Urodynamic study of bladder function following nerve sparing radical hysterectomy

to occur in up to 85% of patients [1] treated with radical hysterec tomy. Urinary symptoms include stress incontinence, sensory loss, bladder voiding dysfunction as hypotonic and hypertonic detrusor function [1]. These symptoms may affect the quality of life of patients surviving cervical cancer. Voiding disorders have been related to the damage of the hypogastric nerve and of the inferior hypogastric plexus due to the radical resection of the parametrial tissue. The hypogastric nerve section may occur at the level of the utero-sacral ligament and of the deep layer of the cervico-vesical ligament; the damage of the hypogastric plexus occurs at the level of the cardinal ligament. Urodynamic studies carried out after radical hysterectomy have shown that postoperatively both in the short and long term, bladder compliance is decreased, and residual volume is increased [1,2]. Major changes in bladder function are mainly observed within 12 months from surgery, when vesical function may be restored after adequate bladder care [1]. Nevertheless, significant long-term bladder dysfunction may persist in up to 80% of patients [1]. In order to preserve the bladder function following radical hysterectomy, Raspagliesi et al. [3] and Fuji [4] separately reported on a surgical technique aimed to resect the parametrium radically, while preserving the autonomic hypogastric nerve until the bladder. More recently a detailed laparoscopic nerve sparing radical hysterectomy has been reported [5]. It has been shown that utilizing the nerve sparing technique the bladder resumes a normal voiding function faster than with the traditional technique [3-5]. These promising results have led to an increasing interest toward the nerve sparing technique and to a large body of literature. Nevertheless, few data have been reported about the urodynamic profile of the bladder following nerve sparing radical hysterectomy [6-8]. As a consequence the bladder function following the preservation of the hypogastric nerve and plexus during radical hysterectomy it is only partially known. The nerve sparing technique, by laparotomic or laparoscopic route, includes 4 main steps: the preservation of the superior hypogastric plexus at the level of the presacral area during the presacral lymphadenectomy; the preservation of the hypogastric nerve dorsal to the ureter and lateral to the utero-sacral ligament during the section of the utero-sacral ligaments; the preservation of the inferior hypogastric plexus during the section of the cardinal ligament, since the plexus lie dorsal to the parametrial vessels at the level of the deep uterine vein; and the preservation of the bladder branch during the section of the deep layer of the cervico-vesical ligament. Two main approaches have been proposed: (1) the identification of the hypogastric nerve followed by the section of the parametria medial to the nerve [9], this obtains a type 2 or class B radicality; (2) the identification, clipping and section of the parametrial vessels at the level of the pudendal vessels, followed by the identification of the hypogastric nerve near to the uterosacral ligaments and its separation from the fibrous part of the cardinal ligament, until the fourth space is achieved in order to obtain an adequate resection margin of the cardinal ligament and paracolpium; this technique obtains a type 3-4 or C1 radicality [3,4,8]. As regards the urodynamic aspect, despite the fact that the functional stabilization of the bladder, following radical hysterectomy, is achieved after 12 months from surgery [1], one study reported the bladder function in the early postoperative Urodynamic study of bladder function following nerve sparing radical hysterectomy