Sexual potency following surgery for rectal carcinoma. A followup of 44 patients

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.

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.

Urogenital dysfunctions after treatment of rectal cancer

A significant part of rectal cancer survivors will experience urogenital dysfunction induced by the treatment. Significant progress has been made in order to improve the total mesorectal technique through different approaches (open, laparoscopic, robotic, transanal). Rectal cancer surgery is technically difficult notably deep in the pelvis, and therefore the most frequent cause of the postoperative dysfunction is the surgical nerve damage of the autonomic nerves at this level. The main objectives of these efforts were to obtain maximal oncological results and to achieve better functional outcomes including less postoperative urogenital dysfunctions. Our purpose was to build a comprehensive review of the existing literature data regarding this issue from past to present.

Quality-of-life and surgical treatments for rectal cancer--a longitudinal analysis using the California Cancer Registry

BACKGROUND

Heterogeneous results for research investigating health-related quality of life (HRQL) in patients undergoing sphincter-ablating procedures for rectal cancer are likely due to single institution experiences and measurement of HRQL. To address this heterogeneity, we evaluated HRQL in patients with rectal cancer by type of surgery, location of tumor, and receipt of adjuvant therapy using an HRQL instrument that has not been used to address rectal cancer patients in a population-based sample over time.

METHODS

The Functional Assessment of Cancer Therapy-Colorectal instrument was administered at 9 and 19 months after diagnosis to a consecutive sample of 160 patients in Northern California identified by the California Cancer Registry. A broad multidimensional interpretation of HRQL was used to examine the impact of tumor location and treatment status, stage of disease, age, and gender.

RESULTS

In general, men had lower social well-being scores, and younger patients had lower physical and emotional well-being scores and colorectal concerns scores. We found no differences in HRQL by either tumor location or type of surgery, at either 9 or 19 months after diagnosis. Lower physical well-being and greater adverse colorectal concerns were reported at 9 months among patients who received adjuvant therapy; however, only adverse colorectal concerns persisted over time.

CONCLUSIONS

This study provides additional evidence that sphincter-ablating procedures do not necessarily reduce quality of life in patients with rectal cancer. Distinctive features of this study include a broad multidimensional interpretation of HRQL, the 19 months of longitudinal follow-up, and a prospective population-based study design.

Sexual dysfunction following surgery for rectal cancer - a clinical and neurophysiological study

Background

Sexual dysfunction following surgery for rectal cancer may be frequent and often severe. The aim of the present study is to evaluate the occurrence of this complication from both a clinical point of view and by means of neurophysiological tests.

Methods

We studied a group of 57 patients submitted to rectal resection for adenocarcinoma. All the patients underwent neurological, psychological and the following neurophysiological tests: sacral reflex (SR), pudendal somatosensory evoked potentials (PEPs), motor evoked potential (MEPs) and sympathetic skin responses (SSRs). The results were compared with a control group of 67 rectal cancer patients studied before surgery. Only 10 of these patients could be studied both pre- and postoperatively. 10 patients submitted to high dose preoperative chemoradiation were studied to evaluate the effect of this treatment on sexual function. Statistical analysis was performed by means of the two-tailed Student's t test for paired observations and k concordance test.

Results

59.6% of patients operated reported sexual dysfunction, while this symptom occurred in 16.4% in the control group. Moreover, a significantly higher rate of alterations of the neurophysiological tests and longer mean latencies of the SR, PEPs, MEPs and SSRs were observed in the patients who had undergone resection. In the 10 patients studied both pre and post-surgery impotence occurred in 6 of them and the mean latencies of SSRs were longer after operation. In the 10 patients studied pre and post chemoradiation impotence occurred in 1 patient only, showing the mild effect of these treatments on sexual function.

Conclusion

Patients operated showed severe sexual dysfunctions. The neurophysiological test may be a useful tool to investigate this complication. The neurological damage could be monitored to decide the rehabilitation strategy.

Sexual and urinary dysfunction following rectal dissection compared with segmental colectomy

INTRODUCTION

The aim of this study was to assess the impact of nerve sparing surgery and major abdominal surgery on sexual and urinary function in men and women with colorectal cancer undergoing rectal dissection and segmental colectomy.

METHOD

Forty-eight patients (group A: 22 males, 26 females; median age 55 years) undergoing rectal dissection were compared with 24 having segmental colectomy (group B: 12 male, 12 female; median age 55 years). Preoperative data were also compared with age- and gender-matched controls (group C).

RESULTS

More patients after rectal dissection vs segmental colectomy had urinary tract infections [15 (31%) vs 3 (17.5%), P = 0.04]. At 37 months, urinary dysfunction after rectal excision was seen in 29 (60%; 20 men) vs nine (37.5%; eight men) after segmental colectomy. Postoperative urinary symptoms were significant in group A, but not in group B (pre: vs post; groups A and B: poor stream--13%vs 38%, P = 0.001 and 21%vs 21%, P = NS; incontinence--4.2%vs 17%, P = 0.008 and 8%vs 8%, P = NS; hesitancy--13%vs 35%, P = 0.034 and 17%vs 21%, P = NS). Sexual health was worse after rectal excision compared with segmental colectomy (men--62.5%, women--25%vs 44% of men) respectively. Erectile dysfunction was the chief cause (rectal excision--50%vs segmental colectomy - 33%). After rectal excision, 6% of women had dyspareunia and 19% reported reduced orgasm but none after segmental colectomy. Conclusion More men than women had urinary and sexual impairment after rectal excision than after segmental colectomy. Its aetiology is multifactorial.

