Sexual function after rectal excision

Ventral Rectopexy: An International Expert Panel Consensus and Review of Contemporary Literature

BACKGROUND

Ventral rectopexy has become increasingly used in the surgical management of rectal prolapse. There is a need for a contemporary evaluation of the role of the procedure and a description of its use in clinical practice.

OBJECTIVE

To create an international consensus on ventral rectopexy.

DESIGN

An expert panel undertook a scoping review of the literature to identify subject domains of interest. Literature reviews were completed for each domain with subsequent development of evidence-based and practice-based statements. These statements were compiled and reviewed by the group over a total of 9 meetings. Once statements were confirmed, supportive text was finalized, and an anonymous vote was completed using Research Electronic Data Capture to record consensus.

SETTING

An international expert panel comprising colorectal surgeons who perform ventral rectopexy in a high-volume center.

MAIN OUTCOME MEASURES

Statements and associated expert consensus.

RESULTS

Eleven experts identified 10 domains for review: indications, contraindications, assessment and planning, consent, operative details, prostheses, complications, follow-up, recurrence and reoperative surgery, and specific considerations. After round table review, there were 17 resultant statements for consideration. Experts agreed unanimously with 13 of the statements and their accompanying text, with different experts disagreeing regarding the remaining 4 statements (91% consensus each).

LIMITATIONS

Paucity of high-quality data.

CONCLUSIONS

This international group developed 17 statements with high consensus. These statements provide an up-to-date summary of the literature, identify key areas for research development, and provide a reference point for colon and rectal surgeons who undertake ventral rectopexy as part of their practice. See Video Abstract .

RECTOPEXIA VENTRAL CONSENSO DE UN PANEL INTERNACIONAL DE EXPERTOS Y REVISIN DE LA LITERATURA CONTEMPORNEA

ANTECEDENTES:La rectopexia ventral se ha utilizado cada vez más en el tratamiento quirúrgico del prolapso rectal. Es necesario realizar una evaluación contemporánea del rol del procedimiento y una descripción de su uso en la práctica clínica.OBJETIVO:Crear un consenso internacional sobre la rectopexia ventral.DISEÑO:Un panel de expertos realizó una revisión exhaustiva de la literatura para identificar los dominios temáticos de interés. Se completaron revisiones de la literatura para cada dominio con el desarrollo de declaraciones basadas en la evidencia y la práctica. Estas fueron compiladas y revisadas por el grupo a lo largo de un total de nueve reuniones. Una vez que se confirmaron las declaraciones, se finalizó el texto de apoyo y se completó una votación anónima utilizando REDCap para registrar el consenso.ESCENARIO:Un panel internacional de expertos compuesto por cirujanos colorrectales que realizan rectopexia ventral en un centro de alto volumen.PRINCIPALES MEDIDAS DE RESULTADOS:Declaraciones y consenso de expertos asociado.RESULTADOS:Once expertos identificaron diez dominios a revisar: indicaciones, contraindicaciones, evaluación y planificación, consentimiento, detalles operatorios, prótesis, complicaciones, seguimiento, recurrencia y cirugía reoperatoria y consideraciones específicas. Después de la revisión en mesa redonda, hubo 17 declaraciones resultantes para su consideración. Los expertos estuvieron de acuerdo unánimemente con trece de las declaraciones y su texto acompañante, y diferentes expertos estuvieron en desacuerdo con cuatro declaraciones (91% de consenso cada una).LIMITACIONES:Escasez de datos de alta calidad.CONCLUSIÓN:Este grupo internacional desarrolló 17 declaraciones con alto consenso. Estas declaraciones proporcionan un resumen actualizado de la literatura, identifican áreas claves para el desarrollo de la investigación y un punto de referencia para los cirujanos de colon y recto que realizan rectopexia ventral como parte de su práctica. (Traducción-Dr. Aurian Garcia Gonzalez ).

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.

Total Mesorectal Excision vs. Transanal Endoscopic Microsurgery Followed by Radiotherapy for T2N0M0 Distal Rectal Cancer: A Multicenter Randomized Trial

Introduction

Transanal endoscopic microsurgery (TEM) is an organ-preserving treatment alternative for patients with early rectal cancer. However, TEM alone is associated with greater risk of local recurrence and inferior survival in comparison with total meso-rectal excision (TME). As an important adjuvant therapy, radiotherapy can effectively reduce the local recurrence rate of rectal cancer. This study aimed to investigate whether TEM followed by radiotherapy can be a valid alternative to TME in T2N0M0 distal rectal cancer treatment.

Methods

We plan to recruit 168 participants meeting established inclusion criteria. Following informed consent, participants will randomly receive treatment protocols of TEM followed by radiotherapy (a total dose of 45–50.4 Gy given in 25–28 factions) or TME. Depending on post-operative pathology, the participants will receive either long-term follow-up or further treatment. The primary endpoint of this trial is 3-year local recurrence rate. The secondary end points include 3-year disease-free survival rate, 3-year overall survival rate, 3-year mortality rate, post-operative quality of life, post-operative safety index, intraoperative evaluation index and post-operative short-term evaluation index.

Discussion

This trial is the first prospective randomized trial to investigate the rectum preserving treatment by using transanal local excision followed by radiotherapy.

Clinical trial registration

The trial was prospectively registered at ClinicalTrials.gov NCT04098471 on September 20, 2019.

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

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

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Functional fecal and urinary outcomes after sacrococcygeal mass resection in pediatric patients

BACKGROUND

Sacrococcygeal masses (SCM) are uncommon in children. The purpose of this study is to review the functional fecal and urinary outcomes following resection of SCM and to determine the impact of a multidisciplinary clinic (MDC) on these outcomes.

