Rectal cancer therapy compatible with preservation of function

Rectal cancer surgery causes often postoperative morbidities such as defecation disturbance, dysuria and male sexual impotence. Compatibility of cancer eradication and function preservation are the problem should be resolved in the rectal cancer surgery. Defecation function were preserved in the patients with middle and upper rectal cancer by anterior resection transsacral resection, invagination or pull-through operation. Since 1984, usage of suture instruments made it practicable to increase sphincter preserving operation up to more than 65% of rectal cancer. Postoperative 5-years survivals were 81% of anterior resection, 71% of invagination operation and 57% of pull-through. Autonomic nerves preserving operation (ANP), aimed to prevent the urinary and sexual disfunction were studied both sides of the cancer spreads and extend of nerve plexuses. And ANP were adopted to the 185 cancers, limited to the submucosa or the proper muscle coat, by Study Group of Welfare Ministry. Their postoperative disfunction decreased to 15% of urination and 21% of male potency, while 33% and 81% respectively following conventional operation. Local excision for early cancer, which are defined as mucosal or submucosal cancer are discussed.     

A prospective study on radical and nerve-preserving surgery for rectal cancer in The Netherlands

INTRODUCTION: Preservation of the pelvic autonomic nerves is thought to lower bladder and sexual dysfunction after rectal cancer surgery. A prospective study was undertaken in a Dutch population to evaluate functional outcome, local recurrence and survival of a Japanese operative technique combining nerve preservation with radical tumour resection. METHODS: Forty-seven patients were operated upon by a Japanese surgeon. Voiding and sexual function were prospectively analysed using questionnaires. Two-year follow-up on urinary function was complete in 73%, and 2-year follow-up of male sexual function was complete in 77%. Median follow-up for survival and recurrence was 42 months and was complete in all patients. RESULTS: Five patients (19%) developed minor urinary incontinence in the period between 1 and 2 years of follow-up. Six patients (22%) had a persistently elevated frequency of voiding. There was no statistically significant correlation between the extent of nerve preservation and the reported minor voiding dysfunctions. None of the patients reported major incontinence of urine. Impotence was related to sacrifice of the inferior hypogastric plexus and ejaculatory dysfunction was related to sacrifice of the superior hypogastric plexus. Sexual function did not change during follow-up. Of 42 curatively-operated patients, three (7.1%) developed local recurrence. Sixty-seven per cent were overall free of recurrence. Disease-free survival was 57%. CONCLUSIONS: Preservation of the pelvic autonomic nerves minimizes bladder dysfunction after rectal cancer surgery. The preservation of the total autonomic nerve system is essential for normal sexual function in male patients. Nerve preservation does not compromise radicality in mesorectal excision. Mesorectal excision should involve identification and preservation of the pelvic autonomic nerves.     

直肠癌保留盆腔自主神经手术辅助术后放疗对提高患者生活质量的评估

Objective:Preservation of the pelvic autonomic nerves in order to lower bladder and sexual dysfunction after radical rectal cancer surgery & to evaluate functional outcome,local recurrence.Methods:A prospective study was undertaken on Egyptian patients.Forty one patients participated in the study in the period from December 2002 till June 2004 where they underwent radical surgery but with preservation of the pelvic autonomic nerves this was followed by adjuvant pelvic radiotherapy.Results:Six months,1-year and 2-year follow-up of urinary function was complete in 32 out of 41(78%),30 out of 41 (73%) and 27 out of 41 patients (65%) respectively There was no statistically significant correlation between the extent of nerve preservation and the reported minor voiding dysfunction.None of the patients reported major incontinence.Six months,1-year and 2-year follow-up of sexual function revealed that 22 out of 41 patients (53%) were sexually active.Three out of 41 patients (7.3%) developed local recurrence.38 (92.7%) patients were free of local recurrence,regarding patients who received adjuvant radiotherapy 3 out of the 34 (8.8%) patients developed local pelvic recurrence while 9 patients (26.5%) developed distant metastases (3 of them did not receive adjuvant chemotherapy),while patients who received adjuvant chemotherapy,2 out of 20 patients (10%) developed local recurrence while distant metastases developed in 6 patients (30%).Conclusion:Preservation of the pelvic autonomic nerves minimizes bladder and sexual dysfunction especially in male patients after rectal cancer surgery.     

