Measuring sexual and urinary outcomes in women after rectal cancer excision

Potential sexual function improvement by using transanal mesorectal approach for laparoscopic low rectal cancer excision

OBJECTIVE

Preliminary results of the transanal approach for low rectal cancer suggest better oncological outcomes than the conventional laparoscopic approach. We currently report the functional results.

METHODS

From 2008 to 2012, 100 patients with low rectal cancer and suitable for sphincter-saving resection were randomized between transanal and laparoscopic low rectal dissection. Patients derived from this randomized trial were enrolled for functional assessment. End points were bowel function (LARS bowel and Wexner continence scores) and urogenital function (IPSS, IIEF-5 and FSFI-6 scores) obtained by questionnaires sent to patients with a follow-up more than 12 months.

RESULTS

Overall, 76 patients were eligible and 72 responded to the questionnaire: 38 in the transanal group and 34 in the laparoscopic group. The bowel function did not differ between the transanal and the laparoscopic groups: LARS 36 versus 37 (p = 0.941) and Wexner 9 versus 10 (p = 0.786). The urologic function was also similar between the two groups: IPSS 5.5 versus 3.5 (p = 0.821). Among sexually active patients before surgery, 20 of 28 (71 %) patients in the transanal group and 9 of 23 (39 %) in the laparoscopic group maintained an activity after surgery (p = 0.02). Erectile function was also better in men after transanal compared to laparoscopic low rectal dissection: IIEF 17 versus 7 (p = 0.119).

CONCLUSION

Transanal approach for low rectal cancer did not change bowel and urologic functions compared to the conventional laparoscopic approach. However, there was a trend to a better erectile function with a significantly higher rate of sexual activity in the transanal group.

Pelvic radiotherapy and sexual function in women

BACKGROUND

During the past decade there has been considerable progress in developing new radiation methods for cancer treatment. Pelvic radiotherapy constitutes the primary or (neo) adjuvant treatment of many pelvic cancers e.g., locally advanced cervical and rectal cancer. There is an increasing focus on late effects and an increasing awareness that patient reported outcomes (PROs) i.e., patient assessment of physical, social, psychological, and sexual functioning provides the most valid information on the effects of cancer treatment. Following cure of cancer allow survivors focus on quality of life (QOL) issues; sexual functioning has proved to be one of the most important aspects of concern in long-term survivors.

METHODS

An updated literature search in PubMed was performed on pelvic radiotherapy and female sexual functioning/dysfunction. Studies on gynaecological, urological and gastrointestinal cancers were included. The focus was on the period from 2010 to 2014, on studies using PROs, on potential randomized controlled trials (RCTs) where female sexual dysfunction (FSD) at least constituted a secondary outcome, and on studies reporting from modern radiotherapy modalities.

RESULTS

The literature search revealed a few RCTs with FSD evaluated as a PRO and being a secondary outcome measure in endometrial and in rectal cancer patients. Very limited information could be extracted regarding FSD in bladder, vulva, and anal cancer patients. The literature before and after 2010 confirms that pelvic radiotherapy, independent on modality, increases the risk significantly for FSD both compared to data from age-matched healthy control women and compared to data on patients treated by surgery only. There was only very limited data available on modern radiotherapy modalities. These are awaited during the next five years. Several newer studies confirm that health care professionals are still reluctant to discuss treatment induced sexual dysfunction with patients.

CONCLUSIONS

Pelvic radiotherapy has a persistent deteriorating effect on the vaginal mucosa impacting negatively on the sexual functioning in female cancer patients. Hopefully, modern radiotherapy modalities will cause less vaginal morbidity but results are awaited to confirm this assumption. Health care professionals are encouraged to address potential sexual dysfunction both before and after radiotherapy and to focus more on quality than on quantity.

Urinary and sexual dysfunction rates and risk factors following rectal cancer surgery

OBJECTIVE

The aim of this study was to express the effects of demographic characteristics, the type of the surgery, tumour characteristics and adjuvant therapy on urinary and sexual dysfunctions.

MATERIALS AND METHOD

Pre-operational urinary and sexual dysfunctions of the patients were evaluated by using the surveys prepared according to International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF) in men and Index of Female Sexual Function (IFSF) in women.

FINDINGS

A total of 56 patients were included in the study; 20 of them were women and 36 of them were men. The mean age was 56. Abdominoperineal resection (APR) was performed on 11 patients, and low anterior resection (LAR) was performed on 45. The post-treatment IPSS classes were worsened at a rate of 12.7 % compared to the pre-treatment. The mean post-treatment sexual dysfunction score of both men and women were decreased by 27.5 and 17.8 %, respectively. Rectal tumours located in the lower part resulted in more sexual dysfunction.

CONCLUSION

The tumour in the 1/3 lower part of the rectal area was determined to be the most effective factor that caused both urinary and sexual dysfunction. Patients should be informed about the urinary and sexual dysfunctions in the pre-operative consultations.

Early Removal of the Urinary Catheter After Total or Tumor-Specific Mesorectal Excision for Rectal Cancer Is Safe

BACKGROUND

Total or tumor-specific mesorectal excision can preserve pelvic autonomic nerves during rectal cancer surgery and minimize urinary dysfunction. However, urinary catheterization several days in duration is a common practice after total or tumor-specific mesorectal excision.

