{"paper_id":"2145da5f-ae53-4945-baa6-46d7214d970e","body_text":"J Surg, an open access journal\nISSN: 2575-9760\n1 V olume 10; Issue 09\nResearch Article\nAnatomic Study of the Uterosacral Ligaments: Impact on \nEndometriosis Diagnosis\nNabil Louafi1, Elie Zerbib 1*, Yohann Dabi1, Clément Ferrier 1, Adrien \nCrestani1, Kamila Kolanska 1, Amélia Favier 1, Isabelle Thomassin-\nNaggara2, Marc Bazot2, Cyril Touboul1, Emile Daraï1\n1Department of Gynaecology, Obstetrics and Reproductive Medicine, Sorbonne University, Hôpital Tenon, 4 Rue de la Chine, 75020 \nParis, France\n2Département d’Imageries Radiologiques et Interventionnelles Spécialisées (IRIS), Hôpital Tenon, Assistance Publique-Hôpitaux de \nParis, France; Sorbonne Université, INSERM U938 Équipe Biologie et Thérapeutiques du Cancer, France\nJournal of Surgery\nChang WT, et al. J Surg 10: 11380\nwww.doi.org/10.29011/2575-9760.11380\nwww.gavinpublishers.com\nCorresponding author: Elie Zerbib, Department of Gynaecology, Obstetrics and Reproductive Medicine, Sorbonne University, Hôpital \nTenon, 4 Rue de la Chine, 75020 Paris, France \nCitation: Louafi N, Zerbib E, Dabi Y , Ferrier C, Adrien Crestani A, et al. (2025) Anatomic Study of the Uterosacral Ligaments: Impact \non Endometriosis Diagnosis J Surg 10: 11380 DOI: 10.29011/2575-9760.011380\nReceived Date: 07 July 2025; Accepted Date: 14 July 2025; Published Date: 16 July 2025\nAbstract\nBackground: Uterosacral Ligament (USL) is the most frequent location of deep infiltrating endometriosis. Despite an abundant \nliterature on USL anatomy in genital prolapse, few data are available on normal USL anatomy. This explains the absence of consensus \non criteria to diagnose by imaging techniques this specific endometriosis location. Therefore, the aim of the present study was to \nassess the normal anatomy of USL.\nMaterial and methods: Five fresh and five embalmed cadavers of adult female were dissected. The anatomic characteristics of USL \nat the insertion to the torus uterinum were assessed by measuring the distance between the inner edges of the USLs at the uterine \ninsertion and the distance between the torus uterinum and the upper edge of the posterior vaginal cuff. For the 20 hemipelvis, the \nlength and thickness of the USLs were evaluated every centimeter from the uterus to the sacral insertions. Comparisons of measures \nbetween the right and left USL and between fresh and embalmed cadavers were performed. \nResults: Distance between the inner edges of the USLs at uterine insertion was 1.4±0.3cm. Distance between the torus uterinum and \nthe upper edge of the vaginal cuff was 1.0±0.4cm. For the 20 hemipelvis, the mean length of the USL was 7±0.95cm. USL transverse \nthickness varied according to the distance from uterine insertion and was steady between 2 and 5cm from uterine insertion with a \nmean value of 0.5±0.2cm. The length of the right USL was longer (7.1 vs. 6.8cm) (p<0.01). No difference in the transverse thickness \nwas found between right and left USL. No difference in USLs measures were found between fresh and embalmed cadavers.\nConclusion: Our results allow to determine the portion of USL where the measures are reproducible. Moreover, measures of normal \nUSL were evaluated contributing to define cut-off of abnormal USL applicable to imaging techniques in women with suspicion of \nendometriosis. \n\nCitation: Louafi N, Zerbib E, Dabi Y , Ferrier C, Adrien Crestani A, et al. (2025) Anatomic Study of the Uterosacral Ligaments: Impact \non Endometriosis Diagnosis J Surg 10: 11380 DOI: 10.29011/2575-9760.011380\n2\nV olume 10; Issue 09\nJ Surg, an open access journal\nISSN: 2575-9760\nKeywords: Anatomy; Cranio-caudal thickness; Endometriosis; \nTransverse thickness; Uterosacral ligament\nIntroduction\nEndometriosis, defined histologically by the presence of \nendometrial-like tissue outside the uterus, affects 5-10% of \nsymptomatic women of reproductive age thus representing at \nleast 190 million worldwide [1,2]. Endometriosis diagnosis is \nmainly based on symptoms including