The round ligament of the uterus: Questioning its distal insertion.

PURPOSE: Classically, the round ligament of the uterus (RLU) attaches distally in the ipsilateral labia majora. This attachment has rarely been described in adults. That is why we have performed an anatomical study focused on this distal ending. PATIENTS: We performed in 2015 the cadaveric dissection of 19 RLU. METHODS: In all cases, the RLU was individualized on its entire length from its uterine origin to the inguinal canal. Then this canal was open from its internal orifice to its external orifice. We described the distal attachment of the RLU according four areas: before the internal inguinal ring, after the external inguinal ring, under the pubic bone and in labia majora. RESULTS: We found 3 types of distal attachments with first an attachment after the external inguinal ring in more than half of cases (52.6%). Then, before the internal inguinal ring (26.3%) and under the pubic bone (22.1%). No RLU was found inlabia majora. However, the proximal attachment seems constant at the antero-superior face of uterus, near the tubo-uterine junction like its pelvic path under the broad ligament. CONCLUSION: In adult, the RLU is a structure, which begins at the cranio-ventral part of the uterine bottom near the tubo-uterine junction. Then it passes under the broad ligament and reaches the inguinal canal, that it crosses in more half of cases. However, 3 distal attachment areas have been identified but never in the labia majora. Indeed, some anatomical information available in anatomical treaties seems not correct and should be amended.

Deep pelvic endometriosis: don't forget round ligaments. Review of anatomy, clinical characteristics, and MR imaging features.

Deep infiltrating endometriosis is an important gynecologic disease that may develop during the reproductive years and is responsible for severe pelvic pain. Deep pelvic endometriosis can affect the retrocervical region, uterosacral ligament, rectum, rectovaginal septum, vagina, urinary tract, and other extraperitoneal pelvic sites. Surgery remains the best therapeutic treatment for affected patients and an accurate preoperative evaluation of the extension of endometriotic lesions is essential for a successful outcome. However, many atypical locations for deep pelvic endometriosis exist although still lesser known to both gynecologists and radiologists such as endometriosis of the round ligaments of the uterus (RLUs). In this article, we review embryology and anatomy of the RLUs as well clinical characteristics associated with these endometriotic locations. In addition, we describe magnetic resonance (MR) imaging protocol, normal MR imaging appearances of the RLUs and the most common abnormal findings of endometriotic involvement of these ligaments at MR imaging. Radiologists should always keep in mind the RLUs as a possible site of deep pelvic endometriosis localization and should not forget to carefully look for them on MR images.

Comparative analysis of pelvic ligaments: a biomechanics study.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) affects one third of women of all ages and is a major concern for gynecological surgeons. In pelvic reconstructive surgery, native ligaments are widely used as a corrective support, while their biomechanical properties are unknown. We hypothesized differences in the strength of various pelvic ligaments and therefore, aimed to evaluate and compare their biomechanical properties. MATERIALS AND METHODS: Samples from the left and right broad, round, and uterosacral ligaments from 13 fresh female cadavers without pelvic organ prolapse were collected. Uniaxial tension tests at a constant rate of deformation were performed and stress-strain curves were obtained. RESULTS: We observed a non-linear stress-strain relationship and a hyperelastic mechanical behavior of the tissues. The uterosacral ligaments were the most rigid whether at low or high deformation, while the round ligament was more rigid than the broad ligament. CONCLUSION: Pelvic ligaments differ in their biomechanical properties and there is fairly good evidence that the uterosacral ligaments play an important role in the maintenance of pelvic support from a biomechanical point of view.

Intergender differences in histological architecture of the fascia pelvis parietalis: a cadaveric study.

The fascia pelvis parietalis (FPP) or endopelvic fascia is a well-known structure, but few studies described the detailed histological architecture, including the composite fiber directions. We hypothesized a gender-specific fiber architecture corresponding to the functional demand. For the first step to examine this hypothesis, we investigated specimens from 27 adult cadavers (10 males and 17 females) and 11 midterm fetuses (five males and six females) using immunohistochemistry and aldehyde-fuchsin staining. The adult female FPP was a solid, thick monolayered structure that was reinforced by abundant elastic fibers running across the striated muscle fibers, but it contained little or no smooth muscles (SM). In contrast, the male FPP was multilayered with abundant SM. In midterm fetuses, SM originated from the inferior part of the bladder and extended inferiorly along the gender-specific courses. Thus, we found a clear intergender difference in FPP architecture. However, the functional significance remained unknown because the basic architecture was common between nulliparous and multiparous women. Rather than for meeting the likely mechanical demands of pregnancy and vaginal delivery, the intergender difference of the FPP seemed to result from differences in the amount and migration course of bladder-derived SM as well as in hormonal background.

Vaginal ring and round ligament of the uterus in the female cat.

The peritoneum was examined for the existence of a vaginal ring and the round ligament of the uterus was dissected through the inguinal region in eleven embalmed adult female cats. In all cats, there was no evidence of a peritoneal evagination into the inguinal canal. There was no vaginal ring and no vaginal process. The round ligament of the uterus passed through the inguinal canal and disintegrated in the fascia a short distance beyond the superficial inguinal ring.

