4-2 Genital Anatomic Correlates

Kevin J. Stepp and Matthew D. Barber

The Cleveland Clinic Foundation uses a multidisciplinary surgeon. The anterior superior iliac spine is located ante- approach to the patient with pelvic floor dysfunction. What rior and laterally on the superior ileum. This is easily follows is intended to be a clinical resource for surgical identifiable in all patients and is a clinically useful land- for the pelvic surgeon. This section will cover the mark. The is fused to the . The medial surface anatomic relationships of the , , viscera of of the ilium has two concavities forming the lateral borders the , and their supportive structures as they relate to the of the . The superior and larger of the two is female reproductive tract.A detailed discussion of the urinary the greater sciatic notch. Inferiorly is the lesser sciatic tract and colorectal anatomy is provided elsewhere. A thor- notch. They are separated by a projection medially, called ough mastery of the anatomic concepts presented here will the . The ischial spine is important clinically serve as a foundation for clinical examination and surgical and anatomically because it can be palpated easily through repair of pelvic floor dysfunction and pelvic organ prolapse. a vaginal, rectal, or retropubic approach, and many sup- portive structures attach to it. The ischial spine is useful as a fixed point to describe the relative position of other Bones of the Pelvis anatomic structures. The superior and inferior pubic rami are located anteri- The bones of the pelvis are the rigid foundation to which orly and articulate in the midline at the pubic . all of the pelvic structures are ultimately anchored. It is The ridge along the superior, medial surface of the important to understand and discuss the bony pelvis from superior pubic rami is called the , or Cooper’s the perspective of a standing woman. In the standing posi- . tion, forces are dispersed to minimize the pressures on the In the standing position, the anterior superior iliac spine pelvic viscera and musculature and disperse the forces to and are in the same vertical plane (Figure the bones that are better suited to the long-term, cumula- 4-2.2). This directs the pressure of the intraabdominal and tive stress of daily life. In the upright position, the pubic pelvic contents toward the bones of the pelvis instead of the rami are oriented in an almost vertical plane. Similar to the muscles and endopelvic fascia attachments of the pelvic supports of an archway or bridge, the weight of the woman floor.The posterior surface of the symphysis is located is transmitted along these bony supports to her femurs. in a plane approximately 2 to 3cm inferior to the ischial Where the pubic rami articulate in the midline, they are spine.Therefore,a line drawn connecting the two structures nearly horizontal.Much of the weight of the abdominal and would be almost horizontal in the standing position. pelvic viscera is supported by the bony articulation inferi- Strong ligaments hold the bones together. The ligaments orly. In this way, increases in intraabdominal pressures are of the sacroiliac are rarely encountered during partially supported by the bony pelvis. surgery for pelvic floor dysfunction and are not addressed The pelvic bones are the ilium, ischium, pubic rami, here. The is a strong, easily , and (Figure 4-2.1). The sacrum is com- identifiable ligament that extends from the ischial spine to posed of five sacral vertebrae that are fused together. The the distal sacrum. The ligament fans out to attach on the nerve foramina are positioned anterior and laterally. Over- S1-S4 vertebrae. This ligament divides the lateral pelvic lying the middle of the sacrum is a rich neurovascular bed. outlet into two foramina, the greater sciatic foramen supe- The coccyx is attached inferiorly and is the posterior riorly and the lesser sciatic foramen inferiorly. This is an border of the pelvic outlet. important location for identifying the course of the puden- Attached to the sacrum are the ilium, ischium, and pubic dal nerve, artery, and vein, and will be discussed later in rami. Several landmarks are important to the pelvic the chapter. 79 80 Anatomic Correlates

Anterior Inferior Pubic Ramus Superior Ischial lliac Spine Tuberosity Pubic Symphysis

Sacrospinous Sacrospinous Ligament Ligament Sacrospinous Ligament (cut) Coccyx a b

Figure 4-2.1. Bones and ligaments of the pelvis. a, Front view; b, lithotomy view. (Reprinted with the permission of The Cleveland Clinic Foundation.)

