The neuroanatomical basis for denervation of the urinary bladder following major pelvic surgery

Sexuality of Women after Gynecological Surgeries

(1) Background: Disorders of sexual life negatively impact self-esteem and social relationships. This problem affects patients after gynecological surgery. Providing access to specialist sexologist care constitutes an important aspect of support for this patient group. (2) Objective: The aim of the study was to assess the sexual life of women depending on the time since surgery, extent of gynecological surgery and postoperative chemotherapy and/or radiotherapy. (3) Methods: The study included 136 patients from gynecological outpatient clinics in Szczecin, Poland. The women answered questions from a special three-part questionnaire. Participation was anonymous and voluntary. The data obtained in the survey were subject to statistical analysis. (4) Results: Among patients with a sparing of the cervix, most have never or almost never experienced discomfort or pain during intercourse, and believe that the quality of their sex life has not deteriorated after surgery. It was found that cervical removal, despite the existence of other conditions, increases the chance of pain during sexual activity 11 times. We found that the removal of adnexa did not increase the risk of changing sexual activity. In patients who had not undergone postoperative chemo- and/or radiotherapy, sexual activity did not change after surgery, and they never or almost never experienced discomfort or pain during intercourse. On the other hand, it was shown, despite the smaller study group, that patients treated with postoperative chemo- and/or radiotherapy did not initiate sexual intercourse. (5) Conclusion: The more extended the gynecological surgery of the uterus, the greater the limitation of sexual life.

Patient-reported lower urinary tract symptoms after hysterectomy or hysteroscopy: a study from the Swedish Quality Register for Gynecological Surgery

Introduction and hypothesis

Hysterectomy is sometimes considered the cause of lower urinary tract symptoms (LUTS). We hypothesized that hysterectomy for abnormal uterine bleeding and/or symptoms of fibroids is more likely to cause LUTS than a hysteroscopic procedure for the same indications.

Methods

Two groups of women were compared: one group comprised 3,618 women who had had a hysterectomy due to abnormal uterine bleeding or symptoms of fibroids and the other group comprised 238 women who had had hysteroscopic treatment for the same indications. The main outcome measures were occurrence of LUTS before and 1 year after the surgical intervention. The frequencies of LUTS before and after surgery were compared between the groups. Binary logistic regression was used to model the odds of having postoperative urinary leakage and urgency while controlling for uterine size, surgical procedure and preoperative LUTS.

Results

There were no statistically significant differences between women after hysterectomy and after hysteroscopy in the frequencies of LUTS before or after surgery, when uterine size was comparable. However, there was a difference in the rates of de novo urinary incontinence between women with hysterectomy and women with hysteroscopy (7.6%, 95% CI 6.3–9.0, and 3.2%, 95% CI 1.6–6.5, respectively). Of the women with a large uterus, 58.6% (95% CI 51.5–65.5) reported relief of urinary incontinence and 85.5% (95% CI 82.3–88.4) reported relief of urinary urgency postoperatively.

Conclusions

Our results suggest that it is important to individualize preoperative information in women prior to hysterectomy since the outcome concerning LUTS depends on preoperative symptoms and uterine size.

Is the Uterus a Sexual Organ? Sexual Function Following Hysterectomy

INTRODUCTION

Hysterectomy has been a mainstay of gynecologic therapy for 100 years. It can be postulated that hysterectomy could affect female sexual function due to psychological factors, and also due to disruption of the local nerve and blood supply and the intimate anatomical relationships of the pelvic organs.

AIM

To evaluate the effects of hysterectomy performed for benign conditions on female sexual function.

METHODS

Peer-reviewed publications were identified through a PubMed search using the search terms "hysterectomy," "benign," "sexual function," "dyspareunia," "orgasm," "libido," and "dysfunction." The search was completed through to February 2015 and was limited to articles published in English.

MAIN OUTCOME MEASURE

The main outcome measure was sexual function after hysterectomy for benign conditions. As hysterectomy is performed via various routes, abdominal (open and laparoscopic) and vaginal, sexual function in each group was evaluated.

RESULTS

Studies were of varying methodology. Majority of women demonstrated either unchanged or improved sexual function after hysterectomy performed by any route in the short term. A significant minority of women reported sexual dysfunction following hysterectomy. Deterioration in sexual function was found on long-term follow-up, which is probably an effect of aging and bilateral salpingo-oophorectomy. There were no proven benefits supracervical compared with total hysterectomy either in the short term (up to 2 years postsurgery) or long term (up to 15 years after hysterectomy).

CONCLUSIONS

Women can be positively reassured that hysterectomy does not negatively affect sexuality. Health professions should be aware that a minority of women may develop adverse effects after the operation. Preoperative education about the potential negative sexual outcomes after surgery may enhance satisfaction with hysterectomy, independent of whether negative sexual outcomes are experienced. Thakar R. Is the uterus a sexual organ? Sexual function following hysterectomy.

