直肠癌TME中保留盆腔自主神经对男性排尿及性功能影响的初步研究

目的:探讨保留盆腔自主神经(pelvic autonomic nerve preservation,PANP)的直肠全系膜切除术(total mesorectal excision,TME)对男性排尿及性功能的影响.方法:对2005～2006年48例进行丁ME(对照组)和2007～2008年进行PANP+TME的53例(治疗组)男性直肠癌患者的排尿及性功能情况进行回顾性分析.结果:术后勃起功能障碍的发生率为治疗组28.30%(15/53),对照组72.92%(35/48),2组差异有统计学意义(P<0.001);射精功能障碍的发生率为治疗组24.53%(13/53),对照组62.50%(30/48),2组差异有统计学意义(P=0.001);排尿障碍的发生率为治疗组18.87%(10/53),对照组47.92%(23/48),2组差异有统计学意义(P<0.001).结论:PANP和TME结合可以明显改善患者的排尿功能和性功能,从而提高患者术后生活质量.     

保留盆腔自主神经的全直肠系膜切除术对中、低位直肠癌患者术后排尿和性功能的影响

目的:探讨保留盆腔自主神经的全直肠系膜切除术后患者排尿及性功能的变化。方法:行保留盆腔自主神经(PANP)加全直肠系膜切除术(TME)的中、低位DukesB期的直肠癌患者38例作为研究组,同期行TME的DukesB期患者35例作为对照组。研究组中低位前切除(LAR)21例,经腹会阴联合切除(APR)17例;对照组中LAR20例,APR15例。观察并比较二组患者术前后排尿、性功能之变化。结果:研究组与对照组术后排尿功能障碍发生率分别为15.7%(6/38)与40%(14/35)(P=0.013);研究组LAR与APR组性功能障碍发生率分别为9.5%(2/21)、29.4%(5/17),总的性功能障碍率为18.4%(7/38);对照组中分别为35%(7/20)、73.3%(11/15)和51.4%(18/35),研究组性功能障碍发生率明显低于对照组(P=0.002)。结论:Dukes B期患者行保留盆自主神经的全直肠系膜切除术能明显降低术后排尿、性功能障碍的发生率,提高患者术后生活质量。     

全直肠系膜切除并自主神经保留术治疗直肠癌的疗效评价

目的评价全直肠系膜切除（TME）并保留盆腔自主神经（PANP）的直肠癌根治术对直肠癌患者术后性功能、复发和生存期的影响。方法回顾性分析1997年10月至2004年6月共105例行TME并保留自主神经的男性直肠癌患者（保留自主神经组）术后的随访资料,并与同期110例TME不保留自主神经的男性直肠癌患者（不保留自主神经组）术后的性功能、复发和生存率进行比较。结果勃起障碍保留自主神经组33．3％（35／105）,不保留自主神经组63．2％（68／110）,两组比较差异具有统计学意义（X^2=17．466,P〈0．001）。射精障碍保留自主神经组43．8％（46／105）,不保留自主神经组70．0％（77／110）,两组比较差异具有统计学意义（x。=15．053,P〈0．001）。保留自主神经组局部复发率7．6％（8／105）,不保留自主神经组局部复发率5．5％（6／110）,两组差异无统计学意义（X^2=0．413,P=0．520）。5年生存率保留自主神经组为63．4％,不保留自主神经组为59．7％（P〉0．05）。结论TME并PANP的直肠癌根治术既能保证手术根治,同时术后性功能障碍率低,生存质量提高。     

