Effect of laparoscopic nerve-sparing radical hysterectomy on bladder function, intestinal function recovery and quality of sexual life in patients with cervical carcinoma

Urological Complications in Radical Surgery for Cervical Cancer: A Comparative Meta-Analysis before and after LACC Trial

BACKGROUND

After the LACC trial publication in 2018, the minimally invasive approach (MIS) has severely decreased in favor of open surgery: MIS radical hysterectomy was associated with worse oncological outcomes than open surgery, but urological complications were never extensively explored in pre- versus post-LACC eras, even if they had a great impact on post-operative QoL. The purpose of this meta-analysis is to compare functional and organic urological complication rates before and after LACC trial.

METHODS

An independent search of the literature was conducted 4 years before and after the LACC trial and 50 studies were included.

RESULTS

The overall rate of urologic complications was higher in pre-LACC studies while no differences were found for organic urological complications. Conversely, the overall risk of dysfunctional urological complications showed a higher rate in the pre-LACC era. This is probably related to a sudden shift to open surgery, with potential lower thermal damage to the urinary tract autonomic nervous fibers.

CONCLUSIONS

This meta-analysis showed that the incidence of urological complications in radical cervical cancer surgery was higher before the LACC trial, potentially due to the shift to open surgery. Nevertheless, further studies are needed to shed light on the connection between minimally invasive surgery and urological damage.

Liposomes loaded with dual clinical photosensitizers for enhanced photodynamic therapy of cervical cancer

Photodynamic therapy (PDT) has become a potential anti-cancer strategy owing to its negligible invasiveness, low toxicity, and high selectivity. The photosensitizer (PS) plays an indispensable role in PDT. Herein, a novel type of PS (Ce6-MB@Lips) which can be excited by a near-infrared (NIR) laser was designed and synthesized. Methylene blue (MB) and Chlorin e6 (Ce6), two organic dyes approved by the Food and Drug Administration (FDA), were used to prepare Ce6-MB@Lips by thin-film dispersion method, which improve the water solubility of Ce6 and reduce the cytotoxicity of MB. The Ce6-MB@Lips were shown to have a spherical nanostructure with an average particle size of 160.3 nm and excellent water solubility. Then the optical properties of Ce6-MB@Lips were further studied. Ce6-MB@Lips showed absorption peaks at 413 nm/670 nm and fluorescence peak at 697 nm. Compared with Ce6@Lips and MB@Lips, Ce6-MB@Lips showed better stability, stronger fluorescence intensity, and higher singlet oxygen (1O2) generation ability. Cell experimental analysis exhibited that the stable Ce6-MB@Lips showed low cytotoxicity, high phototoxicity and high reactive oxygen species (ROS) production capacity. After effective cell internalization, the prepared Ce6-MB@Lips showed excellent ability to promote tumor cell apoptosis in vitro. The Ce6-MB@Lips could be a promising candidate for PDT of cervical cancer.

Sexuality and quality of life after nerve-sparing radical hysterectomy for cervical cancer: A prospective study

OBJECTIVE

Nerve-sparing radical hysterectomy (NSRH) decreases the negative postoperative consequences of radical surgery for cervical cancer, such as bladder evacuation disorders, colorectal motility disorders, and sexual dysfunction. The aim of this study was to prospectively assess the sexuality and quality of life in a group of women who underwent NSRH with lymphadenectomy for cervical cancer.

MATERIALS AND METHODS

A total of 65 patients with early-stage cervical cancer underwent NSRH between 2014 and 2016. Patient examinations and questionnaire surveys (Female Sexual Function Index questionnaire and European Organization for Research and Treatment of Cancer questionnaires QLQ-C30 and QLQ-CX24) were conducted, before and one year after the surgery.

RESULTS

After the exclusion of 19 sexually inactive women and 10 women who received adjuvant anticancer treatment, 36 sexually active patients treated solely with nerve-sparing surgery were eligible for evaluation. The mean age was 47 years. The average preoperative vaginal length was 9.4 cm, whereas the postoperative length was shortened to 7.1 cm. This study showed no negative impact of NSRH on sexual desire, arousal, satisfaction, orgasm, pain, sexual activity, sexual enjoyment, and sexual worry. The worsening of sexual functioning was recorded during the one-year follow-up. The QLQ-C30 questionnaire confirmed postoperative improvement in global health status and role, emotional, and social functioning.

