Uterine Broad Ligament Research Articles

Extremely Rare Transitional Cell Carcinoma of The Round Uterine Ligament - Histopathogenesis, Immunohistochemical Analysis, Prognosis and Optimal Complex Treatment

For the first time in the English medical literature is presented an extremely rare transitional cell carcinoma of the round uterine ligament. Transitional cell carcinoma (TCC) of the ovary was first defined by Austin and Norris in 1987. Malignant primary tumors arising in the uterine broad ligament are extremely rare. To date, its pathogenesis is unclear. In the discussion we focus on the pathomorphological and immunohistochemical analysis of transitional cell carcinomas in the genital tract and their differential diagnosis from transitional cell carcinomas of the urinary tract / ureter and bladder. Due to the high malignant potential, the prognosis is unfavorable and requires optimal complex treatment, including radical surgery followed by systemic chemotherapy.

Evaluation of Intraperitoneal and Incisional Bupivacaine or Levobupivacaine for Postoperative Analgesia in Ovariohysterectomized Dogs

Background: Ovariohysterectomy (OHE) is the most commonly performed elective surgical procedure in companion animals. OHE offers benefits of control of population and decreased risk of potentially life-threatening diseases such as mammarian tumours and pyometra. Traditional OHE intervention causes inflammation and pain due to trauma during organ manipulation. The purpose of this study was to compare the effect of intraperitoneal and incisional administration of bupivacaine (BP) or levobupivacaine (LP) on postoperative analgesia in dogs undergoing the OHE procedure.Materials, Methods & Results: A total of 24 mix-breed bitches aged between 1 - 3 years and weighed 19 - 20 kg were used in this study. The animals were divided into three groups as control (n = 8), BP (n = 8) and LP group (n = 8). The animals were kept under surveillance at the hospitalisation unit of the animal hospital for one day before the elective OHE. The dogs were fasted for 12 h before the surgery, with adlib water consumption. Atropine sulphate 0.045 mg/kg was administered subcutaneously approximately 30 min before general anaesthesia. Midazolam (0.3 mg/kg) was intravenously injected into all dogs for pre-anaesthetic medication. After sedation, anaesthesia was induced with propofol (4 mg/kg, IV) and then the dogs were orotracheally intubated using cuffed endotracheal tubes. General anaesthesia was maintained by administration of 2% isoflurane. The ventral abdomen was prepared aseptically for OHE following the general anaesthesia. All animals were operated on by the same surgeon. During surgery, sprayed bupivacaine 0.5% (4.4 mg/kg) with an equal volume of saline in BP group, levobupivacaine 0.5% (4.4 mg/kg) with an equal volume of saline in LP were then applied over the ovaries, uterine broad ligaments and cervix uteri. After removal of the uterine body, either LP or BP was sprayed to left and right, or cranial and caudal parts of the abdominal cavity. Finally, the incision line was sprayed before closing the skin. The control group received only sprayed saline. The pain evaluation was carried out with modified Melbourne pain scoring scale. To determine cortisol concentrations, blood samples were taken before anaesthesia induction (baseline) and postoperative 0, 0.5, 1, 2, 4, 6, 12 and 24 h. Postoperative pain scores were higher in the control group than BP and LP groups following surgery at 30 min, 1st, 4th, and 6th h. In all groups, cortisol levels increased postoperatively, whereas they decreased more rapidly in BP and LP groups. There was a steady increase at postoperative 0 min, 30 min, 1st, 2nd, 4th and 6th h in the control group and at postoperative 0 min, 30 min and 1 h in BP and LP groups (P < 0.05).Discussion: Intraperitoneal and incisional bupivacaine shows significantly superior postoperative pain management benefits after the closure of skin, compared to untreated dogs and it is also superior to lidocaine treatment at 0.5 h following the visual analogy pain assessment system. In the present study, the observation of lower pain scores in BP group at 0.5, 1, 4 and 6 h as compared to the control group was similar to findings of other studies. LP group also showed decreased pain scores at above-mentioned h without any significant difference. However, only in LP group, pain scores at 24 h were lower than postoperative pain scores. In conclusion, it is suggested that sprayed intraperitoneal and incisional BP and LP are very effective for preventing postoperative pain ovariohysterectomized dogs.

