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Chen Z, Zhang XJ, Chang HD, Chen XQ, Liu SS, Wang W, Chen ZH, Ma YB, Wang L. From basic to clinical: Anatomy of Denonvilliers' fascia and its application in laparoscopic radical resection of rectal cancer. World J Gastrointest Surg 2023; 15:2108-2114. [PMID: 37969712 PMCID: PMC10642479 DOI: 10.4240/wjgs.v15.i10.2108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/17/2023] [Accepted: 08/15/2023] [Indexed: 10/27/2023] Open
Abstract
The total mesorectal excision (TME) approach has been established as the gold standard for the surgical treatment of middle and lower rectal cancer. This approach is widely accepted to minimize the risk of local recurrence and increase the long-term survival rate of patients undergoing surgery. However, standardized TME causes urogenital dysfunction in more than half of patients, thus lowering the quality of life of patients. Of note, pelvic autonomic nerve damage during TME is the most pivotal cause of postoperative urogenital dysfunction. The anatomy of the Denonvilliers' fascia (DVF) and its application in surgery have been investigated both nationally and internationally. Nevertheless, controversy exists regarding the basic to clinical anatomy of DVF and its application in surgery. Currently, it is a hotspot of concern and research to improve the postoperative quality of life of patients with rectal cancer through the protection of their urinary and reproductive functions after radical resection. Herein, this study systematically describes the anatomy of DVF and its application in surgery, thus providing a reference for the selection of surgical treatment modalities and the enhancement of postoperative quality of life in patients with middle and low rectal cancer.
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Affiliation(s)
- Zhou Chen
- Department of Gastrointestinal Oncology Surgery, TheAffiliated Hospital of Qinghai University, Xining 810000, Qinghai Province, China
| | - Xiao-Jing Zhang
- Department of Gastrointestinal Oncology Surgery, TheAffiliated Hospital of Qinghai University, Xining 810000, Qinghai Province, China
| | - Hao-Dong Chang
- Department of Gastrointestinal Oncology Surgery, TheAffiliated Hospital of Qinghai University, Xining 810000, Qinghai Province, China
| | - Xiao-Qian Chen
- Department of Gastrointestinal Oncology Surgery, TheAffiliated Hospital of Qinghai University, Xining 810000, Qinghai Province, China
| | - Shan-Shan Liu
- Department of Gastrointestinal Oncology Surgery, TheAffiliated Hospital of Qinghai University, Xining 810000, Qinghai Province, China
| | - Wei Wang
- Department of General Surgery, The Affiliated Hospital of Qinghai University, Xining 810000, Qinghai Province, China
| | - Zhi-Heng Chen
- Department of General Surgery, The Affiliated Hospital of Qinghai University, Xining 810000, Qinghai Province, China
| | - Yu-Bin Ma
- Department of Gastrointestinal Oncology Surgery, TheAffiliated Hospital of Qinghai University, Xining 810000, Qinghai Province, China
| | - Liang Wang
- Department of Gastrointestinal Oncology Surgery, TheAffiliated Hospital of Qinghai University, Xining 810000, Qinghai Province, China
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Chen W, Liu Y, An Y, Shi W, Qiu X, Lin G, Zhou J. The Effectiveness and Safety of Rectal Modular Resection in Low Rectal Cancer: A Retrospective Study. J Laparoendosc Adv Surg Tech A 2023. [PMID: 36946686 DOI: 10.1089/lap.2022.0592] [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: 03/23/2023] Open
Abstract
Background: Described by Heald in 1982, total mesorectal excision (TME) is now routinely performed as the standard procedure for mid-low rectal cancer, with remarkable decrease in local recurrence and improved oncology outcome. However, the integrity of the resected mesentery and damage to autonomic nerves still remain challenging for general surgeons, especially in the cohort of neoadjuvant therapy patients. The concept of rectal modular resection (RMR), based on an integral understanding of the regional anatomy, was proposed as a surgical skill for dissociation of the rectum with shorter surgical duration, function preservation, and improved oncology outcome. Methods: This was a retrospective trial. Patients with resectable rectal lesions, ranging between 3 and 7 cm from the anal verge, were enrolled and grouped by TME surgery based on RMR or classical procedure resection (CPR). We estimated perioperative outcomes, including surgery complications such as anastomotic leak, urine retention, and others. Pathological properties, including distal clearance, harvested lymph nodes, tumor differentiation, and specimen grading, were also taken into account. Patients were followed postoperatively and functional evaluation was recorded at the 3-month and 1-year postoperation visits. Results: From January 2019 to December 2021, a total of 92 patients were enrolled in this study. TME surgery complying with the RMR methodology was performed with a back-to-bilateral-to-front modular proceeding. Duration of operation was significantly shortened in the RMR group, without increase in blood loss or failure rate of anus preservation. The quality of the specimen, graded according to integrity of the mesorectum, stands out in the RMR group. Functional evaluation revealed no statistical difference between RMR and CPR groups regarding sexual ability impairment and defecation disorder since follow-up is still ongoing. Conclusions: RMR-based TME was efficient with compressed operation duration compared with CPR and its safety was well validated with regard to the occurrence of complications and function loss.
