Menke H. Hazewinkel

Long-term cervical cancer survivors suffer from pelvic floor symptoms: A cross-sectional matched cohort study

OBJECTIVE The aim of this study was to determine prevalence of and experienced distress from pelvic floor symptoms in cervical cancer survivors (CCS). METHODS For this cross-sectional matched cohort study, we matched CCS, treated in the Academic Medical Center, Amsterdam between 1997 and 2007, to a random female population sample aged 20 to 70 years (reference group). We assessed prevalence of and distress from bladder and bowel symptoms with validated pelvic-floor-related questionnaires. Severe distress was defined as values above the 90th percentile of reference groups symptom domain scores. RESULTS One-hundred and forty-six CCS underwent radical hysterectomy and pelvic lymph node dissection (RH and LND), 49 underwent surgery and adjuvant radiotherapy (SART), and 47 underwent primary radiotherapy (PRT). Urinary incontinence and obstructive voiding were reported by each treatment group more frequently than by the reference group and caused more distress. Patients treated with RH and LND reported more distress from most uro-genital symptoms, except from overactive bladder symptoms. Patients treated with PRT reported more distress from each uro-genital symptom than matched controls. The RH and LND group reported more distress from constipation and obstructive defecation than the reference group. Patients who underwent primary or adjuvant radiotherapy reported more distress from anal incontinence than their matched controls. CONCLUSIONS Treatment of cervical cancer impairs pelvic floor function. Patients treated with PRT report the most adverse effects on pelvic floor function. The results of our study enable physicians to counsel accurately about specific symptoms. Furthermore, to facilitate referral to pelvic floor specialists when bothersome symptoms occur, we recommend evaluating pelvic floor symptoms as a standard during follow-up.

Reasons for not seeking medical help for severe pelvic floor symptoms: a qualitative study in survivors of gynaecological cancer

Objective  (1) To explore the reasons for not seeking help for severe pelvic floor symptoms after gynaecological cancer treatment. (2) To determine the willingness to undergo treatment for these symptoms. (3) To invite suggestions to improve outpatient care.

Severe pelvic floor symptoms after cervical cancer treatment are predominantly associated with mental and physical well-being and body image: a cross-sectional study.

Objective To identify associations between demographic, disease-related, and psychological variables and severe distress from pelvic floor symptoms (PFSs) after cervical cancer treatment. Methods This study was cross-sectional and questionnaire based. We included patients with cervical cancer treated between 1997 and 2007 in the Academic Medical Center, Amsterdam. Pelvic floor symptoms were assessed with urogenital distress inventory and defecatory distress inventory. Scores were dichotomized into severe (>90th percentile) versus nonsevere distress. Disease-related variables were extracted from medical files. Psychological factors included mental and physical well-being, optimism, and body image, which were assessed with standardized questionnaires. Univariate and multivariate logistic regression analyses were performed. Results A total of 282 patients were included: 148 were treated with radical hysterectomy and pelvic lymph node dissection, 61 patients were treated with surgery and adjuvant radiotherapy, and 73 patients were treated with primary radiotherapy. Demographic: Multivariate analyses showed no significant relation between demographic variables and symptoms. Disease-related: None of these variables were significantly associated in multivariate analyses. Psychosocial: In all treatment groups, multivariate associations were found. In general, better mental and physical well-being was associated with nonsevere PFSs. Increased body image disturbance was associated with severe defecation symptoms. Conclusions Few associations were found between demographic and disease-related variables and distress from PFS after cervical cancer treatment. However, better mental and physical well-being is associated with nonsevere distress from urogenital and defecation symptoms and more body image disturbance with severe PFSs. Improving these factors might reduce distress from PFSs and should be a focus of future research.

Stress urinary incontinence in patients treated for cervical cancer: is TVT-Secur a valuable treatment option?

We present two patients with bothersome stress urinary incontinence (SUI) following radical hysterectomy and pelvic lymphadenectomy for early stage cervical cancer. One patient underwent adjuvant radiotherapy. We selected, after extensive counseling, TVT-Secur in these two patients as we aimed to avoid the pelvic cavity, expecting altered anatomy due to major pelvic surgery, and counting on low risk of developing bladder retention, given results of a case series. Both patients were continent post-operatively. One patient presented with a small tape erosion that was successfully corrected using local analgesics. The other patient developed urgency symptoms that disappeared after treatment with solifenacine. Both patients had detrusor hypo-activity at pre-operative urodynamics, but no bladder retention occurred following surgery. In patients with a history of radical hysterectomy who present with SUI, we would advise to counsel that satisfying results can be expected of TVT-Secur, although it is likely that additional care after surgery is needed.

Renal ultrasound to detect hydronephrosis: A need for routine imaging after radical hysterectomy?

BACKGROUND Hydronephrosis can be a side effect of radical hysterectomy for cervical cancer. The incidence of clinically relevant hydronephrosis has not been studied in a large sample and the benefit of early detection of hydronephrosis is not clear. OBJECTIVE To assess the incidence of hydronephrosis, following radical hysterectomy and evaluate the usefulness of routine renal ultrasound (RH). METHODS Retrospective study, January 1998 and December 2008. Cervical cancer patients (FIGO stage IBI-IIA), treated with radical hysterectomy and pelvic lymph node dissection with or without adjuvant radiotherapy, without surgical lesion of the ureter, followed-up 6 months in the Academic Medical Center Amsterdam. Routine renal ultrasound was performed four weeks after RH, and in some on indication before or after the routine ultrasound. We documented which interventions for hydronephrosis were performed and evaluated the profile of patients at risk for hydronephrosis. RESULTS 281 patients were included: 252 (90%) underwent routine renal ultrasound and 29 (10%) underwent imaging on indication before routine ultrasound. The overall incidence of hydronephrosis was 12%. In symptomatic patients, the incidence was 21% and 9% in asymptomatic women undergoing routine ultrasound. Four patients were invasively treated for hydronephrosis (1% of the total group) after imaging for clinical suspicion of hydronephrosis. Patients with hydronephrosis were significantly more often treated with radiotherapy than patients without (43% versus 25% (p=0.03). CONCLUSION There is no place for routine renal ultrasound following radical hysterectomy. Patients should be instructed about the symptoms that may be related to hydronephrosis, to allow for renal ultrasound on indication.

Treatment of acute radiation cystitis: reply by the authors

Dear Editor, We highly appreciate the comments by Drs. Wang, Horng and Lee regarding our feasibility study on prevention of radiation cystitis by intravesical instillations with chondroitin sulphate [1]. We fully agree that more pre-clinical studies may help to elucidate the mechanisms and treatment of radiation cystitis, and that several clinical studies are needed to assess the efficacy of intravesical instillations with chondroitin sulphate. In fact, we hope soon to start a double-blind study in patients undergoing primary or adjuvant radiotherapy for gynaecological malignancies. In that trial, a wider range of early and late clinical symptoms will be evaluated, as also suggested by Wang et al.