Impact of autonomic nerve-oriented anatomical laparoscopic surgery on recovery in patients with colorectal cancer

Abstract

BACKGROUND

Implementation of an autonomic nerve-oriented anatomical approach in laparoscopic surgery for patients with colorectal cancer may provide a new reference for surgical intervention in this patient population.

AIM

To assess the impact of autonomic nerve-oriented anatomical laparoscopic surgery on recovery and postoperative risks in patients with colorectal cancer.

METHODS

Data from 116 patients diagnosed with colorectal cancer, treated between January 2016 and May 2024, were randomly divided into 2 groups (n = 58 each) according to surgical approach: Control (radical vessel-oriented laparoscopic surgery); and Observation (autonomic nerve-oriented anatomical surgery). Perioperative indicators, and postoperative risk for urinary dysfunction and sexual function were compared between the 2 groups.

RESULTS

Compared with the control group, the observation group experienced less intraoperative blood loss (P < 0.05) and exhibited superior perioperative indicators (P < 0.05). At 2 weeks and 3 months postoperatively, the proportion of patients with urinary dysfunction in the observation group was lower than that in the control group (P < 0.05). Four months postoperatively, there were significant differences in male erectile dysfunction, female dyspareunia, and sexual pleasure grading between the 2 groups (P < 0.05).

CONCLUSION

The autonomic nerve-oriented anatomical approach to laparoscopic surgery for colorectal cancer accelerates postoperative recovery, with decreased intraoperative blood loss, lower impact on urinary and sexual functions, and enhances surgical safety.

Key Words: Colorectal cancer; Autonomic nerve; Laparoscopic surgery; Urinary dysfunction; Sexual function

Core Tip: This study compared the efficacy of autonomic nerve-oriented anatomical laparoscopic surgery with that of conventional vessel-oriented laparoscopic surgery in patients diagnosed with colorectal cancer. Results indicated that the autonomic nerve-oriented approach reduced intraoperative bleeding, enhanced postoperative recovery, and decreased the risk for urinary and sexual dysfunction, thus contributing to improving surgical safety.

INTRODUCTION

Colorectal cancer ranks third and second among all cancer types among adult males and females, respectively, with high mortality rates worldwide[1]. In 2020, over 1.9 million new cases of colorectal cancer were reported, leading to approximately 900000 deaths. Projections indicate that by 2040, the number of newly diagnosed colorectal cancer cases could increase to 3.2 million annually, with an estimated 1.6 million fatalities attributed to the disease[2]. Early stage cancer has no overt symptoms, and some patients may experience changes in bowel habits, such as diarrhea and constipation. As the disease progresses, tumor cells metastasize to involve multiple organs and body tissues thus endangering the lives of those affected[3,4]. With continuous advances in diagnostic and therapeutic concepts and surgical techniques, early diagnosis combined with radiotherapy, chemotherapy, and surgical treatment have improved the survival rate of patients diagnosed with colorectal cancer. In recent years, the advancement of minimally invasive techniques has enabled laparoscopic procedures to become increasingly common in colorectal cancer treatment. This approach has proven effective in minimizing surgical trauma to the body while enhancing safety during operations[5]. Although surgery is the primary treatment for colorectal cancer, it can easily damage the pelvic autonomic nerves, leading to postoperative organ and tissue dysfunctions, such as urinary dysfunction. Therefore, research investigating colorectal cancer surgery is not only limited to tumor resection, but also focuses on how to reduce surgical damage to patients and improve postoperative quality of life. Accordingly, some researchers have proposed nerve-sparing radical surgeries for colorectal cancer. Currently, however, few reports have addressed the utility of the autonomic nerve-oriented anatomical approach in laparoscopic surgery in patients with colorectal cancer. As such, this study aimed to explore the effectiveness of an autonomic nerve-oriented anatomical approach for laparoscopic surgery in 116 patients diagnosed with colorectal cancer.

MATERIALS AND METHODS

General information

Data from 116 patients diagnosed with colorectal cancer and treated at the authors’ hospital between January 2023 and May 2024, were included. The inclusion criteria were as follows: (1) Preoperative pathological diagnosis of primary colorectal cancer and clear diagnosis of mid- to low-rectal cancer (4 cm-11 cm from the anus); (2) No severe pelvic organ dysfunction with normal sexual activity; (3) No preoperative radiotherapy or chemotherapy; and (4) Informed consent from the patient and their family. The exclusion criteria were as follows: (1) Tumor node metastasis (TNM) stage III; (2) Acute surgery required due to obstruction complications; (3) Extensive tumor invasion of the surrounding tissues; and (4) History of major abdominal surgery. Patients were randomly divided into two groups (n = 58 each). The observation group included 34 males and 24 females, with a mean age of 48.46 ± 4.78 years (range 31-66 years). TNM staging was stage I (22), stage II (19), and stage III (17). Tumor location was low in 20 and mid in 38. The control group included 35 males and 23 females, with a mean age of 48.50 ± 4.66 years (30-66 years). TNM staging was stage I (21), stage II (20), and stage III (17). Tumor location was low in 19 and mid in 39. No significant differences in clinical characteristics were found between the groups (P > 0.05) (Table 1).

