Lower urinary tract dysfunction after nerve-sparing radical hysterectomy

Pelvic neural injuries and acute voiding changes in rat models of radical hysterectomy

OBJECTIVE

To establish experimental models of radical hysterectomy based on Querleu-Morrow classification, and clarify the quantitative evaluation of pelvic neural injuries and acute voiding changes postoperatively.

METHODS

Female Sprague Dawley rats were randomized and received sham operation, type A, B1, C1 and C2 radical hysterectomies (as the injury gradually increased), respectively. The excised specimens were collected for hematoxylin and eosin staining and Pgp9.5 (pan-neuronal marker) immunohistochemistry to evaluate the facial and neural resection of paracervix. At 21 days after operation, 5 rats in each group were used for urine spot test, awake cystometry and leak point pressure test, and the other 5 ones were used for hematoxylin and eosin staining of bladder and pelvic neural plane, and Masson's trichrome staining of bladder.

RESULTS

Paracervical Pgp9.5 immunohistochemistry revealed that the resected neural area in C2 group was significantly larger than that in type A, B1, and C1 groups. Compared with type A and B1 groups, the excised paracervical facial area was significant higher in type C1 and C2 groups. The occurrence of urinary retention was 0%, 10%, 40% and 100% in type A, B1, C1 and C2 groups, respectively, which was further confirmed by average residual volume. The incidence of neurogenic bladder and its severity gradually increased from type A to type C2 groups, consistent with the findings of leakage point pressure, bladder size, bladder weight, pathological changes and collagen deposition. Neuropathological evaluation revealed neural injuries involved the main components of pelvic neural plane.

CONCLUSION

The novel rat models of radical hysterectomy based on Querleu-Morrow classification revealed the structural and functional changes of voiding after operation, which reflected the situation in humans.

Prevalence and Risk Factors of Urinary Retention in Patients With Cervical Cancer: A Meta-analysis and Systematic Review

BACKGROUND

The literature is inconsistent on the prevalence and risk factors of urinary retention in patients with cervical cancer.

OBJECTIVE

The aim of this study was to review the literature on the prevalence of urinary retention in patients with cervical cancer and consolidate the risk factors.

METHODS

For this meta-analysis, eligible articles published in English or Chinese by December 10, 2021, were systematically searched for and retrieved from PubMed, Cochrane Library, Ovid-Embase Medline, Web of Science, PsycINFO, CINAHL, and Scopus. Prevalence, odds ratios (ORs), and 95% confidence intervals (CIs) were used for meta-analysis.

RESULTS

Twenty-five studies were included in the analysis. The pooled overall prevalence was 0.26 (95% CI, 0.21-0.30, I2 = 95.0%). The identified risk factors were age (OR, 1.13; 95% CI, 1.08-1.19), urinary tract infection (UTI) (OR, 3.33; 95% CI, 1.48-7.49), surgical extent (OR, 2.95; 95% CI, 1.27-6.85), and catheter indwelling time (OR, 3.44; 95% CI, 2.43-3.87).

CONCLUSIONS

The prevalence of urinary retention in patients with cervical cancer is 0.26. Older age, UTI, longer catheter indwelling time, and a larger surgical extent may increase the risk of urinary retention. Clinicians should identify patients at risk and adopt interventions such as individualized catheter care.

IMPLICATIONS FOR PRACTICE

Nursing staff should assess the risk of urinary retention in a patient with cervical cancer according to her age, presence of UTI, surgical extent, and catheterization time. A carefully chosen surgical procedure and interventions such as individualized education, timely catheter removal, treatment of UTI, and rehabilitation should be offered.

Surgical Anatomy and Dissection of the Hypogastric Plexus in Nerve-Sparing Radical Hysterectomy

Radical hysterectomy is a central surgical procedure in gynecological oncology. A nerve-sparing approach is essential to minimize complications from iatrogenic injury to the pelvic nerves, resulting in postoperative urinary, anorectal, and sexual dysfunction. The hypogastric plexus (HP), a complex network of sympathetic and parasympathetic nerves, plays a critical role in pelvic autonomic innervation. This article offers a comprehensive overview of the surgical anatomy of the HP and provides a step-by-step description of HP dissection, with a particular emphasis on preserving the bladder nerve branches of the inferior HP. A thorough understanding and mastery of the anatomical and surgical nuances of HP dissection are crucial for optimizing outcomes in nerve-sparing gynecologic-oncological procedures.

