Urologic and sexual morbidity following multimodality treatment for locally advanced primary and locally recurrent rectal cancer

Prospective longitudinal trajectory of cancer survivorship among patients with recurrent rectal cancer: impact of treatment modalities and resection status

AIM

Recurrent rectal cancer (RRC) can be morbid and optimising cancer survivorship is a priority. The longitudinal trajectories of survivorship associated with RRC have not been prospectively depicted.

METHODS

We prospectively enrolled patients with RRC. Participants self-reported quality of life (QOL) using validated European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 and CR29, and pain using the Brief Pain Inventory, at baseline and then every 6 months for up to 5 years or until death. Baseline scores and the longitudinal trajectory of scores were examined using linear mixed-effects modelling.

RESULTS

Among 104 patients, 73 (70.2%) received multimodality salvage treatment with curative intent, while the remainder received best palliative treatments. Curative-intent salvage including surgery was associated with a 30-day operative morbidity rate of 49% and a 5-year overall survival of 51%. Patients undergoing curative-intent salvage versus palliative treatments did not differ in baseline QOL or pain, but the longitudinal trajectory after curative-intent salvage showed sustained improvement of QOL and symptoms over time. This contrasted with the initial transient improvement but persistent decline with palliative treatments. Baseline QOL was significantly impacted by the anatomical site of RRC, with posterior location associated with worst QOL (P = 0.012). Long-term QOL was impacted by anatomical site and status of residual tumour. Pain scores were worse among men.

CONCLUSION

Trajectories of cancer survivorship for patients with RRC diverge, mainly influenced by anatomical site of the RCC, residual tumour status, and ability to complete curative-intent salvage. These should inform treatment planning. Optimising selection and success of multimodality therapy remains the cornerstone for durable cancer survivorship.

A Gender Perspective on Coloproctological Diseases: A Narrative Review on Female Disorders

Coloproctological diseases, including both benign and malignant conditions, are among the most common diagnoses in clinical practice. Several disorders affect both men and women, while others are unique to women, or women are at a greater risk of developing them. This is due to anatomical, biological, and social conditions and also due to females' exclusive capabilities of reproduction and pregnancy. In this context, the same proctological disease could differ between men and women, who can experience different perceptions of health and sickness. There is a raised awareness about the impact of different diseases in women and a growing need for a personalized approach to women's health. In this review, we aim to summarize the specific features of the main coloproctological diseases, specifically in the female population. This includes common complaints during pregnancy, conditions linked to vaginal delivery, functional consequences after colorectal resections, and conditions presenting a gender disposition.

A psychoeducational intervention to improve sexual functioning in male rectal and anal cancer patients: A pilot randomized controlled trial study

OBJECTIVES

Male rectal and anal cancer patients demonstrate high rates of sexual dysfunction. This pilot randomized controlled trial tested a psychoeducational intervention designed to improve psychosexual adjustment.

METHODS

Rectal or anal cancer patients were randomized to a Sexual Health Intervention for Men (intervention) or to a referral and information control (control). The intervention included control activities plus 4 sexual health intervention sessions every 4-6 weeks and 3 brief telephone calls timed between these sessions. Assessments were completed pre-intervention (baseline) and 3 months (follow-up 1) and 8 months (follow-up 2) post-intervention. Differences were assessed with statistical significance and Cohen's d effect sizes (d = 0.2, small effect; d = 0.5, moderate effect; d = 0.8, large effect).

RESULTS

Ninety subjects enrolled. Forty-three participants completed at least 1 follow-up assessment (intervention, n = 14; control n = 29). At follow-up 1, men in intervention, compared to control, improved on all domains of the International Index of Erectile Function (IIEF) (p < 0.001 to p < 0.05) and demonstrated large effects (d = 0.8 to d = 1.5). Similarly, at follow-up 2, changes in all domains of the IIEF except the orgasm domain were either statistically significant or marginally statistically significant (p = 0.01 to p = 0.08) and demonstrated moderate to large treatment effects for intervention versus control (d = 0.5 to d = 0.8). Men in the intervention, compared to control, demonstrated decreased sexual bother at follow-up 1 (p = 0.009, d = 1.1), while Self-Esteem and Relationship (SEAR) total scores and the SEAR sexual relationship subscale demonstrated moderate increases for intervention versus control (d = 0.4 to d = 0.6).

SIGNIFICANCE OF RESULTS

This study provides initial evidence for combining a psychoeducational intervention with medical interventions to address sexual dysfunction following rectal and anal cancer. Trials register number: NCT00712751 (date of registration: 7/10/2008).

Functional results after mesorectal excision for rectal cancer: comparative study among surgical approaches

BACKGROUND

We analyzed the evolution of genitourinary dysfunctions in patients undergoing surgical treatment for rectal cancer, and compared open surgery, laparoscopy, robotic and TaTME.

METHODS

Functional outcomes were evaluate using standardized questionnaires, compiled at the start of treatment, after the end of Radiotherapy, at 1 and 6 months after surgery.

RESULTS

In 72 patients 37.5% had low, 27.8% middle, and 34.7% high rectal cancers. Open technique was performed in 25% of cases, while 29.2% underwent laparoscopy, 20.8% TaTME and 25% robotic. We noted a deterioration in urogenital function: surgical technique can influence the result both in urinary and male sexual function but not ejaculation. Robotics and laparoscopy bring better outcomes than open surgery and TaTME. Female sexuality worsening seems not influenced by the technique. In general age, stage, complications and anastomotic leakage appear to be predictive factors for functional dysfunctions. As reported in literature rectal cancer treatment leads to urogenital worsening: this seems to be progressive in male sexuality only, while female one and urinary function show a slight improvement in the first months, although a full recovery possibility is discussed. Is also reported how robotic and laparoscopy have a lower functional impact. TaTME has gained consensus thank to the excellent oncological and function outcomes, but in our study leads to worse results.

CONCLUSIONS

Mini-invasive techniques guarantee the same oncological result than more invasive ones, but with better functional outcomes and tolerability; robotic surgery seems to be slight superior than laparoscopy, but with longer operative time.

Omission of neoadjuvant radiotherapy for clinical T2/N1 and T3N0/1 middle and low rectal cancers with safe circumferential resection margins

Purpose

For moderately advanced rectal cancers with safe circumferential margins, the oncologic benefit of neoadjuvant radiotherapy must be reconsidered because of the possibility of overtreatment, resulting in complications from radiotoxicity. To evaluate the oncologic safety of the omission of neoadjuvant radiotherapy for moderately advanced rectal cancers, we evaluated and compared the prognoses of patients who underwent radical resection with and without neoadjuvant radiotherapy for T2/N1 and T3N0/1 middle and low rectal cancers with safe circumferential resection margins.

