Cardinal Ligament Research Articles

Evaluation of adjuvant chemotherapy after abdominal trachelectomy for cervical cancer: a single-institution experience.

To avoid the loss of fertility, chemotherapy should be chosen as an adjuvant treatment after trachelectomy. Our study evaluated the effectiveness and safety of adjuvant chemotherapy after abdominal trachelectomy for cervical cancer. Our institutional review board approved this clinical study, and informed consent was obtained from each patient. We began performing abdominal trachelectomy at our institution in 2005. Deep stromal invasion (more than two-thirds) with lymphovascular space invasion, diffuse cervical invasion, skip lesions in the vagina, and lymphovascular space invasion in the cardinal ligament and vagina were defined as intermediate-risk factors, and parametrial invasion and pelvic lymph node metastasis were defined as high-risk factors. Patients who had intermediate- or high-risk factors received post-trachelectomy adjuvant treatment. The medical records and information of the patients were reviewed retrospectively. Through January 2020, we performed 212 trachelectomies. Among the included patients, 16 and 7 patients with intermediate- and high-risk cancer, respectively, received adjuvant chemotherapy after trachelectomy (2 and 21 patients underwent abdominal modified radical trachelectomy and radical trachelectomy, respectively). Among these patients, only one (4.3%) experienced relapse and subsequent death of the disease after a median postoperative follow-up of 80months (range 12-146months). The 5-year survival rate was 95.5%. Chemotherapy-related life-threatening acute adverse events were not observed. Persistent ovarian dysfunction and late adverse events did not occur. One woman achieved three pregnancies, and two infants were delivered. Adjuvant chemotherapy after abdominal trachelectomy could be an alternative treatment option from the aspects of effectiveness, safety, and fertility preservation.

58: Vaginal hysterectomy 101: A step-by-step guide for learners emphasizing surgical anatomy

The purpose of this video is to provide learners with a step-by-step resource that reviews important surgical anatomy of the vaginal hysterectomy using a combination of diagrams and surgical video. Vaginal hysterectomy is cited to be the safest and most cost-effective route of hysterectomy. Despite these findings, the proportion of hysterectomies completed vaginally is decreasing. The Society of Gynecologic Surgeons’ Education Committee identifies critical factors that are associated with underuse of vaginal hysterectomy. These factors include inadequate surgical training due to a diminished number of cases completed by residents, as well as difficulty maintaining surgical skills due to low surgical volumes. This video aims to assist learners of vaginal hysterectomy by reviewing the key steps of a vaginal hysterectomy. Visual aids in the form of surgical video and diagrams help illustrate important anatomy and teaching points. In particular, there will be a focus on safe intraperitoneal entry during anterior and posterior colpotomy. The structures highlighted include the cervicovaginal epithelium, supravaginal septum, vesicocervical space, vesicouterine peritoneal fold, rectouterine peritoneal fold, uterosacral ligament, cardinal ligament, ureter, uterine artery, ovarian ligament, round ligament, and Fallopian tube. This video does not demonstrate bilateral salpingectomy or closure of the vaginal cuff. Vaginal hysterectomy is a key surgical skill to be mastered during residency training. This video is meant to be a resource for learners to help elucidate important steps of the vaginal hysterectomy.

83: Technique for retrograde robotic hysterectomy for management of dense bladder adhesions

The primary objective is to show a technique for performing retrograde dissection of densely adherent bladder from anterior uterine wall during robotic-assisted laparoscopic hysterectomy. Many women who undergo hysterectomy have a history of prior cesarean sections, which can result in dense anterior uterine adhesions. Significant adhesions between uterus and bladder create a challenge for safe completion of hysterectomy without injury to lower urinary tract. Here, we show a technique for performing a retrograde hysterectomy in which all major blood supply to the uterus is sealed and the colpotomy completed prior to bladder adhesiolysis. Furthermore, we show a technique for retrograde dissection of the bladder from uterine wall starting inferiorly at the level of the cardinal ligaments and working superiorly towards the fundus of the uterus. With this technique, there is early control of vascular supply thus decreasing intraoperative blood loss, direct visualization of ureters thus decreasing risk of injury, and a 360-degree access to bladder adhesions once colpotomy is complete in order to safely perform adhesiolysis. We show dissection of the pararectal and paravesical spaces, bilateral ureterolysis, and sealing of uterine artery at its origin. Performing a retrograde hysterectomy allows early control of blood supply, constant visibility of ureters, and access to inferior bladder adhesions. Performing a retrograde dissection of the bladder can decrease risk of injury to lower urinary tract. These techniques can be used to safely perform robot-assisted laparoscopic hysterectomy in patients with dense uterine adhesions to the bladder.

Comparison of histomorphological findings of cardinal ligament in patients with and without uterine prolapse

Comparison of histomorphological findings of cardinal ligament in patients with and without uterine prolapse

Evaluation of specific heavy metal levels of pregnant women complicated by neural tube defects

Aim: The etiology of neural tube defect (NTD) is still not clear enough. In our study, we aimed to evaluate plasma heavy metal levels of pregnant women with NTD and to determine whether there is a relationship between heavy metal levels and NTD severity.Material and Methods: TThis study was conducted in Adiyaman University, Department of Gynaecology and Obstetrics. The study included 38 pregnant women with NTD and 42 pregnant women with healthy infants. Pregnant women who have NTD were divided into two groups as NTD Type 1 and NTD Type 2 according to the anomaly type. Levels of heavy metals such as Mercury (Hg), Cadmium (Cd), Cobalt (Co), Lead (Pb), Manganese (Mn) and Arsenic (As) were compared between groups.Results: Plasma Hg, Co, Cd and Pb levels were higher in NTD group than control group. (p values, respectively; p 0.001, p = 0.001, p 0.001, p 0.001). As and Mn levels were not statistically different between the two groups (p values; p = .519, p = .819, respectively). In the NTD group, Hg was found to be higher in NTD Type 1 than NTD Type 2 (p 0.001).Conclusion: It is obvious that some histomorphological changes are formed in the cardinal ligaments of patients with uterine prolapse due to pressure on the uterus. We believe that the increase in the number of extravasated erythrocytes and the thickness of the vascular wall and peripheral nerve should be supported by further studies.

Robot Assisted Laparoscopic Hysterectomy with Fetus in-situ for Placenta Percreta in Second Trimester

Video Objective To describe a technique of robotic-assisted laparoscopic hysterectomy of a second trimester gravid uterus with placenta percreta Setting A step-by-step explanation of the surgery using video (instructive video). Interventions In this video, we describe the surgical approach opted for this patient desiring pregnancy termination and no desire for future fertility. Minimally invasive surgery was recommended considering decreased blood loss, postoperative pain and hospital stay. Also considering her prior surgical history, the laparoscopic approach would offer better visualization for lysis of adhesions. Intraoperatively, the uterus was found to have adhesions anteriorly to the abdominal wall as well as bladder adhesions to the lower uterine segment. Generalized increased vascularity was observed. The blood supply from the utero-ovarian and the uterine vessels were tackled prior to releasing the adhesion of the anterior wall of the uterus to the anterior abdominal wall. The lower uterine segment was adherent to the bladder, thereby the lateral approach was used to enter the paravesicular space to create a bladder flap to mobilize the bladder inferiorly. An End to End (EEA) sizer was used to identify the colpotomy site. The cardinal ligament were coagulated and transected to lateralize the paracervical tissue. The colpotomy was then performed and the specimen was then exteriorized intact vaginally. The vaginal cuff was then closed in a continuous fashion using 0-VLoc. Estimate blood loss was 300mL. Postoperatively, patient was hemodynamically stable, and post-operative labs were found to be within normal limits. Patient was discharged in stable condition on post-operative day one. Conclusion Robot assisted hysterectomy is feasible and superior to open approach in a patient with a second trimester pregnancy complicated by placenta percreta with completion of child bearing.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy (VNOTES): A Walkthrough