Muscles of the Pelvic Sidewalls and Pelvic Floor

The obturator internus and piriformis make up the pelvic sidewalls. The is a fibrous membrane that covers the obturator foramen. The obturator internus muscle lies on the superior (intrapelvic) side of the obtu- rator membrane. The obturator internus origin is on the Sacral Promontory Greater inferior margin of the superior pubic ramus and the pelvic Sciatic Foramen surface of the obturator membrane. Its tendon passes Anterior through the lesser sciatic foramen to insert onto the greater Superior lliac Spine trochanter of the femur to laterally rotate the . The obturator internus receives its innervation from the obtu- rator nerve originating from L5-S2. The obturator vessels and nerve pass through the anterior and lateral border of the obturator membrane to their destination in the adduc- tor compartment of the leg. The piriformis is part of the pelvic sidewall and is Sacrospinous Ligament located dorsal and lateral to the coccygeus. It extends from the anterolateral sacrum to pass through the greater sciatic foramen and insert on the greater trochanter. Lying on top

Sacrotuberous of the piriformis is a particularly large neurovascular Ligament Obturator plexus, the lumbosacral plexus. Foramen There is a linear thickening of the fascial covering of Lesser Sciatic the obturator internus muscle called the arcus tendineus Foramen Ischial Ischial Spine levator ani. This thickened fascia forms an identifiable line Tuberosity from the ischial spine to the posterior surface of the ipsi- lateral pubic ramus. The muscles of the levator ani origi- nate from this musculofascial attachment (Figure 4-2.3). The skeletal muscles of the pelvic floor include the Figure 4-2.2. Bones and ligaments of the pelvis (sagittal view).The dashed line repre- levator ani muscles, the coccygeus muscle, the external sents the vertical plane of the anterior superior iliac spine and pubic symphysis. The arrows represent the distribution of weight of the spinal column and abdominal anal sphincter, the striated urethral sphincter, and the contents and along the ilium. (Reprinted with the permission of The Cleveland Clinic superficial perineal muscles (bulbocavernosus, ischiocav- Foundation.) ernosus, and transverse perinea). The levator ani muscle Genital Anatomic Correlates 81

tribute to fecal continence. Some of the fibers of the muscle may blend with the muscularis of the vagina and rectum. The pubococcygeus has a similar origin, but inserts in the

Ischial Spine midline onto the anococcygeal raphe and the anterolateral borders of the coccyx. The iliococcygeus extends along the arcus tendineus levator ani from the pubis to the ischial Piriformus Muscle spine to insert in the midline onto the anococcygeal raphe. The coccygeus, although not part of the levator ani, does make up the posterior part of the pelvic floor and has a role Arcus Tendineus Levator Ani in support. Its origin is on the ischial spine and sacrospinous ligament. It inserts on the lateral lower

