Uterosacral Ligament Suspension (USLS)
USLS is a native-tissue operation that supports the vaginal apex from the uterosacral ligaments, usually bilaterally. It can accompany hysterectomy for prolapse or repair an existing vaginal vault prolapse. Uterine-preserving variants require a separate operative plan. The central safety issues are ureteral obstruction and injury to adjacent nerves, vessels or rectum. USLS can cause buttock or leg pain; it does not eliminate the neurologic risks associated with apical suspension.[1][3][4]
For overall procedure selection and nonsurgical options, see Prolapse Repair Principles. This page focuses on USLS anatomy, operative decisions and interpretation of its outcomes.
Choosing USLS
USLS is reasonable when a patient wants a reconstructive repair without a prolapse mesh implant and the ligaments can be identified and used safely. Selection depends on symptoms, compartment defects, previous surgery, tissue accessibility, medical fitness and patient priorities. POP-Q stage alone does not determine the operation.
| Alternative | How to frame the discussion |
|---|---|
| Sacrospinous ligament fixation | OPTIMAL did not detect superior composite success for either vaginal repair. The complication patterns differ; the trial did not establish equivalence. |
| Sacrocolpopexy | May offer greater durability, particularly for selected advanced or recurrent prolapse, while adding an abdominal operation and mesh-related risks. Observational USLS comparisons do not establish a mandatory stage cutoff. |
| Uterine preservation | Discuss this before consent for hysterectomy. Uterosacral hysteropexy is distinct from vault suspension; evidence from hysterectomy-based USLS cannot simply be transferred to it. |
| McCall culdoplasty | Provides apical support and cul-de-sac management during vaginal hysterectomy. The precise distinction from high USLS depends on the operative modification used. |
These choices should incorporate the patient's preference about mesh, uterine retention, vaginal function and the possibility of later retreatment.[1][2][8][9][15][20]
Anatomy and safe fixation
Uterosacral ligament suspensionOriginal schematic · v2026-09-13 · Clinical review pendingBilateral sutures support the vaginal vault from uterosacral tissue. Ureteral proximity varies. Check bladder integrity and bilateral ureteral efflux after final suspension and repeat after relevant subsequent repair.View: Female pelvis, superior schematic view. Scale: Conceptual schematic; not to scale. Units: No measured geometry; any dimensions are illustrative.Limits: Conceptual support diagram; not a dissection map or safe suture target. Rectum, sacral/autonomic nerves and other pelvic structures are omitted. Ligament geometry and ureteral proximity vary with anatomy and traction. Normal jets do not exclude all delayed or thermal injury.Source check: 2026-09-13. This is an editorial check with the access limits below. No named clinician has signed off.Uterosacral ligament: anatomic relationships to optimize surgical safety — 2001 anatomical study, ICS workshop copy. Access: Complete original main and all four actual figures read. Complete Buller2001 main and all4actualfigures read in the ICS workshop copy. Source rejects a universal fixed ischial-spine distance; concept does not establish safe suture coordinates.WARWIKI original vector schematic; individual illustrator not recorded. No separate figure reuse license recorded; linked sources are concept references, not artwork licenses.Open original SVG with embedded source record ↗
Conceptual relationship of the vault, uterosacral support and nearby ureters. This is not a map of safe suture sites; the rectum and neural structures are omitted. Ligament segment, traction and individual anatomy change these relationships.
