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Fang J, Wei B, Zheng Z, Xiao J, Han F, Huang M, Xu Q, Wang X, Hong C, Wang G, Ju Y, Su G, Deng H, Zhang J, Li J, Yang X, Chen T, Huang Y, Huang J, Liu J, Wei H. Preservation versus resection of Denonvilliers' fascia in total mesorectal excision for male rectal cancer: follow-up analysis of the randomized PUF-01 trial. Nat Commun 2023; 14:6667. [PMID: 37863878 PMCID: PMC10589235 DOI: 10.1038/s41467-023-42367-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 10/10/2023] [Indexed: 10/22/2023] Open
Abstract
Traditional total mesorectal excision (TME) for rectal cancer requires partial resection of Denonvilliers' fascia (DVF), which leads to injury of pelvic autonomic nerve and postoperative urogenital dysfunction. It is still unclear whether entire preservation of DVF has better urogenital function and comparable oncological outcomes. We conducted a randomized clinical trial to investigate the superiority of DVF preservation over resection (NCT02435758). A total of 262 eligible male patients were randomized to Laparoscopic TME with DVF preservation (L-DVF-P group) or resection procedures (L-DVF-R group), 242 of which completed the study, including 122 cases of L-DVF-P and 120 cases of L-DVF-R. The initial analysis of the primary outcomes of urogenital function has previously been reported. Here, the updated analysis and secondary outcomes including 3-year survival (OS), 3-year disease-free survival (DFS), and recurrence rate between the two groups are reported for the modified intention-to-treat analysis, revealing no significant difference. In conclusion, L-DVF-P reveals better postoperative urogenital function and comparable oncological outcomes for male rectal cancer patients.
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Affiliation(s)
- Jiafeng Fang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, People's Republic of China
| | - Bo Wei
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, People's Republic of China
| | - Zongheng Zheng
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, People's Republic of China
| | - Jian'an Xiao
- Department of Gastrointestinal Surgery, Anyang Cancer Hospital, the Fourth Affiliated Hospital, Henan University of Science and Technology, 1 Huanbin North Road, Anyang, People's Republic of China
| | - Fanghai Han
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, People's Republic of China
| | - Meijin Huang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Erheng Road, Guangzhou, People's Republic of China
| | - Qingwen Xu
- Department of Gastrointestinal Surgery, Affiliated Hospital of Guangdong Medical University, People's Avenue, Zhanjiang, People's Republic of China
| | - Xiaozhong Wang
- Department of Gastrointestinal Surgery, Shantou Central Hospital, Waima Road, Shantou, People's Republic of China
| | - Chuyuan Hong
- Department of Gastrointestinal Surgery, the Second Affiliated Hospital, Guangzhou Medical University, 250 Changgang East Road, Guangzhou, People's Republic of China
| | - Gongping Wang
- Department of Gastrointestinal Surgery, the First Affiliated Hospital, Henan University of Science and Technology, 636 Guanlin Road, Luoyang, People's Republic of China
| | - Yongle Ju
- Department of Gastrointestinal Surgery, Shunde Hospital of Southern Medical University, 1 Licun Jiazi Road, Foshan, People's Republic of China
| | - Guoqiang Su
- Department of Gastrointestinal Surgery, the First Affiliated Hospital, Xiamen University, 55 Zhenhai Road, Xiamen, People's Republic of China
| | - Haijun Deng
- Department of General Surgery, Nanfang Hospital of Southern Medical University, 1838, Guangzhou Avenue North, Guangzhou, People's Republic of China
| | - Jinxin Zhang
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, 74 Zhongshan Second Road, Guangzhou, People's Republic of China
| | - Jun Li
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, People's Republic of China
| | - Xiaofeng Yang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, People's Republic of China
| | - Tufeng Chen
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, People's Republic of China
| | - Yong Huang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, People's Republic of China
| | - Jianglong Huang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, People's Republic of China
| | - Jianpei Liu
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, People's Republic of China
| | - Hongbo Wei
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, People's Republic of China.
