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Meriwether KV. At the Scrub Sink: Uterosacral Ligament Suspension. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024; 30:4-6. [PMID: 37882073 DOI: 10.1097/spv.0000000000001420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
ABSTRACT Uterosacral ligament suspension for repair of prolapse has some challenges, such as visualization in the vagina, choice of suture, and avoidance of dangers such as ureteral kinking. This editorial offers some tips for performing a uterosacral suspension that are commonly discussed "at the scrub sink" before a case.
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Affiliation(s)
- Kate V Meriwether
- From the Department of Obstetrics & Gynecology, University of New Mexico, Albuquerque, NM
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Sun X, Chen Y, Zhong Y, Chen X, Shi H, Liu J, Cai L, Sun P. Recently urodynamic and quality of life assessment in the non-menopausal women with cervical cancer after radical hysterectomy. Support Care Cancer 2023; 31:389. [PMID: 37300713 DOI: 10.1007/s00520-023-07823-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/18/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE The aim of this study was to evaluate the pre- and postoperative changes in the recently urodynamic and quality of life (QoL) in nonmenopausal women diagnosed with cervical cancer and treated with radical hysterectomy (RH). PATIENTS AND METHODS Twenty-eight nonmenopausal women (28-49 years) with cervical carcinoma (FIGO stage Ia2-IIa) underwent a radical hysterectomy. Urodynamic studies were performed 1 week before (U0) and 3-6 months (U1) after surgery. A self-administered condition-specific QoL questionnaire (PFDI-20, PFIQ-7) was applied at U0 and U1. RESULTS Data from the urodynamics analysis performed at U1 showed that the average first sensation volume (119.39 ± 12.28 ml vs 150.43 ± 31.45 ml, P < 0.001), the residual urine volume (6.39 ± 10.44 ml vs. 42.32 ± 33.72 ml, P < 0.001), and the time of urination (46.10 ± 16.65 s vs. 74.31 ± 23.94 s, P < 0.001) were increased, while the bladder volume at a strong desire to void (448.89 ± 86.62 ml vs. 322.82 ± 50.89 ml, P < 0.001), the bladder compliance (82.63 ± 58.06 ml/cmH2O vs. 37.45 ± 28.66 ml/cmH2O, P < 0.001), the average flow rate (Qave) (23.86 ± 4.25 ml/s vs. 12.57 ± 2.37 ml/s, P < 0.001), the maximum natural flow rate (Qmax) (25.42 ± 6.46 ml/s vs. 14.43 ± 5.32 ml/s, P < 0.001), and the pressure at a peak flow rate (PdetQmax) (36.53 ± 11.20 cmH2O vs. 31.43 ± 10.56 cmH2O, P < 0.05) were decreased. At the same time, functional pelvic problems derived from prolapse (PFDI-20 scores) and their impact on the patients' Qol (PFIQ-7 score) were significantly improved at 3-6 months postoperation. CONCLUSION Radical hysterectomy results in urodynamic changes, and 3-6 months postoperation may be an important period for changes in bladder dysfunction after RH. Urodynamic and QoL analyses may provide methods for assessing symptoms.
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Affiliation(s)
- XiaoQi Sun
- Department of Gynaecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, No 18. Dao Shan Road, Fuzhou, 350001, Fujian Province, China
| | - YaoJia Chen
- Laboratory of Gynecologic Oncology, Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, No. 18 Daoshan Road, Fuzhou, 350001, China
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, No. 18 Daoshan Road, Fuzhou, 350001, China
| | - YanLing Zhong
- Department of Gynaecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, No 18. Dao Shan Road, Fuzhou, 350001, Fujian Province, China
| | - XianJing Chen
- Department of Gynaecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, No 18. Dao Shan Road, Fuzhou, 350001, Fujian Province, China
| | - HuiQin Shi
- Department of Gynaecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, No 18. Dao Shan Road, Fuzhou, 350001, Fujian Province, China
| | - Jing Liu
- Department of Gynaecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, No 18. Dao Shan Road, Fuzhou, 350001, Fujian Province, China
| | - LiangZhi Cai
- Department of Gynaecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, No 18. Dao Shan Road, Fuzhou, 350001, Fujian Province, China.
| | - PengMing Sun
- Department of Gynaecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, No 18. Dao Shan Road, Fuzhou, 350001, Fujian Province, China.
- Laboratory of Gynecologic Oncology, Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, No. 18 Daoshan Road, Fuzhou, 350001, China.
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, No. 18 Daoshan Road, Fuzhou, 350001, China.
- Laboratory of Gynaecologic Oncology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.
