Voiding dysfunction after total mesorectal excision in rectal cancer

Optimising functional outcomes in rectal cancer surgery

Background

By improved surgical technique such as total mesorectal excision (TME), multimodal treatment and advances in imaging survival and an increased rate of sphincter preservation have been achieved in rectal cancer surgery. Minimal-invasive approaches such as laparoscopic, robotic and transanal-TME (ta-TME) enhance recovery after surgery. Nevertheless, disorders of bowel, anorectal and urogenital function are still common and need attention.

Purpose

This review aims at exploring the causes of dysfunction after anterior resection (AR) and the accordingly preventive strategies. Furthermore, the indication for low AR in the light of functional outcome is discussed. The last therapeutic strategies to deal with bowel, anorectal, and urogenital disorders are depicted.

Conclusion

Functional disorders after rectal cancer surgery are frequent and underestimated. More evidence is needed to define an indication for non-operative management or local excision as alternatives to AR. The decision for restorative resection should be made in consideration of the relevant risk factors for dysfunction. In the case of restoration, a side-to-end anastomosis should be the preferred anastomotic technique. Further high-evidence clinical studies are required to clarify the benefit of intraoperative neuromonitoring. While the function of ta-TME seems not to be superior to laparoscopy, case-control studies suggest the benefits of robotic TME mainly in terms of preservation of the urogenital function. Low AR syndrome is treated by stool regulation, pelvic floor therapy, and transanal irrigation. There is good evidence for sacral nerve modulation for incontinence after low AR.

Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery

AIM

Disturbance of urinary function is a common complication after rectal cancer surgery, and it may affect patients' psychological well-being, consequently may develop post-traumatic stress disorder. Personal resilience might increase people's ability to manage life's challenges. However, limited study to explore their relationships. This study examined the relationships among lower urinary symptoms, resilience, and post-traumatic stress symptoms (PTSS) in post-surgery patients with rectal cancer.

METHODS

A cross-sectional study design was used and included 188 patients with diagnosed rectal cancer who had undergone surgery over 24 months and were recruited from a hospital in southern Taiwan. The outcome measurements included a resilience scale, International Prostate Symptom Score (IPSS), the Chinese Davidson Trauma Scale, personal characteristics, and disease-related variables.

RESULTS

There were significant relationships among age at diagnosed, self-reported physical status, perceived satisfied with recovery, urinary tract symptoms, resilience, and overall PTSS. The stepwise regression demonstrated that five factors, self-reported physical status, resilience, urinary tract symptoms, age at diagnosed and gender, and together explained 27.7% of overall PTSS variance (10.7, 6.7, 3.7, 4.8 and 1.8% of variance, respectively).

CONCLUSION

The study demonstrates that patients with diagnosed rectal cancers long-term outcomes of PTSS, urinary tract symptoms, and resilience after surgery; in addition, self-reported physical status, resilience, urinary tract symptoms, age at diagnosed and gender are the major predictors of PTSS. A better understanding of the long-term outcomes of post-surgery in rectal cancer patients and its related factors may help to decreasing the PTSS after surviving cancer.

Urinary dysfunction in patients with rectal cancer: a prospective cohort study

AIM

Urinary dysfunction is one of many complications after treatment for rectal cancer. The aim of this study was to evaluate the prevalence of patient-reported urinary dysfunction at the time of diagnosis and at 1-year follow-up and to assess the risk factors linked to urinary incontinence.

METHOD

Patients with newly diagnosed rectal cancer were included in the QoLiRECT study between 2012 and 2015. Questionnaires from the time of diagnosis and 1-year follow-up were analysed, with 1085 and 916 patients, respectively, eligible for analysis. Regression analyses were made to investigate possible risk factors for incontinence. The patient cohort was also compared with a cohort from the Swedish general population.

RESULTS

At baseline, the prevalence of urinary dysfunction (14% of women, 8% of men) was similar to that in the general population. At 1-year follow-up, 20% of patients experienced urinary incontinence (29% of women, 14% of men). Emptying difficulties were experienced by 46% (41% of women, 49% of men) and urgency by 58% across both sexes. Abdominoperineal excision and urinary dysfunction at baseline were found to be independent risk factors for incontinence at 1-year follow-up. Among patients who were continent at baseline, risk factors were female sex, physical inactivity at baseline, comorbidity and abdominoperineal excision.

