Genito-Urinary disorders in 30 consecutive Laparoscopic TME for rectal cancer: a prospective video-controlled study

Andrea Costanzi, MD, Luca Rigamonti, Giulio Mari, MD, Valter Berardi, MD, Angelo Miranda, MD, Jacopo Crippa, Dario Maggioni, MD. Desio Hospital, Italy.

Regardless of advances, radical surgery for rectal cancer jeopardizes pelvic nerves integrity with urinary and sexual disorders ranging from 10 to 30%. This study primary endpoint is to prospectively assess the incidence of genito-urinary dysfunctions in patients undergoing Laparoscopic Total Mesorectal Excision (LTME) without neo-adjuvant treatment. Secondary endpoint is to detect the potential lesion site evaluating videorecordings of operations.

PATIENTS AND METHODS
A court of 30 consecutive patients affected by extra-peritoneal rectal cancer not subjected to neo-adjuvant ChemoRadiation prior to surgery, M:F=19:11, median age 70, was evaluated preoperatively and after LTME. Evaluations of bladder function were determined by uroflowmetry and postvoid residual urine measurement preoperatively and at 1 and 9 months, International Prostatic Symptoms Score (IPSS, score 1 to 35 showing worsening of symptoms) and International Consultation on Incontinence Modular Questionnaire (ICQI UI-Short Form, score 1 to 21 showing worsening of symptoms) preoperatively and at 1, 3 and 9 months. Evaluations of sexual function were carried out by International Index of Erectile Function (IIEF, score 0 to 25, highest value better function) in men and Female Sexual Function Index (FSFI, score 2 to 36, highest value better function) in women preoperatively and at 1, 3 and 9 months. Data were analyzed performing Wilcoxon test and paired samples t test by SPSS 21 statistical package.
Evaluation of surgery reviewing recorded videos was oustourced to an independent expert.

RESULTS
Urinary function: Maximum bladder flow (Vmax) base-line average was 21,16 ± 10,47 ml/sec, decreased to 16,94 ± 10,26 after 1 month and back to 16,94 ± 10,26 after 9 month (p NS). Voiding time baseline average was 36,67 seconds ± 18,74, at 1 month 37,18 ± 18,11, at 9 months 40,75 ± 17,79. IPSS average score moved from baseline 6,03 ± 5,51 to 7,26 ± 5,55, ICIQ scored from baseline 2,67 ± 5,42 to 3,63 ± 5,23, in both cases p=NS. Sexual function: IIEF average score decreased from baseline 19,38 ± 6,25 to 13,44 ± 9,19 at 1 month (p=.04) and to 15,20 ± 8,28 at 9 months, (p NS). FSFI average score remained always close from baseline 29,17 ± 1,86 to 29,37 ± 1,69 at 1 month and 30,25 ± 1,48 at 9 months (p NS). Ejeculation disorders occured in 4 patients out of 30 (2.5%). Operations video review of patients with disorders showed potential damage at the site of ligation of IMA (high hypogastrig plexus) in 2 cases, dissection of posterior mesorectum (right hypogastric nerve) in 2 cases and anterior dissection of the Denonvillers fascia from seminal vescicles possibly affecting the Walsh neurovascular bundles (Erigentes nerves) in 4 cases.

CONCLUSIONS
Although average values of quantitative and qualitative data show significant variations only for sexual function at 1 month from surgery, the incidence of post-surgical urinary and sexual disorders is respectively 30% and 37% of our patients undergoing LTME for rectal cancer. Video review of laparoscopic surgery provides an important tool for detection of lesion sites and raises the issue of mandatory Denonvillers fascia respect whenever this does not compromise radicality.