Effects Of Radical Hysterectomy And Total Hysterectomy On Pelvic Organs And Supporting Structures

Cervical cancer and endometrial cancer are the two most common malignant tumors in women.The incidence of benign diseases such as uterine leiomyoma and adenomyosis is also one of the leading gynecological diseases.Radical hysterectomy is the standard surgical procedure for the treatment of early-mid-stage cervical cancer and stage II endometrial cancer.Total hysterectomy is a common surgical procedure for the treatment of stage I endometrial cancer and some benign gynecological diseases,and its effectiveness is recognized.However,as the rate of young patients in gynecologic diseases has increased,the survival time of these patients becomes longer,and more than 35.0%-48.3%patients have one or more kind of PFD after surgery,which brings serious life troubles to patients.Therefore,pelvic floor dysfunction(PFD)caused by surgical injury has attracted the attention of patients and clinicians.The "integry theory" proposes that pelvic floor dysfunction can occur when the dynamic balance of pelvic floor muscles,fascia and ligaments is broken.The"three-level support theory" holds that the absence or damage at any level can lead to structural changes supported by this layer.From the point of view of female pelvic floor science,both surgeries destroy the dynamic balance of the pelvic floor.In addition,radical hysterectomy removes the uterus,the upper 1/3-1/2 of the vagina and the cardinal-sacral ligament,damages the upper half of the vesicovaginal septum and the rectovaginal septum,damages the pelvic autonomic nerve and corresponding blood vessels,and damages the three-level support of the pelvic floor to varying degrees.Total hysterectomy removes the uterus,cut off the cardinal ligament and sacrum ligament cmplex,and the first level of pelvic floor is affected.Due to the hollowness of the middle pelvic cavity and the damage or disappearance of the first level of pelvic floor caused by the surgery,the pelvic organ position may change downward when the abdominal pressure increases,and pelvic organ prolapse may easily occur with the increase of the pressure action time.The lateral support of pelvic organs is affected and the pelvic organ’s shape is easy to change,which leads to urinary incontinence,fecal incontinence and other disorders.Therefore,in theory,the above changes are more likely to occur after radical hysterectomy.However,we have observed that urination dysfunction,defecation dysfunction and sexual dysfunction are common after radical hysterectomy,and pelvic organ prolapse is rare.The secondary prolapse rate after total hysterectomy is higher than that of radical hysterectomy,but urination dysfunction,defecation dysfunction and sexual dysfunction are rare.However,there is little research on this aspect at present.Domestic research is limited to comparing the changes of pelvic organs and supporting structures after radical hysterectomy or total hysterectomy,without comparing the differences of the effects of the two surgical methods on them.Foreign studies mostly adopt the form of pelvic floor function questionnaire,which is subjective and does not objectively analyze the changes of objective indicators after surgery.Therefore,the above factors need further research and confirmation.Because pelvic structure changes,such as vaginal shortening,vaginal axial changes,pelvic organ inclination changes,etc.,easily lead to changes in pelvic floor function,this study attempts to find out the relationship between structural and functional changes and clinical manifestation disordersThe soft tissue of female pelvic floor has complex structure,hidden location,less research methods and poor visualization.With the development of imaging technology,Magnetic resonance imaging(MRI)is used to study pelvic floor anatomy for its advantages of high soft tissue resolution and multidirectional imaging.In addition to planar analysis of static and dynamic MRI 2D images,three-dimensional models of pelvic organs and supporting structures can also be constructed to comprehensively and intuitively evaluate the three-dimensional spatial structure of pelvic anatomy,making up for the defect that some structures cannot be observed at the same level in 2D space.At present,MRI is also one of the routine examinations(NCCN guidelines)for preoperative and postoperative diagnosis and