Sexual dysfunction following proctocolectomy and abdominoperineal resection

When do defecation function and quality of life recover for patients with non-ostomy and ostomy surgery of rectal cancer?

Background

Rectal cancer (RC) surgery often results in permanent colostomy, seriously limiting the quality of life (QOL) in patients in terms of bowel function. This study aimed to examine defecation function and QOL in RC patients who underwent non-ostomy or ostomy surgery, at different time-points after surgery.

Methods

In total, 82 patients who underwent an ostomy and 141 who did not undergo an ostomy for the treatment of RC at our colorectal surgery department between January 2013 and January 2015 were enrolled. Surgical methods, tumor distance from the anal margin (TD), anastomosis distance from the anal margin (AD) and complications were compered between the non-ostomy and ostomy surgery groups. QOL was compared between the two groups at years 2, 3, and 4 after surgery. The Wexner score and the validated cancer-specific European Organization for Research and Treatment of Cancer (EORTC QLQ-CR30) questionnaire scores were assessed for all patients in January 2017. SPSS 21.0 was utilized for all data analyses.

Results

Surgical methods, TD, and AD significantly differed between the non-ostomy and ostomy surgery groups (all P < .001). However, no differences were found in the number of complications between the groups (P = .483). For the 192 patients undergoing Dixon surgery, role function (RF), global QOL (GQOL), sleep disturbance, and the incidence of constipation showed significant differences between the two groups (P = .012, P = .025, P = .036, and P = .015, respectively). In the 31 cases of permanent ostomy, we observed significant differences in GQOL scores, dyspnea incidence, and financial difficulties across the different years (P = .002, P = .036, and P < .01, respectively). Across all 223 cases, there were significant differences in social function and GQOL scores in the second year after surgery (P = .014 and P < .001, respectively). However, no differences were observed in the other indices across the three time-points.

Conclusions

RC patients undergoing ostomy surgery, especially those with low and super-low RC, revealed poorer defecation function and QOL in the present study. However, 2 years after surgery, most of the defecation and QOL indicators showed recovery.

Male issues of the ileal pouch

: Restorative proctocolectomy with ileal pouch-anal anastomosis is the standard surgical treatment modality for patients with ulcerative colitis who require colectomy. There are special issues related to male gender. We performed systemic literature review on the topic, incorporating the experience in our specialized Center for Ileal Pouch Disorders, and provide recommendations for the identification and management for the gender-specific issues in male patients with ileal pouches. Chronic pouchitis, particularly ischemic pouchitis, anastomotic leak, and presacral sinus are more common in male patients than their female counterparts. Sexual dysfunction can occur after pouch surgery, particularly in those with pouch failure. Diagnosis and management of benign and malignant prostate diseases can be challenging due to the altered pelvic anatomy from the surgery. Digital rectal examination for prostate cancer screening is not reliable. Transpouch biopsy of prostate may lead to pouch fistula or abscess. Pelvic radiation therapy may have an adverse impact on the pouch function. In conclusion, sexual dysfunction and enlarged prostate can occur in patients with the ileal pouch. The measurement of serum prostate-specific antigen is a preferred method for the screening of prostate cancer. If biopsy of the prostate is needed, the perineal route is recommended. The risk for pouch dysfunction and the benefit for oncologic survival of pelvic radiation for prostate cancer should be carefully balanced.

Study of sexual, urinary, and fecal function in females following restorative proctocolectomy

BACKGROUND

The aim was to investigate quality of life, sexual, fecal, and urinary function in females undergoing restorative proctocolectomy (RPC).

METHODS

A prospective case-control study was performed in two tertiary centers. Controls were females with ulcerative colitis, without a stoma or RPC. Validated questionnaires (SF-36, Female sexual function index, King's questionnaire, and the Wexner scale) were administered in the outpatient setting. Pearson chi(2), t-test, and Mann-Whitney U-tests were used to assess significance.