Video Objective To present a thorough yet concise explanation of the methodology for the completion of a successful transvaginal hysterectomy via natural orifice transluminal endoscopic surgery. Design A narrated instructional video guide detailing each procedure (Canadian Task Force Classification III). Setting University Hospital, Baylor College of Medicine, Houston, Texas Patients Our patient is a 46-year-old G2P1011 who had two notable previous surgeries: a tubal ligation and an adnexa removal surgery. She possessed a narrow vagina and non-descent uterus while having a strong preference for maintaining a high level of cosmesis. Interventions A complete transvaginal hysterectomy utilizing solely natural orifice transluminal endoscopic surgery was performed on the patient. Transvaginal entry was established and with the gelpoint mini port in place we began circumferential dissection of the cervix anteriorly at the bladder fold. Utilizing the laparoscopic single tooth tenaculum, we hooked the anterior lip of the cervix for countertraction and hydro dissected the anterior cervix with 20 units of Vasopressin (Pitressin) in 20 ml of saline. Next, the monopolar hook was employed to cut the anterior colpotomy and begin the circumferential incision around the cervix. Following this, we used the LigaSure bipolar forceps to sever bilateral ureteral sacral ligament. The same strategy is used at the anterior cervix to separate the bladder from the uterus. Following bladder mobilization, the cardinal ligaments and uterine arteries were cauterized and transected by LigaSure. The right fallopian tube was removed utilizing the LigaSure first, before proceeding with the left fallopian tube; the pelvis was inspected with hemostasis noted throughout. Finally, the vaginal cuff was closed in traditional vaginal fashion after the deflation of the abdomen. Conclusion Despite certain drawbacks, utilizing pure natural orifice transluminal endoscopic surgery in hysterectomy is a safe and feasible procedure that maintains a high-level of cosmesis for patients while still offering the most minimally invasive route.

Aiming for Recurrence-Free MI-RH/RT for Early Invasive Cervical Cancer - Focusing on Complete Resection and No-Touch Isolation Techniques 1

Video Objective To demonstrate techniques to regulate and improve the safety and completeness of laparoscopic and robotic radical hysterectomy/radical trachelectomy (L-RH/RT+R-RH/RT=MI-RH/RT) for early invasive cervical cancer. We will present our techniques and skills as well as data on our long-term outcomes for MI-RH/RT patients. Setting Urban general hospital in Japan. Interventions 170 early invasive cervical carcinoma stage IA1(LSVI+)-IB1 who underwent MI-RH/RT between 2006-2015 were reviewed. Cases who underwent neo-adjuvant therapy were excluded from this study. In laparoscopy, knowledge laparoscopic anatomy and how to dissect are the most important points for reaching the goals of the surgery. Setting landmarks for dissection boundaries ensures completeness of dissection. For our type C radical hysterectomy/ trachelectomy, our goal is to remove the full length of the cardinal ligament. This is to prevent recurrence. To prevent the scattering of tumor cells, we create a vaginal cuff as an initial stage of our procedure and don't use a uterine manipulator as there is the concern that this could stimulate any tumors in the vicinity. When extracting the specimen, we use a large protection bag. This bag prevents spillage of tumor cells in the abdominal cavity and prevents possible port site/ extraction site contamination. Of the patients included in this study, disease-free survival is 97.1% and the 5 year overall survival in 98.2%. Conclusion In our retrospective study, minimally invasive approach for early-stage non-bulky cervical cancer is feasible and safe in terms of oncological outcomes.

Abdominal Myomectomy for Huge Uterine Myomas with Intra-arterial Balloon Occlusion: Approach to Reduce Blood Loss.

Abdominal myomectomy for a huge myomas, especially uterine cervical myoma, is difficult because of risks, such as intraoperative bleeding or injury to adjacent organs. Therefore, understanding of the positional relationships among a huge myoma, especially cervical or intraligamental myoma, and the vascular plexuses in the right and left cardinal ligaments is important for prevention of massive bleeding during myomectomy. While sufficiently performing preoperative assessment with pelvic examination, ultrasonography, magnetic resonance imaging (MRI), etc., surgeons should always keep in mind how they can reduce the blood loss volume, while safely and surely performing resections. For a cervical myoma of the uterus and giant uterine leiomyoma that leave no intrapelvic space and prevent palpation and identification of the uterine arteries and the internal iliac arteries, surgery can be performed safely by preoperatively placing balloon catheters in the internal iliac arteries. Hemostaic strategies for myomectomy and tips of subsequent pregnancy following myomectomy are also described.

Clinical Significance of Neuropeptide Y Expression in Pelvic Tissue in Patients with Pelvic Floor Dysfunction.

