Urodynamic Assessment of Bladder Storage Function After Radical Hysterectomy for Cervical Cancer

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Urodynamic Assessment of Bladder Storage Function After Radical Hysterectomy for Cervical Cancer

Radical hysterectomy (RH) remains a cornerstone in the treatment of early-stage cervical cancer, offering favorable oncological outcomes. However, lower urinary tract symptoms (LUTS) frequently arise postoperatively, significantly impacting patients’ quality of life. This study aimed to evaluate bladder storage dysfunction using urodynamic studies (UDS) and identify clinical factors influencing its development in cervical cancer patients undergoing RH.

Background

Cervical cancer is a prevalent gynecological malignancy, with RH combined with pelvic lymphadenectomy being the standard treatment for International Federation of Gynecology and Obstetrics (FIGO) stages IA2 to IIB. Despite high survival rates, RH often leads to pelvic organ dysfunction due to surgical disruption of autonomic nerves and blood supply. Bladder dysfunction, particularly storage issues, is common but understudied. Previous studies relied on subjective symptoms or residual urine volume measurements, which lack the precision of UDS. This study addressed this gap by systematically analyzing UDS parameters to identify risk factors for postoperative bladder storage dysfunction.

Methods

A multicenter, retrospective cohort study was conducted across nine hospitals in Beijing, China, involving 203 cervical cancer patients who underwent Piver type III RH between June 2013 and June 2018. Inclusion criteria required patients to be ≥18 years old, without preoperative LUTS or pelvic organ prolapse, and with UDS results available 3–24 months postoperatively. Surgical, demographic, and oncological data were collected, including age, body mass index (BMI), parity, surgical approach, operative time, blood loss, nerve-sparing techniques, vaginal resection length, and adjuvant therapies.

UDS parameters assessed included:

  • Stress urinary incontinence (SUI): Diagnosed if urine leakage occurred during coughing at a bladder volume of 200 mL.
  • Low bladder compliance (LBC): Defined as <20 mL/cm H₂O.
  • Detrusor overactivity (DO): Involuntary detrusor contractions >5 cm H₂O during filling.
  • Decreased maximum cystometric capacity (DMCC): Defined as <350 mL.

Statistical analyses included univariate and multivariate logistic regression to identify risk factors, with variables showing P < 0.10 in univariate analysis included in multivariate models. Kendall’s tau-b coefficient evaluated correlations between UDS parameters.

Results

Patient Characteristics

The cohort had a median age of 47 years (range: 42.3–53.5) and BMI of 23.9 kg/m². Most patients (83.3%) delivered vaginally, and 51.2% had ≥2 pregnancies. FIGO stages included IA2 (6.4%), IB1/IIA1 (70.4%), IB2/IIA2 (17.7%), and IIB (5.4%). Laparoscopic surgery was performed in 70% of cases, with a median operative time of 240 minutes and blood loss of 200 mL. Nerve-sparing techniques were used in 21.7% of patients, and 28.1% received chemoradiotherapy postoperatively.

UDS Findings

  • SUI: 46.8% (95/203) of patients.
  • LBC: 23.2% (47/203).
  • DO: 13.3% (27/203).
  • DMCC: 28.1% (57/203).
  • Composite bladder storage dysfunction: 68.0% (138/203).

Risk Factor Analysis

1. Stress Urinary Incontinence (SUI)

  • Protective Factors:
    • Laparoscopic approach reduced SUI risk (OR: 0.498, 95% CI: 0.261–0.947, P = 0.034).
    • Nerve-sparing procedures significantly lowered SUI incidence (OR: 0.361, 95% CI: 0.164–0.794, P = 0.014).
    • Longer operative time correlated with reduced SUI (P = 0.006).

2. Low Bladder Compliance (LBC)

  • Risk Factors:
    • Vaginal resection >3 cm increased LBC risk (OR: 4.087, 95% CI: 1.612–10.363, P = 0.003).
    • Chemoradiotherapy heightened LBC likelihood (OR: 4.087, P = 0.003).

3. Detrusor Overactivity (DO)

  • Risk Factors:
    • Older age (OR: 1.084 per year, 95% CI: 1.030–1.141, P = 0.002).
    • Laparoscopic surgery (OR: 5.761, 95% CI: 1.156–28.709, P = 0.033).
    • Greater blood loss (OR: 1.001 per mL, P = 0.034).
    • Vaginal resection >3 cm (OR: 3.087, P = 0.048).

4. Decreased Maximum Cystometric Capacity (DMCC)

  • Risk Factor: Chemoradiotherapy (OR: 3.241, 95% CI: 1.165–9.017, P = 0.024).

Key Correlations

  • LBC and DO showed a strong positive correlation (Kendall’s tau-b = 0.542, P < 0.001).
  • Radiotherapy had a stronger negative impact on bladder function than chemotherapy.
  • Follow-up time (median: 12.1 months) did not correlate with bladder dysfunction.

Discussion

This study provides critical insights into bladder storage dysfunction post-RH, highlighting the roles of surgical techniques and adjuvant therapies.

Surgical Approach and Nerve Preservation

Laparoscopic surgery reduced SUI risk, likely due to enhanced precision in nerve preservation. However, it paradoxically increased DO risk, possibly due to thermal injury from energy devices. Nerve-sparing techniques were protective against SUI, underscoring the importance of preserving autonomic innervation during RH.

Vaginal Resection Length

Resecting >3 cm of the vagina disrupted pelvic nerve pathways, increasing LBC and DO risks. This aligns with anatomical studies showing the upper vagina’s proximity to bladder innervation.

Adjuvant Therapies

Chemoradiotherapy significantly impaired bladder compliance and capacity, with radiotherapy causing more damage than chemotherapy. Radiation-induced fibrosis and chemotherapy agents like ifosfamide likely contributed to mucosal and detrusor damage.

Clinical Implications

  • Nerve-Sparing Techniques: Prioritize nerve preservation to mitigate SUI and LBC.
  • Vaginal Resection: Limit resection to ≤3 cm unless oncologically necessary.
  • Adjuvant Therapy: Consider bladder-protective strategies when chemoradiotherapy is unavoidable.

Conclusion

Bladder storage dysfunction affects 68% of cervical cancer patients after RH, with SUI being the most prevalent. Laparoscopic and nerve-sparing techniques reduce SUI risk, while vaginal resection >3 cm and chemoradiotherapy exacerbate dysfunction. These findings advocate for refined surgical protocols and cautious use of adjuvant therapies to preserve bladder function. Future studies should explore long-term outcomes and interventions to improve postoperative quality of life.

doi.org/10.1097/CM9.0000000000001014

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