Avoiding long-term disturbance to bladder and sexual function in pelvic surgery, particularly with rectal cancer

Urinary and sexual dysfunction are common problems after rectal cancer surgery, and the likely cause is damage to the pelvic autonomic nerves during surgery. In recent years, attention has been focused on preserving the autonomic nerves through a technique which is usually combined with total mesorectal excision or radical pelvic lymphadenectomy. The autonomic nerves consist of the paired sympathetic hypogastric nerve, sacral splanchnic nerves, and the pelvic autonomic nerve plexus. We will demonstrate the anatomy of the pelvic autonomic nerves and the relation of these nerves to the mesorectal fascial planes, and review the medical literature on sexual and urinary dysfunction after rectal cancer surgery with and without autonomic nerve preservation.     

直肠癌根治术后患者排尿和性功能的变化

Objective:To investigate the changes in sexual function and urinary function following rectal cancer resection in male patients.Methods:48 male patients with rectal cancer under 65 years old were included in the study and postoperative sexual function and urinary function were investigated through questionnaires and telephone interviews following resection of rectal cancer and the results were analyzed retrospectively.Results:The overall sexual dysfunction rate was 58.33%.The overall urinary dysfunction rate was 56.25%.No statistically significant differences in the incidences of sexual dysfunction and urinary dysfunction were found in the comparison between participants under 50 and above 50 years old,between those who received Mile's operation and Dixon's operation,and among those at different tumor stages respectively.Conclusion:The incidences of sexual dysfunction and urinary dysfunction in male patients following resection of rectal cancer are high.The age,ways of surgical management and stages of tumor are not apparently contributed to these complications.     

腹腔镜中低位直肠癌根治术保留盆自主神经的疗效分析

目的:探讨腹腔镜中低位直肠癌根治术经"Holy plane"间隙保留盆自主神经的疗效.方法:把实施了经"Holy plane"间隙保留盆自主神经中低位直肠癌根治术的69例老年男性患者分为两组.观察组采用腹腔镜手术,对照组采用常规开腹手术.两组均采用全直肠系膜切除术(total mesorectal excision,TME).对两组患者的手术时间,术中出血量、术后排尿功能、性功能,局部复发率及5年生存率进行回顾性总结和比较.结果:观察组手术时间明显延长,术中出血量明显少于对照组,两组患者术后排尿功能及性功能障碍的比较均无显著性差异,术后3年患者局部复发率及5年生存率比较无显著性差异.结论:腹腔镜经"Holy plane"间隙保留盆自主神经的中低位直肠癌根治术具有微创优势.在神经保护方面,可以达到与开腹手术相近的手术效果.二者在局部复发率及5年生存率上无明显差异.     

直肠癌的外科治疗进展

本文介绍直肠癌外科治疗的进展，探讨直肠癌外科治疗方面的一些重要问题，如保肛、膀胱和性功能的损伤和术后复发三个主要的难点。对于直肠癌手术的切缘问题、全系膜切除的概念、局部切除的手术指征、侧方淋巴结清扫的必要性以及直肠癌切除后结肠袋的重建等保肛手术，应把肿瘤的根治始终放在第一位，在不降低根治原则的前提下最大限度的提高保肛机率，应保证足够的下切缘和环形切缘；保护盆腔自主神经的手术的开展有利于减少膀胱和性功能的损伤；直肠癌的局部复发有很多因素值得考虑；直肠全系膜切除大大减少了直肠手术后的局部复发率；直肠肿瘤的局部切除应注意避免指征的过度扩大和缩小；侧方淋巴结清扫宜选择性开展；直肠癌切除后结肠袋的重建具有一定价值。     

Function preservation in rectal cancer surgery

When total mesorectal excision (TME) is accurately performed, dysfunction, theoretically, does not occur. However, there are differences among individuals in the running patterns and the volumes of nerve fibers, and if obesity or a narrow pelvis is present, nerve identification is difficult. Currently, the rate of urinary dysfunction after rectal surgery ranges from 33% to 70%. Many factors other than nerve preservation play a role in minor incontinence. Male sexual function shows impotence rates ranging from 20% to 46%, while 20%–60% of potent patients are unable to ejaculate. In women, information on sexual function is not easily obtained, and there are more unknown aspects than in men. As urinary, sexual, and defecation dysfunction due to adjuvant radiotherapy have been reported to occur at a high frequency, the creation of a protocol that enables analysis of long-term functional outcome will be essential for future clinical trials. In the treatment of rectal cancer, surgeon-related factors are extremely important, not only in achieving local control but also in preserving function. This article reviews findings from recent studies investigating urinary, sexual, and defecation dysfunction after rectal cancer surgery and discusses questions to be studied in the future.     

保留盆腔植物神经的直肠癌根治术32例临床分析

目的探讨保留盆腔植物神经的直肠癌根治术对男性直肠癌患者术后排尿与性功能的影响。方法对32例男性直肠癌患者行保留盆腔植物神经的直肠癌根治术（保留组），其中5例为保留单侧盆腔植物神经术。以22例行传统直肠癌根治术（未明确保留盆腔植物神经）者作为对照（对照组）。结果保留组术后有勃起、射精功能者分别占87．5％（28／32）、75．0％（24／32），其中保留双侧盆腔植物神经的27例术后有勃起、射精功能者分别为88．9％（24／27）、77．7％（21／27），5例保留单侧盆腔植物神经者，分别为80．0％（4／5）、60．0％（3／5）；对照组有勃起、射精功能者分别为31．8％（7／22）、22．7％（5／22）。盆腔植物神经保留组术后排尿功能正常者占84．4％（27／32），对照组排尿功能正常者占31．8％（7／22）。结论保留盆腔植物神经的直肠癌根治术能够有效地保存男性直肠癌患者术后性功能和排尿功能。     

Three-dimensional versus two-dimensional laparoscopic surgery for rectal cancer: better promote postoperative sexual and urinary function of a propensity-matched study

Laparoscopic total mesorectal excision (TME) with autonomic nerve preservation (ANP) is a common procedure for rectal cancer (RC), associated with a high prevalence of postoperative urogenital and anorectal dysfunctions. Compared to 2D laparoscopy, 3D laparoscopy provides better depth perception of the surgical field and hand-eye coordination to achieve better outcomes. We compared the performance of 2D and 3D laparoscopy on preserving urogenital and anorectal function in TME+ANP surgery for rectal cancer using propensity-score matching. Data were collected from consecutive male patients who underwent 3D or 2D laparoscopic TME+ANP for primary RC at our institution between March 2012 and December 2020. The primary outcome was sexual and urinary function 1 year after surgery. A total of 450 male patients were eligible. After 1:1 matching, 146 cases were included in each group for analysis. One year after surgery, the prevalence of sexual dysfunction (International Index of Erectile Function score <26) was 8.22% in the 3D laparoscopic group and 44.52% in the 2D laparoscopic group, respectively (P=0.000) and a significant difference in the incidence of urinary retention was observed (n=3 and 24, respectively (P=0.000)). Moreover, blood loss, operative time, duration of hospital stay, and the time to first flatus in the 3D laparoscopic group were significantly less than in the 2D laparoscopic group. In conclusion, 3D laparoscopic TME is associated with lower incidences of postoperative sexual and urinary dysfunction than 2D laparoscopic TME for rectal cancer in male patients.     

保留盆腔自主神经在男性直肠癌根治术中的应用

目的探讨保留盆腔自主神经直肠癌根治术对减少男性患者术后排尿功能障碍和性功能障碍的作用。方法采用病例对照法,分析56例直肠癌根治术中保留盆腔自主神经组和不保留组患者术后排尿和性功能障碍的发生率及局部复发率。结果排尿功能障碍总发生率为研究组25.00%(14/56),对照组为60.71%(34/56),两组比较差异有统计学意义(P<0.01)。研究组和对照组病人术后勃起功能障碍的发生率分别为26.79%和75.00%,射精功能障碍发生率分别为28.57%和69.64%,两组比较差异有统计学意义(P<0.01)。局部复发率分别为7.14%和8.93%,差异无统计学意义。结论保留盆腔自主神经的直肠癌根治术在不增加局部复发率的情况下,可以改善患者术后的性功能和排尿功能,提高患者术后的生活质量。     

应用全直肠系膜切除和保留植物神经的三腔清扫技术治疗中晚期直肠癌247例

 【摘要】　目的　分析应用全直肠系膜切除（TME）、保留植物神经（PANP）的三腔清扫（TSD）技术治疗中晚期直肠癌的效果。方法　247例中晚期直肠癌患者采用TME和（或）TSD技术行根治性切除。其中,185例（74.9 %）进行了PANP（P组）的直肠癌根治术治疗,其余患者由于怀疑侵犯植物神经丛而行植物神经非保留式（P-组）切除术,P组中行TME者139例（Pm组）,行TSD者46例（Ps组）。结果　247例患者中无手术死亡病例。Pm组在手术时间、手术操作难度等方面优于Ps组（P ＜0.05）。P组在术后泌尿和性功能上明显好于P-组（P <0.05）。P组与P-组、Pm组与Ps组在肛门直肠功能、2年生存率及远期复发率、转移率及生存期等方面差异均无统计学意义（均P >0.05）。结论　TME技术PANP对绝大多数中晚期直肠癌均是应该优先选择的术式,应争取行"三明治"疗法。TSD手术操作相对复杂。TME、TSD的术后生存率差异无统计学意义,术后生存期主要取决于癌肿的早期发现与干预。     

40例中下段直肠癌行直肠全系膜切除术（TME）的临床观察

目的：回顾性分析比较传统术式与TME在直肠癌术后对局部复发、排尿功能和性功能的影响。方法：2005-2009年我院40例行TME治疗中下段直肠癌,其中男性16例,女性24例,同期观察40例行传统术式治疗中下段直肠癌,跟踪随访3年,局部复发以CT和肠镜结果为准,排尿功能以拔尿管时间和尿残留为指标,性功能以问卷形式进行调查。结果：病人术后随诊3年,局部复发率为5.0%,3年生存率92.5%,排尿障碍17.5%,勃起障碍25%。结论：TME治疗中下段直肠癌对降低局部复发,减少对排尿功能和性功能影响明显优于传统术式。     

40例中下段直肠癌行直肠全系膜切除术(TME)的临床观察

目的:回顾性分析比较传统术式与TME在直肠癌术后对局部复发、排尿功能和性功能的影响。方法:2005-2009年我院40例行TME治疗中下段直肠癌,其中男性16例,女性24例,同期观察40例行传统术式治疗中下段直肠癌,跟踪随访3年,局部复发以CT和肠镜结果为准,排尿功能以拔尿管时间和尿残留为指标,性功能以问卷形式进行调查。结果:病人术后随诊3年,局部复发率为5.0%,3年生存率92.5%,排尿障碍17.5%,勃起障碍25%。结论:TME治疗中下段直肠癌对降低局部复发,减少对排尿功能和性功能影响明显优于传统术式。     

经“Ｈｏｌｙｐｌａｎｅ”间隙保留盆腔自主神经侧方淋巴结清扫术的临床观察

目的　探讨经“Ｈｏｌｙｐｌａｎｅ”间隙保留盆腔自主神经（ＨＰＡＮＰ）侧方淋巴结清扫术在男性直肠癌低位保肛术中的临床应用价值。方法　比较传统手术与ＨＰＡＮＰ侧方淋巴结清扫术在男性直肠癌低位保肛术中的应用情况,对各组患者的排尿功能、性功能、局部复发率和３年生存率等指标进行分析、评价。结果　ＨＰＡＮＰ侧方淋巴结清扫术组肿瘤下缘距肛门距离较传统手术组明显缩短（Ｐ＜０.０５）;术后排尿障碍、勃起障碍、射精障碍的发生率均低于传统手术组,组间比较差异有统计学意义（Ｐ＜０.０５）;ＨＰＡＮＰ手术术式分型与排尿障碍、勃起障碍、射精障碍分级之间呈正相关（Ｐ＜０.０５）;两组３年生存率无明显差异;局部复发率ＨＰＡＮＰ组明显低于传统手术组（Ｐ＜０.０５）。结论　ＨＰＡＮＰ侧方淋巴结清扫术对降低局部复发率、预防术后排尿障碍、勃起障碍、射精障碍等有较好的临床价值。     

Nerve-sparing surgery in rectal cancer: feasibility and functional results

Traditional rectal cancer surgery has been burdened with a high rate of sexual and urinary dysfunctions due to intraoperative injury or the cutting of the sympathetic and/or parasympathetic nerves. The experience acquired in the last ten years with total mesorectal excisions has permitted the use of the "nerve-sparing" technique. The present study regards 239 patients from two surgical centres, most of whom underwent sphincter-saving radical surgery between 1994 and 1998 with the above mentioned technique for resectable colon cancer. Details regarding the technique were recorded in the last 58 patients, in order to examine the severity of the surgical damage. The subgroup with the longest follow-up, which included 36 patients, was diagnostically evaluated by a surgeon, psychologist, urologist and neurologist to analyze the risk of sexual and urinary dysfunctions. A complete nerve-sparing was performed in 86.3% of the cases. The parasympathetic nerve trunks were those most often damaged because of perineural tumor spreading. Partial to complete sexual impotence was observed in 44% of the patients and surprisingly, preoperative dysfunctions were detected by means of the multidisciplinary approach in one third of these patients. Therefore, only 30.5% of the patients presented with strictly postoperative sexual impotency, above all, those who had undergone high-dose preoperative chemoradiation for T3 or T4 middle to low rectal cancer. A prospective study was initiated to evaluate the genitourinary dysfunctions after rectal cancer surgery in all of the clinical phases by means of a multidisciplinary approach aimed at functional recovery and improved quality of life.     

Quality of life in patients with urinary diversion after operation for locally advanced rectal cancer.