OBJECTIVE

This study aimed to evaluate the optimal duration of urinary catheterization after total or tumor-specific mesorectal excision for rectal cancer.

DESIGN

This is a retrospective review of patients who underwent total or tumor-specific mesorectal excision for rectal cancer.

SETTINGS

This study was performed in the colorectal division of a university-affiliated hospital.

PATIENTS

Between March 2009 and February 2013, 236 patients fulfilled the inclusion criteria. Patients who underwent combined pelvic surgery and those who had postoperative complications with a Dindo grade III or more and a known urinary disease were excluded; the remaining 189 patients were evaluated.

MAIN OUTCOME MEASURES

The primary outcome measure of this study was the incidence of postoperative urinary retention.

RESULTS

The incidence of acute urinary retention was 4.8%. Urinary retention was not associated with the postoperative urinary catheterization duration (p = 0.99). Patients were assigned to 2 groups according to urinary catheterization duration (1 vs ≥ 2 days). No significant differences were observed between the 2 groups regarding urinary retention (4.8% for 1 day vs 4.7% for ≥ 2 days; p = 1.0). In a logistic regression analysis, age, sex, ASA classification, surgical procedure, surgical approach, stage, distance from the anal verge, rate of preoperative radiotherapy, duration of urinary catheterization, and time period of surgery were not associated with urinary retention.

LIMITATIONS

This was a retrospective, single-center study. There is potential for selection bias.

CONCLUSIONS

Our study showed that the urinary catheter could be safely removed on the first postoperative day after total or tumor-specific mesorectal excision.

Urinary and sexual dysfunction in women after resection with and without preoperative radiotherapy for rectal cancer: a population-based cross-sectional study

AIM

Knowledge of urinary and sexual dysfunction in women after rectal cancer treatment is limited. This study addresses this in relation to the use of preoperative radiotherapy, type of surgery and the presence of bowel dysfunction.

METHOD

All living female patients who underwent abdominoperineal excision (APE) or low anterior resection (LAR) for rectal cancer in Denmark between 2001 and 2007 were identified. Validated questionnaires (the ICIQ-FLUTS and the SVQ) on urinary and sexual function were completed by 516 (75%) and 482 (72%) recurrence-free patients in 2009.

RESULTS

Urgency and incontinence were reported by 77 and 63% of respondents, respectively. Vaginal dryness, dyspareunia and reduced vaginal dimensions occurred in 72, 53 and 29%, respectively, and 69% reported that they had little/no sexual desire. Preoperative radiotherapy was associated with voiding difficulties (OR = 1.63, 95% CI 1.09-2.44), reduced vaginal dimensions (OR = 4.77, 95% CI 1.97-11.55), dyspareunia (OR = 2.76, 95% CI 1.12-6.79), lack of desire (OR = 2.22, 95% CI 1.09-4.53) and reduced sexual activity (OR = 0.55, 95% CI 0.30-0.98). Patients undergoing APE had a higher risk of dyspareunia (OR = 2.61, 95% CI 1.00-6.85). Bowel dysfunction after LAR was associated with bladder storage difficulties (OR = 1.64, 95% CI 1.01-2.65), symptoms of incontinence (OR = 2.17, 95% CI 1.35-3.50), lack of sexual desire (OR = 2.69, 95% CI 1.21-5.98), sexual inactivity (OR = 0.48, 95% CI 0.24-0.96) and sexual dissatisfaction (OR = 0.40, 95% CI 0.20-0.82).

CONCLUSION

Urinary and sexual problems are common in women after treatment for rectal cancer. Preoperative radiotherapy interferes with several aspects of urinary and sexual functioning. Bowel dysfunction after LAR is associated with urinary dysfunction and a reduction in sexual desire, activity and satisfaction.

Clinical results and toxicity for short-course preoperative radiotherapy and total mesorectal excision in rectal cancer patients

Short-course preoperative radiotherapy (SCPRT) is an alternative method to chemoirradiation for patients with Stage II and III rectal cancer when no downsizing is needed, but there is still widespread reluctance to use this method because of fear of side effects from high-fraction doses. This paper reports on a single institution patient cohort of operated rectal cancer patients after SCPRT, evaluated for chronic adverse effects, local control, progression-free survival and overall survival. Altogether, 257 patients were treated with SCPRT and surgery including total mesorectal excision (92% total mesorectal excision = TME) between 2002 and 2009. Local control and survival were analyzed. Chronic adverse effects for 154 patients without local relapse were evaluated according to the NCI-CTCAE version 4.0 classification, with a median follow-up of 48 months. We found a 5-year disease-free survival (DFS) and overall survival (OS) of 71%. The 5-year estimated local control (LC) rate was 94%. A positive resection margin was found in 4% of the patients and was significantly correlated with decreased DFS, OS and LC. Chronic adverse effects were reported by 58% of the patients, of which 10% were Grade 3 toxicities. The most frequent Grade 2 toxicity was stool incontinence (13%). Sexual dysfunction was found in 36% of the patients (31% Grade 1 or 2, and only 5% Grade 3). SCPRT combined with TME produced excellent LC rates together with a low rate of high-grade chronic adverse effects.

