title: Precise anatomy of the vesico-uterine ligament for radical hysterectomy.
abstract: OBJECTIVE
  To clarify the anatomy of the vesico-uterine ligament (VUL), we meticulously separated the VUL under magnification (x2.5) during Okabayashi's radical hysterectomy.
  
  
  METHODS
  Fifty-nine patients (TNM nomenclature: pTIb: 39, pT2a: 5, pT2b: 7, after trans-arterial anticancer-drug infusion treatment for the cervical cancer: 8) underwent this meticulous operation. Blood loss was recorded at two separate time points: during the separation of the VUL and after removal of the uterus.
  
  
  RESULTS
  After complete separation of the uterine artery and superficial uterine vein from the ureter, we could identify the genuine connective tissue of the anterior leaf of the VUL in which we isolate and divide a distinct bundle of blood vessels: the cervicovesical vessels that cross over the ureter from the bladder to the cervix. The remaining tissues in the anterior leaf is only avascular connective tissue. The posterior leaf of the VUL is the tissue residing under the ureter connecting the posterior wall of the bladder and the lateral cervix/upper lateral vagina. In the connective tissues, we identified the middle and inferior vesical veins connecting with the deep uterine vein. The division of these veins could separate the urinary bladder with ureters completely from the lateral cervix and upper vagina. The mean blood loss during the separation of the VUL was 20+/-10 g (N=59) and after radical hysterectomy was 189+/-91.6 g (N=59).
  
  
  CONCLUSIONS
  A precise network of blood vessels in the VUL is identified. The knowledge of this anatomy is important to perform radical hysterectomy.
authors.affiliation: Department of Gynecology and Obstetrics, Postgraduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan. sfu@kuhp.kyoto-u.ac.jp
authors.forename: Shingo
authors.initials: S
authors.lastname: Fujii
authors.forename: Kenji
authors.initials: K
authors.lastname: Takakura
authors.forename: Noriomi
authors.initials: N
authors.lastname: Matsumura
authors.forename: Toshihiro
authors.initials: T
authors.lastname: Higuchi
authors.forename: Shigeo
authors.initials: S
authors.lastname: Yura
authors.forename: Masaki
authors.initials: M
authors.lastname: Mandai
authors.forename: Tsukasa
authors.initials: T
authors.lastname: Baba
mesh_terms: D001158:Arteries / Q000033:anatomy & histology / Q000601:surgery; D016063:Blood Loss, Surgical / Q000517:prevention & control; D001956:Broad Ligament / Q000033:anatomy & histology* / Q000098:blood supply / Q000601:surgery; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000379:methods*; D009367:Neoplasm Staging; D002583:Uterine Cervical Neoplasms / Q000473:pathology / Q000601:surgery*; D014599:Uterus / Q000033:anatomy & histology* / Q000098:blood supply / Q000601:surgery