We present a case of a sacrospinous ligament hysteropexy in the setting of complete procedentia. Our patient is a 63-year-old para 4 with a past medical history significant for hepatitis C, tobacco use, and current IV drug use, who presented to our clinic with symptomatic stage 4 pelvic organ prolapse and right-sided hydronephrosis. She had previously failed multiple attempts at conservative management with Gjelhorn pessary, with resultant 3 centimeter ulceration along the vaginal sidewall, and sought definitive surgical repair. Traditionally, pelvic organ prolapse has been treated with a hysterectomy and concomitant vaginal vault suspension. Approximately 70,000 hysterectomies performed annually in the United States are due to pelvic organ prolapse, making it the third most common indication for benign hysterectomy. Uterine sparing techniques, such as copal cliasis or hysteropexy, are alternative therapeutic interventions. Although most efficacious, a copal cliasis was not a good option for this patient, as she was sexually active. Given her regular IV drug and daily tobacco use, the complication profile associated with abdominal or vaginal mesh was unacceptably high, ruling these options out as well. Consideration was also given to a traditional vaginal hysterectomy with apical suspensory procedure, but given that she did not have any uterine abnormalities appreciated on vaginal sonography, an extraperitoneal suspension was deemed to be less invasive, affording a more beneficial risk-benefit profile for the patient. The vaginal approach to hysterepexy dates back to the 1880s, with a sacrospinous hysterepexy approach being the most studied uterine sparing vaginal procedure. Multiple studies have shown comparable success for apical compartment support with sacrospinous hysterepexy as compared to total vaginal hysterectomy with utero-sacral ligament suspension. Advantages of hysterepexy include uterine preservation, decreased blood loss, and shorter operative time. After induction of anesthesia and positioning in neutral dorsal lithotomy, the approximate location of the ureters and uterine arteries were outlined with a marking pen. The prolapse was then reduced with the cervix in normal anatomic position, and the right ischial spine was palpated. A two-centimeter incision was created at the cervical vaginal margin, and the vaginal epithelium was incised in the midline towards the urethrovesical junction. The dissection was carried three centimeters laterally on each side until intact fibromuscularis was identified. Two layers of interrupted sutures were placed in the midline to reduce the anterior defect. The redundant vaginal epithelium was then trimmed, and this incision was partially closed. The posterior vaginal epithelium was then incised in the midline, and the rectovaginal space was developed by dissecting laterally towards the sulci and apically to within two centimeters of the cervix. The right perirectal space was then developed with blunt finger dissection just above the levator complex towards the ischial spine. A digital rectal exam was performed to help sweep the rectosigmoid immediately, and confirmed that the dissection was sufficient for placement of a sacrospinous stitch. Two proline sutures were then placed two and three finger breaths from the ischial spine with the use of a suture capture device. Good capture of the ligament was noted from both. The proline sutures were then passed through the posterior aspect of the cervix above the cervical vaginal margin. These sutures were then tied to create a point of fixation and ultimately a pulley stitch to elevate the cervix toward the right sacrospinous ligament. Inspection of the posterior vaginal wall revealed very little redundancy, as most of her defect was apical. The vaginal epithelium was closed with absorbable suture with vertical mattress apposition at the perineal body to re-approximate and close the outlet. At the two-week post-operative visit, the patient was healing well, with plans to follow up at six weeks post-op. The majority of literature available suggests that a sacrospinous hystereopexy compared to a vaginal hysterectomy with utero-sacral ligament suspension have a relatively similar anatomical outcome profile. In summary, a sacrospinous hystereopexy offers the advantage of uterine preservation, decreased blood loss, and a shorter operating time. With judicious patient selection and thorough counseling, this can be a viable alternative technique for uterine prolapse. Further research is needed to describe long-term efficacy. Thank you.

sacrospinous ligament hysteropexy

pelvic organ prolapse

hydronephrosis

uterine preservation

sacrospinous hysterepexy