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Su J, Liu Q, Zhou D, Yang X, Jia G, Huang L, Tang X, Fang J. The status of low anterior resection syndrome: data from a single-center in China. BMC Surg 2023; 23:110. [PMID: 37149588 PMCID: PMC10164312 DOI: 10.1186/s12893-023-02008-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 04/15/2023] [Indexed: 05/08/2023] Open
Abstract
AIM The incidence and risk factors of low anterior resection syndrome (LARS) largely variate in different studies. In addition, there is lack of study on how patients evaluate the therapeutic effect of LARS. This single-center retrospective study aims to investigate the status of LARS in Chinese patients undergoing laparoscopic low anterior resection (LAR). METHODS Consequent patients undergoing laparoscopic LAR and free from disease recurrence from January 2015 to May 2021 were issued with both LARS questionnaire and satisfaction survey. Related data were collected and analyzed. RESULTS Both LARS questionnaires and self-made satisfaction survey were received from 261 eligible patients. The overall incidence of LARS was 47.1% (minor in 19.5%, major in 27.6%), decreased with the passage of postoperative time (64.7% within 12 months, and 41.7% within 12-36 months), and became stable 36 months later (39.7%). The most common symptoms were defecation clustering (n = 107/261, 41.0%) and defecation urgency (n = 101/261, 38.7%). According to the multivariable regression analysis, risk factors of major LARS were: 1 year increase in age (OR 1.035, 95% CI 1.004-1.068), protective stoma (OR 2.656, 95% CI 1.233-5.724) and T3 - 4 stage (OR 2.449, 95% CI 1.137-5.273). Most patients complained defecation disorder (87.3%) to doctors and 84.5% got suggestions or treatments for it. However, only 36.8% patients thought the treatments worked for them. CONCLUSIONS LARS frequently occurs after laparoscopic LAR, while the therapeutic effect is not satisfying. Elder, advanced T-stage and protective stoma were risk factors for postoperative major LARS.
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Affiliation(s)
- Jing Su
- Department of Nursing, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qianhui Liu
- Department of Gastrointestinal Surgery, the Third Affiliated Hospital of Sun Yat- sen University, Tianhe Road 600, 510630, Guangzhou, China
| | - Dagui Zhou
- Department of Gastrointestinal Surgery, the Third Affiliated Hospital of Sun Yat- sen University, Tianhe Road 600, 510630, Guangzhou, China
| | - Xiaofeng Yang
- Department of Gastrointestinal Surgery, the Third Affiliated Hospital of Sun Yat- sen University, Tianhe Road 600, 510630, Guangzhou, China
| | - Guiru Jia
- Department of Gastrointestinal Surgery, the Third Affiliated Hospital of Sun Yat- sen University, Tianhe Road 600, 510630, Guangzhou, China
| | - Lijun Huang
- Department of Gastrointestinal Surgery, the Third Affiliated Hospital of Sun Yat- sen University, Tianhe Road 600, 510630, Guangzhou, China
| | - Xiao Tang
- Department of Gastrointestinal Surgery, the Third Affiliated Hospital of Sun Yat- sen University, Tianhe Road 600, 510630, Guangzhou, China
| | - Jiafeng Fang
- Department of Gastrointestinal Surgery, the Third Affiliated Hospital of Sun Yat- sen University, Tianhe Road 600, 510630, Guangzhou, China.
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Foskey J, Loomis M. An Open-Book Approach to Pelvic Dissection for the Male Genitourinary System. Cureus 2023; 15:e39257. [PMID: 37342738 PMCID: PMC10278584 DOI: 10.7759/cureus.39257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/20/2023] [Indexed: 06/23/2023] Open
Abstract
Cadaveric dissections of the male pelvis are predominately conducted using either an anterior approach with the pelvis intact, or via pelvic hemi-section. The anterior approach leaves more tissue in-situ, but has limited visualization of retropubic structures, such as the prostate, seminal vesicles, vas deferens, and urethra. Hemi-section of the pelvis provides increased visualization at the expense of transecting midline structures. This article describes a novel cadaveric dissection, which offers enhanced visualization of pelvic structures in-situ. Using a posterior approach, the pelvis was dissected in an "open-book" manner, which fully exposed the posterior aspects of the prostate, seminal vesicles, ureters, and vas deferens. The delicate neurovascular bundle supplying these structures remained undisturbed. The visualization provided by this dissection correlated well with a coronal MRI of the pelvic region. This open-book dissection provides a novel posterior vantage point of the male genitourinary system, which can help medical students and residents solidify their understanding of anatomical relationships within the pelvis.
