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Chen W, Liu Y, An Y, Shi W, Qiu X, Lin G, Zhou J. The Effectiveness and Safety of Rectal Modular Resection in Low Rectal Cancer: A Retrospective Study. J Laparoendosc Adv Surg Tech A 2023. [PMID: 36946686 DOI: 10.1089/lap.2022.0592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
Background: Described by Heald in 1982, total mesorectal excision (TME) is now routinely performed as the standard procedure for mid-low rectal cancer, with remarkable decrease in local recurrence and improved oncology outcome. However, the integrity of the resected mesentery and damage to autonomic nerves still remain challenging for general surgeons, especially in the cohort of neoadjuvant therapy patients. The concept of rectal modular resection (RMR), based on an integral understanding of the regional anatomy, was proposed as a surgical skill for dissociation of the rectum with shorter surgical duration, function preservation, and improved oncology outcome. Methods: This was a retrospective trial. Patients with resectable rectal lesions, ranging between 3 and 7 cm from the anal verge, were enrolled and grouped by TME surgery based on RMR or classical procedure resection (CPR). We estimated perioperative outcomes, including surgery complications such as anastomotic leak, urine retention, and others. Pathological properties, including distal clearance, harvested lymph nodes, tumor differentiation, and specimen grading, were also taken into account. Patients were followed postoperatively and functional evaluation was recorded at the 3-month and 1-year postoperation visits. Results: From January 2019 to December 2021, a total of 92 patients were enrolled in this study. TME surgery complying with the RMR methodology was performed with a back-to-bilateral-to-front modular proceeding. Duration of operation was significantly shortened in the RMR group, without increase in blood loss or failure rate of anus preservation. The quality of the specimen, graded according to integrity of the mesorectum, stands out in the RMR group. Functional evaluation revealed no statistical difference between RMR and CPR groups regarding sexual ability impairment and defecation disorder since follow-up is still ongoing. Conclusions: RMR-based TME was efficient with compressed operation duration compared with CPR and its safety was well validated with regard to the occurrence of complications and function loss.
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Affiliation(s)
- Weijie Chen
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuxin Liu
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yang An
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Weikun Shi
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoyuan Qiu
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Guole Lin
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jiaolin Zhou
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Laohawiriyakamol S, Chewatanakornkul S, Wanichsuwan W, Ruangsin S, Sunpaweravong S, Bejrananda T. Urogenital dysfunction after laparoscopic surgery for rectal or sigmoid colon cancer. Asian J Surg 2023; 46:492-500. [PMID: 35717291 DOI: 10.1016/j.asjsur.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 05/29/2022] [Accepted: 06/01/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/OBJECTIVE Urogenital dysfunction is a common complication after surgery for sigmoid colon or rectal cancers and may result from various causes. Herein, we evaluated urogenital dysfunction and the associated factors after laparoscopic surgery at different follow-up times. METHODS We conducted a prospective study on 91 patients who were diagnosed with sigmoid colon and rectal cancers and underwent laparoscopic surgery during 2014-2016. Voiding and male and female sexual dysfunctions following surgery were evaluated by the International Prostate Symptom Score (IPSS), International Index of Erectile Function-5 (IIEF-5), and Female Sexual Function Index-6 (FSFI-6), respectively. Urogenital function was compared at pre-surgery and 3 and 12 months postoperatively, and factors associated with urogenital dysfunction were identified. RESULTS The overall urinary function after surgery was better when compared to that at pre-surgery; however, there was deterioration in both male and female sexual functions. The mean preoperative IPSS, IIEF-5, and FSFI-6 scores were 9.35, 12.18, and 6.09, respectively. The mean differences among IPSS, IIEF-5, and FSFI-6 at 12 months postoperatively and pre-surgery were -3.08 (95% confidence interval [CI] -4.77 to -1.40), -2.57 (95% CI -4.33 to -0.80), and -2.58 (95% CI -4.73 to 0.42), respectively. Multivariate analysis demonstrated that age ≤60 years (odds ratio 4.22) and postoperative complications (odds ratio 2.77) were correlated with erectile dysfunction. CONCLUSION Voiding function improved after laparoscopic surgery in both sigmoid colon and rectal cancer patients. However, sexual function in both male and female patients was worse. Age ≤60 years and postoperative complications were strongly associated with male sexual dysfunction.
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Affiliation(s)
- Supparerk Laohawiriyakamol
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.
| | - Siripong Chewatanakornkul
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Worawit Wanichsuwan
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Sakchai Ruangsin
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Somkiat Sunpaweravong
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Tanan Bejrananda
- Urologic Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
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Berehova N, Buckle T, van Meerbeek MP, Bunschoten A, Velders AH, van Leeuwen FWB. Nerve Targeting via Myelin Protein Zero and the Impact of Dimerization on Binding Affinity. MOLECULES (BASEL, SWITZERLAND) 2022; 27:molecules27249015. [PMID: 36558148 PMCID: PMC9786614 DOI: 10.3390/molecules27249015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/07/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Surgically induced nerve damage is a common but debilitating side effect. By developing tracers that specifically target the most abundant protein in peripheral myelin, namely myelin protein zero (P0), we intend to support fluorescence-guided nerve-sparing surgery. To that end, we aimed to develop a dimeric tracer that shows a superior affinity for P0. METHODS Following truncation of homotypic P0 protein-based peptide sequences and fluorescence labeling, the lead compound Cy5-P0101-125 was selected. Using a bifunctional fluorescent dye, the dimeric Cy5-(P0101-125)2 was created. Assessment of the performance of the mono- and bi-labeled compounds was based on (photo)physical evaluation. This was followed by in vitro assessment in P0 expressing Schwannoma cell cultures by means of fluorescence confocal imaging (specificity, location of binding) and flow cytometry (binding affinity; KD). RESULTS Dimerization resulted in a 1.5-fold increase in affinity compared to the mono-labeled counterpart (70.3 +/- 10.0 nM vs. 104.9 +/- 16.7 nM; p = 0.003) which resulted in a 4-fold increase in staining efficiency in P0 expressing Schwannoma cells. Presence of two targeting vectors also improves a pharmacokinetics of labeled compounds by lowering serum binding and optical stability by preventing dye stacking. CONCLUSIONS Dimerization of the nerve-targeting peptide P0101-125 proves a valid strategy to improve P0 targeting.
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Affiliation(s)
- Nataliia Berehova
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Tessa Buckle
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Maarten P. van Meerbeek
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Anton Bunschoten
- Laboratory of BioNanoTechnology, Wageningen University & Research, Bornse Weilanden 9, 6708 WG Wageningen, The Netherlands
| | - Aldrik H. Velders
- Laboratory of BioNanoTechnology, Wageningen University & Research, Bornse Weilanden 9, 6708 WG Wageningen, The Netherlands
| | - Fijs W. B. van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
- Laboratory of BioNanoTechnology, Wageningen University & Research, Bornse Weilanden 9, 6708 WG Wageningen, The Netherlands
- Correspondence:
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Gaessler J, Anderhuber F, Kuchling S, Pilsl U. Topography of the pelvic autonomic nerves – an anatomical study to facilitate nerve-preserving total mesorectal excision. Acta Chir Belg 2022; 122:396-402. [DOI: 10.1080/00015458.2021.1920660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Jan Gaessler
- Division of Macroscopic and Clinical Anatomy, Medical University of Graz, Graz, Austria
| | - Friedrich Anderhuber
- Division of Macroscopic and Clinical Anatomy, Medical University of Graz, Graz, Austria
| | - Sabine Kuchling
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Ulrike Pilsl
- Division of Macroscopic and Clinical Anatomy, Medical University of Graz, Graz, Austria
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Positional relationship between the lateral border of Denonvilliers' fascia and pelvic plexus. Anat Sci Int 2021; 97:101-109. [PMID: 34529236 DOI: 10.1007/s12565-021-00629-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 09/08/2021] [Indexed: 01/02/2023]
Abstract
Denonvilliers' fascia is an important landmark of the dissection layer during prostate or rectal surgeries. However, there are few reports on its lateral extension. This anatomical study aimed to define the lateral border of Denonvilliers' fascia and use it as an anatomical landmark to identify the origin and distribution of the nerve branches of the pelvic plexus. We investigated the lateral extent and position of the lateral border of Denonvilliers' fascia through macroscopic examination of 12 pelvic halves from eight cadavers and histological examination of two cadavers. The Denonvilliers' fascia extended laterally to be attached to the pelvic plexus on the lateral border. The origins of nerve branches from the pelvic plexus to the pelvic organs, except the rectum, were located anterior or anterosuperior to the lateral border of Denonvilliers' fascia. The origins of nerve branches to the prostate were mainly anterior to the lateral border of Denonvilliers' fascia; however, in 3/12 pelvic halves, the nerve branches originated in the region posteroinferior to the lateral border of Denonvilliers' fascia. The attachment point of Denonvilliers' fascia to the prostate was more superior in these three pelvic halves (distance from the top point of the posterior surface of the prostate to the attachment point, 5.6 ± 1.9 mm) than that in the other nine pelvic halves (10.1 ± 3.6 mm). The lateral border of Denonvilliers' fascia is closely related to the pelvic plexus, suggesting its usefulness as an anatomical landmark to identify the origin of nerve branches from the pelvic plexus.
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Teste B, Rullier E. Intraoperative complications during laparoscopic total mesorectal excision. Minerva Surg 2021; 76:332-342. [PMID: 33944516 DOI: 10.23736/s2724-5691.21.08691-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Intraoperative complication during laparoscopic mesorectal excision for rectal cancer is a common complication occurring in 11% to 15% of the cases. They are probably underestimated because not systematically reported. The most frequent intraoperative complications are haemorrhage (3-7%), tumour perforation (1-4%), bowel injury (1-3%), ureter injury (1%), urogenital injury (2%), other organ injury (<1%), and anastomotic complications (1%). The mechanisms, management and prevention of vascular port injury, inferior mesenteric artery bleeding, small bowel and colon perforation, ureteral and urethral injury, pelvic nerve damage, tumour perforation and anastomotic failure are described. This review underlines the necessity to prevent intraoperative complication to avoid operative death and severe side-effects.