Mesorectal excision: Surgical anatomy of the rectum, mesorectum, and pelvic fascia and nerves and clinical relevance

Biologic behavior and management of rectal cancer differ significantly from that of colon cancer. The surgical treatment is challenging since the rectum has dual arterial blood supply and venous drainage, extensive lymphatic drainage and is located in a bony pelvic in close proximity to urogenital and neurovascular structures that are invested with intricate fascial covering. The rectum is encased by fatty lymphovascular tissue (mesorectum) that is surrounded by perirectal fascia that act as barrier to the spread of the cancer and constitute the surgical circumferential margin. Locoregional recurrence after rectal cancer surgery is influenced by tumor-related factors and adequacy of the resection. Local recurrence is associated with incomplete excision of circumferential margin, violation of perirectal fascia, transmesorectal dissection, presence of isolated deposits in the mesorectum and tumor in regional lymph nodes and incomplete lymph node clearance. Hence to eradicate the primary rectal tumor and control regional disease, the rectum, first area of lymph node drainage and surrounding tissue must be completely excised while maintaining an intact fascial envelope around the rectum and preserving surrounding structures. This is achieved with extrafascial dissection and removal of the entire mesorectum including the portion distal to the tumor (total mesorectal excision) within its enveloping fascia as an intact unit. Total mesorectal excision is the standard of care surgical treatment of mid and low rectal cancer and can be performed in conjunction with low anterior resection, abdominoperineal resection, extralevator abdominoperineal resection, and extraregional dissection. To accomplish such a resection, thorough knowledge of the surgical anatomy of the rectum and pelvic structures and fascial planes is paramount.

The effect of total hysterectomy on sexual function and depression

BACKGROUND & OBJECTIVES

To investigate whether the operations of Type 1 hysterectomy and bilateral salpingo-oophorectomy performed for benign reasons have any effect on sexual life and levels of depression.

METHOD

This is a multi-center, comparative, prospective study. Healthy, sexual active patients aged between 40 and 60 were included into the study. Data was collected with the technique of face-to-face meeting held three months before and after the operation by using the demographic data form developed by the researchers i.e. the Female Sexual Function Index (FSFI) and the Beck Depression Scale (BDS).

RESULTS

In the post-operative third month, there was an improvement in dysuria in terms of symptomatology (34% and 17%, P<0.001), while in FSFI (41.47±25.46 to 34.20±26.67, P<0.001) and BDS (12.87±11.19 to 14.27±10.95, P=0.015) there was a deterioration. For FSFI, 50-60 age range, extended family structure; and for BDS, educational status, not working and extended family structure were statistically important confounding factors for increased risk in the post-operative period.

CONCLUSION

While hysterectomy and bilateral salpingo-oophorectomy performed for benign reasons brought about short-term improvement in urinary problems after the operation for sexually active and healthy women, they resulted in sexual dysfunction and increase in depression. The age, educational status, working condition and family structure is also important.

Should we screen for and treat lower urinary tract dysfunction after major pelvic surgery? ICI-RS 2011

AIMS

Given the relative frequency of lower urinary tract dysfunction (LUTD) after major pelvic surgery, the main question for this debate is: "Should we [actively] screen for LUTD after major pelvic surgery," with the intention to treat and improve patient care.

METHODS

The discussants selected relevant papers from a limited review of the literature [PubMed/Medline database (January 1966 to May 2011)] and prepared the YES versus NO presentations.

RESULTS

The evidence was presented for the following major pelvic procedures: colorectal surgery, hysterectomy, and surgery for other benign gynecologic conditions, radical prostatectomy, brachytherapy, and primary cryotherapy for prostate cancer. Based on the presentations, the audience voted in favor of screening for LUTD after major pelvic surgery.

CONCLUSIONS

Irreversible treatment should be delayed in case of LUTD after major pelvic surgery. In fact, most symptoms spontaneously subside within 6 months after the surgery. Once the period of 6-12 months of conservative management has been completed and if LUTD persists, a new urodynamic screening should be followed by appropriate treatment.

Predicting the development of stress urinary incontinence 3 years after hysterectomy

Introduction and hypothesis

We aimed to develop a prediction rule to predict the individual risk to develop stress urinary incontinence (SUI) after hysterectomy.

Methods

Prospective observational study with 3-year follow-up among women who underwent abdominal or vaginal hysterectomy for benign conditions, excluding vaginal prolapse, and who did not report SUI before surgery (n = 183). The presence of SUI was assessed using a validated questionnaire.

Results

Significant prognostic factors for de novo SUI were BMI (OR 1.1 per kg/m², 95% CI 1.0–1.2), younger age at time of hysterectomy (OR 0.9 per year, 95% CI 0.8–1.0) and vaginal hysterectomy (OR 2.3, 95% CI 1.0–5.2). Using these variables, we developed the following rule to predict the risk of developing SUI: 32 + BMI − age + (7.5 × route of surgery).

Conclusions

We defined a prediction rule that can be used to counsel patients about their individual risk on developing SUI following hysterectomy.

Hysterectomy and risk of stress-urinary-incontinence surgery: nationwide cohort study

BACKGROUND

Hysterectomy for benign indications has been associated with an increased risk for lower-urinary-tract sequela, but results have been inconclusive. We aimed to establish the risk for stress-urinary-incontinence surgery after hysterectomy for benign indications.

METHODS

We did a nationwide, population-based, cohort study from 1973 to 2003 in Sweden. We identified our population from the Swedish Inpatient Registry. We selected 165 260 women who had undergone hysterectomy (exposed cohort) and a control group of 479 506 individuals who had not had this procedure (unexposed cohort), matched by year of birth and county of residence. In both cohorts, occurrence of stress-urinary-incontinence surgery was established from the Swedish Inpatient Registry. Hazard ratios with 95% CIs were calculated by Cox's proportional-hazards regression.