Male sexual and urinary function after laparoscopic total mesorectal excision

Background  Urinary and sexual dysfunction are potential complications of rectal surgery for cancer. This study retrospectively evaluated the frequency of such complications after laparoscopic total mesorectal excision (LTME) with autonomic nerve preservation. Methods  For this study, 50 men younger than 75 years who underwent radical LTME for mid and low rectal cancer were followed up for at least 12 months, interviewed, and administered a standardized questionnaire about postoperative functional outcomes and quality of life. Results  Sexual desire was maintained by 55.6%, ability to engage in intercourse by 57.8%, and ability to achieve orgasm and ejaculation by 37.8% of the patients. Distance of the tumor from the anal verge and adjuvant or neoadjuvant treatments were the significant predictors of poor postoperative sexual function. Seven patients (14%) presented transitory postoperative urinary dysfunction, all of whom were medically treated. Tumor stage and distance from the anal verge were independently associated with the postoperative global International Prostatic Symptom Score (IPSS). No differences were observed in urinary quality of life. Conclusions  In this series, LTME did not reproduce or improve on sexual and urinary dysfunction outcomes obtained in the best open TME series. Further trials are needed to evaluate functional outcome in rectal cancer patients.     

实时神经监测在腹腔镜直肠癌全直肠系膜切除术中盆腔自主神经丛保护的应用

目的 探讨实时神经监测在腹腔镜直肠癌全直肠系膜切除术中盆腔自主神经丛保护的应用。方法 选取2017年1月至2020年12月非急诊收治的直肠癌患者,共11例。所有患者均进行腹腔镜直肠癌全直肠系膜切除术,术中使用实时神经监测进行盆腔自主神经丛保护,术后评估排尿、肛管直肠功能,并分析两者相关性。结果 所有患者均成功进行术中实时神经监测,神经监测电生理结果均为阳性,术后第6月进行功能评估,均未发生排尿、肛管直肠功能不全,两者相关性良好（r=1.0）。结论 实时神经监测在腹腔镜直肠癌全直肠系膜切除术中盆腔自主神经丛保护的应用安全、有效,结果阳性提示术后排尿、肛管直肠功能完好。     

Impact of laparoscopic surgery on bladder and sexual function after total mesorectal excision for rectal cancer

Background  Bladder and sexual dysfunction are well-documented complications of rectal cancer surgery. This study aimed to determine whether laparoscopy can improve the outcome of these dysfunctions or not. Methods  The study included 63 of the 116 patients who underwent surgery for rectal cancer between 2002 and 2006. Bladder and male sexual function were studied by means of a questionnaire on the basis of the International Prostatic Symptom Score (IPSS) and International Index of Erectile Function (IIEF). In addition, bladder function was determined by means of postvoid residual urine measurement and uroflowmetry. Postoperative functions were compared with the preoperative data to detect subjective functional deterioration. Outcomes were compared between patients who underwent open (group 1, n = 29) and laparoscopic (group 2, n = 34) total mesorectal excision. Results  Only minor disturbances of bladder function were reported for one patient (3%) in group 1 and three patients (9%) in group 2 (p > 0.05). Impotency after surgery was experienced by 6 of 17 preoperatively sexually active males (29%) in group 1 and 1 of 18 males (5%) in group 2 (p = 0.04). Similarly, 5 of 10 women (50 %) in group 1 and 1 of 14 women (7%) in group 2 felt that their overall level of sexual function had decreased as a result of surgery (p = 0.03). Conclusions  Open rectal cancer resection is associated with a higher rate of sexual dysfunction, but not bladder dysfunction, compared with laparoscopic surgery. Laparoscopic rectal cancer surgery offers a significant advantage with regard to preservation of postoperative sexual function and constitutes a true advance in rectal cancer surgery compared with the open technique. The proposed advantages can be attributed to improvement in visibility by the magnification feature of laparoscopic surgery. Presented orally at the 8th National Endoscopic Laparoscopic Surgery Congress, Antalya, Turkey, 1–4 July 2007.     

