Anatomic variations of the Uterine Artery. Review of the literature and their clinical significance

Uterine artery projection relative to anatomical bony landmarks in CT-angiographies

PURPOSE

The aim was to find bony landmarks of the pelvis for the origins and routes of uterine arteries, hoping to improve speed and safety of embolization procedures (leiomyoma, post-partum bleedings…).

METHODS

We carried out a study based on the analysis of CT-angiographies in arterial phases of whole-body scans. Two measurements were done per artery, one from the origin of uterine arteries to a first perpendicular line passing through the lowest part of the sacroiliac joint, another one from the beginning of the parametrial segment from a second parallel line passing by the acetabular roof. Mean distances across all these measurements were calculated, as were potential associations with known variables such as anatomical variants, age, parity and any pelvic surgical history.

RESULTS

Two hundred uterine arteries were analyzed. Concerning the origin, 83.5% of uterine arteries were located approximately one centimeter around the first line defined above, with a mean distance of + 4.8 mm. Concerning parametrial segment beginning, 88% were located approximately one centimeter around the second line defined, with a mean distance of only + 3.9 mm above the acetabular roof. Some significant differences were observed in subgroups, notably with a small trend to higher arising of uterine arteries in patients who had at least one childbirth, and expectedly lower arising in distal anatomical variants.

CONCLUSION

Clear pelvic anatomic landmarks exist and could help the guidance of arteries catheterization, and therefore indirectly lead to faster embolization and optimize procedures safety.

A rare case of spontaneous rupture of the uterine artery

Spontaneous rupture of the uterine artery is extremely rare in nonpregnant women, and bleeding can be rapidly controlled by laparoscopy.

CT Angiography-Guided Needle Insertion for Interstitial Brachytherapy in Locally Advanced Cervical Cancer

CT angiography might be a suitable procedure to avoid arterial puncture in combined intracavitary and interstitial brachytherapy for cervical cancer curatively treated with combined chemoradiation and brachytherapy boost. Data in the literature about this technique are scarce. We introduced this method and collected brachytherapy data from patients treated in our department between May 2021 and April 2024. We analyzed the applicator subtype, needle insertion (planned versus implanted), implanted depth and the role of CT angiography in selecting needle trajectories and insertion depths. None of the patients managed through this protocol experienced atrial puncture and consequent hemorrhage. Needle positions were accurately selected with the aid of CT angiography with proper coverage of brachytherapy targets and avoidance of organs at risk. CT angiography is a promising method for guiding needle insertion during interstitial brachytherapy.

Anatomic variation of a duplicated uterine artery

During the anatomical dissection of the pelvis, a duplication of the uterine artery was identified unilaterally on the left side in a 59-year-old Korean female cadaver. The first uterine artery was found to arise directly from the anterior division of the internal iliac artery and supply the upper uterine body and tube. The second uterine artery shared a common stem with the superior and inferior vesical arteries, supplying the lower uterine body. The external diameter of each uterine artery at its origin on the left side was smaller than that of the right uterine artery. One vaginal artery was identified to arise from the left internal pudendal artery. Embryologically, a duplicated uterine artery could imply the presence of two primordial arteries separately supplying the cranial and caudal parts of the Müllerian duct during the early fetal period. This case of variational anatomy is noteworthy: clinicians could elucidate it and successfully perform uterine artery embolization or hysterectomy with minimal complications.

Iatrogenic Bladder Injury During Laparoscopic Hysterectomy: A Case Report and Discussion of Anatomic Variations

Hysterectomy, one of the most common surgical procedures performed in women worldwide, assumes a very important role in the definitive management of diverse gynecologic conditions. This case report presents a compelling instance of an iatrogenic bladder perforation that occurred during laparoscopically assisted vaginal hysterectomy in a 47-year-old woman with a high body mass index, extensive surgical history, and postural orthostatic tachycardia syndrome. Despite considerable preoperative planning and the use of minimally invasive techniques, the occurrence of physician-induced bladder perforation highlights the significance of understanding anatomical relationships and variations. The patient's previous abdominal surgeries including two cesarean sections, appendectomy, and cholecystectomy likely contributed to scar formation and adhesions, making dissection challenging. The case report and following discussion delve into anatomical variations, as well as the diagnosis and management of iatrogenic bladder injuries. The presented case serves as a valuable addition to the literature, contributing insights into the challenges and considerations surrounding urinary tract injuries during hysterectomy. This paper aims to review current research and guide practicing obstetricians and gynecologists in the management of intraoperative bladder injuries.

