Pelvic organ prolapse (POP) is a common complaint of specially multiparous women. Sacrospinous ligament fixation (SSLF) is a frequently used procedure to manage apical prolapse. Since the original description of the surgical technique, several modifications have been published. Most of them are variations on the passage of the suture through the sacrospinous ligament. There is no proper review study regarding complications caused by different surgical methods, using in different techniques of sacrospinous ligament fixation. The aim of this study was to evaluate and compare the rate of complications among different suture passing techniques at the time of sacrospinous ligament fixation

A systematic review of eligible articles was conducted using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. A comprehensive search of the literature was conducted on February 2023 in PubMed, Embase, Scopus, Web of Science, Cochrane Library, and Proquest databases, Using the following search strategy: ((DFS stapler) OR (SeraPro)) ) OR ((Suturing method*) AND (prolapse surgery))) OR (Miyazaki)) OR (long needle holder)) OR (Suture-Capturing)) OR (Suture-Capturing)) OR (Enplace)) OR (Anchor)) OR (Anchorsure)) OR (Arthrotek)) OR (Miya hook)) OR ("i stitch")) OR (Endostitch)) OR (Caspari)) OR (Capio)) OR (Deschamp aneurysm needle)) OR (Laurus needle driver)) OR (vis-à-vis technique*)) OR (RSD-Ney)) AND (Sacrospinous suspension). Studies were screened in two stages of title abstract and full text by two independent reviewers for subsequent analyses. We also monitored the abstracts from the international congresses. We included randomized controlled trials, and cohort studies related to sacrospinus ligament fixation (SSLF) in females with pelvic organ prolapse (POP) that reported the complication of different suture passing techniques. The prevalence of complications related to the passage of the suture through the sacrospinous ligament, such as nerve damage (pain in the buttock, lower limb or numbness in the vulva, perineum and lower limb), reoperation (surgery to eliminate the nerve problem), hematoma and blood transfusion were assessed as outcomes of the current systematic review and meta-analysis. Risk of bias was assessed using the Joanna Briggs Institute appraisal checklist according to the appropriate study design tools. Meta analysis of the data was done by using the Mantel Haenszel method with Comprehensive Meta-Analysis software (ver.2.2; Biostat, Englewood, NJ, USA). A fixed-effect model was used when there was no statistically significant difference in the heterogeneity (P<0.05); otherwise, a random-effect model was applied.

Twenty-three published articles were selected from a total 485 studies in the initial search. Most of the included studies were randomized control trials, and cohort studies. The articles were selected which mentioned the technique of passing the suture through the sacrospinous ligament. All of the included studies achieved a moderate to high quality based on the JBI critical appraisal checklist. The total prevalence of complications was 2.1% (95% CI: 1.3%-3.2%; Q-value: 831.45, I2:89.89%) in the random effect model. The rate of complications for each suture technique is summarized in the table 1. According to the results, the highest complications was observed in Capio (50%; 95% CI: 45.1%-57.0% in the fixed model, and 7.7% in random model analysis) among five eligible included studies. While the lowest complication (0.9%; 95% CI: 0.2%-4.6%) was observed in anchorsure among three included studies. In general, the prevalence of hematoma, blood transfusion, nerve injury, and reoperation were 2% (95%CI: 1%-3%) for both hematoma and blood transfusion, 6% (95% CI: 3%-11%) for nerve injury, and 1% for reoperation.

The total prevalence of complications was 2.1% in this systematic review. 
We found the highest complications in capio group because of immediate gluteal or posterior thigh pain from (about 45%) nerve injury, but just 15.3% were found to have persistent pain at 6 weeks.
And Five (2.1%)subject required intervention as physiotherapy, trigger point injection and no patient required reoperation.
We found higher hematoma formation and transfusion in direct visualization, deschamps and miya hook groups. this is not surprising because these mentioned SSLF methods require more dissection. There was not mortality or persistent morbidity in all 23 eligible studies.

The SSLF procedure has been reported to be an effective management option for patients with apical prolapse.
Several modifications and techniques of SSLF have been described in the literatures.
There is limited data for some utilized instruments like luarus, neuguide….
Low income countries choose reusable instruments like deschamp for repairing  apical prolapse.
Previous investigators have reported a low morbidity and mortality associated with this procedure.
On the other hand, our present review showed low complications with deferent techniques.
So it seems any techniques of SSLF based on  availability in deferent countries could be perform for pelvic organ prolapse repair.

Hanifi Sahin , Ibrahim Yalçin , Eda Adeviye Sahin , Mustafa Erkan Sari , Ali Ayhan. Outcome of sacrospinous ligament fixation with conventional instruments in the treatment of Stage 3-4 vaginal vault prolapse. Cukurova Medical Journal 2019;44(2):549-555
J. Pollak , P. Takacs , C. Medina. Complications of three sacrospinous ligament fixation techniques International Journal of Gynecology and Obstetrics (2007) 99, 18–22.
Cecile A. Unger, MD, MPH and Mark D. Walters, MD. Gluteal and Posterior Thigh Pain in the Postoperative Period and the Need for Intervention After SacrospinousLigament Colpopexy. Female Pelvic Medicine & Reconstructive Surgery & Volume 20, Number 4, July/August 2014