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Affiliation(s)
- Blanche Teste
- Department of Colorectal Surgery, Haut-Levèque Hospital, University of Bordeaux, Pessac, France
| | - Eric Rullier
- Department of Colorectal Surgery, Haut-Levèque Hospital, University of Bordeaux, Pessac, France -
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Robotic versus transanal total mesorectal excision in sexual, anorectal, and urinary function: a multicenter, prospective, observational study. Int J Colorectal Dis 2021; 36:2749-2761. [PMID: 34537862 PMCID: PMC8589758 DOI: 10.1007/s00384-021-04030-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Improved long-term survival after low anterior resection (LAR) for rectal cancer highlights the importance of functional outcome. Urogenital and anorectal dysfunction is frequently reported after conventional LAR. Advanced minimally invasive techniques such as robotic (RoTME) and transanal total mesorectal excision (TaTME) might improve functional results by precisely dissecting and preserving autonomic nerves. We compared functional outcomes after RoTME or TaTME in a multicenter study. METHODS One hundred twenty patients (55 RoTME/65 TaTME) were prospectively included in four participating centers. Anorectal (Wexner and low anterior resection syndrome (LARS) Score), urinary (International Consultation on Incontinence-Male/Female Lower Urinary Tract Symptoms Score (ICIQ-MLUTS/ICIQ-FLUTS) and International Prostate Symptom Scale (IPSS)), and sexual (International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI)) outcomes at 12 months after surgery were compared to preoperative scores. The response rate to the 1-year postoperative functional assessment by questionnaire was 79.5%. RESULTS RoTME enabled better anorectal function compared to TaTME (LARS score 4.3 ± 2.2 vs. 9.8 ± 1.5, p = 0.038, respectively). TaTME proved superior at preserving male urinary function, while female urinary function was comparable in both groups, with only mild postoperative impairment (RoTME vs. TaTME, respectively: ICIQ-MLUTS 13.8 ± 4.9 vs. 1.8 ± 5.8, p = 0.038; ICIQ-FLUTS Incontinence Score - 0.3 ± 1.0 vs. - 0.2 ± 0.9, p = 0.844). Both techniques demonstrated comparable male (RoTME - 13.4 ± 2.7 vs. TaTME - 11.7 ± 3.4, p = 0.615) and female (RoTME 5.2 ± 4.6 vs. TaTME 10.5 ± 6.4, p = 0.254) sexual function. CONCLUSION After adjustment for risk factors, RoTME provided better anorectal functional results, whereas TaTME was better at preserving male urinary function. Overall, both techniques demonstrated only mild postoperative functional impairment.
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Abstract
BACKGROUND The architecture of perirectal fasciae is complex as mirrored by different anatomical concepts. OBJECTIVE This study aimed to perform a comprehensive visualization of perirectal fasciae to facilitate strategies of rectal surgery such as total mesorectal excision, intersphincteric resection, and transanal total mesorectal excision. DESIGN Macroscopic dissection and histologic studies of perirectal fasciae and autonomic pelvic nerves were performed. SETTINGS This study was conducted in a university laboratory of macroscopic and microscopic anatomy. PATIENTS Thirteen (5 female) pelvic specimens were obtained from body donors (67-92 years of age). MAIN OUTCOME MEASURES The primary outcomes measured were the photodocumentation of perirectal fasciae, spaces and fusion zones, and histologic and immunohistochemical analysis of key structures. RESULTS The retrorectal space is a mesofascial interface between the mesorectal fascia and the parietal pelvic fascia. The parietal pelvic fascia is composed of 2 lamellae ensheathing the autonomic pelvic nerves. The outer lamella of the parietal pelvic fascia and the presacral fascia confine the presacral space. The presacral fascia covers the median sacral blood vessels. Approximately at the fourth sacral vertebra, all fascial layers fuse in the midline and are densely connected to the posterior rectal wall via the rectosacral ligament. The parietal pelvic fascia fuses with the pubococcygeal and longitudinal rectal muscles at the anorectal junction. Anterolaterally, the neurovascular bundles are closely related to this fascial fusion zone and the rectogenital septum. LIMITATIONS Because of the increased age of the body donors, the findings may be subjected to age-related degenerative processes. CONCLUSIONS The 2 lamellae of the parietal pelvic fascia and the fascial fusion zones are key structures of perirectal anatomy. For autonomic nerve preservation, the recognition of the inner lamella of the parietal pelvic fascia is crucial. To avoid inadvertent rectal perforation or accidental presacral dissection, the rectosacral ligament must be identified and transected for complete rectal mobilization. See Video Abstract at http://links.lww.com/DCR/B389. ANATOMÍA FASCIAL PERIRRECTAL: NUEVOS CONCEPTOS SOBRE UN ANTIGUO PROBLEMA: La arquitectura de las fascias perirrectales es compleja, reflejada por distintos conceptos anatómicos.Integración de conceptos sobre las fascias perirrectales para facilitar las estrategias de cirugía rectal, como la escisión mesorrectal total, la resección interesfintérica y la escisión mesorrectal total transanal.Disección macroscópica y estudios histológicos de fascias perirrectales y nervios pélvicos autonómicos.Laboratorio universitario de anatomía macroscópica y microscópica.Trece (5 mujeres) muestras pélvicas obtenidas de donantes de cuerpo (67-92 años).Foto documentación de fascias perirrectales, espacios y zonas de fusión, análisis histológico e inmunohistoquímico de estructuras claves.El espacio retrorectal es una interfaz mesofascial entre la fascia mesorrectal y la fascia pélvica parietal. Este último se compone de dos láminas que envuelven los nervios pélvicos autonómicos. La lámina externa de la fascia pélvica parietal y la fascia presacra definen el espacio presacro. La fascia presacra cubre los vasos sanguíneos sacros medianos. Aproximadamente en la cuarta vértebra sacra, todas las capas fasciales se unen en la línea media y están densamente conectadas a la pared rectal posterior a través del ligamento rectosacro. La fascia pélvica parietal se une con los músculos rectal pubococcígeo y longitudinal en la unión anorrectal. Anterolateralmente, los haces neurovasculares están estrechamente relacionados con esta zona de fusión fascial y el tabique rectogenital.Debido al aumento de la edad de los donantes de cuerpos, los hallazgos pueden estar sujetos a procesos degenerativos relacionados con la edad.Las dos láminas de la fascia pélvica parietal y las zonas de fusión fascial son estructuras claves de la anatomía perirrectal. Para la preservación del nervio autónomo de nervios pélvicos autonómicos, el reconocimiento de la lámina interna de la fascia pélvica parietal es importante. Para evitar la perforación rectal inadvertida o la disección presacra accidental, el ligamento rectosacro debe ser identificado y seccionado para una movilización rectal completa. Consulte Video Resumen en http://links.lww.com/DCR/B389.
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Fung TLD, Tsukada Y, Ito M. Essential anatomy for total mesorectal excision and lateral lymph node dissection, in both trans-abdominal and trans-anal perspective. Surgeon 2020; 19:e462-e474. [PMID: 33248924 DOI: 10.1016/j.surge.2020.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/10/2020] [Accepted: 09/02/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Total Mesorectal Excisions (TME) is the standard treatment of rectal cancer. It can be performed under laparoscopic, robotic or transanal approach. Inadvertent injury to surrounding structure like autonomic nerves is avoidable, no matter which approach is adopted. Lateral lymph node dissection (LLND) is a less commonly performed pelvic operation involving dissection in an unfamiliar area to most general surgeons. This article aims to clarify all the essential anatomy related to these procedures. METHODS We performed thorough literature search and revision on the pelvic anatomy. Our cases of TME and LLND, under either laparoscopic or transanal approach, were reviewed. We integrated the knowledge from literatures and our own experience. The result was presented in details, together with original figures and intra-operative photos. MAIN FINDINGS Anatomy of pelvic fascia, autonomic nerve system, anal canal and sphincter complex are core knowledge in performing TME and LLND. CONCLUSIONS Thorough understanding of the pelvic anatomy enables colorectal surgeons to master these procedures, avoid complication and perform extended resection. On the other hand, surgeons can appreciate the complex pelvic anatomy easier by seeing the pelvis in opposite angles (transabdominal and transaanal view).
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Affiliation(s)
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
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Soares AS, Chand M. Future Directions. Clin Colon Rectal Surg 2020; 33:180-186. [PMID: 32368200 PMCID: PMC7192688 DOI: 10.1055/s-0039-3402781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Transanal total mesorectal excision (taTME) is a novel technique that has evolved over the years to address the challenges of low rectal cancer surgery by applying the principles and benefits of laparoscopic surgery to more historic transanal techniques. It has been popularized through its use in rectal cancer, but the transanal approach is slowly being expanded to tackle different clinical scenarios including benign conditions such as inflammatory bowel disease and endometriosis. For all of these new indications, it is the desire to access and begin the dissection in native tissue beyond the pathology which makes this approach applicable to other diseases where anatomy can be challenging. Training pathways to safely introduce taTME in a standardized manner are being developed and implemented in a bid to ensure adequate training to all the surgeons using this technique and thus minimize complications and patient morbidity. The future directions of this promising technique include the use of image and optical technological enhancement to aid navigation, the use of pneumorectum stabilization, and perhaps the use of fluorescence as a safety improvement. Developments have come also from the field of robotics. After a demonstration of feasibility in cadaver models, a growing experience has been gathered in the robotic approach to taTME, covered in the last part of this chapter.
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Affiliation(s)
- António S. Soares
- Department of Surgery and Interventional Sciences, GENIE Centre, University College London, University College London Hospitals, NHS Trust, London, UK
| | - Manish Chand
- Department of Surgery and Interventional Sciences, GENIE Centre, University College London, University College London Hospitals, NHS Trust, London, UK
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Pallisera-Lloveras A, Planelles-Soler P, Hannaoui N, Mora-López L, Muñoz-Rodriguez J, Serra-Pla S, Dominguez-Garcia A, Prats-López J, Navarro-Soto S, Serra-Aracil X. Dissection of the inferior mesenteric vein versus of the inferior mesenteric artery for the genitourinary function after laparoscopic approach of rectal cancer surgery: a randomized controlled trial. BMC Urol 2019; 19:75. [PMID: 31382934 PMCID: PMC6683580 DOI: 10.1186/s12894-019-0501-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 07/18/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Total Mesorectal Excision (TME) is the standard surgical technique for the treatment of rectal cancer. However, rates of sexual dysfunction ofup to 50% have been described after TME, and rates of urinary dysfunction of up to 30%. Although other factors are involved, the main cause of postoperative genitourinary dysfunction is intraoperative injury to the pelvic autonomic nerves. The risk is particularly high in the inferior mesenteric artery (IMA). The aim of this study is to compare pre- and post-TME sexual dysfunction, depending on the surgical approach usedin the inferior mesenteric vessels: either directly on the IMA, or from the inferior mesenteric vein (IMV) to the IMA. METHODS Prospective, randomized,controlled study of patients with rectal adenocarcinoma with neoadjuvant chemoradiotherapy, who will be randomly assigned to one of two groups depending on the surgical approach to the inferior mesenteric vessels. The main variable is pre- and postoperative sexual dysfunction; secondary variables are visualization and preservation of the pelvic autonomic nerves, pre- and postoperative urinary dysfunction, and pre- and postoperative quality of life. The sample will comprise 90 patients, 45 per group. DISCUSSION The aim is to demonstrate that the dissection route from the IMV towards the IMA favors the preservation of the pelvic autonomic nerves and thus reducesrates of sexual dysfunction post-surgery. TRIAL REGISTRATION Ethical and Clinical Research Committee, Parc Taulí University Hospital: ID 017/315. ClinicalTrials.gov TAU-RECTALNERV-PRESERV-2018 (TRN: NCT03520088 ) (Date of registration 04/03/2018).
