Male sexual function and lower urinary tract symptoms after laparoscopic total mesorectal excision

S. O. Breukink 0 1 3 4 M. F. van Driel 0 1 3 4 J. P. E. N. Pierie 0 1 3 4 C. Dobbins 0 1 3 4 T. Wiggers 0 1 3 4 W. J. H. J. Meijerink 0 1 3 4 0 J. P. E. N. Pierie Department of Surgery, Medical Centre Leeuwarden , Leeuwarden, The Netherlands 1 M. F. van Driel Department of Urology, University Medical Centre Groningen, University of Groningen , Groningen, The Netherlands 2 ) 42 Marlboroughstreet, Brighton, South Australia 5048, Australia 3 W. J. H. J. Meijerink Department of Surgery, VU Medical Centre , Amsterdam, The Netherlands 4 C. Dobbins Department of Surgery, The Queen Elizabeth Hospital , Adelaide, Australia Background and aims The aim of this study was to investigate sexual function and the presence of lower urinary tract symptoms (LUTS) in male patients with rectal cancer following short-term radiotherapy and laparoscopic total mesorectal excision (LTME) by physical and psychological measurements. Materials and methods Sexual function and LUTS were assessed by the use of questionnaires [International Index of Erectile Function (IIEF), International Prostate Symptom Score]. Sexual function was further assessed by the use of pharmaco duplex ultrasonography of the cavernous arterial blood flow and nocturnal penile tumescence and rigidity monitoring (NPTR). All investigations were performed prior to the start of preoperative radiotherapy and 15 months after surgery. Results Nine patients (mean age 60 years) participated. Erectile function was maintained in 71% and ejaculation function in 89%. Compared with pre-operative scores on the IIEF, a significant deterioration in intercourse satisfaction was seen following radiotherapy and LTME (7.9 vs 10.3, p = 0.042), but overall satisfaction remained unchanged (8.0 vs 7.0, p = 0.246). NPTR parameters (duration of erectile episodes, duration of tip rigidity 60%) decreased following radiotherapy and LTME. Patients reported a deterioration in micturition frequency (2.0 vs 1.0, p = 0.034) and quality of life due to urinary symptoms (8.0 vs 1.8, p = 0.018). Conclusion Based on these first preliminary findings, data suggest that 15 months after short-term radiotherapy and LTME in men with rectal cancer, objectively assessed sexual dysfunction was considerable, but overall sexual satisfaction had not changed. - Erectile dysfunction (ED), ejaculatory dysfunction (EJD) and lower urinary tract symptoms (LUTS) are well-known problems after total mesorectal excision for rectal cancer. These problems are related to damage to pelvic autonomic nerves caused by pre-operative radiotherapy and iatrogenic surgical injury [1, 2]. Laparoscopic total mesorectal excision (LTME) offers short-term advantages such as earlier diet re-establishment, less postoperative pain, less narcotic use and shorter hospital stay [35]. Furthermore, the magnification effect of laparoscopy enhances the exposure of the pelvic cavity. This magnification facilitates sharp dissection of the lateral, anterior and presacral spaces, all being autonomic nerve locations. However, the technical demands of LTME may just predispose to nerve injury [6]. Until now, very little is known concerning sexual functioning and lower urinary tract symptoms after LTME on the long term [6, 7]. A retrospective, questionnairebased study showed an ED incidence of 47% and an EJD incidence of 40% [7]. Another questionnaire-based study showed a non-significant trend towards more sexual dysfunction after LTME [6]. These two studies showed no differences with regard to LUTS after LTME or open TME (OTME). In this study, we assessed sexual functioning by an international validated questionnaire, the International Index of Erectile Function (IIEF), repeated pharmaco duplex-ultrasonographic investigations of the cavernous arteries and nocturnal penile tumescence and rigidity (NPTR) monitoring. Lower urinary tract symptoms were assessed by the International Prostate Symptom Score (IPSS). Materials and methods The study was performed between July 2003 and January 2006. All patients underwent an elective LTME at Medical Centre Leeuwarden [8]. The patients were included if they were heterosexually active and if the LTME had a curative intention. Patients with advanced T3 (cT3b) or T4 carcinoma diagnosed on magnetic resonance imaging (MRI) were excluded. A tumour-free circumferential resection margin of at least 2.0 mm is defined as a R0resection [9] and can be predicted with a high degree of certainty when the distance on MRI is at least 6.0 mm [10]. An advanced T3 tumour was defined when the MRI distance was less than 6.0 mm. According to the national Dutch protocol, all patients received a short preoperative course of 5 5 Gy radiotherapy. The above-mentioned investigations (questionnaires, duplex ultrasonography of the cavernous arterial blood flow at rest and after intracavernous injection of vasoactive substances, and nocturnal erections monitoring) were done just before the start of the preoperative radiotherapy and at 15 months follow-up. At that time, the late side effects of radiotherapy and the natural restoration of both psychological and surgical factors reach their plateau phase. The study was approved by the Committee on Medical Research Ethics, and all patients provided written informed consent. The patients completed two questionnaires: the International Index of Erectile Function [11] and the International Prostate Symptom Score [12]. The IIEF was used to assess psychological male sexual function in short. In this questionnaire, 15 items are checked, including erectile frequency, erection firmness, penetration ability, maintenance frequency, maintenance ability, intercourse frequency, intercourse satisfaction, intercourse enjoyment, ejaculation frequency, orgasm frequency, desire frequency, desire level, overall satisfaction, relationship satisfaction and erection evidence. The IIEF can only be used for heterosexual men. The scoring systems are from 0 to 5 (0, none; 1, almost; 2, a few; 3, sometimes; 4, most times; 5, almost always) on the first ten items and from 1 to 5 (1, very low; 2, low/a few; 3, moderate; 4, most/high; 5, very high/almost always) on the last five items. The IIEF is subdivided into five response domains (erectile function, orgasmic function, intercourse satisfaction, sexual desire, overall satisfaction). The domain scores are computed by adding the scores of individual items in each domain. Complete ED is defined as an erectile function domain score <10 and partial ED as a score <17 but 10. The international validated IPSS was used to assess bladder function. The IPSS is subdivided into seven items which include incomplete bladder emptying, frequency, intermittency, urgency, weak stream, straining and nocturia. The scoring system is based on a 0 to 5 scale, 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. The total score is calculated by addi (...truncated)