reexamination of malignant tumor patients,which makes us agree with the diagnosis of tumor when studying the anatomical changes of pelvic floor affected by the above surgical procedures.Therefore,on the basis of static MRI two-dimensional images and three-dimensional models,combined with dynamic MRI images and models,our study intends to compare the effects and differences of radical hysterectomy and total hysterectomy on pelvic organs and vulvar morphology.The first part compares the differences of organ positions before and after surgery.The second part compares the morphological changes and differences before and after surgery.The third part compares the changes and differences of anatomical structures of levator ani and vulvar morphology before and after the two surgical procedures.The first part Effects on position of pelvic organs before and after radical hysterectomy and total hysterectomy[Purpose]Construct three-dimensional models of pelvic organs by using MRI data before and after radical hysterectomy and total hysterectomy.The differences of pelvic organ position before and after the two types of surgery were compared,and the characteristics of pelvic organ position changes after the two types of surgery were analyzed.[Methods]1.The subject include 30 patients who underwent QM-B radical hysterectomy due to IA2-IIA2 cervical cancer at Nanfang Hospital of Southern Medical University from October 2017 to October 2019 and were returned to the hospital 6-12 months before and after the surgery were classified as the radical hysterectomy group.20 patients who underwent total hysterectomy due to stage I endometrial cancer,hysteromyoma and adenomyosis and were returned to the hospital 6-12 months before and after the surgery were classified as the total hysterectomy group.General data and pelvic static and dynamic MRI data of 6-12 months before and after surgery were collected.Inclusion criteria:no pelvic floor dysfunction diseases before surgery;no serious constipation,diabetes,hypertension,chronic cough and other diseases;no radiotherapy was performed before or after the surgery.Hormone drugs were not used for a long time before and after the surgery.Sign the informed consent form.Exclusion criteria:pelvic floor operations before surgery;poor coordination of breath-holding movements;unclear images;history of genital tract malformation and pelvic mass;pelvic floor function exercise and other treatment for restoration of pelvic floor function were performed after the surgery.Finally,30 sets of preoperative and postoperative static and dynamic MRI data were included in the radical hysterectomy group,20 sets of preoperative and postoperative static MRI data in the total hysterectomy group,6 sets of preoperative dynamic MRI data,and 18 sets of postoperative dynamic MRI data.2.The pelvic static T2W TSE sequence and the best SS-TSE sequence under breath-holding force were collected.All data are saved in Dicom3.0 format.3.Mimics 21.0 software was used to build a 3D static and dynamic MRI model of pelvic organs,and STL format files of the model were imported into UG software.The distance from bladder neck(BN),mid-point of posterior wall of vagina apex(V)and the anorectal junction(R)to the pubic-sacrococcygeal joint line(SCIPP),the horizontal distance to the left and right pubic spines(PIS),the distance to the sciatic spines line(IS)before and after the surgery were measured,and the movement degrees of static and dynamic organs in all directions before and after the surgery were calculated.[Results]1.There was no significant difference in age,BMI,parity,menopausal state before surgery and ovarian resection between two groups(P>0.05).2.Changes of pelvic organs position and mobility before and after radical hysterectomy:(1)Using pubic-sacrococcygeal joint line(SCIPP line),left and right pubic spines line(PIS line)and ischial spines line(IS line)can evaluate the position change characteristics of pelvic organs in vertical,horizontal,anterior and posterior directions.(2)Before and after hysterectomy,the lengths of SCIPP line,left and right PIS line and IS line in rest and dynamic states have no statistical difference(P>0.05).