Self reported experience of sexual function and quality after abdominoperineal excision in a prospective cohort

INTRODUCTION

Rectal cancer treatment, especially abdominoperineal excision (APE), can cause sexual dysfunction. There are indications that pre-operative information regarding sexual dysfunction is inadequate. The aim of this study was to explore self reported sexual function in a group of patients operated with APE and the patients' remembrance of preoperative information more than one year after their surgical procedure.

METHODS

Consecutive patients with rectal cancer operated with APE in one institution between 2004 and 2009 were included. Data was collected from hospital records and the Swedish Colorectal cancer registry. A detailed questionnaire was sent out to the patients 13-84 months post-operatively.

RESULTS

One hundred and eight patients were alive in February 2011, 84 agreed to participate and 89% returned the questionnaire. Men and women did not differ regarding age, tumour stage, neoadjuvant treatment or type of surgical procedure. More men were involved in a relationship; men had more thoughts about sex, were less satisfied and were more bothered than women by their sexual dysfunction. A majority of patients did not retain sufficient knowledge from the preoperative information regarding sexual dysfunction.

DISCUSSION

This exploratory study shows that although sexual activity was similar between the two genders, men reported more bother by their self-reported sexual dysfunction after an APE than women did. However, both men and women felt that the preoperative information was inadequate.

CONCLUSION

Surgeons should focus more on information about the risk of sexual dysfunction as well as on its treatment at follow-up.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01323166.

A prospective video-controlled study of genito-urinary disorders in 35 consecutive laparoscopic TMEs for rectal cancer

INTRODUCTION

Genito-urinary disorders (GUD) for radical rectal cancer surgery range from 10 to 30%. In this study, primary endpoint is to prospectively assess their incidence in patients undergoing Laparoscopic Total Mesorectal Excision (LTME) without neoadjuvant chemo-radiation (NCR). Secondary endpoint is to detect the potential lesion site evaluating video-recordings of surgery.

PATIENTS AND METHODS

A study of 35 consecutive patients treated by LTME for extra-peritoneal rectal cancer not subjected to NCR, M:F = 23:12, median age 70, was evaluated preoperatively by Uroflowmetry and US postvoid residual urine measurement (PVR), International Prostatic Symptoms Score (IPSS), and International Consultation on Incontinence Modular Questionnaire (ICIQ) at 1 and 9 months post-operatively. Evaluation of sexual function was carried out by International Index of Erectile Function (IIEF) in males. Data were analyzed performing Fisher and paired samples t tests. Surgical videos of patients affected by GUD were reviewed to identify lesion sites.

RESULTS

Urinary function:IPSS average score: baseline 6.03 ± 5.51, 8.93 ± 6.42 (p = .005) at 1 month, and 7.26 ± 5.55 (p = .041) at 9 months. ICIQ baseline 2.67 ± 5.42, 4.27 ± 6.19 (p = NS) at 1 month, and 3.63 ± 5.23 (p = NS) at 9 months. Maximum urine flow rate baseline 15.95 ± 4.78 ml/s, 14.23 ± 5.27 after 1 month (p = .041), and 15.22 ± 4.01 after 9 months (p = NS). Mean urine flow rate baseline 9.15 ± 2.96 ml/s, 7.99 ± 4.12 ml/s at 1 month (p = .044), and 8.54 ± 4.19 ml/s at 9 months (p = NS). PVR baseline 59.62 ± 54.49, 64.59 ± 58.71 (p = NS) at 1 month, and 68.82 ± 77.72 (p = NS) at 9 months. Sexual function: IIEF baseline 19.38 ± 6.25, 14.06 ± 8.65 at 1 month (p = .011), and 15.4 ± 8.41 at 9 months, (p = NS). Video review of patients with disorders showed potential damage at the site of ligation of IMA (high hypogastric plexus) in 1 case, lateral and posterior mesorectum dissection (hypogastric nerves) in 2 cases, anterior dissection of the Denonvilliers fascia from seminal vesicles in 2 cases.

CONCLUSIONS

GUD at 1 month from LTME for rectal cancer are significant but improve at 9 months. Surgical video review of patients with GUD provides an important tool for detection of lesion sites.

Addressing sexual dysfunction in colorectal cancer survivorship care

Despite the high prevalence of sexual dysfunction in survivors of colorectal cancer, studies have shown that patients and providers rarely discuss how these symptoms may be influencing overall quality of life. The type and severity of symptoms of sexual dysfunction can vary greatly depending on the type of colorectal cancer and treatment, and assessment of sexual dysfunction is key to understanding how patients may be affected by these symptoms. Although patients would like to discuss these issues with their provider, they are often reluctant to ask questions about sexual functioning during appointments. Likewise, health care providers may hesitate to address sexual dysfunction due to time limitations or lack of knowledge regarding treatment of sexual problems. Health care providers can facilitate discussion of sexual dysfunction by (I) assessing sexual functioning throughout treatment; (II) initiating discussions about symptoms of sexual dysfunction at each appointment; and (III) maintaining adequate referral resources for treatment of sexual dysfunction.