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Affiliation(s)
- Anna Pallisera-Lloveras
- Coloproctology Unit, General and Digestive Surgery Department, Parc Taulí University Hospital, Sabadell, UniversitatAutònoma de Barcelona, Parc Taulí s/n. 08208 Sabadell, Barcelona, Spain.
| | - Paula Planelles-Soler
- Urology Department, Parc Taulí University Hospital, Sabadell, Universitat Autònoma de Barcelona, Parc Taulí s/n 08208, Sabadell, Barcelona, Spain
| | - Naim Hannaoui
- Urology Department, Parc Taulí University Hospital, Sabadell, Universitat Autònoma de Barcelona, Parc Taulí s/n 08208, Sabadell, Barcelona, Spain
| | - Laura Mora-López
- Coloproctology Unit, General and Digestive Surgery Department, Parc Taulí University Hospital, Sabadell, UniversitatAutònoma de Barcelona, Parc Taulí s/n. 08208 Sabadell, Barcelona, Spain
| | - Jesús Muñoz-Rodriguez
- Urology Department, Parc Taulí University Hospital, Sabadell, Universitat Autònoma de Barcelona, Parc Taulí s/n 08208, Sabadell, Barcelona, Spain
| | - Sheila Serra-Pla
- Coloproctology Unit, General and Digestive Surgery Department, Parc Taulí University Hospital, Sabadell, UniversitatAutònoma de Barcelona, Parc Taulí s/n. 08208 Sabadell, Barcelona, Spain
| | - Arturo Dominguez-Garcia
- Urology Department, Parc Taulí University Hospital, Sabadell, Universitat Autònoma de Barcelona, Parc Taulí s/n 08208, Sabadell, Barcelona, Spain
| | - Joan Prats-López
- Urology Department, Parc Taulí University Hospital, Sabadell, Universitat Autònoma de Barcelona, Parc Taulí s/n 08208, Sabadell, Barcelona, Spain
| | - Salvador Navarro-Soto
- Coloproctology Unit, General and Digestive Surgery Department, Parc Taulí University Hospital, Sabadell, UniversitatAutònoma de Barcelona, Parc Taulí s/n. 08208 Sabadell, Barcelona, Spain
| | - Xavier Serra-Aracil
- Coloproctology Unit, General and Digestive Surgery Department, Parc Taulí University Hospital, Sabadell, UniversitatAutònoma de Barcelona, Parc Taulí s/n. 08208 Sabadell, Barcelona, Spain
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Hirata Y, Nozawa H, Kawai K, Hata K, Tanaka T, Nishikawa T, Otani K, Sasaki K, Kaneko M, Emoto S. The influence of neoadjuvant chemoradiation for lower rectal cancer on urinary function. Asian J Surg 2019; 42:731-739. [DOI: 10.1016/j.asjsur.2018.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/07/2018] [Accepted: 11/12/2018] [Indexed: 12/12/2022] Open
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Abstract
Over the past four decades, the treatment algorithms for rectal cancer have fundamentally changed, which resulted in a considerable improvement of oncological outcomes. In this context, the surgical concept of total mesorectal excision and the implementation of multimodal treatment strategies represent key milestones. These improvements were complemented by a standardized histopathological work-up of the surgical specimen and the introduction of high-resolution magnetic resonance imaging (MRI) diagnostics. In addition, novel surgical techniques have been introduced, such as laparoscopic and robotic rectal resection. Other technological innovations include intraoperative pelvic neuromonitoring and fluorescence imaging. This review highlights the current evidence for selected, sometimes controversially discussed principles of surgical treatment strategies in rectal cancer.
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Zhou MW, Huang XY, Chen ZY, Li ZY, Zhou YM, Yang Y, Wang ZH, Xiang JB, Gu XD. Intraoperative monitoring of pelvic autonomic nerves during laparoscopic low anterior resection of rectal cancer. Cancer Manag Res 2018; 11:411-417. [PMID: 30643466 PMCID: PMC6317465 DOI: 10.2147/cmar.s182181] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background Some patients with low rectal cancer experience anorectal and urogenital dysfunctions after surgery, which can influence the long-term quality of life. In this study, we aimed to protect nerve function in such scenarios by performing intraoperative monitoring of pelvic autonomic nerves (IMPAN). Patients and methods We retrospectively investigated a series of 87 patients undergoing laparoscopic low anterior resection of rectal cancer. Nerve-sparing was evaluated both visually and electrophysiologically. IMPAN was performed by stimulating the pelvic autonomic nerves under processed electromyography of the internal anal sphincter. Urination, defecation, sexual function, and the quality of life were evaluated using validated and standardized questionnaires preoperatively and at follow-up, 12 months after surgery. Results Among a total of 87 patients (53 male and 34 female patients), IMPAN with simultaneous electromyography of the internal anal sphincter was performed in 58 (66.7%) patients. Bilateral positive IMPAN results for both measurements, indicating successfully confirmed pelvic autonomic nerve preservation, were obtained in 45 (51.7%) patients. No significant difference was found in terms of urogenital and anorectal functions between preoperative and postoperative patients with bilateral positive IMPAN (P>0.05). Compared to preoperative patients with IMPAN (unilateral) or without IMPAN, these patients exhibited higher International Prostate Symptom Score, a lower International Index of Erectile Function-5, and a lower Female Sexual Function Index score at 12 months postoperatively (P<0.05). Conclusion IMPAN is an appropriate method with which to laparoscopically protect nerve function.
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Affiliation(s)
- Min-Wei Zhou
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China, ;
| | - Xiao-Yun Huang
- Department of Electromyogram, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Zong-You Chen
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China, ;
| | - Zhen-Yang Li
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China, ;
| | - Yi-Ming Zhou
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China, ;
| | - Yi Yang
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China, ;
| | - Zi-Hao Wang
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China, ;
| | - Jian-Bin Xiang
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China, ;
| | - Xiao-Dong Gu
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China, ;
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15
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Ishii M, Shimizu A, Lefor AK, Kokado Y, Nishigori H, Noda Y. Reappraisal of the lateral rectal ligament: an anatomical study of total mesorectal excision with autonomic nerve preservation. Int J Colorectal Dis 2018; 33:763-769. [PMID: 29556755 DOI: 10.1007/s00384-018-3010-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE The term "lateral rectal ligament" in surgery for rectal cancer has caused confusion regarding its true existence and contents. In previous studies, investigators claimed the existence of the ligament and described its topographical features as neurovascular structures and their surrounding connective tissues located at the anterolateral aspect of the distal rectum or the posterolateral aspect of the middle rectum. The purpose of this study is to evaluate the structure of the so-called "lateral rectal ligament" in cadaver dissections. METHODS Dissection was performed in nine cadavers (eight males and one female, aged 73 to 94 years) in accordance with typical total mesorectal excision techniques. During dissection, structures related to "the ligament" were examined and images recorded. RESULTS At the anterolateral aspect of the distal rectum, the middle rectal artery was noted to be crossing the fusion of Denonvilliers' fascia and the proper rectal fascia. At the posterolateral aspect of the middle rectum, there was a structure which consisted of the rectal nerves running through the fusion of the pelvic fasciae. Although called "ligaments," neither structure contained discrete strong connective tissue fixing the rectum to the pelvic wall. CONCLUSIONS The proper rectal fascia and surrounding pelvic fasciae fuse firmly anterolaterally and posterolaterally where neurovascular structures course toward the rectum. During a total mesorectal excision, the surgical dissection plane coincides with the fused part of the fasciae, which had long been considered the "lateral rectal ligament."
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Affiliation(s)
- Masayuki Ishii
- Department of Anatomy, Bio-imaging and Neuro-cell Science, Jichi Medical University, Tochigi, Japan.
- Colorectal and Pelvic Surgery Division, Shinko Hospital, 1-4-47, Wakinohamacho, Chuo-Ku, Kobe, Japan.
| | - Atsushi Shimizu
- Department of Surgery, Jichi Medical University, Tochigi, Japan
| | | | - Yujirou Kokado
- Colorectal and Pelvic Surgery Division, Shinko Hospital, 1-4-47, Wakinohamacho, Chuo-Ku, Kobe, Japan
| | - Hideaki Nishigori
- Colorectal and Pelvic Surgery Division, Shinko Hospital, 1-4-47, Wakinohamacho, Chuo-Ku, Kobe, Japan
| | - Yasuko Noda
- Department of Anatomy, Bio-imaging and Neuro-cell Science, Jichi Medical University, Tochigi, Japan
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16
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Vlek SL, Lier MCI, Koedam TWA, Melgers I, Dekker JJML, Bonjer JH, Mijatovic V, Tuynman JB. Transanal minimally invasive rectal resection for deep endometriosis: a promising technique. Colorectal Dis 2017; 19:576-581. [PMID: 27885759 DOI: 10.1111/codi.13569] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 09/20/2016] [Indexed: 01/04/2023]
Abstract
AIM Surgical management of patients with deep endometriosis (DE) of the rectum is difficult. Inflammation and subsequent adhesions due to DE impede access to the lower pelvis and may lead to complications during laparoscopic low anterior resection (LAR). Transanal minimally invasive surgery (TAMIS) is an alternative to an abdominal approach with potential advantages. The aim of this study was to provide a description of the TAMIS technique and to present the perioperative results of TAMIS and of conventional LAR in patients with DE. METHOD A prospective consecutive cohort of patients undergoing rectal resection for DE had either conventional laparoscopic LAR or TAMIS rectal excision. Pre-, intra- and postoperative parameters, such as patient symptomatology, operating time and postoperative complications were compared between the groups. Quality of life was assessed using the EORTC-QLQ-29/30 questionnaires. RESULTS Between May 2014 and March 2016 a total of 11 rectal resections were performed, including five TAMIS procedures. No differences were found in the pre-, intra- or postoperative parameters. Two major complications occurred after conventional LAR and none after TAMIS. No differences in quality of life were found between the groups. CONCLUSION Transanal minimally invasive surgery for DE of the rectum is feasible. Potential advantages include better surgical access to the pelvis, possibly fewer complications than LAR and no extraction incision with no difference in quality of life. Larger prospective studies are required to compare TAMIS with conventional rectal resection.