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Affiliation(s)
- Weijie Chen
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuxin Liu
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yang An
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Weikun Shi
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoyuan Qiu
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Guole Lin
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jiaolin Zhou
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Li Y, Zhao YM, Ma YB, Zhou JS, Tong C, Yan LK. The "Y"-shaped Denonvilliers' fascia and its adjacent relationship with the urogenital fascia based on a male cadaveric anatomical study. BMC Surg 2023; 23:13. [PMID: 36650515 PMCID: PMC9843937 DOI: 10.1186/s12893-023-01913-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 01/11/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Controversies regarding the anatomical structure of Denonvilliers' fascia and its relationship with surrounding fasciae have sparked a heated discussion, especially concerning whether Denonvilliers' fascia is multilayered. This study aimed to expound on the anatomical structure of Denonvilliers' fascia and its correlation with the peritoneum from the sagittal view and clarify the complex fascial relationship. METHODS Our study was performed on 20 adult male pelvic specimens fixed in formalin, including 2 entire pelvic specimens and 18 semipelvic specimens. The local adjacent organs and fasciae were dissected, and Denonvilliers' fascia was observed and removed for histological examination. RESULTS Denonvilliers' fascia was typically single-layered and tough. On the sagittal plane, the peritoneum constituting the peritoneal reflection and Denonvilliers' fascia formed a "Y" shape. Denonvilliers' fascia originated from the peritoneal reflection, extended along the ventral side of the seminal vesicles and prostate, continuing caudally; its bilateral sides closely connected to the urogenital fascia (UGF) of the pelvic wall. In addition, histology preliminarily indicated that the basal cell layers of the peritoneum and Denonvilliers' fascia were continuous and formed a "Y" shape. Furthermore, the basal cells of the two peritonea extended to Denonvilliers' fascia, creating a fused double-layered structure. Some tiny blood vessels or a network of such vessels extended from the peritoneum to Denonvilliers' fascia. CONCLUSION Denonvilliers' fascia, the extension of the peritoneum in the pelvic floor, appears as a single-layered "Y"-shape on the sagittal plane. Our study provides new support for the peritoneal fusion theory. Understanding the anatomical characteristics of Denonvilliers' fascia and its relationship with the UGF is of guiding significance for inexperienced colorectal surgeons to conduct rectal cancer surgery.
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Affiliation(s)
- Yi Li
- grid.440288.20000 0004 1758 0451First Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, 710068 Shaanxi China
| | - Ya-Min Zhao
- Department of General Surgery, Shandong Provincial Linyi Jinluo Hospital, Linyi, 276036 Shandong China
| | - Yan-Bing Ma
- grid.43169.390000 0001 0599 1243Department of Human Anatomy, Histology and Embryology, School of Basic Medical Sciences, Xi’an Jiaotong University Health Science Center, Xi’an, 710061 Shaanxi China
| | - Jin-Song Zhou
- grid.43169.390000 0001 0599 1243Department of Human Anatomy, Histology and Embryology, School of Basic Medical Sciences, Xi’an Jiaotong University Health Science Center, Xi’an, 710061 Shaanxi China
| | - Cong Tong
- grid.440288.20000 0004 1758 0451First Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, 710068 Shaanxi China
| | - Li-Kun Yan
- grid.440288.20000 0004 1758 0451First Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, 710068 Shaanxi China
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García-Gausí M, García-Armengol J, Pellino G, Mulas C, Roig JV, García-Granero A, Moro D, Valverde A. Navigating surgical anatomy of the Denonvilliers’ fascia and dissection planes of the anterior mesorectum with a cadaveric simulation model. Updates Surg 2022; 74:629-636. [PMID: 35286602 PMCID: PMC8995278 DOI: 10.1007/s13304-022-01252-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/01/2022] [Indexed: 11/28/2022]
Abstract
Anterior dissection of the rectum in the male pelvis represents one of the most complex phases of total meso-rectal excision. However, the possible existence of different anatomical planes is controversial and the exact anatomical topography of Denonvilliers’ fascia is still debated. The aim of the study is to accurately define in a cadaveric simulation model the existence and boundaries of Denonvilliers’ fascia, identifying the anatomical planes suitable for surgical dissection. The pelvises of 31 formalin-preserved male cadavers were dissected. Careful and detailed dissection was carried out to visualize the anatomical structures and the potential dissection planes, simulating an anterior meso-rectum dissection. Denonvilliers’ fascia was identified in 100% of the pelvises, as a single-layer fascia that originates from the peritoneal reflection and descends until its firm adhesion to the prostate capsule. The fascia divides the space providing an anterior and a posterior plane. Anteriorly to the fascia, during the caudal dissection, its firm adhesion to the prostate capsule forces to section it sharply. The cadaveric simulation model allowed an accurate description of Denonvilliers’ fascia, defining several planes for anterior dissection of the meso-rectum.
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Affiliation(s)
- María García-Gausí
- Surgical Anatomy Unit, Department of Human Anatomy and Embryology, Faculty of Medicine and Dentistry, University of Valencia, Avenida Blasco Ibañez, 15, 46010 Valencia, Spain
- Coloproctology Unit, European Center for Colorectal Surgery, Vithas Valencia 9 of October Hospital, Valencia, Spain
- Department of General and Digestive Surgery, Punta de Europa Hospital, Algeciras, Spain
| | - Juan García-Armengol
- Surgical Anatomy Unit, Department of Human Anatomy and Embryology, Faculty of Medicine and Dentistry, University of Valencia, Avenida Blasco Ibañez, 15, 46010 Valencia, Spain
- Coloproctology Unit, European Center for Colorectal Surgery, Vithas Valencia 9 of October Hospital, Valencia, Spain
| | - Gianluca Pellino
- Surgical Anatomy Unit, Department of Human Anatomy and Embryology, Faculty of Medicine and Dentistry, University of Valencia, Avenida Blasco Ibañez, 15, 46010 Valencia, Spain
- Coloproctology Unit, European Center for Colorectal Surgery, Vithas Valencia 9 of October Hospital, Valencia, Spain
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy
| | - Claudia Mulas
- Surgical Anatomy Unit, Department of Human Anatomy and Embryology, Faculty of Medicine and Dentistry, University of Valencia, Avenida Blasco Ibañez, 15, 46010 Valencia, Spain
- Coloproctology Unit, Department of General and Digestive Surgery, University General Hospital Consortium, Valencia, Spain
| | - José V. Roig
- Surgical Anatomy Unit, Department of Human Anatomy and Embryology, Faculty of Medicine and Dentistry, University of Valencia, Avenida Blasco Ibañez, 15, 46010 Valencia, Spain
- Coloproctology Unit, European Center for Colorectal Surgery, Vithas Valencia 9 of October Hospital, Valencia, Spain
| | - Alvaro García-Granero
- Surgical Anatomy Unit, Department of Human Anatomy and Embryology, Faculty of Medicine and Dentistry, University of Valencia, Avenida Blasco Ibañez, 15, 46010 Valencia, Spain
- Coloproctology Unit, Department of General and Digestive Surgery, Son Espases University Hospital, Palma, Spain
| | - David Moro
- Surgical Anatomy Unit, Department of Human Anatomy and Embryology, Faculty of Medicine and Dentistry, University of Valencia, Avenida Blasco Ibañez, 15, 46010 Valencia, Spain
- Coloproctology Unit, Department of General and Digestive Surgery, Clinic University Hospital, Valencia, Spain
| | - Alfonso Valverde
- Surgical Anatomy Unit, Department of Human Anatomy and Embryology, Faculty of Medicine and Dentistry, University of Valencia, Avenida Blasco Ibañez, 15, 46010 Valencia, Spain
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Tzelves L, Protogerou V, Varkarakis I. Denonvilliers’ Fascia: The Prostate Border to the Outside World. Cancers (Basel) 2022; 14:cancers14030688. [PMID: 35158956 PMCID: PMC8833507 DOI: 10.3390/cancers14030688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 01/23/2022] [Accepted: 01/27/2022] [Indexed: 11/27/2022] Open
Abstract
Simple Summary Prostate cancer is a very common neoplasm in men, with surgery being a valuable tool for its successful management. The prostate gland lies deep in the male pelvis with several sheets of fibrous membranes surrounding it along anterior, lateral, and posterior surfaces. These membranes are called fasciae. Arteries, veins, and nerve fibers that are important for erectile function and continence can be found within these fasciae. An important fascia covering the posterior surface of the prostate and separating it from the rectum is Denonvilliers’ fascia. This structure is important for the confinement of cancer within the prostate and for completing an operation without damaging the nerves responsible for erectile function and continence while also removing all neoplastic tissue. This review covers the anatomical aspects of this structure, along with providing some clinical insight on how to use this knowledge to improve clinical outcomes. Abstract The fascial structure around the prostate has been a controversial issue for several decades, but its role in radical prostatectomy is crucial to achieving successful nerve-sparing surgery. One of the fasciae surrounding the prostate is Denonvilliers’ fascia, forming its posterior border with the rectum and enclosing along its layers several fibers of the neurovascular bundle. This review focuses on embryological and anatomical points of Denonvilliers’ fascia, aiming to provide a summary for the operating general surgeons and urologists of this area.
