Efficacy and oncologic safety of nerve-sparing radical hysterectomy for cervical cancer: a randomized controlled trial

Abstract

Objective: A prospective, randomized controlled trial was conducted to evaluate the efficacy of nerve-sparing radical hysterectomy (NSRH) in preserving bladder function and its oncologic safety in the treatment of cervical cancer.

Methods: From March 2003 to November 2005, 92 patients with cervical cancer stage IA2 to IIA were randomly assigned for surgical treatment with conventional radical hysterectomy (CRH) or NSRH, and 86 patients finally included in the analysis. Adequacy of nerve sparing, radicality, bladder function, and oncologic safety were assessed by quantifying the nerve fibers in the paracervix, measuring the extent of paracervix and harvested lymph nodes (LNs), urodynamic study (UDS) with International Prostate Symptom Score (IPSS), and 10-year disease-free survival (DFS), respectively.

Results: There were no differences in clinicopathologic characteristics between two groups. The median number of nerve fiber was 12 (range, 6 to 21) and 30 (range, 17 to 45) in the NSRH and CRH, respectively (p<0.001). The extent of resected paracervix and number of LNs were not different between the two groups. Volume of residual urine and bladder compliance were significantly deteriorated at 12 months after CRH. On the contrary, all parameters of UDS were recovered no later than 3 months after NSRH. Evaluation of the IPSS showed that the frequency of long-term urinary symptom was higher in CRH than in the NSRH group. The median duration before the postvoid residual urine volume became less than 50 mL was 11 days (range, 7 to 26 days) in NSRH group and was 18 days (range, 10 to 85 days) in CRH group (p<0.001). No significant difference was observed in the 10-year DFS between two groups.

Conclusion: NSRH appears to be effective in preserving bladder function without sacrificing oncologic safety.

Keywords: Disease-Free Survival; Hysterectomy; Urinary Bladder, Neurogenic; Uterine Cervical Neoplasms.

Fig. 1. Flow diagram of the patients enrolled in this study. CRH, conventional radical hysterectomy; LN, lymph node; NSRH, nerve-sparing radical hysterectomy.

Fig. 2. Three-dimensional (3D) illustration and key steps in nerve-sparing radical hysterectomy. (A) Schematic 3D-illustration of the nervous system of the pelvis which should be preserved during nerve-sparing radical hysterectomy. (B) Separation and preservation of the superior hypogastric plexus on the sacral promontory (arrow, SHP). (C) Isolation and tracing of the hypogastric nerve on the lateral border of the rectum (arrow, HN). (D) Identification and preservation of the inferior hypogastric plexus composed of the hypogastric nerve and pelvic splanchnic nerve below the vascular part of the paracervix (arrow, IHP). (E) Vesical branch of the inferior hypogastric plexus during dissection of the vesicouterine ligament (arrow, vesical branch of IHP). B, bladder; HN, hypogastric nerve; IHP, inferior hypogastric plexus; R, rectum; SHP, superior hypogastric plexus; U, ureter; Ut, uterus.

Fig. 3. (A) Bladder compliance and (B) volume of residual urine were evaluated by urodynamic study preoperatively, and at 1, 3, and 12 months after conventional radical hysterectomy (CRH) or nervesparing radical hysterectomy (NSRH). (C) Subjective urinary symptoms were evaluated with the International Prostate Symptom Score (IPSS). Postoperative results were compared with preoperative basal values by Wilcoxon signed rank test. ^*p<0.05.

Fig. 4. (A) Disease-free survival and (B) overall survival in patients with cervical cancer treated by conventional radical hysterectomy (CRH) or nerve-sparing radical hysterectomy (NSRH).