Abstract
Introduction and hypothesis
The aim of this review is to provide a comprehensive overview of the current role of nerve-sparing radical hysterectomy (NSRH) in reducing the incidence of postoperative lower urinary tract dysfunction (LUTD) and in improving quality of life.
Methods
A detailed online search was performed using the following keywords: nerve sparing, radical hysterectomy, cervical cancer, and all these terms in combination with urinary dysfunction or bladder dysfunction in order to analyze the effect of NSRH on urinary functional outcomes. Articles retrieved were analyzed and assigned a level of evidence (LE) according to the criteria of the Centre for Evidence-Based Medicine in Oxford, UK.
Results
Our review highlights the heterogeneity of conducting and reporting studies in the literature. Autonomic pelvic nerve injuries during the procedure are thought to be the major cause of LUTD. The amount of LUTD depends upon the extent and type of nerve injury. Anatomically based surgical techniques are developed to avoid nerve injury without compromising oncological control. All studies comparing NSRH to standard RH yielded promising results with respect to postoperative LUTD. A recent meta-analysis showed similar cancer control rates between the two techniques. However, controversies remain about the ideal surgical approach for nerve sparing and there is no consensus as to the level and landmarks of dissection to preserve the maximal amount of nerves without compromising oncological outcomes.
Conclusions
Available evidence suggests that NSRH is safe and associated with lower incidence of LUTD. However, there is no standardized technique for NSRH and controversies remain about its oncological safety. Long-term oncological data from multicenter surgical trials are needed as well as a universally accepted standard to report studies on NSRH.
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References
Corusić A, Skrgatić L, Mahovlić V, Mandić V, Planinić P, Karadza M (2010) Cervical cancer as a public health issue—what next? Coll Antropol 34(1):301–307
Arbyn M, Castellsagué X, de Sanjosé S, Bruni L, Saraiya M, Bray F, Ferlay J (2011) Worldwide burden of cervical cancer in 2008. Ann Oncol 22(12):2675–2686
Wallace A, Havrilesky L, Valea F, Barnett J, Berchuck A, Myers E (2010) Projecting the need for gynecologic oncologists for the next 40 years. Obstet Gynecol 116(6):1366–1372
Zullo M, Mancini N, Angioli R, Muzii L, Benedetti Panici P (2003) Vesical dysfunctions after radical hysterectomy for cervical cancer: a critical review. Crit Rev Oncol Hematol 48:287–293
Watson M, Saraiya M, Benard V, Coughlin SS, Flowers L, Cokkinides V, Schwenn M, Huang Y, Giuliano A (2008) Burden of cervical cancer in the United States, 1998–2003. Cancer 113(10 Suppl):2855–2864. doi:10.1002/cncr.23756
Kim SM, Choi HS, Byun JS (2000) Overall 5-year survival rate and prognostic factors in patients with stage IB and IIA cervical cancer treated by radical hysterectomy and pelvic lymph node dissection. Int J Gynecol Cancer 10(4):305–312
Phillips B, Ball C, Sackett D, et al. Levels of evidence and grades of recommendation. Oxford Centre for Evidence-Based Medicine. Available via http://www.cebm.net/index.aspx
Wells G, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa Hospital Research Institute. Available via http://www.ohri. ca/programs/clinical_epidemiology/oxford.asp
Turner L, Shamseer L, Altman DG, Weeks L, Peters J, Kober T, Dias S, Schulz KF, Plint AC, Moher D (2012) Consolidated standards of reporting trials (CONSORT) and the completeness of reporting of randomised controlled trials (RCTs) published in medical journals. Cochrane Database Syst Rev 11:MR000030. doi:10.1002/14651858.MR000030.pub2
