Bladder and sexual dysfunction after mesorectal excision for rectal cancer

BACKGROUND

Urinary and sexual dysfunction are recognized complications of rectal excision for cancer. The aim of this study was to examine the frequency of such complications after mesorectal excision, shortly after this method was introduced.

METHODS

Spontaneous flowmetry, residual volume of urine measurement and urodynamic examination, including cystometry and simultaneous detrusor pressure and urinary flow recording, was carried out before and 3 months after curative rectal excision. Urinary symptoms and sexual function were evaluated by means of questionnaires before and after operation. Each patient served as his or her own control.

RESULTS

Forty-nine consecutive patients, 39 of whom had a total mesorectal excision (TME) and ten a partial mesorectal excision, were examined before surgery and 35 again after operation. In two patients, a weak detrusor was detected before operation. Two patients developed signs of bladder denervation after operation. Transitory moderate urinary incontinence appeared in four other women. Six of 24 men reported some reduction in erectile function and one became impotent. Two men reported retrograde ejaculation. All the complications were seen in the TME group.

CONCLUSION

Mesorectal excision for rectal cancer resulted in a low frequency of serious bladder and sexual dysfunction.

[Patients with diagnosed colonic diverticulitis admitted to a department of surgery]

In 1995-96, 148 patients with the diagnosis diverticulitis of the colon were admitted a total of 176 times to the Department of Gastroenterologic Surgery at Ullevaal Hospital in Oslo. Data on treatment and outcome were recorded retrospectively from patient files. 92% of the hospitalisations were emergency cases of abdominal pain. In 113 hospitalisations, patients were initially treated with intravenous antibiotics, aspiration of the stomach, later oral antibiotics. No deaths were recorded. In 8 out of 64 patients (13%) hospitalised with diverticulitis for the first time, the diagnosis could not be verified by coloscopy or bowel enema. In 63 hospitalisations (36%), the patients underwent surgery. Hartmann's procedure was performed in 31 out of 49 emergency cases. 22 patients undergoing surgery in an emergency setting had perforated diverticulitis; 5 of these patients died within 15 days. 14 patients had planned surgery with bowel resection and 15 patients had a planned closing of the stoma. Two of these 29 patients died post-operatively. Acute diverticulitis is a serious condition, especially when the bowel has perforated. Complications develop both after emergency and elective surgery. We recommend careful selection of patients.

[Surgical treatment of ulcerative colitis]

Continence-preserving coloproctectomy for ulcerative colitis is technically demanding and is relatively often afflicted with complications. We have retrospectively reviewed the files of all patients being operated for ulcerative colitis at Ullevål Hospital from 1992 to 1997 (n = 53). Most of the patients (n = 50) were examined clinically; 12 patients had anal manometry before and after operation. 44 patients were operated with continence-preserving coloproctectomy with J-pouch and handsewn anastomosis; of these, 42 were followed more than six months. Eight had pouchitis, four perianal abscess/fistula, three septicaemia and three were operated for ileus. Two had anastomotic leakage and pelvic abscess that required transanal drainage. One had the pouch removed six years after operation due to chronic pouchitis and pouch-vaginal fistula. There was no deterioration of anal maximal resting and squeezing pressures on pre- and post-operative anal manometry. Mean number of stools from the reservoir per 24 hours were 6.2 (range 3-11); 11 patients had leakage of air and loose stool, three at day-time and eight at night. Two patients (4%) died from colorectal cancer and three (7%) had Crohn's disease. Nine patients were unfit for pouch surgery and underwent coloproctectomy (n = 7) or subtotal colectomy (n = 2). Our results indicate that pouch surgery for ulcerative colitis is a good option for most patients.

