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Michigan Four-Wall Sacrospinous Ligament Suspension

The Michigan Four-Wall Sacrospinous Ligament Suspension is a University of Michigan modification of sacrospinous ligament fixation (SSLF) developed by John O.L. DeLancey and colleagues. Through an apical incision, it attaches the anterior, posterior and two lateral walls of the vaginal apex directly to the sacrospinous ligament; a standard posterior-incision SSLF usually attaches the upper posterior vaginal wall. It was described for post-hysterectomy vaginal vault prolapse. Other compartment repairs may be added when indicated, but they are not the defining four-wall maneuver.[1][2][3]

For the underlying procedure, see Sacrospinous Ligament Fixation. For comparative apical-suspension framing, see Sacrocolpopexy and Uterosacral Ligament Suspension.

Conceptual Foundation​

The Michigan modification treats apical support by selecting attachment points on each wall of the vaginal apex rather than assuming the hysterectomy scar is the best new apex. Coexisting anterior or posterior defects may need separate repair.[1][2][3]

Surgical Technique​

The published Michigan technique uses the following sequence:[1][2][3]

  1. Apical incision. Identify and excise redundant vaginal apex when present, selecting where each wall can reach the ligament without excess tension. The new suspension point is often not the hysterectomy scar:
    • Apex was at the hysterectomy scar in only 9% of Kearney & DeLancey cases[1]
    • Posterior to the scar in 76%[1]
    • Anterior to it in 14%[1]
  2. Pararectal dissection. Approach the sacrospinous ligament through the apical incision. Maintain exposure during dissection and suture passage: injury to nearby venous plexuses or branches of the inferior gluteal artery can cause significant hemorrhage.[9] S3/S4 branches course near the ligament; a 14-cadaver study suggested that limiting needle depth and avoiding entry or exit above its superior border may reduce nerve entrapment and postoperative gluteal pain.[12] In the Larson report, a Deschamps carrier and looped delayed-absorbable PDS created four ligament suture strands.[2]
  3. Repair other defects as indicated. Perform anterior colporrhaphy, paravaginal repair, posterior repair or perineorrhaphy when separately indicated; none is automatically part of the four-wall fixation.[2][3] Address symptomatic or occult SUI as a separate decision: a 2026 Cochrane review found that a concomitant midurethral sling may reduce postoperative SUI in women with symptomatic SUI (low-certainty evidence) and probably reduces it in women with occult SUI (moderate-certainty evidence); a staged continence procedure remains feasible.[10]
  4. Four-wall apical attachment and closure. Bring the ligament sutures through the apical incision and tie them to elevate the newly configured vaginal apex, incorporating the four apical walls.[2] After reconstruction, perform cystoscopy to inspect the bladder and urethra and confirm bilateral ureteral efflux, as recommended by AUGS.[11]

In the 76-patient Kearney & DeLancey series, mean redundant vaginal length excised was 4.6 ± 2.5 cm, but seven women had no excision; mean measured vaginal length changed from 9.7 to 9.4 cm.[1]

Outcomes​

Long-Term Patient Satisfaction (Larson 2013)[2]​

This retrospective cohort identified 453 patients by billing code for operations from 1998 to 2003, all by urogynecology faculty. Of these, 392 were eligible for contact and 242/392 (62%) answered the satisfaction items at a mean 8.0 ± 1.7 years, on a mailed visual analog scale that was not validated for prolapse.[2] Anatomy was available for 162/242 responders from their most recent clinic or study examination (mean 4.3 years):[2]

OutcomeResult
Satisfied with surgical outcome90% of the 242 responders, not 90% of all 453 operated patients[2]
Highly satisfied ("completely" or "very")76%[2]
Moderately satisfied14%[2]
Would choose the surgery again89% (202/227 who answered)[2]
Vaginal support at or above the hymen (most recent exam available for 162/242 responders)86% at mixed follow-up; in the separate 70-person study examination at mean 8 years, 57/70 (81%) had this degree of support[2]
Support at or above the hymen at the clinic visit (mean 1.8 years)90% (127/141)[2]
Patients with prior failed prolapse surgery in cohort57%[2]
Patients with preop prolapse ≥ 4 cm beyond hymen56%[2]

Factors associated with being highly satisfied:

  • Lower postoperative PFDI-20 scores
  • Fewer concomitant pubovaginal slings (4% of the highly satisfied versus 19% of the less satisfied group in bivariate analysis; not significant in the multivariable model)[2]
  • Preoperative Baden-Walker grade 3 or 4 prolapse (women with these grades were more likely than those with grade 2 to be highly satisfied)
  • Women with grade 2 postoperative support (at the hymen) were as likely to be highly satisfied as those with grade 0–1 support; women with grade 3 or 4 postoperative prolapse were less likely to be

