Pelvic floor dysfunction and radical hysterectomy

Key Anatomical Concepts, Landmarks, and Proposed Terminology for Nerve-Sparing Gynecologic Surgery: A Narrative Review

OBJECTIVE

To synthesize the terminology utilized in nerve-sparing surgical literature and propose standardized and nonconflicting terms to allow for consistent vocabulary.

DESIGN

We performed a literature search on PubMed using the search terms "pelvis" and "nerve-sparing." Nongynecologic surgery and animal studies were excluded. A narrative review was performed, focusing on nerves, fasciae, ligaments, and retroperitoneal spaces. Terms from included papers were discussed by all authors, who are surgeons versed in nerve-sparing procedures and one anatomist, and recommendations were made regarding the most appropriate terms based on the frequency of occurrence in the literature and the possibility of overlapping names with other structures.

RESULTS

224 articles were identified, with 81 included in the full-text review. Overall, 48% of articles focused on cervical cancer and 26% on deeply infiltrating endometriosis. Findings were synthesized both narratively and visually. Inconsistencies in pelvic anatomical nomenclature were prevalent across publications. The structure with the most varied terminology was the rectal branch of the inferior hypogastric plexus with 14 names. A standardized terminology for pelvic autonomic nerve structures, fasciae, ligaments, and retroperitoneal spaces was proposed to avoid conflicting terms.

CONCLUSION

Surgeons and anatomists should use consistent terminology to facilitate increased uptake of nerve-sparing techniques in gynecologic surgery through a better understanding of surgical technique description. We have proposed a standardized terminology believed to facilitate this goal.

Urinary symptoms and sexual function after hysterectomy secondary to cervical cancer: A prospective, cohort study

INTRODUCTION AND HYPOTHESIS

The estimated worldwide incidence of cervical cancer (CC) is half a million cases per year. Surgical treatment is the mainstay approach for this condition.

OBJECTIVES

To assess the effects of hysterectomy due to cervical cancer in urinary symptoms and sexual function and the disorder related impact on the quality of patients life.

STUDY DESIGN

A cohort study was performed in Fortaleza/CE (Brazil) with 71 patients; of these, 31 were diagnosed with cervical cancer (G-CCU) and 40 with gynecological benign disease (G-PB). Sexual function (FSFI questionnaire), quality of life (SF-36 questionnaire) and urinary symptoms (KHQ instrument) were investigated in both groups at baseline (T0), one month (T1) and four months after surgery (T2).

RESULTS

Both groups presented at baseline, similar urinary symptoms (p > 0.05), but this frequency doubled for the G-CCU group at T1 and remained unchanged at T2 (p = 0.012). G-PB's frequency of symptoms remained the same for 4 months after surgery. At baseline G-PB had higher risk for sexual dysfunction than G-CCU (82.5 % versus 54.8 %, p = 0.011). However for G-CCU, an increase of this percentage was perceived at T2.Women from the G-CCU group presented worse general and specific quality of life results.

CONCLUSION

Women underwent to hysterectomy due to cervical cancer presented higher percentages of urinary symptoms, higher risk for sexual dysfunction and worse general and specific quality of life scores.

A reappraisal of the deep uterine vein: a multimodal exploration with implications for pelvic surgery

PURPOSE

Pelvic gynecological surgeries, whether for malignant or benign conditions, frequently result in functional complications due to injuries to the autonomic nervous system. Recognizing the deep uterine vein (DUV) as an essential anatomical reference can aid in preserving these structures. Despite its significance, the DUV is infrequently studied and lacks comprehensive documentation in Terminologia Anatomica. This research endeavors to elucidate a detailed characterization of the DUV.

METHODS

We undertook a systematic literature review aligning with the "PRISMA" guidelines, sourcing from PUBMED and EMBASE. Our comprehensive anatomical examination encompassed cadaveric dissections and radio-anatomical evaluations utilizing the Anatomage® Table.

RESULTS

The literary exploration revealed a consensus on the DUV's description based on both anatomical and surgical observations. It arises from the merger of cervical, vesical, and vaginal veins, coursing through the paracervix in a descending and rearward direction before culminating in the internal iliac vein. The hands-on anatomical study further delineated the DUV's associations throughout its course, highlighting its role in bifurcating the uterus's lateral aspect into two distinct zones: a superior vascular zone housing the uterine artery and ureter and an inferior nervous segment below the DUV representing the autonomic nerve pathway.

CONCLUSION

A profound understanding of the subperitoneal space anatomy is paramount for pelvic surgeons to mitigate postoperative complications. The DUV's intricate neurovascular interplays underscore its significance as an indispensable surgical guide for safeguarding nerves and the ureter.

Pelvic floor dysfunction in gynecologic cancer survivors

Pelvic floor dysfunction (PFD) is a common complication in gynecologic cancer survivors (GCS) and is now a worldwide medical and public health problem because of its great impact on the quality of life of GCS. PFD after comprehensive gynecologic cancer treatment is mainly reflected in bladder function, rectal function, sexual dysfunction and pelvic organ prolapse (POP), of which different types of gynecologic cancer correspond to different disease incidence. The prevention strategies of PFD after comprehensive gynecologic cancer treatment mainly included surgical treatment, physical therapy and behavioral guidance, etc. At present, most of them still focus on physical therapy, mostly using Pelvic Floor Muscle Training (PFMT) and multi-modal PFMT treatment of biofeedback combined with electrical stimulation, which can reduce the possibility of PFD after surgery in GCS to some extent. This article reviews the clinical manifestations, causes and current research progress of prevention and treatment methods of PFD after comprehensive treatment for GCS.

The Effects of Hysterectomy on Urinary and Sexual Functions of Women with Cervical Cancer: A Systematic Review

OBJECTIVE

 This systematic review aims at describing the prevalence of urinary and sexual symptoms among women who underwent a hysterectomy for cervical cancer.

METHODS

 A systematic search in six electronic databases was performed, in September 2019, by two researchers. The text search was limited to the investigation of prevalence or occurrence of lower urinary tract symptoms (LUTS) and sexual dysfunctions in women who underwent a hysterectomy for cervical cancer. For search strategies, specific combinations of terms were used.

RESULTS

 A total of 8 studies, published between 2010 and 2018, were included in the sample. The average age of the participants ranged from 40 to 56 years, and the dysfunctions predominantly investigated in the articles were urinary symptoms (n = 8). The rates of urinary incontinence due to radical abdominal hysterectomy ranged from 7 to 31%. The same dysfunction related to laparoscopic radical hysterectomy varied from 25 to 35% and to laparoscopic nerve sparing radical hysterectomy varied from 25 to 47%. Nocturia ranged from 13%, before treatment, to 30%, after radical hysterectomy. The prevalence rates of dyspareunia related to laparoscopic radical hysterectomy and laparoscopic nerve sparing radical hysterectomy ranged from 5 to 16% and 7 to 19% respectively. The difficulty in having orgasm was related to laparoscopic radical hysterectomy (10 to 14%) and laparoscopic nerve sparing radical hysterectomy (9 to 19%).

