Risk factors for sexual dysfunction after rectal cancer treatment

Factors associated with sexual dysfunction in patients with colorectal cancer in Iran: a cross-sectional study

Sexual dysfunction is a prevalent issue among individuals diagnosed with colorectal cancer (CRC), significantly impacting their quality of life. However, limited research has explored the factors associated with sexual dysfunction in CRC patients in Iran. This cross-sectional study aimed to identify the demographic factors that may contribute to sexual dysfunction in this population. A cross-sectional study involving CRC patients was conducted from April 1, 2022, to May 1, 2022, in Tabriz, Iran. Ethical approvals were obtained, and convenience sampling was employed at outpatient chemotherapy centers in five Tabriz hospitals. Validated questionnaires, including participants characteristics form, the Female Sexual Function Index (FSFI) for females and International Index of Erectile Function (IIEF) for males, were utilized. Data were analyzed using IBM SPSS Statistics version 24, employing descriptive statistics and stepwise linear regression to assess association between mentioned factors and sexual function. Among 256 participants, 50.4% were males, 49.6% were females, and 80.5% were married. The predominant age range was 50-60 years. The study findings revealed a high prevalence of sexual dysfunction among both female (Mean ± SD: 10.91 ± 8.67, Min-Max: 3.20-33.00) and male (Mean ± SD: 27.64 ± 16.28, Min-Max: 11-62) CRC patients. Factors such as the presence of a colostomy for FSFI (P < 0.001), type of treatment received for both FSFI and IIEF (P < 0.001), type of housing for both FSFI and IIEF (P < 0.001), occupation for FSFI (P < 0.001), presence of other diseases for FSFI (P = 0.047), and time since the last chemotherapy session for FSFI (P = 0.018), Education for IIEF (P = 0.026), and Age for IIEF (P = 0.002) were identified as significant factors of sexual dysfunction. These demographic factors demonstrated varying effects on sexual function, underscoring the complexity of this issue. The results underscore the significance of addressing sexual health concerns in CRC patients and highlight the necessity for tailored interventions to enhance their overall well-being. Healthcare providers should recognize the influence of demographic factors on sexual function and contemplate integrating sexual health assessments and interventions into the care of CRC patients. Further research is needed to comprehend better the underlying mechanisms and devise effective strategies for managing sexual dysfunction in this population.

Adoption of Total Neoadjuvant Therapy in the Treatment of Locally Advanced Rectal Cancer

Local and metastatic recurrence are primary concerns following the treatment of locally advanced rectal cancer (LARC). Chemoradiation (CRT) can reduce the local recurrence rates and has subsequently moved to the neoadjuvant setting from the adjuvant setting. Pathological complete response (pCR) rates have also been noted to be greater in patients treated with neoadjuvant CRT prior to surgery. The standard approach to treating LARC would often involve CRT followed by surgery and optional adjuvant chemotherapy and remained the treatment paradigm for almost two decades. However, patients were often unable to complete adjuvant chemotherapy due to a decreased tolerance of chemotherapy following surgery, which led to upfront treatment with both CRT and chemotherapy, and total neoadjuvant therapy, or TNT, was created. The efficacy outcomes of local recurrence, disease-free survival, and pCR have improved in patients receiving TNT compared to the standard approach. Additionally, more recent data suggest a possible improvement in overall survival as well. Patients with a complete clinical response following TNT have the opportunity for watch-and-wait surveillance, allowing some patients to undergo organ preservation. Here, we discuss the clinical trials and studies that led to the adoption of TNT as the standard of care for LARC, with the possibility of watch-and-wait surveillance for patients achieving complete responses. We also review the possibility of overtreating some patients with LARC.

Sexual dysfunction among early-onset colorectal cancer survivors: Sex-specific correlates of sexual health discussions between patients and providers

PURPOSE

To examine the prevalence of female sexual dysfunction (FSD), male erectile dysfunction (ED), and the prevalence and correlates of sexual health discussions between early-onset CRC survivors and their health care providers.

METHODS

An online, cross-sectional survey was administered in partnership with a national CRC advocacy organization. Respondents (n = 234; diagnosed < 50 years, 6-36 months from diagnosis/relapse) were colon (36.8%) and rectal (63.3%) cancer survivors (62.5% male). The Female Sexual Function Index (FSFI-6) was used to measure FSD, and the International Index of Erectile Function (IIEF-5) was used to measure ED. Survivors reported whether a doctor communicated with them about sexual issues during/after treatment.

RESULTS

Among females (n = 87), 81.6% had FSD (mean FSFI-6 score = 14.3 [SD±6.1]). Among males (n = 145), 94.5% had ED (mean IIEF-5 score = 13.6 [SD±3.4]). Overall, 59.4% of males and 45.4% of females reported a sexual health discussion. Among the total sample, older age of diagnosis and relapse were significantly associated with reporting a discussion, while female sex was negatively associated with reporting a sexual health discussion. Among males, older age at diagnosis and relapse, and among females, older age of diagnosis, were significantly associated with reporting a sexual health discussion.

CONCLUSION

The prevalence of FSD and ED were high (8 in 10 females reporting FSD, almost all males reporting ED), while reported rates of sexual health discussion were suboptimal (half reported discussion). Interventions to increase CRC provider awareness of patients at risk for not being counseled are needed to optimize long-term health outcomes.

Evaluation of Depression, Anxiety, and Sexual Function in Rectal Cancer Patients Before and After Neoadjuvant Chemoradiotherapy

OBJECTIVE

The association of treatment-related side effects and tumor characteristics with sexual function, depression, and anxiety were investigated in patients with locally advanced rectum cancer (LARC) receiving neoadjuvant chemoradiotherapy (CRT).

MATERIAL AND METHODS

Thirty-two patients who received neoadjuvant CRT with LARC were included. The Arizona Sexual Experiences (ASEX) Scale was used to determine the sexual function status whereas the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) were used to evaluate the depression and anxiety status of the patient, respectively. The patients were asked to fill these scales before and at least 4 weeks after the neoadjuvant CRT. T-test and Mann-Whitney U test were used for the comparison of values.

RESULTS

Median age was 52.5 years (range: 33-76). Twenty-six patients were male, and 6 patients were female. At presentation, the tumor was located mostly in lower third rectum (72%), and 69% of the patients had T3 tumors. There was a statistically significant deterioration in the sexual functions of the patients (p < 0.001), a statistically significant decrease in their anxiety level after CRT (p: 0.037). Depression level was changed from mild to minimal during this process (p: 0.17). A significant deterioration in the ASEX scale was observed especially in patients with grade 2 and above gastrointestinal side effects (p: 0.01).

CONCLUSION

This prospective study showed that the patient's anxiety and depression levels had decreased during the treatment process probably due to the decrease in the patient's symptoms. However, deterioration of the sexual function status which might be correlated to increased gastrointestinal side effects during CRT has been observed. So, clinical and psychiatric support including therapies for sexual dysfunctions is needed for LARC patients during and after the neoadjuvant CRT.

Gender Differences in Psychosocial Outcomes and Coping Strategies of Patients with Colorectal Cancer: A Systematic Review

(1) Background: Gender is an important factor impacting cancer experience. This review mainly aimed to summarize colorectal cancer (CRC) patients' gender differences in psychosocial outcomes and coping strategies. (2) Methods: Relevant studies were searched for in four electronic databases from 2007 to July 2023. And manual searching was performed on the included studies' reference lists to identify additional eligible studies. (3) Results: A total of 37 eligible articles were included in this review. These studies were conducted in 19 countries, and they targeted CRC patients at various treatment stages. Significant results showed that female patients tended to have more psychological distress, complex social functioning, and less sexual distress and to choose more positive coping strategies than male patients. But there was no gender difference in psychosocial outcomes and/or coping strategies in some studies, which implied that gender similarity also existed. (4) Conclusions: The findings support the fact that there are both gender differences and similarities in CRC patients' psychosocial outcomes and coping strategies. A perspective beyond the simple masculine-feminine binary improved our in-depth understanding of gender tendency. Importantly, taking gender tendency into account is critical for medical staff to provide more personalized support and communication interventions.