Anatomic failures were mostly anterior: the anterior wall lay below the hymen in 10.1% at the clinic visit and 17.1% at the eight-year study examination. Below-hymen apical and posterior support each occurred in under 1% at the clinic examination; at the mean eight-year study examination, below-hymen support occurred in 1.4% at the apex and 2.8% posteriorly.[2]

Suspension-Point Selection (Kearney & DeLancey 2003, n = 76)[1]​

  • New vaginal apex was posterior to the hysterectomy scar in 76% of cases[1]
  • Mean vaginal length preserved (9.7 to 9.4 cm, a 0.3 cm difference)
  • Excess vagina excised in 69/76 patients (91%); mean measured vaginal length changed from 9.7 to 9.4 cm[1]

Comparison with Standard SSLF​

FeatureMichigan Four-Wall SSLFStandard SSLF
Apical walls attachedAnterior, posterior and two lateral walls of the vaginal apexUpper posterior vaginal wall in the conventional description
Apex selectionFour apical-wall attachment points may differ from the hysterectomy scarPosterior vaginal-wall attachment in the conventional description
Excess vagina excisionWhen redundant; mean 4.6 cm in one 76-patient series, with none in seven women[1]Not the defining maneuver
Other compartment repairAdded when indicated, not intrinsic to four-wall fixationAlso added when indicated
Comparative effectivenessNo direct matched or randomized comparison with standard SSLFHistorical series use different populations, endpoints and follow-up

Advantages​

  • Four-wall apical support. The technique attaches all walls of the apex directly, and separate compartment repairs can be combined when indicated. Lower recurrence than standard SSLF has not been shown.[1][2]
  • Individualized apex selection. The surgeon chooses the suspension point on each wall rather than assuming the hysterectomy scar marks the apex.[1]
  • Excess-vagina management. Selective excision in the original series did not substantially shorten mean measured vaginal length.[1]
  • High reported long-term satisfaction. Ninety percent of 242 responders were satisfied at mean 8 years, and 62% of eligible patients responded.[2]
  • Native-tissue, no mesh. Avoids implant-specific mesh events.[2]
  • Anterior assessment. An anterior repair may be combined when indicated; the four-wall attachment alone is not proven to prevent anterior recurrence relative to standard SSLF.[2][4]

Limitations and Considerations​

  • No direct comparative RCT of Michigan four-wall versus standard SSLF, USLS or sacrocolpopexy is cited here; the 90% figure comes from responder follow-up.[2]
  • Retrospective design and responder bias. The 62% response rate and a difference between responders and non-responders in prior hysterectomy limit generalization.[2]
  • Single-center experience. The published data come primarily from the University of Michigan.[1][2]
  • Incomplete or anatomically mixed follow-up. Larson et al. had postoperative anatomic data for 162/242 responders, mostly from a prior clinic visit; only 70 returned for an approximately eight-year study examination.[2]
  • Reoperation context. In a 2026 Danish nationwide cohort of 1,374 women, SSLF had the highest overall reoperation rate (30.7%; aHR 2.14, 95% CI 1.26–3.62) and sacrocolpopexy the lowest apical reoperation rate (1.3%). The cohort did not isolate Michigan four-wall fixation; the prior SSLF review discusses broader options.[5]
  • Buttock pain and vaginal axis. In an OPTIMAL secondary analysis, new or worsening buttock pain at 4–6 weeks occurred in 10.5% after SSLF versus 4.6% after uterosacral suspension; the trial enrolled women having a concurrent retropubic midurethral sling, and Michigan four-wall fixation was not isolated.[13] Axis change after sacrospinous suspension is a technical consideration.[4][6]

Context Within Apical Suspension Options​

The OPTIMAL trial (Jelovsek 2018, JAMA) compared standard SSLF with uterosacral ligament suspension and found no significant difference at 2 or 5 years, with estimated surgical failure of 61.5% (uterosacral) and 70.3% (SSLF) at 5 years by a composite definition that included bothersome bulge symptoms.[7] Failure rates rose between 2 and 5 years while prolapse symptom scores remained improved, so counseling can convey both the higher long-term failure rate and the sustained symptom improvement.[7]