Methods

We retrospectively enrolled 66 patients who underwent radical resection for clinical (c) T2N1 and T3N0/1 middle and low rectal cancers between 2008 and 2014. Patients with distant metastasis; cT4, cN2, or positive lateral pelvic lymph nodes; positive circumferential resection margin; signet-ring cell carcinoma; cT1/2N0; or those who had received adjuvant radiotherapy were excluded. The clinical and pathological characteristics and 5-year oncologic outcomes of the no-radiotherapy (n = 34) and radiotherapy (n = 32) groups were compared.

Results

The rates of abdominoperineal resection and ileostomies and the proportion of patients who received adjuvant chemotherapy were significantly higher in the radiotherapy group. There were no significant differences in tumor location, clinical stage, surgery type, pathologic N stage, anastomotic leakage, or long-term oncologic outcomes including 5-year disease-free survival, overall survival, and local recurrence and distant metastasis rates between both groups.

Conclusion

The oncologic benefit of neoadjuvant radiotherapy for cT2/N1 and T3N0/1 middle and low rectal cancers with safe circumferential resection margins is considered unclear, and it can be omitted to prevent radiotoxicity and facilitate prompt essential treatment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality of life assessment in the late postoperative period of patients with rectal cancer submitted to total mesorectal excision

After the introduction of total mesorectal excision (TME) and radiochemotherapy, excellent results have been achieved in the treatment of patients with rectal cancer. With better oncologic control of the disease, the functional results of this type of therapeutic approach and their impact on the quality of life (QOL) of patients started to be increasingly valued. The aims of this study were to evaluate the QOL of patients with rectal cancer submitted to TME in the late postoperative period and the possible factors that directly influence their quality of life. A total of 72 patients submitted to TME due to extraperitoneal rectal tumor were assessed, after at least one postoperative year, by applying QOL questionnaires (EORTC QLQ-C30 and EORTC QLQ-CR38), in addition to a specific clinical questionnaire and rectal examination. Patients were evaluated regarding gender, age, indication of radiotherapy and chemotherapy preoperatively, length of postoperative period, distance from the anastomosis to the anal verge and general health status. The mean overall health status of patients was satisfactory (82.06). There was no difference in overall health status between patients with respect to gender, but the male patients had less insomnia (p = 0.002), better future prospects (p = 0.011), fewer effects of chemotherapy (p = 0.020) and better sexual function (p < 0.0001). Patients younger than 50 years had fewer urinary problems (p = 0.035), whereas those older than 65 years reported poorer sexual function (p = 0.012). Patients who underwent neoadjuvant therapy had more diarrhea (p = 0.012). Quality of life did not change significantly with time after surgery and the distance from the anastomosis to the anal verge. We conclude that patients undergoing TME have a good quality of life one year after the surgery and that the factors capable of affecting QOL should be identified and improved.

Management of synchronous lateral pelvic nodal metastasis in rectal cancer in the era of neoadjuvant chemoradiation: A systemic review

BACKGROUND

Lateral pelvic lymph node (LLN) metastasis (LLNM) occur in up to 28% of patients with low rectal tumours. While prophylactic lateral pelvic lymph node dissection (LLND) has been abandoned by most western institutions in the era of neoadjuvant chemoradiation therapy (CRT), the role of selective LLND in patients with enlarged LLN on pre-CRT imaging remains unclear. Some studies have shown improved survival and recurrence outcomes when LLNs show “response” to CRT. However, no management algorithm exists to differentiate treatment for “responders” vs “non-responders”.

AIM

To determine if selective LLND in patients with enlarged LLNs results in improved survival and recurrence outcomes.

METHODS

A systemic search of PubMed and Embase databases for studies reporting on patients with synchronous radiologically suspicious LLNM (s-LLNM) in rectal cancer receiving preoperative-CRT was performed.

RESULTS

Fifteen retrospective, single-centre studies were included. 793 patients with s-LLNM were evaluated: 456 underwent TME while 337 underwent TME with LLND post-CRT. In the TME group, local recurrence (LR) rates range from 12.5% to 36%. Five-year disease free survival (DFS) was 42% to 75%. In the TME with LLND group, LR rates were 0% to 6%. Five years DFS was 41.2% to 100%. Radiological response was seen in 58%. Pathologically positive LLN was found in up to 94% of non-responders vs 0% to 20% in responders. Young age, low tumour location and radiological non-response were associated with final positive LLNM and lowered DFS.

CONCLUSION

LLND is associated with local control in patients with s-LLNM. It can be performed in radiological non-responders given a large majority represent true LLNM. Its role in radiological responders should be considered in selected high risk patients.

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.

Prospective study of sexual dysfunction after proctectomy for rectal cancer

BACKGROUND

Although rectal cancer is a common malignancy and has an improved cure rate in response to oncological treatment, research on rectal-cancer survivors' sexual function remains limited.

OBJECTIVE

The aim of this prospective study is to assess sexual dysfunction after rectal cancer surgery.

PATIENTS AND METHODS

Patients undergoing curative rectal cancer surgery were included in the study. Sexual function before and 6 months after the operation was measured using the validated questionnaires. Primary outcome was to determine the rates of Sexual dysfunction after rectal cancer surgery. Furthermore, the factors which can have an impact on sexual function after radical treatment have been assessed.

RESULTS

A total of 187 patients [117 (63%) men and 70 (37%) women] with rectal cancer who underwent radical resection were included in the study. Sexual function has significantly decreased after surgery. Among male patients, sexual dysfunction increased from the baseline 4% (n = 5) up to 41% (n = 48) after the operation. Among female patients, sexual dysfunction increased from the baseline 53% (n = 37) up to 77% (n = 54) after the operation. A significant lower rate of laparoscopic surgery has been found in both males and females who reported sexual dysfunction after surgery. The patients who have locally advanced disease and those who received postoperative chemotherapy or radiotherapy have higher rates of sexual dysfunction.

CONCLUSION

This study, showed that sexual dysfunction is common in patients with rectal cancer after radical treatment. However, patients who underwent laparoscopic surgery have lower rates of sexual dysfunction than those who underwent open surgery.

