Nerve-sparing versus non-nerve-sparing radical hysterectomy: surgical and long-term oncological outcomes

Postsurgical urodynamic study of total laparoscopic nerve-sparing radical hysterectomy for uterine cervical cancer

AIM

To evaluate the impact on urodynamic results between the laparoscopic nerve-sparing radical hysterectomy (LRH) following a step-by-step procedure and abdominal nerve-sparing radical hysterectomy (ARH) for patients with uterine cervical cancer.

METHODS

This retrospective study enrolled 76 patients with cervical cancer: 35 in the LRH group and 41 in the ARH group. We analyzed their postoperative bladder function in a urodynamics study and examined the volume of resected pelvic nerves contained in parametrial sections using S-100 antibody staining.

RESULTS

Estimated blood loss and hospital stay after operation for the LRH group were significantly better than those in the ARH group (p < 0.0001). As well, the number of harvested lymph nodes was significantly higher in the LRH group (p = 0.044). There was no difference in perioperative complications between the two groups in this study. The 5-year disease-free survival rates and overall survival rates were 91.2% and 94.0% in the LRH group and 87.8% and 95.1% in the ARH group, both respectively. Although the median residual urine volume were no statistical differences between the LRH group and the ARH group, the recovery of postoperative bladder function (uroflowmetry) in the LRH group rapidly reached presurgery levels at 1 month, and the LRH group had a smaller number of s-100 antibody stained nerves contained the parametrial sections.

CONCLUSION

We demonstrated that LRH following a step-by-step procedure could achieve a higher level of prevention of damage to the bladder branch of the pelvic splanchnic nerve plexus and thus restore bladder function more rapidly.

How to dissect the pelvic nerves: from microanatomy to surgical rules. An evidence-based clinical review

Background: Advanced gynaecological procedures often include extensive pelvic dissections, with the nervous structures involved in the disease. Nerve-sparing and preservation is a key factor in reducing postoperative morbidity. Objectives: The goal of this review is to describe in detail the structure of the pelvic nerves and to gather information from other surgical specialties to give recommendations for safe nerve dissection applied in different gynaecological subspecialties. Materials and methods: An extensive literature review was carried out in PubMed and Google Scholar. The search included articles concerning peripheral nerve anatomy, mechanisms of injury and different dissection techniques, with the most exhaustive being analysed for the review. Articles from different fields of medicine like orthopaedics, plastic surgery, maxillofacial surgery dealing with peripheral nerve injuries and repair have been reviewed. Results: The following review demonstrates the in-depth anatomy and mechanism of injury of the peripheral nerves, describes the different techniques for neurolysis and proposes some directions for safe nerve dissection. Conclusion: When performing complex gynaecological surgeries, the surgeon should avoid unnecessary nerve handling, apply nerve-sparing techniques whenever possible and use the new devices to preserve the nervous structures. Advanced gynaecological surgeries should be performed in specialised centres by expert surgeons with comprehensive knowledge in neuropelveology. What is new? To our knowledge, this is the first article focused on peripheral nerves that collects data from such a wide range of specialties in order to propose the most comprehensive recommendations that could be applied in pelvic surgery.

Comparison of safety and efficacy between laparoscopic myomectomy and traditional laparotomy for patients with uterine fibroids and their effect on pregnancy rate after surgery

The aim of this retrospective study was to compare the safety and efficacy between laparoscopic myomectomy and traditional laparotomy for patients with uterine fibroids and determine their effect on the pregnancy rate after surgery. In total, 86 cases with uterine fibroids were selected among patients who were admitted in the Zhangqiu District Maternal and Child Health Care Hospital during the period of April, 2016 to April, 2017. Patients who underwent laparoscopic myomectomy were enrolled in group A (n=42), and those who underwent traditional laparotomy were placed in group B (n=44). The general linear data and the operative indicators were compared. The VAS scores, serum IFN-γ, IL-6, VEGF levels and clinical efficacy of the two groups were also compared one week after surgery. Postoperative pregnancy rates and complications in both groups were also compared. No significant differences were observed in general data between the two groups (P>0.05). The intra-operative blood loss in the group A was lower than that in group B (P<0.05), the average time of operation, hospital stays (days), and anal exhaust time in group A were shorter than those in group B (P<0.05). The pain degrees at 3, 6 and 18 h after surgery for patients in the group A were significantly lower than those of the group B (P<0.05). There was no significant difference IL-6 and VEGF levels in the serum between groups A and B before and after surgery (P>0.05); however, the level of IFN-γ expression, one week after surgery, in group B was significantly higher than that in group A (P<0.05). The pregnancy rate in the experimental group was higher than that in the control group (P<0.05), and the incidence rate of complications in group A was significantly lower than that in group B (P<0.05). Results presented in the present study suggested that compared to traditional laparotomy, laparoscopic myomectomy is a more advantageous method in terms of safety, efficacy and pregnancy rate after surgery.

Nerve-Sparing Modified Radical Hysterectomy for Severe Endometriosis and Complex Pelvic Pathology

Background Laparoscopic nerve-sparing modified radical hysterectomy with or without robotic assistance is known for its benefits as a definitive treatment for severe endometriosis. Undiagnosed endometriosis is common in patients with symptomatic fibroids or chronic pelvic pain. There are minimal studies that outline the safety and feasibility of nerve-sparing modified radical hysterectomy for other complex pelvic pathology in addition to endometriosis. Objectives The aim of this study is to evaluate the incidence of hospital readmission, intraoperative and postoperative complications, and long-term pain relief after laparoscopic nerve-sparing modified radical hysterectomy for severe endometriosis and complex benign pelvic pathology. Study design We performed a retrospective observational study of patients who underwent laparoscopic nerve-sparing modified radical hysterectomy with and without robotic-assistance with a high-volume minimally invasive endoscopic surgeon between November 2017 and December 2019. Results A total of 112 patients met the inclusion criteria. There were no cases of vaginal cuff dehiscence, venous thromboembolism, genitourinary system injury, gastrointestinal tract injury, vessel injury, nerve injury, sepsis, or death. Three patients required postoperative hospital admission for the management of umbilical cellulitis, acute blood loss anemia, and possible Addison's crisis. Other postoperative complications included allergic reaction to adhesives (1.8%) and urinary retention (0.9%). All patients reported significant pain relief at the time of their postoperative visits. Three patients reported return of pain symptoms within the first seven months after surgery, with one requiring an additional surgery for persistent pain. Conclusions Laparoscopic nerve-sparing modified radical hysterectomy with or without robotic assistance is a safe and feasible alternative that provides long-term symptom relief in patients undergoing hysterectomy for a variety of indications.