American Journal of Obstetrics and Gynecology (2005) 193, 1565–73

www.ajog.org

Terminologia Anatomica versus unofficial descriptions

and nomenclature of the fasciae and ligaments of the
female pelvis: A dissection-based comparative study
Alfredo Ercoli, PhD,a Vincent Delmas, MD,b Francesco Fanfani, MD,c
Pierre Gadonneix, MD,d Marcello Ceccaroni, MD,a Anna Fagotti, MD,c
Salvatore Mancuso, MD,a Giovanni Scambia, MDc,*

Department of Gynecology, Catholic University, Rome, Italya; Institute of Anatomy, Universite´ Paris, Paris, Franceb;
Department of Oncology, Catholic University, Campobasso, Italyc; Department of Visceral and Gynecologic Surgery,
Diaconesses Hospital, Paris, Franced

Received for publication October 20, 2004; revised February 11, 2005; accepted April 25, 2005

KEY WORDS Objective: The aims of this study were: (1) to define and classify those connective structures of
Pelvic anatomy the female pelvis that are of potential clinical interest, (2) to evaluate the adequacy of the
Pelvic fascia Terminologia Anatomica (official nomenclature) and (3) to establish a correspondence between
Pelvic ligaments the official nomenclature and the most commonly used terms.
Endopelvic fascia Study design: The results of 30 macroscopic and laparoscopic dissections of fresh cadavers with
Terminologia and without vessel injection of colored latex solutions were compared with the descriptions and
Anatomica definitions in the Terminologia Anatomica and the most frequently cited English and non-English
literature from 1890 to 2003.
Results: We identified 3 groups of fasciae, parietal pelvic fascia, visceral pelvic fascia, and
extraserosal pelvic fascia, which could be divided into diverse clinically relevant anatomical
structures characterized by different locations, spatial orientation, and consistency. These
structures differed considerably with regard to number and nomenclature from those described in
the Terminologia Anatomica and part of the literature.
Conclusion: Our results suggest that the official terminology applied to the connective structures
of the female pelvis could be profitably revised and expanded. We offer a complete description of
these structures and suggest a classification that may be useful for teaching and clinical purposes.
Ó 2005 Mosby, Inc. All rights reserved.

For more than a century, the organization, nomen-

* Reprint requests: Prof. G. Scambia, MD, Department of Gyne-
cology, Catholic University of the Sacred Heart, L.go A. Gemelli,
8-00168, Rome, Italy.
E-mail: giovanni.scambia@rm.unicatt.it
clature, and function of the female pelvic fasciae and
ligaments has been discussed by many authors including
anatomists and surgeons. Farabeuf and Delbet in 1891
and Mackenrodt in 1895 first devoted their attention to
these structures from a purely descriptive point of view.
A clinical approach to the organization of the female