Diurnal rhythm in serum levels of inhibin B in normal men: relation to testicular steroids and gonadotropins

Inhibin B is a testicular glycoprotein that is secreted from the Sertoli cells and believed to play a role in FSH secretion. We characterized the diurnal profile of serum inhibin B and the relation to gonadotropins and testicular steroids. Serum inhibin B was measured in 13 healthy normal male volunteers (median age, 30 yr) by continuous blood drawing, with sampling every 30 min for 24 h. Blood samples were also analyzed for FSH, LH, testosterone, estradiol, and sex hormone-binding globulin. We found a significant diurnal variation in inhibin B, with peak values in the early morning and nadirs in the late afternoon, followed by gradual increasing nocturnal values. An average decline of 3%/h from 0900 until 1700 h was calculated. Significant cross-correlation was found between inhibin B and testosterone as well as estradiol, whereas no cross-correlation was found between inhibin B and FSH. Two-dimensional time-series analyses revealed a statistically significant influence of testosterone on inhibin B. In addition, estradiol and inhibin B had a significant influence on one another. In conclusion, we found a significant diurnal variation in inhibin B levels in normal men, with a pattern of higher values in the early morning hours and lower values in the late afternoon and evening. We did not find evidence for a role of FSH in this diurnal variation of inhibin B. However, covariation with serum levels of testosterone and estradiol suggested that these hormones might play a role in the diurnal rhythm of inhibin B, although some other common influence could not be excluded.

Loop ileostomy: technical aspects and complications

OBJECTIVE

To study the incidence of complications of construction and closure of loop ileostomies and the final outcome for the patients.

DESIGN

Retrospective study.

SETTING

University hospital, Norway.

SUBJECTS

100 patients with 103 loop ileostomies, operated on between 1980 and 1990.

MAIN OUTCOME MEASURES

Number of complications after ileostomy construction and closure.

RESULTS

7 required re-operation after construction of the loop ileostomy and 11 after its closure. The most common cause was small intestinal obstruction (4 after construction and 6 after closure). 2 developed stomal necrosis. The mean duration of hospital stay was 13 and 10 days for primary and secondary loop ileostomy, respectively, and the mean time before closure was 31 weeks. After closure another 6 developed leaks from the ileal anastomosis that required further operation. Patients with secondary loop ileostomies had their stomas significantly longer than those with primary loop ileostomies (21 compared with 43 weeks, p = 0.00005).

CONCLUSION

Despite the number of complications, we think that faecal diversion is still justified in complex pelvic surgery and we should try to reduce the complication rate further.

Mesorectal excision for rectal cancer: a view from Europe

The local recurrence rate after rectal cancer surgery is discussed as related to conventional and total mesorectal excision (TME) techniques. Studies now show that the wide variation in results between centers and among surgeons depends, at least in part, on differences in surgical technique. We conclude that local tumor recurrence rate is lower after TME than after conventional surgery and emphasize the importance of a standardized macroscopic evaluation of the resected specimen. Population-based registration to evaluate the quality of surgery is recommended. It is also suggested that randomized studies on adjuvant treatment for rectal cancer should include a "surgery only" arm when a local tumor recurrence rate of 10% or less is being studied. Until such investigations are performed, we conclude that the role for adjuvant treatment is questionable and that TME surgery is preferred as the treatment option for Stage T1-T3 rectal cancers.

Penile vibratory stimulation and electroejaculation before anticancer therapy in two pubertal boys

PURPOSE

Because more than 70% of children with cancer become long-term survivors, more emphasis is put on reducing late effects. Cryopreservation of semen and the intracytoplasmic sperm injection technique makes it possible to obtain pregnancy with very poor sperm quality. Two new semen retrieval methods are described that are applicable in pubertal boys with a fertility potential, although not psychologically ready to produce a semen sample, who are likely to become infertile because of anticancer therapy.

PATIENTS AND METHODS

Two pubertal boys (aged 14 and 15 years) had a late testicular relapse of pre-B acute lymphoblastic leukemia and Hodgkin disease, stage II, respectively. In patient 1, penile vibratory stimulation (PVS) was tried under general anesthesia without success and electroejaculation (EEJ) was performed. Before alkylating chemotherapy and testicular irradiation, PVS was performed with success in patient 2.