Impact of timing of urinary catheter removal on voiding dysfunction after radical hysterectomy for early cervical cancer

OBJECTIVES

To evaluate whether the timing of postoperative urinary catheter removal is associated with voiding dysfunction after radical hysterectomy for early cervical cancer within contemporary surgical practice.

METHODS

We performed an institutional retrospective cohort study of patients who underwent Piver type II-III open or minimally invasive radical hysterectomy for early-stage cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IA1 with lymphovascular invasion to stage IIA) between January 2006 and December 2019. We compared voiding dysfunction (inability to spontaneously void with a post-void residual <100 mL after catheter removal) and outcomes based on postoperative timing of urinary catheter removal using univariate and multivariate logistic regressions.

RESULTS

Among 234 patients, 86 (36.8%) underwent open surgery and 112 (47.9%) used enhanced recovery after surgery (ERAS) pathways. 29 (12.4%) patients had urinary catheter removal between 1-5 days postoperatively (group 1), 141 (60.3%) between 6-10 days (group 2), and 64 (27.3%) between 11-15 days (group 3). The overall rate of voiding dysfunction was 11.5%, with no difference between group 1 (17.2%), group 2 (11.3%), and group 3 (9.4%) (p=0.54). Group 1 had a significantly shorter time from surgery to spontaneous voiding (4 days, IQR 3-5 days) compared with group 2 (8 days, IQR 7-10 days) and group 3 (13 days, IQR 11-15 days) (p<0.01). There was no difference in hospital length of stay, urinary tract infection, or re-admission due to a genitourinary complication within 60 days of surgery based on timing of catheter removal. On multivariate analysis, the odds of voiding dysfunction did not differ by tumor size, type of hysterectomy, cancer stage, surgical approach, ERAS timeframe, or timing of catheter removal group.

CONCLUSION

There was no difference in voiding dysfunction or postoperative genitourinary complications based on timing of urinary catheter removal after radical hysterectomy. Early catheter removal should be considered in this population.

Increased incidence of neurogenic bladder after radical hysterectomy for cervical cancer: A nationwide population-based cohort study

BACKGROUND

The effect of radical hysterectomy for patients with cervical cancer on voiding function remains controversial. The purpose of this study was to examine the association between radical hysterectomy for patients with cervical cancer and the odds of developing neurogenic bladder by using data from the National Health Insurance Research Database (NHIRD) in Taiwan.

METHODS

We identified 17 936 patients who underwent radical hysterectomy for cervical cancer between 2000 and 2013 among inpatients registered in the Longitudinal Health Insurance Database in Taiwan. Of the patients, those diagnosed as having cervical cancer without radical hysterectomy were selected and compared as a matched control group. Patients diagnosed as having cervical cancer before the index date, those with neurogenic bladder dysfunction before tracking, and those aged <20 years were excluded. The hazard ratios (HRs) of neurogenic bladder and other variants of interest were further calculated using a multivariate Cox regression analysis. The cutoff p value of <0.05 was regarded as statistically significant.

RESULTS

The adjusted HR (aHR) of subsequent neurogenic bladder was higher in the hysterectomy group (aHR = 1.205; 95% CI, 1.086-1.440; p = 0.029) than in the control group during the follow-up period. As to the age subgroups, the patients aged 20 to 44 years (aHR = 3.321, p = 0.001) had a significantly increased risk of developing neurogenic bladder after radical hysterectomy as compared with those aged 45 to 64 years (aHR = 1.193, p = 0.012).

CONCLUSION

Patients with cervical cancer undergoing radical hysterectomy have an increased risk of neurogenic bladder, which may result from nerve denervation caused by the operation. These patients should be informed of the potential risk of voiding dysfunction during discussion of the subsequent management for cervical cancer.

[Impact of hysterectomy on urinary incontinence: A systematic review]

INTRODUCTION

The impact of a hysterectomy on urinary incontinence is a controversial subject in the literature.

OBJECTIVE

To evaluate the prevalence and incidence of urinary incontinence after a hysterectomy as well as associated risk factors such as the type of hysterectomy, the surgical approach, urodynamic criteria and uterine disease.

