SGS Meeting Papers www. AJOG.

org

Uterosacral ligament suspension sutures: Anatomic

relationships in unembalmed female cadavers
Cecilia K. Wieslander, MD; Shayzreen M. Roshanravan, MD; Clifford Y. Wai, MD; Joseph I. Schaffer, MD;
Marlene M. Corton, MD

OBJECTIVE: The objective of the study was to characterize anatomic
relationships of uterosacral ligament suspension (USLS) sutures.
STUDY DESIGN: The relationship of USLS sutures to the ureters, rectal
lumen, and sidewall neurovascular structures was examined in 15 un-
embalmed female cadavers.
RESULTS: The mean distance of the proximal sutures to the ureters
and rectal lumen was 14 mm (range, 0-33) and 10 mm (range, 0-33),
respectively. The mean distance of the distal sutures to the ureters was
14 mm (range, 4-33) and to the rectal lumen 13 mm (range, 3-23).
Right sutures were noted at the level of S1 in 37.5%, S2 in 37.5%, and
S3 in 25% of specimens. Left sutures were noted at the level of S1 in
50%, S2 in 29.2%, and S3 in 20.8% of cadavers. Of 48 sutures
passed, 1 entrapped the S3 nerve. Sutures perforated the pelvic side-
wall vessels in 4.1% of specimens.
CONCLUSION: USLS sutures can directly injure the ureters, rectum,
and neurovascular structures in the pelvic walls.
Key words: anatomy, nerve injury, rectal injury, ureteral injury,
uterosacral ligament

Cite this article as: Wieslander CK, Roshanravan SM, Wai CY, et al. Uterosacral ligament suspension sutures: Anatomic relationships in unembalmed female
cadavers. Am J Obstet Gynecol 2007;197:672.e1-672.e6.

T he uterosacral ligament vaginal

vault suspension (USLS) is a com-
mon vaginal surgical procedure used to
restore support of the vaginal apex and
to correct apical enteroceles.1,2 The
USLS fixates the anterior and posterior
walls of the vaginal apex to the uterosa-
cral ligaments at or above the level of the
ischial spines.1 Even though only short-
term follow-up results are available,
many advocate this over the more tradi-
tional vaginal procedures for the suspen-
sion of the vaginal apex.2,3 In contrast to
the posterior and lateral deflection of the
vaginal axis noted with the sacrospinous
ligament fixation, this procedure aligns
the vagina in its normal axis and is there-
From the Division of Urogynecology and
Reconstructive Surgery, Department of
Obstetrics and Gynecology, University of
Texas Southwestern Medical Center, Dallas,
TX.
Presented at the 33rd Annual Scientific
Meeting of the Society of Gynecologic
Surgeons, Orlando, FL, April 12-14, 2007.
Received Jan. 17, 2007; revised May 16,
2007; accepted Aug. 27, 2007.
Reprints not available from the authors.
0002-9378/$32.00
© 2007 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2007.08.065
fore believed to yield more anatomic re-
sults.2 Attachment of the vaginal vault to
the uterosacral ligaments (USLs) at or
above the level of the ischial spine is also
thought to provide greater vaginal depth
than suspension of the vault anterior to
the ischial spine as done with the iliococ-
cygeus fixation.2
The USLs are condensations of fibro-
elastic and smooth muscle tissue con-
taining autonomic nerves. They repre-
sent the lateral boundaries of the
posterior cul-de-sac and are positioned
lateral to the rectum and medial to the
ureters (Figure 1). Whereas they attach
distally to the cervix and/or upper
vagina,4-6 their proximal site of attach-
ment(s) remains controversial. Ana-
tomic dissection studies have noted at-
tachments of the ligament to the
presacral fascia and the first 4 sacral ver-
tebrae.4,5 Yet no direct attachments of
the USL to the sacrum were noted in a
study of plastinated cross-sections.7 A
recent magnetic resonance imaging
analysis of 61 USLs showed that the liga-
ment overlaid the coccygeus muscle–sa-
crospinous ligament complex in the ma-
jority of cases and that only 7% of the
insertion points were to the sacrum.6
Ureteral compromise is a well-de-
scribed complication of USLS, with re-
ported injury rates ranging between
0.24-11%.1-3,8,9 Other findings, such as
perineal, buttock, and lower extremity
pain and neuropathy, have recently been
reported in patients following USLS pro-
cedures.10-12 Although several anatomic
studies have evaluated the relationship
of the USL to the ureters,5,13,14 only 1 has
evaluated the relationship of the liga-
ments to the sacral nerves.11 The objec-
tive of this study was to examine the an-
atomic relationships of the USLS sutures
to the pelvic sidewall neurovascular
structures, ureter, and rectum and to
correlate these findings to clinical
symptoms.
M ATERIALS AND M ETHODS
The cadavers were obtained from the
Willed Body Program at the University
of Texas Southwestern Medical Center
in Dallas. This study was considered ex-
empt by the University of Texas South-
western Medical Center Institutional Re-
view Board in accordance with the Code
of Federal Regulations, Title 45. Age,
race, height, weight, and cause of death
of the body donor at the time of death
were available for all cadavers. Cadavers
with evidence of pelvic malignancy or
pelvic surgery (excluding hysterectomy)
were excluded.