CONCLUSION

Our study showed using standardized questionnaires that NSRH has no negative impact on sexual desire, arousal, satisfaction, orgasm, pain, sexual activity, frequency of sexual intercourse, sexual enjoyment, and sexual worry, while only the worsening of sexual functioning was recorded. Moreover, NSRH did not cause postoperative deterioration in the quality of life parameters.

Objective and subjective assessment of bladder function after robot-assisted laparoscopic radical hysterectomy for early stage cervical cancer

STUDY OBJECTIVE

To examine whether objective bladder function following robot-assisted radical hysterectomy (RRH) for early-stage cervical cancer is correlated with subjective patient-reported outcomes as well as quality of life during the first year after RRH.

DESIGN

Prospective observational study SETTING: Karolinska University Hospital, Sweden PATIENTS: Women with early stage cervical cancer (FIGO stage IA2-IB1) between July 2017 and May 2019 were assessed for eligibility.

INTERVENTIONS

Robotic radical hysterectomy (RRH) MEASUREMENTS AND MAIN RESULTS: Subjective bladder function was evaluated with the Female Lower Urinary Tract Symptoms and Urinary Incontinence Quality of Life modules of the International Consultation on Incontinence Questionnaire. Objective urinary function was characterized with urodynamic tests and the nerves ablated at RRH were quantified by using immunohistochemical staining of biopsies from the resected paracervix, vesico-uterine and sacro-uterine ligaments. Twenty-seven women were included for analysis at baseline, two weeks, three months and 12 months after surgery. RRH caused hypotonia of the urinary bladder (p<.05). Patient reported outcomes of voiding and filling dysfunction were most significant 2 weeks after surgery (p<.05) but for most of the women bladder function recovered within 3 months. No correlations were found with either subjective nor objective urinary function and the number of ablated nerves.

CONCLUSION

For the majority of women, objective and subjective urinary bladder dysfunction recovered within 3 months after RRH. The absence of correlation between functional outcomes and ablated autonomous nerves suggest that other underlying causes play a significant role. Early detection of bladder overextension after RRH is paramount and the role of postoperative bladder catherization needs further investigation.

The Diagnosis of Perineural Invasion: A Crucial Factor in Novel Algorithm of Coexistence of Conventional and Nerve-Sparing Radical Hysterectomy

Nerve-sparing radical hysterectomy (NSRH) was introduced to mitigate adverse effects associated with conventional radical hysterectomy (CRH) in cervical cancer. However, the introduction of NSRH was compromised by possible existence of perineural invasion (PNI). Additionally, the coexistence of NSRH and CRH is currently the fact. The aim of the study was to review the literature and attempt to construct a novel and preliminary PNI diagnostic algorithm that would establish the coexistence of NSRH and CRH in one system of early-stage cervical cancer (ESCC) surgical treatment. This algorithm takes into account the PNI risk factors and current and future diagnostic methods such as imaging and biopsy.

Postoperative interventions for preventing bladder dysfunction after radical hysterectomy in women with early-stage cervical cancer

BACKGROUND

Bladder dysfunction is a common complication following radical hysterectomy, caused by the damage to pelvic autonomic nerves that innervate the muscles of the bladder, urethral sphincter, and pelvic floor fasciae. Bladder dysfunction increases the rates of urinary tract infection, hospital visits or admission, and patient dissatisfaction. In addition, bladder dysfunction can also negatively impact patient quality of life (QoL). Several postoperative interventions have been proposed to prevent bladder dysfunction following radical hysterectomy. To our knowledge, there has been no systematic review evaluating the effectiveness and safety of these interventions for preventing bladder dysfunction following radical hysterectomy in women with cervical cancer.