Physiology of penile erection and pathophysiology of erectile dysfunction

This article reviews the physiology of penile erection, the components of erectile function, and the pathophysiology of erectile dysfunction. The molecular and clinical under-standing of erectile function continues to gain ground at a particularly fast rate. Advances in gene discovery have aided greatly in working knowledge of smooth muscle relaxation/contraction pathways. The understanding of the nitric oxide pathway has aided not only in the molecular understanding of the tumescence but also greatly in the therapy of erectile dysfunction.

Sexual function after rectal excision

BACKGROUND

Rectal excision is associated with a risk of autonomic nerve damage and associated sexual dysfunction (SD). The evolution of our understanding of the anatomy and physiology of sexual function together with continual refinement of surgery for both benign and malignant disease has led to a decrease in the incidence of SD after rectal surgery. A knowledge of the degree of risk of postoperative SD is important both for the patient and as a benchmark for audit of individual colorectal practice.

METHODS

The available literature on the anatomy, physiology and surgical aspects of this topic has been researched through the Medline database. The more recently available data are reviewed in the context of the historical evolution of surgery for benign and malignant rectal disease.

RESULTS AND CONCLUSIONS

In the best hands, permanent impotence occurs in less than 2% of patients following restorative proctocolectomy and at a similarly low rate after proctocolectomy and ileostomy. Isolated ejaculatory dysfunction is also numerically a minor problem post operation for benign disease. Patient age is the most important predictor of SD after surgery for rectal cancer. The incidence of permanent impotence remains high (>40%) after abdomino-perineal excision of the rectum (APE) but the continued decline in the use of this operation in favour of low anterior resection (LAR), which carries about half the risk of impotence compared to sphincter ablating surgery, is likely to have resulted in a fall in the absolute number of patients rendered impotent as a result of rectal cancer surgery. Anatomical dissection of the pelvis with preservation of the named autonomic fibres results in a low and predictable rate of sexual morbidity. Surgeons could profitably spend more time with their patients discussing the possible effects of surgery on sexual function. Further research is required to determine the effects of adjuvant therapy for rectal cancer on sexual function.

The impact of radiation on functional outcomes in patients with rectal cancer and sphincter preservation

Radiation therapy (RT) plays an important role in the management of patients with rectal cancer. However, there is mounting evidence that RT results in functional changes. The purpose of this study was to review the published data on bowel and sexual functional changes associated with RT and to determine the optimal strategy. The data suggest that studies are generally small, retrospective studies, use various RT regimens, and assess function with various nonstandardized parameters. In general, bowel function as measured by frequency, urgency, evacuation, sensation, and/or continence is impaired after RT when compared with patients not treated with RT. Although limited, preoperative RT tends to cause less impairment than postoperative RT. Sexual function is poorly studied, but data suggest that RT has a negative impact in both men and women. Further study is necessary to understand the extent of impairment, optimize radiation strategies, and select patients who will gain the most with RT.

Controversies in the surgical management of rectal cancer

At the present time, standard therapy for potentially curable rectal cancer consists of transabdominal surgical resection and adjuvant chemoradiation for American Joint Committee on Cancer stage II/III disease. Controversial issues include the use of local excision as opposed to formal resection and total mesorectal excision (TME) alone without adjuvant therapy. Although early stage tumors are the ideal potential candidates for local excision, clinical staging with endoscopic ultrasound is extremely variable in accurately predicting T and N stage. In addition, even low-grade or T1 tumors are associated with a 7% to 14% chance of nodal metastatic disease. Overall, the risk for local recurrence is higher after local excision but may be reduced by adjuvant therapy. Salvage rates for recurrent disease range from 21% to 91%. In regard to TME, local recurrence rates are an impressive 0% to 12% without adjuvant radiation. However, the addition of radiation therapy may further reduce these already low rates, especially in higher-risk groups. The results of 2 large European studies show acceptable complication rates and the applicability of this technique to a diverse patient population.

Do we still need a permanent colostomy in XXI-st century?

The aim of this paper is to answer the question: do we still need a permanent colostomy and present the quality of life of patients operated on for rectal cancer. A comparative analysis of patients after abdomino-perineal resection of the rectum vs. patients after low anterior resection of the rectum with preservation of sphincters is presented. When assessing the quality of life of patients, the following issues were considered: a) function of the whole organism and general condition (physical function); b) psychological well-being (psychological function); c) professional activity, relations with relatives and friends, leisure activities (social function) and d) intimate relations (sexual function). In both groups of patients, both after abdomino-perineal resection of the rectum and after low-anterior resection, a significant deterioration in the quality of life was noted. In spite of a good general health condition in the majority of cases (over 60% in both groups), frequent are irregular stools and diarrhoea. Stomy patients complain about uncontrolled passing of gas and urologic problems, while patients with preserved sphincter complain about constipation. Stomy patients significantly more often suffer depression, loneliness and even despair due to low self-esteem and feeling of unfavourable change in body appearance. This feeling is present more often in younger patients and in women. Rectal cancer may cause social disfunction, like reluctance to resume professional activity after surgery, limitation of social contacts, change of model of rest and leisure activities towards more passive forms and forms which do not require the attendance of many people. These phenomena apply to both groups but are more prominent among stomy patients. As stomy patients are usually older, some of these alterations may be due to age. Sexual dysfunction is significantly more frequent in stomy patients. Age may be one of the causes thereof. These problems are significantly more frequent in males. In some cases of colorectal cancer, the best way of management is colostomy. Further studies are needed to elaborate more clear criteria for optimal management of patients with colorectal cancer.