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Affiliation(s)
- Jesse Foskey
- Clinical Anatomy, Sam Houston State University College of Osteopathic Medicine, Conroe, USA
| | - Mario Loomis
- Clinical Anatomy, Sam Houston State University College of Osteopathic Medicine, Conroe, USA
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Li Y, Zhao YM, Ma YB, Zhou JS, Tong C, Yan LK. The "Y"-shaped Denonvilliers' fascia and its adjacent relationship with the urogenital fascia based on a male cadaveric anatomical study. BMC Surg 2023; 23:13. [PMID: 36650515 PMCID: PMC9843937 DOI: 10.1186/s12893-023-01913-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 01/11/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Controversies regarding the anatomical structure of Denonvilliers' fascia and its relationship with surrounding fasciae have sparked a heated discussion, especially concerning whether Denonvilliers' fascia is multilayered. This study aimed to expound on the anatomical structure of Denonvilliers' fascia and its correlation with the peritoneum from the sagittal view and clarify the complex fascial relationship. METHODS Our study was performed on 20 adult male pelvic specimens fixed in formalin, including 2 entire pelvic specimens and 18 semipelvic specimens. The local adjacent organs and fasciae were dissected, and Denonvilliers' fascia was observed and removed for histological examination. RESULTS Denonvilliers' fascia was typically single-layered and tough. On the sagittal plane, the peritoneum constituting the peritoneal reflection and Denonvilliers' fascia formed a "Y" shape. Denonvilliers' fascia originated from the peritoneal reflection, extended along the ventral side of the seminal vesicles and prostate, continuing caudally; its bilateral sides closely connected to the urogenital fascia (UGF) of the pelvic wall. In addition, histology preliminarily indicated that the basal cell layers of the peritoneum and Denonvilliers' fascia were continuous and formed a "Y" shape. Furthermore, the basal cells of the two peritonea extended to Denonvilliers' fascia, creating a fused double-layered structure. Some tiny blood vessels or a network of such vessels extended from the peritoneum to Denonvilliers' fascia. CONCLUSION Denonvilliers' fascia, the extension of the peritoneum in the pelvic floor, appears as a single-layered "Y"-shape on the sagittal plane. Our study provides new support for the peritoneal fusion theory. Understanding the anatomical characteristics of Denonvilliers' fascia and its relationship with the UGF is of guiding significance for inexperienced colorectal surgeons to conduct rectal cancer surgery.
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Affiliation(s)
- Yi Li
- grid.440288.20000 0004 1758 0451First Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, 710068 Shaanxi China
| | - Ya-Min Zhao
- Department of General Surgery, Shandong Provincial Linyi Jinluo Hospital, Linyi, 276036 Shandong China
| | - Yan-Bing Ma
- grid.43169.390000 0001 0599 1243Department of Human Anatomy, Histology and Embryology, School of Basic Medical Sciences, Xi’an Jiaotong University Health Science Center, Xi’an, 710061 Shaanxi China
| | - Jin-Song Zhou
- grid.43169.390000 0001 0599 1243Department of Human Anatomy, Histology and Embryology, School of Basic Medical Sciences, Xi’an Jiaotong University Health Science Center, Xi’an, 710061 Shaanxi China
| | - Cong Tong
- grid.440288.20000 0004 1758 0451First Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, 710068 Shaanxi China
| | - Li-Kun Yan
- grid.440288.20000 0004 1758 0451First Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, 710068 Shaanxi China
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Chang X, Cao G, Pu J, Li S, Zhang X, Tang ST. Robot-assisted anorectal pull-through for anorectal malformations with rectourethral and rectovesical fistula: feasibility and short-term outcome. Surg Endosc 2021; 36:1910-1915. [PMID: 33877410 DOI: 10.1007/s00464-021-08473-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 03/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Multiple structures in the anorectal area are closely related to defecation, voiding and sexual function. Although laparoscopic-assisted anorectal pull-through is widely accepted as a minimally invasive surgical technique, controversy still exists for ARMs with rectourethral fistulas. Intraoperative injuries more or less involve the perirectal sphincters and neurovascular tissue. METHODS Seventeen selected infants with ARMs underwent robot-assisted anorectal pull-through (RAARP) between October 2016 and January 2018. The application of nerve- and sphincter-sparing technique in RAARP was detailed. The feasibility and early outcomes were evaluated. RESULTS All procedures were completed without conversion. The robotic system facilitated clear dissections between different anatomical layers. Under direct vision, the fistula was easier to repair, and the rectal pouch was precisely placed in the center of the striated muscle complex. During the follow-up of 11.6 months, 13 patients resumed normal defecation. The other four children experienced mild constipation or fecal incontinence. Their continence and defecation functions showed favorable evolution. CONCLUSION RAARP is a safe and effective alternative for the treatment of ARMs, which provides an advantage in further minimizing the injury to perirectal nerves and sphincters.
