Postoperative bladder and sexual function in patients undergoing surgery for rectal cancer: a systematic review and meta-analysis of laparoscopic versus open resection of rectal cancer

Applications of Near-Infrared Fluorescence Imaging and Angiography of Inferior Vesical Artery in Laparoscopic Lateral Lymph Node Dissection: A Prospective Nonrandomized Controlled Study

BACKGROUND

Near-infrared imaging with indocyanine green has been used to guide lateral lymph node dissection, yet its efficacy and benefits need further investigation.

OBJECTIVE

To investigate the efficacy and feasibility of near-infrared fluorescence imaging and angiography of the inferior vesical artery in laparoscopic lateral lymph node dissection.

DESIGN

A prospective nonrandomized controlled study.

SETTINGS

Single-center study.

PATIENTS

Patients with lower rectal cancer who underwent total mesorectal excision plus lateral lymph node dissection.

MAIN OUTCOME MEASURES

A cohort of 108 patients was enrolled. After propensity score matching, 29 patients in the near-infrared group and 50 patients in the non-near-infrared group were matched. The total number of harvested lateral lymph nodes, positive lateral lymph nodes, inferior vesical artery preservation, and postoperative urinary function were compared.

RESULTS

After propensity score matching, both groups had similar baseline characteristics. The total number of harvested lateral lymph nodes in the near-infrared group was significantly higher (12 vs 9, p = 0.013), but positive lateral lymph nodes were similar between the 2 groups (1 vs 1, p = 0.439). The inferior vesical artery preservation ratio was significantly increased with the aid of indocyanine green angiography (93.1% vs 56.0%, p < 0.001). The non-near-infrared group required more days for urinary catheter removal than the near-infrared group (5 vs 4, p = 0.046). Urinary recatheterization tended to occur more frequently in the non-near-infrared group, with a marginally significant trend (16% vs 0%, p = 0.059). The non-near-infrared group tended to have more cases with residual urine volume ≥50 mL than the near-infrared group (20.0% vs 3.4%, p = 0.087), especially in the bilateral dissection subgroup (41.2% vs 0%, p = 0.041).

LIMITATIONS

Small sample size.

CONCLUSIONS

Near-infrared imaging increased the number of harvested lateral lymph nodes, whereas real-time indocyanine green fluorescence angiography ensured the preservation of the inferior vesical artery and tended to improve postoperative urinary function.

Comparison of the clinical efficacy of laparoscopic extralevator abdominoperineal excision (ELAPE) and non-ELAPE for low rectal cancer

This study was performed to retrospectively analyze and compare the related clinical indicators between extralevator abdominoperineal excision (ELAPE) and non-ELAPE under laparoscopic for low rectal cancer. From June 2018 to September 2021, a total of 80 patients with low rectal cancer who underwent either of the above two types of surgeries at our Hospital were enrolled. Patients were divided into the ELAPE group and non-ELAPE group based on the different surgical methods. Preoperative general indicators, intraoperative indicators, postoperative complications, positive circumferential resection margin rate, local recurrence rate, hospital stay length, hospital expenses, and other related indicators were compared between the two groups. There were no significant differences in the comparison of preoperative indexes between the ELAPE group and non-ELAPE group, including age, preoperative BMI, and gender. Similarly, there were no significant differences in abdominal operation time, total operation time, and the number of intraoperative lymph nodes dissected between the two groups. However, the perineal operation time, intraoperative blood loss, intraoperative perforation rate, and positive circumferential resection margin rate were significantly different between the two groups. In the comparison of postoperative indexes, perineal complications, postoperative hospital stay length, and IPSS score were significantly different between the two groups. The use of ELAPE in treating T3-4NxM0 phase low rectal cancer was superior to non-ELAPE in reducing intraoperative perforation rate, positive circumferential resection margin rate, local recurrence rate, etc.

Urogenital dysfunction after laparoscopic surgery for rectal or sigmoid colon cancer

BACKGROUND/OBJECTIVE

Urogenital dysfunction is a common complication after surgery for sigmoid colon or rectal cancers and may result from various causes. Herein, we evaluated urogenital dysfunction and the associated factors after laparoscopic surgery at different follow-up times.

METHODS

We conducted a prospective study on 91 patients who were diagnosed with sigmoid colon and rectal cancers and underwent laparoscopic surgery during 2014-2016. Voiding and male and female sexual dysfunctions following surgery were evaluated by the International Prostate Symptom Score (IPSS), International Index of Erectile Function-5 (IIEF-5), and Female Sexual Function Index-6 (FSFI-6), respectively. Urogenital function was compared at pre-surgery and 3 and 12 months postoperatively, and factors associated with urogenital dysfunction were identified.

RESULTS

The overall urinary function after surgery was better when compared to that at pre-surgery; however, there was deterioration in both male and female sexual functions. The mean preoperative IPSS, IIEF-5, and FSFI-6 scores were 9.35, 12.18, and 6.09, respectively. The mean differences among IPSS, IIEF-5, and FSFI-6 at 12 months postoperatively and pre-surgery were -3.08 (95% confidence interval [CI] -4.77 to -1.40), -2.57 (95% CI -4.33 to -0.80), and -2.58 (95% CI -4.73 to 0.42), respectively. Multivariate analysis demonstrated that age ≤60 years (odds ratio 4.22) and postoperative complications (odds ratio 2.77) were correlated with erectile dysfunction.

CONCLUSION

Voiding function improved after laparoscopic surgery in both sigmoid colon and rectal cancer patients. However, sexual function in both male and female patients was worse. Age ≤60 years and postoperative complications were strongly associated with male sexual dysfunction.

Identification of Risk Factors for Sexual Dysfunction after Multimodal Therapy of Locally Advanced Rectal Cancer and Their Impact on Quality of Life: A Single-Center Trial

PURPOSE

Sexual function is crucial for the quality of life and can be highly affected by preoperative therapy and surgery. The aim of this study was to identify potential risk factors for poor sexual function and quality of life.

METHODS

Female patients were asked to complete the Female Sexual Function Index (FSFI-6). Male patients were demanded to answer the International Index of Erectile Function (IIEF-5).

