Effects of modified nerve plane sparing radical hysterectomy on postoperative bladder function and prognosis

doi:10.3877/cma.j.issn.1673-5250.2015.01.006

Objective

To study effects of modified nerve plane sparing radical hysterectomy (NPSRH) on patients' postoperative bladder function and prognosis.

Methods

From January 2007 to December 2010, a total of 51 cases of International Federation of Gynecology and Obstetrics (FIGO) clinical stages Ⅰ_A1-Ⅱ_A2 cervical cancer were treated by NPSRH, and they were included into NPSRH group. During the same period, a total of 102 cases of FIGO clinical stages Ⅰ_A1-Ⅱ_A2 who underwent conventional radical hysterectomy (CRH) were randomly selected as CRH group. Operation related index, recovery of bladder function after operation, relapse and survival condition were analyzed. And within 6 months after operation, the bladder function was evaluated by duration of catheterization. While 6 months after operation, it was evaluated by quality of life survey method. Factors affecting the prognosis of patients with cervical cancer were analyzed by single factor and multi factor Cox regression model. The study protocol was approved by the Ethical Review Board of Investigation in Human Being of Jiangjin District Center Hospital of Chongqing. Informed consent was obtained from all participants. There were no significant differences between two groups among age, body mass index, FIGO clinical stage, pathological type, whether or not to accept new adjuvant chemotherapy, and postoperative adjuvant therapy, etc. (P>0.05).

Results

① The median operation time in NPSRH group was much shorter than that in CRH group, and there was significant difference (P<0.01). There were no significant differences between two groups among median intraoperative blood loss volumes, median rates of blood transfusion, incidence rates of postoperative complications, and median durations of hospitalization (P>0.05). ② The median duration of catheterization in NPSRH group was much shorter than that in CRH group, and there was significant difference (P<0.01). The incidence rates of long-term (6 months after operation) urinary frequency, urinary incontinence, urinary retention and straining to void in NPSRH group were significantly lower than those in CRH group, and all the differences were statistically significant (P<0.05). There was no significant difference between two groups in rate of urgency (P=0.111). ③There were no significant differences between two groups in risk factors of histopathologic, such as rate of deep myometrial invasion, lymph node metastasis, parametrial invasion and vaginal invasion (P>0.05). But the rate of lymph vascular space invasion rate in NPSRH group was much lower than that in CRH group, and there was significant difference (P=0.006). There was no significant difference between two groups in rate of receiving adjuvant treatment after operation (P=0.283). ④ A total of 43 cases of patients in NPSRH group and 84 patients in CRH group completed the telephone interview about long-term bladder function. The lost of follow-up rates and case fatality rates of two groups were 7.0% (3/43) and 4.8% (4/84), 7.0% (3/43) and 8.3% (7/84), respectively. And there were no significant differences among those two rates between two groups (P>0.05). ⑤ There were no significant differences between two groups among rates of recurrence, three-year recurrence-free survival (RFS), three-year overall survival (OS) (P=0.05). ⑥ The univariate analysis by Cox regression model showed that pathological type, lymph node metastases, and lymph-vascular space invasion (LVSI) presented the trend for a lower rates of 3-year RFS and OS (rate of 3-year RFS: RR=3.47, 5.41, 3.09; rate of 3-year OS: RR=3.49, 8.23, 3.82; P<0.05); Whether reserveing nerve plane or not had no influences on rates of 3-year RFS and OS (RR=1.12, 1.20; P>0.05). The multivariate analysis by Cox regression model showed that both pathological type and lymph node metastases were associated with a lower rate of 3-year RFS (RR= 2.51, 3.68; P<0.05). Lymph node metastases was a significant independent predictor of rate of 3-year OS (RR=4.76, P=0.001). NPSRH was not a significant independent predictor by Cox regression model analysis.

Conclusions

NPSRH treatment can significantly improve bladder function of cervical cancer patients with FIGO clinical stagesⅠ_B1-Ⅱ_A2, and does not affect the prognosis of patients.

Key words: Neoplasm cervix uteri, Nerve plane sparing radical hysterectomy, Autonomic nervous system, Urinary bladder

表1 两组宫颈癌患者的一般临床病理学特征比较[例数(%)]

Table 1 Comparison of general characteristics of clinical pathology between two groups [case(%)]

组别	例数	FIGO临床分期				病理学类型		深肌层受侵		淋巴结转移		宫旁受侵		阴道受侵		淋巴管间隙受侵		术前新辅助化疗		术后辅助治疗			卵巢处理
组别	例数	Ⅰ_B1	Ⅰ_B2	Ⅱ_A1	Ⅱ_A2	鳞癌	非鳞癌	无	有	无	有	无	有	无	有	无	有	无	有	化疗	同步放化疗	无	切除	移位
NPSRH组	51	24(47.1)	21(41.2)	4(7.8)	2(3.9)	45(88.2)	6(11.7)	28(54.9)	23(45.1)	42(82.4)	9(17.6)	50(98.0)	1(2.0)	45(88.2)	6(11.8)	36(70.6)	15(29.4)	34(66.7)	17(33.3)	4(7.8)	25(49.0)	22(43.1)	33(64.7)	18(35.3)
CRH组	102	48(47.1)	42(41.2)	8(7.8)	4(3.9)	90(88.2)	11(11.7)	60(58.8)	42(41.2)	84(82.4)	18(17.6)	100(98.0)	2(2.0)	89(87.3)	13(12.7)	86(84.3)	16(15.7)	67(65.7)	35(34.3)	9(8.8)	58(56.9)	35(34.3)	67(65.7)	35(34.3)
χ²值	?	0.000				0.000		0.667		0.000		0.000		0.060		7.557		0.030		2.528			0.115
P值	?	1.000				1.000		0.414		1.000		1.000		0.806		0.006		0.863		0.283			0.735