Comparison of sexual function of people with colorectal cancer with and without colostomy bag in Iran: a comparative cross-sectional study

The aim of this study was to investigate and compare sexual function in individuals with colorectal cancer, with and without a colostomy bag. A quantitative, descriptive-comparative design was employed, and a cluster random sampling method was used to recruit 252 patients with colorectal cancer. Data collection tools included a participants characteristics form, the International Index of Erectile Function (IIEF) for men, and the Female Sexual Function Index (FSFI) for women. The mean IIEF total score for men with a colostomy was 26.17 ± 15.30, and for men without a colostomy, it was 29.05 ± 17.14. The mean FSFI total score for women with a colostomy was 6.40 ± 7.21, and for women without a colostomy, it was 9.10 ± 14.67. There was no statistically difference in IIEF scores between men with and without colostomy bags (p > 0.05). However, women with colostomy bags had significantly lower FSFI scores compared to women without colostomy bags (p < 0.05). Addressing sexual concerns in individuals with colorectal cancer is crucial for enhancing their sexual well-being and overall quality of life. Comprehensive support, timely interventions, and targeted services are essential to help patients navigate the challenges and improve their overall well-being.

Patient perspectives on consequences of resection for colorectal cancer: A qualitative study

BACKGROUND

Colorectal cancer is diagnosed in approximately 500,000 patients each year in Europe, leading to a high number of patients having to cope with the consequences of resection for colorectal cancer. As treatment options tend to grow, more information on the effects of these treatments is needed to engage in shared decision-making. This study aims to explore the impact of resection for colorectal cancer on patients' daily life.

METHODS

Patients (≥18 years of age) who underwent an oncological colorectal resection between 2018 and 2021 were selected. Purposeful sampling was used to include patients who differed in age, comorbidity conditions, types of (neo)adjuvant therapy, postoperative complications and the presence/absence of a stoma. Semi-structured interviews were conducted, guided by a topic guide. Interviews were fully transcribed and subsequently thematically analysed using the framework approach. Analyses were carried out using the following predefined themes: (1) daily life and activities; (2) psychological functioning; (3) social functioning; (4) sexual functioning; and (5) healthcare experiences.

RESULTS

Sixteen patients with a follow-up period of between 0.6 and 4.4 years after surgery were included in this study. Participants reported several challenges experienced because of poor bowel function, a stoma, chemotherapy-induced neuropathy, fear of recurrence and sexual dysfunction. However, they reported these as not interfering much with daily life.

CONCLUSION

Colorectal cancer treatment leads to several challenges and treatment-related health deficits. This is often not recognized by generic patient-reported outcome measures, but the findings on treatment-related health deficits presented in this study contain valuable insights which might contribute to improving colorectal cancer care, shared decision making and value-based health care.

Advances in diagnosis and treatment of low anterior resection syndrome

Rectal cancer is one of the most common cancers. As much as 90% of patients with low rectal cancer complain of increased frequency of defecation, fecal incontinence, and evacuation problems after surgery, which is termed as low anterior resection syndrome (LARS). LARS detrimentally affects the quality of life for patients with rectal cancer. In this paper, we review the pathogenesis, risk factors, assessment tools, and treatment strategies for LARS.

Protective effect of laparoscopic functional total mesorectal excision on urinary and sexual functions in male patients with mid-low rectal cancer

BACKGROUND

Urinary and sexual dysfunctions are among the most common complications in rectal cancer surgery. This study aimed to investigate the protective effect of laparoscopic functional total mesorectum excision (TME) on urinary and sexual functions in male patients.

METHODS

A total of 248 male patients with mid-low rectal cancer were recruited in this study between February 2017 and July 2020. To overcome selection bias, we performed a 1:1 match using six variables, including age, BMI, ASA score, tumor distance, clinical T stage, and tumor size. The urinary function was assessed by the International Prostate Symptom Score (IPSS), sexual function was assessed by a 5-item version of the International Index of Erectile Function (IIEF-5) and ejaculation grading at postoperative 3 and 12 months.

RESULTS

79 patients received functional TME surgery (FTME group), and 169 patients received routine TME surgery (RTME group). After the propensity score, 79 pairs were balanced and analyzed. Patients in the FTME group showed a lower IPSS score and higher IIEF-5 score than patients in the RTME group at postoperative 3 and 12 months. The incidence of ejaculation dysfunction for patients in the FTME group was lower than patients in the RTME group at postoperative 3 and 12 months.

CONCLUSION

Laparoscopic functional total mesorectal excision was beneficial to faster recovery of urinary and sexual function for patients with rectal cancer, and it could be used as a superior surgical technique for pelvic autonomic nerve preservation in mid-low rectal cancer.

Essential updates 2020/2021: Advancing precision medicine for comprehensive rectal cancer treatment

In the paradigm shift related to rectal cancer treatment, we have to understand a variety of new emerging topics to provide appropriate treatment for individual patients as precision medicine. However, information on surgery, genomic medicine, and pharmacotherapy is highly specialized and subdivided, creating a barrier to achieving thorough knowledge. In this review, we summarize the perspective for rectal cancer treatment and management from the current standard-of-care to the latest findings to help optimize treatment strategy.

Impact of radiotherapy on bone health in women with rectal cancer - A prospective cohort study

INTRODUCTION

Pelvic radiotherapy (RT) increases the risk of pelvic insufficiency fractures. The aim was to investigate if RT is associated with changes in serum bone biomarkers in women with rectal cancer, and to examine the incidence of radiation-induced bone injuries and the association with bone biomarkers.

MATERIAL AND METHODS

Women diagnosed with rectal cancer stage I-III, planned for abdominal surgery ± preoperative (chemo) RT, were prospectively included and followed one year. Serum bone biomarkers comprised sclerostin (regulatory of bone formation), CTX (resorption), BALP and PINP (formation). A subgroup was investigated with annual pelvic magnetic resonance imaging (MRI). The association between RT and bone biomarkers was explored in regression models.

RESULTS

Of 134 included women, 104 had surgery with preoperative RT. The formation markers BALP and PINP increased from baseline to one year in the RT-exposed group (p < 0.001, longitudinal comparison). In the adjusted regression analysis, the mean increase in PINP was higher in the RT-exposed than the unexposed group (17.6 (3.6-31.5) μg/L, p = 0.013). Sclerostin and CTX did not change within groups nor differed between groups. Radiation-induced injuries were detected in 16 (42%) of 38 women with available MRI. At one year, BALP was higher among women with than without bone injuries (p = 0.018, cross-sectional comparison).

CONCLUSIONS

Preoperative RT was associated with an increase in the formation marker PINP, which could represent bone recovery following RT-induced injuries, commonly observed in participants evaluated with MRI. These findings should be further explored in larger prospective studies on bone health in rectal cancer patients.

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.

Short-term outcomes of robotic-assisted surgery following neoadjuvant chemotherapy for lower rectal cancer

INTRODUCTION

There have been reports about robotic surgery for rectal cancer with chemoradiotherapy (CRT), but only a few studies have compared the use of robotic surgery with and without neoadjuvant chemotherapy (NAC). The aim of our study was to compare the perioperative outcomes of robotic surgery with and without NAC for lower rectal cancer and to examine the effects of NAC on robotic surgery.

METHODS

From January 2016 to July 2021, we compared the short-term outcomes of 45 patients who did not undergo NAC and 55 patients who underwent NAC.

RESULTS

The rate of sphincter-preserving surgeries was higher in the NAC group than in the non-NAC group (P = .024). The total operative time was significantly longer in the NAC group than in the non-NAC group (P < .001). The rate of lateral lymph node dissection was significantly higher in the NAC group than in the non-NAC group (P < .001). No significant differences were identified in the rate of incisional surgical site infections (SSI), organ/space SSI postoperative bleeding, small bowel obstruction, anastomotic leakage, urinary dysfunction, or urinary infections between the groups. There were eight incidences of lateral lymph node metastasis (15%) and two cases with positive resection margins (4.0%) in the NAC group.

CONCLUSIONS

Robotic surgery after NAC has few complications and a higher sphincter-preserving rate that without NAC.

Sexual Functioning in Female Patients Undergoing Surgical Treatment for Colorectal Cancer-A Single-Center, Prospective Triple Timepoint Yearly Follow-Up

The study was aimed at assessing the quality of sexual functioning in female patients having undergone surgical treatment for cancer depending on the type of surgery. The prospective cohort consisted of 48 female patients (23 patients with stoma [A2] and 25 patients with maintained continuity of the GI tract [A1]). Study methods included a diagnostic survey and the analysis of medical records of patients. Research tools consisted of a standardized FSFI questionnaire and a proprietary form for evaluation of sociodemographic data. Measurements were performed at threetimepoints: On the day before the surgery (Measurement I) as well as six and 12 months after the surgery (Measurements II and III, respectively). Statistically significant differences in results were observed in Measurements II and III in the subscales of arousal (II:p = 0.0068, III:p = 0.0018), lubrication (II:p = 0.0221, III:p = 0.0134), orgasm (II:p = 0.0044, III:p = 0.0021), satisfaction (II:p = 0.0021, III:p = 0.0433), and pain/discomfort (II:p = 0.0343, III:p = 0.0473). In all cases, lower scores corresponding to lower quality of sexual functioning were observed in patients in whom stoma had been performed. Statistically significant differences in sexual functioning were observed at Measurements II and III in each group, with the results being significantly (p > 0.05) worse in patients having undergone Hartmann’s procedure or abdominoperineal resection). Variables significantly affecting self-assessed sexual satisfaction included marital status, age, and modality of neoadjuvant treatment. Restoration of the continuity of the gastrointestinal tract is a chance for better self-assessment of the patient’s quality of life as regards sexual functioning.

A Prospective Multicenter Phase II Study on the Feasibility and Efficacy of S-1 and Oxaliplatin Neoadjuvant Chemotherapy for Locally Advanced Rectal Cancer

BACKGROUND

Neoadjuvant chemoradiotherapy and total mesorectal excision compose the standard of care for rectal cancer in multiple guidelines. However, neoadjuvant chemoradiotherapy has not exhibited clear survival benefits but rather has led to an increase in adverse events. Conversely, neoadjuvant chemotherapy is expected to prevent adverse events caused by radiation, yet this treatment is still controversial.

OBJECTIVE

The purpose of this study was to evaluate the feasibility and efficacy of S-1 and oxaliplatin neoadjuvant chemotherapy together with total mesorectal excision for resectable locally advanced rectal cancer.

DESIGN

The study was a prospective, single-arm phase II trial.

SETTINGS

The study was conducted at multiple institutions.

PATIENTS

Fifty-eight patients with resectable locally advanced rectal cancer were enrolled.

INTERVENTION

Three cycles of S-1 and oxaliplatin were administered before surgery. S-1 was administered orally at 80 mg/m2 per day for 14 consecutive days, followed by a 7-day resting period. Oxaliplatin was given intravenously on the first day at a dose of 130 mg/m2 per day. The duration of 1 cycle was considered to be 21 days. Total mesorectal excision with bilateral lymph node dissection was carried out after neoadjuvant chemotherapy.

MAIN OUTCOME MEASURES

The study was designed to detect the feasibility and efficacy of S-1 and oxaliplatin as neoadjuvant chemotherapy.

RESULTS

The completion rate of 3 courses of S-1 and oxaliplatin as neoadjuvant chemotherapy was 94.8% (55/58). The reasons for discontinuation were thrombocytopenia (3.4%) and liver injury (1.7%). The most common severe (grade ≥3) adverse effect of neoadjuvant chemotherapy was thrombocytopenia (3.4%). There were no severe adverse clinical symptoms. Consequently, R0 resection was achieved in 51 (98.1%) of 52 patients. Pathologic complete response occurred in 10 patients (19.2%).

LIMITATIONS

This was a single-arm, nonrandomized phase II study.

CONCLUSIONS

The combination of S-1 and oxaliplatin neoadjuvant chemotherapy and total mesorectal excision is a feasible and promising treatment option for resectable locally advanced rectal cancer. See Video Abstract at http://links.lww.com/DCR/B555.

UN ESTUDIO PROSPECTIVO MULTICNTRICO FASE II SOBRE LA FACTIBILIDAD Y EFICACIA DE LA QUIMIOTERAPIA NEOADYUVANTE SCON OXALIPLATINO PARA EL CNCER DE RECTO LOCALMENTE AVANZADO

ANTECEDENTES:La quimiorradioterapia neoadyuvante y la escisión mesorrectal total constituyen el estándar de atención para el cáncer de recto en varias guías. Sin embargo, la quimiorradioterapia neoadyuvante no ha mostrado beneficios claros en la sobrevida, pero si ha creado un aumento de eventos adversos. Por otro lado, se espera que la quimioterapia neoadyuvante prevenga los eventos adversos asociados a la radiación, aunque este tratamiento sigue siendo controvertido.OBJETIVO:Evaluar la factibilidad y eficacia de la quimioterapia neoadyuvante S-1 con oxaliplatino en conjunto con la escisión mesorrectal total para el cáncer de recto localmente avanzado resecable.DISEÑO:El estudio fue un ensayo prospectivo fase II de brazo único.AMBITO:Estudio realizado en múltiples instituciones.PACIENTES:Se incluyeron 58 pacientes con cáncer de recto localmente avanzado resecable.INTERVENCIÓN:Se administraron tres ciclos de S-1 con oxaliplatino antes de la cirugía. Se administró S-1 por vía oral a 80 mg / m2 / día durante 14 días consecutivos, seguido de un período de descanso de 7 días. El oxaliplatino se administró por vía intravenosa el primer día a una dosis de 130 mg / m2 / día. Se consideró la duración de un ciclo de 21 días. Posterior a la quimioterapia neoadyuvante se realizó la excisión total mesorrectal con disección ganglionar bilateral.PRINCIPALES VARIABLES EVALUDADAS:El estudio fue diseñado para conocer la factibilidad y eficacia de S-1 con oxaliplatino como quimioterapia neoadyuvante.RESULTADOS:La tasa de conclusión con tres ciclos de S-1 con oxaliplatino como quimioterapia neoadyuvante fue del 94,8% (55/58). Los motivos de interrupción fueron trombocitopenia (3,4%) y daño hepático (1,7%). El efecto adverso grave más común (grado ≥ 3) de la quimioterapia neoadyuvante fue la trombocitopenia (3,4%). No hubo síntomas clínicos adversos graves. Como resultado, la resección R0 se logró en 51 de 52 pacientes (98,1%). Una respuesta patológica completa se obtuvo en 10 pacientes (19,2%).LIMITACIONES:Fue un estudio de fase II no aleatorizado de un solo brazo.CONCLUSIONES:La combinación de S-1 con oxaliplatino como quimioterapia neoadyuvante y escisión mesorrectal total es factible y es una opción de tratamiento prometedora para el cáncer de recto localmente avanzado resecable. Consulte Video Resumen en http://links.lww.com/DCR/B555. (Traducción-Dr Juan Antonio Villanueva-Herrero).

Functional outcomes after lateral pelvic lymph node dissection for rectal cancer: a systematic review and meta-analysis

PURPOSE

Lateral pelvic lymph node dissection (LPLND) may improve oncological outcomes for select patients with rectal cancer, though functional outcomes may be adversely impacted. The aim of this study is to assess the functional outcomes associated with LPLND for rectal cancer and compare these outcomes with standard surgical resection.

METHODS

A systematic search was undertaken to identify relevant studies reporting on urinary dysfunction (UD), sexual dysfunction (SD), and defecatory dysfunction (DD) for patients who underwent LPLND for rectal cancer. Studies comparing functional outcomes in patients who underwent surgery with and without LPLND were assessed. In addition, a comparison of functional outcomes in patients who underwent LPLND before and after the year 2000 was performed.

RESULTS

Twenty-one studies of predominantly non-randomised observational data were included. Ten were comparative studies. Male SD was worse in patients who underwent LPLND compared with those who did not (RR 1.68 (95% CI 1.41-1.99, P < 0.001)). No difference was observed for the rate of UD between treatment groups. The rates of UD and male SD in patients who underwent LPLND after the year 2000 were significantly lower than those who underwent LPLND before the year 2000 ((UD) RR = 4.5, p value = 0.0034; male SD RR = 28.7, p value < 0.001).

CONCLUSION

Lateral pelvic lymph node dissection is associated with worse male sexual dysfunction compared to standard surgical resection. However, the rates of urine dysfunction and male sexual dysfunction are better in contemporary cohorts which may reflect improved surgical technique and autonomic nerve preservation.

Cumulative 5-year Results of a Randomized Controlled Trial Comparing Biological Mesh With Primary Perineal Wound Closure After Extralevator Abdominoperineal Resection (BIOPEX-study)

OBJECTIVE

To determine long-term outcomes of a randomized trial (BIOPEX) comparing biological mesh and primary perineal closure in rectal cancer patients after extralevator abdominoperineal resection and preoperative radiotherapy, with a primary focus on symptomatic perineal hernia.

SUMMARY BACKGROUND DATA

BIOPEX is the only randomized trial in this field, which was negative on its primary endpoint (30-day wound healing).

METHODS

This was a posthoc secondary analysis of patients randomized in the BIOPEX trial to either biological mesh closure (n = 50; 2 dropouts) or primary perineal closure (n = 54; 1 dropout). Patients were followed for 5 years. Actuarial 5-year probabilities were determined by the Kaplan-Meier statistic.

RESULTS

Actuarial 5-year symptomatic perineal hernia rates were 7% (95% CI, 0-30) after biological mesh closure versus 30% (95% CI, 10-49) after primary closure (P = 0.006). One patient (2%) in the biomesh group underwent elective perineal hernia repair, compared to 7 patients (13%) in the primary closure group (P = 0.062). Reoperations for small bowel obstruction were necessary in 1/48 patients (2%) and 5/53 patients (9%), respectively (P = 0.208). No significant differences were found for chronic perineal wound problems, locoregional recurrence, overall survival, and main domains of quality of life and functional outcome.

CONCLUSIONS

Symptomatic perineal hernia rate at 5-year follow-up after abdominoperineal resection for rectal cancer was significantly lower after biological mesh closure. Biological mesh closure did not improve quality of life or functional outcomes.

Fertility and sexual dysfunction in young male cancer survivors

Background

Newly emerging serious post‐treatment complications among young male cancer survivors involve fertility and sexual function, preventing them from pursuing a normal family life.

Methods

We studied and summarized published studies that assess the relationship between cancer treatments and reduced spermatogenesis or sexual dysfunction.

Main findings

Infertility often occurs because of anticancer therapies that impair spermatogenesis. While some patients postremission functionally recover fertility, others experience a decreased sperm count and azoospermia. Fertility‐preserving modalities are currently being promoted worldwide to preserve spermatogenesis following cancer therapy. Patients who can ejaculate and have sperm in their semen should cryopreserve semen. However, for patients who have never ejaculated before puberty or in whom spermatogenesis has not been established, testis biopsy is performed to collect and preserve sperm or germ cells. Fertility preservation is gaining popularity and requires continuous information dissemination to oncologists and cancer treatment professionals. Furthermore, male sexual dysfunction predominantly involves erectile dysfunction and ejaculation disorder.

Conclusion

Although preventive and therapeutic methods for these disorders have been established within urology, patients and medical professionals in other fields remain uninformed of these advances. Therefore, dissemination of information regarding fertility preservation techniques should be accelerated.

Sexual health and wellbeing among female pelvic cancer survivors following individualized interventions in a nurse-led clinic

PURPOSE

Treatment-induced sexual and intestinal dysfunctions coexist among women after pelvic radiotherapy. We aimed to explore if sexual health and wellbeing may be improved after radiotherapy following nurse-led interventions and if an association exists between improved intestinal health and sexual health.

METHODS

A population-based cohort of women treated with pelvic radiotherapy underwent interventions at a nurse-led clinic at Sahlgrenska University Hospital, Sweden, from 2011 to 2017. Self-reported questionnaires were used, pre- and post-intervention, to compare self-reported changes in sexual health and wellbeing. A regression model was performed to explore the association between intestinal and wellbeing variables.

RESULTS

Among the 260 female pelvic cancer survivors included in the study, more women reported increased than decreased satisfaction with overall sexual health post-intervention (26.0% vs. 15.3%, p = 0.035). They also reported significantly reduced superficial genital pain (25.8% vs. 13.1%, p ≤ 0.025), reduced deep genital pain (23.1% vs. 8.0%, p ≤ 0.001), increased QoL (42.7% vs. 22.4%, p < 0.001), and reduced levels of depression (43.1% vs. 28.0%, p = 0.003) or anxiety (45.9% vs. 24.4%, p < 0.001) post-intervention. We found a significant association between reduced urgency to defecate and improved satisfaction with overall sexual health (RR 3.12, CI 1.27-7.68, p = 0.004) and between reduced urgency to defecate with fecal leakage and reduced anxious mode (RR 1.56, CI 1.04-2.33, p = 0.021).

CONCLUSION

Sexual health and wellbeing can be improved by interventions provided in a nurse-led clinic focusing on physical treatment-induced late effects. Further research to optimize treatment strategies in female pelvic cancer survivors is needed.

Functional outcomes after sphincter-preserving surgeries for low-lying rectal cancer: A review

Sphincter preservation and organ restoration during rectal cancer surgery avoids permanent stoma creation and diminishes psychosocial damages. However, decreased rectal volumes and sphincter dysfunction—including pelvic nerve damage—results in low anterior resection syndrome, as well as urinary and sexual dysfunction after rectal resection. Bowel habit changes such as fecal incontinence, fecal urgency, frequent bowel movements, clustered stools, and difficulties in bowel emptying can be treated using medications, pelvic floor rehabilitation, sacral neuromodulation, or neorectal reservoir reconstruction. Pelvic nerve damage resulting from superior and inferior hypogastric plexi during sphincter-preserving rectal cancer surgery can induce urologic and sexual dysfunctions. Preoperative voiding difficulty, perioperative blood loss, and autonomic nerve injury are considered independent risk factors for postoperative urinary dysfunction. Retrograde ejaculation and erectile dysfunction, female dyspareunia, and vaginal dryness are manifestations of sexual dysfunction resulting from autonomic nerve injury during rectal cancer surgery. Multifactorial causes for functional outcomes after sphincter- preserving surgeries are considered to improve patient’s quality of life with acceptable oncologic outcomes in the treatment of rectal cancer patients.

Low anterior resection syndrome: can it be prevented?

