Stesura Seveso 315Archivio Italiano di Urologia e Andrologia 2022; 94, 3 ORIGINAL PAPER No conflict of interest declared. associated with good outcomes and is the most cost-effec- tive approach to hysterectomy (4). The influence of sim- ple hysterectomy on the lower urinary tract is still debat- ed. However, hysterectomy disrupts the local nerve sup- ply to the pelvic organs and interrupts the anatomical relationship. It has been postulated that the function of the pelvic organs may be adversely affected (5). Thus, the function of the pelvic organs, mainly the urinary func- tion, should be considered when deciding the optimum route of hysterectomy (6). Urodynamics is a study that assesses the lower urinary tract function and attempts to reproduce the patients' symptoms to provide a pathophysiological explanation. In principle and reality, the clinicians use urodynamic testing results to direct therapy, whether surgical, med- ical, or behavioral, alone or in combination. Some of the current approaches are water-filled, ambulatory, and video urodynamic. Urodynamics analyses the functional anatomy of the bladder, urethra, or both, and their reac- tion to filling, storing, and voiding, regardless of the method used (7). Urodynamic testing is essential in urog- ynecology because it provides objective descriptions of incontinence and voiding dysfunction (8). Therefore, the objectives of this study were to analyze the urodynamic changes before and after laparoscopic and vaginal hys- terectomy. PATIENTS AND METHODS Between August 2019 and April 2021, 90 cases present- ing to in-patient departments of the Authors’ institute were enrolled in this study. The ethics review committee approved the study protocol. All patients signed informed consent forms detailing the operation and potential risks. Patients were divided into two groups of equal size: Group I: with a mean age of 59.16-year-old (ranging between 51-66), underwent a vaginal hysterec- tomy. Group II with a mean age of 54.72-year-old (rang- ing between 47-59) underwent laparoscopic hysterecto- my. The route of traditional minimally invasive surgery was chosen by the designated surgeon, with vaginal hys- terectomy as the first choice, followed by laparoscopic hysterectomy. Our study included all patients undergo- ing hysterectomy for benign gynecological diseases. We excluded all patients with a history of diabetes mellitus, Objective: To compare urodynamic changes before and after hysterectomy (laparoscopic vs. vaginal approach) for benign gynecological diseases. Patients and methods: A total of 90 women with a mean age of 56.36-years were enrolled in this study between August 2019 and April 2021. They were divided into two equal groups (45 patients each). Group, I had a vaginal hysterectomy, and Group II had a laparoscopic hysterectomy. All patients were assessed clinically using ICIQ-FLUTS questionnaire and a uro- dynamic study before and six months after surgery. Results: Both vaginal and laparoscopic hysterectomy did not significantly change the maximum flow rate, voiding time, and average flow rate. The increase in residual urine volume in group I was not significant (p = 0.129), as was in Group II (p = 0.217). All the modifications, however, were within permis- sible limits. According to the cystometry result, volume at initial sensation rose in both groups after surgery, with no statistically significant difference (p = 0.364). After both forms of hysterecto- my, maximum bladder capacity did not vary considerably. Preoperatively, all study participants exhibited no overactivity of the detrusor muscle; nevertheless, following surgery, overac- tivity was noted in 9 patients after vaginal hysterectomy com- pared to three patients after laparoscopic hysterectomy, and all the alterations were within a clinically acceptable range. In addition, the ICIQ-FLUTS score was not significantly different between the study groups. Conclusions: According to the urodynamic study, hysterectomy for benign uterine conditions, whether vaginal or laparoscopic, did not adversely affect urinary bladder function. KEY WORDS: Hysterectomy; Uroflowmetry; Urodynamic. Submitted 9 June 2022; Accepted 23 June 2022 INTRODUCTION Hysterectomy is the most common gynecological surgical operation (1). More than 90% of hysterectomies were done for benign conditions. The most common indica- tion of hysterectomy are leiomyomas and dysfunctional uterine bleeding (2). Hysterectomies are performed with different routes, either