Dr. Peter KrugerUrogynecology & Surgery
Vaginal Surgery

Apical Suspension Procedures

Surgical techniques to support the top of the vagina or uterus using native tissue fixation.

Overview

Apical suspension procedures support the top of the vagina (vaginal vault) or the uterus/cervix by anchoring them to strong ligaments or bony structures within the pelvis. These are essential components of prolapse surgery, as adequate apical support is the foundation of a durable repair.

Normal vaginal vault support

Vaginal vault prolapse

Uterosacral Ligament Suspension

The vaginal apex or cervix is sutured to the uterosacral ligaments — strong native ligaments that naturally support the uterus. This can be performed vaginally or laparoscopically.

Advantages:

  • Uses native tissue (no mesh)
  • Re-establishes the natural axis of the vagina
  • Can be combined with other vaginal repairs

Considerations:

  • Small risk (approximately 1-3%) of ureteral kinking requiring intraoperative correction
  • Cystoscopy is routinely performed during the procedure to confirm ureteral function

Sacrospinous Ligament Fixation

The vaginal apex is sutured to the sacrospinous ligament, a strong ligament deep in the pelvis. This is performed through a vaginal approach.

Sacrospinous fixation procedure

Advantages:

  • No abdominal incisions
  • Well-established procedure with good long-term results
  • Particularly useful in combination with vaginal hysterectomy

Considerations:

  • May result in a slightly posterior deviation of the vaginal axis
  • Temporary buttock or leg pain may occur due to proximity to nerves (usually resolves within weeks)

Recovery

  • Hospital stay: typically 1-2 nights
  • Return to light activities: 1-2 weeks
  • Full recovery: approximately 6 weeks

Risks and Success Rates

Apical suspension procedures achieve an 80-90% success rate for correcting vault or uterine prolapse. The specific risk profile depends on the technique used.

Sacrospinous fixation:

  • Buttock pain — approximately 10% of women in the early post-operative period, usually self-limiting
  • New stress urinary incontinence — develops in approximately one-third of patients
  • Voiding difficulty — approximately 10% experience ongoing difficulty with bladder emptying

Uterosacral ligament suspension:

  • Ureteric injury — 1-10% of cases; intraoperative cystoscopy may be performed to check
  • Urinary tract infection — 7-34% depending on catheter use
  • Buttock pain — usually short-term

Common risks for both procedures:

  • Prolapse recurrence or development in another compartment
  • Dyspareunia — rare; most women report improved sexual function
  • Bleeding requiring transfusion — uncommon
  • Venous thromboembolism — rare

Illustrations courtesy of the International Urogynecological Association (IUGA) Patient Information Leaflets.