Male Sexual and Urinary Function After Total Mesorectal Excision

Transcription

1 Eur J Surg Sci 2012;3(2):46-50 ORIGINAL ARTICLE Male Sexual and Urinary Function After Total Mesorectal Excision Bahri ÇAKABAY 1, Bülent AKSEL 1, Salim DEMİRCİ 1, Hikmet AKGÜL 1 1 Department of Surgical Oncology, Faculty of Medicine, University of Ankara, Ankara, Turkey ABSTRACT Introduction: This study evaluated the frequency of male urinary and sexual dysfunction after total mesorectal excision with autonomic nerve preservation. Materials and Methods: Forty men younger than 65 years of age who underwent mesorectal excision for rectal cancer were followed for at least one year, interviewed, and then completed standardized questionnaires regarding postoperative functional outcomes. Exclusion criteria were preoperative erectile and urinary dysfunction, metastatic disease, T4 stage disease (TNM AJCC), and patients who underwent a partial mesorectal excision for an upper rectal tumor or had direct invasion of the autonomic nerves found intraoperatively. Results: Impotence developed in 1 (5%) patient. Two (10%) of the 20 patients who were potent preoperatively lost the ability to ejaculate. None of the patients who were potent postoperatively had developed major urinary symptoms one year after surgery. Minor disturbances in bladder function were reported in 5 (25%) patients. Conclusion: Total mesorectal excision with the autonomic nerve-preserving technique yields good results in terms of sexual and urinary functional outcome, and should be considered for adoption as a standard surgical procedure for primary rectal cancer. Key words: Rectal cancer, Sexual dysfunction, Total mesorectal excision, Urinary dysfunction Re ce ived: March 03, 2012 Accepted: May 18, 2012 ÖZET Total Mezorektal Eksizyon Sonrası Erkek Cinsel ve Üriner Fonksiyonları Amaç: Bu çalışmada otonom sinir koruyucu cerrahi ile birlikte total mezorektal eksizyon uygulanan erkek hastalarda cinsel ve üriner fonksiyon bozukluğu değerlendirildi. Materyal ve Metod: Rektum kanseri nedeniyle mezorektal eksizyon uygulanan 65 yaş altı toplam 40 hasta bir yıl süreyle izlendi. Hastaların postoperatif fonksiyonları standardize edilmiş formlarla değerlendirildi. Preoperatif erektil ve üriner fonksiyon bozukluğu olan hastalar, T4 hastalık (TNM AJCC), üst rektum kanseri nedeniyle parsiyel mezorektal eksizyon uygulanan hastalar ve intraoperatif olarak direkt otonom sinir invazyonu gözlenenen hastalar çalışma dışı bırakıldı. 46

