I'm going to be talking a little bit about pelvic surgical anatomy and native tissue prolapse repair. I'll touch a little on non-native tissue as it relates to anatomy. So there's a bit of an asterisk with this. But mostly, we're going to focus on native tissue repair. So just a brief refresher here. This is the bony hemipelvis up front. You have the pubis. Down in posterior, you have the ischium. And then at the top, there's the ilium. And of course, there's these important landmarks, the ischial spine and the ischial tuberosity, which you guys are all sitting on right now. This is a bony pelvis. Let's see if this works here. So this is looking at the pelvis as it rotates, the superior pubic ramus, the body of the pubis, inferior pubic ramus, ischium, and the inferior part of the ilium, where it fuses there, and then the obturer membrane, which, of course, is filled with tough connective tissue, the obturer membrane. So this is how it's oriented in the lithotomy position. But obviously, women are not in the lithotomy position all the time. So when you're in the standing position, the plane of the pelvic floor lies oblique to the horizontal plane. And the ischial spines form the lateral points of attachment for both the sacrospinous ligament here and the archus tendineus fascia pelvis. Looking down into the pelvis, the pelvic floor is hexagonal with the ventral bound as the pubic bones. Laterally, the archus, dorsally, the sacrum, and the sacrospinous ligaments. And John Delancey, jeez, I guess it's going almost 25 years ago, defined these sort of three levels of normal female pelvic organ support. First level was composed of the cardinal uterus sacral ligament complex, the apical support. Level two is the lateral attachment of the pubocervical and rectovaginal fascia out to the pelvic sidewall and the archus. And then level three was the fusion of the vagina to the surrounding structures distally. Here we see level one, primarily in the healthy patient, is the uterus sacral ligaments. But the portion of the endopelvic fascia that attaches the uterus to the pelvic wall in general is called the parametrium. And it includes the broad cardinal and uterus sacral ligaments. But obviously, there are structures that we can use that aren't related for normal. They're not related to normal pelvic support in women. But you can use them to recreate this level one support. Obviously, the first is the sacrospinous ligament for native tissue repairs and in the past for transvaginal mesh repairs. And the anterior longitudinal ligament of the sacrum for sacral copeplexy. Laterally, you have the portion of the support that attaches the vagina to the pelvic wall that's called the pericopium. And that's lateral attachment. And then again, level three near the introitus, the vagina is fused laterally to the levators, posteriorly to the perineal body. And anteriorly, it blends with the urethra and termed this fusion. And here it is looking in an MRI in the standing sagittal picture here. So again, level two, pericopium, paravaginal attachment to the tendineous arch of the fascia pelvis. And then level one is the parametrium, the cardinal ligament, uterus sacral ligament. So the ligaments, sometimes that term is used loosely in our terminology. But the uterus sacral ligament here, traditionally shown sort of this fanning out motion, getting wider as it gets towards its apical attachment to the sacrum. The archus tendineus fascia pelvis, the white line. The sacrospinous ligament, which I've sort of drawn in here. And then there's this paracervical ring of connective tissue where a lot of these structures fuse towards the area where the uterus, cervix, and vagina all fuse. So let's start talking about these uterus sacral ligaments. This is a traditional sort of netter type drawing of them. This is looking inside laparoscopically with a live patient, looking at the level one support, which includes the cardinal ligament out here laterally, and then the uterus sacral ligaments more apical. So when a patient has a POPQ that looks like this, you know, cervix is the leading edge of the prolapse. It's an inch out, especially if it's a large cervix and they have an enlarged general hiatus. My go-to native tissue repair for this type of patient is going to be a vaginal hysterectomy uterus sacral vault suspension. Now, this isn't meant to be a typical vaginal hysterectomy. It's meant to be sort of super evidence-based. This is the August clinical course. This is just sort of the way I practice. I didn't force, I didn't push to be a speaker here. I was sort of asked to do it. So if you don't like the way I do things, that's 100% fine. I'd love to hear about it, but I'm just giving you my own two cents. And especially if they have this kind of relaxed general hiatus, I will try to renormalize that because we do have pretty good data that suggests native tissue repairs benefit from that, unlike sacral colpopexy, where that kind of seems unnecessary, unless the patient has specific requests for that. Obviously, when we're talking about a uterus sacral ligament suspension, one of the most important things we're trying to avoid is complications with the ureter that runs just superiorly to the uterus sacral ligament. Again, sort of netter drawing here, showing this uterus sacral ligament as