Male sexual and urinary function after laparoscopic total mesorectal excision

High prevalence of erectile dysfunction within the first year after surgery for rectal cancer: A systematic review and meta-analysis

OBJECTIVE

We aimed to determine the prevalence of erectile dysfunction following rectal cancer surgery within the first year.

SUMMARY BACKGROUND DATA

Erectile dysfunction is a late complication of surgery for rectal cancer. Intraoperative mechanical nerve damage is a probable cause, but it can also be attributed to radio- and chemotherapy.

METHODS

We conducted a systematic review per our protocol (CRD42023472998), searching PubMed, Embase, and Cochrane CENTRAL in August 2023. We included studies reporting on men having surgery for rectal cancer and providing a prevalence of erectile dysfunction based on validated questionnaires published after 1997. The prevalence was estimated through forest plots. Bias was evaluated according to a checklist from the Joanna Briggs Institute.

RESULTS

Of the 4105 records identified in the search, we included 74 studies reporting on 9006 patients operated for rectal cancer. The studies evaluated erectile dysfunction through six validated questionnaires, especially the International Index of Erectile Function (IIEF) version 5 or 15 (84 %). The meta-analysis on 22 studies using IIEF showed that the prevalence of moderate to severe erectile dysfunction was 35 % (95 % CI 24-47 %) within the first year after surgery with very low certainty of evidence. Meta-regression on the prevalence of moderate to severe erectile dysfunction did not show a decrease in erectile dysfunction within the first year postoperatively.

CONCLUSIONS

Around every third patient experienced moderate to severe erectile dysfunction within the first year after surgery for rectum cancer, and the prevalence of erectile dysfunction did not improve within the first year after surgery.

MINI-ABSTRACT

This is a meta-analysis investigating the prevalence of erectile dysfunction following rectal cancer surgery within the first year. Erectile dysfunction was determined on the base of validated self-administered questionnaires. Moderate to severe erectile dysfunction was seen in one-third of patients within the first year after surgery for rectal cancer.

Functional outcomes and quality of life following open versus laparoscopic versus robot-assisted versus transanal total mesorectal excision in rectal cancer patients: a systematic review and meta-analysis

BACKGROUND

The standard surgical treatment for rectal cancer is total mesorectal excision (TME), which may negatively affect patients' functional outcomes and quality of life (QoL). However, it is unclear how different TME techniques may impact patients' functional outcomes and QoL. This systematic review and meta-analysis evaluated functional outcomes of urinary, sexual, and fecal functioning as well as QoL after open, laparoscopic (L-TME), robot-assisted (R-TME), and transanal total mesorectal excision (TaTME).

METHODS

A systematic review and meta-analysis, based on the preferred reporting items for systematic reviews and meta-analysis statement, were conducted (PROSPERO: CRD42021240851). A literature review was performed (sources: PubMed, Medline, Embase, Scopus, Web of Science, and Cochrane Library databases; end-of-search date: September 1, 2023), and a quality assessment was performed using the Methodological index for non-randomized studies. A random-effects model was used to pool the data for the meta-analyses.

RESULTS

Nineteen studies were included, reporting on 2495 patients (88 open, 1171 L-TME, 995 R-TME, and 241 TaTME). Quantitative analyses comparing L-TME vs. R-TME showed no significant differences regarding urinary and sexual functioning, except for urinary function at three months post-surgery, which favoured R-TME (SMD [CI] -0 .15 [- 0.24 to - 0.06], p = 0.02; n = 401). Qualitative analyses identified most studies did not find significant differences in urinary, sexual, and fecal functioning and QoL between different techniques.

CONCLUSIONS

This systematic review and meta-analysis highlight a significant gap in the literature concerning the evaluation of functional outcomes and QoL after TME for rectal cancer treatment. This study emphasizes the need for high-quality, randomized-controlled, and prospective cohort studies evaluating these outcomes. Based on the limited available evidence, this systematic review and meta-analysis suggests no significant differences in patients' urinary, sexual, and fecal functioning and their QoL across various TME techniques.

Comparing the effects of retention or resection of the Denonvilliers' fascia on urinary and sexual functions in men who underwent laparoscopic radical

Currently, colorectal cancer has the third highest incidence worldwide. As its incidence is increasing, focus on quality of life after laparoscopic radical resection for colorectal cancer has also increased. This study aimed to compare the effects of retention or resection of the Denonvilliers'fascia on urinary and sexual functions in men who underwent laparoscopic radical resection for rectal cancer. Relevant national and international literature databases, including China Knowledge Network, PubMed, Cochrane Library, and Excerpta Medica Database, were searched according to the established retrieval scheme. Review Manager 5.3 was used to analyze data, and the correct effect model was selected based on heterogeneity. In total, 22 studies involving 2255 patients were included in the meta-analysis. The studies were categorized into the experimental and control groups. The incidence of urinary dysfunction was lower in the experimental group than in the control group at 1 and 6 months postoperatively. In terms of sexual function, the experimental group had lower rates of erectile and ejaculatory dysfunctions than the control group at 1, 3, and 6 months and 1 year postoperatively. However, the experimental group had a longer operation time than the control group. No significant differences in incidence of postoperative complications, intra-operative blood loss, and number of lymph nodes dissections were observed between the two groups. Overall, laparoscopic radical resection for rectal cancer with preservation of the Denonvilliers' fascia has been proven effective in improving postoperative urinary and sexual functions in men without affecting the number of lymph nodes dissected and enhancing postoperative quality of life.

Automated non-invasive identification of pelvic autonomic nerves with a handheld Raman spectrometer and potential application to nerve-sparing colorectal surgery: a preliminary study in surgical specimens

Background

Although minimally invasive surgery for colorectal cancer, whether performed as standard laparoscopic or robotic surgery, has been established as an oncologically safe procedure, postoperative urinary dysfunction and sexual dysfunction remain matters of concern, even when so-called nerve-sparing surgery is performed. We have hypothesized that Raman spectroscopy can be used intraoperatively as a non-invasive label-free means of objective identification of the pelvic nerves, and we conducted a preliminary study by applying a newly developed handheld Raman spectrometer to surgical specimens.

Methods

Samples of nervous tissue, colon cancer tissue, and tissues from surrounding pelvic organs were obtained from 25 patients undergoing colectomy. Raman spectra were obtained by irradiation with the Progeny™ Raman spectrometer. We looked for characteristic Raman shifts to distinguish nervous tissue from cancer tissue. To improve discrimination between nervous tissue and other tissues, the spectral data were subjected to principal component analysis.

Results

We detected characteristic differences in the spectra at 1,309 cm^-1, 1,442 cm^-1, and 1,658 cm^-1. A significant difference was detected at 1,442 cm^-1, and accuracy of the modality for identification of nervous tissue was 75%. The addition of principle component analysis (4 components) yielded 100% sensitivity, 85% specificity, and 90%, notably increasing accuracy from 75% to 90% in discriminating between nervous tissue and cancer tissue.

Conclusions

Raman spectroscopy holds promise for non-invasive intraoperative recognition of nervous tissue. We expect the modality to become a powerful clinical tool, compensating for the lack of tactile feedback intrinsic to minimally invasive colectomy and thus thwarting the risk of postoperative urinary and/or sexual dysfunction.

Mid- and low-rectal cancer: laparoscopic vs open treatment-short- and long-term results. Meta-analysis of randomized controlled trials

BACKGROUND

The laparoscopic approach in the treatment of mid- or low-rectal cancer is still controversial. Compared with open surgery, laparoscopic resection of extraperitoneal cancer is associated with improved short-time non-oncological outcomes, although high-level evidence showing similar short- and long-term oncological outcomes is scarce.

OBJECTIVE

The aim of our paper is to study the oncological and non-oncological outcomes of laparoscopic versus open surgery for extraperitoneal rectal cancer.

DATA SOURCES

A systematic review of MedLine, EMBASE, and CENTRAL from January 1990 to October 2020 was performed by combining various key words.

STUDY SELECTION

Only randomized controlled trials (RCTs) comparing laparoscopic versus open surgery for extraperitoneal rectal cancer were included. The quality of RCTs was assessed using the Cochrane reviewer's handbook. This meta-analysis was based on the recommendation of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

INTERVENTION(S)

This study analyzes laparoscopic versus open surgery for extraperitoneal rectal cancer.

