Acta Obstet Gynecol Scand 54: 297-301, 1975
OBSTRUCTION OF T H E UPPER URINARY TRACT AFTER TREATMENT OF CARCINOMA OF T H E UTERINE CERVIX Ulf Ulmsten From the Department of Obstetrics and Gynecology (Head: Docent Nils Lundgren), Central Hospital of Karlstad, Sweden, and the Department of Obstetrics and Gynecology (Head: Professor Stig Kullander), General Hospital of Malmo, University of Lund, Sweden
Abstract. The frequency of obstruction of the upper urinary tract after treatment of carcinoma of the uterine cervix was assessed in an investigation of 100 consecutive patients. 64 of the women were treated surgically (Wertheim hysterectomy); the remaining 36, with Wertheim hysterectomy combined with radiotherapy (combined treatment). The patients were examined with isotope renography and with i.v. urography before, as well as 14 days, 2 months, 4-6 months, and 1, 2, 3, 4 and 5 years after, the operation. When necessary, these examinations were supplemented by retrograde pyelography, intravenous pyelography and selective renal function tests. Postoperatively 40.3 % of the patients treated with surgery alone showed signs of ureteric obstruction whereas the figure for those treated with the combined treatment was 5 5 % . Of the patients 25 developed in the early postoperative course mild ureteric obstruction which disappeared within half a year. Such mild obstruction was not regarded as a true complication of the treatment given. On the other hand, 21 patients developed obstinate ureteric obstruction. In 14 of these patients surgical intervention was necessary to save renal function. Most of the patients with serious ureteric obstruction had fairly advanced carcinoma (15 of stage 2 and 6 of stage 1). Radiotherapy had been given more often in this group (I5 out of 21) than in the rest. In 4 of the patients the ureteric obstruction was due to a recurrence of a tumour. This means that the true frequency of postoperative ureteric obstruction was 17%. In the group given combined treatment urinary stasis persisted longer than in the group treated with surgery alone. Renography and urography were done on 682 occasions and the results did not agree in 14%.
Several investigations have been published on the urological complications following treatment of carcinoma of the uterine cervix, such as urinary tract infection, uretero-vaginal and vesico-vaginal fistulae as well as disturbances of micturition. Thanks to improved surgical and radiotherapeutic 21-752864
methods the frequency of fistulae has decreased in recent years, but the incidence of ureteric obstruction after treatment of carcinoma of the uterine cervix still appears to be relatively high (32, 16, 27, 37, 24). It is difficult, if not impossible, to predict the later course of this obstruction: it may regress spontaneously, or it may progress and lead to hydronephrosis and reduction of renal parenchyma with impairment of renal function. Ureteric obstruction therefore requires close observation in order to enable early detection of any progression which may require surgical intervention. Formerly, the excretion of urine after treatment of carcinoma of the uterine cervix was checked by intravenous urography alone, but in recent years urography is being supplemented or replaced by radioisotope renography (24, 28, 18). The aim of this study was to assess the frequency, and the later course, of ureteric obstruction following treatment of carcinoma of the uterine cervix, as judged from i.v. urography and isotope renography. MATERIAL AND METHODS The material consisted of 100 consecutive patients with carcinoma of the uterine cervix, stages la-2b. AU of the women were subjected to Wertheim hysterectomy which was supplemented with radiotherapy in 36 of them (Fig. 1). We d o not, as a rule, regard operation as indicated if the woman is over 65 years or if the tumour is more advanced than stage 2b. Women in the reproductive age group with a stage la-lb turnour were generally treated with surgery only and, when possible, both or one of the ovaries were left behind. The age distribution of the series is given in Table I. When any of the lymph nodes excised proved to be carcinoActa Obstet Gynecol Scand 54 (1975)
298 Urf Ulmsten Table 11. Patients which after treatment showed no signs, slight signs, and serious signs of tireteric obstruction
No OF PATIENTS
70’ 60-
50LO
-
No obstruction Simple obstruction Serious obstruction Total
3020.