Clinical competence in the surgery of rectal cancer: the Italian Consensus Conference

BACKGROUND AND AIM

The literature continues to emphasize the advantages of treating patients in "high volume" units by "expert" surgeons, but there is no agreed definition of what is meant by either term. In September 2012, a Consensus Conference on Clinical Competence was organized in Rome as part of the meeting of the National Congress of Italian Surgery (I Congresso Nazionale della Chirurgia Italiana: Unità e valore della chirurgia italiana). The aims were to provide a definition of "expert surgeon" and "high-volume facility" in rectal cancer surgery and to assess their influence on patient outcome.

METHOD

An Organizing Committee (OC), a Scientific Committee (SC), a Group of Experts (E) and a Panel/Jury (P) were set up for the conduct of the Consensus Conference. Review of the literature focused on three main questions including training, "measuring" of quality and to what extent hospital and surgeon volume affects sphincter-preserving procedures, local recurrence, 30-day morbidity and mortality, survival, function, choice of laparoscopic approach and the choice of transanal endoscopic microsurgery (TEM).

RESULTS AND CONCLUSION

The difficulties encountered in defining competence in rectal surgery arise from the great heterogeneity of the parameters described in the literature to quantify it. Acquisition of data is difficult as many articles were published many years ago. Even with a focus on surgeon and hospital volume, it is difficult to define their role owing to the variability and the quality of the relevant studies.

Sexual dysfunction and infertility as late effects of cancer treatment

Sexual dysfunction is a common consequence of cancer treatment, affecting at least half of men and women treated for pelvic malignancies and over a quarter of people with other types of cancer. Problems are usually linked to damage to nerves, blood vessels, and hormones that underlie normal sexual function. Sexual dysfunction also may be associated with depression, anxiety, relationship conflict, and loss of self-esteem. Innovations in cancer treatment such as robotic surgery or more targeted radiation therapy have not had the anticipated result of reducing sexual dysfunction. Some new and effective cancer treatments, including aromatase inhibitors for breast cancer or chemoradiation for anal cancer also have very severe sexual morbidity. Cancer-related infertility is an issue for younger patients, who comprise a much smaller percentage of total cancer survivors. However, the long-term emotional impact of being unable to have a child after cancer can be extremely distressing. Advances in knowledge about how cancer treatments may damage fertility, as well as newer techniques to preserve fertility, offer hope to patients who have not completed their childbearing at cancer diagnosis. Unfortunately, surveys in industrialised nations confirm that many cancer patients are still not informed about potential changes to their sexual function or fertility, and all modalities of fertility preservation remain underutilised. After cancer treatment, many patients continue to have unmet needs for information about restoring sexual function or becoming a parent. Although more research is needed on optimal clinical practice, current studies suggest a multidisciplinary approach, including both medical and psychosocial treatment options.

A randomized pilot trial of a telephone-based couples intervention for physical intimacy and sexual concerns in colorectal cancer

BACKGROUND

We previously developed and piloted a telephone-based intimacy enhancement (IE) intervention addressing sexual concerns of colorectal cancer patients and their partners in an uncontrolled study. The current study tested the feasibility, acceptability, and preliminary efficacy of the IE intervention in a randomized, controlled trial.

METHODS

Twenty-three couples were randomized to either the four-session IE condition or to a wait list control condition and completed sexual and relationship outcomes measures. The IE intervention teaches skills for coping with sexual concerns and improving intimacy. Feasibility and acceptability were assessed through enrollment and post-treatment program evaluations, respectively. Effect sizes were calculated by comparing differences in average pre/post change scores across completers in the two groups (n = 18 couples).

RESULTS

Recruitment and attrition data supported feasibility. Program evaluations for process (e.g., ease of participation) and content (e.g., relevance) demonstrated acceptability. Engaging in intimacy-building activities and communication were the skills rated as most commonly practiced and most helpful. For patients, positive effects of the IE intervention were found for female and male sexual function, medical impact on sexual function, and self-efficacy for enjoying intimacy (≥.58); no effects were found on sexual distress or intimacy and small negative effects for sexual communication, and two self-efficacy items. For partners, positive IE effects were found for all outcomes; the largest were for sexual distress (.69), male sexual function (1.76), communication (.97), and two self-efficacy items (≥.87).

CONCLUSIONS

The telephone-based IE intervention shows promise for couples facing colorectal cancer. Larger multi-site intervention studies are necessary to replicate findings.

Gastrointestinal ostomies and sexual outcomes: a comparison of colorectal cancer patients by ostomy status

PURPOSE

Research examining effects of ostomy use on sexual outcomes is limited. Patients with colorectal cancer were compared on sexual outcomes and body image based on ostomy status (never, past, and current ostomy). Differences in depression were also examined.

METHODS

Patients were prospectively recruited during clinic visits and by tumor registry mailings. Patients with colorectal cancer (N = 141; 18 past ostomy; 25 current ostomy; and 98 no ostomy history) completed surveys assessing sexual outcomes (medical impact on sexual function, Female Sexual Function Index, International Index of Erectile Function), body image distress (Body Image Scale), and depressive symptoms (Center for Epidemiologic Studies Depression Scale-Short Form). Clinical information was obtained through patient validated self-report measures and medical records.