表1 两组宫颈癌患者的一般临床病理学特征比较[例数(%)]

Table 1 Comparison of general characteristics of clinical pathology between two groups [case(%)]

组别	例数	FIGO临床分期				病理学类型		深肌层受侵		淋巴结转移		宫旁受侵		阴道受侵		淋巴管间隙受侵		术前新辅助化疗		术后辅助治疗			卵巢处理
组别	例数	Ⅰ_B1	Ⅰ_B2	Ⅱ_A1	Ⅱ_A2	鳞癌	非鳞癌	无	有	无	有	无	有	无	有	无	有	无	有	化疗	同步放化疗	无	切除	移位
NPSRH组	51	24(47.1)	21(41.2)	4(7.8)	2(3.9)	45(88.2)	6(11.7)	28(54.9)	23(45.1)	42(82.4)	9(17.6)	50(98.0)	1(2.0)	45(88.2)	6(11.8)	36(70.6)	15(29.4)	34(66.7)	17(33.3)	4(7.8)	25(49.0)	22(43.1)	33(64.7)	18(35.3)
CRH组	102	48(47.1)	42(41.2)	8(7.8)	4(3.9)	90(88.2)	11(11.7)	60(58.8)	42(41.2)	84(82.4)	18(17.6)	100(98.0)	2(2.0)	89(87.3)	13(12.7)	86(84.3)	16(15.7)	67(65.7)	35(34.3)	9(8.8)	58(56.9)	35(34.3)	67(65.7)	35(34.3)
χ²值	?	0.000				0.000		0.667		0.000		0.000		0.060		7.557		0.030		2.528			0.115
P值	?	1.000				1.000		0.414		1.000		1.000		0.806		0.006		0.863		0.283			0.735

表2 两组患者术后并发症发生率比较[例数(%)]

Table 2 Comparison of incidence rates of postoperative complications between two groups[case(%)]

组别	例数	淋巴囊肿合并感染率	切口愈合不良率	肠梗阻率	阴道残端出血率	并发症发生率
NPSRH组	52	3(5.9)	4(7.8)	0(0.0)	0(0.0)	7(14.7)
CRH组	102	6(5.9)	4(3.9)	1(1.0)	1(1.0)	12(11.8)
χ²值	?	－	－	－	－	2.819
P值	?	－	－	－	－	0.625

表2 两组患者术后并发症发生率比较[例数(%)]

Table 2 Comparison of incidence rates of postoperative complications between two groups[case(%)]

组别	例数	淋巴囊肿合并感染率	切口愈合不良率	肠梗阻率	阴道残端出血率	并发症发生率
NPSRH组	52	3(5.9)	4(7.8)	0(0.0)	0(0.0)	7(14.7)
CRH组	102	6(5.9)	4(3.9)	1(1.0)	1(1.0)	12(11.8)
χ²值	?	－	－	－	－	2.819
P值	?	－	－	－	－	0.625

表3 两组患者术后远期(术后6个月)膀胱功能各指标的比较[例数(%)]

Table 3 Comparison of long-term (6 months after operation) bladder function between two groups [case(%)]

组别	例数	尿频发生率	尿急发生率	尿潴留发生率	尿失禁发生率	用力排尿发生率
NPSRH组	43	6(14.0)	7(16.3)	10(23.3)	15(34.9)	5(11.6)
CRH组	84	28(33.3)	20(24.8)	33(39.3)	45(53.6)	34(40.5)
χ²值	?	10.777	2.542	5.791	24.100	7.324
P值	?	0.001	0.111	0.015	0.000	0.007

表3 两组患者术后远期(术后6个月)膀胱功能各指标的比较[例数(%)]

Table 3 Comparison of long-term (6 months after operation) bladder function between two groups [case(%)]

组别	例数	尿频发生率	尿急发生率	尿潴留发生率	尿失禁发生率	用力排尿发生率
NPSRH组	43	6(14.0)	7(16.3)	10(23.3)	15(34.9)	5(11.6)
CRH组	84	28(33.3)	20(24.8)	33(39.3)	45(53.6)	34(40.5)
χ²值	?	10.777	2.542	5.791	24.100	7.324
P值	?	0.001	0.111	0.015	0.000	0.007

表4 两组患者复发部位及复发率比较[例数(%)]

Table 4 Comparison of recurrence sites and recurrence rates between two groups[case(%)]

