The aim of this study was to assess the magnitude of the morbidity following radical surgery for early stage cervical cancer. We performed a retrospective survey of all women who had undergone a radical hysterectomy and lymphadenectomy between the months of July 1995 and December 1996 inclusive at either the Royal Marsden or St George's Hospital (n =38), using a detailed questionnaire on bladder, ano-rectal and sexual function, both before and after treatment. Sixteen women (44.4%) received adjuvant radiotherapy. The mean interval between surgery and inquiry was 16.4% months (range 8-25 months). The mean age at the time of surgery was 40.5 years. Thirty-six out of 38 women contacted responded (94.7%). Overall 33 women (91.7%) reported new bladder, ano-rectal or sexual symptoms. Complaints of urinary incontinence, particularly of urge incontinence, and of voiding difficulties increased significantly after surgery (P <0.05). However, only 5.3% of women had sought treatment. Tenesmus increased significantly (P <0.05), while increases in diarrhoea and faecal incontinence were not statistically significant (P =0.051). Although 12.9% of women stated an improvement in their sex lives, 54.8% thought that their sex life was worse after treatment, and 12.9% of women had ceased sexual activity altogether. Of women of childbearing age 53.8% felt adversely affected by their loss of fertility. Bladder, ano-rectal and sexual symptoms are very common following radical hysterectomy for cervical cancer, with adverse effect on quality of life, and persist into the second year after treatment.
Background Women affected by gynaecological cancer are often unaware of the sexual consequences of both the cancer and its treatment. Most do not receive appropriate advice or help to recover sexual function, and the effect on their sexuality may be profound, both physically and emotionally. However, several potential therapies can be effective in helping recover some sexual engagement and change self-perception around sex. A major initial challenge is informing and involving patients in an appropriate and sensitive manner, and a further issue is delivering therapies in busy gynaelogical oncology clinics. This study was conceived in response to a National Institute for Health Research (NIHR) Health Technology Assessment (HTA) call asking for proposals to improve sexual functioning in women treated for gynaecological cancer while taking into account associated issues of mood. Existing evidence-based therapies for improving sexual function after cancer treatment were adapted and placed within a ‘stepped care’ model for delivering these in the NHS setting. An assessment and treatment stepping algorithm was developed in parallel, both to assign women to a treatment level at assessment and to follow their progress session by session to advise on changing intervention level. The assessment tool was applied to all participants on the principle that the problem was sexual difficulty, not the cancer of origin. Participants Women aged > 18 years (with partners at their choice) treated for any gynaecological malignancy with surgery and/or chemotherapy and/or radiation at University College London Hospital or Bristol Gynaecological cancer centres, minimally 3 months post end of treatment, of any sexual orientation, with sexual function difficulties identified by three initial screening questions. Design A feasibility two-arm, parallel-group randomised controlled pilot trial. Setting Two NHS gynaecological cancer centres, one in London and one in Bristol. Interventions A three-level stepped care intervention. Objective To assess the feasibility of conducting a full-scale investigation of stepped therapy and indicate the potential benefits to patients and to the NHS generally. Primary outcome measures Recruitment to study, proportion of women stepping up, number of usable data points of all measures and time points over length of trial, and retention of participants to end of trial. Results Development of the intervention and accompanying algorithm was completed. The study was stopped before the recruitment stage and, hence, no randomisation, recruitment, numbers analysed, outcomes or harms were recorded. Limitations As the study did not proceed, the intervention and its accompanying algorithm have not been evaluated in practice, and the capacity of the NHS system to deliver it has not been examined. Conclusions None, as the study was halted. Future work The intervention could be studied within a clinical setting; however, the experience of the study group points to the need for psychosocial studies in medical settings to establish pragmatic and innovative mechanisms to ensure adequate resource when extending staff clinical skills and time to deliver any new intervention for the duration of the trial. Trial registration Current Controlled Trials ISRCTN12010952 and ClinicalTrials.gov NCT02458001. Funding This project was funded by the NIHR HTA programme and will be published in full in Health Technology Assessment; Vol. 23, No. 5. See the NIHR Journals Library website for further project information.
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Case reportA 27 year old nulliparous woman with irregular vaginal bleeding was found to have a vaginal polyp. Excision of this anterior wall lesion revealed malignant melanoma. She was referred to the Gynaecological Oncology Department at the Royal Marsden Hospital and during her ®rst consultation expressed a strong desire to start a family. Examination under anaesthetic revealed no obvious residual disease, and cystoscopy and sigmoidoscopy were normal. Histological review of the original specimen revealed an amelanotic melanoma. Computed tomography of the abdomen, pelvis, chest and head was normal. Fine needle aspiration cytology of small shotty mobile right inguinal nodes was negative. A further wide local excision of the tumour bed was planned. A subtotal colpectomy, with preservation of the suburethral mucosa, and a McIndoe±Read vaginoplasty using split thickness skin grafts from both buttocks was carried out. Histology showed no residual malignant melanoma, but in situ disease was present at the excision margins. Close follow up was arranged.Six months later she complained of dif®culty passing urine. At examination under anaesthetic a 4 cm mass was present along the length of the urethra. Cystoscopy revealed a normal bladder mucosa but tumour intimately involved the bladder base. Biopsy demonstrated recurrent malignant melanoma. Computed tomography revealed no evidence of disease at other sites. Surgical clearance was not possible without excision of the bladder base, but biopsies of the upper vagina and cervix were normal.The poor prognosis of this tumour was explained to the woman and her husband. Because her urinary symptoms required permanent catheterisation, conventional exenterative surgery was offered as a treatment option. She was informed that a continent urinary diversion could be constructed either in the form of a Mitrofanoff procedure or as a Mainz Sigma II pouch. Excision of the rectum and anal sphincter was not necessary to achieve a good margin of clearance of the known site of disease.Throughout her illness the woman and her husband had expressed an overwhelming desire to retain fertility. She was distressed by the proposal to excise her uterus as part of this procedure. Following extensive counselling, it was agreed that a surgical procedure would be undertaken, but that if it was possible to leave the uterus and reconstruct the anterior vaginal wall this would be the procedure of choice.The operative procedure involved radical subtotal cystourethrectomy, bilateral pelvic lymph node dissection, anterior colpectomy with uterine preservation, dome of bladder vaginoplasty and Maintz Sigma II continent urinary diversion.At laparotomy a large central pelvic mass was identi-®ed which replaced the anterior vaginal wall and posterior aspect of the bladder and urethra. Simultaneous bimanual examination revealed that the tumour mass was mobile, although there was extension almost to the right pelvic side wall. The tumour did not involve the cervix. There were no palpably enlarged pelvic or paraaortic...
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