CONCLUSION

 Urinary and sexual dysfunctions after radical hysterectomy to treat cervical cancer are frequent events. The main reported disorders were urinary incontinence and dyspareunia.

The Most Common Functional Disorders and Factors Affecting Female Pelvic Floor

The pelvic floor (PF) is made of muscles, ligaments, and fascia, which ensure organ statics, maintain muscle tone, and are involved in contractions. This review describes the myofascial relationships of PF with other parts of the body that determine the proper functions of PF, and also provides insight into PF disorders and the factors contributing to them. PF plays an important role in continence, pelvic support, micturition, defecation, sexual function, childbirth, and locomotion, as well as in stabilizing body posture and breathing, and cooperates with the diaphragm and postural muscles. In addition, PF associates with distant parts of the body, such as the feet and neck, through myofascial connections. Due to tissue continuity, functional disorders of muscles, ligaments, and fascia, even in the areas that are distant from PF, will lead to PF disorders, including urinary incontinence, fecal incontinence, prolapse, sexual dysfunction, and pain. Dysfunctions of PF will also affect the rest of the body.

Functional Changes of the Genitourinary and Gastrointestinal Systems before and after the Treatment of Endometrial Cancer-A Systematic Review

The incidence of endometrial cancer (EC), which coexists with such civilization diseases as diabetes, obesity or hypertension, is constantly increasing. Treatment includes surgery as well as brachytherapy, teletherapy, rarely chemotherapy or hormone therapy. Due to the good results of the treatment, the occurrence of side effects of therapy becomes a problem for the patients. One of the large groups of side effects includes the pelvic organ prolapse, urinary and fecal incontinence. The aim of this study was to present current knowledge on the occurrence of pelvic floor dysfunction in women treated for EC. A literature review was conducted in the PubMED and WoS databases, including articles on pelvic floor dysfunction in women with EC. PRISMA principles were followed in the research methodology. A total of 1361 publications were retrieved. Based on the inclusion and exclusion criteria, 24 papers were eligible for the review. Mostly retrospective studies based on different questionnaires were evaluated. No prospective studies were found in which, in addition to subjective assessment, clinical examination and objective assessment of urinary incontinence were used. Studies show a significant increase in the incidence of pelvic floor disorders, including urinary incontinence, after various forms of EC treatment. We believe that assessment of complications after endometrial cancer treatment is clinically relevant. The review emphasizes the importance of programming prospective studies to prevent and address these disorders at each stage of oncologic treatment.

Pelvic Floor Dysfunction After Hysterectomy: Moving the Investigation Forward

The role of hysterectomy in the development of pelvic floor dysfunction (PFD) remains widely disputed. The controversy is fueled by two key factors. The first is conflicting association studies that make it difficult to establish whether a link truly exists. Although many retrospective studies report a correlation between hysterectomy and increased risk of stress urinary incontinence (SUI) or pelvic organ prolapse (POP), prospective studies often fail to replicate these results, leading some to conclude that no association exists. However, most prospective studies do not follow up for a sufficient length of time to account for the long latency of PFD and cannot unilaterally prove the absence of an association. The second source of controversy is the absence of a plausible mechanism to explain how hysterectomy could predispose patients to PFD. In this paper, we investigate autonomic innervation and smooth muscle in the three layers of pelvic floor support and propose a mechanism through which autonomic damage from hysterectomy could predispose patients to PFD. We then identify key research areas needed to evaluate this theory. This report aims to inspire a discussion on how to further the collective understanding of the relationship between hysterectomy and PFD. Clarifying the nature of this connection could have enormous consequences in redefining the risks and benefits of hysterectomy.

Impact of gynecologic cancer on pelvic floor disorder symptoms and quality of life: an observational study

The objective of our observational prospective study was to investigate the severity and prevalence of urinary and pelvic floor disorders in gynecologic cancer survivors. All patients surviving gynecological cancer in the region as well as women receiving invitations to attend breast-screening checkups as the control population were asked to fill-in questionnaires assessing pelvic prolapse symptoms (PFDI-20, Wexner) and associated quality of life (PFIQ-7). Eighty-nine women were included in the cancer survivor group and 1088 in the control group. Pelvic floor symptoms (PFDI-20 questionnaire) were significantly worse in cancer survivors than in control women (score: 33.3 [14.6–74.1] vs. 20 [4.2–50.0], p = 0.0003). Urge incontinence was significantly worse in cancer survivors in both univariable (ORb = 2.061 [95% CI = 1.284–3.309], p = 0.0027) and multivariable analyses (ORa = 1.672 [95% CI = 1.014–2.758], p = 0.0442), as was fecal incontinence in univariable (ORb = 3.836 [95% CI = 1.710–8.602], p = 0.0011) and in multivariable (ORa = 3.862 [95% CI = 1.657–9.001], p = 0.0018) analyses. Women with benign hysterectomies had poorer quality of life and increased pelvic floor disorders compared to women with no history of surgery. Survivors of gynecological cancer experience significantly more pelvic floor symptoms and an associated reduction in quality of life.

Clinical Significance of Neuropeptide Y Expression in Pelvic Tissue in Patients with Pelvic Floor Dysfunction

OBJECTIVES

To investigate the neuropeptide Y (NPY) expression in the tissue of pelvic floor ligament and anterior vaginal wall in female patients with pelvic organ prolapse (POP) and stress urinary incontinence (SUI).

METHOD

Seventeen patients with POP, 6 with SUI, 13 with POP and SUI (POP&SUI), and 10 controls were included in this study from First Affiliated Hospital of JiNan University. Immunohistochemical assay was used to examine NPY expression in the tissue of round ligament, cardinal ligament of uterus, uterosacral ligament, and anterior vaginal wall. NPY expression were compared between POP, SUI, POP&SUI and controls.

RESULTS

NPY was positive expressed in the round ligament, cardinal ligament of uterus, uterosacral ligament, and anterior vaginal subepithelial connective tissue. Compared with the control group, NPY expression in the round, cardinal, and uterosacral ligaments in patients with POP&SUI group was decreased with significant statistical difference (p<0.05). NPY expression in anterior vaginal wall was significantly decreased in POP, SUI, and POP&SUI groups compared to normal group (p<0.05). Compared to POP group, NPY expression in SUI and POP&SUI groups were significantly decreased (p<0.05), however the difference was not statistical different between SUI and POP&SUI groups (p>0.05). In POP and POP&SUI groups, the NPY expression in the cardinal ligament of uterus, uterosacral ligament, and anterior vaginal wall were negatively correlated with age (p<0.05), however, was not correlated with number of pregnancy, number of delivery, and BMI (p>0.05).

CONCLUSIONS

NPY expression was reduced in the round ligament, cardinal ligament of uterus, Uterosacral ligament, and vaginal anterior wall of the patients with POP and SUI. The decreased NPY expression may play an important role in the development of pelvic floordysfunction.