FINDINGS

During the 30-year observational period, the rate of stress-urinary-incontinence surgery per 100,000 person-years was 179 (95% CI 173-186) in the exposed cohort versus 76 (73-79) in the unexposed cohort. Correspondingly, individuals in the exposed cohort were at increased risk for stress-urinary-incontinence surgery compared with those in the unexposed cohort (hazard ratio 2.4; 95% CI 2.3-2.5), irrespective of surgical technique. Risk for stress-urinary-incontinence surgery varied slightly with time of follow-up: the highest overall risk was recorded within 5 years of surgery (2.7; 2.5-2.9) and the lowest risk was seen after an observation period of 10 years or more (2.1, 1.9-2.2).

INTERPRETATION

Hysterectomy for benign indications, irrespective of surgical technique, increases the risk for subsequent stress-urinary-incontinence surgery. Women should be counselled on associated risks related to hysterectomy, and other treatment options should be considered before surgery.

Effects of hysterectomy on bowel function: a three-year, prospective cohort study

PURPOSE

This study was a prospective evaluation of the long-term effects of hysterectomy on bowel function using self-reported outcome measures on symptoms of constipation, rectal emptying difficulties, and anal incontinence.

METHODS

In this prospective cohort study, 120 consecutive patients undergoing hysterectomy for benign conditions answered a questionnaire on bowel habits and anorectal symptoms preoperatively. Forty-four patients underwent vaginal and 76 abdominal hysterectomy. Follow-up was performed one and three years postoperatively. Data were analyzed by using multivariate regression and nonparametric statistics.

RESULTS

The bowel and anorectal survey was answered by 115 of 120 patients (96 percent) after one year and 107 of 120 patients (89 percent) after three years. Abdominal hysterectomy was associated with increased anal incontinence symptoms at one-year (P < 0.01) and three-year follow-up (P < 0.01). Vaginal hysterectomy was not associated with increased anal incontinence symptoms at one year follow-up, although there was a significant increase in incontinence symptoms at the three-year follow-up (P < 0.05). Risk factor analysis indicated that a reported history of obstetric sphincter injury was correlated to an increased risk of developing posthysterectomy anal incontinence (odds ratio, 2.07; 95 percent confidence interval, 1.05-2.87; P < 0.05). There was no significant rise in constipation symptoms or rectal emptying difficulties in either cohort through the follow-up.

CONCLUSIONS

Neither abdominal nor vaginal hysterectomy was associated with constipation, aggravation of constipation, or rectal emptying difficulties three years after surgery. Abdominal and vaginal hysterectomy was, however, associated with an increased risk of mild anal incontinence symptoms, and patients with a reported history of obstetric sphincter injury were at particular risk for posthysterectomy fecal incontinence.

Lymphedema and bladder-emptying difficulties after radical hysterectomy for early cervical cancer and among population controls

The aim of the study was to acquire knowledge that can be used to refine radical hysterectomy to improve quality-of-life outcome. Data were collected in 1996-1997 by means of an anonymous postal questionnaire in a follow-up study of two cohorts (patients and population controls). We attempted to enroll all 332 patients with stage IB-IIA cervical cancer registered in 1991-1992 at the seven departments of gynecological oncology in Sweden and 489 population controls. Ninety three (37%) of the 256 women with a history of cervical cancer who answered the questionnaire (77%) were treated with surgery alone. Three-hundred fifty population controls answered the questionnaire (72%). Women treated with radical hysterectomy, as compared with controls, had an 8-fold increase in symptoms indicating lymphedema (25% reported distress due to lymphedema), a nearly 9-fold increase in difficult emptying of the bladder, and a 22-fold increase in the need to strain to initiate bladder evacuation. Ninety percent of the patients were not willing to trade off survival for freedom from symptoms. Avoiding to induce long-term lymphedema or bladder-emptying difficulties would probably improve quality of life after radical hysterectomy (to cure cervical cancer). Few women want to compromise survival to avoid long-term symptoms.

Pelvis architecture and urinary incontinence in women

OBJECTIVES

To examine anatomic features in the pelvic bones and muscles in women with urinary incontinence (UI).

MATERIAL AND METHODS

Between October 2005 and January 2006, 212 consecutive women underwent pelvic computerized tomography in our center. Preceding the examination, all women completed a clinical and demographic questionnaire including detailed questions about UI. Several anatomic parameters using multiplanar reformation and three-dimensional techniques (volume rendering) were examined. We specifically evaluated different bony parameters, pelvic floor muscle angles, densities, and cross-sectional areas. Ninety-three women (46.5%) had UI; the remaining women served as the control group. A logistic regression model was used to evaluate risk factors for UI.

RESULTS

The mean age was 55.5 yr (range: 19-90). Women who suffered from UI were older (60.97 vs. 50.77 yr, p<0.0001), had higher body mass index (27.65 vs. 25.49, p<0.01), had more previous hysterectomies (21.5% vs. 6.5%, p<0.005), underwent more pelvic irradiation (9.7% vs. 1.8%, p<0.05), and had more diabetes mellitus (31.2% vs. 13.1%, p<0.005). Patient's age and previous hysterectomy were found to be the major clinical risk factors for UI (OR: 1.029, p=0.002; OR: 2.94, p=0.024, respectively). Logistic regression analysis on all clinical and morphologic variables yielded the following risk factors: pelvic-inlet diameter (OR: 1.216, p<0.0001), pelvic-inlet anterior-posterior diameter (OR: 1.109, p=0.003), pelvic-outlet diameter (OR: 1.077, p=0.011) and transverse perineal muscle cross-section diameter (OR: 0.773, p<0.0001).