Coccygeus sacrum and coccyx and overlies the sacrospinous ligament. Muscle The muscle becomes thin and fibrous with age. The coc- cygeus often blends with the sacrospinous ligament and, Ileococcygeus because they have the same origin and insertion, it can be Muscle difficult to distinguish the two. Anococcygeal Pubic The space between the levator ani musculature through Raphe Symphasis which the urethra, vagina, and rectum pass is called the Pubococcygus and Puborectalis levator hiatus. The fusion of levator ani where they meet in Arcus Tendineus External Anal Sphincter Perineal Fascia Pelvis the midline creates the levator plate.The levator plate forms Membrane the basis for pelvic support as will be discussed in detail later in this chapter. The levator ani may be very thin and atten- Figure 4-2.3. Muscles of the pelvis (sagittal view). (Reprinted with the permission of The uated, especially in patients with pelvic organ prolapse. Cleveland Clinic Foundation.) Nerves of the Pelvis complex consists of the puborectalis, pubococcygeus, and Although the muscles of the pelvic floor were initially iliococcygeus muscles (Figure 4-2.4). thought to have innervation both from direct branches of The puborectalis has an attachment to the posterior infe- the sacral nerves on the pelvic surface and via the puden- rior pubic rami and arcus tendineus levator ani. Its fibers dal nerve on the perineal surface, recent anatomic, neuro- pass posteriorly forming a sling around the vagina, rectum, physiologic,and experimental evidence indicates that these and perineal body to form the anorectal angle and con- standard descriptions are inaccurate and that the levator ani muscles are innervated solely by a nerve traveling on the superior (intrapelvic) surface of the muscles without contribution of the pudendal nerve1,2 (Figure 4-2.5). Barber et al.1 performed systematic cadaver dissections to characterize the nerve supply to the pelvic floor muscles. Pubococcygeus Urethra Vagina The nerve supplying the coccygeus muscle and the levator Muscle Arcus Tendineus Cooper’s Ligament Fascia Pelvis ani muscles (all three) originates from S3,S4,and/or S5.The Obturator Obturator Canal and nerve exits the foramina and travels 2 to 3cm medial to the Internus Neurovascular Bundle Muscle and ischial spine and arcus tendineus levator ani across the Fascia Arcus coccygeus, iliococcygeus, pubococcygeus, and puborectalis Tendineus muscles. The nerve is sometimes firmly embedded in the Levator Ani fascia of the muscles or may be loosely attached during its course. There are small branches that penetrate the body of each muscle as the nerve traverses them. Occasionally, a Rectum separate nerve comes directly from S5 to innervate the pub- Ileococcygeus Muscle orectalis muscle. The piriformis receives innervation Ischial Spine directly from sacral nerves (motor efferent) from L5-S2. Coccygeus In the pelvis, the sympathetic nerves to the pelvis origi- Muscle nate at the T5 to L2 spinal level and act to promote storage Piriformis Levator Muscle Plate by causing relaxation of the bladder and rectum and con- traction of the smooth muscle components of the urethral and anal sphincter. The parasympathetic nerve supply to Figure 4-2.4. Muscles of the pelvis (abdominal view).(Reprinted with the permission of The the pelvic viscera originates from the second, third, and Cleveland Clinic Foundation.) fourth sacral nerves. The parasympathetic nerves combine 82 Anatomic Correlates Vagina

Iliolumbar Artery Aorta Posterior Division The human vagina is a fibromuscular tube specialized for of Internal Iliac Common Iliac Artery Artery reception of the penis during coitus and delivery of the Lateral developed fetus during parturition. It needs to be mobile Sacral Artery Ureter and distensible. The upper two-thirds of the vagina is almost horizontal in the standing position. In contrast, the lower one-third is nearly vertical. Superior Histologically, the vaginal wall is composed of three Gluteal External Artery lliac layers. The most superficial layer is stratified squamous Artery epithelium. The middle layer is the lamina propria and Umbilical consists of collagen and elastin. The lamina propria con- Middle Artery Rectal tains no glands.Vaginal lubrication is via a transudate from Artery Obliterated the vessels, cervix, and from the Bartholin’s and Skene’s Umbilical Artery glands. Coursing through the lamina propria are small Pudendal Artery blood vessels. The innermost layer is the muscularis that

Superior consists of smooth muscle. The histology of the vaginal Vaginal Vesicle Artery Artery layers may change with menopause. Obturator The presence of a true fascia between the vagina and Neurovascular adjacent organs has been debated. Although at the time of Bundle Levator Ani surgery there appears to be an identifiable fascial plane, Nerve Uterine 2 3 Artery Weber and Walters and DeLancey have concluded that there is no fascia present histologically. Between adjacent organs is primarily vaginal muscularis. However, an exten- Figure 4-2.5. Nerves and vessels of the pelvis. (Reprinted with the permission of The Cleve- sion of the connective tissue of the perineal body forms land Clinic Foundation.) what some have called the rectovaginal fascia. This tissue extends 2 to 3cm cephalad from the hymenal ring along the posterior vaginal wall. with the hypogastric plexus and pelvic sympathetic nerves to form the pelvic nerve plexus. This plexus of nerves leaves the sacral surface to fan out on either side of the rectum approximately 3 to 4cm superior to the pelvic floor The perineum is divided into two compartments: muscles, then disperse throughout the pelvis through the superficial and deep. These are separated by a fibrous con- endopelvic fascia. nective tissue layer called the perineal membrane. The Pelvic floor muscles have constant tone except during borders of the perineum are the ischiopubic rami, ischial voiding,defecation,and during the Valsalva maneuver.This tuberosities, sacrotuberous ligaments, and coccyx. A line activity serves as a constant support for the pelvic viscera. connecting the ischial tuberosities divides the perineum The levator muscles and the skeletal components of the into the urogenital triangle anteriorly and the anal trian- urethral and anal sphincters all have the ability to contract gle posteriorly. quickly at the time of an acute stress, such as a cough or The perineal body marks the point of convergence of the sneeze, to maintain continence. bulbospongiosus muscles, superficial and deep transverse Because of the nerves’ undefined course and small size, perinei, perineal membrane, external anal sphincter, iatrogenic damage during pelvic surgery is possible. This posterior vaginal muscularis, and the insertion of the pub- may produce a range of effects both sensory and motor in orectalis and pubococcygeus muscles. The bulbospongio- nature. Radical hysterectomy and rectal resection are sus originates on the inferior surface of the superior pubic common causes of pelvic plexus injury resulting in bowel rami and the crura of the clitoris. It inserts on the perineal and/or bladder dysfunction. body, where its fibers blend with the superficial transverse perinei, and external anal sphincter. It is innervated by the pudendal nerve. The superficial transverse perinei are Viscera bilateral muscles that extend from the medial ischial tuberosities to insert on the perineal body. Some fibers The organs of the female upper reproductive tract are the blend with the bulbospongiosus and the external anal uterus, cervix, ovaries, and fallopian tubes. The structure sphincter. It is innervated by the pudendal nerve. The and function of these organs, except as it relates to pelvic ischiocavernosus originate from the medial ischial floor dysfunction, will not be covered in this chapter. tuberosities and ischiopubic rami. They insert on the infe- Genital Anatomic Correlates 83