Topography of the pelvic autonomic nervous system and its potential impact on surgical intervention in the pelvis

Bladder, bowel, and sexual dysfunction caused by iatrogenic lesions of the inferior hypogastric plexus (IHP) are well known and commonly tolerated in pelvic surgery. Because the pelvic autonomic nerves are difficult to define and dissect in surgery, and their importance often ignored, we conducted a gross anatomic study of 90 adult and four fetal hemipelves. Using various non-surgical approaches, the anatomic relations and pathways of the IHP were dissected. The IHP extended from the sacrum to the genital organs at the level of the lower sacral vertebrae. It originated from three different sources: the hypogastric nerve, the sacral splanchnic nerves from the sacral sympathetic trunk (mostly the S2 ganglion), and the pelvic splanchnic nerves, which branched primarily from the third and fourth sacral ventral rami. These fibers converge to form a uniform nerve plate medial to the vascular layer and deep to the peritoneum. The posterior portion of the IHP supplied the rectum and the anterior portion of the urogenital organs; nerve fibers traveled directly from the IHP to the anterolateral wall of the rectum and to the inferolateral and posterolateral aspects of the urogenital organs. The autonomic supply from the IHP was supplemented by nerves accompanying the ureter and the arteries. An understanding of the location of the autonomic pelvic network, including important landmarks, should help prevent iatrogenic injury through the adoption of surgical techniques that reduce or prevent postoperative autonomic dysfunction.

Anatomy of Denonvilliers' fascia and pelvic nerves, impotence, and implications for the colorectal surgeon

BACKGROUND

The development and anatomy of Denonvilliers' fascia have been controversial for many years and confusion exists about its operative appearance. Better appreciation of this poorly understood anatomy, and its significance for impotence after rectal dissection, may lead to further functional improvements in pelvic surgery.

METHOD

A literature review of the embryology and anatomy of Denonvilliers' fascia and impotence after pelvic rectal surgery was undertaken.

RESULTS

Denonvilliers' fascia has no macroscopically discernible layers. The so-called posterior layer refers to the fascia propria of the rectum. The incidence of erectile and ejaculatory dysfunction after rectal excision is high in older patients, and when performed for rectal cancer. There is no consensus about the relationship of Denonvilliers' fascia to the plane of anterior dissection for rectal cancer.

CONCLUSION

Colorectal surgeons should focus on the important anatomy between the rectum and the prostate to improve functional outcomes after rectal excision. A classification of the available anterior dissection planes is proposed. Surgeons should be encouraged to document the plane used as well as outcome in terms of sexual function.

Sexual dysfunction, informed consent and multimodality therapy for rectal cancer

BACKGROUND

This study assessed the presurgical and preradiation discussion of the risk of posttherapy sexual dysfunction among patients who underwent potentially curative therapy for rectal cancer. The incidence of sexual dysfunction after treatment for rectal cancer was then determined.

METHODS

A retrospective review of the medical records of 52 consecutive patients who underwent potentially curative procedures for rectal cancer within 15 cm from the anal verge was performed.

RESULTS

Presurgical discussion of the risk of sexual dysfunction was not documented in the consent in 37 of 52 patients (71%). Among the 5 males who underwent local excision, none reported posttherapy sexual dysfunction. Of the 6 males who were treated by low anterior resection, only 1 had a postoperative complaint of sexual dysfunction. Five of 15 males (33%) treated with abdominoperineal resection (APR) alone reported postprocedure sexual dysfunction, whereas 6 of 8 males (75%) treated with APR and radiation reported dysfunction. Of the entire female cohort, only 1 of the 16 reported sexual dysfunction posttherapy.

CONCLUSION

A discussion of the risks of posttherapy sexual dysfunction was documented for fewer than one third of the patients. Among males after APR, the use of postoperative radiation showed a trend toward an increase in sexual dysfunction. Surgery and/or radiation therapy did not impact on sexual dysfunction in females.

Extrafascial excision of the rectum for cancer: a technique for the avoidance of the complications of rectal mobilization

Serious complications can occur following mobilization of the rectum for cancer including: ureteric injury, rectal perforation, hemorrhage, autonomic nerve damage, and local recurrence of the tumor in the pelvis. Each of these complications can be minimized by careful dissection in correct tissue planes in the pelvis. The rectum and mesorectum are surrounded by the fascia propria, a thin fascial envelope. This envelope offers a surface for dissection that leads the surgeon to a safe plane lying inside the autonomic nerves, the ureter, and the presacral vessels, and lying outside of the mesorectum and its associated vessels and lymphatics. The surgical anatomy of the pelvis is presented, with emphasis on the rectal fascia propria, as a basis for a detailed description of the technique of extrafascial excision of the rectum.

Transcutaneous penile oxygen pressure during bicycling

OBJECTIVE

To evaluate the blood supply to the penis during bicycling and thus determine whether the associated perineal compression might be responsible for some cases of impotence.

SUBJECTS AND METHODS

The transcutaneous penile oxygen partial pressure (pO2 ) at the glans of the penis was measured in 25 healthy athletic men; pO2 is readily measured by noninvasive techniques currently widely used in the management of premature infants, and which have been shown to give pO2 levels that correlate with arterial pO2 levels. The measurements in the healthy subjects were taken in various positions, before, during and after bicycling.