OBJECTIVES

To evaluate the effectiveness and safety of postoperative interventions for preventing bladder dysfunction following radical hysterectomy in women with early-stage cervical cancer (stage IA2 to IIA2).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 4) in the Cochrane Library, MEDLINE via Ovid (1946 to April week 2, 2020), and Embase via Ovid (1980 to 2020, week 16). We also checked registers of clinical trials, grey literature, conference reports, and citation lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating the effectiveness and safety of any type of postoperative interventions for preventing bladder dysfunction following a radical hysterectomy in women with stage IA2 to IIA2 cervical cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected potentially relevant RCTs, extracted data, assessed risk of bias, compared results, and made judgments on the quality and certainty of the evidence. We resolved any disagreements through discussion or consultation with a third review author. Outcomes of interest consisted of spontaneous voiding recovery one week after the operation, quality of life (QoL), adverse events, post-void residual urine volume one month after the operation, urinary tract infection over the one month following the operation, and subjective urinary symptoms.

MAIN RESULTS

We identified 1464 records as a result of the search (excluding duplicates). Of the 20 records that potentially met the review criteria, we included five reports of four studies. Most of the studies had unclear risks of selection and reporting biases. Of the four studies, one compared bethanechol versus placebo and three studies compared suprapubic catheterisation with intermittent self-catheterisation. We identified two ongoing studies. Bethanechol versus placebo The study reported no information on the rate of spontaneous voiding recovery at one week following the operation, QoL, adverse events, urinary tract infection in the first month after surgery, and subjective urinary symptoms for this comparison. The volume of post-void residual urine, assessed at one month after surgery, among women receiving bethanechol was lower than those in the placebo group (mean difference (MD) -37.4 mL, 95% confidence interval (CI) -60.35 to -14.45; one study, 39 participants; very-low certainty evidence). Suprapubic catheterisation versus intermittent self-catheterisation The studies reported no information on the rate of spontaneous voiding recovery at one week and post-void residual urine volume at one month following the operation for this comparison. There was no difference in risks of acute complication (risk ratio (RR) 0.77, 95% CI 0.24 to 2.49; one study, 71 participants; very low certainty evidence) and urinary tract infections during the first month after surgery (RR 0.77, 95% CI 0.53 to 1.13; two studies, 95 participants; very- low certainty evidence) between participants who underwent suprapubic catheterisation and those who underwent intermittent self-catheterisation. Available data were insufficient to calculate the relative measures of the effect of interventions on QoL and subjective urinary symptoms.

AUTHORS' CONCLUSIONS

None of the included studies reported rate of spontaneous voiding recovery one week after surgery, time to a post-void residual volume of urine of 50 mL or less, or post-void residual urine volume at 6 and 12 months after surgery, all of which are important outcomes for assessing postoperative bladder dysfunction. Limited evidence suggested that bethanechol may minimise the risk of bladder dysfunction after radical hysterectomy by lowering post-void residual urine volume. The certainty of this evidence, however, was very low. The effectiveness of different types of postoperative urinary catheterisation (suprapubic and intermittent self-catheterisation) remain unproven.

Urodynamic assessment of bladder storage function after radical hysterectomy for cervical cancer

BACKGROUND

After radical hysterectomy for cervical cancer, the most common complication is lower urinary tract symptoms. Post-operatively, bladder capacity can alter bladder function for a prolonged period. This study aimed to identify factors affecting bladder storage function.

METHODS

A multicenter, retrospective cohort study was conducted. Information of patients with stages IA2 to IIB cervical cancer with urodynamic study results were retrospectively collected from nine hospitals between June 2013 and June 2018 according to the inclusion criteria. Demographic, surgical, and oncological data were collected. The univariate and multivariate logistic regression was used to identify clinical factors associated with bladder storage function.

RESULTS

Two hundred and three patients with cervical cancer had urodynamic testing post-operatively. Ninety-five (46.8%) patients were diagnosed with stress urinary incontinence (SUI). The incidence of low bladder compliance (LBC) was 23.2%. Twenty-seven (13.3%) patients showed detrusor overactivity (DO). Fifty-seven patients (28.1%) presented with a decreased maximum cystometric capacity (DMCC). The probability of composite bladder storage dysfunction was 68.0%. Multivariate analysis confirmed that laparoscopy represents a protective factor for SUI with an odds ratio of 0.498 (P = 0.034). Patients who underwent a nerve-sparing procedure were less odds to experience SUI (P = 0.014). A significant positive correlation between LBC and DO was observed (P < 0.001). A greater length of the resected vagina and chemoradiotherapy were common risk factors for LBC and DO, while radiotherapy exerted a stronger effect than chemotherapy. Additionally, patients who received chemoradiotherapy frequently developed a DMCC. The follow-up time was not correlated with bladder storage function.