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Affiliation(s)
- Xiaopan Chang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Guoqing Cao
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jiarui Pu
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shuai Li
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xi Zhang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shao-Tao Tang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Effect of Denonvilliers’ Fascia Preservation Versus Resection During Laparoscopic Total Mesorectal Excision on Postoperative Urogenital Function of Male Rectal Cancer Patients. Ann Surg 2020; 274:e473-e480. [DOI: 10.1097/sla.0000000000004591] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Huang J, Liu J, Fang J, Zeng Z, Wei B, Chen T, Wei H. Identification of the surgical indication line for the Denonvilliers' fascia and its anatomy in patients with rectal cancer. Cancer Commun (Lond) 2020; 40:25-31. [PMID: 32067419 PMCID: PMC7163926 DOI: 10.1002/cac2.12003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 12/22/2019] [Indexed: 12/13/2022] Open
Abstract
Background The high rate of urogenital dysfunction after traditional total mesorectal excision (TME) has caused doubts among scholars on the standard fashion of dissection. We have proposed the necessity to preserve the Denonvilliers’ fascia in patients with rectal cancer. However, how to accurately locate the Denonvilliers’ fascia is unclear. This study aimed to explore anatomical features of the Denonvilliers’ fascia by comparing autopsy findings and observations of surgical videos so as to propose a dissection method for the preservation of pelvic autonomic nerves during rectal cancer surgery. Methods Five adult male cadaver specimens were dissected, and surgical videos of 135 patients who underwent TME for mid‐low rectal cancer between January 2009 and February 2019 were reviewed to identify and compare the structure of the Denonvilliers’ fascia. Results The monolayer structure of the Denonvilliers’ fascia was observed in 5 male cadaver specimens, and it was located between the rectum, the bottom of the bladder, the seminal vesicles, the vas deferens, and the prostate. The Denonvilliers’ fascia was originated from the rectovesical pouch (or rectum‐uterus pouch), down to fuse caudally with the rectourethral muscle at the apex of the prostate, and fused to the lateral ligaments on both sides. The fascia was thinner on the midline with a thickness of 1.06 ± 0.10 mm. The crown shape of the Denonvilliers’ fascia was slightly triangular, with a height of approximately 5.42 ± 0.16 cm at midline. Nerves were more densely distributed in front of the Denonvilliers’ fascia than behind, especially on both sides of it. Under laparoscopic view, the Denonvilliers’ fascia was originated at the lowest point of the rectovesical pouch (or rectum‐uterus pouch), with a thickened white line which was a good mark for identifying the Denonvilliers’ fascia. Conclusion Identification of the surgical indication line for the Denonvilliers’ fascia could help us identify the Denonvilliers’ fascia, and it would improve our ability to protect the pelvic autonomic function of patients undergoing TME for rectal cancer.
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Affiliation(s)
- Jianglong Huang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, Guangdong, P. R. China
| | - Jing Liu
- Department of Human Anatomy, Histology and Embryology, Guangdong Pharmaceutical University, Guangzhou, 510006, Guangdong, P. R. China
| | - Jiafeng Fang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, Guangdong, P. R. China
| | - Zongheng Zeng
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, Guangdong, P. R. China
| | - Bo Wei
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, Guangdong, P. R. China
| | - Tufeng Chen
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, Guangdong, P. R. China
| | - Hongbo Wei
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, Guangdong, P. R. China
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Ghareeb WM, Wang X, Chi P, Wang W. The 'multilayer' theory of Denonvilliers' fascia: anatomical dissection of cadavers with the aim to improve neurovascular bundle preservation during rectal mobilization. Colorectal Dis 2020; 22:195-202. [PMID: 31496016 DOI: 10.1111/codi.14850] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 07/15/2019] [Indexed: 12/28/2022]
Abstract
AIM Denonvilliers' fascia is thought to be a multilayered fascial structure, based on its embryological development with the neurovascular bundle embedded within it. Recently, this theory had been proven histologically and by confocal microscopy in many published articles. However, the literature does not report on how surgeons can identify these structures. We aimed to determine the optimal surgical approach for preserving these critical structures. METHOD Eighteen cadavers (13 male/five female) were included and treated according to the ethical considerations stated in the donation consent of our institution. Dissection was performed with the assistance of binocular loupes for better anatomical detail. The compositions of the prerectal fascia and the neurovascular bundle were observed and recorded at different levels of dissection using a high-definition camera. RESULTS The theoretical multilayered fascia was found in male specimens as three fascial layers originating from the perineal body, seminal vesicles and posterior bladder neck. The first layer merged posterolaterally and fused with the rectosacral fascia (Waldeyer's fascia). The neurovascular bundle in male specimens was observed piercing the second and third layers, while the first layer acted as a protective cover. Dissection of female specimens demonstrated only one layer in the prerectal space. CONCLUSION Intiating anterior rectal mobilization by incising the peritoneum posterior to its reflection seems to be anatomically correct to preserve DVF. However, its applicability may be difficult in a narrow chanllenging pelvis. The lateral rectal ligaments and Waldeyer's fascia should be dissected from their attachments to the proper fascia of the rectum.
