Nerve-Sparing Class III–IV Radical Hysterectomy: Urodynamic Study and Surgical Technique

Effects of different types of hysterectomies on postoperative urodynamics and lower urinary tract symptoms

Purpose

To evaluate the effects of different hysterectomies—simple hysterectomy (SH) and radical hysterectomy (RH) with or without radiation therapy (RT) on urodynamics and lower urinary tract symptoms (LUTS).

Materials and Methods

Among patients who underwent urodynamic study between 2009 and 2019, those with RH history due to cervical cancer and SH for uterine myoma were included. Clinical parameters were compared after adjusting clinically significant baseline variables with multivariate regression.

Results

A total of 289 patients (RH-only, n=57; RH+RT, n=72; SH, n=160) were included. Age at hysterectomy, gap between urodynamic study and hysterectomy, body mass index, hypertension and vaginal delivery history were adjusted. Stress urinary incontinence was more likely to occur in SH group (p<0.001), while urgency urinary incontinence was more prevalent in patients with history of RH (odds ratio [OR] 6.4, 95% confidence interval 2.171–18.855; p=0.001). There was no difference in OR of mixed urinary incontinence. Higher proportion of RH patients complained of recurrent urinary tract infection and voiding symptoms requiring intermittent catheterization. On urodynamic study, RH groups had lower maximal flow rate, larger post-void residual, decreased bladder sensation and impaired detrusor contractility (all p<0.001) than SH group. Adjuvant RT resulted in decreased compliance and decrease in volume of the first sense to void.

Conclusions

Predominant LUTS differed among patients after different types of hysterectomy. RH resulted in inefficient bladder emptying, leading to recurrent urinary tract infection and voiding symptoms requiring intermittent catheterization. Adjuvant RT exacerbated bladder compliance and increased bladder sensation.

Short and long-term urodynamic and quality of life assessment after nerve sparing radical hysterectomy: a prospective pilot study

OBJECTIVE

The aim of this study was to compare pre- and postoperative bladder function and quality of life (QoL) in women diagnosed with gynecologic malignancy and treated with nerve sparing radical hysterectomy (NSRH).

STUDY DESIGN

Before and after NSRH for uterine malignancy, bladder function was prospectively assessed in a small cohort of 12 women (39-72 years) suffering from uterine malignancy using urodynamic studies and a validated self-administered condition specific QoL questionnaire. Urodynamic studies were performed one day before (U0) as well as one week (U1) and 22 months (U2) after surgery. The questionnaire was applied at U0 and U2.

RESULTS

Cystometry showed detrusor contractions leading to overactive bladder incontinence in six out of nine women at short-term, which persisted in three women at long-term follow-up leading to a significant impaired QoL. Voiding function and bladder sensation remained uncompromised after surgery.

CONCLUSIONS

NSRH preserves voiding function and bladder sensation. However, short and long-term urodynamic detrusor overactivity and urge incontinence was observed in a significant number of women although symptoms improved over time. These data are important for counselling women and for the design of larger studies to assess the benefits of NSRH versus conventional radical hysterectomy (RH).

[Lower urinary tract dysfunction following nerve sparing radical hysterectomy: A systematic review]

INTRODUCTION

Radical hysterectomy represents the cornerstone in the management of localized cervical cancer. Despite its oncologic efficacy, radical hysterectomy is associated with a significant amount of complications and a negative impact on quality of life. Surgical technique seems to influence the functional outcomes.

AIM OF THE STUDY

A systematic review to provide an update on the lower urinary tract dysfunction following nerve sparing radical hysterectomy.

METHODS

An initial search was carried out to identify articles for further review, using Cochrane reviews and PubMed and Embase databases. The search terms used were: "nerve sparing" and "cervical cancer" or "radical hysterectomy". The Preferred Reporting Items for Systematic Reviews and Meta-Analyses process for reporting included and excluded studies was followed, with the recommended flowchart showing the numbers of papers identified and included or excluded at each stage.

RESULTS

Twenty-nine clinical studies were included. The absence of a standardized surgical technique for nerve sparing radical hysterectomy and the poor methodological quality of the studies assessing lower urinary tract dysfunction after such intervention limited clear conclusions. However, all studies reported lower incidence of urinary tract dysfunction, urodynamic abnormalities and clean intermittent catheterization following nerve sparing radical hysterectomy compared to conventional technique.

CONCLUSION

Nerve sparing radical hysterectomy is associated with reduced lower urinary tract dysfunction. A standardization of the surgical technique for nerve sparing radical hysterectomy, tailored to each individual is necessary to allow its wide spread diffusion.

Oncological outcomes of nerve-sparing radical hysterectomy for cervical cancer: a systematic review

BACKGROUND

This study aimed to review the oncologic outcomes of nerve-sparing radical hysterectomy (NSRH) in cervical cancer and to compare them with those of standard conventional radical hysterectomy (CRH).

METHODS

A search of the MEDLINE (Ovid), EMBASE (Ovid), and Cochrane Central Register of Controlled Trials (CENTRAL) databases for studies published to March 3, 2014 was performed using the search term "nerve sparing or radical hysterectomy and cervical cancer." The main outcome measure was the recurrence rate after NSRH. The hazard ratio for recurrence was used to compare NSRH and CRH.

RESULTS

A total of 21 studies reported data on oncologic outcomes of NSRH. The recurrence rate after NSRH was reported to be 0 to 19.6 %. Of the 21 studies, 10 comparing outcomes between NSRH and CRH were assessed for their eligibility to be included in a meta-analysis. However, the scarcity and heterogeneity of effect estimates in these comparison trials precluded performance of a meta-analysis.