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Affiliation(s)
- S L Vlek
- Endometriosis Centre, VU University Medical Center, Amsterdam, The Netherlands.,Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - M C I Lier
- Endometriosis Centre, VU University Medical Center, Amsterdam, The Netherlands.,Department of Reproductive Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - T W A Koedam
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - I Melgers
- Endometriosis Centre, VU University Medical Center, Amsterdam, The Netherlands.,Department of Reproductive Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - J J M L Dekker
- Endometriosis Centre, VU University Medical Center, Amsterdam, The Netherlands.,Department of Reproductive Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - J H Bonjer
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - V Mijatovic
- Endometriosis Centre, VU University Medical Center, Amsterdam, The Netherlands.,Department of Reproductive Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - J B Tuynman
- Endometriosis Centre, VU University Medical Center, Amsterdam, The Netherlands.,Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
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17
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Chapuis PH, Kaw A, Zhang M, Sinclair G, Bokey L. Rectal mobilization: the place of Denonvilliers' fascia and inconsistencies in the literature. Colorectal Dis 2016; 18:939-948. [PMID: 27028138 DOI: 10.1111/codi.13343] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 02/11/2016] [Indexed: 02/08/2023]
Abstract
Confusion remains as to what is meant by Denonvilliers' fascia. This review searched the literature on pelvic surgical anatomy to determine whether there is agreement with Denonvilliers' original description and its implication in defining the correct anterior plane of dissection when mobilizing the rectum. The original French description of the fascia was translated into English and then compared both with French and with English studies identified by searching PubMed, Medline and Scopus from 1836 to June 2015. Special emphasis was given to the years between 1980 and 2015 in order to capture the literature pertinent to, and following on from, the description of total mesorectal excision for rectal cancer. The final literature search revealed 16 studies from the original 2150 citations. Much of the debate was concerned with the origin and development of the fascia, arising from either the 'fusion' or the 'condensation' of local primitive tissue into a mature 'multilayered' structure. Controversy regarding the correct plane of rectal mobilization occurs as a result of different interpretations by surgeons, anatomists and radiologists and bears little resemblance to Denonvilliers' original description. This may reflect wide anatomical variability in the adult pelvis or a form of dissection artefact. Further study is required to investigate this. Logically, for both men and women, the plane of rectal mobilization should be behind Denonvilliers' fascia and between it and the fascia propria of the rectum.
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Affiliation(s)
- P H Chapuis
- Department of Colorectal Surgery, Concord Hospital and Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.
| | - A Kaw
- Department of Anatomy, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand
| | - M Zhang
- Department of Anatomy, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand
| | - G Sinclair
- Department of Colorectal Surgery, Concord Hospital and Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - L Bokey
- Department of Colorectal Surgery, Liverpool Hospital and School of Medicine, University of Western Sydney, Sydney, New South Wales, Australia
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18
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Liu Y, Lu XM, Tao KX, Ma JH, Cai KL, Wang LF, Niu YF, Wang GB. Anatomical basis and clinical research of pelvic autonomic nerve preservation with laparoscopic radical resection for rectal cancer. JOURNAL OF HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGY. MEDICAL SCIENCES = HUA ZHONG KE JI DA XUE XUE BAO. YI XUE YING DE WEN BAN = HUAZHONG KEJI DAXUE XUEBAO. YIXUE YINGDEWEN BAN 2016; 36:211-214. [PMID: 27072964 DOI: 10.1007/s11596-016-1568-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 03/10/2016] [Indexed: 10/22/2022]
Abstract
The clinical effect of laparoscopic rectal cancer curative excision with pelvic autonomic nerve preservation (PANP) was investigated. This study evaluated the frequency of urinary and sexual dysfunction of 149 male patients with middle and low rectal cancer who underwent laparoscopic or open total mesorectal excision with pelvic autonomic nerve preservation (PANP) from March 2011 to March 2013. Eighty-four patients were subjected to laparoscopic surgery, and 65 to open surgery respectively. The patients were followed up for 12 months, interviewed, and administered a standardized questionnaire about postoperative functional outcomes and quality of life. In the laparoscopic group, 13 patients (18.37%) presented transitory postoperative urinary dysfunction, and were medically treated. So did 12 patients (21.82%) in open group. Sexual desire was maintained by 52.86%, un-ability to engage in intercourse by 47.15%, and un-ability to achieve orgasm and ejaculation by 34.29% of the patients in the laparoscopic group. Sexual desire was maintained by 56.36%, un-ability to engage in intercourse by 43.63%, and un-ability to achieve orgasm and ejaculation by 33.73% of the patients in the open group. No significant differences in urinary and sexual dysfunction between the laparoscopic and open rectal resection groups were observed (P>0.05). It was concluded that laparoscopic rectal cancer radical excision with PANP did not aggravate or improve sexual and urinary dysfunction.
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Affiliation(s)
- Yan Liu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiao-Ming Lu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Kai-Xiong Tao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jian-Hua Ma
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Kai-Lin Cai
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Lin-Fang Wang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yan-Feng Niu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Guo-Bin Wang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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19
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Pelvic intraoperative neuromonitoring during robotic-assisted low anterior resection for rectal cancer. J Robot Surg 2015; 10:157-60. [PMID: 26705113 PMCID: PMC4870286 DOI: 10.1007/s11701-015-0556-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 12/06/2015] [Indexed: 12/12/2022]
Abstract
While the oncological outcome of patients with rectal cancer has been considerably improved within the last decades, anorectal, urinary and sexual functions remained impaired at high levels, regardless of whether radical surgery was performed open or laparoscopically. Consequently, intraoperative monitoring of the autonomic pelvic nerves with simultaneous electromyography of the internal anal sphincter and manometry of the urinary bladder has been introduced to advance nerve-sparing surgery and to improve functional outcome. Initial results suggested that pelvic neuromonitoring may result in better functional outcomes. Very recently, it has also been demonstrated that minimally invasive neuromonitoring is technically feasible. Because, to the best of our knowledge, pelvic neuromonitoring has not been performed during robotic surgery, we report the first case of robotic-assisted low anterior rectal resection combined with intraoperative monitoring of the autonomic pelvic nerves.
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20
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Dariane C, Moszkowicz D, Peschaud F. Concepts of the rectovaginal septum: implications for function and surgery. Int Urogynecol J 2015; 27:839-48. [PMID: 26690361 DOI: 10.1007/s00192-015-2878-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 10/26/2015] [Indexed: 12/20/2022]
Abstract
INTRODUCTION In the pelvis, the rectogenital septum (RGS) separates the urogenital compartment from the digestive compartment. In men, it corresponds to Denonvilliers' rectoprostatic fascia or rectovesical septum (RVS). Its purpose-and, indeed, its existence-are controversial in women. The purpose of this review was to update knowledge about the RGS in women and, in particular, to clarify its relationship to pelvic nerves in order to deduce practical consequences of pelvic surgery and compare it to the RVS in men. METHODS A review of the anatomical and surgical literature was undertaken. Evidence for embryological origin, composition, and surgical importance of the RGS in women and men is suggested. RESULTS This manuscript presents evidence of the existence of the RGS in both women (rectovaginal septum, RVaS) and men (rectovesical septum, RVS). It originates from the genital structures and extends from the rectogenital pouch to the perineal body. It is composed of connective tissue associated with bundles of smooth muscle cells and has lateral expansions in close contact with neurovascular bundles originating from the inferior hypogastric plexus. During pelvic surgery for carcinoma, preservation of nerve fibers of erectile bodies is necessary if possible. The RGS is thus an important surgical landmark during urogenital sinus surgery, prolapse surgery, and proctectomy in women as well as during proctectomy and prostatectomy in men. CONCLUSIONS The RGS is present in women as well as in men, with great similarities between the two sexes. It represents an important surgical landmark during pelvic nerve-sparing surgery.
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Affiliation(s)
- Charles Dariane
- Service de Chirurgie Digestive, Oncologique et Métabolique, Hôpital Ambroise-Paré, AP-HP, 92104, Boulogne-Billancourt, France
- Université de Versailles St-Quentin-en-Yvelines, UFR des Sciences de la santé Simone-Veil, 78180, Montigny-Le-Bretonneux, France
| | - David Moszkowicz
- Service de Chirurgie Digestive, Oncologique et Métabolique, Hôpital Ambroise-Paré, AP-HP, 92104, Boulogne-Billancourt, France
- Université de Versailles St-Quentin-en-Yvelines, UFR des Sciences de la santé Simone-Veil, 78180, Montigny-Le-Bretonneux, France
| | - Frédérique Peschaud
- Service de Chirurgie Digestive, Oncologique et Métabolique, Hôpital Ambroise-Paré, AP-HP, 92104, Boulogne-Billancourt, France.
- Université de Versailles St-Quentin-en-Yvelines, UFR des Sciences de la santé Simone-Veil, 78180, Montigny-Le-Bretonneux, France.
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21
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Fang JF, Wei B, Zheng ZH, Chen TF, Huang Y, Huang JL, Lei PR, Wei HB. Effect of intra-operative autonomic nerve stimulation on pelvic nerve preservation during radical laparoscopic proctectomy. Colorectal Dis 2015; 17:O268-76. [PMID: 26362914 DOI: 10.1111/codi.13115] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 06/02/2015] [Indexed: 12/15/2022]
Abstract
AIM This study assessed the effect of intra-operative electrical nerve stimulation (INS) on pelvic autonomic nerve preservation (PANP) during laparoscopic resection for rectal cancer. METHOD A total of 189 consecutive cases of radical laparoscopic proctectomy were included. PANP was assessed visually or with INS. Urinary function was evaluated by residual urine volume (RUV), International Prostatic Symptom Score (IPSS) and recatheterization rate. Erectile function was evaluated using the International Index of Erectile Function (IIEF-5) scale. RESULTS INS successfully confirmed PANP in 65 (91.5%) patients, while direct vision confirmed PANP in only 72 (61.0%) patients. Compared with the successfully confirmed patients, failed patients in the INS group exhibited higher postoperative RUV (100.0 ± 34.6 vs 25.2 ± 13.6 ml, P = 0.003), higher IPSS (7 days, 20.0 ± 8.6 vs 6.5 ± 2.4, P = 0.012; 1 month, 13.5 ± 6.0 vs 5.3 ± 1.9, P = 0.020; 6 months, 11.7 ± 5.1 vs 4.5 ± 1.7, P = 0.018), a greater number of incidences of a micturition disorder (66.7% vs 1.5%, P = 0.000), higher recatheterization rates (33.3% vs 1.5%, P = 0.017) and a lower IIEF score at 3 months (8.25 ± 0.96 vs 10.93 ± 1.99, P = 0.012) and 6 months (12.50 ± 1.29 vs 15.63 ± 1.65, P = 0.001) postoperatively. Compared with the vision group, the INS group had less deterioration in postoperative RUV (31.5 ± 26.4 vs 54.0 ± 46.7 ml, P = 0.000), lower IPSS (7 days, 7.7 ± 5.0 vs 11.0 ± 6.6, P = 0.000; 1 month, 6.0 ± 3.3 vs 7.6 ± 5.4, P = 0.012) and higher IIEF score (3 months, 10.69 ± 2.07 vs 9.42 ± 2.05, P = 0.001; 6 months, 15.36 ± 1.85 vs 13.64 ± 2.00, P = 0.000) as well as a lower incidence of urination disorders (7.0% vs 17.8%, P = 0.038). CONCLUSION INS is effective for the accurate evaluation of PANP during radical laparoscopic proctectomy. Combined with INS, laparoscopic proctectomy is more effective in urogenital function protection.