RESULTS

In total, 79 patients filled in the questionary, yielding a response rate of 41.57%. The proportion of women was represented by 32.91%, and the median age was 76.0 years (66.0-81.0). Sexual dysfunction appeared in 88.46% of female patients. Severe erectile dysfunction occurred in 52.83% of male patients. Univariate analysis showed female patients (OR: 0.17, 95%CI: 0.05-0.64, p = 0.01), older age (OR: 0.34, 95%CI 0.11-1.01, p = 0.05), tumor localization under 6cm from the anal verge (OR: 4.43, 95%CI: 1.44-13.67, p = 0.01) and extension of operation (APR and ISR) (OR: 0.13, 95%CI: 0.03-0.59, p = 0.01) as significant risk factors for poor outcome. Female patients (OR: 0.12, 95%CI: 0.03-0.62, p = 0.01) and tumors below 6 cm from the anal verge (OR: 4.64, 95%CI: 1.18-18.29, p = 0.03) were shown to be independent risk factors for sexual dysfunction after multimodal therapy in the multivariate analysis. Quality of life was only affected in the case of extensive surgery (p = 0.02).

CONCLUSION

Higher Age, female sex, distal tumors and extensive surgery (APR, ISR) are revealed risk factors for SD in this study. Quality of life was only affected in the case of APR or ISR.

Patient-Related Functional Outcomes After Robotic-Assisted Rectal Surgery Compared With a Laparoscopic Approach: A Systematic Review and Meta-analysis

BACKGROUND

Robotic surgery has gained significant momentum in rectal cancer surgery. Most studies focus on short-term and oncological outcomes, showing similar outcomes to laparoscopic surgery. Increasing survivorship mandates greater emphasis on quality of life and long-term function.

OBJECTIVE

This study aimed to compare quality of life and urinary, sexual, and lower GI functions between robotic and laparoscopic rectal surgeries.

DATA SOURCES

A systematic search of Medline, PubMed, Embase, Clinical Trials Register, and Cochrane Library-identified articles comparing robotic with laparoscopic rectal resections was performed.

MAIN OUTCOME MEASURES

The outcome measures were quality of life and urinary, sexual, and GI functions between robotic and laparoscopic rectal resection patient groups. Where comparable data were available, results were pooled for analysis.

RESULTS

The initial search revealed 1777 papers; 101 were reviewed in full, and 14 studies were included for review. Eleven assessed male sexual function; 7 favored robotic surgery, and the remaining studies showed no significant difference. Pooled analysis of 5 studies reporting rates of male sexual dysfunction at 12 months showed significantly lower rates after robotic surgery (OR, 0.51; p = 0.043). Twelve studies compared urinary function. Six favored robotic surgery, but in 2 studies, a difference was seen at 6 months but not sustained at 12 months. Pooled analysis of 4 studies demonstrated significantly better urinary function scores at 12 months after robotic surgery (OR, 0.26; p = 0.016). Quality of life and GI function were equivalent, but very little data exist for these parameters.

LIMITATIONS

A small number of studies compare outcomes between these groups; only 2 are randomized. Different scoring systems limit comparisons and pooling of data.

CONCLUSIONS

The limited available data suggest that robotic rectal cancer resection improves male sexual and urinary functions when compared with laparoscopy, but there is no difference in quality of life or GI function. Future studies should report all facets of functional outcomes using standardized scoring systems.

Functional Outcome of Laparoscopic-Assisted Resection Versus Open Resection of Rectal Cancer: A Secondary Analysis of the Australasian Laparoscopic Cancer of the Rectum Trial

BACKGROUND

Low anterior resection syndrome has a significant impact on the quality of life in rectal cancer survivors. Previous studies comparing laparoscopic to open rectal resection have neglected bowel function outcomes.

OBJECTIVE

This study aimed to assess whether there is a difference in the functional outcome between patients undergoing laparoscopic versus open resection for rectal adenocarcinoma.

DESIGN

Cross-sectional prevalence of low anterior resection syndrome was assessed in a secondary analysis of the multicenter phase 3 randomized clinical trial, Australasian Laparoscopic Cancer of the Rectum Trial (ACTRN12609000663257).

SETTING

There were 7 study subsites across New Zealand and Australia.

PATIENTS

Participants were adults with rectal cancer who underwent anterior resection and had bowel continuity.

MAIN OUTCOME MEASURES

Postoperative bowel function was evaluated using the validated low anterior resection syndrome score and Bowel Function Instrument.

RESULTS

The Australasian Laparoscopic Cancer of the Rectum Trial randomized 475 patients with T1-T3 rectal adenocarcinoma less than 15 cm from the anal verge. A total of 257 participants were eligible for, and invited to, participate in additional follow-up; 163 (63%) completed functional follow-up. Overall cross-sectional prevalence of major low anterior resection syndrome was 49% (minor low anterior resection syndrome 27%). There were no differences in median overall Bowel Function Instrument score nor low anterior resection syndrome score between participants undergoing laparoscopic versus open surgery (66 vs 67, p = 0.52; 31 vs 27, p = 0.24) at a median follow-up of 69 months.

LIMITATIONS

The major limitations are a result of conducting a secondary analysis; the likelihood of an insufficient sample size to detect a difference in prevalence between the groups and the possibility of selection bias as a subset of the randomized population was analyzed.

CONCLUSIONS

Bowel dysfunction affects a majority of rectal cancer patients for a significant time after the operation. In this secondary analysis of a randomized trial, surgical approach does not appear to influence the likelihood or severity of low anterior resection syndrome. See Video Abstract at http://links.lww.com/DCR/B794.