RESULTS

A total of 255 females were identified and 49% (n = 124) recruited. In all, 109 patients fulfilled the inclusion criteria: 55 (50.5%) inflammatory bowel disease (IBD); 54 (49.5%) RPC. The mean age of RPC patients was 41.8 years (± 12.7 SD) vs. 43.8 years (± 15.8) for IBD (P = 0.491). RPC females with urinary symptoms (urgency, frequency, or incontinence) were 10 years younger than IBD (RPC mean age 37.6 ± 7.3 years vs. IBD 47.4 ± 13.5; P = 0.044). Urgency in fecal function was experienced by more IBD patients (IBD 75.0% vs. RPC 47.9%; P = 0.006), although RPC patients had increased day (P < 0.001) and night bowel frequency (P < 0.001) and were more likely to experience night seepage (P = 0.001). RPC females who had a vaginal delivery (VD) were more likely to have day seepage (P = 0.046) and require pads (P = 0.026) than RPC females who had not undergone VD. There was no significant difference in sexual function.

CONCLUSIONS

RPC may adversely impact urinary function in female patients over time. Bowel frequency, seepage, and pad usage are increased following RPC and function may be worse following VD. RPC does not adversely affect overall sexual function.

Figuring out sex in a reconfigured body: experiences of female colorectal cancer survivors with ostomies

Colorectal cancer survivors with ostomies can face complex concerns regarding sexuality. We used an anthropological perspective to examine the experiences of 30 female colorectal cancer survivors with ostomies to shed light on the sexual challenges and adaptations made in the wake of cancer surgery and treatment. Participants fell into four categories with regard to their sexual experience post surgery; however, not all women found their altered sexuality to be particularly problematic. This type of phenomenological examination can inform a more patient-centered, less biomedically focused paradigm for assessing and improving the sexual health of cancer survivors.

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.

Health-related quality of life among long-term rectal cancer survivors with an ostomy: manifestations by sex

PURPOSE

Intestinal stomas can pose significant challenges for long-term (> or = 5 years) rectal cancer (RC) survivors. Specifying common challenges and sociodemographic or clinical differences will further the development of tailored interventions to improve health-related quality of life (HRQOL).

PATIENTS AND METHODS

This was a matched cross-sectional study of long-term RC survivors conducted in three Kaiser Permanente regions. The mailed questionnaire included the modified City of Hope Quality of Life-Ostomy (mCOH-QOL-Ostomy) and Medical Outcomes Study 36-Item Short-Form Health Survey, version 2 (SF-36v2). Groups surveyed were permanent ostomates (cases) and those who did not require an ostomy (controls). RC survivors were matched on sex, age, and time since diagnosis. Comparisons between groups used regression analysis with adjustment for age, comorbidity score, history of radiation therapy, income, and work status.

RESULTS

Response rate was 54% (491 of 909). Cases and controls had similar demographic characteristics. On the basis of the mCOH-QOL-Ostomy, both male and female cases had significantly worse social well-being compared with controls, while only female cases reported significantly worse overall HRQOL and psychological well-being. For younger females (< age 75 years), ostomy had a greater impact on physical well-being compared with older females. Based on the SF-36v2, statistically significant and meaningful differences between female cases and controls were observed for seven of the eight scales and on the physical and mental component summary scores.

CONCLUSION

Men and women report a different profile of challenges, suggesting the need for targeted or sex-specific interventions to improve HRQOL in this population. This may include focus on physical HRQOL for female ostomy survivors younger than age 75.

Coping and acceptance: the greatest challenge for veterans with intestinal stomas

OBJECTIVE

Intestinal stomas (ostomies) create challenges for veterans. The goal of this qualitative analysis was to understand better patients' perspectives regarding their greatest challenge.

METHODS

Ostomates at three Veterans Affairs locations were surveyed using the modified City of Hope Quality of Life-Ostomy questionnaire that contained an open-ended request for respondents to describe their greatest challenge. The response rate was 51% (239 of 467); 68% (163 of 239) completed the open-ended item. Content analysis was performed by an experienced qualitative research team.