vaginally, abdominally, or laparo- scopically. Laparoscopic and vaginal hysterectomy are minimally invasive approaches with short hospitalization time and fast recovery comparable to open abdominal hysterectomy (3). Vaginal hysterectomy, when feasible, is Urodynamic changes following laparoscopic versus vaginal hysterectomy Tamer Abouelgreed 1, 2, Doaa Saleh 3, Mohamed Abdelaal 1, Adel Elatreisy 1, Mohamed Elhelaly 1, El-Sayed El-Agamy 1, Ahmed Elgammal 1, Ashraf Moawad 2, 3 1 Department of Urology, Al-Azhar University, Cairo, Egypt; 2 Al Zahra Private Hospital, NMC Medical group, UAE; 3 Department of Obstetrics & gynaecology, Al-Azhar University, Cairo, Egypt. DOI: 10.4081/aiua.2022.3.315 Summary Archivio Italiano di Urologia e Andrologia 2022; 94, 3 T. Abouelgreed, D. Saleh, M. Abdelaal, A. Elatreisy, M. Elhelaly, El-Sayed El-Agamy, A. Elgammal, A. Moawad 316 neurological disorders, previous urological pelvic sur- gery, previous caesarian section, and urinary tract infec- tion. All the procedures were carried out while the patient was sedated. A reusable umbilical or 12-mm port (Xcel; Ethicon Endo-Surgery, Inc., Somerville, NJ) for the optics and three assistant ports, either three 5-mm or two 5-mm plus one 10-mm port in the lower quadrants, were used for laparoscopic hysterectomy. The vaginal hysterectomy was done conventionally. All study participants were sub- jected to detailed history taking, complete clinical exam- ination, routine preoperative investigation. ICIQ-FLUTS (International Consultation on Incontinence Modular Questionnaire on Female Lower Urinary Tract Symptoms) (9), and Urodynamic evaluation (cystometry and uroflowmetry) were obtained before and six months after surgery. Statistical analysis Data were analyzed using Statistical Program for Social Science (SPSS) version 18.0. Quantitative data were expressed as mean ± stander deviation (SD). Qualitative data were expressed as frequency and percentage. The following tests were done: independent-samples T-test of significance when comparing two continuous means. Paired t-test: t = mean's difference between pre and post. The chi-square (x2) test of significance was applied to compare proportions between two qualitative factors. Pearson's correlation coefficient (r) test was employed for data correlation. P-value (probability): statistical signifi- cance was defined as less than 0.05, and high- ly significant was defined as less than 0.01. RESULTS Demographic Data of both groups The cohorts were comparable regarding patients’ demographics (p > 0.05) (Table 1). Postoperative evaluation of the urinary symptoms in both studies groups Post-operative frequency was noticed in 18 and 9 patients of groups 1 and 2 respectively (p = 0.32). Urgency occurred in 10 and 6 patients of groups 1 and 2 respectively (p = 0.39). Urge incontinence occurred in 9 and 6 patients of groups 1 and 2 respectively (p = 0.37). No other symptoms were noticed in both groups. In group I, the mean preop- erative ICIQ-FLUTS score was 0.64 (range between 0 and 2, median-0), and the postop- erative mean was 1.5 (range between 0 and 6, median = 0) with a significant p-value (p < 0.001). In group II, the mean preoperative ICIQ-FLUTS score was 0.33 (range between 0 and 2, median = 0) and the mean postopera- tive score was 0.82 (ranged between 0 and 6, median = 0) with a significant p-value (p = 0.014). There was no statistically significant difference between groups 1 and 2 regarding preoperative and postoperative ICIQ-FLUTS scores (p = 0.1 & 0.11, respectively). Changes in Urodynamic parameters in the two studied groups before and after surgery According to results of cystometry, volume at first sensa- tion rose after surgery in both groups, with insignificant p-value between pre-and postoperative volumes (p = 0.372 and p = 0.364) for groups 1 and 2, respectively (Table 2). After both forms of hysterectomy, maximum bladder capacity did not vary considerably (Table 3). Preoperatively, no detrusor muscle overactivity was found in either group; however, after surgery, overactivi- ty was observed in 9 patients in the vaginal hysterectomy group compared to three patients in the laparoscopic hys- terectomy group (Table 4). Changes in Uroflowmetry parameters in the two groups before and after surgery: According to uroflowmetry measures, vaginal hysterectomy reduced the maximum flow rate and increased voiding time not significantly and laparoscopic hysterectomy did not affect either. Table 1. Demographic data of both