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Affiliation(s)
- J-F Fang
- Department of Gastrointestinal Surgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - B Wei
- Department of Gastrointestinal Surgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Z-H Zheng
- Department of Gastrointestinal Surgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - T-F Chen
- Department of Gastrointestinal Surgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Y Huang
- Department of Gastrointestinal Surgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - J-L Huang
- Department of Gastrointestinal Surgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - P-R Lei
- Department of Gastrointestinal Surgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - H-B Wei
- Department of Gastrointestinal Surgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Urinary and erectile function in men after total mesorectal excision by laparoscopic or robot-assisted methods for the treatment of rectal cancer: a case-matched comparison. World J Surg 2015; 38:1834-42. [PMID: 24366278 DOI: 10.1007/s00268-013-2419-5] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Urinary and sexual dysfunction are recognized complications of rectal cancer surgery in men. This study compared robot-assisted total mesorectal excision (RTME) and laparoscopic total mesorectal excision (LTME) with regard to these functional outcomes. METHODS A series of 32 men who underwent RTME between February 1, 2009 and December 31, 2010 were matched 1:1 with patients who underwent LTME. The matching criteria were age, body mass index, tumor distance from the anal verge, neoadjuvant chemoradiation therapy, and tumor stage. Urinary and erectile function were evaluated using the International Prostatic Symptom Score (IPSS) and the five-item version of the International Index of Erectile Function (IIEF-5) scale. Data were collected from the two groups at baseline and at 3, 6, and 12 months after surgery and compared. RESULTS The mean IPSS score did not differ between the two groups at baseline at any point of measurement. The mean baseline IIEF-5 score was similar between the two groups and was decreased at 3 months. The mean IIEF-5 score was significantly higher in the RTME group at 6 months than in the LTME group (14.1 ± 6.1 vs. 9.4 ± 6.6; p = 0.024). The interval decrease in IIEF-5 scores was significantly higher in the LTME group than in the RTME group at 6 months (4.9 ± 4.5 vs. 9.2 ± 4.7; p = 0.030). CONCLUSIONS The men in the RTME group experienced earlier restoration of erectile function than did those in the LTME group. Bladder function was similar during the 12 months after RTME or LTME.
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23
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Stelzner S, Wedel T. Anatomische Grundlagen der nervenschonenden Rektumchirurgie. COLOPROCTOLOGY 2015. [DOI: 10.1007/s00053-015-0030-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Broholm M, Pommergaard HC, Gögenür I. Possible benefits of robot-assisted rectal cancer surgery regarding urological and sexual dysfunction: a systematic review and meta-analysis. Colorectal Dis 2015; 17:375-81. [PMID: 25515638 DOI: 10.1111/codi.12872] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 11/12/2014] [Indexed: 12/20/2022]
Abstract
AIM Robot-assisted surgery for rectal cancer may result in lower rates of urogenital dysfunction compared with laparoscopic surgery. A systematic review was conducted of studies reporting urogenital dysfunction after robot-assisted rectal cancer surgery. METHOD PubMed, Embase and the Cochrane Library were systematically searched in February 2014. All studies investigating urogenital function after robot-assisted rectal cancer surgery were identified. The inclusion criteria for meta-analysis studies required comparison of robot-assisted with laparoscopic surgery and the evaluation of urological and sexual function by validated questionnaire. The outcome was evaluated using the International Prostate Symptom Score (IPSS), the International Index of Erectile Function (IIEF) and the Female Sexual Function Index. RESULTS Ten studies including 689 patients were included. For the meta-analysis this fell to four including 152 patients in the robotic group and 161 in the laparoscopic group, without heterogeneity. The IPSS score at 3 and 12 months favoured robot-assisted surgery [mean difference (MD) -1.58; 95% CI (-3.1, -0.0), [P = 0.04; and MD -0.90 (-1.81, -0.02), P = 0.05]. IIEF scores at 3 months' follow-up [MD -2.59 (-4.25, -0.94),] P = 0.002] and 6 months' follow-up [MD -3.06 (-4.53, -1.59), P = 0.0001] were better after robot-assisted than laparoscopic surgery. CONCLUSION Although there were few data and no randomized controlled trials the results of the review suggested that robot-assisted surgery resulted in improved urogenital function than after laparoscopy.
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Affiliation(s)
- M Broholm
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
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25
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Kraima AC, West NP, Treanor D, Magee DR, Rutten HJ, Quirke P, DeRuiter MC, van de Velde CJH. Whole mount microscopic sections reveal that Denonvilliers' fascia is one entity and adherent to the mesorectal fascia; implications for the anterior plane in total mesorectal excision? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2015; 41:738-45. [PMID: 25892592 DOI: 10.1016/j.ejso.2015.03.224] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 03/25/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Excellent anatomical knowledge of the rectum and surrounding structures is essential for total mesorectal excision (TME). Denonviliers' fascia (DVF) has been frequently studied, though the optimal anterior plane in TME is still disputed. The relationship of the lateral edges of DVF to the autonomic nerves and mesorectal fascia is unclear. We studied whole mout microscopic sections of en-bloc cadaveric pelvic exenteration and describe implications for TME. METHODS Four donated human adult cadaveric specimens (two males, two females) were obtained from the Leeds GIFT Research Tissue Programme. Paraffin-embedded mega blocks were produced and serially sectioned at 50 and 250 μm intervals. Sections were stained with haematoxylin & eosin, Masson's trichrome and Millers' elastin. Additionally, a series of eleven human fetal specimens (embryonic age of 9-20 weeks) were studied. RESULTS DVF consisted of multiple fascial condensations of collagen and smooth muscle fibres and was indistinguishable from the anterior mesorectal fascia and the prostatic fascia or posterior vaginal wall. The lateral edges of DVF appeared fan-shaped and the most posterior part was continuous with the mesorectal fascia. Fasciae were not identified in fetal specimens. CONCLUSION DVF is adherent to and continuous with the mesorectal fascia. Optimal surgical dissection during TME should be carried out anterior to DVF to ensure radical removal, particularly for anterior tumours. Autonomic nerves are at risk, but can be preserved by closely following the mesorectal fascia along the anterolateral mesorectum. The lack of evident fasciae in fetal specimens suggested that these might be formed in later developmental stages.
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Affiliation(s)
- A C Kraima
- Department of Anatomy and Embryology, Leiden University Medical Center, P.O. Box 9600, 2300 ZC Leiden, The Netherlands; Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom
| | - N P West
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom
| | - D Treanor
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom
| | - D R Magee
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom
| | - H J Rutten
- Department of Surgery, Catherina Hospital Eindhoven, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands
| | - P Quirke
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom
| | - M C DeRuiter
- Department of Anatomy and Embryology, Leiden University Medical Center, P.O. Box 9600, 2300 ZC Leiden, The Netherlands
| | - C J H van de Velde
- Department of Surgery, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands.
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Kulaylat MN. Mesorectal excision: Surgical anatomy of the rectum, mesorectum, and pelvic fascia and nerves and clinical relevance. World J Surg Proced 2015; 5:27-40. [DOI: 10.5412/wjsp.v5.i1.27] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/10/2014] [Accepted: 12/31/2014] [Indexed: 02/06/2023] Open
Abstract
Biologic behavior and management of rectal cancer differ significantly from that of colon cancer. The surgical treatment is challenging since the rectum has dual arterial blood supply and venous drainage, extensive lymphatic drainage and is located in a bony pelvic in close proximity to urogenital and neurovascular structures that are invested with intricate fascial covering. The rectum is encased by fatty lymphovascular tissue (mesorectum) that is surrounded by perirectal fascia that act as barrier to the spread of the cancer and constitute the surgical circumferential margin. Locoregional recurrence after rectal cancer surgery is influenced by tumor-related factors and adequacy of the resection. Local recurrence is associated with incomplete excision of circumferential margin, violation of perirectal fascia, transmesorectal dissection, presence of isolated deposits in the mesorectum and tumor in regional lymph nodes and incomplete lymph node clearance. Hence to eradicate the primary rectal tumor and control regional disease, the rectum, first area of lymph node drainage and surrounding tissue must be completely excised while maintaining an intact fascial envelope around the rectum and preserving surrounding structures. This is achieved with extrafascial dissection and removal of the entire mesorectum including the portion distal to the tumor (total mesorectal excision) within its enveloping fascia as an intact unit. Total mesorectal excision is the standard of care surgical treatment of mid and low rectal cancer and can be performed in conjunction with low anterior resection, abdominoperineal resection, extralevator abdominoperineal resection, and extraregional dissection. To accomplish such a resection, thorough knowledge of the surgical anatomy of the rectum and pelvic structures and fascial planes is paramount.
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Yang XF, Luo GH, Ding ZH, Li GX, Chen XW, Zhong SZ. The urogenital-hypogastric sheath: an anatomical observation on the relationship between the inferomedial extension of renal fascia and the hypogastric nerves. Int J Colorectal Dis 2014; 29:1417-26. [PMID: 25060217 DOI: 10.1007/s00384-014-1973-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE The study aimed to perform an anatomical observation on the inferomedial extension of the renal fascia (RF) to the pelvis and explore its relationship with the hypogastric nerves (HGNs). METHODS Gross anatomy was performed on 12 formalin-fixed and 12 fresh cadavers. Sectional anatomy was performed on four formalin-fixed cadavers. RESULTS Different from the traditional concept, both the anterior and posterior RF included the outer and inner layer with different inferomedial extensions. The multiple layers of RF extended downward to form a sandwich-like and compound fascia sheath with potential and expandable spaces which was named as "the urogenital-hypogastric sheath." Below the level of the origin of the inferior mesenteric artery, the bilateral urogenital-hypogastric sheath communicated with the counterpart in front of the great vessels in the midline and the superior hypogastric plexus ran into the urogenital-hypogastric sheath which carried the HGNs, ureters, and genital vessels downward to their terminations in the pelvis. In the retrorectal space, the urogenital-hypogastric sheath surrounded the fascia propria of the rectum posterolaterally as a layer of coat containing HGNs. CONCLUSION The multiple layers of RF with different extensions are the anatomical basis of the formation of the urogenital-hypogastric sheath. As a special fascial structure in the retroperitoneal space and the pelvis, emphasis on its formation and morphology may be helpful for not only unifying the controversies about the relationship between the pelvic fascia and HGNs but also improving the intraoperative preservation of the HGNs by dissecting in the correct surgical plane.
