Somatostatin immunoreactivity within the urinary bladder nerve fibers and paracervical ganglion urinary bladder projecting neurons in the female pig.

The study was designed to examine the distribution and chemical coding of somatostatin-immunoreactive (SOM-IR) nerve fibers supplying the urinary bladder wall and to establish the distribution and immunohistochemical characteristics of the subpopulation of paracervical ganglion (PCG) SOM-IR neurons projecting to this organ in female pigs. The PCG-urinary bladder projecting neurons (PCG-UBPN) were visualized with retrograde neuronal tracer Fast Blue (FB). Double-labeling immunohistochemistry performed on cryostat sections from the urinary bladder wall revealed that the greatest density of SOM-IR nerve fibers was found in the muscle layer and around blood vessels, a moderate number of these nerve terminals supplied the submucosa and only single SOM-IR axons were encountered beneath the urothelium. In all the investigated sections the vast majority of SOM-IR nerve fibers were immunopositive to vesicular acetylcholine transporter (VAChT) and many SOM-IR axons contained immunoreactivity to neuropeptide Y (NPY). Approximately 65 % of FB-positive (FB+) PCG-UBPN were immunoreactive to SOM. Moreover, PCG FB+/SOM + nerve cells were simultaneously immunoreactive to choline acetyltransferase (ChAT; 64.6 ± 0.6 %), NPY (59.7 ± 1.2 %), neuronal nitric oxide synthase (nNOS; 46.1 ± 0.7 %), vasoactive intestinal polypeptide (VIP; 29.9 ± 2.2 %), Leu5-enkephalin (L-ENK; 19.5 ± 6.3 %), dopamine ß-hydroxylase (DßH; 14.9 ± 1.9 %) or pituitary adenylate cyclase-activating polypeptide (PACAP; 14.8 ± 2.4 %). The present study reveals the extensive expression of SOM in both the nerve fibres supplying the porcine urinary bladder wall and the PCG neurons projecting to this organ, indicating an important regulatory role of SOM in the control of the urinary bladder function.

Innervation of cervical carcinoma is mediated by cancer-derived exosomes.

OBJECTIVE: Recently, our laboratory identified sensory innervation within head and neck squamous cell carcinomas (HNSCCs) and subsequently defined a mechanism whereby HNSCCs promote their own innervation via the release of exosomes that stimulate neurite outgrowth. Interestingly, we noted that exosomes from human papillomavirus (HPV)-positive cell lines were more effective at promoting neurite outgrowth than those from HPV-negative cell lines. As nearly all cervical tumors are HPV-positive, we hypothesized that these findings would extend to cervical cancer. METHODS: We use an in vitro assay with PC12 cells to quantify the axonogenic potential of cervical cancer exosomes. PC12 cells are treated with cancer-derived exosomes, stained with the pan-neuronal marker (ß-III tubulin) and the number of neurites quantified. To assess innervation in cervical cancer, we immunohistochemically stained cervical cancer patient samples for ß-III tubulin and TRPV1 (sensory marker) and compared the staining to normal cervix. RESULTS: Here, we show the presence of sensory nerves within human cervical tumors. Additionally, we show that exosomes derived from HPV-positive cervical cancer cell lines effectively stimulate neurite outgrowth. CONCLUSIONS: These data identify sensory nerves as components of the cervical cancer microenvironment and suggest that tumor- derived exosomes promote their recruitment.

Uterine Cervical Neurotransmission and Cervical Remodeling.

Cervical remodeling (CR) is a complex process, which, in part, is believed to be induced by physiological inflammation. Even though the female reproductive tissues are richly innervated by nerves from the parasympathetic pelvic autonomic ganglia, sensory dorsal root and nodose ganglia, their roles (neuronal factors) in this process (CR) has been largely attributed to sex steroid hormones, until recently. Here, we discuss the interaction between neuropeptides derived from peripheral nerves associated with uterine cervix and estrogen, and their likely impact on cervical remodeling. It is likely that these neuronal factors, under the influence of estrogen, could induce physiological inflammation during cervical remodeling by promoting the expression of vascular endothelial growth factor, among other factors.

A Qualitative and Quantitative Study of the Innervation of the Human Non Pregnant Uterus.