CONCLUSION

Urinary dysfunction is frequent among patients with rectal cancer, with up to a two-fold increase in symptoms 1 year after diagnosis. Unfortunately, few factors are modifiable and these results stress the importance of informing patients of possible outcomes related to urinary dysfunction after treatment for rectal cancer.

Genito-urinary sequelae after carcinological rectal resection: What to tell patients in 2017

Although we have seen revolutionary changes with multi-disciplinary management of patients with rectal cancer, the evaluation of genito-urinary sequelae remains of great concern. Precise pre-operative evaluation with validated scores allows detection of urinary disorders in 16 to 23% of patients, and sexual disorders in nearly 35% of men and 50% of women. Regardless of the surgical approach, it is fundamental to respect the autonomic innervation during total mesorectal excision in order to prevent these sequelae. Identification of these nerves can be facilitated by intra-operative neuro-stimulation. In spite of these precautions, de novo urinary sequelae are observed in nearly 33% of patients and bladder evacuation disorders in 25% of patients. Advanced age, pre-operative urinary disorders, female gender, and abdomino-perineal resection are independent risk factors for urinary sequelae. Early post-operative urodynamic abnormalities might be predictive of these sequelae and justify early physiotherapy. Likewise, sexual sequelae such as erectile and/or ejaculatory disorders, dyspareunia and lubrication deficits result in de novo cessation of sexual activity in 28% of men and 18% of women. Advanced age, neo-adjuvant radiation therapy, and abdomino-perineal resection are independent risk factors for sexual dysfunction. Pharmacotherapy with sildenafil has proven useful in the treatment of erectile disorders. Genito-urinary and ano-rectal sequelae occur concomitantly in more than one of ten patients, suggesting a potential common pathophysiology.

Current topics in the multimodality treatment of locally advanced rectal cancer

The multimodality approach to the treatment of locally advanced rectal cancer has evolved to include neoadjuvant radiotherapy with or without concurrent chemotherapy, total mesorectal excision and adjuvant fluoropyrimidine-based chemotherapy. Though this broad strategy has yielded improvements in local control compared with historical data, overall survival remains largely unchanged. Current investigations focus on improving patient selection through new imaging modalities, improving surgical techniques, incorporating more aggressive systemic treatment regimens and the selective use of radiation. Here, we review emerging data regarding newer staging techniques, neoadjuvant chemotherapy, optimal timing of surgery, selective use of radiation and nonoperative approaches to the management of locally advanced rectal cancers.

The functional results of radical rectal cancer surgery: review of the literature

Introduction For more than the last 20 years, low anterior resection with total mesorectal excision (TME) is a gold standard for rectal cancer treatment. Oncological outcomes have improved significantly and now more and more reports of functional outcomes appear. Due to the close relationship between the rectum and pelvic nerves, bowel, bladder, and sexual function are frequently affected during TME. Methods A search for published data was performed using the MEDLINE database (from 1 January 2005 to 31 January 2015) to perform a systematic review of the studies that described anorectal, bladder, and sexual dysfunction following rectal cancer surgery. Methodological quality of the included studies was assessed using the MINORS criteria. Results Eighty-nine studies were eligible for analysis. Up to 76% of patients undergoing sphincter preserving surgery will have changes in bowel habits, the so-called "low anterior resection syndrome" (LARS). The duration of LARS varies between a few months and several years. Pre-operative radiotherapy, damage of anal sphincter and pelvic nerves, and height of the anastomosis are the risk factors for LARS. There is no evidence-based treatment available for LARS. Sexual function is more commonly affected after rectal surgery than after urinary function. The main cause of dysfunction is damage to pelvic nerves. Sexual and bladder functional outcomes in females are less well reported. Laparoscopic and robotic surgery allows better visualization of autonomic nerves and, therefore, more precise dissection and preservation. Conclusions It is important that rectal resection is standardized as much as possible, and that new functional outcome research use the same validated outcome questionnaires. This would allow for a high-quality meta-analysis.

Total mesorectal excision for the treatment of rectal cancer

Introduction

In the surgical treatment of rectal cancer, a clear circumferential resection margin and distal resection margin should be obtained. The aim of this study was to determine the morbidity, mortality, survival outcome, and local failure after total mesorectal excision (TME) in the surgical treatment of rectal cancer.

