Urinary and anal dysfunction after laparoscopic versus laparotomic radical hysterectomy.

OBJECTIVE: The aim of this study was to compare urinary and anal dysfunction after laparoscopic (LRH) and abdominal (ARH) radical hysterectomy for cervical cancer. STUDY DESIGN: Consecutive patients who underwent radical hysterectomy for treatment of cervical cancer were enrolled in this study and divided into two groups, according to the surgical approach. Urinary and anal symptoms were evaluated before and 6 months after surgery. RESULTS: Fifty-four women were considered: 27 LRH and 27 ARH. Urinary incontinence was significantly more frequent both after LRH (37% vs 86.9%, p=0.0004) and after ARH (33.3% vs 100%, p<0.0001); urge incontinence (3.7% vs 29.6%, p=0.02) and increased bladder sensation (0 vs 22.2%, p=0.02) were significantly more common postoperatively in patients undergone ARH. In both groups more patients complain about increase of straining during voiding (LRH: 0 vs 34.7%, p=0.009; ARH: 3.7% vs 29.6% p=0.02) after surgery. Postoperative constipation by obstructed defecation was more frequent after ARH (Wexner score: 0 vs 2, p=0.03) but not after LRH. CONCLUSION: From our results, laparoscopic approach for radical hysterectomy seems to reduce the postoperative occurrence of urge incontinence, increased bladder sensation and constipation by obstructed defecation, in comparison with abdominal radical surgery.

Bladder function after radical hysterectomy for cervical cancer.

AIM: To report the effects of radical hysterectomy and nerve-sparing techniques on lower urinary tract function in women. METHODS: A literature search was performed in Pubmed and Medline using the keywords bladder after radical hysterectomy, nerve sparing radical hysterectomy, and urinary dysfunction following radical hysterectomy. Significant results and citations were reviewed manually by the authors. RESULTS: The sympathetic and parasympathetic systems innervating the lower urinary tract may be disrupted due to resection of uterosacral and rectovaginal ligaments, the dorsal and lateral paracervix, the caudal part of the vesico-uterine ligaments, and the vagina. This supports the neurogenic etiology of early and late bladder dysfunction after radical surgery. Bladder disorders are also related to the extent of radical surgery. The neuropathopysiology of lower urinary tract symptoms after radical hysterectomy is not fully understood. Recent data have highlighted the role of urethral sphincter pressure in the etiology of postoperative incontinence. Various surgical approaches have been developed to preserve autonomic pelvic innervation. CONCLUSIONS: Nerve-sparing techniques appear to improve bladder function without compromising overall survival. Studies comparing the effects of nerve-sparing radical hysterectomy with standard surgery yielded encouraging results in respect of postoperative lower urinary tract function. Clinical trials with a long period of follow-up are required for better comprehension of the complex pathophysiology of bladder dysfunction after radical hysterectomy.

Defining female voiding dysfunction: ICI-RS 2011.

Whilst symptoms of bladder outlet obstruction (BOO) and post micturition symptoms are more commonly reported in men a significant number of women may also complain of voiding dysfunction. However, despite the recent advances in the standardisation of terminology of lower urinary tract dysfunction there remains a lack of consensus regarding a precise diagnosis and definition of voiding abnormalities in women. In addition voiding symptoms may co-exist with storage symptoms as well as those associated with urinary incontinence. Consequently many patients present with a spectrum of different urinary symptoms, related to both storage and voiding, which may be multifactorial in origin or be related to one another. The purpose of this paper is to review the current literature in order to accurately define and classify female voiding dysfunction including causes and aetiology. In addition to reviewing the investigation and management of those women with voiding dysfunction recommendations are proposed for management in clinical practice as well as suggestions for future research.

Mesh complications following prolapse surgery: management and outcome.

OBJECTIVE: This is a description of complications following prolapse surgery with the use of alloplastic materials, the management and outcome. STUDY DESIGN: 54 women have been referred to Mainz, urogynecology referral center due to complications following mesh-augmented prolapse surgery. RESULTS: The complaints who lead to the admission are expressed by the new terminology and standardized classification for complications arising directly from the insertion of prostheses and grafts in female pelvic floor surgery [1]. Pain (66.7%), mesh erosion (55.6%) and vaginal discharge (48.1%) were the most frequent complaints. Revision was performed after a median time of 27.2 months post mesh implantation. Nine patients underwent limited excision of the mesh, 49 had a vaginal revision with wide mesh removal and 10 had a laparotomy with wide mesh removal. After 3 months 48 patients had a follow-up, 25 could have been relieved from their complaints. CONCLUSION: Although the incidence is low, complications after prolapse repair with mesh use are difficult to prevent, affect quality of life and often require a new surgical intervention, which should be performed by an experienced and competent surgeon.

Female pelvic congenital malformations. Part II: sexuality, reproductive outcomes and psychological impact.

The second part of this review deals with the quality of life of patients with congenital pelvic malformations, focusing on the sexuality, reproductive outcomes and overall psychological impact of the women affected. The presence of deformed pelvic anatomy, congenital or iatrogenic, and therefore of altered urinary, anal or sexual functions, are not only a physical limitation but seriously compromise psychological health from childhood. These difficulties jeopardise the thorny path from childhood to adult life through adolescence, and if neglected, could be responsible for seriously impairing quality of life in adulthood, in terms of mental health and psychosocial functions. If, in the 1970s, the main objective was to save the lives of newborns/infants, nowadays the therapy concept looks beyond that, focusing on quality of life and aiming to establish a satisfactory sexual life, allow the possibility of becoming a parent and enable the successful psychosocial integration of the patient. Ensuring urinary and fecal continence as well as the possibility of normal sexual activity, are the basis for allowing a normal psychological growth during adolescence, which leads to a satisfactory life later on.