RESULTS

The mean (sd) pO2 of the glans when standing before cycling was 61.4 (7.2) mmHg; it decreased after 3 min of cycling to 19.4 (4. 7) mmHg. After 1 min of cycling in a standing position it increased significantly to 68 (7.6) mmHg; when cycling was continued in a seated position, after 3 min the pO2 fell to 18.4 (4.2) mmHg and there was a full return to normal pO2 values after a 10-min recovery period.

CONCLUSION

The pO2 seems to correlate with the blood supply to the penis. The present results support the hypothesis that as the penile arteries are compressed against the pubic bone by the saddle during bicycling, the pO2 values decrease. Additionally, shifting from a seated to a standing position while cycling significantly improved the pO2 value of the penis and penile blood oxygenation was then even greater. Therefore, we suggest that cyclists change their body position frequently during cycling. Correcting the handlebars or the height of the saddle, tipping the nose of the saddle to produce a more horizontal, or even downward pointing position, and attention to the design of the saddle may be the only required precautions.

Morbidities of adjuvant chemotherapy and radiotherapy for resectable rectal cancer: an overview

PURPOSE

Although adjuvant chemoradiotherapy may improve outcomes after surgery for high-risk rectal cancer, its toxicities are not well documented. This is a review of complications associated with adjuvant therapy in randomized, controlled trials.

METHODS

A MEDLINE and literature search was performed for randomized, controlled trials of adjuvant therapy for rectal cancer. Modalities of adjuvant therapy evaluated included preoperative radiotherapy, preoperative chemoradiotherapy, postoperative radiotherapy, and postoperative chemoradiotherapy. All documented complications were analyzed, including any effect on pelvic floor function and quality of life.

RESULTS

Short-term (acute) complications of preoperative radiotherapy include lethargy, nausea, diarrhea, and skin erythema or desquamation. These acute effects develop to some degree in most patients during treatment but are usually self-limiting. With preoperative radiotherapy the incidence of perineal wound infection increases from 10 to 20 percent. The acute toxicities after postoperative radiotherapy for rectal cancer occur in 4 to 48 percent of cases, and serious toxicities, requiring hospitalization or surgical intervention, occur in 3 to 10 percent of cases. Postoperative radiotherapy is associated with more complications than preoperative radiotherapy. The main problems with postoperative radiotherapy are small-bowel obstruction (5-10 percent), delay in starting radiotherapy caused by delayed wound healing (6 percent) and postoperative fatigue (14 percent), and toxicities precluding completion of adjuvant therapy (49-97 percent). The morbidity and mortality of both preoperative and postoperative radiotherapy are higher in elderly patients and when two-portal rather than three-portal or four-portal radiation technique is used. Meticulous radiation technique is important, and multiple fields of irradiation are mandatory. After combined adjuvant chemotherapy and radiotherapy acute hematologic and gastrointestinal toxic effects are frequent (5-50 percent). Delayed radiation toxicities include radiation enteritis (4 percent), small-bowel obstruction (5 percent), and rectal stricture (5 percent). Pelvic floor function and quality of life have not been well evaluated in randomized, controlled trials.

CONCLUSION

Adjuvant therapy for rectal cancer has considerable adverse effects. Adverse effects on bowel and sphincter function and quality of life have not been defined.

Neurophysiological evaluation of sexual dysfunction in patients operated for colorectal cancer

Sexual dysfunction after colorectal cancer surgery may be severe and occurs in 25% to 100% of cases. Thirty-eight patients underwent colorectal resection; eight (21%) who were totally impotent and two (5%) who had ejaculatory failure were therefore studied to better understand the neurophysiological alterations related to this type of surgery. The patients were evaluated after surgery with electrophysiological testing, including examination of the sacral reflex (SR), pudendal somatosensory evoked potential (PEP), and motor evoked potential (MEP) responses. Sudomotor skin response (SSR) was also studied in a group of patients. Of the 38 patients studied, 29 showed abnormalities: six of SR, three of PEP, six of MEP, and fourteen of SSR. Only a combination of all these tests permits correct evaluation of the sexual dysfunction.

Quality of life after treatment for rectal cancer

BACKGROUND

The studies on patient-reported symptoms and quality of life following the treatment of rectal cancer were evaluated; guidelines for future quality of life studies in this field are proposed.

METHODS

Relevant papers in the English language were identified via Medline from January 1970 to November 1997, supplemented by a manual search for similar articles.

RESULTS

Patients suffer various short- and long-term complications after treatment of rectal cancer, although the reported prevalence of such problems varies from study to study. Recent prospective studies have shown that, despite these problems, global quality of life scores as measured by generic questionnaires improve after surgery.

CONCLUSION

The methodological shortcomings of previous work must be rectified if quality of life studies are to have relevance in patient management.

Sexuality in head and neck cancer patients

OBJECTIVE

To describe sexual functioning and its relationship with age, extent of disfigurement, performance status, and psychological functioning in head and neck cancer patients following radiation therapy with or without surgery.

DESIGN

Descriptive study, self-report survey, convenience sample.

SETTING

Academic tertiary care Veterans Administration Medical Center.

PATIENTS

Fifty-five of 101 consenting patients responded to the questionnaire. Mean age of the patients was 65.1 years (range 48 to 76); 54 were men. The mean duration since diagnosis was 30.6 months (range 3 to 216). All patients received radiation therapy and 26 also underwent surgery.

