Sacrospinous Hysteropexy
Sacrospinous hysteropexy is a vaginal, uterus-preserving apical suspension. Sutures attach the cervix to a sacrospinous ligament; it is not the same operation as sacrospinous ligament fixation for a post-hysterectomy vault, or as mesh-augmented hysteropexy.[1][10]
For the vault operation, see Sacrospinous Ligament Fixation. For the alternatives discussed below, see Manchester-Fothergill Procedure and Sacrohysteropexy.
Selection and counseling
Uterine preservation is guided by symptoms, examination, uterine or cervical assessment, reproductive plans and the patient's values. Abnormal bleeding, abnormal cervical screening, or suspected uterine or cervical disease require appropriate assessment before a uterus-preserving operation. Do not offer uterine preservation when preoperative endometrial histology is abnormal or a hereditary syndrome contraindicates retaining the uterus.[17][22] AUGS lists uterine or cervical malignancy and abnormal uterine bleeding without workup as absolute contraindications; familial cancer syndromes, cervical dysplasia and postmenopausal bleeding with a negative workup need individualized assessment.[18]
If the cervix is elongated and childbearing is complete, consider concomitant cervical amputation (trachelectomy) at the time of uterus-preserving surgery. AUGS grades this a recommendation (grade C) and defines elongation in its table as cervical length above 4 cm; elongation is associated with higher apical recurrence after preservation. The Manchester-Fothergill procedure is a distinct uterus-preserving operation that incorporates cervical amputation (see the SAM comparison below).[18]
The best directly applicable native-tissue randomized evidence is SAVE-U: women had stage 2 or greater uterine prolapse, did not wish to preserve fertility, and had no prior pelvic-floor or prolapse surgery.[10]
Conservative options include pelvic-floor therapy and a pessary; surgery is considered for bothersome symptoms in light of the patient's goals, not the POP-Q stage alone.[1] SAVE-U excluded women wishing to preserve fertility.[10]
Surgical Technique
The operation is performed in dorsal lithotomy under regional or general anesthesia. A posterior approach was used in SAVE-U; anterior and bilateral variants are also described.[5][6][9][10]
- Vaginal incision. Posterior vaginal-wall incision to expose the intended cervical or pararectal dissection.[5][10]
- Pararectal-space dissection. Vagina separated from rectovaginal fascia by sharp and blunt dissection until the pararectal space is entered.[5]
- Sacrospinous-ligament identification. The sacrospinous ligament (running from ischial spine to sacrum) is palpated and exposed; overlying connective tissue cleared to allow accurate suture placement.[5]
- Suture placement. SAVE-U used two permanent sutures in the right sacrospinous ligament under direct vision, at least 2 cm from the ischial spine. Pudendal structures lie near the spine, while S3 lies near the ligament's superior border and S3/S4 branches may pass through coccygeus or between the sacrospinous and sacrotuberous ligaments. The cited cadaver authors advise limiting needle penetration depth and avoiding entry or exit above the superior ligament border. Described suture-passing instruments include Capio, Deschamps carriers and Miya hooks; device-specific handling follows its instructions and the chosen approach.[7][8][10][12]
- Cervical fixation. Sutures passed through the posterior aspect of the cervix and tied, suspending the uterus to the sacrospinous ligament. Right-sided suture fixation was used in SAVE-U and SAM; bilateral anterior suture methods have also been described.[3][10][19] The bilateral anterior technique in reference 9 uses a polypropylene mesh sling and is a mesh-augmented variant.[9]
- Concomitant compartment repair. Perform anterior or posterior colporrhaphy, or both, as indicated; close the vaginal incision. If anterior colporrhaphy or another step with significant bladder or ureter injury risk is performed, use intraoperative cystoscopy to inspect the bladder and confirm ureteral efflux (ACOG/AUGS Level C).[1]
Anterior bilateral technique: Goldberg and Moss
