- Email: [email protected]
Importance of Urodynamic Study before Radical Hysterectomy for Cervical Cancer
Gynecologic Oncology 81, 270 –272 (2001) doi:10.1006/gyno.2001.6155, available online at http://www.idealibrary.com on
Importance of Urodynamic Study before Radical Hysterectomy for Cervical Cancer Ho-Hsiung Lin, M.D., Ph.D., 1 Hong-Jeng Yu, M.D., Ph.D.,* Bor-Ching Sheu, M.D., Ph.D., and Su-Cheng Huang, M.D. Department of Obstetrics and Gynecology and *Department of Urology, College of Medicine and the Hospital, National Taiwan University, Taipei, Taiwan 100 Received November 6, 2000
Objectives. The aim of this study was to characterize the urodynamic findings in patients with cervical cancer before radical hysterectomy and to correlate the results with age, parity, menopausal status, and cancer stage. Methods. All patients with cervical cancer before radical hysterectomy who underwent urodynamic study (UDS) from January 1996 through December 1998 were enrolled. Detailed history, physical examination, and multichannel UDS data including uroflowmetry, filling and voiding cystometry, stress urethral pressure profile, and 20-min pad test were obtained for each patient. The urodynamic findings of each patient were analyzed and correlated with age, parity, menopausal status, and cancer stage. Results. A total of 210 patients with cervical cancer were included in the study. The mean age was 48.9 ⴞ 10.5 years with a mean parity of 3.3 ⴞ 1.7. Forty-two percent (n ⴝ 88) of patients were menopausal, and 88% (n ⴝ 184) belonged to stage IB while 10% (n ⴝ 20) were stage IIA and 2% (n ⴝ 6) stage IIB. Urodynamic study showed that only 17% (n ⴝ 37) of the 210 patients were normal, 10% (n ⴝ 21) had voiding dysfunction, 45% (n ⴝ 94) had storing dysfunction, and 28% (n ⴝ 58) had both voiding and storing dysfunctions. In addition, 51% (n ⴝ 106) had urinary incontinence and 37% (n ⴝ 78) had genuine stress incontinence (GSI), 8% (n ⴝ 16) detrusor instability (DI), and 6% (n ⴝ 12) GSI/DI. Age, parity, and cancer stage did not show any significant differences among these four groups. Conclusions. In this series, only 17% of patients with cervical cancer had normal urodynamic findings before radical hysterectomy. © 2001 Academic Press Key Words: urodynamic study; cervical cancer; radical hysterectomy.
INTRODUCTION It is well known that in cervical cancer patients the function of the urinary tract can be adversely affected by radical hysterectomy [1–5], pelvic irradiation, or both [6 – 8]. Obvious anatomical changes including injury to the bladder or urethra, 1
To whom correspondence and reprint requests should be addressed at Department of Obstetrics and Gynecology, National Taiwan University Hospital, No.7, Chung-Shan South Road, Taipei, Taiwan 100. Fax: ⫹886-2-23934197. E-mail: [email protected]. 0090-8258/01 $35.00 Copyright © 2001 by Academic Press All rights of reproduction in any form reserved.