Surgery remains the cardinal treatment in colorectal cancers but changes in bowel habits after rectal cancer surgery are common and disabling conditions that affect patients' quality of life. Low anterior resection syndrome is a disorder of bowel function after rectal resection resulting in a lowering of the QoL and recently has been defined by an international working group not only by specified symptoms but also by their consequences. This review aims to explore an extensive bibliographic research on preventive strategies for LARS. All "modifiable variables," quantified by the LARS Score, such as type of anastomosis, neoadjuvant therapy, surgical strategy, and diverting stoma, were evaluated, while "non-modifiable variables" such as age, sex, BMI, ASA, preoperative TMN, tumor height, and type of mesorectal excision were excluded from the comparative analysis. The role of defunctioning stoma, local excision, neoadjuvant radiotherapy, and non operative management seems to significantly affect risk of LARS, while type of anastomosis and surgical TME approach do not impact on LARS incidence or gravity in the long term period. Although it is established that some variables are associated with a greater onset of LARS, in clinical practice, technical difficulties and oncological limits often make difficult the application of some prevention plans. Transtomal irrigations, intraoperative neuromonitoring, pelvic floor rehabilitation before stoma closure, and early transanal irrigation represent new arguments of study in preventive strategies which could, if not eliminate the symptoms, at least mitigate them.

Fluorescence-guided surgery in colorectal cancer; A review on clinical results and future perspectives

BACKGROUND

Colorectal cancer is the fourth most diagnosed malignancy worldwide and surgery is one of the cornerstones of the treatment strategy. Near-infrared (NIR) fluorescence imaging is a new and upcoming technique, which uses an NIR fluorescent agent combined with a specialised camera that can detect light in the NIR range. It aims for more precise surgery with improved oncological outcomes and a reduction in complications by improving discrimination between different structures.

METHODS

A systematic search was conducted in the Embase, Medline and Cochrane databases with search terms corresponding to 'fluorescence-guided surgery', 'colorectal surgery', and 'colorectal cancer' to identify all relevant trials.

RESULTS

The following clinical applications of fluorescence guided surgery for colorectal cancer were identified and discussed: (1) tumour imaging, (2) sentinel lymph node imaging, (3) imaging of distant metastases, (4) imaging of vital structures, (5) imaging of perfusion. Both experimental and FDA/EMA approved fluorescent agents are debated. Furthermore, promising future modalities are discussed.

CONCLUSION

Fluorescence-guided surgery for colorectal cancer is a rapidly evolving field. The first studies show additional value of this technique regarding change in surgical management. Future trials should focus on patient related outcomes such as complication rates, disease free survival, and overall survival.

Long-term quality of life, sexual health and gastrointestinal function following colorectal cancer resection in an Asian cohort

AIM

As populations age and cancer management improves, long-term survivorship and quality-of-life (QOL) outcomes are becoming equally important as oncological results. Data from Asian populations are scarce. We aimed to evaluate the sexual health, gastrointestinal function and QOL amongst colorectal cancer survivors in a tertiary referral centre in Singapore.

METHOD

Adults who had undergone elective curative surgery for non-metastatic colorectal cancer at least 2 years prior were included. Exclusion criteria were cognitive disease, serious postoperative complications or recurrent cancer. Participants were invited to complete the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires EORTC-QLQ-C30 and QLQ-CR29. Using multiple bivariate analysis, r scores were used to examine relationship trends between QOL domains and survivor sociodemographic and disease-specific characteristics.

RESULTS

From February 2017 to July 2019, 400 responses were recorded. Median age and follow-up duration were 64 years (range 32-90) and 78 months (interquartile range 49-113) respectively. Patients who had Stage III cancer had better overall QOL scores compared to Stage I/II. Rectal (vs. colon) cancer negatively influenced sexual health and gastrointestinal function, but did not appear to affect overall QOL. Amongst our cohort, 57% (n = 129) of men and 43% (n = 75) of women were sexually active. Markers of socioeconomic status, including employment, education and housing type, were found to significantly impact perception of various aspects of QOL.

CONCLUSION

Knowledge of factors which influence well-being can identify individuals who may benefit from tailored management strategies. Regular patient-doctor contact may play a role in building and maintaining positive perspectives of cancer survivors. Normative data should be obtained from local populations to facilitate future comparative research.

Impact of Androgens on Sexual Function in Women With Rectal Cancer - A Prospective Cohort Study

BACKGROUND

Women treated for rectal cancer are at risk of sexual dysfunction and impaired ovarian androgen production.

AIM

To investigate a possible association between serum levels of endogenous androgens and sexual function in women with rectal cancer.

METHODS

Women diagnosed with stage I-III rectal cancer were consecutively included and prospectively followed with the Female Sexual Function Index (FSFI) questionnaire from baseline to 2 years postoperatively and blood samples for hormone analyses, baseline to 1 year. Androgens were measured with liquid chromatography-mass spectrometry and electrochemiluminescence. The associations between the 4 measured androgens (testosterone, free testosterone, androstenedione, and dehydroepiandrosterone sulphate) and sexual function were assessed with generalized least squares random effects regression analysis in sexually active women.

OUTCOMES

The primary outcome measure was the mean change observed in the FSFI total score when the serum androgen levels changed with one unit. Secondary outcomes were the corresponding mean changes in the FSFI domain scores: sexual desire, arousal, lubrication, orgasm, satisfaction, and pain/discomfort.

RESULTS

In the 99 participants, the median FSFI total score decreased from 21.9 (range 2.0 - 36.0) to 16.4 (3.5 - 34.5) and 11.5 (2.0 to 34.8) at 1 and 2-years follow-up. After adjustment for age, partner, psychological well-being, preoperative (chemo)radiotherapy, and surgery, total testosterone and androstenedione were significantly associated with FSFI total score (β-coefficients 3.45 (95% CI 0.92 - 5.97) and 1.39 (0.46 - 2.33) respectively). Testosterone was significantly associated with the FSFI-domains lubrication and orgasm, free testosterone with lubrication, androstenedione with all domains except desire and satisfaction, and dehydroepiandrosterone sulphate with none of the domains.

STRENGTHS AND LIMITATIONS

This is the first study investigating whether androgen levels are of importance for the impaired sexual function seen in women following rectal cancer treatment. The prospective design allows for repeated measures and the use of the FSFI for comparisons across studies. No laboratory data were collected at the 2-year follow-up, and the missing data could have further clarified the studied associations.

CONCLUSION AND CLINICAL IMPLICATION

Testosterone and androstenedione were associated with sexual function in female rectal cancer patients. The results are of interest for future intervention studies and contribute to the understanding of sexual problems, which is an essential component of the rehabilitation process in pelvic cancer survivors. Svanström Röjvall A, Buchli C, Flöter Rådestad A, et al. Impact of Androgens on Sexual Function in Women With Rectal Cancer - A Prospective Cohort Study. J Sex Med 2021;18:1374-1382.

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.

Intraoperative neuromonitoring in rectal cancer surgery: a systematic review and meta-analysis

PURPOSE

The aim of this study is to evaluate the role of pelvic intraoperative neuromonitoring (pIONM) in rectal cancer surgery.

METHODS

A systematic review of the literature and a meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Overall, nine studies were identified. Quantitative analysis was performed only in three trials. Bilateral pIONM improved postoperative anorectal and urogenital functional outcomes. However, unilateral pIONM displayed a significant effect only on erectile function (p = 0.001).

CONCLUSIONS

Our findings suggest a positive effect of pIONM on postoperative functional outcomes and quality of life after rectal cancer surgery. Due to several limitations, further trials are required in order to elucidate the exact role of pIONM.