Human female reproductive system is closely dependent by hormonal stimulation. Anyway it is now commonly stated that autonomic innervation system regulates, along with hormonal stimulation, the uterine physiology. Cholinergic and adrenergic innervations have a critical role in mediating input to the uterus, but other neurotransmitters and neuropeptides exist that influence uterine physiology, as well. In the present investigation, we analyzed the uterine distribution of a large set of neurotransmitters, focusing on adrenergic, noradredenergic, acetylcholine (AChE) positive, dopaminergic, serotoninergic and peptidergic neurofibers; among these latter, we focused on those releasing prolattine, enkephalines (ENKs), Vasoactive Intestinal Polypeptide (VIP), substance P (SP) and oxytocine. Authors demonstrate the differential localization of these neurofibers in non pregnant uterine fundus, corpus and cervix, sampling myometrial assays of 31 patients submitted to hysterectomy. In fundus uteri, we observed a prevalence of prolactinergic (32.1 ± 1.4 Conventional Unit, C.U.) and adrenergic (36.4 ± 4.5 C.U.) neurofibers; in uterine body VIP positive neurofibers (32.6 ± 4.8 C.U.) and prolactinergic neurofibers (30.3 ± 1.2 C.U.) were the most represented. In uterine cervix, we detected the highest concentration of all the neurofibers analysed, with enkephalinergic neurofibers (94 ± 1.7 C.U.), oxitocinergic neurofibers (72.1 ± 5.1 C.U.), SP positive neurofibers (66.1 ± 4.4 C.U.), acetylcholine positive neurofibers (64.5± 3.6 C.U.), serotoninergic neurofibers (56.4 ± 3.9 C.U.) and VIP positive neurofibers (58.3 ± 5.2 C.U.) being the most expressed. This study demonstrates that uterine cervix harbors a higher concentration of almost all neurotransmitters, compared to the other two uterine anatomic sites. The uterine cervix is largely involved during pregnancy and labor, and the rich neurotransmitters density could contribute to confer to the cervix a proper potential plasticity, necessary for pregnancy and labour.

Step-by-step Type C Laparoscopic Radical Hysterectomy With Nerve-sparing Approach.

STUDY OBJECTIVE: To show the laparoscopic technique to perform type C radical hysterectomy with a nerve-sparing approach and pelvic lymphadenectomy. DESIGN: Educational video with step-by-step explanation of the technique using videos and pictures to highlight the anatomic landmark that guides the procedure. SETTING: The goal of this procedure is to enlarge the resection of the paracervix at the junction with internal iliac vascular system, leaving the neural part of the structure under the deep uterine vein untouched. Type C consists in the resection of the uterosacral ligament at the rectum level and the vesicouterine ligament at the bladder level. The ureter is mobilized completely, and 15 to 20 mm of the vagina from the tumor or cervix is resected. Performing such an enlarged hysterectomy, the preservation of the nerve supply to the bladder is crucial, leading to the creation of the subclasses. Type C1 conserves a nerve-sparing approach remaining above the deep uterine vein, whereas in type C2 a resection beyond this landmark including the neural part of the paracervix is performed. INTERVENTIONS: Total laparoscopic type C1 radical hysterectomy with pelvic lymphadenectomy. CONCLUSION: This video shows the feasibility of type C radical hysterectomy through a minimally invasive approach. The possibility to perform this type of procedure laparoscopically matches with the more conservative approach to cervical cancer, bringing all the advantages of this technique into this field of gynecologic surgery.

Does the uterine cervix become abnormally reinnervated after subtotal hysterectomy and what is the association with future trachelectomy?