severe chronic pelvic pain, \ndysmenorrhea, dyspareunia, dyschezia, and infertility as well as \nnon-specific symptoms such as fatigue [3,4]. However, no single or \ncombined signs are sufficiently specific to allow the diagnosis [5,6]. \nMoreover, except for vaginal endometriosis, clinical examination \ndoes not reach sufficient accuracy to assess the diagnosis [7] \nthus imposing further investigation [2,8,9].Three phenotypes of \nendometriosis, often associated, are distinguished; the Superficial \nPeritoneal Endometriosis (SPE), Ovarian Endometriosis (also \ncalled endometrioma) and Deep Infiltrative Endometriosis (DIE). \nDespite advances in imaging techniques, SPE, representing the \nmost frequent phenotype observed in up to 80% of cases, is often \nignored by both Transvaginal Ultrasonography (TVUS) and MRI \n[1,10,11]. Endometrioma, observed in about one third of women, \nis well diagnosed by both TVUS and MRI with an accuracy over \n90% [2]. Another shortcoming of the diagnosis algorithms is \nlinked to patients with a suspicion of DIE on imaging observed in \n20% of patients with endometriosis. Even using data from expert \ncentres, Nisenblat et al. demonstrated the low accuracy of imaging \nto accurately determine all locations of deep endometriosis \nespecially the Uterosacral Ligament (USL) location that is the \nmost frequent DIE lesion [2,12,13]. The difficulties to assess the \ndiagnosis of USL endometriosis is partially linked to the absence \nof referent measures to define normal USL. In contrast to numerous \nanatomic studies on USL morphology in genital prolapse, few data \nare available on normal anatomy of USL using serial sectioning \n[14-16]. Therefore, the goal of the present study was to analyze \nmacroscopic characteristics of normal USL to determine cut-off  \nof normality to help radiologists to diagnose USL endometriosis.\nMaterial and Methods\nAnatomic consideration on USL\nThe USLs arise from the posterolateral surfaces of the supra-\nvaginal part of the cervix and the vaginal fornix, running along \nthe recto-uterine cul-de-sac, and ending in the pre-sacral vertebrae \nfascia S2 to S4. In their medial part, USL lies the inferior \nhypogastric nerve plexus [17]. Rouvière et al. [17] defined USL \nas “smooth connective and muscular bundles arising from the \nposterior surface of the cervix, near its lateral edges and in the \nimmediate vicinity of the isthmus, run cranially and dorsally, \naround the lateral surfaces of the rectum and terminate on the \nanterior surface of the sacrum. They lift the peritoneum to form \na curved fold, concave medially, which laterally limits the cul-\nde-sac of Douglas. The name USL refers to both the serous fold \nand the conjunctive-muscular elements that define and support it. \nThe thickness of these ligaments contains mixed with the smooth \nconnective and muscular fibers, and part of the hypogastric nerve \nplexus, which in fact constitutes the truly resistant component of \nthe ligament on each side. The USL on one side is joined to the \nligament on the opposite side, behind the cervix, by a transverse \nfold known as the torus uterinum or J.L. Petit ligament. Taken \ntogether, the two USLs form a horseshoe shape. \nMaterial\nThe study involved 20 hemipelvis from 10 menopausal female \ncadavers (five fresh and five embalmed) dissected in the anatomy \nlaboratory of the Saint Pères and at the Fer à Moulin surgical \nschool Paris, France.