RESULTS

Coping and acceptance were the most commonly addressed themes. The most frequently expressed issues and advice were related to a need for positive thinking and insight regarding adjustment over time. Coping strategies included the use of humor, recognition of positive changes resulting from the stoma, and normalization of life with an ostomy.

CONCLUSIONS

Coping and acceptance are common themes described by veterans with an intestinal stoma. Health-care providers can assist veterans by utilizing ostomate self-management strategies, experience, and advice.

A mixed-methods evaluation of health-related quality of life for male veterans with and without intestinal stomas

PURPOSE

Intestinal stomas have a major impact on Cases' lives. It is essential to better understand the areas in which interventions may help to minimize the negative consequences.

METHODS

This was a case-control survey study using validated instruments (City of Hope Quality of Life-Ostomy and Short Form 36 for Veterans). Cases were accrued from Veterans Affairs Medical Centers in Tucson, Indianapolis, and Los Angeles. Eligibility included a major intra-abdominal surgical procedure that led to an ostomy (cases), or a similar procedure that did not mandate a stoma (controls). Analysis included quantitative and qualitative responses.

RESULTS

The response rate was 48 percent (511/1,063). Cases and controls had relatively similar demographic characteristics. Because of low numbers of female respondents (13 cases and 11 controls), only results for males are reported. Based on both the City of Hope Quality of Life-Ostomy and Short Form 36 for Veterans, cases reported significantly poorer scores on scales/domains reflecting psychologic and social functioning and well being. Additionally, cases reported poorer scores on Short Form 36 for Veterans scales reflecting physical functioning and significantly lower scores on multiple items in the social domain of the City of Hope Quality of Life-Ostomy compared with controls. Two-thirds of cases replied to an open-ended question on their "greatest challenge" related to their ostomy, which led to further clarification of major issues.

CONCLUSIONS

Multiple health-related quality of life problems were reported by male veterans with intestinal stomas. The greatest differences between cases and controls were observed in the social and psychologic domains/scales. Findings from this study provide a greater understanding of the challenges faced by ostomates and will inform the development and evaluation of urgently needed intervention strategies.

Urogenital Disorders Associated With Gut Failure and Intestinal Transplantation

PURPOSE

Intestinal transplantation has been increasingly performed in patients with short bowel syndrome and irreversible gut failure with successful outcomes. In parallel a common association was observed between gut failure and different urological disorders. To our knowledge this study is the first to address such an important clinical observation with special reference to the underlying disease.

MATERIALS AND METHODS

The medical records of 175 consecutive adult intestinal recipients were reviewed. Data were compiled and described according to the documented urogenital disorder, cause of intestinal failure and treatment modality, including transplantation.

RESULTS

Of the patients 43 experienced a total of 53 urogenital disorders for an overall incidence of 25%, including 24 (56%) who had the disorder before referral and 19 (44%) in whom the morbidity developed as a result of transplantation. Interestingly hypercoagulability, pseudo-obstruction, Crohn's disease and Gardner's syndrome were the underlying urogenital and intestinal disorder pathologies in 6.3% of the study patients. Treatment for prior urogenital disorders, including malignancy, precipitated intestinal failure in 3.4% of the referred patients. Reciprocally surgical treatment for the primary intestinal disease and management of gut failure by total parenteral nutrition, followed by transplantation, resulted in different urogenital complications in 17.7% of the total population with an 8.6% incidence of chronic renal failure.

CONCLUSIONS

Gut failure and intestinal transplantation are commonly associated with different urogenital disorders. Accordingly a designated urological service should be considered part of the multidisciplinary team required for treating this unique population.

The VA Ostomy Health-Related Quality of Life Study: objectives, methods, and patient sample

OBJECTIVE

To present the design and methods of a multisite study of health-related quality of life (HR-QOL) in veterans living with ostomies.

