Nerve injury during uterosacral ligament fixation: a cadaver study

Ex Vivo Uniaxial Tensile Properties of Rat Uterosacral Ligaments

This manuscript presents new experimental methods for testing the ex vivo tensile properties of the uterosacral ligaments (USLs) in rats. The USL specimens ([Formula: see text]) were carefully dissected to preserve their anatomical attachments, and they were loaded along their main in vivo loading direction (MD) using a custom-built uniaxial tensile testing device. During loading, strain maps in both the MD and the perpendicular direction (PD) were collected using the digital image correlation technique. The mean (± S.E.M.) maximum load and displacement at the maximum load were [Formula: see text] N and [Formula: see text] mm, respectively. The USLs were found to be highly heterogeneous structures, with some specimens experiencing strains in the MD that were lower than [Formula: see text] and others reaching strains that were up to [Formula: see text] in the intermediate region. At 0.5 kPa stress, a value reached by all the specimens, the mean strain in the MD was [Formula: see text] while at 5 kPa stress, a value achieved only by 9 out of the 21 specimens, the mean strain increased to [Formula: see text]. Under uniaxial loading, the specimens also elongated in the PD, with strains that were one order of magnitude lower than the strains in the MD; at the 0.5 kPa stress, the mean strain in the PD was recorded to be [Formula: see text] and, at the 5 kPa stress, the strain in the PD was [Formula: see text]. The directions of maximum principal strains remained almost unchanged with the increase in stress, indicating that little microstructural re-organization occurred due to uniaxial loading. This study serves as a springboard for future investigations on the supportive function of the USLs in the rat model by offering guidelines on testing methods that capture their complex mechanical behavior.

Mechanics of Uterosacral Ligaments: Current Knowledge, Existing Gaps, and Future Directions

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.

Standardized terminology of apical structures in the female pelvis based on a structured medical literature review

The objectives of this study were to review the published literature and selected textbooks, to compare existing usage to that in Terminologia Anatomica, and to compile standardized anatomic nomenclature for the apical structures of the female pelvis. MEDLINE was searched from inception until May 30, 2017, based on 33 search terms generated by group consensus. Resulting abstracts were screened by 11 reviewers to identify pertinent studies reporting on apical female pelvic anatomy. Following additional focused screening for rarer terms and selective representative random sampling of the literature for common terms, accepted full-text manuscripts and relevant textbook chapters were extracted for anatomic terms related to apical structures. From an initial total of 55,448 abstracts, 193 eligible studies were identified for extraction, to which 14 chapters from 9 textbooks were added. In all, 293 separate structural terms were identified, of which 184 had Terminologia Anatomica-accepted terms. Inclusion of several widely used regional terms (vaginal apex, adnexa, cervico-vaginal junction, uretero-vesical junction, and apical segment), structural terms (vesicouterine ligament, paracolpium, mesoteres, mesoureter, ovarian venous plexus, and artery to the round ligament) and spaces (vesicocervical, vesicovaginal, presacral, and pararectal) not included in Terminologia Anatomica is proposed. Furthermore, 2 controversial terms (lower uterine segment and supravaginal septum) were identified that require additional research to support or refute continued use in medical communication. This study confirms and identifies inconsistencies and gaps in the nomenclature of apical structures of the female pelvis. Standardized terminology should be used when describing apical female pelvic structures to facilitate communication and to promote consistency among multiple academic, clinical, and surgical disciplines.

Anatomy and histology of apical support: a literature review concerning cardinal and uterosacral ligaments

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.

A novel transvaginal approach to correct recurrent apical prolapse after failed sacral colpopexy: case series

INTRODUCTION AND HYPOTHESIS

The objective of the study was to describe the transvaginal approach utilizing the existing sacral colpopexy (SC) graft for recurrent apical prolapse following failed SC.

METHODS

Twenty-two patients with recurrent vaginal vault prolapse following a prior SC were treated between January 2000 and December 2009. Twelve patients had a standard uterosacral ligament cuff suspension (USLS) performed. In ten patients, the vaginal cuff was suspended to the left uterosacral ligament and reattached to the graft material from the prior SC. One of these ten subsequently failed and a standard USLS was performed. Patient characteristics, preoperative pelvic floor assessment, operative information, and postoperative follow-up were collected. Cases in which the graft material was used were compared with those undergoing standard USLS.

RESULTS

Demographic characteristics and preoperative Baden-Walker scores were similar. Of 23 cases, 21 (91 %) were a consequence of graft separation from the vagina and not the sacrum. Two of nine patients with follow-up where the SC graft was utilized transvaginally had recurrent prolapse. One required reoperation. Of 13 patients in the group that underwent traditional USLS, 2 had asymptomatic recurrent anterior prolapse; neither required additional surgery.

CONCLUSIONS

A transvaginal surgical approach for recurrent vaginal prolapse after a history of failed abdominal SC should be considered. If feasible, the SC graft material can be used when performing USLS instead of the right uterosacral ligament for these patients with a prior history of abdominal SC.

[Symptomatic approach to chronic neuropathic somatic pelvic and perineal pain]

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).

Abdominal, laparoscopic, and robotic surgery for pelvic organ prolapse

Abdominal correction of pelvic organ prolapse remains a viable option for patients and surgeons. The transition from open procedures to less invasive laparoscopic and robotic-assisted surgeries is evident in the literature. This article reviews the surgical options available for pelvic organ prolapse repair and their reported outcomes. Procedures reviewed include apical support (sacral, uterosacral, and others), and abdominal anterior and posterior vaginal wall support. Long-term follow-up and appropriately designed studies will further help direct surgeons in deciding which approach to incorporate into their practice.