fistula, and urinary dysfunction have been stressed in earlier reports [3, 9, 10]. However, with the improvement of surgical skills, these complications have diminished in frequency [11]. Advances in urodynamic assessment techniques have allowed exploration of the changes of lower urinary tract function following invasive management in patients with cervical cancer. Previous studies have used only one-channel pressure measuring systems, which cannot accurately reproduce pressures and assess urethral and vesical pressure concomitantly [11]. In this study, we used a multichannel recording technique to determine the characteristics of lower urinary tract function prior to radical hysterectomy [4 –7, 11]. The study sought to characterize the urodynamic pathology prior to radical hysterectomy in patients with cervical cancer. The urodynamic findings were correlated with age, parity, menopausal status, and cancer stage. PATIENTS AND METHODS From January 1996 through December 1998, all patients with cervical cancer who underwent urodynamic study (UDS) before radical hysterectomy in our hospital were recruited for study. Detailed patient history was recorded for each patient prior to physical examination and multichannel UDS. The urodynamic assessment included a 20-min pad test [8, 12], uroflowmetry, both filling (with a rate of 60 ml/min) and voiding cystometry with infusion of 35°C distilled water, and stress urethral pressure profile with 200 ml of distilled water in the bladder. The 20-min pad test was used to determine the amount of urine leakage. The average and maximal flow rates, voiding time, voiding amount, and postvoid residual urine amount after catheterization were recorded. The presence of detrusor instability (DI), low bladder compliance, compliance at urgency, and decreased bladder capacity were determined. Electromyography of the pelvic floor with perineal surface electrodes was also recorded while the presence of dyssynergia between the detrusor and urethra was simultaneously observed. The presence of genuine stress incontinence (GSI), pressure equalization, maximal urethral pressure, functional urethral
270
271
URODYNAMIC FINDINGS FOR CERVICAL CANCER
TABLE 1 Menopausal Status, Age, Parity, and Urodynamic Findings before Radical Hysterectomy in 210 Patients with Cervical Cancer
Group
No. (%)
Normal (I) 37 (17) Voiding dysfunction (II) 21 (10) Storing dysfunction (III) 94 (45) II ⫹ III (IV) 58 (28) Total 210 (100)
No. (%) of menopause
Age (years)*
Parity*
14 (38) a,b,c 8 (38) a 37 (39) b 29 (50) c 88 (42)
47.5 ⫾ 11.3 49.3 ⫾ 9.8 48.3 ⫾ 10.1 50.8 ⫾ 10.9 48.9 ⫾ 10.5
3.2 ⫾ 1.7 3.3 ⫾ 2.1 3.4 ⫾ 1.6 3.3 ⫾ 1.8 3.3 ⫾ 1.7
Note. No., case number; %, percentage. a P ⫽ 0.077; b P ⫽ 0.18; c P ⫽ 0.246 by Pearson 2 test. * P ⬎ 0.05 by ANOVA with multiple comparison (Bonferroni) test on age and parity among these four groups.
length, and urethral closure pressure were also recorded. Voiding dysfunction was defined as low average and maximal flow rates (less than 15 mL/s), prolonged voiding time (more than 30 s), abnormal large postvoid residual urine amount (more than 50 ml) during uroflowmetry, or low detrusor pressure (less than 25 cm H 2O) at peak flow during voiding cystometry. Bladder storing dysfunction from urodynamic findings was defined as a decreased bladder capacity (less than 300 ml) at the point of strong desire or the presence of DI or low bladder compliance or GSI when a urine leak occurred following a cough during filling cystometry. The types of urinary incontinence were classified as DI, GSI, or mixed GSI/DI according to the definition recommended by the International Continence Society (ICS) and Urodynamic Society [13–15]. A Life-Tech six-channel urodynamic monitor with computer analysis and urovision Urolab Janus system III (Houston, TX) were used. All terminology conforms to the standards recommended by the ICS or Urodynamic Society [13–15]. All procedures were performed by an experienced technician and the data were interpreted by a single observer to avoid bias. All data were expressed as means ⫾ 1 standard deviation unless otherwise indicated. The urodynamic findings were analyzed and correlated with age, parity, menopausal status, and cancer stage. The raw data for each group were first evaluated by the ANOVA, and then the multiple comparison (Bonferroni) test was utilized for statistical analysis in addition to the Pearson 2 test. A P value of ⬍0.05 was considered statistically significant. RESULTS A total of 210 patients with cervical cancer underwent UDS before radical hysterectomy during the study period. The mean age was 48.9 ⫾ 10.5 years with a mean parity of 3.3 ⫾ 1.7. Forty-two percent (n ⫽ 88) of patients were menopausal and without hormone replacement therapy, and 88% (n ⫽ 184) of
