Treatment-associated morbidities have led clinicians to use a more conventional approach, particularly during surgery. Growing concerns regarding the morbidities associated with adjuvant therapies have heightened awareness of the quality of life among early-stage endometrial cancer patients with expected prolonged survival. In this study, we observed a decreased vaginal length in the radiotherapy group, which may have affected sexual health. Urethral hypermobility was another handicap of radiotherapy, and worse Pelvic Floor Distress Inventory scores in all subcategories of the inventory except for Urogential Distress Inventory-6 were the main findings.
Bernad et. al. reported vaginal length to be 7.4 cm in endometrial cancer patients that received radiotherapy [11]. In our study, the mean vaginal length was 8.3 cm which was 9,1 in control group. Vaginal shortening was reported among the radiotherapy-induced vaginal changes and was graded 1–3 according to the level of vaginal shortening. In our study, a moderate decrease in the total vaginal length suggested that radiotherapy contributed to a grade 1 change in vaginal length. Although radiotherapy had a significant impact on reduction of vaginal length in the current sudy, the absence of Grade III changes such as vaginal stricture suggested a minimal to mild effect of radiotherapy on vagina. The combination of radiation effects on the vaginal mucosa and vaginal length may exacerbate sexual dysfunction. However, the current study lacks information on the effect of radiotherapy on sexual health. Thus, the clinical importance of shortening the vaginal length may be another field of study.
Pelvic floor abnormalities, including urinary incontinence such as urge and stress urinary incontinence, are commonly observed in women receiving treatment for endometrial carcinoma. Stress urinary incontinence has been documented to occur in up to 80% of individuals diagnosed with endometrial cancer [11]. Stress urinary incontinence was less frequent in patients who received radiotherapy. Segal et al. reported that stress urinary incontinence was comparatively less common in endometrial cancer patients who received radiotherapy compared to patients with no adjuvant treatment, yet no statistically significant difference was observed. In addition to vaginal length shortening, increased fibrosis in the vaginal mucosa may have contributed to urethral stabilization, thereby decreasing urethral hypermobility. A significantly lower Q-tip test score observed in the radiotherapy group, potentially linked to the fibrotic effect of radiation therapy. Urethral hypermobility which was measured with dynamic MRI was reported to be as high as 47% [12]. In contrast to MRI evaluation, the Q-tip test provides more accurate functional indicators than MRI, which solely provides an anatomical assessment. As far as we know no study has evaluated the Q-tip test in endometrial cancer patients as an objective measure of urethral hypermobility. A decreased Q-tip angle may be a result of radiation therapy possibly causing fibrosis in the pelvis in endometrial cancer patients.
Pelvic organ prolapse may accompany to endometrial cancer which has been reported to be approximately with the incidence of 0.2–1% [13]. Although grade I cystocele and rectocele were more frequent in the no-radiotherapy group, grade II cystocele and rectocele were more frequent in the radiotherapy group. The fibrosis effect of radiotherapy may ameliorate Grade I posterior and anterior vaginal relaxation. Considering risk factors such as obesity and increased age observed in the current study for endometrial carcinoma, the increased incidence of grade I cystocele and rectocele was an expected result, and similar to urethral hypermobility, radiotherapy may have a favorable effect. Some published studies have included concomitant urogynecologic surgery in addition to surgery for endometrial cancer [14]. Although improvements in urinary incontinence were observed in these studies, none of them reported improvements in quality of life [15]. We believe that concomitant surgery for endometrial cancer patients has potential risks, including fistula formation, mesh erosion, increased operation time, and treatment failure. As a result, we do not perform urogynecologic operations during endometrial cancer surgery. A sequential approach may be more suitable for reducing anti-incontinence surgery-related risks, which may prolong the time for the application of adjuvant treatments.
