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ORIGINAL RESEARCH |
From the Division of Gynecologic Specialties and Department of Art as Applied to Medicine, Johns Hopkins Hospital; Department of Anatomy and Cell Biology, George Washington University School of Medicine and Health Sciences; Department of Anatomy and Neurobiology, University of Maryland at Baltimore School of Medicine; and Department of Gynecology, Greater Baltimore Medical Center, Baltimore, Maryland.
Address reprint requests to: Jerome L. Buller, MD 600 North Wolfe Street Harvey 319 Baltimore, MD 21287 E-mail: jbuller{at}jhmi.edu
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Abstract |
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Methods: Fifteen female cadavers were evaluated between December 1998 and September 1999. Eleven hemisected pelves were dissected to better define the uterosacral ligament and identify adjacent anatomy. Ureteral pressure profiles with and without relaxing incisions were done on four fresh specimens. Suture pullout strengths also were assessed in the uterosacral ligament.
Results: The uterosacral ligament was attached broadly to the first, second, and third sacral vertebrae, and variably to the fourth sacral vertebrae. The intermediate portion of the uterosacral ligament had fewer vital, subjacent structures. The mean ± standard deviation distance from ureter to uterosacral ligament was 0.9 ± 0.4, 2.3 ± 0.9, and 4.1 ± 0.6 cm in the cervical, intermediate, and sacral portions of the uterosacral ligament, respectively. The distance from the ischial spine to the ureter was 4.9 ± 2.0 cm. The ischial spine was consistently beneath the intermediate portion but variable in location beneath the breadth of the ligament. Uterosacral ligament tension was transmitted to the ureter, most notably near the cervix. The cervical and intermediate portions of the uterosacral ligament supported more than 17 kg of weight before failure.
Conclusion: Our findings suggest that the optimal site for fixation is the intermediate portion of the uterosacral ligament, 1 cm posterior to its most anterior palpable margin, with the ligament on tension.
Symptomatic pelvic organ prolapse comprises a large portion of gynecologic practice, with up to 10–15% of women seeking surgical correction during their lifetimes.1,2 Most surgeons agree that reconstructive procedures to maintain vaginal function should address all support defects including anterior, posterior, and apical defects.
There are many techniques for reestablishing support of the vaginal apex. Unilateral or bilateral fixation of the apex to the sacrospinous ligament is widely advocated and used.3–5 Whereas the technique provides sustained support of the vaginal apex, it is associated with a high incidence of recurrent anterior vaginal wall prolapse, believed to be the result of nonanatomic posterior deflection.6,7 Another option is to suspend the vaginal vault bilaterally from the fascia of the iliococcygeus muscle, just anterior to the ischial spine.6 That approach has the advantage of maintaining the normal alignment of the vaginal vault, but the attachment site is caudad to the normal position of the vaginal apex and might cause foreshortening of the vagina.
In 1927, Miller8 first described bilateral suspension of the vaginal vault to the uterosacral ligaments. He secured the vaginal apex with "lifting sutures" in the peritoneum and underlying fascial and muscular structures at the base of the sacrouterine ligament, approximately 1.5 inches below the promontory of the sacrum. Tying those sutures down carries the entire vagina high up into the pelvis and back toward the fixed point of the lifting sutures. Bilateral suspension of the vaginal vault from the origins of the uterosacral ligaments was also described by McCall,9 who combined it with an extensive culdoplasty that plicated the uterosacral ligaments and closed the cul-de-sac. More recently, uterosacral suspension was described from a vaginal10 and laparoscopic approach11 without plication of the uterosacral ligaments. Advocates believe that fixation closer to the origins of the uterosacral ligaments, if sufficiently strong on both sides, allows for better vaginal depth with normal vaginal alignment.8,12
There is relatively little information regarding efficacy of using the uterosacral ligament as an anchorage for suspending the vaginal vault. McCall9 reported no recurrent enteroceles during a 3-year follow-up and Given13 reported a 5% failure rate with an average follow-up of 7 years. The few data in part reflect the popularity of other anchorage sites, but also might echo surgeons’ concerns about subjacent structures. Harris et al14 demonstrated that this reconstructive procedure is one of the most apt to result in unsuspected ureteral compromise. Elkins et al12 also cautioned about proximity of the uterosacral ligaments to ureters; in their report of dissections in 12 unembalmed cadavers, the ureter was an average of 1.4 cm from the uterosacral ligament at the cervix.