Chai TC, Steers WD (1997) Neurophysiology of micturition and continence in women. Int Urogynecol J Pelvic Floor Dysfunct 8:85–97
Clemens QJ (2010) Basic bladder neurophysiology. Urol Clin North Am 37:487–494
DeLancey JO (1988) Structural aspects of the extrinsic continence mechanism. Obstet Gynecol 72:296–301
Stepp K, Walters M (2007) Anatomy of the lower urinary tract, rectum, and pelvic floor. In: Walters M, Karram M (eds) Urogynecology and reconstructive pelvic surgery. Mosby Elsevier, Philadelphia, pp 17–30
Fowler CJ (1996) Investigation of the neurogenic bladder. J Neurol Neurosurg Psychiatry 60:6–13
Benson J, Walters M (2007) Neurophysiology and pharmacology of the lower urinary tract. In: Walters M, Karram M (eds) Urogynecology and reconstructive pelvic surgery. Mosby Elsevier, Philadelphia, pp 31–43
Rob L, Strnad P, Robova H, Charvat M, Pluta M, Schlegerova D, Hrehorcak M (2005) Study of lymphatic mapping and sentinel node identification in early stage cervical cancer. Gynecol Oncol 98(2):281–288
Raspagliesi F, Ditto A, Hanozet F, Martinelli F, Solima E, Zanaboni F, Kusamura F, Fontanelli R (2007) Nerve-sparing radical hysterectomy in cervical cancer: evolution of concepts. Gynecol Oncol 107(1 Suppl 1):S119–S221
Possover M, Stöber S, Plaul K, Schneider A (2000) Identification and preservation of the motoric innervation of the bladder in radical hysterectomy type III. Gynecol Oncol 79:154–157
Andersson KE, Arner A (2004) Urinary bladder contraction and relaxation: physiology and pathophysiology. Physiol Rev 84:935–986
Seski JC, Diokno AC (1977) Bladder dysfunction after radical abdominal hysterectomy. Am J Obstet Gynecol 128:643–651
Glahn B (1970) The neurogenic factor in vesical dysfunction following radical hysterectomy for carcinoma of the cervix. Scand J Urol Nephrol 4(2):107–116
Barclay D, Roman-Lopez J (1975) Bladder dysfunction after radical hysterectomy. One-year follow-up. Am J Obstet Gynecol 123(5):519–526
Forney JP (1980) The effect of radical hysterectomy on bladder physiology. Am J Obstet Gynecol 138:374–382
Low J, Mauger GM, Carmichael J (1981) The effect of Wertheim hysterectomy upon bladder and urethral function. Am J Obstet Gynecol 139:826–834
Griffiths D, Höfner K, van Mastrigt R, Rollema HJ, Spångberg A, Gleason D (1997) Standardization of terminology of lower urinary tract function: pressure-flow studies of voiding, urethral resistance, and urethral obstruction. International Continence Society Subcommittee on Standardization of Terminology of Pressure-Flow Studies. Neurourol Urodyn 16(1):1–18
Hamada K, Kihana T, Kataoka M, Yoshioka S, Nishio S, Matsuura S, Ito M (1999) Urinary disturbance after therapy for cervical cancer: urodynamic evaluation and beta2-agonist medication. Int Urogynecol J Pelvic Floor Dysfunct 10(6):365–370
Axelsen SM, Petersen LK (2006) Urogynaecological dysfunction after radical hysterectomy. Eur J Surg Oncol 32:445–449
Haferkamp A, Dörsam J, Resnick NM et al (2003) Structural basis of neurogenic bladder dysfunction. III. Intrinsic detrusor innervation. J Urol 169:555–562
Chuang TY, Yu KJ, Penn IW et al (2003) Neurourological changes before and after radical hysterectomy in patients with cervical cancer. Acta Obstet Gynecol Scand 82:954–959
Maneschi F, Ianiri P, Sarno M et al (2012) Nerve-sparing class III-IV radical hysterectomy: urodynamic study and surgical technique. Int J Gynecol Cancer 22:675–680
Rees PM, Fowler CJ, Maas CP (2007) Sexual function in men and women with neurological disorders. Lancet 369:512–525
