Long Term Effects Of Radical Hysterectomy On Pelvic Floor Anatomy

Cervical cancer is now the fourth most common female cancer worldwide.Radical hysterectomy(RH)is the main surgical method for the treatment of early and middle stage cervical cancer and stage ii endometrial cancer,and the disease-free survival rate of 5 years after operation can reach 85%～95%.However,due to its large surgical scope,the pelvic floor structure,such as nerve,muscle function and blood vessels,will be damaged to varying degrees.A series of postoperative pelvic dysfunction diseases(PFD)were induced,such as urinary incontinence,urine retention,sexual dysfunction,etc.As the incidence of cervical cancer is getting younger and younger,as well as the improvement of diagnosis and treatment level and the extension of survival cycle,the quality of life of patients caused by postoperative pelvic floor dysfunction has gradually attracted widespread attention.Pelvic floor "integral theory" point out,pelvic floor is an interimally interrelated whole,think one kind or the damage of a variety of connective tissue structure all can bring about pelvic viscera prolapse,or cause the function obstacle of viscera different degree.radical hysterectomy excised the uterus,upper 1/3 to 1/2 of the vagina and the major-sacral ligament,destroyed the vesico-vaginal and vagino-rectal septum,cut off the pelvic autonomic nerve and corresponding blood vessels,resulting in varying degrees of damage to the three levels of pelvic floor support,the anatomical changes of the pelvic floor will inevitably lead to the change of the original supporting function.RH postoperative pelvic floor long-term change and how about the current study is less,the domestic and foreign studies of extensive pelvic floor changes after total hysterectomy more limited to 1 year postoperatively,and long-term changes in the relevant research has focused on the questionnaire analysis,not an objective analysis of postoperative changes of the anatomy of the pelvic floor indicators for a long time,so further research confirmed pelvic floor variations.Changes in the original structure of the pelvic cavity,such as axial changes of the vagina and shortening of the vagina,are likely to lead to changes in pelvic floor function after surgery.Therefore,this study intends to find out the relationship between the long-term structure and function of the pelvic floor after surgery and further analyze its correlation with clinical dysfunction.Due to the deep anatomical position of the female pelvic floor,gynecological examination and ultrasound are greatly influenced by the operator,and it is difficult to find hidden anatomical changes of the pelvic floor.Magnetic resonance imaging(MRI)has been gradually applied due to its advantages of non-invasive and high soft tissue resolution.MRI can not only evaluate the spatial position of all pelvic organs,but also directly observe the pelvic floor tissue support structure,obtain anatomical structure information of muscles,fascia and organs,describe pelvic floor anatomical abnormalities,determine the nature of injury including pelvic floor muscle continuity.In addition,3D MRI reconstruction can also be used for computer post-processing,3D reconstruction of the processed data to display the 3d pelvic floor image,more intuitive stereoscopic,fine display of anatomical structure and spatial position,while qualitative and quantitative analysis can be carried out.Therefore,based on the original MRI images and 3d reconstruction model,this study was intended to compare the anatomical changes of levator ANI muscle,pelvic organs and vulva before,1 year and 5 years after extensive total hysterectomy,and to conclude the association between long-term postoperative anatomical changes and dysfunction.In the first part of this study,the changes of levator ANI muscle before surgery,1 year after surgery and 5 years after surgery were compared.The second part compared the changes of pelvic organs before operation,1 year after operation and 5 years after operation.The third part compared the changes of clitoris and perineal diaphragm before operation,1 year after operation and 5 years after operation.The first partLong-term effects of radical hysterectomy on levator ANI muscle[Purpose]Three-dimensional MRI reconstruction technology was used to construct dynamic and static three-dimensional models of levator ANI muscle before,1 year and 5 years after extensive total hysterectomy.The anatomical changes of levator ANI muscle at different time periods were compared to analyze the long-term effects of surgery on levator ANI muscle.