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Surgical Anatomy of Intrapelvic Fasciae and Vesico- Uterine Ligament in Nerve-Sparing Radical Hysterectomy with Fresh Cadaver Dissections

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Surgical Anatomy of Intrapelvic Fasciae and Vesico- Uterine Ligament in Nerve-Sparing Radical Hysterectomy with Fresh Cadaver Dissections Tohoku J. Exp. Med., Vesico-Uterine2007, 212, 403-413 Ligament in Nerve-Sparing Radical Hysterectomy 403 Surgical Anatomy of Intrapelvic Fasciae and Vesico- Uterine Ligament in Nerve-Sparing Radical Hysterectomy with Fresh Cadaver Dissections 1 1 1 1 HITOSHI NIIKURA, ATSUKO KATAHIRA, HIROKI UTSUNOMIYA, TADAO TAKANO, 1 1 1 1 KIYOSHI ITO, SATORU NAGASE, KOHSUKE YOSHINAGA, HIDEKI TOKUNAGA, 1 2 3 2 MASAFUMI TOYOSHIMA, YUSUKE KINUGASA, EIICHI UCHIYAMA, GEN MURAKAMI, 4 1 YOSHIHIKO YABUKI and NOBUO YAEGASHI 1Department of Gynecology and Obstetrics, Tohoku University School of Medicine, Sendai, Japan 2Department of Anatomy, Sapporo Medical University School of Medicine, Sapporo, Japan 3Department of Surgical Oncology, Tokyo Medical and Dental University, Tokyo, Japan 4Department of Gynecology and Obstetrics, Hokuriku Central Hospital, Oyabe, Japan NIIKURA, H., KATAHIRA, A., UTSUNOMIYA, H., TAKANO, T., ITO, K., NAGASE, S., YOSHINAGA, K., TOKUNAGA, H., TOYOSHIMA, M., KINUGASA, Y., UCHIYAMA, E., MURAKAMI, G., YABUKI, Y. and YAEGASHI, N. Surgical Anatomy of Intrapelvic Fasciae and Vesico-Uterine Ligament in Nerve-Sparing Radical Hysterectomy with Fresh Cadaver Dissections. Tohoku J. Exp. Med., 2007, 212 (4), 403-413 ── Radical hysterectomy has been per- formed for invasive cervical cancer, and autonomic nerve-sparing procedures have been developed to preserve bladder function. To perform and improve the nerve-sparing radical hysterectomy, it is important to understand anatomy of the intra pelvic fasciae, specially vesico-uterine ligament (VUL), because most of injuries to the nerves occurred during incision of the VUL in radical hysterectomy procedures. The objectives of the present study were to provide histological understanding of major structures found in nerve- sparing radical hysterectomy. Serial macroscopic slices (15-20 mm thick) from five female pelves were trimmed and prepared for paraffin-embedded histology. We noted an anatomi- cal entity as “the visceroparietal fascial bridge”, which corresponds with the macroscopi- cally identified arcus tendineus fasciae pelvis. A histologically identifiable neurovascular pedicle to the bladder neck corresponded with the deep portion of VUL. These findings could help better preservation of autonomic nerves during radical hysterectomy and improve patient’s quality of life after the operation. Translation of surgical anatomy into anatomic terminology enables us to have fruitful discussions with persuasive power by excluding any bias from individual surgeons. ──── vesico-uterine ligament; paracolpi- um; parietal fascia; levator ani; radial hysterectomy; autonomic nerve © 2007 Tohoku University Medical Press Radical hysterectomy has been performed serve bladder function. To perform and improve for invasive cervical cancer, and autonomic nerve- the nerve-sparing radical hysterectomy, it is sparing procedures have been developed to pre- important to understand anatomy of the intrapel- Received January 30, 2007; revision accepted for publication June 21, 2007. Correspondence: Hitoshi Niikura, M.D., Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan. e-mail: [email protected] 403 404 H. Niikura et al. Vesico-Uterine Ligament in Nerve-Sparing Radical Hysterectomy 405 vic fasciae, specially vesico-uterine ligament Kato et al. 2002). Additionally, we wanted to (VUL), because most of injuries to the nerves consider whether the VUL is visceral or parietal, occurred during incision of the VUL in radical giving weight to Ercoli’s recent classification of hysterectomy procedures (Katahira et al. 2005). the VUL as a third entity, extraserosal pelvic fas- The deep, posterior leaf (layer) of VUL is a cia, according to fresh cadaver dissections (Ercoli well-known structure developed during radical et al. 2005). Our surgical anatomical study clear- hysterectomy (Sakuragi et al. 2005; Yabuki et al. ly discriminates a definite parietal fascia covering 2005) that contains vesical veins draining into the the levator ani from other fasciae (Fröhlich et al. deep uterine vein (Fujii et al. 2007). Identification 1997). and division of the VUL’s deep layer are neces- sary to access a deep surgical space along the MATERIALS AND METHODS vagina, as well as mobilize the cervix. Recently, The study was undertaken within the provisions of our group reported that intrasurgical electrostimu- the Helsinki 1995 Declaration (Edinburgh revision lation of the VUL’s deep layer results in detrusor 2000); however, the project did not include a specific activity in the bladder (Katahira et al. 2005). protocol requiring approval by the institutional ethics Thus, the deep layer probably contains detrusor committees because the cadavers had already been nerve fibers and ganglions originating from the donated for such research use. The research protocol was approved by the ethics committees of Tohoku pelvic splanchnic nerve and going toward the University Graduate School of Medicine and Sapporo bladder neck via the pelvic plexus (Katahira et al. Medical School. 