External Pudendal Artery

Internal Pudendal Artery

Bulbospongiosis Muscle Ischiocavernosus Inferior Muscle Pubic Ramus

Innervation of the Ilioinguinal Nerve

Innervation of the Perineal Membrane Pudendal Nerve (Urogenital Diaphragm)

Ischial Spine

Superficial Transverse Perineal Muscle

Sacrotuberous Ligament

Pudendal Nerve and Branches Perineal - Clitoral Body Gluteus Maximus Figure 4-2.6. Perineal anatomy with - Perineal Muscle Martius flap inset. The distribution of the - Inferior Rectal Levator Ani pudendal and ilioinguinal innervation is shown.The inset shows the dual vascular External Anal supply to the labial fat pad used during a Sphincter Martius flap procedure. (Reprinted with the permission of The Cleveland Clinic Foundation.) rior aspect of the pubic angle and are innervated by the with rich collateral anastomosis: clitoral,perineal,and infe- pudendal nerve. rior rectal. It is this rich collateral anastomosis that allows The deep perineal compartment is composed of the deep a Martius flap to be utilized by pelvic surgeons. A Martius transverse perineal muscles, portions of the external ure- flap receives its rich blood supply anteriorly and posteri- thral sphincter muscles (compressor urethrae and ure- orly from branches of the external and internal pudendal throvaginal sphincter), portions of the anal sphincter, and arteries, respectively (Figure 4-2.6, inset). Details of the the vaginal musculofascial attachments. anus, urethral sphincter, and external anal sphincter, The neurovascular anatomy of the perineum is illus- and their continence mechanisms are discussed in trated in Figure 4-2.6. The motor and sensory innervation Chapters 4-1 and 4-3. of the perineum is via the pudendal nerve. The pudendal nerve originates from S2-S4 and exits the pelvis through the greater sciatic foramen, hooks around the ischial spine, Mechanisms of Support then reenters the pelvis through the lesser sciatic foramen. It then travels along the medial surface of the obturator The normal axis of the pelvic organs in the standing internus, through the ischiorectal fossa in a thickening of woman places the vagina and rectum directly over the fascia called Alcock’s canal. It emerges posterior and levator plate. The levator plate and muscles of the pelvic medial to the where it pierces the per- floor therefore support the pelvic organs. The remainder of ineal membrane and divides into three branches to supply this section will describe the structures and attachments the perineum: clitoral,perineal,and inferior rectal (inferior that keep the pelvic organs in the proper orientation so that hemorrhoidal). Damage to the pudendal nerve (i.e., birth they may be supported by the pelvic floor musculature. trauma) can result in denervation of the periurethral The endopelvic fascia is the loose connective tissue muscles involved in reflex contraction during increased network appearance of the retroperitoneum that envelops intraabdominal pressure resulting in stress urinary all of the organs of the pelvis and connects them loosely to incontinence. the supportive musculature and bones of the pelvis. The The blood supply to the perineum is from the pudendal term endopelvic fascia is used here to describe the tissues artery, which travels with the pudendal nerve to exit the located between the surfaces of the peritoneum, muscles, pelvis. Similar to the nerve, there are three main branches and pelvic organs. Histologically, it is composed of colla- 84 Anatomic Correlates gen, elastin, adipose tissue, nerves, vessels, lymph channels, pubic rami over the origin of the puborectalis muscle. The and smooth muscle. Its properties provide stabilization arcus tendineus fascia pelvis or “white line” is a thickened and support, yet allow for the mobility of the viscera to condensation of the parietal fascia into which the par- permit storage of urine and stool, coitus, parturition, and avaginal endopelvic fascia connects, supporting and creat- defecation. ing the anterior lateral vaginal sulci. Furthermore, the axis Several areas of the endopelvic fascia (and its associated of both of the arcus tendineus levator ani and the arcus peritoneum) have been named by anatomists. These are tendineus fascia pelvis are nearly horizontal in the stand- really condensations of the endopelvic fascia and not true ing woman, creating the normal axis of the vagina. Anteri- ligaments: uterosacral ligament, cardinal ligament, broad orly, the endopelvic fascia blends with the vaginal