| The classical surgical management of early-stage cervical carcinoma, known as radical hysterectomy(RH), was first described by Wertheim more than one hundred years ago and was then modified and repopularized by Meigs in 1950s. This operation yields 5-year survival rates of 80%~90%. But radical hysterectomy for early cervical cancer is associated with typical postoperative morbidity: bladder disfunction, sexual disfunction and colorectal motility disorders. Accidental damage the pelvic autonomic nerves during the surgery is thought to play a crucial role in the aetiology of the morbidity after radical hysterectomy. Therefore, some gynecologists have focused on preserving the pelvic nerves without reducing the radicality of surgery. The new technique is called nerve sparing radical hysterectomy(NSRH).§1 Nerve sparing radical hysterectomy versus radical hysterectomy for cervical cancer: a Systematic ReviewObjective: To evaluate the clinical efficiency and safety of nerve sparing radical hysterectomy(NSRH) for cervical cancer compare with radical hysterectomy (RH). Methods: We searched the Cochrane Library, MEDLINE, EMbase, CBM, CQVIPand CNKI, we also handsearched some Chinese journals. Using a defined search strategy, randomized controlled trails and controlled clinical trials of comparing NSRH with RH for cervical cancer were identified. Data were extracted and evaluated by two reviewers independently. The quality of the included trails was evaluated by Cochrane's evaluation criterion. Meta–analysis was done using the Cochrane collaboration's Revman4.2.2. Results: Nine controlled clinical trials(749 patients)were included, The meta-analysis showed that: NSRH is beneficial for recover of postoperative bladder function versus RH with a significant difference; The operative time of NSRH is longer than RH with a significant difference; there are no significant difference between the two groups in terms of the blood loss, extension of resection, survival and recrudescent rate and pathologic outcome. One trail showed that NSRH is beneficial for recovery of postoperative anorectal and sexual functions function with a significant difference versus RH. Conclusions: NSRH can improve the recovery of postoperative bladder, anorectal and sexual functions compare with RH, but have no more operative blood loss, less extension of resection, lower survival rates and higher recrudescent rates except longer operation time. NSRH can improve quality of life in patients after operation and is not associated with reducing safety of surgery. However, the trails available for this systematic review are limited, as well as non-randomized controlled trails. Some outcomes were only included by one trail. So there is no confirmed conclusion about these. A prospective randomized controlled trial is warranted to fully investigate.§2 Clinical pelvic anatomical study for NSRHObjective: We studied the composing, place, route of pelvic autonomic nerve through anatomizing cadavers to lay a base for NSRH. Methods: Macroscopical dissection was performented on four female cadavers without pelvic surgery were fixed by 10% formaldehyde. Record ways include character, photo and so on. Results: Inferior hypogastric plexus is composed of hypogastric nerve, pelvic splanchnic nerve and sacral sympathetic nerve, and delivers nerves that dominate bladder, rectum and uterus. Conclusion: Gynecologist should pay attention to pelvic anatomical study because it can lay a base for surgery.§3 Preliminary study on clinical effect of NSRH for cervical cancerObjective: To evaluate the clinical effect of NSRH and the feasibility of this technique. Methods: Between April 2008 and October 2009, sixty-nine patients with FIGO stageⅠb~Ⅱb cervical cancer were selected to receive NSRH(study group, 33 cases)or TypeⅢradical hysterectomy(RH)(control group, 36 cases). The urethra /bladder and anal/ rectum function after the operation, duration of surgery, blood loss and the excision extent were compared between the two groups. Results: The time to achieve a postvoid residual urine volume (PVR) less than 100 ml of study group and control group were 12.64±4.49d and 17.89±4.19d(P<0.001), the time to achieve PVR less than 50ml were 14.30±5.87d and 19.69±4.48d(P<0.001); the first exhaust time were 62.99±11.99h and 79.32±13.22h(P<0.001), the first stool time were 95.42±12.54h and 120.04±21.00h(P<0.001), all with a significant difference. Urodynamic study on postoperative bladder function in partial patients show that there were a significant difference between two groups in storage phase and voiding phase.The median blood loss during whole operation were 750ml (350~1800ml)and 700ml(300~1800ml)(P >0.05), The median blood loss during uterus removal were 610ml(180~1200ml) and 550ml(150~1200ml) (P>0.05), with no significant difference; The median whole operation time were 252min (180~330min) and 205min(150~270min) (P<0.05), The median operation time of uterus removal were 89min(65~105min) and 70min(55~90min)(P<0.05), with a significant difference; There is no difference between two groups in the excision extent of cardinal ligament and uterosacral ligament. Conclusion: Nerve sparing radical hysterectomy(NSRH) for the patients with FIGO stageⅠb~Ⅱb cervical cancer is safe and feasible,and improve the recovery of postoperative bladder and rectum function.§4 Histopathological sdudy on pelvic nerves for NSRHObjective:Compare nerves density of surgical margins of uterosacral ligament, cardial ligament and vesicouterine ligament in NSRH with in RH. Methods: Specimens of surgical margins in NSRH and RH were fixed by 10% formaldehyde. HE staining, silver staining and immunochemistry staining(S100) were performed. Immunohistochemical outcome is analyzed by image analytical method to calculate nerves proportion. Results: Nerves can be show in three staining ways. Nerves were less in sdudy group than in control group under microscopical view. There is a significance difference between two groups according to nerves proportion(P<0.05). Conclusion: NSRH can avoid damaging pelvic nerves during surgery effectively.§5 Investigation of quality of life and sexual function in cervical cancer patients treated by surgeryObjective:To compare quality of life and sexual function in patients with cervical cancer treated with NSRH or RH and the factors influence sexual function after surgery . Methods:Between April 2008 and October 2009, sixty-five patients with FIG0 stageⅠb~Ⅱb cervical cancer were selected to receive NSRH(study group, 31cases) or Piver-RutledgeIII radical hysterectomy (RH)(control group, 34 cases). EORTC QLQ C-30 and FSFI were used to score the quality of life and sexual function, and multivariate linear regression regression was used to analyse the factors influence sexual function. Results:Quality of life and sexual function were impaired in all patients after surgery. Except sexual desire, the remaining five index and overall sores indicate that sexual function is better in study group than in control group(P<0.05). There was a significant difference between two groups in physical function, fatigue, constipation, diarrhea in quality of life(P<0.05). Age, the time of end of treatment, ovariotomy, clinical staging, occupation and education were related to the sexual function of patients with cervical cancer. Conclusion:NSRH compares with RH, can improve postoperative quality of life and sexual function in patients with cervical cancer. Postoperative sexual function is affected not only by surgery technique, but also many factors. Psychological counseling, life guidance and adjuvant therapy should be used to improve the sexual function of patients with cervical cancer after treatment. |
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