Urinary Function following Laparoscopic Lymphadenectomy for Male Rectal Cancer

et al. (2013) Urinary Function following Laparoscopic Lymphadenectomy for Male Rectal Cancer. PLoS ONE 8(11): e78701. doi:10.1371/journal.pone.0078701 Urinary Function following Laparoscopic Lymphadenectomy for Male Rectal Cancer Li-ye Liu. 0 Wei-hui Liu. 0 Yong-kuan Cao 0 Lin Zhang 0 Pei-hong Wang 0 Li-jun Tang 0 Kazuaki Takabe, Virginia Commonwealth University School of Medicine, United States of America 0 Department of General Surgery, Chengdu Military General Hospital , Chengdu, Sichuan Province , P.R. China Objectives: Urinary function can be protected following open lateral node dissection (LND) with pelvic autonomic nerve preservation (PANP) for advanced rectal cancer. However data regarding urinary function after laparoscopic LND with PANP have not been reported. The goal of this study was to determine the effects of laparoscopic LND with PANP on urinary function in male patients with rectal cancer. Methods: Urine flowmetry was performed using an Urodyn flowmeter. Patients were also asked to complete the standardized International Prostate Symptom Score (IPSS) questionnaire before surgery and 6 months after. In total, this study consisted of 60 males with advanced rectal cancer. Results: No significant differences were seen in maximal urinary flow rate, voided volume or residual volume before and after surgery. The total IPSS score increased significantly after surgery and at least 41 patients (68.3%) reported there was no change in one of the seven IPSS questions. Conclusions: Laparoscopic LND with PANP was relatively safe in preserving urinary function. - . These authors contributed equally to this work. It has been reported that the incidence of lateral lymph node metastasis ranges from 10 to 25% in patients with advanced middle and low rectal carcinomas [1]. It has also been suggested that lymphatic spread of cancer cells to lateral pelvic nodes may be a reason for local failure [2,3]. Therefore, some authors have advocated that lateral nodes dissection (LND) is beneficial for local control and long-term survival. Many studies indicated that significant improvement in survival and a reduction in local recurrence can be achieved with LND [4,5]. However, postoperative urinary dysfunction due to damage of the hypogastric nerves and pelvic nerve plexuses was observed in 42% to 73% of patients [6,7]. The majority of surgeons have been reluctant to use LND due to the frequent complication of urinary dysfunctions. Recent studies suggest that the use of pelvic autonomic nerve preservation with lateral node dissection reduces the disturbance in male urinary function [8]. Over the past decade, advancements in surgical techniques and improved laparoscopic instruments have allowed most rectal cancer excision procedures to be performed laparoscopically. Compared to open surgery, laparoscopic rectal cancer resection is associated with less postoperative pain, faster return of bowel function, and shorter hospital stay [9,10]. However, little is known about the incidence of urinary dysfunction after LND with PANP using laparoscopic technique. Theoretically, a magnified view of the pelvis may facilitate autonomic nerve identification. Consequently, lower levels of bladder dysfunction in men after laparoscopic procedures should be observed. Therefore, we conducted this study to test the male urinary function after laparoscopic LND with PANP for rectal cancer. We hypothesized that given the well-illuminated magnified view of laparoscopy, the autonomic nerves and male urinary function can be preserved. Materials and Methods 1. Patients This study was performed between October 2010 and October 2012. The present study conformed to the ethical standards of the World Medical Association Declaration of Helsinki and we get the permission of Chengdu Military General Hospital Medical Ethics Committee (Register Number: 2010051). All patients had signed informed consent form. All patients underwent laparoscopic LND with PANP. Exclusive criteria were as follows: (1) those with intestinal obstruction requiring urgent decompression, (2) males with stage 0, stage I and stage IV tumors with lung metastasis assessed by transrectal ultrasonography upper abdomen and pelvic enhancement CT scan, (3) those with a contraindication to general anesthesia under pneumoperitoneum, (4) those who were obese (body mass index$30 kg/m2), (5) tumors located in the upper third of the rectum. The rectum was divided into three parts: the lower third (within 7 cm of the anal verge), the middle third (8 No. of Patients (n = 60) Age, yr (mean 6 standard deviation) Tumor size, cm2 (mean 6 standard deviation) 12.2368.7 Postoperative chemoradiotherapy 12 cm), and the upper third (1316 cm). This study included 60 rectal cancer patients who were diagnosed with cancer in the mid or lower rectum. All patients underwent preoperative tumor staging with a contrast medium enema, rectoscopy and colonoscopy with biopsies of the tumor, endorectal ultrasonography, abdominal ultrasound, and a chest x-ray. Patients with locally advanced rectal carcinoma (uT3/uT4) and no evidence of distant metastases were candidates for neoadjuvant chemoradiation with the following schedule: 3050 Gy radiotherapy and 5-fluouracil (5-FU) combined with folinic acid over 5 weeks. The operation was carried out two to three weeks after completion of the multimodality treatment. Adjuvant treatment was administered to patients with UICC stage III disease and 2. Assessment of Urinary Function Urinary function was determined based on the following parameters: catheter indwelling, urine flow rate (UrodynH, Dantec, Copenhagen, Denmark), recatheterization rate, longterm catheterization rate (beyond the day of discharge), and International Prostate Symptom Score (IPSS) [11]. The IPSS is subdivided into seven items: incomplete bladder emptying, frequency, intermittency, urgency, weak stream, straining and nocturia. The scoring system is based on a scale from zero to five as follows: 0, not at all; 1, less than one time in five; 2, less than half the time; 3, about half the time; 4, more than half the time; and, 5, almost always. In addition, another question, quality of life due to urinary symptoms, was also included in this questionnaire. The total score is calculated by adding the individual scores of each subdivision. Deterioration of postoperative urinary function was categorized into three groups: mildly symptomatic (IPSS 07 points), moderately symptomatic (IPSS 819), and severely symptomatic (IPSS 2035 points). We defined it no change if the patients total IPSS score at the same category after and before surgery. The IPSS questionnaires were distributed and collected by the author at the outpatient clinic. Urinary flowmetry and IPSS were performed before surgery and 6 months after surgery. 3. Surgical Treatment Autonomic nerve preservation consists of the identification and preservation of the superior hypogastric (sympathetic) and sacral spl (...truncated)