(3)Before hysterectomy,the bladder neck,mid-point of posterior wall of vagina apex were vertically moved down 7.20±6.86mm、5.11±11.29mm(P<0.05),while after hysterectomy,the bladder neck,the mid-point of posterior wall of vagina apex were vertically moved down 3.98±2.96mm、0.79±5.39mm(P<0.05),there was no statistical difference in the vertical movement of anorectal junction before and after the surgery(P>0.05).Before and after hysterectomy,the bladder neck,mid-point of posterior wall of vagina apex and the anorectal junction moved horizontally by 1-3 mm respectively(P<0.05).Before hysterectomy,the bladder neck,mid-point of posterior wall of vagina apex were vertically moved down by 6.56±7.38mm、5.13±10.41mm(P<0.05).After hysterectomy,the bladder neck,mid-point of posterior wall of vagina apex were vertically moved down by 2.92±5.59mm、1.51±3.28mm(P<0.05),there was no statistical difference in the mobility of the anterior-posterior direction of the anorectal junction before and after the surgery(P>0.05).3.Changes of pelvic organs position and mobility before and after total hysterectomy:(1)Before and after hysterectomy,the lengths of SCIPP line,left and right PIS line and IS line in rest and dynamic states have no statistical difference(P>0.05).(2)Before and after hysterectomy,there was no statistical difference in the vertical position movement of bladder neck,mid-point of posterior wall of vagina apex and anorectal junction(P>0.05).Before and after hysterectomy,the bladder neck,mid-point of posterior wall of vagina apex and the anorectal junction moved horizontally by 1-3 mm respectively(P>0.05).Before and after surgery,there was no statistical difference in the anterior-posterior position movement of bladder neck,middle point of posterior wall of vaginal apex and anorectal junction(P>0.05).3.Comparison of pelvic organs mobility changes before and after radical hysterectomy and total hysterectomyBefore and after hysterectomy,there was no significant difference in the mobility of bladder neck,mid-point of posterior wall of vagina apex and anorectal junction in vertical,horizontal and anteroposterior directions between the patients with radical hysterectomy and the patients with total hysterectomy(P>0.05).[Conclusion]1.SCIPP line,PIS line and IS line can be used to evaluate the changes of pelvic organ position and mobility in three-dimensional space.2.The movement direction of bladder and vaginal apex under breath-holding force after radical hysterectomy has not changed compared with that before surgery,The movement direction is backward and downward.But the movement degree is reduced compared with that before surgery,the degree of downward and backward movement of bladder is about 6-7mm before surgery and 3-4 mm after surgery.The vaginal apex moved downward and backward about 5mm before surgery and 1mm after surgery.It is considered to be caused by pelvic fascia adhesion and fibrosis after surgery,resulting in the decrease of pelvic soft tissue elasticity.3.The change of bladder and vaginal apex position after surgery may be one of the anatomical reasons for more dysfunction in radical hysterectomy.4.The above anatomical changes may be one of the anatomical reasons that besides nerve injury,lower urinary tract dysfunction is more likely to occur after radical hysterectomy and pelvic organ prolapse is less likely to occur.The second part Effects on morphology of pelvic organs before and after radical hysterectomy and total hysterectomy[Purpose]Three-dimensional models of pelvic organs before and after radical hysterectomy and total hysterectomy were constructed using MRI data.Static MRI two-dimensional images and three-dimensional models were used to compare the differences of pelvic organ morphology before and after the two types of surgery,and to analyze the effects of the two types of surgery on pelvic organ morphology changes.[Methods]1.The inclusion and exclusion criteria are the same as the first past.2.Collect pelvic static T2W TSE sequence.All data are saved in Dicom 3.0 format.3.Mimics 21.0 software was used to build a static and dynamic MRI three-dimensional model of pelvic organs,and the anatomical parameters of bladder,urethra and vagina before and after the surgery were measured in the software.3.1 Anatomical parameters of bladder and urethra:presence or absence of bladder neck funnel,width and depth of bladder neck funnel,posterior angle of bladder and urethra,urethral fold angle,urethral inclination angle,urethral pubic angle,length of urethra,thickness of urethral sphincter thickness and width of retropubic space.3.2 Anatomical parameters of vagina:angle of upper and lower segments of vagina,angle between upper and lower sections of vagina,vaginal length.