CONCLUSIONS

Pelvic inlet and outlet dimensions are major risk factors for developing UI in women. These findings may lead to a better comprehension of the pathophysiology of UI in women.

Urinary incontinence after hysterectomy—three-year observational study

OBJECTIVES

To perform a prospective evaluation of the long-term effects of hysterectomy on symptoms of urinary incontinence.

METHODS

A prospective observational cohort study was performed. Preoperatively, 120 consecutive patients undergoing hysterectomy for benign conditions answered a questionnaire on symptoms associated with urge and stress urinary incontinence. Of the 120 patients, 44 underwent vaginal and 76 abdominal hysterectomy. Follow-up questionnaires were administered at 1 and 3 years postoperatively.

RESULTS

Postoperatively, the questionnaire was answered by 115 (96%) of 120 patients after 1 year and by 107 (89%) after 3 years of follow-up. At surgery, the mean patient age was 49.5 years (range 32 to 78). In the abdominal hysterectomy cohort, a tendency was found for decreased episodes of urinary incontinence, although the difference was not significant. No significant changes were noted in micturition frequency. In the vaginal hysterectomy cohort, no significant changes were detectable in the symptoms associated with urge or stress incontinence, and no significant changes were noted in micturition frequency. For the entire hysterectomy group, a significant decrease occurred in stress urinary incontinence symptoms (P = 0.03). Subgroup analysis did not identify any particular risk factors for the development of urinary incontinence after hysterectomy.

CONCLUSIONS

In contrast to the results of several studies, the results of our 3-year prospective study showed that total hysterectomy, independent of route, was not associated with an increase in urge or stress urinary incontinence symptoms.

Female sexual dysfunction following vaginal surgery: a review

PURPOSE

Depending on age it has been estimated that up to 40% of women have complaints of sexual problems, including decreased libido, vaginal dryness, pain with intercourse, decreased genital sensation and difficulty or inability to achieve orgasm. In this review we address the etiologies and incidence, evaluation and treatment of female sexual dysfunction following vaginal surgery for indications such as stress urinary incontinence and pelvic organ prolapse; anterior/posterior colporrhaphy, perineoplasty and vaginal vault prolapse.

MATERIALS AND METHODS

Literature on the mechanisms by which vaginal surgery affects female sexual function are discussed along with related pathophysiology to potential causes. The anatomy, neurovascular supply of the clitoris and introitus, and intrapelvic nerve supply are discussed as related to vaginal surgery. Techniques to avoid neurovascular damage during pelvic floor surgery were corroborated by supporting literature. Literature regarding female sexual dysfunction following other procedures, such as vaginal hysterectomy, Martius flap interposition, and vesicovaginal and rectovaginal fistula repair were also discussed.

RESULTS

Current literature does not support an association between vaginal length following vaginal surgery and sexual function. The proportion of women who are sexually active does not appear to be affected by vaginal surgery. Sling surgery for urinary incontinence does not appear to adversely affect overall sexual function, although individual parameters of sexual function scores may vary, eg a significant percent of women report pain during intercourse. Some patients experience improved overall sexual function due to complete relief from coital incontinence

CONCLUSIONS

Symptomatic vaginal narrowing is rare even in women undergoing simultaneous posterior repair. Overall sexual satisfaction appears to be independent of therapy for urinary incontinence or prolapse. Data indicate that defect specific posterior colporrhaphy with the avoidance of levator ani plication may improve sexual function. The possible etiological factors for sexual dysfunction following vaginal surgery deserve further investigations.

Female sexual dysfunction following vaginal surgery: myth or reality?

This article reviews the mechanisms by which vaginal surgery affects female sexual function and related pathophysiology to potential causes. The anatomy, neurovascular supply of the clitoris and introitus, and intrapelvic nerve supply are discussed as they apply to vaginal surgery. Methods to avoid neurovascular damage during pelvic floor surgery have been corroborated by supporting literature. The incidence of female sexual dysfunction after various transvaginal procedures for indications such as stress urinary incontinence and pelvic organ prolapse, anterior/posterior colporrhaphy, perineoplasty, and vaginal vault prolapse has been discussed. Current literature regarding female sexual dysfunction following other procedures such as vaginal hysterectomy, Martius flap interposition, and vesicovaginal and rectovaginal fistula repair also are reviewed.

The long-term voiding function and sexual function after pelvic nerve-sparing radical surgery for rectal cancer

BACKGROUND

The aim of the present study is to symptomatically analyze the extent to which pelvic nerve-sparing radical surgery for rectal cancer impacts on long-term voiding and male sexual function.

METHODS

A self-administered questionnaire was mailed to 68 patients who underwent pelvic nerve-sparing radical surgery for invasive rectal cancer with 52 responses (28 men and 24 women; 27 complete and 25 incomplete preservation; response rate 76.5%). Each patient was asked to record if there had been any changes in lower urinary tract symptoms after surgery. Sexual function was also investigated in men.