METHODS

A retrospective review was performed of patients who underwent SCM resection between 1979 and 2019. Baylor Social Continence Scale (BCS), Vancouver Symptom Score (VSS) and Cleveland constipation score (CSS) surveys were used to assess fecal and urinary continence at time of most recent follow up. Age, tumor characteristics, histopathology, and type of anorectal malformations (ARM), if present, were also recorded.

RESULTS

75 patients were included. 51 (69%) patients were females and 23 (31%) had an associated ARM. The median age at resection was 8.5 months (IQR 0-26.8). 41 (56%) patients were followed in the MDC. 27 (82%) of patients seen in the MDC were clean for stool and 26 (87%) were dry for urine, while only 17 (59%) of patients not seen in the MDC were clean for stool and dry for urine (p<0.05). There was improvement in Baylor, Vancouver and Cleveland scores.

CONCLUSIONS

A multidisciplinary approach to the care of patients following SCM resection may improve bowel and bladder outcomes.

Characterizing the autonomic neural connections between the abdominal aortic and superior hypogastric plexuses: A multimodal neuroanatomical study

The aortic plexus serves as the primary gateway for sympathetic fibers innervating the pelvic viscera. Damage to this plexus and/or its associated branches can lead to an assortment of neurogenic complications such as bladder dysregulation or retrograde ejaculation. The neuroanatomy of this autonomic plexus has only recently been clarified in humans; as such, the precise function of its constituent fibers is still not clear. Further study into the functional neuroanatomy of the aortic plexus could help refine nerve-sparing surgical procedures that risk debilitating neurogenic complications, while also advancing understanding of peripheral sympathetic circuitry. To this end, the current study employed an in vivo electrostimulation paradigm in a porcine model, in combination with lipophilic neuronal tracing experiments in fixed, post-mortem human tissues, to further characterize the functional neuroanatomy of the aortic plexus. Electrostimulation results demonstrated that caudal lumbar splanchnic nerves provide primary control over the porcine bladder neck in comparison to other constituent fibers within the aortic plexus. Ex vivo human data revealed that the prehypogastric ganglion contains a significant number of neurons projecting to the superior hypogastric plexus, and that these neurons are arranged in a topographic manner within the ganglion. Altogether, these findings suggest that a pivotal sympathetic pathway mediating bladder neck contraction courses through the caudal lumbar splanchnic nerves, prehypogastric and inferior mesenteric ganglia and superior hypogastric plexus.

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.

Erectile dysfunction after surgery for rectal cancer: a prospective study

Objectives

Erectile dysfunction may occur as a complication of surgical treatment of rectal cancer in male patients. We compared the rates of postoperative erectile dysfunction and response to medical treatment after low anterior resection (LAR) and Miles' procedures.

Material and Methods

Fifty patients who underwent the Miles' procedure or LAR were prospectively assessed. This study includes fifty patients with stages 1 and stage 2 rectal cancer based on clinical and radiologic assessments, who underwent Miles' (25 out of 50 patients underwent the Miles'procedure and ) or LAR (25 patients underwent LAR) procedures were prospectively assessed. The International Index of Erectile Function (IIEF) form was, used in the assessment to assess erectile dysfunction. This questionnaire, was administered preoperatively and 6 months postoperatively. For the patients with IIEF scores ≤ 25 at postoperative 6th months, tadalafil 5 mg is was given for 12 weeks and IIEF is was repeated after then.

Results

No significant differences were found in mean IIEF scores preoperatively (p= 0.695). In both groups, IIEF scores were significantly lower postoperatively compared with preoperatively (p= 0.00001, LAR; p= 0.00001, Miles'). Mean postoperative IIEF scores were significantly lower in patients who underwent Miles' compared with the LAR procedures (p= 0.0001). For patients with IIEF scores ≤ 25 at 6 months, tadalafil 5 mg was given for 12 weeks and IIEF scores were better in both groups (p= 0.00001).

Conclusion

The erectile dysfunction rate after Miles' procedure was significantly higher than the rate of patients who developed erectile dysfunction after LAR surgery. We tried to emphasize that in after LAR surgery. We should not be concerned only with cancer treatment surgically in rectal tumour patients, but remember that situations affecting their social life, such as postoperative erectile dysfunction, have medical and psychologic importance.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of ulcerative colitis management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of ulcerative colitis. The committee was able to identify some points of major disagreement and suggested strategies to improve the quality of available data and acceptance of guidelines.

Transanal total mesorectal excision: how are we doing so far?

AIM

This subgroup analysis of a prospective multicentre cohort study aims to compare postoperative morbidity between transanal total mesorectal excision (TaTME) and laparoscopic total mesorectal excision (LaTME).

METHOD

The study was designed as a subgroup analysis of a prospective multicentre cohort study. Patients undergoing TaTME or LaTME for rectal cancer were selected. All patients were followed up until the first visit to the outpatient clinic after hospital discharge. Postoperative complications were classified according to the Clavien-Dindo classification and the comprehensive complication index (CCI). Propensity score matching was performed.

RESULTS

In total, 220 patients were selected from the overall prospective multicentre cohort study. After propensity score matching, 48 patients from each group were compared. The median tumour height for TaTME was 10.0 cm (6.0-10.8) and for LaTME was 9.5 cm (7.0-12.0) (P = 0.459). The duration of surgery and anaesthesia were both significantly longer for TaTME (221 vs 180 min, P < 0.001, and 264 vs 217 min, P < 0.001). TaTME was not converted to laparotomy whilst surgery in five patients undergoing LaTME was converted to laparotomy (0.0% vs 10.4%, P = 0.056). No statistically significant differences were observed for Clavien-Dindo classification, CCI, readmissions, reoperations and mortality.

CONCLUSION

The study showed that TaTME is a safe and feasible approach for rectal cancer resection. This new technique obtained similar postoperative morbidity to LaTME.