The uterosacral complex is a visceral support structure containing connective tissue, vessels, fat and autonomic nerves. It is not an isolated cord with a uniform attachment to sacral bone. Its deep portion is closely related to the pelvic plexus; sacral nerve trunks lie beneath the posterior/intermediate region. The rectum is medial and the ureter is generally anterolateral.[3][4]
The ischial spine helps orient the surgeon to the intermediate ligament, but a fixed distance medial to the spine does not define a safe bite. Buller's original cadaver study specifically cautioned against using the spine as a fixed measuring point because ligament width and position vary. The reported ureter distances are averages from dissected specimens, not operative clearance limits.[3]
| Relationship | Operative implication |
|---|---|
| Ureter nearer the cervical end | Low or anterior fixation can capture or distort the ureter. Traction can kink it even when the needle does not directly penetrate it. |
| Neural structures deep to the ligament | Deep or lateral passes into the pelvic sidewall can entrap sacral or autonomic nerves. A more cephalad stitch is not automatically safer. |
| Rectum medial to the support complex | Identify the tissue being incorporated and protect the rectal wall; avoid blind posterior or medial passes. |
| Variable ligament appearance after prolapse or previous surgery | Obtain adequate exposure and identify the actual ligament. Change the plan if its course and neighboring structures cannot be established safely. |
These principles come from anatomical studies and surgical descriptions; no measured offset guarantees freedom from ureteral or nerve injury.[3][4]
Operative framework
Vaginal intraperitoneal suspension
The AUGS/IUGA terminology report distinguishes ipsilateral fixation from midline plication of the uterosacral ligaments. Both require actual ligament incorporation; simply closing peritoneum or reattaching the cuff to distal cut ligament ends is not the same high suspension. The terminology report describes procedures and their variants, rather than selecting the best operation for a patient.[22]
The sequence below describes the decisions in a high vaginal vault suspension. Details depend on previous hysterectomy, associated repairs and the selected technique.[1][3][7][22]
- Confirm the agreed operation. Perform hysterectomy only when it is part of the treatment plan. Establish safe access to the cul-de-sac and adequate exposure; account for adhesions and previous repairs.
- Identify both uterosacral ligaments and adjacent structures. Use palpation, visualization and appropriate retraction. The ischial spine is an orientation landmark, not a ruler for selecting a bite.
- Place controlled suspension sutures in identified ligament tissue. The terminology report describes posteromedial ligament incorporation proximal to the ischial-spine level; this does not specify a universal safe offset or depth. Avoid incorporating the lateral pelvic wall or taking blind deep passes. Protect the ureter, rectum and nearby nerves. Published techniques use different suture numbers and materials.
- Attach the sutures to adequate apical supportive tissue. Incorporate the relevant vaginal fibromuscular/fascial layers. Keep permanent material away from exposed vaginal epithelium. Choose cuff closure and tissue purchase appropriate to the suture material.[22]
- Restore bilateral support without excessive tension. Coordinate apical suspension, cuff closure, enterocele management and clinically indicated compartment repairs. Assess the resulting vaginal length, caliber and axis.
- Perform cystoscopy after the final suspension and relevant repairs. Inspect the bladder and urethra and confirm bilateral ureteral efflux. If further suturing could alter ureteral patency, reassess after that step. An earlier test with untied sutures on traction does not replace this final assessment.[5][16]
Suture choice
Permanent and delayed-absorbable sutures are both used; there is no single mandatory count or material for every USLS. A 2023 systematic review found no clear difference in medium-term success between materials across native vaginal suspensions, but the evidence combines USLS and SSLF, varied techniques and mostly nonrandomized studies. Permanent sutures carry exposure/granulation considerations. The review does not establish that all absorbable products, stitch configurations or long-term results are interchangeable.[6]
The long-term Cola series used two or three delayed-absorbable monofilament sutures on each side. That provides an example of a studied technique, not a universal prescription.[7]
Extraperitoneal suspension
An extraperitoneal approach reaches the support complex without opening the peritoneal cavity vaginally and may be useful when intraperitoneal entry would be difficult. It requires specific familiarity with the pararectal dissection and protection of the urinary tract.[13][14]