Maas CP, de Ruiter MC, Kenter GG, Trimbos JB (1999) The inferior hypogastric plexus in radical hysterectomy. J Gynecol Tech 5:55–62
Trimbos JB, Maas CP, DeRuiter MC, Peters AA, Kenter GG (2001) A nerve-sparing radical hysterectomy: guidelines and feasibility in Western patients. Int J Gynecol Cancer 11:180–186
Vierhout M (2001) Influence of nonradical hysterectomy on the function of the lower urinary tract. Obstet Gynecol Surv 56:381–386
Butler-Manuel S, Buttery L, A’Hern R, Polak J, Barton D (2000) Pelvic nerve plexus trauma at radical hysterectomy and simple hysterectomy: the nerve content of the uterine supporting ligaments. Cancer 89:834–841
Butler-Manuel S, Buttery L, A’Hern R, Polak J, Barton D (2002) Pelvic nerve plexus trauma at radical and simple hysterectomy: a quantitative study of nerve types in the uterine supporting ligaments. J Soc Gynecol Investig 9:47–56
Ralph G, Tamussino K, Lichtenegger W (1988) Urodynamics following radical abdominal hysterectomy for cervical cancer. Arch Gynecol Obstet 243:215–220
Kadar N, Saliba N, Nelson JH (1983) The frequency, causes and prevention of severe urinary dysfunction after radical hysterectomy. Br J Obstet Gynaecol 90:858–863
Riss P, Koelbl H, Neunteufel W, Janisch H (1988) Wertheim radical hysterectomy 1921–1986: changes in urologic complications. Arch Gynecol Obstet 241:249–253
Eicke M, Hohenfellner R, Leissner J (2005) Nerve injuries in urologic surgery. In: Hohenfellner R, Fitzpatrick J, McAninch J (eds) Advanced urologic surgery. Blackwell, Malden, pp 488–493
Zochodne DW (2002) Nerve and ganglion blood flow in diabetes: an appraisal. Int Rev Neurobiol 50:161–202
Dail WG (1996) The pelvic plexus: innervation of pelvic and extrapelvic visceral tissues. Microsc Res Tech 35:95–106
Höckel M, Konerding MA, Heussel CP (1998) Liposuction-assisted nerve-sparing extended radical hysterectomy: oncologic rationale, surgical anatomy, and feasibility study. Am J Obstet Gynecol 178:971–976
Raspagliesi F, Ditto A, Fontanelli R, Solima E, Hanozet F, Zanaboni F, Kusamura S (2004) Nerve-sparing radical hysterectomy: a surgical technique for preserving the autonomic hypogastric nerve. Gynecol Oncol 93:307–314
Barton DP, Butler-Manuel SA, Buttery LD, A’Hern RP, Polak JM (2002) A nerve-sparing radical hysterectomy: guidelines and feasibility in Western patients. Int J Gynecol Cancer 12:319
Yabuki Y, Asamoto A, Hoshiba T, Nishimoto H, Kitamura S (1991) Dissection of the cardinal ligament in radical hysterectomy for cervical cancer with emphasis on the lateral ligament. Am J Obstet Gynecol 164:7–14
Nagai T, Niikura H, Kurosawa H, Tanaka S, Otsuki T, Utunomiya H, Nagase S, Takano T, Ito K, Kaiho Y, Nakagawa H, Arai Y, Yaegashi N (2012) Individualized radical hysterectomy procedure using intraoperative electrical stimulation for patients with cervical cancer. Int J Gynecol Cancer 22(9):1591–1596
Fujii S, Takakura K, Matsumura N, Higuchi T, Yura S, Mandai M, Baba T, Yoshioka S (2007) Anatomic identification and functional outcomes of the nerve sparing Okabayashi radical hysterectomy. Gynecol Oncol 107(1):4–13
Possover M, Quakernack J, Chiantera V (2005) The LANN technique to reduce postoperative functional morbidity in laparoscopic radical pelvic surgery. J Am Coll Surg 201(6):913–917
Sakuragi N, Todo Y, Kudo M, Yamamoto R, Sato T (2005) A systematic nerve-sparing radical hysterectomy technique in invasive cervical cancer for preserving postsurgical bladder function. Int J Gynecol Cancer 15(2):389–397