Anastomotic leakage after sphincter-sparing surgery in a young woman diagnosed with low rectal cancer - case report

Rectal cancer is the third most common site for cancer in the world, with a high morbidity and mortality. The new techniques for the treatment of low rectal cancer have been improved recently, allowing sphincter-sparing surgery to be available for more patients, with an optimal oncological and functional outcome. The most fundamental advance in rectal cancer surgery was the concept of total mesorectal resection (TME) introduced by Heald in 1982. Association with neoadjuvant radio-chemotherapy determines regression of the disease by “down staging” the tumors and allows for sphincter-sparing surgery to be performed, with low recurrence rate and increased overall survival. We present the case of 48-year old woman who had low rectal resection with colorectal anastomosis for middle rectal cancer. The patient had a BMI of 29, was hypertensive, had uterine fibroids and underwent neoadjuvant radiotherapy. During the 4th postoperative day the patient developed an anastomotic leakage grade B which was spontaneously closed on the 15th postoperative day. The patient did not manifest fever or any other symptoms. Normal bowel function resumed on the 5th postoperative day. No recurrence was detected at the one-year follow-up.

Results of intraoperative electron beam radiotherapy containing multimodality treatment for locally unresectable T4 rectal cancer: a pooled analysis of the Mayo Clinic Rochester and Catharina Hospital Eindhoven

BACKGROUND

The aim of this study is to analyse the pooled results of intraoperative electron beam radiotherapy (IOERT) containing multimodality treatment of locally advanced T4 rectal cancer, initially unresectable for cure, from the Mayo Clinic, Rochester, USA (MCR) and Catharina Hospital, Eindhoven, The Netherlands (CHE), both major referral centers for locally advanced rectal cancer. A rectal tumor is called locally unresectable for cure if after full clinical work-up infiltration into the surrounding structures or organs has been demonstrated, which would result in positive surgical margins if resection was the initial component of treatment. This was the reason to refer these patients to the IOERT program of one of the centers.

METHODS

In the period from 1981 to 2010, 417 patients with locally unresectable T4 rectal carcinomas at initial presentation were treated with multimodality treatment including IOERT at either one of the two centres. The preferred treatment approach was preoperative (chemo) radiation and intended radical surgery combined with IOERT. Risk factors for local recurrence (LR), cancer specific survival, disease free survival and distant metastases (DM) were assessed.

RESULTS

A total of 306 patients (73%) underwent a R0 resection. LRs and metastases occurred more frequently after an R1-2 resection (P<0.001 and P<0.001 respectively). Preoperative chemoradiation (preop CRT) was associated with a higher probability of having a R0 resection. Waiting time after preoperative treatment was inversely related with the chance of developing a LR, especially after R+ resection. In 16% of all cases a LR developed. Five-year disease free survival and overall survival (OS) were 55% and 56% respectively.

CONCLUSIONS

An acceptable survival can be achieved in treatment of patients with initially unresectable T4 rectal cancer with combined modality therapy that includes preop CRT and IOERT. Completeness of the resection is the most important predictive and prognostic factor in the treatment of T4 rectal cancer for all outcome parameters. IOERT can reduce the LR rate effectively, especially in R+ resected patients.

Post operative stereotactic radiosurgery for positive or close margins after preoperative chemoradiation and surgery for rectal cancer

BACKGROUND

The incidence of positive margins after neoadjuvant chemoradiation and adequate surgery is very low. However, when patients do present with positive or close margins, they are at a risk of local failure and local therapy options are limited. We evaluated the role of stereotactic body radiotherapy (SBRT) in patients with positive or close margins after induction chemoradiation and total mesorectal excision.

METHODS

This is a retrospective evaluation of patients treated with SBRT after induction chemoradiation and surgery for positive or close margins. Seven evaluable patients were included. Fiducial seeds were place at surgery. The Cyberknife(TM) system was used for planning and treatment. Patients were followed 1 month after treatment and 3-6 months thereafter. Descriptive statistics and Kaplan-Meir method was used to repot the findings.

RESULTS

Seven patients (3 men and 4 women) were included in the study with a median follow-up of 23.5 months. The median initial radiation dose was 5,040 cGy (in 28 fractions) and the median SBRT dose was 2,500 cGy (in 5 fractions). The local control at 2 years was 100%. The overall survival at 1 and 2 years was 100% and 71% respectively. There was no Grade III or IV toxicity.

CONCLUSIONS

SBRT reirradiation is an effective and safe method to address positive or close margins after neoadjuvant chemoradiation and surgery for rectal cancer.

A prospective study of sexual and urinary function before and after total mesorectal excision

PURPOSE

Although rectal cancer is a very common malignancy and has an improved cure rate in response to oncological treatment, research on rectal cancer survivors' urogenital function remains limited. In this study, urogenital dysfunction after surgical rectal cancer treatment was measured and possible predisposing factors that may have an impact on the development of this disorder were discussed.

METHODS

One hundred eight patients undergoing curative rectal cancer surgery from January 2008 to December 2014 were questioned using questionnaires: male urinary function was assessed using the International Prostatic Symptom Score (IPSS) questionnaire, for sexual function-International Index of Erectile Function (IIEF). The Bristol Female Lower Urinary Tract Symptoms (BFLUTS) questionnaire and the Female Sexual Function Index (FSFI) were used for female urogenital function assessment prior to the operation and 6 months postoperatively.

RESULTS

A total of 67.0 % of male (36) and 33.0 % (18) of female patients who completed the questionnaire were included in the study. Preoperatively, male urinary dysfunction was 80.1 % and postoperatively-88.9 %. In female patients, preoperative urinary dysfunction was seen in 75.0 % patients, postoperatively-78.0 %. Erectile dysfunction was seen in 41.7 % males preoperatively and in 63.9 % postoperatively. A total of 83.3 % of female patients had sexual dysfunction preoperatively and 94 % postoperatively.

CONCLUSION

Sexual and urinary problems after surgery for rectal cancer are common. Preoperative genitourinary dysfunction is not uncommon in patients older than 60 years as well. Female patients reported higher rates of sexual dysfunction than males. These results point out the importance of sexual and urinary (dys)function in survivors of rectal cancer. More attention should be drawn to this topic for clinical and research purposes.

Predictors of Long-Term Quality of Life for Survivors of Stage II/III Rectal Cancer in the Cancer Care Outcomes Research and Surveillance Consortium

PURPOSE

Many patients do not receive guideline-recommended neoadjuvant chemoradiotherapy for resectable rectal cancer. Little is known regarding long-term quality of life (QOL) associated with various treatment approaches. Our objective was to determine patient characteristics and subsequent QOL associated with treatment approach.

METHODS

Our study was a geographically diverse population- and health system-based cohort study that included adults age 21 years or older with newly diagnosed stage II/III rectal cancer who were recruited from 2003 to 2005. Eligible patients were contacted 1 to 4 months after diagnosis and asked to participate in a telephone survey and to consent to medical record review, with separate follow-up QOL surveys conducted 1 and 7 years after diagnosis.

RESULTS

Two hundred thirty-nine patients with stage II/III rectal cancer were included in this analysis. Younger age (< 65 v ≥ 65 years: odds ratio, 2.49; 95% CI, 1.33 to 4.65) was significantly associated with increased odds of receiving neoadjuvant or adjuvant chemoradiotherapy. The adjuvant chemoradiotherapy group had significantly worse mean EuroQol-5D (range, 0 to 1) and Short Form-12 physical health component scores (standardized mean, 50) at 1-year follow-up than the neoadjuvant chemoradiotherapy group (0.75 v 0.85; P = .002; 37.2 v 43.3; P = .01, respectively) and the group that received only one or neither form of treatment (0.75 v 0.85; P = .02; 37.2 v 45.1; P = .008, respectively).

CONCLUSION

Neoadjuvant treatment may result in better QOL and functional status 1 year after diagnosis. Further evaluation of patient and provider reasons for not pursuing neoadjuvant therapy is necessary to determine how and where to target process improvement and/or education efforts to ensure that patients have access to recommended treatment options.

[Urinary complications of pelvic exenterations for rectal cancer with urinary invasion]

OBJECTIVE

Pelvic exenteration for rectal cancer is indicated in locally advanced rectal tumors or pelvic recurrence invading adjacent organs. The oncologic goal being a complete R0 resection. Our aim was to study the urinary complications resulting from pelvic exenterations with urinary reconstruction in order to obtain a complete local control of the disease.

METHODS

Between April 2004 and June 2013, 42 patients who underwent pelvic exenteration for primary or recurrent rectal adenocarcinoma with urinary tract reconstruction were included. The urinary reconstruction was performed based on preoperative imaging and intraoperative findings. We studied early (within 30 postoperative days) and late urinary morbidity, as well as postoperative carcinologic control.

RESULTS

Forty-two exenterations were performed for primary rectal cancer (n=15) or pelvic recurrence (n=27). R0 complete resection was achieved in 64% of patients. The resection was incomplete (R1) on the urinary tract in 9.5% of patients. The urinary reconstruction methods used were: 31 transileal ureterostomies after total exenteration (bricker procedure), 6 ureteral reimplantations on psoic bladder, 2 ureteroileoplasties, 2 partial cystectomies and one ureteral resection with simple ligation. The median follow-up was 20 months. The perioperative mortality was 2.3% (n=1) and postoperative overall morbidity was 64%. Early and late urinary morbidity was 23.8% and 21.4% respectively. Six patients developed major urinary complications (≥ Clavien IIIb).

CONCLUSION

Pelvic exenteration with urinary resection resulted in our experience, in a local disease control of 64% (including a 90.5% for the urinary tract) at the price of an acceptable early specific morbidity and a low mortality that seems to justify an aggressive surgical approach.

Systematic review of health-related quality of life issues in locally recurrent rectal cancer

The standardization of surgical techniques supplemented with appropriate neoadjuvant chemoradiation has led to the decline in local recurrence rates of rectal cancer (LRRC) from 25-50% to 5-10%. The outcomes reported for surgical intervention in LRRC is encouraging, however, a number of controversies exist especially in the ultra-advanced and palliative setting. Incorporating health-related quality of life (HRQoL) outcomes in this field could supplement traditional clinical endpoints in assessing the effectiveness of surgical intervention in this cohort. This review aimed to identify the HRQOL themes that might be relevant to patients with LRRC. A systematic review was undertaken to identify all studies reporting HRQoL in LRRC. Each study was evaluated with regards to its design and statistical methodology. A meta-synthesis of qualitative and quantitative studies was undertaken to identify relevant HRQoL themes. A total of 14 studies were identified, with 501 patients, with 80% of patients undergoing surgery. HRQoL was the primary endpoint in eight studies. Eight themes were identified: physical, psychological and social impact, symptoms, financial and occupational impact, relationships with others, communication with healthcare professionals and sexual function. The impact on HRQoL is multifactorial and wide ranging, with a number of issues identified that are not included in current measures. These issues must be incorporated into the assessment of HRQoL in LRRC through the development of a validated, disease-specific tool.

[Sexual functions after treatment for rectal cancer: impact of doses in autonomic pelvic nerves]

PURPOSE

Prospective evaluation of sexual function after treatment of rectal cancer and identification of predictive factors.

PATIENTS AND METHODS

Thirty-three patients were treated with curative intent by chemoradiation and surgery for localized rectal adenocarcinoma. Sexual toxicity was assessed four times (before treatment and at 2, 6 and 12 months) using validated questionnaires: QLQ C30 and EORTC CR38 for all, simplified IIEF for men and FSFI for women. A correlation was sought between the toxicity and clinical and dosimetric parameters by Fisher and Mann-Whitney tests.

RESULTS

In men, erections and sexual satisfaction decreased significantly from the acute phase and then stabilized (respective scores of 84.5 and 86/100 in the initial phase, 66 and 70.4 at the end of radiotherapy, 70 and 70 at 6 months and 68.5 and 70 at 12 months). For women, the changes were not significant. This study confirms some risk factors for sexual toxicity already mentioned (original function, age, tumor volume) and highlights new (dose to the seminal vesicles and above all, doses to pelvic autonomic plexus).

CONCLUSION

Sexual effects of combined treatment of rectal cancer have only recently been described but remain undervalued and poorly understood. The impact of the autonomic pelvic plexus doses is a completely new data that could be extended in the development of intensity-modulated radiotherapy.

Men's experience with sexual dysfunction post-rectal cancer treatment: a qualitative study

In an effort to address reports from men that their sex life is worse after treatment for rectal cancer, this qualitative study was designed to better understand their experience with sexual dysfunction following rectal cancer treatment, thus providing information on the adaptation of a psycho-educational sexual health intervention for male rectal cancer survivors and simultaneously investigating barriers and promoters that would influence their participation in a psycho-educational sexual health intervention. Thirteen male rectal cancer survivors who were treated at Memorial Sloan-Kettering Cancer Center (MSKCC) for rectal cancer participated (median time post-treatment was 6.4 years). Six survivors participated in individual semi-structured phone interviews, and seven others took part in focus groups. We performed standard procedures of qualitative thematic text analysis, which involved independent review of interview and focus group transcripts by several analysts followed by consensus meetings to identify key themes. Participants reported bowel dysfunction (N = 13, or 100%) and erectile dysfunction (N = 12, or 92%) as chief complaints. The participants thought a psychoeducational sexual health intervention post-surgery would be helpful because it would provide educational information regarding the etiology of their problems and treatments to improve their sexual health (N = 8, or 62%). Most participants' primary concern immediately after treatment was surviving their disease; improving sexual functioning seemed to become more important over time. Barriers to potentially participating in a psycho-educational sexual health intervention included geographical distance from MSKCC (N = 3, or 3/13) and the risk of embarrassment when discussing sexual issues (N = 5, or 5/13). Men reported that a psycho-educational sexual health intervention would be helpful to improve their sexual functioning post-treatment. Discussion of bowel issues and logistical concerns gave information on the psycho-educational sexual health intervention.