\nMethods\nThe two USLs of each subject were resected in their entirety. The \ncadaver was placed on a dissecting table in dorsal decubitus position. \nThe peritoneal cavity was opened by a large cross incision, and the \nuterus was fixed by a wire to the wall opposite the pubis to ensure \nmaximum anteversion. The digestive tract was pushed upwards to \nensure better exposure. The first measures (to the nearest 0.1cm) \nwere the distance separating the medial edges of the USLs at their \nuterine insertion and the distance separating the lower limit of the \ntorus uterinum from the upper limit of the posterior vaginal fornix. \nThis measurement was performed after locating the upper limit \nof the posterior vaginal fornix by a vaginal digital examination. \nThen each USL was resected. Once the USLs resected, they were \nrefined from the peritoneum using transillumination.Each USL \nwas oriented and various measurements (to the nearest 0.1cm) \nwere performed including the total length (from uterine insertion \nto sacral insertion), cranio-caudal and transverse thicknesses at the \nlevel of the uterine insertion. Then transverse thickness of USL \nwas measured every centimeter in the ventro-dorsal direction \n(from uterine insertion to sacral insertion) (Figure 1). \n\nCitation: Louafi N, Zerbib E, Dabi Y , Ferrier C, Adrien Crestani A, et al. (2025) Anatomic Study of the Uterosacral Ligaments: Impact \non Endometriosis Diagnosis J Surg 10: 11380 DOI: 10.29011/2575-9760.011380\n3\nV olume 10; Issue 09\nJ Surg, an open access journal\nISSN: 2575-9760\nFigure 1: schematic axial view of the female pelvis.\nStatistical Analysis\nTo compare measures between left and right USL and between \nfresh and embalmed cadavers, Stat View 5.0 software was used.\nResults\nEvaluation of USL at the Uterine Insertion\nThe distance between the internal edges of the USLs at their \nuterine insertion and the distance between the torus uterinum \nand posterior vagina fornix for the 10 cadavers were evaluated. \nThe mean distance between the internal edges of the USLs at \ntheir insertion to the torus uterinum level was 1.4±0.3cm (range: \n1-1.8cm). The mean distance between the torus uterinum and the \nposterior vagina fornix was 1.06±0.38cm (range: 0.5-1.8cm).\nEvaluation of the USL Anatomic Measures \nFor the 20 hemipelvis, the total length, the transverse and the \ncranio-caudal thicknesses of USLs were evaluatedFor the 20 \nhemipelvis, the mean length of USL was 7±0.95cm (range: 5.5-\n8.5cm). For the 20 hemipelvis, the transverse thickness was not \nuniform throughout its length allowing to differentiate three \nsegments (Figure 1), the first segment from the uterine insertion to \nthe first centimeter with a decrease in the transverse thickness, the \nsecond segment from 2 to 5cm from uterine insertion with a steady \ntransverse thickness, and the last segment from 6cm to the sacral \ninsertion with a progressive increase in the transverse thickness. \nIn contrast to the transverse thickness, the cranio-caudal thickness \nevaluation was evaluable only for the first centimeters of USLs \nfrom the uterine insertion. The mean cranio-caudal thickness \nat uterine insertion for the right and left USL were 0.7±0.2 cm \nand 0.7±0.1cm, respectively (not significant). In contrast to the \ntransverse thickness that was adequately delimited, the cranio-\ncaudal thickness of USL according to the three segments was not \nadequately delimited especially their two-thirds dorsal segments \nof USL not permitting an adequate evaluation. \nComparison of Right and Left USL Measures\nThe comparison of right and left USL measures is given in Table 1.\n Left USL Right USL P value \nTT at uterine \ninsertion (cm) 0.8 ± 0.2 0.7 ± 0.1 NS\nTT at 1 cm from \nuterine insertion \n(cm)\n0.6 ± 0.2 0.6 ± 0.2 NS\nTT at 2 cm from \nuterine insertion \n(cm)\n0.5 ± 0.2 0.5 ± 0.1 NS\nTT at 3 cm from \nuterine insertion \n(cm)\n0.5 ± 0.2 0.5 ± 0.1 NS\nTT at 4 cm from \nuterine insertion \n(cm)\n0.5 ± 0.2 0.5 ± 0.1 NS\nTT at 5 cm from \nuterine insertion \n(cm)\n0.6 ± 0.1 0.6 ± 0.1 NS\nTT at 6 cm from \nuterine insertion \n(cm)\n0.7 ± 0.2 0.7 ± 0.2 NS\nTT at 7 cm from \nuterine insertion \n(cm)\n0.7 ± 0.1 0.7 ± 0.1 NS\nTT at 8 cm from \nuterine insertion \n(cm)\n0.9 ± 0.1 0.6 ± 0.1 NS\nTable 1: Evaluation of the transverse thickness (TT) of the \nuterosacral ligament (USL) according to the distance from uterine \ninsertion.