McCall Culdoplasty
McCall culdoplasty is a native-tissue vaginal apical suspension performed at the time of hysterectomy to prevent or treat vaginal vault prolapse and enterocele by incorporating the uterosacral ligaments into the closure of the vaginal cuff and obliterating the cul-de-sac. The original technique is performed vaginally at vaginal hysterectomy; an abdominal variant is described at the time of abdominal hysterectomy, with identical principles. Both share the same anatomy and intent — only the access differs.[1][2]
For the broader prolapse-repair atlas, see Prolapse Repair. For Moschcowitz / Halban variants targeting cul-de-sac obliteration without USL plication, see Moschcowitz Procedure and Halban Culdoplasty. For high USL suspension as a stand-alone apical operation, see Uterosacral Ligament Suspension.
Indications
- Apical support and enterocele prevention at the time of vaginal hysterectomy — the dominant use case; standard adjunct.[1][2]
- Apical support and enterocele prevention at the time of abdominal hysterectomy — same operation performed via the abdominal route.[2]
- Treatment of established vault prolapse or enterocele, in addition to prophylaxis.[1]
- Advanced (stage 3–4) and lesser degrees of uterovaginal prolapse — comparable success rates across severity in the Alas 2018 cohort.[3]
- Prophylactic application has also been described at mini-laparoscopic hysterectomy.[4]
Surgical Technique
Vaginal McCall (original)
- After the uterus is removed during vaginal hysterectomy, identify the uterosacral ligaments bilaterally.[1][2]
- Place one to two sutures incorporating the uterosacral ligaments into the closure of the peritoneum and upper vagina, suspending the cuff to the USLs and obliterating the cul-de-sac.[1]
- Anterior or posterior colporrhaphy is often performed concurrently as compartment-specific support requires.[1]
- Intraoperative cystoscopy is recommended to confirm bilateral ureteral patency before final closure.[8]
Abdominal McCall (variant)
The same anatomic principles applied at the end of an abdominal hysterectomy: USL plication with culdesac obliteration. Used to incorporate apical support into the same operative session as abdominal hysterectomy and prevent future enterocele formation.[2]
Modified McCall variants
| Variant | Description | Outcome highlight |
|---|---|---|
| Extraperitoneal high McCall (Zilberlicht 2021) | Sutures placed extraperitoneally, higher and more lateral into the uterosacral / cardinal ligaments; achieves higher cuff suspension[5] | — |
| Modified McCall with extended dissection (Ettore 2024) | Dissection of USLs to the ischial spines; ligaments shortened and attached to the vaginal apex and to both rectovaginal and vesicovaginal fasciae | Total vaginal length 8.3 vs 6.4 cm; higher patient satisfaction[6] |
| Double ligament suspension (DLS) (Parisi 2020) | Cuff suspended to both USLs and adnexal peduncles | Recurrence 5.9% vs 32.3% vs traditional McCall[7] |
Outcomes
McCall culdoplasty is a durable native-tissue apical operation across modern series.
| Endpoint | Result | Source |
|---|---|---|
| Objective vault support success | 97.1% at mean 2.8 yr | Bushra 2021 (n = 490)[8] |
| Subjective success | 94.1% | Bushra 2021[8] |
| Reoperation for vault recurrence | 1.0% | Bushra 2021[8] |
| Long-term vault prolapse recurrence | 1% at median 8.9 yr (2/200) | Schiavi 2018[9] |
| Advanced (POP-Q ≥ 3) success | 76.3% vs 68.5% for lesser stages (p = 0.36) | Alas 2018[3] |
| Anterior compartment recurrence (cystocele) | 6–18% — most common failure site | Alas 2018, Bushra 2021[3][8] |
A 2025 systematic review identified McCall culdoplasty among the techniques associated with lower recurrence for post-hysterectomy vault prolapse.[14]
Comparison With Other Apical Techniques
| Technique | Apical recurrence | Vaginal length | Notes |
|---|---|---|---|
| Traditional McCall | 1–2.6% | Shorter (6.1–6.4 cm) | Simplicity, speed; standard adjunct to vaginal hysterectomy[1][3] |
| Modified McCall | 2.5–14% | Longer (8.3 cm) | Better anatomy preservation[6] |
| Shull (high USLS) | 1–1.4% | ~8 mm longer | Comparable to modified McCall; preserves vaginal length and may favor sexual function[9][12] |
| Sacrospinous fixation | Variable | Maintained | Avoids ureteral risk; different axis[1] |
| Sacrocolpopexy | Lower (~38% composite failure at 5 yr in SUPeR vs ~53% NTR) | Maintained | Mesh-augmented; durability benchmark[13] |
McCall and Shull suspension show no clinically significant differences in anatomical outcomes, complication rates, or reoperation rates; Shull tends to preserve more vaginal length and may favor sexual function.[9][10][12]
Complications
| Complication | Rate / note |
|---|---|
| Ureteral kinking | ~2.9% — the principal clinically significant complication; typically requires intraoperative release of the McCall suture. Intraoperative cystoscopy is recommended to confirm patency[8] |
| Ureteral injury | 0–1%[10][11] |
| Bladder injury | Rare[11] |
| Vaginal shortening | Recognized limitation of the traditional technique vs Shull or extended-dissection modifications[6][7][9][12] |
| Anterior compartment (cystocele) recurrence | 6–18% — the most common failure site[3][8] |
Key Principles
- McCall culdoplasty is the standard apical adjunct at hysterectomy for prevention or treatment of vault prolapse and enterocele — applicable via either vaginal or abdominal access with identical principles.[1][2]
- Native tissue, durable — long-term vault prolapse recurrence ~1%; reoperation ~1%.[8][9]
- Comparable durability across primary and advanced uterovaginal prolapse (Alas 2018).[3]
- Anterior compartment recurrence (cystocele) is the dominant failure site — assess and address anterior support concurrently.[3][8]
- Intraoperative cystoscopy is mandatory — ureteral kinking ~2.9% is the principal clinically significant complication.[8]
- Modifications that extend USL dissection toward the ischial spines preserve more vaginal length and may improve recurrence (Ettore 2024, Parisi 2020 DLS).[6][7]
- Native tissue repair generally has higher composite failure than sacrocolpopexy at 5 yr (SUPeR ~53% vs ~38%) — frame counseling accordingly.[13]
References
1. Baessler K, Christmann-Schmid C, Haya N, et al. Surgery for women with pelvic organ prolapse with or without stress urinary incontinence. Cochrane Database Syst Rev. 2026;2:CD013108. doi:10.1002/14651858.CD013108.pub2.
2. Yeung E, Baessler K, Christmann-Schmid C, et al. Transvaginal mesh or grafts or native tissue repair for vaginal prolapse. Cochrane Database Syst Rev. 2024;3:CD012079. doi:10.1002/14651858.CD012079.pub2.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.
10. 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.
11. 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. 2025;317:114861. doi:10.1016/j.ejogrb.2025.114861.
12. 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.
13. 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.
14. 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.