Ultrasound Imaging-Urodynamic Study In Urinary Tract Dysfunction After Radical Hysterectomy For Women With Cervical Cancer

Background and objectiveRadical hysterectomy and Pelvic lymphadenectomy have been applied to the management of the cervical carcinoma with stage Ib-Iia. Functional disorders of the lower urinary tract are the most common long-term complications following radical surgery for cancer of the uterine cervix (8%～80%). Furthermore,up to one half of patients undergoing radical hysterectomy experience at least one symptom of lower genitourinary tract disturbance as a result of surgery over longer or shorter periods of time.Serious bladder dysfunction has been reported in up to 10%～32% of patients. It can be manifest itself as an inability to void spontaneously,urinary retention, a decreased force of stream,urinary strain,hestitancy,intermittency, a sense of residual,frequency, urgency, incontinence, and nocturia. These disturbances,namely neurogenic bladder,were associated to the partial interruption of the autonomic fibers innervating the bladder during the resection of anterior, lateral and posterior parametrium and vaginal cuff. The pathophysiology of these changes is actually debated. The nature of the surgical damage appears to be a decentralization rather than a complete denervation and bladder dysfunctions may be either the unmasking of intrinsic detrusor activity, characterized by a loss of beta-adrenergic innervation and a consequent alfa-adrenergic hyperinnervation or the influence of remaining sympathetic innervation.Urodynamic study has been used to evaluate the function of bladder, urethral and pelvic floor during both filling and voiding phrase. The exam is required to imitate the symptoms of daily activities in the controlled circumstances, through which urodynamic machine can determine the function status of bladder and urethral and find out the possible reasons. Today, the role of routine urodynamic techniques is somewhat limited as the improvement of requirement on the disease diagnosis. Routine urodynamic technique can find out only the function changes, but not morphological changes. Ultrasound can clearly observe the position and mobolity of the bladder neck not only at rest and stress,and the deepth of the bladder wall, the activity of the pelvic floor and residual volume. Ultrasound-imaging urodynamics techniques can find out the changes of both function and morphology, and make them support each other, and give a thorough explanation on the diseases. Domestic studies fall behind the western countries because of the poor equipments and skills. With the using of the ultrasound as assist, the risk and the cost will decrease to such a level that most researchers and patients could accept.In order to investigate the function changes of the loewer urinary tract after the operation of the cervical cancer, by means of the ultrasound-imaging urodynamics, Fourty-six women with cervical cancer were accepted surgery of radical hysterectomy and pelvic lymphadenectomy. The main of the research is to evaluated the function of the bladder and urinary before and after the surgery. We hope to find a new skills to benefit for the diagnosis and treat and to prevent form the subsequent damage of the cervical cancer.Materials and methods1. From May 2003 to January 2006, forty-six women (mean 46±9years) with uterine cervical carcinoma at stage Ib or IIa who underwent radical hysterectomy and bilateral lymph node dissection were recurited to this study,and complete pre- and postoperative B ultrasound imging-urodynamic follow-ups were conducted for each patient. There were 35 cases with stage Ib cervical cancer and 11 cases with stage Ha cervical cancer. These women did not receive adjuvant radiation during the interval between the radical hysterectomy and the urodynamic study. The diagnosis was made by over two experienced doctors on gynecological tumor based on the history,clinical appearences,and pathology. The clinical stage was accorded to the standard of the FIGO in 2002.2. We used DUET Logic urodynamic device from Denmark. ICS standards were carried out. The exam included uroflowmetry, cystometry, UPP and EMG Other parameters were max flow rate (MFR), post void residual (PVR), maximum cystometric capacity (MCC), Pdet at Qmax, bladder compliance (BC), and max urethral closure pressure (MUCP). Ultrasound examinations were carried out simultaneously with cystometry.3. DP-8800 ultrasound device (Mindary, China) was used in the exams. Electric convex array probe (65EC10EA, 6.5MHz) was applied in introital ultrasonograph. Introital ultrasound examination was performed in a supine position, Position of bladder neck and deepth of bladder wall were monitored when bladder filling was 200 ml at rest.4. SPSS 11.0 was used. Data was presented as mean±standard deviation. T test for paired- samples were used.α=0.05 was considered as significance.Results1. After the radical hysterectomy ,the lower urinary tract symptoms were reported with urinary frequency, urgency, incontinence, and voiding difficult. The voiding dysfunction was present in 20 patient (43.5%) and stress urinary incontinence in 12 patients (26.1%). Urinary frequency and urgency were found in 8 patients(17.4%). Only 6 patients were satisfied with their sense of voiding.2. Twenty-six women (56.5%) who had preoperatively had normal urinary tract function needed to void by abdominal strainning after radical surgery; and the urinary stream is intermit.3. After the radical hysterectomy , the max flow rate ,average flow rate and voiding volume are decreased significantly(P<0.05), but the postvoid residual volume increased obviously(P<0.05).4. After the radical hysterectomy , the normal desire to void and maximal capacity increased significantly(P<0.05), but the bladder compliance,detrusor function , maxmial detrusor pressure decreased obviously(P<0.05).5. After the radical hysterectomy , the functional urethral length decreased obviously(P<0.05), but the max urethral pressure and max urethral closure pressure did not changed(P>0.05)6. After the radical hysterectomy , no significant changes had been noted about the deepth of the bladder wall and the position of the bladder neck(P>0.05) .7. Four women had preoperative pressures lower than 25 cmH20 at the maxmial detrusor pressure,but fourteen women had postoperative pressures higher than 25 cmH20. Four women had one or two hydronephrosis at the average eleven months after the radical hysterectomy.Conclusions1. The lower urinary tract dysfunction after the radical hysterectomy were the decreased bladder compliance and detrusor function, also including the relaxation of the proximal urethra.2. The free urinary flow measure can be the principial ridding method for detecting voiding dysfunction after operaction.3. The complete ultrasound imaging-urodynamic study is necessary to prevent and treat these urinary dysfunctions advancedly. Careful follow-up including urodynamic study may be mandatory for patients after radical hysterectomy.