Close rectal dissection in benign diseases of the rectum: A review

PURPOSE

Total mesorectal excision (TME) is the gold standard resectional strategy for rectal cancer to minimize loco-regional recurrence and optimize oncological outcomes. This plane is described by many as 'bloodless' but it does contain important pelvic neural plexuses and dissection may be close to the ureters and major vascular structures, particularly in inflammatory conditions of the distal colon and rectum. In such benign diseases a more conservative excision, so-called close rectal dissection, has been advocated to minimize damage to these structures.

METHODS

A review of the literature was conducted to document the evolution of this procedure. Contemporary literature was interrogated to ascertain how this approach is adopted in minimally invasive surgery. Post-operative outcomes are compared to those from TME surgery.

RESULTS

From early descriptions in 1956, this procedure has been adapted for use in laparoscopic surgery. It may be particularly useful in trans-anal mesorectal surgery. Reported benefits include reduced nerve injury and pelvic sepsis. However, this must be balanced against risks of mesorectal bleeding, rectal injury, and ongoing inflammation from the retained mesorectum.

CONCLUSION

Rectal surgery in inflammatory conditions is technically challenging. Close rectal dissection is an alternate approach available to colorectal surgeons in these cases to minimize pelvic morbidity and optimize postoperative outcomes.

Local excision results in comparable survival to radical resection for early-stage rectal carcinoid

BACKGROUND

Controversy exists regarding current National Comprehensive Cancer Network guidelines, which recommend local excision for rectal carcinoids ≤2 cm and radical resection for tumors >2 cm. Given the limited data examining optimal surgical approach for these lesions, we queried a national database to determine the impact of extent of resection on survival.

METHODS

Patients undergoing treatment for clinical stage I and II rectal carcinoid (RC) were identified from the National Cancer Data Base (1998-2012). The association between extent of surgery, tumor size, and the likelihood of pathologic lymph node positivity was examined. Kaplan-Meier analysis was used to compare overall survival.

RESULTS

In total, 1900 patients were identified, of whom 1644 (86.5%) were treated with local excision, and 256 (13.5%) were treated with radical resection. A significant majority of patients with tumors ≤2.0 cm (89.0%) and nearly half with tumors 2.1-4.0 cm (44.8%) or >4.0 cm (45.8%) underwent local excision. Nodal positivity was correlated with tumor size (7.1% positivity with ≤2.0 cm tumors, 31.3% with 2.1-4.0 cm tumors, and 50.0% with >4 cm tumors). However, 5-y survival was equivalent between surgical approaches for tumors ≤2 cm (93.0% versus 93.0%) and tumors 2.1-4.0 cm (76.0% versus 76.0%).

CONCLUSIONS

We demonstrate in early-stage RC that nearly half of intermediate and large tumors are being treated with local excision outside National Comprehensive Cancer Network guidelines. In addition, radical resection does not appear to be associated with improved overall survival for tumors of any size. These findings suggest that the preferred approach to early-stage RCs without aggressive biological characteristics is local excision due to the decreased morbidity and mortality versus radical resection.

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

Aims:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

Denonvilliers' fascia in men: a sheet plastination and confocal microscopy study of the prerectal space and the presence of an optimal anterior plane when mobilizing the rectum for cancer

AIM

The aim of this study was to investigate the detailed, in situ, morphology of Denonvilliers fascia (DVF) in cadavers using sheet plastination and confocal microscopy and to review and describe the optimal anterior plane for mobilisation of the distal rectum..

METHOD

Six, male cadavers (age range, 46-87 years) were prepared as six sets of transverse (x2), coronal (x1) and sagittal (x3) plastinated sections which were examined under a confocal laser scanning microscope.

RESULTS

In this study a consistent space between the anterior rectal wall and the posterior surface of the prostate and seminal vesicles above the level of the perineal body was termed the prerectal space. Within that prerectal space we identified fibres which take their origin from the external urethral sphincter (EUS), together with others from the longitudinal rectal muscle (LRM) and the connective tissue sheaths of neurovascular bundles. Neither the EUS- nor the LRM-originated fibres were continuous with the endopelvic fascia;they are interposed laterally and cranially by multiple neurovascular bundles. Further, our results suggest that the peritoneum does not descend deep within the prerectal space.

CONCLUSION

This study reveals the undisturbed, in situ, structural detail of membrane-like structures in the prerectal space and confirms that the optimal plane for anterolateral mobilization of the rectum is posterior to the multilayered DVF. This article is protected by copyright. All rights reserved.

Sexual Dysfunction and Intimacy for Ostomates

Sex and intimacy presents special challenges for the ostomate. Since some colorectal surgery patients will require either temporary or permanent stomas, intimacy and sexuality is a common issue for ostomates. In addition to the stoma, nerve damage, radiotherapy, and chemotherapy are often used in conjunction with stoma creation for cancer patients, thereby adding physiological dysfunction to the personal psychological impact of the stoma, leading to sexual dysfunction. The purpose of this paper is to describe the prevalence, etiology, and the most common types of sexual dysfunction in men and women after colorectal surgery and particularly those patients with stomas. In addition, treatment strategies for sexual dysfunction will also be described.