RESULTS

Of the 52 patients, 48 (92%) maintained voluntary voiding without catheterization in the long term. Clean intermittent self-catheterization was performed in only four patients with incomplete preservation because of persistent voiding dysfunction. Subjectively, approximately 60% of the patients remained unchanged in lower urinary tract symptoms after surgery. The satisfaction rate regarding the current voiding status was significantly higher in women than in men (83% versus 61%, P = 0.0294), but was not significantly different between those with complete (76%) and incomplete preservation (64%). Despite the acceptable urinary status, 88% of men had some deterioration in the erectile function, regardless of the types of surgical procedures. Overall, 64% of men were unsatisfied with the current sexual function.

CONCLUSIONS

Pelvic nerve-sparing radical surgery for rectal cancer preserved the long-term voiding function in the majority of patients. In completely preserved patients and in women, symptomatic outcomes were more satisfactory. Postoperative erectile dysfunction was found to be a serious problem, even in complete nerve-sparing procedure.

[Effect of classic abdominal and vaginal hysterectomy on lower urinary tract function]

Organi male karlice (mokracna besika sa pelvicnim delom uretera, uterus sa adnexima i rektum) su medjusobno u vrlo bliskom kontaktu, tako da uklanjanje jednog organa nesumnjivo utice na funkciju ostalih organa. Cilj rada je bio da se utvrdi uticaj abdominalne i vaginalne histerektomije na funkciju donjeg urinarnog trakta, sa posebnim osvrtom na razlicite tipove inkontinencije. Analizirani su odgovori dve grupe bolesnica (74 koje su podvrgnute abdominalnoj histerektomiji i 61 koje su podvrgnute vaginalnoj histerektomiji) neposredno pre operacije, mesec dana i 6 meseci nakon operacije. Analiza odgovora je pokazala da 6 meseci nakon abdominalne histerektomije dolazi do porasta stres inkontinencije za 11% (p>0,05), dok se nakon vaginalne histerektomije smanjuje ucestalost stres inkontinencije sa 79% na 8% (p<0,01) zbog primene Kelly-evih suburetralnih plikacija. Niti jedna od analizirane operativne tehnike nije bitno uticala na povecanje niti na smanjenje ucestalosti urgentne inkontinencije, dnevnog i nocnog mokrenja.

Extent of radical hysterectomy: evolving emphasis

OBJECTIVE

As with other oncologic operations, the indications for and the technique of radical hysterectomy for cervical cancer has changed considerably since its initial conception in the late 19th century. This paper reviews the evolution of concepts concerning the extent of radical hysterectomy for cervical cancer.

METHODS

A Medline literature search was performed through looking for articles published in the English language that related to radical hysterectomy for cervical cancer. Specific subjects that were searched included technique, morbidity, and histopathologic assessment of the parametria.

RESULTS

Initial emphasis on local control and potential long-term survival gradually shifted to reduction of mortality and serious morbidity. Early refinements directed attention to the regional lymph nodes, definition of prognostic factors, and determination of the population of patients best suited for the operation. During the mid to late 20th century, a better understanding of regional and local prognostic factors helped clarify the role of adjuvant treatment following radical hysterectomy. By the mid 20th century, the mortality and serious morbidity rates had fallen substantially, and attention turned to reduction of other types of morbidity, especially urinary bladder voiding dysfunction. Reduction of much of the serious morbidity (urinary fistulas) and voiding dysfunction has been related to modifications of the extent of radical hysterectomy. Specific nerve-sparing techniques now have been described. However, maintaining full radicality continues to be emphasized at some centers.

CONCLUSION

The current primary operative approaches to stage 1B cervical cancer include full radical hysterectomy, modified radical hysterectomy followed by adjuvant therapy in selected patients, radical hysterectomy with nerve-sparing, and individualization of surgical management. Studies are needed which further elucidate the significance of parametrial micrometastases, further define and refine broadly feasible nerve-sparing techniques, and more accurately preoperatively identify low and high risk cervical tumors. Optimally, these studies will remove adjuvant treatment as a confounding variable.

Effect of hysterectomy on bowel function

PURPOSE

Hysterectomy is the most common major gynecologic procedure. Unwanted postoperative effects on bowel function are a topic of recent debate. The aim of the present study was to prospectively evaluate the influence of hysterectomy on bowel function.

METHODS

One hundred and twenty consecutive patients undergoing hysterectomy for benign conditions answered a questionnaire covering bowel habits and symptoms preoperatively and at 6 and 12 months postoperatively. Forty-four patients underwent vaginal hysterectomy and 76 underwent abdominal hysterectomy. Concomitant bilateral salpingo-oopherectomy was performed in 17 patients.

RESULTS

After abdominal hysterectomy, patients reported increased symptoms of gas incontinence, urge to defecate, and inability to distinguish between gas and feces ( P < 0.05). There was a tendency of increased fecal incontinence. Subgroup analysis indicated that concomitant bilateral salpingo-oopherectomy resulted in an increased risk of fecal incontinence. No significant changes were detected in symptoms associated with constipation. Mean defecation frequency increased and the frequency of pelvic heaviness symptoms was reduced. After vaginal hysterectomy, there was no increased frequency of incontinence or constipation symptoms. The frequency of pelvic heaviness symptoms was reduced.