RESULTS

Most participants reported sexual function in the dysfunctional range using established cut-off scores. In analyses adjusting for demographic and medical covariates and depression, significant group differences were found for ostomy status on impact on sexual function (p < .001), female sexual function (p = .01), and body image (p < .001). The current and past ostomy groups reported worse impact on sexual function than those who never had an ostomy (p < .001); similar differences were found for female sexual function. The current ostomy group reported worse body image distress than those who never had an ostomy (p < .001). No differences were found across the groups for depressive symptoms (p = .33) or male sexual or erectile function (p values ≥ .59).

CONCLUSIONS

Colorectal cancer treatment puts patients at risk for sexual difficulties and some difficulties may be more pronounced for patients with ostomies as part of their treatment. Clinical information and support should be offered.

Sexual activity and body image: examining gender variability and the influence of psychological distress in cancer patients

Psychosocial factors impacting on the overall quality of life for cancer patients may differ between men and women. This study examined the influence that psychological distress, clinical, and social variables have on sexual activity and body image in adult oncology patients. Symptom data was collected from the Memorial Symptom Assessment Scale (MSAS). Analysis indicated women and patients with reported functional limitations were more likely to be less satisfied with how they looked. The final model showed that younger adults, Caucasians, those who were married and patients with some functional limitations were more likely to have problems with sexual interest/activity. Gender was not a significant predictor of having problems with sexual interest/activity. These results can be used by clinicians to identify patients who may be at an increased risk for negative body image and problems in sexual functioning. Further research regarding gender differences in cancer-related psychological symptoms is needed to assist healthcare professionals in providing comprehensive care while alleviating unresolved and interrelated health and psychosocial symptoms.

Predictors of postoperative urinary retention after colorectal surgery

BACKGROUND

National quality initiatives have mandated the earlier removal of urinary catheters after surgery to decrease urinary tract infection rates. A potential unintended consequence is an increased postoperative urinary retention rate.

OBJECTIVE

The aim of this study was to determine the incidence and risk factors for postoperative urinary retention after colorectal surgery.

DESIGN

This was a prospective observational study.

SETTINGS

A colorectal unit within a single institution was the setting for this study.

PATIENTS

Adults undergoing elective colorectal operations were included.

INTERVENTIONS

Urinary catheters were removed on postoperative day 1 for patients undergoing abdominal operations, and on day 3 for patients undergoing pelvic operations. Postvoid residual and retention volumes were measured.

MAIN OUTCOME MEASURES

The primary outcomes measured were urinary retention and urinary tract infection.

RESULTS

The overall urinary retention rate was 22.4% (22.8% in the abdominal group, 21.9% in the pelvic group) and was associated with longer operative time and increased perioperative fluid administration. Mean operative time for those with retention was 2.8 hours and, for those without retention, the mean operative time 2.2 hours (abdominal group 2 hours vs 1.4 hours, pelvic group 3.9 hours vs 3.1 hours, p ≤ 0.02). Patients with retention received a mean of 2.7L during the operation, whereas patients without retention received 1.8L (abdominal group 1.9L vs 1.4L, pelvic group 3.6L vs 2.2L, p < 0.01). In the abdominal group, patients with and without retention also received different fluid volumes on postoperative days 1 (2.2L vs 1.7L, p = 0.004) and 2 (1.6L vs 1L, p = 0.05). Laparoscopic abdominal group had a 40% retention rate in comparison with 12% in the open abdominal group (p = 0.004). Age, sex, preoperative radiation therapy, preoperative prostatism, preoperative diagnosis, and level of anastomosis were not associated with retention. The urinary tract infection rate was 4.9%.

LIMITATION

The lack of documentation of preoperative urinary function was a limitation of this study.

CONCLUSIONS

The practice of earlier urinary catheter removal must be balanced with operative time and fluid volume to avoid high urinary retention rates. Also important is increased vigilance for the early detection of retention.

Randomized controlled trial of tamsulosin for prevention of acute voiding difficulty after rectal cancer surgery

BACKGROUND

We conducted a randomized clinical trial to investigate the efficacy of the selective α(1A)-adrenoceptor antagonist tamsulosin in preventing acute voiding difficulty after rectal cancer surgery.

METHODS

A total of 94 rectal cancer patients with an International Prostate Symptom Score (IPSS) of ≤7 were randomly assigned (1:1) to the tamsulosin group (0.2 mg/day orally for 7 days) (n = 47) or the control group (n = 47). The primary endpoint was the reinsertion rate of the urinary catheter after its removal on postoperative day (POD) 3. The secondary endpoints included the maximum (Qmax) and average (Qavg) urinary flow rates on POD 3, and the voided volume (VV), residual urine volume (RU), and IPSS on POD 7. Analyses were based on an intention-to-treat population.

RESULTS

The reinsertion rate of the urinary catheter in the tamsulosin group was similar to that in the control group (23.4 vs. 21.3 %, respectively; p = 0.804). The postoperative voiding parameters and IPSS were not better in the tamsulosin group than in the control group after adjustments were made for the baseline measurements with analysis of covariance (Qmax, p = 0.537; Qavg, p = 0.399; VV, p = 0.645; RU, p = 0.703; IPSS, p = 0.761). Multivariate analysis revealed that being male was the only independent risk factor for reinsertion of the urinary catheter (odds ratio 0.239; 95 % confidence interval 0.069-0.823; p = 0.023).