The effect of maternal position on placental blood flow and fetoplacental oxygenation in late gestation fetal growth restriction: a magnetic resonance imaging study

Fetal growth restriction (FGR) and maternal supine going-to-sleep position are both risk factors for late stillbirth. This study aimed to use magnetic resonance imaging (MRI) to quantify the effect of maternal supine position on maternal-placental and fetoplacental blood flow, placental oxygen transfer and fetal oxygenation in FGR and healthy pregnancies. Twelve women with FGR and 27 women with healthy pregnancies at 34-38 weeks' gestation underwent MRI in both left lateral and supine positions. Phase-contrast MRI and a functional MRI technique (DECIDE) were used to measure blood flow in the maternal internal iliac arteries (IIAs) and umbilical vein (UV), placental oxygen transfer (placental flux), fetal oxygen saturation (FO2 ), and fetal oxygen delivery (delivery flux). The presence of FGR, compared to healthy pregnancies, was associated with a 7.8% lower FO2 (P = 0.02), reduced placental flux, and reduced delivery flux. Maternal supine positioning caused a 3.8% reduction in FO2 (P = 0.001), and significant reductions in total IIA flow, placental flux, UV flow and delivery flux compared to maternal left lateral position. The effect of maternal supine position on fetal oxygen delivery was independent of FGR pregnancy, meaning that supine positioning has an additive effect of reducing fetal oxygenation further in women with FGR, compared to women with appropriately grown for age pregnancies. Meanwhile, the effect of maternal supine positioning on placental oxygen transfer was not independent of the effect of FGR. Therefore, growth-restricted fetuses, which are chronically hypoxaemic, experience a relatively greater decline in oxygen transfer when mothers lie supine in late gestation compared to appropriately growing fetuses. KEY POINTS: Fetal growth restriction (FGR) is the most common risk factor associated with stillbirth, and early recognition and timely delivery is vital to reduce this risk. Maternal supine going-to-sleep position is found to increase the risk of late stillbirth but when combined with having a FGR pregnancy, maternal supine position leads to 15 times greater odds of stillbirth compared to supine sleeping with appropriately grown for age (AGA) pregnancies. Using MRI, this study quantifies the chronic hypoxaemia experienced by growth-restricted fetuses due to 13.5% lower placental oxygen transfer and 26% lower fetal oxygen delivery compared to AGA fetuses. With maternal supine positioning, there is a 23% reduction in maternal-placental blood flow and a further 14% reduction in fetal oxygen delivery for both FGR and AGA pregnancies, but this effect is proportionally greater for growth-restricted fetuses. This knowledge emphasises the importance of avoiding supine positioning in late pregnancy, particularly for vulnerable FGR pregnancies.

The anatomy of the uterine artery: A meta-analysis with implications for gynecological procedures

The uterine artery (UA) is an arterial branch of the internal iliac artery in women, usually arising from the anterior division of the internal iliac artery. However, due to the high variability in the anatomy of the UA, embolization of this vessel may be challenging. Therefore, the objective of this meta-analysis was to provide physicians with transparent data on the anatomy of the UA, using the available data in the literature. Databases such as PubMed, Scopus, Embase, Web of Science, and Google Scholar were searched to find all the relevant studies regarding the UA. A total of 16 articles met the required criteria. The UA was found to originate most frequently from the internal iliac artery as the pooled prevalence was set to be 61.72% (95% CI: 41.31%-80.31%). A pooled prevalence of the UA originating from the umbilical artery was established at 13.93% (95% CI: 2.76%-30.44%). A pooled prevalence of the UA originating from the inferior gluteal artery was set to be 5.22% (95% CI: 0.00%-15.44%). In conclusion, we believe that this is the most accurate and up-to-date study regarding the highly variable anatomy of the UA. The UA originates most frequently from the internal iliac artery (61.72%), however, other origins, such as from the umbilical artery (13.93%) or the inferior gluteal artery (5.22%) may occur. It is hoped that the results of the present meta-analysis will be a helpful tool for surgeons performing pelvic or gynecological surgeries.

Comparison of brachial artery flow-mediated dilatation, uterine artery Doppler, and umbilical artery Doppler measurements in obese and normal pregnant women

OBJECTIVE

In this study, we aimed to compare vascular function at trimesters 1, 2, and 3 between obese and normal pregnant women through brachial artery flow-mediated dilatation (FMD), uterine artery Doppler, and umbilical artery Doppler measurements.

