Technical Challenges and Surgical Considerations in Sacrospinous Ligament Fixation for Apical Prolapse Repair

Background/Objectives: Sacrospinous ligament fixation (SSLF) is a well-established native tissue vaginal procedure for uterine/vault prolapse. Despite favorable success rates, the procedure presents technical challenges due to the deep operative field and proximity to critical neurovascular structures. To review current evidence regarding anatomical considerations, surgical technique, fixation strategies, suture materials, device-assisted methods, and perioperative complications in SSLF. Methods: A structured narrative review of the contemporary literature was conducted, focusing on comparative and systematic studies evaluating unilateral versus bilateral fixation, anterior versus posterior approach, suture type and number, and suture-capturing or anchor-based devices. Anatomical, functional, and safety outcomes were critically analyzed. Results: SSLF achieves favorable anatomical success rates with significant symptom improvement. Meticulous knowledge of sacrospinous ligament anatomy is critical to reduce bleeding and neuropathic complications. Unilateral fixation remains the most common technique, while bilateral fixation may benefit selected patients. According to the available evidence, the anterior approach may better preserve vaginal length, although it may be associated with longer operative time and short-term urinary morbidity. Absorbable and permanent sutures appear to provide comparable anatomical durability, while placement of two sutures remains the most commonly used fixation strategy. Device-assisted techniques may facilitate suture placement but require advanced anatomical expertise. Conclusions: SSLF is a safe and effective suspension procedure when individualized and meticulously performed. Further randomized studies evaluating long-term anatomical and patient-reported outcomes are warranted.