Identification of a low risk population for parametrial invasion in patients with early-stage cervical cancer

Background

Recent studies have challenged radical procedures for less extensive surgery in selected patients with early-stage cervical cancer at low risk of parametrial invasion. Our objective was to identify a subgroup of patients at low risk of parametrial invasion among women having undergone surgical treatment.

Methods

Data of 1447 patients with cervical cancer treated between 1996 and 2016 were extracted from maintained databases of 10 French University hospitals. Patients with early-stage (IA2–IIA) disease treated by radical surgery including hysterectomy and trachelectomy, were selected for further analysis. The Kaplan–Meier method was used to estimate the survival distribution. A Cox proportional hazards model including all the parameters statistically significant in univariate analysis, was used to account for the influence of multiple variables.

Results

Out of the 263 patients included for analysis, on final pathology analysis 28 (10.6%) had parametrial invasion and 235 (89.4%) did not. Factors significantly associated with parametrial invasion on multivariate analysis were: age > 65 years, tumor > 30 mm in diameter measured by MRI, lymphovascular space invasion (LVSI) on pathologic analysis. Among the 235 patients with negative pelvic lymph nodes, parametrial disease was seen in only 7.6% compared with 30.8% of those with positive pelvic nodes (p < 0.001). In a subgroup of patients presenting tumors < 30 mm, negative pelvic status and no LVSI, the risk of parametrial invasion fell to 0.6% (1/173 patients).

Conclusion

Our analysis suggests that there is a subgroup of patients at very low risk of parametrial invasion, potentially eligible for less radical procedures.

Electronic supplementary material

The online version of this article (10.1186/s12967-018-1531-6) contains supplementary material, which is available to authorized users.

Predicting factors for resumption of spontaneous voiding following nerve-sparing radical hysterectomy

Objective

To determine factors affecting voiding recovery on the day of Foley catheter removal (postoperative day 7, POD7) after nerve-sparing radical hysterectomy (NSRH) for early-stage cervical cancer.

Methods

Early-stage cervical cancer patients, who underwent type C1 radical hysterectomy between January 2006 and June 2016 were included. Clinical and pathological data were reviewed. Association between inability to attain adequate voiding function on POD7 and potential predicting factors were evaluated in univariate and multivariate analysis.

Results

Of 755 patients, 383 (50.7%) resumed adequate voiding function on POD7 while 372 (49.3%) did not. Tumor size was larger in patients whose voiding function was inadequate (2.5 vs. 2.0 cm, p=0.001). Lengths of resected parametria and adjacent vagina were more extensive in patients with inadequate voiding function (p<0.001). In univariate analysis, factors significantly associated with inability to attain adequate voiding function included tumor size >4 cm (p<0.001), primary surgeon (p<0.001), postoperative urinary tract infection (p<0.01), grossly visible tumor (p<0.01), and not having prior conization (p<0.01). In multivariate analysis, tumor size >4 cm, postoperative urinary tract infection, and primary surgeon were significantly associated with inability to attain adequate voiding function on POD7.

Conclusion

Extent of disease represented by tumor size, urinary tract infection as well as individual surgeon's technique independently predict resumption of adequate voiding function on POD7 following NSRH.

Clinical Impact of a Surgical Energy Device in Advanced Ovarian Cancer Surgery Including Bowel Resection

AIM

To evaluate the clinical impact of the use of the Caiman® articulating energy device in advanced ovarian cancer (AOC) including rectosigmoid resection [e.g. modified posterior exenteration (MPE)].

PATIENTS AND METHODS

This was a prospective single-institution observational study with women undergoing MPE where all soft-tissue dissections and vessel ligations were performed using the Caiman® device. Intraoperative and postoperative surgical data were collected. Bladder function after nerve-sparing surgery was analyzed before and 6 months after surgery.

RESULTS

Forty patients were registered in the study. The median time for specimen removal using Caiman® was 86 min (range=70-120 min). Major vessel ligation was successful in all patients with a median of a single (range=1-4) Caiman® application to seal major vessels. No intraoperative or postoperative complications or bladder dysfunctions associated with the use of Caiman® were noted.

CONCLUSION

Caiman® can be safely used in AOC surgery and may save time through faster dissection. However, comparative studies with other energy devices are needed to confirm this finding.

The relationship between symptom prevalence, body image, and quality of life in Asian gynecologic cancer patients

OBJECTIVE

Gynecologic cancer is associated with long-term effects that can be both physical and emotional. We examined symptom prevalence and body image disturbance in patients with gynecologic cancer and their association with quality of life. Predictors of clinically-relevant body image disturbance were examined.

METHODS

A sample of patients in Singapore (n = 104) was assessed for symptom prevalence, quality of life, and body image dissatisfaction. Clinical factors were extracted from medical records.

RESULTS

The most frequently reported symptoms were fatigue, abdominal bloatedness, weight gain, constipation, hot flashes, and pelvic pain. Approximately one quarter patients reported feeling less physically attractive and dissatisfied with their body. Ordinary least squares regression indicated that symptom prevalence alone predicted physical well-being, b = -1.09, P < .001, 95% CI, -1.45 to -0.73, and functional well-being, b = -0.88, P < .001, 95% CI, -1.32 to -0.45. Body image dissatisfaction alone significantly predicted emotional well-being, b = -0.21, P < .01, 95% CI, -0.35 to -0.06. Younger age was a significant risk factor for clinically-relevant score of body image distress, OR = 0.95 per year older, 95% CI, 0.92 to 0.99, P = .02.

CONCLUSIONS

Symptom prevalence and body image dissatisfaction were associated with different domains of quality of life. Emotional well-being of patients was better explained by body image, rather than extent of symptoms experienced. Patients who are younger appear particularly susceptible to body image disturbance.

Impact of radical hysterectomy on the transobturator sling pathway: a retrospective three-dimensional magnetic resonance imaging study

INTRODUCTION AND HYPOTHESIS

Morphological and functional anomalies of the urethra may cause stress urinary incontinence after radical hysterectomy (RH). We introduce a novel three-dimensional (3D) magnetic resonance imaging (MRI) technique to assess the impact of RH on the transobturator sling pathway.

METHODS

3D-MRI reconstruction models were retrospectively developed for the measurement of various parameters before and after RH, including puncture angle, orientation and distance from the midurethral puncture site to the obturator membrane (DUO), in 31 patients with cervical cancer. Additionally, the correlations between DUO and body height and interspinal diameter were evaluated.

RESULTS

No significant differences were noted between the preoperative and postoperative inclination angle (-7.1 ± 33.5° vs. -0.68 ± 23.9°, ranges -62.4 to 46.8° vs. -54.1 to 42.2°, respectively) or between the preoperative and postoperative left and right mean rotation angles (left 69.0 ± 8.0° vs. 67.8 ± 9.2°; right 65.1 ± 8.38° vs. 64.3 ± 10.5°). Similarly, there were no statistically or clinically significant differences between the preoperative and postoperative DUO, although slight differences were noted between the two sides before and after RH (P = 0.018 and P = 0.023, respectively). None of the parameters differed significantly between the groups with and without postoperative urodynamic stress incontinence. Further, there was no clinically significant correlation between DUO and height or interspinal diameter.

