Urinary Dysfunction after Hysterectomy: Incidence, Risk Factors and Management

Applied anatomy of female pelvic plexus for nerve-sparing radical hysterectomy(NSRH)

BACKGROUND

Nerve-sparing radical hysterectomy(NSRH)has the advantage of reducing postoperative complications and improving postoperative quality of life. The separation and protection of the pelvic plexus in NSRH is extremely important and challenging.

METHODS

24 female cadaveric hemipelves were dissected. Morphologic patterns and compositions of pelvic plexus as well as relationship of pelvic plexus to the surrounding structures were observed and documented.

RESULTS

Two patterns of superior hypogastric plexus were observed, including fenestrated and cord-like shape. The origin of bilateral hypogastric nerves were inferiorly to upper margin of promontory about 1.6 ± 0.1 cm and parallel to the ureter in front of the sacrum. Pelvic splanchnic nerves(PSN)from the second sacral nerve, the third sacral nerve and the forth sacral nerve were observed combing with the hypogastric nerves within the lateral rectal ligament. The sacral sympathetic trunk can be identified anteriorly or medially to the anterior sacral foramen. We identified the boundaries of pelvic plexus as following: the upper margin is formed by the PSNs from the third sacral nerve, posterior margin by inferior rectal artery, and anteriorly by vesical venous plexus. The uterine branches from pelvic plexus were observed accompanying with uterine artery, while other branches were inferiorly to the artery. The PSNs were located beneath the deep uterine veins within the cardinal ligament. The upper margin of pelvic plexus was observed directly approach to urinary bladder within the vesico-vaginal ligament as a single trunk accompanying with ureter, between the middle and inferior vesical veins.

CONCLUSIONS

Our study clarified the intricate arrangement, distribution and relationship of female pelvic plexus and the related structures to provide reference index for NSRH application. The innervation patterns of bladder and uterine were clarified, and by tracing these visceral branches of pelvic plexus, we suggest several new important land markers for NSRH.

Anatomy of the vesicovaginal fascia and its relation to branches of the inferior hypogastric plexus

The inferior hypogastric plexus (IHP) lies in the extraperitoneal pelvis, and supplies branches to pelvic and perineal viscera. In men, the rectoprostatic fascia (Denonvillier's fascia) forms a distinct double fascial layer between the seminal glands and the rectum. The hypogastric nerve projections to the prostate and seminal glands run anterior to this. An analagous fascial layer in women between the vagina and cervix posteriorly and the urinary bladder anteriorly has recently been described. The purpose of this study was to examine the anatomy of the vesicovaginal fascia (VVF) and to determine its relationship to the anterior branches of the IHP. This dissection study examined the fascial layers between the posterior urinary bladder and anterior vagina/cervix (VVF) in 15 female embalmed cadavers and three fresh specimens. Anterior branches of the IHP were identified and followed distally. The relationship between these nerve projections and the VVF was examined. In 16 dissection, the VVF was identified as a complete fascial plane extending beneath the vesicouterine pouch to the neck of the bladder inferiorly and to the endopelvic fascia laterally. Anterior projections from the hypogastric nerves and IHP maintained an extraperitoneal course passing anteriorly to the VVF towards the urinary bladder The VVF is a distinct fascial structure and projections of the hypogastric nerves pass anterior to this. This may have implications for nerve sparing hysterectomy.

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

Purpose

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

Materials and Methods

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

Results

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

Conclusions

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