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Affiliation(s)
- Lazaros Tzelves
- 2nd Department of Urology, National and Kapodistrian University of Athens, Sismanogleion Hospital, 11526 Athens, Greece;
- Correspondence:
| | - Vassilis Protogerou
- Department of Anatomy, School of Medicine, National and Kapodistrian University of Athens, Mikras Asias 21 St., 12462 Athens, Greece;
- 3rd Urological Department, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462 Athens, Greece
| | - Ioannis Varkarakis
- 2nd Department of Urology, National and Kapodistrian University of Athens, Sismanogleion Hospital, 11526 Athens, Greece;
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Roch M, Gaudreault N, Cyr MP, Venne G, Bureau NJ, Morin M. The Female Pelvic Floor Fascia Anatomy: A Systematic Search and Review. Life (Basel) 2021; 11:life11090900. [PMID: 34575049 PMCID: PMC8467746 DOI: 10.3390/life11090900] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/20/2021] [Accepted: 08/26/2021] [Indexed: 12/20/2022] Open
Abstract
The female pelvis is a complex anatomical region comprising the pelvic organs, muscles, neurovascular supplies, and fasciae. The anatomy of the pelvic floor and its fascial components are currently poorly described and misunderstood. This systematic search and review aimed to explore and summarize the current state of knowledge on the fascial anatomy of the pelvic floor in women. Methods: A systematic search was performed using Medline and Scopus databases. A synthesis of the findings with a critical appraisal was subsequently carried out. The risk of bias was assessed with the Anatomical Quality Assurance Tool. Results: A total of 39 articles, involving 1192 women, were included in the review. Although the perineal membrane, tendinous arch of pelvic fascia, pubourethral ligaments, rectovaginal fascia, and perineal body were the most frequently described structures, uncertainties were identified in micro- and macro-anatomy. The risk of bias was scored as low in 16 studies (41%), unclear in 3 studies (8%), and high in 20 studies (51%). Conclusions: This review provides the best available evidence on the female anatomy of the pelvic floor fasciae. Future studies should be conducted to clarify the discrepancies highlighted and accurately describe the pelvic floor fasciae.
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Affiliation(s)
- Mélanie Roch
- Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Faculty of Medicine and Health Sciences, School of Rehabilitation, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada; (M.R.); (N.G.); (M.-P.C.)
| | - Nathaly Gaudreault
- Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Faculty of Medicine and Health Sciences, School of Rehabilitation, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada; (M.R.); (N.G.); (M.-P.C.)
| | - Marie-Pierre Cyr
- Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Faculty of Medicine and Health Sciences, School of Rehabilitation, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada; (M.R.); (N.G.); (M.-P.C.)
| | - Gabriel Venne
- Anatomy and Cell Biology, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3A 0C7, Canada;
| | - Nathalie J. Bureau
- Centre Hospitalier de l’Université de Montréal, Department of Radiology, Radio-Oncology, Nuclear Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada;
| | - Mélanie Morin
- Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Faculty of Medicine and Health Sciences, School of Rehabilitation, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada; (M.R.); (N.G.); (M.-P.C.)
- Correspondence:
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