2 Çakabay B, Aksel B, Demirci S, Akgül H. Bulgular: Bir (%5) hastada impotans gelişti. Preoperatif olarak potent olan 20 hastanın 2 (%10)'sinde ejekülasyon kaybı gözlendi. Potent hastaların hiçbirinde postoperatif bir yıl boyunca majör üriner fonksiyon bozukluğu gözlenmedi. Minör mesane fonksiyon bozukluğu 5 (%25) hastada gözlendi. Sonuç: Otonom sinir koruyucu cerrahi ile birlikte total mezorektal eksizyon tekniği, cinsel ve üriner fonksiyonlar ile ilgili iyi sonuçlar vermektedir. Bu tekniğin primer rektal kanserin standart cerrahi yöntemi olarak düşünülmesi gerekmektedir. Anahtar kelimeler: Rektal kanser, Total mezorektal eksizyon, Cinsel fonksiyon bozukluğu, Üriner fonksiyon bozukluğu Geliş Tarihi: 03 Mart 2012 Kabul Ediliş Tarihi: 18 Mayıs 2012 INTRODUCTION Perifascial rectal excision, also called total mesorectal excision (TME), with preservation of the autonomic nerves has become the gold standard for rectal cancer surgery [1,2]. There are four major goals in the treatment of a patient with rectal cancer: local control; long-term survival; preservation of the anal sphincter, bladder, and sexual function; and maintenance or improvement in quality of life [3]. These can be achieved with accurate preoperative staging, appropriate referral for neoadjuvant therapy, and a precise surgical technique using the principles of TME. Postoperative urinary or sexual dysfunction resulting from inadvertent damage to the pelvic hypogastric and splanchnic nerves is a recognized complication of rectal resection. Before the introduction of TME, the incidence of postoperative urinary and sexual dysfunction was 10-30% and 40-60%, respectively [4-7]. Even with the incorporation of autonomic nerve-preserving techniques in TME, urinary and sexual dysfunctions remain recognized complications in 0-12% and 10-35% of patients, respectively [8-13]. This retrospective clinical study evaluated male sexual and functional outcomes in a consecutive series of patients who underwent TME for lower and middle rectal cancer in our institution. MATERIALS and METHODS We studied 40 males with histologically proven primary adenocarcinoma of the rectum who underwent autonomic nerve-sparing mesorectal excision at Ankara University, Department of Surgical Oncology over the period The patients had no history of urinary operations or preoperative urinary dysfunction. Exclusion criteria were preoperative erectile and urinary dysfunction, metastatic disease, and T4 stage disease [TNM American Joint Committee on Cancer (AJCC)]. In addition, patients who underwent a partial mesorectal excision for an upper rectal tumor or had direct invasion of the autonomic nerves found intraoperatively were excluded from the study. Diagnosis and staging were made through rectal examination, colonoscopy and computed tomography (CT). The position of the tumor and distance from the anal verge were estimated at colonoscopy. Tumors were categorized according to the distance above the anal verge as being in the upper rectum (12-15 cm), mid-rectum (7-11 cm), and lower rectum (up to 6 cm). All patients underwent mechanical bowel preparation preoperatively. A second-generation cephalosporin was administered intravenously before the incision. Deep venous thrombosis prophylaxis was achieved with low-molecular-weight heparin. All surgeries were performed by one surgical team composed of experts in TME techniques and colorectal surgery. The surgeon performed the procedures according to oncological and clinical principles, including total mesorectal excision as described by Heald et al. with adequate resection margins, autonomic nerve preservation, en bloc vascular resection, and lymphadenectomy, and minimal intraoperative manipulation of the tumor mass [14]. When digital examination disclosed a neoplasm reaching the anatomic anal canal, a cylindrical abdominoperineal resection (APR) was performed in the prone position for all patients. Autonomic nerve-sparing TME was performed when no direct invasion of the autonomic nerves was found intraoperatively. In the case of adherence or infiltration of the tumor, the hypogastric nerves and/or the inferior hypogastric plexus were sacrificed unilaterally or bilaterally. Bladder and sexual functions were evaluated with a self-administered questionnaire after the initial surgery. Regarding bladder function, the questionnaire inquired about incomplete bladder emptying, urgency, interruption of micturition, reduced force of flow, need to strain, incontinence, dysuria, and need for self-catheterization based on the International Prostatic Symptom Score [15]. Patients were also given a questionnaire on sexual function, and responded to questions concerning erectile potency and the ability Eur J Surg Sci 2012;3(2):

3 Male Sexual and Urinary Function After Total Mesorectal Excision to accomplish sexual intercourse, ejaculate, and experience orgasm. Bladder dysfunction was classified as major in patients with incontinence or selfcatheterization and as minor with other symptoms. The anastomosis was performed with a stapler. Although not routine practice, a protective stoma with a transverse loop colostomy was performed in all patients with mid- and lower rectal tumors when the TME was performed. The colostomy was closed after approximately 2-3 months. RESULTS Forty patients with adenocarcinoma of the rectum were enrolled. After excluding six patients who were not sexually active or had a history of urinary incontinence before the surgical resection, five with T4 stage disease, two with metastatic disease, two with infiltration of the nerves by the tumor (the hypogastric nerve was sacrificed), and five partial mesorectal excisions (upper rectal tumor), 20 patients were ultimately evaluated. Patient characteristics are summarized in Table 1. The mean age at surgery was 58.3 (48-65) years; the distance of the tumor from the anal verge was 7.6 (3-11) cm; tumor stage was pt1 in 5 (25%) patients, pt2 in 5 (25%), and pt3 in 10 (50%); and node stage was pn0 in 9 (45%), pn1 in 6 (30%), and pn2 in 5 (25%). One patient received preoperative chemoradiotherapy. A temporary loop colostomy was performed in all patients. The complication rate was 20%, with three cases of abdominal wound infection and one case of pneumonia. Table 1. Characteristics of the patient population Variable Patients (n= 20) Age (years) 58.3 (48-65) Distance from the anal verge (cm) 7.6 (3-11) Mid-rectum 16 Lower rectum 4 Type of surgery Lower anterior resection 18 Abdominoperineal resection 2 pt stage T1 5 T2 5 T3 10 pn stage N0 9 N1 6 N2 5 Preoperative radiochemotherapy 1 The results regarding sexual function are reported in Table 2. Impotence developed in 1 (5%) patient. Two (10%) of the 20 men who were potent preoperatively lost the ability to ejaculate. None of the patients had developed major urinary symptoms in the first year after surgery. One patient developed a neurogenic bladder necessitating long-term urinary catheterization. Minor urinary dysfunction was present in 5 (25%) patients. Urinary dysfunction was present in three patients who developed sexual dysfunction. DISCUSSION Surgical performance is one of the most important prognostic factors in patients with rectal cancer [16]. In the quest to reduce recurrence rates and improve survival after surgery for rectal cancer, excision techniques have become more radical [1,17]. Mesorectal excision can improve these results; however, unless meticulous attention is paid to autonomic nerve preservation, this more radical approach may theoretically result in sexual and urinary dysfunction [14]. Normal bladder and sexual function is dependent on the parasympathetic and sympathetic nerve supply. The sympathetic nerves emerge from the thoracic and lumbar spinal cord, synapse in the sympathetic ganglion, and send postganglionic hypogastric fibers to join the preganglionic parasympathetic nerve originating in the pelvic plexus. These autonomic nerves run along the pelvic side walls and then continue anteriorly, and are susceptible to injury during rectal resection at the point where they enter their end-organs. The pattern of injury depends not only on the extent of nerve trauma (e.g., unilateral versus bilateral), but also on the relative components of the autonomic supply injured, giving rise to variable symptoms of bladder and sexual dysfunction. Table 2. Male sexual function after total mesorectal excision (TME) Number of patients (%) Sexual desire No difference 14 (70) Reduced 6 (30) Erections with sexual stimulation No difference 19 (95) Impotent 1 (5) Orgasm and ejaculation Normal orgasm and 14 (70) ejaculation function Absence of orgasm 4 (20) Unable to ejaculate 2 (10) 48 Eur J Surg Sci 2012;3(2):46-50