Our goal was to identify the location of the uterosacral ligaments and their relationship to the adjacent structures, especially the ureter. We also planned to assess how tension on the uterosacral ligament affected the ureter and determine the strength of the uterosacral ligament as a site for suture anchorage. Using cadaveric dissections in fresh and preserved female pelves, anatomic and functional data were recorded.
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Materials and Methods |
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Female cadavers were collected from the Maryland State Anatomy Board. They were excluded if the subjects had previous pelvic or abdominal surgery or prior dissection that might have disturbed normal pelvic anatomy, or if there was gross evidence of disease that distorted pelvic anatomy. Medical, surgical, and obstetric histories were not available. We evaluated 27 specimens between December 1998 and September 1999. Ten preserved and two fresh specimens were excluded from our study and were used only for refining the dissection technique. Eleven hemisected specimens were dissected and provided data for anatomic description of the uterosacral ligament and adjacent structures. Four intact specimens were used to evaluate ureteral pressures and to assess the tensile strength of uterosacral ligaments.
Pelvic specimens were made using a transverse cut with a high-powered band saw through the entire body wall at the level of the fourth or fifth lumbar vertebrae. Lower limbs were removed by transverse cuts made 4–5 cm beyond the greater trochanter. Eleven hemisected specimens (eight preserved and three fresh) were thus prepared and dissected. Each hemipelvis was photographed and three specimens were sketched in resting position and with anterior tension on the uterus.
Gross attachments of the uterosacral ligament at the sacrum, cervix, and adjacent structures were noted and documented. The location of the ischial spine was found by sharp dissection and direct posterior view and by anterior palpation, and the position of the spine under the levator ani muscles was marked anteriorly with a small pushpin. The uterosacral ligament was then dissected with the relationship to subjacent anatomy noted. The ureter, pelvic neurovascular structures, and the sacral nerve routes were clearly identified for each specimen in relationship to the uterosacral ligament. For descriptive purposes, the uterosacral ligament was divided into three equal segments: the cervical portion, intermediate portion, and sacral portion. The descriptive scheme was similar to that of Campbell15 and allowed for clinically useful description of the location of subjacent structures and pelvic sidewall details.
Dissection of the pelvis began with careful removal of the peritoneum overlying the pelvic sidewall. The rectum and extraperitoneal fat were removed to see the uterosacral ligament from origin on the anterior surface of the sacrum to insertion at the cervix. Several measurements were then taken to describe completely the course of the uterosacral ligament in relation to other pelvic structures. Curvilinear measurements were made with string applied directly to surface contour being measured. The string was subsequently straightened and measured with a graduated ruler to the nearest 0.1 cm. Measurements were also made from ureter to all three portions of the uterosacral ligament. The distance from the ischial spine to the ureter and the relationship of ischial spine to uterosacral ligament also were assessed. Measurements were made in duplicate and averaged.
When defined clearly, the uterosacral ligament was elevated from its origin at the sacrum and reflected anteromedially toward its insertion at the cervix. Structures subjacent to the ligament were identified and their relationship to the cervical, intermediate, and sacral portions of the ligament recognized. Dissection then was carried down to the level of the bony pelvis to define the course of the uterosacral ligament in reference to a known landmark, the ischial spine.
We used four intact fresh cadaveric pelves to identify ureteral pressure profiles and uterosacral ligament strength. Those specimens were not bisected to avoid possible weakening of the ligament by cutting midline attachments of uterosacral ligaments or adjacent supporting tissues. Data from right and left sides of the four intact specimens were evaluated individually for ureteral pressure studies and combined for strength assessment of uterosacral ligaments.
