Does the uterine artery pass through the transverse cervical (Mackenrodt's) ligament?

Uterine Artery and the Transverse Cervical Ligament

The uterine artery travels through the parametrium (which includes the transverse cervical/cardinal/Mackenrodt's ligament) as it courses from the internal iliac artery toward the uterus. 1, 2

Anatomical Course Through the Parametrium

The uterine artery follows a specific pathway after originating from the anterior division of the internal iliac artery:

• The artery courses medially and anteriorly toward the uterus through the parametrial tissue in 61.72% of cases. 2, 3

• Within the parametrium, the uterine artery travels alongside the main uterine lymphatic trunks in this same connective tissue space. 1, 2

• The parametrium represents a tunnel-like connective tissue space extending from the lateral cervix to the lateral pelvic wall, and the uterine artery traverses this structure as part of its anatomical course. 2

Critical Anatomical Landmark

• At the level of the uterine-cervical junction, the uterine artery crosses over the ureter while still within the parametrial tunnel, which is the most clinically significant anatomical relationship. 1, 2, 4

• After crossing the ureter, the vessel divides into uterine and cervical branches as it ascends along the lateral border of the uterus within the broad ligament. 1, 2

• The ureter crosses anteriorly to the uterine artery in all cases, with the crossing point occurring at, below, or rarely above the level of the internal os. 4

Clinical Relevance

• During uterine artery embolization procedures, catheters are advanced through the parametrial course of the uterine artery, with the goal of reaching distal to nontarget branches before embolization. 2

• The parametrial pathway is also the route for lymphatic spread in uterine malignancies, as the main uterine lymphatic trunks travel alongside the uterine artery in this space. 2, 5

• Surgeons performing pelvic or gynecological procedures must understand this relationship, as the uterine artery can be identified and ligated at various points along its parametrial course depending on surgical approach and indication. 6