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) in part, and largely, a surgically created bundle containing peripheral branches of the pelvic plexus and middle rectal vessels (Takahashi et al. 2000). # rectovaginal septum; Denonvilliers’ fascia; a visceral fascia between pelvic viscera. # pubovesical ligament; the same as above; viscero-parietal fascial bridge between bladder neck and levator ani. # pubo-urethral ligament; the same as above; note: Vazzoler divided it into three parts (Vazzoler et al. 2002); no distinct connection but circularly arrayed fibrous tissues with venous plexus. # short fibrous band; white line or arcus tendineus fasciae pelvis; viscero-parietal fascial bridge.

Spaces # paravesical space; posterolateral continuation of the retropubic space; loose connective tissues between bladder and parietal fascia along the levator ani. # cranial chamber of the pararectal space; parts of the mesorectum; the same as above (rectal side of the viscero-parietal fascial bridge). # caudal chamber of the pararectal space; parts of the mesorectum and a space between the piriformis fascia and proper rectal fascia; the same as above. # paraprocticum; mesorectum; a loose fatty tissue around the rectum and surrounded by the proper rectal fascia or a kind of vascular sheath along the superior rectal vessels.

terms (Table 1). nective tissue sheath around the pelvic plexus loosely communicated with fasciae around the RESULTS parametrial vessels and nerves (i.e., neurovascular In our cadavers, the superior, or intrapelvic, sheaths), especially around the deep uterine vein. surface of the levator ani was covered by a defi- However, we did not find any fascial structures nite parietal fascia that corresponds with the encircling the whole parametrium. “endopelvic fascia” cited in urology (Hinman The rectum was surrounded by loose fatty 1993; Takenaka et al. 2005). In sections across tissue corresponding with the mesorectum cited in the cervix uteri, the pelvic plexus was identified rectal surgery (Heald and Moran 1998; Bisset et as one to three plate-like condensations of nerve al. 2000; Diop et al. 2003). A border between the elements (Fig. 1). The most inferior of the nerve- vagina and mesorectum was clearly identified contained plates was located near or attached to because of highly contrasting tissue density the parietal fascia along the levator ani. A con- between the mesorectum and vagina and the pres- 406 H. Niikura et al. Vesico-Uterine Ligament in Nerve-Sparing Radical Hysterectomy 407

Fig. 1. Nearly frontal section including the cervix uteri. This section is located in the most posterior (sacral) side of all figures. On the inferior side of the deep uterine vein, loose connective tissue (mesorectum) is present around the rectum. Two conden- sations of nerve elements (PX) correspond with the pelvic plexus. Note thick parietal fascia (arrows) along the intrapelvic surface of the levator ani. Asterisks (*) indicate an entrance into Okabayashi’s space. A definite fascia along the asterisks (probably the meso-ureter) is found between the ureter and cervix. The pelvic plexus is shown at higher magnification in panels B (upper of the two PX areas) and C (lower one). In B, ganglion cells are stained deeply with eosin. ence of a distinct fascia that, on the lateral side, side of the vagina (Figs. 2 and 3). In these sec- communicated loosely with the parietal fascia tions, a viscero-parietal fascial connection con- along the levator ani (Fig. 1). Between the vagina sisting of a bridge-like fibrous bundle was clearly and mesorectum, a thin but definite fascia or rec- discriminated from the parietal fascia covering the tovaginal septum was seen (Figs. 2 and 3) that levator ani. We could identify each fibrous com- might correspond with Denonvilliers’ fascia as ponent in the fascial bridge at a low magnification described in urologic and rectal surgery (Heald (Figs. 2 and 3), whereas the parietal fascia along and Moran 1998; Kourambas et al. 1998). A the levator ani looked like a homogeneous plate- detailed description on the female Denonvilliers’ like structure at higher magnification (Fig. 1C), fascia, especially its interindividual variation, is possibly because of the well-organized and woven now being prepared as another paper. arrangement of thin fibers. Thus, the fascial Notably, the parietal fascia consistently com- bridge was quite different from the parietal fascia. municated with the visceral fascia on the lateral However, in the same sections, the rectum and/or 406 H. Niikura et al. Vesico-Uterine Ligament in Nerve-Sparing Radical Hysterectomy 407