it travels from the uterus up to the sacrum. And this little blue arrow indicates that the higher you are up on this ligament, you're going to be farther and farther away from the ureter because the ureter has to drop down into the pelvis over the bony promontory there. And the higher up you are on the ligament, the further away you're going to be from the ureter. And as they get closer to the uterus, they get closer and closer together. This is a cadaveric dissection here, sagittal, looking at the uterus sacral ligament. And these are from the pelvic anatomy group, SJS, looking at this superficial and deep layer of the sacrum. This is a superficial and deep layer of the uterus sacral, which I always sort of appreciated clinically, but never really knew that these were terms that were being used on a regular basis. Some people who study this anatomically. Because superficially, what you're really seeing, especially with a laparoscopic view, when you see this uterus sacral ligament, what you're seeing is the superficial portion of it. But deep to that, and inferior to that, you can see the deeper uterus sacral ligament. And this is shown in this more cartoonish representation, looking at the superficial and deep components of the uterus sacral ligament. This is, I don't know if Dr. Hickman's still here, I borrowed these pictures from one of her videos that I just did some single shots of. And this shows, you're not going to see it this clearly in a lot of patients, but this shows that more superficial layer and the deep layer of the portion of the uterus sacral ligament. This one, again, being the more superficial, this being the deep. And that's sort of the bite that I like to get in that type of area. And that's going to keep you, again, further away from the ureter. This is another sagittal image, looking at the right hemipelvis, showing a couple of different areas where you can put the uterus sacral suspension suture. This shows the traditional sort of McCall placement. And I remember, I think when I was a resident back in the late 90s, people would do their first bite of their vaginal hysterectomy, call that the uterus sacral, and at the end, they just tie them together. And that was a uterus sacral suspension. And I was like, I don't see why that's going to help anybody. But that's traditionally where that stitch is going to be. And then when you're starting to really do a true uterus sacral, the sort of initial teachings were sort of right about the level of the ischial spine, and then this modification of the high uterus sacral ligament suspension, even closer to the sacrum and more inferior. And again, this is a nice demonstration of the higher you get, the further you are away from the ureter. It also shows some of the stuff that you can get in trouble with if you try and stick needles through those nerve complexes and vessels. Once you have those stitches, well, number one, what do you use? You're going to use a delayed absorbable, like a PDS. Are you going to use an ovicrel? Are you going to use a permanent suture, like a Gore-Tex? The data is mixed on this. Some studies show that permanent sutures make a difference. Some studies show they don't. Again, my own two cents, what I've always done is using Gore-Tex. And rather than just sort of running it through the walls of the vagina above and below, and then tying them down such that there's a lot of suture that's left in the vagina, which is perfectly safe to do with PDS, but with Gore-Tex, that could cause problems. So what I do is, after I get the deep stitch, I then run it through the distal uterus sacral ligament right near the insertion in the cuff, and then bring it out through the vaginal lining lateral to the cuff. And I bring both ends, which both have a double arm suture, bring them out real close to one another so that when you tie down that knot, it tends to get buried in the vaginal wall. But there's still good support, because it's also running through the distal uterus sacral ligament. And with that, I have very little difficulty with post-operative granulation tissue and things of that nature. Not that it never happens. I've been in the same location for almost 21 years. And I probably do 50 or 60 of these a year. And once or twice a year, I get a patient coming back because of spotting, or their GYN saw something in their vagina when they went to do an exam. But in general, I like to use permanent sutures. I know people use variations of combinations. But that's just how I do it. Obviously, you can do a uterus sacral suspension through an abdominal approach as well. And this shows someone in a laparoscopic dissection, where they've dissected the bladder away from the fibromuscular layer of the anterior vagina, otherwise commonly referred to as the pupal cervical fascia, and a stitch going through the vaginal cuff in this post-hysterectomy patient. So just have to couldn't help not just doing a little bit of anatomy when it comes to sacral complexion. I hope I don't step on Dr. Culligan's toes too much here. But this is some of the great work that's been done out of UT Southwestern, looking at cadaveric dissections. And it shows the sacral promontory. And they measured pull-out strength of sutures placed vertically and horizontally at different layers, one centimeter above the