STUDY DESIGN

We conducted a systematic review in Pubmed database with the following keywords and MeSH term: hysterectomy, urinary incontinence.

RESULTS

A total of 1340 articles were retrieved, 42 articles were selected for the final text analysis. The results of the different studies were heterogeneous. Hysterectomy seemed to increase the rate of sphincter deficiency (VLPP<60mmH₂O for 20% of cases versus 1,7% without hysterectomy, P=0.003). The vaginal route could increase the incidence of UI with OR of 2.3 (95%CI 1.0-5.2). Subtotal hysterectomy appears to increase UI with a 0,74 RR for total hysterectomy (95%CI 0.58-0.94). A radical hysterectomy with nerve conservation would preserve urinary functions, unlike pelvic radiotherapy, which is responsible for irreversible nerve damage by demyelination and bladder fibrosis.

Standardized terminology of apical structures in the female pelvis based on a structured medical literature review

The objectives of this study were to review the published literature and selected textbooks, to compare existing usage to that in Terminologia Anatomica, and to compile standardized anatomic nomenclature for the apical structures of the female pelvis. MEDLINE was searched from inception until May 30, 2017, based on 33 search terms generated by group consensus. Resulting abstracts were screened by 11 reviewers to identify pertinent studies reporting on apical female pelvic anatomy. Following additional focused screening for rarer terms and selective representative random sampling of the literature for common terms, accepted full-text manuscripts and relevant textbook chapters were extracted for anatomic terms related to apical structures. From an initial total of 55,448 abstracts, 193 eligible studies were identified for extraction, to which 14 chapters from 9 textbooks were added. In all, 293 separate structural terms were identified, of which 184 had Terminologia Anatomica-accepted terms. Inclusion of several widely used regional terms (vaginal apex, adnexa, cervico-vaginal junction, uretero-vesical junction, and apical segment), structural terms (vesicouterine ligament, paracolpium, mesoteres, mesoureter, ovarian venous plexus, and artery to the round ligament) and spaces (vesicocervical, vesicovaginal, presacral, and pararectal) not included in Terminologia Anatomica is proposed. Furthermore, 2 controversial terms (lower uterine segment and supravaginal septum) were identified that require additional research to support or refute continued use in medical communication. This study confirms and identifies inconsistencies and gaps in the nomenclature of apical structures of the female pelvis. Standardized terminology should be used when describing apical female pelvic structures to facilitate communication and to promote consistency among multiple academic, clinical, and surgical disciplines.

Value of diffusion-weighted and dynamic contrast-enhanced MR in predicting parametrial invasion in cervical stromal ring focally disrupted stage IB-IIA cervical cancers

OBJECTIVES

To compare the effectiveness of diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) imaging in detecting parametrial invasion (PMI) in cervical stromal ring focally disrupted stage IB-IIA cervical cancers.

METHODS

Eighty-one patients with cervical stromal ring focally disrupted stage IB-IIA cervical cancers (PMI positive, n = 35; PMI negative, n = 46) who underwent preoperative MRI and radical hysterectomy were included in this study. Preoperative clinical variables and MRI variables were analyzed and compared.

RESULTS

The K_trans (min, mean, 10%, 25%, 50%, 75%, 90%), K_ep (min, 10%, 25%, 50%, 75%, 90%), and V_e (min, 10%, 25%, 50%, 75%, 90%) values of patients with PMI were significantly higher than patients without PMI. The apparent diffusion coefficient (ADC) value did not show statistical difference between the two groups (1.01 ± 0.21 vs. 0.97 ± 0.20 10^-3 mm²/s, p = 0.360). Tumor craniocaudal planes were higher in PMI-positive group than PMI-negative group (35.84 ± 15.39 vs. 29.70 ± 11.78 mm, p = 0.048). Tumor craniocaudal planes combined with K_epmin value showed the highest area under the curve (AUCs) of 0.775, with a sensitivity of 72.7% and a specificity of 71.1% (p = 0.000).

CONCLUSIONS

DCE parameters combined tumor craniocaudal planes may represent a prognostic indicator for PMI in cervical stromal ring focally disrupted IB-IIA cervical cancers.