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Donaldson K, Thomas J, Zhu Y, Clark-Deener S, Alperin M, De Vita R. In-plane and out-of-plane deformations of gilt utero-sacral ligaments. J Mech Behav Biomed Mater 2022; 131:105249. [PMID: 35526346 DOI: 10.1016/j.jmbbm.2022.105249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/07/2022] [Accepted: 04/17/2022] [Indexed: 11/27/2022]
Abstract
The uterosacral ligaments (USLs) are supportive structures of the uterus and apical vagina. The mechanical function of these ligaments within the pelvic floor is crucial not only in normal physiological conditions but also in reconstructive surgeries for pelvic organ prolapse. Discrepancies in their anatomical and histological description exist in the literature, but such discrepancies are likely due to large variations of these structures. This makes mechanical testing very challenging, requiring the development of advanced methods for characterizing their mechanical properties. This study proposes the use of planar biaxial testing, digital image correlation (DIC), and optical coherence tomography (OCT) to quantify the deformations of the USLs, both in-plane and out-of-plane. Using the gilts as an animal model, the USLs were found to deform significantly less in their main direction (MD) of in vivo loading than in the direction perpendicular to it (PD) at increasing equibiaxial stresses. Under constant equibiaxial loading, the USLs deform over time equally, at comparable rates in both the MD and PD. The thickness of the USLs decreases as the equibiaxial loading increases but, under constant equibiaxial loading, the thickness increases in some specimens and decreases in others. These findings could contribute to the design of new mesh materials that augment the support function of USLs as well as noninvasive diagnostic tools for evaluating the integrity of the USLs.
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Affiliation(s)
- Kandace Donaldson
- Department of Biomedical Engineering and Mechanics, Virginia Tech, 330A Kelly Hall, 325 Stanger Street, Blacksburg, VA, 24061, USA
| | - Joseph Thomas
- Department of Electrical and Computer Engineering, Virginia Tech, 460 Turner Street, Suite 303, Blacksburg, VA, 24061, USA
| | - Yizheng Zhu
- Department of Electrical and Computer Engineering, Virginia Tech, 460 Turner Street, Suite 303, Blacksburg, VA, 24061, USA
| | - Sherrie Clark-Deener
- Department of Large Animal Clinical Sciences, Virginia Tech, 215 Duckpond Drive, Blacksburg, VA, 24061, USA
| | - Marianna Alperin
- Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Female Medicine and Reconstructive Surgery, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Raffaella De Vita
- Department of Biomedical Engineering and Mechanics, Virginia Tech, 330A Kelly Hall, 325 Stanger Street, Blacksburg, VA, 24061, USA.
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Ku CW, Ong I, Chan JKY, Ee TX. Abdominal heterotopic pregnancy post-IVF double embryo transfer. BMJ Case Rep 2022; 15:15/2/e246649. [PMID: 35131787 PMCID: PMC8823037 DOI: 10.1136/bcr-2021-246649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Uterosacral ligament (USL) is an uncommon site of implantation for abdominal ectopic pregnancies. This is the first case of USL heterotopic pregnancy post invitro fertilisation (IVF). The patient presented 6 weeks after a double embryo transfer with acute onset abdominal pain and was diagnosed with a suspected live tubal ectopic pregnancy with a viable intrauterine pregnancy on ultrasound. A diagnostic laparoscopy revealed an ectopic pregnancy implanted on the left USL which was resected and confirmed on histology. The patient was discharged well on postoperative day 2 with a viable intrauterine pregnancy. This case highlights the importance of considering non-tubal heterotopic pregnancies in the context of risk factors including IVF with double embryo transfer presenting with abdominal pain.
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Affiliation(s)
- Chee Wai Ku
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Isabella Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jerry Kok Yen Chan
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tat Xin Ee
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
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Donaldson K, Huntington A, De Vita R. Mechanics of Uterosacral Ligaments: Current Knowledge, Existing Gaps, and Future Directions. Ann Biomed Eng 2021; 49:1788-1804. [PMID: 33754254 DOI: 10.1007/s10439-021-02755-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/17/2021] [Indexed: 12/11/2022]
Abstract
The uterosacral ligaments (USLs) are important anatomical structures that support the uterus and apical vagina within the pelvis. As these structures are over-stretched, become weak, and exhibit laxity, pelvic floor disorders such as pelvic organ prolapse occur. Although several surgical procedures to treat pelvic floor disorders are directed toward the USLs, there is still a lot that is unknown about their function. This manuscript presents a review of the current knowledge on the mechanical properties of the USLs. The anatomy, microstructure, and clinical significance of the USLs are first reviewed. Then, the results of published experimental studies on the in vivo and ex vivo, uniaxial and biaxial tensile tests are compiled. Based on the existing findings, research gaps are identified and future research directions are discussed. The purpose of this exhaustive review is to help new researchers navigate scientific literature on the mechanical properties of the USLs. The use of these structures remains very popular in reconstructive surgeries that restore and augment the support of pelvic organs, especially as synthetic surgical mesh implants continue to be highly controversial.