Optimizing outcomes of colorectal cancer surgery with robotic platforms

Advanced robotic technology makes it easier to perform total mesorectal excision procedures in the narrow pelvis for rectal cancer while maintaining the advantages of minimally invasive surgery. Robotic surgery for rectal cancer leads to lower conversion rates and faster recovery of urogenital function than conventional laparoscopic surgery. However, longer operative time and high cost are major weaknesses of robotic surgery. To date, most other short-term surgical outcomes, pathologic outcomes, and long-term oncologic outcomes of robotic surgery have not shown significant advantages over laparoscopic surgery. However, robotic surgery is still a valid and highly anticipated surgical approach for rectal cancer because it greatly reduces the surgeon's workload and learning curve. There are also advantages when robotic techniques are applied to technically demanding procedures such as lateral pelvic lymph node dissection or intersphincteric resection. The introduction of new surgical robot systems, including the da Vinci® SP system, is expected to expand the applications of robotic surgery and provide new advantages.

Risk factors for sexual dysfunction after rectal cancer surgery in 948 consecutive patients: A prospective cohort study

BACKGROUND

Sexual dysfunctions seriously affect the quality of life of patients. The aim of this study was to identify the risk factors for sexual dysfunction after rectal cancer surgery.

METHODS

A total of 948 consecutive patients undergoing rectal cancer radical resection were included between January 2012 and August 2019. The sexual functions were evaluated by the 5-item version of the International Index of Erectile Function (IIEF-5) in men and Index of Female Sexual Function (IFSF) in women at 12 months postoperatively.

RESULTS

Postoperative sexual dysfunction was observed in 228 patients with rectal cancer (24.05%), which included 150 cases in male patients (25.0%) and 78 cases in female patients (22.5%). A multivariate logistic regression analysis results showed that age ≥45 years old (OR = 1.72, p = 0.001), tumor below the peritoneal reflection (OR = 1.64, p = 0.005), receiving preoperative radiotherapy (OR = 4.12, p < 0.001) and undergoing abdominoperineal resection (APR), intersphincteric resection (ISR) and Hartmann surgery (OR = 2.43, p < 0.001) were the independent risk factors of sexual dysfunction for patients with rectal cancer.

CONCLUSION

Age ≥45 years old, tumors below the peritoneal reflection, receiving preoperative radiotherapy, and undergoing APR, ISR and Hartmann surgery were the independent risk factors of sexual dysfunction. Patients should be informed about the sexual dysfunctions in the pre-operative consultations. More attention should be paid to intraoperative pelvic autonomic nerve preservation on rectal cancer patients with these risk factors for clinic surgeons.

State of Recovery 6 Months After Rectal Cancer Surgery: Postoperative Symptoms and Differences With Regard to Surgical Procedure

Rectal cancer surgery has developed to be highly technological and precise. Nevertheless, postoperative symptoms can affect patients for a long time after surgery and might also be persistent. The purpose of this study was to describe the level of postoperative symptoms 6 months after rectal cancer surgery as well as differences in symptoms with regard to surgical procedure. Data from 117 patients recovering from rectal cancer surgery were collected 6 months after surgery using the Postoperative Recovery Profile (PRP) questionnaire measuring self-reported postoperative symptoms. Results showed that the majority of patients had no or mild problems with the 19 symptoms recorded in the questionnaire. There was a significant difference between surgical procedures: patients after anterior resection experienced mild problems in gastrointestinal function (physical domain) and interest in their surroundings (social domain), whereas most patients after abdominoperineal resection and abdominoperineal resection with myocutaneous flap showed no problems. In all groups, a considerably high proportion of patients reported severe problems in sexual activity (physical domain). Findings in this study emphasize that healthcare professionals should pay attention to patients recovering from anterior resection especially regarding problems in the gastrointestinal function. Moreover, there is a need to acknowledge eventual sexual dysfunctions in all rectal cancer patients.

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.

Effective dissection for rectal cancer with lateral lymph node metastasis based on prognostic factors and recurrence type

PURPOSE

There are no reports showing the significance and effective range of dissection for patients with lateral lymph node metastasis (LLNM). This study aimed to investigate the indications for lateral lymph node dissection (LLND) in patients with LLNM based on prognostic factors and recurrence types.

METHODS

We reviewed 379 patients with advanced rectal cancer who were treated with total mesorectal excision plus LLND. We analyzed background factors and survival times of patients who had LLNM to determine prognostic factors and recurrence types.

RESULTS

Pathological LLNM occurred in 44 (11.6%). Among patients with LLNM, the predictors of poor prognoses, according to univariate analysis, were > 3 node metastases, the presence of node metastasis on both sides, and spreading beyond the internal iliac lymph nodes. Moreover, LLNM beyond the internal iliac region was found to be an independent prognostic risk factor. Twenty-eight of the 44 patients with lateral lymph node metastasis (64%) relapsed, 22 of whom had distant metastases and 11 of whom experienced local recurrences. Among the latter group, nine (20%) and two (5%) had recurrences in the central and lateral pelvis, respectively.

CONCLUSION

The therapeutic benefit of resection was high, especially in patients with ≤ 3 positive lateral lymph nodes, one-sided bilateral lymph node areas, and positive nodes localized near the internal iliac artery.

PDE-5i Management of Erectile Dysfunction After Rectal Surgery: A Systematic Review Focusing on Treatment Efficacy

Erectile dysfunction (ED) is one of the main functional complications of surgical resections of the rectum due to rectal cancers or inflammatory bowel disease (IBD). The present systematic review aimed at revising ED management strategies applied after rectal resections and their efficacy in terms of improvement of the International Index of Erectile Function (IIEF) score. A literature search was conducted on Medline, EMBASE, Scopus, and Cochrane databases by two independent reviewers following the PRISMA guidelines. Randomized and nonrandomized controlled trials (RCTs, NRCTs), case-control studies, and case series evaluating medical or surgical therapies for ED diagnosed after rectal surgery for both benign and malignant pathologies were eligible for inclusion.

Out of 1028 articles initially identified, only five met the inclusion criteria: two RCTs comparing oral phosphodiesterase type-5 inhibitor (PDE-5i) versus placebo; one NRCT comparing PDE-5i versus PDE-5i + vacuum erection devices (VEDs) versus control; and two before-after studies on PDE-5i. A total of 253 (82.7%) rectal cancer patients and 53 (17.3%) IBD patients were included. Based on two RCTs, PDE-5i significantly improved IIEF compared to placebo at 3 months (SMD = 1.07; 95% CI [0.65, 1.48]; p < .00001; I² = 39%). Improved IIEF was also reported with PDE-5i + VED at 12 months. There is a paucity of articles in the literature that specifically assess efficacy of ED treatments after rectal surgery. Many alternative treatment strategies to PDE-5is remain to be investigated. Future studies should implement standardized preoperative, postoperative, and follow-up sexual function assessment in patients undergoing rectal resections.

Quality of life in Mexican colorectal cancer patients: analysis with sociodemographic, medical, and psychological variables

In this study, we evaluated the influence of sex, age, clinical stage, and colostomy/ileostomy variables on the quality of life of Mexican patients with colorectal cancer. Using a descriptive cross-sectional design, 192 colorectal cancer patients were included in the study. Significant differences were observed in emotional functioning between patients with rectal cancer and those with colon cancer. Presence of colostomy/ileostomy was associated with significantly impaired social functioning. Body image was significantly different based on gender and diagnosis. Likewise, significant differences were observed with respect to symptoms of the general and specific quality of life modules for colorectal cancer: these included significant difference between male and female patients with respect to taste; significant difference between rectal and colon cancer with respect to presence of blood and mucous in stool, urinary incontinence, and buttock pain; and significant difference between patients with and without colostomy/ileostomy with respect to constipation, stool frequency, sore skin, and embarrassment. We observed significant correlation of dimensions of the quality of life with distress, post-traumatic stress, and optimism. Interventions for improving the quality of life of patients with colorectal cancer should be individualized based on the specific diagnosis and the presence/absence of colostomy/ileostomy.

Preparing Patients for Sexual Dysfunction After Radiation for Anorectal Cancers: A Systematic Review

PURPOSE

Successful multimodality treatment of anorectal cancers has led to increased numbers of survivors who experience permanent, life-changing side effects of treatment. Little is known about sexual dysfunction (SD) in this population. The etiology of SD after anorectal cancer treatment is complex and multifactorial. However, pelvic radiation plays a significant negative role in anatomic, hormonal, and physiological aspects of sexual function.

METHODS AND MATERIALS

A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols. Information was organized by key concepts useful for patient education, including (1) rates of SD after pelvic radiation for rectal cancer, (2) rates of SD after pelvic radiation for anal cancer, (3) mechanisms of SD and methods to reduce rates of SD, and (4) issues and opportunities related to patient education and discussion of SD after pelvic radiation.

RESULTS

SD after pelvic radiation for anorectal cancers is common in both men and women. Higher radiation doses may increase the risk for vaginal stenosis; however, it is unclear whether there are similar dose-volume relationships for men. Vaginal dilators and advanced radiation techniques can reduce the radiation dose to sexual organs at risk. Improvement is needed regarding counseling and education of patients about SD.

CONCLUSIONS

This review provides information from previously published studies that clinicians may use in their discussions with patients embarking on pelvic radiation for anorectal cancers. More modern, standardized, and complete data are needed to quantify the risk of SD after treatment. Some methods of sexual toxicity reduction have been studied, but further study into interventions aimed at treating postradiation sexual function are needed.

Impact of bowel and stoma dysfunction on female sexuality after treatment for rectal cancer

AIM

The aim of this study was to measure the impact of bowel dysfunction and a poorly functioning stoma on the risk of sexual inactivity and sexual dysfunction in female patients.

METHOD

In a population-based cross-sectional study, Danish rectal cancer patients diagnosed between 2001 and 2014 were invited to answer a comprehensive questionnaire regarding cancer- and treatment-related late side effects after rectal cancer treatment. Bowel function was assessed using the Low Anterior Resection score and stoma function using the Colostomy Impact score. Female sexuality was measured by sexual activity, overall sexual dysfunction (the Rectal Cancer Female Sexuality score) and by different domains of sexual dysfunction (Sexual Vaginal Changes questionnaire).

RESULTS

Eight-hundred and thirteen female patients completed the questionnaire (response rate 49.2%). Major bowel dysfunction did not significantly increase the risk of sexual inactivity (OR 1.39, 95% CI 0.93-2.07) but clearly increased the risk of sexual dysfunction (OR 3.03, 95% CI 1.67-5.51). The most distinct problems were dyspareunia and inability to complete intercourse. On the contrary, poor stoma function increased the risk sexual inactivity (OR 2.26, 95% CI 1.16-4.40) but not the risk of sexual dysfunction (OR 0.74, 95% CI 0.27-1.99). The most distinct problem was dissatisfaction with own physical appearance.

CONCLUSIONS

Both bowel dysfunction and stoma dysfunction negatively, but differently, affect sexuality. After restorative surgery, bowel dysfunction was primarily associated with sexual dysfunction while poor stoma function after abdominoperineal excision was associated with sexual inactivity.

Optimising functional outcomes in rectal cancer surgery

Background

By improved surgical technique such as total mesorectal excision (TME), multimodal treatment and advances in imaging survival and an increased rate of sphincter preservation have been achieved in rectal cancer surgery. Minimal-invasive approaches such as laparoscopic, robotic and transanal-TME (ta-TME) enhance recovery after surgery. Nevertheless, disorders of bowel, anorectal and urogenital function are still common and need attention.

Purpose

This review aims at exploring the causes of dysfunction after anterior resection (AR) and the accordingly preventive strategies. Furthermore, the indication for low AR in the light of functional outcome is discussed. The last therapeutic strategies to deal with bowel, anorectal, and urogenital disorders are depicted.

Conclusion

Functional disorders after rectal cancer surgery are frequent and underestimated. More evidence is needed to define an indication for non-operative management or local excision as alternatives to AR. The decision for restorative resection should be made in consideration of the relevant risk factors for dysfunction. In the case of restoration, a side-to-end anastomosis should be the preferred anastomotic technique. Further high-evidence clinical studies are required to clarify the benefit of intraoperative neuromonitoring. While the function of ta-TME seems not to be superior to laparoscopy, case-control studies suggest the benefits of robotic TME mainly in terms of preservation of the urogenital function. Low AR syndrome is treated by stool regulation, pelvic floor therapy, and transanal irrigation. There is good evidence for sacral nerve modulation for incontinence after low AR.

Robotic surgery for rectal cancer as a platform to build on: review of current evidence

Laparoscopy in colorectal surgery reduces the rate of postoperative complications, shortens the length of stay in hospital, and improves the quality of patient care. Despite these established benefits, the technical challenges of rectal resection for cancer have resulted in most operations being performed through open surgery in the USA. Moreover, controversy in the current literature questions the oncologic safety of a laparoscopic approach for rectal cancer. How then can surgeons innovate to overcome the technical challenges while preserving the critical oncological outcomes of high-quality rectal cancer surgery? Robotics may be a platform that allows us to overcome the technical challenges in the pelvis while maintaining both oncological outcomes and the benefits of a minimally invasive technique. Current evidence suggests that the quality of total mesorectal excision, the rates of circumferential margin involvement, and postoperative outcomes are comparable between robotic and laparoscopic surgery. While a robotic approach demonstrates lower conversion rates and reduced surgeon workload, the operative time is longer and initial costs are higher; however, time and future science will determine its true benefits. We review the current state of robotic surgery and its impact on rectal cancer surgery.

Self-reported sexual dysfunction in patients with rectal cancer

AIM

Patients with rectal cancer often experience sexual dysfunction after treatment. The aim of this study was to evaluate sexual function in a prospective cohort of patients regardless of treatment and tumour stage and explore what factors might affect sexual activity 1 year after diagnosis.

METHOD

The QoLiRECT study (Quality of Life in RECTal cancer) is a prospective study on the health-related quality of life in patients with rectal cancer in Denmark and Sweden. Questionnaires were completed at diagnosis and 1 year. Clinical data were retrieved from national quality registries.

RESULTS

Questionnaire data were available from 1085 patients at diagnosis and 920 patients at 1 year. Median age was 69 years (range 25-100). At diagnosis, 29% of the women and 41% of the men were sexually active, which was lower than an age-matched reference population. This was further reduced to 25% and 34% at 1 year. Risk factors for sexual inactivity were absence of sexual activity prior to the diagnosis and the presence of a stoma. Women experienced reduced lubrication and more dyspareunia at 1 year compared with the time of diagnosis. In men, erectile dysfunction increased from 46% to 55% at 1 year.

CONCLUSION

Sexual activity in patients with rectal cancer is lower at diagnosis compared with the population norm and is further reduced at 1 year. The presence of a stoma contributed to reduced sexual activity after operation. Sexual dysfunction was difficult to evaluate due to low sexual activity in the cohort. In men, erectile dysfunction is common.

Sexual health in colon cancer patients: A systematic review

OBJECTIVE

Despite the impact that diagnosis and treatment can have on patients' sexual health, very little research has been conducted on the impact of colon cancer on sexual health. The aim of this systematic review was to assess the prevalence of sexual dysfunctions in colon cancer and describe the sociodemographic, clinical, and psychological correlates of sexual dysfunction.

METHODS

Four electronic databases (PsycINFO, PubMed, AcademicSearchPremier, Cochrane Library) were searched for studies reporting sexual adjustment outcomes for colorectal cancer patients from January 1990 to July 2019.

RESULTS

Of the 380 articles screened, 14 were included in this review. Sexual function is affected by colon cancer: patients' sexual satisfaction decreases significantly, as does the frequency of sexual intercourse. There is an increase in sexual problems (desire, excitement, or pleasure disorders). Male gender, advanced age, distress, and the comorbidities increase sexual disorders. In addition, it appears that partner distress negatively affects patients' sexual health. Taking such difficulties into account appears key for these patients and their partners. They could benefit from better care throughout treatment and in remission.