保留盆腔植物神经对老年男性患者术后性功能及排尿功能的影响

目的:探讨保留盆腔植物神经的直肠癌手术对老年男性患者性功能及排尿功能的影响。方法:1999~2005年因直肠癌手术的170例老年男性患者分为PANP组(含规范的TME手术方法)和非PANP(TME规范情况不详),对两组术后性功能、排尿功能和局部复发率进行回顾性总结、比较。结果:PANP组性功能与排尿功能明显优于非PANP组,但统计学无显著差异(P<0.05)。而PANP组局部复发率低于非PANP组(P>0.05)。结论:老年直肠癌患者应重视性功能和排尿功能的保护。     

Intraoperative identification and neurophysiologic parameters to verify pelvic autonomic nerve function during total mesorectal excision for rectal cancer

BACKGROUND: Preservation of parasympathetic and sympathetic nerves is required to avoid urogenital function disturbances after total mesorectal excision (TME) for rectal carcinoma. This study sought to determine whether intraoperative stimulation of parasympathetic nerves with monitoring of bladder contraction is useful in meeting this demand. STUDY DESIGN: In a prospective pilot study, 17 patients, 11 men and 6 women, underwent TME with pelvic autonomic nerve preservation performed by an experienced surgeon. The parasympathetic nerves were stimulated by an electrostimulation device (Screener 3625, Medronic), and the resulting bladder contraction was measured manometrically in all patients. Variations in pulse rate and voltage were measured to determine optimal stimulation parameters. A standardized questionnaire was used to record urogenital function disturbances. Residual urine volume was measured by ultrasound pre- and postoperatively. Shortterm outcomes data were evaluated to establish a possible association between intraoperative test results and postoperative bladder function. RESULTS: In 15 of 17 patients undergoing TME with pelvic autonomic nerve preservation for rectal carcinoma, the parasympathetic nerves were identified based on nerve stimulation-induced bladder contraction. Two patients with negative results on intraoperative nerve stimulation had persisting bladder dysfunction requiring an indwelling catheter after discharge from hospital. In spite of a short median followup of 2 months (range 1 to 4 months), in 7 of 10 men with intact erectile function prior to surgery, postoperative erectile dysfunction could be excluded. The study showed a pulse rate of 35 Hz and an electric potential of 12 V to be optimal stimulation parameters, associated with a mean intravesical pressure rise of 12.7 cm H(2)O (range 2.8 to 18.0 cm H(2)O). CONCLUSIONS: Intraoperative nerve stimulation with monitoring of intravesical pressure represents a technically simple procedure for the identification and verification of function of pelvic parasympathetic nerves during TME for rectal carcinoma.     

Bladder and sexual dysfunction after mesorectal excision for rectal cancer

BACKGROUND: Urinary and sexual dysfunction are recognized complications of rectal excision for cancer. The aim of this study was to examine the frequency of such complications after mesorectal excision, shortly after this method was introduced. METHODS: Spontaneous flowmetry, residual volume of urine measurement and urodynamic examination, including cystometry and simultaneous detrusor pressure and urinary flow recording, was carried out before and 3 months after curative rectal excision. Urinary symptoms and sexual function were evaluated by means of questionnaires before and after operation. Each patient served as his or her own control. RESULTS: Forty-nine consecutive patients, 39 of whom had a total mesorectal excision (TME) and ten a partial mesorectal excision, were examined before surgery and 35 again after operation. In two patients, a weak detrusor was detected before operation. Two patients developed signs of bladder denervation after operation. Transitory moderate urinary incontinence appeared in four other women. Six of 24 men reported some reduction in erectile function and one became impotent. Two men reported retrograde ejaculation. All the complications were seen in the TME group. CONCLUSION: Mesorectal excision for rectal cancer resulted in a low frequency of serious bladder and sexual dysfunction.     