\nThe mean total length of the right USL was longer than the left \nUSL, 7.1cm and 6.8cm respectively (p<0.01). No differences in \nthe transverse thicknesses according to the distance from uterine \n\nCitation: Louafi N, Zerbib E, Dabi Y , Ferrier C, Adrien Crestani A, et al. (2025) Anatomic Study of the Uterosacral Ligaments: Impact \non Endometriosis Diagnosis J Surg 10: 11380 DOI: 10.29011/2575-9760.011380\n4\nV olume 10; Issue 09\nJ Surg, an open access journal\nISSN: 2575-9760\ninsertion were observed between left and right USL. No comparison of the cranio-caudal thickness according to sides was possible.\nComparison of USL Measures Between Fresh And Embalmed Cadavers.\nThe measures of the USLs according to the fresh or embalmed are summarized in the Table 2. \n Embalmed cadavers (n=5) Fresh cadavers (n=5) P value\nDistance between the internal edges of the USLs (cm) 1.40 ± 0.27 1.38 ± 0.35 NS\nDistance between the torus uterinum and the posterior vagina fornix \n(cm) 0.98 ± 0.14 1.14 ± 0.54 NS\nMean length of the left USL (cm) 6.64 ± 0.83 6.98 ± 1.20 0.07\nMean length of the right USL (cm) 7.04 ± 0.76 7.18 ± 1.15 NS\nTable 2 : Comparison of the uterosacral ligament (USL) measures between fresh and embalmed cadavers.\nNo differences in the distance between the internal edges of \nthe USLs at their uterine insertion, the distance between torus \nuterinum and posterior vaginal fornix, and the total length of USL, \nwere found between fresh and embalmed cadavers. Except for a \ntrend for a higher length for the right USL in fresh cadavers, no \ndifference in the transverse thickness values was observed between \nfresh and embalmed cadavers. \nDiscussion\nThe present anatomic analysis contributes to determine cut-\noff measure of normal USL. Among the various measures, the \ntransverse thickness values between 2 and 5cm from uterine \ninsertion of the USL was reproducible and steady supporting its \npotential use as criterion of abnormal USL on imaging techniques for \nendometriosis diagnosis. In the present study, we observed that the \nlength of USL was significantly longer for the right USL (p<0.01). \nIn a review including 13 anatomic studies, Ramanah et al. [18] \nunderlined differences in USL length according to series. Indeed, \nSiddique et al. reported an USL length of 8.7cm (95 % confidence \ninterval (CI); 7.5-10.0) [19] while Vu et al. [20] measured the USL \nlength to 12-14cm. However, as in the present study, Campbell et \nal. [21] and Blaisdell et al. [15] observed that the length of USL was \ngreater on the right side. For the 20 hemi-pelvis, when focusing on \nthe transverse thickness of USL according to the distance from \nthe uterine insertion, that is often analyzed on TVUS and MRI \nto diagnose endometriosis involvement, its measure in the current \nstudy remained steady between 2 and 5cm of 0.5±0.2cm without \ndifference between the right and left USL supporting that this \nsegment should be the most adequate portion for reproducibility \nof the measures. In contrast to the evaluation of USL length, to \nour knowledges, few data are available on the serial analysis of the \nUSL transverse thickness according to the distance from uterine \ninsertion. Vu et al. reported that the transverse thickness of the \ndistal section and at uterine insertion of USLs varied between 5 \nand 20mm [20] while Ramanah et al. noted that the mean thickness \nof USL were 5.2±0.9cm, 2.7±1.0, and 2.0±0.5cm at the sacral, \nintermediate, and cervical portions, respectively [18]. However, as \npreviously mentioned [18], this discrepancy can be explained by \ncontroversies on terminology, definition, composition, dissection \nartifacts, and even the existence of USL. Concerning the cranio-\ncaudal thickness, the measures were higher at the uterine and \nsacral insertions without difference between right and left USL \nbut were not adequately evaluable throughout the USL length. \nThis is probably linked to the intricating of muscle fibers as \nwell as the inferior hypogastric nerves fibers, and to anatomic \ndissection artifacts. Consequently, in the absence of other criteria \nof endometriosis such as nodular or spicular features, and hot spot \ncomponent corresponding to hemorrhagic lesion, a USL transverse \nthickness per se inferior or equal to 5mm at its intermediate \nsegment (2-5cm from uterine insertion) on imaging cannot support \nthe diagnosis of endometriosis. Moreover, as aforementioned, USL \ntransverse thickness was measured after refining USL from the \nperitoneum while the measure on imaging includes the peritoneal \ncomponent. This consideration is particularly relevant as among \n344 DIE lesions, Chapron et al. [22] reported that USL was the \nmost frequent location (69.2%). Moreover, they reported that \nthe proportion of isolated lesions differed according to the DIE \nlocation with a highest rate of 83.2% for USL. \nNational and international guidelines recommend for the diagnosis \nof endometriosis an algorithm based on ultrasonography (US) or \nMRI [3,4]. Although these algorithms appear logical to detect \novarian endometriosis, observed in about one-third of patients, \nthanks to the high accuracy of both US and MRI, a debate exists on \nthe accuracy of imaging techniques to detect USL endometriosis \n[2]. When considering the contribution of imaging techniques to \ndiagnose USL endometriosis, it is important to differentiate US from \nMRI. In a retrospective multicenter study involving 878 patients \n\nCitation: Louafi N, Zerbib E, Dabi Y , Ferrier C, Adrien Crestani A, et al. (2025) Anatomic Study of the Uterosacral Ligaments: Impact \non Endometriosis Diagnosis J Surg 10: 11380 DOI: 10.29011/2575-9760.011380\n5\nV olume 10; Issue 09\nJ Surg, an open access journal\nISSN: 2575-9760\nbetween 15 and 45 years-old undergoing Laparoscopy (LPS) for \nsuspected endometriosis, Abrao et al. evaluated transvaginal and \ntransabdominal ultrasonography (US) (index test) to assess sites \nof endometriosis according to the 2021 AAGL Endometriosis \nClassification [23]. The AAGL-US and AAGL-LPS stages were \nconcordant in 586 cases (66.7%) (weighted kappa (WK) 0.759; \nintraclass correlation 0.906), with the highest agreement observed \nin patients with no endometriosis (75.3% concordance). However, \nfor retrocervical/uterosacral ligament the WK was only 0.656. \nAnother prospective study of 172 patients of Ros et al. evaluated \nthe accuracy of TVUS to diagnose DIE involving USL, torus \nuterinum (TU) or posterior vaginal fornix (PVF) compared to \nlaparoscopy [24]. The global sensitivity and specificity of TVUS \nin diagnosing USL, TU and/or PVF endometriosis were 92% and \n87%, respectively. In a meta-analysis, Zhou et al. have evaluated \nthe accuracy of TVUS for USL endometriosis [25]. The respective \npooled sensitivity, specificity, positive probability ratio (LR+) \nand negative probability ratio (LR-) of TVUS for detecting USL \nendometriosis were 65% (95% CI:43-83), 92 % (95% CI:84-\n96), 7.80 (95% CI:4.7-13.0) and 0.38 (95% CI:0.22-0.66) with \na significant heterogeneity in both sensitivity and specificity \nreported. Finally, in a review including 22 studies, focusing \non TVUS for USL endometriosis, Maple et al. found that most \n(20/22) studies described abnormal criteria but only five defined \nthe appearance of normal USL underlining the lack of data and \nconsensus for this specific endometriosis location [26]. \nWhen considering MRI to assess USL endometriosis, using the \nRAND-UCLA Appropriateness Method to attain consensus \nguidelines, Rousset et al. elaborated a lexicon of image interpretation, \nand a standardized region-based reporting of DIE with MRI [27]. \nA consensus regarding pelvic compartment delineation and DIE \nreporting was thereby attained. A consensus was reached for the \nmost frequent locations of DIE, but no consensus was reached \nto define the normal presentation of USL. In a meta-analysis \nincluding 10 prospective studies, Gerges et al. evaluated USL \nendometriosis by TVUS and MRI compared to surgery [28]. For \nUSL endometriosis, for all TVUS and MRI the respective pooled \nsensitivity and specificity techniques were 60% (95%CI 32–82%) \nand 95% (95%CI 90–98%), and 81% (95%CI 66–90%) and 83% \n(95%CI 62–94%). Despite some limits of the