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Affiliation(s)
- W M Ghareeb
- Department of Colorectal Surgery, The Affiliated Union Hospital of Fujian Medical University, Fuzhou, China
| | - X Wang
- Department of Colorectal Surgery, The Affiliated Union Hospital of Fujian Medical University, Fuzhou, China
| | - P Chi
- Department of Colorectal Surgery, The Affiliated Union Hospital of Fujian Medical University, Fuzhou, China
| | - W Wang
- Department of Human Anatomy, School of Basic Medical Science, Fujian Medical University, Fuzhou, China
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Prediction of urinary retention after surgery for rectal cancer using voiding efficiency in the 24 h following Foley catheter removal. Int J Colorectal Dis 2019; 34:1431-1443. [PMID: 31280352 DOI: 10.1007/s00384-019-03333-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Postoperative urinary retention is a common adverse effect after rectal surgery. Current methods for assessing postoperative urinary retention (residual urine volume) are inaccurate and unable to predict long-term retention. Voiding efficiency is an effective indicator of postoperative urinary retention in urological and gynaecological fields, but not in colorectal surgery. We aimed to determine whether voiding efficiency in the initial 24 h after urinary catheter removal was more effective in predicting the incidence of postoperative urinary retention than residual urine volume. METHODS In this retrospective, observational study using prospectively collected data from patients who visited the colorectal department of a single institution, 549 patients who underwent rectal cancer surgery between April 2012 and May 2016 were initially enrolled, of which 46 were excluded and 503 finally included. RESULTS The incidence of postoperative urinary retention was 18.5% (93/503). Multivariable logistic regression analyses revealed that the association of postoperative urinary retention with voiding efficiency < 50% was stronger than that with residual urine volume > 100 mL (odds ratio, 38.30 (residual urine volume) and 138.0 (voiding efficiency)). Voiding efficiency was significantly lower in patients with long-term than in those with short-term postoperative urinary retention (adjusted p value = 0.02), whereas residual urine volume was not different between the two groups. Multivariable logistic regression analysis for long-term postoperative urinary retention showed the strongest association with voiding efficiency < 20% (odds ratio, 25.70). CONCLUSIONS Voiding efficiency is a more effective predictor of postoperative urinary retention than residual urine volume in rectal cancer patients.
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Abstract
INTRODUCTION Previous studies on total mesorectal excision suggested dissection anterior to Denonvilliers' fascia, which might lead to intraoperative pelvic autonomic nerves injury and a high incidence of urogenital dysfunction. TECHNIQUE We dissected 4 cases of cadavers, mainly focusing on anatomy of Denonvilliers' fascia, to study the relationship between Denonvilliers' fascia and rectum. In practice, instead of dissection 1 cm above peritoneal reflection, dissection of the peritoneum was performed at the lowest level of peritoneal reflection during laparoscopic resection for mid-low rectal cancer. RESULTS The cadaveric study revealed that there were loose tissues between Denonvilliers' fascia and rectal specimen, thus a surgical plane posterior to Denonvilliers' fascia did exist. During laparoscopic resection for mid-low rectal cancer, some loose reticulate structures between Denonvilliers' fascia and proper fascia of rectum would present after dissection of peritoneum at the lowest level of peritoneal reflection. Then dissection within the surgical plane posterior to Denonvilliers' fascia became easy and feasible. In this plane, both the pelvic nerves and postoperative urogenital function could be well protected by Denonvilliers' fascia. CONCLUSIONS The anterior surgical plane for total mesorectal excision should be reconsidered, and dissection posterior to Denonvilliers' fascia is feasible and practicable for patients without risk of positive anterior circumferential resection margin.