STUDY OBJECTIVE: To compare nerve fiber density in the cervices removed by trachelectomy from women with pelvic pain with those cervices removed for nonpain indications. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Two university hospitals. PATIENTS: Subjects who underwent trachelectomy during a 10-year time frame were identified. INTERVENTIONS: Two tissue sections were obtained from each preserved cervix specimen and stained for S100 antibody. The numbers of S100-immunoreactive peripheral nerve fibers were assessed in 6 high-powered fields (HPFs) per tissue section (12 total HPFs per patient). Information collected included patient characteristics and surgical findings. We excluded any patients with dysplasia/cancer and those without an available adequate specimen. MEASUREMENTS AND MAIN RESULTS: We evaluated the cervix specimens from 35 patients who underwent trachelectomy for pain (n = 25, group 1) and nonpain (n = 10, group 2) indications in addition to control cervices (n = 15, group 3) from benign hysterectomies performed for nonpain indications. There were increased numbers of nerve fibers in trachelectomy patients with pain versus those without pain (group 1 vs group 2, p = .02). There were also increased numbers of nerve fibers in both trachelectomy groups compared with the control group (group 1 vs group 3, p < .01; group 2 vs group 3, p = .04). Adjusted average cervical nerve counts/HPF were 17.8 (95% confidence interval [CI], 13.2-22.3) for pain-indicated trachelectomies, 11.5 (95% CI, 4.8-18.2) for nonpain, and 6.3 (95% CI, 0.8-11.8) for controls. Regardless of trachelectomy indication, adjusted average nerve counts/HPF were 17.7 (95% CI, 13.4-22.0) for patients with endometriosis and 14.6 (95% CI, 12.2-17.1) for patients without endometriosis. CONCLUSION: Nerve fibers in the cervical stump after supracervical hysterectomy are significantly increased in women undergoing trachelectomy for pain indications compared with those who underwent trachelectomy for nonpain indications and controls. Although not statistically significant, endometriosis may be an independent risk factor for increased nerve fibers. These histopathologic observations may support the idea that the cervix should be removed in women undergoing hysterectomy for chronic pelvic pain or endometriosis.

[Evaluation of postoperative bladder function and prognosis after modified nerve sparing radical hysterectomy].

OBJECTIVE: To compare the nerve plane sparing radical hysterectomy (NPSRH) with conventional radical hysterectomy (CRH) in terms of postoperative bladder function and prognosis. METHODS: One hundred and two patients with International Federation of Gynecology and Obstetrics (FIGO) stage Ib1-IIa2 cervical cancer were treated by open NPSRH (study group) from January 2008 to March 2013. During the same time periods, two hundred and four patients who underwent open CRH were randomly selected as the control group. Age, pathological type and FIGO stage were matched. RESULTS: The median operation time in NPSRH group and CRH group were 268.8 and 242.4 minutes, respectively (P < 0.01). The median hospital stay were 14.6 and 17.2 days (P < 0.01). The median volume of blood loss in the two groups were respectively 394 and 450 ml (P > 0.05). The blood transfusion rate was respectively 46.1% (47/102) and 41.7% (85/204; P > 0.05). The rate of postoperative complications were not significantly difference [14.7% (15/102) vs 11.8% (24/204), P > 0.05]. The median duration of catheterization was 9.1 and 15.2 days between two groups (P < 0.01). Eighty-five patients in NPSRH group and one hundred and sixty-seven patients in CRH group completed the telephone interview about the long-term bladder function. The incidence of long-term urinary frequency [14.1% (12/85) vs 33.5% (56/167)], urinary incontinence [36.5% (31/85) vs 54.5% (91/167) ], urinary retention [23.5% (20/85) vs 38.9% (65/167) ] and straining to void [10.6% (9/85) vs 40.7% (68/167)], there were significantly lower in NPSRH group than those in CRH group ( all P < 0.05). The rate of recurrence was 10.8% (11/102) in NPSRH group and 12.2% (25/204) in CRH group (P = 0.707). Three-year recurrence-free survival (RFS) estimate was 88.5% in NPSRH group and 91.1% in CRH group (P = 0.746). Three-year overall survival (OS) estimate was 93.7% in NPSRH group and 96.3% in CRH group (P = 0.701). The univariate analysis shown that pathological type, lymph node metastases, and lymph-vascular space invasion (LVSI) presented the trend for a worst 3-year RFS and OS (P < 0.05) . The multivariate analyses shown that both pathological type and lymph node metastases were associated with a worst 3-year RFS (P < 0.05) . Lymph node metastases was a significant independent predictor of 3-year OS (P = 0.001) . NPSRH was not a significant independent predictor by Cox regression model analyses. CONCLUSION: NPSRH contributes to bladder function recovery without compromising survival.

Nerve-sparing radical hysterectomy made easy by laparoscopy.