ligament, mesovarium, mesosalpinx, and the round liga- muscularis and is continuous with the supportive struc- ment. The broad ligament, mesovarium, mesosalpinx, and tures of the urethra (see Chapter 4-1). round ligament do not have a role in support of the pelvic Similar to the anterior paravaginal supports, there are organs. posterior lateral supports as well (Figure 4-1.4 Figure DeLancey5 described vaginal support in three levels (see 4-2.7). These fibers blend with the vaginal muscularis ante- Figure 4-1.4 in Chapter 4-1).Level I refers to the uterosacral riorly, rectal muscularis posteriorly, and the perineal body ligament/cardinal ligament complex and is the most cepha- inferiorly. The lateral endopelvic fascia attachments of the lad supporting structures. Level II support is provided by posterior vaginal wall do not have significant connections the paravaginal attachments along the length of the vagina. across the midline. Rather, they anchor the posterior lateral Level III support describes the most inferior or distal por- vaginal sulci to the ipsilateral levator ani.4 tions of the vagina including the perineum. Each of these The endopelvic fascia extends from posterior lateral areas has a significant role in maintaining pelvic organ vagina sulci posteriorly around the rectum to attach the support and will be discussed individually. It is, however, vagina to the pelvic floor. The posterior vaginal muscularis important to remember that levels I, II, and III are all con- is attached through this endopelvic fascia to the fascia of nected through continuation of the endopelvic fascia. the levator ani laterally at the arcus tendineus rectovagi- Comprising level I support, the cardinal and uterosacral nalis.6 The arcus tendineus rectovaginalis represents a con- ligaments attach to the cervix from the lateral and poste- densation of the parietal fascia of the levator ani coursing rior sides, respectively, with fibers intermingling. The car- from the perineal body inferiorly, along the levator ani dinal ligament blends with the uterosacral ligament and laterally, where it intersects the midpoint of the arcus they are difficult, if not impossible, to precisely delineate tendineus fascia pelvis. The arcus tendineus rectovaginalis from one another. Fibers traveling predominately laterally is approximately 4cm in length. The connection to the make up the cardinal ligament, whereas fibers going to the arcus tendineus rectovaginalis creates the change in axis sacrum make up the uterosacral ligament. These fibers toward vertical of the distal vagina. form a three-dimensional complex attaching the upper vagina, cervix, and lower uterine segment to the sacrum and lateral pelvic sidewalls at the piriformis, coccygeus, and the levator ani and perhaps the obturator internus fascia overlying the ischial spine. Together, the uterosacral/ cardinal ligament complex supports the cervix and upper vagina to maintain vaginal length and keep the vaginal axis nearly horizontal so that it rests on the rectum and can be supported by the levator plate. This keeps the cervix just superior to the level of the ischial spine. Contiguous with the uterosacral/cardinal ligament complex at the location of the ischial spine is level II support – the paravaginal attachments. These are the con- nections of the lateral vagina and endopelvic fascia to the arcus tendineus fascia pelvis anteriorly and the arcus tendineus rectovaginalis posteriorly – level II support func- tions to keep the vagina midline directly over the rectum. The arcus tendineus fascia pelvis is similar in composi- tion to the arcus tendineus levator ani. It, however, arises from the levator ani fascia rather than that of the obtura- tor internus. Similar to the arcus tendineus levator ani, it Figure 4-2.7. Photomicrograph of posterior wall attachments. Note the fibers of the originates on the ischial spine; however, as it approaches endopelvic fascia that are attached (outlined by dots) to the lateral sulcus of the poste- rior vaginal wall. OI, obturator internus muscle; LAM, levator ani muscle. (Reprinted from the pubic symphysis, the arcus tendineus fascia pelvis American Journal of Obstetrics and Gynecology,Vol 180,JOL DeLancey,Structural anatomy of the pos- travels medially and inferiorly to the arcus tendineus terior pelvic compartment as it relates to rectocele,p 815–823,© 1999 Mosby,with permission from levator ani, inserting on the inferior aspect of the superior Elsevier) Genital Anatomic Correlates 85

