McCall Culdoplasty
McCall culdoplasty is a native-tissue apical-support and cul-de-sac-obliteration technique most often performed at vaginal hysterectomy for uterovaginal prolapse. Sutures incorporate the uterosacral support complex, posterior vaginal cuff and cul-de-sac peritoneum; technique descriptions differ in the number and course of internal and external sutures.[13]
For the broader prolapse-repair atlas, see Prolapse Repair. For other cul-de-sac closure techniques, see Moschcowitz Procedure and Halban Culdoplasty. In the randomized comparison, the vaginal Moschcowitz-type procedure also approximated the uterosacral-cardinal complex in the midline; McCall additionally elevated the posterior apex.[14] For high USL suspension as a stand-alone apical operation, see Uterosacral Ligament Suspension. For McCall's 1957 description, see the History of Prolapse Surgery & Urogynecology.
Indications
- Apical support and enterocele prevention or repair during vaginal hysterectomy for uterovaginal prolapse. The 2025 ISGE guideline recommends McCall culdoplasty for stage II uterovaginal prolapse (Grade 1B); for stage III or IV prolapse, it recommends considering sacrospinous fixation, sacrocolpopexy or alternatives such as pectopexy (Grade 1B).[17] The original technique and most McCall outcome series concern vaginal hysterectomy.[6][13][14]
- Advanced uterovaginal prolapse. Evidence conflicts. In one retrospective cohort, overall success did not differ significantly between 38 women with exteriorized advanced prolapse and 273 with lesser prolapse (76.3% versus 68.5%), but anterior failure was more frequent in the advanced group (18.4% versus 6.2%).[1] In a separate 68-patient randomized trial of stage III or greater uterine prolapse treated with vaginal hysterectomy, prolapse recurrence occurred in 12/35 after McCall versus 3/33 after vaginally assisted laparoscopic sacrocolpopexy at mean follow-up of approximately 26 months.[16] The comparator and small sample limit transfer to other sacrocolpopexy routes or McCall modifications.[16]
- Support at minimally invasive hysterectomy has been described with vaginal-approach McCall after mini-laparoscopic hysterectomy and with a distinct laparoscopic uterosacral-plication technique.[2][13]
- For established post-hysterectomy vault prolapse, select and counsel among dedicated apical repairs; see Uterosacral Ligament Suspension and the Prolapse Repair atlas.
Surgical Technique
Vaginal McCall at hysterectomy
- After vaginal hysterectomy, identify the uterosacral support and posterior cuff bilaterally and assess the enterocele or cul-de-sac defect.[13]
- Place internal McCall plication sutures through the pararectal or uterosacral support across the cul-de-sac; a described external suture also incorporates posterior vaginal wall and peritoneum. The operative series cited here (Niblock) used one or two internal sutures of 0 monofilament absorbable material, each passed deep into the left pararectal fascia, across the front of the sigmoid colon and deep into the right pararectal fascia, plus a more cephalad external suture. Suture counts vary between descriptions.[13]
- Tie the suspension or cul-de-sac closure without excessive cuff shortening or ureteral traction. Address anterior or posterior wall defects with compartment-specific repair when indicated; many outcome cohorts included these concomitant operations.[6][13]
- Ureteral patency. Check bilateral ureteral patency with intraoperative cystoscopy after suspension sutures are tied. A compromised efflux pattern warrants assessment and, when suture-related, release or repositioning before completion. Both a published McCall series and the 490-case modified-McCall cohort detected intraoperative ureteral obstruction or kinking.[6][13]
Abdominal McCall (variant)
At abdominal or laparoscopic hysterectomy, the uterosacral-cardinal support can be incorporated into cuff closure or plicated for apical support. Wall described a modified McCall culdoplasty during abdominal hysterectomy.[18] In a 50-patient pilot randomized trial at total laparoscopic hysterectomy for benign indications, adding McCall to standard cuff closure showed no detected difference in vaginal apex position at 12 months.[19] Gencdal performed McCall through the vaginal route after mini-laparoscopic hysterectomy, and Niblock compared vaginal McCall with laparoscopic uterosacral plication.[2][13] Exposure, suture path and outcome evidence differ; specify the actual route-adapted operation in the operative record.