MAIN OUTCOME MEASURES

Primary outcomes were oncological parameters.

RESULTS

Fifteen RCTs comprising 4,411 patients matched the selection criteria. Meta-analysis showed a significant difference between laparoscopic and open surgery in short-time non-oncological outcomes. Although laparoscopic approach increased operation time, it decreases significantly the blood loss and length of hospital stay. No significant difference was noted regarding short- and long-term oncological outcomes, but 4 and 5 years disease-free survival were statistically higher in the open group.

LIMITATIONS

There are still questions about the long-term oncological outcomes of laparoscopic surgery for extraperitoneal rectal cancer being comparable to the open technique.

CONCLUSIONS

Considering that all surgical resections have been performed in high volume centers by expert surgeons, the minimally invasive surgery in patients with extraperitoneal cancer could still be not considered equivalent to open surgery in terms of oncological radicality.

Sexual dysfunction following surgery for rectal cancer: a single-institution experience

Although much focus is placed on oncological outcomes for rectal cancer, it is important to assess quality of life after surgery of which sexual function is an important component. This study set about to describe the prevalence of sexual dysfunction by resection type and gender among patients undergoing surgery for rectal cancer, usingretrospective analysis. All English-speaking living patients who underwent surgery for stage I-III rectal cancer with curative intent between 2012 and 2016 were identified from a prospectively maintained database at our institution. Eligible patients were invited to complete either the Female Sexual Function Index (FSFI) or the International Index of Erectile Function (IIEF). Primary outcomes were overall rates of sexual dysfunction, defined as more than one standard deviation below the mean of the normal population for each tool. A total of 147 patients responded, yielding a response rate of 38%. The overall sexual dysfunction rate was 70% at a median time from surgery of 38 months. Sixty-two men (62%) and 41 women (87%) reported overall scores that fell below one standard deviation of the population mean. There was no significant difference in sexual dysfunction for both male and female patients between low anterior resection, coloanal anastomosis, or abdominoperineal resection.. The present study revealed a high rate of sexual dysfunction after rectal cancer surgery, particularly in female patients. This study serves as a reminder to surgeons and their teams to openly discuss the impact of surgery on sexual function and ensure adequate consent and appropriate peri-operative management strategies. The retrospective nature of the analysis is the limitation of this study.

Long-term outcomes of transanal endoscopic microsurgery for clinical complete response after neoadjuvant treatment in T2-3 rectal cancer

BACKGROUND

Organ sparing by the transanal endoscopic microsurgery (TEM) procedure is a treatment for patients with locally advanced rectal cancer after chemoradiotherapy (CRT) and complete clinical response (cCR).

AIMS

To assess the surgical and long-term oncological outcomes of TEM for the treatment in T2-3 rectal cancer after CRT and cCR.

METHODS

This study was a retrospective review of a prospective database of patients with rectal cancer who underwent TEM after CRT and cCR from April 2011 to March 2020.

RESULTS

52 patients underwent TEM during a period of 9 years. This group of patients included 27 females and 25 males. The median age was 62 (32-86) years, lesion size was 2.5 (1-4) cm, and lesion distance from the anal verge 7.3 (4-10) cm. Median operative time was 79.5 (25-120) min and hospital stay was 1 day (14 h-4 days). Morbidity rate was 13.5% and reoperation rate due to major complications was 3.8%. Final histological findings confirmed 34 (65.4%) patients with ypT0, 7 (13.5%), 6 (11.5%), and 5 (9.6%) patients with carcinoma ypT1, ypT2, and ypT3, respectively. After a median follow-up period of 86 (5-107) months, 1 (2.4%) patient had local recurrences and 3 (7.3%) distant metastases. The 5-year disease-free survival was 91.7% and 5-year overall survival 89.5%.

CONCLUSION

Our experience has shown significant rates of ypT0 and ypT1 associated with excellent long-term results. Performing TEM to treat T2-3N0 rectal cancer after CRT and cCR appears to be an oncologically safe and effective procedure.

Potential benefit of laparoscopic surgery for rectal cancer on postoperative male sexual function

AIM

The aim of this retrospective study was to evaluate the incidence of male sexual dysfunction after mid to low rectal cancer surgery and to identify factors associated with postoperative erectile and ejaculatory dysfunction.

METHODS

The subjects were 410 consecutive male patients who underwent surgery for mid to low rectal cancer from 2009 to 2015. Two questionnaires on sexual function were administered: the International Index of Erectile Function, and an original questionnaire on ejaculatory status. Erectile and ejaculatory dysfunction were examined before and 3, 6, 12 months after surgery. In patients without preoperative dysfunction, multivariate regression analyses were performed to identify factors associated with the incidence of erectile and ejaculatory dysfunction at 12 months after surgery.

RESULTS

Of 410 patients, 234 (57%) gave complete responses to the questionnaires, of whom 108 (46%) and 155 (66%) had severe erectile dysfunction, while 115 (49%) and 168 (72%) had severe ejaculatory dysfunction before and 12 months after surgery, respectively. Of the patients who maintained sexual function preoperatively, the incidence of erectile and ejaculatory dysfunction at 12 months after surgery was 51% (64/126) and 49% (58/119), respectively. In multivariate analysis, age >60 years (P = 0.02), laparotomy (P = 0.002), and creation of a diverting ileostomy (P = 0.003) were independent factors associated with postoperative erectile dysfunction, while age >60 years (P = 0.005), laparotomy (P = 0.04), and lateral lymph node dissection (P = 0.001) were independent factors associated with postoperative ejaculatory dysfunction.

CONCLUSION

Sexual dysfunction occurred in almost half of patients after rectal cancer surgery, and was independently associated with several factors, including laparotomy.

Prospective study of sexual function and analysis of risk factors after rectal cancer surgery

AIM

The aim of this study was to assess the evolution of sexual function over time after rectal cancer surgery and to identify risk factors that may have an impact on the deterioration of postoperative function.

METHOD

This was a prospective cohort study of sexual function after rectal cancer surgery using the International Index of Erectile Function (IIEF) and Female Sexual Function Index (FSFI) preoperatively and at 6 and 12 months after surgery. Predictive factors of worsening were identified by univariate and multivariate analysis.

RESULTS

One hundred and one patients were included (56 men and 45 women). In men, the average IIEF showed decreased erectile function and intercourse satisfaction at 6 months (respectively 21.58 ± 7.18 to 16.60 ± 7.96, p = 0.002 and 10.87 ± 2.94, to 8.09 ± 4.45, p = 0.002) with recovery at 1 year. As a percentage, erectile dysfunction increased from the preoperative value to 6 months (64.5% vs 87.1%, p = 0.022) and was observed in 72% at 1 year. Patients with moderate to severe dysfunction increased from 22% preoperatively to 58% (p = 0.009) at 6 months and 44% at 1 year (p < 0.0001). Neoadjuvant chemoradiotherapy (OR 5.4, 95% CI 0.9-29.6; p = 0.041) and erectile worsening at 6 months (OR 20, 95% CI 1.6-238; p = 0.004) were independent factors for worse function at 6 or 12 months, respectively. No significant worsening of the FSFI was found, although there was an improvement in lubrication and orgasm.

CONCLUSION

Temporary deterioration of erectile function in men is common at 6 months after surgery and chemoradiotherapy is the only predictive factor. Furthermore, patients who remain dysfunctional show an increase in the severity of symptoms in relation to the preoperative period.

Prospective study of urinary function and analysis of risk factors after rectal cancer surgery

BACKGROUND

Alterations in urinary function are complications of rectal cancer surgery. The aim of this study was to prospectively analyze the changes in urinary function in patients operated on for rectal cancer, and to identify risk factors that may have an impact on the deterioration of postoperative urinary function.

METHODS

A prospective study of urinary function in rectal cancer patients who had elective oncological resection with curative intention at the Arnau de Vilanova Hospital in Valencia, Spain, from January 2017 to March 2019. The evaluation of urinary function was performed using the International Prostate Symptom Score (IPSS) preoperatively, at 6 and 12 months after surgery. Predictive factors of urinary dysfunction were identified by univariate and multivariate analysis.

RESULTS

Ninety-four patients were enrolled in the study. Eighty-seven of them completed all the follow-up assessments (48 men and 39 women, mean age 65.74 ± 10.95 years,). The mean IPSS was 7.96 ± 7.59 preoperatively, 9.01 ± 6.81 at 6 months, and 8.63 ± 5.59 at 12 months, without statistically significant differences. There were no differences in IPSS between males and females. Preoperative urinary dysfunction was 39% and at 12 months, a deterioration occurred in 23 patients (26.4%). IPSS analysis of symptoms showed a statistically significant worsening of nocturia at 6 months (p = 0.002) and 1 year after surgery (p = 0.037) in women. American Society of Anesthesiologists (ASA) class (OR: 11, [95% CI2.4-53]; p = 0.010), surgical difficulty (OR: 4.5, [95% CI 1-19]; p = 0.027) and anastomotic leakage (OR: 14, [95% CI 1.6-117]; p = 0.010), were identified as independent risk factors for deterioration of urinary function after surgery.

CONCLUSIONS

Our study showed worsening urinary dysfunction after rectal cancer surgery in 26.4% of the patients. However, there were no statistically significant differences in mean IPSS scores at the three assessment times (preoperatively, 6 months, 12 months). ASA class, surgical difficulty, and anastomotic leakage may predict postoperative deterioration.

Long-term Voiding and Sexual Function in Male Patients After Robotic Total Mesorectal Excision With Autonomic Nerve Preservation for Rectal Cancer: A Cross-Sectional Study

BACKGROUND

Robotic surgery can help to identify and preserve the autonomic nerves during total mesorectal excision (TME) compared with open surgery or laparoscopy due to the 3-dimensional image and high dexterity of the robotic system. Therefore, this study aimed to assess voiding and sexual function after robotic TME with autonomic nerve preservation. In particular, we focused on the long-term results in male patients operated by a single experienced surgeon.

MATERIALS AND METHODS

We surveyed male patients aged 50 years and below at the time of robotic rectal cancer surgery between November 2011 and July 2018. Patients who died and those who had a recurrence and underwent abdominoperineal resection were excluded. The questionnaire covered the International Prostate Symptom Score (IPSS) and the 5-item version of the International Index of Erectile Function (IIEF-5) for voiding and sexual function, respectively.

RESULTS

Thirty-nine patients (median age, 44 y) were surveyed. IPSS and IIEF-5 scores were 5.7±5.3 and 14.7±8.4, respectively. Only 6 patients (15.4%) complained of poor quality of life due to their urinary symptoms. In sexual function, 10 patients (25.6%) complained severe reduction compared with their preoperative status. The average of postoperative days defined from surgery to the questionnaire was 37.8 months. A significant change in the IIEF-5 score was observed between 1 and 2 years postoperatively (5.8±6.9 vs. 16.5±8.8; P=0.027).

CONCLUSIONS

As we only included male patients who were operated by a single experienced surgeon, the results of robotic TME with pelvic autonomic nerve preservation showed acceptable data in preserving both voiding and sexual functions. Although related clinical factors for poor functional outcomes was not statistically significant due to the small sample size, we could observe an improvement in sexual function between 1 and 2 years after surgery with long-term functional results.

Association between urinary function and resected pattern of the autonomic nerve system after transanal total mesorectal excision for rectal cancer

AIM

Transanal total mesorectal excision (TaTME) is expected to improve the quality of total mesorectal excision as well as preserve urinary function. We aimed to study the frequency and risk factors of urinary dysfunction in rectal cancer patients after TaTME. Moreover, we analysed the association between urinary function and resected pattern of the autonomic nerve system (ANS) in TaTME.

METHOD

We retrospectively analysed 231 patients who underwent TaTME at our hospital from 2013 to 2018. Independent risk factors for urinary dysfunction were assessed by multivariate analysis. Urinary dysfunction was defined as a condition that requires urethral catheterisation. We intraoperatively judged and classified the preserved or resected pattern of ANS into four categories.

RESULTS

The rate of urinary dysfunction after TaTME was 12.1% at discharge. Multivariate analysis revealed that beyond TME and ANS resection were the two major independent risk factors for urinary dysfunction. Total ANS preservation had reduced rates of urinary dysfunction, and all patients were free from catheterisation 6 months post-surgery. There was a higher rate of urinary dysfunction in total ANS resection than in partial ANS resection at 6 months post-surgery.

CONCLUSION

This study showed that urinary function after TaTME was associated with resection of the ANS. Furthermore, the rate of urinary dysfunction and recovery time were closely related to the pattern of ANS resection.

Robotic Surgery for Rectal Cancer: Hype or Hope? (Indian Experience)

The primary goal to achieve cure in oncology is to reduce recurrence, maximize disease-free survival, maintain function, and optimize quality of life. Surgery remains the mainstay treatment modality in rectal cancer. The current trend is to perform least invasive method of doing complex surgeries while not compromising in the oncological of functional outcomes of patients. Total mesorectal excision (TME) for rectal cancer surgery entails removal of the rectum with its fascia as an intact unit while preserving surrounding vital structures. The procedure is technically challenging because of the narrow and deep pelvic cavity housing the rectum encased by fatty lymph vascular tissue within the perirectal fascia, distally the anal sphincter complex, and an intimate surrounded by vital structures like ureter, vessels, and nerves. Robotic technology enables overcoming these difficulties caused by complex pelvic anatomy. This system can facilitate better preservation of the pelvic autonomic nerve and thereby achieve favorable postoperative sexual and voiding functions after rectal cancer surgery. The nerve-preserving TME technique includes identification and preservation of the superior hypogastric plexus nerve, bilateral hypogastric nerves, pelvic plexus, and neurovascular bundles.

Robotic Total Mesorectal Excision for Rectal Cancer: Current Evidences and Future Perspectives

Despite the technical limitations of minimally invasive surgery, laparoscopic total mesorectal excision (LTME) for rectal cancer has short-term advantages over open surgery, but the pathological outcomes reported in randomized clinical trials are still in controversy. Minimally invasive robotic total mesorectal excision (RTME) has recently been gaining popularity as robotic surgical systems potentially provide greater benefits than LTME. Compared to LTME, RTME is associated with lower conversion rates and similar or better genitourinary functions, but its long-term oncological outcomes have not been established. Although the operating time of RTME is longer than that of LTME, RTME has a shorter learning curve, is more convenient for surgeons, and is better for sphincter-preserving operations than LTME. The robotic surgical system is a good technical tool for minimally invasive surgery for rectal cancer, especially in male patients with narrow deep pelvises. Robotic systems and robotic surgical techniques are still improving, and the contribution of RTME to the treatment of rectal cancer will continue to increase in the future.

Prospective evaluation of the quality of life of patients undergoing surgery for colorectal cancer depending on the surgical technique

PURPOSE

Monitoring of the quality of life of patients in addition to satisfactory survival indexes in order to choose an optimal treatment method is a trend in contemporary oncological surgery. The goal of the study was to prospectively evaluate the quality of life of patients treated for colorectal cancer depending on the type of surgical technique (open surgery (OS) vs. laparoscopic surgery (LS)).

METHODS

The quality of life was evaluated thrice in the study groups (on the day of admission to the ward (I), 6 months (II), and 18 months after the procedure (III)). The following questionnaires were used in this evaluation: QLQ-C30 European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, QLQ-CR29 Quality of Life Questionnaire (module-colorectal cancer), and Acceptance of Illness Scale (AIS).

RESULTS

Sixty-seven patients completed this prospective clinical cohort study (LS-32; OS-35). The QLQ-C30 questionnaire demonstrated improvement in functional scales among patients treated with LS technique (p < 0.05) as well as with regard to overall quality of life 6 months after surgery (p < 0,001), while at 18 months postsurgery, statistically significant differences were noted for physical function (p = 0.001) and overall quality of life (p < 0.0001). AIS scale analysis demonstrated that patients treated with laparoscopy were characterized by better acceptance of illness (p < 0.05). Statistically significant differences between OS and LS groups were noted based on the QLQ-CR29 questionnaire with regard to the following scales: body image (p = 0.041) and body mass problem (p = 0.024)-patients treated with LS technique had better scores.

