Expert Consensus on Standardization of Cervical Cancer Screening (2025 Edition)

Pelvic organ prolapse (POP) is a common female pelvic floor dysfunction disorder characterized by the descent of pelvic organs (such as the uterus, bladder, or rectum) below their normal anatomical positions due to weakened or damaged supporting tissues. Apical prolapse typically refers to the descent of the uterus (cervix) or vaginal vault (after hysterectomy), and patients with this condition often also have anterior and/or posterior vaginal wall bulging. Correction of apical prolapse can resolve 50% of anterior vaginal wall bulges and 30% of posterior vaginal wall bulges.

Sacrospinous ligament fixation (SSLF) is a surgical procedure that restores level I support by anchoring the vaginal apex or cervix to the sacrospinous ligament (SSL). It can be performed via abdominal, vaginal, or laparoscopic approaches, with the vaginal approach being the most common. This surgery offers advantages such as short operative time, no abdominal incisions, and fewer complications, making it one of the classic procedures for correcting apical prolapse. However, due to the deep location of the SSL, limited surgical space, and technical complexity, it requires surgeons to possess solid knowledge of pelvic floor anatomy and proficient vaginal surgical skills.

To standardize its application and promote its wider use, the Vaginal Surgery Committee of the Chinese Maternal and Child Health Association organized domestic pelvic floor experts to develop this consensus, aiming to provide clinical recommendations and references for this technique. The recommendation levels in this consensus are divided into four categories:

Class 1: Based on high-level clinical evidence with strong expert consensus.
Class 2A: Based on high-level clinical evidence with general expert consensus, or low-level clinical evidence with strong expert consensus.
Class 2B: Based on low-level clinical evidence with general expert consensus.
Class 3: Significant expert disagreement regardless of the level of clinical evidence.

01 History and Current Status of Transvaginal Sacrospinous Ligament Fixation

In 1958, Sederl first described the extraperitoneal suspension of the uterine cervix or vaginal apex to the SSL to correct uterine and vaginal vault prolapse. In 1968, Richter developed and popularized this procedure, which remains in use today and is known as the Richter technique. In 1971, Randall introduced the Deschamps' needle threading technique. In 1987, Miyazaki used the Miyazaki suture carrier (Miya hook) as a suturing device for SSLF, making the procedure easier and improving safety to some extent. In 1988, Morley et al. performed suturing under direct visualization of the SSL, reducing complications.

Studies show that SSLF has a subjective success rate of 70%–98% and an objective success rate of 67%–96.8% within 2 years postoperatively, with a 7-year objective success rate as high as 94.28%. A long-term study by Ng et al. with an average follow-up of 13.3 years reported an 88.5% subjective success rate and 77.7% satisfaction rate, with only a 2.9% reoperation rate due to recurrent POP or non-absorbable suture exposure.

Compared to other procedures, SSLF has a complication rate comparable to sacrocolpopexy but significantly lower than transvaginal mesh surgery, demonstrating good safety and cost-effectiveness. After more than 60 years of development, SSLF has been proven to be a safe and effective procedure and is recommended as a primary treatment for apical prolapse in multiple clinical guidelines.

02 Anatomical Key Points for Clinical Application of Sacrospinous Ligament Fixation

2.1 Anatomical Essentials

The SSL is composed of dense connective tissue, extending from the first transverse process of the coccyx and the lateral margin of the fourth sacral foramen to the ischial spine. It runs in the same direction as the coccygeus muscle, together forming the coccygeus muscle-sacrospinous ligament complex (C-SSL). Its position is fixed, and the ligament is tough, making it a reliable anchor point for pelvic floor reconstruction.

Reported lengths vary: internationally, 3.0–6.54 cm; domestically, 5.10–5.96 cm. Thickness ranges from approximately 0.2–0.7 cm.

2.2 Adjacent Nerves and Blood Vessels

The SSL region contains rich nerves and blood vessels, including the pudendal nerve, sacral nerves, sciatic nerve, internal pudendal artery, superior gluteal artery, inferior gluteal artery, and lateral sacral artery. Cadaveric studies show that the fourth sacral nerve runs along the inner 1/3 surface of the SSL and obliquely upward, contributing to the pudendal nerve along with the second and third sacral nerves. Approximately 67% of the pudendal nerve trunk lies on the outer 1/3 upper edge of the SSL, while the sacral nerves are, on average, 0.7 cm from the upper edge of the SSL—sometimes even directly adjacent.

The nerves innervating the coccygeus and levator ani muscles are distributed along the outer 1/3 of the SSL. The internal pudendal artery branches from the anterior division of the internal iliac artery, loops around the ischial spine posteriorly, and exits the pelvis through the greater sciatic foramen. The inferior gluteal artery exits the pelvis between the second and third sacral nerves or the first and second sacral nerves.