ObjectivesTo investigate the neuropeptide Y (NPY) expression in the tissue of pelvic floor ligament and anterior vaginal wall in female patients with pelvic organ prolapse (POP) and stress urinary incontinence (SUI).MethodSeventeen patients with POP, 6 with SUI, 13 with POP and SUI (POP&SUI), and 10 controls were included in this study from First Affiliated Hospital of JiNan University. Immunohistochemical assay was used to examine NPY expression in the tissue of round ligament, cardinal ligament of uterus, uterosacral ligament, and anterior vaginal wall. NPY expression were compared between POP, SUI, POP&SUI and controls.ResultsNPY was positive expressed in the round ligament, cardinal ligament of uterus, uterosacral ligament, and anterior vaginal subepithelial connective tissue. Compared with the control group, NPY expression in the round, cardinal, and uterosacral ligaments in patients with POP&SUI group was decreased with significant statistical difference (p<0.05). NPY expression in anterior vaginal wall was significantly decreased in POP, SUI, and POP&SUI groups compared to normal group (p<0.05). Compared to POP group, NPY expression in SUI and POP&SUI groups were significantly decreased (p<0.05), however the difference was not statistical different between SUI and POP&SUI groups (p>0.05). In POP and POP&SUI groups, the NPY expression in the cardinal ligament of uterus, uterosacral ligament, and anterior vaginal wall were negatively correlated with age (p<0.05), however, was not correlated with number of pregnancy, number of delivery, and BMI (p>0.05).ConclusionsNPY expression was reduced in the round ligament, cardinal ligament of uterus, Uterosacral ligament, and vaginal anterior wall of the patients with POP and SUI. The decreased NPY expression may play an important role in the development of pelvic floordysfunction.

Step by Step Total Laparoscopic Hysterectomy with Uterine Arteries Ligation at the Origin

Study ObjectiveTo reveal principles and the feasibility of a total laparoscopic hysterectomy (TLH) with uterine artery ligation at the origin. DesignStep-by-step demonstration and explanation of technique using videos from patients. SettingGynecologic oncology unit at a university hospital. PatientA 54-year-old woman with uterine fibromatosis and metrorrhagia. InterventionTLH has 7 common components. First, round ligaments are coagulated and cut to enter the retroperitoneum. The ureter is identified. Second, pararectal spaces are entered between the ureter and the internal iliac artery. This maneuver allows the identification of the uterine artery as it leaves its origin from the internal iliac artery. The uterine vessels are stapled with a vascular endoscopic stapler at their origin from the hypogastric vessels or sealed with a bipolar device. Third, adnexal structures are separated from the uterine corpus for subsequent preservation or removal. Fourth, the blood supply is dissected, occluded, and divided before extirpation of the uterine corpus. Fifth, the cardinal ligament complex is transected with colpotomy, and the cervix is amputated from the vaginal apex. Sixth, the specimen is removed. Finally, the vaginal cuff is closed [1]. Measurements and Main ResultsLaparoscopic hysterectomy was first described by Reich et al. [2] in 1989 and has slowly gained popularity. Today, hysterectomy is the most common gynecologic procedure performed. TLH is where the entire operation (including suturing of the vaginal vault) is performed laparoscopically and there is no vaginal component except for the removal of the uterus. Currently, hysterectomies are performed by different approaches, and individual surgeons have different indications for the approach to hysterectomy based largely on their own array and patient characteristics. TLH requires the highest degree of laparoscopic surgical skills [3], and knowledge of pelvic anatomy defines a safe space for sharp entry into the retroperitoneum and safe identification of pelvic vasculature. ConclusionWe present an educational video with step-by-step explanation of the technique to highlight the anatomic landmarks that guides the procedure.

Vault prolapse occurrence after total laparoscopic hysterectomy and total abdominal hysterectomy performed for benign indications, is there a difference? A systematic review of the literature