Modified McCall variants
| Variant | Description | Reported outcome |
|---|---|---|
| Extraperitoneal high McCall (Zilberlicht 2021) | Sutures placed extraperitoneally, higher and more laterally into the uterosacral-cardinal complex to resuspend the cuff; the reported operation also closed large levator-plate hiatal defects when present.[3] | In a longitudinal series of 176 women with stage 3–4 uterovaginal prolapse, any-compartment stage II or greater recurrence occurred in 25/176 (14%) at mean 19.4 months; 6/176 (3%) underwent another operation, all for enterocele recurrence[3] |
Karmakar and Dwyer describe their exposure and fixation sequence for this extraperitoneal high variant at vaginal hysterectomy: after identifying and ligating the uterosacral/cardinal complex, it is dissected free laterally to its mid-portion to allow higher suture placement, while a Breisky-Navratil retractor lateralizes the bladder and ureters out of the operative field. A 1-0 Vicryl suture passes through the posterior vaginal wall and the mid-portion of the uterosacral/cardinal complex on both sides and is tied in the midline; a second pass through the vaginal vault re-supports and closes it, and the last 2-0 PDS suture from the anterior repair ties the complex at the vault to suspend the anterior and apical compartments. This sequence is specific to the chapter authors' modification.[15]
| Variant | Description | Reported outcome |
|---|---|---|
| Modified McCall with extended dissection (Ettore 2024) | USLs dissected to the ischial spines and shortened; at that level, 0 PDS sutures transfix each USL medial to lateral (the authors’ stated precaution against ureteral injury). The Douglas pouch is closed high, and suspension sutures attach to the vaginal apex and duplicated anterior and posterior fasciae.[4] | In a prospective observational comparison, mean vaginal length 8.3 vs 6.4 cm at 12 months; any-compartment stage II or greater recurrence was 2/79 (2.5%) vs 5/75 (6.7%) among patients with complete 12-month follow-up (85 modified vs 86 traditional initially enrolled; the comparison group was an earlier cohort), described by the authors as a tendency toward lower recurrence[4] |
| Double ligament suspension (DLS) (Parisi 2020) | Cuff suspended to both USLs and adnexal peduncles | In a retrospective 34-versus-34 comparison, stage ≥II recurrence was 2/34 with DLS vs 11/34 with traditional McCall at mean 22–23 months; further treatment was 1/34 vs 2/34[5] |
Outcomes
Several observational cohorts report low apical failure after McCall techniques; success definitions, concomitant repairs and follow-up differ.
| Endpoint | Result | Source |
|---|---|---|
| Posterior enterocele after vaginal hysterectomy | 2/32 McCall-type, 10/33 vaginal Moschcowitz-type, 13/33 peritoneal closure only at three years | Cruikshank/Kovac 1999 randomized comparison of these three prophylactic closures[14] |
| Objective vault support / subjective success | 97.1% / 94.1% at mean 2.8 years | Bushra 2021; single-surgeon, retrospective modified-McCall cohort, n = 490[6] |
| Reoperation for vault recurrence | 1.0% | Same Bushra cohort; distinct from anatomic or composite recurrence[6] |
| Vault prolapse after hysterectomy | 2/200 at median 8.9 years | Schiavi 2018 retrospective modified-McCall group; Shull group also 2/214[7] |
| Overall success in advanced versus lesser prolapse | 76.3% of 38 vs 68.5% of 273 at ≥1 year, p = 0.3553 | Alas 2018 retrospective cohort[1] |
| Anterior-compartment failure in advanced versus lesser prolapse | 18.4% vs 6.2% at ≥1 year | Same Alas cohort[1] |
A 2025 systematic review discussed McCall among preventive approaches, but its four included studies (497 women) were heterogeneous and summarized qualitatively.[12]
Comparison With Other Apical Techniques
| Comparison | What the cited study observed | Counseling limit |
|---|---|---|
| Modified McCall vs Shull suspension | Schiavi's retrospective groups had 2/200 vs 2/214 vault prolapses at median 8.9 years; vaginal length shortened more with McCall, while sexual-function scores improved more with Shull.[7] | — |
| Modified McCall vs Shull suspension | Spelzini's retrospective comparison reported roughly 8 mm longer total vaginal length with Shull and no statistically detected anatomic-outcome difference.[10] | Surgeon selection by age/sexual activity limits causal inference. |