0002-9378/$ - see front matter Ó 2005 Mosby, Inc. All rights reserved.
doi:10.1016/j.ajog.2005.05.007
1566
pelvic retroperitoneal tissue was developed at the begin-
ning of the 20th century by Wertheim (1903), who
proposed radical surgery in the treatment of cervical
cancer, and Cameron and Fothergill (1908), who
stressed the functional role of the pelvic fasciae in
sustaining and suspending the pelvic organs. Subse-
quently both anatomists and surgeons contributed to
the knowledge of the gross and microscopic anatomy
of retroperitoneal pelvic structures in women. How-
ever, each author personally interpreted the organiza-
tion and function of the pelvic fasciae and furnished
specific definitions and nomenclature as can be seen in
the literature dealing with the Mackenrodt ligament1,2
and lateral ligament of the rectum.2-4 The lack of
common definitions and nomenclature hinders commu-
nication between those involved in the process of
diagnosis and treatment of pelvic pathologies in every-
day practice.
A great effort has been made in recent years by gross
anatomists to standardize anatomical terminology with
the introduction and constant revision of the Nomina
Anatomica and its more recent version, the Terminolo-
gia Anatomica.5 However, this volume does not yet
adequately describe all the anatomical structures of the
female pelvis that are of potential clinical interest, as
shown by the growing body of literature concerning
pelvic functional and surgical anatomy published over
the last few years.
The aim of this study was to investigate the organi-
zation of connective tissue in the female pelvis and
compare our results with the official nomenclature and
descriptions furnished by the Terminologia Anatomica5
and those reported in the most widely diffused English
and non-English literature. For this purpose we re-
viewed the literature most frequently cited from 1890 to
2003 and performed a large series of dissections on fresh
unoperated female cadavers. We quoted only those
papers that, to our knowledge and in our opinion, first
reported or better described the anatomical structures
investigated.
Materials and methods
For this study pelvic dissection of 30 fresh female cadavers
with no evidence of pelvic operation was performed at the
Institute of Anatomy of the René Descartes University in
Paris between December 2001 and December 2003. The
study was approved by the local institutional review
board. All subjects were adult whites. The mean age at
death was 67.1 G 8.4 years (range 48-92). Classic dissec-
tions were performed on 16 whole pelves and 8 hemipelves
obtained by incising on a sagittal plane passing along the
midline of 4 freshly frozen cadavers. After induction of
adequate pneumoperitoneum laparoscopic dissection
(magnification, !10) was carried out on 10 fresh ca-
Ercoli et al
davers. In 22 cases different dyes were injected into both
arterial and venous vessels. Sixty hemipelves were avail-
able for anatomical dissection. Unless otherwise specified,
the anatomical terms used by us conform to the Termi-
nologia Anatomica5 proposed by the Federative Com-
mittee on Anatomical Terminology. In particular, the
term fascia defines sheaths, sheets, or other dissectible
connective tissue aggregations. The areas delimited by at
least 2 independent fasciae and filled with areolar con-
nective tissue and those that could be developed by
separating 2 independent fasciae along their cleavage
plane were considered ‘‘spaces.’’ The term fossa refers to a
peritoneal depression.
Dissection procedures
Before dissection fresh cadavers were warmed for 24
hours at room temperature. For classic dissection an
arciform incision connecting the lower 12th right costal
margin, right anterior-cranial iliac spine, pubic symphy-
sis, left anterior-cranial iliac spine, and 12th left costal
margin was made. The parietal peritoneum was incised
along the pelvic portions of the psoas muscles, the root
of the mesentery and the pubic bone, and the visceral
peritoneum partially removed. The subjacent retroper-
itoneal areolar tissue was then gently stripped off to
expose any connective structure showing an organized
spatial orientation. The relationships between these
macroscopically identifiable connective structures and
the pelvic organs, vessels, and nerves were then investi-
gated by progressive macroscopic dissection. The intra-
pelvic nerve branches were traced in an anterograde
manner from the superior hypogastric plexus and the
sacral foramens with microsurgical instruments. Lapa-
roscopic dissections were performed as above using
appropriate endoscopic instruments (B-Braun, Tuttlin-
gen, Germany).
Vessel injection technique
Injection of pelvic vessels for classic dissections was
performed as previously described.6 Briefly, a tube of
appropriate diameter was positioned in the abdominal
aorta 2 cm above the origin of the ovarian arteries, and
another 2 other tubes were inserted into the femoral
arteries. The arteries were washed several times with
soapy water to remove serum and coagula before the
injection of 120 mL to 200 mL of latex mixed with 4%
red or green dye. This procedure was repeated for veins
with 160 mL to 240 mL of latex mixed with 4% green or
blue dye. Pelvic dissection was started 48 hours after the
latex-dyeing procedure. For laparoscopic dissections,
total body vessel injection was carried out by incannu-
lating the femoral vessels. Approximately 400 mL of
latex mixed with 4% red or green dye and 500 mL of
latex mixed with a 4% green or blue dye were used for
arteries and veins, respectively.
Ercoli et al 1567

Table I Organization of the connective tissue of the female pelvis

Parietal pelvic fascia Superior fascia of pelvic diaphgram f Pubovesical ligament
Obturator fascia
 Tendinous arch of pelvic fascia
Tendinous arch of levator ani
Tendinous arch of rectovaginal fascia7*
Piriformis fascia
Visceral pelvic fascia Fascia of individual organs
 Vesical fascia
Vaginal fascia
Rectal fascia
Pubocervical fascia8*
Rectovaginal fascia
Uterosacral ligament
Rectovaginal ligament9*
Rectal stalk
Rectosacral fascia
Extraserosal pelvic fascia Parametrium f Vesicouterine lig. (superficial portion)*
Paracervix
 Venous root10*
Vesicouterine ligament (deep portion)2*
Paracolpium11*
Lateral ligament of rectum
Superior vesical ligament13*
Presacral fascia f Mesoureter13*
Pelvic spaces Retropubic space
Paravesical space15*
Retrorectal space
Pararectal space15*
Deep retrorectal space*
Vesicocervical space*
Vesicovaginal space*
Rectovaginal space*
* Structure nonofficially recognized.

