title: Lymphatic drainage pathways from the cervix uteri: implications for radical hysterectomy?
abstract: OBJECTIVE
  Radical hysterectomy with pelvic lymphadenectomy is the treatment of choice for early-stage cervical cancer. Wertheim's original technique has been often modified, mainly in the extent of parametrectomy. Okabayashi's technique is considered as the most radical variant regarding removal of the ventral parametrium and paracolpal tissues. Surgical outcome concerning recurrence and survival is good, but morbidity is high due to autonomic nerve damage. While the autonomic network has been studied extensively, the lymphatic system is less understood. This study describes the lymphatic drainage pathways of the cervix uteri and specifically the presence of lymphatics in the vesico-uterine ligament (VUL).
  
  
  METHODS
  A developmental series of 10 human female fetal pelves was studied. Paraffin embedded blocks were sliced in transverse sections of 8 or 10 μm. Analysis was performed by staining with antibodies against LYVE-1 (lymphatic endothelium), S100 (Schwann cells), alpha-Smooth Muscle Actin (smooth muscle cells) and CD68 (macrophages). The results were three-dimensionally represented.
  
  
  RESULTS
  Two major pathways drained the cervix uteri: a supra-ureteral pathway, running in the cardinal ligament superior to the ureter, and a dorsal pathway, running in the utero-sacral ligament towards the rectal pillars. No lymph vessels draining the cervix uteri were detected in the VUL. In the paracolpal parametrium lymph vessels draining the upper vagina fused with those from the bladder.
  
  
  CONCLUSIONS
  The VUL does not contain lymphatics from the cervix uteri. Hence, the favorable survival outcomes of the Okabayashi technique cannot be explained by radical removal of lymphatic pathways in the ventrocaudal parametrium.
authors.affiliation: Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: A C
authors.initials: AC
authors.lastname: Kraima
authors.affiliation: Department of Gynecology and Obstetrics, Academical Medical Center, Amsterdam, The Netherlands.
authors.forename: M
authors.initials: M
authors.lastname: Derks
authors.affiliation: Computer Graphics and Visualization, Department of Intelligent Systems, Delft University of Technology, Delft, The Netherlands.
authors.forename: N N
authors.initials: NN
authors.lastname: Smit
authors.affiliation: Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: J C
authors.initials: JC
authors.lastname: Van Munsteren
authors.affiliation: Department of Gynecology and Obstetrics, Academical Medical Center, Amsterdam, The Netherlands.
authors.forename: J
authors.initials: J
authors.lastname: Van der Velden
authors.affiliation: Department of Gynecology and Obstetrics, Academical Medical Center, Amsterdam, The Netherlands.
authors.forename: G G
authors.initials: GG
authors.lastname: Kenter
authors.affiliation: Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands. Electronic address: M.C.DeRuiter@lumc.nl.
authors.forename: M C
authors.initials: MC
authors.lastname: DeRuiter
mesh_terms: D004322:Drainage / Q000379:methods*; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000379:methods*; D042601:Lymphatic Vessels / Q000503:physiopathology; D002583:Uterine Cervical Neoplasms / Q000601:surgery*; D033921:Vesicular Transport Proteins / Q000032:analysis
chemical_list: C119248:LYVE1 protein, human; D033921:Vesicular Transport Proteins
keywords: Cervical cancer; Lymphatic drainage pathways; Parametrium; Radical hysterectomy; Utero-sacral ligament; Vesicouterine ligament