CONCLUSIONS

Patients undergoing abdominal hysterectomy may run an increased risk for developing mild to moderate anal incontinence postoperatively and this risk is increased by simultaneous bilateral salpingo-oopherectomy. An increased risk of anal incontience symptoms could not be identified in patients undergoing vaginal hysterectomy. Our study does not support the assumption that hysterectomy is associated with de novo or deteriorating constipation.

Effect of Total Abdominal Hysterectomy on Pelvic Floor Function

Historically, hysterectomy is one of the oldest gynecologic operations, dating back to the 1840s. Currently, it is the most common gynecologic operation performed and is associated with marked improvement in the patients' quality of life. It is widely considered a safe procedure with an extremely low mortality rate (<0.1%). The majority of hysterectomies are done abdominally, with the vast majority being total abdominal hysterectomies. The effect of hysterectomy on pelvic floor function has been a subject of long debate. Various studies have reached different and rather contradictory results. Most of these studies lack stringent methodologic standards, being retrospective, observational, or uncontrolled. A recent excellent study assessed the effect of abdominal hysterectomy on pelvic floor function as 1 functional unit and concluded that both total and subtotal abdominal hysterectomies have no detrimental effect on the pelvic floor function up to 1 year postoperatively.

Hysterectomy and sexual wellbeing: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy

OBJECTIVES

To compare the effects of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy on sexual wellbeing.

DESIGN

Prospective observational study over six months.

SETTING

13 teaching and non-teaching hospitals in the Netherlands.

PARTICIPANTS

413 women who underwent hysterectomy for benign disease other than symptomatic prolapse of the uterus and endometriosis.

MAIN OUTCOME MEASURES

Reported sexual pleasure, sexual activity, and bothersome sexual problems.

RESULTS

Sexual pleasure significantly improved in all patients, independent of the type of hysterectomy. The prevalence of one or more bothersome sexual problems six months after vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy was 43% (38/89), 41% (31/76), and 39% (57/145), respectively (chi2 test, P = 0.88).

CONCLUSION

Sexual pleasure improves after vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. The persistence and development of bothersome problems during sexual activity were similar for all three techniques.

Nerve sheath tumors involving the sacrum. Case report and classification scheme

Nerve sheath tumors that involve the sacrum are rare. Delayed presentation is common because of their slow-growing nature, the permissive surrounding anatomical environment, and nonspecific symptoms. Consequently, these tumors are usually of considerable size at the time of diagnosis. The authors discuss a case of a sacral nerve sheath tumor. They also propose a classification scheme for these tumors based on their location with respect to the sacrum into three types (Types I-III). Type I tumors are confined to the sacrum; Type II originate within the sacrum but then locally metastasize through the anterior and posterior sacral walls into the presacral and subcutaneous spaces, respectively; and Type III are located primarily in the presacral/retroperitoneal area. The overwhelming majority of sacral nerve sheath tumors are schwannomas. Neurofibromas and malignant nerve sheath tumors are exceedingly rare. Regardless of their histological features, the goal of treatment is complete excision. Adjuvant radiotherapy may be used in patients in whom resection was subtotal. Approaches to the sacrum can generally be classified as anterior or posterior. Type I tumors may be resected via a posterior approach alone, Type III may require an anterior approach, and Type II tumors usually require combined anterior-posterior surgery.

Urinary incontinence and vesicourethral dysfunction in pediatric surgical conditions

The most common cause for urinary incontinence in children with pediatric surgical conditions of the pelvic region and perineum is lower urinary tract dysfunction caused by concomitant sacral agenesis, especially in children with anorectal malformations. Another common cause is iatrogenic pelvic nerve damage secondary to reconstructive surgery. Moreover, an intrinsically altered pelvic floor anatomy as seen in some cases of complex cloacas, or disruption of pelvic floor muscles with consecutive loss of supportive structures, as in sacrococcygeal teratoma, should also be taken into consideration. It is important to understand that the causes of urinary incontinence in these children are not isolated problems concerning only the urinary tract. They may have the same negative impact on anorectal function as they have on the bladder and urethral sphincter. Therefore, children with pediatric surgical conditions of the pelvic and perineal region often will present with a combination of both fecal incontinence caused by anorectal dysfunction and urinary incontinence caused by vesicourethral dysfunction. The additional morbidity caused by urinary incontinence may have an enormous impact on the patient's life and well being, not only with regard to physical disability, but also in terms of emotional problems, social handicap, and socioeconomic burden. It is obvious that a patient's quality of life will be significantly reduced if he or she suffers from both fecal and urinary incontinence. Therefore, an integrated approach to the management of both vesicourethral and anorectal dysfunction should be developed to achieve the optimum care for these children.

Abdominosacral resection for primary irresectable and locally recurrent rectal cancer

PURPOSE

The purpose of this study was to present a technique of abdominosacral resection and its results in patients with locally advanced primary or locally recurrent rectal cancer with dorsolateral fixation.

METHODS

Between 1994 and 1999, 13 patients with locally advanced primary rectal cancer and 37 patients with locally recurrent rectal cancer underwent abdominosacral resection as part of a multimodality treatment, i.e., preoperative irradiation, surgery, and intraoperative irradiation. After the abdominal phase, the patient was turned from supine to prone position to perform the transsacral phase of the resection.