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Rexhepi S, Rexhepi E, Stumm M, Mallmann P, Ludwig S. Laparoscopic Bilateral Cervicosacropexy and Vaginosacropexy: New Surgical Treatment Option in Women with Pelvic Organ Prolapse and Urinary Incontinence. J Endourol 2019; 32:1058-1064. [PMID: 30244596 PMCID: PMC6247383 DOI: 10.1089/end.2018.0474] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective: Sacrocolpopexy (SCP) is the gold standard for apical prolapse treatment. However, the technical performance of each SCP is strongly dependent on the surgeon's own discretion and comparison of clinical outcomes with respect to urinary incontinence (UI) is difficult. We developed a comprehensible laparoscopic surgical technique for the treatment of apical prolapse with UI. Methods: A total of 120 women with UI underwent laparoscopic bilateral SCP for apical prolapse. Thereby, the uterosacral ligaments (USLs) were bilaterally replaced by polyvinylidene fluoride (PVDF) tapes of identical length and shape, which were fixed at defined anatomical landmarks (cervix/vaginal vault and S1). Results: The restoration of apical vaginal support was achieved in 116 patients (97%); restoration failed in the first 4 patients owing to the use of fast-absorbable sutures. Seventy-eight patients (65%) with mixed and urgency UI symptoms before surgery achieved continence. The mean hospitalization was 3 days; no major complications were observed intraoperatively. Conclusion: The advantage of laparoscopic cervicosacropexy (laCESA) and laparoscopic vaginosacropexy (laVASA) lies in the comprehensible surgical technique (clearly defined technique) and the minimal amount of material used (no polypropylenes). The possibility of a short operating time and short hospitalization depicts this laparoscopic bilateral USL replacement as one treatment alternative in patients with apical prolapse suffering from UI.
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Affiliation(s)
- Sokol Rexhepi
- 1 Department of Obstetrics and Gynecology, Hospital Eichstätt , Eichstätt, Germany
| | - Entela Rexhepi
- 1 Department of Obstetrics and Gynecology, Hospital Eichstätt , Eichstätt, Germany
| | - Martin Stumm
- 2 Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Cologne , Köln, Germany
| | - Peter Mallmann
- 2 Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Cologne , Köln, Germany
| | - Sebastian Ludwig
- 2 Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Cologne , Köln, Germany
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Paz-Levy D, Yohay D, Neymeyer J, Hizkiyahu R, Weintraub AY. Native tissue repair for central compartment prolapse: a narrative review. Int Urogynecol J 2016; 28:181-189. [PMID: 27209309 DOI: 10.1007/s00192-016-3032-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 04/19/2016] [Indexed: 11/28/2022]
Abstract
Central descent due to a level 1 defect is a main component in pelvic organ prolapse (POP) reconstructive surgery, whether for symptomatic apical prolapse or for the prolapse repair of other compartments. A recent growth in the rate of native tissue repair procedures for POP, following the US Food and Drug Administration (FDA) warnings regarding the safety and efficacy of synthetic meshes, requires a re-evaluation of these procedures. The safety, efficacy, and determination of the optimal surgical approach should be the center of attention. Functional outcome measures and patient-centered results have lately gained importance and received focus. A comprehensive literature review was performed to evaluate objective and subjective outcomes of apical prolapse native tissue repair, with a special focus on studies reporting impact on patients' functional outcomes, quality of life, and satisfaction. We performed a MEDLINE search for articles in the English language by using the following key words: apical prolapse, sacrospinous ligament fixation, uterosacral ligament suspension, sacral colpopexy, McCall culdoplasty, iliococcygeus vaginal fixation, and functional outcomes. We reviewed references as well. Despite a prominent shortage of studies reporting standardized prospective outcomes for native tissue repair interventions, we noted a high rate of safety and efficacy, with a low complication rate for most procedures and low recurrence or re-treatment rates. The objective and subjective results of different procedures are reviewed. Functional outcomes of native tissue repair procedures have not been studied sufficiently, though existing data present those procedures as favorable and not categorically inferior to sacrocolpopexy. Apical compartment prolapse repair using native tissue is not a compromise. Functional outcomes of native tissue repair procedures are favorable, have a high rate of success, improve women's quality of life (QoL), and result in high rates of patient satisfaction. This subject requires further long-term, standardized prospective studies following the International Continence Society/International Urogynecologists Association guidelines for surgical outcomes report, with the focus on patient-centered functional outcomes.