RESULTADO FUNCIONAL DE LA RESECCIN ASISTIDA POR LAPAROSCOPIA VERSUS RESECCIN ABIERTA EN CNCER DE RECTO ANLISIS SECUNDARIO DEL ESTUDIO DE CNCER DE RECTO LAPAROSCPICO DE AUSTRALASIA

ANTECEDENTES:El síndrome de resección anterior baja tiene un impacto significativo en la calidad de vida de los supervivientes de cáncer de recto. Los estudios anteriores que compararon la resección rectal laparoscópica con la abierta no han presentado resultados de la función intestinal.OBJETIVO:Evaluar si existe una diferencia en el resultado funcional entre los pacientes sometidos a resección laparoscópica versus resección abierta por adenocarcinoma de recto.DISEÑO:La prevalencia transversal del síndrome de resección anterior baja se evaluó en un análisis secundario del ensayo clínico aleatorizado multicéntrico de fase 3, Estudio Sobre el Cáncer de Recto Laparoscópico de Australasia (Australasian Laparoscopic Cancer of the Rectum Trial, ACTRN12609000663257).AJUSTE:Siete subsitios de estudio en Nueva Zelanda y Australia.PACIENTES:Los participantes eran adultos con cáncer de recto que se sometieron a resección anterior con anastomosis.PRINCIPALES MEDIDAS DE RESULTADO:La función intestinal posoperatoria se evaluó utilizando el previamente validado puntaje LARS y el Instrumento de Función Intestinal.RESULTADOS:El Estudio Sobre el Cáncer de Recto Laparoscópico de Australasia asignó al azar a 475 pacientes con adenocarcinoma rectal T1-T3 a menos de 15 cm del borde anal. 257 participantes fueron elegibles e invitados a participar en un seguimiento adicional. 163 (63%) completaron el seguimiento funcional. La prevalencia transversal general de LARS mayor fue del 49% (LARS menor 27%). No hubo diferencias en la puntuación media general del Instrumento de Función Intestinal ni en la puntuación LARS entre los participantes sometidos a cirugía laparoscópica versus cirugía abierta (66 frente a 67, p = 0,52; 31 frente a 27, p = 0,24) en una mediana de seguimiento de 69 meses.LIMITACIONES:Las principales limitaciones son el resultado de realizar un análisis secundario; se analizó la probabilidad de un tamaño de muestra insuficiente para detectar una diferencia en la prevalencia entre los grupos y la posibilidad de sesgo de selección como un subconjunto de la población aleatorizada.CONCLUSIONES:La disfunción intestinal afecta a la mayoría de los pacientes con cáncer de recto durante un tiempo significativo después de la operación. En este análisis secundario de un ensayo aleatorizado, el abordaje quirúrgico no parece influir en la probabilidad o gravedad del síndrome de resección anterior baja. Consulte Video Resumen en http://links.lww.com/DCR/B794. (Traducción-Dr. Felipe Bellolio).

Robotic surgery contributes to the preservation of bowel and urinary function after total mesorectal excision: comparisons with transanal and conventional laparoscopic surgery

BACKGROUND

Determine whether robotic surgery is more effective than transanal and conventional laparoscopic surgery in preserving bowel and urinary function after total mesorectal excision (TME).

METHODS

Of 79 lower rectal cancer patients who underwent function-preserving TME between 2016 and 2020, 64 patients consented to a prospective questionnaire-based functional observation study (52 responded). At 6 months post-resection or ileostomy closure, Wexner, low anterior resection syndrome (LARS), modified fecal incontinence quality of life, and international prostate symptom scores were used to evaluate bowel and urinary function, comparing robotic surgery (RTME) with transanal (taTME) or conventional laparoscopic surgery (LTME).

RESULTS

RTME was performed in 35 patients (54.7%), taTME in 15 (23.4%), and LTME in 14 (21.9%). While preoperative bowel/urinary functions were similar in all three procedures, and the distance from the anal verge to tumor was almost the same, more hand-sewn anastomoses were performed and the anastomotic height from the anal verge was shorter in taTME than RTME. At 2 years post-resection, 8 patients (12.5%) had a permanent stoma; RTME showed a significantly lower rate of permanent stoma than taTME (2.9% vs. 40%, p < 0.01). Despite no significant difference, all bowel function assessments were better in RTME than in taTME or LTME. Major LARS was observed in all taTME and LTME cases, but only 78.8% of RTME. No clear difference arose between RTME and taTME in urinary function; urinary dysfunction was more severe in LTME than RTME (36.4% vs. 6.1%, p = 0.02).

CONCLUSIONS

In function-preserving TME for lower rectal cancer, robotic surgery was suggested to be more effective than transanal and conventional laparoscopic surgery in terms of bowel and urinary functions.

Robotic rectal resection preserves anorectal function: Systematic review and meta-analysis

BACKGROUND

Improving survival rates in rectal cancer patients has generated a growing interest in functional outcomes after total mesorectal excision (TME). The well-established low anterior resection syndrome (LARS) score assesses postoperative anorectal impairment after TME. Our meta-analysis is the first to compare bowel function after open, laparoscopic, transanal, and robotic TME.

METHODS

All studies reporting functional outcomes after rectal cancer surgery (LARS score) were included, and were compared with a consecutive series of robotic TME (n = 48).

RESULTS

Thirty-two publications were identified, including 5 565 patients. Anorectal function recovered significantly better within one year after robotic TME (3.8 [95%CI -9.709-17.309]) versus laparoscopic TME (26.4 [95%CI 19.524-33.286]), p = 0.006), open TME (26.0 [95%CI 24.338-29.702], p = 0.002) and transanal TME (27.9 [95%CI 22.127-33.669], p = 0.003).

CONCLUSIONS

Robotic TME enables better recovery of anorectal function compared to other techniques. Further prospective, high-quality studies are needed to confirm the benefits of robotic surgery.

Sexual Dysfunction in Inflammatory Bowel Disease: What the Specialist Should Know and Ask

Inflammatory bowel disease (IBD) is a chronic condition that globally affects the health of people who suffer from it, deteriorating their quality of life (QoL). An aspect rarely explored by healthcare providers is the influence of the disease on the sexual functioning of individuals. This discretion is mainly due to an unconscious resistance when asking our patients about their sexual functioning because of a lack of knowledge and skills to tackle this topic or disinterest on the part of professionals, and fear or shame on the part of patients. Sexual function is a constant concern in IBD patients that has been reflected in several studies, especially if we consider that the prevalence of sexual dysfunction (SD) in IBD is higher than that reported in the general population. The etiology of SD in patients with IBD remains unclear but is likely to be multifactorial, where biological, psychosocial, and disease-specific factors are involved. Currently, there are no formal recommendations in the IBD clinical guidelines on how to manage SD in these patients. The use of validated clinical scales could improve the detection of SD and allow the treatment of the underlying causes in order to improve the QoL of patients with IBD. This review aims to illustrate the different aspects involved in SD in IBD patients and the importance of the participation of a multidisciplinary team in the early detection and treatment of SD at different stages of the disease.