Phosphodiesterase-5 Inhibitors and Vacuum Erection Device for Penile Rehabilitation After Laparoscopic Nerve-Preserving Radical Proctectomy for Rectal Cancer: A Prospective Controlled Trial

The current study sought to clarify the role of phosphodiesterase type 5 inhibitors (PDE-5i) and a vacuum erection device (VED) in penile rehabilitation after laparoscopic nerve-preserving radical proctectomy (LNRP) for rectal cancer. Participants were assigned to one of the following arms-no-intervention, nightly use of sildenafil 25 mg for 3 months after surgery, or concurrent use of nightly sildenafil 25 mg/day for 3 months and a vacuum erection device (VED) 10 to 15 minutes/day for 3 months-in a nonrandomized fashion. All participants had a follow-up of over 12 months prospectively, and patients had baseline, 3-, 6-, and 12-month assessment based on the International Index of Erectile Function-5 (IIEF-5). Seventy-one cases were included in final analyses. In the no-intervention group, the mean baseline IIEF-5 score of 21.9 decreased rapidly to 5.0 at 3 months ( p < .001), 9.2 at 6 months ( p < .001), and stayed at 10.9 at 12 months ( p < .001). In the single therapy group, the mean baseline IIEF-5 score of 22.4 decreased dramatically to 9.0 at 3 months ( p < .001), 14.9 at 6 months ( p = .005), and stayed at 15.1 at 12 months ( p = .005). In the combined therapy group, the mean baseline IIEF-5 score of 23.0 decreased slightly to 15.0 at 3 months ( p = .005), 18.0 at 6 months ( p = .038), and maintained at 18.7 at 12 months ( p = .163). Findings suggested an over 50% decline in the quality of erection function of the patients after LNRP. The early use of PDE-5i alone or combined use of PDE-5i and VED after LNRP maintained erectile function at 12 months.

Survivorship care plans for people with colorectal cancer: do they reflect the research evidence?

AIM

In the present study, we synthesized the published literature about the psychosocial aspects of colorectal cancer (crc) survivorship to support an update of the evidentiary base of the survivorship care plans (scps) created in our jurisdiction.

METHODS

The psychosocial topics identified in the crc scps created by two different initiatives in our province were used as search criteria: quality of life (qol), sexual function, fatigue, and lifestyle behaviors. An umbrella review was conducted to retrieve the best possible evidence. Only reviews that investigated the intended outcomes in crc survivors and those with moderate-to-high methodologic quality scores were included.

RESULTS

Of 462 retrieved reports, eight reviews met the inclusion criteria for the synthesis. Of those eight, six investigated the challenges of crc survivors and two investigated the effect of physical activity on survivor well-being. Our results indicate that emotional and physical challenges are common in crc survivors and that physical activity is associated with clinically important benefits for the fatigue and physical functioning of crc survivors.

CONCLUSIONS

Our study findings update the evidence and indicate that existing scps in our province concerning the physical and emotional challenges of crc survivors reflect the evidence at the time of their issue. However, the literature concerning cancer risks specific to crc survivors is lacking. Although systematic reviews are considered to be the "gold standard" in knowledge synthesis, our findings suggest that much remains to be done in the area of synthesis research to better guide practice in cancer survivorship.

Rectal mobilization: the place of Denonvilliers' fascia and inconsistencies in the literature

Confusion remains as to what is meant by Denonvilliers' fascia. This review searched the literature on pelvic surgical anatomy to determine whether there is agreement with Denonvilliers' original description and its implication in defining the correct anterior plane of dissection when mobilizing the rectum. The original French description of the fascia was translated into English and then compared both with French and with English studies identified by searching PubMed, Medline and Scopus from 1836 to June 2015. Special emphasis was given to the years between 1980 and 2015 in order to capture the literature pertinent to, and following on from, the description of total mesorectal excision for rectal cancer. The final literature search revealed 16 studies from the original 2150 citations. Much of the debate was concerned with the origin and development of the fascia, arising from either the 'fusion' or the 'condensation' of local primitive tissue into a mature 'multilayered' structure. Controversy regarding the correct plane of rectal mobilization occurs as a result of different interpretations by surgeons, anatomists and radiologists and bears little resemblance to Denonvilliers' original description. This may reflect wide anatomical variability in the adult pelvis or a form of dissection artefact. Further study is required to investigate this. Logically, for both men and women, the plane of rectal mobilization should be behind Denonvilliers' fascia and between it and the fascia propria of the rectum.

Comparison of short-term clinical outcomes between transanal and laparoscopic total mesorectal excision for the treatment of mid and low rectal cancer: A meta-analysis

AIM

The objective of this meta-analysis was to evaluate the feasibility, safety, and short-term clinical outcomes of transanal total mesorectal excision (TaTME) comparing with laparoscopy total mesorectal excision (LapTME) for mid and low rectal cancer.

METHODS

Relevant studies were searched from the databases of Pubmed, Embase, and the Cochrane Library. The qualities of all of the included studies were evaluated using Newcastle-Ottawa Scale (NOS). The synthesized outcomes were pooled using fixed-effects models or random-effects models, which weighted the odds ratio (OR) or mean difference (MD) with 95% confidence intervals (95% CI). A funnel plot was used to evaluate the publication bias.

RESULTS

Seven original studies including 209 TaTME patients and 257 LapTME patients with rectal cancer met the inclusion criteria in this meta-analysis. Compared with LapTME, TaTME showed a longer CRM, lower rate of positive CRM, complete TME rate, and less operative time. There were no significant differences in the outcomes of the harvested lymph nodes, distal margin distance, hospital stay, intraoperative complications, anastomotic leakage, postoperative complications, reoperation, readmission, or conversion between the TaTME group and the LapTME group.

CONCLUSIONS

Compared with LapTME, TaTME is a feasible and safe approach for patients with mid and low rectal cancer. In addition, TaTME showed a better short-term clinical outcomes, such as a longer CRM, lower risk of positive CRM, higher complete quality of TME rate, and shorter operative duration. Further prospective studies with long-term follow-up are required.

Sexual dysfunction in males following low anterior resection

AIMS AND OBJECTIVES

The purpose of this study was to explore the prevalence of sexual dysfunction in males one year after undergoing low anterior resection and to determine whether health care professionals discuss sexual issues with patients after surgery.

BACKGROUND

Sexual dysfunction in males may be a complication after low anterior resection for rectal cancer, but few studies have explored this issue in Taiwan.

DESIGN

A descriptive comparison study design.

METHODS

A descriptive comparison design was used, and a group of 133 participants underwent a low anterior resection procedure for rectal cancer. The results were compared with those of a group of males who underwent colectomy (n = 58) for colon cancer. The following instruments were used: the five-item version of the International Index of Erectile Function, personal demographics and medical variables.