CONCLUSION

A nerve-sparing procedure without longer resected vagina is recommended for protecting the bladder storage function.

Early removal of indwelling urinary catheter after radical surgery for early-stage cervical cancer-A cohort study

OBJECTIVE

To evaluate the difference between early and delayed removal of indwelling urinary catheter after radical hysterectomy (RH) or radical trachelectomy (RT).

METHODS

An ambispective study was conducted in early-stage cervical cancer patients who underwent RH or RT. Delayed indwelling urinary catheter removal occurred on a postoperative day (POD) 7 in the retrospective group (January 2012-November 2013), and early removal occurred on POD 1 in the prospective group (May 2014-June 2017). The postvoid residual (PVR) test was performed after indwelling catheter removal in both groups.

RESULTS

Our sample included 47 patients in the delayed group and 48 in the early one. There was no difference in age, body mass index, tumor size, histology, stage, surgical approach, and intraoperative and postoperative complications. Indwelling urinary catheter reinsertion was needed in 16 (34%) patients in the delayed group and 12 (25%) in the early group (P = .37), with no statistical difference between the median PVR volumes -82.5 and 45 mL (P = .06), respectively. Seven (14.9%) patients in the delayed group presented with 30-day urinary tract infection vs two (4.2%) in the early group (P = .09).

CONCLUSIONS

Early indwelling urinary catheter removal, in regard to the rate of catheter reinsertion and PVR volume, does not differ from delayed removal.

Body Image, Sexuality, and Sexual Functioning in Women With Gynecologic Cancer: An Integrative Review of the Literature and Implications for Research

BACKGROUND

Cervical and uterine cancers are common in women. Diagnosis and treatment of these cancers can lead to significant issues with body image, sexuality, and sexual functioning. A comprehensive review can improve understanding of these 3 concepts, in turn enhancing identification and management.

OBJECTIVES

To (1) present the qualitative, descriptive, and correlational research literature surrounding body image, sexuality, and sexual functioning in women with uterine and cervical cancer; (2) identify gaps in the literature; and (3) explore the implications of the findings for future research.

METHODS

A comprehensive search of the literature was undertaken by searching PubMed, CINAHL, and PsycINFO using predetermined subject headings, keywords, and exploded topics. After a comprehensive evaluation using specific criteria, 121 articles were reviewed.

RESULTS

Qualitative studies provided information about women's issues with body image, sexuality, and sexual functioning, whereas quantitative studies focused primarily on sexual functioning. The literature lacks correlational studies examining body image and sexuality. Significant issues regarding communication and quality of life were noted, and few studies were based on clear conceptual models.

CONCLUSION

The state of the science gleaned from this review reveals that while much is known about sexual functioning, little is known about body image and sexuality.

IMPLICATIONS FOR PRACTICE

Further work is warranted to develop conceptual models and research on body image, sexuality, and sexual functioning as a foundation for interventions to improve quality of life.

Surgical, Urinary, and Survival Outcomes of Nerve-sparing Versus Traditional Radical Hysterectomy: A Retrospective Cohort Study in China

Supplemental Digital Content is available in the text.

The purpose of this retrospective study was to compare the surgical, urinary, and survival outcomes between nerve-sparing radical hysterectomy (NSRH) and traditional radical hysterectomy (TRH) for stage IB cervical cancer, in which all the primary procedures were performed by a single physician.

Efficacy of nerve‑sparing radical hysterectomy vs. conventional radical hysterectomy in early‑stage cervical cancer: A systematic review and meta‑analysis

