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

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Abstract

The objective of this work was to collect and summarize relevant literature on the anatomy, histology, and imaging of apical support of the upper vagina and the uterus provided by the cardinal (CL) and uterosacral (USL) ligaments. A literature search in English, French, and German languages was carried out with the keywords apical support, cardinal ligament, transverse cervical ligament, Mackenrodt ligament, parametrium, paracervix, retinaculum uteri, web, uterosacral ligament, and sacrouterine ligament in the PubMed database. Other relevant journal and textbook articles were sought by retrieving references cited in previous PubMed articles. Fifty references were examined in peer-reviewed journals and textbooks. The USL extends from the S2 to the S4 vertebra region to the dorsal margin of the uterine cervix and/or to the upper third of the posterior vaginal wall. It has a superficial and deep component. Autonomous nerve fibers are a major constituent of the deep USL. CL is defined as a perivascular sheath with a proximal insertion around the origin of the internal iliac artery and a distal insertion on the cervix and/or vagina. It is divided into a cranial (vascular) and a caudal (neural) portions. Histologically, it contains mainly vessels, with no distinct band of connective tissue. Both the deep USL and the caudal CL are closely related to the inferior hypogastric plexus. USL and CL are visceral ligaments, with mesentery-like structures containing vessels, nerves, connective tissue, and adipose tissue.

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Abbreviations

CL:

Cardinal ligament

USL:

Uterosacral ligament

POP:

Pelvic organ prolapse

IHP:

Inferior hypogastric plexus or pelvic plexus

MR:

Magnetic resonance

CT:

Computed tomography

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Acknowledgment

We thank Chelsea Noel for editing figures

Conflicts of interest

John DeLancey receives research support from American Medical Systems, Johnson & Johnson, Kimberly Clark and Procter & Gamble.

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Authors and Affiliations

  1. Department of Obstetrics and Gynecology, Besancon University Medical Center, Besancon, France

    Rajeev Ramanah

  2. Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA

    Mitchell B. Berger & John O. L. DeLancey

  3. Pelvic Floor Research Group, University of Michigan, Ann Arbor, MI, USA

    Rajeev Ramanah, Mitchell B. Berger & John O. L. DeLancey

  4. Anatomy Institute, University of Franche-Comte, Besancon, France

    Bernard M. Parratte

  5. L4000 Women’s Hospital, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5276, USA

    John O. L. DeLancey

Authors
  1. Rajeev Ramanah
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  2. Mitchell B. Berger
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  3. Bernard M. Parratte
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  4. John O. L. DeLancey
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Correspondence to John O. L. DeLancey.

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Ramanah, R., Berger, M.B., Parratte, B.M. et al. Anatomy and histology of apical support: a literature review concerning cardinal and uterosacral ligaments. Int Urogynecol J 23, 1483–1494 (2012). https://doi.org/10.1007/s00192-012-1819-7

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