CONCLUSION

The results of this systematic review highlight the importance of taking an interest in the sexual health of patients with colon cancer.

Management and Outcome of Local Regrowths in a Watch-and-wait Prospective Cohort for Complete Responses in Rectal Cancer

OBJECTIVE

To evaluate the management and oncological outcomes of rectal cancer patients with local regrowth in a watch-and-wait (W&W) program.

BACKGROUND

Approximately 15%-30% of patients with a clinical complete response after (chemo) radiotherapy who undergo a W&W policy will experience a local regrowth. The risks of these local regrowths have not yet been fully established and main concerns include high postoperative morbidity, requirement of advanced surgery, and pelvic recurrence after regrowth treatment.

METHODS

All patients with a local regrowth after an initial W&W approach between January 2005 and March 2018 were retrospectively identified from 2 cohorts of rectal cancer patients with a clinical complete response after (chemo) radiotherapy. Type and outcome of regrowth treatment were assessed. Oncological outcome was assessed using Kaplan-Meier estimates.

RESULTS

Eighty-nine out of 385 patients developed a local regrowth after a median of 9 (interquartile range 7-14) months. Median follow-up time was 28 (interquartile range 19-41) months. Eighty-four (94%) patients underwent surgical treatment of the local regrowth: total mesorectal excision was performed in 58 out of 84 (69%) patients and local excision was performed in 26 (31%) patients. The 2-year local recurrence-free rate, distant metastasis-free rate, disease-free survival, and overall survival in the patients undergoing surgical treatment were 97.8%, 91.8%, 90.3%, and 98.4%, respectively.

CONCLUSION

The vast majority (97%) of patients with regrowth after a W&W policy were able to undergo treatment with curative intent for local regrowth. Uncontrolled pelvic disease was very rare.

Magnetic Resonance Guided Radiotherapy for Rectal Cancer: Expanding Opportunities for Non-Operative Management

Colorectal cancer is the third most common cancer in men and the second most common in women worldwide, and the incidence is increasing among younger patients. 30% of these malignancies arise in the rectum. Patients with rectal cancer have historically been managed with preoperative radiation, followed by radical surgery, and adjuvant chemotherapy, with permanent colostomies in up to 20% of patients. Beginning in the early 2000s, non-operative management (NOM) of rectal cancer emerged as a viable alternative to radical surgery in select patients. Efforts have been ongoing to optimize neoadjuvant therapy for rectal cancer, thereby increasing the number of patients potentially eligible to forgo radical surgery. Magnetic resonance guided radiotherapy (MRgRT) has recently emerged as a treatment modality capable of intensifying preoperative radiation therapy for rectal cancer patients. This technology may also predict which patients will achieve a complete response to preoperative therapy, thereby allowing for more appropriate selection of patients for NOM. The present work seeks to illustrate the potential role MRgRT could play in personalizing rectal cancer treatment thus expanding the role of NOM in rectal cancer.

Effect of radiotherapy for rectal cancer on female sexual function: a prospective cohort study

Background

Clinical experience and limited data show that female sexual function is influenced negatively by preoperative radiotherapy (RT) for rectal cancer. The aim of this prospective study was to investigate the impact of RT on sexual function and ovarian reserve measured by levels of anti-Müllerian hormone (AMH).

Methods

Women with stage I–III rectal cancer scheduled for surgery with or without preoperative (chemo)RT were included and followed for 2 years. Female Sexual Function Index (FSFI) questionnaire responses and blood samples for hormone analyses, including AMH in women aged 45 years or less, were collected at baseline and during follow-up.

Results

In the group of 109 women who received preoperative RT, median scores in all FSFI domains decreased over time, as did the total FSFI score (from 18·5 (range 2·0–36·0) at baseline to 10·8 (2·0–34·8) at 2 years; P &lt; 0·001). In the group of 30 women who did not receive preoperative RT, only satisfaction declined over time (from 3·2 (0·8–6·0) to 1·8 (0·8–6·0); P = 0·012). In longitudinal regression analysis, the mean decline in FSFI total score was –9·33 (95 per cent c.i. –16·66 to –1·99; P = 0·013) for women who had preoperative RT compared with those who did not, with adjustment for age, Psychological General Well-being Index score and relationship with partner. A corresponding association was seen for arousal, lubrication, orgasm and pain. Five of six women aged 45 years or less with detectable serum levels of AMH at baseline had undetectable levels after RT.

Conclusion

Preoperative RT was associated with impairment in sexual function in women with rectal cancer. This needs to be considered when discussing choice of treatment and rehabilitation. In younger women, undetectable AMH levels after RT indicate an irreversible loss of ovarian follicles.

Female sexual problems after treatment for colorectal cancer - a population-based study

AIM

There has been limited focus on female sexuality after treatment for colorectal cancer. The aim of this study was to investigate long-term female sexual dysfunction in disease-free colorectal cancer survivors in the Danish population.

METHOD

All female Danish patients treated for colorectal cancer between 2001 and 2014 were included if they reported to have been sexually active at the time of diagnosis. They were requested to answer the validated Sexual Vaginal Changes Questionnaire.

RESULTS

A total of 2402 patients were included for analysis (43%). Overall, rectal cancer patients reported more sexual inactivity and problems compared to colon cancer patients, but there were no differences in any sexual function domains when excluding irradiated patients and patients with a permanent stoma. A permanent stoma was associated with sexual inactivity [OR 2.56 (95% CI 1.42-4.70)] and overall sexual dysfunction [OR 2.95 (95% CI 1.05-6.38)] in colon cancer patients, as well as inactivity [OR 1.43 (95% CI 1.01-2.04)] and overall dysfunction [OR 2.0 (95% CI 1.18-3.41)] in rectal cancer patients. Furthermore, a permanent stoma was associated with dyspareunia [OR 2.17 (95% CI 1.39-3.38)] and reduced vaginal dimension [OR 3.16 (95% CI 1.99-5.01)]. In rectal cancer patients, radiotherapy exposure increased the odds for overall sexual dysfunction [OR 1.80 (95% CI 1.02-3.16)] and was associated with dyspareunia [OR 1.72 (95% CI 0.95-3.12)].

CONCLUSION

Sexual problems after treatment of colorectal cancer are common. Major risk factors are a permanent stoma and radiotherapy. Relevant patients should be offered professional counselling and treatment.

Health-related quality of life in Croatian general population and multiple myeloma patients assessed by the EORTC QLQ-C30 and EORTC QLQ-MY20 questionnaires

Background The impact of disease and treatment on the patient's overall well-being and functioning is a topic of growing interest in clinical research and practice. The aim of this study is to obtain reference data on quality of life of Croatian general population. Further, we aim to assess the impact of the disease and its primary systemic treatment on their health related quality of life (HrQoL) in multiple myeloma (MM) patients. Patients and methods Participants for the first part of the study were randomly selected from adult Croatian population. In the clinical part of the study MM patients were included as prospectively diagnosed within two years in two major Croatian haematological centres. The EORTC QLQ-C30 in both trials and QLQ-MY20 in MM patients only were applied for HrQoL assessment. Results Gender, age and place of residence have great impact on quality of life scores in Croatian population. The MM patients at the time of diagnosis have lower QLQ-C30 scores for global quality of life, functional and symptom scale scores, as well as single items. The type of disease followed by the choice of therapy options are important HrQoL determinants. Conclusions The norm values available now for Croatian population will help to interpret HrQoL for clinicians and aid in planning cancer care interventions. This study identified treatment effect consistent with those from other observational studies and provided new data on HrQoL across two different treatment choices for MM patients.