MAIN OUTCOME MEASURES

Instruments included were: The Derogatis inventory of Sexual Functioning, Multidimensional Health Locus of Control. The Center for Epidemiological Studies Depression Scale, Hopkins Symptom Check List, and List Performance Status Scale.

RESULTS

Eighty-five percent showed interest in sex. Fifty-eight percent were satisfied with their current sexual partner and 49% were satisfied with their current sexual functioning. Most of them were able to fantasize: however, a majority reported arousal problems, 58% did not participate in sexual intercourse, and 58% had orgasmic problems. Most patients were not depressed. As a group these patients reported significantly more somatic distress but significantly less generalized feeling of distress when compared with a group of nonpatient nurses. Patients with "powerful others" locus of control showed significantly worse sexual functioning. There was no correlation between sexual functioning and performance status or severity of disfigurement. Patients younger than 65 years of age had more advanced disease, lower performance status and significantly poorer sexual functioning; those older than 65 years were more satisfied with their sexual partner and current sexual functioning.

CONCLUSION

Despite experiencing sexual problems, sexuality continues to be a priority in the majority of patients studied.

Male sexual function after autonomic nerve-preserving operation for rectal cancer

PURPOSE

Sexual dysfunction after surgery of the rectum is a serious complication to male patients. Autonomic nerve-preserving operation for rectal cancer has been performed within the recent ten years to maintain urinary and male sexual functions without spoiling of therapeutic radicality. To clarify male sexual function as the degree of autonomic nerve-preserving operation, the function was outlined through clinical interview.

METHOD

In a series of 134 male patients who were undergoing autonomic nerve-preserving operation for rectal cancer, a detailed history of postoperative sexual function was obtained by interviews.

RESULTS

In 87.7 and 66.9 percent of patients, erectile and ejaculatory potencies were maintained, respectively, which were higher rates than those after extended and conventional pelvic dissections. According to the preserving extent of autonomic nerve, patients undergoing complete preserving operations showed higher rates of maintained erectile (92.9 percent) and ejaculatory functions (82.5 percent), sexual intercourse (89.9 percent), and orgasm (93.9 percent) compared with those undergoing hemilateral autonomic nerve-preserving (82.3, 47.1, 52.9, 64.7 percent) or partial pelvic plexus-preserving operation (61.1, 0, 26.3, 22.2 percent).

CONCLUSION

Pelvic plexus preservation is necessary to maintain erectile potency, and both hypogastric nerve and pelvic plexus preservation are necessary to maintain ejaculate function and orgasm. To maintain satisfactory sexual function, complete autonomic nerve-preserving operation is suitable.

Quality of life in colorectal cancer. Stoma vs. nonstoma patients

PURPOSE

The bowel and sexual function of colorectal cancer patients undergoing either sphincter-saving or sphincter-sacrificing surgical procedures may be impaired. A legitimate question is how these different surgical techniques affect the patients' quality of life.

METHODS

Seventeen studies were identified that compared at least one of four aspects of patient functioning (i.e., physical, psychologic, social, and sexual) between stoma patients and nonstoma patients.

RESULTS

Although the literature does not yield entirely consistent findings, some long-term effects of surgery can be identified: 1) both patient groups are troubled by frequent or irregular bowel movements and diarrhea; 2) stoma patients report higher levels of psychologic distress than do nonstoma patients; 3) although both stoma patients and nonstoma patients report restrictions in their level of social functioning, such problems are more prevalent among patients with a colostomy; 4) sexual functioning of male and female stoma patients is consistently more impaired than that of male and female patients with intact sphincters. Results of the current review were compared with those of other, related areas.

CONCLUSIONS

Although nonstoma patients generally fare better than do stoma patients, they also suffer from physical impairments induced by sphincter-saving procedures (e.g., impaired bowel and sexual function). These impairments may become more prevalent as ultralow anastomosis is more frequently applied, resulting in bowel and sexual dysfunction and related psychologic distress. Well-designed studies are needed that examine whether quality-of-life benefits are to be gained by use of ultralow anastomosis compared with colostomy.

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.

Local excision of rectal carcinoma

Sixteen published series were reviewed in which local excision was used as definitive treatment for patients with invasive rectal carcinoma located within 6 cm of the anal verge. Ninety-four percent of tumors were T1 or T2 adenocarcinomas with no identified regional metastases. Five-year cancer-specific survival was 89%. Local recurrence was 19%, although more than half of these patients were cured with additional surgery. These results were comparable with those for historical controls treated with abdominoperineal resection (APR). Four pathologic features of the surgical specimen were analyzed to assess their correlation with patient outcome. Positive surgical margins, poorly differentiated histology, and increasing depth of bowel wall invasion were associated with increased local recurrence and decreased survival. Tumor size greater than 3 cm was not a significant factor. When criteria for appropriate patient selection are followed, local excision may provide survival and recurrence rates comparable with those achieved with APR with less morbidity and operative mortality.