[Methods]1.Patients who visited Nanfang Hospital of Southern Medical University from October 2016 to October 2021 and underwent radical hysterectomy cervical cancer were enrolled,and pelvic dynamic and static MRI examinations were performed 2 weeks before surgery,1 year after surgery,and 5 years after surgery,respectively.General data and dynamic and static MRI data of pelvic cavity were collected.Inclusion criteria:no pelvic floor dysfunction diseases before surgery;No MRI contraindications,good coordination with breath-holding force,clear images;Signed informed consent with good compliance.Exclusion criteria:severe neurological diseases,constipation,chronic cough and other diseases;History of large pelvic mass and reproductive tract malformation;Preoperative radiotherapy or chemoradiotherapy;She was menopausal before surgery.Elimination criteria:preservation of ovaries during operation.A total of 129 patients underwent extensive total hysterectomy with preoperative static MRI data,including 82 patients with dynamic and static MRI data.Static MRI data of 115 patients were obtained 1 year after surgery,including 68 patients with dynamic and static MRI data.There were 42 cases with static MRI data 5 years after operation,including 30 cases with dynamic and static MRI data.2.Image acquisition:TR/TE:4000/20ms static T2W TSE sequence,turn Angle 180°,FOV 260mm×260mm,matri×512×512,layer thickness 3.0mm,layer spacing 0.5mm.TR/TE:688/80ms,turn Angle 90°,FOV 260mm×297mm,matrix 184×188,layer thickness 4.0mm,layer spacing 1.0mm were used for dynamic T2W SSTSE sequence under breath holding force.The original MRI images were saved in Dicom 3.0 format.3.Mimics 21.0 software was used to construct static and dynamic MRI 3D models of levator ANI muscle before surgery,1 year after surgery and 5 years after surgery.The transverse diameter and anterior and posterior diameter of the lactation cavity of levator ANI muscle under static and breath-holding force conditions were measured respectively.Angle of levator ANI plate,volume of levator ANI muscle,distance between left and right sides of levator ANI muscle and lower margin of symphysis pubis,Angle of iliococcyx muscle on both sides,thickness of iliococcyx muscle on both sides,thickness of puborectalis muscle on both sides,M line and H line.[Results]1.General data of the patients:age(42.55±12.37)years,BMI(23.02±3.49),pregnancy times(2.00±1.33)2.Changes of levator ANI muscle before and after radical hysterectomy2.1 Dynamic and static changes of levator ANI muscle before and 1 year after radical hysterectomyThere were no statistically significant differences in transverse diameter,anterior and posterior diameter,Angle of levator ANI plate,Angle of iliococcygeal muscle on both sides,distance between levator ANI muscle on both sides and lower margin of symphysis pubis and H line in resting state(P>0.05).The body volume of the anal levator was atrophied,the thickness of the iliocaudal muscle on both sides was thinner,the thickness of the puborectalis muscle on both sides was thinner,and the M-line was prolonged(P<0.05).The transverse diameter,anterior-posterior diameter,the distance between the levator ANI muscle and the pubic symphysis on both sides,and H line did not change in Valsalva condition(P>0.05).The Angle of the levator ANI plate increased,the body volume of the levator ANI muscle atrophy,the Angle of the iliococcyx muscle on both sides increased,the thickness of the iliococcyx muscle on both sides became thinner,the thickness of the puborectalis muscle on both sides became thinner,and the M-line was prolonged(P<0.05).2.2 Dynamic and static changes of levator ANI muscle before and 5 years after radical hysterectomyComparison between before and 5 years after radical hysterectomy showed that there was no statistical significance in the transverse diameter,anterior and posterior diameters,Angle of levator ANI plate,Angle of iliococcygeal muscle on both sides,distance between levator ANI muscle on both sides and lower margin of symphysis pubis,and H-line in resting state(P>0.05).The body volume of the anal levator was atrophied,the thickness of the iliocaudal muscle on both sides was thinner,the thickness of the puborectalis muscle on both sides was thinner,and the M-line was prolonged(P<0.05).The transverse diameter,anterior-posterior diameter,the distance between the levator ANI muscle and the pubic