureteral obstruction is the defining complication of USLS. In a 551-patient series, intraoperative ureteral obstruction detected on cystoscopy occurred in 4.3%, delayed ureteral injury in 0.4%, and obstruction usually resolved after suture removal or revision.[30] Another tertiary series reported ureteral kinking in 6.2%, with higher rates among less experienced surgeons.[32]

Risk reduction strategy:

  • Identify the ischial spines and uterosacral ligaments before placing sutures.
  • Palpate or visualize the ureters when feasible.
  • Place sutures in the intermediate USL, not the cervical portion.
  • Avoid excessive lateral or anterior bites.
  • Perform cystoscopy after the sutures are tied and the apex is on tension.
  • Remove or replace the offending suture immediately if efflux is absent or asymmetric.

AUGS recommends cystoscopy at prolapse repairs involving the anterior vaginal wall and/or vaginal vault.[7] Adjuncts such as mannitol bladder distension and intraureteric indocyanine-green fluorescence have been described to improve intraoperative ureteral assessment, but they supplement rather than replace correct suture placement and cystoscopy.[33][34]

Other Complications​

ComplicationPattern
Suture-related pelvic painUncommon; evaluate for tension, nerve capture, or vaginal exposure.
Rectal proximityUSL sutures can be close to the rectal lumen; maintain controlled posterior dissection.
Sacral nerve proximityMost cranial sutures approach S1-S3 in cadaveric studies.
Recurrent anterior prolapseLess characteristic than SSLF, but still common when anterior support is not repaired.
Mesh exposureNot a native USLS complication unless mesh augmentation or concomitant mesh hysteropexy is used.

Prognostic Factors​

FactorEffect
Preoperative stage IIIHigher recurrence after USLS than sacrocolpopexy.
Premenopausal statusIncreased recurrence risk in 10-year high-USLS data.
Enlarged genital hiatusAssociated with anatomic and surgical failure in prolapse repairs.
Lack of concomitant compartment repairHigher reoperation risk when anterior or posterior defects are left unsupported.
Surgeon experienceHigher ureteral kinking rates among less experienced surgeons.

Operative Pearls​

  • Put the ligament on tension before choosing the bite; the anterior palpable margin is the danger edge.
  • Aim for the intermediate USL, about 1 cm posterior to the anterior margin and near the ischial-spine level.
  • Tie and scope under final tension; a cystoscopy before tying can miss kinking.
  • If a ureter does not efflux, remove the most suspicious ipsilateral suture rather than waiting.
  • Repair clinically important anterior and posterior defects at the same operation.
  • Use sacrocolpopexy rather than USLS when stage III / IV multicompartment durability is the overriding priority and mesh is acceptable.

Summary​

FeatureUSLS
RouteVaginal intraperitoneal, vaginal extraperitoneal, laparoscopic, robotic, or vNOTES
2-year OPTIMAL success64.5%
5-year OPTIMAL composite successAbout 38.5% by strict composite definition
10-year objective success80.9% in high-USLS long-term series
Key advantagePhysiologic vaginal axis; no SSLF-type buttock pain
Key limitationUreteral obstruction / kinking risk
Required safety stepIntraoperative cystoscopy after tying sutures
Best candidatesStage II or moderate apical prolapse, mesh avoidance, native-tissue preference

USLS is a durable, versatile native-tissue apical operation when the surgeon respects the ureter. The procedure's value is not just that it avoids mesh; it restores the apex along a physiologic axis. Its safety depends on intermediate-ligament suture placement, final-tension cystoscopy, and a willingness to remove or replace a suture immediately when ureteral efflux is compromised.