组别	例数	不同部位复发率			复发率
组别	例数	盆腔	阴道残端	远处转移	复发率
NPSRH组	51	2(3.9)	2(3.9)	3(5.9)	7(11.8)
CRH组	102	5(4.9)	2(2.0)	5(4.9)	12(12.7)
χ²值	?	－	－	－	0.142
P值	?	－	－	－	0.707

表4 两组患者复发部位及复发率比较[例数(%)]

Table 4 Comparison of recurrence sites and recurrence rates between two groups[case(%)]

组别	例数	不同部位复发率			复发率
组别	例数	盆腔	阴道残端	远处转移	复发率
NPSRH组	51	2(3.9)	2(3.9)	3(5.9)	7(11.8)
CRH组	102	5(4.9)	2(2.0)	5(4.9)	12(12.7)
χ²值	?	－	－	－	0.142
P值	?	－	－	－	0.707

图1 两组宫颈癌患者的无复发生存曲线

Figure 1 Relapse-free survival curves between two groups

图2 两组宫颈癌患者的总生存曲线

Figure 2 Overall survival curves between two groups

表5 影响宫颈癌患者3年无复发生存率及3年总体生存率预后因素的单因素和多因素分析结果

Table 5 Univariate analysis and multivariate analysis results of prognosis influencing factors in 3-year relapse-free survival and overall survival of patients

类别	3年RFS率						3年OS率
	单因素分析			多因素分析			单因素分析			多因素分析
	RR值	95%CI	P值	RR值	95%CI	P值	RR值	95%CI	P值	RR值	95%CI	P值
保留神经平面与否	1.12	0.55～　2.28	0.747	－	－	－	1.20	0.47～3.10	0.701	－	－	－
FIGO临床分期^a	1.55	0.65～　3.73	0.327	－	－	－	0.79	0.18～3.37	0.746	－	－	－
肿瘤直径^b	0.78	0.41～　1.50	0.457	－	－	－	0.46	0.19～1.14	0.092	－	－	－
组织病理学类型^c	3.47	1.67～　7.19	0.001	2.51	1.18～5.33	0.017	3.49	1.35～8.99	0.010	2.09	0.75～5.79	0.158
组织病理学分级^d	4.00	0.96～16.65	0.057	－	－	－	2.23	0.52～9.59	0.280	－	－	－
宫旁受侵	0.05	0.00～994.16	0.549	－	－	－	0.05	0.00～0.00	0.627	－	－	－
淋巴结转移	5.41	2.80～10.45	<0.01	3.68	1.79～7.56	<0.01	8.23	3.45～19.65	<0.01	4.76	1.84～12.31	0.001
阴道受侵	1.75	0.77～　4.00	0.183	－	－	－	1.61	0.54～4.80	0.392	－	－	－
子宫颈深间质浸润	1.41	0.73～　2.70	0.308	－	－	－	3.61	1.40～9.31	0.008	2.25	0.83～6.05	0.110
淋巴脉管间隙受侵	3.09	1.58～　6.04	0.001	2.03	0.99～4.16	0.053	3.82	1.61～9.09	0.002	2.28	0.90～5.80	0.082

表5 影响宫颈癌患者3年无复发生存率及3年总体生存率预后因素的单因素和多因素分析结果

Table 5 Univariate analysis and multivariate analysis results of prognosis influencing factors in 3-year relapse-free survival and overall survival of patients

类别	3年RFS率						3年OS率
	单因素分析			多因素分析			单因素分析			多因素分析
	RR值	95%CI	P值	RR值	95%CI	P值	RR值	95%CI	P值	RR值	95%CI	P值
保留神经平面与否	1.12	0.55～　2.28	0.747	－	－	－	1.20	0.47～3.10	0.701	－	－	－
FIGO临床分期^a	1.55	0.65～　3.73	0.327	－	－	－	0.79	0.18～3.37	0.746	－	－	－
肿瘤直径^b	0.78	0.41～　1.50	0.457	－	－	－	0.46	0.19～1.14	0.092	－	－	－
组织病理学类型^c	3.47	1.67～　7.19	0.001	2.51	1.18～5.33	0.017	3.49	1.35～8.99	0.010	2.09	0.75～5.79	0.158
组织病理学分级^d	4.00	0.96～16.65	0.057	－	－	－	2.23	0.52～9.59	0.280	－	－	－
宫旁受侵	0.05	0.00～994.16	0.549	－	－	－	0.05	0.00～0.00	0.627	－	－	－
淋巴结转移	5.41	2.80～10.45	<0.01	3.68	1.79～7.56	<0.01	8.23	3.45～19.65	<0.01	4.76	1.84～12.31	0.001
阴道受侵	1.75	0.77～　4.00	0.183	－	－	－	1.61	0.54～4.80	0.392	－	－	－
子宫颈深间质浸润	1.41	0.73～　2.70	0.308	－	－	－	3.61	1.40～9.31	0.008	2.25	0.83～6.05	0.110
淋巴脉管间隙受侵	3.09	1.58～　6.04	0.001	2.03	0.99～4.16	0.053	3.82	1.61～9.09	0.002	2.28	0.90～5.80	0.082

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