Results From a purely descriptive point of view, the PPF can be

In all cases the opening of the pelvic visceral peritoneum
and the gentle progressive stripping of the retroperito-
neal areolar connective tissue evidenced 3 groups of
fasciae partially fused together. These 3 groups were: (1)
the parietal pelvic fascia (PPF), (2) the visceral pelvic
fascia (VPF) and (3) the extraserosal pelvic fascia (EPF).
The PPF, VPF and EPF can all be divided into several
structures characterized by a different location, spatial
orientation, consistency, and function. Table I summa-
rizes our results with regard to the organization of the
retroperitoneal connective structures, evidencing those
structures not included in the official nomenclature.
PPF
The PPF can be defined as the variable dense fascial
system covering the structures limiting the pelvic cavity:
the levator ani, obturator, coccygeus and piriformis
muscles, the anterior surfaces of the sacrum and coxis,
and those structures contiguous to the pelvic walls such
as the hypogastric vessels and the sacral roots (Figure 1).
divided into superior fascia of pelvis diaphragm (fascia
covering the levator ani and coccygeus muscles), obtu-
rator fascia, and piriformis fascia (Table I). The PPF is
pierced by 4 bilateral foramens for the neurovascular
bundles directed toward the legs and the gluteoperineal
region: the obturator, the superior gluteal, the inferior
gluteal, and the internal pudendal bundles. Further-
more, 4 bilateral thickenings can be appreciated: the
tendinous arch of pelvic fascia, the tendinous arch of
levator ani, the tendinous arch of rectovaginal fascia7
and the pubovesical ligament (Figure 2).
The tendinous arch of pelvic fascia is taut between the
ischial spine and the caudal surface of the pubic bone and
symphysis (Figures 1 and 2). It is formed by the line of
fusion of the pubocervical fascia8 with the PPF covering
the obturator muscle. The tendinous arch of levator ani
merges with the tendinous arch of pelvic fascia from the
ischial spine to about the middle portion of the tendinous
arch of pelvic fascia at which at which point it diverges to
rejoin the inferior pubic ramus, allowing insertion of the
pubococcygeus, puborectal, and pubovaginal portions of
the levator ani (Figures 1 and 2). The tendinous arch of
1568
Figures 1 and 2 Fresh cadaver, classic dissection, upper view
of the PPF and VPF. IS, ischial spine; P, pubis; B, bladder.
rectovaginal fascia is taut between the perineal body and
the middle third of the vagina at which point it merges
with the tendinous arch of pelvic fascia. It is formed by
the line of fusion of the rectovaginal fascia with the PPF
covering the levator ani muscle. The pubovesical liga-
ment is a prominent bilateral fold of the superior fascia
of pelvis diaphragm, which is taut between the pubic
symphysis and the bladder neck (Figure 2).
VPF
The VPF can be defined as the fascial system deriving
from the visceral reflection of the PPF, which envelops
the pelvic organs and attaches them to the pelvic walls. It
can be divided into the individual fasciae of pelvic
organs, the so-called pubocervical fascia,8 the rectovagi-
nal fascia, the uterosacral and the so-called rectovaginal
ligaments,9 the rectal stalks, and the rectosacral fascia.
The organization of the VPF is summarized in Table
I. The individual fasciae of pelvic organs originate in the
reflection of the PPF at the level of the urogenital hiatus
(Figure 1). The pubocervical and rectovaginal fasciae
originate in the tendinous arch of pelvic fascia and the
tendinous arch of rectovaginal fascia, respectively.
These 2 fasciae attach the lateral portions of the middle
third of the vagina to the pelvic walls to determine the
H-shaped configuration of the vagina at this level.8 They
Ercoli et al
Figure 3 Organization of the fascial block forming the
uterosacral and rectovaginal ligaments, the rectal stalks, and
the rectosacral fascia. IS, ischial spine; U, uterus; B, bladder;
V, vagina; R, rectum. Yellow portion, uterosacral ligament;
green portion, rectovaginal ligament; violet portion, rectal
stalk; pink line, rectosacral fascia and fasciae of individual
organs; blue line, PPF covering the levator ani muscle.
become progressively thinner, proceeding from the per-
ineum toward the vaginal apex. The pubocervical fascia
fuses without evident cleavage with the anterior surfaces
of the vaginal fascia/vaginal wall to form a single
structure. It supports the bladder and proximal urethra.
The rectovaginal fascia fuses without evident cleavage
with the posterior surfaces of the vaginal fascia/vaginal
wall to form a single structure. It reinforces the posterior
vaginal wall against the anterior pulsion of the rectum
during straining.
The uterosacral and rectovaginal ligaments, the rectal
stalks, and the rectosacral fascia constitute a single
fascial block made up of a series of variably dense
connective fibers originating in a wide region of the