Gender differences in mortality, quality of life and function after restorative procedures for rectal cancer

AIM

Studies investigating the functional outcome after restorative surgery for rectal cancer have mainly focused on the effect of different surgical techniques on bowel habit or sexual activity at a single time-point. The aim of this study was to assess, longitudinally, the effect of rectal cancer treatment on bowel function, quality of life and sexual activity.

METHOD

The study parameters were assessed using self-administered questionnaires, including the Short Form 36 (SF-36), repeatedly, over a 5-year period. Patient details were obtained from the Cleveland Clinic prospective database.

RESULTS

There were 260 (186 male) patients. The mean ages of male and female patients at the time of surgery were 60.5 and 57.5 years, respectively. There was no significant difference in comorbidity or stage between the groups. Women had a better overall survival. More women than men had postoperative radiation and perioperative blood transfusions. Men had a higher percentage of hand-sewn anastomoses (23.9%vs 10.8%, P = 0.018), but there was no overall difference in the mean level of anastomosis (2.3 cm vs 1.9 cm, P = 0.38). Men had worse nocturnal bowel function, more incontinence and a poorer mental component score on the SF-36. Pad use increased over time to a greater degree in women. Sexual activity, which was similar in men and women at baseline, had fallen at 5 years in both genders.

CONCLUSION

After restorative resection for rectal cancer, bowel function is worse in men than in women, especially night evacuation at 3 and 5 years postoperatively. Sexual function in both genders declines sharply initially within 1 year postoperatively and more gradually over 5 years.

Intraoperative pelvic brachytherapy for treatment of locally advanced or recurrent colorectal cancer

BACKGROUND

The aim of this study was to evaluate the efficacy and morbidity of intraoperative radiation therapy (IORT) for advanced colorectal cancer.

METHODS

All patients undergoing IORT for locally advanced rectal cancer from 2001-2009 were reviewed for cancer recurrence, survival, and procedure-related morbidity. Cumulative event rates were estimated using the method of Kaplan and Meier.

RESULTS

Twenty-nine patients with locally advanced (n = 8) or recurrent (n = 21) rectal cancers were treated with IORT and resection. Surgical interventions included low anterior resection, abdominoperineal resection, pelvic exenteration, and a variety of non-anatomic resections of pelvic recurrences. R(0) resections were achieved in 16 patients, while R(1) resections were achieved in 10, and margins were grossly positive in 3 patients. IORT was delivered to all patients over a median area of 48 (42-72) cm(2) at a median dose of 12 (12-15) Gy. Local and overall recurrence rates were 24 % (locally advanced group) and 45 % (recurrent group). Median disease-free and overall survival were 25 and 40 months respectively at a median follow-up of 26 (18-42) months. The short-term (≤30 days) complication rate was 45 %. Eight patients developed local wound complications, 5 of which required operative intervention. Four patients developed intra-abdominal abscesses requiring drainage. Long-term (>30 days) complications were identified in 11 patients (38 %) and included long-term wound complications (n = 3), ureteral obstruction requiring stenting (n = 1), neurogenic bladder (n = 3), enteric fistulae (n = 2), small bowel obstruction (n = 1), and neuropathic pain (n = 1).

CONCLUSIONS

Intraoperative brachytherapy is a viable IORT option during pelvic surgery for locally advanced or recurrent colorectal cancer but is associated with high postoperative morbidity. Whether intraoperative brachytherapy can improve local recurrence rates for locally advanced or recurrent colorectal cancer will require further prospective investigation.

The association between psychosocial and medical factors with long-term sexual dysfunction after treatment for colorectal cancer

PURPOSE

Colorectal cancer patients usually receive treatments (e.g., pelvic surgery or radiotherapy, colostomy) that increase their risk for sexual problems. Previous research has mainly focused on demographic and medical risk factors. Because little is known about the role of psychosocial variables in sexual dysfunction, this research sought to identify the contribution of demographic, medical, and psychosocial factors to sexual dysfunction using multivariate analyses.

METHODS

Male and female colorectal cancer survivors (N = 261; mean, 2.5 years post-treatment) completed paper-pencil questionnaires assessing sexual function, psychosocial variables (e.g., depression, social support, body image, and dyadic adjustment), and demographics. Medical information was obtained from patients' self-report and medical records.

RESULTS

Multiple regression analyses revealed that older age, having received destructive surgery (i.e., abdominoperineal resection), and poor social support were uniquely and significantly associated with low international index of erectile function scores in men. For women, low female sexual function index scores were significantly associated with older age and poor global quality of life. Men, but not women, with rectal cancer reported worse sexual function compared to those with colon cancer.

CONCLUSIONS

Sexual dysfunction after colorectal cancer treatment is related to demographic, medical, and psychosocial factors. These associations can help to identify patients at high risk of sexual problems in order to assist restoring sexual functioning if desired.

Study of sexual, urinary, and fecal function in females following restorative proctocolectomy

BACKGROUND

The aim was to investigate quality of life, sexual, fecal, and urinary function in females undergoing restorative proctocolectomy (RPC).

METHODS

A prospective case-control study was performed in two tertiary centers. Controls were females with ulcerative colitis, without a stoma or RPC. Validated questionnaires (SF-36, Female sexual function index, King's questionnaire, and the Wexner scale) were administered in the outpatient setting. Pearson chi(2), t-test, and Mann-Whitney U-tests were used to assess significance.

RESULTS

A total of 255 females were identified and 49% (n = 124) recruited. In all, 109 patients fulfilled the inclusion criteria: 55 (50.5%) inflammatory bowel disease (IBD); 54 (49.5%) RPC. The mean age of RPC patients was 41.8 years (± 12.7 SD) vs. 43.8 years (± 15.8) for IBD (P = 0.491). RPC females with urinary symptoms (urgency, frequency, or incontinence) were 10 years younger than IBD (RPC mean age 37.6 ± 7.3 years vs. IBD 47.4 ± 13.5; P = 0.044). Urgency in fecal function was experienced by more IBD patients (IBD 75.0% vs. RPC 47.9%; P = 0.006), although RPC patients had increased day (P < 0.001) and night bowel frequency (P < 0.001) and were more likely to experience night seepage (P = 0.001). RPC females who had a vaginal delivery (VD) were more likely to have day seepage (P = 0.046) and require pads (P = 0.026) than RPC females who had not undergone VD. There was no significant difference in sexual function.