672.e1 American Journal of Obstetrics & Gynecology DECEMBER 2007

www.AJOG.org
FIGURE 1
Anatomy of the right pelvic
sidewall
Anatomy of the right pelvic sidewall with the
peritoneum removed and the rectum opened is
shown. Note the relationship of USL to the
rectum, ureter, and other pelvic sidewall struc-
tures. First sacral nerve (S1), second sacral
nerve (S2), third sacral nerve (S3), and fifth
lumbar vertebrae (L5) are shown.
Wieslander. Uterosacral ligament suspension sutures. Am J
Obstet Gynecol 2007
In 15 unembalmed female cadavers, 2
permanent sutures were placed through
each USL via a vaginal approach, using a
similar method to that described by
Shull and Bachofen.1 After the cadavers
were placed in the standard lithotomy
position, the vaginal cuff was opened,
and the bowel was packed away with a
laparotomy towel and displaced upward
with a Deaver retractor. An Allis clamp
was placed on the posterolateral wall of
the vagina at the 4 o’clock and 8 o’clock
position, and gentle traction on the
clamp was applied on the side of the sus-
pension to facilitate palpation of the lig-
ament. The rectum was then retracted
medially using a Briesky–Navratil retrac-
tor. A 2-0 double-armed, braided poly-
ester suture on an SH needle (Ethibond,
Ethicon, Inc, Somerville, NJ) was placed
through the ligament 7.5 cm from the
hymen, a point that should be in prox-
imity to the ischial spine; this was called
the distal suture.
We standardized placement of the dis-
tal suture 7.5 cm from the hymen be-
cause the ischial spines are not always
easy to palpate intraoperatively, and this
length approximates the average length
of the anterior vaginal wall. A second su-
ture was then placed 1-1.5 cm cephalad
to the first, and this was called the prox-
imal suture.
The same procedure was repeated on
the opposite side. Needles were always
passed from lateral to medial. Following
suture placement, traction was applied
on the suture by both the surgeon and
the assistant to confirm placement into
the USL. A laparotomy was then per-
formed, and the small bowel removed to
facilitate dissection. Ureteral stents (7
French) were placed from the pelvic
brim to the bladder and distances be-
tween the most lateral aspect of the su-
ture loops and the ureters were recorded
(Figure 2). The rectum was then opened
and cleaned, and distances between the
rectal lumen and the medial aspect of the
suture loops were documented (Figure
2). Straight, 3-mm diameter metal pins
were placed perpendicular through the
USL at the level of the sutures and an-
chored to the sacrum. The presacral
space was then bluntly and sharply ex-
posed and the anatomic relationships of
the sutures (metal pins) to the anterior
sacral foramina and sacral nerves were
noted (Figure 3).
When the suture loop was noted on
the dorsal or sacral surface of the liga-
ment, the specimens were transected in
the midsagittal plane to facilitate dissec-
tion of the pelvic sidewall neurovascular
structures. All sutures were placed by 1 of
2 female pelvic medicine and recon-
structive surgery fellows under direct
guidance and assistance from a urogyne-
cology attending faculty.
Distances were measured twice and re-
corded using the same calipers and a
10-cm plastic ruler with the pelvis in su-
pine position. In 3 cadavers, a total ab-
dominal hysterectomy was performed
before vaginal placement of the sutures.
The abdominal hysterectomy was per-
formed as part of another study that did
not alter the pelvic sidewall retroperito-
neal structures. Although surgeons were
not blinded to the specific aims of the
study, all surgeons who participated were
trained in the same standardized tech-
nique of USLS before beginning the study.
DECEMBER 2007 American Journal of Obstetrics & Gynecology
SGS Meeting Papers
FIGURE 2
Distances of the USLS sutures
Distances from the proximal and distal USLS
sutures and the medial aspect of the ureter are
shown by the horizontal white lines on the right
side of the pelvis and from the sutures to the
rectal lumen on the left pelvic side.
Wieslander. Uterosacral ligament suspension sutures. Am J
Obstet Gynecol 2007
Statistical analysis was performed us-
ing the SigmaStat 2.03 statistics software
(Systat Software, San Jose, CA). Contin-
uous variables were summarized by
means, standard deviations (SDs), medi-
ans, and ranges. Qualitative data were
summarized by counts and percentages.
R ESULTS
Study population characteristics
Limited demographic characteristics of
the 15 cadavers are provided in Table 1.
Of the 15 cadavers, 12 had undergone a
previous hysterectomy.
Anatomic relationships of
suspension sutures
Relationship to ureters: The average
distance from the lateral aspect of the
suspension sutures to the medial border
of the ureters was 14 mm (range, 0-33;
Table 2). One right proximal suture was
placed immediately adjacent to the right
ureter (0 mm); however, this suture did
not penetrate the connective tissue
sheath or lumen of the ureter.
Relationship to sacral foramina and
sacral nerves: All suspension sutures
were placed between the first and third
672.e2
SGS Meeting Papers www.AJOG.org