groups. Group I n = 45 Group II n = 45 t-test Parameters Mean ± SD Mean ± SD Mean difference t P value Age (years) 59.16 3.68 54.72 4.15 2.43 2.402 0.059 Weight (Kg) 70.02 7.86 69.17 6.92 1.68 0.873 0.388 Parity 2.73 0.79 3.10 0.75 -0.07 -0.338 0.734 t = Independent t-test. Table 3. Comparison between group I and group II as regard cystometric bladder capacity. Cystometric bladder Group I Group II t-test capacity (ml) Mean (ml) ± SD Mean (ml) ± SD Mean difference t P value Pre 518.13 25.32 514.00 25.72 3.33 0.505 0.618 Post 477.00 100.19 486.31 65.93 -33.33 - 1.515 0.297 P value 0.1 0.16 Table 2. Comparison between group I and group II as regard first sensation. First sensation Group I Group II t-test Mean (ml) ± SD Mean (ml) ± SD Mean difference t P value Pre 167.78 24.81 169.43 22.26 -2.00 - 4.379 0.364 NS Post 178.00 14.98 179.90 15.19 -3.50 - 0.904 0.372 NS P value 0.6 0.67 Table 4. Relation between group I and group II as regard post-operative presence of detrusor muscle over activity. Post-operative Groups Total Presence of detrusor Group I Group II muscle over activity No. % No. % No. % -ve 36 80.00 42 93.33 78 86.667 +ve 9 20.00 3 6.67 12 13.333 Total 45 100.00 45 100.00 90 100.000 x2 5.455 P value 0.020 317Archivio Italiano di Urologia e Andrologia 2022; 94, 3 Urodynamic changes post hysterectomy The laparoscopic group had a higher average flow rate, while the vaginal group had a lower average flow rate (Table 5). The increase in residual volume after vaginal hysterectomy was modest (p = 0.129), as was the increase in residual urine after laparoscopic hysterectomy (p = 0.217) (Table 6). All the modifications, however, were within permissible limits. Changes in pre- and postoperative abdominal detrusor leak point pressure in both groups No detectable changes in pre-and postoperative abdomi- nal detrusor leak point pressure in group 2. Only six patient of group 1 has decreased their postoperative abdominal detrusor leak point pressure to less than 60 cm H2O. DISCUSSION To improve life expectancy in women, it is essential to know the long-term adverse outcomes of surgical inter- ventions (10, 11). We designed this study to analyze the effects of laparoscopic versus vaginal hysterectomy on the lower urinary tract symptoms and functions using urody- namic studies and try to detect if the type of operation (whether vaginal or laparoscopic hysterectomy) will affect postoperative lower urinary tract functions or not. The relation between the urinary symptoms and the urody- namic parameters was evaluated pre and postoperatively. Many studies compared abdominal and vaginal hysterec- tomy. Polat et al. (2016) (12) underwent a physiological assessment of bladder, urethra, and anorectum on 26 women before hysterectomy, six weeks, and six months afterward. They reported that after a hysterectomy for benign disease, some women experience a considerable increase in rectal and bladder sensitivity. The alterations lasted for six months, but they weren't linked to any changes in rectal or vesical motor activity being not nec- essarily related to the onset of urinary or gastrointestinal problems. After a total hysterectomy, they ruled out local damage, infection, and edema as plausible causes of the pelvic organs' increased sensitivity. They concluded that the cause of the increase in rectal and vesical sensitivity seen in some women after vaginal and abdominal hys- terectomy is unknown; it's possible that removing a major pelvic organ and its related nerve supply changes the gating of sensations from nearby organs. Heydari et al. (13) reported no noticeable changes in urinary bladder capacity or urethral functions after the operation. They focused on urodynamic measures before and after abdominal and vaginal hysterectomies. They discovered a statistically significant decrease in maximum cystometric capacity and a decline in bladder compliance following abdominal extra-fascial and vaginal hysterectomies. Both findings are linked to a deterioration in the detrusor mus- cle's musculoelastic characteristics due to edema and sur- gical damage. However, they concluded that the decrease in capacity and compliance had little clinical significance. They found no evidence that a hysterectomy caused involuntary detrusor contractions or incontinence. After the hysterectomy, urethral competence was unaltered, and there was no rise in stress incontinence. A second study included 36 women undergoing total hysterecto- my; preoperative complaints were observed in 