The last three decades of the 20th century have brought an important change in the multidisciplinary approach of colorectal cancer. From large-scale surgery, whose only reason was the safety excision of the tumor, gradually developed a new current, the multidisciplinary treatment for colorectal cancer.
Nowadays the main idea is of radical intervention but associated with a good quality of life, idea of radical intervention in terms of a closer to normal functionality.
Technological advances of the past years has steadily improved the results after colorectal surgery but at the same time paved the way for excesses both in positive and negative ways.
Thus, the increasing approach for laparoscopic surgery and use of mechanical suture had led to practice “heroic” surgery, allowing low and ultralow resections with restoring the digestive continuity, but sometimes with questionable radicalism and functional implications.
Moreover, in the therapeutic team, which is formed of a surgeon and oncologist, were added unquestionably the pathologist, the radiotherapist, the radiologist and the stoma-therapist.
However, unfortunately, the reality follows the next scenario: delayed presentation to the surgeon, advanced stage tumors, with anatomic changes, increasingly number of young patients with unwanted consequences, darkening the surgical act, a more difficult acceptance for digestive stomas, a more supported quantification for urinary and sexual dysfunction.
Surgical options for patients with localized cancer in middle and lower third of the rectum include anterior resection followed by anastomosis and abdomino-perineal resection. Both procedures have a significant impact on quality of life, mainly due to the stoma itself, for obvious reasons, but also the presence of a partially functional anastomosis that can disrupt normal rectal function.
Urologic dysfunction immediately detected after surgery requires correct diagnosis and appropriate treatment to avoid permanent damage.
The incidence of urinary tract symptoms after colorectal surgery is between 20 and 40%, higher for male patients (M:F = 4:1) as a result of anatomic differences, the presence of benign prostatic pathology that enhances urological and neurological disorders in men. On the other hand, multiparous female patients may present significant changes of the pelvic floor. However, postoperative symptoms are often transient and usually only 10% of the patients require medical or surgical treatment.
Global results have recorded significant improvements, namely: anterior resections with increased number of sphincter preserving from 15% to 50%, having as an immediate consequence a significant improvement in quality of life by avoiding colostomy; the 5-year survival increased from 30% to 60%, down staging rate increased by 40-60% with neoadjuvant treatment.
Also, unanimous acceptance of the principles of modern rectal surgery, and here we reffer to the abandonment of blunt dissection with no visibility into the pelvic hole, improved considerably immediate and remote results(1).
A look at history shows that before Heald, that has the great merit of imposing TME (total mesorectum excision) since the 80’s, in the 50% Prof. Mandache succeded the total mesorectum excision as lymphatic surgery, extrapolating the knowledge of the Wertheim operation, and after more than 100 years Miles described the abdomino-perineal resection.
In terms of approach, laparoscopy has brought great advantage of a very good visibility in the pelvic hole, with the possibility of a safe performing of a careful dissection that enables good nerve preservation(2,3,4). Laparoscopic TME is feasible for the majority of patients with colorectal cancer, laparoscopic surgery being considered far superior than classic surgery. Our experience did not show a higher rate of positivity for the circumferential margins in the laparoscopic approach compared with classic surgery. However, in terms of survival at 3 years, we have observed notable differences between the two approaches.
We also support, through the prism of personal experience, with a number of patients still statistically unrepresentative compared with international studies, an improvement of sexual function compared with the preoperative status.
Our study includes 54 patients who underwent laparoscopic and classic surgery through a period of 3 years.
Postoperative urinary disorders appeared at 3% of patients who underwent laparoscopic surgery, compared to 10% on patients who underwent classic surgery.
Sexual disorders such as impotence at sexual active patients was encountered in 5% of patients from the laparoscopic surgery group, compared to 29% of patients from the classic surgery group. This data was obtained due to a better visibility offered by the laparoscopic approach.
The patients were evaluated for urinary disorders, too. The results were: in 72% of cases the micturition was normal, satisfactory for 23% of patients and unsatisfactory for 5% of patients. From the group of patients who had satisfactory micturition, in 8 cases the results had a significantly improvement over the next 6 months.
At sexual active patients, ejaculation has been appreciated as normal for 56% of cases, satisfactory for 19% of cases and unsatisfactory for 25% of patients. In the same time, potency was considered unchanged for 62% of patients, satisfactory for 16% and unsatisfactory for 22%.
Urinary disorder represents a well know complication of colorectal surgery. The surgical technique has evolved, also the understanding of anatomy and physiology. Recent studies have confirmed that TME technique leads to a significant lower rate of side effects(5).