Figure 4-2.8. Perineal attachments of the perineal membrane to the inferior pubic rami and direction of tension on fibers uniting through the perineal body (arrows). (Reprinted from American Journal of Obstetrics and Gynecology, Vol 180, JOL Delancey, © Structural anatomy of the posterior pelvic compartment as it relates to rectocele, p 815–823 1999 Mosby, with permission from Elsevier)

Level III support is provided by the perineal body, per- stress is relieved from the lateral paravaginal attachments. ineal membrane, superficial and deep perineal muscles, Furthermore, in times of acute stress, such as a cough or and endopelvic fascia. These structures support and main- sneeze, there is a reflex contraction of the pelvic floor tain the normal anatomic position of the distal one-third musculature countering and further stabilizing the viscera. of the vagina. The condensation of connective tissue at the The genital hiatus responds by narrowing to maintain level point of convergence of the level III structures, distal III support. With pelvic floor weakness, such as with neu- rectum, levator ani, and distal level II attachments forms ropathic injury or mechanical muscular damage, the the perineal body. The perineal body is critical for support endopelvic fascia then becomes the primary mechanism of of the lower part of the vagina and proper function of the support.Over time,this stress can overcome the endopelvic anal canal. The perineal membrane anchors the perineal fascial attachments and result in loss of the normal body and distal vagina laterally and anteriorly to the anatomic position through breaks, stretching, or attenua- ischiopubic rami (Figure 4-2.8). According to DeLancey,4 tion of endopelvic fascia supports. This can result in “When the distal rectum is subjected to increased force changes in the vector forces applied to the viscera and may directed caudally, the fibers of the perineal membrane lead to pelvic organ prolapse and/or dysfunction. Recre- become tight and resist further displacement.” Separation ation of these supportive connections and proper position of the perineal body from the perineal membrane results of the organs while maintaining adequate vaginal length to in perineal decent and can contribute to defecatory keep the vaginal apex in a natural position should be the dysfunction. goal of pelvic reconstructive surgery. The three levels of support are connected and inter- dependent. Level III structures are connected to the endopelvic fascia that surrounds the vagina and rectum Surgical Correlates and are therefore continuous with level II support. Level II support is connected to level I support through the Iliococcygeus and Sacrospinous Vaginal confluence of the lateral endopelvic fascia attachments Vault Suspension and the uterosacral ligament/cardinal ligament complex. Adequate support at all levels maintains the pelvic organs Figure 4-2.9 illustrates the proper suture placement for in their normal anatomic positions. vault suspension to the iliococcygeus muscle and to the When the vagina, bladder, and rectum are kept in the sacrospinous ligament. Note the relationship to surround- horizontal plane over the levator plate and pelvic floor ing structures, notably the pudendal vessels and nerve. muscles, intraabdominal and gravitational forces are During an iliococcygeus vaginal vault suspension, sutures applied perpendicular to the vagina and pelvic floor while are placed 1 to 2cm medial and 1cm inferior to the ischial the pelvic floor musculature counters those forces with its spine. To suspend the vaginal vault to the sacrospinous constant tone. It is this horizontal position and support by ligament, sutures are placed 1cm medial and 1cm cepha- the levator ani that maintain pelvic organ support. With lad to the ischial spine to avoid damage to the underlying proper tone of the pelvic floor muscles (levator ani), the vessels and nerve. 86 Anatomic Correlates