CONCLUSIONS

This controlled trial showed that tamsulosin at 0.2 mg/day does not prevent acute voiding difficulty after rectal cancer surgery.

Sexual dysfunction after colpectomy and vaginal reconstruction with a vertical rectus abdominis myocutaneous flap

BACKGROUND

The use of the vertical rectus abdominis myocutaneous flap in reconstruction after abdominoperineal resection or pelvic exenteration for neoplasia is well documented. However, functional outcomes after vaginal reconstruction, including sexual function, are poorly described.

OBJECTIVE

This study aimed to examine sexual function in women following extensive pelvic surgery with colpectomy and vaginal reconstruction with the use of a vertical rectus abdominis myocutaneous flap.

DESIGN

This study is a retrospective review of medical records in combination with patient questionnaires. Nonresponders were followed up with a second contact.

SETTINGS

This study was performed at a tertiary care university medical center (Colorectal Section, Department of Surgery P, Aarhus University Hospital, Denmark)

PATIENTS

All women undergoing pelvic surgery and simultaneous vaginal reconstruction with the use of a vertical rectus abdominis myocutaneous flap between 2004 and 2010 at our department were identified from a patient database. Thirty women who were alive at the time of identification were included in the study.

MAIN OUTCOME MEASURES

Sexual function before and after surgery was evaluated by the use of the Sexual function Vaginal changes Questionnaire. The main outcome end point was whether the patient was sexually active after vaginal reconstruction.

RESULTS

Twenty-six participants (87%) answered the questionnaire. Fifty percent of patients reported an active sex life before surgery. In general, patients reported an unchanged desire for both physical and sexual contact after surgery. However, only 2 patients (14%) reported being sexually active after surgery.

LIMITATIONS

This was a retrospective study with a heterogeneous cohort involving several types of cancers and surgical procedures. Factors other than vertical rectus abdominis myocutaneous flap reconstruction itself may interfere with the sexual function.

CONCLUSION

Extensive pelvic surgery with colpectomy leads to sexual dysfunction even when the vagina is reconstructed with a vertical rectus abdominis myocutaneous flap. This knowledge may improve the quality of information given to this group of patients before surgery.

Demographics, cancer-related factors, and sexual function in rectal cancer patients in Taiwan: preliminary findings

BACKGROUND

Sexual function has been ignored because survival issues associated with cancer treatment commonly take precedence over sexual issues. Sexual dysfunction remains a recognized complication after cancer treatment despite improvement in survival rates for patients with rectal cancer.

OBJECTIVE

This study investigated the relationships among demographics (ie, age, gender, education, religion) and cancer-related factors (ie, stage of disease, type of treatment, time since operation, comorbid conditions) and sexual function in patients with rectal cancer.

METHODS

A cross-sectional study with a convenience sample of 120 rectal cancer patients from a medical center in southern Taiwan completed the International Index of Erectile Function, Female Sexual Function Index, a demographic questionnaire, and medical data during face-to-face interviews.

RESULTS

In both men and women, better sexual function was significantly associated with younger age but not with religion, time since operation, or number of chronic conditions. In men only, better sexual function was associated with earlier stage of cancer, fewer cancer treatments, and higher education.

CONCLUSION

Sexual function may receive greater attention in Taiwan when rectal cancer patients receive appropriate care. A larger diverse sample is needed for further examination of sexual function over time.

IMPLICATIONS FOR PRACTICE

Health promotion programs for long-term survivors should include a consistent assessment of sexual function before and after an operation, and patients should receive clinical sexual counseling.

Risk Factors for Postoperative Urinary Tract Infection and Urinary Retention in Patients Undergoing Surgery for Colorectal Cancer

The aim of this study was to analyze risk factors for postoperative urinary tract infection (UTI) and urinary retention (UR) in patients with colorectal cancer. Using Nationwide Inpatient Sample 2006–2009, a retrospective analysis of surgical patients with colorectal cancer was conducted. Patients were stratified into groups, with or without UTI/UR. The LASSO algorithm for logistic regression identified independent risk factors. A total of 93,931 surgical patients with colorectal cancer were identified. The incidences of UTI and UR were 5.91 and 2.52 per cent, respectively. Overall in-hospital mortality was 2.68 per cent. The UTI group demonstrated significantly higher in-hospital mortality rates compared with those without. Both UTI and UR groups were associated with prolonged hospital stay and increased hospital charge. Multivariate logistic regression analysis revealed age older than 60 years, females, anemia, congestive heart failure, coagulopathy, diabetes with chronic complications, fluid and electrolyte, paralysis, pulmonary circulation disorders, renal failure, and weight loss were independent risk factors of UTI. Age older than 60 years, male gender, rectal and rectosigmoid cancers, and postoperative anastomotic leakage and ileus were independent risk factors for UR. Postoperative UTI increases in-house mortality. Postoperative UTI/UR in patients with colorectal cancer increases length of stay and hospital charges. Knowledge of these specific risk factors for UTI and UR is needed to counsel patients and prevent these complications in this high-risk population.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sexual function, incontinence, and wellbeing in women after rectal cancer--a review of the evidence

INTRODUCTION

Colorectal cancer (CRC) is the second most common cancer. One-third of these cancers occur in the rectum. Treatment of rectal cancer involves surgery with/without radiotherapy and chemotherapy. Surgery is undertaken to prevent damage to the nerves controlling bladder, bowel, and sexual organs, whether this translates into preservation of urinary and fecal continence and sexual function and, ultimately, quality of life (QoL) is not known.