The aim of the present study was to compare the oncological outcome of nerve-sparing radical hysterectomy (NSRH) and conventional radical hysterectomy (CRH) for early-stage cervical cancer using a meta-analysis. A systematic review and meta-analysis was conducted, including 4 randomized controlled trials (RCT), 8 case-control and 11 comparative cohort studies comparing the morbidity, pelvic dysfunctions and oncological outcome between the two surgical methods. A total of 23 studies were included in this meta-analysis. The studies reported data of patients affected by cervical cancer; were written in English; included ≥20 patients; and reported data of patients with a comparison of clinical outcomes between NSRH and CRH. Data were extracted and risk of bias was assessed by four independent reviewers. A total of 1,796 patients were included: 884 patients (49.2%) undergoing NSRH and 912 (50.8%) undergoing CRH. The meta-analyses were conducted using Review Manager version 5.3 software, which is designed for conducting Cochrane reviews. As regards perioperative parameters, NSRH was found to be associated with a lower intraoperative blood loss and a shorter length of hospital stay in comparison with CRH. Patients undergoing NSRH experienced lower incidence of urinary, colorectal and sexual dysfunction compared with patients undergoing CRH. However, the resected parametrial width was favorable in patients with CRH, suggesting that NSRH was inferior to CRH in terms of radicality. The 5-year disease-free and overall survival rates were similar between the two groups. In this systematic review and meta-analysis, the collected data to date demonstrated that the nerve-sparing approach guarantees minimized surgical-related pelvic dysfunction, with similar oncological outcomes as CRH. However, further RCTs should be conducted to confirm the superiority and safety of NSRH.

Nerve-sparing radical hysterectomy compared to standard radical hysterectomy for women with early stage cervical cancer (stage Ia2 to IIa)

BACKGROUND

Radical hysterectomy is one of the standard treatments for stage Ia2 to IIa cervical cancer. Bladder dysfunction caused by disruption of the pelvic autonomic nerves is a common complication following standard radical hysterectomy and can affect quality of life significantly. Nerve-sparing radical hysterectomy is a modified radical hysterectomy, developed to permit resection of oncologically relevant tissues surrounding the cervical lesion, while preserving the pelvic autonomic nerves.

OBJECTIVES

To evaluate the benefits and harms of nerve-sparing radical hysterectomy in women with stage Ia2 to IIa cervical cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE via Ovid (1946 to May week 2, 2018), and Embase via Ovid (1980 to 2018, week 21). We also checked registers of clinical trials, grey literature, reports of conferences, citation lists of included studies, and key textbooks for potentially relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating the efficacy and safety of nerve-sparing radical hysterectomy compared to standard radical hysterectomy for women with early stage cervical cancer (stage Ia2 to IIa).

DATA COLLECTION AND ANALYSIS

We applied standard Cochrane methodology for data collection and analysis. Two review authors independently selected potentially relevant RCTs, extracted data, evaluated risk of bias of the included studies, compared results and resolved disagreements by discussion or consultation with a third review author, and assessed the certainty of evidence.

MAIN RESULTS

We identified 1332 records as a result of the search (excluding duplicates). Of the 26 studies that potentially met the review criteria, we included four studies involving 205 women; most of the trials had unclear risks of bias. We identified one ongoing trial.The analysis of overall survival was not feasible, as there were no deaths reported among women allocated to standard radical hysterectomy. However, there were two deaths in among women allocated to the nerve-sparing technique. None of the included studies reported rates of intermittent self-catheterisation over one month following surgery. We could not analyse the relative effect of the two surgical techniques on quality of life due to inconsistent data reported. Nerve-sparing radical hysterectomy reduced postoperative bladder dysfunctions in terms of a shorter time to postvoid residual volume of urine ≤ 50 mL (mean difference (MD) -13.21 days; 95% confidence interval (CI) -24.02 to -2.41; 111 women; 2 studies; low-certainty evidence) and lower volume of postvoid residual urine measured one month following operation (MD -9.59 days; 95% CI -16.28 to -2.90; 58 women; 2 study; low-certainty evidence). There were no clear differences in terms of perioperative complications (RR 0.55; 95% CI 0.24 to 1.26; 180 women; 3 studies; low-certainty evidence) and disease-free survival (HR 0.63; 95% CI 0.00 to 106.95; 86 women; one study; very low-certainty evidence) between the comparison groups.

AUTHORS' CONCLUSIONS

Nerve-sparing radical hysterectomy may lessen the risk of postoperative bladder dysfunction compared to the standard technique, but the certainty of this evidence is low. The very low-certainty evidence for disease-free survival and lack of information for overall survival indicate that the oncological safety of nerve-sparing radical hysterectomy for women with early stage cervical cancer remains unclear. Further large, high-quality RCTs are required to determine, if clinically meaningful differences of survival exist between these two surgical treatments.