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Affiliation(s)
- X F Yang
- Department of Gastrointestinal Surgery, Guizhou Provincial People's Hospital, Guiyang, China
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A prospective video-controlled study of genito-urinary disorders in 35 consecutive laparoscopic TMEs for rectal cancer. Surg Endosc 2014; 29:1721-8. [PMID: 25303909 DOI: 10.1007/s00464-014-3876-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 07/20/2014] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Genito-urinary disorders (GUD) for radical rectal cancer surgery range from 10 to 30%. In this study, primary endpoint is to prospectively assess their incidence in patients undergoing Laparoscopic Total Mesorectal Excision (LTME) without neoadjuvant chemo-radiation (NCR). Secondary endpoint is to detect the potential lesion site evaluating video-recordings of surgery. PATIENTS AND METHODS A study of 35 consecutive patients treated by LTME for extra-peritoneal rectal cancer not subjected to NCR, M:F = 23:12, median age 70, was evaluated preoperatively by Uroflowmetry and US postvoid residual urine measurement (PVR), International Prostatic Symptoms Score (IPSS), and International Consultation on Incontinence Modular Questionnaire (ICIQ) at 1 and 9 months post-operatively. Evaluation of sexual function was carried out by International Index of Erectile Function (IIEF) in males. Data were analyzed performing Fisher and paired samples t tests. Surgical videos of patients affected by GUD were reviewed to identify lesion sites. RESULTS Urinary function:IPSS average score: baseline 6.03 ± 5.51, 8.93 ± 6.42 (p = .005) at 1 month, and 7.26 ± 5.55 (p = .041) at 9 months. ICIQ baseline 2.67 ± 5.42, 4.27 ± 6.19 (p = NS) at 1 month, and 3.63 ± 5.23 (p = NS) at 9 months. Maximum urine flow rate baseline 15.95 ± 4.78 ml/s, 14.23 ± 5.27 after 1 month (p = .041), and 15.22 ± 4.01 after 9 months (p = NS). Mean urine flow rate baseline 9.15 ± 2.96 ml/s, 7.99 ± 4.12 ml/s at 1 month (p = .044), and 8.54 ± 4.19 ml/s at 9 months (p = NS). PVR baseline 59.62 ± 54.49, 64.59 ± 58.71 (p = NS) at 1 month, and 68.82 ± 77.72 (p = NS) at 9 months. Sexual function: IIEF baseline 19.38 ± 6.25, 14.06 ± 8.65 at 1 month (p = .011), and 15.4 ± 8.41 at 9 months, (p = NS). Video review of patients with disorders showed potential damage at the site of ligation of IMA (high hypogastric plexus) in 1 case, lateral and posterior mesorectum dissection (hypogastric nerves) in 2 cases, anterior dissection of the Denonvilliers fascia from seminal vesicles in 2 cases. CONCLUSIONS GUD at 1 month from LTME for rectal cancer are significant but improve at 9 months. Surgical video review of patients with GUD provides an important tool for detection of lesion sites.
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Sidorov DV, Frank GA, Mainovskaya OA, Lozhkin MV, Grishin NA, Petrov LO, Troitskiy AA, Kirsanova ON. Total mesorectal excision with water-jet dissection in patients with rectal cancer: surgical and morphological aspects. Colorectal Dis 2014; 16:O182-5. [PMID: 24330465 DOI: 10.1111/codi.12514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 09/15/2013] [Indexed: 02/08/2023]
Abstract
AIM This publication will describe our own experience of using the ERBEJET2(®) water-jet dissector during surgical interventions for rectal cancer. METHOD We utilized the water-jet dissection technique to obtain tissue specimens in 10 patients with rectal cancer. All patients thus underwent nerve-sparing low anterior resection of the rectum along with para-aortic lymphadenectomy. No intraoperative complications were registered. The postoperative period went uncomplicated in all patients. No dysuria was observed. Obtained tissue specimens were examined morphologically. Macroscopic examination included assessments of the preservation of the rectal fascia propria and the amount of cellular tissue along the anterior, posterior, and lateral surfaces of the rectum. We performed microscopy of the circumferential resection margin to characterize the surgical clearance and the intensity and depth of damage to the mesorectal tissue. On morphological examination, the quality of mesorectal excision was found to be good (Grade 3) in all 10 patients. RESULTS As the results of our study demonstrate, the depth of lateral tissue damage is minimal with the water-jet dissector. CONCLUSION Water-jet dissectors have their own place in the long list of armamentarium used in surgical interventions performed for rectal cancer and contribute to improving oncological and functional outcomes of surgical treatment in this patient population.
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Affiliation(s)
- D V Sidorov
- Department of Abdominal Oncology, Moscow Research Institute of Oncology named after P. A. Gertsen, Moscow, Russia
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Urinary and erectile function in men after total mesorectal excision by laparoscopic or robot-assisted methods for the treatment of rectal cancer: a case-matched comparison. World J Surg 2013. [PMID: 24366278 DOI: 10.1007/s00268‐013‐2419‐5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Urinary and sexual dysfunction are recognized complications of rectal cancer surgery in men. This study compared robot-assisted total mesorectal excision (RTME) and laparoscopic total mesorectal excision (LTME) with regard to these functional outcomes. METHODS A series of 32 men who underwent RTME between February 1, 2009 and December 31, 2010 were matched 1:1 with patients who underwent LTME. The matching criteria were age, body mass index, tumor distance from the anal verge, neoadjuvant chemoradiation therapy, and tumor stage. Urinary and erectile function were evaluated using the International Prostatic Symptom Score (IPSS) and the five-item version of the International Index of Erectile Function (IIEF-5) scale. Data were collected from the two groups at baseline and at 3, 6, and 12 months after surgery and compared. RESULTS The mean IPSS score did not differ between the two groups at baseline at any point of measurement. The mean baseline IIEF-5 score was similar between the two groups and was decreased at 3 months. The mean IIEF-5 score was significantly higher in the RTME group at 6 months than in the LTME group (14.1 ± 6.1 vs. 9.4 ± 6.6; p = 0.024). The interval decrease in IIEF-5 scores was significantly higher in the LTME group than in the RTME group at 6 months (4.9 ± 4.5 vs. 9.2 ± 4.7; p = 0.030). CONCLUSIONS The men in the RTME group experienced earlier restoration of erectile function than did those in the LTME group. Bladder function was similar during the 12 months after RTME or LTME.
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Runkel N, Reiser H. Nerve-oriented mesorectal excision (NOME): autonomic nerves as landmarks for laparoscopic rectal resection. Int J Colorectal Dis 2013; 28:1367-75. [PMID: 23666512 DOI: 10.1007/s00384-013-1705-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE We have developed nerve-oriented mesorectal excision (NOME) as a novel concept in rectal cancer surgery by which autonomic pelvic nerves serve as landmarks for a standardized navigation along fascial planes. This article describes the technique step by step and presents our results from 2008 to 2012. MATERIAL AND METHODS The key steps are: preparation of the splanchnic nerves at the mid-posterior sidewall, the hypogastric nerves at the upper sidewall, and the urogenital nerve branches (Walsh) at the caudal-anterior sidewall. The dissection of the lateral ligament is strictly performed as the last step. NOME was applied in 274 consecutive mesorectal excisions (partial 20.4%, total 79.6%); a subgroup of 42 male patients underwent a questionnaire-based interview on sexual activity. RESULTS The conversion rate was 0.7%. High (complete) specimen quality and circumferential margin negativity were achieved in 90.1% and 95.3%, respectively. Anastomotic leaks occurred in 13 (4.7%) patients. Mortality was 1.8%. The frequency of prolonged urinary catheter was 1.8%. Of 22 sexually active males interviewed, 18 (81.8%) maintained activity postoperatively. CONCLUSIONS NOME achieves high-quality mesorectal specimens and a high rate of preservation of autonomic nerve function. The concept of using nerves as laparoscopic landmarks may help to standardize and master laparoscopic rectal cancer surgery.
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Affiliation(s)
- Norbert Runkel
- Department of General Surgery, Schwarzwald-Baar-Klinikum, Teaching Hospital of the University of Freiburg, Vöhrenbacher Str. 25, 78050, Villingen-Schwenningen, Germany,
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Kneist W, Kauff DW, Lang H. Laparoscopic neuromapping in pelvic surgery: scopes of application. Surg Innov 2013; 21:213-20. [PMID: 23892318 DOI: 10.1177/1553350613496907] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND New developments in intraoperative electrophysiological neuromonitoring for conventional surgery are providing further insights into functional neuroanatomy and nerve-sparing in the minor pelvis. The aim of this study was to open up potential scopes of application in laparoscopy. METHODS Ten patients with different indications for surgery (presacral tumor excision, n = 2; resection rectopexy. n = 2; low anterior rectal resection, n = 2; proctocolectomy. n = 2; abdomino-perineal excision of the rectum, n = 2) were investigated prospectively. The pelvic autonomic nerves were bilaterally mapped by laparoscopic electric stimulation under simultaneous electromyography of the internal anal sphincter and manometry of the bladder. Stimulation results were compared to patients' anorectal and urogenital functional outcome. RESULTS In all the operations laparoscopic neuromapping (LNM) was technically feasible. Laparoscopy enabled excellent visibility of pelvic neural structures for simple and differentiated electric stimulation. In all cases LNM resulted in significantly evoked electromyographic potentials and intravesical pressure rises. The technique facilitated electrophysiological determination of functional neuroanatomical topography in the minor pelvis. The stimulation results were suitable to confirm laparoscopic nerve-sparing and compatible with patients' anorectal and urogenital functional outcome. CONCLUSIONS LNM is technically feasible and opens up a new dimension for verification of functional nerve integrity. Further developments and investigations are mandatory to evaluate its role for laparoscopic nerve-sparing procedures.