RESEARCH DESIGN AND METHODS

Veterans from Tucson, Indianapolis, and Los Angeles VA Medical Centers were surveyed using the validated City of Hope ostomy-specific tool (mCOH-QOL-Ostomy) and the SF-36V. Cases (ostomates) had a major gastrointestinal procedure that required an intestinal stoma, while controls had similar procedures for which an ostomy was not required. Ostomy subjects were recruited for four focus groups in each of two sites divided by ostomy type (colostomy versus ileostomy) and overall mCOH-QOL-Ostomy HR-QOL score (highest versus lowest quartile). The focus groups further evaluated barriers, concerns, and adaptation methods and skills.

MAIN OUTCOME MEASURES

This report presents recruitment results, reliability of survey instruments, and demographic characteristics of the sample.

RESULTS

The overall response (i.e., recruitment) rate across all sites was 48% and by site was 53%, 57%, and 37%, respectively (p < 0.001). Internal consistency reliability estimates indicated that both instruments remain reliable in this population (Cronbach's alpha for HR-QOL domains/scales: 0.71-0.96). Cases and controls were similar in demographic characteristics. Proportions of minority subjects matched projections from the site patient populations. Subjects with ostomies had significantly longer time since surgery than controls (p < 0.001). Focus groups were comprised of two to six subjects per group and demonstrated racial diversity at the Los Angeles site.

CONCLUSIONS

The unique design of our study of VA patients with ostomies is an illustration of a successful mixed methods approach to HR-QOL research. We collected meaningful quantitative and qualitative data that will be used in the development of new approaches to care that will lead to improved functioning and well-being in persons living with ostomies. Subsequent reports will provide the results of this research project.

Gender differences in quality of life of patients with rectal cancer. A five-year prospective study

To determine how quality of life changes over time and to assess gender-related differences in quality of life of rectal cancer patients we conducted a 5-year study. Little is known about how quality of life (QoL) changes over time in patients after surgery for rectal cancer, and whether gender of the patients is associated with a different perception of QoL. The aim of this study was to assess prospectively, changes in quality of life after surgery for rectal cancer, with a focus on gender related differences. Over a 5-year period, the EORTC-QLQ-C-30 and a tumor-specific module were prospectively administered to patients before surgery, at discharge, 3, 6, 12, and 24 months postoperatively. Comparisons were made between female and male patients. A total of 519 patients participated in the study, 264 men and 255 women. The two groups were comparable in terms of surgical procedures, adjuvant treatment, tumor stage, and histology. Most QoL scores dropped significantly below baseline in the early postoperative period. From the third month onward, global health, emotional and physical functioning, improved. Female gender was associated with significantly worse global health and physical functioning and with higher scores on treatment strain and fatigue. Men reported difficulties with sexual enjoyment; furthermore, over time, sexual problems created high levels of strain in men, worse than baseline levels in the early postoperative period. These problems tended to continue over the course of time. The findings in this study confirm that QoL changes after surgery and differs between men and women. Women appear to be affected by impaired physical functioning and global health. Female gender is associated with significantly higher fatigue levels and increased strain values after surgery. Through impaired sexual enjoyment, men are put more under strain than woman.

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.

Do geographic and educational factors influence the quality of life in rectal cancer patients with a permanent colostomy?

PURPOSE

This study was designed to evaluate possible social and geographic factors that could have an impact on quality of life in patients after abdominoperineal excision of the rectum. Although the number of patients with rectal cancer who need to be treated with abdominoperineal excision of the rectum and construction of permanent colostomy has greatly decreased in the past, there is still controversy about the influence on quality of life caused by this procedure.

METHODS

In a prospective trial, patients operated on for low rectal cancer by abdominoperineal excision of the rectum were evaluated by a quality of life questionnaire, modified from The American Society of Colon and Rectal Surgeons questionnaire, to assess fecal incontinence. The results for the four domains of quality of life (lifestyle, coping behavior, embarrassment, depression), as well as for subjective general health, were evaluated with regard to age, gender, education, and geographic origin in univariate and multivariate analyses.