sacral promontory, two centimeters, one below, two below, and so forth. And what they showed was that you had really good strength if you put it two centimeters above horizontally. But obviously, you run into some danger there with other structures. And then also below, placed horizontally at SP minus 1 and SP minus 2, meaning one and two centimeters below the sacral promontory, you had good strength and definitely a much safer spot there to put sutures. This is looking down into the pelvis with this L5-S1 disc here, vagina here. And it's showing, again, sort of this area of S1, S2, the middle sacral vessels. And then again, not too far out laterally here, we have our sacral nerve roots and our vessels. One thing that I thought was interesting, if you remember the CARES study, which was published back in 2006, it was open sacral colpopexy, and people were randomized to birch or no birch. And you read those studies, there's zero reports. I think something like 200 sacral colpopexy, zero reports of osteomyelitis, dischitis, anything. Because when you're operating open, it's really pretty easy to get down there to S1, S2. And that's where people were putting their stitches. Soon after that, obviously, the minimally invasive sacral colpopexy became much more of the go-to procedure if you're going to do sacral colpopexy. This shows a straight stick. And it's kind of hard to get over that sacral promontory when you're doing it that way. And you see this stitch, which is going through the sacral promontory. And almost certainly, that's probably going through the disc at L5, S1. And as soon as we started seeing lots of minimally invasive sacral colpopexies, we started seeing a lot more reports of dischitis and osteomyelitis. And I think that's because people were putting stitches in a different place than when they were doing it open. And if you look at these cadaveric studies, it showed that the vast majority of the time, the sacral promontory involves the disc at least partially. But if you get over that promontory, you're kind of in safe territory here down on S1. This was, again, out of UT Southwestern, looking at vasculature and ureters in relation to the sacral midpoint, the midsacral point, or the MSP here. And it shows the distance both in cadaveric dissections. And they also did CT urograms in live patients. And some relationships were much more consistent. And some were very variable. This shows the distance from the internal iliac artery to the midsacral point, about 2 and 1 half centimeters. From the ureter to the midsacral point, just a little bit further. But of interest, you see here in this picture, the left common iliac vein's way down, almost overlapping the sacral promontory off the patient's left side. Whereas this one, it's way up here. And that's definitely something that's important to realize when you're doing these procedures. Because it's not always easy to see that left common iliac vein when it's covered in peritoneum and fat. And it's not pulsating. So you just always have to be cautious of that variation in that anatomy. But these are just some of the numbers that they came up with. When you look at the right ureter to the midsacral point, again, about 2 and 1 half centimeters in cadavers and 2.9 in CT urogram. When you looked at from the right internal iliac artery to the midsacral point, about an inch. Left, about an inch. And then the left common iliac vein, again, this really big variation, anywhere from 9 to 47 millimeters away. All right, back to native tissue repair. So the other structure we use for native tissue repairs for apical support, other than the uterus sacral, is the sacrospinous ligament. And this actually is a true ligament. I think most people would agree a uterus sacral ligament isn't a true ligament. Ligaments should be attaching bone to bone. And in this case, it attaches the ischial spine to the sacrum. Just a little side note, just always find this interesting. There's an island in the Gulf of Naples called Ischia. I don't know if it's Ischia or Ischia. I'm going there next month. I'm very excited. I'm going to check it out. But if you see it, it looks like a little bit of a, like a, and I don't know if that's what the ischial spine was named after or not. And it's also where they filmed The Talented Mr. Ripley. So sacrospinous ligament, it's covered by the coccygeus muscle. And it's bounded laterally by the ischial spine and the pudendal neurovascular bundle, medially by the rectum and the sacrum, superiorly by the sacral nerve roots and piriformis muscle, and inferiorly by the iliococcygeus muscle. And this is the all-important pudendal nerve that runs right underneath the ischial spine and then breaks into an inferior rectal branch, which, of course, if you get that, can cause really significant buttock pain. But then these anterior branches also provide very important functions as well. Anteriorly, it branches into the peroneal nerve, which supplies both the motor innervation to the urinary and anal sphincters, and then the dorsal nerve of the clitoris, which obviously is sensory to the clitoris. So an extremely important nerve that you want to be aware of if you're doing these types of repairs. Try to avoid damage to it. So what's the best approach to gain access to the sacrospinous ligament? And should