The anatomic location of the sacrospinous ligament confers a greater risk of bleeding with SSLF compared to other transvaginal procedures. The sacrospinous ligament runs from the ischial spine to sacrum, forming the inferior border of the greater sciatic foramen. The piriformis muscle, superior and inferior gluteal vessels, and internal pudendal vessels run through this foramen. The gluteal vessels and sciatic nerve are near to the proximal aspect of the ligament, while the pudendal neurovascular bundle runs immediately inferior and medial to the distal aspect. In spite of the close proximity to several major vascular structures, the majority of cases reported in the literature are associated with moderate blood loss. In five RCTs comparing SSLF with other procedures for vault prolapse, the mean blood loss for SSLF was 126–448 mL [2–4]. The reported rate of transfusion is 2–3 % [2, 4, 5]. The best first step in minimizing the risk of clinically significant blood loss is establishing the optimal plane of dissection, as significant blood loss can occur in the setting of an aberrant plane of dissection. Utilizing a vasoconstrictive agent for hydrodissection helps to delineate the optimal plane between the vaginal epithelium and muscularis and offers hemostasis during dissection to aid optimal visualization and avoidance of inadvertent injury to adjacent structures. When significant bleeding is noted during dissection, this is often secondary to interruption of small venous plexuses in the vagina. In this situation, vaginal packing can be performed and held in place for 5 min for tamponade. The extraperitoneal location of the dissection should allow for significant slowing of the hemorrhage with this maneuver. Thereafter, the packing can be systematically removed to facilitate cauterization or placement of hemostatic sutures or clips as needed. Correction of the plane of dissection should be undertaken as soon as adequate hemostasis is obtained.

Optimization of suspension suture placement is also imperative to avoiding significant bleeding. To avoid vascular injury, suspension sutures should be placed in the medial aspect of the ligament, approximately 2 cm medial to the ischial spine, at a depth that only includes the ligament, as many vessels run deep to the underlying iliococcygeus muscle. Suture placement can be carried out with direct visualization or palpation of the ligament, utilizing a needle driver or a suture passing device (i.e., Capio device, Deschamps ligature carrier, Miya hook ligature carrier). In retrospective and prospective series comparing complications associated with traditional direct vision suspension suture placement vs. placement with palpation and use of a suture passing device, there were no differences in rate of transfusion or postoperative hematoma [6, 7]. Selection of approach should be based on surgeon comfort and experience.

When significant bleeding is encountered with suture placement, optimizing visualization is paramount to achieving timely vascular control. Handheld retractors should be utilized to establish proper exposure of the bleeding vessels and adjacent structures and facilitate careful placement of hemostatic sutures and clips. It is important to note that the posterior approach allows for better exposure in this setting than the anterior approach. If visualization remains poor after maximizing exposure with retractors, due to brisk blood loss, firm vaginal packing can be a very effective step to slow blood loss and allow for gradual inspection of the surgical field. Additionally, application of topical hemostatic agents (i.e., fibrin sealants, thrombin, gel matrix) can also be helpful in establishing hemostasis and improving visualization. It is important to keep anesthesia providers informed as to the magnitude of blood loss so that laboratory testing and volume resuscitation can occur in a timely manner.

If adequate hemostasis cannot be obtained vaginally and major vascular injury is suspected, thoughtful consideration should be given to selective embolization with interventional radiology. Vessels can be controlled in this manner without risk to adjacent neural structures.

SSLF itself is not commonly associated with urinary tract injury; however, concomitant surgery (i.e., hysterectomy, anterior or posterior repair, mid urethral sling) is performed in 59–91 % of patients and can confer increased risk [2–4, 6, 8, 9].

In an early systematic review of 17 studies of SSLF outcomes, inclusive of 1080 patients, the rate of cystotomy or bladder laceration was 0.3 % [5]. Several large contemporary series, describing a variety of approaches, have reported no cystotomy unless SSLF is performed with concomitant synthetic mid urethral sling [4, 6, 8, 10, 11]. Ureteral injury is similarly rare. There were no ureteral injuries observed in an RCT of 208 women receiving sacrospinous hysteropexy vs. vaginal hysterectomy with uterosacral ligament fixation [3]. Similarly, no ureteral injuries were observed among 240 women undergoing suspension suture placement under direct visualization or by palpation [6].

The course of the ligament is posterior to the course of the ureter; thus, the placement of fixation sutures should not result in ureteral kinking or occlusion. Intuitively, the risk of bladder injury can be minimized with the choice of approach. The anterior approach requires dissection of the ipsilateral paravaginal space as well as mobilization of the bladder away from the vaginal apex and thus confers the greatest risk of injury. The posterior approach confines dissection to the rectovaginal space and dramatically minimizes the risk of injury. Maintaining the proper plane of dissection can minimize the risk of urinary tract injury with an anterior approach. Excessively deep dissection can result in bleeding and poor visualization, increasing the risk of inadvertent cystotomy.