Localisation and preservation of the autonomic nerves in rectal cancer surgery - technical details (original) (raw)
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Anatomical basis of autonomic nerve-preserving total mesorectal excision for rectal cancer
British Journal of Surgery, 1996
Total mesorectal excision with autonomic nerve preservation for rectal cancer is based on the anatomy of the mesorectum and of the pelvic autonomic nerves. Cadaver dissections were performed to describe the relationship between these structures. Between the rectum and the sacrum a retrorectal space can be developed, lined anteriorly by the visceral leaf and posteriorly by the parietal leaf of the pelvic fascia. The hypogastric nerve runs anterior to the visceral fascia, from the sacral promontory in a laterocaudad direction. The splanchnic sacral nerves originate from the sacral foramina, posterior to the parietal fascia, and run caudad, laterally and anteriorly. After piercing the parietal layer of the pelvic fascia, approximately 4 cm from the midline, the sacral nerves run between a double layer of the visceral part of the pelvic fascia. The relationship between the hypogastric nerves, the splanchnic nerves and the pelvic fascia was comparable in all six specimens examined.
Surgery, 2002
Background. Oncologic resection of rectal cancer has been reported to be associated with a significant (10%-60%) rate of sexual and urinary dysfunction. We hypothesize that curative total mesorectal excision (TME) with autonomic nerve preservation (ANP) can be done with high rates of preservation of such function. Study design. We studied prospectively preoperative and postoperative urinary and sexual function in patients who had sphincter-preserving operations for rectal carcinoma without preoperative irradiation. Standardized questionnaires were used preoperatively and postoperatively, including the International Prostatic Symptom Score and a score of quality of urinary function satisfaction. Urodynamic evaluation was performed preoperatively and 3 months after the operation. The sexual results were evaluated after 1 year. Results. Twenty patients, 13 men and 7 women, had TME, with ANP technique. Fourteen patients had coloanal anastomosis, 4 had a stapled colorectal anastomosis, and 2 had an ileoanal anastomosis. In all patients, hypogastric and sacral splanchnic nerves were identified and preserved. There was no mortality. Tumors are graded by Astler-Coller classification: A1 in 3 cases, A2 in 3, B1 in 7, B2 in 2, C2 in 1, and D in 1. There was no difference in preoperative and postoperative urinary function, International Prostatic Symptom Score, or urodynamic results, nor in the results of the quality of urinary function questionnaire. Four of the 7 women (69%) were sexually active before undergoing the surgical procedure. Sexual activity and ability to achieve orgasm was unchanged in these women. No dyspareunia was reported. Nine of the 13 men (69%) were sexually potent in the preoperative period. Sexual activity and potency were unchanged in these men. Retrograde ejaculation was reported in 1 man who previously had had normal antegrade ejaculation. After 3 months, 4 patients reported a reduced rigidity of erection, returning to normal by 1 year. Conclusions. The authors conclude that TME and ANP for cancer limited to the mesorectum do not impair urinary and sexual function.
Technique for laparoscopic autonomic nerve preserving total mesorectal excision
International Journal of Colorectal Disease, 2006
W ith the introduction of total mesorectal excision (TME) for treatment of rectal cancer, the prognosis of patients with rectal cancer is improved. With this better prognosis, there is a growing awareness about the quality of life of patients after rectal carcinoma. Laparoscopic total mesorectal excision (LTME) for rectal cancer offers several advantages in comparison with open total mesorectal excision (OTME), including greater patient comfort and an earlier return to daily activities while preserving the oncologic radicality of the procedure. Moreover, laparoscopy allows good exposure of the pelvic cavity because of magnification and good illumination. The laparoscope seems to facilitate pelvic dissection including identification and preservation of critical structures such as the autonomic nervous system. The technique for laparoscopic autonomic nerve preserving total mesorectal excision is reported. A three-or four-port technique is used. Vascular ligation, sharp mesorectal dissection and identification and preservation of the autonomic pelvic nerves are described.
Adv Clin Exp …, 2010
Background. Achieving effective local control and obtaining optimal functional outcomes are now both needed in the surgical management for rectal cancer. Objectives. The aim of this study was to assess early functional results after low anterior resection performed with an ultrasound scalpel. Material and Methods. Nineteen consecutive rectal cancer patients surgically treated during the years 2004-2008 with low anterior resection with sharp total mesorectal excision were studied. Dissection was performed with an ultrasound scalpel instead of electrocautery. The frequency of axial vibration and the extension of longitudinal vibration were 55.5 kHz and 75 µm, respectively. Special effort was made to identify and preserve autonomic nerves. Postoperative complications and functional results were analyzed. Results. Surgery was completed with no intraoperative complications. The mean operating time was 150.20 ± 27.09 min. In each case, resection and anastomosis (straight, double-stapled) were done with ease. There was no postoperative mortality. Blood transfusion was not required. Neither anastomotic leakage nor abdominal infectious complications were noticed. Delayed wound healing and prolonged bowel paralysis occurred in two patients (13%) with diabetes and chronic obturative pulmonary disease, respectively. Urinary bladder disturbance developed in one female patient (7%) as stress incontinence. This dysfunction was transient, with symptoms being significantly reduced during the six postoperative months. Conclusions. Based on this initial series, rectal dissection with an ultrasonic knife appears safe and seems to facilitate autonomic nerve preservation, probably due to minimized thermal damage to tissue. Further investigations and cost-effectiveness analysis are needed to assess its usefulness for the routine surgical practice (Adv Clin ).