CONCLUSIONS

RPC may adversely impact urinary function in female patients over time. Bowel frequency, seepage, and pad usage are increased following RPC and function may be worse following VD. RPC does not adversely affect overall sexual function.

Should we screen for and treat lower urinary tract dysfunction after major pelvic surgery? ICI-RS 2011

AIMS

Given the relative frequency of lower urinary tract dysfunction (LUTD) after major pelvic surgery, the main question for this debate is: "Should we [actively] screen for LUTD after major pelvic surgery," with the intention to treat and improve patient care.

METHODS

The discussants selected relevant papers from a limited review of the literature [PubMed/Medline database (January 1966 to May 2011)] and prepared the YES versus NO presentations.

RESULTS

The evidence was presented for the following major pelvic procedures: colorectal surgery, hysterectomy, and surgery for other benign gynecologic conditions, radical prostatectomy, brachytherapy, and primary cryotherapy for prostate cancer. Based on the presentations, the audience voted in favor of screening for LUTD after major pelvic surgery.

CONCLUSIONS

Irreversible treatment should be delayed in case of LUTD after major pelvic surgery. In fact, most symptoms spontaneously subside within 6 months after the surgery. Once the period of 6-12 months of conservative management has been completed and if LUTD persists, a new urodynamic screening should be followed by appropriate treatment.

Sexual (dys)function and the quality of sexual life in patients with colorectal cancer: a systematic review

BACKGROUND

To determine (i) the prevalence of sexual (dys)function in patients with colorectal cancer and (ii) treatment-related and sociodemographic aspects in relation to sexual (dys)function and the quality of sexual life. Recommendations for future studies are provided.

METHODS

A systematic search was conducted during the period 1990 to July 2010 that used the databases PubMed, PsychINFO, The Cochrane Library, EMBASE, and OVID Medline.

RESULTS

Eighty-two studies were included. The mean quality score was 7.2. The percentage of preoperatively potent men that experienced sexual dysfunction postoperatively varied from 5% to 88%. Approximately half of the women reported sexual dysfunction. Preoperative radiotherapy, a stoma, complications during or after surgery, and a higher age predicted more sexual dysfunction with a strong level of evidence. Type of surgery and a lower tumor location predicted more sexual dysfunction with a moderate level of evidence. Insufficient evidence existed for predictors of the quality of sexual life. Current studies mainly focus on biological aspects of sexual (dys)function. Furthermore, existing studies suffer from methodological shortcomings such as a cross-sectional design, a small sample size, and the use of nonstandardized measurements.

CONCLUSION

Sexuality should be investigated prospectively from a biopsychosocial model, hereby including the quality of sexual life.

Female sexual function after abdominoperineal resection for squamous cell carcinoma of the anus and the specific influence of colpectomy and vertical rectus abdominis myocutaneous flap

AIM

Abdominoperineal resection (APR) is the only curative treatment for recurrent or persisting squamous cell carcinoma of the anus after radiochemotherapy. A vertical rectus abdominis myocutaneous (VRAM) flap reduces perineal morbidity. The sexual life (SL) of women after APR is unknown. Aims of this study were to evaluate SF of women after APR.

METHOD

47 women alive after APR performed between 1996 and 2007 were included. SL was evaluated using the female sexual function index (FSFI) score.

RESULTS

29 (62%) women answered the questionnaire: 15 (52%) had a VRAM and 16 (55%) a colpectomy. Among the 21 patients with SL before surgery, 16 (76%) still had intercourse with a mean FSFI score of 19.5 ± 10.9 [4.8-36]. Main difficulties reported were troubles of lubrication, orgasm, and dyspareunia. Confection of a VRAM did not influence the recovery of SL (P = 0.717). Colpectomy reduced return of SL (P = 0.026).

CONCLUSION

Among women who had SL before APR, 76% still had sexual intercourse after. Colpectomy seems to reduce SL.

Late patient-reported toxicity after preoperative radiotherapy or chemoradiotherapy in nonresectable rectal cancer: results from a randomized Phase III study

PURPOSE

Preoperative chemoradiotherapy (CRT) is superior to radiotherapy (RT) in locally advanced rectal cancer, but the survival gain is limited. Late toxicity is, therefore, important. The aim was to compare late bowel, urinary, and sexual functions after CRT or RT.

METHODS AND MATERIALS

Patients (N = 207) with nonresectable rectal cancer were randomized to preoperative CRT or RT (2 Gy × 25 ± 5-fluorouracil/leucovorin). Extended surgery was often required. Self-reported late toxicity was scored according to the LENT SOMA criteria in a structured telephone interview and with questionnaires European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30), International Index of Erectile Function (IIEF), and sexual function-vaginal changes questionnaire (SVQ).

RESULTS

Of the 105 patients alive in Norway and Sweden after 4 to 12 years of follow-up, 78 (74%) responded. More patients in the CRT group had received a stoma (73% vs. 52%, p = 0.09). Most patients without a stoma (7 of 12 in CRT group and 9 of 16 in RT group) had incontinence for liquid stools or gas. No stoma and good anal function were seen in 5 patients (11%) in the CRT group and in 11 (30%) in the RT group (p = 0.046). Of 44 patients in the CRT group, 12 (28%) had had bowel obstruction compared with 5 of 33 (15%) in the RT group (p = 0.27). One-quarter of the patients reported urinary incontinence. The majority of men had severe erectile dysfunction. Few women reported sexual activity during the previous month. However, the majority did not have concerns about their sex life.

CONCLUSIONS

Fecal incontinence and erectile dysfunction are frequent after combined treatment for locally advanced rectal cancer. There was a clear tendency for the problems to be more common after CRT than after RT.

Different irradiation machines and their effects on testes’ exposure levels and sex hormones profile in patients with rectal cancer

Objective: Complications of pelvic irradiation for rectal cancer have gained more attention because of increased survival of patients. The aim of this study was to compare testes doses when pelvis is irradiated using Cobalt 60 (Co60) for rectal cancer in comparison with linear accelerator (LINAC) and its effect on sex hormones levels.

Materials and Methods: In a cohort study, 28 rectal cancer patients that were candidate to receive pelvic radiotherapy were recruited in the study consecutively. They were sequentially assigned to receive radiotherapy using Co60 teletherapy or LINAC. Serum sex hormones levels were measured before and 3–6 weeks after irradiation. Testes absorption doses were measured three times during whole course of irradiation in nine patients.

Results: Testes doses in LINAC group were significantly lower than Co60 group (p < 0.001). Serum follicular-stimulating hormone (FSH) and luteinising hormone (LH ) levels increased after irradiation in both groups and there was not a significant relation between FSH and LH levels with treatment machine (p < 0.2 and p < 0.6, respectively). Serum testosterone level decreased significantly in Co60 group (p < 0.05) but not in LINAC group (p < 0.3).

Discussion: It seems using LINAC for pelvic irradiation in patient with rectal cancer cannot prevent hormonal changes and we suggest using extra shield to decrease testes doses below the toxic levels.

Sexual function in colorectal cancer survivors

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The challenges of colorectal cancer survivorship

With advances in treatment, colorectal cancer (CRC) is being transformed from a deadly disease into an illness that is increasingly curable. With this transformation has come increased interest in the unique problems, risks, needs, and concerns of survivors who have completed treatment and are cancer-free. Research has shown that physical and mental quality of life for CRC survivors was inferior compared with age-matched individuals without cancer. Although issues and symptoms were most prominent during the first 3 years, long-term effects of treatment can persist and include fatigue, sleep difficulty, fear of recurrence, anxiety, depression, negative body image, sensory neuropathy, gastrointestinal problems, urinary incontinence, and sexual dysfunction. The unique challenges and issues of CRC survivors can and should be addressed by health care providers and the research community to ensure effective interventions and models of care to manage these problems. This article discusses what is known about the long-term effects of CRC treatment on quality of life, the care of survivors, and existing models of survivorship care.

Measuring sexual and urinary outcomes in women after rectal cancer excision

PURPOSE

This study was designed to investigate sexual and urinary dysfunction in women who underwent rectal cancer excision, and the influence of tumor and treatment variables on long-term outcomes.

METHODS

Data were prospectively collected on 295 women who underwent rectal cancer excision at a tertiary referral colorectal center from 1998 to 2006. Sexual and urinary function was assessed preoperatively and at intervals up to five years after surgery. Functional outcomes were assessed by using univariate and multivariate regression analysis, chi-squared test for trend, or Kruskal-Wallis test.

RESULTS

The mean age of the patients was 60.9 years. Anterior resection was performed in 222 patients (75.2 percent) and abdominoperineal resection in 73 patients (24.7 percent). Patients who underwent abdominoperineal resection were less sexually active (25 vs. 50 percent; P = 0.02) and had a lower frequency of intercourse than anterior resection patients at one year after surgery (anterior resection, 3 (0-5) (median interquartile range); abdominoperineal resection 0 (0-4); P = 0.029). The frequency of intercourse improved over time for abdominoperineal resection (4 months, 0 (0-0) median interquartile range; 5 years, 3 (0.25-4) median interquartile range; P = 0.028). Abdominoperineal resection was associated with increased dyspareunia (odds ratio, 5.75; 95 percent confidence interval (CI), 1.87-17.6; P = 0.002), urinary urgency (odds ratio, 8.52; 95 percent CI, 2.81-25.8; P < 0.001), incontinence (odds ratio, 2.41; 95 percent CI, 1.11-5.26; P = 0.026), poor stream (odds ratio, 5.64, 95 percent CI, 2.55-12.5; P <or= 0.001), and urinary retention (odds ratio, 11.7; 95 percent CI, 4.15-32.9; P < 0.001). Women who underwent radiotherapy had a 4.68-fold increase in dyspareunia (95 percent CI, 1.84-11.9; P = 0.001). Intra-abdominal sepsis was associated with decreased ability to achieve arousal (odds ratio, 0.085; 95 percent CI, 0.008-0.958; P = 0.046).

CONCLUSIONS

Abdominoperineal resection, radiotherapy, intra-abdominal sepsis, and age 65 years or older are associated with significant impairments in female urinary and sexual outcomes after rectal cancer excision. Sexual and urinary outcomes should be considered when planning treatment for patients with rectal cancer.

Adjuvant and neoadjuvant chemoradiation or radiotherapy in rectal cancer--a review focusing on open questions

BACKGROUND

The therapy of rectal cancer has been a matter of debate since decades, especially with regard to the benefits of neoadjuvant or adjuvant therapies. Principles of additional therapies have been established nearly two decades ago and are questioned nowadays on the basis of more recently modified operative techniques. Benefits and sequelae of therapies have to be balanced against each other, and it seems somewhat likely that a more differentiated strategy than simply stating that every patient with stage II and III rectal cancer needs chemoradiation or radiotherapy will, in long term, be recommended.

CONCLUSION

It should be kept in mind that results of centers of excellence and of phase-III studies with their positively selected patient populations are not representative for all the patients with rectal cancer and physicians treating them.

Sexuality in women with cancer

There are gaps in the research regarding sexuality in women with cancer, making the interventions that are used more expert opinion rather than scientific evidence. There is a need for research about effective interventions, and there is a need to educate nurses to help change practice through communication about a topic that makes both the patient and the nurse uncomfortable.

Quality of life after transanal endoscopic microsurgery and total mesorectal excision in early rectal cancer

OBJECTIVE

Total mesorectal excision (TME) is the gold standard in rectal cancer, if curation is intended. Transanal endoscopic microsurgery (TEM) is a much safer technique and seems to have comparable survival in early rectal cancer. The impact of both procedures on quality of life has never been compared. In this study we compared quality of life after TEM and TME.

METHOD

Fifty-four patients underwent TEM for a T1 carcinoma. Only patients without known locoregional or distant recurrences were included, resulting in 36 eligible patients in whom quality of life after TEM was studied. The questionnaires used included the EuroQol EQ-5D, EQ-VAS, EORTC QLQ-C30 and EORTC QLQ-CR38. The results were compared with a sex-and age-matched sample of T+N0 rectal cancer patients who had undergone sphincter saving surgery by TME and a sex- and age matched community-based sample of healthy persons.

RESULTS

Thirty-one patients after TEM returned completed questionnaires (overall response rate 86%). Quality of life was compared with 31 TME patients and 31 healthy controls. From the patients' and social perspective quality of life did not differ between the three groups. Compared with TEM, significant defecation problems were seen after TME (P < 0.05). A trend towards better sexual functioning after TEM, compared with TME, was seen, especially in male patients, although it did not reach statistical significance.

CONCLUSION

Transanal endoscopic microsurgery and TME do not seem to differ in quality of life postoperatively, but defecation disorders are more frequently encountered after TME. This difference could play a role in the choice of surgical therapy in (early) rectal cancer. Further prospective studies are needed to confirm our conclusions.