RESULTS

An antegrade ejaculate of 0.7 ml with 1% motile spermatozoa and an retrograde ejaculate with 1.6 x 10(6)/ml spermatozoa (5% with fair motility) was obtained from patient 1. An antegrade ejaculate of 1.5 ml with 2.5 x 10(6)/ml spermatozoa (29% with fair motility) was obtained from patient 2.

CONCLUSIONS

PVS should be the first choice of treatment because it is noninvasive, simple, and easily applied. Because EEJ requires general anesthesia, it should be used as a second option.

[Introduction of a new surgical technique in rectal cancer]

Local recurrence rates following surgery for rectal cancer show considerable variation in different series, but impressive results (< 4% local recurrences after five years) have been presented by surgeons using total mesorectal excision as their operative technique. In Norway, local recurrence rates of 30% have been reported. Total mesorectal excision was introduced at Ullevaal Hospital in January, 1994 following a specific training programme. To enable us to compare the results, we followed-up two groups of patients who had undergone surgery for rectal carcinoma; one group (76 patients) before the introduction of total mesorectal excision and the other (76 patients) after total mesorectal excision was introduced. Anastomotic leakages were the main problem in the initial phase, but after faecal diversion became routine only one leakage was observed. After a median observation time of 28 months we had observed two patients (4.3%) with local recurrence in the total mesorectal excision group, and ten (23.8%) in the group where total mesorectal excision had not been performed.

Effect of the introduction of total mesorectal excision for the treatment of rectal cancer

BACKGROUND

Total mesorectal excision (TME) has been reported to reduce local recurrence and improve survival rates in patients with rectal carcinoma. This paper reports the problems that have arisen with the introduction of this new surgical technique.

METHODS

This was a prospective study of two consecutive groups of patients: one who underwent TME (n = 76) and one who did not (non-TME, n = 76).

RESULTS

Postoperative mortality rate in the non-TME and TME group was 5 and 7 per cent respectively, and the rate of anastomotic failure was 8 and 16 per cent respectively. Anastomotic leaks in TME patients were located in the mid and lower rectum. TME patients with anastomotic failure had lower anastomoses and a longer duration of operation than non-TME patients. Intraoperative problems were encountered in 71 per cent of the failures. All TME patients who had a leak required reoperation compared with 25 per cent of non-TME patients. TME patients without postoperative complications stayed significantly longer in hospital than non-TME patients.

CONCLUSION

Anastomotic dehiscence increased after introduction of the TME technique but this improved with experience.

Germ cell cancer and disorders of spermatogenesis: an environmental connection?

Why is there a small peak of germ cell tumours in the postnatal period and a major peak in young age, starting at puberty? And, paradoxically, small risk in old age, although spermatogenesis is a lifelong process? Why is this type of cancer more common in individuals with maldeveloped gonads, including undescended testis, gonadal dysgenesis and androgen insensitivity syndrome? Why has there, during the past 50 years, been a quite dramatic increase in testicular cancer in many developed countries? These are just a few of many questions concerning testicular cancer. However, the recent progress in research in the early stages of testicular cancer (carcinoma in situ testis (CIS)) allows us to begin to answer some of these questions. There is more and more evidence that the CIS cell is a gonocyte with stem cell potential, which explains why an adult man can develop a non-seminoma, which is a neoplastic caricature of embryonic growth. We consider the possibility that CIS cells may loose their stem cell potential with ageing. Along these lines, a seminoma is regarded a gonocytoma where the single gonocytes have little or no stem cell potential. The Sertoli and Leydig cells, which are activated postnatally and during and after puberty, may play a crucial role for both the development of the CIS gonocyte and progression of the neoplasm to invasiveness. The reported increase in testicular cancer is not the only sign that male reproductive health is at risk. There are reports that undescended testis and hypospadias have become more common. Also semen quality has deteriorated, at least in some countries. The epidemiological evidence suggests that environmental factors may play a role. Are the environmental hormone disrupters (e.g. DDT, PCB, nonylphenol, bisphenol A) to be blamed for the apparently synchronised deterioration in these aspects of male reproductive health?