these patients had stage IB while 10% (n ⫽ 20) had stage IIA and 2% (n ⫽ 6) had stage IIB disease. Table 1 further subclassifies the urodynamic findings of all patients into four groups. Only 17% (n ⫽ 37) of the 210 cases were normal (group I); 10% (n ⫽ 21) had voiding dysfunction (group II), 45% (n ⫽ 94) had storing dysfunction (group III), and 28% (n ⫽ 58) had both voiding and storing dysfunctions (group IV). The percentage of postmenopausal women in these four groups was 38, 38, 39, and 50%, respectively, and no statistically significant differences were found among these four groups. Upon analyzing the other possible factors contributing to changes in urodynamic findings, we found no statistically significant differences in age, parity, and cancer stage among the four groups (Table 1). Regarding the distribution of urinary incontinence by urodynamic findings, we found that 51% (n ⫽ 106) of the 210 cases had urinary incontinence (Table 2). The types of urinary incontinence included GSI in 37% (n ⫽ 78), DI in 8% (n ⫽ 16), and mixed GSI/DI in 6% (n ⫽ 12). DISCUSSION In the present study, urodynamic study was assessed in all cases before radical hysterectomy and the differences in distribution of cancer stage among the four groups were not significant. Thus, the possibility that neurogenic bladder was responsible for the findings in this study can be ruled out. We found that only 17% (n ⫽ 37) (group I) of the 210 cervical cancer patients had normal urodynamic findings prior to radical hysterectomy. This figure is very noteworthy and this finding is the first report of the incidence of urodynamic dysfunction in patients scheduled to undergo radical hysterectomy in the literature. The reasons for this low percentage of normal UDS in these 210 cases may be that all except 4 nulliparas were multiparous, and the mean age of the patients was relatively advanced at 48.9 years, as well as the effects of menopause in 42%. Thus, these findings suggest that parity, age, and menopausal status might be possible factors contributing to the low TABLE 2 Types of Urinary Incontinence Identified by Urodynamic Study before Radical Hysterectomy in 210 Patients with Cervical Cancer Types (%) Group
No.
GSI
DI
GSI/DI
Normal (I) Voiding dysfunction (II) Storing dysfunction (III) II ⫹ III (IV) Total
37 21 94 58 210
0 0 48 (23) 30 (14) 78 (37)
0 0 10 (5) 6 (3) 16 (8)
0 0 8 (4) 4 (2) 12 (6)
Note. No., case number; %, percentage; GSI, genuine stress incontinence; DI, detrusor instability.
272
LIN ET AL.
percentage of normal urodynamic findings in these 210 patients, although these three parameters had no statistically significant differences among these four groups. It is better to compare these figures to the data of urodynamic findings in general population; however, such a report is still lacking. Our results also revealed that 38% (n ⫽ 79) of the 210 patients in groups II and IV had voiding dysfunction, as shown in Table 1. In contrast, 73% (n ⫽ 152) of the 210 cases had storing dysfunction as in groups III and VI. Overall, 83% (n ⫽ 173) of the 210 patients had at least one kind of lower urinary tract dysfunction in this study. These findings imply that abnormal urodynamic study is very likely to be present in patients with cervical cancer, and thus that it is mandatory to perform UDS in cases of cervical cancer before radical hysterectomy. The present study found that bladder storing dysfunction was the most prevalent type of lower urinary tract dysfunction and was present in 73%, while urinary incontinence was found in 51%. These two figures are similar to those in our previous report [8]. Since no statistically significant differences were noted in age, parity, and cancer stage among the four groups, the reason that bladder storing dysfunction was the most prevalent dysfunction remains unknown. Concerning the types of urinary incontinence among the 51% (n ⫽ 106) of these 210 cervical cancer cases, we found that cases with GSI or GSI/DI had the highest prevalence (43%), which is similar to our previous results among those patients with urinary symptoms only (unpublished data). Moreover, the low frequency of DI in the surveyed population of this study was rather different from that of other reports [16, 17]. The reason for this discrepancy remains unclear; however, possible reasons include racial factors, although such factors have not been reported. It is also possible that the urodynamic findings obtained by laboratory machine are less sensitive than those using an ambulatory machine for the detection of DI. Another possible reason for this discrepancy is that the provocative test to detect DI in this study was different compared to that of previous studies, using a maximum infusion of carbon dioxide, which can enhance the incidence of DI [18]. In conclusion, our data demonstrate that the urodynamic findings of cervical cancer patients before radical hysterectomy were normal in only 17% of the patients. Thus, it is noteworthy to perform preoperative urodynamic study in patients with cervical cancer. ACKNOWLEDGMENT We thank Ms. Ruey-Fang Liang for her excellent technical assistance in this study.