The vaginal posterior wall approach for SSLF involves sequentially dissecting the rectovaginal space and pararectal space, which is relatively safe and less likely to damage critical nerves and vessels.

Figure 1: SSL Anatomy (Right Sagittal View, Drawn by Foshan Women and Children’s Hospital)

2.3 Optimal Anchor Point

Multiple studies have investigated the safest anchor zone for SSLF.

Lantzsch et al. recommend the middle 1/3 of the SSL, 1.5–3.0 cm medial to the ischial spine.
Barksdale et al. recommend the middle portion of the SSL.
Zhang Xiangxia et al. recommend a point at least 2.5 cm medial to the ischial spine, located in the lower half of the SSL’s superficial 1/2.
Liu Ping et al. recommend a point at least 1.51 cm medial to the right ischial spine and 1.61 cm medial to the left ischial spine.

Recommendation: The optimal anchor point for SSLF is the middle 1/3 of the SSL (1.5–3.0 cm medial to the ischial spine), equivalent to the C-SSL’s middle 1/3, without exceeding the upper edge or penetrating the full thickness. (Recommendation Level: 2A)

03 Indications and Contraindications

3.1 Indications

The Chinese Guidelines for the Diagnosis and Treatment of Pelvic Organ Prolapse (2020 Edition)state that SSLF is primarily indicated for patients with symptomatic apical defects (POP-Q ≥ Stage II) and predominant middle compartment prolapse.

3.2 Contraindications

Acute genital infections (e.g., vaginitis, vaginal ulceration).
Anatomical abnormalities (e.g., vaginal stenosis, short vagina, pelvic malformations, hip prostheses).
Severe systemic comorbidities that preclude surgery.

Recommendation: SSLF is primarily suitable for symptomatic patients with POP-Q ≥ Stage II and predominant middle compartment prolapse. (Recommendation Level: 2A)

04 Preoperative Evaluation

A comprehensive history should be taken, and the "compartment theory" (Petros) and "three-level support theory" (DeLancey) should be applied to assess prolapse type and severity, clarifying treatment goals.

Evaluate urinary, bowel, and sexual function using questionnaires such as the Pelvic Floor Impact Questionnaire-7 (PFIQ-7) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ).

Preoperative POP-Q staging objectively assesses prolapse severity. A bivalve speculum (posterior blade) examines the apex and anterior vaginal wall, while the reversed posterior blade assesses the posterior wall.

After reduction, assess for occult stress urinary incontinence (SUI) and evaluate pelvic floor muscle tone. Additional tests (residual urine, urodynamics, pad tests) help identify SUI types.

Pelvic ultrasound and MRI provide diagnostic support for complex cases.

Recommendation: Comprehensive history-taking, prolapse assessment, and tailored auxiliary examinations based on local conditions and case complexity. (Recommendation Level: 2A)

05 Surgical Steps and Key Points

This consensus describes the right-sided vaginal posterior wall approach (after hysterectomy). The principle is "lateral dissection, midline suturing."

5.1 Patient Positioning

Lithotomy position.

5.2 Incision

Midline or right-sided longitudinal incision (1 cm lateral to midline) on the posterior vaginal wall, ~2–3 cm from the hymen and vaginal apex. Hydrodissection may assist.

5.3 Dissection of Rectovaginal and Pararectal Spaces

Full-thickness posterior vaginal wall incision. Right-sided sharp/blunt dissection of the rectovaginal space and pararectal space toward the ischial spine. Identify the right ischial spine, then dissect the SSL’s ventral peritoneal sac toward the sacrococcygeal region. Expand the pararectal space for vaginal retractor placement.

5.4 Exposure of the SSL

Depress the rectum with a retractor, medialize the peritoneal sac, and dissect the SSL’s membranous covering to expose the ligament.

5.5 Anchor Point Confirmation

Under direct vision (or digital palpation with anoscopy to exclude rectal injury), use a specialized suturing device to place two anchors (1 cm apart) in the SSL’s middle 1/3 (1.5–3.0 cm medial to the ischial spine). Tug-test for strength.

Suturing Techniques:

Avoid exceeding the SSL’s upper edge or full-thickness penetration.
Perpendicular needle entry to reduce nerve injury risk.
Oblique suturing for thinner SSLs to reduce tension.

5.6 Apex Suturing and Fixation

Extend the incision to the vaginal apex. Anchor the two sutures at the farthest point of the uterosacral-cardinal ligament complex (or cervix if retained).

5.7 Vaginal Incision Closure (Upper Segment)

Continuous 2-0 absorbable suture from the apex, burying all non-absorbable sutures to prevent exposure.

5.8 Knot Tying and Apex Repositioning

Tie knots to secure the apex to the SSL without leaving a "suture bridge."

5.9 Vaginal Incision Closure (Lower Segment)

Inspect for bleeding; place a drain if needed.