Figure 4-2.9. Surgical correlates – iliococcygeus and sacrospinous vaginal vault sus- pension. A, Location of suture placement for sacrospinous ligament fixation. B, Location of suture placement for iliococcygeus vaginal vault suspension. (Reprinted with the permission of The Cleveland Clinic Foundation.)

Figure 4-2.10. Surgical correlates – ureter anatomy in relation to the uterus and vaginal apex at total vaginal hysterectomy. Upward traction on the bladder during Ureter Anatomy in Relation to the Uterus and vaginal hysterectomy increases the distance of the ureter away from the area of clamp Vaginal Apex at Total Vaginal Hysterectomy placement. (Reprinted with the permission of The Cleveland Clinic Foundation.) and Anterior Repair

In 1962, Hofmeister and Wolfgram7 showed that while per- forming a vaginal hysterectomy the ureter is 1.5 to 2.1cm from the cervix and 1.0cm from the infundibular liga- ments. During anterior colporrhaphy, sutures can be as close as 0.9cm from the ureter. Figure 4-2.10 illustrates a simple maneuver to increase the safe distance between the cervix and the ureter by 1cm during vaginal hysterectomy by using a right-angled retractor placed in the vesicovagi- nal septum.

Anatomy Surrounding the Uterosacral Ligament

Knowledge of the anatomy surrounding the uterosacral lig- ament is paramount to safety when performing vault sus- pension procedures involving the ligament. Figure 4-2.11 illustrates the close proximity of the ureter and vasculature to the uterosacral ligament. The ureter is closest to the uterosacral ligament at its distal end – approximately 1cm. Figure 4-2.11. Surgical correlates – anatomy surrounding the uterosacral ligament The ureter diverges laterally as the uterosacral ligament is when an Allis clamp is applied at the time of vaginal vault suspension. (Reprinted with the traced toward the sacrum. At the level of the spine, the permission of The Cleveland Clinic Foundation.) Genital Anatomic Correlates 87 ureter is approximately 2.3cm lateral to the uterosacral lig- 3. Weber AM, Walters MD. Anterior vaginal prolapse: review of ament.8 Note the location of the middle rectal and superior anatomy and techniques of surgical repair. Obstet Gynecol gluteal vessels beneath the uterosacral ligament. When 1997;89:331–338. 4. DeLancey JOL. Structural anatomy of the posterior pelvic com- using the uterosacral ligament for suspension procedures, partment as it relates to rectocele. Am J Obstet Gynecol 1999;180: the surgeon should understand the course and proximity 815–823. of these adjacent structures. 5. DeLancey JOL. Anatomic aspects of vaginal eversion after hysterec- tomy. Am J Obstet Gynecol 1992;166:17–28. 6. Leffler KS, Thompson JR, Cundiff GW, Buller JL, Burrows LJ, Schon References Ybarra MA.Attachment of the rectovaginal septum to the pelvic side- wall. Am J Obstet Gynecol 2001;185:41–43. 1. Barber MD, Bremer RE, Thor KB, Dolber PC, Kuehl TJ, Coates KW. 7. Hofmeister FJ, Wolfgram RC. Methods of demonstrating measure- Innervation of the female levator ani muscles. Am J Obstet Gynecol ment relationships between vaginal hysterectomy ligatures and the 2002;187:64–71. ureters. Am J Obstet Gynecol 1962;83:938–948. 2. Pierce LM, Reyes M, Thor KB, et al. Innervation of the levator ani 8. Buller JL, Thompson JR, Cundiff GW, et al. Uterosacral ligament: muscles in the female squirrel monkey. Am J Obstet Gynecol 2003; description of anatomic relationships to optimize surgical safety. 188:1141–1147. Obstet Gynecol 2001;97:873–879.