| McCall vs high USLS (Shull) | Novara's retrospective 155 McCall / 69 Shull cohort recorded objective cuff recurrence 4/155 vs 1/69 at median 15 vs 13 months.[8] | Surgeon familiarity determined technique. |
| Traditional McCall vs double-ligament modification | Parisi found stage ≥II recurrence 11/34 vs 2/34 and longer vaginal length with DLS.[5] | Small, nonrandomized, ~2-year comparison. |
| Vaginal McCall vs laparoscopic uterosacral plication | Niblock's retrospective comparison (two surgeons) recorded post-hysterectomy vault prolapse in 0/70 after vaginal hysterectomy with McCall vs 12/73 after total laparoscopic hysterectomy with uterosacral plication.[13] | Different hysterectomy routes and plication technique; mean follow-up 36 versus 41 months; selection is uncontrolled. |
| Vaginal McCall vs vNOTES high USLS | Arkan reported 6/46 vs 1/46 cuff prolapses at 12 months and mean length 8.2 vs 9.0 cm.[9] | Small prospective cohort; access, visualization and apical technique differ together. |
For a post-hysterectomy vault comparison, the ASPIRe trial studied native-tissue repair (mostly sacrospinous fixation, some USLS) against sacrocolpopexy and transvaginal mesh; it did not test McCall culdoplasty. Its modeled 36-month composite failure was 43% with native repair and 28% with sacrocolpopexy.[11] That endpoint includes anatomy and symptoms or retreatment.[11]
Complications
| Complication | Rate / note |
|---|---|
| Ureteral kinking/obstruction | 2.9% in Bushra's 490 modified-McCall operations; one intraoperative suture release after cystoscopic obstruction in a separate 70-case McCall series. Check patency after suspension sutures.[6][13] |
| Ureteral or bladder injury | Arkan's 46-patient McCall arm reported one ureteral and one bladder injury; this is a small selected cohort, not a general 0–1% McCall risk estimate.[9] |
| Postoperative urinary retention | Niblock reported 6/70 after vaginal hysterectomy with McCall, each managed with intermittent self-catheterization. Most patients also underwent wall repair.[13] |
| Postoperative hemorrhage | In the same cohort, 2/70 returned to theatre for laparotomy within 24 hours for intra-abdominal bleeding.[13] |
| Vaginal shortening / sexual function | Greater length reduction with modified McCall than Shull in Schiavi's retrospective comparison; procedure selection and concomitant repairs limit attribution.[7][10] |
| Other-compartment recurrence | Alas found more anterior failure in the advanced subgroup; posterior and anterior defects warrant separate assessment.[1] |
Key Principles
- The best-described McCall use is apical support and cul-de-sac closure at vaginal hysterectomy.[2][13] Describe abdominal or laparoscopic adaptations by their actual suture path.[2][13]
- Check bilateral ureteral patency after suspension sutures; published series document suture-related obstruction detected intraoperatively.[6][13]
- Modified-McCall cohorts report favorable vault results alongside anterior or posterior failure.[1][6]
- Extended-dissection and double-ligament variants may preserve more vaginal length or improve anatomy in their cohorts.[4][5]
Videos
References
1. Alas A, Chandrasekaran N, Devakumar H, et al. Advanced uterovaginal prolapse: is vaginal hysterectomy with McCall culdoplasty as effective as in lesser degrees of prolapse? Int Urogynecol J. 2018;29(1):139-144. doi:10.1007/s00192-017-3436-y.
2. Gencdal S, Demirel E, Soyman Z, Kelekci S. Prophylactic McCall culdoplasty by a vaginal approach during mini-laparoscopic hysterectomy. Biomed Res Int. 2019;2019:8047924. doi:10.1155/2019/8047924.
3. Zilberlicht A, Dwyer PL, Karmakar D, Carswell F, Schierlitz L. Extraperitoneal high vaginal cuff suspension at the time of vaginal hysterectomy for advanced uterovaginal prolapse: results of a modified McCall technique from a longitudinal clinical study. Aust N Z J Obstet Gynaecol. 2021;61(2):258-262. doi:10.1111/ajo.13288.
4. Ettore G, Torrisi G, Grimaldi RL, Ettore C. A modified McCall culdoplasty in pelvic organ prolapse surgery: anatomical and functional outcomes. Int Urogynecol J. 2024;35(12):2341-2348. doi:10.1007/s00192-024-05886-1.
5. Parisi S, Novelli A, Olearo E, Basile A, Puppo A. Traditional McCall culdoplasty compared to a modified McCall technique with double ligament suspension: anatomical and clinical outcomes. Int Urogynecol J. 2020;31(10):2147-2153. doi:10.1007/s00192-020-04403-4.