Karmakar's observational series included 472 women with posthysterectomy vault prolapse, many with previous prolapse surgery. It reported 89% vault-support success at approximately five years. 138 women also had mesh augmentation, so the results should not be presented as those of an entirely mesh-free cohort. There was no randomized comparison establishing superiority or elimination of ureteral risk.[13]
Laparoscopic, robotic and vNOTES approaches
Laparoscopy permits magnified identification of the ureter and access to the retroperitoneal anatomy. It does not remove the need for careful dissection, avoidance of thermal injury or final cystoscopy. Evidence for laparoscopy cannot automatically be generalized to every robotic or vNOTES modification.[4][5][10]
Vermeulen's 2023 review included 13 nonrandomized cohorts with 933 patients and an average follow-up of 22 months. Its roughly 90% pooled success estimate referred to apical anatomical support, with substantial heterogeneity; it was not an all-compartment, lifetime or randomized comparison with vaginal USLS.[10]
Comparative reviews published in 2024 and 2025 suggest possible advantages of laparoscopic approaches for some recurrence or perioperative outcomes. Their conclusions remain limited by observational evidence, different concomitant hysterectomy/repair patterns and short or variable follow-up. They do not establish one preferred route for all patients or justify omitting cystoscopy.[11][12]
Ureteral assessment and complications
AUGS recommends cystoscopy for prolapse reconstructive surgery except operations confined to the posterior compartment. USLS requires assessment of bilateral ureteral efflux after repair. Visualization of the ureter or apparent peristalsis during laparoscopy is not an equivalent test of drainage into the bladder.[5]
If efflux is absent or concerning, first establish a clear view of both orifices and consider urine output, visualization and possible anatomical variation. Investigate obstruction promptly. When a suspension or anterior-repair suture is implicated, release or revise it and repeat the assessment. Persistent concern requires further urinary-tract evaluation and appropriate urologic assistance; do not finish the case with unexplained suspected obstruction.[5][17]
A normal cystoscopy does not exclude every partial obstruction, delayed thermal injury or evolving postoperative problem. New flank pain, fever, oliguria/anuria, renal dysfunction or suspicious vaginal urinary leakage warrants prompt investigation even after intraoperative efflux was seen.[5][17]
| Complication | Evidence and practical response |
|---|---|
| Ureteral obstruction | Corrected OPTIMAL supplementary data record six intraoperative obstructions among 188 women assigned USLS: five managed by suture removal and one by stenting. One additional delayed ureteral injury occurred. These are distinct events, not a universal complication rate. |
| Buttock, groin or leg pain | OPTIMAL recorded new neurologic pain requiring additional treatment in 13/188 USLS patients and 23/186 SSLF patients. Assess significant or persistent symptoms for suture-related nerve entrapment; USLS is not free of this risk. |
| Suture exposure or granulation | Can cause bleeding, discharge or discomfort. Examine the cuff and assess exposed material; a native-tissue prolapse repair can still have suture complications. |
| Rectal or vascular injury | Protect the structures adjoining the ligament and reassess if dissection, bleeding or needle passage raises concern. |
| Voiding dysfunction or incontinence | Assess postoperative emptying and symptoms. Concomitant continence surgery changes the risk profile and should be considered separately from apical support. |
The OPTIMAL pain outcome required altered care and was not a measure of all postoperative pain; many participants also underwent hysterectomy and a retropubic midurethral sling.[1][4][6]
Cystoscopic adjuncts may help show efflux, but agent selection follows patient factors and institutional protocols. A 925-patient historical-cohort study associated mannitol bladder distension with fewer postoperative unrecognized ureteral injuries than saline. Its comparison of different calendar periods does not prove that mannitol prevents injury, and a delayed obstruction still occurred in the mannitol group.[17]
Outcomes: keep the endpoint and population visible
Randomized vaginal-repair evidence
| Study | Result | Interpretation |
|---|---|---|
| OPTIMAL, corrected two-year analysis | Composite success: 100/155 (64.5%) USLS versus 94/149 (63.1%) SSLF; adjusted OR 1.1, 95% CI 0.7–1.7. | Neither procedure was superior in this trial. The composite required anatomical support, absence of bothersome bulge and no retreatment; it was not isolated apical success. |
| E-OPTIMAL, five-year extension | Estimated first composite failure: 61.5% USLS versus 70.3% SSLF; adjusted difference −8.8 percentage points, 95% CI −24.2 to 6.6. | No statistically clear difference. The endpoint counted a first failure even if later symptoms or anatomy improved. It does not mean that this proportion required another operation. |
OPTIMAL enrolled women with apical prolapse and stress urinary incontinence, with planned concomitant retropubic sling surgery; it was not a uterine-preservation trial. E-OPTIMAL enrolled 285 of the original participants and 244 completed extended follow-up. Symptom improvement persisted despite the increasing cumulative composite-failure estimates.[1][2]