Fig. 2. Nearly frontal section including the proximal vagina and vesico-uterine pouch of the peritoneal cavity. The peritoneum is seen in the upper side of panel A, while the anus is in the lower side. A also includes Alcock’s canal (a fascia-made canal for the pudendal nerve and external pudendal vessels) on the right side, as well as fatty tissues in the ischiorectal fossa. Panel B shows histology corre- sponding with a square in panel A. Note a bundle of thick fibrous components (semicircle) con- necting the lateral side of the vagina and parietal fascia covering the levator ani (the viscero-parietal fascial bridge). The deep uterine vein is embedded in the fascial bridge. Red dots indicate nerve elements: Most are cut transversely. Arrows in a space between vagina and rectum indicate the rec- to-uterine septum of Denonvilliers’ fascia. The rectal lumen was highly dilated with feces.

mesorectum did not issue any distinct fibers to and Kinugasa 2006). either the fascial bridge or parietal fascia. But in Nerve elements did not run along fibrous levels posterior to the present figures, especially components of the fascial bridge, but instead at and near the ischial bony spine, a fascia around crossed them. They appeared to run along the the mesorectum (the proper rectal fascia or fascia long axis of the vagina. Conversely, the deep propria of the rectum [Heald and Moran 1998; uterine vein and tributaries such as vesical veins Bisset et al. 2000]) joined a bridge-like fibrous ran almost along the fascial bridge. However, at bundle from the cervix uteri that terminated at the the superior side of the fascial bridge, no specific parietal fascia (Tamakawa et al. 2003; Murakami fasciae encircled the most distal portion of the 408 H. Niikura et al. Vesico-Uterine Ligament in Nerve-Sparing Radical Hysterectomy 409

Fig. 3. Nearly frontal section including openings of the ureter into the bladder. This figure is located 15 mm anterior to Fig. 3. The bladder trigone is seen in the upper side of Panel A, while the anus is in the lower side. Panel B shows histology corresponding with a square in panel A. Note a bundle of thick fibrous components (semicircle) packed more tightly than in Fig. 3. This fascial bridge is evident between the lateral side of the vagina and parietal fascia cover- ing the levator ani. Other abbreviations are the same as in Fig. 3. ureters. Vesical veins were associated with abun- was located in the posterolateral end of the recto- dant nerve elements near the bladder neck (Fig. 4). pubic (or prevesical) fatty mass. Where the blad- When a slice was incidentally made almost along der disappeared in the sections, the connective the course of a vesical vein, a neurovascular bun- tissue was not evident. Instead, a web-like loose dle or pedicle was seen standing on the levator ani tissue mass containing abundant veins became (Fig. 4). This pedicle was located in the anterior thick in anteroposterior and mediolateral direc- end or half of the fascial bridge between the leva- tions at the lateral side of the urethra and vagina tor ani and vagina. (Fig. 6). The tissue mass was regarded as the par- In two of five specimens, a connective tissue acolpium, which was located between the urogen- band clearly connected the bladder neck and leva- ital viscera and levator ani. The paracolpium tor ani in the ventral or distal side of the pedicle, contained irregularly arrayed connective tissue including the vesical veins (Fig. 5). This was fibers. Nerve elements were almost evenly dis- regarded as the visceroparietal fascial bridge; it tributed in the loose tissue. 408 H. Niikura et al. Vesico-Uterine Ligament in Nerve-Sparing Radical Hysterectomy 409

