Does Pretreatment Cystoscopy Improve Staging in Carcinoma Cervix? A prospective study

INTRODUCTION: Carcinoma of the cervix is one of the commonest malignancies among women in India. About 1, 00,000 women are diagnosed with cervical cancer each year. An accurate pre-treatment staging of cervical cancer is critical, as it determines the therapeutic approach. The International Federation of Gynecology and Obstetrics (FIGO) in collaboration with the World Health Organization (WHO) and the International Union against Cancer (IUCC) established the most commonly used staging system for cervical cancer. FIGO guidelines allow the following examinations for establishing the stage of disease, but it is not mandatory to perform all of these tests on every patient. Palpation and inspection of the primary tumor, palpation of groin and supraclavicular lymph nodes , colposcopy , endocervical curettage, conization, hysteroscopy, cystoscopy, proctoscopy, intravenous pyelogram (IVP) and radiographic examination of the lungs and skeleton. Women in resource-poor countries, which have a high prevalence of cervical cancer, generally do not have access to advanced imaging modalities and specialized surgical care, and the majority of patients are treated with primary radiation. AIM OF THE STUDY: The aim of this study was to assess the usefulness of cystoscopy in staging of carcinoma cervix and to determine the potential of transabdominal ultrasonography to demonstrate the presence or absence of bladder infiltration in patients with cervical carcinoma. MATERIALS AND METHODS: This study was performed in the department of urology, Christian Medical college, Vellore, to assess the usefulness of cystoscopy in comparison to transabdominal ultrasonogram in staging of carcinoma cervix, on 92 adult patients with newly diagnosed carcinoma of cervix with FIGO stage 2B and higher stages. Emphasis was given to any sonographic evidence for bladder involvement. All of them underwent bladder ultrasonography before performing cystoscopy. Transabdominal ultrasound was done and reported in a unified format with particular emphasis for urinary bladder involvement and hydronephrosis. The technique required a full bladder in order to visualize the posterior bladder wall, which then examined by transverse and coronal sections. A normal posterior bladder wall shows up as a smooth echo-dense lining about 3 mm thick. Bladder infiltration is seen as a nodular irregularity. Study design: Descriptive Study. Setting: Outpatient procedure room of the urology department. Period of Recruitment: 1st May 2009 to 31st Jan 2010. Study population: Ninety two consecutive patients with histologically proven carcinoma of the cervix. Inclusion Criteria: Patients evaluated in Radiotherapy/Gynaecology OPD and diagnosed to have carcinoma of cervix, FIGO stage 2B and above, were included in this study. Exclusion Criteria: Ca cervix with FIGO stage lesser than 2B and post radiotherapy patients (recurrent disease and partly treated patients). RESULTS: Ninetytwo patients were enrolled into the study as per the inclusion criteria. Those with recurrent disease and partly treated with radiotherapy were excluded from the study. All underwent ultrasonogram examination of the abdomen and pelvis before cystoscopy. CONCLUSION: In this study “Does Pretreatment Cystoscopy improve Staging in Carcinoma Cervix?” it was found that the incidence of bladder infiltration due to cervical carcinoma was 5.4%. Those who presented with haematuria had bladder invasion on transabdominal ultrasonogram and confirmed by cystoscopic bladder biopsy. Those with hydronephrosis had 15.8 times more possibility of having bladder infiltration. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of ultrasonogram in the detection of bladder involvement were 66.7%, 94.38%. 28.57%, 98.8% and 93.55% respectively. Transabdominal ultrasonogram is a useful triage method for the evaluation of the bladder for infiltration by cervical carcinoma. It has an excellent sensitivity and negative predictive value in detecting bladder involvement. There was no false negative cases. Hydronephrosis and gross haematuria were predictors of bladder involvement. All presented with haematuria had bladder infiltration. Based on the findings of our study, we recommend the use of transabdominal ultrasonography of the bladder as a screening test for bladder infiltration by cervical carcinoma. Cystoscopy may be performed in those with abnormal findings on ultrasonography. This is more cost-effective, non-invasive and less time consuming. This will avoid cystoscopy in all patients with cervical carcinoma and cystoscopy can be tailored to those with ultrasonogam findings suggestive of bladder carcinoma. This approach is highly appropriate for countries with high incidence as well as delayed presentation of cervical carcinoma