Ligaments were identified by palpation aided by tension applied to the vaginal apex by grasping and elevating the vaginal tissue immediately adjacent to the uterine cervix. Three sutures of 0-polygalactin 910 (Ethicon Inc., Somerville, NJ) were placed in each uterosacral ligament, one in each portion. All sutures were perpendicular to ligament fibers with the ligament on tension. Sutures were placed with a CT-1 needle (Ethicon Inc.), using only the most distal 1 cm of the needle. This method allowed for precise suture placement and equal purchase of tissue within each suture. The first suture was placed in the cervical segment of the uterosacral ligament 1 cm proximal to the vaginal apex; the second at the level of the ischial spine; and the third within 2 cm of the sacrum on the palpable uterosacral ligament. Sutures were not tied down to eliminate mechanical effects of individual knots, and were tagged and placed laterally.
A right-angle clamp was placed in the vagina to localize the vaginal apex. A 2–3-mm wide incision was made on each lateral aspect of the vaginal posterior fornix for passage of the sutures through the vagina. Incisions were in the usual location where the vaginal apex and uterosacral ligaments would be attached after hysterectomy. Sutures were then placed through the appropriate incision at the vaginal apex and verified as cervical, intermediate, or sacral in origin. Each suture was then tied as a loop within 10 cm of the vaginal introitus. Hemipelvises were oriented in the low lithotomy position and secured in place on an apparatus designed to stabilize specimens and allow for axis traction to be applied to each uterosacral ligament suture individually.
A 4-French fiberoptic pressure catheter (MedAmicus Corp., Plymouth, MN) was used to measure ureteral pressure profiles. The pressure catheter was passed through the urethra into the bladder and a cystotomy was used to pass the catheter retrograde through the ureteral orifice, through each ureter to the level of the pelvic brim. Tension on the uterosacral ligament was applied by attaching weight to the individual suture loops in the uterosacral ligament. With fixed tension applied to various portions of the uterosacral ligament, the pressure catheter was slowly withdrawn from the ureter similarly to urethral pressure profiles. Adding known volumes of water to a preweighed container precisely varied the weight. The container was connected to suture loops by a 
-inch braided steel rope over a 2-inch, single-action pulley system and was suspended freely off the end of our dissection table.
Ureteral pressures were measured with 115-, 615-, and 1115-g weights applied to the uterosacral ligament sutures. Pressures were measured in duplicate or triplicate, providing agreement between measurements of up to 10%. Ureteral pressures were assessed with only a container weighing 115 g attached to the respective suture in the uterosacral ligament and subsequently adding 500 and 1000 mL of fluid to the same container. Ureteral pressures also were measured at 2000 and 2500 g for the first two specimens.
After ureteral pressure profiles, relaxing incisions were made to determine whether they had any affect on ureteral pressure. Incisions 3–4 cm long were made in the peritoneum above the uterosacral ligament and ureteral pressure profiles were repeated.
We assessed bilateral uterosacral ligament suspension strength by determining the weight each fixation point would support before failure of the suspension. We attempted to reconstruct the normal axis of traction after the cuff was appropriately suspended by bilateral uterosacral ligament suspension procedure. At each portion of the ligament, suture loops from the right and left sides were subjected to tension simultaneously. Tension was increased incrementally by the slow addition of fluid into the suspended container until the suture material pulled through the uterosacral ligament or the uterosacral ligament was detached from its usual attachments. The total volume of fluid that resulted in failure of the suspension was measured. The fluid volume used was converted to weight in grams and recorded as weight in kilograms.
Descriptive statistics were used to describe mean and standard deviation for measurements. Analysis of variance was used to describe the relationship between ureteral pressure profiles and uterosacral ligament portion assessed. The two-tailed, paired t test was used to evaluate the effect of relaxing incisions that compared ureteral pressure profiles before and after making relaxing incisions. The Mann–Whitney U test was used for comparison of mean maximum ureteral pressures and suture pullout strength recorded at the cervix, spine, and sacrum along the uterosacral ligament.
