Sexual function after rectal excision

Sexual and urinary dysfunction after proctectomy for rectal cancer

Sexual and urinary dysfunction occur frequently after rectal surgery. Total mesorectal excision (TME) is currently the optimal technique for resection of rectal cancer, providing superior carcinological and functional outcomes. Age, pre-operative radiation therapy, abdominoperineal resection, and surgery which fails to respect the "sacred planes" of TME are the four major risk factors for post-operative sexual and urinary sequelae. In the era of TME, postoperative sexual dysfunction ranges from 10-35%, depending on the scores used to assess it, while urinary sequelae have decreased to less than 5%. The place of laparoscopic surgery remains to be defined, particularly with respect to these complications. It is essential to inform the patient pre-operatively about the possibility of such disorders not only for patient informed consent but also to help with correct post-operative management of the problem. Management is multifaceted, and includes psychological, pharmacological, and sometimes surgical therapy.

Sexual function in colorectal cancer survivors

BACKGROUND

Findings from clinical and research studies suggest that the overall health-related quality of life of many colorectal cancer survivors is good. However, many survivors report significant sexual dysfunction after treatment that may adversely affect their quality of life in survivorship.

METHODS

This article examines studies investigating sexual function in men and women treated for colorectal cancer. Also included are data on the prevalence and nature of sexual dysfunctions in colorectal cancer survivors, the impact of specific treatment modalities for colorectal cancer on sexual function, and the management of sexual dysfunction in men and women.

RESULTS

Published studies investigating sexual dysfunction after colorectal cancer treatment generally have been limited conceptually and methodologically. However, findings suggest that the prevalence of sexual dysfunction among colorectal cancer survivors is high.

CONCLUSIONS

Sexual dysfunction is often a long-term and late effect of treatment for colorectal cancer. The assessment and management of sexual dysfunction in men and women treated for colorectal cancer should be standard practice throughout treatment and in survivorship.

Sexuality among patients with a colostomy: an exploration of the influences of gender, sexual orientation, and Asian heritage

A large number of patients undergoing surgery for rectal cancer experience construction of a colostomy and subsequent sexual dysfunction. However, sexual problems are easily neglected or concealed by patients, partners, and medical staff. This literature review explores sexual concerns, dysfunctions, and related factors that directly or indirectly influence sexuality after rectal cancer surgery, including gender differences, sexual orientation, sexual partners, and cultural beliefs. Results of this literature review suggest that additional research is needed that focuses on both anatomical and physiological changes after creation of a colostomy as well as psychological, gender based, and sociocultural factors affecting sexuality.

Nerve growth factor modulation of the cavernous nerve response to injury

INTRODUCTION

Surgical therapies for prostate cancer and other pelvic malignancies often result in neuronal damage and debilitating loss of sexual function due to cavernous nerve (CN) trauma. Advances in the neurobiology of growth factors have heightened clinical interest in the development of protective and regenerative neuromodulatory strategies targeting CN recovery following injury.

AIM

The aim of this review was to offer an examination of current and future nerve growth factor (NGF) modulation of the CN response to injury with a focus on brain-derived nerve growth factor (BDNF), growth differentiation factor-5 (GDF-5), and neurturin (NTN).

METHODS

Information for this presentation was derived from a current literature search using the National Library of Medicine PubMed Services producing publications relevant to this topic. Search terms included neuroprotection, nerve regeneration, NGFs, neurotrophic factors, BDNF, GDF-5, NTN, and CNs.

MAIN OUTCOME MEASURES

Basic science studies satisfying the search inclusion criteria were reviewed.

RESULTS

In this session, BDNF, atypical growth factors GDF-5 and NTN, and their potential influence upon CN recovery after injury are reviewed, as are the molecular pathways by which their influence is exerted.

CONCLUSIONS

Compromised CN function is a significant cause of erectile dysfunction development following prostatectomy and serves as the primary target for potential neuroprotective or regenerative strategies utilizing NGFs such as BDNF, GDF-5, and NTN, and/or targeted novel therapeutics modulating signaling pathways.

Impact of laparoscopic surgery on bladder and sexual function after total mesorectal excision for rectal cancer

BACKGROUND

Bladder and sexual dysfunction are well-documented complications of rectal cancer surgery. This study aimed to determine whether laparoscopy can improve the outcome of these dysfunctions or not.

METHODS

The study included 63 of the 116 patients who underwent surgery for rectal cancer between 2002 and 2006. Bladder and male sexual function were studied by means of a questionnaire on the basis of the International Prostatic Symptom Score (IPSS) and International Index of Erectile Function (IIEF). In addition, bladder function was determined by means of postvoid residual urine measurement and uroflowmetry. Postoperative functions were compared with the preoperative data to detect subjective functional deterioration. Outcomes were compared between patients who underwent open (group 1, n = 29) and laparoscopic (group 2, n = 34) total mesorectal excision.