symphysis on both sides,and H line did not change in Valsalva condition(P>0.05).The Angle of the levator ANI plate increased,the body volume of the levator ANI muscle atrophy,the Angle of the iliococcyx muscle on both sides increased,the thickness of the iliococcyx muscle on both sides became thinner,the thickness of the puborectalis muscle on both sides became thinner,and the M-line was prolonged(P<0.05).2.3 Differences of dynamic and static changes of levator ANI muscle 1 year and 5 years after radical hysterectomyradical hysterectomy after 1 year and 5 years after contrast found that anal resting state levator in transverse diameter,diameter,before and after the anus,anal muscle mass levator plate Angle,right,left and right sides of the iliac muscle Angle of pubic rectum,left and right sides of the anus levator muscle thickness and edge of pubic symphysis distance,H line difference has no statistical significance(P>0.05),The thickness of iliocaudal muscle on both sides was thinner,volume of levator ANI muscle,the thickness of puborectalis muscle on the left side was thinner,and the M-line was prolonged(P<0.05).There were no statistically significant differences in the transverse diameter,anterior and posterior diameters,Angle of levator ANI plate,Angle of iliococcygeal muscle on both sides,distance between levator ANI muscle and pubic symphysis on both sides and H-line under Valsalva movement(P>0.05).The thickness of iliocaudal muscle on both sides was thinner,volume of levator ANI muscle,the thickness of puborectalis muscle on both sides was thinner and the M-line was prolonged(P<0.05).[Conclusion]1.Dynamic MRI evaluation of anatomical changes of levator ANI muscle can reveal potential abnormalities not found in its resting state.2.Long-term pelvic floor muscles tend to relax and gradually atrophy after surgery.Preventive pelvic floor exercise can be carried out early after surgery as soon as possible.The second part Long-term effects of radical hysterectomy on pelvic floor viscera[Purpose]Combined with 2D pelvic MRI images and 3D reconstruction model,the long-term changes of bladder,urethra and vagina after radical hysterectomy were analyzed,and the long-term effects of surgical methods on pelvic organs were analyzed.[Methods]1.Inclusion and exclusion criteria are the same as those in part I.2.Pelvic static T2W TSE sequences were collected and pelvic data were saved in Dicom format.3.Mimics 21.0 software was used to construct 3D MRI models in the resting state before surgery,1 year after surgery and 5 years after surgery,and the anatomical parameters of bladder,urethra and vagina in 2D and 3D MRI models before and after surgery were measured respectively.3.1 Bladder and urethral measurement parameters:bladder neck funnel,width and depth of bladder neck funnel,bladder and urethral posterior Angle,urethral folding Angle,urethral length,urethral rhabdomy thickness,posterior pubic space,urethral inclination Angle,urethral pubic Angle.3.2 Vaginal measurement parameters:the Angle between the upper and lower segments of the axial force point of the vagina,the length of the front and back walls of the vagina,and the coordinates of the inflection point of the vagina.[Results]1.Comparison of anatomical parameters of bladder and urethra and vagina before and after radical hysterectomy1.1 Anatomical changes of bladder and urethra and vagina before and 1 year after radical hysterectomy1.1.1 Changes of bladder and urethra parametersOne year after radical hysterectomy,the bladder neck funnel widened,with an average width of(1.45±0.51)mm.The posterior Angle of bladder and urethra increased by(4.24±7.74)° on average.The urethral folding Angle increased by(6.63±1.40)° on average.The urethral inclination Angle decreased by(7.99±2.72)° on average,and the pubic Angle increased by(10.32±1.40)° on average.The urethra length was shortened by(0.17±0.06)cm on average.The posterior pubic space widened,with an average of(5.47±0.37)mm(P<0.05).There was no statistical difference between bladder neck funnel depth and urethral rhabdomy thickness(P>0.05).1.1.2 Changes in vaginal parametersOne year after radical hysterectomy,the axial Angle of vaginal stress point increased(19.99±4.26)°(P<0.05);The Angle between upper and lower vaginal segment at corresponding point P1 ’was(27.57±5.13)° higher than that at P1(P<0.05).The length of anterior vaginal wall was shortened by(1.79±0.03)cm(P<0.05).The posterior wall of vagina shrank(5.55±0.60)cm(P<0.05).Preoperative stress point