Table 1 Basic information of the study groups, mean ± SD/n (%).

Clinical data	Observation (n = 58)	Control (n = 58)	t/F value	P value
Age, years	48.46 ± 4.78	48.50 ± 4.66	0.660	0.520
Sex
Male	34 (58.62)	35 (60.34)	0.392	0.696
Female	24 (41.38)	23 (39.66)
Tumor stage
I	22 (37.93)	21 (36.21)	0.956	0.419
II	19 (32.76)	20 (34.48)
III	17 (29.31)	17 (29.31)

Protocol

The observation group underwent an autonomic nerve-oriented anatomical approach for laparoscopic radical surgery for colorectal cancer. Under the modified lithotomy position, the trocar positions for the five-port method were determined, and the surgery was performed using a medial approach, as follows.

At the root of the inferior mesenteric artery: The sigmoid colon was lifted, the right rectal paracolic groove was tautened, and the sacral promontory was incised. The upper abdominal nerve plexus was used as a guide, extending the cephalad along the tangent to the inferior mesenteric plexus, dissecting the root of the inferior mesenteric artery, ligating and transecting it, ligating the inferior mesenteric vein, and trimming the mesentery.

Anterior to the sacral promontory: Along the horizontal direction of the sacral promontory towards the leg side, in front of the preperitoneal fascia, the rectal visceral fascia was freed. After exposing the retrorectal space, a sharp dissection was performed.

Posterior and lateral to the seminal vesicles: The space in front of Denonvilliers’ fascia was incised, and the anterior leaf of Denonvilliers’ fascia was transected 0.5 cm away from the base of the bilateral seminal vesicles. It then entered the posterior space of Denonvilliers’ fascia, freed, and separated the space between the prostatic capsule and the rectal visceral fascia, dissecting the rectum to the levator muscle level.

Lateral space dissection of the rectum: The rectum was freed, the lateral ligaments and pelvic plexus were retracted, the surface of the visceral fascia was dissected, and the lateral side of the rectum was freed from top to bottom. The rectum was denuded 2 cm below the tumor tissue, transected, and a small incision (5 cm) was made in the lower midline of the abdomen to remove the bowel, rectal mesentery, transect, and anastomose the ends. The pelvic cavity was irrigated and a pelvic drainage tube was placed.

The control group underwent vessel-oriented laparoscopic radical surgery for colorectal cancer. The approach was the same as that used in the observation group, starting from the sacral promontory along the abdominal aorta to open the rectosigmoid mesentery, clearly defining the dissection plane of the inferior mesenteric artery, denuding the vessel at its root, vascularizing the inferior mesenteric artery and accompanying vessels, and transecting the inferior mesenteric vein. Selected mesenteric vessels were used to expand the retrorectal space plane.

Observational indices

Perioperative indices: Intraoperative blood loss, urethral catheter, and drainage tube dwell time.

Risk for urinary dysfunction: At 2 weeks and 3 months postoperatively, the Saito urinary function grading method was used to evaluate the risk for urinary dysfunction, which was divided into 4 grades based on the frequency of micturition and residual urine volume, with grades II, III, and IV considered to have a risk for urinary dysfunction[6].

Sexual function: At 4 months postoperatively, the international index of erectile function-5 (IIEF-5) and female sexual function index (FSFI) were used to assess sexual performance of male and female patients, respectively. IIEF-5 scores were graded based on 3 levels of erectile function: I (≥ 12 points); II (8-11 points); and III (≤ 7 points). The FSFI scores included two parts: Dyspareunia (yes or no), and sexual pleasure acquisition (levels I-III).

Statistical analysis

Statistical analysis was performed using SPSS version 22.0 (IBM Corp., Armonk, NY, United States), with categorical data (%) compared using the χ² test. Quantitative data (mean ± SD) that were normally distributed were compared using the t-test, and ranked data were analyzed using rank sum tests. Differences with P < 0.05 were considered to be statistically significant.

RESULTS

Perioperative indicators

Intraoperative bleeding was lower in the observation group than that in the control group, while the remaining indicators required less time in the observation group than those in the control group (P < 0.05) (Table 2).

Table 2 Perioperative indicators, mean ± SD.

Variable	Observation (n = 58)	Control (n = 58)	t value	P value
Intraoperative bleeding, mL	62.77 ± 4.55	78.40 ± 4.43	18.744	< 0.001
Urinary tube line time, hour	1.40 ± 0.33	1.79 ± 0.34	6.269	< 0.001
Time to recovery of bowel function, hour	2.11 ± 0.36	2.73 ± 0.41	8.654	< 0.001
Dwelling time of drainage tube, hour	5.54 ± 0.77	6.19 ± 0.68	4.819	< 0.001

Comparison of risk between the groups

At 2 weeks and 3 months postoperatively, the proportion of patients with urination disorders in the observation group was lower than that in the control group (P < 0.05) (Table 3).

Table 3 Comparison of voiding disturbance risk between the 2 groups, n (%).

Variable	Observation (n = 58)	Control (n = 58)	χ2 value	P value
Urination disorder
Two weeks after surgery	8 (13.79)	17 (29.31)	4.130	0.042
Three months after surgery	2 (3.45)	8 (13.79)	3.940	0.047

Comparison of sexual function

Four months after surgery, the grades of erectile dysfunction, and sexual pain and pleasure between the different surgical methods varied significantly (P < 0.05) (Table 4 and Table 5).

Table 4 Comparison of male sexual function between the two groups, n (%).

Variable	Observation (n = 34)	Control (n = 35)	χ2 value	P value
Erectile dysfunction grade
I	0 (0)	0 (0)
II	3 (8.82)	6 (17.14)
III	0 (0.00)	4 (11.43)
Total	3 (8.82)	10 (28.57)	4.399	0.036

Table 5 Comparison of female sexual function between the 2 groups, n (%).

Variable	Observation (n = 24)	Control (n = 23)	χ2/Z	P value
Dyspareunia			4.905	0.027
Yes	3 (8.33)	8 (34.78)
No	21 (91.67)	15 (65.22)
Pleasure with sexual intercourse			2.022	0.043
Grade I	20 (83.33)	12 (52.17)
Grade II	4 (16.67)	7 (30.43)
Grade III	0 (0.00)	4 (17.39)

DISCUSSION

While the exact cause of colorectal cancer is still unknown, it is thought to result from the interplay of environmental, dietary, and genetic factors. As well, chronic diarrhea, constipation, and prolonged mental stress can heighten the risk of developing the disease. As medical technology continues to advance, laparoscopic surgery known for minimal trauma and faster postoperative recovery has become a primary treatment method for colorectal cancer. However, the pelvic autonomic nerves are susceptible to damage during surgery, which can significantly increase the risk of urinary and sexual dysfunction and severely impact postoperative quality of life[7,8]. Thus, safeguarding the pelvic autonomic nerves during surgery to enhance the prognosis of patients undergoing laparoscopic colorectal cancer treatment has emerged as a key challenge in the field. A precise grasp of the anatomical concepts for preserving pelvic autonomic nerves during laparoscopic surgery is crucial to improving the technique’s effectiveness for colorectal cancer[9,10].

Findings of this study demonstrated that an autonomic nerve-oriented anatomical approach to laparoscopic surgery significantly reduced intraoperative bleeding, accelerated postoperative recovery, improved postoperative urinary function, and minimized the impact on sexual function in patients with colorectal cancer. These results align with those of previous studies that have highlighted the benefits of nerve-sparing techniques in colorectal cancer surgery[10,11]. Specifically, our findings regarding reduced urinary dysfunction and improved sexual function are consistent with those reported by Kim et al[9], who observed similar benefits in males after robotic total mesorectal excision with autonomic nerve preservation. However, our results should be interpreted in the context of the existing literature, which suggests that, while nerve-sparing techniques can reduce postoperative dysfunction, they may not be universally beneficial and may be technically challenging[12,13]. The precision required in these procedures necessitates advanced surgical skills and a thorough understanding of the pelvic anatomy, which can vary among surgeons. This variability could potentially influence outcomes, as suggested by Grosek et al[13], who emphasized the importance of surgeon experience in achieving successful nerve preservation.

The present study had some limitations, the first of which was its retrospective design, which is prone to selection bias and confounding factors that may have influenced the results. As noted by Moris et al[14], such biases can affect the generalizability of findings. Future studies should consider using prospective designs to mitigate these issues and provide more reliable data[15-18]. Moreover, a discussion of potential confounding factors, such as patient comorbidities and variations in postoperative care, would have added depth to our analysis[19,20]. These factors can significantly affect recovery and functional outcomes after surgery, as discussed in an analysis of perioperative outcome[21-24].

While our study provides valuable insights into the benefits of an autonomic nerve-oriented anatomical approach in laparoscopic surgery for patients with colorectal cancer, it is essential to acknowledge its limitations and consider the broader context of the existing research. Future studies with larger sample sizes, longer follow-up periods, and prospective designs are crucial for validating our findings and exploring the nuances of nerve-sparing techniques in colorectal cancer surgery.

CONCLUSION

Implementing an autonomic nerve-oriented anatomical approach in laparoscopic surgery for patients with colorectal cancer can significantly reduce intraoperative bleeding, accelerate postoperative recovery, improve postoperative urinary function, reduce the risk for urinary dysfunction, minimize the impact on sexual function, and enhance surgical safety. Therefore, it can be considered an ideal surgical method for patients diagnosed with colorectal cancer.