2007). Therefore, adequate treatment of the VUL Pelvic viscera including the uterus, vagina, distal deep layer may become the most critical step of ureter, urethra, and rectum were removed from five for- any nerve-sparing procedure. malin-fixed female cadavers (age, 72-85 years). Special The deep layer of the VUL has been clearly attention was paid to preserve the attachment of the leva- demonstrated using cadaveric dissections (Ercoli tor ani muscle to the visceral mass. Nearly frontal serial et al. 2005; Sakuragi et al. 2005; Yabuki et al. slices were made macroscopically (15-20 mm thick); 2005) as well as surgery. However, detailed slices were used to depict gross topographical relations descriptions of nerve elements, such as terms for among pelvic viscera and related structures by photo- localization of ganglion cells and immunohisto- graphs. This “nearly frontal plane” corresponded with a chemical characterization of nerve elements, frontal plane tilted almost 30° anteriorly (Tamakawa et require histologic terms corresponding with each al. 2003). A similar plane has been used to display a clear- step of dissection. A histological understanding cut topographical relation of female pelvic viscera such may provide in situ topographical relations as “the bladder at the second floor, the vagina at the first between the VUL and surrounding structures. floor and the rectum at the ground floor” (Peham and Moreover, in situ topographical relations repre- Amreich 1934). Conversely, it is difficult to include sented by histology may provide valuable insights these three major pelvic viscera in the actual frontal plane. In the present study, the anterior parts of the spec- on postoperative magnetic resonance imaging imen, including the urethra, distal vagina, and rectum, findings without inevitable inclusion of individual were cut at almost a right angle to the vaginal longitudi- surgeons’ bias (Höckol and Fritsch 2006). Thus, nal axis. Some macroscopic slices were trimmed and the first aim of the present study was to use histol- prepared for paraffin-embedded histology (10-20 μ m ogy to understand surgical anatomy at and around thick). All of those specimens overlapped sections pre- the VUL. In other words, we tried to represent pared for our previous work (Kato et al. 2002; Tamakawa surgical procedures with two-dimensional sec- et al. 2003; Kurihara et al. 2004). tions and interpret them using histologic and ana- Although the terminology for pelvic fasciae and lig- tomical terminology. Moreover, such study is aments has not yet systematically been determined (Ercoli able to reveal whether intrapelvic fasciae or liga- et al. 2005), we tried to work toward future consensus by ments carry an anatomical entity or is a surgically using terms very familiar in the literature for urologic developed artifact (Range and Woodburne 1964; and rectal surgery along with standard gynecological 404 H. Niikura et al. Vesico-Uterine Ligament in Nerve-Sparing Radical Hysterectomy 405 TABLE 1. Comparison between terminologies of intrapelvic spaces and fasciae and their histological entities. Gynecology; Urology or Rectal surgery; Histological entity Ligaments and fasciae # cardinal ligament; parametrium; largely, surgical artifact made of vascular sheaths in the parametrium (Kato et al. 2002), but partly, parts of the lateral ligament of the rectum (see below). # uterosacral ligament; Note: Morrow (2005) emphasized that this ligament does not attach to the sacrum; uterosacral peritoneal fold, parts of the lateral ligament of the rectum and parts of the presacral fascia; viscero-parietal fascial bridge at and near the ischial spine (Murakami and Kinugasa 2006) in part, and in the major parts, a surgically created structure from the piriformis fascia near the pelvic splanchnic nerves as well as from the hypogastric nerve sheath (Tamakawa et al. 2003). In addition, probably a connective tissue including the pelvic plexus. # superficial layer of the vesico-uterine ligament; vesico-uterine fold (Hinman 1993), meso-ureter, and parts of the parametrium; probably surgical artifact. # deep layer of the vesico-uterine ligament; rectovaginal fold (Hinman 1993) or lateral pelvic fascia; neurovascular pedicle containing the vesical veins; viscero-parietal fascial bridge. # lateral ligament of the rectum; the same as above; viscero-parietal fascial bridge at and near the ischial spine (Murakami and Kinugasa 2006)
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