dorsolateral portions of the pelvic walls situated be-
tween the S2 and S4 sacral foramens and the ischial
spines, which constitute a center of convergence of the
fibers of the PPF and VPF (Figure 3). This fascial block
fuses with the EPF and the fasciae of individual pelvic
organs to establish a firm attachment between the latter
and the pelvic walls, thus opposing the downward
movement (prolapse) of these organs.
The distinction among uterosacral ligament, rectova-
ginal ligament, rectal stalks, and rectosacral fascia
resides in an arbitrary topographic division of the
connective fibers forming this fascial block depending
on their origin and target structure/organ (Figure 3). In
particular, the fibers forming the uterosacral ligament
converge toward the dorsolateral portions of the uterine
cervix (Figures 3 and 4B), those forming the rectovagi-
nal ligament converge toward the dorsolateral portions
Ercoli et al
Figure 4 Fresh cadavers, classic dissection, lateral view of
the left hemipelvis at different stages of dissection. Red latex
and green or blue latex was injected into arteries and veins,
respectively. A. IS, ischial spine; Ur, ureter; R, rectum. B.
IS, ischial spine; Ur, ureter; R, rectum. The blue dots mark the
S1-S3 sacral roots. C. IS, ischial spine; R, rectum.
of the proximal and middle vaginal thirds (Figures 3 and
4C), those forming the rectal stalk converge toward the
dorsolateral portions of the rectum (Figure 3 and 4C),
and those forming the rectosacral fascia fuse ventrally
with the presacral fascia and laterally with the rectal
stalks (Figures 3 through 5).
EPF
The EPF can be defined as the mass of variably dense
connective tissue between the PPF and VPF in which the
pelvic organs are embedded. This mass of connective
tissue accomplishes 2 main functions: it acts as a mesen-
tery providing support to the vascular and neural struc-
tures of the pelvis and permits the physiological volume
changes of the pelvic organs and relatively free, indepen-
dent movements of each organ with respect to the others.
The EPF consists of: (1) the parametrium, (2) the para-
cervix, (3) the so-called superior vesical ligament,10 (4) the
lateral ligament of rectum, and (5) the presacral fascia.
Some of these structures can be divided into a number of
ligaments that are in part officially recognized (Table I).
1569
Figure 5 Left hemipelvis obtained by incising on a sagittal
plane along the midline of a freshly frozen cadaver, classic
dissection, view from the right side. Red latex and blue latex
were injected into arteries and veins, respectively. S1-S5, sacral
vertebras; C, coxis; R, rectum; U, uterus; B, bladder; P, pubis.
Parametrium and paracervix
Both the parametrium and paracervix consist of con-
nective mesenteries formed mainly by areolar tissue
enveloping the visceral branches of the hypogastric
vessels during their course toward the uterus and vagina.
Dissections showed that in these masses of tissue, it is
possible to arbitrarily distinguish different structures
according to the number and types of vascular pedicles
found in each specimen. Conventionally the tissues
crossing over the ureter are to be identified with the
parametrium, whereas those that cross below the ureter
are to be considered paracervix. We found the parame-
trium to be formed by the connective mesenteries
enveloping the uterine artery and an inconstant branch
of the uterine vein crossing over the ureter that in
accordance with the literature we called superficial
uterine vein11 (Figure 4, A and B). This vein was found
in 23 of 60 hemipelves (38%). The parametrium showed
a constant bilateral ventral expansion organized around
the cervicovesical branches of the uterine artery that we
called superficial portion of the vesicouterine ligament
as reported in the literature2 (Figure 4, A and B). This
structure contributes to the roof of the ureteral tunnel.
The paracervix can be identified with the cardinal
ligament in virtue of its solidity. In fact, it is mainly
formed by the thick connective mesentery enveloping
the so-called venous root12 and the thinner mesenteries
enveloping the inferior vesical and the vaginal vessels.
The venous root is formed by 1 or more superimposed,
transversally oriented venous vessels that drain the
paravisceral venous plexus into the hypogastric vein(s)
(Figure 4, A and B). The most cranial vein is to be
identified with the so-called deep uterine vein.1 The
inferior vesical and vaginal arteries form 2 anterior ex-
pansions of the paracervix stretched like a wing between
the hypogastric vessels and the lateral surfaces of the
bladder and vagina. These vessels share a common
origin in the hypogastric artery in 46 of 60 (77%) speci-
mens analyzed. We identify the so-called deep portion of
the vesicouterine ligament2 and the paracolpium13 with
1570
the connective mesenteries enveloping the inferior ves-
ical and vaginal vessels, respectively (Figure 4A).
