| Cervical cancer is one of the most common malignant tumor in women worldwide. The morbidity is the first in the developing countries. Surgery is proved to be the main means to treat cerical cancer after nearly100years of practice. Radical hysterectomy (RH) which turns into a standard operation can obtain apparent curative effect. However, it usually results in a series of complications, such as:lower urethra/bladder、anus/rectum and cunnus/vagina dysfunction etc, which becomes the troublesome issues gradually. The improvement of the postoperative quality of life of the patients becomes a development trend with the trend of patient of cervical cancer becomes younger and the increased of postoperative survival. Researches based on several reports from literatures and our initial results of the study show that the intraoperative damage of pelvic autonomic nerve (PAN) is the the main reason leading to above-mentioned complications. So, systematic nerve-sparing radical hysterectomy(SNSRH) has been a research hotspot to gynecological tumors science. But the anatomical is not clear, the nerve is hard to identify, the nerve damage standards is lack, which makes the new technology hard to spread.Preliminary studies show that the following three procedures lead to injury of PAN:(1) hypogastric nerves and partial proximate of inferior hypogastric plexus are damaged during the resection of uterosacral ligament(USL) near the posterior wall of pelvis,(2) the injury of pelvic splanchnic nerves occur with cardinal ligament(CL) resected close to lateral wall of wall of pelvis,(3)the distal bladder branches steming from the inferior hypogastric plexus are cut while the deep part of vesico-cevical-vaginal ligament (VCVL) and paracolpium tissue are resected. We have studied the CL, VCVL and paracolpium tissue qualitatively and quantitatively. And with the development of the SNSRH, people are more and more focus on the USL, but the study is superficial. They almost concentrate on the distribution of the nerve. They study discovered that there were many nvers in the USL, there were sympathetic nerves, parasympathetic nerves and feeling-motion nerves, and the sympathetic and parasympathetic nerves were less in the segment near the uterine than the segment away from uterine. However, the understanding of the organization function is based on the understanding of the basic organization structure, therefore, it is necessary to study the detailed structure of the USL qualitatively and quantitatively to understand its function fully.Through the qualitative and quantitative research of the USL, we try to find out: First:the quality of the fine histological structure in the USL. Second:the distribution of the blood vessels, lymphs and nevers in the USL, and construct the distribution diagram about uterosacral ligament based on the quantitative result. The main purpose is to clear the characteristics of the organizational structure of the USL, and make the fine histological structure intuitively.This experiment is divided into two parts, research details:The first part:The qualitative research on the fine histological structure of the uterosacral ligament.Objective:To investigate the fine structural composition of the uterosacral ligament and understand its functionsMethods:29uterosacral ligaments were collected from15patients who had underwent radical hysterectomy (One sample was removed because of incrassation, but the result of the pathology was no tumor invasion). Each uterosacral ligament is cut to three parts by one centimeter, starting from the part where the uterosacral ligament is inserted to cervix. They are named the near part, the middle part and the distal part, the near part and the middle part is one centimeter length, and the left part is the distal part. And there are87pieces of tissues in total. Then every tissue is fixed up by10%formalin, to be embedded by routine paraffine, to be sliced up to four slices. At last, HE staining, immunohistochemical staining and some other specific stain were used for qualitative research.Results:One:HE staining results:The basic organization structures are the similar in the uterosacral ligament. The USL contains a large number of fibrous connective tissues, adipocyte, ganglia and vessels (contents the medium and small arterys and veins). The vessels are usually distributed besides the nevers. In addition, a lot of lymphatic vessels and a little lymphoaccumulation and lymph node could be found.Two:Special staining results:Masson’s trichromatic improved dyeing method shows collagen fiber is dark green which is the most numerous connective tissue, a few smooth muscle fiber bright red, crossing with collagen fiber.Gomori’s dyeing demonstrates the tan-yellow collagen fiber and brownish-black reticular fiber, and the reticular fiber is obviously less than collagen fibers.Unna dyeing illustrates elastic fibers is brownish red, the elastic fibers is less than collagen fibers.Schiff’s double staining shows that the arterys are rose Bengal.Modified Loyes’ dyeing demonstrates nerve fibers (neuraxial) is yellowish-white, myelin has no color (the positive is Dark blue), it has confirmed that this organization has no myelin.Three:Immunohistochemical staining:The positive result of the CD34antibody