Goldberg and Moss describe an anterior bilateral approach used at their center. A vertical anterior vaginal incision runs from the bladder neck to the apex just distal to the cervix; the paravesical plane is developed laterally to the descending pubic rami and cephalad to the cervix, then swept along the medial obturator surface toward the ischial spine. With the spine and sacrospinous-coccygeus complex palpated, they describe exposure sufficient for a finger and a push-and-catch suture device, placing a suture approximately 2 cm medial to the spine on each side. In their bilateral method, each suspension suture is anchored to the vaginal apex approximately 1 cm lateral to the cervical edge at 3 and 9 o'clock, elevating the cervix with the apex rather than suturing it directly, differing from the chapter's description of true unilateral cervical fixation and from the posterior SAVE-U technique above. The authors note that posterior bilateral fixation may restrict the anterior rectal wall, while their anterior approach permits bilateral vaginal fixation without that constraint; this reflects their operative judgment, not comparative trial evidence.[6][19] A 2026 retrospective cohort of 162 anterior and 154 posterior native-tissue approaches found earlier bulge symptoms after posterior repair after adjustment, but more minor 30-day complications after anterior repair (21.6% versus 7.1%).[23]
Kapoor's 2017 review and meta-analysis summarizes sacrospinous hysteropexy outcomes and study methods.[2]
Concomitant continence surgery remains a separate decision based on symptoms and assessment. For significant apical or anterior prolapse, evaluate for occult stress urinary incontinence with the prolapse reduced (ACOG/AUGS Level C). Discuss concomitant versus staged surgery: a midurethral sling probably reduces postoperative stress incontinence in women with occult stress incontinence, while its added adverse effects remain uncertain.[1][4]
Outcomes
SAVE-U: native-tissue hysteropexy versus vaginal hysterectomy plus USLS
In the five-year SAVE-U intention-to-treat analysis using last observation carried forward, apical failure with bothersome bulge symptoms or repeat apical-prolapse surgery was reported in 1/102 (1%) after hysteropexy and 8/102 (7.8%) after vaginal hysterectomy plus uterosacral suspension (difference −6.7 percentage points, 95% CI −12.8 to −0.7). The trial's composite success definition was no prolapse beyond the hymen, no bothersome bulge symptoms, and no repeat surgery or pessary for recurrence; in the intention-to-treat analysis using last observation carried forward, it was 89/102 (87%) versus 77/102 (76%), respectively. Time-to-event analyses did not show a between-group difference.[10] Anterior anatomical recurrence at POP-Q stage 2 or greater occurred in 41/102 (40%) after hysteropexy and 36/101 (36%) after hysterectomy/USLS, whereas anterior descent beyond the hymen occurred in 6/102 (6%) and 8/101 (8%).[10]
At ten-year SAVE-U follow-up, apical surgical failure occurred in 3/44 women (7%) after sacrospinous hysteropexy and 7/49 (14%) after vaginal hysterectomy with uterosacral suspension (difference −6.6 percentage points, 95% CI −19.9 to 6.7). Posterior anatomical failure (POP-Q stage 2 or greater) occurred in 5/43 (11.6%) after hysteropexy versus 24/46 (52.2%) after hysterectomy/USLS. Obstructive-micturition scores were higher after hysteropexy despite a median of zero in both groups (IQR 0–33.3 versus 0–0; p = 0.01); the clinical importance of that distributional difference is uncertain.[20]
LAVA: vaginal sacrospinous versus laparoscopic mesh sacrohysteropexy
In LAVA, 126 women with stage 2 or greater uterine prolapse and no prior pelvic-floor surgery were randomized. Laparoscopic mesh sacrohysteropexy met the noninferiority criterion against vaginal sacrospinous hysteropexy for symptomatic apical failure or retreatment at 12 months (one versus two events). Bothersome overactive bladder and fecal incontinence were more frequent after laparoscopy, and dyspareunia was more frequent after vaginal repair.[24]
Manchester comparison
The SAM trial compared native-tissue sacrospinous hysteropexy with Manchester repair in women with POP-Q point D at or proximal to −1 cm (D ≤ −1 cm). At two years, composite success (no prolapse beyond the hymen in any compartment, no bothersome bulge and no retreatment) was 172/197 (87.3%) after Manchester repair versus 151/196 (77.0%) after sacrospinous hysteropexy; the prespecified noninferiority criterion for sacrospinous hysteropexy was not met.[3]
Keep mesh evidence separate
SUPeR tested polypropylene Uphold LITE mesh sacrospinous hysteropexy against vaginal hysterectomy with bilateral USLS in postmenopausal women with prolapse beyond the hymen. The primary 3-year analysis did not show a significant difference: model-estimated 36-month failure was 24% after mesh hysteropexy versus 36% after hysterectomy (adjusted hazard ratio 0.61, 95% CI 0.37–1.02; p = 0.06), and mesh exposure occurred in 7/88 (8%) women.[27] The five-year report tabulated cumulative first-failure proportions of 29/79 (37%) versus 42/78 (54%) at the five-year visit.[11] The interval-censored five-year analysis, a secondary objective of the trial, favored mesh hysteropexy (adjusted hazard ratio 0.58, 95% CI 0.36–0.94), but proportional hazards were not met.[11] The specific mesh product is no longer marketed in the United States for transvaginal POP repair.[11]
