LAUSR

With the increase in life expectancy and the expectation for higher quality of life and an active lifestyle among postmenopausal women with pelvic organ prolapse (POP), apical support repair has emerged as an essential central surgical procedure [1]. Advanced age and often multiple co-morbidities require a procedure that is minimally invasive, effective and well tolerated even for patients in the 8th or 9th decade of their life. Therefore, vaginal apical POP repair with and without uterine preservation is in the center of a long-lasting discussion in the field of reconstructive pelvic medicine and surgery [2]. The principal decision on the appropriate surgical method of POP repair has to be weighed with the individual patient [3]. If a vaginal approach is preferred by the patient or by the surgeon, and the patient wishes to preserve sexual function, then anatomical restoration should be a major goal [4]. A wide array of surgical procedures are available for repairing apical pelvic organ prolapse and there is no strong evidence to support the anatomical or functional superiority of one procedure over the others [5]. Until 2016, mesh materials were frequently used worldwide for transvaginal apical prolapse repair[6]. However, following the reclassification of vaginal surgical mesh to the highest risk class of devices (class III) by the American Food and Drugs Administration (FDA) [7] and the 2019 order to stop distributing vaginal surgical mesh products in the USA [8] (though vaginal meshes are continued to be used in some European countries), sacrospinous ligament Fixation (SSLF) regained new interest. The use of the sacrospinous ligament (SSL) for apical prolapse repair with the option of hysteropexy and uterine preservation is an excellent option when we are striving for minimal invasiveness and effectiveness to be a major tool for pelvic reconstructive surgeons. As the clinical presentation of pelvic organ prolapse might be a central support defect alone or a combination of several compartment defects, for many experienced vaginal surgeons, the vaginal approach is favored for POP reconstruction as it facilitates the straightforward concomitant repair of other vaginal defects as well as stress urinary incontinence. Apical support is crucial for the success of any surgical repair in advanced prolapse [9] and repair of the anterior/posterior vaginal walls may deteriorate if the apex is not supported [10]. Sacrospinous ligament fixation can provide this apical support. The utilization of the SSL as a suspension site of the vault was first described by Kurt Richter [11] (Fig. 1) It is less extensive and has a shorter operation time, recovery and returning to activities of daily living, as well as fewer complications than abdominal sacrocolpopexy and vaginal hysterectomy with uterosacral ligament suspension (USLS) [12]. When choosing the type of vaginal surgery for POP repair we need to take into consideration the surgical approach to access the SSL, the fixation technique, and material used like absorbable or non-absorbable sutures or synthetic meshes or other grafts. Currently there are different vaginal surgical approaches to access the SSL available to enable the suspension of the vaginal vault or the uterus/cervix in the event of uterine preservation including: