Preservation of urine voiding and sexual function after rectal cancer surgery

The urinary and sexual outcomes of robot-assisted versus laparoscopic rectal cancer surgery: a systematic review and meta-analysis

To compare the urinary and sexual outcomes between robot-assisted rectal cancer (RC) surgery (RRCS) and laparoscopic RC surgery (LRCS) using a meta-analysis, searches were conducted of the Embase, PubMed, Cochrane Library, CNKI, and Wanfang databases. The International Prostate Symptom Score (IPSS) was the primary outcome. Eleven studies (790 patients with RRCS and 888 with LRCS) were included. The IPSS scores were significantly lower for RRCS than LRCS from baseline to 3 months (weighted mean difference [WMD] =  - 1.21, 95% confidence interval [CI]: - 1.8,-0.62, I2 = 89.9%), to 6 months (WMD =  - 1.13, 95% CI: - 1.74, - 0.52, I2 = 93.3%), and to 12 months (WMD =  - 0.93, 95% CI: - 1.59, - 0.26, I2 = 93.8%). The International Index of Erectile Function (IIEF) scores were significantly higher for RRCS than LRCS from baseline to 3 months (WMD = 3.36, 95% CI: 1.28, 5.44, I2 = 92.7%). The female sexual function index (FSFI) scores were significantly higher for RRCS than LRCS from baseline to 3 months (WMD = 1.31, 95% CI: 0.87, 1.76, I2 = 0), to 6 months (WMD = 2.36, 95% CI: 1.93, 2.79, I2 = 24.3%), and to 12 months (WMD = 1.67, 95% CI: 0.41, 2.93, I2 = 90.9%). RRCS also achieved a better recovery of the urological and sexual function than LRCS for patients with RC. Larger-scale prospective randomized control trials are needed to verify these results.

Multicentre, prospective, randomized control non-inferiority trial of bladder catheter management in colon surgery

AIM

Perioperative bladder catheterization is a controversial issue. Most current recommendations are based on data from open surgery extrapolated to enhanced recovery after surgery or fast-track programmes ranging between 24 and 48 h. The aim of this study is to provide a rationale for reducing catheterization time while at the same time avoiding acute urine retention (AUR), in patients undergoing scheduled laparoscopic colon surgery.

METHOD

This is a multicentre, prospective, controlled, randomized non-inferiority study of bladder catheter management in patients undergoing scheduled laparoscopic colon surgery, randomized into two groups: experimental (with catheter removal immediately after surgery) and control (with catheter removal 24 h post-surgery). The main outcome will be the development of AUR, and secondary outcomes the development of urinary infection within the first 30 days and hospital stay. Demographic, surgical and pathological variables will also be evaluated, especially the development of adverse effects assessed according to the Clavien scale and the Comprehensive Complication Index. Following the literature, we assume an incidence of AUR of 11% and a margin of non-inferiority (delta) of 8% and estimate that a sample size of 208 patients per group will be required (with an estimated 10% of losses per group).

CONCLUSIONS

In this study we try to demonstrate that the bladder catheter can be removed immediately after scheduled laparoscopic colon surgery, without increasing acute urine retention. This measure would offers the benefits of earlier mobilization and reduces catheter-related morbidity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Urogenital dysfunction after laparoscopic surgery for rectal or sigmoid colon cancer

BACKGROUND/OBJECTIVE

Urogenital dysfunction is a common complication after surgery for sigmoid colon or rectal cancers and may result from various causes. Herein, we evaluated urogenital dysfunction and the associated factors after laparoscopic surgery at different follow-up times.

METHODS

We conducted a prospective study on 91 patients who were diagnosed with sigmoid colon and rectal cancers and underwent laparoscopic surgery during 2014-2016. Voiding and male and female sexual dysfunctions following surgery were evaluated by the International Prostate Symptom Score (IPSS), International Index of Erectile Function-5 (IIEF-5), and Female Sexual Function Index-6 (FSFI-6), respectively. Urogenital function was compared at pre-surgery and 3 and 12 months postoperatively, and factors associated with urogenital dysfunction were identified.

RESULTS

The overall urinary function after surgery was better when compared to that at pre-surgery; however, there was deterioration in both male and female sexual functions. The mean preoperative IPSS, IIEF-5, and FSFI-6 scores were 9.35, 12.18, and 6.09, respectively. The mean differences among IPSS, IIEF-5, and FSFI-6 at 12 months postoperatively and pre-surgery were -3.08 (95% confidence interval [CI] -4.77 to -1.40), -2.57 (95% CI -4.33 to -0.80), and -2.58 (95% CI -4.73 to 0.42), respectively. Multivariate analysis demonstrated that age ≤60 years (odds ratio 4.22) and postoperative complications (odds ratio 2.77) were correlated with erectile dysfunction.

CONCLUSION

Voiding function improved after laparoscopic surgery in both sigmoid colon and rectal cancer patients. However, sexual function in both male and female patients was worse. Age ≤60 years and postoperative complications were strongly associated with male sexual dysfunction.

Validation of a scoring system to predict bladder dysfunction after laparoscopic rectal cancer surgery

PURPOSE

A recent trend in  urinary catheter management in patients who underwent laparoscopic rectal cancer surgery is early removal. However, some patients develop bladder dysfunction and require urinary re-catheterization. In 2016, a scoring system to predict bladder dysfunction after laparoscopic rectal cancer surgery was developed in our institution. The aim of this study was to demonstrate the validity of this scoring system and to determine the suitability of patients for early removal of urinary catheter.

METHODS

A single-center, retrospective study from a prospective database was conducted on 234 patients who underwent elective laparoscopic rectal cancer surgery between January 2016 and December 2019. According to bladder dysfunction predictive score, the urinary catheter was removed on the first postoperative day (low-risk group) and fifth postoperative day (high-risk group). After catheter removal, all patients were managed using in-house protocols.

RESULTS

Of 234 patients, 130 (55.6%) were classified as a low-risk group. The overall incidence of bladder dysfunction was 8.5% (11/130) in the low-risk group and 13.5% (14/104) in the high-risk group.

CONCLUSION

The scoring system developed to predict bladder dysfunction showed good overall performance for discriminating between patients suitable or not for early removal of urinary catheter after laparoscopic rectal cancer surgery.

Laparoscopic total mesorectal excision with urogenital fascia preservation for mid-low rectal cancer: Anatomical basis and clinical effect - Experimental research

BACKGROUND

Total mesorectal excision (TME) is conventionally performed according to Heald's principles through the so-called 'holy plane', between the visceral and parietal fasciae. However, urinary and sexual dysfunctions remain frequent postoperative complications. We proposed to preserve urogenital fascia (UGF) in TME, and this study aimed to clarify the anatomical basis of this technique and evaluate its efficacy and safety.

MATERIALS AND METHODS

Cadaveric dissection was performed on 26 pelvises, and laparoscopic TME with UGF preservation was performed in 212 patients with mid-low rectal cancer. The fasciae and spaces related to TME were observed and described, and the clinical effect of UGF-preserving TME was analyzed.

RESULTS

In the 26 cadavers, fascia propria of the rectum (FPR) presents as a fibrous capsule enveloping the mesorectum. UGF extends postero-laterally to the rectum, enveloping the hypogastric nerves and ureters. We demonstrated that the visceral fascia is actually the UGF, and FPR and visceral fascia (i.e. UGF) are two independent layers of fascia. Thus, FPR, UGF and parietal fascia form two avascular spaces behind the rectum. The plane ventral to the UGF is the real 'holy plane' for TME, rather than that dorsal to the UGF as is traditionally thought. Laparoscopic TME with UGF preservation was successfully performed in all 212 patients, with low perioperative complications (10.8%) and a low 3-year local recurrence rate (4.2%). Furthermore, the incidences of urinary and sexual dysfunctions at postoperative 6 months were only 6.1% and 10.8%, respectively.

CONCLUSION

The avascular plane between the FPR and UGF (i.e. visceral fascia) is the real 'holy plane'. Laparoscopic TME with UGF preservation is a feasible radical surgery for mid-low rectal cancer, with better protection of urinary and sexual functions.

Lower Incidence of Postoperative Urinary Retention in Robotic Total Mesorectal Excision for Low Rectal Cancer Compared with Laparoscopic Surgery

INTRODUCTION

The incidence and clinical significance of postoperative urinary retention (POUR) remain high. This study aimed to evaluate the incidence of POUR and related risk factors in patients who underwent total mesorectal excision (TMR) for low rectal cancer.

METHODS

This study is a retrospective review of a prospectively collected colorectal database from a single center. Data from patients who underwent surgery for low rectal cancer between September 2006 and May 2017 were analyzed to assess the risk factors of POUR. POUR was considered inability to void after urinary catheter removal requiring catheter reinsertion and difficulty in bladder emptying requiring intermittent catheterization.

RESULTS

Of 555 patients with low rectal cancer, 78 (14.1%) developed POUR. Based on multivariate logistic regression analysis, laparoscopic TMR (odds ratio [OR]; 2.114, 95% confidence interval [CI]; 1.212-3.689, p = 0.008) and postoperative ileus (OR; 2.389, 95% CI; 1.282-4.450, p = 0.006) were independent risk factors of POUR. Male gender, advanced age, neoadjuvant chemoradiation, longer operative time, abdominoperineal resection, and lateral pelvic lymph node dissection were not associated with POUR. Advanced age over 65 years also failed to show statistical significance (OR; 1.604, 95% CI; 0.965-2.668, p = 0.068).

CONCLUSION

Laparoscopic approach and postoperative ileus are risk factors for POUR after low rectal cancer surgery. We postulate that the benefits of robotic surgical systems compared to a laparoscopic approach may reduce the incidence of POUR.

Comparison of the quality of total mesorectal excision after robotic and laparoscopic surgery for rectal cancer: a multicenter, propensity score-matched study

Purpose

This study aimed to evaluate and compare the quality of total mesorectal excision (TME) and disease-free and overall survival rates between robotic and laparoscopic surgeries for rectal cancer.

Methods

From January 2015 to December 2018, 234 patients underwent curative robotic or laparoscopic surgery for rectal cancer at two centers. Ultimately, 201 patients were enrolled. To control for different demographic factors in the two groups, propensity score matching was used at a 1:1 ratio. Propensity scores were generated with the baseline characteristics, including age, sex, body mass index, American Society of Anesthesiologists score, previous abdominal surgery, tumor location, preoperative chemotherapy, and preoperative radiation. Finally, 134 patients were matched with 67 patients in the robotic surgery group and 67 patients in the laparoscopic surgery group.

Results

There was no significant difference in the pathologic stages between the robotic and laparoscopic surgery groups. Distal margin involvement was only observed in the robotic surgery group (1/67, 1.5%). Circumferential resection margin involvement was not different between the robotic surgery and laparoscopic surgery groups (3/67 [4.5%] and 4/67 [6.0%], respectively, P=1.000). The quality of TME (complete, nearly complete, and incomplete) was similar between the robotic surgery and laparoscopic surgery groups (88.0%, 6.0%, 6.0% and 79.1%, 9.0%, 11.9%, respectively, P=0.358). The disease-free and overall survival rates were not significantly different between the groups.

Conclusion

The quality of TME and disease-free and overall survival rates between the two surgeries were similar. There was no oncologic advantage of robotic surgery for rectal cancer compared to laparoscopic surgery.

Lateral lymph node dissection in advanced low rectal cancer treatment

Lateral lymph node (LLN) metastasis is a determinant of local recurrence in advanced low rectal cancer. Lateral lymph node dissection (LLND) is effective in removing metastatic lymph nodes, and has been shown to have a decreased local recurrence rate. However, because of its complexity and complications it induces, there is still tremendous controversy about its usage. Neoadjuvant chemoradiotherapy (nCRT) and total mesorectal excision (TME) are recommended as a conventional treatment for advanced rectal cancer. However, LLN metastasis and local recurrence still occur despite nCRT with TME. In Japan, TME with LLND is the standard surgical treatment for Stage II/III of advanced low rectal cancer. Before surgery, a proper evaluation of LLN status should be performed. Laparoscopic LLND and robotic-assisted LLND are useful for this. More research is necessary to improve the oncological outcomes of LLND. In this review, we retrospectively examine previous reports about LLND, aiming to emphasize its application prospects to improve patient survival and life quality.

Systematic Early Urinary Catheter Removal Integrated in the Full Enhanced Recovery After Surgery (ERAS) Protocol After Laparoscopic Mid to Lower Rectal Cancer Excision: A Feasibility Study

Purpose

Enhanced Recovery After Surgery (ERAS) programs advocate early urinary catheter removal after rectal cancer surgery; however, the optimal duration remains unclear. This study assessed the feasibility of the early urinary catheter removal protocol after rectal cancer surgery within an ERAS pathway and identified predictive factors for failure of this strategy.

Methods

Between March 2017 and October 2018, all unselected and consecutive patients who underwent rectal cancer resection and benefited from our ERAS program were included. Urinary complications (infection and retention) were prospectively recorded. Success was defined as catheter removal on postoperative day (POD) 3 without urinary complications.

Results

Of 135 patients (male, 63.7%; neoadjuvant chemoradiation, 57.0%; urology history, 17.8%), 120 had early urinary catheter removal with no complications (success rate, 88.9%), 8 did not have urinary catheter removal on POD 3 due to clinical judgment or prescription error, 5 experienced a urinary tract infection, and 2 had acute urinary retention. Obesity (odds ratio [OR], 0.16; P = 0.003), American Society of Anesthesiologists physical status classification > II (OR, 0.28; P = 0.048), antiaggregant platelet medication (OR, 0.12; P < 0.001), absence of anastomosis (OR, 0.1; P = 0.003), and prolonged operative time (OR, 0.21; P = 0.020) were predictive factors for failure. Conversely, optimal compliance with the ERAS program (OR, 7.68; P < 0.001), postoperative nonsteroidal anti-inflammatory drug use (OR, 21.71; P < 0.001), and balanced intravenous fluid therapy (OR, 7.87; P = 0.001) were associated with increased strategy success.

Conclusion

Withdrawal of the urinary catheter on POD 3 was successfully achieved after laparoscopic rectal resection and can be safely implemented in the ERAS program.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Implementation of robot-assisted total mesorectal excision by multiple surgeons in a large teaching hospital: Morbidity, long-term oncological and functional outcome

BACKGROUND

Robot-assisted total mesorectal excision (TME) might offer benefits in less morbidity, better functional and long-term outcome over laparoscopic TME.

METHODS

All consecutive patients undergoing robot-assisted TME for rectal cancer during implementation between May 2015 and December 2019 performed by five surgeons in a single centre were included. Outcomes included local recurrence rate at 3 years, conversion rate, circumferential resection margin (CRM) positivity rate, 30-day postoperative morbidity and outcomes of low anterior resection syndrome (LARS) questionnaires.

RESULTS

In 105 robot-assisted TME, local recurrence rate at 3 years was 7.4%, conversion to open surgery rate was 8.6%, CRM positivity rate was 5.7%, 73.3% had good quality specimen, postoperative morbidity rate was 47.6% and anastomotic leakage rate was 9.0%. Incidence of major LARS was 55.3%.

CONCLUSIONS

results of this study described acceptable morbidity, functional and long-term outcome during implementation of robotic TME for rectal cancer by multiple surgeons in a single centre.

Comparison of Clinical Efficacy and Safety Between da Vinci Robotic and Laparoscopic Intersphincteric Resection for Low Rectal Cancer: A Meta-Analysis

Background and Aims: The intersphincteric resection (ISR) is beneficial for saving patients' anus to a large extent and restoring original bowel continuity. Laparoscopic ISR (L-ISR) has its drawbacks, such as two-dimensional images, low motion flexibility, and unstable lens. Recently, da Vinci robotic ISR (R-ISR) is increasingly used worldwide. The purpose of this article is to compare the feasibility, safety, oncological outcomes, and clinical efficacy of R-ISR vs. L-ISR for low rectal cancer. Methods: PubMed, EMBASE, Cochrane Library, and Web of Science were searched to identify comparative studies of R-ISR vs. L-ISR. Demographic, clinical, and outcome data were extracted. Mean difference (MD) and risk ratio (RR) with their corresponding confidence intervals (CIs) were calculated. Results: Five studies were included. In total, 510 patients were included, of whom 273 underwent R-ISR and 237 L-ISR. Compared with L-ISR, R-ISR has significantly lower estimated intraoperative blood loss (MD = -23.31, 95% CI [-41.98, -4.64], P = 0.01), longer operative time (MD = 51.77, 95% CI [25.68, 77.86], P = 0.0001), hospitalization days (MD = -1.52, 95% CI [-2.10, 0.94], P < 0.00001), and postoperative urinary complications (RR = 0.36, 95% CI [0.16, 0.82], P = 0.02). Conclusions: The potential benefits of R-ISR are considered as a safe and feasible alternative choice for the treatment of low rectal tumors.

Postoperative morbidity and mortality after mesorectal excision with laparoscopic versus conventional open lateral lymph node dissection for advanced rectal cancer: A meta-analysis

Lateral lymph node dissection (LLND) is a challenging procedure due to its technical difficulty and higher incidence of surgical morbidity, thus the purpose of this study is to compare the postoperative morbidity and mortality between laparoscopic and conventional open LLND after mesorectal excision (ME) for advanced rectal cancer. A comprehensive search was conducted in August 2019 based on data from PubMed, Embase, Cochrane Library, CNKI and Wanfang Data to identify relevant studies, and studies comparing laparoscopic with conventional open LLND were included. Seven studies with 335 cases in the laparoscopic LLND group and 841 cases in the conventional open LLND group were finally included. Compared with the conventional open LLND group, the laparoscopic LLND group enjoys a lower postoperative morbidity (OR = 0.47,95% CI [0.23, 0.97], P = 0.04), same postoperative mortality (Postoperative mortality in both groups was zero), shorter length of postoperative hospitalization (WMD = -5.30, 95% CI [-8.42, -2.18], P = 0.0009), less wound infection (OR = 0.40,95% CI [0.21, 0.77], P = 0.006), less intestinal obstruction (OR = 0.50,95% CI [0.29, 0.84], P = 0.009), and less urinary retention (OR = 0.61,95% CI [0.38, 0.97], P = 0.04). There were no significant differences in the incidence of anastomotic leakage, abdominal pelvic abscess and urinary tract infection between the two groups (P > 0.05). But in the sensitivity analysis, there was a significant change of urinary tract infection (OR = 0.22, 95%CI [0.06, 0.89], P = 0.03), and the degree of between-study heterogeneity decreased greatly. In conclusion, laparoscopic LLND may be a better alternative to conventional open LLND for advanced rectal cancer with lower postoperative morbidity and shorter postoperative hospital stay.

A controlled study on the efficacy and quality of life of laparoscopic intersphincteric resection (ISR) and extralevator abdominoperineal resection (ELAPE) in the treatment of extremely low rectal cancer

BACKGROUND

The aim of this study is to compare the postoperative quality of life (QoL) and survival outcomes in lower rectal cancer (LRC) patients who undergo either laparoscopic- intersphincteric resection or extralevator abdominoperineal excision (L-ELAPE) after long-course neoadjuvant chemoradiation therapy (nCRT).

METHODS

This prospective, single-center, non-randomized, controlled, non-blinded, phase I/II clinical trial is designed to enroll 159 eligible LRC patients who achieved favorable response to long-course nCRT (2 × 25 Gy). After informed consent, the patients will be assigned into the laparoscopic intersphincteric resection group or L-ELAPE group according to their own will. Standard radical laparoscopic surgeries will be performed for every participant. Then every participant will be followed up for 3 years. The primary outcomes are scores of QoL questionnaire-core 30, QoL questionnaire-colorectum 29, Wexner incontinence score, International Prostate Symptom Score (for male), International Index of Erectile Function-5 (for male) and Female Sexual Function Index (for female). The secondary outcomes consist of incomplete circumferential resection margin rate, 3-year local recurrence, 3-year disease-free survival, 3-year overall survival and other surgical outcomes.

DISCUSSION

This is the first prospective clinical controlled trial to assess postoperative QoL and efficacy for LRC patients after favorable long-course nCRT. The result is expected to provide new evidence for a more detailed individualized treatment guideline for LRC.

TRIAL REGISTRATION

This trial was registered at Chinese Clinical Trial Registry (ChiCTR1800017512; ChiCTR.org) on August 2, 2018.

Intraoperative radiotherapy for resectable advanced lower rectal cancer-final results of a randomized controlled trial (UMIN000021353)

AIM

Pelvic autonomic nerve preservation (PANP) is useful to preserve voiding and sexual function after rectal cancer surgery. The aim of this study was to investigate the benefit of intraoperative radiotherapy (IORT) to have complete PANP without affecting oncological outcomes.

METHODS

Patients undergoing potentially curative resection of the rectum were included. They were randomized to intraoperative radiotherapy of the completely preserved bilateral pelvic nerve plexuses (IORT group) or the control group without IORT, but with limited nerve preservation. The primary endpoint was pelvic sidewall recurrence. Moreover, patients' clinicopathologic parameters, postoperative complications, voiding function, and other oncologic outcomes were compared.

RESULTS

From 79 patients, three were excluded from analysis, resulting in 38 patients in each group. Patients' demographic and pathological parameters were well balanced between the two groups. The trial was terminated prematurely in July 2017, because distant metastasis-free survivals were found to be significantly worse in the IORT group compared to the control group (odds ratio 2.554; 95% CI, 1.041 ~ 6.269; p = 0.041). Neither overall survival nor pelvic sidewall recurrence did differ between the two groups (overall survival: odds ratio 1.264; 95% CI, 0.523~3.051; p = 0.603/pelvic sidewall recurrence; odds ratio 1.350; 95% CI, 0.302~6.034; p = 0.694). Postoperative complications did not differ between the groups; however, the urinary function was significantly better in the IORT group in the short and long term.

CONCLUSION

With the aid of IORT, complete PANP can be done without increase of pelvic sidewall recurrence; however, IORT may increase the incidence of distant metastases. Therefore, IORT cannot be recommended as a standard therapy to compensate less radical resection for advanced lower rectal cancer.

Update on indications for lateral lymph node dissection in the management of lower rectal cancer

The presence of lateral lymph node (LLN) metastasis was associated with higher local recurrence risk in patients with lower rectal cancer. The role of LLN dissection has not been fully determined despite prolonged debate that last for few decades. The practical difference between Japan and the West was the main culprit. Japanese used to rely on surgical removal of LLN as local control while the West believed that LLN dissection could be spared after giving neoadjuvant chemoradiotherapy. As time passed, it is getting more common to combine both treatments. With the quality improvement in magnetic resonance imaging, we can now predict the chance of LLN metastasis and evaluate the treatment response with good accuracy. Few large analyses have been published recently and provided us more insight into this topic. In this review, we summarized and provided an update on the latest evidence. We have proposed a treatment algorithm on the management of LLNs which may help clinical decision and provide idea for further research.

The risk factors for urinary dysfunction after autonomic nerve-preserving rectal cancer surgery: a multicenter retrospective study at Yokohama Clinical Oncology Group (YCOG1307)

AIM

The aim of this retrospective study was to evaluate the frequency and risk factors of urinary dysfunction after autonomic nerve-preserving surgery for rectal cancer.

METHODS

This was a retrospective multiinstitution study of 1002 rectal cancer patients conducted between January 2008 and December 2012 in Yokohama Clinical Oncology Group. Patients who had preoperative urinary dysfunction or had not undergone autonomic nerve preservation surgery were excluded. Urinary dysfunction was defined as that with a Clavien-Dindo classification grade ≥ 2. Patient-, tumor-, and surgery-related variables were examined by univariate and multivariate analyses.

RESULTS

A total of 887 patients were analyzed. Postoperative urinary dysfunction was observed in 77 patients (8.8%). A multivariate logistic analysis showed that a tumor location in lower rectum (odds ratio [OR] 2.16; 95% confidence interval [CI] 1.15-3.71; p = 0.02), tumor diameter ≥ 40 mm (OR 2.07; 95% CI 1.19-4.44; p < 0.01), operation time ≥ 240 min (OR 2.07; 95% CI 1.19-4.44; p < 0.01), blood loss ≥ 300 ml (OR 2.35; 95% CI 1.12-3.84; p = 0.02), and diabetes (OR 3.26; 95% CI 1.80-5.89; p < 0.01) were independent risk factors of urinary dysfunction. The incidence of urinary dysfunction exceeded 20% in patients with 3 preoperative predictors (tumor location, tumor diameter, diabetes).

CONCLUSIONS

This result demonstrated that high-risk patients with more than two risk factors should be informed of the risk of urinary dysfunction.

TRIAL REGISTRATION

UMIN000033688.

Laparoscopic versus Open Surgery in Lateral Lymph Node Dissection for Advanced Rectal Cancer: A Meta-Analysis

Aim

To compare the clinical efficacies between laparoscopic and conventional open surgery in lateral lymph node dissection (LLND) for advanced rectal cancer.

Methods

We comprehensively searched PubMed, Embase, Cochrane Library, CNKI, and Wanfang Data and performed a cumulative meta-analysis. According to inclusion criteria and exclusion criteria, all eligible randomized controlled trials (RCTs) or retrospective or prospective comparative studies assessing the two techniques were included, and then a meta-analysis was performed by using RevMan 5.3 software to assess the difference in clinical and oncological outcomes between the two treatment approaches.

Results

Eight studies involving a total of 892 patients were finally selected, with 394 cases in the laparoscopic surgery group and 498 cases in the traditional open surgery group. Compared with the traditional open group, the laparoscopic group had a longer operative time (WMD = 81.56, 95% CI (2.09, 142.03), P = 0.008), but less intraoperative blood loss (WMD = −452.18, 95% CI (-652.23, -252.13), P < 0.00001), shorter postoperative hospital stay (WMD = −5.30, 95% CI (-8.42, -2.18), P = 0.0009), and higher R0 resection rate (OR = 2.17, 95% CI (1.14, 4.15), P = 0.02). There was no significant difference in the incidence of surgical complications between the two groups (OR = 0.52, 95% CI (0.26, 1.07), P = 0.08). Lateral lymph node harvest, lateral lymph node metastasis, local recurrence, 3-year overall survival, and 3-year disease-free survival did not differ significantly between the two approaches (P > 0.05).

Conclusion

Laparoscopic LLND has a similar efficacy in oncological outcomes and postoperative complications to the conventional open surgery, with the advantages of reduced intraoperative blood loss, shorter postoperative hospital stay, and higher R0 resection rate, and tumor radical cure is similar to traditional open surgery. Laparoscopic LLND is a safe and feasible surgical approach, and it may be used as a standard procedure in LLND for advanced rectal cancer.

Association of Thoracic Epidural Pain Management with Urinary Retention after Complex Abdominal Wall Reconstruction

The association of thoracic epidural analgesia and urinary retention after complex abdominal wall reconstruction (CAWR) is unknown. The purpose of this study was to investigate the association between the presence of a thoracic epidural, timing of Foley catheter removal, and the rates of urinary retention and catheter-associated urinary tract infections (CAUTIs) in patients undergoing CAWR. All patients undergoing CAWR, who had an epidural catheter for postoperative pain management at our institution from September 2015 through April 2016, were prospectively followed. Patients were divided into two groups. Group 1 had their Foley catheters removed on postoperative day one, whereas Group 2 had their Foley catheters removed after epidural removal. The incidence of urinary retention and CAUTI were compared between the two groups. A total of 67 patients met inclusion criteria; 27 (40.3%) patients were in Group 1. Patients in Group 1 were significantly more likely to experience urinary retention requiring Foley catheter replacement ( P = 0.02). There was no statistically significant difference in the rate of CAUTI between the two groups ( P = 0.51). Patients undergoing CAWR with thoracic epidural pain management are at risk of experiencing postoperative urinary retention. Foley catheter removal after epidural removal does not place the patient at an increased risk for CAUTI and therefore should be strongly considered in this patient population.

Voiding Dysfunction After Non-urologic Pelvic Surgery

PURPOSE OF REVIEW

Urinary dysfunction is a common entity in patients undergoing radical pelvic surgery for non-urologic malignancies. These dysfunctions may manifest as lower urinary tract symptoms (LUTS) or signs such as urinary retention or leakage. Review of current literature is performed to describe the differing urinary dysfunctions that manifest after colorectal resection, hysterectomy, and sacrectomy.

RECENT FINDINGS

Conventional radical surgery for pelvic malignancies often will result in debilitating functional problems. As advances in surgical techniques and management options become more available, patients can have better functional outcomes, specifically in the lower urinary tract. Nerve-sparing techniques as well as vascular preservation are becoming more important to preserve function as patient survival is improving. Additionally, newer methods are being explored, such as nerve stimulation for those who are unable to empty adequately. This article also addresses different management options for specific voiding dysfunction that may result from pelvic surgery. Preventative strategies such as nerve preservation during surgery are an important concept to prevent urinary dysfunction. The goal to good functional outcomes includes maintaining reservoir compliance and capacity as well as allowing proper outlet for voiding. We discuss different modalities to help achieve a functional lower urinary tract for patients with lower urinary tract dysfunction after pelvic surgery.

The impact of robotic surgery on quality of life, urinary and sexual function following total mesorectal excision for rectal cancer: a propensity score-matched analysis with laparoscopic surgery

AIM

Quality of life (QoL) and functional outcomes are at risk of being impaired after rectal surgery, but there has been no large prospective study to thoroughly assess QoL according to surgical approach. We have investigated the impact of laparoscopic and robotic total mesorectal excision (TME) on QoL and functional outcomes.

METHOD

Patients undergoing laparoscopic or robotic TME for rectal cancer between 2009 and 2013 were prospectively included in this questionnaire-based survey of QoL together with variations in urinary and sexual function. A propensity score analysis was retrospectively conducted to compare outcomes between groups in a cohort matched 1:1 for age, sex, body mass index, preoperative chemoradiation status and tumour height. The survey was performed preoperatively and 3, 6 and 12 months after surgery.

RESULTS

Global health status/QoL was similar between the two groups for 130 matched pairs, but the robotic group showed better role, emotional and social functioning and experienced less fatigue and financial difficulty. International Prostatic Symptom Scores in men increased postoperatively, with significantly less impairment in the robotic group at 6 months. These scores were comparable to preoperative scores at 6 months in the robotic group and at 12 months in the laparoscopic group. Of 48 sexually active men in each group, International Index of Erectile Function-5 scores decreased postoperatively, returning to preoperative levels at 6 months in the robotic group and at 12 months in the laparoscopic groups.

CONCLUSION

The robotic approach for TME was associated with less impairment of urinary and sexual function; QoL was comparable to the laparoscopic approach.

Urinary dysfunction after rectal cancer surgery: Results from a randomized trial comparing mesorectal excision with and without lateral lymph node dissection for clinical stage II or III lower rectal cancer (Japan Clinical Oncology Group Study, JCOG0212)

BACKGROUND

Postoperative urinary dysfunction is a major complication of rectal cancer surgery. A randomized controlled trial (JCOG0212) concluded that the noninferiority of mesorectal excision alone to mesorectal excision with lateral lymph node dissection was not confirmed in terms of relapse-free survival.

METHODS

Eligibility criteria included histologically proven clinical stage II/III rectal cancer, a main lesion located in the rectum with the lower margin below the peritoneal reflection, and the absence of lateral lymph node enlargement. After confirming R0 resection by mesorectal excision, patients were randomized intraoperatively. The residual urine volume was measured three times. Urinary dysfunction was defined as ≥50 mL residual urine occurring at least once or no measurement of residual urinary volume. This trial was registered with the UMIN Clinical Trials Registry, number C000000034.

RESULTS

In the mesorectal excision alone and the mesorectal excision with lateral lymph node dissection groups, the incidence of early urinary dysfunction were 58% and 59%, respectively. A tumor location in the lower rectum (vs. upper rectum) and a blood loss of ≥500 mL (vs. <500 mL) were associated with an increased risk of early urinary dysfunction. However, only blood loss was independently predictive of early urinary dysfunction (relative risk, 1.25 [95% CI: 1.10-1.55], p = .04).

CONCLUSIONS

Mesorectal excision with lateral lymph node dissection is not associated with a significant increase in the incidence of urinary dysfunction. Urinary dysfunction is associated with tumor location and blood loss.

Is There Any Reason to Still Consider Lateral Lymph Node Dissection in Rectal Cancer? Rationale and Technique

Nodal dissemination in locally advanced rectal cancer occurs mainly in two directions: upward and lateral. Lateral node involvement has been demonstrated; however, lateral lymph node dissection (LLND) is not routinely performed in Western countries and the focus is more on neoadjuvant treatment regimens. The main reasons for this are the high morbidity associated with the operation and the uncertain oncological benefit. There is, however, recent evidence that in selected cases, neoadjuvant treatment combined with total mesorectal excision only might not be sufficient. In this article, the historical developments in the East and the West, the current evidence regarding lateral nodal disease, and the surgical steps in the LLND are discussed.

Genito-urinary sequelae after carcinological rectal resection: What to tell patients in 2017

Although we have seen revolutionary changes with multi-disciplinary management of patients with rectal cancer, the evaluation of genito-urinary sequelae remains of great concern. Precise pre-operative evaluation with validated scores allows detection of urinary disorders in 16 to 23% of patients, and sexual disorders in nearly 35% of men and 50% of women. Regardless of the surgical approach, it is fundamental to respect the autonomic innervation during total mesorectal excision in order to prevent these sequelae. Identification of these nerves can be facilitated by intra-operative neuro-stimulation. In spite of these precautions, de novo urinary sequelae are observed in nearly 33% of patients and bladder evacuation disorders in 25% of patients. Advanced age, pre-operative urinary disorders, female gender, and abdomino-perineal resection are independent risk factors for urinary sequelae. Early post-operative urodynamic abnormalities might be predictive of these sequelae and justify early physiotherapy. Likewise, sexual sequelae such as erectile and/or ejaculatory disorders, dyspareunia and lubrication deficits result in de novo cessation of sexual activity in 28% of men and 18% of women. Advanced age, neo-adjuvant radiation therapy, and abdomino-perineal resection are independent risk factors for sexual dysfunction. Pharmacotherapy with sildenafil has proven useful in the treatment of erectile disorders. Genito-urinary and ano-rectal sequelae occur concomitantly in more than one of ten patients, suggesting a potential common pathophysiology.

Urinary Retention following Colorectal Surgery

Literature on postoperative urinary retention (POUR) after colorectal resections is limited. The aim of our study was to evaluate the incidence of and risk factors for POUR after elective colorectal resections in men ≥55 years without genitourinary issues. A retrospective review of elective colorectal resections (June 1, 2014 to June 1, 2015) in men ≥55 years without genitourinary conditions was performed at our institution. Patient demographics, American Society of Anesthesiologist score, body mass index (BMI), surgical history, type of disease, extent of resection, surgical approach, operating room (OR) time, volume of OR fluids administered, and intra- and postoperative urine output were included for analysis. Seventy patients were identified. Nine (12.9%) experienced POUR. Patients with POUR experienced longer OR time (324 vs 239 minutes; P = 0.048) and had a lower median BMI (23.8 vs 28 kg/m2; P = 0.038). There were no significant differences in regards to age, comorbidities, diagnosis, type of resection, surgical approach, intravenous fluids administered operatively, or postoperative urine output. The incidence of POUR in male patients at least 55 years of age after elective colorectal resection in our institution was 12.9 per cent. Longer operative time and lower BMI were associated with a higher incidence of POUR.

Open Surgery Against Laparoscopic Surgery for Mid-Rectal or Low-Rectal Cancer of Male Patients: Better Postoperative Genital Function of Laparoscopic Surgery

PURPOSE

To evaluate retrospectively the postoperative genital function, the local recurrence, and the survival rate impacted by laparoscopic or open surgery for rectal cancer (RC) in male patients.

METHODS

A total of 398 male RC patients after laparoscopic or open total mesorectal excision (TME) of rectomy (205 patients in the TME with laparoscopy group, and 193 patients in the control group) were included in our study, between October 1997 and December 2013. Postoperative genital function, local recurrence, and the 5-year survival rate were analyzed, retrospectively.

RESULTS

The rate of erection dysfunction was lower in the laparoscopic group (60.0%) than in the open group (82.4%, P<0.05); the rate of ejaculation dysfunction in the laparoscopic group (56.6%) was also lower than in the open group (82.4%, P<0.05). No significant difference was found regarding the local recurrence (P=0.87) and the survival rate (P=0.17). Interestingly, for patients with preoperative obstruction, the survival rate was lower in the laparoscopy group compared with the control group (P=0.002).

CONCLUSIONS

Laparoscopic surgery should be recommended for mid-RC or low-RC patients to preserve the postoperative genital function. However, for patients with preoperative obstruction, laparoscopy surgery was not recommended.

Pelvic autonomic nerve preservation in radical rectal cancer surgery: changes in the past 3 decades

The advent of total mesorectal excision (TME) together with minimally invasive techniques such as laparoscopic colorectal surgery and robotic surgery has improved surgical results. However, the incidence of bladder and sexual dysfunction remains high. This may be particularly distressing for the patient and troublesome to manage for the surgeon when it does occur. The increased use of neoadjuvant and adjuvant radiotherapy is also associated with poorer functional outcomes. In this review, we evaluate current understanding of the anatomy of pelvic nerves which are divided into the areas of the inferior mesenteric artery pedicle, the lateral pelvic wall and dissection around the urogenital organs. Surgical techniques in these areas are discussed. We also discuss the results in functional outcomes of the various techniques including open, laparoscopic and robotic over the last 30 years.

Male sexual dysfunction after rectal cancer surgery: Results of a randomized trial comparing mesorectal excision with and without lateral lymph node dissection for patients with lower rectal cancer: Japan Clinical Oncology Group Study JCOG0212

BACKGROUND

We conducted a randomized controlled trial (JCOG0212) to determine whether the outcome of mesorectal excision (ME) alone for rectal cancer is not inferior to that of ME with lateral lymph node dissection (LLND). The present study focused on male sexual dysfunction after surgery.

METHODOLOGY

Eligibility criteria included clinical stage II/III rectal cancer, the lower margin of the lesion below the peritoneal reflection, the absence of lateral pelvic lymph node enlargement, and no preoperative radiotherapy. After confirmation of R0 resection by ME, patients were intraoperatively randomized. Questionnaires using the International Index of Erectile Function (IIEF-5) about the sexual function of men were collected before and 1 year after surgery. Sexual dysfunction incidence was defined as the ratio of patients showing sexual dysfunction after surgery relative to the number who had no erectile dysfunction before surgery.

RESULTS

Among 701 patients enrolled between June 2003 and August 2010, 472 males were included. Among them, 343 (73%) completed preoperative and postoperative questionnaires. According to the study protocol, the incidences of sexual dysfunction in patients who underwent ME alone and ME with LLND were 68% (17/25; 95%CI, 47-85%) and 79% (23/29; 95%CI, 60-92%), respectively (p = 0.37). Incidences of sexual dysfunction in patients with no or only mild erectile dysfunction before surgery who underwent ME alone and ME with LLND were 59% (48/81) and 71% (67/95), respectively (p = 0.15). Multivariate analysis identified age as the only risk factor for sexual dysfunction after surgery (p = 0.02).

CONCLUSIONS

LLND may not increase sexual dysfunction incidence after rectal cancer surgery. This incidence is associated with increased age. This trial is registered with ClinicalTrials.gov, number NCT00190541 and University Hospital Medical Information Network Clinical Trials Registry, number C000000034.

Meta-analysis of application of lateral lymph node dissection for low rectal cancer in China

AIM: To assess the value of the application of lateral lymph node dissection (LLND) for low rectal cancer in China.

METHODS: By meta-analysis we made a comprehensive analysis of the application of LLND for low rectal cancer based on 11 articles published in China between January 2005 and September 2015.

RESULTS: Operative time was significantly longer in the LLND group than in the non-LLND (NLLND) group [weighted mean difference (WMD) = 47.79 min, P < 0.00001]. Intra-operative blood loss was significantly greater in the LLND group than in the NLLND group (WMD = 27.84, P < 0.0001). Five-year survival rate was significantly higher in the LLND group than in the NLLND group (59.38% vs 51.3%, P = 0.02). Three-year survival rate was also significantly higher in the LLND group than in the NLLND group (81.6% vs 63.5%, P < 0.00001). Local recurrence rate for the NLLND group (16.9%) was significantly higher than that of the LLND group (8.4%) (P = 0.0003). Local recurrence rate showed no statistical difference between the LLND group and the NLLND group for stage I or IIA low rectal cancer, but was significantly lower in the LLND group than in the NLLND group for stage Ⅲ rectal cancer (14.5% vs 22.1%, P = 0.01).

CONCLUSION: Lateral lymph node dissection in Chinese patients with low rectal cancer can effectively prolong the 5-year survival rate and 3-year survival rate, decrease the local recurrence rate (especially in stage Ⅲ low rectal cancer) and improve the patient's prognosis, but it increases the operative time and the amount of bleeding.

Prognosis and postoperative genital function of function-preservative surgery of pelvic autonomic nerve preservation for male rectal cancer patients

Background

To retrospectively evaluate postoperative genital function, local recurrence rate and survival rate after total mesorectal excision (TME) combined with or without pelvic autonomic nerve preservation (PANP) in male patients with rectal cancer.

Methods

A total of 953 male patients with rectal cancer after TME (518 patients received TME combined with PANP [PANP group] and 434patients received TME alone [TME group]) were included. Assessments of postoperative genital function, local recurrence rate, and 5 year survival rate were collected.

Results

Rate of erection dysfunction in PANP group (41.9 %) was significantly lower than that in TME group (76.7 %, P < 0.05). Rate of ejaculation dysfunction in PANP group (42.5 %) was also significantly lower than that in TME group (67.3 %, P < 0.05). Local recurrence rate (P = 0.66) and survival rate (P = 0.26) did not differ between the two groups. For patients with preoperative obstruction, local recurrence rate was significantly higher (P = 0.01) and survival rate significantly lower (P = 0.03) in PANP group.

Conclusions

PANP surgery has significant advantage with respect to preservation of genital function and should be recommended as surgical treatment for rectal cancer patients. However, PANP surgery should be considered with caution in patients with preoperative obstruction in view of the poorer long-term outcomes in these patients.

Male urinary and sexual function after robotic pelvic autonomic nerve-preserving surgery for rectal cancer

BACKGROUND

Urinary and sexual dysfunction is the potential complication of rectal cancer surgery. The aim of this study was to evaluate the urinary and sexual function in male patients with robotic surgery for rectal cancer.

METHODS

This prospective study included 137 of the 336 male patients who underwent surgery for rectal cancer. Urinary and male sexual function was studied by means of a questionnaire based on the International Prostatic Symptom Score and International Index of Erectile Function. All data were collected before surgery and 12 months after surgery.

RESULTS

Patients who underwent robotic surgery had significantly decreased incidence of partial or complete erectile dysfunction and sexual dysfunction than patients with laparoscopic surgery. The pre- and post-operative total IPSS scores in patients with robotic surgery were significantly less than that with laparoscopic surgeries.

CONCLUSIONS

Robotic surgery shows distinct advantages in protecting the pelvic autonomic nerves and relieving post-operative sexual dysfunction.

Lower urinary tract dysfunction in patients with peripheral nervous system lesions

The prevalence of lower urinary tract (LUT) dysfunction in peripheral nervous system (PNS) disorders is larger than in comparable control populations. This is particularly true for polyneuropathies with autonomic nervous system involvement, and for localized lesions with LUT innervation. LUT symptoms may be the guide to the diagnosis of processes localized in the lumbosacral spinal canal (as in cauda equina syndrome), and in the pelvis. Typical LUT dysfunctions (LUTD) caused by PNS involvement include bladder and sphincter hypoactivity with poor emptying, and incontinence. Paradoxically, bladder overactivity may also occur in pure PNS lesions. The acute cauda equina syndrome is an emergency requiring magnetic resonance imaging and surgery; in chronic neurogenic LUTD due to PNS involvement, the diagnosis of the lesion may be clarified by clinical neurophysiologic testing. Other important causes of neurogenic LUT dysfunction are perineoabdominal and pelvic surgeries. Surgeons are devising nerve-sparing techniques to prevent such major and often persistent complications in patients who are otherwise cured of the underlying disease. LUTD significantly affects the quality of life in patients and may lead to recurring urinary infections and upper urinary tract involvement. Thorough assessment of LUT function by urodynamics may be necessary in patients who are not improved by simple conservative measures.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Colorectal surgery and its impact on male sexual function

The quality of functional outcome has become increasingly important in view of improvement in prognosis with colorectal cancer patients. Sexual dysfunction remains a common problem after colorectal cancer treatment, despite the good oncologic outcomes achieved by expert surgeons. Although radiotherapy and chemotherapy contribute, surgical nerve damage is the main cause of sexual dysfunction. The autonomic nerves are in close contact with the visceral pelvic fascia that surrounds the mesorectum. The concept of total mesorectal excision (TME) in rectal cancer treatment has led to a substantial improvement of autonomic nerve preservation. In addition, use of laparoscopy has allowed favorable results with regards to sexual function. The present paper describes the anatomy and pathophysiology of autonomic pelvic nerves, prevalence of sexual dysfunction, and the surgical technique of nerve preservation in order to maintain sexual function.

Current status of rectal cancer treatment in China

AIM

Colorectal cancer (CRC) is the fourth most common carcinoma in China. For economic reasons, a national CRC registry has not been established and a large-scale screening programme has not been implemented.

METHOD

Clinical studies (since 2000) of CRC epidemiology which originated from China were summarized, and data was analyzed.

RESULTS

In China, the majority of hospitals in central cities and even in county hospitals are able to provide medical care for CRC patients. Due to socio-economic disparities, medical conditions and skill level, there is a wide variation in the treatment. Most oncologists make their clinical decisions based on the National Comprehensive Cancer Network (NCCN) guidelines, although some domestic guidelines are now available. On 11 October 2011, the China Ministry of Health released national guidelines for CRC treatment. Owing to language difficulties, research on CRC in China has only had a limited exposure in the international literature, due in some part to lack of understanding of the current position in the country.

CONCLUSION

The national guidelines for CRC treatment will give a degree of standardization of the treatment of CRC nationwide and will ensure that higher quality care will be available, especially in rural areas. Chinese colorectal surgeons urgently need to exchange their knowledge and experience with international colleagues.

Identification of the origin of adrenergic and cholinergic nerve fibers within the superior hypogastric plexus of the human fetus

Nerve fibers contributing to the superior hypogastric plexus (SHP) and the hypogastric nerves (HN) are currently considered to comprise an adrenergic part of the autonomic nervous system located between vertebrae (T1 and L2), with cholinergic aspects originating from the second to fourth sacral spinal segments (S2, S3 and S4). The aim of this study was to identify the origin and the nature of the nerve fibers within the SHP and the HN, especially the cholinergic fibers, using computer-assisted anatomic dissection (CAAD). Serial histological sections were performed at the level of the lumbar spine and pelvis in five human fetuses between 14 and 30 weeks of gestation. Sections were treated with histological staining [hematoxylin-eosin (HE) and Masson's trichrome (TriM)] and with immunohistochemical methods to detect nerve fibers (anti-S100), adrenergic fibers (anti-TH), cholinergic fibers (anti-VAChT) and nitrergic fibers (anti-nNOS). The sections were then digitalized using a high-resolution scanner and the 3D images were reconstructed using winsurf software. These experiments revealed the coexistence of adrenergic and cholinergic fibers within the SHP and the HNs. One-third of these cholinergic fibers were nitrergic fibers [anti-VACHT (+)/anti-NOS (+)] and potentially pro-erectile, while the others were non-nitrergic [anti-VACHT (+)/anti-NOS (-)]. We found these cholinergic fibers arose from the lumbar nerve roots. This study described the nature of the SHP nerve fibers which gives a better understanding of the urinary and sexual dysfunctions after surgical injuries.