[Results]1.There was no significant difference in age,BMI,parity,menopausal state before surgery and ovarian resection between two groups(P>0.05).2.Morphological changes of pelvic organs before and after radical hysterectomy2.1 Comparison of anatomical parameters of bladder and urethra before and after surgeryAfter radical hysterectomy,the bladder neck funnel widened by 1.81±2.48mm,posterior angle of bladder and urethra decreased by 6.56±14.08°,the urethral fold angle increased by 9.88±13.41°,the urethral inclination angle recreased by 5.43±6.71°,the urethral pubic angle increased by 7.27±9.07°,the length of urethra shortened by 1.27±2.03mm,the thickness of urethral sphincter increased by 0.17±0.41mm,the thickness of retropubic space increased by 2.55±2.44 mm(P<0.05),and there was no statistical difference in the change of bladder neck funnel depth(P>0.05).2.2 Comparison of vaginal anatomical parameters before and after surgeryAfter radical hysterectomy,the axial angle of the upper vagina was increased 32.74±15.62°(P<0.05),while the axial angle of the lower vaginal segment showed no significant difference(P>0.05).The angle between upper and lower vagina increased by 36.28±19.18°(P<0.05).The vaginal length was shortened by 23.69± 10.21 mm(P<0.05).After radical hysterectomy,the upper segment of the vaginal axis leaned forward with an angle increase of 32.74±15.62°(P<0.05).There was no statistical difference in the direction and angle of the lower segment of the vaginal axis(P>0.05).The angle between the upper and lower segments of the vaginal axis increased by 36.28±19.18°(P<0.05).The vaginal length was shortened by23.69±10.21 mm(P<0.05).3.Morphological changes of pelvic organs before and after total hysterectomy3.1 Comparison of anatomical parameters of bladder and urethra before and after surgeryAfter total hysterectomy,the bladder neck funnel widened by 2.22±3.58 mm(P<0.05).There was no statistical difference in bladder neck funnel depth,posterior angle of bladder and urethra,urethral fold angle,urethral inclination angle,urethral pubic angle,urethral length,urethral sphincter thickness and thickness of retropubic space(P>0.05).3.2 Comparison of vaginal anatomical parameters before and after surgeryAfter total hysterectomy,the axial angle of the upper vagina was increased 23.10±12.77°(P<0.05),while the axial angle of the lower vaginal segment showed no significant difference(P>0.05).The angle between upper and lower vagina increased by 16.41±14.14°(P<0.05).The length of vagina was shortened by 16.50±10.12 mm(P<0.05).After total hysterectomy,the upper segment of the vaginal axis leaned forward with an angle increase of 23.10±12.77°(P<0.05).There was no statistical difference in the direction and angle of the lower segment of the vaginal axis(P>0.05).The angle between the upper and lower segments of the vaginal axis increased by 16.41±14.14°(P<0.05).The length of vagina was shortened by 16.50±10.12mm(P<0.05).4.Morphological changes of pelvic organs before and after radical and total hysterectomy4.1 Comparison of anatomical parameters of bladder and urethra before and after surgery.The increase of thickness of retropubic space before radical hysterectomy was larger than that of total hysterectomy,and the reduction of urethral inclination angle was larger than that of total hysterectomy(P<0.05).There was no statistical difference in the width and depth of bladder neck funnel,posterior angle of bladder and urethra,urethral fold angle,urethral pubic angle,urethral sphincter thickness and urethral length between the two types of surgery(P>0.05).4.2 Comparison of vaginal anatomical parameters before and after surgeryThe axial angle increment of the upper vagina before and after radical hysterectomy is greater than that of total hysterectomy.There was no difference in the changes of axial angle of the lower vagina after extensive hysterectomy and total hysterectomy.The anteversion angle of upper vaginal axis before and after radical hysterectomy is larger than that of total hysterectomy(P<0.05).There was no difference in the angle change of the inferior segment of the vaginal axis after radical hysterectomy and total hysterectomy(P>0.05).The axial increment of the upper and lower vaginal segments before and after radical hysterectomy was greater than that of total hysterectomy(P<0.05).The reduction of vaginal length after radical hysterectomy was greater than that after total hysterectomy(P>0.05).