Broad Band Ligament Hernias: A Case Report

Internal hernias account for 1% of all mechanical obstructions. However, internal hernias by defect of the broad ligament of the uterus are uncommon. This review aims to update our knowledge regarding this unusual pathology in order to understand its etiology and symptoms, and to aid in early diagnosis and management. Since the end of the nineteenth century, fewer than 100 cases of internal hernias secondary to a defect of the broad ligament have been described. It is known that this defect in the broad uterine ligament can be congenital or acquired, leading to symptoms such as chronic pelvic pain or dyspareunia in the absence of intestinal obstruction. Because of the evolution of laparoscopic surgery, management in these cases in recent years has evolved to less invasive surgical techniques. Abdominal wall hernias are a frequent cause of intestinal obstruction. By contrast, internal hernias represent a low incidence, with the exception of internal hernias caused by a defect of the uterine broad ligament. In this article we review all published cases of hernia related to the uterine broad ligament, and add to that series the case of a 44-year-old patient with no medical/surgical history of interest who arrived at the emergency department due to abdominal pain and absence of bowel movement, clinically compatible with intestinal obstruction. Internal hernias due to defect of the broad ligament are an unusual cause of intestinal obstruction in women. They require a high index of clinical suspicion, and their treatment is fundamentally surgical. Laparoscopy is current an appropriate approach for trained surgeons.

Maternl and Neonatal Outcomes of Elective and Emergency Cesarean Sections

Cesarean section is safe surgical procedure, but increased cesarean section incidence leads to higher maternal and neonatal complications intraoperatively and postoperatively. This study aimed to assess the maternal and fetal outcomes of different types of cesarean sections in Kirkuk city. Hence, a prospective study was conducted in Obstetrics and Gynecology department of Azadi Teaching Hospital in Kirkuk city during 1st of October, 2013 to 31st of May, 2014, included 600 term pregnant women indicated for elective and emergency cesarean sections. It had been found that second stage Cesarean sections were significantly associated with womens’ obesity and irregular antenatal care (p<0.001). Extension of lower uterine incision, bladder injury and broad ligament hematoma were the reported introperative complication while, postoperative maternal complications were postpartum hemorrhage and secondary suturing of skin wound. Neonatal complications after first and second stage cesarean section were transient tachypnea, sepsis, admission to neonatal intensive care unit, hypoxic ischemic encephalopathy, birth asphyxia and low apgar score. In conclusion, the second stage cesarean section is obviously accompanied by many maternal and neonatal complications in comparison to elective and first stage cesarean sections.

Successful treatment of advanced stage yolk sac tumour of extragonadal origin: a case report and review of literature.

Background.Yolk sac tumour diagnosis should be considered for young age patients admitted to the hospital with non-specific complaints of widespread disease. Correct diagnosis and carefully planned treatment is the key to a successful outcome.Methods and materials. We present a rare case of a widespread yolk sack tumour of a uterine broad ligament. Our team directed a special attention towards the patient’s young age, advanced disease, and fertility sparing strategy of treatment.Results and conclusions.Stage IV yolk sac tumours of extragonadal origin are rarely reported in the literature. Hence, diagnosis and treatment often pose a challenge for emergency care unit doctors, gynaecologists, and oncologists. However, it can be a potentially curable disease. Moreover, patients’ fertility can also be preserved. We believe that further analysis of similar cases is necessary to study outcomes and evaluate patients’ responses to a sequence of medical decisions taken for this specific case.