coordinates P1(3.19±0.69,1.59±0.52),vaginal stress point coordinates P2(2.52±0.38,0.94±0.87)1 year after surgery.1.2 Anatomical changes of bladder and urethra and vagina before and 5 years after radical hysterectomy1.2.1 Changes of bladder and urethra parametersFive years after radical hysterectomy,the bladder neck funnel widened,with an average of(5.05±0.51)mm.The posterior Angle of bladder and urethra increased by(7.24±5.46)° on average.The urethral folding Angle increased by(11.24±0.27)° on average.The urethral inclination Angle decreased by(13.86±2.72)° on average,and the pubic Angle increased by(17.01±7.31)° on average.The urethral length was shortened by(0.47±0.02)cm on average.The posterior pubic space widened,with an average width of(8.09±0.78)mm(P<0.05).There was no statistical difference between the depth of bladder neck funnel and the thickness of urethral rhabdomy muscle(P>0.05).1.2.2 Changes in vaginal parameters5 years after radical hysterectomy,the axial Angle of vaginal stress point increased(24.50±4.33)° compared with that before surgery(P<0.05).The Angle between upper and lower vaginal segment at corresponding point P1 "increased by(32.15±5.13)° compared with P1(P<0.05);The length of anterior wall of vagina was shortened by(2.18±0.53)cm(P<0.05).The posterior vaginal wall was shortened by(5.95±1.13)cm(P<0.05).Preoperative stress point coordinates P1(3.19±0.69,1.59±0.52),5 years postoperatively P3(2.39±0.46,0.69±0.59).1.3 Anatomical changes of bladder and urethra and vagina 1 year and 5 years after radical hysterectomy1.3.1 Changes of bladder and urethra parametersAt 5 years after radical hysterectomy,compared with 1 year after surgery,the bladder neck funnel widened,with an average width of(3.61±0.51)mm.The posterior Angle of bladder and urethra increased by(3.10±2.46)° on average.The urethral folding Angle increased by(4.61±2.27)° on average.The urethral Angle decreased by(5.87±2.72)° on average,and the pubic Angle increased by(6.69±5.31)° on average.The urethral length was shortened by(0.30±0.02)cm on average.The posterior pubic space widened,with an average width of(2.62±0.78)mm(P<0.05).There was no statistical difference between the depth of bladder neck funnel and the thickness of urethral rhabdomy muscle(P>0.05).1.3.2 Changes in vaginal parametersIn 5 years after radical hysterectomy,compared with 1 year after surgery,the axial Angle of vaginal stress point increased by(4.51±0.33)°(P<0.05).The Angle between upper and lower vaginal segment at corresponding point P1 "was(4.58±1.13)° higher than that at P"(P<0.05);The length of anterior vaginal wall was shortened by(0.39±0.53)cm(P<0.05).Posterior vaginal wall shrinkage(0.42±0.53)cm(P<0.05).The coordinates of the stress point of the vagina 1 year after surgery were P2(2.52±0.38,0.94±0.87),and P3(2.39±0.46,0.69±0.59)5 years after surgery.[Conclusion]1.Long-term support force around the bladder and urethra after RH surgery gradually decreased,and the activity of the upper vaginal segment gradually increased.2.The long-term stress point position of the vaginal axis after RH surgery is more stable,which may be one of the reasons for less long-term pelvic organ prolapse after RH surgery.The third part Long-term effects of radical hysterectomy on the perineal diaphragm and clitoris[Purpose]The changes of perineal diaphragm and clitoris after radical hysterectomy were analyzed in combination with two-dimensional pelvic MRI images and three-dimensional reconstruction model,and the long-term effects of surgical methods on the perineal diaphragm and clitoris were analyzed.In combination with sexual function questionnaire,the relationship between postoperative anatomical changes of vulva and sexual function was analyzed.[Methods]1.Inclusion and exclusion criteria are the same as those in part Ⅰ.2.Pelvic static T2W TSE sequences were collected and pelvic data were saved in Dicom format.Mimics 21.03.software was used to construct 3D MRI models in resting state before surgery,1 year after surgery and 5 years after surgery.Anatomical parameters of clitoris and perineal diaphragm in 2D and 3D MRI models before and after surgery were measured respectively.3.1 Measurement parameters of clitoris and perineal diaphragm:length,width and volume of clitoris,distance between the head of clitoris and urethral opening,distance between the head of clitoris and vaginal opening,parallel and swelling distance of perineal diaphragm.4.The patients filled in Female Sexual Function Index(FSFI)questionnaire before and after surgery.Indicators reflecting female sexual function were selected and the scale was divided into six dimensions of sexual desire,sexual arousal,vaginal moisture,orgasm,sexual satisfaction and pain during intercourse,a total of 36 points.