CONCLUSIONS

The sling procedure via the transobturator approach is technically safe from a 3D anatomical standpoint. However, wide variability in the anatomical parameters must be taken into account when planning the procedure.

Perioperative morbidity, bowel function and oncologic outcome after radical cystectomy and ileal orthotopic neobladder reconstruction: Studer-pouch versus I-pouch

OBJECTIVE

To investigate whether the length of ileum used for ileal orthotopic neobladder (ONB) reconstruction (60 cm vs. 40 cm) after radical cystectomy (RC) for bladder cancer (BC) impacts on bowel function, postoperative complications or survival outcome.

MATERIAL AND METHODS

In this retrospective study, we included 56 patients who received an ONB (Studer (S)-Pouch: 23 patients; I-Pouch: 33 patients) after RC for BC between 2003 and 2011. Preoperative comorbidities were assessed by the Charlson Comorbidity Index (CCI) and surgical complications as graded by the Clavien-Dindo classification. Changes of perioperative bowel habits were retrospectively evaluated by the validated Gastrointestinal Quality of Life Index (GIQLI). Kaplan-Meier analyses calculated survival outcomes between both ONB types.

RESULTS

Preoperative CCI was comparable between S- and I-pouch patients. No significant differences were observed for 30-day major- (p = 0.33) and minor (p = 0.96) complication rates between both neobladder types. S-Pouch patients reported higher preoperative stool frequencies (S-pouch: mean 2.7; I-pouch: mean 3.4; p = 0.049) and tended to suffer from urgency (S: mean 2.9; I: mean 3.4; p = 0.059). No significant differences in postoperative bowel disorders were found between both neobladder types (S-Pouch: 15.9, IQR; I-Pouch: 16.6 IQR; p = 0.84). Furthermore, we observed no overall-, cancer specific- or recurrence free survival advantage for either of both ONB variants (p = 0.81; 0.65 and 0.78), respectively.

CONCLUSION

Comorbidities, perioperative complication rates and bowel habits were similar between both ONB substitutes and did not influence survival outcomes. These stratified data suggest that the length of ileum used for ONB reconstruction (60- vs. 40 cm) does not impact per se on postoperative bowel function.

Fertility Preservation and Sexual Health After Cancer Therapy

Recent developments in cancer diagnostics and treatments have considerably improved long-term survival rates. Despite improvements in chemotherapy regimens, more focused radiotherapy and diverse surgical options, cancer treatments often have gonadotoxic side-effects that can manifest as loss of fertility or sexual dysfunction, particularly in young cancer survivors. In this review, we focus on two pertinent quality-of-life issues in female cancer survivors of reproductive age-fertility preservation and sexual function. Fertility preservation encompasses all clinical and laboratory efforts to preserve a woman's chance to achieve future genetic motherhood. These efforts range from well-established protocols such as ovarian stimulation with cryopreservation of embryos or oocytes, to nascent clinical trials involving cryopreservation and re-implantation of ovarian tissue. Therefore, fertility preservation strategies are individualized to the cancer diagnosis, time interval until initiation of treatments must begin, prognosis, pubertal status, and maturity level of patient. Some patients choose not to pursue fertility preservation, and the conversation then centers around other quality of life issues. Not all cancer treatments cause loss of fertility; however, most treatments can directly impact the physical and psychosocial aspects of sexual function. Cancer treatment is also associated with fear, anxiety, and depression, which can further decrease sexual desire, function, and frequency. Sexual dysfunction after cancer treatment is generally ascertained by compassionate inquiry. Strategies to promote sexual function after cancer treatment include pelvic floor exercises, clitoral therapy devices, pharmacologic agents, as well as couples-based psychotherapeutic and psycho-educational interventions. Quality-of-life issues in young cancer survivors are often best addressed by utilizing a multidisciplinary team consisting of physicians, nurses, social workers, psychiatrists, sex educators, counselors, or therapists.

Central control of micturition in women: Brain-bladder pathways in continence and urgency urinary incontinence

Urinary incontinence disproportionately affects women. Anatomical textbooks typically describe continence mechanisms in women in the context of the pelvic floor support of the urinary bladder and the urethral sphincters. However, the urinary bladder and urethral sphincters are under the central control of the brain through a complex network of neurons that allow storage of urine followed by voiding when socially appropriate. Recent studies suggest that the most common type of urinary incontinence in women, urgency urinary incontinence, involves significant dysfunction of the central control of micturition. In this paper, we review the anatomy and functional connectivity of the nervous system structures involved in the control of micturition. Clinical application of this anatomy in the context of urgency urinary incontinence is also discussed. Understanding the anatomy of the neural structures that control continence will allow clinicians to better understand the underlying pathology of urge incontinence and consider new ways of treating this distressing condition. Clin. Anat. 30:373-384, 2017. © 2017 Wiley Periodicals, Inc.

Expression of transient receptor potential ankyrin 1 correlating to the recovery of colonic transit after pelvic nerve denervation in rats

BACKGROUND

It has been reported that colorectal motility dysfunction due to pelvic nerve (PN) damage is restored overtime. However, the adaptive mechanism is unknown. Previous studies implied that transient receptor potential ankyrin 1 (TRPA1) mediated sensory nerve signal input plays a crucial role in gut motility regulation. The present study aimed to observe the colorectal motility restoration in rats after PN transection and to explore the change of TRPA1 protein expression in this adaptive process.

METHODS

Seventy-eight adult rats were divided into two groups randomly: sham and PN cut. Colonic transit function was determined with radioisotope method by calculating the geometric center (GC) of the distribution of 51Cr at postoperative days (POD) 1, 3, and 7. Expression of TRPA1 in the proximal and distal colon mucosa was detected with Western blotting at POD 1, 3, and 7.

RESULTS

At POD 1, the colonic transit in PN cut group was significantly delayed (GC = 4.91 ± 0.41, P < 0.05), when compared with the sham group (GC = 5.76 ± 0.85). A significant trend toward recovery was noted in the PN cut group at POD 3 (GC = 5.58 ± 0.36) and POD 7 (GC = 6.44 ± 0.78). Western blot demonstrated attenuated expression of TRPA1 in the distal colon mucosa after PN denervation at POD 1 (0.39 ± 0.12) compared with that of the shams. A significant trend of increasing expression of TRPA1 was demonstrated in the PN cut group at POD 3 (0.78 ± 0.10) and at POD 7 (1.06 ± 0.13).

CONCLUSIONS

Delayed colonic motility due to PN denervation gradually restored overtime, which may relate to the corresponding expression of TRPA1 in the distal colonic mucosa of rats.

Prevalence of pelvic floor disorders in women with suspected gynecological malignancy: a survey-based study

INTRODUCTION AND HYPOTHESIS

Understanding of pelvic floor disorders among women with gynecological cancer is limited. The objective of this study was to describe the prevalence of pelvic floor disorders in women with suspected gynecological malignancy before surgery.

