Pelvic organ prolapse is a common problem amongst women. Apical prolapse affects up to 11% women [1]. Various options utilizing vaginal, abdominal or laparoscopic approach are available for the treatment of apical compartment defects. 
Uterosacral ligament (USL) suspension is one of the two most commonly reported transvaginal apical (uterus or vault) prolapse repair procedures, performed using native tissue [2]. High USL suspension (HUSLS) is a modification which has led to a more stable point of fixation however it is burdened by the risk for hypogastric nerve and ureteral injury, especially with the utilization of the vaginal approach [3]. Laparoscopic approach is therefore preferred by many as it allows to overcome these complications.
There are many studies that demonstrate the feasibility and outcomes of HSULS via transvaginal approach or laparoscopic approach. However there is no case/video presentation or study reporting the natural orifice translumenal endoscopic surgery (NOTES) implementation of HUSLS.
The objective of this video is to present our technique of HUSLS via NOTES and to present the short-term outcomes and feasibility of the procedure.

A 52-year-old woman with symptomatic anterior and apical prolapse admitted to our unit. The patient had no previous gynecological surgeries. The examination of the patient revealed stage III anterior, stage III apical and stage II posterior prolapse (POP-Q: Aa +2, Ba +2, C +4, gh 4, pb 3, tvl 9, Ap -2, Bp 0, D +3).
After disccussing the available surgery options and obtaining informed consent, the patient underwent vaginal hysterectomy followed by NOTES bilateral salpingo-oopherectomy and HUSLS (according to the technique described below)  and anterior colporraphy.

The technique for NOTES HUSLS included the following steps:

1-	Placement of self-constructed NOTES port following vaginal hysterectomy
2-	Identification of USLs and ureters on both sides
3-	Suspension of the bowels to the anterior abdominal wall to improve exposure (optional)
4-	Ureterolysis on both sides
5-	Insertion of one braided non-absorbable suture into the proximal USLs on both sides via NOTES
6-	Removal of the NOTES port and insertion of two additional late absorbable sutures into the distal USLs on both sides transvaginally
7-	Suturing and tying of the HUSLS sutures to the vaginal cuff
8-	Closure of the vaginal cuff

Technique described was performed successfully to correct the prolapse. There were no peri-operative or post-operative complications and patient was discharged from the hospital on the second day following surgery.
Post-operative 1-month and 3-month examinations showed significant objective cure (POP-Q: Aa -3, Ba -3, C -8, gh 4, pb 3, tvl 9, Ap -3, Bp -3, D -) with high patient satisfaction in terms of quality of life and sexual function.

Although vaginal approach is the first defined one and is still commonly preferred, it is burdened mainly by the risk for ureteral injury which is reported to be up to %11. Therefore laparoscopic approach is preferred by many since it provides better visualisation of the USLs and the ureters and allows the surgeon to dissect retroperitoneum and to place the sutures more securely. Furthermore salpingo-oophorectomy at the time of vaginal hysterectomy can sometimes be challenging which may make this option less favorable.
NOTES implementation of HUSLS we described in this video may be useful to urogynecologists since it combines traditional vaginal approach and endoscopic approach. Since all the procedure is carried out transvaginally it is a scarless surgery and we believe that it provides better pain scores and allows earlier recovery to daily life compared to laparoscopy with eliminating risks related to the traditional vaginal approach.
In conclusion NOTES HUSLS is a feasible and safe procedure to restore apical compartment support using native tissue in a minimally invasive fashion.

Cruikshank SH, Kovac SR. Randomized comparison of three surgi- cal methods used at the time of vaginal hysterectomy to prevent posterior enterocele. Am J Obstet Gynecol. 1999;180(4):859–65.
Jeffery ST, Doumouchtsis SK, Franco AVM, Fynes MM. High uterosacral ligament vault suspension at vaginal hysterectomy: ob- jective and subjective outcomes of a modified technique. J Obstet Gynaecol Res. 2009;35(3):539–44.
Margulies RU, Rogers MAM, Morgan DM. Outcomes of transvaginal uterosacral ligament suspension: systematic review and metaanalysis. Am J Obstet Gynecol. 2010;202(2):124–34.