it be used for vault suspension, either at the time of hysterectomy or in post-hysterectomy patients? Or can it be used for hysterepexy? Traditionally, sacrospinous ligament fixation was approached posteriorly. And mostly, it was used for post-hysterectomy vault prolapse. But that's not always the case now. This was a systematic review. And it's looking at studies of sacrospinous ligament hysterepexy. But most of these were posterior and unilateral approaches to this ligament. So not surprisingly, since anterior compartment defects seem to be the hardest to correct in the long term, there's some data that suggests an anterior approach might be superior to a posterior approach to the ligament. And this is a study out of Rogers Stomping Grounds, looking back in the late 1990s, published in 2000, looking at an anterior approach to sacrospinous ligament fixation or suspension as opposed to a posterior approach. And when they looked at this, they saw that when you approach the ligament posteriorly, a little bit of sagging here in the anterior wall. C is supported, but not quite as well as when you do this anterior approach. You get better apical and anterior support. And you also got a little more vaginal length out of it when you did the anterior approach. All right. And how do we easily get to the sacrospinous ligament via an anterior approach? Well, first, let's just talk a little bit about drop bladders and bladder tucks, tacks, lifts, whatever. I have so many patients that say, oh, I had a bladder lift. Sorry, I wish I knew what that meant. But in any event, so we talk about level 2 support. I think that there's always this question of, is it really a level 2 support defect, or is it a level 1? And I love this picture. I show this to all my residents. But let's talk about level 2. So it's this lateral attachment out here, the paravaginal attachment to the archis tendinous fascia pelvis. And when you have defects of this support, that's the putative cause of rectocele, cystocele, paravaginal defect repair. So where is the defect? Is it level 1 or level 2? And if it's level 2, how do we fix it? Traditionally, we fix cystoceles with anterior colporaphy. That's dissecting the vaginal epithelium off the underlying pubocervical fascia, plication of that fascia, then trimming the epithelium and closing the incision. So where really are we dissecting when we do these anterior colporaphies, and what are we plicating when we do this? Is there really even such thing as pubocervical fascia? Is it really just the fibromuscular as the anterior vaginal wall? Maybe we should just call it the good stuff. But we're traditionally taught that the good stuff begins superiorly at the level of the cervix, where it's continuous with the fibers of the carotid uterine complex, laterally attaches to the pelvic sidewall on the archis, and then distally, it passes under the pubic symphysis to fuse with the perineal membrane. So the limitations to an anterior colporaphy for a cystocele repair is that we might not be restoring normal anatomy, if you believe that little cartoon I showed earlier, where there's maybe not an absence of level one support. We know that anterior colporaphies by themselves have pretty high recurrence rate, and they may constrict or shorten the vagina. But it makes sense. If you have a central distension defect with good apical support. But how often is that really the case? In my opinion, and I think the conventional wisdom at this point, is most anterior compartment defects are caused by apical and lateral detachment, in addition to whatever central distension there might be. So rather than an anterior colporaphy, maybe a paravaginal defect repair makes more sense in these patients. This is showing a open repair of a paravaginal defect. Here's the pubic symphysis. Here's the bladder. And here's suturing that pubocervical fascia to where it has separated from the white line. And if you're doing it these days, most people are doing it laparoscopically. But I would take a wager there's not a lot of people out here doing this on a real regular basis. Show of hands, who does like five of these a week? All right, five of them a month. All right. So you probably believe that your patients are like Cullen Richardson's patients. So Cullen Richardson was a gynecologist. I think he sort of was the guy who brought back the whole idea of the importance of paravaginal defects and separation of fascia from the white line. And in his patient population, he thought that 80% Oh, well. My pointer's dying. Do we have another laser by any chance? OK. Anyway, he thought that most of his defects for anterior prolapse were caused by lateral paravaginal defect repairs. So if they're so common, why are these done infrequently these days? And is it because most apical repairs fix most prolapses? I don't know about all of you, but I see this pop cue in my office on a very regular basis. So anteriors, plus 2, plus 1, plus 3. Cervix, down at minus 2, minus 1, minus 3. And I see this all the time. As opposed to the other ones that I see sometimes, which is the big cervix staring you in the face as soon as you do a pelvic exam. So for that type of repair, or that type of defect, I was a big fan of anterior vaginal mesh repairs. And doing a lot of the dissection for that procedure made