2. Kadar N, Salbia N, Nelson JH. The frequency, causes and prevention of severe urinary dysfunction after radical hysterectomy. Br J Obstet Gynaec 1983;90:858 – 63. 3. Vervesst HAM, Barents JW, Haspels AA, Debruyne FMJ. Radical hysterectomy and the function of lower urinary tract. Acta Obstet Gynecol Scand 1989;68:331– 40. 4. Chen KK, Chang LS, Chen MT, Huang JK, Yuan CC, Tsai KH, Chang KC, Ng HT. Prospective urodynamic study before and after radical hysterectomy. Chin Med J 1988;41:333– 8. 5. Stolz W, Walliener D, Brandner P, Grischke E, Bastert G. Detrusor and compliance changes of the bladder after radical hysterectomy. Eur J Gynecol Oncol 1989;10:378 – 83. 6. Hamada K, Kihana T, Takeda Y, Inoue Y, Matsuura S, Kataoka M, Yoshioka S, Iio S, Iwata H. Urodynamic study on urinary disturbance after therapy of uterine cancer. Acta Obstet Gynecol Jpn 1992;44:440 – 6. 7. Iio S, Yoshida S, Nishio S, Yokoyama M, Iwata H, Takeuchi M. Urodynamic evaluation for bladder dysfunction after radical hysterectomy. Jpn J Urol 1993;84:535– 40. 8. Lin HH, Sheu BC, Lo MC, Huang SC. Abnormal urodynamic findings after radical hysterectomy or pelvic irradiation for cervical cancer. Int J Gynecol Obstet 1998;63:169 –74. 9. Westby M, Asmussen M. Anatomical and functional changes in the lower urinary tract after radical hysterectomy with lymph node dissection as studied by dynamic urethrocystography and simultaneous urethrocystometry. Gynecol Oncol 1985;21:261–76. 10. Farquharson DIM, Shingleton HM, Soong SJ, Sanford SP, Levy DS, Hatch KD. The adverse effects of cervical cancer treatment on bladder function. Gynecol Oncol 1987;27:15–23. 11. Scotti RJ, Bergman NN, Hatia NN, Ostergard DR. Urodynamic changes in urethrovesical function after radical hysterectomy. Obstet Gynecol 1986; 68:111–20. 12. Sand PK, Ostergard DR. Pad testing. In: Sand PK, Ostergard DR, editors. Urodynamics and the evaluation of female incontinence: a practical guide. London: Springer-Verlag, 1995:20 –3. 13. Abrams P, Blaivas JG, Stanton SL, Anderson JT, Fowler CJ, Gerstenberg T, Murray K. Sixth report on the standardization of terminology of lower urinary tract function. Procedures related to neurophysiological investigation: electromyography, nerve conduction studies, reflex latencies, evoked potential and sensory testing. Scand J Urol Nephrol 1986;20:161– 4. 14. Andercon JT, Blaivas JG, Cardozo L, Thuroff J. Seventh report on the standardization of terminology of lower urinary tract function: lower urinary tract rehabilitation techniques. Int Urogynecol J 1992;3: 75–9. 15. Blaivas JG, Appell RA, Fantl JA, LeakG, McGuire EJ, Resnick NM, Raz S, Wein AJ. Definition and classification of urinary incontinence: recommendation of the urodynamic society. Neurourol Urodyn 1997;16:149 – 51. 16. Sandvik H, Hunskaar S, Vanvik A, Bratt H, Seim A, Hermstad R. Diagnostic classification of female urinary incontinence: an epidemiological survey corrected for validity. J Clin Epidemiol 1995;48:339 – 43.
REFERENCES
17. Fantl JA, Wyman JF, McClish DK, Bump RC. Urinary incontinence in community-dwelling women: clinical, urodynamic, and severity characteristics. Am J Obstet Gynecol 1990;162:946 –51.
1. Forney JP. The effect of radical hysterectomy on bladder physiology. Am J Obstet Gynecol 1980;138:374 – 82.
18. Choe JM, Gallo ML, Staskin DR. A provocative maneuver to elicit cystometric instability: measuring instability at maximum infusion. J Urol 1999;161:1541– 4.