RESULTS

Only minor disturbances of bladder function were reported for one patient (3%) in group 1 and three patients (9%) in group 2 (p > 0.05). Impotency after surgery was experienced by 6 of 17 preoperatively sexually active males (29%) in group 1 and 1 of 18 males (5%) in group 2 (p = 0.04). Similarly, 5 of 10 women (50 %) in group 1 and 1 of 14 women (7%) in group 2 felt that their overall level of sexual function had decreased as a result of surgery (p = 0.03).

CONCLUSIONS

Open rectal cancer resection is associated with a higher rate of sexual dysfunction, but not bladder dysfunction, compared with laparoscopic surgery. Laparoscopic rectal cancer surgery offers a significant advantage with regard to preservation of postoperative sexual function and constitutes a true advance in rectal cancer surgery compared with the open technique. The proposed advantages can be attributed to improvement in visibility by the magnification feature of laparoscopic surgery.

A proposed classification of ileal pouch disorders and associated complications after restorative proctocolectomy

Both medical and surgical therapies for ulcerative colitis have inherent advantages and disadvantages that must be balanced for patients with moderate to severe disease. Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for the majority of patients with ulcerative colitis who require proctocolectomy. However, adverse sequelae of mechanical, inflammatory, functional, neoplastic, and metabolic conditions related to the pouch can occur postoperatively. Recognition and familiarization of the disease conditions related to the ileal pouch can be challenging for practicing gastroenterologists. Accurate diagnosis and classification of the disease conditions are imperative for proper management and prognosis.

Rectourethralis muscle and pitfalls of anterior perineal dissection in abdominoperineal resection and intersphincteric resection for rectal cancer

When performing nerve-sparing abdominoperitoneal resection or intersphincteric resection of lower rectal cancer, difficulty is sometimes encountered during dissection, separation and treatment in the area anterior to the anorectum passing through the levator hiatus between the bilateral levator ani slings owing to missing the surgical plane or venous bleeding. The rectourethralis muscle, which is a mass of smooth muscle, occupies the levator hiatus. The present histological study using nine male cadaveric specimens demonstrated that: (i) the external anal sphincter is likely to be tightly connected to the rectourethralis muscle; (ii) the rectal muscularis propria communicates with the rectourethralis muscle; (iii) the anorectal veins take a tortuous course across the rectourethralis muscle; (iv) Denonvilliers' fascia ends at the rectourethralis muscle; and (v) the rectourethralis muscle provides posterior attachment for the rhabdosphincter. Moreover, the cavernous nerve has been reported to penetrate the rectourethralis muscle. Therefore, careful treatment of the muscle seems to be necessary to avoid male sexual dysfunction. Owing to muscle fiber communications between the rectal muscularis propria and the rectourethralis muscle, and the fact that Denonvilliers' fascia terminates in the rectourethralis muscle, the surgical plane would tend to deeply penetrate the muscle mass. However, mass ligation of the anterior tissues for control of venous bleeding should be avoided. When the tumor is non-anterior, an abdominal surgical plane behind Denonvilliers' fascia is recommended to avoid excess invasion into the rectourethralis muscle.

The Effects of Cavernous Nerve Grafting following Surgically Induced Loss of Erectile Function in a Large-Animal Model

BACKGROUND

Prostate cancer is the second most common cause of cancer deaths in men in the United States. Many patients experience partial or complete loss of erectile function following prostatectomy. The cavernous nerves can be reconstructed intraoperatively using sural nerve grafts in an attempt to restore erectile function.

METHODS

In this study, multiple anatomical dissections and neurologic assessments were used to define the position and histologic parameters of the cavernous nerve in a canine model. The subsequent experimental design included three groups of adult mongrel dogs followed for an 8-month period. Group 1, the control group, underwent bilateral nerve ablation to substantiate surgically induced loss of erectile function. Group 2, the "sham" group, underwent exploration only. Group 3 underwent bilateral cavernous nerve ablation with bilateral sural nerve graft reconstruction. Erectile function was evaluated with indirect electrical nerve and manual penile stimulation preoperatively and 1, 2, 4, 6, and 8 months postoperatively. Direct nerve stimulation and histologic analysis was preformed at the first operation and at the time the animals were euthanized at 8 months.

RESULTS

Bilateral cavernous nerve ablation resulted in a significant loss of erectile function for 8 months postoperatively in the control animals. The sham animals demonstrated preservation of erectile function immediately following exploration. The animals in the grafted group demonstrated a significant return of erectile function by 4 months compared with preoperative measurements and by 2 months compared with control animals.