Methods

This retrospective study was conducted on 101 patients treated for rectal cancer using low anterior resection (LAR), abdominoperinial resection (APR), or Hartmaan’s technique. In all operative procedures, total mesorectal excisions (TMEs) were done. The patients were treated from November 2000 to April 2011 in the South Egypt Cancer Institute (SECI) of Assuit University (Egypt). Neo-adjuvant therapy was given to those patients with serosalin filtration, lymph node involvement, and sexual and urinary function impairment. Data were analyzed using IBM-SPSS version 21, and survival rates were estimated using the Kaplan-Meier method.

Results

One hundred one patients were evaluable (61 males, 40 females). Regarding the operative procedure used, it was: (APR), LAR, Hartmaan’s technique in 15.8%, 71.3%, and 12.9% of patients, respectively. Operation-related mortality during the 30 days after surgery was 3%. The operations resulted in morbidity in 25% of the patients, anastomotic site leak in 5.9% of the patients, urinary dysfynction in 9.9% of the patients, and erectile dysfunction in 15.8% of the male patients. Regarding safety margin, the median distances were distal/radial margin, 23/12 mm, distal limit 7 cm. Median lymph nodes harvest 19 nodes. Primary tumor locations were anteriorly 23.8%, laterally 13.9%, posteriorly 38.6%, and circumferential 23.8%. Protective stoma 16.8%. Primary Tumor TNM classification (T1, T2, T3, and T4; 3, 28.7, 55.4, and 12.9%, respectively). Nodes Metastases (N0, N1, and N2; 57.4, 31.7, and 10.9%, respectively). TNM staging (I, II, III, and IV; 15.8, 29.7, 46.5, and 7.9%, respectively). Chemotherapy was administered to 67.3% of the patients. Radiotherapy (short course neoadjuvant, long course neoadjuvant, and adjuvant postoperative used in 33.7, 20.8, and 19.8% of patients, respectively). Survival 5-years CSS was 73% and 5-years RFS 71%. Mean operative time was 213 minutes. The average amount of intraoperative blood loss was 344 mL.

Conclusion

Total mesorectal excision (TME) represents the gold-standard technique in rectal cancer surgery. It is safe with neoadjuvent chemoradiotherapy and provides both maximal oncological efficiency (local control and long-term survival and maintenance of a good quality of life).

The multidisciplinary approach to the treatment of rectal cancer: 2015 update

The multidisciplinary approach to the management of rectal cancer continues to evolve with developments in surgery, radiation therapy as well as systemic chemotherapy. Refinement of surgical techniques to improve organ preservation, selective use of neoadjuvant (or adjuvant) therapies, improvements in staging modalities and emerging criteria for the selection of tailored therapies are some of the advancements made over the last three decades. In addition, neoadjuvant treatment alternatives, multimodality sequencing and adaptive therapies based on treatment response continue to be a subject of clinical investigation. The current article reviews the salient topics related to the multidisciplinary treatment of resectable rectal cancer.

Functional and molecular changes of the bladder in rats with crushing injury of nerve bundles from major pelvic ganglion to the bladder: role of RhoA/Rho kinase pathway

Voiding dysfunction is a common complication after radical pelvic surgery. To reduce this complication, nerve-sparing radical pelvic surgery was introduced. However, several patients experienced voiding difficulty despite nerve-sparing radical pelvic surgery. Thus, we investigated the functional and molecular changes of the bladder in rats, which demonstrated voiding dysfunction induced by nerve damage during nerve-sparing radical pelvic surgery. Male rats were used and assigned to normal, sham-operated, and bilateral crushing nerve bundles from major pelvic ganglion (MPG) to bladder group. After one, two, and four-week crushing injury, significantly decreased contractile response and increased connective tissue of the detrusor were observed and these results were reliable findings with voiding difficulty following nerve-sparing radical pelvic surgery. After crushing injury, significantly increased M2 muscarinic receptor expression was observed and this might be regarded as the compensatory response. However, M3 muscarinic receptor expression was not significantly changed. The expression of RhoA, ROCK-α, and ROCK-β was significantly increased after one, two, and four-week crushing injury. From these results, the down-regulation of RhoA/Rho kinase pathway might lead to the decreased bladder contractility after crushing injury of nerve bundles from MPG to the bladder despite of the compensated up-regulation of M2 muscarinic receptor.