Fig. 4. Section along a neurovascular pedicle to the bladder neck. Bladder wall and lumen near the neck or tri- gone is seen in the upper side of the figure. Vesical veins, tributaries of the deep uterine Fig. 5. Nearly frontal section including the viscero- vein, were cut almost longitudinally. Note a parietal fascial bridge between bladder and neurovascular pedicle (semicircle) connecting levator ani. to the parietal fascia (arrows) covering the The fascial bridge is sandwiched by arrows. levator ani. Thus, the parietal fascia continues Abundant nerve elements (red dots) are associ- to a fascia encircling the pedicle. Abundant ated with the fascial bridge and embedded in a nerves and ganglia (red dots) are associated venous plexus near the levator ani. The venous with the veins. In contrast to Figs. 3 and 4, plexus continues to the plexus in the paracolpi- most nerve elements are cut obliquely or longi- um at levels anterior or distal to this section (not tudinally. shown). In this section, the viscero-parietal connection was not evident at the lateral side of the vagina. Between the vagina and mesorectum, the rectovaginal septum or Denonvilliers’ fascia (see above) was seen at the level of the mid-urethra was evident between urethra and vagina. In the (Fig. 6). Conversely, a fibrous connection tight connective tissue, we did not find any striat- between rectum and vagina comparable with the ed muscle fibers belonging to the urethral external recto-urethral muscle in males (Matsubara et al. sphincter. Conversely, a relatively loose fibrous 2003) was not evident. A tight fibrous connection tissue occupied the space between the pubis and 410 H. Niikura et al. Vesico-Uterine Ligament in Nerve-Sparing Radical Hysterectomy 411

Fig. 6. Section across the midurethra and paracolpium. This section is located in the most anterior or pubic side of all figures. The anterior end of the leva- tor ani is included in the left side of the figure. Note a wide connective tissue area (the paracolpi- um) at the lateral side of the urethra and vagina. Veins in the paracolpium communicated with those at the anterior side of the urethra (asterisks: *). Arrows in a space between vagina and rectum indi- cate the recto-uterine septum of Denonvilliers’ fascia. Under higher magnification of the area of the rhabdosphincter (square at the upper margin of panel A), striated muscle fibers are stained deeply with eosin (panel B). The pubis was located immediately to the upper side of panel B. Fibrous tissues are not arrayed in the anteroposterior direction but rather irregular or circular in the pubo- urethral ligament. urethra, and regarded as the pubo-urethral liga- have been reported in the anorectum (Arakawa et ment. However, the composite fibers were not al. 2004). arrayed in the anteroposterior direction along a suggested tension vector between the pubis and DISCUSSION urethra but were usually arranged in a rather cir- The arcus tendineus fasciae pelvis has been cular or irregular pattern (Fig. 6). Moreover, a macroscopically identified as a condensation of venous plexus was embedded in and interrupted the parietal fascia covering the levator ani (Pit et the pubo-urethral ligament. This anterior venous al. 2003). However, the present study’s histology plexus communicated with veins in the paracolpi- clearly demonstrated that another bridge-like um. fibrous tissue communicated between parietal and The striated muscle fibers in the urethral visceral fasciae at the lateral side of the vagina. external sphincter, called rhabdosphincter, were The parallel array of fibrous tissue suggests this scattered or embedded in the circularly arrayed structure plays an active role as viscero-parietal fibrous tissue on the pubic side of the urethra (Fig. fascial connection. Conversely, some well-known 6). The paracolpium became thin in sections near viscero-parietal connections, such as the pubo- the perineum and, finally, the levator ani directly urethral ligament, seemed to be simple space- attached to the lateral side of the vaginal wall occupying connective tissues given their irregu- without any special interface structures such as larly arrayed organization. We strongly believe 410 H. Niikura et al. Vesico-Uterine Ligament in Nerve-Sparing Radical Hysterectomy 411