腹腔镜直肠癌根治术中保留盆自主神经的关键技术与意义

直肠癌术中盆自主神经(PAN)的损伤是患者术后排尿功能和性功能障碍的主要原因之一。术中盆自主神经的精准辨认和保护始终是直肠癌根治术的要点与难点。术者应熟悉PAN的走行,把握直肠周围筋膜的解剖层次,才能维持正确的外科平面(surgical plane),最大程度降低盆神经损伤概率。高清腹腔镜设备及应用解剖技术的进展使外科医生更精准地辨认PAN、血管、筋膜等重要解剖结构。本文对腹腔镜下直肠癌根治术中保留PAN的关键技术和意义作一综述。     

Male sexual function after laparoscopic total mesorectal excision

Aim The aim of this prospective study was to clarify the frequency of male sexual dysfunction after laparoscopic total mesorectal excision (LTME) and to examine the relationship between pelvic autonomic nerve (PAN) preservation status and functional outcomes. Method Candidates for LTME were included in this study. PAN preservation status after LTME was examined in detail by video review. Patients completed a functional questionnaire (the International Index of Erectile Function) before and 3, 6 and 12 months after the operation. Results Twenty‐six patients who underwent LTME were assessable. Detailed video reviews identified inadvertent PAN damage during surgery. PAN injury was observed in 11 cases (41%), including eight cases (32%) of inadvertent PAN damage (incomplete preservation group). There was a trend toward increasing inadvertent PAN injury rate in patients with high body mass index and large tumours. The results from all patients who underwent LTME showed no deterioration in total International Index of Erectile Function or its domain scores 12 months after surgery. In the incomplete preservation group, these scores temporarily decreased (3 and 6 months after surgery), but such deterioration was not observed in the complete preservation group. Most of the 12 patients with potentially active erectile function before the operation recovered this function, and only one patient (7%) with PAN injury was still judged as inactive 12 months after surgery. Conclusion The proportion of patients with sexual dysfunction after LTME is low. With the enhanced visibility of the laparoscope, inadvertent PAN injury was detected in a significant number of cases and associated with transient deterioration of sexual function.     

保留盆腔自主神经的全直肠系膜切除的临床应用及评价

目的探讨保留盆腔自主神经（PANP）的全直肠系膜切除（TME）在男性直肠癌低位保肛术中的应用。方法回顾性分析传统手术、TME和PANP＋TME在男性直肠癌保肛手术中的应用，对各组病人肿瘤下缘距肛门距离、3年存活率、局部复发率、排尿功能、性功能作一评价。结果TME组和PANP＋TME组手术病人的肿瘤下缘距肛门距离较传统手术组明显缩短（P〈0．05）；3组的3年存活率分析差异无显著性（P〉0．05）；TME组和PANP＋TME组的局部复发率较传统手术组明显降低（P〈0．05）；传统手术组、TME组、PANP＋TME组的排尿障碍、勃起功能障碍和射精功能障碍的发生率逐渐降低，3组间两两比较差异均有显著性（P〈0．05）。PANP手术分型与排尿障碍、勃起功能障碍和射精功能障碍分级呈正相关（P〈0．05）。结论TME可以降低直肠癌的局部复发率，降低排尿障碍和性功能障碍的发生率；PANP和TME结合使排尿障碍和性功能障碍的发生率更加降低，PANP手术保留神经越彻底，手术后排尿障碍、性功能障碍的发生率越低。     

A prospective evaluation of anorectal function after total mesorectal excision in patients with a rectal carcinoma

BACKGROUND: Rectum resection with total mesorectal excision (TME) and neorectal anastomosis often compromises anorectal function. Insight into the underlying mechanisms is lacking. Therefore, a prospective study was designed to investigate the relationship between clinical and functional outcomes preoperatively and postoperatively. METHODS: Eleven patients with rectal cancer were examined before and 4 and 12 months after surgery and compared with 11 healthy volunteers (HVs). Anorectal (neorectal) function was examined by clinical outcome questionnaire, anal manometry, rectal compliance, and sensation. Six HVs also underwent barostat measurements in the sigmoid colon. RESULTS: Clinical parameters of soiling and passive incontinence (loss of stool without sensation) increased significantly until 12 months postoperatively, whereas urgency and tenesmus increased temporarily, returning to preoperative values at 12 months. In anorectal measurements, anal sphincter function was grossly preserved; however, rectal-anal inhibitory reflex (RAIR) was decreased at 4 months but recovered after 1 year. Neorectal compliance was similar to that of HV sigmoid, increasing slightly after 12 months but still significantly lower than that of normal rectum. Neorectal sensation to pressure distention was similar to that of normal rectum, however accompanied by smaller volumes. Neorectal distention induced contractions of large amplitude at 4 months, returning to normal after 12 months. CONCLUSIONS: Our results suggest that the transient increase in urgency and tenesmus after surgery results from a temporary increase in neorectal "irritability" accompanied by some adaptation of compliance in time. In contrast, episodes of incontinence and soiling are increased after 1 year most likely because of reduced neorectal capacity and RAIR recovery in the presence of a low basal anal sphincter pressure.     