METHODS

A cross-sectional study was performed of women aged ≥18 with a suspected gynecological malignancy who enrolled in the University of North Carolina Health Registry/Cancer Survivorship Cohort (HR/CSC) from August 2012 to June 2013. Demographics were obtained from the HR/CSC self-reported data; clinical data were abstracted from the electronic medical record. Subjects completed validated questionnaires (Rotterdam Symptom Checklist and the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms) to assess bladder and bowel function.

RESULTS

Among 186 women scheduled for surgery for gynecological malignancy, 152 (82 %) completed baseline assessments before surgery. Mean age was 58.1 ± 13.3 years, and mean BMI was 33.6 ± 8.8 kg/m(2). The majority of subjects had uterine cancer (61.8 %), followed by ovarian (17.1 %) and cervical (11.1 %). At baseline, the rate of urinary incontinence (UI) was 40.9 %. A third of subjects reported stress UI, and one quarter reported urge UI. The overall rate of fecal incontinence was 3.9 %, abdominal pain was 47.4 %, constipation was 37.7 %, and diarrhea was 20.1 %. When comparing cancer types, there were no differences in pelvic floor symptoms.

CONCLUSION

Pelvic floor disorders are common in women with suspected gynecological malignancy at baseline before surgery. Recognizing pelvic floor disorders in the preoperative setting will allow for more individualized, comprehensive care for these women.

Interventions for sexual dysfunction following treatments for cancer in women

BACKGROUND

The proportion of people living with and surviving cancer is growing. This has led to increased awareness of the importance of quality of life, including sexual function, in those affected by cancer. Sexual dysfunction is a potential long-term complication of many cancer treatments. This includes treatments that have a direct impact on the pelvic area and genitals, and also treatments that have a more generalised (systemic) impact on sexual function.This is an update of the original Cochrane review published in Issue 4, 2007, on interventions for treating sexual dysfunction following treatments for cancer for men and women. Since publication in 2007, there has been an increase in the number of trials for both men and women and this current review critiques only those for women. A review in press will present those for men.

OBJECTIVES

To evaluate the effectiveness of interventions for treating sexual dysfunction in women following treatments for cancer. To assess adverse events associated with interventions.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 9), MEDLINE, EMBASE, PsycINFO, AMED, CINAHL, Dissertation Abstracts and the NHS Research Register. The searches were originally run in January 2007 and we updated these to September 2015.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that assessed the effectiveness of a treatment for sexual dysfunction. The trial participants were women who had developed sexual dysfunction as a consequence of a cancer treatment. We sought evaluations of interventions that were pharmaceutical, mechanical, psychotherapeutic, complementary or that involved physical exercise.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed trial quality. We considered meta-analysis for trials with comparable key characteristics.

MAIN RESULTS

Since the original version of this review we have identified 11 new studies in women. The one study identified in the earlier version of this review was excluded in this update as it did not meet our narrower inclusion criteria to include only interventions for the treatment, not prevention, of sexual dysfunction.In total 1509 female participants were randomised across 11 trials. All trials explored interventions following treatment either for gynaecological or breast cancer. Eight trials evaluated a psychotherapeutic or psycho-educational intervention. Two trials evaluated a pharmaceutical intervention and one pelvic floor exercises. All involved heterosexual women. Eight studies were at a high risk of bias as they involved a sample of fewer than 50 participants per trial arm. The trials varied not only in intervention content but in outcome measurements, thereby restricting combined analysis. In the trials evaluating a psychotherapeutic intervention the effect on sexual dysfunction was mixed; in three trials benefit was found for some measures of sexual function and in five trials no benefit was found. Evidence from the other three trials, two on different pharmaceutical applications and one on exercise, differed and was limited by small sample sizes. Only the trial of a pH-balanced vaginal gel found significant improvements in sexual function. The trials of pharmaceutical interventions measured harm: neither reported any. Only one psychological intervention trial reported that no harm occurred because of the intervention; the other trials of psychological support did not measure harm.

AUTHORS' CONCLUSIONS

Since the last version of this review, the new studies do not provide clear information on the impact of interventions for sexual dysfunction following treatments for cancer in women. The sexual dysfunction interventions in this review are not representative of the range that is available for women, or of the wider range of cancers in which treatments are known to increase the risk of sexual problems. Further evaluations are needed.

A Modified Nerve-Sparing Panhysterectomy for Benign Uterine Diseases: Techniques and Evaluation of Postoperative Pelvic Dysfunctions

OBJECTIVE

To describe a modified nerve-sparing panhysterectomy and to investigate the feasibility and impact of this nerve-sparing technique in improving postoperative pelvic visceral dysfunctions of benign uterine disease patients.

METHODS

From January 2008 to January 2010, a total of 300 patients diagnosed with benign uterine diseases at the Second Affiliated Hospital of Nantong University were enrolled. Of those, 150 randomly selected patients underwent modified panhysterectomy (research group), while the other 150 patients underwent conventional panhysterectomy (control group). The surgery-related parameters, including operation time, intraoperative blood loss, length of hospital stay, postoperative indwelling catheter time, and first voiding and defecation time were compared between the two groups. The extent of nerve damage in both groups was examined using the nerve-specific marker S-100 via immunohistochemistry. Besides, postoperative assessments of bladder and bowel functions were conducted within 1 year after the operation.

RESULTS

The surgery-related parameters in the two groups showed no significant difference (p > 0.05). Immunohistochemistry results showed significantly reduced damage of the nerves in the research group. We also found a better bladder and bowel function in the research group (p < 0.05) and in younger patients (p < 0.05) compared with that in the control group. Recovery trends of the bladder and bowel function were found in both groups (χ(2) = 7.512, p = 0.006 in the research group; χ(2) = 7.299, p = 0.007 in the control group).

CONCLUSION

Modified panhysterectomy for benign uterine diseases seems feasible and safe, with the main advantage of improving postoperative urocystic and rectal dysfunctions through the preservation of the pelvic autonomic nerves.

Social support buffers the effect of self-esteem on quality of life of early-stage cervical cancer survivors in Taiwan

PURPOSE

The purpose of this study was to examine the effects of self-esteem and social support on quality of life (QoL) in stage I and II cervical cancer survivors.

METHOD

The sample consisted of 110 participants who had been diagnosed with stage I-II cervical cancer and had completed their treatment 5 years or more before data collection. Each participant completed four structured questionnaires: a demographic-disease survey, the Rosenberg Self-Esteem Scale, Medical Outcomes Study Social Support Survey, and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire 30. Data were analyzed using descriptive statistics, independent sample t-test, one-way ANOVA, and hierarchical multiple linear regression analyses.

RESULTS

The participants' mean age was 60.74 ± 10.69 years. Better QoL was significantly associated with younger age, higher self-esteem, and stronger social support; in addition, social support buffered the effect of self-esteem on global QoL. Together, five variables (age, time since treatment, self-esteem, social support, and the interaction term of self-esteem and social support) explained 36% of the variance in global QoL, with self-esteem being the strongest predictor.