At the late of the 80’s TME set forth by Heald was introduced in surgical practice(6). TME had become a wide used procedure, due to its oncological success, combined with better functional results. Recently, wide research in anatomy and physiology of pelvic nerves had brought data that allow us to make a macroscopic map in terms of pelvic neuro-anatomy(6,7,8).
However, a possible negative aspect, that is closely related to a great number of individual anatomic variability and morphological abnormalities of the pelvis, can lead to intraoperative identifying difficulties of the nerve plexus. Finally, the moment when patients present at oncologic-surgery service is unfortunately many times in advance stage of the disease and presumes that the nerve plexus are already invaded by the tumor, that can lead to a severe functional damage.
In terms of anatomy, the next landmarks must be mentioned.
The mesorectum represents a layer of connective soft tissue, which contains vascular, lymphatic and nervous pedicles, that surrounds that rectum. In its posterior part, a thin fascia, the visceral fascia, covers the mesorectum. Its pelvic part, that is situated posterior of the rectum and its own fascia, is covered by a thin fascia called parietal fascia. The two fascia allow the surgeon to enter in a dissection plan that is located behind the rectum that contains connective tissue. Resection of this tissue allows the access to the retrorectal space and allows its mobilization from its place. The nervous plexus contains sympathetic and parasympathetic nerves with origin in L2 and L3 region. Both of this nerves form the first aortic plexus, then the inferior hipogastric plexus under the peritoneum at the level were the aorta divides. Distal of the sacral promontory this fibers form the hipogastric nerves, nerves that are placed lateral of the ureter and internal iliac artery. Parasympathetic fibers come from S3-S4 plexus at men and from S2-S4 plexus at women.
The vegetative pelvic plexus, known as the inferior hipogastric plexus, is made of nervous tissues that are located in the pelvic wall, near to the prostate and seminal vesicles at men. At women, this plexus is located anterior and lateral of the rectum and reaches at the lateral wall of the vagina and at the base of the bladder. The main part of the plexus is located at the cervix. The sacral autonomous plexus is made from fibers that come from the hipogastric nerve and sacral splanchnic nerves, and innervates the rectum, genital and urinary organs.
The parasympathetic fibers are evolved in the lifting mechanism of the penis, in increasing the blood flow through the penis, vulva and vagina. This fibers also contributes for the innervation of the detrusor muscle and furthermore for the micturition mechanism. On the other hand, the sympathetic fibers are linked with the ejaculation and sustain the rhythmic contraction of the genital organs during the orgasm for males and probably the same thing happens for women. More, the sympathetic fibers are involved in inhibiting of the detrusor muscle, participating this way to the continence mechanism(9,10,11,12).
The actual rate of urinary disorders after surgery for rectal cancer varies between 25% and 72%. More factors are involved in the pathology of urinary incontinence besides preservation of nervous fibers(13,14,15,16,17,18,19).
Bladder disorder is a very frequent complication after surgical interventions performed in the pelvic region. In consequence, the patient may encounter micturition disorder, to full incontinence and loss of the filling sensation of the bladder. In change, a part of these symptoms may be canceled by postoperative repositioning of the bladder. Inferior urinary infections may be the result of the incomplete drainage of the bladder.
Finally, damage to the pudendal nerves, not so frequently after anterior resection of the rectum, may reduce the susceptibility of the bladder and erectile dysfunction. The clinical results are often multiple, associated, confounding.
Discussions
Bladder dysfunction is common after pelvic surgical intervention, especially after rectal cancer surgery. Clinical manifestations may vary depending on the locations and extent of the surgical injury.
A surgical approach with preservation of the nervous fibers may minimize the injury of the pelvic nerves. This technique is however difficult, because of the complex anatomy of the neural fibers. Also there are two notions which apparently are in contradiction: the lateral margins after rectal cancer surgery are 3-5cm, distance that interfere with the nervous plexus and most frequently, physically there is impossible to do that, because of the many anatomical varieties.
Three territories are identified as areas with high risk of nerve damage: one in the abdomen and two in the pelvic region. Inside the abdomen, the risk is linked with the ligation of the inferior mesenteric artery that may lead to deteriorate the hipogastric plexus. At the pelvic region, a critic moment is represented by the posterior mobilization of the rectum. Lateral dissection may put in danger the pelvic sympathetic and parasympathetic plexus. Finally, anterior mobilization of the rectum may lead to cavernous nerves damage during the dissection.
In terms of radicalness and oncological principles in rectal cancer, there is mandatory to excise the first lymphatic station and then at least one normal station. In terms of vertical resection this thing is easy to obtain. In lateral dissection TME takes only one lymphatic node, at the level of rectal wings and this thing is considered to be sufficient. WHY?
Not only the surgeon, but also the patient should be aware of the possibility of functional complications that inevitably must be assumed. Such complications can be prevented, monitored and successfully treated.