RESULTS

Thirteen institutions in 11 countries included data from 257 patients. Although the analysis of general health did not reveal any significant differences, the analysis of the four quality of life domains showed the significant influence of geographic origin. The presence of a permanent colostomy showed a consistently negative impact on patients in southern Europe as well as for patients of Arabic (Islamic) origin. On the other hand, age, gender, and educational status did not reveal a statistically significant influence.

CONCLUSIONS

This is the first study to show the influence of geographic origin on quality of life of patients with a permanent colostomy. Possible factors that may influence the outcome of patients after surgical treatment of rectal cancer, such as weather, religion, or culture, should be taken into account when quality of life evaluations are considered.

Male sexual function improves after ileal pouch anal anastomosis

PURPOSE

Restorative Proctocolectomy and Ileal Pouch Anal Anastomosis has become the gold standard surgical therapy for the majority of patients with mucosal ulcerative colitis. However sexual functional disturbances after this procedure can be a concern for patients. Therefore the aim of this study was to determine the outcome of sexual-function related quality of life in male patients undergoing restorative proctocolectomy.

METHODS

One hundred and twenty-two male patients who underwent restorative proctocolectomy with ileal pouch anal anastomosis between 1995 and 2000 were evaluated by the validated International Index of Erectile Function (IIEF) scoring instrument. This index scale examines sexual function in five categories. These are erectile function, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction. The IIEF instrument was administered after surgery and then scores before and after RP/IPAA were evaluated and compared. The significance of age at the time of the surgery, type of surgery, type of anastomotic technique (mucosectomy vs stapled) and septic complications on sexual functional outcome were also investigated.

RESULTS

Mean age at the time of the surgery was 39.9 +/- 11.5 years. The mean follow-up period (time between pouch surgery and IIEF completed) was 3.6 +/- 1.8 years. There was statistically significant improvement in 4 of 5 categories of sexual function (erectile function, sexual desire, intercourse satisfaction, and overall satisfaction) where patients had improved scores after surgery compared to prior to surgery. The mean erectile function score increased pre to post surgery by 2.12 points (P = 0.02), which indicates better sexual results. Anastomotic technique and septic complication did not influence the results, however, older age had a negative impact on results.

CONCLUSIONS

Despite some adverse sexual functions, male patients who undergo RP/IPAA for the surgical management of their colitis may preserve or improve their overall sexual functional outcome.

Prospective Evaluation of Quality of Life of Patients Receiving Either Abdominoperineal Resection or Sphincter-Preserving Procedure for Rectal Cancer

BACKGROUND

Study results on quality of life (QoL) between patients receiving an anterior resection (AR) or abdominoperineal resection (APR) for rectal cancer vary greatly. A main reason is grounded in unequal methodology. The aims of this study were to assess differences in perceived QoL over time among patients treated with AR or APR with a recommended study design and methodology.

METHODS

In a prospective study, the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 and a tumor-specific module were administered to patients with rectal cancer before surgery, at discharge, and 3, 6, and 12 months after the operation. Comparisons were made between patients receiving an AR and those receiving an APR.

RESULTS

Two hundred forty-nine patients were included; 46 patients received an APR and 203 an AR. QoL data were available for 212 patients, of which 112 were female and 100 male. No differences in the distribution of age, sex, or tumor stage were observed between groups. EORTC function scales showed no significant differences, including body image scales, between patients receiving an AR and those receiving an APR. In symptom scores, AR patients had more difficulty with diarrhea and constipation, whereas patients with APR experienced more impaired sexuality and pain in the anoperineal region. At discharge, patients receiving an AR were more confident about their future.

CONCLUSIONS

QoL in patients receiving an AR and those receiving an APR is not different. Although patients with APR experience more impaired sexuality, patients receiving an AR experience decreases in QoL because of impaired bowel function.