that the anatomical entity “viscero-parietal fascial developed, identified, and treated. The VUL’s bridge” corresponds with the macroscopic entity deep layer seems to contain most parts of the his- “arcus tendineus fasciae pelvis” although the tologically identified fascial bridge. In particular, arcus becomes distinct only after separation of the a neurovascular pedicle containing the vesical levator ani from pelvic viscera. The fascial bridge veins and associated nerve elements was evident was quite different from the parietal fascia in his- in the present study. The pedicle was also identi- tological organization as well as location. The fied as a mesentery-like structure between the interpretation of surgical anatomy using histologi- parietal and visceral structures, such as the levator cal terms that we will present next is essentially ani and bladder. Actually, Yabuki (Yabuki et al. based on the hypothesis that the arcus tendineus 1996) demonstrated that a surgically identified fasciae pelvis can be identified by its histological deep layer of the VUL is composed of the vesical structure. veins and nerves. In contrast, we did not find any Recently, Yabuki et al. (2005) demonstrated distinct fascial structures corresponding with the that, during radical hysterectomy, surgeons are superficial layer of the VUL because the area able to enter the caudal chamber of the pararectal around the most distal part of the ureter was loose space via an opening or division of the arcus ten- except for the so-called meso-ureter communicat- dineus fasciae pelvis. The arcus tendineus fasciae ing between ureter and cervix. In the present his- pelvis seems to correspond with the histologically tology, in contrast to the VUL’s deep layer, the identified fascial bridge between the parietal fas- paracolpium was defined as a vein-rich loose con- cia and another fascia around the vagina. The nective tissue “mass” without a clear bridge-like next surgical step is to make a communication structure. The tissue mass might allow surgeons between the cranial and caudal chambers of the to create the so-called paravaginal space by divid- pararectal space. Morrow explained this proce- ing the histologically identified paracolpium into dure simply (Morrow 2005): “The cranial and a vein-rich part and a fibrous tissue-rich part. In caudal portions of the pararectal space can be other words, the paravaginal space could be connected by opening of the thin membrane developed easily in levels distal to the VUL’s between the posterior limit of the cardinal liga- deep layer or the vesical vein-containing pedicle. ment and the levator ani muscle”. This thin mem- Nevertheless, when the distal vagina is retracted brane seems to correspond with a loose connec- from the levator ani, the arcus tendineus fasciae tion between the neurovascular sheath for the pelvis is likely to be developed macroscopically deep uterine vein and parietal fascia covering the even along the loose and wide paracolpium. levator ani. Yabuki et al. (2005) demonstrated In the present study, the viscero-parietal fas- that Okabayashi’s space, developed between the cial bridge was made of fibrous tissues connecting mesorectum and proper rectal fascia in their the proximal vagina and levator ani. However, understanding, enters the cranial chamber of the possibly in contrast to the actual mesentery of the pararectal space. This entry might correspond intestine, nerves and vessels did not always run with a space between the hypogastric nerve and along the mediolateral axis of the fascial bridge, histologically identified meso-ureter (asterisks in but rather crossed connective tissue fibers. This Fig. 1). Höckel and Fritsch (2006) regarded the suggests a mechanical demand for support of the surgically developed short fibrous band as the pelvic viscera in a direction different from the result of degeneration with aging. However, we neurovascular courses. The fascial arrangement believe the histologically identified fascial bridge and neurovascular course seem to be determined exists even in young women, although our by different rules. Thus, according to a concept research materials were