FIGURE 3 TABLE 2
Relationship of the USLS Distances from suspension suture to pelvic structure
sutures to the anterior sacral Distance from suspension suture (mm)
foramina and sacral nerves
Pelvic structure n Mean ⴞ SD Median Range
Ureter
.....................................................................................................................................................................................................................................
Right proximal suture 14 13 ⫾ 8 13 0-33
.....................................................................................................................................................................................................................................
Left proximal suture 13 14 ⫾ 7 14 5-31
.....................................................................................................................................................................................................................................
Right distal suture 15 14 ⫾ 7 14 4-33
.....................................................................................................................................................................................................................................
Left distal suture 13 13 ⫾ 7 10 6-30
..............................................................................................................................................................................................................................................
Rectal lumen
.....................................................................................................................................................................................................................................
Right proximal suture 13 11 ⫾ 8 10 0-33
.....................................................................................................................................................................................................................................
Left proximal suture 13 9⫾4 10 0-15
.....................................................................................................................................................................................................................................
Right distal suture 12 12 ⫾ 5 11 3-23
.....................................................................................................................................................................................................................................
Left distal suture 11 13 ⫾ 5 13 5-22
Wieslander. Uterosacral ligament suspension sutures. Am J Obstet Gynecol 2007

Metal pins (arrowhead) were placed through the

sacral foramina (Table 3 and Figure 4). specimens. The first suture was the same
sutures into the sacrum prior to displacing the
Suspension sutures were noted at the right proximal suspension suture that
rectum and loose connective tissue to expose
level of S1 in 43.8 %, S2 in 33.3%, and S3 incorporated the third sacral nerve (Fig-
the presacral space. Ball pins (arrow) were then
in 22.9% of specimens. One of 48 sutures ure 5). The second suture was a left prox-
placed on the medial aspect of the sacral fo-
(2.1%) entrapped the third sacral nerve imal suspension suture in the same ca-
ramina, and the relationship of the metal pins to
on the right (Figure 5). daver specimen that had rectal injury
the foramina was examined. The lumbosacral
Approximately two-thirds of the su- and perirectal endometriosis. Both in-
trunk (LST), first sacral nerve (S1), second sa-
tures were placed at a level just anterior jured vessels appeared to be venous trib-
cral nerve (S2), and fifth lumbar vertebra (L5)
to or lateral to the sacral foramina (Ta- utaries of the internal iliac.
are shown.
Wieslander. Uterosacral ligament suspension sutures. Am J
ble 4 and Figure 4). The proximal su-
Obstet Gynecol 2007 tures were located at a level medial to
the sacral foramina in 38.5% of the C OMMENT
specimens, anterior in 42.3%, and lat- Before starting this study, we did not ex-
eral in 19.2% of the specimens. The pect the USLS sutures to be able to di-
TABLE 1 distal sutures were located at a level rectly entrap sacral nerves. We believed
Demographics of study medial to the sacral foramina in 31.8%, that some of the symptoms reported af-
population anterior in 10.9%, and lateral in only ter USLS could be explained by stretch-
27.3% of the specimens. ing of the somatic nerve roots when the
Demographic
characteristic Value Relationship to rectum: The average vaginal apex was suspended to the liga-
distance from the medial aspect of the ments, which contain autonomic nerves
Total number cadavers, n 15
........................................................................................................... suspension sutures to the lateral border arising from the same sacral nerve roots
Age, mean ⫾ SD, y 77.3 ⫾ 12.6 of the rectal lumen was 11 mm (range, as the somatic nerves. However, based
...........................................................................................................
Race, n (%) 0-33; Table 2). Two of the proximal sus- on the results of this study, neurologic
..................................................................................................
White 15 (100) pension sutures penetrated the rectal lu- complications following USLS could re-
...........................................................................................................
men, 1 on the right and 1 on the left side. sult from 3 mechanisms: (1) direct injury
BMI, mean ⫾ SD, kg/m 2
25.9 ⫾ 5.3
........................................................................................................... These injuries occurred in separate ca- to the sacral nerves, (2) irritation of the
Reported cause of death, davers, and the sutures were placed by sacral nerve roots from bleeding, and (3)
n (%)
.................................................................................................. different surgeons. The first cadaver ap- irritation of the somatic nerve roots from
Neurologic 4 (26.7) peared to have normal pelvic anatomy, stretching of the autonomic nerves that
..................................................................................................
Cardiopulmonary 8 (53.3) whereas the second had scarring of the course in the USL and adjacent tissue.
..................................................................................................
Cancer 2 (13.3) right uterosacral ligament and what ap- Although direct injury to the sacral
..................................................................................................
peared to be perirectal endometriosis nerves was observed in only 1 of 48 su-
Other 1 (6.7)
........................................................................................................... upon pelvic dissection. tures placed (2.1%), all sutures were
BMI, body mass index. Pelvic side wall vessel injury: Two of placed at a level between the first and
Wieslander. Uterosacral ligament suspension sutures.
Am J Obstet Gynecol 2007
48 USLS sutures (4.1%) perforated pel- third sacral foramina, and two-thirds of
vic sidewall vessels in 2 separate cadaver them were placed anterior to or lateral to