a lot of surgeons, including me, more comfortable with an anterior approach to the sacrospinous ligament. And there was really great data with uterine preservation, with doing a hystereopexy with this type of repair. And it also allowed for an easy concomitant anterior coporaphy. So what do we do with all these patients now that these kits are off the market? So it's no longer commercially available. You can use a mesh for a sacrospinous anterior hystereopexy. It just would be an off-label use of mesh. I've recently consented someone for that procedure, but I haven't done it yet. Should we just do vag hystereopsy on everybody? Or should we just do robotic hysterectomy and mesh sacral copepxy on everyone? Well, I already told you who I like to do vag hystereopsy sacral on, and that doesn't look like that pop Q I just showed you in the last slide. And I do like to do robotic sacral copepxies, but generally I'm going to reserve this for advanced stage 3 or stage 4 sexually active patients. But for a lot of my patients, especially ones who are a bit older, only stage 2 or early stage 3, with that traditional, that very typical pop Q that I see, I now commonly perform an anterior bilateral native tissue hystereopexy. So the dissection I use for this is the same dissection I used when I did transvaginal mesh. I do placate, but I'm not placating pubocervical fascia. When you're doing this dissection, which I'm going to show you a video in a second, you're really just placating the sort of loose connective tissue that's found in the vescovaginal space. And it has nothing to do with the strength of the pair. It's just sort of to get that bulge out of the way so that I can easily get to the paravaginal space and so that I have a nice clear path to put my stitches into the paracervical ring of connective tissue. And then suspend that up to the ligaments. So again, I suspend the uterus, cervix, paracervical ring, apex of the vagina with permanent suture up to the sacrospinous ligament. And the benefit of doing that way is you can use permanent sutures. And in that situation, you don't even have to bring the sutures through the vaginal wall because you've made the dissection in the vescovaginal space, anchored it in there. I do have to close the bottom half of the incision first before I tie it down or else it would be pretty hard to get to the top of the incision. But I close the bottom half first, tie them down, then close the top half. So the dissection I do for this is shown here. This is my partner, Dr. Vince Lucente, showing this video. We do pretty similar, a little bit differently. But in any event, you can use this epidural needle that he's using. In that case, as you come through the full thickness of the vaginal wall, you'll feel a little pop as you get into the vescovaginal space. I simply use a regular 18-gauge needle, provide just a little bit of support, a little bit of pressure on the plunger as I place it in. And as soon as I hit that vescovaginal space, I can feel the resistance go away. And that's where I put all that fluid. I then don't take the needle out like he showed here. I just separate the needle from the syringe, attach another syringe, because I usually use about 40 cc's. And the first 20 just go centrally, and then the second 20 go laterally and up and down a little bit to really potentiate and open up that vescovaginal space. You then make an incision, at which point, hopefully, if it went into the right space, you get this little bleb of sort of gray, fluid-filled tissue in the vescovaginal space. And then you can extend the incision superiorly and inferiorly from there. I generally go from the bladder neck down to, again, I do this mostly in people with uteruses, so down to maybe a centimeter shy of the cervix. When you're doing this dissection, you're going to note this is not just the vaginal epithelium coming off the underlying connective tissue of the vaginal wall. You're cutting through full thickness, so you're ending up in the same place that you are when you're going abdominally and doing a sacral copal pexy. And you'll see that that vaginal wall is quite thick at that point, because it's got the good stuff and the vaginal epithelium within it. And if you are in this space, it should be a pretty bloodless dissection. And hopefully, you're going to see some fat. And that fat, that adipose tissue, is going to let you know that you're in the proper space. And once you are, it's sharp dissection laterally, superiorly and inferiorly. And basically, when you can't see your scissor tips anymore at that point, you can usually just do blunt dissection down to the ischial spine, and then work laterally to medially off the ischial spine to clear off the sacrospinous ligament. And I really like to really clear off that ligament. There's obviously a lot of procedures now where we're not doing that. We're going straight through the vaginal wall to the ligament. That's a procedure I have not adopted yet. There's obviously some advantages to that. But there's some downsides to it in my mind as well. So anyway, patient comes in with this pop cue. I'm using the sacrospinous ligaments and using permanent suture to bilaterally suspend the cervix, uterus, and apex of the vagina up to those ligaments. You can certainly do a uterus-sacral hysterepexy