STUDY OBJECTIVE: To evaluate the technical feasibility of nerve-sparing radical hysterectomy performed laparoscopically. PATIENTS: Thirty-five women with cervical cancer stage Ia1 or Ib1. INTERVENTIONS: All patients underwent laparoscopic nerve-sparing hysterectomy. MEASUREMENTS AND MAIN RESULTS: Oncologic results were comparable to those of conventional laparoscopic radical hysterectomy. There was complete recovery of bladder function after removal of the Foley catheter. Results of urodynamic studies at 3 weeks after surgery were normal. CONCLUSION: Oncologic and functional results are comparable to those of conventional laparoscopic radical hysterectomy. Magnification enabled by laparoscopy is helpful in better dissection and preservation of nerve anatomy.

A historical perspective and evolution of our knowledge on the cardinal ligament.

AIMS: The objective of our review is to provide a critical appraisal of the literature on the anatomy, structure and roles of cardinal ligaments (CL) in pelvic organ support, in conjunction with the currently evolving evidence based mainly on imaging and biomechanical modeling studies. We aim to contribute to the understanding of the pathophysiology of pelvic organ prolapse (POP) and stimulate new insights in research and development of novel surgical approaches for POP. METHODS: PubMed, Embase, Scopus-Elsevier, and Cochrane Databases were searched in English and German. Studies from 1870 to 2012 were identified. The keywords used were "cardinal ligament," "transverse cervical ligament," "Mackenrodt ligament," "parametrium," and "paracervix." Cross check and Google search of the reference lists were used for missing articles. RESULTS: We identified 35 related articles. Located at the base of the broad ligament, the CL is a supportive structure that attaches the cervix and upper vagina to the pelvic wall. The ligament contains the uterine vessels and hypogastric plexus. It conducts most of the pelvic loading forces. On MRI, it appears as a web-like structure around the axis of the internal iliac vessels. Their clinical importance is based on the apical supportive role and lymphatic-rich structure, involved in dissemination of cervical cancer. CONCLUSIONS: The structure and role of the CL have been long studied, but remained unclear. Recent studies on imaging and biomechanics have improved our understanding and provide new insights which may enable the development of new techniques in prolapse surgery.

Distribution of lymphatic tissues and autonomic nerves in supporting ligaments around the cervix uteri.

To investigate the distribution of lymphatic tissues and nerves in the supporting ligaments around the cervix uteri for their tomographical relationship, 9 adult female cadavers were used in this study. Following the incision of all supporting ligaments around the cervix, hematoxylin and esosin (H&E) and immunohistochemical staining of various sections of these ligaments was performed to enable the distribution of lymph tissues and autonomic nerves to be observed. Four lymph nodes were identified in three cadaver specimens. Three lymph nodes were present at a distance of 2.0 cm from the cervix in the cranial side of the cardinal ligaments (CLs), and one lymph node was located at a distance of 4.0 cm from the cervix in the cranial side of the uterosacral ligament (USL). The lymphatic vessels were dispersed in the CLs, scattered in the cervical side of the USLs, and occasionally distributed in the vesicouterine ligaments (VULs). In the CLs, parasympathetic nerves were located at the pelvic lateral wall and went downwards and medially into the cervix, while sympathetic fibers were located in the middle and lower parts of the ligaments. In the USLs, the autonomic nerves, which consisted primarily of sympathetic fibers, went downwards and laterally from the pelvic wall to the cervix. In the VULs, parasympathetic and sympathetic nerves were located in the inner sides of the vesical veins in the deep layers of the ligaments. It is concluded that there are few lymphatic tissues in the supporting ligaments around the cervix uteri, and that nerve­sparing radical hysterectomy (NSRH) may be a safe method for the treatment of early­stage cervical cancer.

Prognostic significance of perineural invasion in cervical cancer.

