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Kneist W, Ghadimi M, Runkel N, Moesta T, Coerper S, Benecke C, Kauff DW, Gretschel S, Gockel I, Jansen-Winkeln B, Lang H, Gorbulev S, Ruckes C, Kronfeld K. Pelvic Intraoperative Neuromonitoring Prevents Dysfunction in Patients With Rectal Cancer: Results From a Multicenter, Randomized, Controlled Clinical Trial of a NEUROmonitoring System (NEUROS). Ann Surg 2023; 277:e737-e744. [PMID: 36177851 PMCID: PMC9994806 DOI: 10.1097/sla.0000000000005676] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This NEUROmonitoring System (NEUROS) trial assessed whether pelvic intraoperative neuromonitoring (pIONM) could improve urogenital and ano-(neo-)rectal functional outcomes in patients who underwent total mesorectal excisions (TMEs) for rectal cancer. BACKGROUND High-level evidence from clinical trials is required to clarify the benefits of pIONM. METHODS NEUROS was a 2-arm, randomized, controlled, multicenter clinical trial that included 189 patients with rectal cancer who underwent TMEs at 8 centers, from February 2013 to January 2017. TMEs were performed with pIONM (n=90) or without it (control, n=99). The groups were stratified according to neoadjuvant chemoradiotherapy and sex, with blocks of variable length. Data were analyzed according to a modified intention-to-treat protocol. The primary endpoint was a urinary function at 12 months after surgery, assessed with the International Prostate Symptom Score, a patient-reported outcome measure. Deterioration was defined as an increase of at least 5 points from the preoperative score. Secondary endpoints were sexual and anorectal functional outcomes, safety, and TME quality. RESULTS The intention-to-treat analysis included 171 patients. Marked urinary deterioration occurred in 22/171 (13%) patients, with significantly different incidence between groups (pIONM: n=6/82, 8%; control: n=16/89, 19%; 95% confidence interval, 12.4-94.4; P =0.0382). pIONM was associated with better sexual and ano-(neo)rectal function. At least 1 serious adverse event occurred in 36/88 (41%) in the pIONM group and 53/99 (54%) in the control group, none associated with the study treatment. The groups had similar TME quality, surgery times, intraoperative complication incidence, and postoperative mortality. CONCLUSION pIONM is safe and has the potential to improve functional outcomes in rectal cancer patients undergoing TME.
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Affiliation(s)
- Werner Kneist
- Department of General and Visceral Surgery, St. Georg Hospital Eisenach GmbH, Eisenach, Germany
- Department of General, Abdominal, and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Michael Ghadimi
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Goettingen, Goettingen, Germany
| | - Norbert Runkel
- Department of Surgery, AMEOS Spital Einsiedeln, Einsiedeln, Switzerland
- Department of General and Visceral Surgery, Schwarzwald-Baar Hospital Villingen-Schwenningen, Villingen-Schwenningen, Germany
| | - Thomas Moesta
- University Medical Center Halle, Halle (Saale), Germany
- Hospital Region Hannover (KRH) Hospital Siloah, Hannover, Germany
| | - Stephan Coerper
- Department of General and Visceral Surgery, Hospital Martha-Maria, Nuernberg, Germany
| | - Claudia Benecke
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Daniel W. Kauff
- Department of General, Abdominal, and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of General, Visceral, and Vascular Surgery, Hospital Nagold, Nagold, Germany
| | - Stephan Gretschel
- Department of General, Visceral, Thoracic, and Vascular Surgery, Faculty of Health Brandenburg, Brandenburg Medical School, University Hospital Neuruppin, Neuruppin, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Boris Jansen-Winkeln
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Hauke Lang
- Department of General, Abdominal, and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Stanislav Gorbulev
- Interdisciplinary Center for Clinical Trials (IZKS), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Christian Ruckes
- Interdisciplinary Center for Clinical Trials (IZKS), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Kai Kronfeld
- Interdisciplinary Center for Clinical Trials (IZKS), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