The ASPIRe trial also informs counseling for selected women with posthysterectomy vault prolapse: sacrocolpopexy had lower adjusted composite failure than its native-tissue group. However, the latter included both USLS and SSLF, so its overall result is not a USLS-specific randomized estimate. See Sacrocolpopexy for the trial population and full comparison.[21]
Long-term cohort evidence
Cola and colleagues evaluated 287 women at approximately ten years after vaginal hysterectomy with high USLS. There were 55 anatomical recurrences, 18 reports of bulge symptoms and six repeat prolapse operations. The anatomical definition included stage II or greater prolapse in any compartment. Of 353 eligible women, 66 were lost to long-term follow-up. These results are useful for counseling but are not directly comparable with E-OPTIMAL's cumulative first-event endpoint.[7]
Premenopausal status and concomitant compartment repair were associated with outcomes in that cohort. These observational analyses, including only six repeat operations, do not establish that prophylactic repair of a normal anterior or posterior compartment prevents failure.[7]
Large observational reoperation studies add longer follow-up but measure a different outcome from anatomical recurrence. Shah's nearly 10,000-patient cohort found lower recurrence-related reoperation after sacrocolpopexy, while all-cause reoperation was not clearly different among reconstructive procedures. A 2026 Danish cohort likewise reported compartment-specific differences across techniques, with selection and residual confounding remaining important. Neither study supports an invariant ranking of procedures for every patient.[18][19]
Comparison with sacrocolpopexy
In Lavelle's retrospective cohort, stage III recurrence was more frequent after USLS than sacrocolpopexy. Stage II events were few, and only eight stage IV patients underwent USLS. Follow-up duration and patient characteristics differed between groups. These findings support a discussion about durability, not a rule that every stage III/IV prolapse requires mesh or that stage II repairs are proven equivalent.[8]
Campagna's matched retrospective comparison also favored laparoscopic sacrocolpopexy for all-compartment anatomical success. The groups still differed in compartment severity, hysterectomy type and associated repairs. The study does not prove that a particular route or operation is best solely because prolapse is described as moderate, isolated or advanced.[9]
Follow-up and operative documentation
Record the route, ligament identification, suture material and configuration, attachment sites, concomitant procedures, final support and urinary-tract assessment. Document any released/replaced sutures and the findings after reassessment.
At follow-up, assess bulge symptoms, vaginal support, voiding and bowel symptoms, pain, vaginal healing and sexual-function concerns. Explain that an examination finding, bothersome recurrence, pessary treatment and repeat surgery are separate outcomes. Manage recurrent prolapse according to symptoms, anatomy and patient goals rather than a single success percentage.[1][2][7]
Videos
References
1. 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 Corrected June 2015; correction notice.
2. 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
3. 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
4. Ramanah R, Berger MB, Parratte BM, DeLancey JO. "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
5. 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
6. Pollack BL, Popiel P, Toaff MC, et al. "Permanent Compared With Absorbable Suture in Apical Prolapse Surgery: A Systematic Review and Meta-analysis." Obstetrics & Gynecology. 2023;141(2):268–283. doi:10.1097/AOG.0000000000005032
7. 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
8. 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
9. 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
10. 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
11. 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
12. Azadi A, Ulibarri H, Arroyo A, et al. "Meta-Analysis of Laparoscopic Versus Vaginal Uterosacral Ligament Suspension." Journal of Minimally Invasive Gynecology. 2025;32(10):877–888. doi:10.1016/j.jmig.2025.07.001
13. 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
14. 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
15. 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
16. 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
17. 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
18. 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
19. 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
20. 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
21. Menefee SA, Richter HE, Myers D, et al. "Apical Suspension Repair for Vaginal Vault Prolapse: A Randomized Clinical Trial." JAMA Surgery. 2024;159(8):845–855. doi:10.1001/jamasurg.2024.1206
22. 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.