672.e3 American Journal of Obstetrics & Gynecology DECEMBER 2007

www.AJOG.org SGS Meeting Papers

explain findings of sensory and/or motor

TABLE 3 FIGURE 4
deficits with longer recovery periods.
Frequency distribution of suture Distribution of USLS sutures
Siddique et al,11 in their anatomic
location relative to sacral study of the uterosacral ligaments and
foramina in craniocaudal sacral nerve trunks in 6 embalmed fe-
orientation male cadavers, demonstrated that occa-
Total sionally the S1, and more commonly S2-
number of S4, nerve trunks were vulnerable to
cadavers
(n ⴝ 15)
injury during USLS. These structures
passed under the intermediate portion of
Right proximal suture, n (%) 13
.................................................................................................. the USL, in which sutures are commonly
First sacral foramen (S1) 6 (46.2) placed. Their data support our findings
..................................................................................................
Second sacral foramen 4 (30.8) that sacral nerves can be ligated if USLS
(S2) sutures are placed lateral to the ligament
..................................................................................................
Third sacral foramen 3 (23.0) fibers or too deep into the pelvic side- The distribution of USLS sutures in reference to
(S3) wall. Similarly, in a retrospective case se- the anterior sacral foramina in the craniocaudal
..................................................................................................
ries of 182 women who had undergone a and mediolateral orientations is shown. All su-
Fourth sacral foramen 0 (0.0)
(S4) USLS, Flynn et al12 identified 7 women tures were placed at a level between the first and
..................................................................................................
with sensory neuropathy and pain in the third sacral foramina as indicated by the area
Fifth sacral foramen (S5) 0 (0.0)
...........................................................................................................
S2-S3 dermatomes immediately postop- inside the larger rectangle. Two thirds of the
Left proximal suture, n (%) 13 sutures were placed at a level anterior to or
.................................................................................................. eratively. Three of these women had re-
First sacral foramen (S1) 9 (69.2) duction of pain after removal of the su- lateral to the sacral foramina as indicated by the
..................................................................................................
Second sacral foramen 2 (15.4) ture within 4 days postoperatively, area inside the outer rectangles. The first to third
(S2) suggesting that the nerve was injured sacral nerves (S1-S3) are shown.
..................................................................................................
Wieslander. Uterosacral ligament suspension sutures. Am J
Third sacral foramen 2 (15.4) within the pelvis by the USLS sutures. Obstet Gynecol 2007
(S3) Injury to the pelvic sidewall venous
..................................................................................................
Fourth sacral foramen 0 (0.0) plexus was noted with 2 of 48 sutures
(S4) placed (4.2%). The venous plexus that
.................................................................................................. of the vaginal apex may cause stretching