immunohistochemical staining confirms that uterosacral ligament contains arterial and venous blood vessels. The results of S-100antibody immunohistochemical staining of specific marked nerves is positive (Nerve is tan-yellow), combining the results of the improved Loyes’s special staining and HE staining results, we can conclude that USL contains neural composition.The positive results of TH (sympathetic nerve specific antibodies) antibody specific marked sympathetic nerve and the VIP (parasympathetic nerve specific antibodies) antibody specific marked parasympathetic prove that the uterosacral ligament contains sympathetic nerves and parasympathetic nerves.The result of D2-40antibody immunohistochemical staining on specific marked lymphatic is positive. The quantity of the scattered lymphatic vessels is rich, occasionally lymph nodes shows.Conclusions:One:The uterosacral ligament contains a large number of vessels, the medium and small vessels were more numerous, in addition, a lot of arteriole and veinule could be found.Two:Ganglia and autonomic nerves were abundant, the autonomic nervous is mainly sympathetic nerves. There are only three visual fields of parasympathetic nerves in the near part of the USL, each positive visual field has only one parasympathetic nerves. No parasympathetic nerve node is found in all the samples.Three:Lymphatic vessels are rich, and few lymph nodes and lymph cells exit in the USL.Four:Collagen fibers are the main ingredient in fibrous connective tissue of the uterosacral ligament, besides, lattice fibers, elastic fibers and muscle fibers could be found.Five:Adipose tissue was abundant in the uterosacral ligament.The second part:The quantitative analyse of nerve and haemal tube and the geometric modeling of uterosacral ligamentObjective: To explore the disposition, quantity and proportion of vessel, lymphatic and autonomic nerve in uterosacral ligament, provide pathobiological evidence for the designs of systematic nerve-sparing radical hysterectomy (SNSRH) and construct the geometric modeling of uterosacral ligament.Methods:For description and comparison easily, the uterosacral ligament was marked the upper part, the lower part and the facies medialis, the facies lateralis when collecting the specimes. The superior margins of the slices were coincidence with that of the glasses when dredging, and then marked the upper part, the lower part and the facies medialis, the facies lateralis according the sign marked in the specimens. According to the scale of the microscope, we divided the uterosacral ligament into upper part and lower part or the facies medialis and the facies lateralis in average.Places the slides under the microscope models to collected images, each slide is randomly checked10field of vision on the upper half and lower half. Each slide of the sympathetic nerves and the lymphatic vessels is randomly checked10field of vision again when the slide was devided into facies medialis and facies lateralis. The sympathetic nevers, parasympathetic, lymphatic and vascular had87slides separately in29fresh specimens of USL. So, the sympathetic nerves and the lymphatic vessels collected3840photos separately, and the blood vessels and the parasympathetic collected1740photos separately. We collected10440photos in total.Autonomic nerves, lymphatic and vascular were quantitative analysis using Impro image analysis software and biosystem stereology after Immune organization chemical dyeing and take photos. After calculating the volume density of the total uterosacral ligament of every component in every segment, we used statistics software SPSS13.0to analyse data. If P<0.05then the difference has statistical significance. The results are expressed by average±standard deviation (x±s). The target data of near part, middle and distal of uterosacral ligament are analyzed by the One-way ANOVA analysis of variance. If homogeneity of variance was assumed LSD (Least Significant Deffence) test method was used in group comparison, DunnettT3test method was adopted if the hypothesis was not established. The target data of the upper part, the lower part or the facies medialis, the facies lateralis are analyzed by Independent-Samples T test.Results:ONE:The volume density of sympathetic nerve in uterosacral ligament (Vv):1. The USL was subdivided into upper half and lower half from the middle.1)The total volume density of sympathetic nerve of uteroscarcal ligament is (0.0071±0.0183);2) The upper half (0.0037±0.0100) and the lower half (0.0104±0.0235), the volume density of sympathetic nerve is higher in the lower half than in upper half (t=-2.428, P=0.017).3) The near part (0.0047±0.0110), the middle part (0.0041±0.0110) and the distal part (0.0123±0.0271). The volume density of sympathetic nerve during the three parts has obvious difference (F=3.738, P=0.026), the volume density of sympathetic nerve is higher in the distal part than the near part (P=0.025) and the middle part (P=0.015).4) The upper half of near part (0.0031±0.0096) and the lower half of near part (0.0064±0.0122), the volume density of sympathetic nerve between the two parts has no obvious difference (t=-1.114, P=0.27).The upper half of middle part (0.0012±0.0031) and the lower half of the middle part (0.0070±0.0148), the volume density