RESULTS

Margins were microscopically negative in 26 patients (52 percent), microscopically positive in 18 (36 percent), and positive with gross residual disease in 6 patients. Operation time ranged from 210 to 590 (median, 390) minutes, and blood loss ranged from 400 to 10,000 (median, 3,500) ml. No operative or hospital deaths occurred. Postoperative complications occurred in 41 patients (82 percent); most notable were perineal wound infections or dehiscence (n = 24, 48 percent). Other complications were postoperative urinary retention or incontinence (n = 9, 18 percent), peritonitis (n = 4), grade II neuropathy (n = 1), and fistula formation (n = 3). Kaplan-Meier 3-year overall survival, disease-free survival, and local control rates were, respectively, 41 percent, 31 percent, and 61 percent. Completeness of the resection (negative vs. positive margins) was a significant factor influencing survival (P = 0.04), disease-free survival (P = 0.0006), and local control (P = 0.0002).

CONCLUSION

The abdominosacral resection provides wide access and may be the therapeutic solution for the accomplishment of a radical resection for distally situated, dorsally or dorsolaterally fixed primary or locally recurrent rectal cancers.

The effect of rectosigmoidectomy and Duhamel-type pull-through procedure on lower urinary tract function in children with Hirschsprung's disease

BACKGROUND/PURPOSE

The aim of this study was to investigate the effect of rectosigmoidectomy and Duhamel-type pull-through procedure on lower urinary tract function in children with Hirschsprungs disease.

METHODS

During a 3-year period the authors assessed 11 consecutive children with Hirschsprung's disease prospectively by standard urodynamic investigations, before and after surgery. Urodynamics included simultaneous measurement of abdominal pressure, bladder pressure, detrusor pressure, and pelvic floor electromyography during filling and voiding. All children were submitted to laparoscopic resection of the aganglionic bowel segment below the cul de sac and a Duhamel-type pull-through procedure. Postoperatively, the children were assessed urodynamically and evaluated every 3 months for urologic problems.

RESULTS

Mean age at first urodynamic study was 5 months (range, 2 to 10). Postoperative urodynamics were performed at a mean age of 10 months (range, 5 to 159). The mean interval between operation and postoperative urodynamic study was 6 months (range, 2 to 10). No child had structural urologic anomalies or urologic problems before surgery, and all had normal preoperative urodynamic findings. After surgery, urodynamics were considered normal in 3 children. In 7 children cystometric bladder capacity (CBC) was abnormally large, and 6 of these children had significant residuals. However, all had detrusor contractility and were able to void spontaneously. One child had low bladder compliance postoperatively. Despite the urodynamic changes, no child had clinical urologic problems at further follow-up. Mean follow-up after surgery was 24 months.

CONCLUSIONS

This study found that after rectosigmoidectomy below the cul de sac alterations of bladder function can be observed. In 7 of the 11 patients studied, mean cystometric bladder capacity was 87% higher than capacity estimated for age. Moreover, postoperative residuals were 156% higher than the preoperative values. These findings suggest that partial detrusor denervation is likely in these patients. However, because detrusor contractility was present, and none of the children had retention or any urologic problems, the findings must be interpreted carefully. Because children with Hirschsprung's disease generally do not have preexisting urologic problems, routine preoperative urodynamic screening is not necessary. However, children with voiding problems after operation should be investigated urodynamically. For legal reasons parents should be informed of possible urologic problems, especially if subtotal resection of the aganglionic bowel segment is planned.

Pelvic nerve plexus trauma at radical hysterectomy and simple hysterectomy: the nerve content of the uterine supporting ligaments

BACKGROUND

A major cause of the pelvic morbidity after a radical hysterectomy (RH) is thought to be damage to the pelvic nerve plexus, but direct evidence is lacking. We set out to determine the nerve content of the uterosacral ligaments (USLs) and cardinal ligaments (CLs) at the level at which they are divided during a radical hysterectomy and a simple hysterectomy.

METHODS

Intraoperative cross-sectional biopsies were collected from the lateral third of the uterosacral ligaments (USLs) and cardinal ligaments (CLs) in 20 women undergoing radical hysterectomy (RH) and from the uterine insertion of these ligaments in 11 women undergoing a simple hysterectomy. Quantitative immunocytochemistry was utilized to demonstrate and quantify the nerve content of the uterine supporting ligaments at the level at which they are divided in a RH and in a simple hysterectomy. Indirect immunofluorescence staining of frozen cryostat sections was performed using primary antibodies to PGP 9.5 (a pan-neuronal marker). A computer-assisted image analyzer measured the percentage area of immunoreactivity (PAI) that was used to quantify the nerve density. Confocal microscopy was used to determine the composition and spatial arrangement of nerve fibers in the ligaments.

RESULTS

The PAI was significantly greater in the RH biopsies than in the simple hysterectomy biopsies, for both the CLs (P < 0.001) and the USLs (P < 0.001). In the RH biopsies, more nerve tissue was present in the USL than CL (P = 0.01), and compared with the CL more of the nerve fibers in the USL were concentrated in large trunks. Excluding these trunks and autonomic ganglia, the free nerve content of the USL was lower than that of the CL (P < 0.001). The presence of nerve trunks, autonomic ganglia, and free nerve fibers within the lateral third of the USL and CL is consistent with extension of the inferior hypogastric plexus along these ligaments to the pelvic organs.