Only op.
Op.+Ra
39 19 6 64
15
6 15
36
100-
w1 YEARS
Fig. 1 . Number of patients, divided into two groups, only operated, or treated with a combination of surgery and radiotherapy. The time of observation is also demonstrated.
matous, the patient was treated postoperatively with external 6oCo, in a dose of 6 000 rad. Patients with a stage 2a-2b tumour received 3 treatments with brachy-radium before the operation as well as external X-radiation or E°Co. The operation was performed 1-2 months after the end of the radiotherapy. Though treatment was in principle largely uniform it was nevertheless individualised. The operation was performed by Wertheims method including lymph node dissection and always done by one and the same operator. The patients were examined preoperatively with isotope renography, urography, determination of the serum creatinine and culture of the urine, as well as cystoscopy, and conventional routine procedures. During the first 2 weeks after the operation the urine output should not fall below 1 200 m1/24 hours. This sometimes required a parenteral supply of fluid. The patients had an indwelling ‘catheter for 10 days after the operation. During the first 2 weeks after the operation the urine was repeatedly cultured. If necessary, the women were treated with appropriate antibiotics. On the 14th day after the operation the patient was examined by isotope renography and intravenous urography. When neither of these examinations showed anything remarkable and the patient’s condition was satisfactory she was sent home. The patients were reviewed after 2, 4 and 6 months, and in the absence of demonstrable abnormalities, twice a year for the following 5 years. Intravenous urography was done in the conventional way and isotope renography, according to a modification of Martensson & Victerlov’s technique (24).
As a rule, the interval between renography and urography was at most 1-2 days. If the interval exceeded one week the patient was excluded from the series (in 30 cases).
RESULTS The results are summarised in Tables 11, 111, IV and Figs. 2 and 3. I n 54 patients the urinary excretion after operation appeared to be normal. In 46 renography and/or urography demonstrated impaired flow on at least one occasion (Table 11). In 25 of these cases the renography or urography showed signs of mild urinary stasis in the early postoperative course (Table 11). The nature of such obstructions is obscure. As they disappeared spontaneously within half a year, they were not classified as true complications. In the remaining 21 patients the ureteric stasis was more pronounced and persisted (Table 111). The women in this group had to be examined at shorter intervals and 14 of them were treated surgically due to progressive obstruction with hydronephrosis. These patients fell into three groups viz. stasis alone, stasis with fistula, stasis with recurrence (Table 111). 15 of these 21 patients belonged to the group that had received combined treatment and 15 of them had a carcinoma stage 2 (Table 111). In 14% of the examinations the results of urography and renography did not agree. In 13%
Table I. Age distribution of the entire material Agegroup
26-30
31-35
3640
41-45
46-50
51-55
56-60
61-65
6670
Total
Onlyop. Op+Ra Total
2 3 5
2 2 4
12 4 16
15 5
10
15
8
7 17
9 24
1
0 3 3
0 2 2
64 36 100
Acta Obstet Gynecol Scand 54 (1975)
20
9
Obstruction of the upper urinary tract
Table 111. Analysis of the patients which showed serious ureteric obstruction and the extent of the carcinoma in these patients. See also text
N o of patients Surgery necessary Renal function lost (one side) Nefrectomy Ad exitus Ra-therapy Stage I Stage II
Obstr. only
Obstr. et fistula
I1 6
4
No OF PATIENTS
301
Obstr. et recidive
6
0
0 0 I
7
4
2a
2
299
4
2
7
4
Refused plastic surgery. MONTHS
renography was positive (showed signs of obstruction) and urography negative (normal), while in 1 % urography was positive and renography negative. Stasis was significantly more common on the right side (Pt year postoperatively) are usually caused by fibrosis or recurrence of the tumour. As in earlier investigations (2, 27, 37, 10) severe obstruction was found to be more common after combined treatment (4). It is difficult to estimate to what extent the obstruction in a given patient should be ascribed to surgery or to radiotherapy, respectively. In a large series of women treated with radiation for carcinoma of the uterine cervix Slater 62 Fletcher (35) found that ureteric stricture after radiotherapy alone was uncommon. This Acta Obstet Gynecol Scand 54 (1975)