[Conclusion]1.Bladder-urethra changes in different degrees after radical hysterectomy,while bladder-urethra morphology has no obvious change after total hysterectomy.Considering that the support around bladder and urethra decreases after radical hysterectomy,the above changes may be one of the anatomical causes of lower urinary tract dysfunction after radical hysterectomy.2.The retropubic space increased after radical hysterectomy and was mostly filled with fat signal,but it did not change after total hysterectomy.It is considered that radical hysterectomy will cause greater damage to the lateral support structure of vagina,thus easily weakening the support force around bladder and urethra.3.The ante version degree of the upper part of the vaginal axis after radical hysterectomy is more obvious than that of total hysterectomy,and the vaginal length is shorter,so pelvic organ prolapse is less likely to occur after radical hysterectomy.The third part Effects on levator ani and vulvar morphology before and after radical hysterectomy and total hysterectomy[Purpose]Three-dimensional models of levator ani,clitoris and perineum of patients with radical hysterectomy and with total hysterectomy were constructed using MRI data.Static MRI two-dimensional images and three-dimensional models were used to compare the morphological changes of levator ani and vulva before and after the two types of surgery.Combined with sexual function questionnaire,the relationship between morphological changes of vulva and sexual function after the two types of surgery was analyzed.[Methods]1.The inclusion and exclusion criteria are the same as the first past.2.Collect pelvic static T2W TSE sequence.All data are saved in Dicom3.0 format.3.Mimics 21.0 software was used to build a static MRI three-dimensional model of levator ani,clitoris and perineum body,and the anatomical parameters of each part before and after the surgery can be measured in the software.3.1 Levator ani parameterMorphological parameters:levator ani hiatus width and length,levator ani plate angle,levator ani volume;Biomechanical parameters:levator ani strain rate.3.2 Anatomical parameters of clitoris and perineum body include:length,width and volume of clitoris head,distance between clitoris head and urethral orifice,distance between clitoris head and vaginal orifice,length of pubic fissure and thickness of perineum body.4.All patients received regular follow-up before and 6-12 months after surgery.A professionally trained clinician conducted a face-to-face or telephone survey in a quiet and private room.The patients answered the questionnaire autonomously.The content is based on the International Feminist Function for Women Scale(BISF-W)and Female sexual function index,FSFI),and the five indexes of libido,sexual arousal,orgasm,sexual pain and sexual aversion are selected.[Results]1.There was no significant difference in age,BMI,parity,menopausal state before surgery and ovarian resection between two groups(P>0.05).2.Morphological changes of levator ani and vulva before and after radical hysterectomy2.1 Changes of levator ani before and after surgeryBefore and after radical hysterectomy,the levator ani hiatus width and length,levator ani plate angle and levator ani volume didn’t change in resting state(P>0.05).the levator ani hiatus width and length,levator ani plate angle and levator ani volume didn’t change under valsalva(P>0.05).There was no difference in the size of levator ani hiatus and levator ani plate angle in the static and dynamic state before and after surgury(P>0.05).2.2 Changes of clitoris and perineal body before and after surgeryAfter radical hysterectomy,the length of clitoris head was reduced by 2.69±2.50mm,the width was reduced by 0.64±0.72mm,the volume was reduced by 101.51±110.85mm,and the thickness of perineum body was reduced by 4.86±2.77 mm(P<0.05).There was no statistical difference in the distance between clitoris head and urethral orifice and the vaginal orifice(P>0.05).2.3 Changes of sexual function before and after surgeryAfter radical hysterectomy,the proportion of sexual arousal disorder(postoperative vs.preoperative=40.00%vs.16.67%)and orgasmic disorder(postoperative vs.preoperative=56.67%vs.6.67%)is higher than that before