CONCLUSIONS

The uterine supporting ligaments contain autonomic nerves and ganglia, as extensions of the inferior hypogastric plexus. The USLs have a greater nerve density than the CLs. Because RH disrupts more nerve tissue than a simple hysterectomy, these data provide further evidence for the neurogenic etiology of pelvic morbidity after RH.

Leaking urine in Australian women: prevalence and associated conditions

The paper aims to (1) assess the prevalence of leaking urine and to (2) explore associations between leaking urine and a variety of other symptoms, conditions, surgical procedures and life events in three large cohorts of Australian women, who are participants in the Australian Longitudinal Study on Women's Health. Young women aged 18-23 (N = 14,000), mid-age women, 45-50 (N = 13,738) and older women, 70-75 (N = 12,417), were recruited randomly from the national HIC/Medicare database. Leaking urine was reported by approximately one in eight young women [estimated prevalence 12.8% (95% CI: 12.2-13.3)] and one in three mid-age women [36.1% (CI: 35.2-37.0)] and older women [35.0% (CI: 34.1-35.9)]. Leaking urine was significantly associated with parity, conditions which increase the pressure on the pelvic floor such as constipation and obesity, past gynecological surgery and conditions which can impact on bladder control. The study showed that fewer than half the women had sought help for the problem and that younger women were less likely to be satisfied with the help available for this problem. Strategies for continence promotion, including opportunistic raising of the issue at the time of cervical screening and pregnancy care are suggested, so that the health and social outcomes of untreated chronic incontinence in women might be improved.

Peripheral neuropathy and peripheral nerve injury

The peripheral nerves to the bladder can be altered by several disease processes. Voiding symptoms alone are not reliable in predicting the exact neurogenic bladder dysfunction. Urodynamic evaluation is crucial to optimize therapy and to rule out concomitant pathology.

Lumbosacral plexopathy after gynecologic surgery: case report and review of the literature

Very unusual lumbosacral plexopathy, symptoms appearing after an uncomplicated abdominal hysterectomy prompted a review of the literature. The patient's symptoms spanned the somatic and autonomic systems and ranged from T-11 to S-4; a cause that would explain these is perplexing. Pelvic neuroanatomy and plexopathy symptoms are presented. Etiologies of neurologic symptoms are discussed and preventive strategies are explored.

Patterns of recurrence after nerve-sparing surgery for rectal adenocarcinoma with special reference to loco-regional recurrence

PURPOSE

Since the early 1980s to relieve functional disturbances after rectal excision, we have been performing nerve-sparing surgery for rectal cancer. The aim of this study was to analyze patterns of recurrences, especially concerning causes of local ones. Furthermore, we would like to address the criteria we used in patient selection to effect successful nerve-sparing surgery.

METHODS

From 1982 to 1991, 306 patients underwent nerve-sparing operations, which may be categorized into three types: 1) total autonomic nerve preservation (125 cases), 2) complete pelvic nerve preservation (105 cases), and 3) partial pelvic nerve preservation with removal of parasympathetic nerve (79 cases). Single and multivariant regression analyses were conducted to investigate patterns of recurrence, especially causes of local ones.

RESULTS

Sixty-five patients (21 percent) developed recurrent tumors, 19 of which (6.2 percent) were local. Using Dukes terms, there were five patients with Dukes A 13 with Dukes B, and 47 (35 percent) with Dukes C stages. Rate of local recurrences was 13 percent in patients with Dukes C tumor. According to single-variant analysis of Dukes C patients, the following factors are thought to influence local recurrences: number of lymph nodes metastases, level of primary growth, and direction of lymphatic spread. Multivariate regression analysis suggested that lymph node metastasis was the most important and influencing factor on local regrowth (P < 0.002).

CONCLUSIONS

Compared with local recurrences is so-called extended surgery appeared to be lower. Our current policy is aggressive application of nerve-sparing surgery, even to patients with node-positive rectal cancer, taking into consideration the exact extent of cancer spread. From the viewpoint of neuroanatomy related to mesorectum, we discussed patient determination for our nerve-sparing surgery.

Nerve-sparing surgery with lateral node dissection for advanced lower rectal cancer

133 patients who underwent nerve-sparing surgery with lateral dissection for lower rectal cancer were analysed for survival and functional results, operative burdens, and modes of recurrence. In 84% of patients an acceptable urinary function was preserved. Operative time averaged 334 min, and blood loss averaged 935 ml. The 5-year survival rate was 67% in all patients, and 88% for Dukes' A, 74% for Dukes' B and 59% for Dukes' C. According to the number of positive nodes, the 5-year survival rate comprised 83% of patients with up to three nodes, and 34% of those with more than four nodes. Local recurrent rates were 2.7% in patients with Dukes' B and 13% with Dukes' C. At present, pelvic nerve-sparing procedures with lateral dissection is the most promising surgery, guaranteeing both adequate lymphadenectomy and preservation of urinary function.

Le basi anatomiche della prevenzione dei danni neurogeni in corso di chirurgia radicale pelvica nella donna

Radical pelvic surgery in women is considerably handicapped by serious neurogenic complications, commonly due to lesions in the inferior hypogastric plexus or its branches, which cannot be easily identified in the female pelvic cavity. The pelvic cavities of 42 adult female cadavers were studied and the relations between the nervous structures and the cardinal and utero-sacral ligaments were analysed. The possibility of identifying and recognising in vivo anatomical findings of the pelvic plexus is the fulcrum of nerve sparing pelvic surgery.