Neurologic sequelae of abdominoperineal resection

Preoperative urinary function does not predict postoperative acute urinary retention in men after rectal resection

AIM

Acute urinary retention (AUR) is a well-known complication after rectal surgery. It can be associated with additional morbidity. Causes of postoperative AUR are often multifactorial - involving patient-, pathology- and treatment-related factors. A proportion of men undergoing total mesorectal excision (TME) have preexisting urinary dysfunction and this may predispose to AUR. The aim of this study was to prospectively assess the influence of preoperative urinary function on postoperative AUR in men undergoing TME.

METHOD

A prospective multicentre cohort study was conducted. All adult men undergoing rectal resection between June 2016 and January 2018 were recruited. Combined pelvic resections, inability to void per urethra and emergency surgery were excluded. Preoperative urinary function was assessed with uroflowmetry, prostate ultrasound and the International Prostate Symptom Score (IPSS). The incidence of postoperative AUR, urinary tract infection (UTI) and length of hospital stay (LOS) were measured.

RESULTS

Seventy-seven patients (mean age 61 years) were recruited. The overall incidence of AUR was 21%. Preoperative urinary function, IPSS and past urological history were not predictive for postoperative AUR. AUR was not associated with UTI and did not affect LOS. Patients with UTI had a higher intravesical protrusion of the prostate.

CONCLUSION

Preoperative urinary dysfunction in men is not predictive of postoperative AUR after TME. It should not preclude early trial of void after TME. AUR did not predispose to UTI, nor did it prolong LOS.

Major urinary dysfunction after mesorectal excision for rectal carcinoma

Background

Urinary dysfunction may occur after mesorectal excision and pelvic autonomic nerve preservation (PANP) in patients with rectal carcinoma. The aim of this prospective study was to identify factors predictive of long-term urinary catheterization.

Methods

Two hundred and ten patients without significant urological problems underwent resection of rectal cancer with mesorectal excision. The number of patients with complete, partial or no identification of the nerves was documented and correlated with possible predictive factors for postoperative major urinary dysfunction.

Results

Eight patients (3·8 per cent) required long-term urinary catheterization: two after complete PANP (two of 168) and six in whom PANP was incomplete (six of 42) (P = 0·001). Multiple regression analysis identified incomplete PANP (odds ratio 13·8 (95 per cent confidence interval 2·7 to 71·3); P = 0·002) as a predictive factor for major urinary dysfunction.

Conclusion

Major urinary dysfunction after mesorectal excision for rectal cancer is associated with an incomplete nerve-sparing technique.

Residual urine volume after total mesorectal excision: an indicator of pelvic autonomic nerve preservation? Results of a case-control study

OBJECTIVE

The rate of bladder dysfunctions after total mesorectal excision (TME) for rectal cancer can be decreased by bilateral pelvic autonomic nerve preservation (PANP). However, it is not clear yet, how often partial nerve impairment may lead to bladder dysfunction. It was the aim of a case-control study, to examine the residual urine volume in patients before and after TME with and without complete PANP, in order to clarify, whether this parameter allows conclusions on the quality of PANP.

PATIENTS AND METHODS

Regarding bladder function, a case group (n = 26) without complete PANP was compared with a control group (n = 26) with complete identification and nerve preservation according to standadized intra-operative documentation. Twenty-six match pairs were established, identical regarding gender, wall infiltration depth, tumour site, operation procedure and operation extent. Rates of neoadjuvant therapy, R0-classification, anastomotic leakage, wound and urinary tract infection were equally distributed for both the case- and control group (P > 0.05). Residual urine volume was pre- and post-operatively determined by sonography.

RESULTS

Pre-operatively, residual urine volumes differed neither between the pairs nor between both groups with and without nerve preservation. In the case group with incomplete PANP there was a difference between pre- and post-operative residual urine volume (median; quartil: 2.5 ml; 0.0-32.5 ml vs 130 ml; 0.0-317 ml; P = 0.001). In the control group there was no difference (median; quartile: 0.0 ml; 0.0-20 ml vs 15.5 ml; 0.0-62.0 ml; P = 0.07). The difference between the postoperatively measured volumes of the case and control group were significant (P = 0.001). With residual urine volume = 100 ml, the risk of incomplete PANP was 14 times higher (odds ratio).

CONCLUSIONS

Residual urine volume is an indicator of the completeness of PANP during TME. It should be determined pre- and post-operatively, and besides the recording of the neurogenic bladder, serve as a quality control.

Abdominoperineal resection for adenocarcinoma of the low rectum

Current understanding of the routes of spread of rectal cancer along with technical innovations such as the circular stapler have allowed surgeons to treat most rectal cancers with an anterior resection and low anastomosis. Appropriate use of local therapy options has further decreased the need for abdominoperineal resection (APR). Nonetheless, APR remains the procedure of choice for many distal rectal adenocarcinomas. Numerous factors influence the decision to perform an APR and are discussed in detail. Although mortality for APR has been reduced significantly, morbidity remains high. Specific complications commonly seen after APR are discussed. Operative technique is outlined since much of the specific morbidity of APR can be reduced by attention to detail in the conduct of this complex procedure.

Delayed bladder dysfunction after abdominoperineal resection: an indicator of local recurrence

It is generally not appreciated that the delayed onset of voiding dysfunction after abdominoperineal resection for rectal carcinoma may be the first sign of local pelvic recurrence. We herein present a series of 5 patients who were referred for urodynamic evaluation of voiding dysfunction beginning nine to twenty-four months after the original operative procedure. Urodynamic evaluation revealed low bladder wall compliance in 4 patients, and detrusor hyperreflexia in 1 patient. Computerized tomography scans confirmed the local tumor recurrence in all cases. The delayed onset of voiding complaints after abdominoperineal resection should prompt a high index of suspicion that a local tumor recurrence may be present.

Bladder and sexual function after surgery for rectal cancer

Bladder function and sexual potency were studied before and after surgery for rectal carcinoma. Urinary voiding after postoperative removal of indwelling catheter was impaired in seven of 22 men, leading to prostatic surgery in four. Two years later, eight of 16 men reported disturbed voiding, but no significant changes were found in bladder capacity, residual volume, flow rate, or detrusor pressure. Sexual potency was reduced in five of ten men, in one with retrograde ejaculation; and three did not achieve erection. Objective postoperative bladder disturbance was surprisingly rare. Symptoms of denervation were more commonly attributable to sympathetic rather than parasympathetic lesions, possibly as a result of more energetic dissection in the anteroposterior plane than along the lateral pelvic walls. No patient had total autonomic denervation. Wide indications are advocated for prostatic resection in patients who have prostatic symptoms in association with surgery for rectal carcinoma.