The uterosacral ligaments are paired condensations of the endopelvic fascia connecting the posterior cervix and upper vagina to the anterior sacrum (S1-S3) through the parametrium, providing the primary posterior uterine support.
The primary posterior support of the uterus and upper vagina — suspends the cervix from the sacrum, maintains the horizontal vaginal axis that protects against prolapse, and contains autonomic nerve fibres to the bladder and bowel.
Uterosacral ligament deficiency is the primary structural basis of uterine and vault prolapse. Uterosacral ligament suspension (McCall culdoplasty or bilateral uterosacral ligament vault suspension) is a primary native tissue repair for apical prolapse after hysterectomy. The ureter crosses the uterosacral ligament 1-2 cm lateral to the cervix — the critical ureteral danger zone in hysterectomy.
The ureter crossing near the uterosacral ligament insertion is at risk during hysterectomy uterosacral ligament clamping and division — the most common site of iatrogenic ureteral injury in gynaecological surgery.
Bilateral uterosacral ligament colpopexy for vaginal vault prolapse after hysterectomy, providing apical support through native tissue at the level of the ischial spines.
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