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Affiliation(s)
- Dorit Paz-Levy
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - David Yohay
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Joerg Neymeyer
- Department of Urology, Charitè University, Berlin, Germany
| | - Ranit Hizkiyahu
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Adi Y Weintraub
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
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Maldonado PA, Stuparich MA, McIntire DD, Wai CY. Proximity of uterosacral ligament suspension sutures and S3 sacral nerve to pelvic landmarks. Int Urogynecol J 2016; 28:77-84. [DOI: 10.1007/s00192-016-3039-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/02/2016] [Indexed: 11/24/2022]
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Lamblin G, Delorme E, Cosson M, Rubod C. Cystocele and functional anatomy of the pelvic floor: review and update of the various theories. Int Urogynecol J 2015; 27:1297-305. [PMID: 26337427 DOI: 10.1007/s00192-015-2832-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 08/14/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We updated anatomic theories of pelvic organ support to determine pathophysiology in various forms of cystocele. METHODS PubMed/MEDLINE, ScienceDirect, Cochrane Library, and Web of Science databases were searched using the terms pelvic floor, cystocele, anatomy, connective tissue, endopelvic fascia, and pelvic mobility. We retrieved 612 articles, of which 61 matched our topic and thus were selected. Anatomic structures of bladder support and their roles in cystocele onset were determined on the international anatomic classification; the various anatomic theories of pelvic organ support were reviewed and a synthesis was made of theories of cystocele pathophysiology. RESULTS Anterior vaginal support structures comprise pubocervical fascia, tendinous arcs, endopelvic fascia, and levator ani muscle. DeLancey's theory was based on anatomic models and, later, magnetic resonance imaging (MRI), establishing a three-level anatomopathologic definition of prolapse. Petros's integral theory demonstrated interdependence between pelvic organ support systems, linking ligament-fascia lesions, and clinical expression. Apical cystocele is induced by failure of the pubocervical fascia and insertion of its cervical ring; lower cystocele is induced by pubocervical fascia (medial cystocele) or endopelvic fascia failure at its arcus tendineus fasciae pelvis attachment (lateral cystocele). CONCLUSIONS Improved anatomic knowledge of vaginal wall support mechanisms will improve understanding of cystocele pathophysiology, diagnosis of the various types, and surgical techniques. The two most relevant theories, DeLancey's and Petros's, are complementary, enriching knowledge of pelvic functional anatomy, but differ in mechanism. Three-dimensional digital models could integrate and assess the mechanical properties of each anatomic structure.
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Affiliation(s)
- Géry Lamblin
- Département de Chirurgie Urogynécologique, Hôpital Femme Mère Enfant, Université Claude Bernard Lyon 1, Villeurbanne, France.
- Faculté de Médecine Henri Warembourg, Université Lille 2, 42 Rue Paul Duez, 59000, Lille, France.
- Department of Urogynecology, Femme Mère Enfant University Hospital, 59 Boulevard Pinel, 69677, Lyon-Bron, France.
| | - Emmanuel Delorme
- Service de Chirurgie Urologique, Hôpital Privé Sainte Marie, 4 Allée Saint Jean des Vignes, 71100, Chalon-sur-Saône, France
| | - Michel Cosson
- Faculté de Médecine Henri Warembourg, Université Lille 2, 42 Rue Paul Duez, 59000, Lille, France
- Clinique de Chirurgie Gynécologique, Hôpital Jeanne de Flandre, Université Lille 2, Avenue E Avinée, 59037, Lille Cedex, France
| | - Chrystèle Rubod
- Faculté de Médecine Henri Warembourg, Université Lille 2, 42 Rue Paul Duez, 59000, Lille, France
- Clinique de Chirurgie Gynécologique, Hôpital Jeanne de Flandre, Université Lille 2, Avenue E Avinée, 59037, Lille Cedex, France
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Recognition and management of nerve entrapment pain after uterosacral ligament suspension. Obstet Gynecol 2012; 120:292-5. [PMID: 22825087 DOI: 10.1097/aog.0b013e31826059f7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate the incidence, risk factors, and characteristics of neuropathic pain related to nerve entrapment after uterosacral ligament suspension. METHOD A review of patients who underwent uterosacral ligament suspension from January 2007 to August 2011 was performed. Patients with neuropathic pain attributable to nerve entrapment from uterosacral ligament suspensory suture placement were identified. Factors including surgeon's dominant hand, side of pain, onset of pain, day of suture removal, number of sutures placed and removed, patient age, and body mass index (BMI) were collected. Follow-up of patients with neuropathic pain was performed at postoperative visits and by telephone contact. RESULT Eight (1.6%) of 515 patients had neuropathic pain requiring suture removal from the affected side. The postoperative pain was recognized after discontinuation of intravenous narcotics on postoperative day 1. Patients reported their pain improved after removal of all sutures on the affected side. Patients with neuropathic pain did not differ from those without in regard to age, BMI, and preoperative prolapse stage, or in the number of sutures placed. None of the eight had recurrent pelvic organ prolapse (POP), with a median follow-up of 5 months. CONCLUSION Eight patients (1.6%) had postoperative neuropathic pain that resolved after all sutures were removed on the affected side. The removal of sutures was not associated with recurrent POP in the short-term. LEVEL OF EVIDENCE II.