CONCLUSIONS

Laparoscopic surgery gives patients a chance for better quality of life.

Prediction of urinary retention after surgery for rectal cancer using voiding efficiency in the 24 h following Foley catheter removal

PURPOSE

Postoperative urinary retention is a common adverse effect after rectal surgery. Current methods for assessing postoperative urinary retention (residual urine volume) are inaccurate and unable to predict long-term retention. Voiding efficiency is an effective indicator of postoperative urinary retention in urological and gynaecological fields, but not in colorectal surgery. We aimed to determine whether voiding efficiency in the initial 24 h after urinary catheter removal was more effective in predicting the incidence of postoperative urinary retention than residual urine volume.

METHODS

In this retrospective, observational study using prospectively collected data from patients who visited the colorectal department of a single institution, 549 patients who underwent rectal cancer surgery between April 2012 and May 2016 were initially enrolled, of which 46 were excluded and 503 finally included.

RESULTS

The incidence of postoperative urinary retention was 18.5% (93/503). Multivariable logistic regression analyses revealed that the association of postoperative urinary retention with voiding efficiency < 50% was stronger than that with residual urine volume > 100 mL (odds ratio, 38.30 (residual urine volume) and 138.0 (voiding efficiency)). Voiding efficiency was significantly lower in patients with long-term than in those with short-term postoperative urinary retention (adjusted p value = 0.02), whereas residual urine volume was not different between the two groups. Multivariable logistic regression analysis for long-term postoperative urinary retention showed the strongest association with voiding efficiency < 20% (odds ratio, 25.70).

CONCLUSIONS

Voiding efficiency is a more effective predictor of postoperative urinary retention than residual urine volume in rectal cancer patients.

Quality of life in patients with loco-regional rectal cancer after ELRR by TEM versus VLS TME after nChRT: long-term results

BACKGROUND

Endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgery (TEM) may be an alternative treatment option to Laparoscopic total mesorectal excision (LTME), in selected patients with N0 rectal cancer. Post-operative quality of life (QoL) evaluation is an important parameter of outcomes related to high percentage of functional sequelae. We reported, in a previous paper, the short and medium term results of QoL in patients who underwent ELRR or LTME. The aim is to evaluate the 3 year QoL in patients with iT2-T3 N0/+ rectal cancer who underwent ELRR by TEM or LTME after neoadjuvant radio-chemotherapy (nChRT) in a retrospective analysis of prospectively collected data.

METHODS

We enrolled in this study, 39 patients with iT2-T3 rectal cancer who underwent ELRR (n = 19) or LTME (n = 20), according to predefined criteria. QoL was evaluated by EORTC QLQ-C30 and QLQ-CR38 questionnaires at admission, after n-RCT and 1, 6, 12, and 36 months after surgery.

RESULTS

No statistically significant differences in QoL evaluation were observed between the two groups, both at admission and after n-RCT. In short term (1-6 months) period, significantly better results were observed in ELRR group by QLQ-C30 in global health status (p = 0.03), physical functioning (p = 0.026), role functioning (p = 0.04), emotional functioning (p = 0.04), cognitive functioning, fatigue (p < 0.05), dyspnoea (p < 0.001), insomnia (p < 0.05), appetite loss (p < 0.05), constipation (≤ 0.05), and by QLQ-CR38 in: body image (p = 0.03) and defecation (p = 0.025). At 1 year, the two groups were homogenous as assessed by QLQ-C30, whereas the QLQCR38 still showed better results of ELRR versus LTME in body image (p = 0.006), defecation problems (p = 0.01), and weight loss (p = 0.005). At 3 years, no statistically significant differences were observed between the two groups.

CONCLUSIONS

In selected patients with rectal cancer, who underwent ELRR by TEM or LTME, QoL tests at 3 years do not show any statistical differences on examined items.

Sexual and urinary outcomes in robotic rectal surgery: review of the literature and technical considerations

Several studies have reported high rates of urogenital dysfunction after open and laparoscopic surgery for rectal cancer. Robotic surgery has several features that could facilitate identification and preservation of autonomic nerves. This manuscript aims to summarize the literature regarding urogenital function after robotic rectal cancer surgery and focus on technical aspects of nerve-sparing total mesorectal excision. Comprehensive searches were conducted through online databases. Selection criteria included: original articles assessing urinary and sexual function after robotic surgery of males and/or females with standardized questionnaires. A total of 16 articles were included in the review. Seven of the nine cohort studies evaluating male sexual function showed earlier recovery or better outcomes in patients operated with robotic techniques. Two studies did not find any statistically significant difference. Three out of four case series found no difference in sexual function scores measured preoperatively and after 1 year. Female sexual function was assessed in seven studies: two case series show no deterioration of at 1 year. Three comparative studies showed no difference between robotic and laparoscopic groups. Two randomized control trials showed different results in terms of male and female sexual functions with better preservation at 1 year in the robotic group in one and no difference in another. Urinary functions assessed in males and/or females in the 16 studies showed no statistically significant differences at long-term follow-up. At present, there is no evidence of superiority of robotic surgery for performing nerve-sparing rectal cancer surgery.

Sexual and urinary dysfunction following laparoscopic total mesorectal excision in male patients: A prospective study

Aims:

Even with the use of nerve-sparing techniques, there is a risk of bladder and sexual dysfunction after total mesorectal excision (TME). Laparoscopic TME is believed to improve this autonomic nerve dysfunction, but this is not demonstrated conclusively in the literature. In Indian patients generally, the stage at which the patients present is late and presumably the risk of autonomic nerve injury is more; however, there is no published data in this respect.

Materials and Methods:

This prospective study in male patients who underwent laparoscopic TME evaluated the bladder and sexual dysfunction using objective standardised scores, measuring residual urine and post-voided volume. The International Prostatic Symptom Score (IPSS) and International Index of Erectile Function score were used respectively to assess the bladder and sexual dysfunction preoperatively at 1, 3, 6 months and at 1 year.

Results:

Mean age of the study group was 58 years. After laparoscopic TME in male patients, the moderate to severe bladder dysfunction (IPSS <8) is observed in 20.4% of patients at 3 months, and at mean follow-up of 9.2 months, it was seen only in 2.9%. There is more bladder and sexual dysfunction in low rectal tumours compared to mid-rectal tumours. At 3 months, 75% had sexual dysfunction, 55% at median follow-up of the group at 9.2 months.

Conclusion:

After laparoscopic TME, bladder dysfunction is seen in one-fifth of the patients, which recovers in the next 6 months to 1 year. Sexual dysfunction is observed in 75% of patients immediately after TME which improves to 55% over 9.2 months.

Sexual dysfunction following rectal cancer surgery

INTRODUCTION

Sexual and urological problems after surgery for rectal cancer are common, multifactorial, inadequately discussed, and untreated. The urogenital function is dependent on dual autonomic sympathetic and parasympathetic innervation, and four key danger zones exist that are at risk for nerve damage during colorectal surgery: one of these sites is in the abdomen and three are in the pelvis. The aim of this study is to systematically review the epidemiology of sexual dysfunction following rectal cancer surgery, to describe the anatomical basis of autonomic nerve-preserving techniques, and to explore the scientific evidence available to support the laparoscopic or robotic approach over open surgery.

METHODS

According to the PRISMA guidelines, a comprehensive literature search of studies evaluating sexual function in patients undergoing rectal surgery for cancer was performed in Medline, Scopus, Web of Science, Embase, and Cochrane Central Register of controlled trials.

RESULTS

An increasing number of studies assessing the incidence and prevalence of sexual dysfunction following multimodality treatment for rectal cancer has been published over the last 30 years. Significant heterogeneity in the prevalence of sexual dysfunction is reported in the literature, with rates between 5 and 90%.

CONCLUSIONS

There is no evidence to date in favor of any surgical approach (open vs laparoscopic vs robotic). Standardized diagnostic tools should be routinely used to prospectively assess sexual function in patients undergoing rectal surgery.

McKittrick Wheelock Syndrome Treated by Transanal Minimally Invasive Surgery: A Single-Center Experience and Review of the Literature

INTRODUCTION

McKittrick Wheelock Syndrome (MKWS) is a rare syndrome characterized by secretory diarrhea, dehydration, prerenal acute kidney injury, and severe electrolyte abnormalities caused by a large hypersecretory villous adenoma located in the rectum or rectosigmoid junction. Transabdominal (laparoscopic) procedures are the most described procedures in the treatment of MKWS. We report an alternative surgical approach, transanal minimally invasive surgery (TAMIS), to solve this syndrome.