In the 2026 ten-year SUPeR extension, composite failures accumulated in 35/88 women (40%) assigned to mesh hysteropexy and 46/87 (53%) assigned to hysterectomy plus USLS; only 112/175 analyzed participants entered the years 6–10 extension. The adjusted time-to-failure hazard ratio was 0.64 (95% CI 0.41–1.00; p = 0.05), and the expected additional mesh-durability gain during years 6–10 was not observed. No between-group difference in patient-reported outcomes or clinically important complications was demonstrated.[21]
Complications
Buttock / gluteal pain
Pain around the buttock or posterior thigh can follow sacrospinous dissection and suture placement. The sacral branches crossing the coccygeus–sacrospinous complex and pudendal structures are relevant anatomy; attributing every pain episode to one nerve is unreliable.[7][12]
Pain studies include vault SSLF and device-specific series. Their early pain frequencies depend on the operation and assessment time. Persistent, severe or neuropathic symptoms merit assessment for suture-related nerve irritation or entrapment. In SAM, 217 women were randomized to sacrospinous hysteropexy; among the 207 in the adverse-event table, 4 had severe or persistent buttock pain requiring treatment, and 3 underwent suture removal and another prolapse operation.[3] See the SSLF page for the shared anatomy and pain literature.[5][13][14]
Other complications and operative considerations
| Issue | Clinical context |
|---|---|
| Bleeding / hematoma | The pudendal and adjacent pelvic vessels make exposure, visualization and hemostasis important. |
| Nerve symptoms | New radiating pain, altered sensation or weakness require assessment; symptoms and anatomy guide management. |
| Recurrent prolapse | May occur in the anterior, posterior or apical compartment; distinguish examination recurrence, bothersome bulge and retreatment. |
| Urinary or bowel symptoms | Can persist or arise after combined repairs. |
| Mesh exposure | Applies to mesh-augmented variants such as SUPeR, not to a mesh-free native-tissue operation. |
These risks are described in the clinical and technical literature; their rates vary with the precise procedure and follow-up.[5][8][10][11]
Factors associated with failure
A secondary analysis of SUPeR explored baseline features including BMI and symptom duration in relation to composite failure.[15] These are prognostic associations in a trial of mesh hysteropexy versus hysterectomy/USLS.[15]
Advantages and trade-offs
| Domain | Practical consideration |
|---|---|
| Uterine preservation | Meets a preference to retain the uterus. |
| Operative route | Vaginal access avoids abdominal mesh dissection. The operation and concomitant repairs determine the total surgical burden. |
| Implant | Native-tissue sacrospinous hysteropexy uses sutures without a mesh implant; mesh-augmented variants are separate procedures. |
| Durability | Trial results depend on the comparator, eligibility, outcome definition and duration of follow-up. |
| Ongoing care | Continue appropriate cervical screening and investigate abnormal bleeding. |
These trade-offs are best discussed alongside the specific SAVE-U and SAM results above.[3][10][17] In a 2026 U.S. retrospective cohort, pooled sacrospinous and uterosacral native-tissue hysteropexy was associated with more prolapse reoperations after matching than hysterectomy with apical suspension (11.1% versus 6.5%; HR 1.77, 95% CI 1.27–2.45) and more retreatment, including pessary use (15.0% versus 9.6%; HR 1.63, 95% CI 1.24–2.14).[25]
Guideline context and follow-up
ACOG/AUGS guidance describes hysteropexy as a viable alternative to hysterectomy for uterine prolapse, although there is less available evidence on its safety and efficacy than for hysterectomy (Level B). The 2025 AUGS Clinical Practice Statement recommends offering uterine-preserving surgery to adults with a uterus considering prolapse surgery with apical suspension who have no previous or current uterine or cervical pathology and are at low or average risk of current or future pathology , after an individualized benefit-risk discussion.[18][1][16]
Continue appropriate cervical screening; investigate abnormal bleeding and reassess recurrent bulge, urinary, bowel or pain symptoms. NICE recommends a review around six months after prolapse surgery that includes a vaginal examination; if a mesh-augmented variant was used, check for exposure.[26] AUGS recommends counseling (grade B, recommendation) that later hysterectomy after uterine-preserving prolapse surgery is uncommon (<5%) and is most often for recurrent prolapse; reviewed cohorts reported 0%–6.6% over 1–7 years.[18] Counseling should include recurrence in any compartment, possible later treatment, and limited pregnancy evidence.[1][17][18]
Videos
References
1. Committee on Practice Bulletins—Gynecology and American Urogynecologic Society. Pelvic organ prolapse: ACOG Practice Bulletin, Number 214. Obstet Gynecol. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519.