Urodynamic outcomes after pelvic nerve-sparing radical hysterectomy with or without neoadjuvant chemotherapy

OBJECTIVE: Our purposes of this study were to characterize a group of bulky cervical cancer patients who underwent a nerve sparing radical hysterectomy (NSRH) with or without neoadjuvant chemotherapy (NAC), to compare surgical outcomes and the preservation of bladder function, and to compare prognoses.

RESULTS: Fifty-three patients had NSRH without NAC (Group A), and 33 patients had NSRH after NAC (Group B). With regard to prognostic factors, there was only a significant difference between both groups with regard to lymph node metastasis (15% vs 42%, P = 0.01). Moreover, bladder function in Group B patients improved to the same extent as the preoperative rate three months postoperatively. These data were similar to the results in Group A. With regard to overall survival, the 5-year survival rate was 98.1% (95% confidence interval (CI) 87.8–99.7) in Group A and 86.7% (95% CI 71.7–96.7) in Group B (P > 0.1).

METHODS: We retrospectively identified 86 patients with cervical cancer who underwent NSRH at Osaka Medical College from May 2009 to November 2016. NAC was performed via balloon occluded arterial infusion. We extracted data on the patient's stage of progress, tumor volume, histological subtype, bleeding volume, urodynamic study results, and postoperative complications. The data were divided into two groups - those patients who received NAC and those who did not - and then compared.

CONCLUSIONS: According to our analysis, NSRH surgery after NAC via balloon occluded arterial infusion brings beneficial results to patients with bulky IB2 to IIB cervical cancers.

Perineural invasion in cervical cancer: pay attention to the indications of nerve-sparing radical hysterectomy

Perineural invasion (PNI) in early-stage cervical cancer, is associated with multiple high-risk factors and represents a poor outcome in the patients. For nerve-sparing radical hysterectomy (NSRH) to become a standard and widely used treatment for cervical cancer, we need to define its oncological safety, and to establish standardized surgical procedures and indications of NSRH. Here, we review the definition and mechanisms, and clinical significance of PNI in cervical cancer, and discuss the indications of NSRH. PNI should be regarded as one of the main pathological features of cervical cancer and a factor affecting prognosis. A deeper understanding of PNI in cervical cancer, hopefully, will provide clear indications of NSRH.

Neurovascular and lymphatic vessels distribution in uterine ligaments based on a 3D reconstruction of histological study: to determine the optimal plane for nerve-sparing radical hysterectomy

OBJECTIVE

To present the distribution of neurovascular and lymphatic vessels in uterine ligaments using 3D models based on the pathological staining of serial 2D sections of postoperative specimens.

METHODS

Serial transverse sections of fresh uterine ligaments from a patient with stage IB1 cervical squamous cell carcinoma were studied using the computer-assisted anatomic dissection (CAAD) technique. The sections were stained with hematoxylin and eosin, Weigert elastic fibers, D2-40 and immunostainings (sheep anti-tyrosine hydroxylase and rabbit anti-vasoactive intestinal peptide). The sections were then digitalized, registered and reconstructed three-dimensionally. Then, the 3D models were analyzed and measured.

RESULTS

The 3D models of the neurovascular and lymphatic vessels in uterine ligaments were created, depicting their precise location and distribution. The vessels were primarily located in the upper part of the ligaments model, while the pelvic autonomic nerves were primarily in the lower part; the lymphatic vessels were scattered in the uterine ligaments, without obvious regularity.

CONCLUSION

CAAD is an effective anatomical method to study the precise distribution of neurovascular and lymphatic vessels in uterine ligaments. It can present detailed anatomical information about female pelvic autonomic innervation and the spatial relationship between nerves and vessels and may provide a better understanding of nerve-sparing radical hysterectomy.