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Anatomy and histology of apical support: a literature review concerning cardinal and uterosacral ligaments. Int Urogynecol J 2012; 23:1483-94. [PMID: 22618209 DOI: 10.1007/s00192-012-1819-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 04/24/2012] [Indexed: 01/01/2023]
Abstract
The objective of this work was to collect and summarize relevant literature on the anatomy, histology, and imaging of apical support of the upper vagina and the uterus provided by the cardinal (CL) and uterosacral (USL) ligaments. A literature search in English, French, and German languages was carried out with the keywords apical support, cardinal ligament, transverse cervical ligament, Mackenrodt ligament, parametrium, paracervix, retinaculum uteri, web, uterosacral ligament, and sacrouterine ligament in the PubMed database. Other relevant journal and textbook articles were sought by retrieving references cited in previous PubMed articles. Fifty references were examined in peer-reviewed journals and textbooks. The USL extends from the S2 to the S4 vertebra region to the dorsal margin of the uterine cervix and/or to the upper third of the posterior vaginal wall. It has a superficial and deep component. Autonomous nerve fibers are a major constituent of the deep USL. CL is defined as a perivascular sheath with a proximal insertion around the origin of the internal iliac artery and a distal insertion on the cervix and/or vagina. It is divided into a cranial (vascular) and a caudal (neural) portions. Histologically, it contains mainly vessels, with no distinct band of connective tissue. Both the deep USL and the caudal CL are closely related to the inferior hypogastric plexus. USL and CL are visceral ligaments, with mesentery-like structures containing vessels, nerves, connective tissue, and adipose tissue.
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Sensory neuropathy following suspension of the vaginal apex to the proximal uterosacral ligaments. Int Urogynecol J 2012; 23:1735-40. [PMID: 22588137 DOI: 10.1007/s00192-012-1810-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Accepted: 04/22/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Reports of sensory neuropathy attributed to uterosacral ligament suspension (USLS) have emerged. The objectives of this study were to assess the rate of sensory neuropathy symptoms following transvaginal USLS at a single institution during a 5-year period and to describe the evaluation, management, and outcomes in these patients. METHODS A retrospective review of records identified 278 women who underwent transvaginal USLS during the study period. Inpatient and outpatient records within the first 4 weeks postsurgery were reviewed. Women with new-onset buttock and/or lower-extremity pain, numbness, weakness or a combination of these symptoms were identified. Demographic data, intraoperative data, and management modalities and outcomes were collected. RESULTS Nineteen (6.8 %) women met criteria for inclusion. The most common symptom was buttock pain (73.7 % of cases). Pain radiation to the ipsilateral posterior thigh was present in 11 cases (57.9 %). The majority of women (73.7 %) reported pain symptoms on the right side. Conservative treatment modalities were initially implemented in all women. Four women (21 %) underwent suture removal a median of 1.75 months after USLS. Full symptom resolution was reported in 13 (68.4 %) women a median of 6 months after USLS. The remaining women experienced partial symptom resolution with ongoing conservative management. CONCLUSIONS Sensory neuropathy is common in women who undergo transvaginal USLS. As quality of life may be significantly affected, any symptoms of buttock or lower-extremity pain in the immediate postoperative period warrant a thorough evaluation and close follow-up, with early suture removal consideration.
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Apte G, Nelson P, Brismée JM, Dedrick G, Justiz R, Sizer PS. Chronic Female Pelvic Pain-Part 1: Clinical Pathoanatomy and Examination of the Pelvic Region. Pain Pract 2011; 12:88-110. [DOI: 10.1111/j.1533-2500.2011.00465.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rigaud J, Delavierre D, Sibert L, Labat JJ. [Management of chronic postoperative pelvic and perineal pain due to parietal somatic nerve damage]. Prog Urol 2010; 20:1158-65. [PMID: 21056398 DOI: 10.1016/j.purol.2010.08.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Accepted: 08/16/2010] [Indexed: 12/01/2022]
Abstract
INTRODUCTION All surgical procedures require an incision with a risk of nerve damage at the site of the scar or as a result of fibrotic scar tissue. The purpose of this article is to describe the management of chronic postoperative pelvic and perineal pain due to parietal somatic nerve damage. PATIENTS AND METHODS A comprehensive review of the literature was performed by searching PUBMED for articles on the management of chronic postoperative pelvic and perineal pain due to parietal somatic nerve damage. RESULTS Postoperative lesions of parietal somatic nerves (ilioinguinal, iliohypogastric, genitofemoral, pudendal, obturator, femoral) are frequent after pelvic surgery. Clinical examination of the scars (trigger zone) and detailed analysis of the topography and type of pain are essential elements in the analysis of this pain. Infiltration of local anaesthetic at the trigger point or along the nerve has a diagnostic value. Corticosteroid infiltrations and minimally invasive treatments such as pulsed radiofrequency have provided more or less lasting improvement of the symptoms. Surgical nerve release together with resection of fibrosis and removal of prosthetic material provides good long-term results. The surgical approach depends on the nerve concerned and the level of the lesion. CONCLUSION The management of chronic postoperative pelvic and perineal pain due to parietal somatic nerve damage is based on local infiltration of anaesthetics and corticosteroids. Nerve release surgery with resection of fibrosis provides the best long-term results.