view is shared also by Kottmeier (21), while Gansau (12), Monch & Halltorff (30) claim that strictures are more common after radiotherapy than after operation. According to Benson & Hinman ( l ) , however, strictures are more common after surgery alone. The significance of tumour infiltration of the parametrium in the development of later ureteric stasis (later after hysterectomy) has been debated in the literature (4, 30, 22). This investigation shows a clear correlation between the extent of the carcinoma and later serious impairment of urinary flow through the ureter (Table 111). This is in variance with Mayer et al. (27). The obstruction persisted longer in the patients that had received combined treatment (Figs. 2 and 3). Moreover, postrenal obstruction not due to a recurrence occurred for the first time, after more than one year in the group that had received combined treatment. In the group treated with surgery alone post-renal obstruction never occurred for the first time later than 6 months after the operation. This accords with earlier reports (6, 9, 20, 25). Table 111 summarised the serious obstructions found: in 6 of the cases there was coexisting fistula and in 4 the obstruction was due to a recurrence of the tumour. In 2 the recurrence was demonstrated first by renography and confirmed by urography, and not until 2-3 months later could any tumour change be palpated. Postrenal obstruction has been described as an early sign of recurrence also by other authors (10, 37) and underlines the value of close postoperative urinary output controls with renography and/or urography . As pointed out by Lundgren et al. (24), renography may be used as a screening method for detecting postoperative postrenal obstruction. Should the renogram prove signs of obstruction, the patient should be examined with urography to visualise the nature and significance of this obstruction. As in previous reports (13, 23, 37) postrenal obstruction was significantly (p
OBSTRUCTION OF T H E UPPER URINARY TRACT AFTER TREATMENT OF CARCINOMA OF T H E UTERINE CERVIX Ulf Ulmsten From the Department of Obstetrics and Gynecology (Head: Docent Nils Lundgren), Central Hospital of Karlstad, Sweden, and the Department of Obstetrics and Gynecology (Head: Professor Stig Kullander), General Hospital of Malmo, University of Lund, Sweden
Abstract. The frequency of obstruction of the upper urinary tract after treatment of carcinoma of the uterine cervix was assessed in an investigation of 100 consecutive patients. 64 of the women were treated surgically (Wertheim hysterectomy); the remaining 36, with Wertheim hysterectomy combined with radiotherapy (combined treatment). The patients were examined with isotope renography and with i.v. urography before, as well as 14 days, 2 months, 4-6 months, and 1, 2, 3, 4 and 5 years after, the operation. When necessary, these examinations were supplemented by retrograde pyelography, intravenous pyelography and selective renal function tests. Postoperatively 40.3 % of the patients treated with surgery alone showed signs of ureteric obstruction whereas the figure for those treated with the combined treatment was 5 5 % . Of the patients 25 developed in the early postoperative course mild ureteric obstruction which disappeared within half a year. Such mild obstruction was not regarded as a true complication of the treatment given. On the other hand, 21 patients developed obstinate ureteric obstruction. In 14 of these patients surgical intervention was necessary to save renal function. Most of the patients with serious ureteric obstruction had fairly advanced carcinoma (15 of stage 2 and 6 of stage 1). Radiotherapy had been given more often in this group (I5 out of 21) than in the rest. In 4 of the patients the ureteric obstruction was due to a recurrence of a tumour. This means that the true frequency of postoperative ureteric obstruction was 17%. In the group given combined treatment urinary stasis persisted longer than in the group treated with surgery alone. Renography and urography were done on 682 occasions and the results did not agree in 14%.