Laparoscopic Dissection and Anatomy of Sacral Nerve Roots and Pelvic Splanchnic Nerves

Study ObjectiveTo demonstrate the technique of laparoscopic dissection for identification of sacral nerve roots and pelvic splanchnic nerves. DesignCase report (Canadian Task Force classification III). SettingPrivate practice hospital in São Paulo, Brazil. PatientA 31-year-old woman with suspected iatrogenic and/or compression of sacral nerve roots. She reported debilitating pelvic, gluteal, and perineal unilateral left-sided pain (score 8 on a pain scale of 0–10), and had primary infertility with 1 previous failed attempt at in vitro fertilization. Surgical history included laparoscopic excision of endometriosis 10 months before the procedure and left oophoroplasty during adolescence because of a benign neoplasm. InterventionsStandard 4-puncture laparoscopy was performed. The peritoneum of the left pelvic sidewall was resected to preclude eventual residual endometriosis. This also enabled identification of uterine vessels including the deep uterine vein, which is the limit between the pars vascularis superiorly and the pars nervosa inferiorly in the uterine broad ligament. Surgery was using the laparoscopic neuro-navigation (LANN) technique, previously described by one of us (M. P.). For identification of the sacral roots, dissection was begun medial to the ureter and lateral to the uterosacral ligament. The Okabayashi pararectal space was entered as deep as possible via blunt dissection in avascular spaces. Hemostasis was performed using 5-mm bipolar forceps, and harmonic energy was not used. The hypogastric fascia was entered from medial to lateral, and the piriformis muscle was identified. The sacral nerve root S1 was identified lying over it. Dissection then proceeded caudally, and sacral roots S2 and S3 were sequentially identified. Small and delicate fibers forming the pelvic splanchnic nerves were isolated emerging from sacral roots S2 and S3. Other nerve fibers were identified caudally, probably representing pelvic splanchnic nerves emerging from S4. Measurements and Main ResultsThe surgical operative time was 70 minutes, and bleeding was minimal. No suspected compression or iatrogenic injury was identified. The patient was discharged on the day after the procedure. At 8-month follow-up, she had partial resolution of pain (score 5, pain scale 0–10), and another failed attempt at in vitro fertilization was attributed to unsatisfactory quality of the embryos. There were no symptoms or dysfunctions attributable to manipulation of the nerves. ConclusionLaparoscopy is a useful tool for identification of sacral roots and pelvic splanchnic nerves in suspected diseases. Its application in the field of neuropelveology can be expanded with proper knowledge and training.

Damage to the Right Rectus Abdominus Muscle and Hematoma of the Right Uterine Broad Ligament: Rare Complications of a Road Accident during Pregnancy

Severe damage to the right rectus abdominus muscle associated with a uterine broad right ligament hematoma is rare complications of an accident during pregnancy. We report the case of a 31 years old primiparous pregnant woman, who had been victim of a road accident at 28 weeks of pregnancy, when as a pediatrian she was hit by a car. The site of impact was in the right anterolateral area on the abdomen. The pregnancy continued normally and she was ultimately delivered vaginally at 41 weeks of gestation. The baby was normally grown and had Apgar scores of 9 and 10 at 1 and 5 minutes of life. She underwent a laparotomy in the immediate postpartum period for a significant hemoperitoneum; this revealed the lesions and allowed treatment. The postoperative course was uneventful and the patient was discharged on the 6th post-partum day.

Prophylactic Ureteral Stenting in the Excision of Large Broad Ligament Fibroid

Leiomyomas in uterine broad ligaments are usually asymptomatic but may grow to a very large size and alter the pelvic anatomy. This may result in difficulties during surgical excision with attendant complications, the most serious one being ureteral injury. A 45 year old lady presented with pain and distension of abdomen. On evaluation, a pelvic mass of 28 weeks size of varying consistency was observed. Ultra sonogram and Magnetic Resonance Imaging confirmed the diagnosis of right sided broad ligament fibroid. Anticipating possible ureteral injury owing to its size, preoperative stenting of the ureters was performed. Laparotomy was performed with the excision of tumour in toto, followed by total abdominal hysterectomy and bilateral salpingo-oopherectomy. With the postoperative period being uneventful, ureteral stent was removed.

