Prognosis and postoperative genital function of function-preservative surgery of pelvic autonomic nerve preservation for male rectal cancer patients

Liu et al. BMC Surgery (2016) 16:12 DOI 10.1186/s12893-016-0127-4 RESEARCH ARTICLE Open Access Prognosis and postoperative genital function of function-preservative surgery of pelvic autonomic nerve preservation for male rectal cancer patients Zhihua Liu1, Meijin Huang1, Liang Kang1, Lei Wang1, Ping Lan1, Ji Cui2 and Jianping Wang1* Abstract Background: To retrospectively evaluate postoperative genital function, local recurrence rate and survival rate after total mesorectal excision (TME) combined with or without pelvic autonomic nerve preservation (PANP) in male patients with rectal cancer. Methods: A total of 953 male patients with rectal cancer after TME (518 patients received TME combined with PANP [PANP group] and 434patients received TME alone [TME group]) were included. Assessments of postoperative genital function, local recurrence rate, and 5 year survival rate were collected. Results: Rate of erection dysfunction in PANP group (41.9 %) was significantly lower than that in TME group (76.7 %, P < 0.05). Rate of ejaculation dysfunction in PANP group (42.5 %) was also significantly lower than that in TME group (67.3 %, P < 0.05). Local recurrence rate (P = 0.66) and survival rate (P = 0.26) did not differ between the two groups. For patients with preoperative obstruction, local recurrence rate was significantly higher (P = 0.01) and survival rate significantly lower (P = 0.03) in PANP group. Conclusions: PANP surgery has significant advantage with respect to preservation of genital function and should be recommended as surgical treatment for rectal cancer patients. However, PANP surgery should be considered with caution in patients with preoperative obstruction in view of the poorer long-term outcomes in these patients. Keywords: Rectal cancer, Total mesorectal excision, Pelvic autonomic nerve preservation, Genital function, Survival rate Background It has been estimated that over one million patients are diagnosed with colorectal cancer (CRC) every year, along with 500,000 related deaths in the world [1, 2]. Mortality and morbidity of CRC have been rising in recent years [3] and CRC has become the third most common type and the fourth most common mortality of malignant carcinoma all over the world [4]. The overall incidence of CRC is up to 5 % in general population and the overall 5 year survival rate is less than 60 % in the world [5]. * Correspondence: 1 Gastrointestinal Institute of Sun Yat-Sen University, Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-Sen University (Guangdong Gastrointestinal Hospital), 26 Yuancun Erheng Road, Guangzhou, Guangdong 510655, People’s Republic of China Full list of author information is available at the end of the article It has also been estimated that the lifetime risk of developing CRC was up to 6 % [6]. In developing countries like China, especially in major cities such as Guangzhou, Beijin, and Shanghai, as lifestyle alters,burden of CRC has rapidly increased [7, 8]. Moreover, the epidemiological characteristics of CRC in Chinese patients, known as “three high and one low” [9, 10], present as a severe threat [11]. These include high proportion of rectal cancer (RC, about 60 %), high proportion of distal RC (about 65–70 %), and high proportion of young patients (10–15 % of patients less than 30 years old), and low early diagnostic rate (less than 10 %) [12]. Low position of RC tumor increase ssurgical difficulty andyoung age raises the issue of genital function preservation. © 2016 Liu et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Liu et al. BMC Surgery (2016) 16:12 Severe genital dysfunction associated with the injury of autonomic nerve is a common complication of middle and distal RC surgery. It has been suggested that total mesorectal excision (TME) combined with pelvic autonomic nerve preservation (PANP) for the treatment of RC could lower the rate of postoperative genital dysfunction [13]. However, whether PANP can retain the radical cure effect is still in debate. In this study, we aimed to compare the radical cure effect of TME combined with and without PANP as surgical treatments for RC and to compare postoperative genital function, local recurrence, and survival rate between the two treatments. Methods Patients All male patientsaged between 18 and 60 years old who had a diagnosis of RC and underwent radical proctectomy surgery in the Sixth Affiliated Hospital of Sun Yatsen University between October 1997 and December 2013 were reviewed for inclusion in this study. Diagnosis of RC was established based on comprehensive review of medical history, physical examination, three-phase contrast-enhanced computed tomography (CT) findings, magnetic resonance imaging (MRI) findings, colonoscopy features, and surgical findings as previously described [14]. Inclusion criteria were: 1) CT scan, MRI or colonoscopy suggesting RC; 2) adenocarcinoma; and 3) no metastasis. Exclusion criteria were: 1) genital dysfunction after neoadjuvant chemo-radiotherapy and before operation; 2) symptoms suggesting bowel perforation; 3) septic symptoms; 4) patients at Dukes B and C stages who rejected neoadjuvant chemo-radiotherapy; 5) adjacent small bowel involvement. This study was approved by the Ethics Committee of Sun Yat-sen University and was conducted in accordance to the Declaration of Helsinki. All participants provided written informed consent. Page 2 of 7 incision of about 5 cm for extraction of the specimen. Patients were placed in the modified lithotomy position [16] with the surgeon standing on the right side of the patient. Clips or vascular staplers were used form obilization, isolation and ligation for the main vessels from medial to lateral of rectal tissues [17]. TME was performed using monopolar diathermy and ultrasonic scalpel [15, 18]. A wound protector was used to protect of the sample extraction site, and anastomoses were performed intracorporeally. A loop ileostomy was routinely planted for mid and low rectal anastomoses for postoperative recovery of anastomotic stoma. The PANP surgery had three steps, including revealing sacral nerve plexus and hypogastric nerve (Ejaculation nerve), preservation of the integrity of at least one-side parietal pelvic fascia and preservation of the envelop of seminal vesicle (Denonvilliers facia). We classified PANP into four types. Type I referred to complete preservation of the pelvic autonomic nerve. For typ (...truncated)