An index for estimating the probability of lymph node metastasis in rectal cancers. Lymph node metastasis and the histopathology of actively invasive regions of cancer

We examined resected specimens from 40 cases of advanced rectal cancer to determine the extent of microtubular cancer nests and undifferentiated cancer cells (budding). We investigated the relationship between this budding and lymphatic invasion (ly), venous invasion (v), and lymph node metastasis (n), respectively. Moreover, we examined the relationship between ly, budding, and n in the preoperative biopsy specimens of 112 patients, including those of the 40 cases mentioned above. The degree of budding, which was abundant in the actively invasive region, showed a strong correlation with the degree of ly and the existence of n in the resected specimens. Also, budding was recognized in a relatively large portion of the biopsy specimens (52 of 112 [46.4%]) and lymph node metastasis was found in 41 of 52 specimens (78.8%). In 57 specimens, neither ly nor budding was found, and 16 of these specimens (28.1%) had positive lymph nodes. These results implied that the degree of budding in the actively invasive region can be a great help in predicting the presence of n. The presence or absence of budding in preoperative biopsy specimens also can be an important factor (along with the degree of differentiation and ly) in estimating the probability of n.

Radical pelvic surgery with preservation of sexual function

Recent neuroanatomical findings make it possible to identify the pelvic plexus and branches that innervate the corpora cavernosa intraoperatively. These anatomical principles have been used to modify standard radical prostatectomy and cystoprostatectomy to prevent postoperative sexual dysfunction. Radical retropubic prostatectomy has been performed on 320 men, who have been followed for 1-5 years after surgery; 74% of these men are now potent after surgery. Positive surgical margins were present in 10% of the cases; the actuarial overall local recurrence at 5 years (with or without distant metastases) is 10%. These results are consistent with past experience and data reported elsewhere in the literature. Radical cystoprostatectomy has been performed on 25 men over the past 5 years. Pathologic evaluation of all specimens demonstrated negative surgical margins, no patient has developed local recurrence, and of the patients who had cystectomy alone, 83% are now potent after surgery. With application of these principles to colorectal surgery, similar favorable impact on quality of life with improved surgical accuracy may be possible.

Rehabilitation of the cancer patient

Cancer patients often require extensive rehabilitation after treatment. Organization of a rehabilitation team and determination of its goals are a primary aim of such programs. Studies of job security and insurability demonstrate significant problems and biases toward the cancer patient. Discussion has been made of specific male and female sexual rehabilitation programs as well as programs directed at other physical disabilities secondary to head and neck or amputation surgery. Attention is drawn toward familiarizing the surgeon with these problems in order to enhance his treatment of the cancer patient.

Sexual function after resection for rectal cancer

Major rectal operation, that is, abdominoperineal or anterior resection, for cancer frequently damages the autonomic pelvic nerve supply with resultant sexual dysfunction. The anatomic characteristics and function of the autonomic nervous system in the pelvis has been reviewed. Sexual function after rectal excision for cancer was studied in 25 male patients who were less than 60 years of age and exhibited normal sexual activity preoperatively. Of nine patients who had abdominoperineal resection, four were impotent and two reported no ejaculation with normal potency postoperatively. Of 4 patients who had high anterior resection, only 1 reported no ejaculation, whereas of 12 patients with low anterior resection, 4 were impotent and 3 reported no ejaculation. A higher incidence of sexual dysfunction was noted after abdominoperineal resection compared with after anterior resection (66 percent and 50 percent, respectively). However, the incidence after low and very low anterior resection was comparable with that after abdominoperineal resection (58 percent and 66 percent, respectively). Advanced patient age and very low resection were the two main factors effecting sexual dysfunction after major rectal operation. Although we believe that careful operative technique might reduce the incidence of sexual disturbances attributable to sympathetic fiber damage, avoidance of parasympathetic damage during operation cannot be accomplished because the most likely site of injury, namely the periprostatic plexus, is usually within the operative field, the exception being cases in which the tumor is small, thus allowing preservation of the rectoprostatic fascia.

The surgical anatomy of the rectum--a review with particular relevance to the hazards of rectal mobilisation

The major complications of rectal surgery that are wholly or partially avoidable by the use of an anatomically based dissection are haemorrhage from presacral veins, perforation of the rectum, damage to pelvic autonomic nerves and inadequate clearance of a rectal cancer. Important technical points in minimising the incidence of these complications are: (1) posterior dissection in the presacral space; (2) entry to this space by sharp dissection immediately posterior to the superior rectal artery; (3) deliberate incision of the rectosacral fascia; (4) anterior dissection posterior to Denonvilliers fascia in benign disease; (5) removal of the entire mesorectum for low rectal cancer. Other anatomical points not widely appreciated are: 1. The middle rectal artery does not run in the lateral ligaments of the rectum, but below them, on levator ani. It reaches the rectum by penetrating Denonvilliers' fascia. 2. The lateral ligaments may contain an accessory middle rectal artery in 25% of cases. 3. The pelvic autonomic nerves are buried in endopelvic fascia on the pelvic side wall, but come to lie close to the anterior aspect of the rectum at the level of the prostate or upper vagina.

Sexual function in women after proctocolectomy

One hundred women who had undergone proctocolectomy with a continence-preserving procedure (50 Kock pouches, 50 ileoanal anastomoses) for ulcerative colitis or polyposis coli were interviewed regarding their preoperative and postoperative sexual function. Frequency of intercourse increased and the incidence of dyspareunia decreased after operation in both groups. Patients who had a Kock pouch had a greater incidence of persistent postoperative dyspareunia than patients who underwent an ileoanal procedure (38% vs. 18%, p less than 0.02). Only one patient in each group reported a postoperative disturbance in ability to achieve orgasm. Most women reported no change in their menstrual cycle, but patients with a Kock pouch had more episodic vaginal discharge than patients with an ileoanal anastomosis (18% vs. 0%, p less than 0.001). Postoperative fertility was minimally impaired. Overall, the majority of women in this study who underwent proctocolectomy for benign diseases experienced enhanced sexual function after operation, which they attributed mainly to improved health.

