A 69 year old patient presented for evaluation and treatment of uterovaginal prolapse. Examination demonstrated stage 3 vaginal prolapse with bilateral paravaginal defects. Options were discussed, she declined hysterectomy or use of any mesh. Treatment options were discussed and she elected to proceed with a uterosacral uterine suspension and bilateral paravaginal repair. She opted for a bilateral salpingo oophorectomy at the same time as her uterovaginal suspension. Some people feel traditional uterosacral uterine suspensions are more prone to recurrent anterior apical prolapse. There is anatomic evidence to support this concept, as MRI data demonstrates anterior apical vaginal support is provided by the uterosacral cardinal ligament complex. This anatomic diagram shows the uterosacral attachments to the anterior cervix and anterior vagina. Emphasis is added to show the anterior support given by the uterosacral cardinal ligament complex. Traditional uterosacral uterine suspension does not address this anterior component. We will demonstrate a novel modification to the traditional uterosacral uterine suspension. This modification may improve anterior vaginal prolapse by supporting the proximal anterior vagina. Following the bilateral salpingo oophorectomy, the uterus can be seen anteriorly and the rectum posteriorly. Starting on the patient's left side, the left ureter is visualized. The peritoneum overlying the left uterosacral ligament is then incised. The left uterosacral ligament is then isolated and identified. Attention is then turned to the patient's right side, where in like manner the ureter is visualized, followed by identification of the right uterosacral ligament. Attention is then turned to creating the bladder flap. The peritoneum overlying the lower uterine segment is tented up and incised. A Breisky retractor serves to delineate the vaginal fibromuscularis. Care is taken to safely mobilize the bladder. Attention is then returned to the uterosacral ligaments. Starting on the patient's left side, permanent suture is passed through the uterosacral ligament while staying medial to the ureter. The suture is then passed through the uterosacral ligament a second time for ensured security. The suture is then reefed through the posterior peritoneum to avoid the potential of internal bowel herniation. A large portion of the posterior cervix is then obtained. The suture is then passed from posterior to anterior through the cardinal ligament complex, exiting in the previously created bladder flap. Care is taken to pass medially to the uterine artery to avoid vascular compromise to the uterus. To aid visualization, the approximate location of the uterine arteries has been highlighted. The suture is also passed through the fibromuscularis of the proximal anterior vaginal wall. The suture then travels from anterior to posterior back through the uterosacral cardinal ligament complex, and the needle is removed from the operative field. The suture is held and attention is turned to the right uterosacral suture. Again, non-absorbable suture is passed through the uterosacral ligament in two separate passes. The suture is again reefed through the peritoneum, and a good purchase is obtained through the posterior cervix. On the right side, the suture is again passed from posterior to anterior through the uterosacral cardinal ligament complex, staying medial to the uterine vessels. The suture then exits through the previously created bladder flap. The suture incorporates the anterior proximal vagina on the right side. The suture then passes from anterior to posterior back through the cardinal ligament complex. Excercoporal knots are then used to placate the left uterosacral suture, providing support to the anterior and posterior vaginal apex. The suture is also tied and cut on the right. Ureteral peristalsis is visualized, and the vaginal apical support can be appreciated. This anatomic depiction shows the pubocervical fascia separated from the arcus tendineus pelvic fascia. This depiction visually demonstrates a completed paravaginal defect repair. The parietal peritoneum is incised, and the space of retzius is exposed. Here we see the obturator bundle exiting the obturator fossa. The obturator membrane and arcus tendineus pelvic fascia can also be seen. For reference, the bladder neck and urethra are in the center of the screen. A 2-0 non-absorbable suture is then passed through the arcus tendineus fascia pelvis, followed by two passes through the vagina. Suture is tied extracorporeally. The surgeon's finger is placed in the vagina to ensure a full thickness purchase while avoiding the vaginal epithelium. The right paravaginal defect is then repaired by re-approximating the arcus tendineus pelvic fascia to the vaginal apex with a series of sutures through the vaginal fibromuscularis. Extracorporeal knots are then tied. This view allows us to visualize the completed paravaginal repairs. We can compare this image to the previously viewed paravaginal schematic. This modification, which takes care to incorporate both traditional uterosacral bites as well as portions of the uterosacral cardinal ligament complex and anterior vaginal fibromuscularis, may add support to the anterior vagina, an area which has historically been vulnerable to recurrence.

surgical demonstration

uterosacral uterine suspension

anterior vaginal prolapse

support

paravaginal defects