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Marchegiani F, Palatucci V, Capelli G, Guerrieri M, Belluco C, Rega D, Morpurgo E, Coco C, Restivo A, De Franciscis S, Aschele C, Perin A, Bonomo M, Muratore A, Spinelli A, Ramuscello S, Bergamo F, Montesi G, Spolverato G, Del Bianco P, Gambacorta MA, Delrio P, Pucciarelli S. Rectal Sparing Approach After Neoadjuvant Therapy in Patients with Rectal Cancer: The Preliminary Results of the ReSARCh Trial. Ann Surg Oncol 2021; 29:1880-1889. [PMID: 34855063 DOI: 10.1245/s10434-021-11121-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/12/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Rectum-preservation for locally advanced rectal cancer has been proposed as an alternative to total mesorectal excision (TME) in patients with major (mCR) or complete clinical response (cCR) after neoadjuvant therapy. The purpose of this study was to report on the short-term outcomes of ReSARCh (Rectal Sparing Approach after preoperative Radio- and/or Chemotherapy) trial, which is a prospective, multicenter, observational trial that investigated the role of transanal local excision (LE) and watch-and-wait (WW) as integrated approaches after neoadjuvant therapy for rectal cancer. METHODS Patients with mid-low rectal cancer who achieved mCR or cCR after neoadjuvant therapy and were fit for major surgery were enrolled. Clinical response was evaluated at 8 and 12 weeks after completion of chemoradiotherapy. Treatment approach, incidence, and reasons for subsequent TME were recorded. RESULTS From 2016 to 2019, 160 patients were enrolled; mCR or cCR at 12 weeks was achieved in 64 and 96 of patients, respectively. Overall, 98 patients were managed with LE and 62 with WW. In the LE group, Clavien-Dindo 3+ complications occurred in three patients. The rate of cCR increased from 8- to 12-week restaging. Thirty-three (94.3%) of 35 patients with cCR had ypT0-1 tumor. At a median 24 months follow-up, a tumor regrowth was found in 15 (24.2%) patients undergoing WW. CONCLUSIONS LE for patients achieving cCR or mCR is safe. A 12-week interval from chemoradiotherapy completion to LE is correlated with an increased cCR rate. The risk of ypT > is reduced when LE is performed after cCR.
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Affiliation(s)
- Francesco Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy
| | - Valeria Palatucci
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy
| | - Giulia Capelli
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy
| | - Mario Guerrieri
- Surgery Clinic, Marche Polytechnic University, Ancona, Italy
| | - Claudio Belluco
- Oncological Surgery Department, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Daniela Rega
- National Cancer Institute, IRCCS Fondazione "G.Pascale", Naples, Italy
| | - Emilio Morpurgo
- Department of Surgery, Regional Center for Laparoscopic and Robotic Surgery, Camposampiero Hospital, Padua, Italy
| | - Claudio Coco
- Department of Surgical Sciences, Catholic University of Rome, Rome, Italy
| | - Angelo Restivo
- Department of Surgery, Colorectal Surgery Center, University of Cagliari, Cagliari, Italy
| | | | | | - Alessandro Perin
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy
| | | | - Andrea Muratore
- Division of General Surgery, E. Agnelli Hospital, Pinerolo, Turin, Italy
| | - Antonino Spinelli
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | | | | | - Giampaolo Montesi
- Radiation Oncology Unit, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Gaya Spolverato
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy.
| | | | | | - Paolo Delrio
- National Cancer Institute, IRCCS Fondazione "G.Pascale", Naples, Italy
| | - Salvatore Pucciarelli
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy
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Ohara N, Takahashi H, Katsuyama S, Doki Y, Mori M, Nakajima K. Electrical contraction of the anal sphincter for intraoperative visualization of anal function. MINIM INVASIV THER 2020; 31:127-136. [DOI: 10.1080/13645706.2020.1773855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Nobuyoshi Ohara
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Hidekazu Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Shinsuke Katsuyama
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
- Department of Next Generation Endoscopic Intervention (Project ENGINE), Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Kiyokazu Nakajima
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
- Department of Next Generation Endoscopic Intervention (Project ENGINE), Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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A Prospective Analysis of the Effects of Nerve-Sparing Radical Prostatectomy on Urinary Continence Based on Expanded Prostate Cancer Index Composite and International Index of Erectile Function Scoring Systems. Int Neurourol J 2018; 22:123-132. [PMID: 29991234 PMCID: PMC6059911 DOI: 10.5213/inj.1836052.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 04/30/2018] [Indexed: 11/08/2022] Open
Abstract
PURPOSE This study aims to objectively characterize the effect of successful nerve sparing (NS) during radical prostatectomy (RP) on postoperative urinary continence (UC) using International Index of Erectile Function (IIEF)-scores and a previously described Expanded Prostate Cancer Index Composite (EPIC) score cutoff value (COV) for UC. Several notable studies on this topic present conflicting outcomes. This is largely due to a lack of clear definitions and consensus regarding preserved erectile function (EF) and UC. METHODS This study is comprised of all patients who underwent RP at the Kantonsspital Baden, Switzerland, between 2004 and 2013. Patients completed self-assessment questionnaires for UC (EPIC) and EF (IIEF) pre- and postoperatively (3, 6, 9, 12, 18, and 24 months; yearly thereafter). We used a previously described EPIC subscore COV, with "satisfactory continence" signified by a score >85. Statistical analysis was performed using Kaplan-Meier and Cox regression analyses for "surgeon-" and "IIEF-defined" NS definitions. RESULTS Of 236 men with a median age of 63 years (interquartile range [IQR], 59-66 years) and median follow-up time of 48 months (IQR, 30-78 months), 176 underwent unilateral (n=33) or bilateral (n=143) NS RP. Fifty-four underwent non-NS (NNS) RP. Kaplan-Meier analyses identified the following risk factors for UC: age, prostate volume, cancer risk group, and NS status. In surgeon-defined NS RP cases, multivariate analysis for regaining continence demonstrated no significant difference (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.48-1.25; P=0.3). With successful IIEF-defined NS RPs, regression analysis demonstrated no significant difference (HR, 0.89; 95% CI, 0.59-1.35; P=0.58). Conclusions In our population, analysis and comparison of surgeon- and IIEF-defined NS and NNS cohorts revealed that NS RP did not improve postoperative UC. The conservation of UC alone should not motivate surgeons or patients to pursue NS RP.
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Wałęga P, Romaniszyn M, Wałęga M, Szymon Świrta J, Nowak W. Intraoperative neuromonitoring of hypogastric plexus branches during surgery for rectal cancer - preliminary report. POLISH JOURNAL OF SURGERY 2017; 89:69-72. [PMID: 28537567 DOI: 10.5604/01.3001.0009.9161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIM The aim of this study was to present our preliminary experience with intraoperative neuromonitoring during rectal resection. MATERIALS AND METHODS We qualified 4 patients (2 women, 2 men; age 42 - 53 years) with rectal cancer for surgery with intraoperative neuromonitoring. In all patients, functional tests of the anorectal area were performed before surgery. Action potentials from the sphincter complex in response to nerve fiber stimulation were recorded with electrodes implanted before surgery. Moreover, we inserted a standard, 18FR Foley's urinary catheter to which a T-tube was connected to allow urine outflow and measurement of pressure changes in the bladder induced by detrusor contractions during stimulation. RESULTS Setting up neuromonitoring prolonged surgery time by 30 to 40 minutes, or even by 60 to 80 minutes in the case of the first two patients. Neuromonitoring itself took additional 20 to 30 minutes during surgery. In all patients, we stimulated branches of the inferior hypogastric plexus in their anatomical position during dissection. In three patients, we evoked responses both from the bladder and the sphincter in all planes of stimulation. In one patient, there was no response from the left side of the bladder, and in the same patient, we observed symptoms of neurogenic bladder. CONCLUSIONS Based on the available literature and our own experience, we state that monitoring of bladder pressure and electromyographic signals from rectal sphincters enables visualization and preservation of autonomic nervous system structures, both sympathetic and parasympathetic. Intraoperative signals seem to be correlated with clinical presentation and functional examinations after surgery. In order to objectify our results, it is necessary to perform functional examinations before and after surgery in a larger group of patients.
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Affiliation(s)
- Piotr Wałęga
- III Katedra i Klinika Chirurgii Ogólnej UJCM Oddział Kliniczny Chirurgii Ogólnej Szpitala Miejskiego Specjalistycznego im G. Narutowicza
| | - Michał Romaniszyn
- III Katedra i Klinika Chirurgii Ogólnej UJCM Oddział Kliniczny Chirurgii Ogólnej Szpitala Miejskiego Specjalistycznego im G. Narutowicza, Kraków
| | - Maciej Wałęga
- III Katedra i Klinika Chirurgii Ogólnej UJCM Oddział Kliniczny Chirurgii Ogólnej Szpitala Miejskiego Specjalistycznego im G. Narutowicza
| | - Jarosław Szymon Świrta
- III Katedra i Klinika Chirurgii Ogólnej UJCM Oddział Kliniczny Chirurgii Ogólnej Szpitala Miejskiego Specjalistycznego im G. Narutowicza, Kraków
| | - Wojciech Nowak
- III Katedra i Klinika Chirurgii Ogólnej UJCM Oddział Kliniczny Chirurgii Ogólnej Szpitala Miejskiego Specjalistycznego im G. Narutowicza, Kraków
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Kochenov АV, Poddubnaya EP, Makedonsky IA, Korogod SМ. Biophysical Processes in a Urinary Bladder Detrusor Smooth Muscle Cell during Rehabilitation Electrostimulation: a Simulation Study. NEUROPHYSIOLOGY+ 2015. [DOI: 10.1007/s11062-015-9518-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kochenov АV, Poddubnaya YP, Makedonsky IA, Korogod SМ. Excitability Characteristics of a Urinary Bladder Detrusor Smooth Muscle Cell as a Basis for Choosing Parameters of Rehabilitation Electrostimulation: A Simulation Study. NEUROPHYSIOLOGY+ 2015. [DOI: 10.1007/s11062-015-9504-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kneist W, Kauff DW, Rubenwolf P, Thomas C, Hampel C, Lang H. Intraoperative monitoring of bladder and internal anal sphincter innervation: a predictor of erectile function following low anterior rectal resection for rectal cancer? Results of a prospective clinical study. Dig Surg 2014; 30:459-65. [PMID: 24481247 DOI: 10.1159/000357349] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 11/10/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND The objective was to investigate whether two-dimensional intraoperative neuromonitoring (IONM) of pelvic autonomic nerves has the potential to predict erectile function (EF) following surgery for rectal cancer. METHODS A consecutive series of 17 sexually active male rectal cancer patients undergoing IONM-based nerve-sparing low anterior rectal resection were evaluated prospectively. IONM was performed by electric stimulation of the pelvic splanchnic nerves with concomitant electromyography of the internal anal sphincter and cystomanometry. Sexual function was assessed using a validated questionnaire. RESULTS The degree of agreement between electromyography-based and cystomanometry-based IONM with postoperative EF was moderate and good (κ = 0.43 and κ = 0.66). Combined assessment yielded the best agreement (κ = 0.76) with sensitivity of 90%, specificity of 86%, positive predictive value of 90%, negative predictive value of 86%, and overall accuracy of 88%, respectively, in terms of prediction of postoperative EF. CONCLUSION The method may be suitable to predict male EF following rectal resection.
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Affiliation(s)
- Werner Kneist
- Department of General, Visceral and Transplant Surgery, University Medicine of the Johannes Gutenberg University Mainz, Mainz, Germany
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Evaluation of two-dimensional intraoperative neuromonitoring for predicting urinary and anorectal function after rectal cancer surgery. Int J Colorectal Dis 2013; 28:659-64. [PMID: 23440364 DOI: 10.1007/s00384-013-1662-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2013] [Indexed: 02/07/2023]
Abstract
PURPOSE The aim of this study was to compare the results of two-dimensional intraoperative neuromonitoring (IONM) with the postoperative urinary and anorectal function of rectal cancer patients. METHODS A consecutive series of 35 patients undergoing low anterior resection were investigated prospectively. IONM was performed with electric stimulations of the pelvic splanchnic nerves under simultaneous manometry of the bladder and electromyography (EMG) of the internal anal sphincter (IAS). Urinary and anorectal function were evaluated preoperatively and at follow-up by standardized questionnaires, digital rectal examination scoring system, and long-term catheterization rate. RESULTS The rate of postoperative newly developed bladder dysfunction was 17 %. IONM with bladder manometry had a sensitivity of 100 %, specificity of 96 %, positive predictive value of 83 %, negative predictive value of 100 %, and overall accuracy of 97 %, respectively. The proportion of patients with severely impaired anorectal function at follow-up was 8 %. The sensitivity, specificity, and positive and negative predictive values for IONM with EMG of the IAS were, respectively, 100, 96, 67, and 100 % with an accuracy of 96 %. The degree of agreement for IONM with EMG of the IAS was good for anorectal function (к = 0.780) and poor for urinary function (к = 0.119). IONM with bladder manometry yielded a very good degree of agreement for urinary function (к = 0.891) and a fair agreement for anorectal function (к = 0.336). CONCLUSIONS The two-dimensional IONM method is suitable for verification of bladder and IAS innervation. Accurate prediction of urinary and anorectal function necessitates both bladder manometry and EMG of the IAS.
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Lange MM, Marijnen CAM, Maas CP, Putter H, Rutten HJ, Stiggelbout AM, Meershoek-Klein Kranenbarg E, van de Velde CJH. Risk factors for sexual dysfunction after rectal cancer treatment. Eur J Cancer 2009; 45:1578-88. [PMID: 19147343 DOI: 10.1016/j.ejca.2008.12.014] [Citation(s) in RCA: 168] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Revised: 12/11/2008] [Accepted: 12/12/2008] [Indexed: 12/14/2022]
Abstract
This study aimed to identify risk factors for long-term sexual dysfunction (SD) after rectal cancer treatment. Patients with resectable rectal cancer were randomised to total mesorectal excision with or without preoperative radiotherapy (PRT). Preoperatively and at 3, 6, 12, 18 and 24 months postoperatively, SD scores were filled out in questionnaires. Possible risk factors for postoperative deterioration of sexual functioning, including patients' demographics, tumour-specific factors and treatment-related variables, were investigated with univariate and multivariable regression analyses. Increase in general SD, erectile dysfunction and ejaculatory problems were reported by 76.4, 79.8 and 72.2 percent of the male patients, respectively. Risk factors were nerve damage, blood loss, anastomotic leakage, PRT and the presence of a stoma. In female patients, increase in general SD, dyspareunia and vaginal dryness were reported by 61.5, 59.1 and 56.6 percent, respectively. This was associated with PRT and the presence of a stoma. SD occurs frequently after rectal cancer treatment and is caused by surgical (nerve) damage with an additional effect of PRT. Patients should be informed preoperatively, and education of surgeons in neuroanatomy may provide the key to the improvement of functional outcome.
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Affiliation(s)
- M M Lange
- Department of Surgery, Leiden University Medical Center, K6-R, P.O. Box 9600, 2300 RC Leiden, The Netherlands
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Abstract
Marilyne Lange and Cornelis van de Velde discuss the differential diagnosis and management of incontinence after rectal cancer treatment.
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Lange MM, Maas CP, Marijnen CAM, Wiggers T, Rutten HJ, Kranenbarg EK, van de Velde CJH. Urinary dysfunction after rectal cancer treatment is mainly caused by surgery. Br J Surg 2008; 95:1020-8. [PMID: 18563786 DOI: 10.1002/bjs.6126] [Citation(s) in RCA: 162] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Urinary dysfunction (UD) is common after rectal cancer treatment, but the contribution of each treatment component (surgery and radiotherapy) to its development remains unclear. This study aimed to evaluate UD during 5 years after total mesorectal excision (TME) and to investigate the influence of preoperative radiotherapy (PRT) and surgical factors. METHODS Patients with operable rectal cancer were randomized to TME with or without PRT. Questionnaires concerning UD were completed by 785 patients before and at several time points after surgery. Possible risk factors, including PRT, demographics, tumour location, and type and extent of resection, were investigated by multivariable regression analysis. RESULTS Long-term incontinence was reported by 38.1 per cent of patients, of whom 72.0 per cent had normal preoperative function. Preoperative incontinence (relative risk (RR) 2.75, P = 0.001) and female sex (RR 2.77, P < 0.001) were independent risk factors. Long-term difficulty in bladder emptying was reported by 30.6 per cent of patients, of whom 65.0 per cent had normal preoperative function. Preoperative difficulty in bladder emptying (RR 2.94, P < 0.001), peroperative blood loss (RR 1.73, P = 0.028) and autonomic nerve damage (RR 2.82, P = 0.024) were independent risk factors. PRT was not associated with UD. CONCLUSION UD is a significant clinical problem after rectal cancer treatment and is not related to PRT, but rather to surgical nerve damage.
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Affiliation(s)
- M M Lange
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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Evidence and research in rectal cancer. Radiother Oncol 2008; 87:449-74. [PMID: 18534701 DOI: 10.1016/j.radonc.2008.05.022] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Revised: 05/14/2008] [Accepted: 05/15/2008] [Indexed: 12/20/2022]
Abstract
The main evidences of epidemiology, diagnostic imaging, pathology, surgery, radiotherapy, chemotherapy and follow-up are reviewed to optimize the routine treatment of rectal cancer according to a multidisciplinary approach. This paper reports on the knowledge shared between different specialists involved in the design and management of the multidisciplinary ESTRO Teaching Course on Rectal Cancer. The scenario of ongoing research is also addressed. In this time of changing treatments, it clearly appears that a common standard for large heterogeneous patient groups have to be substituted by more individualised therapies based on clinical-pathological features and very soon on molecular and genetic markers. Only trained multidisciplinary teams can face this new challenge and tailor the treatments according to the best scientific evidence for each patient.
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Kneist W, Junginger T. Long-term urinary dysfunction after mesorectal excision: A prospective study with intraoperative electrophysiological confirmation of nerve preservation. Eur J Surg Oncol 2007; 33:1068-74. [PMID: 17524598 DOI: 10.1016/j.ejso.2007.03.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2006] [Accepted: 03/29/2007] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Bladder dysfunctions are well-recognized complications after nerve-sparing mesorectal excision for rectal cancer. This study sought to symptomatically analyze the extent of recovery from major and minor urinary symptoms in patients with signs of bladder denervation. METHODS Sixty-two patients with mesorectal excision for rectal cancer were investigated prospectively. Pelvic autonomic nerve preservation (PANP) was assessed macroscopically and with the aid of intraoperative electrical stimulation of pelvic autonomic nerves (INS). Bladder function was evaluated with the International Prostate Symptom Score (IPSS) and the Quality of life index (Qol). Median follow-up was 20 months (range 3-40 months). RESULTS Forty-six patients with INS-confirmed preservation of parasympathetic nerves remained unchanged in early and long-term urinary function (IPSS: median 1; range 0-24 and Qol 0; range 0-5). In 15 patients without confirmation of PANP (unilaterally or bilaterally) on INS, voiding function was significantly more impaired postoperatively (IPSS: median 10; range 0-25 and Qol 3; range 0-6) and at long-term follow-up (IPSS: median 9; range 0-25 and Qol 3; range 0-6) (p<0.001). Voiding function was improved in 4 of 10 patients with major and minor symptoms. In 5 of 6 patients with long-term bladder dysfunction INS assessed parasympathetic nerve damage unilaterally (3/5) and bilaterally (2/5). CONCLUSION Long-term voiding disturbance after mesorectal excision was found to be a serious complication. INS while monitoring intravesical pressure is a valuable aid in predicting long-term bladder function after TME. The device may serve a secondary preventive function in enabling the initiation of early urologic therapy.
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Affiliation(s)
- W Kneist
- Clinic of General and Abdominal Surgery, Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany.
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Abstract
BACKGROUND Since 1977, restorative proctocolectomy with ileoanal anastomosis (IAA) has evolved into the surgical treatment of choice for most patients with intractable ulcerative colitis. Construction of an ileal pouch reservoir is now standard, usually in the form of J pouch (IPAA). The aim of this report is to review selection criteria for, and functional outcomes, follow-up and management of complications of IPAA after 30 years of widespread clinical application. METHODS AND RESULTS Literature published in English on the clinical indications, surgical technique, morbidity, complications and outcome following IAA and IPAA was sourced by electronic search, performed independently by two reviewers who selected potentially relevant papers based on title and abstract. Additional articles were identified by cross-referencing from papers retrieved in the initial search. CONCLUSION The functional results of IPAA are good. Pouchitis, irritable pouch syndrome and cuffitis are specific long-term complications but rarely result in failure. Pouch salvage is possible in selected patients with poor functional outcomes. One-stage operations are increasingly performed.
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Affiliation(s)
- B B McGuire
- Department of Colorectal Surgery, Mater Misericordiae University Hospital and School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
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Kneist W, Junginger T. Intraoperative electrostimulation objectifies the assessment of functional nerve preservation after mesorectal excision. Int J Colorectal Dis 2007; 22:675-82. [PMID: 17036224 DOI: 10.1007/s00384-006-0203-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND To improve nerve-sparing surgery, intraoperative electrical stimulation of pelvic autonomic nerves (INS) has been proposed in urology, gynecology, and visceral surgery. The aim of this study was to assess the impact of INS while monitoring intravesical pressure on the accurate evaluation of pelvic autonomic nerve preservation (PANP) after mesorectal excision. It was sought to determine whether this confirmation is useful in the prediction of postoperative urinary function. METHODS Sixty-two patients with mesorectal exzision for rectal cancer were examined prospectively. PANP was assessed visually by the surgeon and with INS. Bladder function was evaluated by post voiding residual volume measurement, rate of recatheterization, rate of long-term urinary catheterisation, and the international prostatic symptom score with quality of life index. RESULTS INS confirmed bilateral preservation of parasympathetic nerves in 46 patients (74%), and in 10 patients (16%) in at least one side. In six patients (10%), INS failed to confirm PANP. Eleven patients (18%) developed urinary symptoms postoperatively. INS results had a higher sensitivity than visual assessment by the surgeon (82 vs 46%). Values for specificity ranged at 90 and 92%, respectively. Accuracy of INS in predicting PANP was higher (88 vs 83%). The correlation between urinary function and the findings on INS was good (kappa-value: 0.65), correlation between urinary function and visual assessment by the surgeon was fair (kappa-value: 0.40). CONCLUSION INS, while monitoring intravesical pressure, accurately predicts bladder function after mesorectal excision. It may provide further insight into pelvic autonomic nerve sparing techniques.
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Affiliation(s)
- W Kneist
- Clinic of General and Abdominal Surgery, Johannes Gutenberg-Universität Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
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18
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Kneist W, Junginger T. Male Urogenital Function After Confirmed Nerve-Sparing Total Mesorectal Excision with Dissection in Front of Denonvilliers’ Fascia. World J Surg 2007; 31:1321-8. [PMID: 17464540 DOI: 10.1007/s00268-007-9008-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This prospective study addresses the rate of male genital dysfunction following total mesorectal excision (TME) for rectal carcinoma using the anterior extramesorectal plane and its correlation with early urinary function, pelvic autonomic nerve preservation (PANP), and intraoperative neurostimulation (INS). A consecutive series of 44 men operated on by the same surgical team was analyzed. After excluding 18 patients considered to be impotent preoperatively, urogenital function was evaluated in 26 patients on the basis of the International Prostatic Symptom Score and International Index of Erectile Function. PANP was assessed with INS of parasympathetic nerves. PANP was complete in 21 patients (80.8%). Deterioration of urinary function was observed in six patients (23.1%) at early follow-up. Postoperative erectile dysfunction assessed in seven patients (26.9%) was associated with micturition disturbances in four (57%). Despite dissection in front of Denonvilliers fascia, the incidence of erectile dysfunction was low in patients with nonanterior tumors (1/10). INS results had higher sensitivity for predicting urinary dysfunction than for predicting erectile dysfunction (67% vs. 43%). Values for specificity and accuracy were 95% and 90%, and 89% and 77%, respectively. The correlation between the findings on INS and urinary function was good (kappa = 0.66) at a fair (kappa = 0.36) correlation for erectile function. Nerve-sparing TME using the anterior extramesorectal plane results in a justifiable rate of postoperative impotence in patients with nonanterior tumors. Patients with negative results on INS or early urinary dysfunction are at greater risk of erectile dysfunction.
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Affiliation(s)
- W Kneist
- Clinic of General and Abdominal Surgery, Johannes Gutenberg-University, Mainz, Germany.
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19
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Konishi T, Watanabe T, Kiyomatsu T, Nagawa H. Perioperative radiation for rectal cancer and sexual dysfunction after TME: cause and effect? Ann Surg 2007; 245:155. [PMID: 17197984 PMCID: PMC1867928 DOI: 10.1097/01.sla.0000250943.83211.f1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Turkof E, Wulkersdorfer B, Bukaty A. Reconstruction of cavernous nerves by nerve grafts to restore potency: contemporary review of technical principles and basic anatomy. Curr Opin Urol 2006; 16:401-6. [PMID: 17053519 DOI: 10.1097/01.mou.0000250279.52613.28] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The review discusses the efficacy of reconstructing the neurovascular bundle to regain sexual function if nerve-sparing prostatectomy is unfeasible. RECENT FINDINGS Eleven studies could be found describing the reconstruction of neurovascular bundles. All reconstructive procedures displayed technical inadequacies. The effectiveness of unilateral neurovascular bundle reconstruction remains statistically insignificant when compared with procedures without reconstruction. The efficacy of reconstructing both neurovascular bundles ranges between 0 and 43%. Concerning basic anatomy, the neurovascular bundle contains fibers innervating the cavernous nerves, prostate, rectum, and levator ani muscle. The terms cavernous nerve and neurovascular bundle have often been wrongly considered synonymous. The pelvic splanchnic nerves probably do not join the neurovascular bundle proximal to the bladder/prostate junction but rather at variable distances from 10 to 20 mm distal to it. Therefore, described proximal coaptation sites at the bladder/prostate junction possibly encompass only the hypogastric nerve. SUMMARY Modest clinical results are partly due to inadequate surgical techniques and are mainly due to the anatomical and topographical complexity of the cavernous nerves. Contemporary nerve grafting techniques probably do not allow for the regeneration of all cavernous nerves.
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Affiliation(s)
- Edvin Turkof
- Department of Plastic and Reconstructive Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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21
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Sadoughi B, Hans S, de Monès E, Brasnu DF. Preservation of the Marginal Mandibular Branch of the Facial Nerve Using a Plexus Block Nerve Stimulator. Laryngoscope 2006; 116:1713-6. [PMID: 16955012 DOI: 10.1097/01.mlg.0000234914.76667.7f] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Preserving the marginal mandibular branch of the facial nerve is essential in submandibular neck dissection to avert disfiguring complications. Despite the high incidence of postoperative palsy, old-fashioned techniques of nerve identification remain widespread. The use of disposable plexus block nerve stimulators as a safe and accurate method to localize the nerve intraoperatively is suggested herein. Such devices are significantly more affordable and user-friendly than larger facial nerve monitoring devices, which are rather favored for those procedures more extensively jeopardizing the branches of the facial nerve. In this report, disposable stimulators led to successful identification of the nerve in 100% of 25 patients between 2003 and 2005, with no postoperative paralysis. In addition, stimulation devices are constantly gaining in reliability and safety, and the number of surgical fields supporting their use is expanding. Therefore, their routine use for surgery on the submandibular area is recommended by the authors.
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Affiliation(s)
- Babak Sadoughi
- Department of Otorhinolaryngology-Head and Neck Surgery, Hôpital Européen Georges Pompidou, René Descartes University (Paris V), Paris, France
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Vironen JH, Kairaluoma M, Aalto AM, Kellokumpu IH. Impact of functional results on quality of life after rectal cancer surgery. Dis Colon Rectum 2006; 49:568-78. [PMID: 16583289 DOI: 10.1007/s10350-006-0513-6] [Citation(s) in RCA: 162] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE Quality of life is an important outcome measure that has to be considered when deciding treatment strategy for rectal cancer. The aim of this study was to find out the impact of surgery-related adverse effects on quality of life. METHODS The RAND-36 questionnaire and questionnaires assessing urinary, sexual, and bowel dysfunction were administered to 94 patients with no sign of recurrence a minimum of one year after curative surgery. Results were compared with age-matched and gender-matched general population. RESULTS Eighty-two (87 percent) patients answered the questionnaires. Major bowel dysfunction was as common after high anterior resection as after low anterior resection. Urinary complaints occurred as often after anterior resection as after abdominoperineal resection, but sexual dysfunction was more common after abdominoperineal resection. Overall, the patients reported better general health perception but poorer social functioning than population controls. In particular, elderly patients reported a significantly better quality of life in many dimensions than their population controls. There was no significant difference in quality of life between treatment groups. Major bowel dysfunction after anterior resection impaired social functioning compared with that of patients without such symptoms. Urinary dysfunction impaired social functioning and impotence impaired physical and social functioning. CONCLUSIONS Quality of life after rectal cancer surgery is not worse than that of the general population. The major adverse impact of bowel and urogenital dysfunction is on social functioning. These adverse effects need to be discussed with the patient and preoperative function needs to be taken into account when choosing between treatment options. Permanent colostomy is not always the factor that disrupts a person's quality of life most.
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Affiliation(s)
- Jaana H Vironen
- Helsinki University Central Hospital, Jorvi Hospital, Espoo, Finland
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Yucel S, Erdogru T, Baykara M. Recent neuroanatomical studies on the neurovascular bundle of the prostate and cavernosal nerves: clinical reflections on radical prostatectomy. Asian J Androl 2005; 7:339-49. [PMID: 16281080 DOI: 10.1111/j.1745-7262.2005.00097.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The neurovascular bundle of the prostate and cavernosal nerves have been used to describe the same structure ever since the publication of the first studies on the neuroanatomy of the lower urogenital tract of men, studies that were prompted by postoperative complications arising from radical prostatectomy. In urological surgery every effort is made to preserve or restore the neurovascular bundle of the prostate to avoid erectile dysfunction (ED). However, the postoperative potency rates are yet to be satisfactory despite all advancements in radical prostatectomy technique. As the technology associated with urological surgery develops and topographical studies on neuroanatomy are cultivated, new observations seriously challenge the classical teachings on the topography of the neurovascular bundle of the prostate and the cavernosal nerves. The present review revisits the classical and most recent data on the topographical anatomy of the neurovascular bundle of the prostate and cavernosal nerves and their implications on radical prostatectomy techniques.
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Affiliation(s)
- Selcuk Yucel
- Department of Urology, Akdeniz University School of Medicine, Kampus 07070, Antalya, Turkey.
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