AIMS: When locally advanced or recurrent rectal cancer involves the bladder or prostate, curative treatment often requires pelvic exenteration. The aim was to assess the quality of life (QoL) in disease-free patients with urinary diversion after extensive surgery for advanced rectal cancer. METHODS: Twelve patients with urinary diversion (cases) were compared with 25 randomly selected patients given the same treatment, but without urinary diversion (controls). An age- and gender-adjusted general population was identified (reference). QoL was assessed with the EORTC questionnaires QLQ-C30, QLQ-CR38, and parts of the QLQ-BLM30. RESULTS: The cases did not report significantly worse overall QoL than the controls or the reference population. Both cases and controls had low mean scores of sexual function, and high mean scores of male sexual problems. In the nine cases that had two stomas, overall QoL was not worse than in the control or reference groups. CONCLUSIONS: Tumour-free patients did not report worse QoL scores than the controls or the general population, despite most having two stomas and low sexual function. Fear of reducing the patient's QoL should not be a major contraindication when surgery with urinary diversion is warranted to obtain curative resection.     

Miles术与Dixon术在低位直肠癌患者围术期指标及疗效比较

目的对比分析采用经腹会阴联合直肠癌切除术(Miles术)与经腹前切除术(Dixon术)治疗低位直肠癌的围术期指标及疗效。方法选择低位直肠癌患者60例,对其临床资料进行回顾性分析。按照手术方式分为Miles术组(29例)和Dixon术组(31例)。Miles术组采用经腹会阴联合直肠癌切除术,Dixon术组采用经腹前切除术,2组均接受3年随访。对比2组手术时间、术中失血量、肛门排气时间、住院时间、淋巴结清除数量、环周切缘阳性率、术后1年生存质量评分(PAC-QOL)、排尿功能、男性患者性功能及并发症情况,并比较2组3年无瘤生存期、总生存期、局部复发率、远处转移率。结果Dixon术组的手术时间、术中失血量、肛门排气时间、住院时间均少于Miles术组(P<0.05),PAC-QOL评分低于Miles术组(P<0.05),排尿功能、男性患者勃起功能及射精功能优于Miles术组(P<0.05)。结论Dixon术治疗低位直肠癌与Miles术相比,可明显缩短手术时间、肛门排气时间、住院时间,减少术中出血量,并可改善术后患者生活质量、排尿功能及男性患者的性功能。     

Clinical significance and problems of sentinel node identification for individualization of rectal cancer therapy

In the surgical treatment of advanced rectal cancer, wide lymphadenectomy has been replaced by autonomic nerve preservation because of serious problems such as postoperative urinary and sexual dysfunction. This may offer a considerable clue to as whether metastasis of lateral lymph node can be diagnosed by a new technique in order to provide more benefits to many patients with advanced rectal cancer. Moreover the sentinel lymph node (SLN) concept has lately attracted attention as a new technique. We studied SLN in 40 patients with advanced lower rectal cancer using 99mTc-Sn colloid as a tracer. SLN was successfully identified in 35 (87.5%) of 40 patients, and the mean number of SLNs identified per patient was 5.6 lymph nodes (range 1-14). In this study overall accuracy was 86%, and it was suggested that lateral lymphadenectomy was excluded in 91%, thanks to application of the SLN technique. Although the role this technique plays in the individualization of the therapy for rectal cancer will be large in the near future, many problems remain to be solved in the exact identification of SLN.     

男性直肠癌根治术后尿潴留的影响因素分析

目的:探讨男性直肠癌根治术后尿潴留发生的影响因素。方法:回顾性分析2013年07月至2021年06月于我院普外科行直肠癌根治术的236例男性患者的临床资料。记录术后尿潴留的发生情况，对可能影响男性直肠癌根治术后尿潴留的指标进行单因素分析和多因素Logistic分析。结果:236例男性患者行直肠癌根治术，术后有24例发生尿潴留，术后尿潴留的发生率为10.2%。单因素分析显示，年龄≥65岁、低位肿瘤、腹会阴联合切除手术、术后首次拔除尿管时间<4天与男性直肠癌根治术后尿潴留的发生相关（P<0.05）。多因素 Logistic 回归分析显示，腹会阴联合切除手术是男性直肠癌根治术后尿潴留发生的独立危险因素（OR=10.886，P<0.05）。结论:腹会阴联合切除手术是男性直肠癌根治术后尿潴留发生的独立危险因素。行直肠癌根治术前，应筛选可能出现术后尿潴留的高危患者，并采取合理的预防措施，以期减少术后尿潴留的发生。