"Spermatocele" following abdominoperineal resection and radiotherapy

A 60-year-old man developed repeated spermatic fluid collection in the small pelvis following abdominoperineal resection and radiotherapy for carcinoma of the rectum. The "spermatocele" was due to a fistula originating in the vasoseminal vesicle junction. This complication has not been described previously.

Proctectomy for inflammatory bowel disease

Between July 1973 and October 1984, we performed proctectomy either as part of a primary proctocolectomy or as a secondary staged procedure in 388 patients with ulcerative colitis and in 39 patients with Crohn's disease. The proctectomies were performed using a two-team synchronous approach. An intersphincteric or perimuscular technique was employed. All perineal wounds were closed and drained by suction drainage and the pelvic peritoneum was closed in all cases. Two patients died in the early postoperative period, one from a pulmonary embolus and one from sepsis. Three patients had to be reexplored for postoperative hemorrhage, in all cases from a branch of the superior hemorrhoidal artery. Postoperative perineal hematoma developed in two patients and perineal abscess developed in four patients which necessitated opening of the perineal skin wound. Nonhealing of the perineal wound occurred in 3 of 388 patients with ulcerative colitis and in 5 of 39 patients with Crohn's disease. No perineal dehiscence or hernias were seen. Postoperatively, one man was permanently impotent and two had prolonged but temporary impotence. Three patients had retrograde ejaculation at last follow-up.

Incidence of sexual dysfunction in male patients treated surgically for rectal malignancy

Sixty male patients surgically treated for colorectal cancer were interviewed by structured questionnaire to evaluate the etiology of sexual dysfunction and quality of life. Patients were divided into three groups: 20 who underwent low anterior resection, 20 subjected to Miles' abdominoperineal amputation, and 20 who underwent high anterior resection. Statistical evaluation of the three groups, by use of the chi-square test and Student's t test, showed that extent of the surgical dissection plays the most important role, although psychologic problems are also involved.

Sexual and urinary dysfunction following surgery for sigmoid colon cancer

We investigated sexual and urinary dysfunction following surgery for sigmoid colon cancer. Thirteen (46.4 per cent) of the 28 male patients with a normal sexual life prior to surgery could no longer ejaculate, but all could maintain erection. With the extension of lymph node dissection, the incidence of a disappearance of ejaculation tended to increase. In particular, in patients undergoing an extended lymph node dissection, the incidence was 53.8 per cent. Urinary dysfunction occurred in 7 (10.3 per cent) of the 68 patients (37 men and 31 women), but was slight to mild. There were no significant differences between the extent of lymph node dissection and urinary dysfunction. In surgery for sigmoid colon cancer, care should be taken to preserve the hypogastric nerves.

Stigma in patients with rectal cancer: a community study

A self-rating measure of stigma and several supplementary questions were devised in order to assess perceived stigma in a community survey of the quality of life in 420 rectal cancer patients, of whom 265 had a permanent colostomy. Half the patients felt stigmatised, higher proportions being observed among younger patients and among those with a colostomy. Feelings of stigma were associated with poor health, particularly emotional disorders, with the presence of other medical problems, and with disablement. Patients who perceived stigma made more use of medical services but were less satisfied with them, particularly with regard to communication with health professionals. Socio-economic factors, such as employment status, higher income, and higher social and housing class, did not protect patients against feeling stigmatised by cancer or by colostomy. Most patients, with or without stigma, enjoyed close relationships with intimates, but the stigmatised were more likely to have withdrawn from participation in social activities. Assessing stigma by self-rating gives information which adds to that obtained by the usual methods of assessing quality of life.

Measurement of the conduction velocity of the dorsal nerve of the penis

We describe an orthodromic nerve conduction technique of the dorsal nerve of the penis in 27 normal men. The mean compound nerve action potential was 12.0 plus or minus 6.1 microV. The nerve conduction velocity was 24.4 plus or minus 3.2 milliseconds when the penis was at rest. Gentle stretch of the penis with a 1-pound weight increased the conduction velocity to 33.0 plus or minus 3.8 milliseconds. Since the dorsal nerve of the penis has an important role in erection the new methodology may be useful in the evaluation of male impotence.

Sexual function and perineal wound healing after intersphincteric excision of the rectum for inflammatory bowel disease

The technique of intersphincteric excision of the rectum in patients with inflammatory bowel disease was introduced with the aim of avoiding postoperative sexual dysfunction and, combined with primary perineal suture, should decrease morbidity from delayed perineal wound healing. In a series of 98 patients so treated at St. Mark's Hospital, permanent sexual dysfunction from sympathetic nerve damage occurred in one male patient among 23 aged 60 years or less assessed postoperatively. No patient exhibited evidence of permanent parasympathetic nerve damage. Primary healing of the perineal wound was successful in 50 per cent of the cases and in 69 per cent the wound healed within three months of operation. It is suggested that this combination of operative techniques significantly decreases morbidity from rectal excision compared with more extensive procedures and should be more widely adopted.