as well. This is a laparoscopic shot with someone who still has their uterus. And these suspension sutures, that's going to be done in most people. They're going to use the uterus-sacrals through an abdominal approach, either open or laparoscopic. Not a lot of data on that compared to the sacrospinous hysterepexy. So what is the best structure to use for native tissue apical suspension? Well, when we're talking about hysterepexies, I think the jury's still out, even though I clearly have my feelings on it. But in post-hysterectomy patients, we pretty much conclusively know at this point, from the optimal trial, that they're both kind of comparable. This showed, really, sorry, I don't have my laser anymore. But if you see up in here in yellow, it looks at the two arms of uterus-sacral versus sacrospinous with surgical success, and they're virtually identical. And this also randomized people to doing pelvic muscle exercises or not, and that also didn't show a difference, which is interesting, but not really germane to this discussion so much. Those were the two-year outcomes. These are the five-year outcomes. Again, didn't really show any differences further out as well. So as per the 2017 ACOG's practice bulletin, uterus-sacral and sacrospinous suspensions are equally effective. So rectoceles. Well, I only gave myself 35, 40 minutes to do this talk, so you guys are going to have to come back next year to know about rectoceles. All right, that's it. Thank you very much. from Invercargill, New Zealand. I just wanted to ask a question that when you're doing the bilateral sacrospinous hysterepexy and the order of placing the sutures when you're also repairing an anterior defect, what is your timing of placing them, tying them down so that you don't get all ten of them tangled up together? What is the order of placing them and tying them down? Yeah, so I'm just doing two sutures, one on each side. You're talking about a bilateral anterior? Bilateral anterior approach. Also, are you doing any kind of cystic seal repair when you do that? Yeah, so I'm making a vertical incision, dissecting laterally, then doing my blunt dissection, sorry, doing my blunt dissection, doing my blunt dissection down to the sacrospinous ligaments, placing my two suspension sutures. Excuse me, before I place the suspension sutures, then I will placate that loose connective tissue. Then I'll run the sutures through the paracervical ring of connective tissue where the cervix uterus and vagina meet. I will then trim both full thickness vaginal lining. So instead of placating pubocervical fascia, endopelvic fascia, I'm just trimming it away from each side and then closing it. So in my opinion, I'm kind of placating it while removing what's in the middle of the placation. I put the sutures through, I close the bottom half of the incision, then I tie down the suspension sutures, then I scope, make sure that I haven't kinked a ureter or put a stitch in the bladder. Once that looks good, then I cut the ends of my suture because you want to be able to access those sutures in case you did. And just an interesting fact, I used to use branded Gore-Tex suture and I was getting a lot of kinked ureters that I had to take stitches out. And then branded Gore-Tex stopped coming on a bullet needle. I used a suture that has the bullet, I'm not going to say the device's name. But they stopped making that. And so all you had was generic PTFE and ever since I've done that, I've not had one ureter or kink with that. And then once I do that, then I close the top half of the incision and that's it. And I look one more time. the anterior repair does not restore the normal anatomy. And everybody's sober now, but I wonder if I got a couple of old fashions in people, how many would admit that their anterior repairs are less than satisfying? And I listened to Cullen Richardson, I just, I wish his talks were recorded because he had this elegant southern drawl and he was an excellent speaker, but I also think he was right in that the paravaginal repair, 95 out of 100 times, restores the normal anatomy if it's done correctly. There's still about 5% where there's this large anterior defect that you've got to do something with. But if we don't restore the normal anatomy, you know, you're going to get recurrences. And I think we have to function that way. But I'm going to end just by asking, how many of you feel, how many of you are happy with your anterior repairs? Well, hopefully we're not doing too many procedures that we're unhappy with or we shouldn't be doing them. I think that the key is that you either have to get a paravaginal repair or you have to have an apical suspension. I think if you have an apical suspension, it can cover a lot of that paravaginal repair. Because I think it's, you know, when you see these pictures of the paravaginal defect, the defect is down by the spine, right? The defect gets smaller and smaller as you get towards the pubic bone. So I think that the key is getting that apical suspension or a paravaginal repair that goes all the way down to the spine. But that's just a kind of hard, do you do it open or do you do it?

pelvic surgical anatomy

native tissue prolapse

ischial spine

uterus sacral ligament

anterior colporrhaphy

sacrospinous ligament fixation

paravaginal defect repairs