Fifth sacral foramen (S5) 0 (0.0) drain the rectum and other pelvic viscera of the somatic nerve roots and result in
...........................................................................................................
and that are tributaries of the internal il- pain and even motor deficits in the area
Right distal suture, n (%) 11
.................................................................................................. iac vein course in the pelvic sidewall lat- of distribution. This mechanism may ex-
First sacral foramen (S1) 3 (27.3) eral to the USL. Hematoma formation
.................................................................................................. plain some of the transient sensory defi-
Second sacral foramen 5 (45.4) may cause irritation or compression of cits reported by some women.
(S2) the nerve roots, resulting in some of the
..................................................................................................
Third sacral foramen 3 (27.3) sensory or even motor findings de-
(S3)
..................................................................................................
scribed in the immediate postoperative FIGURE 5
Fourth sacral foramen 0 (0.0) period. In their case series, Flynn et al12 Third sacral nerve and pelvic
(S4) noted 4 women who did not have pain sidewall vein
..................................................................................................
Fifth sacral foramen (S5) 0 (0.0) exacerbation with traction of the ipsilat-
...........................................................................................................
eral uterosacral suture. The sutures were
Left distal suture, n (%) 11
.................................................................................................. left in place and the patients were treated
First sacral foramen (S1) 3 (27.3) medically. In 3 of 4 women, the pain re-
..................................................................................................
Second sacral foramen 5 (45.4) solved by 12-14 weeks. Lack of direct
(S2) nerve injury may explain why symptoms
..................................................................................................
Third sacral foramen 3 (27.3) resolve within weeks postoperatively.
(S3) Parasympathetic fibers that supply the
..................................................................................................
Fourth sacral foramen 0 (0.0) pelvic viscera arise from the second
(S4) through the fourth sacral nerves roots
..................................................................................................
Fifth sacral foramen (S5) 0 (0.0) and join sympathetic fibers from the su-
perior hypogastric nerve plexus to form
Wieslander. Uterosacral ligament suspension sutures. Am J Third sacral nerve (S3) and pelvic sidewall vein
Obstet Gynecol 2007 the inferior hypogastric or pelvic plexus.
encircled by the right cephalad USLS suture.
Fibers from this plexus follow branches
The pubic symphysis (PS) and fifth lumbar
these foramina. Therefore, it is possible of the internal iliac artery to innervate
vertebra (L5) are also shown.
for sutures that are placed “too deep” the pelvic viscera. Many of these fibers Wieslander. Uterosacral ligament suspension sutures. Am J
through the USL to directly perforate or course through the USL.4 Therefore, Obstet Gynecol 2007
entrap these neural structures. This may traction on the USL during suspension