Trimbos J, van den Tillaart S, Maas C, Peters A, Gaarenstroom K, DeRuiter M, Kenter G (2008) The Swift operation: a modification of the Leiden nerve-sparing radical hysterectomy. Gynecol Surg 5(3):193–198
Höckel M, Horn L, Hentschel B, Höckel S, Naumann G (2003) Total mesometrial resection: high resolution nerve-sparing radical hysterectomy based on developmentally defined surgical anatomy. Int J Gynecol Cancer 13:791–803
Kato T, Murakami G, Yabuki Y (2003) A new perspective on nerve-sparing radical hysterectomy: nerve topography and over-preservation of the cardinal ligament. Jpn J Clin Oncol 33(11):589–591
Shen-Gunther J, Shank L (2010) Nerve-sparing radical hysterectomy using modern bipolar electrosurgical instruments based on the Force Triad energy platform. Mil Med 175(8):610–615
Mantzaris G, Rodolakis A, Vlachos G, Athanasiou S, Theocharis S et al (2008) Magnifying lenses assisted nerve-sparing radical hysterectomy and prevention of nerve plexus trauma. Int J Gynecol Cancer 18:868–875
Zhu T, Yu AJ, Shou HF, Chen X, Zhu JQ et al (2011) Feasibility of unilateral or bilateral nerve-sparing radical hysterectomy in patients with cervical cancer and evaluation of the post-surgery recovery of the bladder and rectal function. Zhonghua Zhong Liu Za Zhi 33:53–57
Chen C, Huang L, Liu P, Su G, Li W, Lu L, Wang L, Li X, Hui Duan H, Zou C, Hatch K (2014) Neurovascular quantitative study of the uterosacral ligament related to nerve-sparing radical hysterectomy. Eur J Obstet Gynecol Reprod Biol 172:74–79
Chen C, Li W, Li F, Liu P, Zhou J, Lu L, Su G, Li X, Guo Y, Huang L (2012) Classical and nerve-sparing radical hysterectomy: an evaluation of the nerve trauma in cardinal ligament. Gynecol Oncol 125(1):245–251
Chen Y, Li Y, Xu HC, Li JN, Li YY et al (2009) Laparoscopic anatomical nerve sparing radical hysterectomy for cervical cancer: a clinical analysis of 37 cases. Zhonghua Fu Chan Ke Za Zhi 44:359–363
Long Y, Yao DS, Gao K, Xie XL (2010) Preliminary study on clinical effect of nerve sparing radical hysterectomy for cervical cancer. Chin Clin Oncol 15:1083–1090
Liang Z, Chen Y, Xu H, Li Y, Wang D (2010) Laparoscopic nerve-sparing radical hysterectomy with fascia space dissection technique for cervical cancer: description of technique and outcomes. Gynecol Oncol 119:202–207
Lu Y, Yao DS, Mo LZ, Li F, Pan ZM (2012) Preliminary clinical study of laparoscopic pelvic autonomic nerve-plane sparing radical hysterectomy. Chin Clin Oncol 17:347–350
Long Y, Yao DS, Pan X, Ou T (2014) Clinical efficacy and safety of nerve-sparing radical hysterectomy for cervical cancer: a systematic review and meta-analysis. PLoS One 9(4):e94116. doi:10.1371/journal.pone.0094116
Raspagliesi F, Ditto A, Fontanelli R, Zanaboni F, Solima E et al (2006) Type II versus type III nerve-sparing radical hysterectomy: comparison of lower urinary tract dysfunctions. Gynecol Oncol 102:256–262
Todo Y, Kuwabara M, Watari H, Ebina Y, Takeda M et al (2006) Urodynamic study on postsurgical bladder function in cervical cancer treated with systematic nerve-sparing radical hysterectomy. Int J Gynecol Cancer 16:369–375
Li B, Zhang R, Wu LY, Zhang GY, Li X et al (2008) A prospective study on nerve-sparing radical hysterectomy in patients with cervical cancer. Zhonghua Fu Chan Ke Za Zhi 43:606–610
Sun L, Wu LY, Zhang WH, Li XG, Song Y et al (2009) Preliminary study of nerve sparing radical hysterectomy in patients with cervical cancer. Zhonghua Zhong Liu Za Zhi 31:607–611
van den Tillaart SA, Kenter GG, Peters AA, Dekker FW, Gaarenstroom KN et al (2009) Nerve-sparing radical hysterectomy: local recurrence rate, feasibility, and safety in cervical cancer patients stage IA to IIA. Int J Gynecol Cancer 19:39–45