Anatomical basis of neuropathies and damage to the ilioinguinal nerve during repairs of groin hernias. (about 100 dissections).

Surgical access to the inguinal region, notably during hernia repairs, exposes the ilioinguinal nerve to the risk of damage at the origin of the neuralgia. The incidence of these post-operative neuropathies and their medicolegal consequences justify this study about the anatomical variations of the ilioinguinal nerve. With the aim of preventing its damage during repairs of groin hernias and identifying the factors of onset of chronic spontaneous neuropathy of the ilioinguinal nerve, we dissected 100 inguinal regions of 51 fresh adult corpses. The nerve was absent in seven cases and double in one case. Out of the 94 ilioinguinal nerves observed, we analyzed the path in relation to the inguinal ligament and the connections with the walls of the inguinal canal and its content. The ilioinguinal nerve travels along the superficial surface of the internal oblique muscle, passing on average 1.015 cm from the inguinal ligament. In one case, the fibers of the internal oblique muscle spanned it in several places. The nerve was antero-funicular in 78.72% of cases and perforated the fascia of the external oblique in 28.72% of cases. The terminal division took place in the inguinal canal in 86% of cases, with terminal branches that sometimes perforated the fascia of the external oblique. These results enabled us to better understand the etiopathogenic aspects of certain neuropathies of the groin and to propose techniques useful for the protection of the nerve during repairs of groin hernias.

Smooth muscle fraction of the round ligament in women with pelvic organ prolapse: a computer-based morphometric analysis.

Our objective was to compare the collagen and muscle content of the round ligament of uteri in women with pelvic organ prolapse. We evaluated the tissue samples obtained from the round ligaments of 22 patients with uterine prolapse who underwent vaginal hysterectomy (group A, study) and from 26 patients with no pelvic relaxation in whom total abdominal hysterectomy was performed for benign reasons (group B, controls). Morphometric analysis was performed on histologic cross-sections of the round ligament. Sections from each sample were stained with hematoxylin and eosin and Masson's trichrome methods. A computer system was used for morphometric measurements. We used independent samples t-test or Mann-Whitney U test to investigate the difference between the two groups. It was found that the smooth muscle fraction of the round ligament in women with uterine prolapse was significantly decreased compared with that of healthy control subjects and concluded that decreased smooth muscle content may be an important pathogenetic factor in uterine prolapse.

A reevaluation of the structures accepted to represent the postnatal gubernaculum.

INTRODUCTION: The structure called the residual gubernaculum (G) has been evaluated to define its origin. MATERIALS AND METHODS: Girls operated for inguinal hernia (n = 7) and boys operated for undescended testis (n = 12), inguinal hernia (n = 7), hydrocele of the cord (n = 1), and ectopic (n = 1) and entrapped (n = 1) testes were evaluated. Attachments of the structures coursing distally from the sacs were identified, and they were removed en block. Three samples, first from the distal part of the sac with the beginning of the fibrous structure, second from the midportion, and third from the most distal part, were prepared and stained with hematoxylin-eosin, trichrome and elastic van Gieson. Histologic structures within the samples were determined and compared with Mann-Whitney U test. RESULTS AND CONCLUSIONS: Structures called the residual G differed from the walls of accompanying sacs by only the absence of mesothelial lining. Therefore, the structure called the residual G in boys with an undescended testis and the round ligament in girls actually represent the obliterated processus vaginalis.

The anatomy of the female gubernaculum is different from the male.

The round ligament, or female gubernaculum, is believed to terminate in the labium majorum. In the 30-week old male foetus, however, the gubernaculum ends outside the external ring, later migrating into the scrotum under androgenic control. We studied the round ligament anatomy in the female to define its position and to see whether it reaches the labium. Post-mortem examination of 10 females (0-11 years), dying of non-genital disorders defined the anatomy of the round ligament by dissection and photography. The round ligament ended just outside the external ring in all females, with neither attachment, nor extension, to the caudal labium. A short processus vaginalis (canal of Nuck) was found in 1 patient. This study showed that the round ligament fails to reach the caudal labium, which is the homologue of the hemiscrotum. The migration of the male gubernaculum into the scrotum to enable descent of the testis does not occur in females. The description of the round ligament in standard textbooks of anatomy should be amended.

Extraperitoneal paravesical spaces: CT delineation with US correlation.

The extraperitoneal space around the urinary bladder is lamellate, just like the retroperitoneal space around the kidneys. The bladder, urachus, and obliterated umbilical arteries lie within the perivesical space, surrounded by umbilicovesical fascia, analogous to the perinephric space within the renal fascia. A much larger prevesical space, analogous to the anterior pararenal space, lies anterior and lateral to the umbilicovesical fascia. Posterior to the urinary bladder, the lower uterine segment or seminal vesicles lie within the perivesical space, rather than in a separate compartment, corresponding to the posterior pararenal space. The cul-de-sac, and the inferolateral extension of its peritoneal layers as the rectovaginal or rectovesical septum, separate the posterior perivesical space from the rectum. The sectional anatomy of these spaces, and particularly their computed tomographic and ultrasound appearances, were noted in normal anatomic sections, patients with extraperitoneal fluid collections, and a cadaver into which fluid was injected.