CONCLUSIONS

The results of this study advance current knowledge of QoL in cervical cancer survivors by demonstrating that survivors with low self-esteem and social support tend to have lower QoL than those with low self-esteem but high social support. Health professionals should help survivors seek support and provide appropriate strategies to expand their social networks and enhance their self-esteem to improve their global QoL after cervical cancer.

Clinical tumor diameter and prognosis of patients with FIGO stage IB1 cervical cancer (JCOG0806-A)

OBJECTIVE

In order to determine indications for less radical surgery such as modified radical hysterectomy, the risk of pathological parametrial involvement and prognosis of FIGO stage IB1 cervical cancer patients undergoing standard radical hysterectomy with pre-operatively assessed tumor diameter≤2 cm were investigated.

METHODS

We conducted a retrospective multi-institutional chart review of patients with FIGO stage IB1 cervical cancer who underwent primary surgical treatment between 1998 and 2002. The eligibility criteria for the analyses were (i) histologically-proven squamous cell carcinoma, adenocarcinoma or, adenosquamous cell carcinoma, (ii) radical hysterectomy performed, (iii) clinical tumor diameter data available by MR imaging or specimens by cone biopsy, and (iv) age between 20 and 70. Based on the clinical tumor diameter, patients were stratified into those with the following tumors: i) 2 cm or less (cT≤2 cm) and ii) greater than 2 cm (cT>2 cm). We expected 5-year OS of ≥95% and parametrial involvement<2-3% for patients with cT≤2 cm who underwent radical hysterectomy.

RESULTS

Of the 1269 patients enrolled, 604 were eligible for the planned analyses. Among these, 571 underwent radical hysterectomy (323 with cT≤2 cm and 248 with cT>2 cm). Parametrial involvement was present in 1.9% (6/323) with cT≤2 cm and 12.9% (32/248) with cT>2 cm. Five-year overall survivals were 95.8% (95% CI 92.9-97.6%) in cT≤2 cm and 91.9% (95% CI 87.6-94.8%) in cT>2 cm patients.

CONCLUSION

Patients with cT≤2 cm had lower risk of parametrial involvement and more favorable 5-year overall survival. They could therefore be good candidates for receiving less radical surgery.

Cervical cancer survivorship: long-term quality of life and social support

PURPOSE

Surgery, radiotherapy, and chemotherapy are the mainstays of cervical cancer treatment. Many patients receive multiple treatment modalities, each with its own long-term effects. Given the high 5-year survival rate for cervical cancer patients, evaluation and improvement of long-term quality of life are essential.

METHODS

Pertinent articles were identified through searches of PubMed for literature published from 1993 to 2014. We summarize quality of life data from long-term follow-up studies of cervical cancer patients. We additionally summarize small group interviews of Hispanic and non-Hispanic cervical cancer survivors regarding social support and coping.

FINDINGS

Data are varied in terms of the long-term impact of treatment on quality of life, but consistent in suggesting that patients who receive radiotherapy as part of their treatment have the highest risk of increased long-term dysfunction of bladder and bowel, as well as sexual dysfunction and psychosocial consequences. Rigorous investigations regarding long-term consequences of treatment modalities are lacking.

IMPLICATIONS

Continued work to improve treatment outcomes and survival should also include a focus on reducing adverse long-term side effects. Providing supportive care during treatment and evaluating the effects of supportive care can reduce the prevalence and magnitude of long-term sequelae of cervical cancer, which will in turn improve quality of life and quality of care.

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

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

Early postoperative bladder training in patients submitted to radical hysterectomy: is it still necessary? A randomized trial

OBJECTIVES

To evaluate the role of bladder training during postoperative hospital stay in patients submitted to nerve-sparing radical hysterectomy, and to identify any clinical or surgical factor associated with postoperative bladder dysfunction.

DESIGN, SETTING, AND PARTICIPANTS

Parallel group randomized single institution trial, on gynaecologic malignancies patients conducted in Catholic University of Sacred Heart Rome, between April 2009 and November 2011. Randomization was on 1:1, using a block randomized computer-generated list.

INTERVENTIONS

Patients underwent Querleu-Morrow type B2 or C1 radical hysterectomy. After 2 days from surgery, patients were randomized to perform or not bladder training (scheduled clamping and unclamping of the trans-urethral catheter every three hours). Main outcome measures Necessity and duration of clean intermittent self catheterization.

RESULTS

Randomized participants were 111 women (bladder training arm n = 55; control arm n = 56). A total of 22 women (19.8%) required clean intermittent self catheterization, equally distributed in the two arms. At univariate analysis, only the type of radical hysterectomy was significantly associated with need of clean intermittent self catheterization (type C1 vs. type B2; p = 0.013). At univariate analysis, duration of clean intermittent self-catheterization was not associated with age, BMI, type of hysterectomy and of neo-adjuvant treatment.

CONCLUSIONS

Functional bladder disfunctions are the most common long-term complications following radical hysterectomy. Systematic postoperative bladder training following nerve-sparing radical hysterectomy does not influence the rate of urinary retention or re-admission for bladder catheterization.

Jejunal torsion around the right ureter presenting as postoperative bowel obstruction: a case report

Introduction

Since abdominal radical hysterectomy was first described by Clark and Reis in 1895, it has been commonly used in the primary surgical treatment of carcinoma of the cervix. We report the case of a 45-year-old woman who was diagnosed with a small bowel obstruction due to jejunal torsion to her right ureter mimicking postoperative adhesion ileus.

Case presentation

A 45-year-old Turkish woman was admitted to our emergency department with complaints of abdominal pain, constipation, nausea and vomiting. She had undergone an abdominal radical hysterectomy for cervical carcinoma three years earlier. Computed tomography scans revealed intestinal dilatation, a large amount of free fluid in the abdominal cavity and an area suspicious for jejunal perforation. Because of these radiological findings suggestive of obstruction and bowel ischemia, our patient underwent emergency surgery. Operative findings that showed a jejunal segment was turned around her right ureter so that it was mimicking a fibrous band.

Conclusions

In this current case, we present the first determined complication of radical hysterectomy. According to our case report, surgical oncologists should be aware of this complication and review the surgical technique. It is considered that readaptation of the dorsolateral peritoneal layer after extended pelvic lymph node dissection resulted in fewer complications.

Autonomic nerve regulation of colonic peristalsis in Guinea pigs

Background/Aims

Colonic peristalsis is mainly regulated via intrinsic neurons in guinea pigs. However, autonomic regulation of colonic motility is poorly understood. We explored a guinea pig model for the study of extrinsic nerve effects on the distal colon.

Methods

Guinea pigs were sacrificed, their distal colons isolated, preserving pelvic nerves (PN) and inferior mesenteric ganglia (IMG), and placed in a tissue bath. Fecal pellet propagation was conducted during PN and IMG stimulation at 10 Hz, 0.5 ms and 5 V. Distal colon was connected to a closed circuit system, and colonic motor responses were measured during PN and IMG stimulation.