DECEMBER 2007 American Journal of Obstetrics & Gynecology 672.e4

SGS Meeting Papers www.AJOG.org

mm (⫾9 mm). Both our proximal and parisons between the right and left and
TABLE 4 distal sutures were noted, on average, 14 proximal and distal sutures. Addition-
Frequency distribution of suture mm from the ureter. Discrepancies be- ally, there was no histologic confirma-
location relative to sacral tween this and the results of Buller et al5 tion that the sutures were actually placed
foramina in mediolateral may be related to the following: (1) the in the USL. However, the goal of this
orientation effects of embalming process on tissue, study was to characterize the relation-
Total (2) pliability of fresh tissue potentially ship of the suspension sutures, not the
number of affecting ureteral position with stent USL, to the ureter, rectal lumen, and
cadavers
(n ⴝ 15)
placement, and (3) lateral entry point of sidewall neurovascular structures. Fi-
the needle relative to the ligament. Al- nally, although we can not say with 100%
Right proximal suture, 13
n (%)
though we did not directly injure the certainty that all metal pins were placed
.................................................................................................. ureter with our suspension sutures, we at exactly 90 degrees to the anterior sur-
Medial 4 (30.8) are unable to comment on what effects face of the sacrum, we took meticulous
..................................................................................................
Anterior 7 (53.8) the proximity of the sutures has on ure- care to attempt placing the pins directly
..................................................................................................
Lateral 2 (15.4) teral kinking. perpendicular to the bony surface of the
...........................................................................................................
In this study, 2 of 48 suspension su- anterior sacrum as palpated through the
Left proximal suture, 13
n (%) tures (4.2%) penetrated the rectal lu- peritoneum and underlying loose con-
..................................................................................................
men. To our knowledge, rectal injury be- nective tissue, vessels, and nerves.
Medial 6 (46.1)
.................................................................................................. cause of USLS sutures has not been Exposing the bony surface of the ante-
Anterior 4 (30.8) reported in the literature. Five case series rior sacrum prior to placing the pins
..................................................................................................
Lateral 3 (23.1) including more than 800 patients did not would have increased accuracy but
...........................................................................................................
Right distal suture, n 11 report injury to the rectum from USLS would have completely distorted the
(%) sutures.1-3,8,9,16 It is unclear whether the anatomy of the uterosacral ligaments,
..................................................................................................
Medial 4 (36.4) high rate of rectal injury in our study is making any conclusions meaningless.
..................................................................................................
related to the limitations inherent to any Another method that could increase ac-
Anterior 6 (54.5)
.................................................................................................. cadaver study. It is possible that the rec- curacy would be placement of the pins