surgery(P<0.05),while the proportion of sexual hyposexuality,sexual aversion and coital pain after surgery is not statistically different from that before surgery(P>0.05).2.4 Relationship between vulvar morphology and sexual function before and after surgerySex desire,sexual arousal,orgasm,sexual aversion,and coital pain are taken as dependent variables,and clitoral head length difference,clitoral head width difference,clitoral head volume difference,genital hiatus length,clitoral head distance from urethral orifice and vaginal orifice,and perineal body thickness difference are taken as independent variables into Logistic regression analysis,and it is concluded that the reduction degree of clitoral head volume is a risk factor for sexual desire disorder(OR=1.018,95%CI 1.001-1.034,P<0.05),while the reduction of clitoral head length and width,the change of clitoral head distance from urethral orifice and vaginal orifice,the change of reproductive hiatus,and the shortening of perineal body are not risk factors for postoperative sexual dysfunction(P>0.05).3 Morphological changes of levator ani and vulva before and after total hysterectomy3.1 Changes of levator ani before and after surgeryBefore and after total hysterectomy,the levator ani hiatus width and length,levator ani plate angle and levator ani volume didn’t change in resting state(P>0.05).the levator ani hiatus width and length,levator ani plate angle and levator ani volume didn’t change under valsalva(P>0.05).There was no difference in the size of levator ani hiatus and levator ani plate angle in the static and dynamic state before and after surgury(P>0.05).3.2 Changes of clitoris and perineal body before and after total hysterectomyAfter total hysterectomy,the length of clitoris head was reduced by 1.31±1.24mm,and the volume was reduced by 33.20±36.57 mm(P<0.05).There was no statistical difference in the volume of clitoris head,the distance between clitoris head and urethra orifice,the distance between clitoris head and vaginal orifice,the length of pubic fissure and the thickness of perineum body(P>0.05).3.3 Changes of sexual function before and after surgeryAfter total hysterectomy,the proportion of hyposexuality(postoperative vs.preoperative=25.00%vs.0.15%)was higher than preoperative(P<0.05).The proportion of sexual arousal disorder,orgasm disorder,sexual aversion and coital pain was not statistically different from that before operation(P>0.05).2.4 Relationship between vulvar morphology and sexual function before and after surgeryMethods the same as 2.4.Logistic regression analysis showed that the length,width and volume reduction of clitoris head,the change of clitoris head distance from urethral orifice and vaginal orifice,the change of reproductive hiatus,and the shortening of perineum were not risk factors for sexual dysfunction(P>0.05).4.Changes of levator ani,clitoris and perineal body before and after radical hysterectomy and total hysterectomy4.1 Changes of levator ani before and after surgeryThere was no difference in levator ani hiatus size and levator ani plate angle between the two groups before and after surgery(P>0.05).4.2 Changes of clitoris and perineal body before and after surgeryThe reduction value of clitoris head length after radical hysterectomy is 1.38mm more than that after total hysterectomy,the reduction value of clitoris head volume is 68.31mm3 more than that of total hysterectomy group,and the reduction value of perineal body thickness is 4.18 mm more than that of total hysterectomy group(P<0.05).However,there is no statistical difference in the difference of clitoris head width,the difference of distance from clitoris head to urethral orifice and vaginal orifice,and the difference of vaginal fissure between the two groups(P>0.05).[Conclusion]1.Levator ani has not changed significantly before and after radical hysterectomy and total hysterectomy..2.After radical hysterectomy,clitoris and perineum can undergo obvious atrophic changes.The reduction of clitoris size,volume and perineum thickness is greater than that of total hysterectomy..3.Significant sexual dysfunction can occur after radical hysterectomy,and the reduction of clitoral volume is a risk factor for sexual dysfunction after radical hysterectomy.The incidence of sexual dysfunction after total hysterectomy is relatively low,and no changes of clitoris and perineum have been found to be related to it.