Importance of Urodynamic Study before Radical Hysterectomy for Cervical Cancer Ho-Hsiung Lin, M.D., Ph.D., 1 Hong-Jeng Yu, M.D., Ph.D.,* Bor-Ching Sheu, M.D., Ph.D., and Su-Cheng Huang, M.D. Department of Obstetrics and Gynecology and *Department of Urology, College of Medicine and the Hospital, National Taiwan University, Taipei, Taiwan 100 Received November 6, 2000
Objectives. The aim of this study was to characterize the urodynamic findings in patients with cervical cancer before radical hysterectomy and to correlate the results with age, parity, menopausal status, and cancer stage. Methods. All patients with cervical cancer before radical hysterectomy who underwent urodynamic study (UDS) from January 1996 through December 1998 were enrolled. Detailed history, physical examination, and multichannel UDS data including uroflowmetry, filling and voiding cystometry, stress urethral pressure profile, and 20-min pad test were obtained for each patient. The urodynamic findings of each patient were analyzed and correlated with age, parity, menopausal status, and cancer stage. Results. A total of 210 patients with cervical cancer were included in the study. The mean age was 48.9 ⴞ 10.5 years with a mean parity of 3.3 ⴞ 1.7. Forty-two percent (n ⴝ 88) of patients were menopausal, and 88% (n ⴝ 184) belonged to stage IB while 10% (n ⴝ 20) were stage IIA and 2% (n ⴝ 6) stage IIB. Urodynamic study showed that only 17% (n ⴝ 37) of the 210 patients were normal, 10% (n ⴝ 21) had voiding dysfunction, 45% (n ⴝ 94) had storing dysfunction, and 28% (n ⴝ 58) had both voiding and storing dysfunctions. In addition, 51% (n ⴝ 106) had urinary incontinence and 37% (n ⴝ 78) had genuine stress incontinence (GSI), 8% (n ⴝ 16) detrusor instability (DI), and 6% (n ⴝ 12) GSI/DI. Age, parity, and cancer stage did not show any significant differences among these four groups. Conclusions. In this series, only 17% of patients with cervical cancer had normal urodynamic findings before radical hysterectomy. © 2001 Academic Press Key Words: urodynamic study; cervical cancer; radical hysterectomy.
INTRODUCTION It is well known that in cervical cancer patients the function of the urinary tract can be adversely affected by radical hysterectomy [1–5], pelvic irradiation, or both [6 – 8]. Obvious anatomical changes including injury to the bladder or urethra, 1
To whom correspondence and reprint requests should be addressed at Department of Obstetrics and Gynecology, National Taiwan University Hospital, No.7, Chung-Shan South Road, Taipei, Taiwan 100. Fax: ⫹886-2-23934197. E-mail: [email protected]. 0090-8258/01 $35.00 Copyright © 2001 by Academic Press All rights of reproduction in any form reserved.