Functional outcome and quality of life following treatment for rectal cancer

Introduction Over the last decades, treatment for rectal cancer has substantially improved with development of new surgical options and treatment modalities. With the improvement of survival, functional outcome and quality of life are getting more attention.

Study objective To provide an overview of current modalities in rectal cancer treatment, with particular emphasis on functional outcomes and quality of life.

Results Functional outcomes after rectal cancer treatment are influenced by patient and tumor characteristics, surgical technique, the use of preoperative radiotherapy and the method and level of anastomosis. Sphincter preserving surgery for low rectal cancer often results in poor functional outcomes that impair quality of life, referred to as low anterior resection syndrome. Abdominoperineal resection imposes the need for a permanent stoma but avoids the risk of this syndrome. Contrary to general belief, long-term quality of life in patients with a permanent stoma is similar to those after sphincter preserving surgery for low rectal cancer.

Conclusion All patients should be informed about the risks of treatment modalities. Decision on rectal cancer treatment should be individualized since not all patients may benefit from a sphincter preserving surgery “at any price”. Non-resection treatment should be the future focus to avoid the need of a permanent stoma and bowel dysfunction.

Male erectile function after treatment for colorectal cancer: a population-based cross-sectional study

AIM

The aim of this work was to determine the knowledge gap in the field of erectile function (EF) after colorectal cancer surgery and investigate and compare long-term male EF in colon and rectal cancer survivors in a national population.

METHOD

Danish male patients alive without evidence of recurrence who were treated for colon or rectal cancer between May 2001 and December 2014 were invited to participate. Using the International Index of Erectile Function (IIEF) score the derived dichotomized erectile dysfunction (ED) was defined as moderate/severe or no/mild. Patients were grouped based on type of surgery [colon resection, rectal resection (RR) or local resection] and stratified for stoma, preoperative radiotherapy (RT), age and American Society of Anesthesiologists (ASA) score.

RESULTS

Of 10 037 eligible patients, 4334 responded (43.18%). The EF score was significantly lower for RR (mean 12.14) compared with both colon resection (mean 15.82) and local resection (mean 14.81) (p < 0.0001). No significant difference between colon resection and local resection was found (p = 0.29). Both a stoma and the use of RT were independent risk factors for ED. After excluding patients with stoma and RT and adjusting for age and ASA score, RR still had a higher risk of ED (OR 1.42, CI 1.20-1.67) compared with colon resection.

CONCLUSION

RR has a negative affect on EF. No difference between patients who underwent colon resection and local resection was found. RT and stoma were independent risk factors for ED.

Robotic versus transanal total mesorectal excision in sexual, anorectal, and urinary function: a multicenter, prospective, observational study

PURPOSE

Improved long-term survival after low anterior resection (LAR) for rectal cancer highlights the importance of functional outcome. Urogenital and anorectal dysfunction is frequently reported after conventional LAR. Advanced minimally invasive techniques such as robotic (RoTME) and transanal total mesorectal excision (TaTME) might improve functional results by precisely dissecting and preserving autonomic nerves. We compared functional outcomes after RoTME or TaTME in a multicenter study.

METHODS

One hundred twenty patients (55 RoTME/65 TaTME) were prospectively included in four participating centers. Anorectal (Wexner and low anterior resection syndrome (LARS) Score), urinary (International Consultation on Incontinence-Male/Female Lower Urinary Tract Symptoms Score (ICIQ-MLUTS/ICIQ-FLUTS) and International Prostate Symptom Scale (IPSS)), and sexual (International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI)) outcomes at 12 months after surgery were compared to preoperative scores. The response rate to the 1-year postoperative functional assessment by questionnaire was 79.5%.

RESULTS

RoTME enabled better anorectal function compared to TaTME (LARS score 4.3 ± 2.2 vs. 9.8 ± 1.5, p = 0.038, respectively). TaTME proved superior at preserving male urinary function, while female urinary function was comparable in both groups, with only mild postoperative impairment (RoTME vs. TaTME, respectively: ICIQ-MLUTS 13.8 ± 4.9 vs. 1.8 ± 5.8, p = 0.038; ICIQ-FLUTS Incontinence Score - 0.3 ± 1.0 vs. - 0.2 ± 0.9, p = 0.844). Both techniques demonstrated comparable male (RoTME - 13.4 ± 2.7 vs. TaTME - 11.7 ± 3.4, p = 0.615) and female (RoTME 5.2 ± 4.6 vs. TaTME 10.5 ± 6.4, p = 0.254) sexual function.

CONCLUSION

After adjustment for risk factors, RoTME provided better anorectal functional results, whereas TaTME was better at preserving male urinary function. Overall, both techniques demonstrated only mild postoperative functional impairment.

Latest Advances in Intersphincteric Resection for Low Rectal Cancer

Background

Intersphincteric resection (ISR) has been a preferable alternative to abdominoperineal resection (APR) for anal preservation in patients with low rectal cancer. Laparoscopic ISR and robotic ISR have been widely used with the proposal of 2 cm or even 1 cm rule of distal free margin and the development of minimally invasive technology. The aim of this review was to describe the newest advancements of ISR.

Methods

A comprehensive literature review was performed to identify studies on ISR techniques, preoperative chemoradiotherapy (PCRT), complications, oncological outcomes, and functional outcomes and thereby to summarize relevant information and controversies involved in ISR.

Results

Although PCRT is employed to avoid positive circumferential resection margin (CRM) and decrease local recurrence, it tends to engender damage of anorectal function and patients' quality of life (QoL). Common complications after ISR include anastomotic leakage (AL), anastomotic stricture (AS), urinary retention, fistula, pelvic sepsis, and prolapse. CRM involvement is the most important predictor for local recurrence. Preoperative assessment and particularly rectal endosonography are essential for selecting suitable patients. Anal dysfunction is associated with age, PCRT, location and growth of anastomotic stoma, tumour stage, and resection of internal sphincter.

Conclusions

The ISR technique seems feasible for selected patients with low rectal cancer. However, the postoperative QoL as a result of functional disorder should be fully discussed with patients before surgery.

Laparoscopic Versus Open Extralevaor Abdominoperineal Excision for Lower Rectal Cancer: A Retrospective Cohort Study in Single Institute

Background: To explore the safety and efficacy of laparoscopic extralevator abdominoperineal excision (La-ELAPE) and open extralevator abdominoperineal excision (Op-ELAPE) for patients with lower rectal cancer. Materials and Methods: Consecutive 101 patients with lower rectal cancer who underwent La-ELAPE or Op-ELAPE in our institution from January 2014 and May 2018 were analyzed retrospectively. The patients' clinicopathological data and postoperative outcomes were compared between the two groups. Results: A total of 101 patients were enrolled in the study, 43 (42.6%) patients successfully underwent La-ELAPE and 58 (57.4%) Op-ELAPE. The Op-ELAPE group had more intraoperative blood loss (P = .03), and longer postoperative hospital stay (P = .01) compared with the La-ELAPE group. There were no significant differences between the two group in terms of the operation time (P = .08), circumferential resection margin positivity (P = 1.00), intraoperative perforation (P = .73), and number of positive lymph nodes (P = .91). There were no significant differences in postoperative complications such as colostomy-associated issues (P = .79), intestinal obstruction (P = 1.00), urinary retention (P = 1.00), perineal wound complications (P = .64), and chronic perineal pain (P = .70) between the two groups. According to the Kaplan-Meier survival analysis and log rank test, the overall survival rate and progression-free survival rate between the two groups also showed no significant difference. Conclusion: This study showed that La-ELAPE significantly reduced the intraoperative blood loss and the postoperative hospital stay without increasing postoperative morbidity for patients with lower rectal cancer when compared with Op-ELAPE. It suggests that La-ELAPE is safe and effective for patients with lower rectal cancer. For the experienced endoscopic surgeons, the La-ELAPE might be an alternative surgical treatment.

Men With Inflammatory Bowel Disease: Sexual Function, Fertility, Medication Safety, and Prostate Cancer

Half of patients with inflammatory bowel disease (IBD) are men, yet less attention has been focused on their sexual issues despite higher rates of sexual dysfunction and infertility than the general population. Depression and IBD disease activity are the most consistently reported risk factor for sexual dysfunction among men with IBD. Methotrexate and sulfasalazine have been rarely associated with impotence. Sulfasalazine reversibly reduces male fertility. No other medications used in IBD significantly affect fertility in humans. There is no increase in adverse fetal outcomes among offspring of fathers with IBD. Patients with IBD seem to be at a higher risk for prostate cancer; therefore, screening as recommended for high-risk patients should be considered.

Oncofertility in adult and pediatric populations: options and barriers

Cancer and its treatments can affect fertility in a variety of ways, and recent advances in cancer detection and treatment have led to an increasing number of cancer survivors for whom future fertility is a primary concern. Oncofertility is the study of interactions between cancer, anti-cancer therapy, fertility, and reproductive health. Fertility preservation aims to optimize fertility potential before initiation of gonadotoxic therapies. Sperm cryopreservation from an ejaculated sample is the gold standard for adults and post-pubertal adolescents, though added maneuvers such as medical therapy, penile vibratory stimulation, and electroejaculation can be employed when appropriate. When all these approaches fail, testicular sperm extraction can be used to obtain and cryopreserve testicular sperm from the azoospermic patient. Fertility preservation in the pre-pubertal pediatric patient is still experimental, but recent scientific breakthroughs with use of spermatogonial stem cells and testicular tissue transplantation offer great promise for the future. While there may be several practical, cultural, religious, and other barriers to fertility preservation, the establishment of a dedicated fertility preservation team can help to overcome these obstacles and optimize the utilization of fertility preservation in cancer patients of all ages.

Comparison of preoperative and postoperative sexual function in patients with deeply infiltrating endometriosis with and without bowel resection

OBJECTIVE

To analyze preoperative and postoperative sexual function following surgery for deeply infiltrating endometriosis (DIE) with and without bowel involvement.

STUDY DESIGN

Patients with DIE who underwent surgery between 2001 and 2011 with segmental bowel resection (WB) or without segmental bowel resection (WOB) were surveyed using the German version of the Massachusetts General Hospital Sexual Functioning Questionnaire (KFSP). Responses were given on a six-point scale for the items sexual interest, sexual arousal, orgasm, lubrication, and general sexual satisfaction. As there are no cut-off values for the existence of sexual function disorders, a control group with no history of endometriosis was evaluated. Differences between the preoperative and postoperative results, as well as between WB, WOB, and a control group, were compared using the Wilcoxon test, Mann-Whitney U test, and Fisher's exact test.

RESULTS

Eighty-nine patients without bowel resection (mean age 34.3 years; mean follow-up 63.2 months), 87 patients with bowel resection (mean age 37.7 years; mean follow-up 69.6 months), and 100 control patients aged 21-58 years (mean age 35.0 years) were evaluated. Preoperatively, both treatment groups had significantly poorer scores in all categories in comparison with the control group. The WOB group improved significantly in all categories postoperatively, with no further significant differences from the control group. No significant postoperative improvement was observed in the WB group, and the group had significantly poorer scores in comparison with the control group. The number of previous operations is associated with significantly poorer postoperative KFSP results. Sterility and age > 40 years are associated with significantly less improvement in the KFSP, although with lower initial values.

CONCLUSIONS

Patients with DIE with or without bowel involvement have significantly impaired sexual function preoperatively. Complete resection of endometriosis in the WOB group was able to improve sexual function, as the women had sexual scores similar to those in the healthy control group postoperatively. Possible explanations for the lack of postoperative improvement of sexual function after segmental bowel resection include the type of surgery carried out, or injury to the affected nerves resulting from the endometriosis.