MATERIALS AND METHODS

All patients who underwent transanal endoscopic microsurgery or TAMIS were included in a prospectively collected database in our center. Between 1996 and 2015, 3 patients were found to have MKWS and treated by TAMIS. Demographics, characteristics of the adenoma, surgery-related data, and outcome were analyzed.

RESULTS

The first patient had a villous adenoma 0-12 cm from the anal verge. After TAMIS, she complained of a stenosis that was successfully treated by dilatation. The second patient had an impressive bulky tumor in the rectum. An endoscopic mucosal resection was attempted twice, but incompletely. Pathology analysis showed villous adenoma with high-grade dysplasia and intramucosal carcinoma. One year after TAMIS, a recurrence was detected and treated by an abdominal-perineal resection. A TAMIS was performed in the third patient because of a giant villous circular adenoma, but because of high mucus and fluid production, no proper overview could be obtained. Together with opening of the peritoneum, this prompted us to convert to a laparoscopic Hartmann procedure. Besides this technical difficulty, the patient recovered uneventful.

CONCLUSIONS

MKWS is a rare syndrome and missed diagnosis could result in life-threatening situations. Different endoscopic and surgical treatments are described to solve this syndrome. TAMIS should be considered as a rectum-preserving surgical treatment option for such extensive adenomas.

Urogenital function in robotic vs laparoscopic rectal cancer surgery: a comparative study

PURPOSE

Urological and sexual dysfunction are recognised risks of rectal cancer surgery; however, there is limited evidence regarding urogenital function comparing robotic to laparoscopic techniques. The aim of this study was to assess the urogenital functional outcomes of patients undergoing laparoscopic and robotic rectal cancer surgery.

METHODS

Urological and sexual functions were assessed using gender-specific validated standardised questionnaires. Questionnaires were sent a minimum of 6 months after surgery, and patients were asked to report their urogenital function pre- and post-operatively, allowing changes in urogenital function to be identified. Questionnaires were sent to 158 patients (89 laparoscopy, 69 robotic) of whom 126 (80 %) responded. Seventy-eight (49 male, 29 female) of the responders underwent laparoscopic and 48 (35 male, 13 female) robotic surgery.

RESULTS

Male patients in the robotic group deteriorated less across all components of sexual function and in five components of urological function. Composite male urological and sexual function score changes from baseline were better in the robotic cohort (p < 0.001). In females, there was no difference between the two groups in any of the components of urological or sexual function. However, composite female urological function score change from baseline was better in the robotic group (p = 0.003).

CONCLUSION

Robotic rectal cancer surgery might offer better post-operative urological and sexual outcomes compared to laparoscopic surgery in male patients and better urological outcomes in females. Larger scale, prospective randomised control studies including urodynamic assessment of urogenital function are required to validate these results.

The pathophysiology of delayed ejaculation

Delayed ejaculation (DE) is probably least studied, and least understood of male sexual dysfunctions, with an estimated prevalence of 1–4% of the male population. Pathophysiology of DE is multifactorial and including psychosexual-behavioral and cultural factors, disruption of ejaculatory apparatus, central and peripheral neurotransmitters, hormonal or neurochemical ejaculatory control and psychosocial factors. Although knowledge of the physiology of the DE has increased in the last two decade, our understanding of the different pathophysiological process of the causes of DE remains limited. To provide a systematic update on the pathophysiology of DE. A systematic review of Medline and PubMed for relevant publications on ejaculatory dysfunction (EjD), DE, retarded ejaculation, inhibited ejaculation, and climax was performed. The search was limited to the articles published between the January 1960 and December 2015 in English. Of 178 articles, 105 were selected for this review. Only those publications relevant to the pathophysiology, epidemiology and prevalence of DE were included. The pathophysiology of DE involves cerebral sensory areas, motor centers, and several spinal nuclei that are tightly interconnected. The biogenic, psychogenic and other factors strongly affect the pathophysiology of DE. Despite the many publications on this disorder, there still is a paucity of publications dedicated to the subject.

Anatomical basis and clinical research of pelvic autonomic nerve preservation with laparoscopic radical resection for rectal cancer

The clinical effect of laparoscopic rectal cancer curative excision with pelvic autonomic nerve preservation (PANP) was investigated. This study evaluated the frequency of urinary and sexual dysfunction of 149 male patients with middle and low rectal cancer who underwent laparoscopic or open total mesorectal excision with pelvic autonomic nerve preservation (PANP) from March 2011 to March 2013. Eighty-four patients were subjected to laparoscopic surgery, and 65 to open surgery respectively. The patients were followed up for 12 months, interviewed, and administered a standardized questionnaire about postoperative functional outcomes and quality of life. In the laparoscopic group, 13 patients (18.37%) presented transitory postoperative urinary dysfunction, and were medically treated. So did 12 patients (21.82%) in open group. Sexual desire was maintained by 52.86%, un-ability to engage in intercourse by 47.15%, and un-ability to achieve orgasm and ejaculation by 34.29% of the patients in the laparoscopic group. Sexual desire was maintained by 56.36%, un-ability to engage in intercourse by 43.63%, and un-ability to achieve orgasm and ejaculation by 33.73% of the patients in the open group. No significant differences in urinary and sexual dysfunction between the laparoscopic and open rectal resection groups were observed (P>0.05). It was concluded that laparoscopic rectal cancer radical excision with PANP did not aggravate or improve sexual and urinary dysfunction.

Morphological study of the neurovascular bundle to elucidate nerve damage in pelvic surgery

PURPOSE

Postoperative sexual and urinary dysfunction may occur after rectal cancer surgery involving the pelvis, but this problem cannot be solved. The aim of this study was to examine the nerve morphology of the neurovascular bundle in cadavers to determine possible causes of nerve damage during surgery.

METHODS

Twenty-two formalin-fixed cadavers were used in the study. The cadavers were donated to the Tokyo Medical University. The study comprised histological evaluation of paraffin-embedded bilateral neurovascular bundle specimens from the cadavers. Four slides of 3-cm thick were made every 1 cm in a plane perpendicular to the rectum towards the pelvic floor from the peritoneal reflection in bilateral neurovascular bundles in 22 cadavers. The number of nerves, the mean nerve area, and the mean nerve diameter were measured in each slide.

RESULTS

The results were categorized into cases with high (group H) and low (group L) positions of the pelvis 1 cm above and 2 cm below the peritoneal reflection, respectively. There was no significant difference in the number of nerves between these groups. The nerve area and nerve diameter were significantly smaller in group L, and these characteristics were more marked in males.

CONCLUSIONS

Our results show that the nerves of the neurovascular bundle became smaller in the deep pelvis. This may cause these nerves to be more susceptible to injury, resulting in nerve damage in the deep pelvis that leads to postoperative dysfunction. Particularly, this type of nerve damage may be a cause of postoperative sexual dysfunction in males.

A systematic review of transanal total mesorectal excision: is this the future of rectal cancer surgery?

AIM

The surgical technique used for transanal total mesorectal excision (TaTME) was reviewed including the oncological quality of resection and the peri-operative outcome.

METHOD

A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify studies reporting on TaTME.

RESULTS

Thirty-six studies (eight case reports, 24 case series and four comparative studies) were identified, reporting 510 patients who underwent TaTME. The mean age ranged from 43 to 80 years and the mean body mass index from 21.7 to 31.8 kg/m(2) . The mean distance of the tumour from the anal verge ranged from 4 to 9.7 cm. The mean operation time ranged from 143 to 450 min and mean operative blood loss from 22 to 225 ml. The ratio of hand-sewn coloanal to stapled anastomoses performed was 2:1. One death was reported and the peri-operative morbidity rate was 35%. The anastomotic leakage rate was 6.1% and the reoperation rate was 3.7%. The mean hospital stay ranged from 4.3 to 16.6 days. The mesorectal excision was described as complete in 88% cases, nearly complete in 6% and incomplete in 6%. The circumferential resection margin was negative in 95% of cases and the distal resection margin was negative in 99.7%.