Videos​

High Uterosacral Ligament Suspension (HULS): Abdominal Approach
Urogynecology for Beginners (2024)
Robotic High Uterosacral Ligament Suspension
Tanu Rao (2024)

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. 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

3. 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

4. Buller JL, Thompson JR, Cundiff GW, et al. "Uterosacral Ligament: Description of Anatomic Relationships to Optimize Surgical Safety." Obstetrics & Gynecology. 2001;97(6):873-879. doi:10.1016/S0029-7844(01)01346-1

5. 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." American Journal of Obstetrics and Gynecology. 2018;219(2):129-146.e2. doi:10.1016/j.ajog.2018.01.018

6. 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

7. Cohen SA, Carberry CL, Smilen SW. "American Urogynecologic Society Consensus Statement: Cystoscopy at the Time of Prolapse Repair." Female Pelvic Medicine & Reconstructive Surgery. 2018;24(4):258-259. doi:10.1097/SPV.0000000000000529

8. Ramanah R, Berger MB, Parratte BM, DeLancey JOL. "Anatomy and Histology of Apical Support: A Literature Review Concerning Cardinal and Uterosacral Ligaments." International Urogynecology Journal. 2012;23(11):1483-1494. doi:10.1007/s00192-012-1819-7

9. Wieslander CK, Roshanravan SM, Wai CY, Schaffer JI, Corton MM. "Uterosacral Ligament Suspension Sutures: Anatomic Relationships in Unembalmed Female Cadavers." American Journal of Obstetrics and Gynecology. 2007;197(6):672.e1-672.e6. doi:10.1016/j.ajog.2007.08.065

10. Jackson LA, Ramirez DMO, Carrick KS, et al. "Gross and Histologic Anatomy of the Pelvic Ureter: Clinical Applications to Pelvic Surgery." Obstetrics & Gynecology. 2019;133(5):896-904. doi:10.1097/AOG.0000000000003221

11. Lavelle ES, Giugale LE, Winger DG, et al. "Prolapse Recurrence Following Sacrocolpopexy vs Uterosacral Ligament Suspension: A Comparison Stratified by Pelvic Organ Prolapse Quantification Stage." American Journal of Obstetrics and Gynecology. 2018;218(1):116.e1-116.e5. doi:10.1016/j.ajog.2017.09.015

12. Campagna G, Vacca L, Panico G, et al. "Laparoscopic High Uterosacral Ligament Suspension vs. Laparoscopic Sacral Colpopexy for Pelvic Organ Prolapse: A Case-Control Study." Frontiers in Medicine. 2022;9:853694. doi:10.3389/fmed.2022.853694

13. Manodoro S, Frigerio M, Milani R, Spelzini F. "Tips and Tricks for Uterosacral Ligament Suspension: How to Avoid Ureteral Injury." International Urogynecology Journal. 2018;29(1):161-163. doi:10.1007/s00192-017-3497-y

14. Milani R, Frigerio M, Spelzini F, Manodoro S. "Transvaginal Uterosacral Ligament Suspension for Posthysterectomy Vaginal Vault Prolapse Repair." International Urogynecology Journal. 2017;28(9):1421-1423. doi:10.1007/s00192-017-3277-8

15. Nager CW, Visco AG, Richter HE, et al. "Effect of Vaginal Mesh Hysteropexy vs Vaginal Hysterectomy With Uterosacral Ligament Suspension on Treatment Failure in Women With Uterovaginal Prolapse: A Randomized Clinical Trial." JAMA. 2019;322(11):1054-1065. doi:10.1001/jama.2019.12812

16. Pal M, Bandyopadhyay S. "Extraperitoneal Uterosacral Ligament Suspension by Using the Cervix as a Traction Device." International Urogynecology Journal. 2020;31(8):1701. doi:10.1007/s00192-019-04147-w

17. Montoya TI, Dillon SJ, Balgobin S, Wai CY. "Functional and Anatomic Comparison of 2 Versus 3 Suture Placement for Uterosacral Ligament Suspension: A Cadaver Study." American Journal of Obstetrics and Gynecology. 2013;209(5):486.e1-486.e5. doi:10.1016/j.ajog.2013.06.010

18. Karmakar D, Dwyer PL, Thomas E, Schierlitz L. "Extraperitoneal Uterosacral Suspension Technique for Post Hysterectomy Apical Prolapse in 472 Women: Results From a Longitudinal Clinical Study." BJOG. 2019;126(4):536-542. doi:10.1111/1471-0528.15560