of sympathetic nerve is higher in the lower half than in upper half (t=-2.056, P=0.048).The upper half of distal part (0.0069±0.0136) and lower half of the distal part (0.0178±0.0352), the volume density of sympathetic nerve between the two parts has no obvious difference (t=-1.558, P=0.128).5) The volume density of sympathetic nerve during the near part (0.0031±0.0096), the middle part (0.0012±0.0031) and the distal part (0.0069±0.0136) of upper half has no obvious difference (F=2.501, P=0.088).The volume density of sympathetic nerve during the near part (0.0063±0.0122), the middle part (0.0070±0.0148) and the distal part (0.0178±0.0352) of lower half has no obvious difference (F=2.230, P=0.114).2. The USL was subdivided into facies medialis and facies lateralis from the middle.1) The facies medialis (0.0035±0.0098) and the facies lateralis (0.0106±0.0235), the volume density of sympathetic nerve is higher in the facies lateralis than in facies medialis (t=-2.604, P=0.010).2) The near part (0.0041±0.0081), the middle part (0.0104±0.0268) and the distal part (0.0066±0.0145). The volume density of sympathetic nerve among the three parts has no obvious difference (F=1.769, P=0.174).3) The facies medialis of near part (0.0014±0.0026) and the facies lateralis of near part (0.0068±0.0106), the volume density of sympathetic nerve is higher in the facies lateralis than in facies medialis(t=-2.677, P=0.001).The facies medialis of middle part (0.0052±0.0115) and the facies lateralis of the middle part (0.0157±0.0357), the volume density of sympathetic nerve during the two facies has no obvious difference (t=-1.503, P=0.142).The facies medialis of distal part (0.0039±0.0121) and facies lateralis of the distal part (0.0093±0.0164), the volume density of sympathetic nerve is higher in the facies lateralis than in facies medialis (t=-1.441, P=0.048).4) The volume density of sympathetic nerve during the near part (0.0014±0.0026), the middle part (0.0052±0.0115) and the distal part (0.0039±0.0121) of upper half has no obvious difference (F=1.129, P=0.328).The volume density of sympathetic nerve during the near part (0.0068±0.0106), the middle part (0.0157±0.0357) and the distal part (0.0093±0.0164) of lower half has no obvious difference (F=1.093, P=0.340).TWO:The volume density of parasympathetic nerve in uterosacral ligament (Vv):There are only three parasympathetic nerves in three visual fields of the near part, the volume density of each visual field are:0.0012,0.0008,0.0004.THREE:The vascular volume density of uterosacral ligament (Vv):1) The total vascular volume density of uterosacral ligament (0.0904±0.0781).2) The upper half (0.0854±0.0734) and the lower half (0.0954±0.0826), the volume density of vascular between the two halfs has no obvious difference (t=-0.848, P=0.397).3) The near part (0.1096±0.0936), the middle part (0.0826±0.0641)and the distal part (0.0790±0.0712), the vascular volume density during the three parts is not obvious difference (F=2.709, P=0.069).4) The upper half of near part (0.948±0.0879) and the lower half of the near part (0.1243±0.0983), the vascular volume density between the two parts is not obvious difference (t=-1.203, P=0.234).The upper half of middle part (0.0719±0.0470) and the lower half of middle part (0.0933±0.0769). the vascular volume density between the two parts is not obvious difference (t=-1.276, P=0.208).The upper half of distal part (0.0894±0.0795) and the lower half of distal part (0.0687±0.0614), the vascular volume density between the two parts is not obvious difference (t=1.107, P=0.273).5) The vascular volume density during the three parts, the near part (0.0948±0.0879), the middle part (0.0719±0.0470) and the distal part (0.0894±0.0795) of upper half has no obvious difference (F=0.765, P=0.468).The vascular volume density during the three parts, the near part (0.1243±0.0983), the middle part (0.0933±0.0769) and the distal part (0.0687±0.0614) of lower half has obvious difference (F=3.495, P=0.035), the volume density of the middle part is larger than the distal part (P=0.010).FOUR:The volume density of lymphatic vessels in uterosacral ligament (Vv):1. The USL was subdivided into upper half and lower half from the middle.1)The total volume density of lymphatic vessels of uteroscarcal ligament is (0.0087±0.0121);2) The upper half (0.0097±0.1340) and the lower half (0.0074±0.0106), the volume density of lymphatic vessels between the two parts has no obvious difference (t=1.250,P=0.213).3) The near part (0.0130±0.0149), the middle part (0.0068±0.0100) and the distal part (0.0058±0.0094). The volume density of lymphatic vessels during the three parts has obvious difference (F=6.419, P=0.002), the volume density of lymphatic vessels is higher in the near part than in the middle part (P=0.005) and in the distal part (P=0.001), and there is no obvious different between the middle part and the distal part (P=0.657).4) The upper half of near part (0.0124±0.0163) and the lower half of near part (0.0137±0.0137), the volume density of lymphatic vessels between the two parts has no obvious difference (t=-0.322, P=0.748).The upper half of middle part (0.0095±0.0126) and the lower half of the middle part (0.0041±0.0055), the volume density of lymphatic vessels is higher in the upper