Aim: To systematically review published data on vault prolapse occurrence after total laparoscopic hysterectomy versus abdominal hysterectomy for benign uterine pathology. Materials and Methods: Medline and PubMed were searched for clinical studies reporting on vault prolapse occurrence after laparoscopic or abdominal hysterectomy. The studies included were randomized and non-randomized clinical trials reporting on the occurrence of vaginal vault prolapse as a long-term complication of either abdominal or laparoscopic hysterectomy for nonmalignant conditions. Results: The search yielded only one study reporting on vaginal cuff prolapse after laparoscopic assisted vaginal hysterectomy (LAVH) or total abdominal hysterectomy (TAH). The additional articles that were retrieved using the ‘search for related articles’ function as well as from references of eligible studies were 581. Of these, 473 studies were excluded by title, 45 by abstract, 32 by full text, seven for which the full text could not be retrieved, and 24 by language. For this study two groups of women were followed up after LAVH (n=150) and TAH (n=146). No statistically significant difference in the likelihood of vault prolapse was revealed between the two groups (p = 0.592).Conclusion: In the literature, various measures are recommended to avoid vaginal vault prolapse such as the suspension of the vaginal apex to the cardinal and uterosacral ligament or to the sacrospinous ligaments at the time of hysterectomy. More studies are needed with a greater number of cases and longer follow up to assess whether abdominal or laparoscopic hysterectomy is more appropriate to prevent vaginal vault prolapse.

Extraperitoneal radical trachelectomy with pelvic lymphadenectomy.

Radical trachelectomy combined with pelvic lymphadenectomy has been used to treat patients with early-stage cervical cancer who wish to preserve their fertility. Vaginal, abdominal, laparoscopic, and robotic approaches have been employed during this procedure, but all cause peritoneal damage, which could result in periadnexal adhesion. As periadnexal adhesion can lead to female infertility due to restricted sweeping of the fimbria over the ovary, it is important to minimize peritoneal damage during the fertility-preserving surgery. Aiming to minimize peritoneal damage, we recently developed a new surgical approach. The techniques used are similar to those used for type III radical hysterectomy; however, all procedures are performed via the extraperitoneal approach.In this video article, we describe a step-by-step technique of this new fertility-preserving surgical procedure. Surgical procedures are as follows: (1) extraperitoneal pelvic lymphadenectomy, (2) excision of the vesicohypogastric fascia and median umbilical ligament, (3) bladder dissection from the peritoneum and identification of uterine cervix, (4) transection of the cardinal ligaments and vesicouterine ligaments, (5) transection of the vagina, (6) excision of the rectovaginal and uterosacral ligaments, (7) transection of the uterine cervix, (8) cervical cerclage and placement of a Foley catheter, (9) anastomosis of the uterine cervix, (10) suture of the median umbilical ligament and vesicohypogastric fascia. During these procedures, the uterine arteries, inferior hypogastric nerve, and pelvic splanchnic nerve were preserved. The advantages of this new surgical approach are first, peritoneal injuries can be completely avoided as the procedure is performed extraperitoneally, and second, it can be carried out using conventional low-cost instruments. In view of these features, we consider that this technique could be an ideal treatment option for selected women with early-stage cervical cancer. The oncological and reproductive outcomes of this new surgical approach need to be evaluated in future clinical studies.

Basic Standard Procedure of Abdominal Hysterectomy: Part 1.

Total abdominal hysterectomy (TAH) is commonly referred to as extrafascial hysterectomy. This article explains the basic surgical procedure of TAH as taught to residents. TAH is an operation to remove the uterus with the outer wall of the uterus, and is a fundamental operation that gynecologists must master. Possible complications during TAH include ureteral injury, intestinal damage, and bladder injury. To avoid operative complications, it is important to follow the correct release layer procedure and ensure that “the uterus has been naturally removed.”The two most important points of the authors' method to avoid complications are as follows: (1) cut sequentially from the ligament away from the ureter which moves the ureter further away from the cervix with each transection stage; (2) cut the parametrial tissue along the circumference of the cervix in the next three steps:First step: clamping and cutting the uterine artery and upper part of the cardinal ligament; second step: clamping and cutting the sacrouterine ligament and the posterior half of the cardinal ligament; third step: clamping and cutting the vesicouterine ligament and anterior half of the cardinal ligament.