Factors predicting parametrial invasion in patients with early-stage cervical carcinomas

We aimed to identify factors predicting parametrial invasion in early-stage cervical cancer patients undergoing radical hysterectomy. We recruited women with invasive cervical cancer who underwent radical hysterectomy at a single medical institute from 2000–2011. The clinical and pathological characteristics and outcomes were retrospectively recorded, and the risk factors for parametrial invasion were analyzed. We enrolled 339 patients, including 7 with stage IA1 carcinomas, 10 with stage IA2, 266 with stage IB1, 39 with stage IB2, 14 with stage IIA1, and 3 with stage IIA2. The majority (237/339, 69.9%) had squamous cell carcinoma, while 32 (12.4%) had parametrial invasion. The 16 patients with stage IB1 tumors and parametrial invasion were older (55.9±9.5vs. 49.0±9.9 years, p = 0.005, Mann-Whitney U test), and had deeper cervical stromal invasion (9.59±4.87 vs. 7.47±5.48 mm, p = 0.048, Mann-Whitney U test), larger tumor size (2.32±1.15 vs. 1.74±1.14cm, p = 0.043, Mann-Whitney U test), higher incidences of lymphovascular space invasion (87.5% vs. 28.8%, p<0.001, chi-square test), and greater lymph node metastasis (68.8% vs. 10.8%, p<0.001, chi-square test) than the 260 patients without parametrial invasion. Among the patients with stage IB1 tumor size >2 cm,10% had parametrial invasion and 24.2% had lymph node metastasis compared with only 4% and 9.4% of stage IB1 patients with a tumor size <2 cm, respectively. Only one (0.9%) of the 109 patients aged less than 50 years had parametrial invasion compared with 6 (9.7%) of the 62 patients aged over 50 years. Patients with stage IA2 and IB1 tumors <2 cm may not need radical hysterectomy owing to the low incidence of parametrial invasion.

Limited energy parametrial resection/dissection during modified laparoscopic nerve-sparing radical hysterectomy

Objective

The aim of this study was to investigate the feasibility of using ultrasonic scalpel combined with vascular clip in parametrial management, called limited energy parametrial resection/dissection (LEPRD), in laparoscopic nerve plane-sparing radical hysterectomy (NPSRH), a modified nerve-sparing radical hysterectomy (NSRH); and to evaluate its effectiveness in pelvic autonomic nerve preservation.

Methods

From July 2012 to January 2016, 257 consecutive patients with stage IB1 to IIA2 cervical cancer who underwent NPSRH were included in this study. Patients were divided into three cohorts according to the different parametrial resection modality. The clinical, pathological and surgery-related parameters were compared between the three groups. Short- and long-term postoperative bladder functions were evaluated.

Results

LEPRD was attempted in 94 patients, and was successful in 65 (69.1%) patients (LEPRD group). The remaining 29 (30.9%) patients required bipolar coagulation after failure of vascular clipping (combined modality group). Routine bipolar cautery was used in the other 163 patients during the parametrial resection (bipolar group). The blood loss in the LEPRD group was significantly lower than those in the other two groups (P<0.001). The rate of successful Foley removal on postoperative day 7 was significantly higher in the LEPRD group than in the bipolar group (P=0.022). The incidence of chronic voiding dysfunction was significantly lower in the LEPRD group than in the bipolar group (P=0.019).

Conclusions

It is feasible to perform LEPRD in NPSRH for cervical cancers. This kind of limited energy surgical technique is associated with less blood loss, and leads to improved postoperative bladder function.

Impact of radical hysterectomy on the transobturator sling pathway: a retrospective three-dimensional magnetic resonance imaging study

INTRODUCTION AND HYPOTHESIS

Morphological and functional anomalies of the urethra may cause stress urinary incontinence after radical hysterectomy (RH). We introduce a novel three-dimensional (3D) magnetic resonance imaging (MRI) technique to assess the impact of RH on the transobturator sling pathway.

METHODS

3D-MRI reconstruction models were retrospectively developed for the measurement of various parameters before and after RH, including puncture angle, orientation and distance from the midurethral puncture site to the obturator membrane (DUO), in 31 patients with cervical cancer. Additionally, the correlations between DUO and body height and interspinal diameter were evaluated.

RESULTS

No significant differences were noted between the preoperative and postoperative inclination angle (-7.1 ± 33.5° vs. -0.68 ± 23.9°, ranges -62.4 to 46.8° vs. -54.1 to 42.2°, respectively) or between the preoperative and postoperative left and right mean rotation angles (left 69.0 ± 8.0° vs. 67.8 ± 9.2°; right 65.1 ± 8.38° vs. 64.3 ± 10.5°). Similarly, there were no statistically or clinically significant differences between the preoperative and postoperative DUO, although slight differences were noted between the two sides before and after RH (P = 0.018 and P = 0.023, respectively). None of the parameters differed significantly between the groups with and without postoperative urodynamic stress incontinence. Further, there was no clinically significant correlation between DUO and height or interspinal diameter.

