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

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.

Mechanical Analysis of the Uterosacral Ligament: Swine vs. Human

“…2). In early studies by Fung on mesenteric membranes, 19,20 which are similar to the USLs, 40 the loading and unloading curves which were obtained by cyclically loading the membranes at a constant amplitude and elongation rate, never reached a steady state, even after several cycles. However, the difference in load recorded in successive cycles was observed to decrease with the number of cycles as in our study.…”

“…It is primarily composed of collagen fibers and smooth muscle cells with an automic nerve supply and a network of blood vessels. 40 …”

What's new in the functional anatomy of pelvic organ prolapse?

“…34 There is no band of dense regular connective tissue that connects the uterus laterally to the pelvic walls. 35 These structures are bilateral mesenteries going to the pelvic organs and consist of vascular, neural, lymphatic and areolar tissue that consist of fat and a delicate meshwork of connective tissue between different elements.…”

Biaxial mechanical properties of swine uterosacral and cardinal ligaments

“…They form a thin, membrane-like complex that is composed of smooth muscle, blood vessels, nerve fibers, collagen, and elastin. The relative amount of these components and their organization remain unknown (Ramanah et al 2012). These visceral ligaments can provide support to the pelvic organs while also accommodating highly mobile organs such as the uterus, owing to their structure and composition (Ramanah et al 2012).…”

“…The relative amount of these components and their organization remain unknown (Ramanah et al 2012). These visceral ligaments can provide support to the pelvic organs while also accommodating highly mobile organs such as the uterus, owing to their structure and composition (Ramanah et al 2012). The loading experienced by these ligamentous membranes is likely biaxial in vivo, with larger forces occurring along the axis normal to the upper vagina/cervix.…”