RESULTS

The results showed that the prevalence of erectile dysfunction among the low anterior resection patients was 97·0% (129/133), and the erectile dysfunction prevalence was 75·9% (44/58) for the males who underwent colectomy. The generalised linear model showed that after controlling for hypertension and stoma, the low anterior resection group had worse sexual function than those in the colectomy group, and stoma was also a factor that impacted patients' sexual function. The results also revealed that only 32·8-35·3% of health care providers talked about sexual dysfunction with people who have rectal cancer prior to surgery.

CONCLUSION

This study demonstrated that men who have undergone low anterior resection have a high risk of sexual dysfunction and that health care professionals infrequently discuss these issues with patients.

RELEVANCE TO CLINICAL PRACTICE

When patients are diagnosed with rectal cancer and before they undergo surgery, an assessment and discussion of sexual function issues should be incorporated into standard care. Continued follow-up after hospital discharge and evaluations of sexual function are vital factors for male postoperative rectal cancer patients.

Sexual function after treatment for sacrococcygeal teratoma during childhood

BACKGROUND

Children treated for sacrococcygeal teratoma (SCT) may suffer from sexual dysfunction later in life because of the extended pelvic surgery performed, however, structured evaluations have not been performed yet.

METHODS

The Female Sexual Function Index (FSFI), the International Index of Erectile Function (IIEF) and the Body Image Questionnaire (BIQ) were sent to patients (≥18years) treated for SCT in the Dutch pediatric surgical centers after 1970.

RESULTS

Forty-five of 76 patients returned the questionnaires; 28 women (median age 27.3years, range 18.3-41.0) and seven men (median age 22.0years, range 19.1-36.5) were eligible for analysis. The FSFI and IIEF results were compared to healthy controls. Female patients scored significantly lower on the desire (p=0.014), arousal (p=0.013) and lubrication domain (p=0.019). FSFI total-scores of female patients were significantly lower compared to controls [median 30.5 (IQR 28.6-31.4) vs. median 32.4 (IQR 30.6-33.45) p≤0.001] but were above the threshold value for sexual dysfunction. Males reported normal erectile function and penetration ability with normal ejaculation. Females had significant lower BIQ results compared to males; BIQ-cosmesis scores were moderately correlated to the FSFI-desire score (r=-0.37, p=0.028).

CONCLUSION

SCT resection in girls may result in diminished sexual function at adult age with worse self-perceived body image. The possibility of sexual complaints should be integrated in the surveillance strategies for these patients.

Outcomes of ultra-low anterior resection combined with or without intersphincteric resection in lower rectal cancer patients

PURPOSE

We evaluated the current practice of ultra-low anterior resection (uLAR) in patients with lower rectal cancer and compared uLARs using mostly transabdominal approach with or without intersphincteric resection (ISR).

METHODS

A total of 624 consecutive lower rectal cancer patients undergoing curative uLAR were prospectively enrolled as ISR+ vs. ISR- groups (329 vs. 295 patients) between 2005 and 2012. The ISR+ group additionally received levator-sphincter reinforcement after distal resection.

RESULTS

The circumferential resection margin (CRM) + rate (≤1 mm) was 2.1 % in the two groups. Postoperative ileus occurred more in the ISR- group than in the ISR+ group (p = 0.02). Substantial erectile dysfunction occurred 1.8 times more frequently in the ISR- group than in the ISR+ group (32 vs. 18.1 %; p = 0.01) among male patients at 2 years postoperatively. The urge to defecate volume and maximal tolerance volume, closely correlated with maximal squeezing pressure and/or mean resting pressure, did not differ between patients with and without chemoradiotherapy until 24 months postoperatively. Nevertheless, the urge to defecate volume was lesser in the ISR- group than in the ISR+ group at 24 months postoperatively (p = 0.022). For 301 patients in which >5 years had elapsed postoperatively, the mean 5-year local recurrence rate was 4.3 %, and the 5-year disease-free and overall survival rates were 78.9 and 92 %, respectively, without differences between the two groups.

CONCLUSIONS

Compared with uLAR without ISR, the transabdominal ISR with levator-sphincter reinforcement provides a safe resection plane with competent CRM, concurrently reduces substantial complications, and marginally promotes recovery of neorectal function.

URINARY DYSFUNCTION AFTER SURGICAL TREATMENT FOR RECTAL CANCER

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

Animal models of erectile dysfunction

Erectile dysfunction (ED) is a prevalent male sexual dysfunction with profound adverse effects on the physical and the psychosocial health of men and, subsequently, on their partners. The expanded use of various types of rodent models has produced some advances in the study of ED, and neurophysiological studies using various animal models have provided important insights into human sexual dysfunction. At present, animal models play a key role in exploring and screening novel drugs designed to treat ED.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Penile rehabilitation after pelvic cancer surgery

Erectile dysfunction is the most common complication after pelvic radical surgery. Rehabilitation programs are increasingly being used in clinical practice but there is no high level of evidence supporting its efficacy. The principle of early penile rehabilitation stems from animal studies showing early histological and molecular changes associated with penile corporal hypoxia after cavernous nerve injury. The concept of early penile rehabilitation was developed in late nineties with a subsequent number of clinical studies supporting early pharmacologic penile rehabilitation. These studies included all available phosphodiesterase type 5 inhibitors, intracavernosal injection and intraurethral use of prostaglandin E1 and to lesser extent vacuum erectile devices. However, these studies are of small number, difficult to interpret, and often with no control group. Furthermore, no studies have proven an in vivo derangement of endothelial or smooth muscle cell metabolism secondary to a prolonged flaccid state. The purpose of the present report is a synthetic overview of the literature in order to analyze the concept and the rationale of rehabilitation program of erectile dysfunction following radical pelvic surgery and the evidence of such programs in clinical practice. Emphasis will be placed on penile rehabilitation programs after radical cystoprostatectomy, radical prostatectomy, and rectal cancer treatment. Future perspectives are also analyzed.