CONCLUSION

TaTME is a feasible and reproducible technique, with good quality of oncological resection. Standardization of the technique is required with formal training. Clear indications for this procedure need to be defined and its safety further assessed in future trials.

Effect of intra-operative autonomic nerve stimulation on pelvic nerve preservation during radical laparoscopic proctectomy

AIM

This study assessed the effect of intra-operative electrical nerve stimulation (INS) on pelvic autonomic nerve preservation (PANP) during laparoscopic resection for rectal cancer.

METHOD

A total of 189 consecutive cases of radical laparoscopic proctectomy were included. PANP was assessed visually or with INS. Urinary function was evaluated by residual urine volume (RUV), International Prostatic Symptom Score (IPSS) and recatheterization rate. Erectile function was evaluated using the International Index of Erectile Function (IIEF-5) scale.

RESULTS

INS successfully confirmed PANP in 65 (91.5%) patients, while direct vision confirmed PANP in only 72 (61.0%) patients. Compared with the successfully confirmed patients, failed patients in the INS group exhibited higher postoperative RUV (100.0 ± 34.6 vs 25.2 ± 13.6 ml, P = 0.003), higher IPSS (7 days, 20.0 ± 8.6 vs 6.5 ± 2.4, P = 0.012; 1 month, 13.5 ± 6.0 vs 5.3 ± 1.9, P = 0.020; 6 months, 11.7 ± 5.1 vs 4.5 ± 1.7, P = 0.018), a greater number of incidences of a micturition disorder (66.7% vs 1.5%, P = 0.000), higher recatheterization rates (33.3% vs 1.5%, P = 0.017) and a lower IIEF score at 3 months (8.25 ± 0.96 vs 10.93 ± 1.99, P = 0.012) and 6 months (12.50 ± 1.29 vs 15.63 ± 1.65, P = 0.001) postoperatively. Compared with the vision group, the INS group had less deterioration in postoperative RUV (31.5 ± 26.4 vs 54.0 ± 46.7 ml, P = 0.000), lower IPSS (7 days, 7.7 ± 5.0 vs 11.0 ± 6.6, P = 0.000; 1 month, 6.0 ± 3.3 vs 7.6 ± 5.4, P = 0.012) and higher IIEF score (3 months, 10.69 ± 2.07 vs 9.42 ± 2.05, P = 0.001; 6 months, 15.36 ± 1.85 vs 13.64 ± 2.00, P = 0.000) as well as a lower incidence of urination disorders (7.0% vs 17.8%, P = 0.038).

CONCLUSION

INS is effective for the accurate evaluation of PANP during radical laparoscopic proctectomy. Combined with INS, laparoscopic proctectomy is more effective in urogenital function protection.

Urogenital dysfunctions after treatment of rectal cancer

A significant part of rectal cancer survivors will experience urogenital dysfunction induced by the treatment. Significant progress has been made in order to improve the total mesorectal technique through different approaches (open, laparoscopic, robotic, transanal). Rectal cancer surgery is technically difficult notably deep in the pelvis, and therefore the most frequent cause of the postoperative dysfunction is the surgical nerve damage of the autonomic nerves at this level. The main objectives of these efforts were to obtain maximal oncological results and to achieve better functional outcomes including less postoperative urogenital dysfunctions. Our purpose was to build a comprehensive review of the existing literature data regarding this issue from past to present.

URINARY DYSFUNCTION AFTER SURGICAL TREATMENT FOR RECTAL CANCER

BackgroundThe impact on quality of life attributed to treatment for rectal cancer remains high. Deterioration of the urinary function is a relevant complication within that context.ObjectiveTo detect the presence of urinary dysfunction and its risk factors among individuals underwent surgical treatment for rectal cancer.MethodsThe present prospective study analyzed 42 patients from both genders underwent surgical treatment for rectal adenocarcinoma with curative intent. The version of the International Prostatic Symptom Score (IPSS) questionnaire validated for the Portuguese language was applied at two time-points: immediately before and 6 months after surgery. Risk factors for urinary dysfunction were analysed by means of logistic regression and Student’s t-test.ResultsEight (19%) participants exhibited moderate-to-severe urinary dysfunction 6 months after surgery; the average IPSS increased from 1.43 at baseline to 4.62 six months after surgery (P<0.001). None of the variables assessed as potential risk factors exhibited statistical significance, i.e., age, gender, distance from tumour to anal margin, neoadjuvant therapy, adjuvant therapy, type of surgery, surgical approach (laparoscopy or laparotomy), and duration of surgery.ConclusionThis study identified an incidence of 19% of moderate to severe urinary dysfuction after 6 months surveillance. No risk factor for urinary dysfunction was identified in this population.

Effects of robotic rectal surgery on sexual and urinary functions in male patients

PURPOSES

This study prospectively assessed the sexual and urinary functions, as well as factors influencing these functions, in patients who underwent open or robotic surgery for rectal cancer.

METHODS

Forty-five consecutive male patients who underwent rectal resection for rectal cancer were prospectively enrolled in this study. Their sexual and urinary functions were assessed through self-administered questionnaires comprising the International Index of Erectile Function (IIEF; sexual function) and the International Prostate Symptom Score (IPSS; urinary function) before and at 3, 6, and 12 months after surgery.

RESULTS

Fifteen patients who underwent robotic surgery and 22 who underwent open surgery were finally analyzed in this study. The total IIEF score and the individual score items did not change at 3, 6 or, 12 months after open or robotic surgery compared with the preoperative values. However, a univariate analysis revealed that age affected the urinary function 12 months after surgery, while both univariate and multivariate analyses revealed that postoperative complications affected the sexual function 12 months after surgery.

CONCLUSIONS

In this non-randomized comparison, the postoperative sexual and urinary functions were comparable between patients who underwent open rectal surgery and those who underwent robotic rectal surgery. Postoperative complications were a risk factor for sexual dysfunction, while age was a risk factor for urinary dysfunction.

Urinary and erectile function in men after total mesorectal excision by laparoscopic or robot-assisted methods for the treatment of rectal cancer: a case-matched comparison

BACKGROUND

Urinary and sexual dysfunction are recognized complications of rectal cancer surgery in men. This study compared robot-assisted total mesorectal excision (RTME) and laparoscopic total mesorectal excision (LTME) with regard to these functional outcomes.

METHODS

A series of 32 men who underwent RTME between February 1, 2009 and December 31, 2010 were matched 1:1 with patients who underwent LTME. The matching criteria were age, body mass index, tumor distance from the anal verge, neoadjuvant chemoradiation therapy, and tumor stage. Urinary and erectile function were evaluated using the International Prostatic Symptom Score (IPSS) and the five-item version of the International Index of Erectile Function (IIEF-5) scale. Data were collected from the two groups at baseline and at 3, 6, and 12 months after surgery and compared.

RESULTS

The mean IPSS score did not differ between the two groups at baseline at any point of measurement. The mean baseline IIEF-5 score was similar between the two groups and was decreased at 3 months. The mean IIEF-5 score was significantly higher in the RTME group at 6 months than in the LTME group (14.1 ± 6.1 vs. 9.4 ± 6.6; p = 0.024). The interval decrease in IIEF-5 scores was significantly higher in the LTME group than in the RTME group at 6 months (4.9 ± 4.5 vs. 9.2 ± 4.7; p = 0.030).

CONCLUSIONS

The men in the RTME group experienced earlier restoration of erectile function than did those in the LTME group. Bladder function was similar during the 12 months after RTME or LTME.

The Role of Robotic Surgery for Rectal Cancer: Overcoming Technical Challenges in Laparoscopic Surgery by Advanced Techniques

The conventional laparoscopic approach to rectal surgery has several limitations, and therefore many colorectal surgeons have great expectations for the robotic surgical system as an alternative modality in overcoming challenges of laparoscopic surgery and thus enhancing oncologic and functional outcomes. This review explores the possibility of robotic surgery as an alternative approach in laparoscopic surgery for rectal cancer. The da Vinci® Surgical System was developed specifically to compensate for the technical limitations of laparoscopic instruments in rectal surgery. The robotic rectal surgery is associated with comparable or better oncologic and pathologic outcomes, as well as low morbidity and mortality. The robotic surgery is generally easier to learn than laparoscopic surgery, improving the probability of autonomic nerve preservation and genitourinary function recovery. Furthermore, in very complex procedures such as intersphincteric dissections and transabdominal transections of the levator muscle, the robotic approach is associated with increased performance and safety compared to laparoscopic surgery. The robotic surgery for rectal cancer is an advanced technique that may resolve the issues associated with laparoscopic surgery. However, high cost of robotic surgery must be addressed before it can become the new standard treatment.