fistula, and urinary dysfunction have been stressed in earlier reports [3, 9, 10]. However, with the improvement of surgical skills, these complications have diminished in frequency [11]. Advances in urodynamic assessment techniques have allowed exploration of the changes of lower urinary tract function following invasive management in patients with cervical cancer. Previous studies have used only one-channel pressure measuring systems, which cannot accurately reproduce pressures and assess urethral and vesical pressure concomitantly [11]. In this study, we used a multichannel recording technique to determine the characteristics of lower urinary tract function prior to radical hysterectomy [4 –7, 11]. The study sought to characterize the urodynamic pathology prior to radical hysterectomy in patients with cervical cancer. The urodynamic findings were correlated with age, parity, menopausal status, and cancer stage. PATIENTS AND METHODS From January 1996 through December 1998, all patients with cervical cancer who underwent urodynamic study (UDS) before radical hysterectomy in our hospital were recruited for study. Detailed patient history was recorded for each patient prior to physical examination and multichannel UDS. The urodynamic assessment included a 20-min pad test [8, 12], uroflowmetry, both filling (with a rate of 60 ml/min) and voiding cystometry with infusion of 35°C distilled water, and stress urethral pressure profile with 200 ml of distilled water in the bladder. The 20-min pad test was used to determine the amount of urine leakage. The average and maximal flow rates, voiding time, voiding amount, and postvoid residual urine amount after catheterization were recorded. The presence of detrusor instability (DI), low bladder compliance, compliance at urgency, and decreased bladder capacity were determined. Electromyography of the pelvic floor with perineal surface electrodes was also recorded while the presence of dyssynergia between the detrusor and urethra was simultaneously observed. The presence of genuine stress incontinence (GSI), pressure equalization, maximal urethral pressure, functional urethral
270
271
URODYNAMIC FINDINGS FOR CERVICAL CANCER
TABLE 1 Menopausal Status, Age, Parity, and Urodynamic Findings before Radical Hysterectomy in 210 Patients with Cervical Cancer
Group
No. (%)
Normal (I) 37 (17) Voiding dysfunction (II) 21 (10) Storing dysfunction (III) 94 (45) II ⫹ III (IV) 58 (28) Total 210 (100)
No. (%) of menopause
Age (years)*
Parity*
14 (38) a,b,c 8 (38) a 37 (39) b 29 (50) c 88 (42)
47.5 ⫾ 11.3 49.3 ⫾ 9.8 48.3 ⫾ 10.1 50.8 ⫾ 10.9 48.9 ⫾ 10.5
3.2 ⫾ 1.7 3.3 ⫾ 2.1 3.4 ⫾ 1.6 3.3 ⫾ 1.8 3.3 ⫾ 1.7
Note. No., case number; %, percentage. a P ⫽ 0.077; b P ⫽ 0.18; c P ⫽ 0.246 by Pearson 2 test. * P ⬎ 0.05 by ANOVA with multiple comparison (Bonferroni) test on age and parity among these four groups.
length, and urethral closure pressure were also recorded. Voiding dysfunction was defined as low average and maximal flow rates (less than 15 mL/s), prolonged voiding time (more than 30 s), abnormal large postvoid residual urine amount (more than 50 ml) during uroflowmetry, or low detrusor pressure (less than 25 cm H 2O) at peak flow during voiding cystometry. Bladder storing dysfunction from urodynamic findings was defined as a decreased bladder capacity (less than 300 ml) at the point of strong desire or the presence of DI or low bladder compliance or GSI when a urine leak occurred following a cough during filling cystometry. The types of urinary incontinence were classified as DI, GSI, or mixed GSI/DI according to the definition recommended by the International Continence Society (ICS) and Urodynamic Society [13–15]. A Life-Tech six-channel urodynamic monitor with computer analysis and urovision Urolab Janus system III (Houston, TX) were used. All terminology conforms to the standards recommended by the ICS or Urodynamic Society [13–15]. All procedures were performed by an experienced technician and the data were interpreted by a single observer to avoid bias. All data were expressed as means ⫾ 1 standard deviation unless otherwise indicated. The urodynamic findings were analyzed and correlated with age, parity, menopausal status, and cancer stage. The raw data for each group were first evaluated by the ANOVA, and then the multiple comparison (Bonferroni) test was utilized for statistical analysis in addition to the Pearson 2 test. A P value of ⬍0.05 was considered statistically significant. RESULTS A total of 210 patients with cervical cancer underwent UDS before radical hysterectomy during the study period. The mean age was 48.9 ⫾ 10.5 years with a mean parity of 3.3 ⫾ 1.7. Forty-two percent (n ⫽ 88) of patients were menopausal and without hormone replacement therapy, and 88% (n ⫽ 184) of
