Women with pelvic organ prolapse (POP) are defined as experiencing a downward descent of the pelvic organs. Barber found that up to 50% of women were affected by POP, based on vaginal examination. However, only 3–6% of women will have symptoms, which can significantly impact their quality of life[1]. The causes of POP are multifactorial, with vaginal delivery, advancing age, and a high body-mass index being the most consistent risk factors. The prevalence and management of POP are increasing.

Pelvic prolapse can occur in the bladder (cystocele), uterus (hysterocele) or post-hysterectomy vaginal cuff (colpocele), as well as the small bowel (enterocele) or large bowel (rectocele). Apical and anterior prolapse are commonly associated; therefore, apical suspension is important when correcting anterior wall prolapse.

Patients may present with a feeling of a bulge in the perineum, low back pain, difficulty with voiding or defecating, the need to place a hand or fingers in the vagina or on the perineum or around the anus to urinate or defecate[2]. The diagnosis is established through clinical examination (assisted by the POP-Q score to evaluate prolapse characteristics).

POP often does not present with symptoms, but when it becomes symptomatic, treatment options include pelvic-floor physical therapy, pessary use, and surgery. The incidence of POP surgery ranges from 1.5 to 1.8 per 1000 women per year and peaks in women aged 60–69[1]. The cumulative incidence of surgery for POP is as high as 11% in women over 70 years old[3]. Unfortunately, no effective prevention strategy has been identified.

Anterior sacrospinous ligament fixation (ASSLF) is a feasible and relatively safe technique that has emerged as an alternative to Posterior sacrospinous ligament fixation (PSSLF) for treating apical prolapse vaginally[4,5]. It provides satisfactory anatomical and functional results in the short term[6,7].

The procedure involves attaching unilaterally or bilaterally the cervix or vaginal vault to the sacrospinous ligament (SSL) using a non-absorbable suture that passes through an opening in the paravaginal space. Very few publications study the superiority of bilateral spinofixation over unilateral fixation[8]. Most of the publications about ASSLF include the bilateral technique[9,10]. Boukerrou et al. found a slight lateral deviation of the vaginal axis, which was visible in MRI scans when unilateral fixation was performed. However, this deviation was not found to be statistically significant[11].

Initially, surgeons were more accustomed to approaching the sacrospinous ligament (SSL) through the posterior route. Both ASSLF and PSSLF are autologous techniques that preserve the uterus. It can also be used for previously hysterectomized patients or in combination with a hysterectomy[12], [13], [14].

These techniques have gained particular interest as vaginal mesh implants were removed from the market by the Food and Drug Administration (FDA) in the United States since 2019 and in France since 2020. ASSLF appears to be as effective as the posterior approach in managing apical POP[10,15].

Vaginal surgery, in comparison to laparoscopic approaches, allows for the use of locoregional anesthesia, has lower morbidity and cost, can simultaneously address stress urinary incontinence, isolated cystoceles, or rectoceles, and is better suited for managing recurrences.

The anterior approach offers advantages over the traditional posterior technique, even though dissection of the sacrospinous ligament is performed without direct visualization. An associated advanced cystocele can be easily treated simultaneously by performing a vaginal patch plastron or anterior colporrhaphy[9,16].

The rate of occurrence or recurrence of anterior vaginal prolapse after ASSLF or PSSLF is high, as demonstrated in a French retrospective cohort study involving 50 cases. This study explored the feasibility of ASSLF surgery with concomitant anterior native tissue repair, revealing a recurrence rate of approximately 37%, although all cases were limited to stage II. The most frequent perioperative complications reported in this study included urinary tract infection (14%), difficulty in resuming voiding (16%), and ureteric kinking (2%). The latter two could be perceived as specific complications of ASSLF when compared to PSSLF[4].

Compared to the posterior approach, De Gracia et al. found that anterior SSLF, whether using mesh or native repair, was linked to a slightly increased frequency of complications (1.47%), although this disparity did not reach statistical significance. The anterior approach is associated with a lower risk of reoperation for recurrence compared to the posterior approach, as it better respects the anatomical axis[10]. This could be explained by the higher risk of postoperative cystocele with the posterior approach. ASSLF, when combined with anterior repair, may reduce the rate of anterior compartment recurrence[17].