Female pelvic organ prolapse is common. The incidence of prolapse surgery ranges from 11-19% of women will undergo surgery of prolapse by age 80 to 85 years. Data suggest that the risk of vaginal vault prolapse is almost five times higher in women whose initial hysterectomy was indicated for prolapse, and eight times higher if the preoperative prolapse was stage II or more. Because of its recurrent nature, vaginal vault prolapse remains a challenging problem for the patient and surgeon. 
Transvaginal native tissue prolapse repairs are a valuable safe option compared to a sacral colpopexy or mesh-augmented vaginal repairs. Sacrospinous, Uterosacral or Iliococcygeus Fascia Ligament Colpopexy are all native tissue options performed for apical prolapse after hysterectomy. 
Different techniques are presented in the literature and numerous observational studies describe the vaginal approach to apical prolapse repair. In our practice the majority of the apical prolapse reconstruction are carried out through a transvaginal Bilateral Uterosacral Ligament Colpopexy.

This educational video demonstrates our teaching technique in transvaginal bilateral uterosacral ligament colpopexy for apical prolapse.

Methods:
 
The vaginal epithelium is grasped with Allis clamps, the vaginal epithelium is dissected off the cystocele, enterocele and rectocele.
Traction on Allis clamps placed at approximately the 5 o’clock and 7 o’clock positions allows palpation of the uterosacral ligaments extraperitonealy .
Usually, one to two delayed absorbable sutures are passed through the uterosacral ligament bilaterally.
The delayed absorbable sutures that had been passed through the uterosacral ligaments are then passed through the full thickness of the vaginal wall at the level of the new apex.
In the vast majority of cases a concomitant anterior and posterior colporrhaphy is performed. 
The vagina is trimmed and closed with a 2-0 delayed absorbable suture.
Tying the vault suspension sutures elevates the vagina.
Cystoscopy after intravenous injection of indigo carmine is recommended to document bilateral ureteral patency.

The Transvaginal Uterosacral Ligament Colpopexy provide level 1 suspension of the vagina apex without any distortion of the vaginal axis.

Transvaginal extraperitoneal Bilateral Uterosacral Ligament Colpopexy offers an excellent effective option for the management of the vaginal vault prolapse.