The objective of this video is to demonstrate a minimally invasive vaginal approach to uterine sparing utero-sacral ligament suspension. Surgical management of pelvic organ prolapse is a growing field, with up to 19% of women undergoing surgery for prolapse or incontinence by age 85. Pelvic organ prolapse surgery has traditionally involved performing a hysterectomy at the time of repair for apical compartment prolapse. For years, the majority of gynecologic surgeons have counseled their patients on the benefits of hysterectomy at the time of utero-vaginal prolapse repair. Reasons for concomitant hysterectomy include historical patterns, better pelvic exposure, and the theoretical benefit of a decreased risk of uterine or cervical pathology in the future. There are many clinical reasons surgeons choose hysterectomy during prolapse repairs, including postmenopausal bleeding, cervical dysplasia, familial cancer syndromes with increased risk of endometrial cancer, tamoxifen therapy use, and other uterine abnormalities. In recent years, providers and patients have called the medical necessity of this practice into question. There is growing evidence that uterine conservation may be a viable option during the time of prolapse repair. Many women request uterine preservation at the time of pelvic organ prolapse surgery. Their reasons may include gender identity, sexual function, or a sense of self. Studies show up to 60% of women would opt for retaining their uterus at the time of prolapse surgery. Advantages of uterine sparing pelvic organ prolapse surgery include maintaining fertility, using a less invasive approach, reducing surgical time and blood loss, and avoiding a possible unnecessary procedure. There are other methods available for uterine sparing pelvic organ prolapse surgery. Here we will describe and demonstrate the uterine sparing uterosacral ligament suspension. There are limited studies on this procedure. One retrospective study compared uterine sparing uterosacral ligament suspension procedure to uterosacral ligament suspension at the time of vaginal hysterectomy and found similar objective results two years post-operatively. Certain instruments can facilitate the vaginal uterine sparing uterosacral ligament suspension. This is a 51-year-old G5-P4-015 with no significant past medical history or surgical history. She has symptomatic stage 3 anterior, stage 2 apical, and stage 2 posterior pelvic organ prolapse. This technique involves entering the peritoneal cavity through a posterior copotomy in a uterine sparing technique or entering the vaginal cuff in a post-hysterectomy patient. We then pack the bowel away with a moist laparotomy sponge. Sometimes packing is not necessary as the uterine fundus can hold the bowel out of the surgical field. A right angle retractor and a Breisky retractor are used for visualization of the uterosacral ligament. An Alice Adair is placed at the level of the distal uterosacral ligament and is placed on tension in order to identify the uterosacral ligament. A long curved Alice is placed on the uterosacral ligament at the level of the ischial spine. One delayed absorbable suture is placed through the uterosacral ligament at the level of the ischial spine. The second suture is permanent and is placed through the uterosacral ligament one centimeter above the ischial spine. The same procedure is performed on the contralateral side. Cystoscopy is performed after giving the patient 0.1 milliliters of sodium fluorescein IV to assure bilateral ureteral patency with and without tension on the uterosacral ligaments. If an anterior repair is indicated, it is performed prior to suspending the apex. The sutures are then attached to the intraperitoneal side of the posterior cervix. The sutures are then sequentially tied down, suspending the apex. If a posterior repair is indicated, it is completed in the usual fashion after suspending the apex. At the conclusion of the procedure, the vaginal length is maintained and the apex is well supported. The vaginal approach to uterine sparing uterosacral ligament suspension provides a minimally invasive, effective and novel method for pelvic organ prolapse repair in women who desire uterine preservation.

minimally invasive

vaginal approach

uterine sparing

utero-sacral ligament suspension

pelvic organ prolapse repair