title: Pelvic nerve plexus trauma at radical and simple hysterectomy: a quantitative study of nerve types in the uterine supporting ligaments.
abstract: 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 analyzer 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.
authors.affiliation: Division of Gynaecological Oncology, St. George's Hospital, London, United Kingdom.
authors.forename: Simon A
authors.initials: SA
authors.lastname: Butler-Manuel
authors.forename: Lee D K
authors.initials: LD
authors.lastname: Buttery
authors.forename: Roger P
authors.initials: RP
authors.lastname: A'Hern
authors.forename: Julia M
authors.initials: JM
authors.lastname: Polak
authors.forename: Desmond P J
authors.initials: DP
authors.lastname: Barton
mesh_terms: D001706:Biopsy; D015740:Calcitonin Gene-Related Peptide / Q000032:analysis; D005260:Female; D006801:Humans; D007001:Hypogastric Plexus / Q000601:surgery*; D007044:Hysterectomy / Q000009:adverse effects*; D007091:Image Processing, Computer-Assisted; D007150:Immunohistochemistry; D008022:Ligaments / Q000294:innervation* / Q000601:surgery; D009478:Neuropeptide Y / Q000032:analysis; D013373:Substance P / Q000032:analysis; D014446:Tyrosine 3-Monooxygenase / Q000032:analysis; D002583:Uterine Cervical Neoplasms / Q000601:surgery; D014599:Uterus / Q000294:innervation* / Q000601:surgery; D014660:Vasoactive Intestinal Peptide / Q000032:analysis
chemical_list: D009478:Neuropeptide Y; D013373:Substance P; D014660:Vasoactive Intestinal Peptide; D014446:Tyrosine 3-Monooxygenase; D015740:Calcitonin Gene-Related Peptide