Urinary incontinence after gynecologic cancer treatment

Abstract

Dear Sir, Recently, Skjeldestad and Hagen reported an interesting study where urinary incontinence among long-term survivors of gynecological cancer was detailed 1. They enrolled 160 recurrence-free survivors of gynecological cancer and 432 controls without a history of gynecological cancer. They reported that the prevalence of total, stress, urge and mixed urinary incontinence was 34.3, 24, 0.8 and 9%, respectively. In addition, they found that previous gynecological cancer treatment was not associated with any outcomes of urinary incontinence (p = 0.79). They concluded that recurrence-free long-term survivors of gynecological cancer are not at increased risk for urinary incontinence. In this respect, we would like to give our contribution to the argument as follows: It is well known that all forms of cancer therapy have the potential to cause complications that vary according to surgical treatment. On the other hand, the different type of radical procedure performed in endometrial, ovarian and cervical cancer patients may have a different impact on urinary function after surgery. According to the FIGO guidelines 2, type 3 radical hysterectomy is considered the standard treatment for patients affected by early stage (FIGO stage IA2–IB1) cervical carcinoma. Urinary incontinence after type 3 radical hysterectomy is the consequence of damage to nerve fibers from the pelvic plexus. During radical hysterectomy, pelvic nerves and fascial structures can be interrupted in the anterior, posterior and lateral parametrium, leading to various degrees of bladder dysfunction with an incidence of about 80% at 12 months urodynamic evaluation 3. On the other hand, the standard treatment of ovarian and endometrial cancer does not require radical parametrectomy with the possibility of preservation of pelvic nerve structures during surgery. Moreover, it is well known that intraoperative modulation of radicality (reducing extent of parametrectomy) is feasible and safe in selected cases of cervical cancer patients 4 and it can reduce the incidence of bladder dysfunction to 9% 2. Skjeldestad and Hagen have enrolled 66 (41.3%), 34 (21.3%) and 60 (37.5%) patients affected cervical, endometrial and ovarian cancer, respectively. Thus, probably each patient group had previously received a different type of surgery. However, the type of surgery and the stage of the gynecologic cancers were not reported. We think that the most important factor that influences urinary function after cancer treatment is the type of radical surgery performed in accordance with what is indicated for the type of gynecologic cancer. However, in order to avoid misinterpretation of the results, patients enrolled in such a study should be stratified according to the type of previous surgery received for the different type and stage of gynecologic cancers. Thus until these points are clarified the present conclusions should be interpreted with caution.