Lateral ligament of the rectum
In 43 of 60 (72%) specimens, we found a structure
stretched between the caudal portion of the hypogastric
vessels and the rectum that we identified with the lateral
ligament of the rectum (Figure 4C). This inconstant
structure is formed by the middle rectal artery and/or vein
and surrounding connective tissue and is stretched be-
tween the hypogastric vessels and the rectum so that it is
independent of the paracervix. In 12 of 60 (20%) hemi-
pelves, the middle rectal vessels emerged from the vaginal
and/or inferior vesical vessels so that their configuration
was not that of an individual structure stretched between
the hypogastric vessels and pelvic organs. In the remain-
ing 5 cases (8%), we were not able to identify a middle
rectal vessel. Along its course the lateral ligament of
rectum runs close to the pelvic splanchnic nerves in the
vast majority of cases, and traverses the pelvic plexus at
the level of its fusion with the VPF (Figure 4C).
Superior vesical ligament
This ligament is a constant bilateral structure consisting
of an extremely thin, transversally oriented connective
mesentery accompanying the superior vesical artery(ies)
(1 to 3 vessels) in its (their) course from the umbilical
artery to the bladder (Figure 6).
Presacral fascia
The presacral fascia is the pelvic continuation of the
visceral abdominal fascia. It traces a curve covering the
pelvic walls laterally and the sacrum dorsally and fuses
ventrally with the parametrium and paracervix, laterally
and dorsally with the uterosacral and rectovaginal
ligaments and the rectal stalks, and caudally with the
rectosacral fascia (Figure 6). The presacral fascia gives
support to the rectum, the adnexal vessels, the ureter,
the hypogastric and sacral splanchnic nerves, and the
inferior hypogastric plexus and efferent branches (Fig-
ure 6). The perirectal fat contained between the presa-
cral fascia and the visceral peritoneum is referred to as
the mesorectum. Within the presacral fascia, one finds a
thin, sagittally oriented connective mesentery envelop-
ing the ureter that, in accordance with the literature, we
called mesoureter14 (Figure 4, A and B).
Pelvic spaces
In our classification of the pelvic fasciae, we identified
several spaces in the female pelvis. The retropubic space
is an arciform space with the concavity facing dorsally
and delimited ventrally by the pubic bone, laterally by
the obturator fascia, caudally by the superior fascia of
the pelvic diaphragm, dorsally by the parametrium and
paracervix, and cranially by the peritoneum.
Ercoli et al
Figure 6 Fresh cadaver, classic dissection. Upper view of the
right hemipelvis. Green latex and blue latex were injected into
arteries and veins, respectively.
As reported in the literature, one can envisage this
space to be arbitrarily divided by the umbilical arteries
into a median space, the ‘‘true‘‘ retropubic space, and 2
spaces that are commonly known as the paravesical
spaces (2)15 because they correspond the paravesical
fossae (2). The retrorectal space is a virtual space that
can be developed by separating the presacral fascia from
the PPF covering the anterior surface of the sacrum
along their cleavage plane. We define this space as
delimited laterally by the uterosacral/rectovaginal/rectal
stalk fascial block up to the hypogastric vessels; ventrally
and anteriorly by the hypogastric vessels, the parame-
trium, the paracervix, and the lateral ligament of the
rectum; and caudally by the rectosacral fascia. We apply
the term pararectal spaces (2)15 to the lateral portions of
the retrorectal space because they correspond to the
pararectal fossae (2). The opening in the rectosacral
fascia permits the development of a space between the
VPF and PPF that we call deep retrorectal space (Figure
5). The development of the cleavage planes between the
pubocervical fascia/vaginal wall and the vesical fascia
and between the rectovaginal fascia/vaginal wall and
rectal fascia opens the so-called vesicocervical, vesico-
vaginal, and rectovaginal spaces (Figure 5).
Comparison of the present study results, the
Terminologia Anatomica,5 and unofficial
nomenclature
In Table II a correspondence among the results of the
present study, the Terminologia Anatomica,5 and the
most currently adopted terms9,12,13,16-20 is established.
Considerable differences among our results, the Termi-
nologia Anatomica,5 and the literature are immediately
evident in the definition, number, and nomenclature of
the anatomical structures identified. The Terminologia
Anatomica5 fails to recognize several anatomical struc-
tures representing the division of the VPF and EPF,
which are of both anatomical and clinical inter-
est,2,6,18,21-24 as shown in Table III. Figure 7 compares
the organization of the pelvic fasciae as reported by the
Terminologia Anatomica5 (Figure 7A) with those of the
present study (Figure 7B).
Ercoli et al 1571

Table II Correspondence among results of the present study, Terminologia Anatomica, and unofficial nomenclature
Present study Terminologia Anatomica Unofficial term(s)
Parietal pelvic fascia Parietal pelvic fascia, endopelvic fascia
Superior fascia of the pelvic diaphgram Superior fascia of the pelvic diaphgram
U Pubovesical ligament Pubovesical ligament U Posterior pubourethral ligament16;
urethropelvic ligament17
Obturator fascia Obturator fascia
Piriformis fascia Piriformis fascia
Visceral pelvic fascia Visceral pelvic fascia Endopelvic fascia
Fascia of individual organs Fascia of individual organs
Pubocervical fascia d Halban’s fascia
Rectovaginal fascia Rectovaginal fascia; rectovaginal septum Denonvillier’s fascia
Uterosacral ligament Uterosacral ligament, rectouterine ligament Posterior parametrium (cranial portion)18
Rectovaginal ligament d Posterior parametrium (caudal portion)18;
rectal pillar
Rectal stalk Rectal stalk Rectal pillar
Rectosacral fascia Rectosacral fascia
Extraserosal pelvic fascia Extraserosal pelvic fascia Endopelvic fascia; Tela subserosa9; corpus
intrapelvinum11
Parametrium Parametrium Lateral parametrium (cranial portion),18
cardinal lig.ament (cranial portion)
U Vesicouterine ligament (superf. portion) d U Anterior parametrium
(cranial portion)18; bladder pillar
Paracervix Paracervix Lateral parametrium (caudal portion),18
Mackenrodt ligament; cardinal ligament
(caudal portion)
U Venous root d
U Vesicouterine lig. (deep portion) d U Amreich’s fleboduct19
U Paracolpium d U Anterior parametrium (caudal portion)18
Lateral ligament of rectum Lateral ligament of rectum, rectal stalk Rectal pillar
Presacral fascia Presacral fascia
U Mesoureter d U Lamina neuroducens,19 nerve root12
Pelvic spaces
Retropubic space Retropubic space
Paravesical space d
Retrorectal space Retrorectal space
Pararectal space d
Deep retrorectal space Retrorectal space Postanal space20
Vesicocervical space d
Vesicovaginal space d
Rectovaginal space d

As far as the discrepancies between official and
unofficial nomenclature are concerned, these depend
on the different traditions of national anatomical
schools and the different functional role depicted for
each a structure by different authors.
Comment
This study investigated the macroscopic organization of
retroperitoneal pelvic connective tissue in a large series
of dissections of unoperated fresh female cadavers with
the aim of defining and classifying those structures that
are of potential clinical interest, evaluating the adequacy
of the Terminologia Anatomica5 (official nomencla-
ture), and establishing a correspondence between the
official nomenclature and the most commonly adopted
terms.
We found that the retroperitoneal pelvic connective
tissue is organized into 3 main groups of fasciae fused
together so that their intersections delimit the pelvic
spaces and form the septa. These 3 main groups of
fasciae are the PPF, which is the fascial system covering
the structures lining the pelvic cavity; the VPF, which is
the fascial system enveloping the pelvic organs and
attaching them to the pelvic walls; and the EPF, which is
the mass of connective tissue between the PPF and VPF
that acts as a mesentery for the vascular and neural
pelvic structures. The PPF, VPF, and EPF can all be
1572 Ercoli et al

Table III Clinical interest of anatomical structures not

officially recognized included in the present study
Structure Clinical interest
Pubocervical fascia Prolapse surgery (paravaginal
repair, anterior colporraphy)21
Rectovaginal Prolapse surgery (colposuspension to
ligament the complex uterosacral-
rectovaginal ligament)22
Superior vesical Pelvic oncologic surgery
ligament (preservation of bladder and
ureteral vascular supply)18
Vesicouterine Pelvic oncologic surgery (preservation
ligament (superficial of bladder and ureteral vascular
and deep portion) supply and nerve-sparing surgery)2
Venous root Pelvic oncologic surgery
(nerve-sparing surgery)2,6
Paracolpium Pelvic oncologic surgery18
Mesoureter Pelvic oncologic surgery (preservation
of ureteral vascular supply and
nerve-sparing surgery)6,18
Paravesical space Pelvic oncologic surgery (pelvic
lymphadenectomy)
Pararectal space Pelvic oncologic surgery (pelvic
lymphadenectomy and
nerve-sparing surgery)
Deep retrorectal Pelvic oncologic surgery (posterior
space pelvectomy, rectal cancer surgery)23
and prolapse surgery
(colposuspensions to the
sacrospinous ligament and
Figure 7 Comparison of the organization of the female Ileococcygeus fascia)24
pelvic fasciae. A. According to the Terminologia Anatomica.5
B. According to the present study.