these patients had stage IB while 10% (n ⫽ 20) had stage IIA and 2% (n ⫽ 6) had stage IIB disease. Table 1 further subclassifies the urodynamic findings of all patients into four groups. Only 17% (n ⫽ 37) of the 210 cases were normal (group I); 10% (n ⫽ 21) had voiding dysfunction (group II), 45% (n ⫽ 94) had storing dysfunction (group III), and 28% (n ⫽ 58) had both voiding and storing dysfunctions (group IV). The percentage of postmenopausal women in these four groups was 38, 38, 39, and 50%, respectively, and no statistically significant differences were found among these four groups. Upon analyzing the other possible factors contributing to changes in urodynamic findings, we found no statistically significant differences in age, parity, and cancer stage among the four groups (Table 1). Regarding the distribution of urinary incontinence by urodynamic findings, we found that 51% (n ⫽ 106) of the 210 cases had urinary incontinence (Table 2). The types of urinary incontinence included GSI in 37% (n ⫽ 78), DI in 8% (n ⫽ 16), and mixed GSI/DI in 6% (n ⫽ 12). DISCUSSION In the present study, urodynamic study was assessed in all cases before radical hysterectomy and the differences in distribution of cancer stage among the four groups were not significant. Thus, the possibility that neurogenic bladder was responsible for the findings in this study can be ruled out. We found that only 17% (n ⫽ 37) (group I) of the 210 cervical cancer patients had normal urodynamic findings prior to radical hysterectomy. This figure is very noteworthy and this finding is the first report of the incidence of urodynamic dysfunction in patients scheduled to undergo radical hysterectomy in the literature. The reasons for this low percentage of normal UDS in these 210 cases may be that all except 4 nulliparas were multiparous, and the mean age of the patients was relatively advanced at 48.9 years, as well as the effects of menopause in 42%. Thus, these findings suggest that parity, age, and menopausal status might be possible factors contributing to the low TABLE 2 Types of Urinary Incontinence Identified by Urodynamic Study before Radical Hysterectomy in 210 Patients with Cervical Cancer Types (%) Group
No.
GSI
DI
GSI/DI
Normal (I) Voiding dysfunction (II) Storing dysfunction (III) II ⫹ III (IV) Total
37 21 94 58 210
0 0 48 (23) 30 (14) 78 (37)
0 0 10 (5) 6 (3) 16 (8)
0 0 8 (4) 4 (2) 12 (6)
Note. No., case number; %, percentage; GSI, genuine stress incontinence; DI, detrusor instability.
272
LIN ET AL.
percentage of normal urodynamic findings in these 210 patients, although these three parameters had no statistically significant differences among these four groups. It is better to compare these figures to the data of urodynamic findings in general population; however, such a report is still lacking. Our results also revealed that 38% (n ⫽ 79) of the 210 patients in groups II and IV had voiding dysfunction, as shown in Table 1. In contrast, 73% (n ⫽ 152) of the 210 cases had storing dysfunction as in groups III and VI. Overall, 83% (n ⫽ 173) of the 210 patients had at least one kind of lower urinary tract dysfunction in this study. These findings imply that abnormal urodynamic study is very likely to be present in patients with cervical cancer, and thus that it is mandatory to perform UDS in cases of cervical cancer before radical hysterectomy. The present study found that bladder storing dysfunction was the most prevalent type of lower urinary tract dysfunction and was present in 73%, while urinary incontinence was found in 51%. These two figures are similar to those in our previous report [8]. Since no statistically significant differences were noted in age, parity, and cancer stage among the four groups, the reason that bladder storing dysfunction was the most prevalent dysfunction remains unknown. Concerning the types of urinary incontinence among the 51% (n ⫽ 106) of these 210 cervical cancer cases, we found that cases with GSI or GSI/DI had the highest prevalence (43%), which is similar to our previous results among those patients with urinary symptoms only (unpublished data). Moreover, the low frequency of DI in the surveyed population of this study was rather different from that of other reports [16, 17]. The reason for this discrepancy remains unclear; however, possible reasons include racial factors, although such factors have not been reported. It is also possible that the urodynamic findings obtained by laboratory machine are less sensitive than those using an ambulatory machine for the detection of DI. Another possible reason for this discrepancy is that the provocative test to detect DI in this study was different compared to that of previous studies, using a maximum infusion of carbon dioxide, which can enhance the incidence of DI [18]. In conclusion, our data demonstrate that the urodynamic findings of cervical cancer patients before radical hysterectomy were normal in only 17% of the patients. Thus, it is noteworthy to perform preoperative urodynamic study in patients with cervical cancer. ACKNOWLEDGMENT We thank Ms. Ruey-Fang Liang for her excellent technical assistance in this study.