经肛门全直肠系膜切除和腹腔镜全直肠系膜切除对直肠癌的疗效对比

目的分析比较经肛门全直肠系膜切除（TaTME）与腹腔镜全直肠系膜切除（LaTME）在中低位直肠癌治疗中的疗效及预后。 方法选择东营市东营区人民医院2015年2月至2016年2月收治的64例择期行全直肠系膜切除术（TME）的中低位直肠癌患者,随机分为TaTME组与LaTME组,各32例。观察并比较两组患者的手术时间、术中出血量、标本完整率、环周切缘（CRM）阳性率、远端切缘（DRM）阴性率、淋巴结清扫数目、保肛率、中转开放手术率、术中及术后并发症、术后住院时间、局部复发率、远处转移率、2年总体生存率（OS）各指标间的差异。 结果TaTME组患者的术中出血量、中转开放手术率、手术时间、标本完整率、CRM阳性率、保肛率、术后住院时间、尿潴留发生率均显著优于LaTME组（均P<0.05）。患者均获随访2~24个月,TaTME组中位生存时间为23.9个月,局部复发率、转移率分别为6.2%（2/32）、3.1%（1/32）。LaTME组中位生存时间为19.7个月,局部复发率、转移率均为3.1%（1/32）。两组术后复发率、转移率比较,差异无统计学意义（χ²=0.350、0.516,P=0.554、0.472）。TaTME组与LaTME组1年OS分别为100.00%、93.75%,2年OS分别为96.87%、81.25%。两组1年OS比较,差异无统计学意义（χ²=0.516,P=0.472）,TaTME组的2年OS显著高于LaTME组患者（χ²=4.402,P=0.036）。 结论与LaTME术相比,TaTME术治疗中低位直肠癌具有较高的安全性和有效性,且术后并发症较少,术后住院时间短,可以改善患者预后。     

直肠癌根治术中保留盆腔自主神经对男性性功能、排尿功能及局部复发率的影响

排尿功能及性功能障碍是直肠癌根治术后较常见的并发症,近年来国内外一些研究发现,在直肠癌根治术中实施全直肠系膜切除(TME)时,完全或部分保留盆腔自主神经(Pelyic autonomic nerve preservation,PANP),可以降低术后排尿和性功能障碍的发生率.但PANP是否会影响手术的根治性,是否会增加患者术后的局部复发率,存在争议.本文回顾分析我院2000年1月～2003年6月在直肠根治术中实施和未实施PANP各46例病人术后排尿及性功能障碍的发生率及局部复发率,研究PANP在直肠癌根治术的应用价值.     

Quality of life after total mesorectal excision for rectal cancer

BACKGROUND: After total mesorectal excision for rectal cancer, many surgeons try to avoid an abdominoperineal resection (APR) by performing a transanally double stapled low colo-rectal anastomosis (LRA), frequently without a pouch. This policy is mainly based on the assumption that the quality of life after such LRA is higher than after APR. It has been suggested that a better functional outcome and therefore a higher quality of life might be achieved by a colo-anal J-pouch anastomosis (CPA). The aim of this study was to assess quality of life among disease-free survivors after APR, LRA and CPA. METHODS: The charts of 301 consecutive patients who had undergone surgery for cancer in the middle or lower third of the rectum were analysed. Two hundred four patients were eligible for inclusion. The quality of life among these patients was assessed using one generic (EQ-5D) and two disease-specific questionnaires (EORTC QLQ-C30 and EORTC QLQ-CR38). RESULTS: The response rate was 82%. The median follow-up was 31 months. Overall, quality of life was good but CPA patients had better quality of life scores than APR and LRA patients. This difference was not only due to the better functional outcome but also to the lower incidence of disturbed micturition and sexual problems in the CPA group. CONCLUSION: The quality of life after colo-anal J-pouch anastomosis is better than after abdominoperineal resection (APR) and low colo-rectal anastomosis (LRA). The quality of life after APR is similar to that after LRA.     