Skret-Magierlo J, Naróg M, Kruczek A, Kluza R, Kluz T et al (2010) Radical hysterectomy during the transition period from traditional to nerve-sparing technique. Gynecol Oncol 116:502–505
Wu J, Liu X, Hua K, Hu C, Chen X et al (2010) Effect of nerve-sparing radical hysterectomy on bladder function recovery and quality of life in patients with cervical carcinoma. Int J Gynecol Cancer 20:905–909
Ditto A, Martinelli F, Mattana F, Reato C, Solima E et al (2011) Class III nerve-sparing radical hysterectomy versus standard class III radical hysterectomy: an observational study. Ann Surg Oncol 18:3469–3478
Kanao H, Fujiwara K, Ebisawa K, Hada T, Ota Y, Andou M (2014) Various types of total laparoscopic nerve-sparing radical hysterectomies and their effects on bladder function. J Gynecol Oncol 25(3):198–205
Tseng CJ, Shen HP, Lin YH, Lee CY, Wei-Cheng CW (2012) A prospective study of nerve-sparing radical hysterectomy for uterine cervical carcinoma in Taiwan. Taiwan J Obstet Gynecol 51:55–59
Zhang Y, Wang D, Ma Y, Pan CQ (2010) A clinical study of surgical treatment of the cervical cancer with laparoscopic nerve sparing radical hysterectomy. Prog Obstet Gynecol 19:31–32
Wang W, Li B, Zuo J, Zhang G, Yang Y, Zeng H, Li X, Wu L (2014) Evaluation of pelvic visceral functions after modified nerve-sparing radical hysterectomy. Chin Med J 127(4):696–701
Cibula D, Velechovska P, Sláma J, Fischerova D, Pinkavova I, Pavlista D, Dundr P, Hill M, Freitag P, Zikan M (2010) Late morbidity following nerve-sparing radical hysterectomy. Gynecol Oncol 116(3):506–511
Ceccaroni M, Roviglione G, Spagnolo E, Casadio P, Clarizia R, Peiretti M, Bruni F, Peters I, Aletti G (2012) Pelvic dysfunctions and quality of life after nerve-sparing radical hysterectomy: a multicenter comparative study. Anticancer Res 32(2):581–588
Kavallaris A, Hornemann A, Chalvatzas N, Luedders D, Diedrich K, Bohlmann MK (2010) Laparoscopic nerve-sparing radical hysterectomy: description of the technique and patients’ outcome. Gynecol Oncol 119(2):198–201
Sakamoto S, Takizawa K (1988) An improved radical hysterectomy with fewer urological complications and with no loss of therapeutic results for invasive cervical cancer. Baillieres Clin Obstet Gynaecol 2(4):953–962
Lin YS (2003) Preliminary results of laparoscopic modified radical hysterectomy in early invasive cervical cancer. J Am Assoc Gynecol Laparosc 10(1):80–84
Park NY, Chong GO, Hong DG et al (2011) Oncologic results and surgical morbidity of laparoscopic nerve-sparing radical hysterectomy in the treatment of FIGO stage IB cervical cancer: long-term follow-up. Int J Gynecol Cancer 21:355–362
Puntambekar SP, Patil A, Joshi SN et al (2010) Preservation of autonomic nerves in laparoscopic total radical hysterectomy. J Laparoendosc Adv Surg Tech A 20:813–819
Magrina JF, Pawlina W, Kho RM et al (2011) Robotic nerve-sparing radical hysterectomy: feasibility and technique. Gynecol Oncol 121:605–609
Querleu D, Narducci F, Poulard V, Lacaze S, Occelli B, Leblanc E et al (2002) Modified radical vaginal hysterectomy with or without laparoscopic nerve-sparing dissection: a comparative study. Gynecol Oncol 85:154–158
Rob L, Halaska M, Robova H (2010) Nerve-sparing and individually tailored surgery for cervical cancer. Lancet Oncol 11:292–301
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Aoun, F., van Velthoven, R. Lower urinary tract dysfunction after nerve-sparing radical hysterectomy. Int Urogynecol J 26, 947–957 (2015). https://doi.org/10.1007/s00192-014-2574-8
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DOI: https://doi.org/10.1007/s00192-014-2574-8