Nerve-sparing radical hysterectomy for cervical carcinoma

Vaginal drug delivery for the localised treatment of cervical cancer

Cervical cancer is usually treated by surgery, with the more advanced cancers requiring adjuvant chemotherapy or radiotherapy. The location of the cervix makes it easily accessible through the vagina for the localised delivery of chemotherapeutic drugs. Localised delivery has the advantage of direct delivery to the site of action resulting in a lower dose having to be required and a reduction in systemic side effects. This approach would be advantageous for fertility sparing surgery, whereby localised delivery could be used to reduce tumour size allowing for a much smaller tumour to be removed, reducing the risk of preterm birth. Furthermore, localised delivery could be used after surgery to reduce the risk of recurrence, which is significantly higher in fertility sparing surgery compared to standard surgery. In this paper, we discuss the number of vaginal dosage forms that have investigated for this purpose, including tablets, rings, bioadhesive and cervical caps. APIs under investigation have ranged from well-established chemotherapeutic drugs to more experimental compounds.

Laparoscopic Nerve-Sparing Radical Hysterectomy for Cervical Carcinoma: Emphasis on Nerve Content in Removed Cardinal Ligaments

Objective

To evaluate the histopathology of autonomic nerve removal within the cardinal ligaments (CLs), patients’ postoperative urinary function, and the feasibility and safety of laparoscopic nerve-sparing radical hysterectomy (LNSRH) for treatment of early-stage cervical cancer.

Methods

Perioperative and postoperative parameters were compared between patients with biopsy-proven, early-stage cervical carcinoma treated with LNSRH (n = 64) versus those treated with laparoscopic radical hysterectomy (LRH, n = 42) in a retrospective study. Nerves within CLs were identified by hematoxylin-eosin staining. Rates of the following complications were compared: bladder function, sexual dysfunction, and defecation problems.

Results

Duration of surgery, intraoperative blood loss, duration of hospitalization, and morbidity did not differ significantly between the LNSRH and LRH groups. Patients who underwent LNSRH had a significantly earlier return of bladder and bowel functions, with an average time to achieve residual urine of 50 mL or less of 10.22 days and a mean first defecation time of 3.58 days. Nerves were observed mainly in the CLs of the LRH group. Disease-free survival rate did not differ between the LNSRH (90.6%) and LRH (88.1%) groups (P = 0.643).

Conclusions

The LNSRH is a safe, feasible, and easy procedure for trained laparoscopic surgeons. Patients who underwent LNSRH had a more satisfactory quality of life than patients who underwent LRH.

Pelvic nerve injury negatively impacts female genital blood flow and induces vaginal fibrosis-implications for human nerve-sparing radical hysterectomy

OBJECTIVE

This study sought to develop a novel animal model to study the impact of nerve-sparing radical hysterectomy (NSRH) on female genital blood flow.

DESIGN

In vivo animal study.

POPULATION

Thirty Sprague-Dawley female rats.

MATERIALS AND METHODS

Female rats underwent either unilateral pelvic nerve (PN) crush (PNC; n = 9), or crush of both the PNs and all efferent nerves in the pelvic plexus ('clock-nerve crush', CNC; n = 9). Under anaesthesia, we electrically stimulated the crushed PN at 3 and 10 days after crush while monitoring blood pressure and recording clitoral and vaginal blood flows by laser Doppler. Uninjured PNs were stimulated as an internal control. Twelve additional rats were assigned either to bilateral PNC or sham surgery, and genital tissues were processed 10 days after injury for in vitro analysis.

MAIN OUTCOME MEASURES

Genital blood flow, nNOS, eNOS, collagen I-III.

RESULTS

Stimulation of the crushed PN in both groups subjected to PNC and CNC induced significantly lower peak genital blood flow at 3 and 10 days (P < 0.05) compared to stimulation of the non-crushed control PN. The immunofluorescence and Western blot analyses revealed that all injured rats exhibited more vaginal collagen III and collagen I than rats did that ad undergone sham surgeries (P < 0.05). PCN reduced nNOS expression in both clitoral and vaginal tissue.

CONCLUSIONS

Based on our study it may be hypothesised that NSRH might cause reductions of genital blood flow and vaginal fibrosis due to neurapraxia of the pelvic nerve and reductions of nNOS nerve fibres in clitoral and distal vaginal tissue.