Lateral 1 (9.1) tum was distended with stool above the under radiological guidance. The high
...........................................................................................................
Left distal suture, n 11 pelvic floor, artificially displacing it cost of fluoroscopy, however, prohibited
(%) closer to the USL. Additionally, absent its use in this study. We believe our find-
..................................................................................................
Medial 3 (27.3) tone may have made the rectum more ings regarding the general location of the
..................................................................................................
difficult to palpate and see while retract- USLS sutures relative to the sacral nerves
Anterior 3 (27.3)
.................................................................................................. ing it medially during suture placement. are still meaningful.
Lateral 5 (45.4) It is also possible that suture penetration In conclusion, uterosacral ligament
Wieslander. Uterosacral ligament suspension sutures. Am J
Obstet Gynecol 2007
of the rectum is more common than pre- suspension sutures can directly injure
viously believed but does not cause any the ureters, rectum, and neurovascular
symptoms and therefore is unrecog- structures in the pelvic sidewalls. Al-
In a review of 52 patients who under- nized. Although placing permanent su- though the anatomic variability of the
went a USLS, Tugbiyele et al10 noted 9 tures through the muscular wall of the uterosacral ligaments and surrounding
cases of vaginal, vulvar, and buttock pain rectum does not generally lead to signif- structures precludes making precise rec-
and 12 cases of lower extremity neuro- icant morbidity, sutures that enter the ommendations on bite size, we believe
pathy. Similarly, Siddique et al11 noted 2 rectal lumen may track stool and bacteria that to minimize injury to the ureter and
cases of perineal and lower extremity into the peritoneal cavity and lead to ab- rectum, the following recommendations
pain. Although stretch and/or compres- scess formation. would be useful. To minimize ureteral
sion injury to the sciatic nerve or sacral It was our experience that palpation of injury, sutures should be placed from
nerve plexus from the lithotomy posi- the sutures by a rectal finger was very dif- lateral to medial because the ureter is lo-
tion may lead to buttock and lower ex- ficult because of the prominent anterior cated lateral to the USL and it is generally
tremity deficits, it is unlikely to explain transverse rectal folds. Therefore, one accepted that the surgeon has greater
the vulvar pain. should be especially cognizant of the control on the location of the entry point
Ureteral injury because of direct liga- proximity of the rectum to the uterosa- of the needle, compared with its exit
tion or kinking of the ureter is the most cral ligaments. If severe endometriosis or point. In addition, the entry point of the
commonly reported complication of the scarring of the cul-de-sac is suspected or needle should be at the most medial and
USLS procedure.1-3,8,9,15 After careful identified intraoperatively, an alterna- palpable portion of the ligament and not
dissection of 11 cadavers (3 fresh, 11 em- tive site of vaginal vault suspension lateral to or around it.
balmed), Buller et al5 found the mean should be considered. To minimize rectal injury, a thorough
distance between the ureter and the USL The small sample size of this study did bowel preparation should aid with
at the level of the ischial spine to be 23 not allow statistically significant com- proper displacement of the rectum to the