Identification of Displaced Endometrial Glands and Embryonic Duct Remnants in Female Fetal Reproductive Tract: Possible Pathogenetic Role in Endometriotic and Pelvic Neoplastic Processes

Background: Recent findings strongly promoted the hypothesis that common pelvic gynecological diseases including endometriosis and ovarian neoplasia may develop de novo from ectopic endometrial-like glands and/or embryonic epithelial remnants. To verify the frequency, the anatomical localization and the phenotype of misplaced endometrial tissue along the fetal female reproductive tract, histological and immunohistochemical analyses of uteri, fallopian tubes, and uterosacral ligaments were performed. Methods: Reproductive organs were collected from seven female fetuses at autopsy, five of them from gestational ages between 18 and 26 weeks and two fetuses with gestational ages of 33 and 36 weeks deceased of placental anomalies. Serial sections from areas containing ectopic glands and embryonic duct residues were analyzed by histological and immunohistochemical procedures. Results: Numerous ectopic endometrial glands and stroma were detected in the myometrium in two fetuses with low levels of expression of estrogen receptor-alpha (ER-α) and progesterone receptors (PR). The embryonic ducts were localized in the uterine broad and ovarian ligaments and under the fallopian tube serosa in six fetuses. Low levels of steroid receptors expression were found in the embryonic residues, whereas the carcino-embryonic antigen (CEA) and the tumor marker Ca 125 were not detected. The embryonic residues stromal component strongly expressed the CD 10 and vimentin proteins. Conclusion: The anatomical and the immunohistochemical features of the ectopic organoid structures identified in fetal female reproductive tract suggest that endometriotic as well as neoplastic disease in adult women may develop on the basis of misplaced endometrial glands and/or embryonic cell remnants.

Expression of VEGF-A, Flt-1, and Flk-1 in the arterial endothelial cells of the uterine broad ligament throughout the estrous cycle

The aim of the present study was to determine the immunoreactivity of vascular endothelial growth factor (VEGF-A) and its two receptors, viz., Flt-1 (fms-like tyrosine kinase) and Flk-1 (fetal liver kinase), on the surface of endothelial cells of the uterine artery and its branches and of the arcuate arteries in the area of the uterine broad ligament during various phases of the estrous cycle in the pig. We also investigated their expression to determine whether this was phase-related. The highest immunoreactivity for VEGF-A was observed in the uterine artery and arcuate arteries at the early luteal phase and in the branches of the uterine artery during the follicular phase of the estrous cycle. The strongest immunostaining intensity of Flt-1 was found in the uterine artery and its branches at the follicular phase and in arcuate arteries at the mid-luteal phase, whereas Flk-1 immunostaining was at its highest in the uterine artery at the mid-luteal phase and in the branches of the uterine artery and arcuate arteries at the follicular phase. Additionally, VEGF-A expression was assessed by semi-quantitative Western blot analysis, which revealed significantly higher levels of VEGF-A protein during the early luteal and the follicular phase of the estrous cycle (P < 0.001). The phase-related differences in the immunoreactivity and expression of VEGF-A and VEGF receptors suggest that these factors are hormone-dependent during the estrous cycle in the pig.

Internal Herniation Through a Defect in the Broad Ligament of the Uterus

Summary Objective Intestinal obstruction caused by internal herniation of the bowel at a tear in the uterine broad ligament is extremely rare. Accurate preoperative diagnosis is very difficult. Here, we present a case with internal herniation through a defect in the broad ligament of the uterus. Case Report A 41-year-old female complained of colicky pain over the lower abdomen, nausea, and vomiting for 2 days. No significant history except cesarean section was given. Transvaginal ultrasound revealed a cystic structure with peristalsis located at the broad ligament of the uterus. Highly suspicious of bowel obstruction, we performed an emergency laparoscopy and discovered intestinal herniation at a broad ligament tear. The herniated bowel loop was reduced and the tear was sutured primarily. The reduced bowel loop was viable with no evidence of gangrene or perforation. The patient recovered uneventfully. Conclusion Good prognosis relies on early surgical correction before bowel gangrene or perforation of the strangulated bowel, especially in patients with previous gynecologic or obstetric surgery. Transvaginal ultrasound by an experienced operator may be helpful for this diagnosis.