Perineural invasion (PNI) has attracted attention as a new prognostic factor for cancer. We aimed to investigate the prognostic value of PNI in patients with cervical cancer. Clinical data of 185 patients with early-stage cervical cancer (stages IA2-IIA2) who underwent radical hysterectomy and pelvic lymphadenectomy between 2003 and 2011 were investigated. PNI was detected in 7% (13 of 18 cases) of patients. Moreover, 92% (12 of 13 cases) of patients with PNI received radiation therapy or concurrent chemoradiation therapy after surgery. We investigated whether PNI can be a new indication for adjuvant therapy for cervical cancer. In our study, PNI had a significant association with well-known indications for adjuvant therapy (92.3% sensitivity, 50% specificity, odds ratio 12.0, P = 0.003). Multivariate analysis showed that parametrial invasion and lymphovascular invasion were independently associated with PNI (P < 0.05). However, statistical analysis did not show differences in disease-free survival (P = 0.292) or overall survival (P = 0.346) according to the presence of PNI. In conclusion, PNI as an independent predictor for prognosis was limited, but PNI had a significant association with prognostic factors. PNI may be a new risk factor candidate for cervical cancer. PNI is expected to help in decision making for the need for adjuvant therapy.

Dorsal root activity evoked by stimulation of vagina-cervix-uterus junction in the rat.

In the present study, we characterized the evoked electrical activity from T(13) to S(2) dorsal roots (DRs) during glass probe-stimulation of the vagina-cervix-uterus junction (VCUJ) of female Wistar rats. The results showed that gentle stimulation of VCUJ evoked high-amplitude electrical activity in L(3) and L(6) DRs. Hypogastric or pelvic nerve transection failed to abolish this activity. L(6)-S(1) spinal trunk transection abolished the high-amplitude electrical activity evoked in L(6) DR, while transection of the lumbosacral trunk blocked the high-amplitude electrical activity evoked in L(3) DR. These data suggest that during copulation, penile intromission likely activates the low-threshold sensory receptors of the VCUJ, thereby evoking sensory neural activity that enters the spinal cord via L(3) and L(6) dorsal roots, whose axons travel through the lumbosacral trunk and pudendal nerve.

Laparoscopic nerve-sparing radical parametrectomy for occult early-stage invasive cervical cancer after simple hysterectomy.

OBJECTIVE: To investigate the feasibility and surgical outcomes of laparoscopic nerve-sparing radical parametrectomy (LNSRP) and lymphadenectomy for treatment of occult early-stage invasive cervical cancer after simple hysterectomy. METHODS: From 2006 to 2010, 28 patients who were discovered to have occult early-stage invasive cervical cancer after a simple hysterectomy underwent LNSRP, upper vaginal resection, and pelvic lymphadenectomy. A retrospective analysis of these cases was performed. RESULTS: All patients underwent successful LNSRP. There was no conversion to laparotomy. The mean ± SD operation time was 173.30 ± 56.20 minutes. The mean ± SD estimated blood loss was 230.00 ± 109.55 mL. Two intraoperative complications were recorded. The median number of extracted pelvic and para-aortic lymph nodes was 23 (range, 12-36) and 7 (range, 3-15), respectively. The mean ± SD time before Foley catheter removal was 5.6 ± 2.74 days (range, 3-14 days ), and bladder voiding function recovery to grade 0 to grade 1 was observed in 26 patients (92.9%). Of the 28 patients, 3 patients received further adjuvant therapy. The median follow-up period was 38 (range, 4-62) months for all patients. No recurrence case was found in this series. CONCLUSION: Laparoscopic nerve-sparing radical parametrectomy is a therapeutic option for occult early-stage invasive cervical cancer discovered after hysterectomy. Nerve-sparing radical surgery in indicated patients may lead to optimal preservation of bladder function.

Cervical stimulation activates A1 and locus coeruleus neurons that project to the paraventricular nucleus of the hypothalamus.

In female rats, stimulation of the uterine cervix during mating induces two daily surges of prolactin. Inhibition of hypothalamic dopamine release and stimulation of oxytocin neurons in the paraventricular nucleus (PVN) are required for prolactin secretion. We aim to better understand how stimulation of the uterine cervix is translated into two daily prolactin surges. We hypothesize that noradrenergic neurons in the A1, A2, and locus coeruleus (LC) are responsible for conveying the peripheral stimulus to the PVN. In order to determine whether projections from these neurons to the PVN are activated by cervical stimulation (CS), we injected a retrograde tracer, Fluoro-Gold (FG), into the PVN of ovariectomized rats. Fourteen days after injection, animals were submitted to artificial CS or handling and perfused with a fixative solution. Brains were removed and sectioned from the A1, A2, and LC for c-Fos, tyrosine hydroxylase (TH), and FG triple-labeling using immunohistochemistry. CS increased the percentage of TH/FG+ double-labeled neurons expressing c-Fos in the A1 and LC. CS also increased the percentage of TH+ neurons expressing c-Fos within the A1 and A2, independent of their projections to the PVN. Our data reinforce the significant contributions of the A1 and A2 to carry sensory information during mating, and provide evidence of a functional pathway in which CS activates A1 and LC neurons projecting to the PVN, which is potentially involved in the translation of CS into two daily prolactin surges.