The ASPIRe trial (Menefee 2024) compared a native-tissue arm (SSLF in 110 of 134, uterosacral suspension in 24), transvaginal mesh and sacrocolpopexy after total hysterectomy. Adjusted 36-month composite failure incidence was 43%, 29% and 28% for native tissue, transvaginal mesh and sacrocolpopexy, respectively; sacrocolpopexy was superior to native-tissue repair at its prespecified threshold (aHR 0.57, 99% CI 0.33–0.98), while the mesh-versus-native comparison did not meet that threshold.[8] Its transvaginal mesh arm used Uphold LITE, and the FDA halted sales of transvaginal prolapse-mesh kits in the United States in 2019.[8]

Summary​

Michigan four-wall fixation is a specific apical attachment modification, not automatic repair of all vaginal compartments. The original cohorts show that the new apex often differs from the hysterectomy scar and report 90% satisfaction among 242/392 eligible responders at a mean eight years; only 70 had an examination at that interval.[1][2]

See Also​

Operative Video​

Michigan Four-Wall Sacrospinous Ligament Suspension
Supplementary operative video accompanying the Larson 2013 Michigan four-wall outcomes paper
Open source video

References​

1. Kearney R, DeLancey JO. "Selecting Suspension Points and Excising the Vagina During Michigan Four-Wall Sacrospinous Suspension." Obstet Gynecol. 2003;101(2):325-30. doi:10.1016/s0029-7844(02)02464-x

2. Larson KA, Smith T, Berger MB, et al. "Long-Term Patient Satisfaction With Michigan Four-Wall Sacrospinous Ligament Suspension for Prolapse." Obstet Gynecol. 2013;122(5):967-975. doi:10.1097/AOG.0b013e3182a7f0d5

3. Morgan DM, Larson K. "Uterosacral and Sacrospinous Ligament Suspension for Restoration of Apical Vaginal Support." Clin Obstet Gynecol. 2010;53(1):72-85. doi:10.1097/GRF.0b013e3181cf2d51

4. Paraiso MF, Ballard LA, Walters MD, Lee JC, Mitchinson AR. "Pelvic Support Defects and Visceral and Sexual Function in Women Treated With Sacrospinous Ligament Suspension and Pelvic Reconstruction." Am J Obstet Gynecol. 1996;175(6):1423-30. doi:10.1016/s0002-9378(96)70085-6

5. Teilmann-Jørgensen D, Gommesen D, Wu C, Klarskov N, Rudnicki M. "Long-Term Risk of Reoperation After Vaginal Vault Suspension by Surgical Technique: A Nationwide Cohort Study." BJOG. 2026;133(5):1046-1055. doi:10.1111/1471-0528.70138

6. Goldberg RP, Tomezsko JE, Winkler HA, et al. "Anterior or Posterior Sacrospinous Vaginal Vault Suspension: Long-Term Anatomic and Functional Evaluation." Obstet Gynecol. 2001;98(2):199-204. doi:10.1016/s0029-7844(01)01446-6

7. Jelovsek JE, Barber MD, Brubaker L, et al. "Effect of Uterosacral Ligament Suspension vs Sacrospinous Ligament Fixation With or Without Perioperative Behavioral Therapy for Pelvic Organ Vaginal Prolapse on Surgical Outcomes and Prolapse Symptoms at 5 Years in the OPTIMAL Randomized Clinical Trial." JAMA. 2018;319(15):1554-1565. doi:10.1001/jama.2018.2827

8. 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

9. Pahwa AK, Arya LA, Andy UU. "Management of arterial and venous hemorrhage during sacrospinous ligament fixation: cases and review of the literature." Int Urogynecol J. 2016;27(3):387-391. doi:10.1007/s00192-015-2818-2

10. 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(2):CD013108. doi:10.1002/14651858.CD013108.pub2

11. Cohen SA, Carberry CL, Smilen SW. "American Urogynecologic Society Consensus Statement: Cystoscopy at the Time of Prolapse Repair." Female Pelvic Med Reconstr Surg. 2018;24(4):258-259. doi:10.1097/SPV.0000000000000529

12. Florian-Rodriguez ME, Hare A, Chin K, Phelan JN, Ripperda CM, Corton MM. "Inferior gluteal and other nerves associated with sacrospinous ligament: a cadaver study." Am J Obstet Gynecol. 2016;215(5):646.e1-646.e6. doi:10.1016/j.ajog.2016.06.025

13. Barber MD, Brubaker L, Nygaard I, et al. "Pain and activity after vaginal reconstructive surgery for pelvic organ prolapse and stress urinary incontinence." Am J Obstet Gynecol. 2019;221(3):233.e1-233.e16. doi:10.1016/j.ajog.2019.06.004