TWEETABLE ABSTRACT

Pelvic nerve neurapraxia during nerve-sparing radical hysterectomy could lead to sexual arousal dysfunction.

Postoperative Health-Related Quality of Life of Cervical Cancer Patients - A Comparison between the Wertheim-Meigs Operation and Total Mesometrial Resection (TMMR)

Introduction: The present study compares for the first time the standard therapy for cervical cancer in FIGO-stages IB-IIB, radical hysterectomy according to the Wertheim-Meigs operation, with the newly developed, nerve-sparing surgical technique, total mesometrial resection (TMMR) with regard to postoperative, health-related quality of life. Method: In the framework of a multicentre, retrospective cohort study a total of 110 cervical cancer patients were interviewed once by means of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and the cervical cancer module (EORTC QLQ-CX24). The influence of the surgical method was investigated by analysis of covariance under control of age and the time elapsed between treatment and interview. Results: An influence of the therapeutic method was demonstrated in the EORTC scales physical function (p = 0.047), role function (p = 0.016), fatigue (p = 0.028), pain (p = 0.018), shortness of breath (p = 0.034), lack of appetite (p = 0.006) and diarrhoea (p = 0.012) in favour of the 74 women treated by TMMR. With regard to cognitive, emotional and social functioning as well as cervical cancer-specific symptoms, no significant differences between the therapy groups were found. Conclusion: The findings presented in this study suggest a superiority of TMMR in comparison to the previously employed radical hysterectomy according to Wertheim-Meigs with regard to the postoperative quality of life, especially in the fields of physical activity and fatigue. This needs to be validated in the course of prospective, multicentre studies. In addition, it must be clarified as to what extent the found effects are, in particular, due to the omission of an additional radiotherapy.

Bowel dysfunction following nerve-sparing radical hysterectomy for cervical cancer: a prospective study

OBJECTIVE

To objectively assess anorectal dysfunction following nerve-sparing radical hysterectomy in stage I-II cervical carcinoma patients.

MATERIAL AND METHODS

Between 2008 and 2012, 21 patients with primary cervical cancer stage FIGO I-II were enrolled in this prospective study. All women underwent nerve-sparing radical hysterectomy. Anorectal manometry was performed preoperatively and 6 months after surgery. A paired Student t test was used to assess the statistical difference between the manometric evaluations. A p value <0.05 was considered statistically significant.

RESULTS

Twenty-one patients were available for follow-up. Maximal and mean anal resting and squeezing pressures were unaffected by the surgical procedure, rectoanal inhibitory reflex and length of the high anal pressure zone did not change after the operation. The minimal volume to elicit rectal sensation, urge to defecate and maximal tolerable volume did not change significantly in the postoperative period, although they decreased in 2 and increased in 3 patients. In addition, rectal compliance did not change after surgery. Furthermore, no significant differences were found between patients who were or were not treated with adjuvant radiotherapy.

CONCLUSIONS

Our findings suggest that nerve-sparing radical hysterectomy for cervical cancer does not seem to be associated with long-term anorectal dysfunction. © 2014 S. Karger AG, Basel.

Acupuncture for preventing complications after radical hysterectomy: a randomized controlled clinical trial

We aimed to investigate the preventive effects of acupuncture for complications after radical hysterectomy. A single-center randomized controlled single-blinded trial was performed in a western-style hospital in China. One hundred and twenty patients after radical hysterectomy were randomly allocated to two groups and started acupuncture from sixth postoperative day for five consecutive days. Sanyinjiao (SP6), Shuidao (ST28), and Epangxian III (MS4) were selected with electrical stimulation and Zusanli (ST36) without electrical stimulation for thirty minutes in treatment group. Binao (LI14) was selected as sham acupuncture point without any stimulation in control group. The main outcome measures were bladder function and prevalence of postoperative complications. Compared with control group, treatment group reported significantly improved bladder function in terms of maximal cystometric capacity, first voiding desire, maximal flow rate, residual urine, and bladder compliance, and decreased bladder sensory loss, incontinence, and urinary retention on fifteenth and thirtieth postoperative days. Treatment group showed significant advantage in reduction of urinary tract infection on thirtieth postoperative day. But no significant difference between groups was observed for lymphocyst formation. By improving postoperative bladder function, early intervention of acupuncture may provide a valuable alternative method to prevent bladder dysfunctional disorders and urinary tract infection after radical hysterectomy.