Female orgasm(s): one, two, several.

INTRODUCTION: There is general agreement that it is possible to have an orgasm thru the direct simulation of the external clitoris. In contrast, the possibility of achieving climax during penetration has been controversial. METHODS: Six scientists with different experimental evidence debate the existence of the vaginally activated orgasm (VAO). MAIN OUTCOME MEASURE: To give reader of The Journal of Sexual Medicine sufficient data to form her/his own opinion on an important topic of female sexuality. RESULTS: Expert #1, the Controversy's section Editor, together with Expert #2, reviewed data from the literature demonstrating the anatomical possibility for the VAO. Expert #3 presents validating women's reports of pleasurable sexual responses and adaptive significance of the VAO. Echographic dynamic evidence induced Expert # 4 to describe one single orgasm, obtained from stimulation of either the external or internal clitoris, during penetration. Expert #5 reviewed his elegant experiments showing the uniquely different sensory responses to clitoral, vaginal, and cervical stimulation. Finally, the last Expert presented findings on the psychological scenario behind VAO. CONCLUSION: The assumption that women may experience only the clitoral, external orgasm is not based on the best available scientific evidence.

Robotic nerve-sparing radical parametrectomy: feasibility and technique.

BACKGROUND: The objective of this research was to evaluate the feasibility of robotic nerve-sparing radical parametrectomy for cervical cancer after simple hysterectomy. METHODS: A 41 year-old patient was diagnosed with invasive cervical adenocarcinoma after simple hysterectomy. Hysterectomy margins were negative. A robotic nerve-sparing radical parametrectomy was offered and performed 5 weeks later. RESULTS: Total operating time was 330 min, blood loss was 145 ml and length of hospitalization 2 days. Pathology revealed no residual tumour. Normal bladder function resumed on postoperative day 9. At a follow-up of 16 months, the patient remains with no evidence of disease and with normal bladder and bowel function. CONCLUSIONS: Robotic nerve-sparing radical parametrectomy is safe and feasible and can be offered to patients with indications for radical parametrectomy.

Women's clitoris, vagina, and cervix mapped on the sensory cortex: fMRI evidence.

INTRODUCTION: The projection of vagina, uterine cervix, and nipple to the sensory cortex in humans has not been reported. AIMS: The aim of this study was to map the sensory cortical fields of the clitoris, vagina, cervix, and nipple, toward an elucidation of the neural systems underlying sexual response. METHODS: Using functional magnetic resonance imaging (fMRI), we mapped sensory cortical responses to clitoral, vaginal, cervical, and nipple self-stimulation. For points of reference on the homunculus, we also mapped responses to the thumb and great toe (hallux) stimulation. MAIN OUTCOME MEASURES: The main outcome measures used for this study were the fMRI of brain regions activated by the various sensory stimuli. RESULTS: Clitoral, vaginal, and cervical self-stimulation activated differentiable sensory cortical regions, all clustered in the medial cortex (medial paracentral lobule). Nipple self-stimulation activated the genital sensory cortex (as well as the thoracic) region of the homuncular map. CONCLUSION: The genital sensory cortex, identified in the classical Penfield homunculus based on electrical stimulation of the brain only in men, was confirmed for the first time in the literature by the present study in women applying clitoral, vaginal, and cervical self-stimulation, and observing their regional brain responses using fMRI. Vaginal, clitoral, and cervical regions of activation were differentiable, consistent with innervation by different afferent nerves and different behavioral correlates. Activation of the genital sensory cortex by nipple self-stimulation was unexpected, but suggests a neurological basis for women's reports of its erotogenic quality.