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.

Urologic manifestations of nonurologic diseases gastrointestinal disorders

A variety of common, gastrointestinal diseases result in significant genitourinary tract pathology. In general, knowledge of these associated disease processes permit rapid and accurate diagnosis and treatment. The underlying thread is the recognition of one pathophysiological process to explain patterns of a single disease.

Impotence after mesorectal and close rectal dissection for inflammatory bowel disease

PURPOSE

Close rectal dissection is a surgical technique used by some surgeons in inflammatory bowel disease. It is performed within the mesorectum, close to the rectal muscle wall, with the aim of minimizing damage to the pelvic sexual nerves. Other surgeons dissect in the more anatomical mesorectal plane. Our aim was to determine whether close rectal dissection is more protective of the pelvic sexual nerves than mesorectal dissection.

METHOD

Patients undergoing surgery for inflammatory bowel disease were entered prospectively into a database. Male patients were mailed a standardized, validated, urologic impotence questionnaire: the International Index of Erectile Function.

RESULTS

There was an 81 percent response rate. Six of 156 assessable patients were totally impotent (3.8 percent). They were all in the 50-year-old to 70-year-old age group, with no impotence in patients younger than 50 years old. Twenty-one patients complained of minor diminution of erectile function (13.5 percent), where sexual activity was still possible. There was no statistical difference in the rate of complete (2.2 percent vs. 4.5 percent, P = 0.67) or partial (13.5 percent vs. 13.3 percent, P = 0.99) impotence between close rectal and mesorectal dissection (Fisher's exact test). There were no ejaculatory difficulties. The time elapsed since surgery ranged from 2.7 months to 192.7 months, with a median of 74.5 months.

CONCLUSION

Rectal excision for inflammatory bowel disease can be conducted with low rates of impotence. Minor degrees of erectile dysfunction may be more common than currently recognized. We could not demonstrate that close rectal dissection significantly protects the patient from impotence compared with operating in the anatomical mesorectal plane. Age appears to be the most important risk factor for postoperative impotence.

Comparison of quality of life in patients undergoing abdominoperineal extirpation or anterior resection for rectal cancer

OBJECTIVE

To evaluate the quality of life (QoL) in patients undergoing anterior resection (AR) or abdominoperineal extirpation (APE) for rectal cancer in a sample of patients recruited from a field trial.

SUMMARY BACKGROUND DATA

Abdominoperineal resection has been reported to put patients at higher risk of disruption to QoL than sphincter-preserving surgery.

METHODS

Fifty patients treated with AR and 23 patients treated with APE were prospectively followed up. All patients were treated in curative attempt and were disease-free throughout the study. QoL was assessed before surgery and 6 to 9 and 12 to 15 months after surgery.

RESULTS

Multivariate analysis of variance and subsequent post hoc comparisons revealed a main effect for time (role function, emotional function, body image, future perspective, and micturition-related problems) and group in favor of APE (sleeping problems, constipation, diarrhea), and a time-by-group interaction (role function). No significant results were obtained for the remaining scores, but patients undergoing APE consistently had more favorable QoL scores than those undergoing AR. Multivariate analysis and post hoc comparisons revealed a particularly poor QoL for patients undergoing low AR. They had a significantly lower total QoL, role function, social function, body image, and future perspective, and more gastrointestinal and defecation-related symptoms than patients undergoing high AR.

CONCLUSION

Patients undergoing APE do not have a poorer QoL than patients undergoing AR. Patients undergoing low AR have a lower QoL than those undergoing APE. Attention should be paid to QoL concerns expressed by patients undergoing low AR.

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.