divided into several separate structures characterized by
a different constitution, location, spatial orientation,
and solidity as shown in Table I.
Our results concerning the global organization of the
retroperitoneal pelvic connective tissue are in full agree-
ment with the officially accepted description in the
Terminologia Anatomica5 and the vast majority of the
studies cited in the literature. However, establishing a
correspondence between the official nomenclature and
the most common terms was particularly difficult be-
cause the nomenclature reported in the literature is
extremely variable and sometimes confusing, as can be
seen from Table II.
In this context the Terminologia Anatomica5 is to be
recognized for its work in harmonizing the different
descriptions reported in the literature and providing a
clear, precise anatomical classification of the principal
pelvic structures. However, as far as the fine organiza-
tion of the pelvic connective tissue is concerned, the
Terminologia Anatomica5 includes only a small minor-
ity of the anatomical structures described in the litera-
ture.
On the basis of our dissections and from an analysis
of the literature, we identified and defined some subdi-
visions of the main pelvic fasciae and spaces that are not
officially recognized. In particular, we identified and
defined a group of anatomical structures of definite
clinical interest. All these structures are in effect useful
anatomical landmarks in retroperitoneal pelvic surgery
for both benign and malignant conditions, as reported
in Table III. It is our opinion that an accurate and
standardized anatomical nomenclature is a prerequisite
for a safe, standardized clinical practice.
In this context our results and the ever-increasing
body of literature investigating the anatomy of the
female pelvis testify and underline the need for a revised
and expanded edition of the Terminologia Anatomica.5
We believe that the organization of the retroperitoneal
connective tissue we suggest in this paper offers a
relatively complete description of the anatomical struc-
tures of the female pelvis that may be useful for both
teaching and clinical purposes.
Acknowledgments
We gratefully acknowledge Mr Maurice Harras for his
excellent technical help and Mr Adolfo Bigioni for his
illustrations.
Ercoli et al
References
1. Yabuki Y, Asamoto A, Hoshiba T, Nishimoto H, Nishikawa Y,
Nakajima T. Radical hysterectomy: An anatomic evaluation of
parametrial dissection. Gynecol Oncol 2000;77:155-63.
2. Yabuki Y, Asamoto A, Hoshiba T, Nishimoto H, Kitamura S.
Dissection of the cardinal ligament in radical hysterectomy for
cervical cancer with emphasis on the lateral ligament. Am J Obstet
Gynecol 1991;164:7-14.
3. Sato K, Sato T. The vascular and neuronal composition of the
lateral ligament of the rectum and the rectosacral fascia. Surg
Radiol Anat 1991;13:17-22.
4. Nano M, Dal Corso HM, Lanfranco G, Ferronato M, Hornung
JP. Contribution to the surgical anatomy of the ligaments of the
rectum. Dis Colon Rectum 2000;43:1592-7.
5. Terminologia Anatomica. International anatomical terminology/
Federative Committee on Anatomical Terminology (FCAT).
Stuttgart/New York: Thieme; 1998.
6. Ercoli A, Delmas V, Gadonneix P, Fanfani F, Villet R, Paparella
P, Mancuso S, Scambia G. Classical and nerve-sparing radical
hysterectomy: an evaluation of the risk of injury to the autono-
mous pelvic nerves. Surg Radiol Anat 2003;25:200-6.
7. Leffler KS, Thompson JR, Cundiff GW, Buller JL, Burrows LJ,
Schon Ybarra MA. Attachment of the rectovaginal septum to the
pelvic sidewall. Am J Obstet Gynecol 2001;185:41-3.
8. DeLancey JO. Anatomic aspects of vaginal eversion after hyster-
ectomy. Am J Obstet Gynecol 1992;166:1717-24.
9. Curtis AH, Anson BJ, Beaton LE. The anatomy of the subperi-
toneal tissues and ligamentous structures in relation to surgery of
the female pelvic viscera. Surg Gynecol Obstet 1940;70:643-56.
10. Kamina P, Chansigaud JP. Soutenement et suspension des visceres
pelviens chez la femme. J Gynecol Obstet Biol Reprod 1988;17:
835-48.
1573
11. Magara M, Iwaya H, Senda T. Abdominal radical operation for
cancer of the cervix. Oncology 1967;21:283-99.
12. Richter K, Frick H. Die Anatomie der fascia pelvis visceralis
aus didaktischer sicht. Geburtshilfe Frauenheilkd 1985;45:
282-7.
13. von Peham H, Amreich I. Gynäkologische Operationslehre.
Berlin/Basel: Verlag S. Karger; 1930.
14. Reiffenstuhl G. The clinical significance of the connective tissue
planes and spaces. Clin Obstet Gynecol 1982;25:811-20.
15. Pernkopf E. Topographische Anatomie des Menschen. 2nd ed.
Berlin/Vienna: Urban Scharzenberg; 1943.
16. Zacharin RF. The suspensory mechanism of the female urethra.
J Anat 1963;97:423-7.
17. Klutke CG, Siegel CL. Functional female pelvic anatomy. Urol
Clin North Am 1995;22:487-98.
18. Novak F. Die gynäkologische operationstechnikk. New York/
Berlin/Vienna: Springer; 1978.
19. Luisi M. Anatomia clinica ginecologica. Milan: Ambrosiana; 1978.
20. Crapp AR, Cuthebertson AM. William Waldeyer and the recto-
sacral fascia. Surg Gynecol Obstet 1974;138:252-6.
21. Weber AM, Walters MD. Anterior vaginal prolapse: review of
anatomy and techniques of surgical repair. Obstet Gynecol
1997;89:311-8.
22. Ross JW. Apical vault repair, the cornerstone of pelvic vault
reconstruction. Int Urogynecol J Pelvic Floor Dysfunct 1997;8:
146-52.
23. Havenga K, DeRuiter MC, Enker WE, Welvaart K. Anatomical
basis of autonomic nerve-preserving total mesorectal excision for
rectal cancer. Br J Surg 1996;83:384-8.
24. Lovatsis D, Drutz P. Vaginal surgical approach to vaginal vault
prolapse: consideration of anatomic correction and safety. Curr
Opin Obstet Gynecol 2003;15:435-7.