Functional Urologic Surgery in Neurogenic and Oncologic Diseases by Antonio Carbone Giovanni Palleschi Antonio Luigi Pastore & Aurel Messas

Author:Antonio Carbone, Giovanni Palleschi, Antonio Luigi Pastore & Aurel Messas
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

The primary aim of rectal cancer surgery is a curative resection. Even so, quality of life (QoL) may be considered as crucial as life expectancy. In particular, during surgery for rectal cancer, the maintenance of a proper genitourinary function by autonomic nerves preservation has become essential [10].

Nevertheless, even during correct TME with nerve preservation, rates of genitourinary dysfunctions remain high, particularly after abdominal-perineal resection. Before the introduction of TME technique, the incidence of postoperative voiding and sexual dysfunction was unacceptable, with reported rates from 10 to 30 % and 40–60 %, respectively. Recent studies on autonomic nerve preservation during TME have described reduced postoperative rates of voiding and sexual dysfunction in the range of 0–12 % and 10–35 %, respectively [11]. However, the real impact of the problem is probably higher, due to difficulties in conducting exhaustive clinical studies on this matter.

The COLOR II randomized trial, published in 2014 [12], compared genitourinary dysfunction after laparoscopic versus open surgery for rectal cancer. The evaluation of outcomes was made with the administration of QLQ-CR38 questionnaire before surgery and after 4 weeks, 6, 12, and 24 months. Among 617 patients enrolled (all with single rectal carcinoma located within 15 cm from the anal verge in a 2:1 ratio/randomization of laparoscopic to open), only 385 completed this phase of trial, thus confirming the difficulty to conduct functional evaluations in such patients. Genitourinary function was altered after 4 weeks in both groups (patients with a single rectal cancer within 15 cm from the anal verge), even if without significant differences. After 12 months, slight improvement in sexual function was observed. The erectile dysfunction, observed in 64.5 % of patients treated by laparoscopy and 55.6 % of patients treated by open access, worsened at 81.1 % and 80.5 %, respectively, 4 weeks after surgery and 76.3 and 75.5 % after 12 months (with no significant difference between the two groups).

A recent meta-analysis reported controversial results of laparoscopic versus open surgery. In fact, while some studies reported similar functional results (9.5 % of cases with postoperative erectile dysfunction and 3.1 % of cases with late bladder dysfunction), others report worse results in laparoscopic approach than open surgery (increase of impotence or retrograde ejaculation) [13]. Hence, it remains unclear whether a mini-invasive approach may affect genitourinary function more than open surgery, as these results may be due to limited available data or different criteria of analysis.

Urinary and sexual damage can be attributed to somatic and autonomic pelvic nerve injury during surgery. However, analyzing the functional outcomes after laparoscopic TME, we should consider that they may be biased by the multimodal therapy (preoperative chemotherapy and radiotherapy) employed in these patients and not only be directly caused only by the intraoperative preservation of the anatomy. Contin [14] compares late functional outcomes following preoperative neoadjuvant radiotherapy (RT) or combined chemoradiotherapy (CRT) plus surgery or surgery alone in the treatment of rectal cancer. This study highlighted that CRT negatively affects sexual functionality and concludes that the potential benefits of RT or CRT need to be balanced against the risk of increased genitourinary dysfunctions, independently of the surgical technique used.

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