Prilozi, 2006
Life quality of the patients operated from rectal cancer is a serious problem. Despite the curing as a primary objective in the treatment of the rectal cancer, special attention is paid to the life quality upon the performed operation on the subjected patients. The analyzed series consists of 29 patients with rectal cancer, operated on at the Digestive Surgery Clinic within the framework of the Clinical Centre in Skopje, in the period between 2001-2006. Our series involves patients from the T2 and T3 stage of the illness, where it possible to preserve the vegetative pelvic nerves, that are characterized by a relatively long-lasting symptomatology and relatively high percentage of lymphatic metastases. The standardization of the operative intervention resulted in an increase in the number of patients with continuous operations and preservation of the neuro-vegetative plexus without influencing the radicalism of the intervention. The application of the Stapler and Double Stapler techn...
British Journal of Surgery, 2005
Background Autonomic nerve preservation has been advocated as a means of preserving urinary and sexual function after surgery for rectal cancer, but may compromise tumour clearance. The aim of this study was to determine the incidence of micrometastasis in the connective tissues surrounding the pelvic plexus. Methods The study included 20 consecutive patients who underwent rectal surgery with bilateral lymph node dissection for advanced cancer. A total of 78 connective tissues medial and lateral to the pelvic plexus and 387 lymph nodes were sampled during surgery. All connective tissue samples and 260 lymph nodes were examined for micrometastases by reverse transcriptase–polymerase chain reaction (RT–PCR) after operation. All patients were followed prospectively for a median of 36·0 months. Results Of 245 histologically negative lymph nodes, 38 (15·5 per cent) were shown by RT–PCR to harbour micrometastases. However, micrometastases to tissues surrounding the pelvic plexus were dete...
Diseases of The Colon & Rectum, 1994
PURPOSE: The aim of this study was to evaluate 5-year and 10-year disease-free survival, urinary dysfunction, and sexual activity after nerve-sparing radical surgery, including lumboaortic lymphadenectomy for rectosigmoid cancer. METHODS: Since 1980 to 1992, 302 consecutive patients affected with rectal (188) or sigmoid (114) resectable cancer underwent radical surgery. Lumboaortic lymphadenectomy was routinely performed and total mesorectal dissection was always accomplished in rectal cancer. Splanchnic nerves, superior hypogastric plexus, hypogastric nerves, and sacral parasympathetic nerves were sought, identified, and preserved or, when necessary, unilaterally sacrificed. Fifty-three (17.6 percent) patients were classified Dukes A, 145 (48.0 percent) B, 46 (15.2 percent) C1, and 17 (5.6 percent) C2. Thirtynine (12.9 percent) patients were Dukes D. In 85 rectal cancer patients, tumor was located at the lower third. Eighty-six of 210 Dukes B and C patients were submitted to systemic chemotherapy and/or high-dose pelvic radiotherapy. RESULTS: The actuarial 5-year disease-free survival was 58.5 percent in rectal and 65.7 percent in sigmoid cancer patients, median follow-up time was 47 months. During the follow-up, each patient was interviewed about sexual activity and urinary dysfunction and a questionnaire was filled out. Urinary dysfunction was not frequently observed, while a definitive sexual impotence was reported in 27.6 percent of the patients. The age under 60 years and sphincter-saving surgery were demonstrated as significantly contributing to retaining a satisfactory sexual activity. CONCLUSIONS: Unexpectedly high disease-free survival was observed in the Dukes C2 subgroup. It allows us to hypothesize that lumboaortic lymphadenectomy could remove neoplastic microfoci present at this level in those patients, enhancing surgical chances of cure. The majority of male patients under 60 years old can retain a satisfactory sexual activity after undergoing a nerve-sparing sphincter-saving cancer surgery.
Advances in rectal cancer surgery
Diseases of the Colon & Rectum, 1994
We discuss our experience in radical rectal cancer surgery and critically review the results of the current literature. In particular, the importance of distal clearance, total excision of the mesorectum, and pelvic lymphadenectomy is stressed. METHODS AND RESULTS: The rationale for determining a pelvic lymphadenectomy is identified in the high percentage (20 percent) of lateral endopelvic metastatic nodes demonstrated in cases of extraperitoneal rectal cancers. The results after pelvic lymphadenectomy and the eventual complications are observed. The autonomic nerve-sparing procedure is described and the preliminary results, with a decreased rate of urinary and sexual sequelae, are discussed. CONCLU-SIONS: It was concluded that, in cases of an advanced rectal cancer, radical surgery, if associated with the nervesparing technique, can improve survival without affecting the incidence of major complications. [
Journal of Clinical Oncology, 2008
Purpose Total mesorectal excision (TME) for rectal cancer may result in anorectal and urogenital dysfunction. We aimed to study possible nerve disruption during TME and its consequences for functional outcome. Because the levator ani muscle plays an important role in both urinary and fecal continence, an explanation could be peroperative damage of the nerve supply to the levator ani muscle. Methods TME was performed on cadaver pelves. Subsequently, the anatomy of the pelvic floor innervation and its relation to the pelvic autonomic innervation and the mesorectum were studied. Additionally, data from the Dutch TME trial were analyzed to relate anorectal and urinary dysfunction to possible nerve damage during TME procedure. Results Cadaver TME surgery demonstrated that, especially in low tumors, the pelvic floor innervation can be damaged. Furthermore, the origin of the levator ani nerve was located in close proximity of the origin of the pelvic splanchnic nerves. Analysis of the TME ...