2. Kapoor S, Sivanesan K, Robertson JA, Veerasingham M, Kapoor V. Sacrospinous hysteropexy: review and meta-analysis of outcomes. Int Urogynecol J. 2017;28(9):1285-1294. doi:10.1007/s00192-017-3291-x.
3. Enklaar RA, Schulten SFM, van Eijndhoven HWF, et al. Manchester procedure vs sacrospinous hysteropexy for treatment of uterine descent: a randomized clinical trial. JAMA. 2023;330(7):626-635. doi:10.1001/jama.2023.13140. Author-name correction: 10.1001/jama.2023.17655.
4. 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.
5. Goh JTW, Ganyaglo GYK. Sacrospinous fixation: review of relevant anatomy and surgical technique. Int J Gynaecol Obstet. 2023;162(3):842-846. doi:10.1002/ijgo.14751.
6. Plair A, Matthews C. Native tissue sacrospinous hysteropexy from an anterior approach. Int Urogynecol J. 2021;32(6):1591-1593. doi:10.1007/s00192-020-04601-0.
7. Giraudet G, Ruffolo AF, Lallemant M, Cosson M. The anatomy of the sacrospinous ligament: how to avoid complications related to the sacrospinous fixation procedure for treatment of pelvic organ prolapse. Int Urogynecol J. 2023;34(9):2329-2332. doi:10.1007/s00192-023-05496-3.
8. Amiri E, Bastani P, Mallah F, Mostafaei H, Salehi-Pourmehr H. Comparison of the complications rate of different suture-passing techniques at the time of sacrospinous ligament fixation: a systematic review and meta-analysis. Arch Gynecol Obstet. 2024;310(6):2791-2809. doi:10.1007/s00404-024-07788-5.
9. Naumann G, Börner C, Naumann LJ, Schröder S, Hüsch T. A novel bilateral anterior sacrospinous hysteropexy technique for apical pelvic organ prolapse repair via the vaginal route: a cohort study. Arch Gynecol Obstet. 2022;306(1):141-149. doi:10.1007/s00404-022-06486-4.
10. Schulten SFM, Detollenaere RJ, Stekelenburg J, et al. Sacrospinous hysteropexy versus vaginal hysterectomy with uterosacral ligament suspension in women with uterine prolapse stage 2 or higher: observational follow-up of a multicentre randomised trial. BMJ. 2019;366:l5149. doi:10.1136/bmj.l5149.
11. Nager CW, Visco AG, Richter HE, et al. Effect of sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral ligament suspension on treatment failure in women with uterovaginal prolapse: 5-year results of a randomized clinical trial. Am J Obstet Gynecol. 2021;225(2):153.e1-153.e31. doi:10.1016/j.ajog.2021.03.012.
12. Florian-Rodriguez ME, Hare A, Chin K, et al. 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. Ferrando CA, Walters MD. A randomized double-blind placebo-controlled trial on the effect of local analgesia on postoperative gluteal pain in patients undergoing sacrospinous ligament colpopexy. Am J Obstet Gynecol. 2018;218(6):599.e1-599.e8. doi:10.1016/j.ajog.2018.03.033.
