Objective:Using neuropeptide and enzyme markers to autonomic nerves, we sought to demonstrate and quantify the nerve types contained within the uterosacral ligaments (USLs) and cardinal ligaments (CLs) that are divided during radical hysterectomy (RH).
Methods:Cross-sectional biopsies were collected from the lateral third of the USL and the CL in 24 women who had an RH for cervical cancer, and from the uterine insertion of these ligaments in 11 women who had a simple hysterectomy for benign disease. We applied indirect immunofluorescence with FITC-conjugated secondary antibodies, using polyclonal primary antibodies to neuropeptide markers that predominate within somatic and autonomic nerves, to show different populations of the following nerve types within the biopsies: neuropeptide Y (NPY) and tyrosine hydroxylase (TH) for sympathetic nerves; vasoactive intestinal polypeptide (VIP) for parasympathetic nerves; substance P (SP) for nociceptive and sensory-motor nerves; and calcitonin gene-related peptide (CGRP) for sensory and sensory-motor nerves. The percentage area of immunoreactivity (PAI), determined by a computer-assisted image analyzed attached to a fluorescent microscope, was used as an objective quantitative measure of nerve density. Confocal microscopy was used to determine the composition and spatial arrangement of nerve fibers in the ligaments.
Results:The PAI was greater for all markers tested in both the USL and CL (P < .001) in RH compared with simple hysterectomy biopsies. For RH specimens, the PAI was greater for the sympathetic, sensory, and sensory-motor nerve markers in the USL compared with the CL (P < .01), but the PAI for VIP was similar (P > .05). Conversely, excluding the large trunks and associated ganglia, the free nerve fiber PAI in the CL was greater than that of the USL for all nerve markers (P < .001). The staining of peripheral autonomic ganglia and associated fibers, for NPY and TH, indicates that some sympathetic nerves are preganglionic with their cell bodies within the pelvic plexus.
Conclusions:Significantly more autonomic nerves are transected in the more lateral division of the uterine supporting ligaments during a radical hysterectomy than during a simple hysterectomy. Sympathetic, parasympathetic, sensory, and sensory-motor nerve types are present within the CL and USL. The proportions of each nerve type differ between the two ligaments, and sympathetic nerves in the USL are the single largest nerve type. The uterine supporting ligaments are a major pathway for autonomic nerves to the pelvic organs.
1. Seski JC, Diokno AC. Bladder dysfunction after radical abdominal hysterectomy. Am J Obstet Gynecol1977;128:643-651.
2.
2. Forney P. The effects of radical hysterectomy on bladder physiology. Am J Obstet Gynecol1980;138:374-382.
3.
3. Zanolla R, Monzeglio C, Campo B, Ordesi G, Balzarini A, Martino G. Bladder and urethral dysfunction after radical abdominal hysterectomy. J Surg Oncol1985;28:190-194.
4.
4. Barnes W, Waggoner S, Delgado G, et al. Manometric characterization of rectal dysfunction following radical hysterectomy. Gynecol Oncol1991;42:116-119.
5.
5. Flay LD, Mathews JHL. The effects of radiotherapy and surgery on the sexual function of women treated for cervical cancer. Int J Radiat Oncol Biol Phys1995;31:399-404.
6.
6. Andersen BL. Sexual functioning morbidity among cancer survivors, current status and future research directions. Cancer1985;55:1835-1842.
7.
7. Andersen BL. Predicting sexual and psychologic morbidity and improving the quality of life for women with gynecologic cancer. Cancer1993;71(4 suppl):1678-1690.
9. Butler-Manuel SA, Summerville K, Ford AM, et al. Self-assessment of morbidity following radical hysterectomy for cervical cancer. J Obstet Gynaecol1999;19:180-183.
10.
10. Baljet B, Drukker J, The extrinsic innervation of the pelvic organs in the female rat. Acta Anat1980;107:241-267.
11.
11. Gu J, Polak JM, Su HC, Blank MA, Morrison JFB, Bloom SR. Demonstration of paracervical ganglion origin for the vasoactive intestinal polypeptide-containing nerves of the rat uterus using retrograde tracing techniques combined with immunocytochemistry and denervation procedures. Neurosci Lett1984;51:377-382.
12.