included studies, \nMRI outperformed TVUS for the diagnosis of USL with higher \nsensitivities but similar specificities. Finally, whatever imaging \ntechniques, a publication bias exists as studies primarily emerge \nfrom expert centers, thereby not reflecting the full scope of routine \npractice [2]. Moreover, Leonardi et al. underlined the difficulties \nfor patients to find an expert sonographer [29]. Some limits of the \npresent study deserve to be underlined. First, the limited sample \nsize cannot exclude all bias even if homogenous evaluation of USL \nlength and transverse thickness measures was observed. Second, \nthe use of fresh and embalmed cadavers might be a potential \nbias, but our results support the absence of difference in USL \ncharacteristics between these two groups. Third, all cadavers were \nfrom menopausal women with a possible underestimation of USL \nmeasures linked to hormonal deficiency. However, none of the \ncadavers had a genital prolapse that is known as a cause of USL \nalterations. Indeed, Kökçü et al. showed a decreased cellularity in \nconnective tissue in patients with genital prolapse compared with \npatients without prolapse [30]. Finally, the present study underlined \nthe difficulties to evaluate the cranio-caudal thickness of USL due \nto the absence of clear delimitation of the connective tissue from \nadjacent muscle and inferior hypogastric nerves. In conclusion, \ndespite some limits of the present study, our results underlined \nthe need to consider data of anatomic analysis to define normal \nanatomy of USL. Further studies evaluating the morphology and \ndimensions of USL by imaging techniques in patients with and \nwithout symptoms suggestive of endometriosis are required to \ndetermine the characteristics of both normal and abnormal pelvic \nstructures. \nReferences\n1. \nZondervan KT, Becker CM, Missmer SA (2020) Endometriosis. New \nEngland Journal of Medicine. 26 mars 382: 1244‑1256. \n2. Nisenblat V, Bossuyt PMM, Farquhar C, Johnson N, Hull ML (2016) \nImaging modalities for the non‑invasive diagnosis of endometriosis. \nCochrane Database Syst Rev. 26 févr 2: CD009591. \n3. Collinet P, Fritel X, Revel‑Delhom C, Ballester M, Bolze PA, et al. \n(2018) Management of endometriosis: CNGOF/HAS clinical practice \nguidelines – Short version. Journal of Gynecology Obstetrics and \nHuman Reproduction. 1 sept 47: 265‑274. \n4. Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, et al. (2022) \nESHRE guideline: endometriosis. Hum Reprod Open. 2022: hoac009. \n5. Bendifallah S, Dabi Y, Suisse S, Jornea L, Bouteiller D, et al. (2022) \nMicroRNome analysis generates a blood‑based signature for \nendometriosis. Sci Rep. 8 mars 12: 4051. \n6. Grover SR, Joseph K (2021) Endometriosis and pelvic pain: Time to \ntreat the symptoms not the assumptions? Aust N Z J Obstet Gynaecol. \naoût 61: 625‑627. \n7. Roditis A, Florin M, Rousset P, Touboul C, Bendifallah S, et al. \n(2023) Accuracy of combined physical examination, transvaginal \nultrasonography, and magnetic resonance imaging to diagnose deep \nendometriosis. Fertil Steril. avr 119: 634‑643. \n8. Nisenblat V, Bossuyt PMM, Shaikh R, Farquhar C, Jordan V, et \nal. (2016) Blood biomarkers for the non‑invasive diagnosis of \nendometriosis. Cochrane Database Syst Rev. 1 mai 2016: CD012179. \n9. Nisenblat V, Prentice L, Bossuyt PMM, Farquhar C, Hull ML, et al. \n(2016) Combination of the non‑invasive tests for the diagnosis of \nendometriosis. Cochrane Database Syst Rev. 13 juill 7: CD012281. \n10. Horne AW, Missmer SA (2022) Pathophysiology, diagnosis, and \nmanagement of endometriosis. BMJ. 14 nov 379: e070750. \n11. Koninckx PR (1994) Is mild endometriosis a condition occurring \n\nCitation: Louafi N, Zerbib E, Dabi Y , Ferrier C, Adrien Crestani A, et al. (2025) Anatomic Study of the Uterosacral Ligaments: Impact \non Endometriosis Diagnosis J Surg 10: 11380 DOI: 10.29011/2575-9760.011380\n6\nV olume 10; Issue 09\nJ Surg, an open access journal\nISSN: 2575-9760\nintermittently in all women? Hum Reprod. déc 