14. Mowat A, Wong V, Goh J, et al. A descriptive study on the efficacy and complications of the Capio (Boston Scientific) suturing device for sacrospinous ligament fixation. Aust N Z J Obstet Gynaecol. 2018;58(1):119-124. doi:10.1111/ajo.12720.
15. Richter HE, Sridhar A, Nager CW, et al. Characteristics associated with composite surgical failure over 5 years of women in a randomized trial of sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral ligament suspension. Am J Obstet Gynecol. 2023;228(1):63.e1-63.e16. doi:10.1016/j.ajog.2022.07.048.
16. American College of Obstetricians and Gynecologists and American Urogynecologic Society. Pelvic organ prolapse (joint publication of ACOG Practice Bulletin No. 214). Female Pelvic Med Reconstr Surg. 2019;25(6):397-408. doi:10.1097/SPV.0000000000000794.
17. Meriwether KV, Antosh DD, Olivera CK, et al. Uterine preservation vs hysterectomy in pelvic organ prolapse surgery: a systematic review with meta-analysis and clinical practice guidelines. Am J Obstet Gynecol. 2018;219(2):129-146.e2. doi:10.1016/j.ajog.2018.01.018.
18. Chang OH, Carter Ramirez A, Edwards A, et al. The role of uterine preservation at the time of pelvic organ prolapse surgery. Urogynecology (Phila). 2025;31(5):482–495. doi:10.1097/SPV.0000000000001667. AUGS Clinical Practice Statement.
19. Goldberg RP, Moss NP. Uterine Preservation and Hysteropexy. In: Cardozo L, Staskin D, eds. Textbook of Female Urology and Urogynecology. Vol 2: Surgical Perspectives. 5th ed. CRC Press; 2023:945-957. doi:10.1201/9781003144243-95
20. Oegema K, Schulten SFM, Stekelenburg J, Kluivers KB, van Eijndhoven HWF. "Sacrospinous Hysteropexy Versus Vaginal Hysterectomy in Women with Uterine Prolapse: 10-year Follow-up of a Randomised Controlled Trial." Int Urogynecol J. 2026. doi:10.1007/s00192-026-06822-1
21. Nager CW, Visco AG, Richter HE, et al. "Sacrospinous Hysteropexy With Mesh vs Vaginal Hysterectomy for Treatment of Uterovaginal Prolapse: 10-Year Results of a Randomized Clinical Trial." JAMA Surg. 2026;161(8):764-774. doi:10.1001/jamasurg.2026.2263
22. Gupta A, Grimes CL, Badlani G, et al. "A Global Consensus Conference on Surgical Management of Primary Uterovaginal Prolapse and Lower Urinary Tract Dysfunction: Combining Evidence with Expert Opinion." Int Urogynecol J. 2026. doi:10.1007/s00192-026-06758-6.
23. Mezes CM, Coghlan MK, Meyer I, et al. "Recurrence After Anterior Versus Posterior Approach to Sacrospinous Hysteropexy." Urogynecology (Phila). 2026;32(3):279-288. doi:10.1097/SPV.0000000000001799.
24. van IJsselmuiden MN, van Oudheusden AMJ, Veen J, et al. "Hysteropexy in the treatment of uterine prolapse stage 2 or higher: laparoscopic sacrohysteropexy versus sacrospinous hysteropexy—a multicentre randomised controlled trial (LAVA trial)." BJOG. 2020;127(10):1284-1293. doi:10.1111/1471-0528.16242.
25. Akavian I, Reuveni-Salzman A, Zilberman T, Nitzan I, Shveiky D, Chill HH. "Long-Term Outcomes After Native Tissue Hysteropexy Compared With Hysterectomy for Treatment of Pelvic Organ Prolapse." Obstet Gynecol. 2026;148(3):365-372. doi:10.1097/AOG.0000000000006371.
26. National Institute for Health and Care Excellence. "Urinary incontinence and pelvic organ prolapse in women: management." NICE guideline NG123. 2019. Guideline.
27. Nager CW, Visco AG, Richter HE, et al. "Effect of Vaginal Mesh Hysteropexy vs Vaginal Hysterectomy With Uterosacral Ligament Suspension on Treatment Failure in Women With Uterovaginal Prolapse: A Randomized Clinical Trial." JAMA. 2019;322(11):1054–1065 (corrected February 2021). doi:10.1001/jama.2019.12812