AIM

The aim of this review was to summarize the literature regarding the impact of treatment for rectal cancer on bladder and bowel continence, sexual function and QoL in women.

MAIN OUTCOME MEASURES

A comprehensive review of the current literature on sexual function, incontinence and wellbeing in women after treatment for rectal cancer highlighting prevalence rates, trial design, and patient population.

METHODS

We conducted a systematic search of the literature using A systematic search of the literature using Medline (Ovid, 1946-present) and PubMed (1966-2011) for English-language studies that included the following search terms: "colorectal cancer," or "rectal cancer," or "rectal neoplasm," and "sexual function," or "sexual dysfunction," or "wellbeing," or "QoL," or "urinary or fecal incontinence."

RESULTS

Although around 1/3 of women aged 50 to 70 years report lack of sexual desire, sexual function problems after treatment for rectal cancer are in the order of 60% among women. QoL improves with length of survival. Urinary and fecal incontinence are ongoing concerns for many women after treatment with rates up to 60%.

CONCLUSION

There is a gap in our knowledge of the effects of rectal cancer and its treatment on urinary and fecal continence, sexual function and QoL in women. There is a need for studies of sufficient size and duration to gain a better understanding of the disease and its management and the long-term effects on these parameters. This information is needed to develop preventative health care plans for women treated for rectal cancer that target those most at risk for these adverse outcomes.

Robotic-assisted total mesorectal excision: should it be considered as the technique of choice in the management of rectal cancer?

The feasibility of robotic surgery has been extensively explored over the past decade with a more recent shift towards defining focused clinical applications for which quantifiable patient benefits can be directly attributed to its use. The aim of this article is to review the current literature on the use of daVinci robotic surgery for the management of rectal cancer and identify the potential benefits, if any, that robotic-assisted total mesorectal excision (RTME) may provide over the current conventional approach. A comprehensive search strategy was used to identify relevant evidence in order to explore the oncological, operative and functional outcome measures for the RTME in addition to quantifying the level of evidence which describes the clinical effectiveness of the daVinci robot in oncological surgery. Both robotic assisted techniques and the primary outcomes are discussed. In total, 23 studies were reviewed across 11 institutions, including one pilot randomised control trial. When data repetition is disregarded, a total of 452 robotic assisted laparoscopic anterior resections and 60 robotic-assisted laparoscopic abdomino-perineal excision of the rectum have been published since the introduction of the daVinci into clinical practice. Feasibility of the daVinci robotic assisted total mesorectal excision is demonstrated, with comparable oncological outcomes presented for rectal cancer excision. A demonstration of a reduced open conversion rate as well as of reduced hospital stay with the use of the robot is highlighted, although further trials are required to confirm both these findings. No functional benefit in using the daVinci could be confirmed due to the lack of focused trials in this area.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Online signal processing of internal anal sphincter activity during pelvic autonomic nerve stimulation: a new method to improve the reliability of intra-operative neuromonitoring signals

AIM

Intra-operative neuromonitoring is increasingly applied in several surgical disciplines and has been introduced to facilitate pelvic autonomic nerve preservation. Nevertheless, it has been considered a questionable tool for the minimization of risk, as the results are variable and might be misleading. The aim of the present experimental study was to develop an intra-operative neuromonitoring system with improved reliability for monitoring pelvic autonomic nerve function.

METHOD

Fifteen pigs underwent low anterior rectal resection with pelvic autonomic nerve preservation. Intra-operative neuromonitoring was performed under autonomic nerve stimulation with observation of electromyographic signals of the internal anal sphincter and bladder manometry. As the internal anal sphincter frequency spectrum during stimulation was found to be mainly in the range of 5-20 Hz, intra-operative neuromonitoring signals were postoperatively processed by implementation of matching band pass filters.

RESULTS

In 10 preliminary experiments, signal processing was performed offline in the postoperative analysis. Of 163 stimulations intra-operatively assessed by the surgeon as positive responses, 135 (83%) were confirmed after signal processing. In the following five consecutive experiments intra-operative online signal processing was realized and demonstrated reliable intra-operative neuromonitoring signals of internal anal sphincter activity with significant increase during pelvic autonomic nerve stimulation [0.5 μV (interquartile range = 0.3-0.7) vs 4.8 μV (interquartile range = 2.5-7.5); P < 0.001].

CONCLUSION

Online signal processing of internal anal sphincter activity aids reliable identification of pelvic autonomic nerves with potential for improvement of intra-operative neuromonitoring in pelvic surgery.

Deep pelvic anatomy revisited for a description of crucial steps in extralevator abdominoperineal excision for rectal cancer

BACKGROUND

Extralevator abdominoperineal excision results in superior oncologic outcome for advanced low rectal cancer. The exact definition of surgical resection planes is pivotal to achieving negative circumferential resection margins.

OBJECTIVE

This study aims to describe the surrounding anatomical structures that are at risk for inadvertent damage during extralevator abdominoperineal excision.