Female pelvic congenital malformations. Part I: embryology, anatomy and surgical treatment.

This review covers the most important female congenital pelvic malformations. The first part focuses on the embryological development of the urogenital and anorectal apparatus, morphological features, and the diagnostic and surgical approach to abnormalities. Comprehension of the embryological development of the urogenital and anorectal apparatus is essential to understand the morphology of congenital pelvic abnormalities and their surgical treatment. Congenital pelvic malformations are characterized by specific common features; the severity of which often subverts the pelvic morphology completely and makes it difficult to comprehend before surgery. The development of imaging, mainly magnetic resonance imaging and ultrasound, in the investigation of pelvic floor disorders has recently become a fundamental tool for surgeons to achieve better understanding of the anatomy. Forty years ago, the primary aim of clinicians was to save the lives of such patients and to achieve anatomical normality. However, nowadays, functional reconstruction and recovery are essential parts of surgical management. Introduction of minimally invasive surgery has allowed the improvement of cosmetic results that is so important in paediatric or adolescent patients after reconstructive surgery. The option of sharing the complexity of pelvic congenital diseases by entrusting specific competencies to subspecialists (paediatric urologists, urogynaecologists, neurourologists, paediatric endocrinologists and neonatologists) has improved the quality of care for patients. However, at the same time, active interaction between various specialists remains fundamental. The exchange of knowledge and expertise, not only during the diagnostic-therapeutic process but also during follow-up, is crucial to obtain the best anatomical and functional results throughout the life of the patient.

Sexual function after radical hysterectomy for early-stage cervical cancer: is there a difference between laparoscopy and laparotomy?

INTRODUCTION: Surgical treatment for cervical cancer is associated with a high rate of late postoperative complications, and in particular with sexual dysfunction. AIM: To evaluate sexual function in women who underwent radical hysterectomy (RH), in comparison with a control group of healthy women, using a validated questionnaire (Female Sexual Function Index [FSFI]). Then we tried to evaluate the possible differences between laparoscopic RH and abdominal RH in terms of their impact on sexuality. METHODS: Consecutive sexually active women, who underwent RH for the treatment of early-stage cervical cancer between 2003 and 2007, were enrolled in this study (cases) and divided into two groups, according to the surgical approach. All women were administered the FSFI. The results of this questionnaire were compared between patients who underwent laparoscopic RH (LPS group) vs. women who underwent laparotomic RH (LPT group). The cases of RH were also compared with a control group of healthy women, who were referred to our outpatient clinic for a routine gynecologic evaluation. MAIN OUTCOME MEASURES: FSFI questionnaire on six domains of female sexuality (desire, arousal, lubrication, orgasm, satisfaction, pain). RESULTS: A total of 38 patients were included. We also enrolled 35 women as healthy controls. FSFI score was significantly higher in the healthy controls vs. the cases of RH. In the LPS group, the total score and all the domains of the FSFI were lower in comparison with the healthy controls, whereas three of the six domains (arousal, lubrication, orgasm) and the total score of FSFI were lower in the LPT group if compared with the controls. There were no significant differences between LPS and LPT group. CONCLUSIONS: RH worsens sexual function, regardless of the type of surgical approach. In our experience, laparoscopy did not show any benefit on women's sexuality over the abdominal surgery for cervical cancer.

Natural history of cervical intraepithelial neoplasia during pregnancy.

OBJECTIVE: It is uncertain whether pregnancy influences the natural history of cervical intraepithelial neoplasia (CIN). Our aim was to evaluate the evolution of CIN in pregnant women. DESIGN: Prospective study. SETTING: Department of Obstetrics and Gynaecology, University of Insubria, Italy. POPULATION: Women with histological CIN during pregnancy. METHODS AND MAIN OUTCOME MEASURES: Between 2003 and 2007, women with an abnormal Pap-smear during pregnancy underwent colposcopy. Patients with histological CIN were followed during pregnancy with colposcopy every 8 weeks and post-partum evaluation was scheduled 3-6 months after delivery. Women with post-partum histological diagnosis of CIN 2-3 underwent conization. To understand the impact of pregnancy on the evolution of CIN, women with CIN 1 discovered during pregnancy were compared to a group of non-pregnant fertile patients with first diagnosis of CIN 1. RESULTS: A total of 78 women were included: 36 (46.2%) with CIN 2-3 and 42 (53.8%) with CIN 1. In women with CIN 2-3, no invasion was suspected during pregnancy and at post-partum evaluation, no invasive or microinvasive cancer, and 19 (52.7%) persistent CIN 2-3, and 17 (47.3%) regressions were diagnosed. In the group of CIN 1, we recorded six (14.3%) progressions to CIN 2-3, seven (16.6%) persistent CIN 1 and 29 (69%) regressions. The control group of non-pregnant women had a lower regression rate (37/76: 48.7%) in comparison to pregnant women (p=0.03). CONCLUSIONS: Expectant management for CIN 2-3 diagnosed during gestation is safe. When discovered during pregnancy, CIN 1 has a significantly higher tendency to spontaneous regression in comparison to non-pregnant condition.