CONCLUSIONS

The sling procedure via the transobturator approach is technically safe from a 3D anatomical standpoint. However, wide variability in the anatomical parameters must be taken into account when planning the procedure.

Self-Reported Long-Term Autonomic Function After Laparoscopic Total Mesometrial Resection for Early-Stage Cervical Cancer: A Multicentric Study

OBJECTIVES

This multicentric retrospective study investigates the early and long-term self-reported urinary, bowel, and sexual dysfunctions in early-stage cervical cancer patients who submitted to laparoscopic total mesometrial resection (L-TMMR), total laparoscopic radical hysterectomy, vaginal-assisted laparoscopic radical hysterectomy, and laparoscopic-assisted radical vaginal hysterectomy.

METHODS

Cervical cancer patients, FIGO (International Federation of Gynecology and Obstetrics) stage IA2-IB1/IIA1 who submitted to nerve-sparing radical hysterectomy were recruited. Pelvic functions were assessed within 30 days (early outcome) and 12 months after surgery (long-term outcome).

RESULTS

Two hundred thirteen subjects receiving nerve-sparing radical hysterectomy were enrolled. Laparoscopic total mesometrial resection was performed in 46 patients (21.6%), total laparoscopic radical hysterectomy in 65 patients (30.5%), vaginal-assisted laparoscopic radical hysterectomy in 54 patients (25.4%), and laparoscopic-assisted radical vaginal hysterectomy in 48 women (22.5%). Operative time was significantly lower in the L-TMMR group (240 minutes; range, 120-670 minutes; P = 0.001). The overall perioperative complication rate was 11.3%, with no statistically significant differences among the 4 groups. Stress incontinence and sensation of bladder incomplete emptying were detected, respectively, in 54 patients (25.6%) and 65 patients (30.7%) with a significantly lower prevalence among those in the L-TMMR group, which resulted, respectively, in 11.1% (P = 0.022) and 13.3% (P = 0.036). The prevalence rates of constipation, sensation of incomplete bowel emptying, and effort during evacuation were significantly higher among those in the L-TMMR group, resulting in, respectively, 37% (P = 0.001), 42.3% (P = 0.012), and 50% (P = 0.039). One hundred forty-nine patients (70%) were sexually active. Fifty-eight women (38.9%) reported low enjoyment, 83 women (55.7%) medium enjoyment, and 8 women (5.4%) reported high enjoyment, without statistically significant differences among the 4 groups.

CONCLUSIONS

Laparoscopic total mesometrial resection is associated with improved long-term urinary autonomic functions and worse gastrointestinal autonomic outcome. Further larger prospective trials are needed to evaluate both the oncological and functional outcomes in order to establish the most appropriate surgical approach for early-stage cervical cancer patients.

Magnetic Resonance Imaging as a Valuable Tool for Predicting Parametrial Invasion in Stage IB1 to IIA2 Cervical Cancer

Objectives

The aims of study were to determine the predictive value of preoperative magnetic resonance imaging (MRI) for parametrial invasion (PMI) and to develop a predictive model for PMI in patients with stage IB1 to IIA2 cervical cancer.

Methods

We retrospectively analyzed patients with stage IB1 to IIA2 cervical cancer (n = 215) who underwent radical hysterectomy between 2003 and 2014. The presence of PMI from postoperative pathological reports and its association with preoperative MRI findings were evaluated. We developed a predictive model for PMI using independent predictive factors identified by logistic regression and estimated its predictive performance.

Results

Thirty patients (14.0%) had PMI from postoperative pathological reports. Among the preoperative MRI findings, a greater tumor diameter (4.2 vs 2.0 cm;P <0.001), a larger tumor volume (92.6 vs 12.7 cm3;P< 0.001), the presence of PMI (53.3% vs 8.6%;P< 0.001), and upper vaginal involvement (73.3% vs 22.7%;P< 0.001) were significantly associated with PMI. Multivariate analysis identified tumor volume (odds ratio, 7.0; 95% confidence interval, 2.63–18.53;P< 0.001) and PMI (odds ratio, 6.1; 95% confidence interval, 2.31–15.97;P< 0.001) from preoperative MRI findings as independent predictive factors for PMI. Our predictive model demonstrates that the presence of PMI or a tumor volume of greater than 18.0 cm3has a higher sensitivity (86.7% vs 53.3%) and lower specificity (74.6% vs 91.4%) than the presence of PMI alone. Specifically, the model's negative predictive value was superior to that of PMI only (97.2% vs 92.3%). In the low-risk group, defined as preoperative MRI findings suggesting no PMI and a tumor volume of 18.0 cm3or less, the proportion of false negative cases was just 2.8%.

