Long-term lower urinary tract dysfunction after radical hysterectomy in patients with early postoperative voiding dysfunction: reply to comments by Sansone et al.

Abstract

Dear Editor, We would like to thank Sansone et al. [1] for their interest in our article [2]. In response, we have the following comments. Late lower urinary tract (LUT) dysfunction such as decreased bladder compliance, detrusor overactivity, urinary incontinence, and voiding dysfunction usually resolve within 6–12 months. We hypothesized that some of them may persist beyond 1 year. LUT dysfunction is the most common long-term complication which may affect quality of life. Our focus was on the long-term sequelae. Since cancer recurrence beyond 2 year is infrequent, we chose to explore the LUT dysfunction at least 2 years after radical hysterectomy. Median time since surgery in our study was 5 years (2–11 years), which was similar in both groups (groups A and B). Age has been determined to be the most significant risk factor for LUT dysfunction [3]. Although median age in the patients after surgery (groups A and B) is higher than the patients before surgery (group C), there was no statistical significance. Voiding dysfunctions in the difference were diagnosed from both validated questionnaire (UDI and IIQ) and urodynamic studies and were more prevalent in the patients after surgery. Patients who had early postoperative voiding dysfunction (group A) were particularly affected. In contrast, storage dysfunction as diagnosed by urodynamic studies was similar in all groups. We agree that the followup timing may be one of the major factors that influence the detection of bladder dysfunction after radical hysterectomy. However, it is interesting to note that only voiding dysfunction was significantly higher in the patients after surgery, despite that storage dysfunction should be more common. If the follow-up timing had an effect to the incidence of LUT dysfunction, patients after surgery should have a significantly higher incidence of both storage and voiding dysfunction. From our result, it was possible that only voiding dysfunction may persist in the long term. Early voiding dysfunction might influence late voiding dysfunction. However, we agree that large prospective trials should be conducted to prove this possibility. Neurological damage from radical surgery, especially the loss of control from alpha adrenergic receptors, will relax the internal urethral sphincter at the bladder neck and proximal urethra, causing stress urinary incontinence. Benedetti-Panici et al. reported that maximal urethral closure pressure (MUCP) decreased significantly after type 3–4 radical hysterectomy [4]. Although, MUCP was lower in patients after surgery and lowest in group A, there was no significant difference noted. This parameter was shown in Table 2 (page 98). No patient had MUCP lower than 20 cmH2O even in patients who were diagnosed as experiencing urodynamic stress incontinence. Our finding was similar to the report of Lin et al. [5]. We agree that large prospective trials with a translational component including multicenter collaboration would be beneficial to draw definite conclusions. T. Manchana :C. Prasartsakulchai Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand