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01-06-2007

Male Urogenital Function After Confirmed Nerve-Sparing Total Mesorectal Excision with Dissection in Front of Denonvilliers’ Fascia

Authors: W. Kneist, T. Junginger

Published in: World Journal of Surgery | Issue 6/2007

Abstract

This prospective study addresses the rate of male genital dysfunction following total mesorectal excision (TME) for rectal carcinoma using the anterior extramesorectal plane and its correlation with early urinary function, pelvic autonomic nerve preservation (PANP), and intraoperative neurostimulation (INS). A consecutive series of 44 men operated on by the same surgical team was analyzed. After excluding 18 patients considered to be impotent preoperatively, urogenital function was evaluated in 26 patients on the basis of the International Prostatic Symptom Score and International Index of Erectile Function. PANP was assessed with INS of parasympathetic nerves. PANP was complete in 21 patients (80.8%). Deterioration of urinary function was observed in six patients (23.1%) at early follow-up. Postoperative erectile dysfunction assessed in seven patients (26.9%) was associated with micturition disturbances in four (57%). Despite dissection in front of Denonvilliers´ fascia, the incidence of erectile dysfunction was low in patients with nonanterior tumors (1/10). INS results had higher sensitivity for predicting urinary dysfunction than for predicting erectile dysfunction (67% vs. 43%). Values for specificity and accuracy were 95% and 90%, and 89% and 77%, respectively. The correlation between the findings on INS and urinary function was good (κ = 0.66) at a fair (κ = 0.36) correlation for erectile function. Nerve-sparing TME using the anterior extramesorectal plane results in a justifiable rate of postoperative impotence in patients with nonanterior tumors. Patients with negative results on INS or early urinary dysfunction are at greater risk of erectile dysfunction.

Lindsey I, Mortensen NJMC (2002) Iatrogenic impotence and rectal dissection. Br J Surg 89:1493–1494PubMedCrossRef

Havenga K, deRuiter MC, Enker WE, Welvaart K (1996) Anatomical basis of autonomic nerve-preserving total mesorectal excision for rectal cancer. Br J Surg 83:384–388PubMedCrossRef

Junginger T, Kneist W, Heintz A (2003) Influence of identification and preservation of pelvic autonomic nerves in rectal cancer surgery on bladder dysfunction after total mesorectal excision. Dis Colon Rectum 46:621–628PubMedCrossRef

Enker WE (1992) Potency, cure, and local control in the operative treatment of rectal cancer. Arch Surg 127:1396–1402PubMed

Heald RJ (1997) Total mesorectal excision: History and anatomy of an operation. In: Soreide O, Norstein J (eds). Rectal cancer surgery: Optimisation - Standardisation - Documentation. Berlin Heidelberg New York: Springer, 203–219

Havenga K, Enker WE, McDermott K, et al. (1996) Male and female sexual and urinary function after total mesorectal excision with autonomic nerve preservation for carcinoma of the rectum. J Am Coll Surg 182:495–502PubMed

Stelzner F, Fritsch H, Fleischhauer K (1989) Die chirurgische Anatomie der Genitalnerven des Mannes und ihre Schonung bei der Excision des Rektums. Chirurg 60:228–234PubMed

Quah HM, Jayne DG, Eu KW, et al. (2002) Bladder and sexual dysfunction following laparoskopically assisted and conventional open mesorectal resection for cancer. Br J Surg 89:1551–1556PubMedCrossRef

Mundy AR (1982) An anatomical explanation for bladder dysfunction following rectal and uterine surgery. Br J Urol 54:501–504PubMedCrossRef

10.

Lindsey I, Guy RJ, Warren BF, et al. (2000) Anatomy of Denonvilliers‘ fascia and pelvic nerves, impotence, and implications for the colorectal surgeon. Br J Surg 2000;87:1288–1299CrossRef

11.

Lindsey I, George BD, Kettlewell MGW, et al. (2001) Erectile dysfunction after rectal cancer surgery: anterior tumors at greater risk. Colorectal Dis 2(Suppl):27

12.

Heald RJ, Moran BJ, Browen G, et al. (2004) Optimal total mesorectal excision for rectal cancer is by dissection in front of Denonviller´s fascia. Br J Surg 91:121–123PubMedCrossRef

13.

Lindsey I, Warren BF, Mortensen NJ (2005) Denonvilliers´ fascia lies anterior to the fascia propria and rectal dissection plane in total mesorectal excision. Dis Colon Rectum 48:37–42PubMedCrossRef

14.

Rosen RC, Riley A, Wagner G, et al. (1997) The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology 49:822–830PubMedCrossRef

15.

Mebust W, Roizo R, Schroeder F, et al. (1991) Correlation between pathology, clinical symptoms and course of the disease. In: Cocket AT, Aso V, Chatelain C, et al. (eds) Proceedings of the International Consultation on Benign Prostatic Hyperplasia. WHO, Geneva, 51–62

16.

Leveckis J, Boucher NR, Parys BT, et al. (1995) Bladder and erectile dysfunction before and after rectal surgery for cancer. Br J Urol 76:752–756PubMed

17.

Nesbakken A, Nygaard K, Bull-Njaa T, et al. (2000) Bladder and sexual dysfunction after mesorectal excision for rectal cancer. Br J Surg 87:206–210PubMedCrossRef

18.

Mancini R, Cosimelli M, Filippini A, et al. (2000) Nerve-sparing surgery in rectal cancer: feasibility and functional results. J Exp Clin Cancer Res 19:35–40PubMed

19.

Da Silva GM, Zmora O, Borjesson L, et al. (2004) The efficacy of a nerve stimulator (CaverMap) to enhance autonomic nerve identification and confirm nerve preservation during total mesorectal excision. Dis Colon Rectum 47:2032–2038PubMedCrossRef

20.

Kneist W, Heintz A, Wolf HK, et al. (2004) Identification of pelvic autonomic nerves during partial and total mesorectal excision – influence parameters and significance for neurogenic bladder. Chirurg 75:276–283PubMedCrossRef

21.

Lee JF, Maurer VM, Block GE (1973) Anatomic relations of pelvic autonomic nerves to pelvic operations. Arch Surg 107:324PubMed

22.

Lue TF, Zeineh SJ, Schmidt RA, et al. (1984) Neuroanatomy of penile erection: its relevance to iatrogenic impotence. J Urol 131:273–280PubMed

23.

Lepor H, Gregerman M, Crosby R, et al. (1985) Precise localization of the autonomic nerves from the pelvic plexus to the corpora cavernosa: a detailed anatomical study of the adult male pelvis. J Urol 133:207–212PubMed

24.

Kinugasa Y, Murakami G, Uchimoto K, et al. (2006) Operating behind Denonvilliers´ fascia for reliable preservation of urogenital autonomic nerves in total mesorectal excision: A histologic study using cadaveric specimens, including a surgical experiment using fresh cadaveric models. Dis Colon Rectum 49:1024–1032PubMedCrossRef

25.

Bonnel C, Parc YR, Pocard M, et al. (2002) Effects of preoperative radiotherapy for primary resectable rectal adenocarcinoma on male sexual and urinary function. Dis Colon Rectum 45:934–939PubMedCrossRef

26.

Pocard M, Zinzindohoue F, Haab F, et al. (2002) A prospective study of sexual and urinary function before and after total mesorectal excision with autonomic nerve preservation for rectal cancer. Surgery 131:368–372PubMedCrossRef

27.

Maeda K, Maruta M, Utsumi T, et al. (2003) Bladder and male sexual functions after autonomic nerve-sparing TME with or without lateral node dissection for rectal cancer. Tech Coloproctol 7:29–33PubMedCrossRef

28.

Maas CP, Moriya Y, Steup WH, et al. (1998) Radical and nerve-preserving surgery for rectal cancer in The Netherlands: a prospective study on morbidity and functional outcome. Br J Surg 85:92–97PubMedCrossRef

29.

Jayne DG, Brown JM, Thorpe H, et al. (2005) Bladder and sexual function following resection for rectal cancer in a randomized clinical trial of laparoscopic versus open technique. Br J Surg 92:1124–1132PubMedCrossRef

30.

Shah EF, Huddy SPJ (2001) A prospective study of genito-urinary dysfunction after surgery for colorectal cancer. Colorectal Dis 3:122–125PubMedCrossRef

31.

Cosimelli M, Mannella E, Giannarelli D, et al. (1994) Nerve-sparing surgery in 302 resectable rectosigmoid cancer patients: genitourinary morbidity and 10-year survival. Dis Colon Rectum 37(Suppl):42–46CrossRef

32.

Kim NK, Aahn TW, Park JK, et al. (2002) Assessment of sexual and voiding function after total mesorectal excision with pelvic autonomic nerve preservation in males with rectal cancer. Dis Colon Rectum 45:1178–1185PubMedCrossRef

33.

Kneist W, Junginger T (2006) Intraoperative electrostimulation objectifies the assessment of functional nerve preservation after mesorectal excision. Int J Colorectal Dis Oct 12; [Epub ahead of print]

34.

Kinn AC, Öhman U (1986) Bladder and sexual function after surgery for rectal cancer. Dis Colon Rectum 29:43–48PubMedCrossRef

35.

Walsh PC, Schlegel PN (1988) Radical pelvic surgery with preservation of sexual function. Ann Surg 208:391–400PubMedCrossRef

36.

Baader B, Herrmann M (2003) Topography of the pelvic autonomic nervous system and its potentional impact on surgical intervention in the pelvis. Clin Anat 16:119–130PubMedCrossRef

Title: Male Urogenital Function After Confirmed Nerve-Sparing Total Mesorectal Excision with Dissection in Front of Denonvilliers’ Fascia
Authors: W. Kneist
T. Junginger
Publication date: 01-06-2007
Publisher: Springer-Verlag
Published in: World Journal of Surgery / Issue 6/2007
Print ISSN: 0364-2313
Electronic ISSN: 1432-2323
DOI: https://doi.org/10.1007/s00268-007-9008-4

At a glance: The STEP trials

Springer Medicine

Male Urogenital Function After Confirmed Nerve-Sparing Total Mesorectal Excision with Dissection in Front of Denonvilliers’ Fascia

Abstract

At a glance: The STEP trials

Springer Medicine

Abstract

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