Results

PN stimulation increased pellet velocity to 24.6 ± 0.7 mm/sec (n = 20), while IMG stimulation decreased it to 2.0 ± 0.2 mm/sec (n = 12), compared to controls (13.0 ± 0.7 mm/sec, P < 0.01). In closed circuit experiments, PN stimulation increased the intraluminal pressure, which was abolished by atropine (10⁻⁶ M) and hexamethonium (10⁻⁴ M). PN stimulation reduced the incidence of non-coordinated contractions induced by NG-nitro-L-arginine methyl ester (L-NAME; 10⁻⁴ M). IMG stimulation attenuated intraluminal pressure increase, which was partially reversed by alpha-2 adrenoceptor antagonist (yohimbine; 10⁻⁶ M).

Conclusions

PN and IMG input determine speed of pellet progression and peristaltic reflex of the guinea pig distal colon. The stimulatory effects of PN involve nicotinic, muscarinic and nitrergic pathways. The inhibitory effects of IMG stimulation involve alpha-2 adrenoceptors.

Antitumor activity of G-quadruplex-interactive agent TMPyP4 with photodynamic therapy in ovarian carcinoma cells

The aim of the present study was to investigate the potential effects of photodynamic therapy (PDT) mediated by the cationic porphyrin, 5,10,15,20-tetra-(N-methyl-4-pyridyl)porphine (TMPyP₄), on an ovarian carcinoma cell line and the underlying mechanisms by which TMPyP₄-PDT exerts its actions. The analysis of cell viability, hematoxylin and eosin staining and flow cytometric apoptosis assays revealed that TMPyP₄-PDT potently suppressed the growth of the A2780 cells in a laser energy- and dose-dependent manner. Mechanically, it was observed that TMPyP₄-PDT suppressed the proliferation and motility of the A2780 cells. In addition, the expression levels of minichromosome maintenance protein-2 (MCM2) and carbonic anhydrase IX (CA-IX) were detected by western blot analysis. The results indicated that the TMPyP₄-PDT-induced apoptosis and antimetastatic activity in the A2780 cells was accompanied by the inhibition of the expression of MCM2 and CA-IX. Therefore, TMPyP₄-PDT may represent a potential therapeutic method for the treatment of ovarian carcinoma.

Urological complications after treatment of cervical cancer

Several urological complications can occur after treatment of cervical cancer. Stage IB and IIA cervical tumours are mainly treated by radical hysterectomy; advanced-stage tumours are treated by chemoradiotherapy. In the past two decades, a decrease in complications has been seen due to improvements in therapy, although the exact incidence of lower urinary tract dysfunction is unknown. The main urological complications after radical surgery are hypocontractility of the bladder, detrusor overactivity, incontinence, low-compliance bladder, fistula and hydronephrosis. As a result of improved neuroanatomical knowledge, and consequently nerve-sparing surgery, bladder morbidity has been decreasing. Late radiation-induced urological complications include haemorrhagic cystitis, ureteric stenosis, low-compliance bladder and fistulas. Owing to technological improvements, such as dose reduction and decreased radiation fields, a decrease in radiation morbidity has been observed since 1990.

Urinary retention following laparoscopic gynaecological surgery with or without 4% icodextrin anti-adhesion solution

BACKGROUND

Urinary retention is a recognised complication of laparoscopic surgery. Previous work showed an association with 4% icodextrin solution and urinary retention.

AIMS

To determine the incidence of urinary retention following laparoscopic gynaecological surgery with or without the use of 4% icodextrin.

METHODS

A prospective observational study of 147 women undergoing laparoscopic gynaecological surgery for benign pathology. Women had their planned laparoscopic procedure and either received icodextrin solution or nothing as determined by their treating surgeon at the time of the operation.

RESULTS

From May 2011 to February 2012, 147 women were approached to participate in the study; of whom, 124 women were included: 62 received icodextrin and 62 did not. The women in the non-icodextrin group were significantly older (P = 0.007) and had a higher BMI (P = 0.03) than those in the icodextrin group. Following surgery, 27/124 (21.8%) women had post-operative urinary retention. Icodextrin was associated with significantly more urinary retention (P = 0.017), but did not extend hospital admission significantly (P = 0.14). The administration of icodextrin was associated with resection of moderate- or severe-stage endometriosis involving multiple surgical sites, whereas women in the non-icodextrin group were more likely to be having a hysterectomy.

CONCLUSIONS

In this non-randomised study, there were significantly more women with post-operative urinary retention when icodextrin was used; however, this did not contribute to an extended hospital admission. While there may be confounding factors, women receiving icodextrin should be warned of the possibility of urinary retention post-operatively, but that this is unlikely to affect their stay in hospital.

Lymphatic and nerve distribution throughout the parametrium

BACKGROUND

Our objective was to concomitantly assess distribution of lymphatic and nerve structures in the parametrium.

METHODS

Twenty hemipelvises from ten fresh cadavers were dissected to differentiate between, three different parts of the parametrium: the lateral parametrium, the proximal and the distal part of the posterior parametrium. Histologic and immunofluorescence analyses of nerve and lymphatic structures were performed using NSE and LYVE-1 staining, respectively. The percentage of structures was independently scored as 0 (0%), 1 (1-20%), 2 (20-50%), 3 (50-80%), 4 (>80%).

RESULTS

The lateral parametrium and the proximal part of the posterior parametrium contained both nerve (scored 2.25 and 2.50, respectively) and lymphatic (scored 2.50 and 2.00, respectively) structures. The distal part of the posterior parametrium also contained numerous nerve structures (scored 2.00) but lymphatic structures were rare (scored 0.88). No difference in nerve distribution was found according to the parts of parametrium while a significantly lower distribution of lymphatic vessels was observed in the distal part of the posterior parametrium (p=0.03).

CONCLUSION

The distal part of the posterior parametrium is of high nerve density and low lymphatic density raising the issue as to whether it should be removed during radical hysterectomy.

Urinary function following laparoscopic lymphadenectomy for male rectal cancer

OBJECTIVES

Urinary function can be protected following open lateral node dissection (LND) with pelvic autonomic nerve preservation (PANP) for advanced rectal cancer. However data regarding urinary function after laparoscopic LND with PANP have not been reported. The goal of this study was to determine the effects of laparoscopic LND with PANP on urinary function in male patients with rectal cancer.

METHODS

Urine flowmetry was performed using an Urodyn flowmeter. Patients were also asked to complete the standardized International Prostate Symptom Score (IPSS) questionnaire before surgery and 6 months after. In total, this study consisted of 60 males with advanced rectal cancer.

RESULTS

No significant differences were seen in maximal urinary flow rate, voided volume or residual volume before and after surgery. The total IPSS score increased significantly after surgery and at least 41 patients (68.3%) reported there was no change in one of the seven IPSS questions.

CONCLUSIONS

Laparoscopic LND with PANP was relatively safe in preserving urinary function.