Retained Intrauterine Device (IUD): Triple Case Report and Review of the Literature

Background Throughout the world, intrauterine contraceptive devices (IUDs) are a frequently used, reversible, popular contraceptive method. They are usually placed without major complications. Uterine perforation is a rarely observed complication. Migration of the IUD to the pelvic/abdominal cavity or adjacent structures can occur after perforation. We present 3 cases of uterine perforation, possibly due to scarred myometrium associated with a cesarean delivery. We describe 3 perforations with IUDs lodged in the bladder serosa, the posterior cul-de-sac, and tissue adjacent to the cardinal ligament and external iliac artery. Cases Case 1. 26-year-old, Gravid 4, Para 2113, nonpregnant female with a history of a cesarean delivery underwent placement of an IUD one year after an elective pregnancy termination, presenting with abdominal pain requesting removal of the IUD. On speculum, although the IUD strings were visualized, the IUD could not be removed. Sonogram imaging identified an empty endometrial cavity with the IUD in posterior cul-de-sac. The IUD was removed via laparoscopy. Case 2 34-year-old Gravida 5, Para 4004, at 27 weeks and 3 days gestation, female with history of two previous cesarean deliveries underwent a third cesarean after spontaneous rupture of membranes with comorbid chorioamnionitis. Reproductive history was significant for placement of an IUD that had not been removed or imaged during obstetrical sonograms. The clinical evaluation revealed that the IUD had been spontaneously expelled. On the fifth operative day, the patient is febrile with CT demonstrating the IUD penetrating the anterior surface of bladder. On cystoscopy the bladder mucosa was intact. The IUD was removed via laparotomy with repair of the bladder, serosa, and muscular layer. Case 3 26-year-old, Gravid 4, P3013, nonpregnant female with three previous Cesarean deliveries had an IUD in place. However, with the IUD in situ, the patient conceived and had a spontaneous abortion. After the spontaneous abortion, she presented to clinic to have the IUD removed due to pain that was present since placement. Although the IUD strings were visualized, attempts to remove it were unsuccessful. Imaging identified the IUD outside the uterine cavity. Palpation with a blunt probe laparoscopically revealed a hard object within the adhesion band, close to the cardinal ligament. As per radiology evaluation, IUD was embedded 1cm from the external iliac artery on the right side outside the uterus in the adnexal region. A multidisciplinary procedure with gynecologic-oncologist was scheduled for removal due to the high risk of perioperative bleeding. Conclusion Patients in whom uterine perforation and IUD migration are suspected should have appropriate evaluation that includes transvaginal or transabdominal ultrasound or radiographs to confirm the position of the IUD, regardless of whether they are asymptomatic or present with symptoms. It is particularly important in the presence of a scarred uterus that imaging is used to identify the location of a missing IUD. The uterine scar of a cesarean may facilitate migration of the IUD. Cross sectional imaging, such as CT or MRI scan, may be needed to rule out adjacent organ involvement before surgical removal.

An Anatomic Approach to the Excision of Cardinal Ligament Endometriosis

An Anatomic Approach to the Excision of Cardinal Ligament Endometriosis

The role of ADAMTS-2, collagen type-1, TIMP-3 and papilin levels of uterosacral and cardinal ligaments in the etiopathogenesis of pelvic organ prolapse among women without stress urinary incontinence

Objective(s)To investigate the potential role of ‘a disintegrin-like and metalloproteinase with thrombospondin type motifs-2 (ADAMTS-2), collagen type-1, tissue inhibitor of metalloproteinases-3 (TIMP-3) and papilin’ levels in the uterosacral ligament (USL) and cardinal ligament (CL) of the uterus on the etiopathogenesis of pelvic organ prolapse (POP) among postmenopausal women without stress urinary incontinence (SUI). Study designA total of 45 postmenopausal women, 22 diagnosed as POP stage III–IV and 23 age- and body mass index (BMI)-matched controls referred for hysterectomy due to POP or benign gynecological disease, respectively, were recruited prospectively for our study. The biopsies of the USL and CL were obtained during hysterectomy. ADAMTS-2, collagen type-1, TIMP-3 and papilin levels were determined by enzyme-linked immunosorbent assay (ELISA) method after tissue homogenization. We excluded patients who smoked or presented with SUI. ResultsThere were no differences in terms of demographic features including age, BMI, obesity, duration of menopause, gravidity, parity, delivery modes and family history for POP between the POP and non-POP groups. Significant differences in the levels of ADAMTS-2, collagen type-1, TIMP-3 and papilin of USL were noted among the groups. Females with POP had lower levels of ADAMTS-2, collagen type-1, TIMP-3 and papilin in the USL compared to non-POP females. All investigated markers in the CL were also decreased in the POP group, but this relationship was not statistically significant. When age, duration of menopause, gravidity, parity and obesity were taken as covariates, only the USL papilin levels were negatively predictive for the development of POP. Conclusion(s)ADAMTS-2, collagen type-1, TIMP-3 and papilin levels of the USL play essential roles in the etiopathogenesis of POP among postmenopausal women without SUI. Moreover, significantly decreased USL papilin levels in females with POP suggest the importance of the USL and the impact of papilin on the development of POP.