Several investigations have been published on the urological complications following treatment of carcinoma of the uterine cervix, such as urinary tract infection, uretero-vaginal and vesico-vaginal fistulae as well as disturbances of micturition. Thanks to improved surgical and radiotherapeutic 21-752864
methods the frequency of fistulae has decreased in recent years, but the incidence of ureteric obstruction after treatment of carcinoma of the uterine cervix still appears to be relatively high (32, 16, 27, 37, 24). It is difficult, if not impossible, to predict the later course of this obstruction: it may regress spontaneously, or it may progress and lead to hydronephrosis and reduction of renal parenchyma with impairment of renal function. Ureteric obstruction therefore requires close observation in order to enable early detection of any progression which may require surgical intervention. Formerly, the excretion of urine after treatment of carcinoma of the uterine cervix was checked by intravenous urography alone, but in recent years urography is being supplemented or replaced by radioisotope renography (24, 28, 18). The aim of this study was to assess the frequency, and the later course, of ureteric obstruction following treatment of carcinoma of the uterine cervix, as judged from i.v. urography and isotope renography. MATERIAL AND METHODS The material consisted of 100 consecutive patients with carcinoma of the uterine cervix, stages la-2b. AU of the women were subjected to Wertheim hysterectomy which was supplemented with radiotherapy in 36 of them (Fig. 1). We d o not, as a rule, regard operation as indicated if the woman is over 65 years or if the tumour is more advanced than stage 2b. Women in the reproductive age group with a stage la-lb turnour were generally treated with surgery only and, when possible, both or one of the ovaries were left behind. The age distribution of the series is given in Table I. When any of the lymph nodes excised proved to be carcinoActa Obstet Gynecol Scand 54 (1975)
298 Urf Ulmsten Table 11. Patients which after treatment showed no signs, slight signs, and serious signs of tireteric obstruction
No OF PATIENTS
70’ 60-
50LO
-
No obstruction Simple obstruction Serious obstruction Total
3020.
Only op.
Op.+Ra
39 19 6 64
15
6 15
36
100-
w1 YEARS
Fig. 1 . Number of patients, divided into two groups, only operated, or treated with a combination of surgery and radiotherapy. The time of observation is also demonstrated.
matous, the patient was treated postoperatively with external 6oCo, in a dose of 6 000 rad. Patients with a stage 2a-2b tumour received 3 treatments with brachy-radium before the operation as well as external X-radiation or E°Co. The operation was performed 1-2 months after the end of the radiotherapy. Though treatment was in principle largely uniform it was nevertheless individualised. The operation was performed by Wertheims method including lymph node dissection and always done by one and the same operator. The patients were examined preoperatively with isotope renography, urography, determination of the serum creatinine and culture of the urine, as well as cystoscopy, and conventional routine procedures. During the first 2 weeks after the operation the urine output should not fall below 1 200 m1/24 hours. This sometimes required a parenteral supply of fluid. The patients had an indwelling ‘catheter for 10 days after the operation. During the first 2 weeks after the operation the urine was repeatedly cultured. If necessary, the women were treated with appropriate antibiotics. On the 14th day after the operation the patient was examined by isotope renography and intravenous urography. When neither of these examinations showed anything remarkable and the patient’s condition was satisfactory she was sent home. The patients were reviewed after 2, 4 and 6 months, and in the absence of demonstrable abnormalities, twice a year for the following 5 years. Intravenous urography was done in the conventional way and isotope renography, according to a modification of Martensson & Victerlov’s technique (24).
As a rule, the interval between renography and urography was at most 1-2 days. If the interval exceeded one week the patient was excluded from the series (in 30 cases).