Local methods of treatment of rectal cancer

Over 11 000 new cases of rectal cancer are reported in the UK each year. Recent technical advances have increased interest in local management of the disease. The introduction of screening for colorectal cancer will potentially lead to an increased number of early rectal cancers suitable for local curative treatment. In addition, as the proportion of elderly patients in the population rises, local methods of treatment of rectal cancer will become increasingly important in this group of patients with comorbid disease. A literature search was performed on Medline database for English language publications on local treatments of rectal carcinoma. Preoperative assessment, selection of patients, local therapeutic and palliative methods of treatment were evaluated. Local methods of treatment can be used for potentially curative operations for rectal cancer. Preoperative endoanal ultrasound appears to be the most useful investigation for determining depth of local invasion. Transanal endoscopic microsurgery has extended the boundaries of local surgery and permits access to the mid and upper rectum with results similar to those of conventional local techniques. Laser therapy and transanal resection provide the best form of palliation for more advanced rectal carcinomas.

Neural pathways and central sites involved in penile erection: neuroanatomy and clinical implications

Penile erection occurs in response to tactile, visual, and imaginative stimuli in humans. In animals olfactory and auditory cues are particularly important. The participation of multiple sites with the brain and spinal cord, and coordination of somatic and autonomic pathways make sexual behavior in general, and erection in particular, vulnerable to neurologic injury and disease. Sites within the brain and spinal cord act in concert to process, coordinate, then distribute the neural inputs necessary for sexual behavior including erection. Activation of neurons in some of these regions either pharmacologically or by electrical stimulation has been associated with penile tumescence. This review will provide a geographic framework for understanding the neuroanatomical basis of penile erection based primarily on animal data. Following discussion of the anatomical substrates, a clinical correlation is then provided to confirm and reinforce these experimental observations.

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.

Local Excision and Chemoradiation for Low Rectal T1 and T2 Cancers Is an Effective Treatment

Lesions located in the distal third of the rectum are usually treated with abdominoperineal resection or a low anterior resection with a coloanal anastomosis. However, in a select group of patients with favorable histology and a low probability of lymphatic spread, sphincter-sparing procedures will afford long-term disease-free survival and cure without the need for extensive, complicated surgery. We performed a 10-year retrospective review, including pathologic examination of specimens by a single pathologist, in an attempt to identify factors associated with a decreased disease-free survival. Thirty-five patients (median age, 71 years; range, 48–88) with low rectal carcinomas were treated with full-thickness disc excision (with or without chemoradiation), with curative intent Median follow-up was 46 months (range, 8–120). There were 15 T1, 16 T2, and 4 T3 lesions. Tumors with poor histologic factors or greater than T1 received adjuvant radiation (with or without 5-fluorouracil). Four patients developed a local failure at a median of 21.5 months (range, 9–30) and were salvaged with abdominoperineal resection. The 5-year cancer-specific survival was 91 per cent. Negative margins approached statistical significance (P < 0.07) in influencing local control. We conclude that, when combined with chemoradiation for lesions deeper than submucosa or with adverse histologic factors, local resection of rectal cancer is an effective treatment in selected patients.

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.

Renal and urologic complications of inflammatory bowel disease

Renal and urologic complications are not uncommon in patients with inflammatory bowel disease, and can be directly or indirectly related to the underlying disease process or its treatment. Many of these patients have asymptomatic disease, or the urinary symptoms are nonspecific or overshadowed by bowel symptoms. By the time a urinary complication is considered, significant disease progression or renal damage may have occurred. These risks necessitate a high degree of diligence and periodic urologic evaluation as part of the long-term management of patients with inflammatory bowel disease.

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.

Social and sexual function following ileal pouch-anal anastomosis

PURPOSE

Patients who undergo surgery for ulcerative colitis are usually young and active. When surgery becomes necessary, their future social and sexual function is of major concern. This study was performed to be able to give more detailed information of what is to be expected.

METHODS

Forty-nine consecutive patients (26 men and 23 women) who underwent ileal J-pouch-anal anastomosis for ulcerative colitis between November 1983 and September 1986 in the authors' institution were personally interviewed regarding details of their preoperative and postoperative social and sexual functions.

