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Surgical Anatomy in Pelvic Gynaecologic Oncology 1039
Figure 19. Ureteral tunnel (left side). Ur, ureter; VVS, vesicov-
aginal space; VUL- anterior leaf of the vesicouterine ligament; YS, OS, Okabayashi´s space; RVS, rectovaginal space; US, uterosacral
Yabuki´s space (fourth space).
Figure 20. Posterior leaf of the vesicouterine ligament.Ur, ureter; single anatomical fascial block that arises from the region
YS, Yabuki´s space (fourth space). The vesical plexus (efferent of
the inferior hypogastric plexus) runs outside and underneath
the ureter (yellow lines), so any dissection of this area should be ligament) and rectum (rectal stalk). Lateral to this
avoided and careful haemostasis is advisable.
parametrium into vesicouterine and lateral ligament of
the bladder and the vesicouterine ligament into anterior
and posterior leafs.
Pelvic Connective Tissue
The anatomy of the female pelvic connective tissue
has been discussed from more than a century. The
description given in this chapter is in our opinion the
most comprehensive one.
The pelvic connective tissue can is divided into three
groups: parietal, visceral and extraserosal pelvic fascias.
These fascias are partially fused together.
The parietal pelvic fascia covers the structures (bones
and muscles) limiting the pelvis. This fascia presents
fibrous bands: the tendinous arch of the pelvic fascia
(and the one of the levator ani), both important in pelvic
reconstructive surgery (Figure 4).
The visceral pelvic fascia envelops the pelvic viscera
and attaches them to the pelvic walls, preventing the
prolapse of the organs. It is formed by the pubocervical
fascia, rectovaginal fascia, uterosacral ligaments,
rectovaginal ligaments, rectal stalks and rectosacral
fascia. The last four structures should be considered a
Figure 21. Uterosacral ligament (left side). HN, hypogastric nerve;
ligament.
of S2-S4 sacral vertebrae and run to different organs:
the uterus (uterosacral ligament), vagina (rectovaginal
structure runs the hypogastric nerve (Figure 21).
The last group is the extraserosal pelvic fascia. It is
responsible for providing support to vascular, neural
and lymphatic structures and to allow expansion and
contraction of the pelvic organs. It is formed by the
cardinal ligament (parametrium and paracervix),
superior vesical ligament, lateral ligament of the rectum
and the presacral fascia.
Surgically the cardinal ligament is observed and
dissected after the opening of the paravesical and
pararectal spaces and it is located between the origin
of the internal iliac artery and the cervix and/or upper
vagina. In terms of the Terminologia Anatomica the
cardinal ligament includes the parametrium (which
consists of the tissues that cross over the ureter and the
paracervix (below the ureter). Histologically it contains
vessels, areolar connective tissue and nerve fibers.
The cranial portion is more vascular, consisting of an
extension of the vascular sheath of the internal iliac vessel
branches (corresponding to the parametrium) and the
caudal portion has a higher neural content since it is an
extension of the IHP (corresponding to the paracervix)
(Figure 22). Remarkably, between these two portions
there is a cleavage plan of loose connective tissue. The
deep uterine vein is an important anatomical landmark;
below is located the IHP. Some authors consider the
superficial portion of the vesicouterine ligament as a
ventral expansion of the parametrium.
Pelvic Spaces
The pelvic viscera and the pelvic connective divide the
subperitoneal pelvis into different spaces, the so-called
pelvic spaces. These spaces are virtual, filled with fatty
or areolar connective tissue and are relatively avascular,
working as surgical cleavage planes. Their knowledge is
imperative for pelvic surgery.