Long-term prospective longitudinal evaluation of emotional distress and quality of life in cervical cancer patients who remained disease-free 2-years from diagnosis

Background

A long-term prospective assessment of QoL in cervical cancer patients is still lacking. Here, we provide the first 2-years prospective, longitudinal study evaluating emotional distress and QoL in early stage (ECC) and locally advanced (LACC) cervical cancer patients who remained disease-free 2-years from diagnosis.

Methods

The questionnaires: Hospital Anxiety and Depression Scale (HADS), Global Health Status items of EORTC QLQ-C30 (GHS), and EORTC QLQ-CX24 (CX24) have been administered by a dedicated team of psycho-oncologists, administered at baseline, and after 3, 6, 12 and 24 months from surgery The Generalized Linear Model for repeated measure was used to analyze modifications of QoL measures over time.

Results

In both groups, an early reduction of the percentage of patients with anxiety levels ≥11 was observed at the 3-month evaluation (ECC: 25.7% at baseline Vs 14.7% after 3 months, p value=0.001; LACC: 22.2% at baseline Vs 15.4% after 3 months, p value=0.001). Despite this favorable trend, after 2 years from diagnosis, 11.9% of ECC and 15.6% of LACC patients still showed an anxiety score ≥11. No significant changes over time were observed in term of Depression levels. Focusing on QoL issues, mean GHS and Sexual Activity scores showed an improvement over time in both groups compared to baseline (GHS: 5.7% difference for ECC, p value=0.001, and 11.0% in LACC, p value=0.001; SXA: 13.9% difference for ECC, p value=0.001; and 6.1% in LACC, p value=0.008). On the other hand, Body Image mean scores were significantly impaired by chemoradiation administration in LACC patients, without long-term recovery (7.5% difference, p value=0.001). Finally, in both groups, lymphedema (LY) and menopausal symptoms (MS) showed an early worsening which persisted 2-year after surgery (LY: 19.5% difference for ECC, p value=0.014, and 27.3% in LACC, p value=0.001; MS: 14.4% difference for ECC, p value=0.004, and 16.0% in LACC, p value=0.002).

Conclusions

Despite a significant improvement over time, elevated anxiety levels are still detectable at 24 months after surgery in approximately 10% of cervical cancer patients. Much more attention should be focused on surgical/medical approaches able to minimize the negative impact of lymphedema and menopausal symptoms on QoL.

Perioperative betamethasone treatment reduces signs of bladder dysfunction in a rat model for neurapraxia in female urogenital surgery

BACKGROUND

Information on autonomic neurapraxia in female urogenital surgery is scarce, and a model to study it is not available.

OBJECTIVE

To develop a model to study the impact of autonomic neurapraxia on bladder function in female rats, as well as to assess the effects of corticosteroid therapy on the recovery of bladder function in this model.

DESIGN, SETTING, AND PARTICIPANTS

Female Sprague-Dawley rats were subjected to bilateral pelvic nerve crush (PNC) and perioperatively treated with betamethasone or vehicle. Bladder function and morphology of bladder tissue were evaluated and compared with sham-operated rats.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Western blot, immunohistochemistry, organ bath experiments, and cystometry.

RESULTS AND LIMITATIONS

Sham-operated rats exhibited regular micturitions without nonvoiding contractions (NVCs). Crush of all nerve branches of the pelvic plexus or PNC resulted in overflow incontinence and/or NVCs. Betamethasone treatment improved recovery of regular micturitions (87.5% compared with 27% for vehicle; p<0.05), reduced lowest bladder pressure (8 ± 2 cm H(2)O compared with 21 ± 5 cm H(2)O for vehicle; p<0.05), and reduced the amplitude of NVCs but had no effect on NVC frequency in PNC rats. Compared with vehicle, betamethasone-treated PNC rats had less CD68 (a macrophage marker) in the pelvic plexus and bladder tissue. Isolated bladder from betamethasone-treated PNC rats exhibited better nerve-induced contractions, contained more cholinergic and sensory nerves, and expressed lower amounts of collagen III than bladder tissue from vehicle-treated rats.