6. Bushra M, Anglim B, Al-Janabi A, Lovatsis D, Alarab M. Long-term experience with modified McCall culdoplasty in women undergoing vaginal hysterectomy for pelvic organ prolapse. J Obstet Gynaecol Can. 2021;43(10):1129-1135. doi:10.1016/j.jogc.2021.04.012.
7. Schiavi MC, Savone D, Di Mascio D, et al. Long-term experience of vaginal vault prolapse prevention at hysterectomy time by modified McCall culdoplasty or Shull suspension: clinical, sexual and quality of life assessment after surgical intervention. Eur J Obstet Gynecol Reprod Biol. 2018;223:113-118. doi:10.1016/j.ejogrb.2018.02.025.
8. Novara L, Sgro LG, Pecchio S, et al. Transvaginal high uterosacral ligament suspension: an alternative to McCall culdoplasty in the treatment of pelvic organ prolapse. Eur J Obstet Gynecol Reprod Biol. 2019;240:278-281. doi:10.1016/j.ejogrb.2019.07.007.
9. Arkan K, Cavusoglu Colak G, Bırol Ilter P, Akdenız E, Akgol S. Effectiveness and comparison of vNOTES-assisted uterosacral ligament suspension and vaginal McCall culdoplasty in apical prolapse. Eur J Obstet Gynecol Reprod Biol. 2026;317:114861. Epub 2025 Nov 28. doi:10.1016/j.ejogrb.2025.114861.
10. Spelzini F, Frigerio M, Manodoro S, et al. Modified McCall culdoplasty versus Shull suspension in pelvic prolapse primary repair: a retrospective study. Int Urogynecol J. 2017;28(1):65-71. doi:10.1007/s00192-016-3016-6.
11. Menefee SA, Richter HE, Myers D, et al. Apical suspension repair for vaginal vault prolapse: a randomized clinical trial. JAMA Surg. 2024;159(8):845-855. doi:10.1001/jamasurg.2024.1206.
12. Silva AKS, Bonfim MB, Ferreira LL, Miguel L, Hermes TA. Surgical approaches to prevent vaginal vault prolapse after hysterectomy, and risk factors for vaginal vault prolapse. Eur J Obstet Gynecol Reprod Biol. 2025;314:114684. doi:10.1016/j.ejogrb.2025.114684.
13. Niblock K, Bailie E, McCracken G, Johnston K. Vaginal McCall culdoplasty versus laparoscopic uterosacral plication to prophylactically address vaginal vault prolapse. Gynecol Surg. 2017;14:3. doi:10.1186/s10397-017-1006-4.
14. Cruikshank SH, Kovac SR. Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele. Am J Obstet Gynecol. 1999;180:859-865. doi:10.1016/S0002-9378(99)70656-3.
15. Karmakar D, Dwyer PL. Vaginal approach to apical suspension. In: Cardozo L, Staskin D, eds. Textbook of Female Urology and Urogynecology. Vol 2: Surgical Perspectives. 5th ed. CRC Press; 2023:925-929. doi:10.1201/9781003144243-93
16. Karadag B, Mulayim B, Karadag C, et al. "McCall culdoplasty vs. vaginally assisted laparoscopic sacrocolpopexy in the treatment of advanced uterine prolapse: A randomized controlled study." Taiwan J Obstet Gynecol. 2023;62(2):325-329. doi:10.1016/j.tjog.2022.11.013
17. Chrysostomou A, Noé G, Linnamägi A, van Herendael BJ, Djokovic D. "Evidence-based recommendations of the International Society for Gynecologic Endoscopy (ISGE) for the prevention of apical prolapse following vaginal hysterectomy for prolapsed and non-prolapsed uterus." Eur J Obstet Gynecol Reprod Biol. 2025;312:114559. doi:10.1016/j.ejogrb.2025.114559
18. Wall LL. "A technique for modified McCall culdeplasty at the time of abdominal hysterectomy." J Am Coll Surg. 1994;178(5):507-509. PMID:8167889
19. Till SR, Hobbs KA, Moulder JK, Steege JF, Siedhoff MT. "McCall Culdoplasty during Total Laparoscopic Hysterectomy: A Pilot Randomized Controlled Trial." J Minim Invasive Gynecol. 2018;25(4):670-678. doi:10.1016/j.jmig.2017.10.036