[Results]1.Study on changes of perineal diaphragm and clitoris before and after radical hysterectomy1.1 Changes of perineal diaphragm and clitoris before and 1 year after radical hysterectomyThere were 1 cases(2.4%)of perineal diaphragm bulging before operation,and 4 cases(3.4%)1 year after operation.One year after radical hysterectomy,the distension distance of perineal septum increased by(2.53±0.61)mm on average.The length of clitoral head decreased by(2.51±0.63)mm on average.The clitoral head width decreased by(0.77±0.72)mm on average.The volume of clitoral head decreased by(132.69±38.43)mm3(P<0.05).The distance between the clitoris head and urethral orifice and the distance between the clitoris head and vaginal orifice were not statistically significant.(P>0.05).1.2 Changes of perineal diaphragm and clitoris before and 5 years after radical hysterectomyThere were 1 cases(2.4%)of perineal diaphragm bulging before operation,and 9 cases(21.4%)5 years after operation.5 years after radical hysterectomy,the distension distance of perineal septum increased by(5.43±1.07)mm on average.The length of clitoral head decreased by(4.62±0.64)mm on average.The clitoral head width decreased by(1.33±0.62)mm on average.The clitoral head volume decreased by(253.54±33.84)mm3 on average(P<0.05).The distance between the clitoris head and urethral orifice and the distance between the clitoris head and vaginal orifice were not statistically significant.(P>0.05).1.3 Changes of perineal diaphragm and clitoris 1 year and 5 years after radical hysterectomyThere were 4 cases(3.4%)and 9 cases(21.4%)of perineal diaphragm bulging 1 year after operation.5 years after radical hysterectomy compared with 1 year after operation,the perineal septum distention increased by(2.91±0.86)mm on average.The length of clitoral head decreased by(2.11±0.75)mm on average.The clitoral head width decreased by(0.64±0.72)mm on average.The clitoral head volume decreased by(120.85±33.78)mm3 on average(P<0.05).The distance between the clitoris head and urethral orifice and the distance between the clitoris head and vaginal orifice were not statistically significant.(P>0.05).1.4 Sexual function changes before and after radical hysterectomyAfter radical hysterectomy,sexual desire disorder(5 years after surgery vs.before surgery=54.8%vs.43.5%vs.14.7%),sexual arousal disorder(5 years after surgery vs.14.7%)Preoperative=11.9%vs.9.6%vs.6.2%),vaginal wetting disorder(5 years after surgery vs.6.2%)Preoperative=64.3%vs.47.8%vs.3.9%),orgasmic disorder(5 years after surgery vs.Preoperative=73.8%vs.54.8%vs.17.1%)was higher than that before surgery(P<0.05),and 5 years after surgery,sexual desire disorder,vaginal wetting disorder and orgasm disorder were higher than 1 year after surgery(P<0.05),and there was no statistical significance between 5 years after surgery and 1 year after surgery for sexual arousal disorder(P>0.05).There was no significant difference in the proportion of postoperative sexual aversion and sexual pain compared with that before surgery(P>0.05).1.5 Study on the relationship between clitoris and sexual function before and after radical hysterectomyOne year after surgery,the reduction of clitoris volume was a risk factor for sexual dysfunction(OR=1.018,95%CI 1.014-1.048,P<0.05),but the length and width of clitoris,the distance between the head of clitoris and the vaginal opening,the distance between the clitoris and the vaginal opening were not risk factors for sexual dysfunction(P>0.05).5 years after surgery,compared with 1 year after surgery,reduced clitoris volume was a risk factor for sexual dysfunction(OR=1.794,95%CI 1.475-1.973,P<0.05),but clitoris length and width,distance from the head of the clitoris to the uremic opening,and distance from the clitoris to the vaginal opening were not risk factors for sexual dysfunction(P>0.05).[Conclusion]1.After radical hysterectomy,he supporting capacity gradually weakened;2.After radical hysterectomy,the clitoral gradually atrophic,and the sexual dysfunction gradually worsened,which was more obvious as hypolibido,orgasm disorder and vaginal dryness;3.Postoperative gradual shrinkage of clitoral volume is an independent risk factor for aggravated sexual dysfunction after radical hysterectomy.