19. Ow LL, Walsh CE, Rajamaheswari N, Dwyer PL. "Technique of Extraperitoneal Uterosacral Ligament Suspension for Apical Suspension." International Urogynecology Journal. 2016;27(4):637-639. doi:10.1007/s00192-015-2873-8

20. Mounir D, Vasquez-Tran NO, Lindo FM, Antosh DD, Muir TW. "Vaginal Intraperitoneal Versus Extraperitoneal Uterosacral Ligament Vault Suspensions: A Comparison of a Standard and Novel Approach." International Urogynecology Journal. 2021;32(4):913-918. doi:10.1007/s00192-020-04462-7

21. Vermeulen CKM, Schuurman B, Coolen AWM, et al. "The Effectiveness and Safety of Laparoscopic Uterosacral Ligament Suspension: A Systematic Review and Meta-Analysis." BJOG. 2023;130(13):1568-1578. doi:10.1111/1471-0528.17565

22. Campagna G, Panico G, Lombisani A, et al. "Laparoscopic Uterosacral Ligament Suspension: A Comprehensive, Systematic Literature Review." European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2022;277:57-70. doi:10.1016/j.ejogrb.2022.08.006

23. Douligeris A, Kathopoulis N, Zachariou E, et al. "Laparoscopic Versus Vaginal Uterosacral Ligament Suspension in Women With Pelvic Organ Prolapse: A Systematic Review and Meta-Analysis of the Literature." Journal of Minimally Invasive Gynecology. 2024;31(6):477-487. doi:10.1016/j.jmig.2024.03.007

24. Spelzini F, Frigerio M, Manodoro S, et al. "Modified McCall Culdoplasty Versus Shull Suspension in Pelvic Prolapse Primary Repair: A Retrospective Study." International Urogynecology Journal. 2017;28(1):65-71. doi:10.1007/s00192-016-3016-6

25. Ettore G, Torrisi G, Grimaldi RL, Ettore C. "A Modified McCall Culdoplasty in Pelvic Organ Prolapse Surgery: Anatomical and Functional Outcomes." International Urogynecology Journal. 2024;35(12):2341-2348. doi:10.1007/s00192-024-05886-1

26. Arkan K, Cavusoglu Colak G, Birol Ilter P, Akdeniz E, Akgol S. "Effectiveness and Comparison of vNOTES Assisted Uterosacral Ligament Suspension and Vaginal McCall Culdoplasty in Apical Prolapse." European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2025;317:114861. doi:10.1016/j.ejogrb.2025.114861

27. Cola A, Marino G, Milani R, et al. "Native-Tissue Prolapse Repair: Efficacy and Adverse Effects of Uterosacral Ligaments Suspension at 10-Year Follow Up." International Journal of Gynecology & Obstetrics. 2022;159(1):97-102. doi:10.1002/ijgo.14096

28. 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

29. 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

30. Chang OH, Tewari S, Sun JY, Ferrando CA. "Risk Factors for Ureteral Obstruction and the Diagnostic Value of the 'Cysto-Under-Tension' Technique at the Time of Uterosacral Colpopexy." International Urogynecology Journal. 2021;32(11):2985-2992. doi:10.1007/s00192-020-04650-5

31. 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

32. Richter LA, Boileau J, Janni M, Tefera E, Iglesia CB. "Intraoperative Ureteral Kinking During Uterosacral Ligament Suspension: Effect of Training Level on Occurrence." Journal of Reproductive Medicine. 2016;61(1-2):17-21.

33. Barba M, Cola A, Costa C, Frigerio M. "Impact of Mannitol Bladder Distension in the Intraoperative Detection of Ureteral Kinking During Pelvic Floor Surgery." International Urogynecology Journal. 2024;35(3):689-694. doi:10.1007/s00192-024-05745-z

34. Barba M, Cola A, Frigerio M. "Intraoperative Fluorescent Ureter Visualization for Transvaginal High Uterosacral Ligament Suspension for Severe Pelvic Organ Prolapse." International Urogynecology Journal. 2024;35(7):1549-1551. doi:10.1007/s00192-024-05816-1