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Results |
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). The ligament was attached broadly to the first three sacral vertebrae and variably to the fourth. We also noted fibrous attachments of uterosacral ligament to the sacral periosteum.
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). In the intermediate portion, the middle rectal artery was found consistently near the inferior margin of the uterosacral ligament (Figure 2).
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). The mean (±SD) distance from the ureter to the uterosacral ligament at the level of the sacrum was 4.1 ± 0.6 cm. The mean (±SD) distance from the ureter to the uterosacral ligament at the level of the ischial spine was 2.3 ± 0.9 cm. The mean distance (±SD) from the ureter to the uterosacral ligament at the level of the cervix was 0.9 ± 0.4 cm. Also, the mean (±SD) distance from the ureter to the ischial spine was 4.9 ± 2.0 cm.
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. At all weights tested, the effect on the ureter was greatest at the level of the cervix (P < .001). There was no statistically significant difference between measurements before and after relaxing incisions; however, with significance of P < .05, the power of this test was only .24.
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Discussion |
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Our findings from the anatomic dissections confirm the intimate relationship of the uterosacral ligament to the ureter noted by other researchers,12,14,15 a finding that is particularly true near the cervix. Besides direct injury from proximity, the ureter is also vulnerable to forces transmitted from nearby sutures, which are most likely caused by attachments between the cervical portion of the uterosacral ligament and the fibrous tissue of the ureteral sheath.
An important concept is that the most easily accessible and palpable region of the ligament, the cervical portion, is also the most vulnerable with regard to the ureter. Using that portion of the ligament for vaginal vault suspension greatly increases risk of ureteral injury, which can be from direct incorporation of the ureter in a suture or ureteral kinking from traction on adjacent tissue. By measuring ureteral pressure profiles we found a graded response between uterosacral ligament tension and increased intraluminal ureteral pressures.
In all our specimens, anterior displacement of the uterus allowed easy identification of the ligaments. Caudal displacement of the uterus, as with vaginal hysterectomy, is not nearly as effective for finding the ligament. During vaginal hysterectomy, anterior displacement of the ligament pedicles usually facilitates identification. Concurrent rectal examination with lateral palpation of the ligament might help as an adjunct for locating the ligament.
The intrapelvic ureter, along the lateral pelvic sidewall, lies close to the insertion of the uterosacral ligament at the cervix. Understanding that association between the ureter and the uterosacral ligament is crucial to routine gynecologic and urogynecologic surgeries. However, the courses of the ureter and uterosacral ligament diverge farther as the ureter courses over the pelvic brim, anterior to the uterosacral ligament. The proximity of the ureter to the distal uterosacral ligament warrants concern during vaginal vault repairs that use the ligament.
A limitation to assessing breaking strength is that this measurement implies that the mechanism of failure is related to breaking strength of the tissue. Tissue breakage, however, might occur from sutures cutting through tissue over time, or many other possibilities that cannot be simulated in cadaveric material. This study also should be evaluated in light of the fact that the age, parity, and extent of pelvic organ prolapse remained unknown. Our specimens appeared to have grossly normal vaginal support, although accurate assessment of support in cadavers is difficult. In addition, it is not yet known whether uterosacral ligament support defects represent stretching or breaking of the ligament. Anatomic relationships between the uterosacral ligaments and ureters might have been different in those scenarios.