Voiding dysfunction after repair of giant trigonal vesicovaginal or urethrovesicovaginal fistulae: A need for long-term follow-up

Introduction:

Urodynamic findings of lower urinary tract of women presenting with voiding dysfunction after successful repair of complex trigonal vesicovaginal fistulas at our institute are presented.

Materials and Methods:

In this retrospective case series, women presenting with voiding dysfunction after successful repair of obstetric fistulae were evaluated. In addition of standard clinical evaluation with history and clinical examination, all underwent kidney-ureter-bladder ultrasonography, renal function test, urine culture, and multichannel urodynamics. The latter consisted of free uroflowmetry, filling and voiding cystometry.

Results:

Five women (median age 35 years; range 30–45) presented with difficulty in voiding after the successful repair; two presented within 1 year and 3 after 10 years. The latter three presented with bilateral hydroureteronephrosis; one of these had chronic kidney disease (CKD) grade IV at presentation. Urodynamics (UDS) of all patients revealed poor detrusor compliance (median 11 ml/cm H₂O; range 5–22), high-end filling detrusor pressures (median 41 cm H₂O; range 11–46) and no detrusor overactivity. All patients attempted voiding with abdominal straining; with little contribution of detrusor contraction (median 6 cm H₂O; range 0–9). Two patients could not void during the study, one with Tanagho reconstruction and another with CKD.

Conclusion:

Even after successful repair, patients with complex trigonal or urethra-vesicovaginal fistulae warrant indefinite long-term follow-up for voiding dysfunction in view of possibility of developing poorly compliant bladder.

Upregulation of mucosal 5-HT3 receptors is involved in restoration of colonic transit after pelvic nerve transection

BACKGROUND

Colonic dysfunction occurs after pelvic autonomic nerve damage. The enteric nervous system can compensate. We investigated the role of mucosal serotonin receptors, 5-HT(3) and 5-HT(4) , in the colonic motility restoration over 2 weeks after parasympathetic pelvic nerve transection in a rat model.

METHODS

Male Sprague-Dawley rats underwent pelvic nerve transection or sham operation. Colonic transit was expressed as the geometric center of (51) Cr distribution. Mucosal 5-HT(3) and 5-HT(4) receptor expression was evaluated by Western blot. Intraluminal pressure increase was measured after 5-HT(3) (ondansetron) or 5-HT(4) receptor antagonist (GR125487) administration in vitro in sham and denervated distal colons.

KEY RESULTS

At 2 weeks, colonic transit in the denervated group was 30% slower compared to the sham group (P < 0.01). At 1 and 2 weeks, 5-HT(3) receptor expression was increased two-fold in the denervated group, compared to shams (P < 0.05). A three-fold smaller dose of ondansetron was required in denervated tissues to inhibit intraluminal pressure rise than in sham colons (P < 0.01). There was no difference in the expression of 5-HT(4) receptor or the response to GR125487 in denervated vs sham colons.

CONCLUSIONS & INFERENCES

Colonic motility was restored to approximately 70% normal over 1 week without further improvement at 2 weeks. Enteric nervous system compensated by upregulating mucosal 5-HT(3,) but not 5-HT(4,) receptors.

Effect of a pelvic floor muscle training program on gynecologic cancer survivors with pelvic floor dysfunction: a randomized controlled trial

OBJECTIVE

To investigate the effects of a pelvic floor rehabilitation program (PFRP) on pelvic floor function and quality of life (QoL) in gynecological cancer survivors in a prospective, randomized, controlled trial.

METHODS

Thirty-four patients with gynecological cancers recruited between July 2009 and December 2009 were randomly allocated into two groups: a PFRP group (n=17), who participated in a 4-week PFRP exercise program, and a non-PFRP group (n=17), who received the usual health care. The pelvic floor strength, the motor evoked potentials (MEPs) elicited by sacral and transcranial magnetic stimulation, the pelvic floor questionnaire, and the scores on two QoL questionnaires, (QLQ)-C30 and QLQ-CX 24, from the European Organization for Research and Treatment of Cancer (EORTC) were evaluated to assess changes in pelvic floor function and QoL before and after the exercise program.

RESULTS

Twenty four patients (12 from each group) completed the exercise program. The PFRP group improved in pelvic floor strength (mean difference (MD)=14.22, t(9)=2.389, P=0.036) and sexual functioning. The PFRP group also improved in physical and sexual function compared with the non-PFRP group.

CONCLUSIONS

The results suggest that the PFRP improved pelvic floor dysfunction and QoL of gynecological cancer patients. A larger randomized controlled trial is planned.

Severe Pelvic Floor Symptoms After Cervical Cancer Treatment Are Predominantly Associated With Mental and Physical Well-Being and Body Image: A Cross-Sectional Study

Objective

To identify associations between demographic, disease-related, and psychological variables and severe distress from pelvic floor symptoms (PFSs) after cervical cancer treatment.

Methods

This study was cross-sectional and questionnaire based. We included patients with cervical cancer treated between 1997 and 2007 in the Academic Medical Center, Amsterdam. Pelvic floor symptoms were assessed with urogenital distress inventory and defecatory distress inventory. Scores were dichotomized into severe (>90th percentile) versus nonsevere distress. Disease-related variables were extracted from medical files. Psychological factors included mental and physical well-being, optimism, and body image, which were assessed with standardized questionnaires. Univariate and multivariate logistic regression analyses were performed.

Results

A total of 282 patients were included: 148 were treated with radical hysterectomy and pelvic lymph node dissection, 61 patients were treated with surgery and adjuvant radiotherapy, and 73 patients were treated with primary radiotherapy. Demographic: Multivariate analyses showed no significant relation between demographic variables and symptoms. Disease-related: None of these variables were significantly associated in multivariate analyses. Psychosocial: In all treatment groups, multivariate associations were found. In general, better mental and physical well-being was associated with nonsevere PFSs. Increased body image disturbance was associated with severe defecation symptoms.

Conclusions

Few associations were found between demographic and disease-related variables and distress from PFS after cervical cancer treatment. However, better mental and physical well-being is associated with nonsevere distress from urogenital and defecation symptoms and more body image disturbance with severe PFSs. Improving these factors might reduce distress from PFSs and should be a focus of future research.

Origins and distribution of nerves to the female urinary bladder: new anatomical findings in the sex differences

The development of nerve-sparing procedures is important in preventing bladder dysfunction following radical hysterectomy. In this study, we dissected 14 halves of 7 female pelvises (age range: 46-86 years; mean age: 74 years) to examine the origins, courses, and distributions of nerve branches to the bladder in females in detail, and 6 halves of 3 male pelvises (age range: 71-85 years, mean age: 78 years) to compare with the female specimens. Nerve branches to the bladder originated mainly from the inferior hypogastric plexus, but independent direct branches running along the ureter from the hypogastric nerve were also distributed particularly to the trigone in all female specimens. We classified these independent branches into four types according to their relationship to the ureter. In males the numbers of the independent branches were small and they were difficult to find. The present observations indicate that nerve distribution patterns to the bladder differ between females and males. In nerve sparing procedures for radical hysterectomy, the area between the ureter and the hypogastric nerve is important.