58.3% of patients, although only 38.9% had urodynamically con- firmed impairment. Seventy-five percent of women were symptomatic after hysterectomy, with another 30.6 per- cent developing a urodynamic abnormality. They con- cluded that total hysterectomy is linked to a higher sub- jective and objective incidence of vesicourethral dysfunc- tion (14). El-Toukhy et al. did a study that looked at the effects of various hysterectomy procedures, including total abdominal, vaginal, laparoscopic, and subtotal. They looked at 187 women between the ages of 29 and 73 who had a hysterectomy for various reasons. Urinary symp- toms occurred less frequently (p = 0.01) six months following surgery, whereas urodynam- ic investigations remained unaltered. Furthermore, regardless of the hysterectomy technique employed, the patients reported sig- nificantly reduced rates of stress incontinence (p = 0.005) and urgency (p = 0.03) than before the procedure. They concluded that subtotal hysterectomy, whether performed abdominal- ly, vaginally or laparoscopically, has no nega- tive impact on urine function six months fol- lowing surgery (15). In our study, according to pre-and postopera- tive urodynamic studies in both groups, all changes were within the clinically acceptable range. Thus, we can say that urodynamic stud- Table 5. Uroflowmetry parameters in the two studied groups before and after surgery. Group I n = 45 Group II n = 45 Pre- Post- Pre- Post- operative operative operative operative Voided volume (ml) 264.5 ± 48.7 274.7 ± 60.8 274.8 ± 58.2 284.5 ± 56.9 P value 0.156 0.157 Maximum flow rate (ml/sec) 26.4 ± 5.3 24.3 ± 5.2 25.7 ± 4.8 27.2 ± 4.6 P value 0.068 0.069 Voiding time (sec) 50.4 ± 11.5 61.1 ± 9.9 48.8 ± 8.6 46.4 ± 9.5 P value 0.059 0.061 Average flow rate (ml/sec) 7.5 ± 2.2 6.7 ± 1.3 6.5 ± 1.7 8.8 ± 2.7 P value 0.063 0.067 Table 6. Residual urine volume in both groups. Groups Time Residual urine Paired Paired sample of testing volume (ml) differences t-test Mean (ml) ± SD Mean (ml) ± SD t P value Group I Pre 54.10 7.58 1.29 4.81 0.129 Post 57.32 5.58 3.28 NS Group II Pre 50.73 3.97 1.41 1.03 3.776 0.217 Post 52.13 3.01 NS Residual urine Group I Group II Mean t-test volume (ml) Mean (ml) ± SD Mean (ml) ± SD difference t P value Pre 54.10 7.59 50.73 3.97 -1.33 - 0.854 0.396 NS Post 57.32 5.58 52.13 3.01 2.54 3.507 0.082 NS Archivio Italiano di Urologia e Andrologia 2022; 94, 3 T. Abouelgreed, D. Saleh, M. Abdelaal, A. Elatreisy, M. Elhelaly, El-Sayed El-Agamy, A. Elgammal, A. Moawad 318 ies showed no clinically significant effect of vaginal or laparoscopic hysterectomy on bladder function and capacity. Some studies suggest a rational and credible anatomical explanation for why a subtotal hysterectomy may not have a negative impact on pelvic organ function. The nerve content of the uterosacral and cardinal liga- ments differs along their length, with much more nerve content in the middle two lateral thirds, closer to their origin at the pelvic side wall than in the medial third, closer to their insertion into the uterine body and cervix. The ligaments, and hence the nerves, are split extremely close to the uterus and cervix during a subtotal hysterec- tomy. As a result, only the nerves that innervate the uterus and cervix are disrupted, whereas those that inner- vate the bladder and rectum are unaffected (16). CONCLUSIONS Hysterectomy for benign uterine condition, whether vagi- nal or laparoscopic, did not adversely affect urinary blad- der function. According to uroflowmetry and cystometry, hysterectomy for benign uterine conditions, whether vaginal or laparoscopic, did not adversely affect urinary bladder function. 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Correspondence Tamer Abouelgreed, MD (Corresponding Author) dr_tamer_ali@yahoo.com tamerali.8@azhar.edu.eg Department of Urology, Al-Azhar University, Cairo, Egypt. & Al Zahra Private Hospital, NMC Medical group, UAE Doaa Saleh, MD Doaa.m.saleh@azhar.edu.eg Department of Obstetrics & Gynaecology, Al-Azhar University, Cairo, Egypt Mohamed Abdelaal, MD maal_uro@yahoo.com Mohamed Elhelaly, MD elhelalymohammed@yahoo.com El-Sayed El-Agamy, MD abuamr1978@yahoo.com Adel Elatreisy, MD Egypt. dr_adelelatreisy@yahoo.com Ahmed Elgammal, MD aelgammal36@gmail.com Department of Urology, Faculty of medicine, Al-Azhar University, Cairo, Egypt Ashraf Moawad, MD ganin1@hotmail.com Department of Obstetrics & gynaecology, Al-Azhar University, Cairo, Egypt & Al Zahra Private Hospital, NMC Medical group, UAE