CONCLUSIONS

PNC causes autonomic neurapraxia and functional and morphologic changes of isolated bladder tissue that can be recorded as bladder dysfunction during awake cystometry in female rats. Perioperative systemic betamethasone treatment reduced macrophage contents of the pelvic plexus and bladder, partially counteracted changes in the bladder tissue, and had protective effects on micturition function.

Quality of life and emotional distress in early stage and locally advanced cervical cancer patients: a prospective, longitudinal study

OBJECTIVES

This prospective, longitudinal study investigates QoL issues and emotional distress in early stage cervical cancer (ECC) patients undergoing radical surgery (RS) and in locally advanced cervical cancer (LACC) patients triaged to chemoradiation (CT/RT) followed by RS.

METHODS

The Global Health Status scale of EORTC QLQ-C30 (GHS), the EORTC QLQ-CX24 (CX24) and the Hospital Anxiety and Depression Scale (HADS) questionnaire were administered at baseline, and after 3, 6, and 12 months from surgery. For LACC patients QoL assessment was also performed after CT/RT. Statistical analysis was performed by the ANOVA for repeated measures and the Between Subject test.

RESULTS

In ECC and LACC patients, the GHS scores improved over time (5.5% difference in mean scores compared to baseline in ECC, and 7.0% difference in mean score compared to baseline in LACC patients). An early worsening of lymphedema scores was documented in ECC cases (14.6% difference in mean values compared to baseline, p value=0.001), and in LACC patients (difference up to 28.3% of mean values, value=0.0001). Menopausal symptoms persistently worsened over time reaching >15% difference of mean values compared to baseline in both groups. Sexual activity scores markedly improved both in ECC and LACC patients (difference of mean score values compared to baseline was 16.5% in ECC, and 6.7% in LACC patients). Both ECC and LACC patients experienced an improvement of anxiety scores.

CONCLUSIONS

Lymphedema and menopausal symptoms were the most disabling treatment-related sequelae; the amount of QoL issues and their multifaceted aspects require the cooperation of multidisciplinary teams.

A comparison of the feasibility and safety of nerve-sparing radical hysterectomy with the conventional radical hysterectomy

BACKGROUND

Radical hysterectomy has been the treatment of choice for early-stage cervical cancer. Since its introduction in oncology, modifications to the original technique were made to enhance feasibility, improve cure rate, and decrease postoperative complications. Among these are the identification and preservation of pelvic autonomic nerves, known as the nerve-sparing radical hysterectomy (RH). This retrospective study was conducted to compare the nerve-sparing with the conventional RH in terms of feasibility and safety, including bladder dysfunction and perioperative and postoperative complications and morbidities.

METHODS

Patients with biopsy-proven early-stage cervical carcinoma, cervical carcinoma with central tumor recurrence or persistence after primary radiotherapy, and endometrial carcinoma with cervical involvement treated with RH with or without nerve-sparing technique were included. The perioperative and postoperative complications and bladder function of these patients were analyzed.

RESULTS

Ninety-seven patients with early-stage cervical cancer and 24 patients with clinical stage II endometrial cancer underwent RH with or without nerve-sparing technique in a nonrandomized fashion. There was no statistically significant difference between the 2 procedures in terms of duration of surgery, intraoperative blood loss, duration of hospitalization, and morbidity. Patients who underwent the nerve-sparing approach had a statistically significant earlier return of bladder function, with a mean of 9.4 days for the cervical cancer cases (vs 21 days in the non-nerve-sparing group) and a mean of 8.5 days for the endometrial cancer cases (vs 22.6 days in the non-nerve-sparing group).

CONCLUSIONS

The technique of sparing the pelvic autonomic nerves during RH for early-stage cervical cancer and clinical stage II endometrial cancer is comparable to the conventional method in terms of perioperative complications and morbidity, but is more favorable in terms of return of bladder function.

The measurement of vesical detrusor electromyographic activity during nerve-sparing radical hysterectomy

OBJECTIVE

To evaluate the feasibility for confirming the preservation of the parasymphathetic nerve pathway innervating the bladder during nerve-sparing radical hysterectomy (RH).