Total mesorectal excision for rectal cancer with emphasis on pelvic autonomic nerve preservation: Expert technical tips for robotic surgery

The primary goal of surgical intervention for rectal cancer is to achieve an oncologic cure while preserving function. Since the introduction of total mesorectal excision (TME), the oncologic outcome has improved greatly in terms of local recurrence and cancer-specific survival. However, there are still concerns regarding functional outcomes such as sexual and urinary dysfunction, even among experienced colorectal surgeons. Intraoperative nerve damage is the primary reason for sexual and urinary dysfunction and occurs due to lack of anatomical knowledge and poor visualization of the pelvic autonomic nerves. The rectum is located concavely along the curved sacrum and both the ischial tuberosity and iliac wing limit the pelvic cavity boundary. Thus, pelvic autonomic nerve preservation during dissection in a narrow or deep pelvis, with adherence to the TME principles, is very challenging for colorectal surgeons. Recent developments in robotic technology enable overcoming these difficulties caused by complex pelvic anatomy. This system can facilitate better preservation of the pelvic autonomic nerve and thereby achieve favorable postoperative sexual and voiding functions after rectal cancer surgery. The nerve-preserving TME technique includes identification and preservation of the superior hypogastric plexus nerve, bilateral hypogastric nerves, pelvic plexus, and neurovascular bundles. Standardized procedures should be performed sequentially as follows: posterior dissection, deep posterior dissection, anterior dissection, posterolateral dissection, and final circumferential pelvic dissection toward the pelvic floor. In future perspective, a structured education program on nerve-preserving robotic TME should be incorporated in the training for minimally invasive surgery.

A Novel Device for Measuring Forces in Endoluminal Procedures

In this paper a simple but effective measuring system for endoluminal procedures is presented. The device allows measuring forces during the endoluminal manipulation of tissues with a standard surgical instrument for laparoscopic procedures. The force measurement is performed by recording both the forces applied directly by the surgeon at the instrument handle and the reaction forces on the access port. The measuring system was used to measure the forces necessary for appropriate surgical manipulation of tissues during transanal endoscopic microsurgery (TEM). Ex-vivo and in-vivo measurements were performed, reported and discussed. The obtained data can be used for developing and appropriately dimensioning novel dedicated instrumentation for TEM procedures.

Have early postoperative complications from laparoscopic rectal cancer surgery improved over the past 20 years?

AIM

Laparoscopic rectal cancer surgery has been increasingly used since 1991 following the publication of the first case series. Since then, several studies have confirmed that laparoscopic surgery for rectal cancer is challenging with associated morbidity and mortality. The aim of this study was to determine if the rates of early postoperative complications in laparoscopic rectal cancer surgery have improved over the past 20 years.

METHOD

A literature search of the EMBASE and MEDLINE databases between August 1991 and August 2011 was conducted using the keywords laparoscopy, rectal cancer and postoperative complications. Data were analysed using linear regression ANOVA performed in GNUMERICS software.

RESULTS

Ninety-seven studies were included for analysis. Over the last 20 years there has been no significant change in the rate of any early postoperative complications (anastomotic leak, conversion, sexual, urinary or faecal dysfunction, wound infection, overall morbidity or mortality). However, in the last 3 years, the rate of positive resection margins has decreased significantly (P = 0.01).

CONCLUSION

There was no evidence of a statistically significant change in early postoperative complications until 3 years ago. This may reflect the inherent morbidity associated with rectal surgery regardless of the approach used, the limitations of the current laparoscopic instrumentation or the relatively long learning curve. With increasing experience, a repeat analysis in the near future following the publication of ongoing randomized clinical trials might show improved outcomes.

A prospective video-controlled study of genito-urinary disorders in 35 consecutive laparoscopic TMEs for rectal cancer

INTRODUCTION

Genito-urinary disorders (GUD) for radical rectal cancer surgery range from 10 to 30%. In this study, primary endpoint is to prospectively assess their incidence in patients undergoing Laparoscopic Total Mesorectal Excision (LTME) without neoadjuvant chemo-radiation (NCR). Secondary endpoint is to detect the potential lesion site evaluating video-recordings of surgery.

PATIENTS AND METHODS

A study of 35 consecutive patients treated by LTME for extra-peritoneal rectal cancer not subjected to NCR, M:F = 23:12, median age 70, was evaluated preoperatively by Uroflowmetry and US postvoid residual urine measurement (PVR), International Prostatic Symptoms Score (IPSS), and International Consultation on Incontinence Modular Questionnaire (ICIQ) at 1 and 9 months post-operatively. Evaluation of sexual function was carried out by International Index of Erectile Function (IIEF) in males. Data were analyzed performing Fisher and paired samples t tests. Surgical videos of patients affected by GUD were reviewed to identify lesion sites.

RESULTS

Urinary function:IPSS average score: baseline 6.03 ± 5.51, 8.93 ± 6.42 (p = .005) at 1 month, and 7.26 ± 5.55 (p = .041) at 9 months. ICIQ baseline 2.67 ± 5.42, 4.27 ± 6.19 (p = NS) at 1 month, and 3.63 ± 5.23 (p = NS) at 9 months. Maximum urine flow rate baseline 15.95 ± 4.78 ml/s, 14.23 ± 5.27 after 1 month (p = .041), and 15.22 ± 4.01 after 9 months (p = NS). Mean urine flow rate baseline 9.15 ± 2.96 ml/s, 7.99 ± 4.12 ml/s at 1 month (p = .044), and 8.54 ± 4.19 ml/s at 9 months (p = NS). PVR baseline 59.62 ± 54.49, 64.59 ± 58.71 (p = NS) at 1 month, and 68.82 ± 77.72 (p = NS) at 9 months. Sexual function: IIEF baseline 19.38 ± 6.25, 14.06 ± 8.65 at 1 month (p = .011), and 15.4 ± 8.41 at 9 months, (p = NS). Video review of patients with disorders showed potential damage at the site of ligation of IMA (high hypogastric plexus) in 1 case, lateral and posterior mesorectum dissection (hypogastric nerves) in 2 cases, anterior dissection of the Denonvilliers fascia from seminal vesicles in 2 cases.

CONCLUSIONS

GUD at 1 month from LTME for rectal cancer are significant but improve at 9 months. Surgical video review of patients with GUD provides an important tool for detection of lesion sites.

Genotypic characteristics of resistant tumors to pre-operative ionizing radiation in rectal cancer

Due to a wide range of clinical response in patients undergoing neo-adjuvant chemoradiation for rectal cancer it is essential to understand molecular factors that lead to the broad response observed in patients receiving the same form of treatment. Despite extensive research in this field, the exact mechanisms still remain elusive. Data raging from DNA-repair to specific molecules leading to cell survival as well as resistance to apoptosis have been investigated. Individually, or in combination, there is no single pathway that has become clinically applicable to date. In the following review, we describe the current status of various pathways that might lead to resistance to the therapeutic applications of ionizing radiation in rectal cancer.

Male sexual function after total mesorectal excision: a comparison between laparoscopic and open surgery during the learning curve period

INTRODUCTION

This study assessed male sexual function using a specific and validated questionnaire, the International Index of Erectile Function (IIEF), in patients subjected to open total mesorectal excision (OTME) and laparoscopic total mesorectal excision (LTME) and compared it with a control group.

PATIENTS AND METHODS

The inclusion criteria consisted of male patients with an active sexual life before surgery subjected to OTME or LTME at the Coloproctological Unit of the Clinics Hospital, Minas Gerais Federal University, between January 2005 and September 2009. The IIEF questionnaire was used. The control group comprised 30 randomly selected men (older than 35 y of age) without previous pelvic or abdominal surgery and without any genitourinary complaints.