DESIGN AND SETTING

Joint surgical and macroanatomical dissection was performed in a university laboratory of clinical anatomy.

METHODS

A stepwise dissection study was conducted according to the technique of extralevator abdominoperineal excision by abdominal and perineal approaches in 4 human cadaveric pelvises. Muscular, fascial, tendinous, and neural structures were carefully exposed and related to the corresponding surgical resection planes.

RESULTS

In addition to the autonomic nerves to be identified and preserved during total mesorectal excision, further structures endangered during extralevator abdominoperineal excision can be clearly identified. Terminal pudendal nerve branches come close to the surgical resection plane at the outer surface of the puborectal sling. Likewise, the pelvic plexus and its neurovascular bundles embedded within the parietal pelvic fascia extend close to the apex of the prostate where the parietal pelvic fascia has to be divided. These neural structures converge in the region of the perineal body, an area that provides no "self-opening" planes for surgical dissection. Thus, the necessity to sharply detach the anorectal specimen anteriorly from the perineal body and the superficial transverse perineal muscle bears the risk of both inadvertent damage of the aforementioned anatomical structures and perforation of the specimen.

LIMITATIONS

The study focused primarily on the macroscopic topography relevant to the surgical procedure, so that previously published histologic examinations were not performed.

CONCLUSION

The present anatomical dissection study highlights those anatomical landmarks that require clear identification for the successful achievement of both negative circumferential resection margins and preservation of urogenital functions during extralevator abdominoperineal excision.

Sexual function after treatment for rectal cancer: a review

Sexual function is one element of QOL that may be significantly altered following treatment for rectal cancer, but the incidence and contributing risk factors are generally poorly understood. Nevertheless, the impact of rectal cancer therapy on sexual function should be conveyed to patients preoperatively. In addition to helping patients evolve realistic expectations, it will help clinicians identify those for whom interventions may be appropriate. In the past 10 years, there has been an increase in the number of studies reporting sexual dysfunction following rectal cancer treatment. However, these studies are difficult to interpret collectively for a variety of reasons. Most importantly, sexual dysfunction lacks a standardized definition, which leads to poor comparability between studies. The best inclusive definitions describe sexual dysfunction as a collection of distinct symptoms, which differ for men and women. The absence of sexual activity is sometimes used as a surrogate for sexual dysfunction, but this is confounded by an individual's desire and opportunity for sexual activity, and may not be an accurate reflection of physiologic functionality. Additional factors complicating assimilation of studies include the absence of baseline data, missing data, small sample sizes, and heterogeneity in use of validated and nonvalidated instruments. The purpose of this article is to systematically review the contemporary literature reporting sexual function after rectal surgery to determine the overall risk of sexual dysfunction, evaluate possible contributing factors, and identify questions that should be addressed in future studies.

Gynecologic problems following abdominoperineal resection of the anus and rectum - the post-miles syndrome

BACKGROUND

: Abdominoperineal resection is a surgical technique used to treat a variety of colorectal diseases. Although there are several published studies describing long-term pelvic floor functioning in women who have undergone this procedure, little is known specifically about gynecologic problems that may develop after surgery.

CASES

: We describe a series of 3 patients all presenting with similar gynecologic complaints status-post abdominoperineal resection, including copious vaginal discharge, dyspareunia, and difficulty on the part of their health care providers in seeing the cervix during speculum examinations. The presenting syndrome is felt to be due to a reduction in vaginal caliber and steep angulation of the upper vagina due to the plication of the levator ani during the typical closure of the pelvic floor at the completion of surgery. Successful therapy has been achieved with conservative measures as well as surgical treatment.

CONCLUSIONS

: Abdominoperineal resection may result in a syndrome of gynecologic complaints. Medical and/or surgical therapies are effective in controlling symptoms.

Sexual function in females after radiotherapy for rectal cancer

BACKGROUND

Knowledge about female sexual problems after pre- or postoperative (chemo-)radiotherapy and radical resection of rectal cancer is limited. The aim of this study was to compare self-rated sexual functioning in women treated with or without radiotherapy (RT+ vs. RT-), at least two years after surgery for rectal cancer.

METHODS AND MATERIALS

Female patients diagnosed from 1993 to 2003 were identified from a national database, the Norwegian Rectal Cancer Registry. Eligible patients were without recurrence or metastases at the time of the study. The Sexual function and Vaginal Changes Questionnaire (SVQ) was used to measure sexual functioning.

RESULTS

Questionnaires were returned from 172 of 332 invited and eligible women (52%). The mean age was 65 years (range 42-79) and the time since surgery for rectal cancer was 4.5 years (range 2.6-12.4). Sexual interest was not significantly impaired in RT+ (n=62) compared to RT- (n=110) women. RT+ women reported more vaginal problems in terms of vaginal dryness (50% vs. 24%), dyspareunia (35% vs. 11%) and reduced vaginal dimension (35% vs. 6%) compared with RT- patients; however, they did not have significantly more worries about their sex life.

CONCLUSION

An increased risk of dyspareunia and vaginal dryness was observed in women following surgery combined with (chemo-)radiotherapy compared with women treated with surgery alone. Further research is required to determine the effect of adjuvant therapy on female sexual function.