RESULTS

Eighty-eight percent had reduced capacity to work preoperatively compared with 6 percent postoperatively. Thirty-one percent resumed work in the period with diverting ileostomy. Leisure time activities were reduced in 47 percent preoperatively, whereas 6 percent had limitations postoperatively. In 35 percent of women, frequency of intercourse was increased postoperatively, and none reported a decreased frequency. None of the women who were able to achieve orgasm preoperatively reported a postoperative disturbance of this ability, and 16 percent experienced an increased quality of orgasm. Postoperatively none reported dyspareunia, vaginal discharge, or changes in their menstrual cycle. Frequency of intercourse and ability to achieve orgasm remained unchanged for the majority of men; however, one developed erectile dysfunction, and one complained of retrograde ejaculation. Sexual activity in men was less affected by the presence of an ileostomy, and 69 percent had intercourse in the period with ileostomy compared with 30 percent of women. None of the patients complained of anal pain, soiling, or fecal leakage during intercourse, but one women reported some discomfort from the pouch during intercourse. None of the patients wanted to return to a life with an ileostomy.

CONCLUSION

The social and sexual function, quality of life, after ileal J-pouch anastomosis is improved when compared with the period with ulcerative colitis and the time with diverting ileostomy. In men, however, a frequency of sexual dysfunction similar to what is seen after proctectomy for benign diseases should be underlined.

Management of rectourethral fistulas in Crohn's disease

We report the thirteenth case of a recto-urethral fistula in Crohn's disease. The patient, a 37-year-old white male, had a 20-year history of intestinal Crohn's disease and had undergone numerous bowel resections. His symptoms were fecaluria, urorrhea and passing of urine from an orifice just outside the base of the scrotum. He had urinary infection and severe ileocolitis. He underwent a diagnostic evaluation (cystourethroscopy, proctoscopy, retrograde pyelography, intravenous urography, voiding cystourethrography) that revealed a fistula comprising the membranous urethra, the rectum, the perineum and the scrotum. He was treated with Metronidazole (20 mg/kg/day/12 mo). At 1 year no signs of intestinal disease and urinary sepsis were noted. The external orifice and the perineal fistulous network were closed, and the drainage from the rectum and the urethra had improved. No side effects limited use of the drug. No relapse was observed in the 3 months, after the therapy was discontinued. We present a review of the literature on the management of rectourethral fistulas in Crohn's disease. Surgeons have used successfully several approaches in the repair of this lesion, but no single procedure has proved optimal or even universally applicable. We emphasize, as the literature suggests, that the management must be individualized. Medical therapy with metronidazole has an important role in a patient with rectourethral fistula and concomitant proctitis, ileocolitis, urinary sepsis and multiple previous surgical procedures.

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.

Postcolectomy syndromes

Resection of the colon and rectum may produce both transient and permanent alterations in colonic function. Furthermore, the nature of some operative techniques may result in autonomic denervation of the rectum and associated pelvic viscera. An understanding of the mechanism of injury and the subsequent functional abnormalities is necessary to provide adequate therapy.

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.

Surgical treatment of dorsocaudal dislocation of the vagina after excision of the rectum. The Kylberg operation

Retained menstrual blood, colpitis, chronic discharge from the vagina, and dyspareunia are not uncommon symptoms after proctectomy. In patients suffering from this syndrome, the vaginal drainage is impaired because of a pouch caused by adhesions formed between the coccyx and the vagina, and an angulation of the upper part of the vagina. Surgical treatment consists of extirpation of the coccyx, separation of the posterior fornix from the lower part of the sacrum, and interposition of muscle flaps from the right and left gluteus maximus muscle, which shifts the vagina to a more vertical position. The authors report the results of this procedure in nine women observed for more than two years. Wound infection occurred in two patients, and one underwent a second operation because of relapsing symptoms. Eight patients were relieved of impaired drainage of the vagina; one patients empties her menstrual blood by straining. Dyspareunia disappeared in all patients. The operation can be recommended in patients with "the horizontal vagina syndrome."

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.