4 Çakabay B, Aksel B, Demirci S, Akgül H. Table 3. Studies on urinary and sexual function published after the introduction of total mesorectal excision (TME) Author Number of patients Bladder dysfunction (%) Loss of erection (%) Enker [19] Leveckis et al. [20] Havenga et al. [8] Maas et al. [11] Saito et al. [21] Nesbakken et al. [12] Nagawa et al. [22] Maurer et al. [23] Quah et al. [24] Kim et al. [13] Morino et al. [25] Injury to the autonomic pelvic nerves is one of the most important causes of sexual and urinary dysfunction after rectal cancer surgery. Since these nerves are susceptible to injury during mesorectal resection, they should be avoided based on knowledge of their relationship with the pelvic organs. Injury to the sympathetic supply results in bladder instability and ejaculatory difficulty, whereas injury to the parasympathetic supply results in poor detrusor contraction and erectile dysfunction [18]. Before the introduction of TME, the reported incidences of postoperative urinary and sexual dysfunction were 10-30% and 40-60%, respectively [4-7]. Even with the incorporation of autonomic nerve-preserving techniques in TME, urinary and sexual dysfunctions remain recognized complications in 0-12% and 10-35% of patients, respectively [8-13]. In our study, good clinical results were obtained with mesorectal dissection, taking care to reproduce the sharp dissection as described by Heald et al. [14]. Even with extreme attention to technical details, impotence developed in 1 (5%) patient. Although our series was small, this percentage is better than the reported results (Table 3). The assessment of sexual function is problematic because it touches on both physical and psychological factors, so the results of symptom recording via questionnaires should be interpreted with caution. In our series, orgasm was absent in 20% and 10% were unable to ejaculate, which is consistent with the literature (Table 3). The incidence of bladder dysfunction was low following TME (Table 3). In our series, only a patient who had diabetes mellitus developed a neurogenic bladder, necessitating long-term urinary catheterization. Minor urinary dysfunction was present in 25% in our study; this result is similar to that described in the literature (Table 3). In conclusion, attention to autonomic nerve preservation is of paramount importance if urinary and sexual dysfunction outcomes are to be avoided. Our study confirms that the incidence of permanent urinary and sexual dysfunction is low. This was achieved after TME with the autonomic nerve-preserving technique. The oncological results after TME are promising, and the low frequency of urinary and sexual complications further supports the contention that mesorectal excision should be the standard treatment for rectal cancer. RE FE REN CES 1. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery - the clue to pelvic recurrence? Br J Surg 1982; 69: Enker WE, Thaler HT, Cranor ML, Polyak T. Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg 1995; 181: Balch GC, De Meo A, Guillem JG. Modern management of rectal cancer: a 2006 update. World J Gastroenterol 2006; 12: Chang PL, Fan HA. Urodynamic studies before and/or after abdominoperineal resection of the rectum for carcinoma. J Urol 1983; 130: Kinn AC, Ohman U. Bladder and sexual function after surgery for rectal cancer. Dis Colon Rectum 1986; 29: Eur J Surg Sci 2012;3(2):

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