CONCLUSIONS

The results showed that the evidence addressing the oncologic safety of NSRH over that of CRH in cervical cancer is neither adequate nor statistically relevant. A properly designed, prospective randomized noninferiority trial is needed to assess the oncologic outcomes of NSRH before this surgical approach is adopted as the standard of care for patients with tumors that have unfavorable prognostic features. Until then, NSRH should be considered primarily for patients with small tumors due to the very low risk of parametrial and lymph node involvement, with maximum benefit conferred to the patient from autonomic nerve preservation without any requirement for adjuvant treatment.

Lower urinary tract dysfunction in pelvic gynecologic cancer: the role of urodynamics

The exact incidence of lower urinary tract dysfunction is not known and its pathogenesis is not completely understood. Advances in urodynamic assessment and widespread availability of a standardized technique have facilitated its exploration prior to and subsequent to the surgical management of patients with gynecologic pelvic cancer. We performed a PubMed and Medline literature search using the following keywords: bladder dysfunction, urinary dysfunction, and urodynamics and all these terms in combination with radical hysterectomy in order to analyze the role of urodynamics in patients with pelvic gynecologic cancer in the preoperative as well as in the early and late postoperative settings.

Lower urinary tract dysfunction after nerve-sparing radical hysterectomy

INTRODUCTION AND HYPOTHESIS

The aim of this review is to provide a comprehensive overview of the current role of nerve-sparing radical hysterectomy (NSRH) in reducing the incidence of postoperative lower urinary tract dysfunction (LUTD) and in improving quality of life.

METHODS

A detailed online search was performed using the following keywords: nerve sparing, radical hysterectomy, cervical cancer, and all these terms in combination with urinary dysfunction or bladder dysfunction in order to analyze the effect of NSRH on urinary functional outcomes. Articles retrieved were analyzed and assigned a level of evidence (LE) according to the criteria of the Centre for Evidence-Based Medicine in Oxford, UK.

RESULTS

Our review highlights the heterogeneity of conducting and reporting studies in the literature. Autonomic pelvic nerve injuries during the procedure are thought to be the major cause of LUTD. The amount of LUTD depends upon the extent and type of nerve injury. Anatomically based surgical techniques are developed to avoid nerve injury without compromising oncological control. All studies comparing NSRH to standard RH yielded promising results with respect to postoperative LUTD. A recent meta-analysis showed similar cancer control rates between the two techniques. However, controversies remain about the ideal surgical approach for nerve sparing and there is no consensus as to the level and landmarks of dissection to preserve the maximal amount of nerves without compromising oncological outcomes.

CONCLUSIONS

Available evidence suggests that NSRH is safe and associated with lower incidence of LUTD. However, there is no standardized technique for NSRH and controversies remain about its oncological safety. Long-term oncological data from multicenter surgical trials are needed as well as a universally accepted standard to report studies on NSRH.

Bladder function after radical hysterectomy for cervical cancer

AIM

To report the effects of radical hysterectomy and nerve-sparing techniques on lower urinary tract function in women.

METHODS

A literature search was performed in Pubmed and Medline using the keywords bladder after radical hysterectomy, nerve sparing radical hysterectomy, and urinary dysfunction following radical hysterectomy. Significant results and citations were reviewed manually by the authors.

RESULTS

The sympathetic and parasympathetic systems innervating the lower urinary tract may be disrupted due to resection of uterosacral and rectovaginal ligaments, the dorsal and lateral paracervix, the caudal part of the vesico-uterine ligaments, and the vagina. This supports the neurogenic etiology of early and late bladder dysfunction after radical surgery. Bladder disorders are also related to the extent of radical surgery. The neuropathopysiology of lower urinary tract symptoms after radical hysterectomy is not fully understood. Recent data have highlighted the role of urethral sphincter pressure in the etiology of postoperative incontinence. Various surgical approaches have been developed to preserve autonomic pelvic innervation.

CONCLUSIONS

Nerve-sparing techniques appear to improve bladder function without compromising overall survival. Studies comparing the effects of nerve-sparing radical hysterectomy with standard surgery yielded encouraging results in respect of postoperative lower urinary tract function. Clinical trials with a long period of follow-up are required for better comprehension of the complex pathophysiology of bladder dysfunction after radical hysterectomy.

Individualized radical hysterectomy procedure using intraoperative electrical stimulation for patients with cervical cancer

OBJECTIVE

In this study, by monitoring the varied distributions of nerve fascicles using intraoperative electrical stimulation (IES), we sought to establish an individualized operation based on the patient's unique nerve distribution pattern, and to determine whether this technique would result in a higher preservation rate.

MATERIALS/METHODS

Radical hysterectomy was performed from 2002 to 2010. Patients in group A are the 48 cases from 2002 to 2007 in which nerve-sparing radical hysterectomy using IES as our previous report was performed. Patients in group B are the 38 cases from 2008 to 2010 in which we used our new method, which was individualized to each patient. Urodynamic study (UDS) was used to confirm nerve preservation. Nerve preservation was defined as confirming distinct detrusor contraction during urinary voiding.

RESULTS

In group B, nerve preservation rate was higher than in group A (75% vs 9 0%, P = 0.067). We classified the case-by-case nerve anatomy as whether the nerve fascicle was mainly on the medial side or on the lateral side of the deep uterine vein. The lateral type anatomy was observed unilaterally in 6 cases and bilaterally in 1 case. In summary, the lateral type anatomy was observed in 8 (29%) of 28 sides. In the cases evaluated by UDS, the positive predictive value of IES was 95% in group A and 100% in group B.

CONCLUSIONS

Our method of IES showed a high positive predictive value of nerve preservation as confirmed by UDS. By delineating the nerve tract in detail using IES, it is possible to individualize the operation based on each patient's anatomy, with an improved nerve preservation rate.