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Affiliation(s)
- J Rigaud
- Clinique urologique, centre fédératif de pelvipérinéologie, hôpital Hôtel-Dieu, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France.
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Labat JJ, Robert R, Delavierre D, Sibert L, Rigaud J. [Symptomatic approach to chronic neuropathic somatic pelvic and perineal pain]. Prog Urol 2010; 20:973-81. [PMID: 21056374 DOI: 10.1016/j.purol.2010.08.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Accepted: 08/16/2010] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine the characteristics of neuropathic pain and the somatic nerve lesions most frequently encountered in the context of chronic pelvic and perineal pain. MATERIAL AND METHODS Review of the literature devoted to pelvic and perineal neuralgia. RESULTS The diagnosis of pelvic and perineal pain related to a somatic nerve lesion is essentially clinical. The topography of the pain and its characteristics (burning, paraesthesia, etc.) can help to link the pain to the neurological territory involved. Complementary investigations are poorly contributive. Two main systems are involved in this region: sacral nerve roots that give rise to the pudendal nerve and the posterior cutaneous nerve of the thigh, thoracolumbar nerve roots that give rise to the ilioinguinal, iliohypogastric, genitofemoral and obturator nerves. The first system is essentially perineal and the second is essentially anterior inguinoperineal. DISCUSSION Pudendal neuralgia is the most common and most disabling form of pelvic pain. It presents as unilateral or bilateral burning pain of the anterior or posterior perineum that is worse on sitting and relieved by standing, not usually associated with night pain. It is related to a ligamentous nerve compression mechanism. Inferior cluneal neuralgia tends to be experienced as ischial and lateroperineal pain, and is sometimes accompanied by pain in a truncated sciatic territory, corresponding to projections of the posterior cutaneous nerve of the thigh. This neuralgia can be related to a piriformis syndrome or an ischial lesion. Sacral nerve root lesions do not cause acute pain, but are accompanied by sacral sensory loss and urinary, anorectal or sexual disorders. Pain related to ilioinguinal, iliohypogastric and genitofemoral nerves is generally secondary to surgical trauma and scars. Although these various lesions are sometimes difficult to distinguish from each other, an essential part of management consists of performing a local anesthetic block at the trigger point detected in the scar. Referred pain derived from the spinal cord due to thoracolumbar painful minor intervertebral dysfunction is experienced in the inguinal region, pubis, labium majorum and sometimes the trochanter, and only a complete clinical examination of the thoracolumbar region can demonstrate local signs (posterior facet joint pain at several levels, fibromyalgia).
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Affiliation(s)
- J-J Labat
- Centre fédératif de pelvipérinéologie, clinique urologique, CHU Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes, France.
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Vu D, Haylen BT, Tse K, Farnsworth A. Surgical anatomy of the uterosacral ligament. Int Urogynecol J 2010; 21:1123-8. [PMID: 20458468 DOI: 10.1007/s00192-010-1147-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Accepted: 03/05/2010] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND HYPOTHESIS This study aims to elucidate and expand current knowledge of the uterosacral ligament (USL) from a surgical viewpoint. METHODS Studies were performed on 12 unembalmed cadaveric pelves and five formalin-fixed pelves. RESULTS The USL, 12-14-cm long, can be subdivided into three sections: (1) distal (2-3 cm), intermediate (5 cm), and proximal (5-6 cm). The thick (5-20 mm) distal section, attached to cervix and upper vagina, is confluent laterally with the cardinal ligament. The proximal section is diffuse in attachment and generally thinner. The relatively unattached intermediate section is wide, and thick, well defined when placed under tension, more than 2 cm from the ureter and suitable for surgical use. The strength of the USL is perhaps derived not only from the ligament itself, but also from the addition of extraperitoneal connective tissue. CONCLUSIONS The USL can be subdivided into three sections according to thickness and attachments with the intermediate section suitable for surgical use, particularly for vaginal vault support.
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Affiliation(s)
- Dzung Vu
- School of Medical Sciences, University of New South Wales, Kensington, NSW, Australia
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High levator myorraphy versus uterosacral ligament suspension for vaginal vault fixation: a prospective, randomized study. Int Urogynecol J 2010; 21:515-22. [DOI: 10.1007/s00192-009-1064-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Accepted: 11/19/2009] [Indexed: 11/26/2022]
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Schön Ybarra MA, Gutman RE, Rini D, Handa VL. Etiology of post-uterosacral suspension neuropathies. Int Urogynecol J 2009; 20:1067-71. [PMID: 19399353 DOI: 10.1007/s00192-009-0894-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 04/05/2009] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The goal of our investigation was to find a neurological explanation for neuropathies reported following some uterosacral ligament suspension (USLS) [2-3]. METHODS We dissected the neural structures beneath the USL in seven female, adult, embalmed cadavers. We made a literature review to determine the spinal nerve sensory fiber composition of each exposed neural structure and the dermatome(s) that it innervates. We then compared anticipated sensory neuropathies for each neural structure with neuropathies following USLS to determine which neural structure entrapment could explain the reported symptoms. RESULTS Several neural structures located beneath the uterosacral ligament (USL) are vulnerable to suture entrapment during USLS. Anticipated clinical outcomes of entrapments are discussed. CONCLUSIONS Entrapment of S2 sensory fibers in the second trunk of the sacral plexus or in the intrapelvic portion of the sciatic nerve is the most plausible etiology for reported neuropathies following USLS.