RESULTS The results are summarised in Tables 11, 111, IV and Figs. 2 and 3. I n 54 patients the urinary excretion after operation appeared to be normal. In 46 renography and/or urography demonstrated impaired flow on at least one occasion (Table 11). In 25 of these cases the renography or urography showed signs of mild urinary stasis in the early postoperative course (Table 11). The nature of such obstructions is obscure. As they disappeared spontaneously within half a year, they were not classified as true complications. In the remaining 21 patients the ureteric stasis was more pronounced and persisted (Table 111). The women in this group had to be examined at shorter intervals and 14 of them were treated surgically due to progressive obstruction with hydronephrosis. These patients fell into three groups viz. stasis alone, stasis with fistula, stasis with recurrence (Table 111). 15 of these 21 patients belonged to the group that had received combined treatment and 15 of them had a carcinoma stage 2 (Table 111). In 14% of the examinations the results of urography and renography did not agree. In 13%
Table I. Age distribution of the entire material Agegroup
26-30
31-35
3640
41-45
46-50
51-55
56-60
61-65
6670
Total
Onlyop. Op+Ra Total
2 3 5
2 2 4
12 4 16
15 5
10
15
8
7 17
9 24
1
0 3 3
0 2 2
64 36 100
Acta Obstet Gynecol Scand 54 (1975)
20
9
Obstruction of the upper urinary tract
Table 111. Analysis of the patients which showed serious ureteric obstruction and the extent of the carcinoma in these patients. See also text
N o of patients Surgery necessary Renal function lost (one side) Nefrectomy Ad exitus Ra-therapy Stage I Stage II
Obstr. only
Obstr. et fistula
I1 6
4
No OF PATIENTS
301
Obstr. et recidive
6
0
0 0 I
7
4
2a
2
299
4
2
7
4
Refused plastic surgery. MONTHS
renography was positive (showed signs of obstruction) and urography negative (normal), while in 1 % urography was positive and renography negative. Stasis was significantly more common on the right side (Pt year postoperatively) are usually caused by fibrosis or recurrence of the tumour. As in earlier investigations (2, 27, 37, 10) severe obstruction was found to be more common after combined treatment (4). It is difficult to estimate to what extent the obstruction in a given patient should be ascribed to surgery or to radiotherapy, respectively. In a large series of women treated with radiation for carcinoma of the uterine cervix Slater 62 Fletcher (35) found that ureteric stricture after radiotherapy alone was uncommon. This Acta Obstet Gynecol Scand 54 (1975)
view is shared also by Kottmeier (21), while Gansau (12), Monch & Halltorff (30) claim that strictures are more common after radiotherapy than after operation. According to Benson & Hinman ( l ) , however, strictures are more common after surgery alone. The significance of tumour infiltration of the parametrium in the development of later ureteric stasis (later after hysterectomy) has been debated in the literature (4, 30, 22). This investigation shows a clear correlation between the extent of the carcinoma and later serious impairment of urinary flow through the ureter (Table 111). This is in variance with Mayer et al. (27). The obstruction persisted longer in the patients that had received combined treatment (Figs. 2 and 3). Moreover, postrenal obstruction not due to a recurrence occurred for the first time, after more than one year in the group that had received combined treatment. In the group treated with surgery alone post-renal obstruction never occurred for the first time later than 6 months after the operation. This accords with earlier reports (6, 9, 20, 25). Table 111 summarised the serious obstructions found: in 6 of the cases there was coexisting fistula and in 4 the obstruction was due to a recurrence of the tumour. In 2 the recurrence was demonstrated first by renography and confirmed by urography, and not until 2-3 months later could any tumour change be palpated. Postrenal obstruction has been described as an early sign of recurrence also by other authors (10, 37) and underlines the value of close postoperative urinary output controls with renography and/or urography . As pointed out by Lundgren et al. (24), renography may be used as a screening method for detecting postoperative postrenal obstruction. Should the renogram prove signs of obstruction, the patient should be examined with urography to visualise the nature and significance of this obstruction. As in previous reports (13, 23, 37) postrenal obstruction was significantly (p