12. Inyama CO, Hacker GW, Gu J, Dhal D, Bloom SR, Polak JM. Cytochemical relationships in the paracervical ganglion (Frankenhauser) of rat studied by immunocytochemistry. Neurosci Lett1985;55:311-315.
13.
13. Lundberg LM, Alm P, Wharton J, Polak JM. Protein gene product 9.5 (PGP 9.5). A new neuronal marker visualizing the whole uterine innervation and pregnancy-induced and developmental changes in the guinea pig. Histochem Cell Biol1988;90:9-17.
14.
14. Mitchell BS. Morphology and neurochemistry of the pelvic and paracervical ganglia. Histol Histopathol1993;8:761-773.
15.
15. Papka RE, Thompson BD, Schmidt HHW. Identification of uterine-related sympathetic neurons in the rat inferior mesenteric ganglion: Neurotransmitter content and afferent input. J Auton Nerv Syst1996;59:51-59.
16.
16. Dhami D, Mitchell BS. The effects of decentralisation on substance P-immunoreactivity in the anterior major pelvic ganglion of the male guinea pig. J Auton Nerv Syst1992;38:167-176.
17.
17. Lakomy M, Kaleczyc W, Majewski M, Mienkiewicz W. Peptidergic innervation of the bovine vagina and uterus. Acta Histochem1995;97:53-66.
18.
18. Papka RE, McNeil DL, Thompson D, Schmidt HHW. Nitric oxide nerves in the uterus are parasympathetic, sensory, and contain neuropeptides. Cell Tissue Res1995;279:339-349.
19.
19. Mundy AR. An anatomical explanation for bladder dysfunction following rectal and uterine surgery. Br J Urol1982;54:501-504.
20.
20. Twombly GH, Landers D. The innervation of the bladder with reference to radical hysterectomy. Am J Obstet Gynecol1956;71:1291-1291.
21.
21. Smith PH, Ballantyne B. The neuroanatomical basis of the urinary bladder dysfunction following major pelvic surgewry. Br J Surg1968;55:929-933.
22.
22. Hockel M, Konerding MA, Heussel CP. Liposuction-assisted nerve-sparing extended radical hysterectomy: Oncologic rationale, surgical anatomy, and feasibility study. Am J Obstet Gynecol1998;178:971-976.
23.
23. Maas CP, DeRuiter MC, Kenter GG, Trimbos JB. The inferior hypogastric plexus in gynecologic surgery. J Gynecol Technol1999;5:55-62.
24.
24. Last RJ. Anatomy: Regional and applied. 7th ed.New York: Churchill Livingstone, 1984:344-345.
25.
25. Sadler TW. Langman's medical embryology. 5th ed.Baltimore: Williams & Wilkins, 1985:247-280.
26.
26. Burnstock G, Milner P, O'Brien. Autonomic nervous system. In: Williams PL, Bannister LH, Berry MM, Collins P, Dyson M, Dussek JE, Ferguson MWJ, eds. Gray's anatomy. 38th ed.New York: Churchill Livingstone, 1995:1292-1312.
27.
27. Diokno AC, Davis R, Lapides J. The effect of pelvic nerve stimulation of detrusor contraction. Investig Urol1973;11:178-181.
28.
28. Brindley GS. The actions of parasympathetic and sympathetic nerves in human micturition, erection and seminal emission and their restoration in paraplegic patients by implanted electrical stimulators. Proc R Soc Lond B Biol Sci1988;B235:111-120.
29.
29. Fox CA, Fox B. A comparative study of coital physiology, with special reference to the sexual climax. J Reprod Fertil1971;24:319-336.
30.
30. Levin RJ. The physiology of female sexual function in women. Clin Obstet Gynecol1980:7:213-252.
31.
31. Lynch EM, Wharton J, Bryant MG, Bloom SR, Polak JH, Elder MG. The differential distribution of vasoactive intestinal peptide in the normal human female genital tract. Histochem Cell Biol1980;67:169-170.
32.
32. Burnstock G. Do some nerve cells release more than one transmitter?Neuroscience1976;1:239-248.
33.
33. Burnstock G. Co-transmission. The fifth Heymans lecture. Arch Int Pharmacodyn Ther1990;304:7-33.
34.
34. Kupfermann I. Functional studies of co-transmission. Physiol Rev1991;71:683-732.
35.