Human (and some other primates') uterine teres ligament represents a mammalian developmental novelty

Background The primordia of the structures developing into the mammalian male cremaster sacs emerge as well in females fetuses. In most species the structures developing from these primordia in females remain inconspicuous: the so-called uterine teres ligament consisting of a slender part across the uterine broad ligament and a more or less developed bulbous structure at the site where this ligament inserts into the inguinal abdominal bottom. Not many data are available concerning the growth, development, or function of the uterine teres ligament. In humans—and also in other “higher” female primates—the uterine teres ligament is a major structure consisting mainly of smooth musculature. It is attached to the ventral aspect of the tubo-uterine junction. From there it courses across the uterine broad ligament and extends, retroperitoneally, to the inguinal region where it pierces through the inguinal canal to end in the tissues ventral of the pubic bones. Observations: Analysis of the fetal development of the human uterine teres ligament, as compared with that of various other non-primate mammals, offers an explanation for its unusual anatomical condition. Evidence is conferred that, in human fetuses, there is no counterpart for the slender ligament across the broad ligament in other mammals. Instead, the homologue of the rudimentary bulbous structure in the abdominal bottom of non-primate females develops into a strong muscular structure which is directly connected to the (para-)menonephric duct wall. Conclusion It is concluded that the human uterine teres ligament is to be judged a structure different from that of other, non-primate, mammals. It is speculated that the unusual structure of the human teres ligament is related to one or more of the many unusual features of human uterine development: as a single organ (uterus simplex), with a position deep in the abdominal cavity below the pelvic brim, and far away from the posterior abdominal wall. The unusual anatomical position may require an unusual construction of the uterine suspensory apparatus of which the teres ligament is one component. © 1996 Wiley-Liss, Inc.

Intestinal Obstruction Secondary to a Hiatus in the Uterine Broad Ligament

Intestinal Obstruction Secondary to a Hiatus in the Uterine Broad Ligament

CHORIOCARCINOMA: GROWTH PATTERNS IN HAMSTER TISSUES.

CHORIOCARCINOMA is a highly invasive tumour that retains some of the peculiar properties of normal immature human trophoblast1. In order to study the manner in which it invades tissues, we inoculated small fragments of transplantable human choriocarcinoma into the following sites in 19 young (70–90 g) female Syrian hamsters (Dennen): uterine broad ligament, peritoneal cavity, lung, liver, brain, thigh muscle, vena cava, hepatic portal vein, and internal jugular vein. Testicular inoculation was carried out in one male hamster. The tumour used was the Greene choriocarcinoma (kindly supplied by Dr. Roy Hertz), originally isolated in 1960 by Roy Hertz, carried by serial passage in the hamster cheek pouch, and similar in behaviour to the WO strain described by Hertz2. Although cortisone is not needed to maintain growth of the Greene choriocarcinoma in the cheek pouch, we gave it to 15 of the 19 hamsters in this preliminary work with the hope of ensuring tumour growth at the various inoculated sites3. For direct implantation into organs, two–ten 3-mm tumour fragments were inoculated into each site by cannula (Lundy–Irving caudal needle). For intravenous inoculation, the tumour was minced with Bard Parker knives into fragments less than 1 mm in diameter. About 50 of these tiny fragments were suspended in 0.1 ml. or less of Gey's balanced salt solution, and slowly injected with a tuberculin syringe through a 21-gauge hypodermic needle. All hamsters were autopsied within 7–16 days.