全直肠系膜切除术中保留男性盆腔自主神经的解剖基础

目的 探讨成年男性盆腔自主神经的筋膜层次及其解剖标记,明确全直肠系膜切除术中保留男性盆腔自主神经的解剖基础.方法 对12具男性尸体盆腔(24侧半盆腔)进行解剖.结果 盆腔自主神经走行筋膜层次为:腹下神经走行于脏筋膜后叶内,盆丛位于膀胱腹下筋膜与脏筋膜间,精囊前列腺分支位于Denonvilliers筋膜前侧方.骶骨岬、输...     

腹腔镜直肠全系膜切除术

目的探讨腹腔镜外科技术在直肠全系膜切除术(TME)的应用。方法对39例腹腔镜直肠全系膜切除术患者进行随访和回顾性分析。结果腹腔镜直肠前切除术30例,中转手术1例;腹腔镜辅助Miles手术9例。无手术死亡,术中盆底静脉丛破裂出血1例(发生率2.6%)。平均手术时间185min,平均出血量85ml,平均术后住院日为8.5d。术后发生吻合口瘘1例,尿潴留1例。39例患者术后随访1～28个月,仅1例DukesC1期的低分化腺癌患者,术后12个月盆腔局部肿瘤复发。全组患者的trocar穿刺孔及腹壁切口无肿瘤种植。结论腹腔镜直肠全系膜切除术创伤小、疼痛轻、恢复快。只要严格掌握手术适应证,正确应用腹腔镜技术就能完成此类手术。     

Laparoscopic versus open total mesorectal excision with anal sphincter preservation for low rectal cancer

Background The Laparoscopic approach has been applied to colorectal surgery for many years; however, there are only a few reports on laparoscopic low and ultralow anterior resection with construction of coloanal anastomosis. This study compares open versus laparoscopic low and ultralow anterior resections, assesses the feasibility and efficacy of the laparoscopic approach of total mesorectal excision (TME) with anal sphincter preservation (ASP), and analyzes the short-term results of patients with low rectal cancer.Methods We analyzed our experience via a prospective, randomized control trail. From June 2001 to September 2002, 171 patients with low rectal cancer underwent TME with ASP, 82 by the laparoscopic procedure and 89 by the open technique. The lowest margin of tumors was below peritoneal reflection and 1.5–8 cm above the dentate line (1.5–4.9 cm in 104 cases and 5–8 cm in 67 cases). The grouping was randomized.Results Results of operation, postoperative recovery, and short-term oncological follow-up were compared between 82 laparoscopic procedures and 89 controls who underwent open surgery during the same period. In the laparoscopic group, 30 patients in whom low anterior resection was performed had the anastomosis below peritoneal reflection and more than 2 cm above the dentate line, 27 patients in whom ultralow anterior resection was performed had anastomotic height within 2 cm of the dentate line, and 25 patients in whom coloanal anastomosis was performed had the anastomosis at or below the dentate line. In the open group, the numbers were 35, 27, and 27, respectively. There was no statistical difference in operation time, administration of parenteral analgesics, start of food intake, and mortality rate between the two groups. However, blood loss was less, bowel function recovered earlier, and hospitalization time was shorter in the laparoscopic group.Conclusion Totally laparoscopic TME with ASP is feasible, and it is a minimally invasive technique with the benefits of much less blood loss during operation, earlier return of bowel function, and shorter hospitalization.