Class I hysterectomy in stage Ia2-Ib1 cervical cancer

Introduction

During the last 3 decades, the standard treatment for stage Ia2-Ib1 cervical cancer has been Piver-Rutledge class II or III radical hysterectomy. However, this surgery is associated with a high rate of urologic morbidity.

Aim

To determine the efficacy of class I radical hysterectomy compared with class III radical hysterectomy in terms of morbidity, overall survival, and patterns of relapse in patients with Ia2-Ib1 cervical cancer undergoing primary surgery.

Material and methods

A total of 101 patients with stage Ia2-Ib1 cervical cancer < 2 cm were randomized to class I and class III hysterectomy groups. Clinical, pathologic, and follow-up data were prospectively collected. Univariate analysis was carried out. Of the total patients, 45 were randomized to class I surgery and 56 to class III surgery. No significant differences were observed in terms of pathologic findings or adjuvant treatment (p > 0.05). The morbidity rates were higher after class III surgery.

Results

The difference in recurrence rate between the class I and class III groups was not statistically significant (p > 0.05). The 5-year overall survival rate was 93% and 91%, respectively (p > 0.05). There were no significant differences in terms of recurrence rate or overall survival among patients with stage Ia2-Ib1 cervical cancer < 2 cm who underwent class I or radical (class III) hysterectomy. Morbidity was proportional to the extent of radicality.

Conclusions

These data confirm the need for reducing surgical radicality in the treatment of patients with early cervical cancer, by tailoring the extent of resection according to the extent of disease.

Laparoscopic Nerve-Sparing Radical Hysterectomy vs Laparoscopic Radical Hysterectomy in Cervical Cancer: A Systematic Review and Meta-Analysis of Clinical Efficacy and Bladder Dysfunction

It is widely accepted that nerve-sparing radical hysterectomy is associated with less postoperative morbidity compared with radical hysterectomy, whereas clinical safety is similar in the 2 procedures. However, there is insufficient evidence to compare these procedures performed via a laparoscopic approach. We performed a systematic review and meta-analysis of studies to compare the clinical efficacy and the rate of bladder dysfunction, including urodynamic assessment, in laparoscopic nerve-sparing radical hysterectomy (LNSRH) and laparoscopic radical hysterectomy (LRH). Thirty articles including a total of 2743 participants were analyzed. Operating times were shorter (MD, 29.88 minutes; 95% confidence interval [CI], 11.92-47.83 minutes) and hospital stays were longer (MD, -1.56 days; 95% CI, -2.27 to -0.84 days) in the LRH group compared with the LNSRH group. In addition, blood loss and the number of resected lymph nodes were not significantly different between the 2 groups. However, resected parametrium length (MD, -0.02 cm; 95% CI, -0.05 to -0.00 cm) and vaginal cuff width (MD, -0.06 cm; 95% CI, -0.09 to -0.04) were smaller in the LNSRH group. Furthermore, LNSRH tended to result in more satisfactory micturition (odds ratio, 2.90; 95% CI, 2.01-4.19), shorter catheterization time (MD, -7.20 days; 95% CI, -8.10 to -6.29 days), and shorter recovery to normal postvoid residual urine time (MD, -7.71 days; 95% CI, -8.92 to -6.50 days). Other bladder dysfunction symptoms, including urinary retention, nocturia, dysuria, urinary incontinence, and frequency/urgency were more frequent in the LRH group. Furthermore, LNSRH achieved better results in urodynamic assessments (all p < .05). In conclusion, LNSRH was associated with lower rates of impaired bladder function and a shorter extent of resection compared with LRH. Clinical applications involving LNSRH should be explored with caution.