Anterior resection syndrome--a risk factor analysis

BACKGROUND

Evacuatory dysfunction after distal colorectal resection varies from incontinence to obstructed defaecation and is termed anterior resection syndrome. The aim of this study was to identify risk factors for the development of anterior resection syndrome.

METHODS

All anterior resections undertaken at Auckland Hospital from 2002 to 2012 were retrospectively evaluated. An assortment of patient and peri-operative variables were recorded. Cases were stratified by the occurrence of anterior resection syndrome symptoms from 1 to 5 years post-operatively.

RESULTS

A total of 277 patients were identified. Prevalence of anterior resection syndrome decreased progressively from 61 % at 1 year to 43 % at 5 years. Univariate analysis identified anastomotic height, surgeon, pT stage, procedure year and temporary diversion ileostomy as recurring significant correlates (p < 0.05). Logistic regression identified lower anastomotic height (odds ratio (OR) 2.11, 95 % confidence interval (CI) 1.05-4.27; p = 0.04) and obstructive presenting symptoms (OR 6.71, 95 % CI 1.00-44.80; p = 0.05) as independent predictors at 1 and 2 years, respectively. Post-operative chemotherapy was a predictor at 1 year (OR 1.93, 95 % CI 1.04-3.57; p = 0.03). Temporary diverting ileostomy was an independent predictor at 2 (OR 2.49, 95 % CI 1.04-5.95; p = 0.04), 3 (OR 4.17, 95 % CI 1.04-16.78; p = 0.04), 4 (OR 8.05, 95 % CI 1.21-53.6; p = 0.03), and 5 years (OR 49.60, 95 % CI 2.17-1134.71; p = 0.02) after adjusting for anastomotic height.

CONCLUSIONS

Anastomotic height, post-operative chemotherapy and obstructive presenting symptoms were independent predictors at 1 and 2 years. Temporary diversion ileostomy was an independent predictor for the occurrence of anterior resection syndrome at 2, 3, 4 and 5 years even after correcting for anastomotic height. Prospective assessment is required to facilitate more accurate risk factor analysis.

Meta-analysis of oncological outcome after abdominoperineal resection or low anterior resection for lower rectal cancer

In lower rectal cancer, postoperative outcome is still subject of controversy between the advocates of abdominoperineal resection (APR) and low anterior resection (LAR). Reports suggest that low anterior resection may be oncologically superior to abdominoperineal excision, although no good evidence exists to support this. Publications were identified which assessed the differences comparing 5-year survival, local recurrence, circumferential resection margin rate, complications and so on. A meta-analysis was performed to clarify the safety and feasibility of the two procedures with several types of outcome measures. A total of 13 studies met the inclusion criteria, and comprised 6,850 cases. Analysis of these data showed that LAR group was highly correlated with 5-year survival (pooled OR = 1.73, 95%CI: 1.30-2.29, P = 0.0002 random-effect). And local recurrence rate of APR group was significantly higher than that in LAR group (pooled OR = 0.63, 95%CI: 0.53-0.75, P < 0.00001 fixed-effect). Also, the circumferential resection margin (CRM) were high involved in APR group than in LAR group. (5 trials reported the data, pooled OR = 0.43, 95%CI: 0.36-0.52, P < 0.00001 fixed-effect). Besides, the incidents of overall complications of APR group was higher compared with LAR group (pooled OR = 0.52, 95%CI: 0.29-0.92, P = 0.03 random-effect). Patients treated by APR have a higher rate of CRM involvement, a higher local recurrence, and poorer prognosis than LAR. And there is evidence that in selected low rectal cancer patients, LAR can be used safely with a better oncological outcome than APR. due to the inherent limitations of the present study, for example, the trails available for this systematic review are limited and the finite retrospective data, future prospective randomized controlled trials will be useful to fully investigate these outcome measures and to confirm this conclusion.

NOTES total mesorectal excision (TME) for patients with rectal neoplasia: a preliminary experience

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopy are emerging, minimally invasive techniques. Total mesorectal excision (TME), the gold standard treatment for patients with resectable distal rectal tumors, is usually performed in an "up-to-down" approach, either laparoscopically or via open techniques. A transanal, "down-to-up" TME has already been reported. Our NOTES variant of TME (NOTESTME) is based on a transperineal approach without any form of abdominal assistance. The aim was to reduce further the invasiveness of the procedure while optimizing the anatomical definition of the distal mesorectum. This approach may lead to reduced postoperative pain, decreased hernia formation and improved cosmesis when compared to standard laparoscopy.

METHODS

NOTESTME was attempted in 16 patients with distal rectal neoplasia (i.e., distal edge of the tumor lower than the pouch of Douglas, between 0 and 12 cm from the dentate line). Additional inclusion criteria consisted of an ASA status ≤III and the absence of previous abdominal surgery.

RESULTS

NOTESTME was completed in all patients. Additional abdominal, single-incision laparoscopic assistance was required in 6 (38 %) patients. Mean operative time was 265 min (range 155-440 min). The morbidity rate was 18.8 % (two small bowel obstructions and one pelvic abscess), requiring re-operation in each case. No leaks occurred, and the mortality rate at 30 and 90 days was 0 %. Resection margins were negative in all patients. A median of 17 nodes (range 12-81) was retrieved per specimen. Mean length of hospital stay was 10 days (range 4-29 days). Patients were followed for an average of 7 months (range 3-23 months).

CONCLUSION

NOTESTME was feasible and safe in this series of patients with mid- or low rectal tumors. The short-term mortality and morbidity rates are acceptable, with no apparent compromise in the oncological quality of the resection. Larger, randomized controlled trials with long-term follow-up are warranted.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Abdominoperineal resection and low anterior resection: comparison of long-term oncologic outcome in matched patients with lower rectal cancer

PURPOSE

The current study aimed to compare the oncologic outcome and pattern of metastasis after abdominoperineal resection (APR) and low anterior resection (LAR) treating lower rectal cancer.

METHODS

A total of 804 patients undergoing curative resection (R0) were enrolled prospectively. The APR and LAR groups (n = 402, respectively) were matched for gender, age, and stage, for a retrospectively comparative analysis.

RESULTS

In a multivariate analysis with potential variables, APR itself was not a risk factor for increased local recurrence (LR) or reduced survival (P = 0.243-0.994). Circumferential resection margin (CRM) involvement as an operation-related risk was 1.6-fold more frequent in the APR group and was significantly associated with LR and systemic recurrence (OR, 2.487-4.017; P < 0.01). Circumferential margin positivity (CRM+) was concurrently correlated with advanced stage, larger tumor (long diameter, >4 cm), and longer sagittal midpelvic diameter (>10 cm) in a multivariate analysis (P < 0.001-0.05). The site of metastasis did not differ between the two groups, with the exception of lung metastasis which was more frequent in the APR group (APR vs. LAR: 15.9 vs. 10 %, P = 0.015). In the APR group, CRM+ and the presence of an infiltrating tumor were correlated with disease-free survival (hazard ratio (HR), 1.644 and 1.654, respectively), whereas elevated serum carcinoembryonic antigen and LVI+ were correlated with overall survival (HR, 1.57 and 1.671, respectively), in a multivariate analysis with potential variables (P < 0.05).

CONCLUSIONS

When performed with appropriate skill to achieve R0 resection, APR can be used safely without impairing oncological outcome, although sphincter-preserving surgery should remain the preferred option.

Open versus robot-assisted sphincter-saving operations in rectal cancer patients: techniques and comparison of outcomes between groups of 100 matched patients

BACKGROUND

Although open resection using a sphincter-saving operation (SSO) remains the standard of care for rectal cancer, few studies have compared open and robot-assisted (RA) SSOs. This study aimed to compare the operative features, functional outcomes, and oncological validity of open and RA SSO for rectal cancer.

METHODS

A total of 200 rectal cancer patients undergoing curative SSO were enrolled prospectively. The open and RA groups (n = 100, respectively) were matched for clinical stage and operation type.

RESULTS

The mean operation time was significantly longer in the RA group than in the open group (188 vs. 103 min, P < 0.001), but it was significantly reduced in the latter half of the RA patients compared with that in the first half (164 vs. 214 min, P < 0.001). The mean distal resection margin was significantly longer in the RA than in the open group (2.7 vs. 1.9 cm; P = 0.001), but only one patient in either group had positive circumferential resection margin. Bowel peristalsis returned one day earlier in the RA than in the open group (P < 0.001). Postoperative complication rates and anorectal functional outcomes were comparable between the two groups. The operator's physical discomfort, assessed on a visual analog scale, was significantly lower in the RA than in the open group (P < 0.001).

CONCLUSIONS

According to this short-term study, the RA SSO showed equivalent oncological safety, functional outcome, and morbidities to open SSO. Although the operation takes longer, the robotic system enables a technically versatile SSO with fine dissection in a limited surgical field.

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.

Urinary and sexual disorders after laparoscopic TME for rectal cancer in males

BACKGROUND

Urinary and sexual dysfunctions are frequent after surgery for rectal cancer. Total mesorectal excision (TME) improves local recurrence and survival rates, and does not hamper recognition and sparing of hypogastric and pelvic splanchnic nerves. It is not known how laparoscopic rectal resection could change functional complication rates.

MATERIALS AND METHODS

From a global series of 1,216 laparoscopic interventions for colorectal diseases, 35 cases of males less than 70 years old, undergoing rectal resection and TME for a T1-3M0 medium and low rectal cancer were selected. Urinary and sexual functions after the operations were retrospectively recorded by means of specific tools (International Prostate Symptom Score (IPSS) and IIEF questionnaires, respectively).

RESULTS

None of the patients necessitated permanent or intermittent catheterization. More than half the patients had no complaints about urinary functions; about one third had nocturia; 72% of the patients had an IPSS less that 10, and no case of IPSS worse that 31 was recorded. Sexual desire was reduced and spontaneous erectile function was impaired in almost half the cases, while induced erections were possible in about 90% of cases; about 70% of patients still had the possibility of penetration and a normal ejaculation and orgasm after the intervention.

DISCUSSION AND CONCLUSIONS

The present series confirms previous data and contribute to the creation of a benchmark specifically related to the laparoscopic approach to which surgeons should face when informing the patients before the operation. While severe urinary dysfunction is rare, sexual impairment remains a serious concern after rectal resection with TME.

Tumour budding correlates with local recurrence of rectal cancer

AIM

Predictive tools for local recurrence (LR) of rectal cancer are needed. This study assessed the predictive value of tumour budding detected by MNF-116 and laminin-5 γ2 chain (Ln-5 γ2).

METHOD

In a case-control study, the surgical specimens of 48 patients with LR after from primary resection of rectal carcinoma and 82 control patients matched for gender and preoperative radiation from a population of 1180 patients operated with total mesorectal excision were studied. The presence of budding was examined using immunohistochemistry with Ln-5 γ2 and pan-cytokeratin staining with MNF-116.

