URINARY DYSFUNCTION AFTER SURGICAL TREATMENT FOR RECTAL CANCER

ARTIGO ORIGINAL / ORIGINAL ARTICLE ARQGA/1788 DOI: 10.1590/S0004-28032015000300005 URINARY DYSFUNCTION AFTER SURGICAL TREATMENT FOR RECTAL CANCER Fernando Bray BERALDO1, Sonia Ahlaim Ibrahim YUSUF1, Rogério Tadeu PALMA1,2, Silvia KHARMANDAYAN2, José Eduardo GONÇALVES1 and Jaques WAISBERG1,2 Received 1/1/2015 Accepted 6/3/2015 ABSTRACT – Background – The impact on quality of life attributed to treatment for rectal cancer remains high. Deterioration of the urinary function is a relevant complication within that context. Objective – To detect the presence of urinary dysfunction and its risk factors among individuals underwent surgical treatment for rectal cancer. Methods – The present prospective study analyzed 42 patients from both genders underwent surgical treatment for rectal adenocarcinoma with curative intent. The version of the International Prostatic Symptom Score (IPSS) questionnaire validated for the Portuguese language was applied at two time-points: immediately before and 6 months after surgery. Risk factors for urinary dysfunction were analysed by means of logistic regression and Student’s t-test. Results – Eight (19%) participants exhibited moderate-to-severe urinary dysfunction 6 months after surgery; the average IPSS increased from 1.43 at baseline to 4.62 six months after surgery (P<0.001). None of the variables assessed as potential risk factors exhibited statistical significance, i.e., age, gender, distance from tumour to anal margin, neoadjuvant therapy, adjuvant therapy, type of surgery, surgical approach (laparoscopy or laparotomy), and duration of surgery. Conclusion – This study identified an incidence of 19% of moderate to severe urinary dysfuction after 6 months surveillance. No risk factor for urinary dysfunction was identified in this population. HEADINGS – Rectal neoplasms. Neurogenic urinary bladder. Colorectal surgery. Neoadjuvant therapy. Hypogastric plexus. INTRODUCTION Surgical treatment is the basis of curative rectal cancer treatment(8, 9, 10, 18). The concept of total mesorectal excision (TME), which includes anatomical dissection of the pelvic fascia and recognition of vascular and nerve structures, has allowed better outcomes in terms of local recurrence and functional morbidity of the pelvic organs(11, 12, 15). The function of the pelvic organs depends on the neural integrity of the pelvic autonomic plexuses; thus, its preservation is one of the priorities in surgery(6, 27). The voluntary control of the lower urinary tract depends on the adequate interaction of the autonomic innervation, mediated by sympathetic and parasympathetic fibres, with the somatic innervation, mediated by the pudendal nerves(7, 19). Although results relative to oncological radicality have exhibited significant improvement, the impact on quality of life in rectal cancer treatment can also be affected by the presence of urinary disfunction which might be as high as 30% (16, 30). Dysfunction of the lower urinary tract is associ- ated with neural injury during surgery, which might occur even when TME is properly performed(27, 30). Lesions of the pelvic autonomic nerve plexus might occur either alone or in association with other lesions and are due to tumour infiltration, difficult dissection of large tumours, or inadequate dissection of the anatomic planes(27). The aim of this study was to detect the presence of urinary dysfunction and to identify the risk factors for its occurrence among patients with rectal cancer that underwent surgery with curative intent. METHODS This prospective study was conducted with patients with rectal cancer underwent to curative surgery from January 2011 to January 2012. Forty-nine adults from both genders with rectal cancer TNM stages I, II or III were initially included(24). Subjects with distant metastasis, with moderate or severe urinary dysfunction, and urgency surgery were excluded from the study. The preoperative tumour staging was based on the results of colonoscopy, rigid proctosigmoidoscopy, Declared conflict of interest of all authors: none. Financial support: This study had financial support of master’s degree scholarship by Coordenação de Aperfeiçoamento de Pessoal de Nivel Superior (CAPES). 1 Serviço de Gastroenterologia Cirúrgica, Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP; 2 Departamento de Cirurgia, Faculdade de Medicina do ABC, Santo André, SP. Brasil. Correspondence: Fernando Bray Beraldo. Rua Pedro de Toledo, 1800, 11°andar. Ala central. São Paulo, SP, Brasil. Email: 180 Arq Gastroenterol v. 52 no. 3 - jul./set. 2015 Beraldo FB, Yusuf SAI, Palma RT, Kharmandayan S, Gonçalves JE, Waisberg J. Urinary dysfunction after surgical treatment for rectal cancer the following urinary symptoms in the previous 4 weeks: incomplete emptying of the bladder, frequency, intermittency, urgency, weak stream, straining and nocturia. The total score was calculated by adding the score assigned to each individual question. Scores are assigned based on the intensity of symptoms on a scale ranging from zero (absent) to five (strong) (Figure 1), and the total score varies from zero to 35. The severity of urinary dysfunction was categorised based on the total score as follows: mild (one to seven points), moderate (eight to 19 points) and severe (20 to 35 points). To assess the correlation of risk factors for urinary dysfunction, the participants were divided into two groups: subjects with no worsening of the urinary symptoms 6 months after surgery, i.e., those who showed the same scores at baseline and reassessment, and patients who showed an increase in the IPSS at reassessment compared to baseline. The variables selected as potential risk factors were median age < or ≥ 63 years old; gender; distance from the tumour lower margin to the anal margin ≤9 cm or >9 cm; performance or not of neoadjuvant and/or adjuvant therapy; type of surgery; surgical approach (laparoscopy or laparotomy); and duration of surgery. The surgical procedures were categorised as rectosigmoid resections (low anterior rectosigmoid resection, high anterior rectosigmoid resection, anterior rectosigmoid resection with proximal colostomy + burying of the distal stump) or abdominoperineal resection. The average surgical duration was categorised as ≤ or > 4 hours. Descriptive analysis included calculation of the arithmetic mean, standard deviation and median, relative frequency expressed as percentage, minimum and maximum values, a logistic regression model and Student’s t-test. The significance level was set at 5% (P≤0.05). Analysis was performed using the SPSS V17 software (SPSS Inc., Chicago, IL, USA). carcinoembryonic antigen (CEA) plasma levels, magnetic resonance imaging of the pelvis and helical computed tomography of the abdomen and chest. The presence of stage II or III extraperitoneal rectal carcinoma was the criterion selected for indication of neoadjuvant therapy. The patients underwent surgery 6 to 8 weeks after the end (...truncated)