Incontinence as a disease which is common among the elderly women is a condition that reduce quality of life. The severity of incontinence is associated with the reduction of quality of life. It is important to identify and manage additional conditions that may further impair the already compromised quality of life in patients undergoing long and arduous treatments for cancer. Among the scales the Incontinence Severity Index was reported to be a useful tool for evaluating quality of life and incontinence-related finding [16]. It was surprising to observe a positive impact of radiotherapy, which is a factor that compromises quality of life, on another quality of life-impairing condition, urinary incontinence. In addition to frequency of urinary inconytinence, the Incontinence Severity Index revealed decreased incontinence severity in the radiotherapy treatment group in the current study. The observation of better scores in the Incontinence Severity Index scoring with radiotherapy led us to consider that radiotherapy might have a corrective effect on urinary incontinence particularly on stress urinary incontinence. Since the results for urge incontinence were similar between the study and control groups, it suggests that in this study, the effect of radiotherapy on urinary incontinence is predominantly on stress urinary incontinence. In the present study, all inventories evaluating urinary incontinence was found in favor of no-radiotherapy group suggesting that radiotherapy may have positive effect on the severity of urinary incontinence. Lipetskai et al. also evaluated the Incontinence Impact Questionaire score in endometrial cancer patients, with the study group and control groups divided according to the type of lymphadenectomy performed [17]. The authors reported a mean score of 10, whereas in the present study, the score was 7.6. [17]. Radiotherapy is known to increase voiding dysfunctions such as urgency and bladder spasm. Enhanced stress urinary outcomes following radiotherapy represent a new finding, as prior research predominantly focused on addressing stress urinary incontinence management rather than assessing the effect of radiotherapy
Preliminary evidence suggests that pelvic radiotherapy can detrimentally impact pelvic floor function, potentially exacerbating issues related to urinary continence [18]. However, the dose, route of radiotherapy, and technique used during treatment may influence the severity of radiation therapy [19]. Lakomy et al. reported similar Pelvic Floor Distress Inventory scores in endometrial cancer patients and patients with noncancerous gynecologic diseases [20]. Endometrial cancer surgery has also been shown to increase symptoms related to pelvic floor dysfunction independent of adjuvant therapies. Urinary problems are the leading problems, followed by colorectal and anal problems related to pelvic organ prolapse [21]. Both studies included patients who underwent radical hysterectomy. Urinary problems, reported as the most common pelvic floor dysfunction, may be considered the result of radical hysterectomy. In the present study, we excluded radical hysterectomy patients, which should be considered a confounder for pelvic floor dysfunction. As a result the outcomes presented in the current study may be attributed to the effect radiotherapy.
This study has several strengths. The study had criterias to eliminate any factor that would include or exclude patients in order not to interfere with pelvic floor dysfunction. Furthermore, acute effects of surgery and radiotherapy were excluded by including patients in the study at the first follow-up, which should be at least three months. This single-institution study avoided heterogeneity between institutions. Possible confounders, such as age, Body mass ındex, parity and vaginal delivery status, and menopausal status, which may affect the urinary incontinence, pelvic floor functions, and similar occurrences in the study and control groups, were considered, increasing the reliability of the outcomes related to radiotherapy. The main limitation of this study is the lack of preoperative and pre-radiotherapy baseline urogynecological evaluation of the included patients, as well as the non-application of the scoring systems used. Therefore, a study that evaluates both pre- and posttherapy periods may produce more accurate results.
Clinicians should exercise caution when considering concomitant stress urinary incontinence surgery in endometrial cancer patients undergoing endometrial cancer surgery. The observed ameliorating effect of radiotherapy on stress urinary incontinence suggests that additional surgical interventions may not be necessary and could potentially introduce unnecessary risks and complications. Given the decrease in vaginal length and potential implications for sexual function, comprehensive studies evaluating sexual health before and after radiotherapy are warranted. Incorporating preoperative and preradiotherapy evaluations of pelvic floor function and sexual health could provide valuable insights into the baseline status and changes induced by treatment. Additionally, longitudinal studies assessing long-term outcomes beyond the immediate post-treatment period would further elucidate the durability of radiotherapy effects and inform survivorship care strategies for endometrial cancer patients.
Our study suggested that radiotherapy is associated with unfavorable pelvic floor dysfunction outcomes but may lead to better stress urinary incontinence outcomes in endometrial cancer patients.