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Affiliation(s)
- M A Schön Ybarra
- Department of Art as Applied to Medicine and Cell Molecular Medicine Program, Johns Hopkins University School of Medicine, 1830 E. Monument St., Suite 7000, Baltimore, MD, USA.
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Uterosacral ligament vaginal vault suspension: anatomy, outcome and surgical considerations. Curr Opin Obstet Gynecol 2009; 20:484-8. [PMID: 18797273 DOI: 10.1097/gco.0b013e32830eb8c6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW With aging populations, primary pelvic organ and recurrent pelvic organ prolapse have become a large-scale public health concern. Surgical options for patients include both abdominal and vaginal approaches, each with its own safety and efficacy profiles. This review summarizes the most recent anatomic, surgical and outcome data for uterosacral ligament vault suspension. It offers data on methods to avoid complications and difficult surgical scenarios. RECENT FINDINGS Uterosacral ligament suspension allows reattachment of the vaginal vault high within the pelvis. New modifications in technique including the extraperitoneal and laparoscopic approaches allow surgeons more freedom when planning surgery. Five-year data on the durability of the procedure make it a viable surgical option. SUMMARY As a technique widely used by many pelvic reconstructive surgeons, uterosacral ligament vault suspension provides a safe, anatomically correct and durable approach to uterine and vault prolapse. It requires advanced surgical training and an intimate understanding of pelvic anatomy to avoid and identify ureteral injury.
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Collins SA, Downie SA, Olson TR, Mikhail MS. Nerve injury during uterosacral ligament fixation: a cadaver study. Int Urogynecol J 2009; 20:505-8. [PMID: 19172214 DOI: 10.1007/s00192-009-0803-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Accepted: 01/02/2009] [Indexed: 10/21/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective of this study was to identify nerve(s) vulnerable to entrapment during uterosacral ligament fixation (USLF), which could cause postoperative lower extremity pain previously described in the literature. METHODS Preserved cadavers in a medical anatomy course were used. Before the students' pelvic dissections, a 2-0 prolene suture was placed in the middle third of each left uterosacral ligament visualized. The sutures were re-evaluated at the end of the course. RESULTS Nine sutures remained in place after the course, and one entrapped a nerve. It was part of the inferior hypogastric plexus, included fibers from S2 and S3, and radiated to the bladder and rectum. The posterior femoral cutaneous nerve was lateral and posterior to this nerve. CONCLUSIONS The inferior hypogastric plexus is vulnerable during USLF. Entrapment of S2 and S3 fibers could cause pain in their respective dermatomes and could be responsible for the postoperative pain previously described.
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Affiliation(s)
- Sarah A Collins
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, Bronx, New York, NY, USA.
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Shahryarinejad A, Vardy MD. Comparison of Human to Macaque Uterosacral–Cardinal Ligament Complex and Its Relationship to Pelvic Organ Prolapse. Toxicol Pathol 2008. [DOI: 10.1177/0192623308327115] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The uterosacral–cardinal ligament complex is thought to be the critical structure responsible for uterine and apical vaginal support. It is ill defined and can be difficult to dissect in the cadaver lab and in the operating room. Even less information is available on the analogous structures in the monkey model. We present this report to bring together what little is known to aid in studying this model and pelvic organ prolapse (POP), and to point out the need for critical assessment of this hormone-responsive tissue in the process of drug development. Competing Interests: This article was sponsored by Covance Inc. and Schering-Plough. The authors did not declare any other competing interests.
