Iliococcygeal vaginal suspension involves the attachment, usually bilaterally, of the vaginal apex to the iliococcygeus muscle and fascia (61,65,66). Extraperitoneal access is achieved via the posterior vagina. Compared with other vaginal suspension procedures, the iliococcygeal suspension has the fewest case series in the literature (65–67); however, cure rates appear comparable to the sacrospinous suspension technique (51). The dissection of the area to the ischial spine is approached from a midline posterior vaginal wall incision using the ischial spine as a landmark for identifying the sacrospinous ligament and the iliococcygeal fascia anteriorly and caudad to it. A no. 1 polydioxanone suture is placed through the fascia and attached to the vaginal apex as a pulley stitch. This procedure is more easily performed bilaterally than the sacrospinous suspension and should be considered preferentially in the presence of a shortened vagina. Risk of major vessel, nerve, or ureteral injury should be relatively low compared with other transvaginal suspensions.
Surgical variations of the uterosacral ligament suspension originally described in 1938 have been used prophylactically during hysterectomy or therapeutically for vaginal apical suspension (68).
A therapeutic procedure in which the vaginal apex is suspended to the uterosacral ligaments above the level of the ischial spines had excellent success rates in an observational study of 302 participants (69). When access to the posterior cul-de-sac is attained, the uterosacral ligament remnant can usually be found adjacent to the pelvic sidewall peritoneum just cephalad to the palpable ischial spine. Up to three sutures are placed in each ligament and incorporated into the anterior and posterior fibromuscular layer of the vagina. Some surgeons approximate the ligaments in the midline to close the cul-de-sac with the intention to treat or prevent enterocele formation (70). Other surgeons suspend the right and left vaginal apex to the ipsilateral uterosacral ligament, leaving the cul-de-sac open to avoid impinging on the rectum and adversely affecting bowel function.
Outcome studies have shown that recurrent apical prolapse occurs in 2% to 5% of cases within the first few years following the procedure, which is a rate comparable or superior to other transvaginal apical repairs, and the incidence of recurrent anterior defects may be less than that reported with sacrospinous suspensions (69,71). The most common serious complication was ureteral obstruction secondary to ureteral kinking or incorporation of an ureter in a suspension stitch. This occurred in as many as 11% of cases (71). Intraoperative cystoscopy— with documentation of ureteral patency after administration of indigo carmine dye, whereby such a problem can be corrected—is recommended.