METHODS

A total of 20 patients underwent nerve-sparing RH. Intraoperative electrical stimulation (IES) were performed on the root of pelvic splanchnic nerve (PSN) trunk while recording the electromyographic (EMG) activity of the vesical detrusor. The average duration achieving residual urine ≤50 mL and urodynamic study (UDS) was observed.

RESULTS

Evoked potentials were recorded when stimulating, in 18 patients who were referred IES-positive. Its duration was 9.89 days. The UDS results indicated that all voided normally. The remaining 2 IES-negative cases with no evoked potentials had longer duration and the micturitions were performed using abdominal pressure.

CONCLUSION

During nerve-sparing RH, IES based on the measurement of EMG activity is a useful tool for confirmation of the preservation of parasymphathetic nerve pathway innervating the bladder and prediction of the postoperative bladder function.

Reconstitution of experimental neurogenic bladder dysfunction using skeletal muscle-derived multipotent stem cells

BACKGROUND.: Postoperative neurogenic bladder dysfunction is a major complication of radical hysterectomy for cervical cancer and is mainly caused by unavoidable damage to the bladder branch of the pelvic plexus (BBPP) associated with colateral blood vessels. Thus, we attempted to reconstitute disrupted BBPP and blood vessels using skeletal muscle-derived multipotent stem cells that show synchronized reconstitution capacity of vascular, muscular, and peripheral nervous systems. METHODS.: Under pentobarbital anesthesia, intravesical pressure by electrical stimulation of BBPP was measured as bladder function. The distal portion of BBPP with blood vessels was then cut unilaterally (experimental neurogenic bladder model). Measurements were performed before, immediately after, and at 4 weeks after transplantation as functional recovery. Stem cells were obtained from the right soleus and gastrocnemius muscles after enzymatic digestion and cell sorting as CD34/45 (Sk-34) and CD34/45 (Sk-DN). Suspended cells were autografted around the damaged region, whereas medium alone and CD45 cells were transplanted as control groups. To determine the morphological contribution of the transplanted cells, stem cells obtained from green fluorescent protein transgenic mouse muscles were transplanted into a nude rat model and were examined by immunohistochemistry and immunoelectron microscopy. RESULTS.: At 4 weeks after surgery, the transplantation group showed significantly higher functional recovery ( approximately 80%) than the two controls ( approximately 28% and 24%). The transplanted cells showed an incorporation into the damaged peripheral nerves and blood vessels after differentiation into Schwann cells, perineurial cells, vascular smooth muscle cells, pericytes, and fibroblasts around the bladder. CONCLUSION.: Transplantation of multipotent Sk-34 and Sk-DN cells is potentially useful for the reconstitution of damaged BBPP.

Radical hysterectomy during the transition period from traditional to nerve-sparing technique

OBJECTIVE

The aim of the study was to compare peri- and postoperative data from patients operated on using the new nerve-sparing technique of radical hysterectomy with data gathered from those who underwent traditional radical hysterectomy.

MATERIALS AND METHODS

A total of 20 patients with cervical cancer were included in the study. The study was carried out at a time when the authors had started to perform the nerve-sparing technique by using the descriptions from the literature. During the study period 10 patients underwent the nerve-sparing procedure while the other 10 patients underwent traditional radical hysterectomy. The two groups of patients were comparable in terms of mean age, body mass index, FIGO stage, and histological type; additionally, the follow-up period was similar for both groups.

RESULTS

On the one hand, the mean total operative time (197.5+/-51.4 vs. 155.5+/-39.6 min) and the mean time for the hysterectomy itself (154.5+/-35.4 vs. 123.0+/-29.8 min) were significantly longer in the group operated on with nerve-sparing technique (p=0.05). Postoperatively, on the other hand, a post-void residual urine volume of less than 50 ml was noted to occur significantly faster in the patients who had undergone the nerve-sparing technique (3.5+/-1.4 vs. 9.1+/-4.2 days, p=0.00078).

CONCLUSIONS

Although during the introductory period nerve-sparing technique brings about an improvement in voiding function, it prolongs the total operative time in comparison to traditional radical hysterectomy.