Nerve-Sparing Approach Improves Outcomes of Patients Undergoing Minimally Invasive Radical Hysterectomy: A Systematic Review and Meta-Analysis

Few studies have investigated the efficacy and safety of the nerve-sparing approach via minimally invasive surgery for the treatment of cervical cancer. We aimed to review the current evidence comparing nerve-sparing minimally invasive radical hysterectomy (NS-MRH) with conventional minimally invasive radical hysterectomy (MRH). This systematic review was registered in the International Prospective Register of Systematic Reviews (CRD#57655). Overall, 675 patients were included: 350 (51.9%) and 325 (48.1%) patients undergoing MRH and NS-MRH, respectively. MRH was associated with a shorter operative time in comparison with NS-MRH (mean difference = 32.57 minutes; 95% CI, 22.87-42.48). The estimated blood loss (mean difference = 97.14 mL, 20.01-214.29) and transfusion rate (odds ratio [OR] = 0.67; 95% confidence interval [CI], 0.15-3.01) did not differ statistically between the 2 groups. The risk of developing intraoperative (OR = 0.43; 95% CI, 0.08-2.23) and severe postoperative (OR = 0.63; 95% CI, 0.17-2.39) complications was similar between NS-MRH and MRH. Patients undergoing NS-MRH experienced lower voiding (OR = 0.39; 95% CI, 0.19-0.81) dysfunction rates than patients undergoing MRH. Moreover, a trend toward lower sexual (OR = 0.25; 95% CI, 0.06-1.07) and rectal (OR = 0.12; 95% CI, 0.01-1.02) issues was observed for patients having NS-MRH compared with patients undergoing MRH. Survival outcomes are not influenced by the type of surgical approach (recurrence [OR = 1.27; 95% CI, 0.49-3.28] and death [OR = 1.01; 95% CI, 0.36-2.83]) rates. The pooled data suggested that NS-MRH is equivalent to MRH for the treatment of cervical cancer and may be superior in reducing pelvic floor dysfunction rates. However, because of the low level of evidence of the included studies, further randomized trials are warranted.

The Effect of Targeted Therapy for Genitourinary Malignancies on Sexual Function and Fertility

PURPOSE OF REVIEW

Targeted therapy for genitourinary cancer is being used at an increasing rate. These medications show great survival benefit but are relatively lacking in long-term adverse effect data. With increasing survivability, measures to improve quality of life must be considered for GU cancer and a large proponent of this is sexual function.

RECENT FINDINGS

mTOR inhibitors have shown an effect on testosterone levels and may have a link to abnormal semen parameters. Tyrosine kinase inhibitors (TKIs) have shown no adverse sexual outcomes in the literature. There are laboratory links to tyrosine kinases having a beneficial effect on erectile and sexual function. Possible sexual side effects must be discussed with patients receiving a diagnosis of cancer. Further research is required to determine the exact mechanisms and outcomes of sexual function with new and emerging targeted therapy.

Current concepts and practical techniques of nerve-sparing laparoscopic radical hysterectomy

Laparoscopic radical hysterectomy has been widely performed for patients with early-stage cervical cancer. The operative techniques for nerve-sparing to avoid bladder dysfunction have been established during the past three decades in abdominal radical hysterectomy, but how these techniques can be applied to laparoscopic surgery has not been fully discussed. Prolonged operation time or decreased radicality due to less accessibility via a limited number of trocars may be a disadvantage of the laparoscopic approach, but the magnified visual field in laparoscopy may enable fine manipulation, especially for preserving autonomic nerve tracts. The present review article introduces the practical techniques for sparing bladder branches of pelvic nerves in laparoscopic radical hysterectomy based on understanding of the pelvic anatomy, clearly focusing on the differences from the techniques in abdominal hysterectomy.

Nerve-sparing radical hysterectomy versus conventional radical hysterectomy in early-stage cervical cancer. A systematic review and meta-analysis of survival and quality of life

BACKGROUND AND AIMS

Survival after radical hysterectomy (RH) for early-stage cervical cancer is good. Hence quality of life (QOL) after treatment is an important issue. Nerve-sparing radical hysterectomy (NSRH) improves QOL by selectively sparing innervation of bladder, bowel and vagina, reducing therapy-induced morbidity. However, the oncological outcome and the functional outcome after NSRH are subjects of debate. We aim to present the best possible evidence available regarding both QOL and survival after NSRH in early-stage cervical cancer.

METHODS

Systematic review and meta-analysis on studies comparing NSRH and RH.