Neuroanatomy of penile erection: its relevance to iatrogenic impotence

The neuroanatomy of erection in men is not well defined. Recently, we isolated successfully the cavernous nerves for acute and chronic neurostimulation to induce penile erection in dogs and monkeys. We then investigated the anatomy of these nerves in humans by cadaveric dissection and serial histologic sectioning. Our experience in tracing the spinal nuclei responsible for vesical and urethral function by transportation of horseradish peroxidase enabled us to explore the location and organization of the spinal center for erection. Thus, systemic knowledge of the neuroanatomy of erection was accumulated. The spinal nuclei for control of erection are located in the intermediolateral gray matter at the S1 to S3 and T12 to L3 levels in dogs, and the S2 to S4 and T10 to L2 levels in humans. From these sacral nuclei axons issue ventrally and join the axons of the nuclei for the bladder and rectum to form the sacral visceral efferent fibers. These fibers emerge from the anterior root of S2 to S4, and join the sympathetic fibers to form the pelvic plexus, which then branches out to innervate the bladder, rectum and penis. The fibers innervating the penis (cavernous nerves) travel along the posterolateral aspect of the seminal vesicle and prostate, and then accompany the membranous urethra through the genitourinary diaphragm. These fibers are located on the lateral aspect of the membranous urethra and ascend gradually to the 1 and 11 o'clock positions in the proximal bulbous urethra. Some of the fibers penetrate the tunica albuginea of the corpus spongiosum, while others spread to the trifurcation of the terminal internal pudendal artery and innervate the dorsal, deep and urethral arteries. Shortly before the 2 corpora cavernosa merge the cavernous nerves penetrate the tunica albuginea along with the deep artery and cavernous vein. The terminal branches of these nerves innervate the helicine arteries and the erectile tissue within the corpora cavernosa. Because of the intimate relationship of the cavernous nerves to the rectum, prostate and urethra, they can be damaged easily during urological and pelvic procedures. This systemic knowledge of the human cavernous nerves from the spinal center to the erectile tissue should permit a better understanding of erection and impotence. Furthermore, with the aid of intraoperative neurostimulation, the cavernous nerves may be identified and preserved, thereby preventing iatrogenic impotence.

A survey of postoperative function after rectal anastomosis with circular stapling devices

Seventy-five patients, who had previously undergone anterior resection or sigmoid colectomy using a circular stapling device, were interviewed and examined. Their postoperative bowel, sexual and bladder function was noted. 22 patients had anastomoses more than 10 cm from the anal verge (Group A); 32 between 5-10 cm (Group B); 21 below 5 cm (Group C). The lower anastomoses were associated with less perfect function but only 2 patients were incontinent. Some impairment of sexual function was noted in one-third of patients in Group B and one half of patients in Group C. Changes in bladder function were rare.

Sexual dysfunction following operation for carcinoma of the rectum

In a retrospective study, sexual and urologic dysfunction were evaluated after a personal interview with 110 patients operated upon for carcinoma of the rectum with a long observation period. Following abdominoperineal resection in 93 patients, sexual dysfunction was found in 32 per cent, and 18 per cent were totally impotent. In 17 patients who had low anterior resections, none became totally impotent, but six patients had reduced potency or no ejaculation. No relation was found between age, tumor classification, size and localization, or perineal wound infection and postoperative sexual dysfunction. Potency was usually regained within two years. One-third of the patients had experienced urologic symptoms following abdominoperineal resection. Sixteen per cent had minor symptoms at follow-up. Patients were not evaluated by cystometry. No correlation was found between postoperative sexual dysfunction and urologic problems.

Male sexual function after abdominoperineal resection for rectal cancer

In a series of 26 male patients undergoing abdominoperineal resection of the rectum for malignant disease, a detailed history of sexual function was obtained, using a questionnaire before and 12 months after the operation. The overall incidence of sexual dysfunction was 61.5 per cent, total and partial erectile impotence being, respectively, both 27 per cent. Taking age into account, among men of the youngest age group (41-48 yrs), incidence of complete and partial erectile impotence was 14 per cent. In the middle age group (49-57 yrs), 22 per cent reported total and 33 per cent reported partial erectile impotence, whereas in patients of the oldest group (58-65 yrs), total erectile impotence was present in 40 per cent and partial in an additional 30 per cent. The extent of the disease (Dukes' stage) was found to be of no value as a prognostic index of postoperative sexual dysfunction. It is concluded that the age of the patients is the most important factor related to sexual activity after abdominoperineal resection for cancer.

The quality of life after rectal excision for low rectal cancer

The quality of life for patients with carcinoma of the lower two-thirds of the rectum (5-12 cm from the anal verge) treated by abdominoperineal resection (APER, n = 38) was compared with that of a similar group of patients treated by low sphincter saving resection (SSR, n = 40). Assessment was by questionnaire conducted a minimum of one year after operation. Thirty patients (75 per cent) after SSR were entirely continent and ten patients (25 per cent) had occasional episodes of incontinence. Each patient with a colostomy was incontinent and 25 (66 per cent) had leaks from their appliance (12 frequent; 13 occasional). Patients after APER avoided more items in the diet and took more medication to control their bowel habit than patients after SSR. Fifteen of the 18 patients (83 per cent) who were employed before SSR returned to work after operation; only 6 of 15 patients (40 per cent) returned to work after APER (P less than 0.05). Sexual function was impaired in 6 of 20 men (30 per cent) after SSR and in 12 of 18 men (67 per cent) after APER (P less than 0.06). Depression was significantly more prevalent after APER than after SSR. Patients with low rectal cancer who are treated by modern sphincter saving resection have a quality of life superior to those who are treated by APER.