672.e5 American Journal of Obstetrics & Gynecology DECEMBER 2007

www.AJOG.org
contralateral side. Lastly, after perforat-
ing the ligament, a quick turn of the nee-
dle should be used.
To avoid injury to the deeper structures
in the pelvic sidewall such as the sacral
nerves and vessels, strategies to make the
ligament “stand out” from the overlying
peritoneum and loose connective tissue
should be utilized. These include gentle
upward traction of the posterolateral vagi-
nal wall with an Allis clamp; careful retrac-
tion of the pelvic sidewall structures supe-
riorly and laterally with a Deaver retractor;
and displacement of the rectum medially
with a Briesky–Navratil or similar retrac-
tor. Packing of the bowel with moist lapa-
rotomy sponges is also essential. Isolation
and enhancement of the ligament with
these maneuvers before suture placement
should help avoid the need for placement
of sutures “too deep” into the pelvic side-
wall to obtain a good purchase of the liga-
ment. Although some ureteral, rectal, and
neurovascular injuries to the pelvic side-
wall structures may be unavoidable, these
recommendations should help reduce the
incidence of these complications. f 1995;8:17-24.
REFERENCES
1. Shull BL, Bachofen C, Coates KW, Kuehl TJ.
A transvaginal approach to repair of apical and
other associated sites of pelvic organ prolapse
with uterosacral ligaments. Am J Obstet
Gynecol 2000;183:1365-74.
2. Barber MD, Visco AG, Weidner AC, Amund-
sen CL, Bump RC. Bilateral uterosacral liga-
ment vaginal vault suspension with site-specific
endopelvic fascia defect repair for treatment of
pelvic organ prolapse. Am J Obstet Gynecol
2000;183:1402-11.
3. Karram M, Goldwasser S, Kleeman S, Steele
A, Vassallo B, Walsh P. High uterosacral vaginal
vault suspension with fascial reconstruction for
vaginal repair of enterocele and vaginal vault
prolapse. Am J Obstet Gynecol 2001;185:
1339-43.
4. Campbell RM. The anatomy and histology of
the sacrouterine ligaments. Am J Obstet Gy-
necol 1950;59:1-12.
5. Buller JL, Thompson JR, Cundiff GW, Sulli-
van LK, Schon Ybarra MA, Bent AE. Uterosa-
cral ligament: description of anatomic relation-
ships to optimize surgical safety. Obstet
Gynecol 2001;97:873-9.
6. Umek WH, Morgan DM, Ashton-Miller JA,
DeLancey JOL. Quantitative analysis of utero-
sacral ligament origin and insertion points by
magnetic resonance imaging. Obstet Gynecol
2004;103:447-51.
7. Fritsch H, Hotzinger H. Tomographical anat-
omy of the pelvis, visceral pelvic connective tis-
sues, and its compartments. Clin Anat
8. Aronson MP, Aronson PK, Howard AE,
Morse AN, Baker SP, Young SB. Low risk of
ureteral obstruction with “deep” (dorsal/poste-
rior) uterosacral ligament suture placement for
transvaginal apical suspension. Am J Obstet
Gynecol 2005;192:1530-6.
DECEMBER 2007 American Journal of Obstetrics & Gynecology
SGS Meeting Papers
9. Amundsen CL, Flynn BJ, Webster GD. Ana-
tomical correction of vaginal vault prolapse by
uterosacral ligament fixation in women who also
require a pubovaginal sling. J Urol 2003;
169:1770-4.
10. Tugbiyele FA, Bent AE, Ellerkman RM, et al..
A comparison of colpopexy and uterosacral lig-
ament vaginal vault suspension for apical pro-
lapse. J Pelvic Med Surg 2005;11:S43.
11. Siddique SA, Gutman RE, Schon Ybarra
MA, Rojas F, Handa VL. Relationship of the
uterosacral ligament to the sacral plexus and
the pudendal nerve. Int Urogynecol J
2006;17:642-5.
12. Flynn MK, Weidner AC, Amundsen CL.
Sensory nerve injury after uterosacral ligament
suspension. Am J Obstet Gynecol 2006;195:
1869-72.
13. Elkins T, Hopper J, Goodfellow K, Gasser
R, Nolan T, Schexnayder M. Initial report of
anatomic and clinical comparisons of the sa-
crospinous ligament fixation to the high Mc-
Call culdoplasty for vaginal cuff fixation at hys-
terectomy for uterine prolapse. J Pelvic Surg
1995;1:12-7.
14. Culligan PJ, Miklos JR, Murphy M, et al. The
tensile strength of uterosacral ligament sutures:
a comparison of vaginal and laparoscopic tech-
niques. Obstet Gynecol 2003;101:500-3.
15. Silva WA, Pauls RN, Segal JL, Rooney CM,
Kleeman SD, Karram MM. Uterosacral ligament
vault suspension: five-year outcomes. Obstet
Gynecol 2006;108:255-63.
16. Jenkins VR. Uterosacral ligament fixation
for vaginal vault suspension in uterine and vag-
inal vault prolapse. Am J Obstet Gynecol
1997;177:1337-44.
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