Reproductive history and cigarette smoking as risk factors for thyroid cancer in women: a population-based case-control study

A population-based case-control study was conducted in Northern Norway and Central Sweden to investigate hormonal and reproductive factors and cigarette smoking as determinants of papillary and follicular thyroid carcinoma in women. Information on 191 histologically confirmed cases and 341 age-matched controls was included. No clear association was found with regard to the number of live births, number of pregnancies, a history of incomplete pregnancies, or the use of oral contraceptives or hormonal replacement therapy. However, an early first childbirth (before 20 years of age, or less than 5 years after menarche) was associated with an increased risk of thyroid cancer. There was an increased risk of thyroid cancer among women with a history of artificial menopause compared to those with a spontaneous menopause [odds ratio (OR), 2.52; 95% confidence interval (CI), 0.96-6.62], which was more pronounced for the papillary carcinoma and after adjustment for age at menopause and use of replacement therapy. Cigarette smokers had a decreased risk of borderline statistical significance compared to nonsmokers (OR, 0.69; 95% CI, 0.47-1.01), particularly among premenopausal women (OR, 0.60; 95% CI, 0.38-0.96). This negative association persisted after adjustment for parity, hormonal treatments, and education. Women who started smoking before the age of 15 experienced a marked reduction in risk (OR, 0.38%; 95% CI, 0.18-0.80¿). Moreover, there was a suggestion of a dose-response effect with the amount of cigarettes smoked daily and with duration of the habit. Both the increased risk of artificial menopause and the negative association with smoking are compatible with a relation between levels of estrogens and thyroid cancer among women.

[Diagnosis and treatment of gastrointestinal hemorrhage]

The handling of gastrointestinal bleeding was discussed at a national expert symposium in February 1995. Internists are in charge of therapeutic endoscopy of upper gastrointestinal bleeding at the majority of Norwegian hospitals, but close collaboration with the surgeon on call is vital. The need for intensive care and monitoring may have been underestimated, since decompensation of co-existing diseases is a more frequent cause of death than the haemorrhage itself. Endoscopic treatment is the primary choice in all parts of the gut where endoscopy is possible, but surgery must be considered for patients who rebleed. Injection of sclerosering agents is the most prevalent mode of treatment for oesophageal varices and ulcers, but thermal probes and rubber band ligation are probably equally effective in experienced hands. Major lower bowel haemorrhage can render colonoscopy impossible, and emergency resections may be warranted, but preferably after angiography or peroperative endoscopic localisation of the area of bleeding.

[Administrative handling of gastrointestinal hemorrhage in Norway]

Rapid and adequate endoscopic treatment is a vital part of the initial handling of gastrointestinal haemorrhage. A national survey was carried out to study the logistics of the initial handling of these patients. Replies were received from 97% of the hospitals, each of which received an average of 11 patients per month with haematemesis/melena or rectal bleeding. Patients with haematemesis or melena were admitted primarily to medical departments or intensive care units, while patients with haematochezia were admitted most often to the surgical department. 47% of the hospitals performed emergency endoscopy as a routine on patients with red haematemesis, but even in this group of patients, endoscopy was postponed until the first working day in some instances, provided that the patient's condition was stable. The majority of emergency flexible endoscopies are performed by internists, but most hospitals describe close inter-departmental cooperation in the handling of these patients. The situation was deemed satisfactory at 91% of the hospitals.

Declining semen quality and increasing incidence of testicular cancer: is there a common cause?

Male reproduction has been given little attention in science and in medical practice. However, a recent metaanalysis on semen quality, which clearly pointed to a decrease over the past 50 years, has been repeatedly quoted. Three recent reports have found that semen quality has declined among candidate semen donors during the past 20 years. The evidence of decline in the quality of semen is not the only indicator that the human testis is at risk. During the past 50 years, cancer of the testis has also become more common. This is a disorder of young men, and it is associated with a high rate of other abnormalities of the testis including undescended testis and poor semen quality. Furthermore, the incidence of both hypospadias and undescended testis has been reported to be rising in the general population. We believe that the evidence of declining semen quality should be seen in the light of these trends in other reproductive disorders of men. However, the etiology is unknown. A recent hypothesis that links the trends in the health of the male reproductive system to xenoestrogens in the environment is discussed.

