Thus, the concept of a “high” uterosacral attachment came to be proposed to provide a strong midline site of support for the vaginal apex.5,6 Further modifications include attachment of the uterosacral ligaments to pubocervical and rectovaginal connective tissues to create continuity of these level II fibers and prevent subsequent enterocele.7
With a high uterosacral attachment, the uterosacral ligaments need not be brought together in the midline.
Technique for modified approach
To locate each ligament, place traction on the vaginal apex toward the contralateral side. Palpate the pelvic structures posterior and medial to the ischial spines, at the 4 and 8 o’clock positions, to identify the strong tissue emanating from the sacrum.
Place several nonabsorbable sutures through the medial aspect of each uterosacral ligament, working from lateral to medial to minimize the risk of ureteral trauma. Then place 1 strand of each suture through the pubocervical and rectovaginal connective tissues. Tie the sutures to move the vaginal apex to the proximal segment of the uterosacral ligament (near the sacrum) and establish continuity of the pubocervical and rectovaginal connective tissues (FIGURES 4-6).
FIGURE 4 Suture placement is bilateral
Three sutures are placed in the uterosacral ligament pedicles on each side, with 1 arm of each suture placed in the transverse portion of the pubocervical and rectovaginal fascia.
FIGURE 5 Suspensory suture
Sagittal view of a suspensory suture in left uterosacral ligament with 1 arm through pubocervical fascia (PCF) and 1 arm through rectovaginal fascia (RVF).
FIGURE 6 The suspended vaginal vault
Sagittal view of pubocervical fascia (PCF) and rectovaginal fascia (RVF) suspended from uterosacral ligaments.
Main concern is ureteral injury
The ureter lies near the anterior margin of the uterosacral ligament, with a mean distance of 4.1±0.6 cm at the level of the sacrum and 2.3±0.9 cm at the level of the ischial spine.8 In 1 series of high uterosacral ligament suspension with site-specific endopelvic fascia defect repair, ureteral complications occurred in 11% of patients.5 Other series have reported rates of ureteral trauma in the range of 0.7%9 to 2.4%.6
Evaluate ureteral patency
After performing this procedure, the surgeon should ensure ureteral patency. For this reason, I believe that only surgeons skilled in cystoscopy and able to treat ureteral injury (or with ready access to those capable of treating this complication) should undertake high uterosacral suspension.
Integrating evidence and experience
How the McCall procedure compares with other approaches
Cruikshank SH, Kovac SR. Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele. Am J Obstet Gynecol. 1999;180:859–865
Although many techniques and modifications have been described for management of the cul-de-sac and vaginal cuff, few comparative data exist. In McCall’s original series,4 43 patients undergoing vaginal hysterectomy with posterior culdoplasty were followed for a minimum of 3 months and a maximum of 3 years. Mean and median lengths of follow-up were not provided, nor were the indications for hysterectomy or the method of assessing the patient for recurrent defects. McCall reported that no patients developed an enterocele after the surgery.
The first and only randomized study
Cruikshank and Kovac performed the only prospective, randomized comparison of procedures used at the time of hysterectomy to prevent enterocele. In their study, 100 patients undergoing vaginal hysterectomy for various indications (excluding prolapse of the posterior superior segment of the vagina) were randomized to 1 of 3 surgical methods to prevent enterocele:
- Moschcowitz-type closure (n=33), in which the peritoneum was closed using a purse-string technique, incorporating the distal ends of the uterosacral and cardinal ligaments and thereby drawing these structures to the midline
- modified McCall culdoplasty (n=33), in which a higher purse-string closure of the peritoneum was performed superior to the “yellow fat line,” incorporating the uterosacral-cardinal ligament complex (thus drawing these structures to the midline) and including the vagina (similar to the external McCall sutures) to move the apex superiorly
- simple closure of the peritoneum with a purse-string suture (n=34), with none of the uterosacral-cardinal ligaments incorporated into the repair.
Three years of follow-up
Of the 100 patients, 98 were followed with serial examinations for 3 years, and the outcomes at all vaginal segments were documented, with particular attention to the posterior superior segment, using staging from the Pelvic Organ Prolapse Quantification (POP-Q) system.10
McCall procedure was most effective
Overall, 11 patients (11.2%) were found to have stage II prolapse of the posterior superior vagina, none of them in the McCall group. An additional 14 patients (14.3%) had stage I prolapse, with only 2 (2%) of these in the McCall group.
The McCall repair was significantly more effective than the other 2 types of repair, with a 6.1% risk of subsequent prolapse, versus 30.3% in women who had a Moschcowitz-type closure and 39.4% in those who underwent simple closure of the peritoneum. No patients in any group had prolapse greater than stage II at follow-up.
Limitations of the study
Although Cruikshank and Kovac designed their study to analyze appropriate prophylaxis against enterocele in patients without prolapse, several patients did have some form of prolapse—although it was unrelated to the posterior superior vagina. Therefore, several patients underwent concomitant reconstructive procedures that included: anterior colporrhaphy (13), posterior colporrhaphy (4), sacrospinous ligament fixation (3), bilateral paravaginal repair (10), and anti-incontinence procedures (10).
It is not clear which groups these patients fell into and whether the distribution was similar across all groups.