06 Complication Management and Prevention

6.1 Buttock/Thigh Pain

Nerve injury (3%–15%)—often from pudendal nerve branches—causes buttock/thigh pain. Rarely, sciatic nerve injury occurs. Most cases resolve within 4–6 weeks with conservative treatment (physical therapy, NSAIDs, local anesthetics). Persistent severe pain (positive straight leg raise) may require suture removal to prevent permanent damage.

Recommendation: Pain usually resolves in 4–6 weeks; severe cases warrant early suture removal. (Recommendation Level: 2A)

6.2 Bleeding & Hematoma

Life-threatening bleeding risk: 0.2%–2%. High-risk vessels: superior/inferior gluteal and internal pudendal arteries (inferior gluteal most vulnerable).

Management:

Compression, direct ligation, vaginal packing, or angiographic embolization.
Most bleeds stop within 5–10 minutes with hemostatics/packing.
Hematomas: Small asymptomatic ones resolve spontaneously (3–6 months). Symptomatic hematomas (anemia, pain) may require transfusion, medication, or surgical evacuation if expanding.

Recommendation: Control bleeding via compression/ligation/packing/embolization; evacuate persistent hematomas. (Recommendation Level: 2A)

6.3 Rectal/Bladder Injury

Rectal injury: 0.6%–1.3%; bladder injury is rare (usually from concurrent anterior repair). Prompt recognition and repair (possibly requiring surgical assistance) are essential.

Bowel Dysfunction: Common after bilateral SSLF (constipation, straining). Vaginal width/length adjustments or graft augmentation may help.

Recommendation: Identify and repair injuries promptly; seek surgical help if needed. (Recommendation Level: 2B)

6.4 Infection

Wound infection rate: ~3.7% (linked to bleeding/hematoma). Prophylactic antibiotics are routine.

Recommendation: Use prophylactic antibiotics. Treat infections with hematoma/bowel abscess evaluation. (Recommendation Level: 2B)

6.5 Suture Exposure

Incidence: 3%–8.6% (vaginal spotting, discharge, exposed sutures/polyps).

Management:

Preferred suture: 1-0 non-absorbable (higher erosion/granulation risk).
Delayed-absorbable PDS II sutures reduce exposure.
Exposed sutures >6 months should be removed.

Recommendation: Routine follow-up for healing/suture issues. (Recommendation Level: 2A)

6.6 Anterior Vaginal Wall Prolapse

SSLF pulls the apex posteriorly, increasing anterior prolapse risk (6%–21%, mostly asymptomatic; 3%–5% require surgery).

Recommendation: Correct concurrent anterior prolapse intraoperatively. (Recommendation Level: 2A)

6.7 Recurrent Apical Prolapse

Early failure (within 1 year) rates: 36.6%–37.9% (anchor failure is common). Risk factors: age, BMI, smoking, high preoperative Ba point.

Prevention:

Use two non-absorbable sutures for "double insurance."
Confirm anchor strength and apex fixation.
Educate patients on avoiding heavy lifting/chronic cough.

Recommendation: First-year recurrence is common; use dual sutures and patient counseling. (Recommendation Level: 2A)

07 Surgical Variations, Developments, and Controversies

7.1 Unilateral vs. Bilateral SSLF

Unilateral SSLF is standard.
Bilateral SSLF provides better midline stability for severe (Stage III–IV) or multi-compartment prolapse but has limited evidence.

Recommendation: Unilateral SSLF is typical; bilateral SSLF is considered for severe/profound prolapse with adequate vaginal length/width. (Recommendation Level: 2A)

7.2 Uterus Preservation vs. Hysterectomy

Uterine prolapse stems from Level I support deficiency, not the uterus itself. Hysterectomy is not mandatory for POP repair.

Evidence:

No difference in long-term outcomes between uterus-retained and hysterectomy groups (Ng et al., 13.3-year follow-up).
Faster recovery and fewer complications with uterus retention (VanBrummen et al.).
Lower blood loss and shorter OR time (Kovac et al.).
Successful vaginal births after SSLF (Hefni et al.).

Recommendation: Uterus-retained SSLF is safe and effective if no uterine pathology exists. (Recommendation Level: 2A)

7.3 Vaginal Anterior Wall Approach

Both anterior and posterior vaginal approaches are viable, with selection based on surgeon expertise and concurrent compartment defects.

Recommendation: Choose based on combined prolapse and surgeon skill. (Recommendation Level: 2B)

7.4 Vaginal Endoscopic SSLF

A 2022 study (Lyu et al., 60 patients) showed improved visualization, anchor success, and reduced blood loss/complications vs. traditional SSLF, but longer OR time/hospital stay. Limited high-quality evidence exists.

Recommendation: Endoscopic SSLF has visualization benefits but lacks robust evidence. (Recommendation Level: 2B)

Conclusion

This consensus synthesizes global research and expert consensus to provide standardized guidance for SSLF. However, individualized treatment plans—tailored to patient needs and surgeon judgment—remain essential.