The uterosacral ligaments, which provide support to the cervix and upper vagina and interdigitate with fibers from the cardinal ligament near the cervix 3.
The cardinal ligaments, which provide support to the cervix and upper vagina and contribute to the support of the bladder
Anteriorly, the uterus is separated from the bladder by the vesicouterine pouch and from the rectum posteriorly by the rectouterine pouch or Douglas cul-de-sac. Laterally, the bilateral broad ligaments carry the neurovascular pedicles and their respective fascial coverings, attaching the uterus to the lateral pelvic sidewall.
The broad ligament is in contact inferiorly with the paravesical space, the obturator fossa, and the pelvic extension of the iliac fossa, to which it provides a peritoneal covering, and with the uterosacral ligament. Superiorly, it extends into the infundibulopelvic ligament.
Ureter In its pelvic path in the retroperitoneum, several relationships are of significance and identify areas of greatest vulnerability to injury of the ureter (Fig. 5.25): 1.
The ovarian vessels cross over the ureter as it approaches the pelvic brim and lie in lateral proximity to the ureter as it enters the pelvis.
2.
As the ureter descends into the pelvis, it runs within the broad ligament just lateral to the uterosacral ligament, separating the uterosacral ligament from the mesosalpinx, mesovarium, and ovarian fossa.
Figure 5.25 The course of the ureter and its relationship to the sites of greatest vulnerability.
Pubovesical lig. Bladder Obturator a.
Uterine a. Ureter Sup. vesical a.
Vagina Uterosacral lig.
Ureter Ovarian a. (infundibulopelvic lig.) 3.
At about the level of the ischial spine, the ureter crosses under the uterine artery in its course through the cardinal ligament; the ureter divides this area into the supraureteric parametrium surrounding the uterine vessels and the infraureteric paracervix molded around the vaginal vessels and extending posteriorly into the uterosacral ligament. In this location, the ureter lies 2 to 3 cm lateral to the cervix and in proximity to the insertion of the uterosacral ligament at the cervix. This proximity warrants caution when using the uterosacral ligament for vaginal vault suspension (44,45).
4.
The ureter then turns medially to cross the anterior upper vagina as it traverses the bladder wall.
About 75% of all iatrogenic injuries to the ureter result from gynecologic procedures, most commonly abdominal hysterectomy (46). Distortions of pelvic anatomy, including adnexal masses, endometriosis, other pelvic adhesive disease, or fibroids, may increase susceptibility to injury by displacement or alteration of usual anatomy. Careful identification of the course of the ureter before securing the infundibulopelvic ligament and uterine artery is the best protection against ureteric injury during hysterectomy or adnexectomy. Even with severe intraperitoneal disease, the ureter can always be identified using a retroperitoneal approach and noting fundamental landmarks and relationships.
Pelvic Floor The pelvic ﬂoor includes all of the structures closing the pelvic outlet from the skin inferiorly to the peritoneum superiorly. It is commonly divided by the pelvic diaphragm into a pelvic and a perineal portion (47). The pelvic diaphragm is spread transversely in a hammocklike fashion across the true pelvis, with a central hiatus for the urethra, vagina, and rectum. Anatomically and physiologically, the pelvic diaphragm can be divided into two components: the internal and external components.