Technical aspects and complications of end-ileostomies

During a period of 10 years (1980-1990) we constructed or reconstructed 358 end-ileostomies: 224 were primary constructions, 96 were reconstructed by laparotomy, and 38 were local reconstruction. Only 2 ileostomies were primarily located on the left side. The mean length was 5 cm. We had 11.6% reoperations after primary stomy and 7.3% and 7.9% reoperations after reconstruction by laparotomy and local approach, respectively. There were 12.9% and 8.7% reoperations after emergency and elective primary operations, respectively. Closing the lateral gutter or fixation of ileum to the rectus fascia did not influence significantly the number of reoperations. Postoperative discolored stomy did not indicate more dysfunction of the ileostomy. Stenosis of the ileostomy, peristomal fistulas, and peristomal dermatitis were seen in 23 (10.3%), 21 (9.4%), and 18 (8%) of the patients after primary ileostomies, respectively. Patients with Crohn's disease had significantly more of these problems than patients with ulcerative colitis. Only a few patients had retraction of the ileostomy (2.7%), stomal prolapse (1.8%), or parastomal herniation (1.8%). Women had significantly more parastomal herniation than men; otherwise there were no differences between the sexes.

[Decline in semen quality from 1930 to 1991]

It has been suspected for years that semen quality has declined. However, the issue is still controversial since previous studies were criticized for methodological errors. We therefore attempted to systematically review the complete international literature on semen quality since 1930 with rigorous selection criteria and statistical analysis. Based on a literature search using Cumulated Index Medicus and Current List (1930-1965) and MEDLINE Silver Platter database (1966-august 1991), we identified 61 papers concerning sperm density in a total of 14,957 males without a history of infertility. A significant decline in mean sperm density from 113 x 10(6)/ml in 1940 to 66 x 10(6)/ml in 1990 (p < 0.0001) and in mean seminal volume from 3.40 ml to 2.75 ml (p = 0.027) was noted. The incidence of testis cancer and possibly also that of cryptorchidism and hypospadias has increased during the same relatively short time period. Such a remarkable deterioration in male genitourinary function is more likely to be due to environmental rather than genetic factors.

Evidence for increasing incidence of abnormalities of the human testis: a review

Recent reports have suggested that the incidence of genitourinary abnormalities in human males has increased during the past 50 years, including congenital abnormalities such as cryptorchidism and hypospadia, which seem to be occurring more commonly. Also, the incidence of testicular cancer has increased 3- to 4-fold since the 1940s. This increase seems to be worldwide including countries with a very high frequency of testicular neoplasia as well as those in which this cancer is rather uncommon. It has also been postulated that semen quality has been decreasing for the last half century. A recent study showed that the average sperm density has decreased significantly from 113 million/mL in 1940 to 66 million/mL in 1990. The mean seminal volume has also declined, indicating that the decrease in the total sperm count is even more pronounced than the fall in sperm density would indicate. The remarkable increase in frequency of testicular abnormalities over a relatively short period of time may be due to environmental rather than genetic factors. There is an epidemiological link between the occurrence of different testicular abnormalities. Therefore, common prenatally acting etiological factors with adverse effects on the fetal male gonad might be suspected. However, postnatal influences may also have a deleterious effect on male fertility. From the reproductive point of view, an increased impact on the human male gonad is of concern.

[Extracerebral metastases from cerebral glioblastoma]

A patient with glioblastoma multiforme in the right cerebral hemisphere had extracranial metastases, probably mediated via a ventriculoperitoneal shunt. Extracranial spread of malignant tumours of the central nervous system is very rare. We point out the possibility of metastases in patients who have undergone craniotomy or who have a systemic shunt. We discuss other possible ways of spreading, prophylactic measures, and the various modalities of treatment for these metastases.