RESULTS

Tumour budding counts ranged from 0 to 106 buds (mean 43, median 38) for all patients. Significantly more tumours with more than 35 buds were seen in the LR than in the control group (67 vs 44%; P = 0.02). The spread of budding was also more extensive in the LR than in the control group (63 vs 49%, P = 0.03). In a multivariate analysis with tumour, node, metastasis stage, MNF-116-stained budding was an independent predictor of local failure (P = 0.02). The budding frequency was higher in irradiated tumours in comparison with tumours that had not received irradiation (mean 53 vs 38, P = 0.03). For Ln-5 γ2, more tumours with ≥ 10 buds were seen in the group with LR than among the control patients, but this difference was not statistically significant (73 vs 57%; P = 0.09). No additive value was found in the multivariate logistic regression model when Ln-5 γ2-stained budding frequency was added to MNF-116 and tumour, node, metastasis stage. The agreement between budding frequency determined by MNF-116 and Ln-5 γ2 was moderate, with a κ-coefficient of 0.34 (0.16-0.51).

CONCLUSION

Tumour budding determined by MNF-116 staining may serve as a predictive marker for LR in rectal cancer.

Sexual and urinary functioning after rectal surgery: a prospective comparative study with a median follow-up of 8.5 years

PURPOSE

The purpose of this study was to prospectively compare rectal resection (RR) with colonic resection on sexual, urinary and bowel function and quality of life in both short-term and long-term.

METHODS

Eighty-three patients who underwent RR were compared to 53 patients who underwent a colonic resection leaving the rectum in situ (RIS). A questionnaire assessing sexual, urinary and bowel functioning with a quality of life questionnaire (SF-36) was sent to all participants preoperatively, 3 and 12 months postoperatively and approximately 8 years after the onset of the study.

RESULTS

Short-term dysfunction included diminished sexual activity in female RR patients at 3 months and significantly more erectile dysfunction in RR patients 1 year postoperatively. Long-term dysfunction included more frequent and more severe erectile dysfunction in RR patients compared to RIS patients. These short-term and long-term outcomes did not influence overall quality of life. The incidence of urinary dysfunction was comparable between both groups. Bowel functioning was significantly better in the RIS group compared to the RR group 3 months and 1 year postoperatively.

CONCLUSIONS

Patients who underwent RR experienced up to 1 year postoperatively more sexual and bowel function problems than RIS patients. However, short-term and long-term dysfunction did not influence overall quality of life. Erectile dysfunction in male RR patients persisted in time, whereas other aspects of sexual, urinary and bowel function after RR and colonic resection are similar after a median follow-up of 8.5 years.

Voiding and sexual function after autonomic-nerve-preserving surgery for rectal cancer in disease-free male patients

Purpose

We evaluated the effects of surgery for rectal cancer on postoperative voiding and sexual function over the course of time.

Materials and Methods

Data from 28 patients who underwent autonomic nerve preserving rectal cancer surgery were retrospectively analyzed. Operations were performed between October 2005 and July 2007 and all patients were followed-up for more than 3 years. Preoperatively, all patients underwent urodynamic studies including uroflowmetry, and filled out the International Prostate Symptom Score (IPSS). The evaluation of sexual function consisted of Erectile Function domain score in International Index of Erectile Function (IIEF-EFD) and Ejaculation domain score in Male Sexual Health Questionnaire (MSHQ-EjD). Data from uroflowmetry and questionnaires were examined.

Results

At 3 years postoperatively the prostate volume was similar to the preoperative value (p=0.727). There were no statistically significant postoperative changes in the average maximum flow rate (15.9 ml/s vs. 16.2 ml/s, p=0.637) and post-void residual urine volume (34.7 ml vs. 36.8 ml, p=0.809). No statistically significant differences were observed in the IPSS (13.2 vs. 12.2, p=0.374). However, although pelvic autonomic nerve preservation have been performed, a significant proportion of rectal cancer patients suffer from sexual dysfunction and the average of IIEF-EFD and MSHQ-EjD scores was decreased postoperatively until 3 years (25.1 vs. 16.1 and 28.3 vs. 14.2 respectively, p<0.001).

Conclusions

Voiding function was not affected after autonomic nerve-preserving rectal cancer surgery, however sexual function was significantly aggravated. We recommend that the baseline genitourinary function should be evaluated before the treatment for male rectal cancer patients, and penile rehabilitation is necessary for their quality of life after treatment.

Consenting for pelvic nerve injury in colorectal surgery: need to address age and gender bias

INTRODUCTION

Pelvic nerve injury is a recognised complication following pelvic dissection in colorectal surgery. It can lead to urinary and sexual dysfunction in men and women, which varies from 5-40% depending on the surgery and the underlying pathology. Sexual dysfunction can manifest as erectile dysfunction in men and as dyspareunia and failure to achieve sexual arousal/orgasm in women. The aim of this study was to evaluate consent for these complications prior to surgery.

PATIENTS AND METHODS

We carried out a retrospective audit on patients who had undergone elective colorectal surgery involving pelvic dissection over a 2-year period (June 2006 to June 2008) at University Hospital of North Staffordshire. We reviewed the consent forms and medical records of these patients, specifically looking for documentation of pelvic nerve injury, sexual dysfunction or erectile dysfunction prior to surgery. Only patients who had documented pelvic dissection in their operative notes were included in the audit, and those who were deemed unable to consent were excluded.

RESULTS

Medical records of 118 patients were reviewed. Of this cohort, 31% were women (n = 37). Malignancy was the indication for surgery in 79% of women and 88% of men. Consent for the procedure was obtained by a consultant in 73% (n = 86) of patients and by a middle-grade surgeon in the remaining 27% (n = 32). Only two women were consented for pelvic nerve injury whilst this number was 41 for men (5% vs 51%). Patients younger than 50 years were more consistently informed of the risks (50%) compared to the over 50-year-olds (34%). Only eight patients (males 6, females 2) were consented for urinary dysfunction.

CONCLUSIONS

The risk of pelvic nerve injury is not frequently stated, which is more common in women and the elderly. Overall, only 36% of patients were consented for pelvic nerve injury, while only 5% of women were consented. Is this professional discretion, or evidence that surgeons are not being assiduous enough when obtaining consent, which may leave them vulnerable to medicolegal claims? Introduction of procedure-specific consent forms would be a method to address this issue.