RESULTS

Forty-one studies were included, and 27 were used for the meta-analysis. There was no difference in 2-, 3- and 5-year overall survival: the risk ratios (RRs) were respectively 1.02 (95% CI 0.99-1.05, n=879), 1.01 (95% CI 0.95-1.08, n=1324) and 1.03 (95% CI 0.99-1.08, n=638). No difference was found in 2-, 3- and 5-year disease-free survival: RR 1.01 (95% CI 0.95-1.05, n=1175), 0.99 (95% CI 0.94-1.03, n=1130) and 1.00 (95% CI 0.95-1.06, n=933) respectively. Post-operative time to micturition was significantly shorter in the NSRH group: standardized mean difference (SMD) -0.84 (CI 95% -1.07 to -0.60).

CONCLUSIONS

NSRH can be considered safe and effective for early-stage cervical cancer since short- and long-term survival do not differ from those of conventional RH, while bladder function after NSRH is significantly less impaired.

Efficacy and oncologic safety of nerve-sparing radical hysterectomy for cervical cancer: a randomized controlled trial

OBJECTIVE

A prospective, randomized controlled trial was conducted to evaluate the efficacy of nerve-sparing radical hysterectomy (NSRH) in preserving bladder function and its oncologic safety in the treatment of cervical cancer.

METHODS

From March 2003 to November 2005, 92 patients with cervical cancer stage IA2 to IIA were randomly assigned for surgical treatment with conventional radical hysterectomy (CRH) or NSRH, and 86 patients finally included in the analysis. Adequacy of nerve sparing, radicality, bladder function, and oncologic safety were assessed by quantifying the nerve fibers in the paracervix, measuring the extent of paracervix and harvested lymph nodes (LNs), urodynamic study (UDS) with International Prostate Symptom Score (IPSS), and 10-year disease-free survival (DFS), respectively.

RESULTS

There were no differences in clinicopathologic characteristics between two groups. The median number of nerve fiber was 12 (range, 6 to 21) and 30 (range, 17 to 45) in the NSRH and CRH, respectively (p<0.001). The extent of resected paracervix and number of LNs were not different between the two groups. Volume of residual urine and bladder compliance were significantly deteriorated at 12 months after CRH. On the contrary, all parameters of UDS were recovered no later than 3 months after NSRH. Evaluation of the IPSS showed that the frequency of long-term urinary symptom was higher in CRH than in the NSRH group. The median duration before the postvoid residual urine volume became less than 50 mL was 11 days (range, 7 to 26 days) in NSRH group and was 18 days (range, 10 to 85 days) in CRH group (p<0.001). No significant difference was observed in the 10-year DFS between two groups.

CONCLUSION

NSRH appears to be effective in preserving bladder function without sacrificing oncologic safety.

Cavitron Ultrasonic Surgical Aspirator in Laparoscopic Nerve-Sparing Radical Hysterectomy: A Pilot Study

Objective

Pelvic autonomic nerve preservation during radical hysterectomy for cervical cancer has become a priority in recent years. This pilot study was undertaken to evaluate laparoscopic nerve-sparing radical hysterectomy (L-NSRH) using the Cavitron Ultrasonic Surgical Aspirator (CUSA) in women with cervical cancer.

Methods

Patients with stage IB1 or IIA1 cervical cancer underwent L-NSRH with pelvic lymphadenectomy. The patients were randomly assigned to receive L-NSRH using a CUSA (CUSA group; n = 24) or using other techniques (non-CUSA group; n = 21). Recovery of bladder function (indwelling catheter time and time to spontaneous voiding) blood loss, duration of hospital stay, lymph node harvesting, and postoperative complications were compared between the 2 groups. Patients were followed for up to 3 years to determine the maintenance of effect.

Results

All patients underwent L-NSRH successfully. Intraoperative blood loss was significantly less in the CUSA than in the non-CUSA group (P = 0.005). Length of hospital stay (P = 0.006) and indwelling catheter time (P = 0.008) were both significantly reduced in the CUSA group compared with that in the non-CUSA group. The spontaneous voiding rate 10 days postoperatively was 95.8% with CUSA and 85.7% with non-CUSA techniques. Two patients developed postoperative complications in the CUSA group as did 3 patients in the non-CUSA group. These were cases of lymphocyst formation or urinary tract infection.

Conclusions

Laparoscopic nerve-sparing radical hysterectomy using CUSA was safe and feasible in patients with cervical cancer. Our results provide initial evidence that L-NSRH using CUSA preserves pelvic autonomic nerve function.

[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.