Conclusions

When tumor volume with findings suggesting that PMI is considered, preoperative MRI is useful in excluding PMI. A predictive model based on preoperative MRI findings seems to be valuable in identifying potential candidates for less radical surgery in stage IB1 to IIA2 cervical cancer.

Impaired contraction and decreased detrusor innervation in a female rat model of pelvic neuropraxia

INTRODUCTION AND HYPOTHESIS

Bilateral pelvic nerve injury (BPNI) is a model of post-radical hysterectomy neuropraxia, a common sequela. This study assessed the time course of changes to detrusor autonomic innervation, smooth muscle (SM) content and cholinergic-mediated contraction post-BPNI.

METHODS

Female Sprague-Dawley rats underwent BPNI or sham surgery and were evaluated 3, 7, 14, and 30 days post-BPNI (n = 8/group). Electrical field-stimulated (EFS) and carbachol-induced contractions were measured. Gene expression was assessed by qPCR for muscarinic receptor types 2 (M2) and 3 (M3), collagen type 1α1 and 3α1, and SM actin. Western blots measured M2 and M3 protein expression. Bladder sections were stained with Masson's trichrome for SM content and immunofluorescence staining for nerve terminals expressing vesicular acetylcholine transporter (VAChT), tyrosine hydroxylase (TH), and neuronal nitric oxide synthase (nNOS).

RESULTS

Bilateral pelvic nerve injury caused larger bladders with less SM content and increased collagen type 1α1 and 3α1 gene expression. At early time points, cholinergic-mediated contraction increased, whereas EFS-mediated contraction decreased and returned to baseline by 30 days. Protein and gene expression of M3 was decreased 3 and 7 days post-BPNI, whereas M2 was unchanged. TH nerve terminals surrounding the detrusor decreased in all BPNI groups, whereas VAChT and nNOS terminals decreased 14 and 30 days post-BPNI.

CONCLUSIONS

Bilateral pelvic nerve injury increased bladder size, impaired contractility, and decreased SM and autonomic innervation. Therapeutic strategies preventing nerve injury-mediated decline in neuronal input and SM content may prevent the development of a neurogenic bladder and improve quality of life after invasive pelvic surgery.

Comparative analyses of postoperative complications and prognosis of different surgical procedures in stage II endometrial carcinoma treatment

OBJECTIVE

To investigate the impact of surgical resection extent on the postoperative complications and the prognosis in patients with stage II endometrial cancer.

METHODS

A total of 54 patients were retrospectively reviewed, 35 patients underwent subradical hysterectomy and 19 patients received radical hysterectomy, both with simultaneous bilateral salpingo-oophorectomy and pelvic and paraaortic lymphadenectomy.

RESULTS

Comparing the surgical outcomes in subradical hysterectomy group vs radical hysterectomy group, there were no significant differences in operative time, estimated blood loss, and hospital stay. After surgery, 37.1% vs 36.8% patients received postoperative radiotherapy in the subradical hysterectomy group vs radical hysterectomy group, without statistically significant difference. As for postoperative complications, the early postoperative complication rate in patients who underwent subradical hysterectomy was 14.3%, significantly lower than that in patients submitted to radical hysterectomy (14.3% vs 42.1%), with P=0.043. However, there was no significant difference in late postoperative complication rate between the two surgical procedures. Regarding the clinical prognosis, patients receiving the subradical hysterectomy showed similar survival to their counterparts undergoing the radical procedures. The relapse rate was 5.71% vs 5.26%, respectively, without significant difference. There were no deaths in both surgical groups.

CONCLUSION

For stage II endometrial carcinoma, subradical hysterectomy presented with less early postoperative complications and similar survival duration and recurrence compared with radical hysterectomy and should be advocated in clinical treatment.