half than in lower half (t=2.090, P=0.043).The upper half of distal part (0.0072±0.0106) and lower half of the distal part (0.0044±0.0081), the volume density of lymphatic vessels between the two parts has no obvious difference (t=1.136, P=0.261).5) The volume density of lymphatic vessels during the near part (0.0123±0.0163), the middle part (0.0094±0.0126) and the distal part (0.0072±0.0106) of upper half has no obvious difference (F=1.078, P=0.345).The volume density of lymphatic vessels during the near part (0.0136±0.0137), the middle part (0.0041±0.0055) and the distal part (0.0044±0.0081) of lower half has obvious difference (F=9.029, P=0.0003). The volume density of lymphatic vessels is higher in the near part than in the middle part (P=0.000) and in the distal part (P=0.000).2. The USL was subdivided into facies medialis and facies lateralis from the middle.1) The facies medialis (0.0091±0.0103) and the facies lateralis (0.0026±0.0038), the volume density of lymphatic vessels is higher in the facies medialis than in facies lateralis (t=5.559, P=0.000).2) The near part (0.0063±0.0079), the middle part (0.0058±0.0083) and the distal part (0.0054±0.0090). The volume density of lymphatic vessels during the three parts has no obvious difference (F=0.188, P=0.0829). 3) The facies medialis of near part (0.0095±0.0092) and the facies lateralis of near part (0.0031±0.0048), the volume density of lymphatic vessels is higher in the facies medialis than in the facies lateralis (t=3.329, P=0.002).The facies medialis of middle part (0.0095±0.0103) and the facies lateralis of the middle part (0.0021±0.0025), the volume density of lymphatic vessels is higher in the facies medialis than in facies lateralis (t=3.747, P=0.001).The facies medialis of distal part (0.0083±0.0115) and facies lateralis of the distal part (0.0025±0.0039), the volume density of lymphatic vessels is higher in the facies medialis than in facies lateralis (t=2.574, P=0.015).4) The volume density of lymphatic vessels during the near part (0.0095±0.0092), the middle part (0.0095±0.0103) and the distal part (0.0083±0.0115) of upper half has no obvious difference (F=0.136, P=0.873).The volume density of lymphatic vessels during the near part (0.0031±0.0048), the middle part (0.0021±0.0025) and the distal part (0.0025±0.0039) of lower half has no obvious difference (F=0.559, P=0.574).FIVE:According to the quantitative results above, we can construct USL fine anatomical distrubition diagram.Conclusion:ONE:The distribution of autonomic nerve:1.The sympathetic nerve distribution:(1)The USL was subdivided into upper half and lower half from the middle.1) the lower half> the upper half (P=0.017),2) the middle part:the lower half of> the upper half (P=0.048),3) the distal part> the near part(P=0.025), the distal part> the middle part(P=0.015)4) The sympathetic nerve is concentrate on the distal part of the lower half.(2) The USL was subdivided into facies medialis and facies lateralis from the middle.1) the facies lateralis> the facies medialis(P=0.000): In the near part:the facies lateralis> the facies medialis (P=0.001),In the middle part:there is a treat of the increasing from the facies medialis to the facies lateralis,In the distal part:the facies lateralis> the facies medialis (P=0.048).2) The sympathetic nerve is concentrate on the facies lateralis.2. The parasympatheticu nerve distribution:There are only a few parasympatheticu nerves in the near part of the USL.TWO:The distribution of vascular:There is no obvious distribution regular of vascular in the USL.THREE:The distribution of lymphatic vessels:(1)The USL was subdivided into upper half and lower half from the middle.1) the middle part:the upper half>the lower half (P=0.043),2) the near part> the middle part(P=0.005), the near part> the distal part (P=0.001),3) the upper half:the near part> the middle part(P=0.000), the near part> the distal part(P=0.000),4) The lymphatic vessels is concentrate on the near part in the USL.(2) The USL was subdivided into facies medialis and facies lateralis from the middle.1) the facies medialis> the facies lateralis(P=0.000): In the near part:the facies medialis> the facies lateralis(P=0.002), In the middle part:the facies medialis> the facies lateralis(P=0.001), In the distal part:the facies medialis> the facies lateralis(P=0.015).2) The lymphatic vessels are concentrated on the facies medialis in the USL.FOUR:From the analysis of the above sample, we discovered the characteristics of distribution of autonomic nerve, vascular and lymphatic vessels in the USL:the sympathetic nerves are concentrated on the facies lateralis, the lower part is larger than the upper part, the distribution of the vasculars are irregular, the location of the lymphatic vessel is significantly greater in the facies medialis, and highest in the proximal segment. The distribution diagram about uterosacral ligament based on the quantitative and qualitative study on the fine microstructure make us understanding the USL intuitively, which provided the reference of the improvement of the SNSRH and the design of the operation steps. It also provides the possibility of simulation training for laparoscopic nerve-spring radical hysterectomy. |
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