obtainedfrom elderly of fascial connection or bridge, we postulate three cadavers. categories of intrapelvic fasciae and ligaments, After the previously described surgical pro- e.g., the parietal fascia, visceral fascia, and con- cedures, the deep layer of the VUL is clearly necting part between them. Ercoli et al. (2005) 412 H. Niikura et al. Vesico-Uterine Ligament in Nerve-Sparing Radical Hysterectomy 413 recently classified pelvic fasciae and ligaments Monnier, G. (2003) Mesorectum: the surgical value of an anatomical approach. Surg. Radiol. Anat., 25, 290-304. into three categories: 1) parietal pelvic fascia (the Ercoli, A., Delmas, V., Fanfani, F., Gadonneix, P., Ceccaroni, M., pubovesical ligament), 2) visceral pelvic fascia Fagotti, A., Mancuso, S. & Scambia, G. (2005) (the uterosacral and rectovaginal ligaments) and 3) Terminologia anatomica versus unofficial descriptions and nomenclature of the fasciae and ligaments of the female the connecting part (the parametrium, paracervix, pelvis: a dissection-based comparative study. Am. J. lateral ligament of the rectum, presacral fascia, Obstet. Gynecol., 193, 1563-1573. and superior vesical ligament). In fact, the con- Fujii, S., Takakura, K., Matsumura, N., Higuchi, T., Yura, S., Mandai, M. & Baba, T. (2007) Precise anatomy of the cepts “visceral” and “parietal” have been con- vesico-uterine ligament for radical hysterectomy. Gynecol. fused, resulting in strange terms such as “visceral Oncol., 104, 186-191. Fröhlich, B., Hötzinger, H. & Fritsch, H. (1997) Tomographical endopelvic fascia” (Uhlenhuth et al. 1948), anatomy of the pelvis, pelvic floor and related structures. although the term endopelvic fascia is now Clin. Anat., 10, 223-230. typically used for the pelvic parietal fascia along Heald, R.J. & Moran, B.J. (1988) Embryology and anatomy of the rectum. Semin. Surg. Oncol., 15, 66-71. the levator ani (Hinman 1993; Takenaka et al. Hinman, F., Jr. (1993) Atlas of Urosurgical Anatomy. Philadel- 2005). However, a term containing “extraserosal” phia, Saunders. may include the meaning of “parietal”. We Höckel, M. & Fritsch, H. (2006) Dissection bias of in subperi- toneal pelvic anatomy. Am. J. Obstet. Gynecol., 194, 504. hypothesize that the term parietal fascia should be Katahira, A., Niikura, H., Kaiho, Y., Nakagawa, H., Kurokawa, limited to fasciae along the parietal structures K., Arai, Y. & Yaegashi, N. (2005) Intraoperative electrical stimulation of the pelvic splanchnic nerves during nerve- such as levator ani, coccygeus, piriformis, sacro- sparing radical hysterectomy. Gynecol. Oncol., 98, spinous ligament, sacrum, and pubis. Thus, the 462-466. pubovesical ligament seems to be classified as Katahira, A., Niikura, H., Ito, K., Takano, T., Nagase, S., Murakami, G. & Yaegashi, N. (2007) Vesicouterine liga- one of the viscero-parietal connections or fascial ment contains abundant autonomic nerve ganglion cells: bridges, whereas the presacral fascia should be the distribution in histology concerning nerve-sparing radi- parietal fascia. cal hysterectomy. Int. J. Gynecol. Cancer, in press. Kato, T., Murakami, G. & Yabuki, Y. (2002) Does the cardinal Overall, translation of surgical anatomy into ligament of the uterus contain a nerve that should be histologic terminology enables us to have fruitful preserved in radical hysterectomy? Anat. Sci. Int., 77, discussions with persuasive power because histo- 161-168. Kourambas, J., Angus, D.G., Hosking, P. & Chou, S.T. (1998) logic terminology excludes any bias from individ- A histological study of Denonvilliers’ fascia and its ual surgeons/authors. relationship to the neurovascular bundle. Br. J. Urol., 82, 408-410. Kurihara, M., Murakami, G., Kajiwara, M., Taguchi, K., Acknowledgments Tsukamoto, T. & Usui, T. (2004) Lack of the complete cir- This study was supported in part by a Grant-in- cular rhabdosphincter and a distinct circular smooth muscle layer around the proximal urethra in elderly Japanese aid for Scientific Research on a priority area from women: an anatomical study. Int. Urogynecol. J., 15, the Ministry of Education, Science, Sports and 85-94. 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