2. Kadar N, Salbia N, Nelson JH. The frequency, causes and prevention of severe urinary dysfunction after radical hysterectomy. Br J Obstet Gynaec 1983;90:858 – 63. 3. Vervesst HAM, Barents JW, Haspels AA, Debruyne FMJ. Radical hysterectomy and the function of lower urinary tract. Acta Obstet Gynecol Scand 1989;68:331– 40. 4. Chen KK, Chang LS, Chen MT, Huang JK, Yuan CC, Tsai KH, Chang KC, Ng HT. Prospective urodynamic study before and after radical hysterectomy. Chin Med J 1988;41:333– 8. 5. Stolz W, Walliener D, Brandner P, Grischke E, Bastert G. Detrusor and compliance changes of the bladder after radical hysterectomy. Eur J Gynecol Oncol 1989;10:378 – 83. 6. Hamada K, Kihana T, Takeda Y, Inoue Y, Matsuura S, Kataoka M, Yoshioka S, Iio S, Iwata H. Urodynamic study on urinary disturbance after therapy of uterine cancer. Acta Obstet Gynecol Jpn 1992;44:440 – 6. 7. Iio S, Yoshida S, Nishio S, Yokoyama M, Iwata H, Takeuchi M. Urodynamic evaluation for bladder dysfunction after radical hysterectomy. Jpn J Urol 1993;84:535– 40. 8. Lin HH, Sheu BC, Lo MC, Huang SC. Abnormal urodynamic findings after radical hysterectomy or pelvic irradiation for cervical cancer. Int J Gynecol Obstet 1998;63:169 –74. 9. Westby M, Asmussen M. Anatomical and functional changes in the lower urinary tract after radical hysterectomy with lymph node dissection as studied by dynamic urethrocystography and simultaneous urethrocystometry. Gynecol Oncol 1985;21:261–76. 10. Farquharson DIM, Shingleton HM, Soong SJ, Sanford SP, Levy DS, Hatch KD. The adverse effects of cervical cancer treatment on bladder function. Gynecol Oncol 1987;27:15–23. 11. Scotti RJ, Bergman NN, Hatia NN, Ostergard DR. Urodynamic changes in urethrovesical function after radical hysterectomy. Obstet Gynecol 1986; 68:111–20. 12. Sand PK, Ostergard DR. Pad testing. In: Sand PK, Ostergard DR, editors. Urodynamics and the evaluation of female incontinence: a practical guide. London: Springer-Verlag, 1995:20 –3. 13. Abrams P, Blaivas JG, Stanton SL, Anderson JT, Fowler CJ, Gerstenberg T, Murray K. Sixth report on the standardization of terminology of lower urinary tract function. Procedures related to neurophysiological investigation: electromyography, nerve conduction studies, reflex latencies, evoked potential and sensory testing. Scand J Urol Nephrol 1986;20:161– 4. 14. Andercon JT, Blaivas JG, Cardozo L, Thuroff J. Seventh report on the standardization of terminology of lower urinary tract function: lower urinary tract rehabilitation techniques. Int Urogynecol J 1992;3: 75–9. 15. Blaivas JG, Appell RA, Fantl JA, LeakG, McGuire EJ, Resnick NM, Raz S, Wein AJ. Definition and classification of urinary incontinence: recommendation of the urodynamic society. Neurourol Urodyn 1997;16:149 – 51. 16. Sandvik H, Hunskaar S, Vanvik A, Bratt H, Seim A, Hermstad R. Diagnostic classification of female urinary incontinence: an epidemiological survey corrected for validity. J Clin Epidemiol 1995;48:339 – 43.
REFERENCES
17. Fantl JA, Wyman JF, McClish DK, Bump RC. Urinary incontinence in community-dwelling women: clinical, urodynamic, and severity characteristics. Am J Obstet Gynecol 1990;162:946 –51.
1. Forney JP. The effect of radical hysterectomy on bladder physiology. Am J Obstet Gynecol 1980;138:374 – 82.
18. Choe JM, Gallo ML, Staskin DR. A provocative maneuver to elicit cystometric instability: measuring instability at maximum infusion. J Urol 1999;161:1541– 4.