[Surgical treatment of recurrent locoregional rectal cancer]

Local recurrence (LR) after curative surgery for rectal cancer occurs in 4 to 33% of cases especially if surgery is sub-optimal (without total excision of the mesorectum). In many cases, diagnosis of LR is made at a late stage because of the high rate of asymptomatic patients, 56% in the experience of the Mayo Clinic. MRI and PETscan are most effective for assessing local and general extension, with a high diagnostic accuracy. Surgical treatment alone or with radiation (preoperative and/or intraoperative) is the only curative treatment of LR with R0 resectability rates of 30% to 45%. Morbidity and mortality rates are high, especially for total exenteration and abdomino-sacral resection. After curative surgery, 5-year global survival is between 30% and 40%. Palliative resection of macroscopic residues is not recommended. Careful patient selection for curative surgery is the best way to optimize treatment in these cases.

Laparoscopic Pelvic Autonomic Nerve-Preserving Surgery for Patients with Lower Rectal Cancer after Chemoradiation Therapy

OBJECTIVE

This is a phase II study, the aim of which is to determine if a laparoscopic approach can be used in pelvic autonomic nerve-preserving surgery for patients with lower rectal cancer following chemoradiation therapy.

METHODS

Patients with T3 lower rectal cancer treated by preoperative chemoradiation were recruited and subjected to laparoscopic pelvic autonomic nerve-preserving surgery with total mesorectal excision and a sphincter-saving procedure. This study was performed with the approval of the ethics committee of National Taiwan University Hospital. Because the quality of a surgical trial is highly dependent on the skill of the surgeon with respect to the technique under study, it is imperative that a surgical trial only be implemented after the surgical technique has been judged to be mature. Before the start of this clinical trial, we gained a sound knowledge of surgical anatomy through conventional open surgery for rectal cancer and mastered the related laparoscopic skills from other sound and proven laparoscopic approaches, including right hemicolectomy, left hemicolectomy, among others. We determined that the learning curve for this surgical technique necessitated that colorectal surgeons carry out at least 20 such procedures. At this point we conducted this clinical trial. The details of the surgical procedures have been shown in the attached video. Briefly, the dissection commences at the pelvic promontory with exposure and preservation of the superior hypogastric plexus. The pre-aortic plexus and inferior mesenteric plexus are preserved by sparing the pre-aortic connective tissue and leaving a 1- to 2-cm-long stump of the inferior mesenteric artery in situ. Subsequently, the "holy plane" at the transition of the mesosigmoid to the mesorectum is meticulously dissected to progressively displace the hypogastric nerves dorsally and laterally and, therefore, preserving them. Following adequate dorsal and lateral dissection down to the floor of the pelvis, the so-called lateral ligament is reached at which the mesorectum appears to be adherent, anteriorly and laterally, to the inferior hypogastric plexus (at roughly 10:00-2:00 O'clock or within an angle of 60 degrees about symphysis on both sides). The ligaments are divided immediately at the endopelvic fascia of the mesorectum to avoid damage to the inferior hypogastric plexus (pelvic plexus). Finally, great care was taken to dissect the lateral border of Denonvilliers' fascia where the inferior hypogastric plexus joins the neurovascular bundle described by Walsh. Postoperatively, only patients successfully operated on by total pelvic autonomic nerve-preserving surgery were included in the statistical analysis of surgical outcomes. Preoperatively, all patients were screened for their genitourinary function by a questionnaire-based interview. Patients with abnormal preoperative baseline functional data were excluded from further postoperative assessment of sexual or urinary function. The male sexual function was evaluated by potency and ejaculation. In female patients, the sexual function was assessed by vaginal lubrication, dyspareunia, sexual arousal, and orgasm. The reason for these four parameters is because the influence of pelvic autonomic nerve damage on female sexual function has been ambiguous but would most likely result in impairment of vaginal lubrication and congestion of the genitals. We evaluated sexual function at 6 months postoperatively, when the temporary colostomy had been closed and the patients were completely recovered from surgical disability. In evaluating urinary function, the duration between initial voiding trial and spontaneous voiding was recorded. The questionnaire used for the assessment of urinary dysfunction was based on the International Prostate Symptom Score and the following parameters from this Score were used: incomplete emptying, frequency, intermittency, urgency, week stream, straining, and nocturia. Any voiding problems recovered within 3 months after the operation were considered to be transient bladder voiding dysfunction; all other voiding problems were deemed persistent. The interview and scoring of the questionnaire were done by the research assistant blinded to operation procedures. The genitourinary function was ranked as good, fair (decreased), and poor (impaired).

RESULTS

Between June 2003 and December 2005, a total of 98 patients (stage II: n = 44; stage III: n = 54; male: n = 50; female: n = 48) were enrolled in this study. Technically, although the dissection plane is a little blurred by preoperative chemoradiation therapy, the laparoscopic pelvic nerve-preserving procedure with total mesorectal excision was successfully performed in 89 (90.8%) patients with an acceptable operation time (284.4 +/- 44.8 minutes; mean +/- standard deviation) and little blood loss (114.5 +/- 24 ml). The number of dissected lymph nodes was 16.4 +/- 4.0. With respect to scrutiny of surgical specimens, the distal safety margin was adequate (mean: 2.4 cm; range: 1.2-5.6 cm), and the circumferential resection margins were free of tumor invasion (mean: 8.6 mm; range: 2-18 mm). A total of 74 patients completed the evaluation of urinary function. For these 74 patients, the median duration of training for the Foley catheter was 7 days (range: 4-64 days). The voiding function after removal of the Foley catheter were good in 53 (71.6%) patients, fair in 17 (23.0%), and poor in four (5.4%). Of the 17 patients with fair bladder function, eight were transient dysfunction and recovered thereafter. Thirty-two male and 28 female patients who were sexually active before the operation responded to the assessment of sexual function. In male patients, the ejaculation was good in 18 (56.3%) patients, fair (decrease in ejaculatory amounts) in six (18.7%), and poor (retrograde ejaculation, failure to ejaculate) in eight (25%). The potency was good in 20 (62.5%) patients, fair in five (15.6%), and poor in seven (21.9%). In female patients, the sexual function was good in 15 (53.6%) patients, fair in four (14.3%), and poor in nine (32.1%). Specific sexual problems in women included lubrication (46.6%, n = 13), dyspareunia (39.2%, n = 11), sexual arousal (28.6%, n = 8), and orgasm in (32.1%, n = 9).

CONCLUSIONS

By the laparoscopic approach, total preservation of pelvic autonomic nerves without compromise of the radical extirpation of tumor is technically feasible in the vast majority of patients with lower rectal cancer who have undergone concurrent chemoradiation therapy, thus facilitating the retention of genitourinary function in a significant proportion of such patients.