CONCLUSIONS

This study establishes the first large-animal model for surgically induced loss of erectile function with successful cavernous nerve graft reconstruction, and it provides the unique opportunity to explore the effects of changes to this model in the future.

Sexual dysfunction after pelvic surgery

Pelvic surgeries are among the most common causes of organic sexual dysfunction in men and women. The impact of nerve-sparing surgery on potency has been well documented in radical prostatectomy. However, its impact on potency needs to be evaluated in other pelvic surgeries. Sexual dysfunction is highly prevalent even after multiple technical advances in the field of oncological surgeries. The prevalence varies from 8 to 82%, depending on the type of pelvic surgery. In females, sexual dysfunction has not been evaluated adequately using validated questionnaires. However, in subspecialized circles, treatment for female sexual dysfunction is becoming routine. Currently, physicians have several options for the treatment of erectile dysfunction (ED) in men. Since the introduction of oral PDE-5 inhibitors, oral therapy has become the first-line treatment option for ED, irrespective of etiology. Currently available treatment options for the female sexual dysfunction include estrogens, androgens, phosphodiesterase inhibitors, and dopamine receptor antagonists. Initial reports regarding the role of early rehabilitation are encouraging and may become the part of routine practice in the management of ED after pelvic surgery. In this article, we summarize the sexual dysfunction following pelvic surgeries and their management.

Impact of functional results on quality of life after rectal cancer surgery

PURPOSE

Quality of life is an important outcome measure that has to be considered when deciding treatment strategy for rectal cancer. The aim of this study was to find out the impact of surgery-related adverse effects on quality of life.

METHODS

The RAND-36 questionnaire and questionnaires assessing urinary, sexual, and bowel dysfunction were administered to 94 patients with no sign of recurrence a minimum of one year after curative surgery. Results were compared with age-matched and gender-matched general population.

RESULTS

Eighty-two (87 percent) patients answered the questionnaires. Major bowel dysfunction was as common after high anterior resection as after low anterior resection. Urinary complaints occurred as often after anterior resection as after abdominoperineal resection, but sexual dysfunction was more common after abdominoperineal resection. Overall, the patients reported better general health perception but poorer social functioning than population controls. In particular, elderly patients reported a significantly better quality of life in many dimensions than their population controls. There was no significant difference in quality of life between treatment groups. Major bowel dysfunction after anterior resection impaired social functioning compared with that of patients without such symptoms. Urinary dysfunction impaired social functioning and impotence impaired physical and social functioning.

CONCLUSIONS

Quality of life after rectal cancer surgery is not worse than that of the general population. The major adverse impact of bowel and urogenital dysfunction is on social functioning. These adverse effects need to be discussed with the patient and preoperative function needs to be taken into account when choosing between treatment options. Permanent colostomy is not always the factor that disrupts a person's quality of life most.

Women's sexual dysfunction: a review of the "surgical landscape"

OBJECTIVES

To assess the impact of urogynaecologic surgery for stress urinary incontinence, oncologic pelvic surgery, and hysterectomy on women's overall sexual health.

METHODS

We used Ovid and PubMed (updated January 2006) to conduct a literature electronic search on MEDLINE that included peer-reviewed English-language articles. We analysed all studies identified that provided any functional outcome data about urogynaecologic surgery for the treatment of stress urinary incontinence, radical cystectomy for bladder cancer, surgery for rectal cancer, and hysterectomy. Because of the substantial heterogeneity of outcome measures and follow-up intervals in case studies, we did not apply meta-analytic techniques to the data.

RESULTS

Most studies showed that either urogynaecologic or oncologic pelvic surgery may have a significant impact on women's sexual health. Epidemiology varied widely among the studies and reported either improvement or impairment of postoperative sexual functioning, due to different definitions, study designs, and small cohorts of patients. An increasing number of studies have prospectively examined this issue and have found often controversial findings about the role of pelvic and perineal surgery in women's sexual health.

CONCLUSIONS

Although numerous controversies exist, data demonstrate an overall positive impact of the surgical repair for stress urinary incontinence on resolution of coital incontinence, coupled with an improvement of overall sexual life. In contrast, genitourinary and rectal cancers are commonly associated with treatment-related sexual dysfunction, but few studies rigorously assessed women's postoperative sexual function after major oncologic pelvic surgery. Data about the functional outcome after hysterectomy are often contradictory. Adequately powered prospective clinical trials are needed.