9: 2202‑2205. \n12. Koninckx PR, Ussia A, Adamyan L, Wattiez A, Donnez J (2012) Deep \nendometriosis: definition, diagnosis, and treatment. Fertil Steril. sept \n98: 564‑571. \n13. Bazot M, Jarboui L, Ballester M, Touboul C, Thomassin‑Naggara I, et \nal. (2012) The value of MRI in assessing parametrial involvement in \nendometriosis. Hum Reprod. août 27: 2352‑2358. \n14. Umek WH, Morgan DM, Ashton‑Miller JA, DeLancey JOL (2004) \nQuantitative analysis of uterosacral ligament origin and insertion points \nby magnetic resonance imaging. Obstet Gynecol. mars 103: 447‑451. \n15. Blaisdell: The anatomy of the sacro‑uterine ligaments.\n16. Gabriel B, Denschlag D, Göbel H, Fittkow C, Werner M, et al. (2005) \nUterosacral ligament in postmenopausal women with or without pelvic \norgan prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 16: 475‑479. \n17. Rouvière: Anatomía humana. \n18. Ramanah R, Berger MB, Parratte BM, DeLancey JOL (2012) Anatomy \nand histology of apical support: a literature review concerning cardinal \nand uterosacral ligaments. Int Urogynecol J. nov 23: 1483‑1494. \n19. Siddique SA, Gutman RE, Schön Ybarra MA, Rojas F, Handa VL \n(2006) Relationship of the uterosacral ligament to the sacral plexus \nand to the pudendal nerve. Int Urogynecol J Pelvic Floor Dysfunct. \nnov 17: 642‑645. \n20. Vu D, Haylen BT, Tse K, Farnsworth A (2010) Surgical anatomy of the \nuterosacral ligament. Int Urogynecol J. sept 21: 1123‑1128. \n21. Campbell RM (1950) The anatomy and histology of the sacrouterine \nligaments. Am J Obstet Gynecol. janv 59: 1‑12, illust. \n22. Chapron C, Fauconnier A, Vieira M, Barakat H, Dousset B (2003) \nAnatomical distribution of deeply infiltrating endometriosis: surgical \nimplications and proposition for a classification. Hum Reprod. janv 18: \n157‑161. \n23. Abrao MS, Andres MP, Gingold JA, Rius M, Neto JS, et al. (2023) \nPreoperative Ultrasound Scoring of Endometriosis by AAGL 2021 \nEndometriosis Classification Is Concordant with Laparoscopic \nSurgical Findings and Distinguishes Early from Advanced Stages. J \nMinim Invasive Gynecol. mai 30: 363‑373. \n24. Ros C, de Guirior C, Mension E, Rius M, Valdés‑Bango M, et al. (2021) \nTransvaginal ultrasound for diagnosis of deep endometriosis involving \nuterosacral ligaments, torus uterinus and posterior vaginal fornix: \nprospective study. Ultrasound Obstet Gynecol. déc 58: 926‑932. \n25. Zhou Y, Su Y, Liu H, Wu H, Xu J, et al. (2021) Accuracy of transvaginal \nultrasound for diagnosis of deep infiltrating endometriosis in the \nuterosacral ligaments: Systematic review and meta‑analysis. J \nGynecol Obstet Hum Reprod. mars 50: 101953. \n26. Maple S, Chalmers KJ, Bezak E, Henry K, Parange N (2023) \nUltrasound Characteristics and Scanning Techniques of Uterosacral \nLigaments for the Diagnosis of Endometriosis: A Systematic Review. J \nUltrasound Med. juin 42: 1193‑1209. \n27. Rousset P, Florin M, Bharwani N, Touboul C, Monroc M, et al. (2023) \nDeep pelvic infiltrating endometriosis: MRI consensus lexicon and \ncompartment‑based approach from the ENDOVALIRM group. Diagn \nInterv Imaging. mars 104: 95‑112. \n28. Gerges B, Li W, Leonardi M, Mol BW, Condous G (2021) Meta‑analysis \nand systematic review to determine the optimal imaging modality for \nthe detection of uterosacral ligaments/torus uterinus, rectovaginal \nseptum and vaginal deep endometriosis. Hum Reprod Open. 4 nov \n2021: hoab041. \n29. Leonardi M, Uzuner C, Mestdagh W, Lu C, Guerriero S, et al. \n(2022) Diagnostic accuracy of transvaginal ultrasound for detection \nof endometriosis using International Deep Endometriosis Analysis \n(IDEA) approach: prospective international pilot study. Ultrasound in \nObstetrics & Gynecology. 60: 404‑413. \n30. Kökçü A, Yanik F, Cetinkaya M, Alper T, Kandemir B, et al. (2002) \nHistopathological evaluation of the connective tissue of the vaginal \nfascia and the uterine ligaments in women with and without pelvic \nrelaxation. Arch Gynecol Obstet. avr 266: 75‑78.","source_license":"CC0","license_restricted":false}