Current status of robotic rectal cancer surgery

SUMMARY After the introduction of robotic surgery for rectal cancer, the safety and feasibility of robotic rectal cancer surgery was demonstrated. However, early comparative studies between laparoscopic and robotic surgery did not show a significant postoperative benefit. Recently, it was reported that robotic rectal surgery showed better postoperative outcomes than laparoscopic surgery with regard to postoperative recovery, pain and function preservation. In addition, robotic transanal specimen extraction was safely performed while maintaining a lower level of postoperative pain and recovery time. All of these findings should be validated with well-designed comparative studies. As robotic technology advances and continues to be studied, the use of robotic surgical systems will become more common among colorectal surgeons.

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.

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.

Gender differences in quality of life among long-term colorectal cancer survivors with ostomies

PURPOSE/OBJECTIVES

To describe how gender shapes the concerns and adaptations of long-term (i.e., more than five years) colorectal cancer survivors with ostomies.

DESIGN

Qualitative study using content analysis of focus group content.

SETTING

Oregon, southwestern Washington, and northern California.

SAMPLE

Four female and four male focus groups (N = 33) selected from 282 quantitative survey participants with health-related quality-of-life (HRQOL) scores in the highest or lowest quartile.

METHODS

Eight focus groups discussed the challenges of living with an ostomy. Content was recorded, transcribed, and analyzed using directive and summative content analysis.

MAIN RESEARCH VARIABLES

HRQOL domains of physical, psychological, social, and spiritual well-being.

FINDINGS

All groups reported avoiding foods that cause gas or rapid transit and discussed how limiting the amount of food eaten controlled the output. All groups discussed physical activities, getting support from friends and family, and the importance of being resilient. Both genders identified challenges with sexuality and intimacy. Coping and adjustment difficulties mostly were discussed by women, with men only discussing these issues to a small extent. Difficulties with sleep primarily were identified by women with low HRQOL. Problems with body image and depression were discussed only by women with low HRQOL.

CONCLUSIONS

Common issues included diet management, physical activity, social support, and sexuality. Although both genders identified challenges, women described more specific psychological and social issues than men.

IMPLICATIONS FOR NURSING

Application of these gender-based differences can inform educational interventions for colorectal cancer survivors with ostomies.

Where does pelvic nerve injury occur during rectal surgery for cancer?

AIM

Optimal treatment of rectal adenocarcinoma involves total mesorectal excision with nerve-preserving dissection. Urinary and sexual dysfunction is still frequent following these procedures. Improved knowledge of pelvic nerve anatomy may help reduce this and define the key anatomical zones at risk.

METHOD

The MEDLINE database was searched for available literature on pelvic nerve anatomy and damage after rectal surgery using the key words 'autonomic nerve', 'pelvic nerve', 'colorectal surgery', and 'genitourinary dysfunction'. All relevant French and English publications up to May 2010 were reviewed. Reviewed data were illustrated using 3D reconstruction of the foetal pelvis.

RESULTS

The ligation of the inferior mesenteric artery and dissection of the retrorectal space can cause damage to the superior hypogastric plexus and/or hypogastric nerve. Anterolateral dissection in the 'lateral ligament' area and division of Denonvilliers' fascia can damage the inferior hypogastric plexus and efferent pathways. Perineal dissection can indirectly damage the pudendal nerve.

CONCLUSIONS

In most cases, the pelvic nerves can be preserved during rectal surgery. Complete oncological resection may require dissection close to the nerves where the tumour is located anterolaterally where it is fixed and when the pelvis is narrow.

The role of lateral lymph node dissection in the management of lower rectal cancer

INTRODUCTION

Lateral lymph node involvement is a problem encountered in patients with low rectal cancers. This has been documented in both anatomical and pathological studies. Currently, the vast majority of centers have concentrated on the use of chemoradiation to obtain better local control and manage these nodes indirectly. In Japan, extended nodal dissection for the control of pelvic nodal disease has seen further advancement. This paper discusses the key issues involved in the management of pelvic lateral nodes in low rectal cancers.

METHODS

A review of available literature and critical appraisal of the entity of lateral nodes in low rectal cancers, the treatment options, and oncological and functional results were performed.

RESULTS

There are good data showing that the entity of pelvic lateral nodes in low rectal cancers should not be ignored. Recent data have emerged showing that radiotherapy is associated with significant long-term functional side effects. Refinement of the technique, lateral node dissection, has led to good local control as well as good functional outcomes.

CONCLUSION

In this context, there needs to be a reevaluation of the role of chemoradiation as the sole treatment for lateral nodal disease in centers outside of Japan. Individualization of the treatment of rectal cancer may require all centers to be able to offer both modalities.

Regeneration and functional recovery of intrapelvic nerves removed during extensive surgery by a new artificial nerve conduit: a breakthrough to radical operation for locally advanced and recurrent rectal cancers

PURPOSE

In the current strategy against locally advanced and recurrent rectal cancers possibly involving intrapelvic nerves, there has been a serious dilemma between extensive surgery and limited surgery. The former can attain high tumor curability by sacrificing the nerve functions while the latter prioritizes the patient quality of life by preserving the nerve functions but with a compromised curability. Here we present a new surgical strategy for locally advanced and recurrent rectal cancers, which realize both high tumor curability and good quality of life.

METHODS

A new artificial nerve conduit (polyglycolic acid collagen tube) developed by in site tissue engineering technology was applied to recovery the disturbed functions after removing the nerves from 11 patients undergoing extensive surgery for intrapelvic advanced or recurrent colorectal cancers. The reconstructed nerves included eight autonomic nerves which are essential for the genitourinary function and three somatic nerves which control the sensation and mobility of the legs.

RESULTS

Out of ten cases followed up more than 2 years and evaluated fully, eight including two report cases showed a functional recovery of the disturbed autonomic and somatic nerves clinically. The nerve function started to recover from 3 to 6 months after the operation and continued to improve with times. No specific complications associated with the nerve repair have been noted.

CONCLUSIONS

The new strategy utilizing the nerve conduit can be a breakthrough in radical operations for locally advanced and recurrent rectal cancers to resolve the problems between tumor curability and the patient quality of life.