Subacute Complications The subacute effects of radical hysterectomy are postoperative bladder dysfunction and lymphocyst formation. For the first few days after radical hysterectomy, bladder volume is decreased, and filling pressure is increased. The sensitivity to filling is diminished, and the patient is unable to initiate voiding. The cause of this dysfunction is unclear. It is important to maintain adequate bladder drainage during this time to prevent overdistention. Bladder drainage is usually accomplished with a suprapubic catheter. It is more comfortable for the patient and allows the physician to perform cystometrography and determine residual urine volume without the need for frequent catheterization. In addition, the patient is able to accomplish voiding trials at home by clamping the catheter, voiding, and releasing to check the residual urine level. Cystometrography may be performed 3 to 4 weeks after surgery. For the catheter to be discontinued, the patient must be able to sense the fullness of the bladder, initiate voiding, and void with a residual urine level of less than 75 to 100 mL. Otherwise, voiding trials should continue at home until these criteria can be fulfilled.
Lymphocyst formation occurs in fewer than 5% of patients, and the cause is uncertain (75). Adequate drainage of the pelvis after radical hysterectomy may be an important step in prevention. However, routine placement of retroperitoneal drains did not reduce this morbidity (73). Ureteral obstruction, partial venous obstruction, and thrombosis may occur from lymphocyst formation. Simple aspiration of the lymphocyst is generally not curative, but percutaneous catheters with chronic drainage may allow healing. If this treatment is unsuccessful, operative intervention with excision of a portion of the lymphocyst wall and placement of either large bowel or omentum into the lymphocyst should be performed.
Chronic Complications The most common chronic effect of radical hysterectomy is bladder hypotonia or, in extreme instances, atony. This condition occurs in about 3% of patients, regardless of the method of bladder drainage used (76,77). It may be a result of bladder denervation and not simply a problem associated with bladder overdistention (78). Voiding every 4 to 6 hours, increasing intra-abdominal pressure with Cred´e’s maneuver, and intermittent selfcatheterization may be used to manage bladder hypotonia.
Ureteral strictures are uncommon in the absence of postoperative radiation therapy, recurrent cancer, or lymphocyst formation (78). If the stricture is associated with lymphocyst formation, treatment of the lymphocyst usually alleviates the problem. Strictures that occur after radiation therapy should be managed with ureteral stenting. If a ureteral stricture is noted in the absence of radiotherapy or lymphocyst formation, recurrent carcinoma is the most common cause. A CT scan of the area of obstruction should be obtained and cytologic assessment by FNA should be performed if there is a target lesion to exclude carcinoma. If the results of these tests are negative, a ureteral stent may be placed to relieve the stricture. Close observation for recurrent carcinoma is necessary, and the diagnosis of recurrence may ultimately require laparotomy.
Nerve-sparing radical hysterectomies were described in recent years in an attempt to diminish the bladder dysfunction, sexual dysfunction, and colorectal motility disorders commonly encountered after traditional radical hysterectomy. Multiple techniques were described involving the identification of the pelvic autonomic nerves at the sacral promontory followed by various surgical methods of nerve preservation as the nerves transit the cardinal ligaments. These techniques are promising and in small series did reduce postoperative bladder dysfunction (79,80).