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Affiliation(s)
- Azin Shahryarinejad
- Mount Sinai School of Medicine, Department of Obstetrics and Gynecology, New York, New York, USA
| | - Michael David Vardy
- Mount Sinai School of Medicine, Department of Obstetrics and Gynecology, New York, New York, USA
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Ramanah R, Parratte B, Arbez-Gindre F, Maillet R, Riethmuller D. The uterosacral complex: ligament or neurovascular pathway? Anatomical and histological study of fetuses and adults. Int Urogynecol J 2008; 19:1565-70. [DOI: 10.1007/s00192-008-0692-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Accepted: 07/07/2008] [Indexed: 11/30/2022]
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Altman D, Falconer C, Cnattingius S, Granath F. Pelvic organ prolapse surgery following hysterectomy on benign indications. Am J Obstet Gynecol 2008; 198:572.e1-6. [PMID: 18355787 DOI: 10.1016/j.ajog.2008.01.012] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Revised: 11/15/2007] [Accepted: 01/11/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of the study was to determine the risk for pelvic organ prolapse surgery attributed to hysterectomy on benign indications STUDY DESIGN In a nationwide longitudinal study, 162,488 women with hysterectomy from 1973 through 2003 were matched to 470,519 population-based control women. Hazard ratios (HR) with 95% confidence interval (CI) were calculated using Cox regression analyses. RESULTS In all, 3.2% (n = 5270) of women with hysterectomy had pelvic organ prolapse surgery, compared with 2.0% (n = 9437) in nonhysterectomized controls. Compared with nonhysterectomized controls, the overall HR for prolapse surgery was 1.7 (95% CI, 1.6 to 1.7) with the highest risks observed in women having had a vaginal hysterectomy (HR 3.8; 95% CI, 3.1 to 4.8). Compared with hysterectomized women with no vaginal births, the HR for prolapse surgery was 2.0 (95% CI, 0.9 to 4.1) among women with 1 vaginal childbirth and 11.3 (95 % CI, 6.0. to 21.1) among women with at least 4 vaginal births. CONCLUSION Hysterectomy is associated with an increased risk for subsequent pelvic organ prolapse surgery with multiparous women at particular risk.
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Affiliation(s)
- Daniel Altman
- Department of Medical Epidemiology and Biostatistics, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.
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Uterosacral ligament suspension sutures: Anatomic relationships in unembalmed female cadavers. Am J Obstet Gynecol 2007; 197:672.e1-6. [PMID: 18060977 DOI: 10.1016/j.ajog.2007.08.065] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2007] [Revised: 05/16/2007] [Accepted: 08/27/2007] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The objective of the study was to characterize anatomic relationships of uterosacral ligament suspension (USLS) sutures. STUDY DESIGN The relationship of USLS sutures to the ureters, rectal lumen, and sidewall neurovascular structures was examined in 15 unembalmed female cadavers. RESULTS The mean distance of the proximal sutures to the ureters and rectal lumen was 14 mm (range, 0-33) and 10 mm (range, 0-33), respectively. The mean distance of the distal sutures to the ureters was 14 mm (range, 4-33) and to the rectal lumen 13 mm (range, 3-23). Right sutures were noted at the level of S1 in 37.5%, S2 in 37.5%, and S3 in 25% of specimens. Left sutures were noted at the level of S1 in 50%, S2 in 29.2%, and S3 in 20.8% of cadavers. Of 48 sutures passed, 1 entrapped the S3 nerve. Sutures perforated the pelvic sidewall vessels in 4.1% of specimens. CONCLUSION USLS sutures can directly injure the ureters, rectum, and neurovascular structures in the pelvic walls.
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Altman D, Granath F, Cnattingius S, Falconer C. Hysterectomy and risk of stress-urinary-incontinence surgery: nationwide cohort study. Lancet 2007; 370:1494-9. [PMID: 17964350 DOI: 10.1016/s0140-6736(07)61635-3] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hysterectomy for benign indications has been associated with an increased risk for lower-urinary-tract sequela, but results have been inconclusive. We aimed to establish the risk for stress-urinary-incontinence surgery after hysterectomy for benign indications. METHODS We did a nationwide, population-based, cohort study from 1973 to 2003 in Sweden. We identified our population from the Swedish Inpatient Registry. We selected 165 260 women who had undergone hysterectomy (exposed cohort) and a control group of 479 506 individuals who had not had this procedure (unexposed cohort), matched by year of birth and county of residence. In both cohorts, occurrence of stress-urinary-incontinence surgery was established from the Swedish Inpatient Registry. Hazard ratios with 95% CIs were calculated by Cox's proportional-hazards regression. FINDINGS During the 30-year observational period, the rate of stress-urinary-incontinence surgery per 100,000 person-years was 179 (95% CI 173-186) in the exposed cohort versus 76 (73-79) in the unexposed cohort. Correspondingly, individuals in the exposed cohort were at increased risk for stress-urinary-incontinence surgery compared with those in the unexposed cohort (hazard ratio 2.4; 95% CI 2.3-2.5), irrespective of surgical technique. Risk for stress-urinary-incontinence surgery varied slightly with time of follow-up: the highest overall risk was recorded within 5 years of surgery (2.7; 2.5-2.9) and the lowest risk was seen after an observation period of 10 years or more (2.1, 1.9-2.2). INTERPRETATION Hysterectomy for benign indications, irrespective of surgical technique, increases the risk for subsequent stress-urinary-incontinence surgery. Women should be counselled on associated risks related to hysterectomy, and other treatment options should be considered before surgery.
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Affiliation(s)
- Daniel Altman
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
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