RESULTS

Between January 2005 and September 2009, 77 male patients were subjected to total mesorectal excision, with 26 meeting the inclusion criteria and answering the questionnaire: 13 in the OTME group and 13 in the LTME group. When the 3 groups were compared in each IIEF domain, there were significant differences in erectile function (P=0.05), orgasm and ejaculation (P=0.009), sexual intercourse satisfaction (P=0.01), and overall satisfaction (P=0.025), favoring the LTME and control groups. No difference was found in sexual desire (P=0.285).

CONCLUSIONS

LTME may have the benefit of preserving male sexual function compared with OTME, even in the learning curve period.

Patient-reported outcomes after neoadjuvant therapy for rectal cancer: a systematic review

Neoadjuvant therapy followed by total mesorectal excision is standard of care for locally advanced rectal cancer. However, this approach has been previously shown to be associated with high rate of morbidity and it may have a negative effect on patients' reported outcomes (PROs). In order to summarize findings on the effect of the neoadjuvant approach on PROs, we systematically reviewed articles published in the last five years. Thirty-five articles met the inclusion criteria. Ten articles compared the effect of surgery with and without neoadjuvant therapy, six articles compared different neoadjuvant therapies, ten articles reported on patients who were all treated with neoadjuvant therapy, and nine articles examined the effect of neoadjuvant therapy in the analyses. The results are summarized by function investigated and critically commented.

Colorectal surgery and its impact on male sexual function

The quality of functional outcome has become increasingly important in view of improvement in prognosis with colorectal cancer patients. Sexual dysfunction remains a common problem after colorectal cancer treatment, despite the good oncologic outcomes achieved by expert surgeons. Although radiotherapy and chemotherapy contribute, surgical nerve damage is the main cause of sexual dysfunction. The autonomic nerves are in close contact with the visceral pelvic fascia that surrounds the mesorectum. The concept of total mesorectal excision (TME) in rectal cancer treatment has led to a substantial improvement of autonomic nerve preservation. In addition, use of laparoscopy has allowed favorable results with regards to sexual function. The present paper describes the anatomy and pathophysiology of autonomic pelvic nerves, prevalence of sexual dysfunction, and the surgical technique of nerve preservation in order to maintain sexual function.

Urinary and erectile function in men after total mesorectal excision by laparoscopic or robot-assisted methods for the treatment of rectal cancer: a case-matched comparison

BACKGROUND

Urinary and sexual dysfunction are recognized complications of rectal cancer surgery in men. This study compared robot-assisted total mesorectal excision (RTME) and laparoscopic total mesorectal excision (LTME) with regard to these functional outcomes.

METHODS

A series of 32 men who underwent RTME between February 1, 2009 and December 31, 2010 were matched 1:1 with patients who underwent LTME. The matching criteria were age, body mass index, tumor distance from the anal verge, neoadjuvant chemoradiation therapy, and tumor stage. Urinary and erectile function were evaluated using the International Prostatic Symptom Score (IPSS) and the five-item version of the International Index of Erectile Function (IIEF-5) scale. Data were collected from the two groups at baseline and at 3, 6, and 12 months after surgery and compared.

RESULTS

The mean IPSS score did not differ between the two groups at baseline at any point of measurement. The mean baseline IIEF-5 score was similar between the two groups and was decreased at 3 months. The mean IIEF-5 score was significantly higher in the RTME group at 6 months than in the LTME group (14.1 ± 6.1 vs. 9.4 ± 6.6; p = 0.024). The interval decrease in IIEF-5 scores was significantly higher in the LTME group than in the RTME group at 6 months (4.9 ± 4.5 vs. 9.2 ± 4.7; p = 0.030).

CONCLUSIONS

The men in the RTME group experienced earlier restoration of erectile function than did those in the LTME group. Bladder function was similar during the 12 months after RTME or LTME.

Comparative study of voiding and male sexual function following open and laparoscopic total mesorectal excision in patients with rectal cancer

BACKGROUND

This study aimed to compare voiding and male sexual dysfunction between open and laparoscopic rectal cancer surgery.

METHODS

Ninety-seven patients (62 male and 35 female) who underwent open (n = 41) or laparoscopic (n = 56) surgery for rectal cancer were prospectively enrolled. Urine flowmetry, the international prostate symptom score, and the international index of erectile function were assessed preoperatively and postoperatively.

RESULTS

Voiding function score increased 1 month after surgery (open: 9.3 ± 4.6 to 14.0 ± 8.2, laparoscopic: 8.3 ± 5.3 to 12.3 ± 5.2; P = 0.002 and P < 0.001). The score was even higher in both groups after 6 months, but the increases were not statistically significant (open: 9.9 ± 4.5, laparoscopic: 9.2 ± 5.6; P = 0.546 and P = 0.280). Male patients who underwent open surgery (n = 22) experienced declining sexual function until 12 months post surgery (before: 55.2 ± 9.8, 12 months: 48.7 ± 15.9, P = 0.031). In laparoscopic group (n = 28), sexual function decreased until 6 months after surgery, but rose again by 12 months (before: 55.4 ± 9.0, 12 months: 52.2 ± 11.7, P = 0.134).

CONCLUSIONS

Voiding dysfunction recovered after 6 months following both open and laparoscopic surgery. Male sexual function recovered more quickly in laparoscopic group and returned to preoperative levels after 12 months.

Nerve-oriented mesorectal excision (NOME): autonomic nerves as landmarks for laparoscopic rectal resection

PURPOSE

We have developed nerve-oriented mesorectal excision (NOME) as a novel concept in rectal cancer surgery by which autonomic pelvic nerves serve as landmarks for a standardized navigation along fascial planes. This article describes the technique step by step and presents our results from 2008 to 2012.

MATERIAL AND METHODS

The key steps are: preparation of the splanchnic nerves at the mid-posterior sidewall, the hypogastric nerves at the upper sidewall, and the urogenital nerve branches (Walsh) at the caudal-anterior sidewall. The dissection of the lateral ligament is strictly performed as the last step. NOME was applied in 274 consecutive mesorectal excisions (partial 20.4%, total 79.6%); a subgroup of 42 male patients underwent a questionnaire-based interview on sexual activity.

RESULTS

The conversion rate was 0.7%. High (complete) specimen quality and circumferential margin negativity were achieved in 90.1% and 95.3%, respectively. Anastomotic leaks occurred in 13 (4.7%) patients. Mortality was 1.8%. The frequency of prolonged urinary catheter was 1.8%. Of 22 sexually active males interviewed, 18 (81.8%) maintained activity postoperatively.

CONCLUSIONS

NOME achieves high-quality mesorectal specimens and a high rate of preservation of autonomic nerve function. The concept of using nerves as laparoscopic landmarks may help to standardize and master laparoscopic rectal cancer surgery.

A systematic review of the correlates and management of nonpremature ejaculatory dysfunction in heterosexual men

INTRODUCTION

A better understanding of ejaculatory disorders has led to an increasing interest in nonpremature ejaculatory dysfunction (non-PE EjD). Current reviews on the subject use a symptom-based classification to describe ejaculatory dysfunction even when it is a single case report. While these reviews provide important information on the disorder, a clearer picture of the prevalence of non-PE EjD in relation to the community and various pathophysiologic states is needed.

OBJECTIVES

The objective of this study was to provide a systematic review of studies of non-PE EjD excluding single case reports.

METHODS

A systematic review of Medline for terms including ejaculation, orgasm or hematospermia. Association with terms delay, pain or headache was made. The search was restricted to male gender and articles written in English. Abstracts were reviewed and those mainly concerned with premature ejaculation were excluded.

RESULTS

A total of 333 articles on non-PE EjD were identified. The condition was reported in community-based studies. In certain patient populations, non-PE EjD was commonly reported in association with antidepressant and antipsychotic treatments, in patients with chronic prostatitis/chronic pelvic pain syndrome, patients with lower urinary tract symptoms particularly in association with medical or surgical treatment, patients with retroperitoneal surgery and in patients with neurological diseases. Few articles were concerned with treatment options.

CONCLUSION

There is a significant prevalence of non-PE EjD in the community and in association with particular disease states or as a side effect of medical or surgical interventions. There is a need to direct efforts to prevent and treat these conditions.