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Affiliation(s)
- Werner Kneist
- 1University Medicine of the Johannes Gutenberg-University Mainz, Germany
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Lee YS, Chong GO, Lee YH, Hong DG, Cho YL, Park IS. Robot-assisted total preservation of the pelvic autonomic nerve with extended systematic lymphadenectomy as part of nerve-sparing radical hysterectomy for cervical cancer. Int J Gynecol Cancer 2013; 23:1133-8. [PMID: 23792607 DOI: 10.1097/igc.0b013e31829b10db] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate our short-term clinical outcomes of robot-assisted autonomic nerve-sparing extended systematic lymphadenectomy as part of nerve-sparing radical hysterectomy. METHODS Between March 2011 and June 2012, we observed prospectively 28 consecutive patients who underwent robot-assisted autonomic nerve-sparing extended systematic lymphadenectomy, including the superior and inferior gluteal, presacral (subaortic), common iliac, and lower para-aortic nodes. RESULTS The predominant International Federation of Gynecology and Obstetrics stage was IB1 (15 patients), followed by IB2 (5 patients), IA2 (3 patients), IIA1 (3 patients), and IIA2 (2 patients). The mean ± SD total operating time was 308.8 ± 54.9 minutes, and the mean ± SD console time was 280.0 ± 46.0 minutes. The mean ± SD blood loss was 102.7 ± 153.8 mL. The mean ± SD acquired pelvic lymph node was 27.1 ± 9.3, the mean ± SD extended lymph node was 19.2 ± 9.6, and the mean ± SD total lymph node was 46.3 ± 14.5. A total of 10 patients (35.7%) had nodal metastasis; among them, 6 patients (21.4%) had single pelvic nodal metastasis, 3 patients (10.7%) had concurrent pelvic and extended nodal metastasis, and one patient (3.6%) had single extended nodal metastasis. No intraoperative complications that required treatment occurred; however, ureterovaginal fistula was identified in 4 patients (14.3%) and ureter stricture in 4 patients (14.3%) after radiotherapy. After a median follow-up of 10 months (range, 1-16 months), there was no pelvic recurrence; however, one patient had recurrence at transposition site of ovary. CONCLUSIONS With the advantage of delicate movement of robot instrument, robot-assisted systematic extended lymphadenectomy with total preservation of pelvic autonomic nerves did not compromise the radicality, and its surgical technique was feasible and safe. By using this approach, we could harvest more lymph nodes and have a high rate of metastatic nodes without disturbing voiding function; however, there was increased rate of urological complications. Moreover, long-term survival benefit after an extended systematic lymphadenectomy must be evaluated.
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Affiliation(s)
- Yoon Soon Lee
- Department of Obstetrics and Gynecology, School of Medicine, Kyungpook National University Medical Center, Daegu, Korea.
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Biomechanical origin of the Denonvilliers’ fascia. Surg Radiol Anat 2013; 36:71-8. [DOI: 10.1007/s00276-013-1142-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Accepted: 05/22/2013] [Indexed: 10/26/2022]
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Zaitouna M, Alsaid B, Diallo D, Benoit G, Bessede T. Identification of the origin of adrenergic and cholinergic nerve fibers within the superior hypogastric plexus of the human fetus. J Anat 2013; 223:14-21. [PMID: 23668336 DOI: 10.1111/joa.12061] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2013] [Indexed: 01/08/2023] Open
Abstract
Nerve fibers contributing to the superior hypogastric plexus (SHP) and the hypogastric nerves (HN) are currently considered to comprise an adrenergic part of the autonomic nervous system located between vertebrae (T1 and L2), with cholinergic aspects originating from the second to fourth sacral spinal segments (S2, S3 and S4). The aim of this study was to identify the origin and the nature of the nerve fibers within the SHP and the HN, especially the cholinergic fibers, using computer-assisted anatomic dissection (CAAD). Serial histological sections were performed at the level of the lumbar spine and pelvis in five human fetuses between 14 and 30 weeks of gestation. Sections were treated with histological staining [hematoxylin-eosin (HE) and Masson's trichrome (TriM)] and with immunohistochemical methods to detect nerve fibers (anti-S100), adrenergic fibers (anti-TH), cholinergic fibers (anti-VAChT) and nitrergic fibers (anti-nNOS). The sections were then digitalized using a high-resolution scanner and the 3D images were reconstructed using winsurf software. These experiments revealed the coexistence of adrenergic and cholinergic fibers within the SHP and the HNs. One-third of these cholinergic fibers were nitrergic fibers [anti-VACHT (+)/anti-NOS (+)] and potentially pro-erectile, while the others were non-nitrergic [anti-VACHT (+)/anti-NOS (-)]. We found these cholinergic fibers arose from the lumbar nerve roots. This study described the nature of the SHP nerve fibers which gives a better understanding of the urinary and sexual dysfunctions after surgical injuries.
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Affiliation(s)
- Mazen Zaitouna
- Laboratory of Experimental Surgery, EA4122, Faculty of Medicine, University Paris Sud, 63 avenue Gabriel Péri, Le Kremlin-Bicetre, France.
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Impact of robotic surgery on sexual and urinary functions after fully robotic nerve-sparing total mesorectal excision for rectal cancer. Ann Surg 2013; 257:672-8. [PMID: 23001075 DOI: 10.1097/sla.0b013e318269d03b] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Urinary and sexual dysfunctions are recognized complications of rectal cancer surgery. Their incidence after robotic surgery is as yet unknown. The aim of this study was to prospectively evaluate the impact of robotic surgery for rectal cancer on sexual and urinary functions in male and female patients. METHODS AND PROCEDURES From April 2008 to December 2010, 74 patients undergoing fully robotic resection for rectal cancer were prospectively included in the study. Urinary and sexual dysfunctions affecting quality of life were assessed with specific self-administered questionnaires in all patients undergoing robotic total mesorectal excision (RTME). Results were calculated with validated scoring systems and statistically analyzed. RESULTS The analyses of the questionnaires completed by the 74 patients who underwent RTME showed that sexual function and general sexual satisfaction decreased significantly 1 month after intervention: 19.1 ± 8.7 versus 11.9 ± 10.2 (P < 0.05) for erectile function and 6.9 ± 2.4 versus 5.3 ± 2.5 (P < 0.05) for general satisfaction in men; 2.6 ± 3.3 versus 0.8 ± 1.4 (P < 0.05) and 2.4 ± 2.5 versus 0.7 ± 1.6 (P < 0.05) for arousal and general satisfaction, respectively, in women. Subsequently, both parameters increased progressively, and 1 year after surgery, the values were comparable to those measured before surgery. Concerning urinary function, the grade of incontinence measured 1 year after the intervention was unchanged for both sexes. CONCLUSIONS RTME allows for preservation of urinary and sexual functions. This is probably due to the superior movements of the wristed instruments that facilitate fine dissection, coupled with a stable and magnified view that helps in recognizing the inferior hypogastric plexus.
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Resection rectopexy--laparoscopic neuromapping reveals neurogenic pathways to the lower segment of the rectum: preliminary results. Langenbecks Arch Surg 2013; 398:565-70. [PMID: 23435617 DOI: 10.1007/s00423-013-1064-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 02/08/2013] [Indexed: 12/15/2022]
Abstract
PURPOSE Nerve sparing in functional pelvic floor surgery is strongly recommended as intraoperative damage to the autonomic nerves may predispose to persistent or worsened anorectal and urogenital function. The aim of this study was to investigate the intraoperative neural topography above the pelvic floor in patients undergoing laparoscopic resection rectopexy in combination with electrophysiologic neuromapping. METHODS Ten consecutive female patients underwent laparoscopic resection rectopexy for rectal prolapse. Intraoperative identification of pelvic autonomic nerves was carried out with a novel intraoperative neuromonitoring system based on electric stimulation under simultaneous electromyography of the internal anal sphincter and manometry of the bladder. Neuromonitoring results were compared to patients' preoperative anorectal and urogenital function and their functional results at the 3-month follow-up. RESULTS Laparoscopy in combination with electrophysiologic neuromapping revealed neurogenic pathways to the lower segment of the rectum during surgical mobilization. In all procedures, intraoperative neuromonitoring finally confirmed functional nerve integrity to the internal anal sphincter and the bladder. Patients with preoperatively diagnosed fecal incontinence were continent at the 3-month follow-up. The Wexner score improved in median from preoperative 4 (range 1-18) to 1 (range 0-3) at follow-up (p = 0.012). Cleveland Clinical Constipation Score improved in median from 10 (range 5-17) to 3 (range 1-7; p = 0.005). In none of the investigated patients a new onset of urinary dysfunction did occur. No change in sexual function was observed. CONCLUSIONS Laparoscopy in combination with electrophysiologic neuromapping during nerve-sparing resection rectopexy identified and preserved neurogenic pathways heading to the lower segment of the rectum above the level of the pelvic floor.
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Preservation of genital innervation in women during total mesorectal excision: which anterior plane? World J Surg 2012; 36:201-7. [PMID: 21976012 DOI: 10.1007/s00268-011-1313-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Erectile dysfunction, principally related to injury of the autonomic nerve fibers in men, is a major cause of postoperative morbidity after anterolateral dissection during total mesorectal excision (TME) for rectal adenocarcinoma. However, the autonomic innervation of erectile bodies is less known in women, and the anterolateral plane of dissection during TME remains unclear. The existence of the rectovaginal septum(RVS) is controversial. The purpose of the present study was to identify the RVS in the human fetus and adult female by dissection, immunohistochemistry, and three-dimensional reconstruction, and to define its relationship with erectile nerve fibers so as to determine the anterolateral plane of dissection during TME, which could reduce postoperative sexual dysfunction in women. METHOD Macroscopic dissection, histologic studies, and immunohistochemistry examination with 3D reconstruction were performed in six fresh female adult cadavers and six female fetuses. RESULTS The RVS was clearly definable in all adult specimens. It was composed of multiple connective tissue, with smooth muscle fibers originating from the uterus and the vagina. It is closely applied to the vagina and has a relationship with the neurovascular bundles (NVBs) that contain erectile fibers intended for the clitoris. The NVBs are situated anteriorly to the posterior extension of rectovaginal septum. This posterior extension protects the NVBs during the anterior and anterolateral dissection for removal of rectal cancer. CONCLUSIONS To reduce the risk of postoperative sexual dysfunction in women undergoing TME for rectal cancer, we recommend careful dissection to the anterior mesorectum to develop a plane of dissection behind the posterior extension of the RVS if oncologically reasonable.
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Total mesorectal excision--does the choice of dissection technique have an impact on pelvic autonomic nerve preservation? J Gastrointest Surg 2012; 16:1218-24. [PMID: 22450951 DOI: 10.1007/s11605-012-1870-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 03/07/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aim of this experimental study was to assess the quality of pelvic autonomic nerve preservation of different dissection techniques. MATERIAL AND METHODS Twelve pigs underwent low anterior rectal resection (LARR) with scissors, ultracision, monopolar diathermy, and waterjet, each in three animals. Assessment of pelvic autonomic nerve preservation was carried out by stimulation of the pelvic splanchnic nerves under electromyography of the internal anal sphincter (IAS). Neurostimulation was performed bilaterally after posterior dissection, after complete mesorectal dissection, and after rectal resection. RESULTS Stimulation resulted in significantly increased amplitudes of the time-based electromyographic signal of the IAS, confirming nerve preservation. The stimulation results after complete mesorectal dissection showed comparable median amplitude increases for dissection with scissors (10.34 μV (interquartile range [IQR], 5.58; 14.74)) and ultracision (9.79 μV (IQR, 7.63; 11.6)). Lower amplitude increases were observed for monopolar diathermy (4.47 μV (IQR, 2.52; 10.46)) and waterjet (0.61 μV (IQR, 0.07; 2.11)) (p = 0.038). All animals undergoing dissection with scissors, ultracision, and monopolar diathermy had bilateral positive results. Of three animals undergoing LARR with waterjet, one had bilateral positive results. Two had unilateral negative results, indicating incomplete nerve preservation. CONCLUSION Scissors, ultracision, and monopolar diathermy might have comparable nerve-sparing potentials and differed from waterjet.