35. Alm P, Lundberg LM. Co-existence and origin of peptidergic and adrenergic nerves in the guinea pig uterus. Retrograde tracing and immunocytochemistry, effects of chemical sympathectomy, capsaicin treatment and pregnancy. Cell Tissue Res1988;254:517-530.
36.
36. Burnstock G. Changing face of autonomic and sensory nerves in the circulation. In: Edvinsson L, Uddman R, eds. Vascular innervation and receptor mechanisms: New perspectives. Oxford: Academic Press, 1993:1-22.
37.
37. Lundberg JM, Franco-Cereceda A, Hua X, Hökfelt T, Fischer JA. Co-existence of substance P and calcitonin gene-related peptide-like immunoreactivities in sensory nerves in relation to cardiovascular and bronchoconstrictor effects of capsaicin. Eur J Pharmacol1985;108:315-319.
38.
38. Maggi CA. The pharmacology of the efferent function of capsaicin-sensitive sensory nerves. J Auton Pharmacol1991;11:173-208.
39.
39. X-Y Hua, Theodorsson-Norheim E, Lundberg JM, Kinn AC, Hokfelt T, Cuello AC. Co-localization of tachykinnis and calcitonin gene-related peptide in capsaicin-sensitive afferents in relation to motility effects on the human ureter in vitro. Neuroscience1987;27:693-703.
40.
40. Senba E, Tohyama M. Calcitonin gene-related peptide containing efferent pathways to the pelvic ganglia of the rat. J Auton Nerv Syst1988;50:386-390.
41.
41. Maggi CA, Meli A. The sensory-efferent function of capsaicin-sensitive sensory nerves. Gen Pharmacol1988;19:1-43.
42.
42. Marron K, Yacoub MH, Polak JM, et al. Innervation of human atrioventricular and arterial valves. Circulation1996;94:368-375.
43.
43. Piver SM, Rutledge F, Smith JP. Five classes of extended hysterectomy for women with cervical cancer. Obstet Gynecol1974;44:623-644.
44.
44. Butler-Manuel SA, Buttery LDK, A'Hern RP, Polak JM, Barton DPJ. Pelvic nerve plexus trauma at radical hysterectomy and simple hysterectomy: The nerve content of the uterine supporting ligaments. Cancer2000;89:834-841.
45.
45. Zamboni L, De Martino C. Buffered picric acid formaldehyde: A new rapid fixative for electron microscopy. J Cell Biol1967;35:148A-148A.
46.
46. Cohen T. Quantification of nerves and neurotransmitters using image analysis. In: Wooton R, Springall DR, Polak JM, eds. Image analysis in histology: Conventional and confocal microscopy. Cambridge, United Kingdom: Cambridge University Press, 1995:355-380.
47.
47. Mokrzycki ML, Mittal K, Smilen SW, Blechman AN, Porges RF, Demopolous RI. Estrogen and progesterone receptors in the uterosacral ligament. Obstet Gynecol1997;90:402-404.
48.
48. Campbell RM. The anatomy and structure of the sacrouterine ligaments. Am J Obstet Gynecol1950;59:1-12.
49.
49. Lundberg JM, Alm P, Thorbert G. Local mechanical effects and humoral factors evoke degeneration of guinea pig uterine denervation. Acta Obstet Gynecol scand1989;68:487-496.
50.
50. Asmussen M, Ulmsten UG. Effects of radical hysterectomy with lymph nodes dissection. Zentralbl Gynakol1982;104:868-873.
51.
51. Sasaki H, Yoshida, Noda K, Yachiku S, Minami K, Kaneko S. Urethral pressure profiles following radical hysterectomy. Obstet Gynecol1982;59:101-104.
52.
52. Sakamoto S, Takizawa K. An improved radical hysterectomy with fewer urological complications and with no loss of therapeutic results for invasive cervical cancer. Balliere's Clin Obstet Gynaecol1988;2:953-962.
53.
53. Sakamoto S. Radical hysterectomy with pelvic lymphadenectomy—the Tokyo method. In: Coppleson M, ed. Gynecologic oncology. 2nd ed.New York: Churchill Livingstone, 1994:1257-1268.
54.
54. Trimbos JB, Maas CP, Deruiter MC, Peters AAW, Kenter GG. A nerve-sparing radical hysterectomy: Guidelines and feasibility in western patients. Int J Gynecol Oncol2001;11:180-186.