Several corollaries between Campbell’s studies and ours deserve further discussion. Campbell15 grossly evaluated the uterosacral ligament in 33 cadavers, ten preserved and 23 fresh, 12 of which were evaluated histologically. Both studies identified attachments of the cervical portion of the ligament to the posterior lateral aspects of the vagina and the cervix by an interweaving connective tissue meshwork. Both also noted discrete strands of fibrous tissue that attached the sacral portion of the ligament directly to the presacral fascia. Campbell identified three distinct histologic regions of the ligament. At the cervical attachment, the ligament was made up of closely packed bundles of smooth muscle, abundant medium-sized and small blood vessels, and small nerve bundles. The intermediate third of the ligament was composed of predominantly connective tissue and only a few scattered smooth muscle fibers, nerve elements, and blood vessels. The sacral third was almost entirely composed of loose strands of connective tissue and intermingled fat, few vessels, nerves, and lymphatics. That provides a potential explanation for the observed lower pullout strengths in the sacral region, based on histologic composition of the ligament.
Our findings suggest that the optimum site of fixation is in the intermediate portion of the ligament, which appears to have fewer vital adjacent structures that could be compromised during reparative procedures. In addition, the intermediate portion is a strong fixation site, where tension has little effect on the ureter. The ischial spine can be used reliably to identify the intermediate portion of the ligament, but should not be used as a specific point of measure for suture placement because of the location variability of the spine relative to the ligament. Sutures at the level of the ischial spine, 1 cm posterior to the anterior-most palpable margin of the uterosacral ligament on tension, should provide an adequate fixation site for vaginal vault suspension while limiting injury to adjacent anatomy.
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Footnotes |
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Received June 28, 2000. Received in revised form January 2, 2001. Accepted February 8, 2001.
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References |
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2. Olson A, Smith V, Bergstrom J, Colling J, Clark A. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501–6.[Abstract]
3. Richter K, Albrich W. Long-term results following fixation of the vagina on the sacrospinal ligament by the vaginal route (vaginaefixatio sacrospinalis vaginalis). Am J Obstet Gynecol 1981;136: 957–8.
4. Nichols D. Sacrospinous fixation for massive eversion of the vagina. Am J Obstet Gynecol 1982;142:901–4.[Medline]
5. Myazaki F. Miya hook ligature carrier for sacrospinous ligament suspension. Obstet Gynecol 1987;70:286–8.
6. Shull B, Capen C, Riggs M, Kuehl T. Bilateral attachment of the vaginal cuff to iliococcygeus fascia: An effective method of cuff suspension. Am J Obstet Gynecol 1993;168:669–77.
7. Paraiso M, Ballard L, Walters M, Lee J, Mitchinson A. Pelvic support defects and visceral and sexual function in women treated with sacrospinous ligament suspension and pelvic reconstruction. Obstet Gynecol 1996;175:1423–31.
8. Miller N. A new method of correcting complete inversion of the vagina: With or without complete prolapse; report of two cases. Surg Gynecol Obstet 1927:550–5.
9. McCall M. Posterior culdoplasty: Surgical correction of enterocele during vaginal hysterectomy; a preliminary report. Obstet Gynecol 1957;10:595–602.
10. Jenkins V. Uterosacral ligament fixation for vaginal vault suspension in uterine and vaginal vault prolapse. Am J Obstet Gynecol 1997;177:1337–44.[Medline]
11. Miklos J, Kohli N, Lucente V, Saye W. Site-specific fascial defects in the diagnosis and surgical management of enterocele. Am J Obstet Gynecol 1998;179:1418–23.[Medline]
12. Elkins T, Hopper J, Goodfellow K, Gasser R, Nolan T, Schexnayder M. Initial report of anatomic and clinical comparison of the sacrospinous ligament fixation to the high McCall culdeplasty for vaginal cuff fixation at hysterectomy for uterine prolapse. J Pelvic Surg 1995;1:12–7.
13. Given F. "Posterior culdeplasty": Revisited. Am J Obstet Gynecol 1985;153:135–9.[Medline]
14. Harris R, Cundiff G, Theofrastous J, Yoon H, Bump R, Addison W. The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery. Am J Obstet Gynecol 1997;177:1367–71.[Medline]
15. Campbell R. The anatomy and histology of the sacrouterine ligaments. Am J Obstet Gynecol 1950;59:1–12.
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