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Fang J, Huang J, Zheng Z, Wei B, Liu J, Huang Y, Chen T, Wei H. How to find Denonvilliers' fascia during laparoscopic TME. Tech Coloproctol 2019; 23:391-392. [PMID: 31020449 DOI: 10.1007/s10151-019-01964-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 03/08/2019] [Indexed: 11/26/2022]
Affiliation(s)
- J Fang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Tianhe Road 600, Guangzhou, 510630, China
| | - J Huang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Tianhe Road 600, Guangzhou, 510630, China
| | - Z Zheng
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Tianhe Road 600, Guangzhou, 510630, China
| | - B Wei
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Tianhe Road 600, Guangzhou, 510630, China
| | - J Liu
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Tianhe Road 600, Guangzhou, 510630, China
| | - Y Huang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Tianhe Road 600, Guangzhou, 510630, China
| | - T Chen
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Tianhe Road 600, Guangzhou, 510630, China
| | - H Wei
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Tianhe Road 600, Guangzhou, 510630, China.
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Liu J, Huang P, Liang Q, Yang X, Zheng Z, Wei H. Preservation of Denonvilliers' fascia for nerve-sparing laparoscopic total mesorectal excision: A neuro-histological study. Clin Anat 2019; 32:439-445. [PMID: 30664277 DOI: 10.1002/ca.23336] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/10/2019] [Accepted: 01/12/2019] [Indexed: 11/06/2022]
Abstract
Urogenital complications due to pelvic autonomic nerve damage frequently occur following rectal surgery. We investigated whether total mesorectal excision (TME) with preservation of the Denonvilliers' fascia (DVF) can effectively prevent the removal of pelvic autonomic nerves through microscopy. Twenty consecutive male patients with mid-low rectal cancer who received TME with preservation or resection of the Denonvilliers' fascia (P and R groups, respectively) were included. Serial transverse sections from surgical specimens were studied histologically. Nerve fibers at the surfaces of the mesorectum were counted. Clinical correlation between the amount of nerve fibers removed and post-operative sexual function was analyzed. Nerve fibers closely localized to the DVF in the R group displaying rich erectile activity (positive anti-nNOS immunostaining). At the anterior surface of the mesorectum, the mean numbers of nNOS-positive nerve fibers per specimen in the P group were significantly lower than the R group (3.0 ± 1.8 vs. 5.0 ± 2.3, P < 0.05). Compared to the R group, patients in the P group had higher IIEF scores and better erectile function at 3 and 6 months post-operatively. The DVF is a key risk zone for pelvic denervation during laparoscopic TME. Preservation of the DVF can prevent the removal of autonomic nerves and protect post-operative erectile function. Clin. Anat. 32:439-445, 2019. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Jianpei Liu
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Pinjie Huang
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qiong Liang
- Department of Pathology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaofeng Yang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zongheng Zheng
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hongbo Wei
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Ding YB, Wang P. Ponderings on low rectal surgery. Shijie Huaren Xiaohua Zazhi 2017; 25:3109-3114. [DOI: 10.11569/wcjd.v25.i35.3109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer is one of the most common malignant tumors. As the development of modern medicine and the wide application of early cancer screening, rectal cancer has been found and treated timely nowadays. At present, sphincter-preserving surgery for low rectal cancer is getting more and more popular. Low rectal anastomotic fistula and pelvic autonomic nerve injuries are common complications. Improving the oncological clearance and reducing the complications have been the goals of surgeons. This article discusses several problems in low rectal surgery: (1) the selection of the cut-off location of the inferior mesenteric artery; (2) the protection of pelvic autonomic nerve plexus; (3) the anatomy of Denonvilliers' fascia; (4) the surgical strategy for preventive stoma; and (5) the improvement of drainage in pelvic floor.
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Affiliation(s)
- Yong-Bin Ding
- Department of General Surgery, Shengze Branch of The First Affiliated Hospital of Nanjing Medical University, Suzhou 215228, Jiangsu Province, China
| | - Peng Wang
- Department of General Surgery, Shengze Branch of The First Affiliated Hospital of Nanjing Medical University, Suzhou 215228, Jiangsu Province, China
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Abstract
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