METHODS

Pregnant women between the ages of 18 and 40 who presented to our clinic were included. Brachial artery FMD, uterine and umbilical artery Doppler, and clinical parameters of 40 obese pregnant women from each trimester between 11 and 14 weeks, 24 and 28 weeks, 37 and 40 weeks and control pregnant group in the same number and gestational week were examined.

RESULTS

In all three trimesters, the FMD value was lower in obese pregnant women compared to normal women with adequate weight (p < 0.001). In obese pregnant women, lower FMD values were observed in the second trimester compared to other trimesters (p = 0.011) Cut-off value of FMD below 14.35 in obese pregnant women was found to be associated with gestational diabetes mellitus. Uterine artery Doppler in obese pregnant women started to increase from the second trimester compared to normal women with adequate weight.

CONCLUSION

Obese pregnant women have endovascular dysfunction compared to normal pregnant women and this becomes evident from the second trimester.

Primary bilateral ovarian artery embolization for uterine leiomyomatosis in the setting of a rare anatomic variant - hypoplastic uterine arteries

We present the case of a 50-year-old female who underwent bilateral ovarian artery embolization for uterine fibroids in the setting of hypoplastic uterine arteries. Ovarian artery embolization is usually conducted during uterine artery embolization for fibroids to increase the procedure success when ovarian feeders are seen. The bilateral ovarian artery embolization is rarely performed due to fears of amenorrhea and early menopause from decreased blood supply to both ovaries. According to our knowledge, this the first case report describing primary bilateral ovarian artery embolization in the setting of a rare anatomic variant- hypoplastic uterine arteries. The patient had complete resolution of symptoms from her uterine fibroids after treatment with bilateral ovarian artery embolization with no ovarian failure findings on the follow-up.

Analysis of clinical features of 231 cases with pernicious placenta previa: A retrospective cohort study

Pernicious placenta previa (PEPP) is a severe complication of late pregnancy, which might result in adverse maternal-fetal outcome. To explore the application value of placenta accreta score (PAS) for PEPP and its association with maternal-fetal outcome.In this retrospective cohort study, the clinical data of PEPP patients were analyzed. According to the ultrasonic PAS, patients were grouped into 3 groups: scores ≤5, a scores between 6 and 9, and scores ≥10. The clinical data, intraoperative and postoperative outcomes were collected. Receiver operating characteristic (ROC) curves were used to evaluate the performance of PAS in disease severity evaluation. Multivariate logistic and linear regression analysis were performed to assess associations of PAS with intraoperative and postoperative outcomes.A total of 231 patients were enrolled. There were significant differences in intraoperative, postoperative and neonatal outcomes, such as operation time, bladder repair, ICU admission, postoperative hospitalization days, operation complications, Apgar score of newborns in 1 minute and premature delivery among the 3 groups (all P < .05), while the worst outcomes were found in those with a score ≥ 10 (all P < .05). According to ROC curves, scores <5.5, between 5.5 and 7.5, and >7.5 indicated placenta accreta, placenta increta and placenta percreta, respectively. PAS was independently associated with longer time of operation, surgical complications, intraoperative bleeding volume, and postoperative hospitalization days (all P < .05).Placenta accreta score might help with PEPP subtype diagnosis and predict the maternal-fetal outcome of PEPP patients.

Pelvic Lymphadenectomy in Gynecologic Oncology-Significance of Anatomical Variations

Pelvic lymphadenectomy is a common surgical procedure in gynecologic oncology. Pelvic lymph node dissection is performed for all types of gynecological malignancies to evaluate the extent of a disease and facilitate further treatment planning. Most studies examine the lymphatic spread, the prognostic, and therapeutic significance of the lymph nodes. However, there are very few studies describing the possible surgical approaches and the anatomical variations. Moreover, a correlation between anatomical variations and lymphadenectomy in the pelvic region has never been discussed in medical literature. The present article aims to expand the limited knowledge of the anatomical variations in the pelvis. Anatomical variations of the ureters, pelvic vessels, and nerves and their significance to pelvic lymphadenectomy are summarized, explained, and illustrated. Surgeons should be familiar with pelvic anatomy and its variations to safely perform a pelvic lymphadenectomy. Learning the proper lymphadenectomy technique relating to anatomical landmarks and variations may decrease morbidity and mortality. Furthermore, accurate description and analysis of the majority of pelvic anatomical variations may impact not only gynecological surgery, but also spinal surgery, urology, and orthopedics.