Analysis of Clinical Efficiency and Safety of Laparoscopic Anus-Conserving Operation for Ultralow Rectal Cancer

To explore the efficiency and safety of laparoscopic anus-conserving operation for ultralow rectal cancer, we retrospectively reviewed 236 patients with ultralow rectal cancer who underwent laparoscopic anus-conserving operation (experimental group, n = 124) or conventional open surgery (control group, n = 112). Operation-related indexes, pathological results of mesentery, incidence rates of postoperative complications, anus preservation rates, anal sphincter controllability after surgery, and survival rates of the first, second, and third years after operation were compared between the two groups. The amount of intraoperative bleeding, first postoperative exhaust time, abdominal drainage, pain score, and hospital stay in the experimental group were significantly less than those in the control group ( P < 0.05). There were no significant differences in the postoperative circumferential resection margin, distal resection margin, number of dissected lymph nodes, successful resection rate, and quality of mesorectum between the two groups ( P > 0.05). The total incidence rate of postoperative complications, anal sphincter controllability, and survival rates after surgery were similar between the two groups ( P > 0.05). The anus preservation rate of the experimental group (84.7%) was significantly higher than that of the control group (69.6%) ( P < 0.05). Laparoscopic anus-conserving operation is effective and safe in treatment of patients with ultralow rectal cancer, which has advantages such as small trauma, less intra-operative bleeding, short hospital stay, rapid recovery, a low incidence rate of postoperative complications, and a high anus-preserving rate, so it is worthy of clinical application.

Survival outcome of adjuvant radiotherapy after local excision for T2 early rectal cancer: An analysis based on the surveillance, epidemiology, and end result registry database

BACKGROUND

Major resection (MR) is recommended for cases with T2 finding after local excision (LE) of early rectal cancer, but the revision procedure is accompanied with high morbidity. We evaluated the oncological safety of LE followed by adjuvant radiotherapy as a rectum-preserving alternative to MR for T2 early rectal cancer.

METHODS

A total of 3786 patients with T2N0M0 rectal adenocarcinoma between 1998 and 2013 were included from the SEER database. Survival rates were compared using the Kaplan-Meier method with a log-rank test, and multivariate analyses were performed using Cox proportional regression models.

RESULTS

Of these patients included, 429 (11.3%) treated with LE alone (LE group), 3067 (81.0%) treated with MR (MR group), and 290 (7.7%) treated with LE followed by adjuvant radiotherapy (LE + adjuvant RT group). The 5-year cancer specific survival (CSS) rate and 5-year overall survival (OS) rate were significantly lower in LE patients group than those in MR patients group (70.5% vs. 81.8%, P < 0.001; 57.3% vs. 72.3%, P < 0.001). The 5-year CSS rate and 5-year OS rate were similar between LE + adjuvant RT and MR groups (78.4% vs. 81.8%, P = 0.975, and 70.7% vs. 72.3%, P = 0.311, respectively). Multivariate Cox regression revealed that treatment strategies, age and CEA status were independently associated with CSS and OS. After age adjustment, LE was associated with reduced CSS (using MR as a reference, HR, 1.784; P < 0.001) and reduced OS (HR, 1.739; P < 0.001). However, CSS and OS related to LE + adjuvant RT of T2 rectal cancer group weren't be affected (HR, 0.994; P = 0.962 and HR, 0.904; P = 0.302, respectively).

CONCLUSIONS

When MR is inappropriate for T2 early rectal cancer patients because of patients refusal or co-morbidities, LE + adjuvant RT can provide acceptable levels of long-term survival.

Defunctioning ileostomy and mechanical bowel preparation may contribute to development of low anterior resection syndrome

INTRODUCTION

Laparoscopic surgery is an approved technique in colorectal cancer treatment. Functional and quality-of-life studies have revealed significant changes in faecal continence.

AIM

To assess the incidence and risk factors of low anterior resection syndrome (LARS) in patients undergoing rectal resections for cancer.

MATERIAL AND METHODS

We enrolled patients undergoing rectal resections in a general surgery department of a university hospital. The primary outcomes were the Jorge-Wexner scale and the LARS score 6 months after the end of treatment. The secondary outcomes were the risk factors for LARS development.

RESULTS

Fifty-six patients were included; 15 (26%) developed major LARS and 10 (18%) had minor LARS at 6 months. In univariate analysis the risk factors were: preoperative radiotherapy (p < 0.001, OR = 11.9, 95% CI: 2.98-47.48); shorter distance of the tumour from the anal verge (p = 0.001, OR = 0.69, 95% CI: 0.55-0.86); bowel preparation (p = 0.01, OR = 6.27, 95% CI: 1.51-26.07); low anterior rectal resection (p = 0.01, OR = 17.07, 95% CI: 1.86-156.83); and protective ileostomy (p = 0.001, OR = 15.97, 95% CI: 4.07-61.92). The risk factors for a higher Jorge-Wexner score in univariate analysis were greater diameter of tumour (p = 0.035), radiotherapy (p = 0.001), shorter distance from the anal verge (p = 0.002), bowel preparation (p = 0.042), low anterior rectal (LAR) (p = 0.01), ileostomy (p = 0.001), perioperative complications (p = 0.032), and readmission within 30 days (p = 0.034). In the multivariate analysis, readmissions and perioperative complications were significant.

CONCLUSIONS

In addition to typically described risk factors, two new ones have been identified. Mechanical bowel preparation and defunctioning ileostomy may also contribute to LARS development. However, due to the limitations of this study our observations require further confirmation in future trials.

Perioperative radiotherapy is an independent risk factor for major LARS: a cross-sectional observational study

PURPOSE

Sphincter-preserving surgery for rectal cancer is often associated with low anterior resection syndrome (LARS). The aim of our study was to determine the prevalence of LARS in our institution and identify possible risk factors for LARS. Furthermore, we evaluated which of the LARS symptoms was considered most disabling by patients and whether or not there is an adaptation of the LARS score over time.

METHODS

This study includes a prospective database of 100 patients who underwent total or partial mesorectal excision between January 2009 and September 2014. Patients were contacted after a median postoperative time of 38 (5-45) months to determine the LARS score and to identify LARS symptoms that were considered most disabling. Uni- and multivariate regression analysis was performed to identify risk factors for LARS and major LARS. Finally, the LARS score was evaluated over time after restoration of bowel continuity.

RESULTS

Out of the 100 patients, 16 had minor LARS (score 21-29) and 51 patients had major LARS (score 30-42). Radiotherapy was an independent risk factor for major LARS (p = 0.04). For the majority of patients with major LARS (22%), fragmentation was considered the most disabling complaint. There was no correlation between interval after restoration of bowel continuity and the severity of the LARS score.

CONCLUSIONS

Perioperative radiotherapy is an independent risk factor for major LARS. Fragmentation is considered the most disabling complaint in the majority of patients with major LARS. There is no significant adaptation of the LARS score over time.