Gender differences in quality of life of patients with rectal cancer. A five-year prospective study

To determine how quality of life changes over time and to assess gender-related differences in quality of life of rectal cancer patients we conducted a 5-year study. Little is known about how quality of life (QoL) changes over time in patients after surgery for rectal cancer, and whether gender of the patients is associated with a different perception of QoL. The aim of this study was to assess prospectively, changes in quality of life after surgery for rectal cancer, with a focus on gender related differences. Over a 5-year period, the EORTC-QLQ-C-30 and a tumor-specific module were prospectively administered to patients before surgery, at discharge, 3, 6, 12, and 24 months postoperatively. Comparisons were made between female and male patients. A total of 519 patients participated in the study, 264 men and 255 women. The two groups were comparable in terms of surgical procedures, adjuvant treatment, tumor stage, and histology. Most QoL scores dropped significantly below baseline in the early postoperative period. From the third month onward, global health, emotional and physical functioning, improved. Female gender was associated with significantly worse global health and physical functioning and with higher scores on treatment strain and fatigue. Men reported difficulties with sexual enjoyment; furthermore, over time, sexual problems created high levels of strain in men, worse than baseline levels in the early postoperative period. These problems tended to continue over the course of time. The findings in this study confirm that QoL changes after surgery and differs between men and women. Women appear to be affected by impaired physical functioning and global health. Female gender is associated with significantly higher fatigue levels and increased strain values after surgery. Through impaired sexual enjoyment, men are put more under strain than woman.

Continent urinary diversion

During the last decade continent urinary diversion, especially orthotopic bladder substitution has become increasingly popular following radical cystectomy for bladder cancer. In general, if sphincter sparing surgery is possible, orthotopic bladder substitution is performed, if not then continent catheterisable reservoirs are a viable option. Strict patient selection criteria and improved surgical technique have had a positive influence on outcome, not only on survival but also on quality of life issues. It is becoming increasingly obvious, that a nerve sparing surgical technique not only improves sexual function but also continence. In addition, the length of the intestinal segment has an influence on continence and the degree of metabolic consequences, which are discussed in detail. Postoperative surveillance and instruction of patients is of utmost value for good functional results. Overall patient satisfaction and quality of life seem comparable in the various types of continent urinary diversions, and improved when compared to a urinary stoma. Continent urinary diversion offers a good quality of life with few long-term complications and should be considered the treatment of choice in the majority of patients, independent of sex.

Estándares de calidad de la cirugía del cáncer de recto

The results of surgery for rectal cancer have classically been measured through indicators such as morbidity, mortality, and length of hospital stay. In the last few years other parameters have been included that evaluate healthcare quality such as the functional results of the surgical technique employed and quality of life. Total resection of the mesorectum, performed by experienced surgeons, is the surgical technique of choice. Currently, the sphincter can be preserved in 70% of patients. Anastomotic dehiscence after anterior resection of the rectum is the most serious complication and the most important risk factor is the height of the anastomosis. The overall dehiscence rate should be less than 15% and operative mortality should be between 2% and 3%. The colonic reservoir improves functional outcome and consequently it is the procedure of choice to reconstruct transit after low anterior resection. Local recurrence should be less than 10% and 5-year survival should be between 70% and 80%. In general, quality of life is better after anterior resection of the rectum than after abdominoperineal amputation, despite the functional deterioration presented by some patients.

Clinical Indications and Outcomes with Nerve-sparing Cystectomy in Patients with Bladder Cancer

The autonomic sympathetic and parasympathetic nerve fibers from the pelvic plexus pass through the dorsomedial pedicle of the bladder ending as the paraprostatic neurovascular bundle or paravaginal plexus before supplying the urogenital diaphragm, sphincter, and erectile organs. Preservation of the autonomic innervation is important for sexual, lower urinary tract, and bowel function. Oncologic outcome is not compromised by a nerve-sparing cystectomy if adequate selection criteria are applied. During pelvic lymphadenectomy nerve sparing is not impaired as long as the dissection is performed on the lateral, not medial side of the ureters, where the nerves lie. Nerve-sparing radical cystectomy preserves sexual function and, in the case of orthotopic bladder substitution, better continence, and decreased catheterization rates (especially in women) are achieved. Therefore, under the proper circumstances, nerve-sparing radical cystectomy is to be strongly recommended.

Minimally invasive surgery for rectal cancer

The present scarcity of literature on laparoscopic rectal cancer surgery makes it premature to determine whether laparoscopic surgery should be the standard of care for rectal cancer. Notwithstanding that, the available evidence proves its safety and adequate oncological clearance. Moreover, current data do not suggest any detrimental effect on the postoperative and early oncological outcomes. On the contrary, there is level three evidence showing that laparoscopic technique results in less blood loss, shorter length of stay, and reduced abdominal wound disorders and pulmonary complications, albeit the overall morbidity remains similar to that of open surgery. Long-term survival outcomes remain largely unclear, however. Hence, it is high time that laparoscopic technique should be further evaluated, preferably by means of large-scale randomized trials, to define its exact role in the treatment of rectal cancer.