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Kauff DW, Kempski O, Koch KP, Huppert S, Hoffmann KP, Lang H, Kneist W. Continuous intraoperative monitoring of autonomic nerves during low anterior rectal resection: an innovative approach for observation of functional nerve integrity in pelvic surgery. Langenbecks Arch Surg 2012; 397:787-92. [PMID: 22350611 DOI: 10.1007/s00423-011-0900-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Accepted: 12/22/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE The aim of this study was to develop a methodological setup for continuous intraoperative neuromonitoring with intent to improve nerve-sparing pelvic surgery. METHODS Fourteen pigs underwent low anterior rectal resection. Continuous stimulation of pelvic autonomic nerves was carried out with a newly developed tripolar surface electrode during lateral, anterolateral, and anterior mesorectal dissection. Neuromonitoring was performed under electromyography of the autonomic innervated internal anal sphincter. RESULTS Continuous neuromonitoring resulted in significantly increased electromyographic amplitudes of the internal anal sphincter, confirming intact innervation throughout the whole dissection in each animal (median 0.9 μV, interquartile range 0.5; 1.5 vs. median 3.4 μV, interquartile range 2.1; 4.7) (p < 0.001). The median dissection time in each animal was 10 min within a median number of ten (range 8-13) tripolar electric stimulations. CONCLUSION The present study is the first to demonstrate that continuous intraoperative monitoring of pelvic autonomic nerves during low anterior rectal resection is feasible.
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Affiliation(s)
- D W Kauff
- Department of General and Abdominal Surgery, University Medicine of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
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Moszkowicz D, Alsaid B, Bessede T, Penna C, Nordlinger B, Benoît G, Peschaud F. Where does pelvic nerve injury occur during rectal surgery for cancer? Colorectal Dis 2011; 13:1326-34. [PMID: 20718836 DOI: 10.1111/j.1463-1318.2010.02384.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM Optimal treatment of rectal adenocarcinoma involves total mesorectal excision with nerve-preserving dissection. Urinary and sexual dysfunction is still frequent following these procedures. Improved knowledge of pelvic nerve anatomy may help reduce this and define the key anatomical zones at risk. METHOD The MEDLINE database was searched for available literature on pelvic nerve anatomy and damage after rectal surgery using the key words 'autonomic nerve', 'pelvic nerve', 'colorectal surgery', and 'genitourinary dysfunction'. All relevant French and English publications up to May 2010 were reviewed. Reviewed data were illustrated using 3D reconstruction of the foetal pelvis. RESULTS The ligation of the inferior mesenteric artery and dissection of the retrorectal space can cause damage to the superior hypogastric plexus and/or hypogastric nerve. Anterolateral dissection in the 'lateral ligament' area and division of Denonvilliers' fascia can damage the inferior hypogastric plexus and efferent pathways. Perineal dissection can indirectly damage the pudendal nerve. CONCLUSIONS In most cases, the pelvic nerves can be preserved during rectal surgery. Complete oncological resection may require dissection close to the nerves where the tumour is located anterolaterally where it is fixed and when the pelvis is narrow.
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Affiliation(s)
- D Moszkowicz
- Laboratory of Experimental Surgery, Faculty of Medicine, University Paris-Sud 11, Le Kremlin-Bicêtre, France
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Holubar SD, Kane S. Prevention and Treatment of Postproctectomy Infertility. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2011.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Stelzner S, Holm T, Moran BJ, Heald RJ, Witzigmann H, Zorenkov D, Wedel T. Deep pelvic anatomy revisited for a description of crucial steps in extralevator abdominoperineal excision for rectal cancer. Dis Colon Rectum 2011; 54:947-57. [PMID: 21730782 DOI: 10.1097/dcr.0b013e31821c4bac] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Extralevator abdominoperineal excision results in superior oncologic outcome for advanced low rectal cancer. The exact definition of surgical resection planes is pivotal to achieving negative circumferential resection margins. OBJECTIVE This study aims to describe the surrounding anatomical structures that are at risk for inadvertent damage during extralevator abdominoperineal excision. DESIGN AND SETTING Joint surgical and macroanatomical dissection was performed in a university laboratory of clinical anatomy. METHODS A stepwise dissection study was conducted according to the technique of extralevator abdominoperineal excision by abdominal and perineal approaches in 4 human cadaveric pelvises. Muscular, fascial, tendinous, and neural structures were carefully exposed and related to the corresponding surgical resection planes. RESULTS In addition to the autonomic nerves to be identified and preserved during total mesorectal excision, further structures endangered during extralevator abdominoperineal excision can be clearly identified. Terminal pudendal nerve branches come close to the surgical resection plane at the outer surface of the puborectal sling. Likewise, the pelvic plexus and its neurovascular bundles embedded within the parietal pelvic fascia extend close to the apex of the prostate where the parietal pelvic fascia has to be divided. These neural structures converge in the region of the perineal body, an area that provides no "self-opening" planes for surgical dissection. Thus, the necessity to sharply detach the anorectal specimen anteriorly from the perineal body and the superficial transverse perineal muscle bears the risk of both inadvertent damage of the aforementioned anatomical structures and perforation of the specimen. LIMITATIONS The study focused primarily on the macroscopic topography relevant to the surgical procedure, so that previously published histologic examinations were not performed. CONCLUSION The present anatomical dissection study highlights those anatomical landmarks that require clear identification for the successful achievement of both negative circumferential resection margins and preservation of urogenital functions during extralevator abdominoperineal excision.
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Affiliation(s)
- Sigmar Stelzner
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Dresden, Germany.
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Laparoscopic-assisted low anterior resection of the rectum--a review of the fascial composition in the pelvic space. Int J Colorectal Dis 2011; 26:405-14. [PMID: 21190027 DOI: 10.1007/s00384-010-1107-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/03/2010] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Outcomes of rectal cancer treatment depend on the operative technique, and complication rates vary. Complications can occur during mobilization of the rectum, with damage to the ureter, autonomic nerves, and the rectum itself. Frequencies of these complications can be reduced by careful dissection of the correct tissue plane in the pelvic space. METHODOLOGY This paper reviews the fascial composition of the rectum for low anterior resection of the rectum. To date, fascial composition of the pelvic space has been considered based on clinical anatomy and histological examination of cadaveric specimens. However, clarification of fascial composition is clearly limited, to a certain extent, in histological examinations compared with clinical anatomy. CONCLUSIONS First, some degree of dissociation must exist between the histological examination and clinical anatomy. Second, surgeons should not consider fascia encountered intraoperatively as an artifact. To address these difficult issues, consideration should be made purely from the perspective of clinical anatomy. Originally, the trunk was embryologically regarded as a multi-layered structure (like an onion). Understanding the fascial composition of the abdomen is comparatively easy when approached from this perspective. If this theory is adapted to the pelvic space in order to avoid antilogy, an understanding of the fascial composition of the pelvic space should also be possible. We review previous papers based on this theory.
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Correia JAP, De-Ary-Pires B, Pires-Neto MA, De Ary-Pires R. The developmental anatomy of the human superior hypogastric plexus: A morphometrical investigation with clinical and surgical correlations. Clin Anat 2011; 23:962-70. [PMID: 20949499 DOI: 10.1002/ca.21027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The superior hypogastric plexus (SHP) is the part of the autonomic nervous system, which is responsible for the sympathetic innervation of pelvic organs and extrapelvic genitals in humans of both sexes. The SHP also functions as the anatomic pathway for the major part of visceral sensitive fibers originating from pelvic viscera. In this study, the morphology of the SHP was analyzed through anatomical dissections performed both in human adult and fetal cadavers. A computerized morphometrical investigation of the SHP was also performed and the resulting quantitative data statistically assessed. The comparison between fetal and adult SHP revealed that in the male group there was a developmental increase of six times (in height) and of about five times (in width); while in the female group, there was a developmental increase of 3.5 times both in height and width values. In addition, the distance from the superior border of the SHP to the bifurcation of the common iliac arteries presented a developmental increase of about six times in the male group, and about four times in the female group. We propose an original morphological classification with six types, based upon the anatomical arrangement of the nervous fibers in this autonomic plexus.
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Kneist W, Kauff DW, Koch KP, Schmidtmann I, Heimann A, Hoffmann KP, Lang H. Selective pelvic autonomic nerve stimulation with simultaneous intraoperative monitoring of internal anal sphincter and bladder innervation. ACTA ACUST UNITED AC 2011; 46:133-8. [PMID: 21311193 DOI: 10.1159/000323558] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 12/14/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pelvic autonomic nerve preservation avoids postoperative functional disturbances. The aim of this feasibility study was to develop a neuromonitoring system with simultaneous intraoperative verification of internal anal sphincter (IAS) activity and intravesical pressure. METHODS 14 pigs underwent low anterior rectal resection. During intermittent bipolar electric stimulation of the inferior hypogastric plexus (IHP) and the pelvic splanchnic nerves (PSN), electromyographic signals of the IAS and manometry of the urinary bladder were observed simultaneously. RESULTS Stimulation of IHP and PSN as well as simultaneous intraoperative monitoring could be realized with an adapted neuromonitoring device. Neurostimulation resulted in either bladder or IAS activation or concerted activation of both. Intravesical pressure increase as well as amplitude increase of the IAS neuromonitoring signal did not differ significantly between stimulation of IHP and PSN [6.0 cm H(2)O (interquartile range [IQR] 3.5-9.0) vs. 6.0 cm H(2)O (IQR 3.0-10.0) and 12.1 μV (IQR 3.0-36.7) vs. 40.1 μV (IQR 9.0-64.3)] (p > 0.05). CONCLUSIONS Pelvic autonomic nerve stimulation with simultaneous intraoperative monitoring of IAS and bladder innervation is feasible. The method may enable neuromonitoring with increasing selectivity for pelvic autonomic nerve preservation.
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Affiliation(s)
- W Kneist
- Department of General and Abdominal Surgery, University Medicine of the Johannes Gutenberg University Mainz, Mainz, Germany.
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He JH, Wang Q, Cai QP, Dang RS, Jiang EP, Huang HL, Sun YP. Quantitative anatomical study of male pelvic autonomic plexus and its clinical potential in rectal resection. Surg Radiol Anat 2010; 32:783-90. [DOI: 10.1007/s00276-010-0677-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Accepted: 04/27/2010] [Indexed: 01/04/2023]
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