Gastro-intestinal surgery and fertility

In France, 10 to 15% of couples in the overall population have a fertility problem. Preservation of sexual and reproductive function should be a major concern for all patients capable of procreation who undergo treatment for gastro-intestinal disease. The gastro-intestinal diseases most often responsible for fertility disorders include chronic inflammatory diseases, intestinal cancer and hereditary diseases, such as the Lynch syndrome and familial adenomatous polyposis. Obesity is responsible for a 20% loss of fertility but the effects of bariatric surgery on fertility are controversial. Nonetheless, in the light of progress in surgical techniques and better knowledge of gastro-intestinal disease the negative impact of surgery on fertility warrants attention. Effectively, fertility can be preserved after certain major gastro-intestinal operations such as cytoreductive surgery with intraperitoneal chemotherapy, total coloprotectomy with ileo-anal anastomosis and rectosigmoid resection, as long as the patient's age permits and resection of the reproductive organs is not necessary.

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.

Genito-urinary sequelae after carcinological rectal resection: What to tell patients in 2017

Although we have seen revolutionary changes with multi-disciplinary management of patients with rectal cancer, the evaluation of genito-urinary sequelae remains of great concern. Precise pre-operative evaluation with validated scores allows detection of urinary disorders in 16 to 23% of patients, and sexual disorders in nearly 35% of men and 50% of women. Regardless of the surgical approach, it is fundamental to respect the autonomic innervation during total mesorectal excision in order to prevent these sequelae. Identification of these nerves can be facilitated by intra-operative neuro-stimulation. In spite of these precautions, de novo urinary sequelae are observed in nearly 33% of patients and bladder evacuation disorders in 25% of patients. Advanced age, pre-operative urinary disorders, female gender, and abdomino-perineal resection are independent risk factors for urinary sequelae. Early post-operative urodynamic abnormalities might be predictive of these sequelae and justify early physiotherapy. Likewise, sexual sequelae such as erectile and/or ejaculatory disorders, dyspareunia and lubrication deficits result in de novo cessation of sexual activity in 28% of men and 18% of women. Advanced age, neo-adjuvant radiation therapy, and abdomino-perineal resection are independent risk factors for sexual dysfunction. Pharmacotherapy with sildenafil has proven useful in the treatment of erectile disorders. Genito-urinary and ano-rectal sequelae occur concomitantly in more than one of ten patients, suggesting a potential common pathophysiology.

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.

Critical analysis of the literature investigating urogenital function preservation following robotic rectal cancer surgery

AIM

To analyses the current literature regarding the urogenital functional outcomes of patients receiving robotic rectal cancer surgery.

METHODS

A comprehensive literature search of electronic databases was performed in October 2015. The following search terms were applied: “rectal cancer” or “colorectal cancer” and robot* or “da Vinci” and sexual or urolog* or urinary or erect* or ejaculat* or impot* or incontinence. All original studies examining the urological and/or sexual outcomes of male and/or female patients receiving robotic rectal cancer surgery were included. Reference lists of all retrieved articles were manually searched for further relevant articles. Abstracts were independently searched by two authors.

RESULTS

Fifteen original studies fulfilled the inclusion criteria. A total of 1338 patients were included; 818 received robotic, 498 laparoscopic and 22 open rectal cancer surgery. Only 726 (54%) patients had their urogenital function assessed via means of validated functional questionnaires. From the included studies, three found that robotic rectal cancer surgery leads to quicker recovery of male urological function and five of male sexual function as compared to laparoscopic surgery. It is unclear whether robotic surgery offers favourable urogenital outcomes in the long run for males. In female patients only two studies assessed urological and three sexual function independently to that of males. In these studies there was no difference identified between patients receiving robotic and laparoscopic rectal cancer surgery. However, in females the presented evidence was very limited making it impossible to draw any substantial conclusions.

CONCLUSION

There seems to be a trend towards earlier recovery of male urogenital function following robotic surgery. To evaluate this further, larger well designed studies are required.

Comparative analysis focusing on surgical and early oncological outcomes of open, laparoscopy-assisted, and robot-assisted approaches in rectal cancer patients

PURPOSE

Because there are few comparative studies of open, laparoscopy-assisted (LA), and robot-assisted (RA) total mesorectal excision (TME) for rectal cancer, we aimed to compare these three procedures in terms of sphincter-saving operation (SSO) achievement, surgical complications, and early oncological outcomes.

METHODS

The short-term outcomes of 2114 patients with rectal cancer consecutively enrolled between July 2010 and February 2015 at Asan Medical Center (Seoul, Korea) were retrospectively evaluated. Patients underwent either open, LA, or RA TME (n = 1095, 486, and 533, respectively) performed by experienced surgeons.

RESULTS

RA TME was a significant determinant of SSO in multivariate analysis that included potential variables such as tumor location and T4 category (odds ratio, 2.458; 95 % confidence interval, 1.497-4.036; p < 0.001). The cumulative rates of 3-year local recurrence, overall survival, and disease-free survival did not differ among the three groups: 2.5-3.4, 91.9-94.6, and 82.2-83.1 % (p = 0.85, 0.352, and 0.944, respectively). Early general surgical complications occurred more frequently in the open group than in the LA and RA groups (19.3 versus 13.0 versus 12.2 %, p < 0.001), specifically ileus and wound infection.

CONCLUSIONS

There were no significant differences in 3-year survival outcomes and local recurrence among open, LA, and RA TME. RA TME is useful for SSO achievement, regardless of advanced stage and location of rectal cancer. The open procedure had a slightly but significantly higher incidence of postoperative complications than LA and RA.

Management of postoperative bladder emptying after proctectomy in men for rectal cancer. A retrospective study of 190 consecutive patients

PURPOSE

Evaluation of urinary drainage after rectal resection and identification of criteria associated with postoperative urinary dysfunction (UD). UD remains a clinical problem for up to two thirds of patients after rectal resection. Currently, there are no guidelines concerning duration or type of drainage.

METHODS

One hundred ninety consecutive rectal resections (abdomino-perineal resection (APR = 47), mechanical coloanal anastomosis (MechCAA = 48), manual coloanal anastomosis (ManCAA = 47), colorectal anastomosis (CRA = 48)) in male patients were included. In patients with a transurethral catheterization (TUC), the drainage was removed at day 5. Patients with a suprapubic catheterization (SPC) underwent drainage removal according to the results of a clamping test at day 5. UD was defined as drainage removal after day 6 and/or acute urinary retention (AUR).