Oxidative status of cardinal ligament in pelvic organ prolapse.

Pelvic organ prolapse (POP) is a common and distressing health problem in adult women, but the pathophysiological mechanism is yet to be fully elucidated. Previous studies have indicated that oxidative stress may be associated with POP. Thus, the aim of the present study was to investigate the oxidative status of pelvic supportive tissue in POP and further demonstrate that oxidative stress is associated with the pathogenesis of POP. A total of 60 samples were collected from females undergoing hysterectomy for POP or cervical intraepithelial neoplasia (CIN). This included 16 females with POP II, 24 females with POP III–IV (according to the POP-Q system) and 20 females with CIN II–III as the control group. Immunohistochemistry was utilized to measure the expression of oxidative biomarkers, 8-hydroxydeoxyguanosine (8-OHdG) and 4-hydroxynonenal (4-HNE). Major antioxidative enzymes, mitochondrial superoxide dismutase (MnSOD) and glutathione peroxidase 1 (GPx1) were measured through reverse transcription-quantitative polymerase chain reaction, western blotting and enzyme activity assays. The results demonstrated that in the cardinal ligament, the expression of 8-OHdG and 4-HNE was higher in the POP III–IV group compared with the POP II group and control group. The MnSOD and GPx1 protein level and enzyme activity were lower in the POP III–IV group compared with the POP II or the control group, while the mRNA expression level of MnSOD and GPx1 was increased. In conclusion, oxidative damage is increased in the pelvic supportive ligament of female patients with POP and the antioxidative defense capacity is decreased. These results support previous findings that oxidative stress is involved in the pathogenesis of POP.

PET/CT imaging analysis of recurrent sites and patterns of spread following modified radical surgery (type B) for stage Ib-IIa cervical cancer.

The aim of the present study was to use imaging to retrospectively analyze the recurrent sites and patterns of spread of early cervical cancer following radical surgery. A total of 86 patients with cervical cancer (stage IB or IIA) showed postoperative pelvic recurrences and distant metastases. Based on positron emission tomography or computed tomography, the correlation between clinicopathologic factors and sites of recurrence was determined and the pattern of spread was evaluated. Among the 86 patients with postoperative recurrence of early cervical cancer, 76 exhibited pelvic recurrence involving the cardinal and uterosacral ligaments. Other recurrences were paravaginal (n=14) and vaginal (n=10). Seven cases of recurrence were in the pelvic lymph nodes and 10 patients had distant metastases. The rate of paracervical ligament recurrence in patients with stromal invasion ≥1/2 depth was higher, compared with that in patients with stromal invasion <1/2 depth, however, the difference was not statistically significant. The rate of distant metastases in patients with positive pelvic lymph nodes was higher, compared with that in patients with negative lymph nodes (P=0.001). Recurrent lesions spread along the residual ligament to the lateral pelvic wall. It was found that, following radical surgery for early cervical cancer, recurrent tumor spread was predominantly confined to the subperitoneal residual ligaments of the cervix and vagina. For patients with positive lymph nodes, the incidence of distant metastases increased significantly.

Comprehensive Review of the Cardinal Ligament.

The cardinal ligament is thought to be one of the important structures in providing support and stabilization for the pelvic organs e.g., the uterus. However, many discrepancies exist in the literature regarding terminology, anatomy, and histology. The cardinal ligament attaches the lateral side of the vagina and cervix to the lateral pelvic wall, which provides support to the vagina and cervix. Studies have shown variable findings in the collagen content and distribution in the cardinal ligaments of women with a prolapsed uterus. Uterine vessels and the branches of the inferior hypogastric plexus travel in the cardinal ligament, which is of great importance during pelvic surgeries. Cervical cancer may lead to metastatic spread to the lymph nodes juxtaposed to the cardinal ligaments. This review aims to highlight the clinical significance and surgical importance of the cardinal ligament with a comparison with previous studies.