RESULTS

Drainage types were SPC (n = 136, 72%) and TUC (n = 54, 28%). SPC was used more frequently after total mesorectal excision (TME) (APR, ManCAA, MechCAA) (83-92%). Complications rates of SPC and TUC were 20 and 9%. The clamping test was positive for 61 patients (48%), and SPC was removed before/on POD6 without any episode of AUR. After TUC removal, two patients (4%) had AUR. Seventy-two (38%) patients had UD: 11 (6%) were discharged with an indwelling catheter, and in 61 (32%), the catheter was removed after day6. Three independent factors were associated with UD: diabetes (OR = 2.9 (1.2-7.7)), urological history (OR = 2.9 (1.2-7.6)), and TME (OR = 5.2 (2.3-13.5)).

CONCLUSION

The UD rate after surgery for rectal cancer was 38%. The clamping test is accurate to prevent AUR after SPC removal. The three risk factors may serve to select good candidates for early catheter removal.

Does robotics improve minimally invasive rectal surgery? Functional and oncological implications

OBJECTIVE

Robot-assisted surgery has been reported to be a safe and effective alternative to conventional laparoscopy for the treatment of rectal cancer in a minimally invasive manner. Nevertheless, substantial data concerning functional outcomes and long-term oncological adequacy is still lacking. We aimed to assess the current role of robotics in rectal surgery focusing on patients' functional and oncological outcomes.

METHODS

A comprehensive review was conducted to search articles published in English up to 11 September 2015 concerning functional and/or oncological outcomes of patients who received robot-assisted rectal surgery. All relevant papers were evaluated on functional implications such as postoperative sexual and urinary dysfunction and oncological outcomes.

RESULTS

Robotics showed a general trend towards lower rates of sexual and urinary postoperative dysfunction and earlier recovery compared with laparoscopy. The rates of 3-year local recurrence, disease-free survival and overall survival of robotic-assisted rectal surgery compared favourably with those of laparoscopy.

CONCLUSIONS

This study fails to provide solid evidence to draw definitive conclusions on whether robotic systems could be useful in ameliorating the outcomes of minimally invasive surgery for rectal cancer. However, the available data suggest potential advantages over conventional laparoscopy with reference to functional outcomes.

Laparoscopic surgery: A qualified systematic review

AIM: To review current applications of the laparoscopic surgery while highlighting the standard procedures across different fields.

METHODS: A comprehensive search was undertaken using the PubMed Advanced Search Builder. A total of 321 articles were found in this search. The following criteria had to be met for the publication to be selected: Review article, randomized controlled trials, or meta-analyses discussing the subject of laparoscopic surgery. In addition, publications were hand-searched in the Cochrane database and the high-impact journals. A total of 82 of the findings were included according to matching the inclusion criteria. Overall, 403 full-text articles were reviewed. Of these, 218 were excluded due to not matching the inclusion criteria.

RESULTS: A total of 185 relevant articles were identified matching the search criteria for an overview of the current literature on the laparoscopic surgery. Articles covered the period from the first laparoscopic application through its tremendous advancement over the last several years. Overall, the biggest advantage of the procedure has been minimizing trauma to the abdominal wall compared with open surgery. In the case of cholecystectomy, fundoplication, and adrenalectomy, the procedure has become the gold standard without being proven as a superior technique over the open surgery in randomized controlled trials. Faster recovery, reduced hospital stay, and a quicker return to normal activities are the most evident advantages of the laparoscopic surgery. Positive outcomes, efficiency, a lower rate of wound infections, and reduction in the perioperative morbidity of minimally invasive procedures have been shown in most indications.

CONCLUSION: Improvements in surgical training and developments in instruments, imaging, and surgical techniques have greatly increased safety and feasibility of the laparoscopic surgical procedures.

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.

Organ preservation in rectal cancer: current status and future perspectives

With the introduction of population screening initiatives, more patients may be amenable to local, transanal excision (LE) of early-stage rectal cancer. The most important drawback of LE is the risk of understaging node-positive disease. The most powerful predictors of node-positive disease are lymphatic invasion, submucosal invasion depth and width, tumor budding and poor differentiation. Therefore, LE should be reserved for low-risk T1 tumors in those reluctant or unable to undergo major surgery. Neoadjuvant chemoradiation followed by LE for T2 tumors allows adequate local control, and is currently being compared with anterior resection alone in randomized trials. A mere watchful waiting approach has been proposed in clinical complete responders to chemoradiation. However, given the very poor accuracy of current imaging modalities to predict a true pathological complete response, this strategy should not be offered outside of well-controlled trials.

Short-course radiotherapy with delayed surgery versus conventional chemoradiotherapy: A comparison of the short- and long-term outcomes in patients with T3 rectal cancer

INTRODUCTION

The aim of this study was to compare the short- and long-term outcomes between short-course radiotherapy with delayed surgery (SRT-delay) and a standard conventional chemoradiotherapy (CRT) regimen.

METHODS

Two collaborating institutions adopted different regimens; the SRT-delay regimen was selected by Meiwa Hospital and the CRT regimen was selected by Hyogo College of Medicine. The inclusion criteria were T3 middle and low rectal cancer patients treated with radical surgery after preoperative therapy. The median follow-up period was 44 months (range, 12-85).

RESULTS

From 2007 to 2013, 104 patients were treated using the SRT-delay regimen and 61 patients were treated using the CRT regimen. The pretreatment characteristics of the 2 groups were not significantly different. The sphincter-preserving rate (93.3%, 85.2%), T downstaging (37.5%, 37.7%), ypN(-) (74.0%, 67.2%), postoperative complications and the bowel, and urinary and sexual functioning of the SRT-delay regimen were noninferior to those of the CRT regimen. The 3-year local recurrence-free survival, recurrence-free survival, and overall survival in the SRT-delay and CRT groups were 90.6% and 90.6% (P = .764), 83.8% and 78.3% (P = .687) and 96.0% and 92.8% (P = .833), respectively.

CONCLUSION

The SRT-delay regimen was noninferior in terms of the downstaging effect, and oncologic and functional outcomes compared with the CRT regimen for T3 middle and low rectal cancer.