Abstract Objective To investigate the pelvic autonomic nerve preservation rectal surgery to reduce male patients with postoperative voiding dysfunction and sexual dysfunction. The method of using the case-control method, analysis of 56 cases of rectal cancer reserves the pelvic autonomic nervous group and does not retain the group of patients with postoperative voiding and sexual dysfunction incidence of local recurrence rate. Results voiding dysfunction total incidence study group 25.00% (14/56), the control group was 60.71% (34/56), the difference was statistically significant (P <0.01). The study group and the control group patients after the incidence of erectile dysfunction were 26.79% and 75.00%, and the incidence of ejaculatory dysfunction were 28.57% and 69.64%, the difference was statistically significant (P <0.01). The local recurrence rate was 7.14% and 8.93%, respectively, the difference was not statistically significant. Conclusion rectal cancer pelvic autonomic nerve preservation does not increase the local recurrence rate can improve postoperative sexual function and urinary function, improve the quality of life of patients.
Key words Rectal reserved pelvic autonomic nerve urination disorder disorder local recurrence
Rectal cancer one of the common malignant tumors in the digestive tract, surgery is still the most important treatment. With the clinical application of widely accepted principles of total mesorectal excision and stapling, the anal sphincter preservation and survival rates of patients with rectal cancer surgery has been significantly improved. Postoperative urinary and sexual dysfunction (especially men) remains a serious problem. Currently considered after surgery for rectal voiding and sexual dysfunction and pelvic autonomic nerve injury in surgery. Our hospital from January 2003 to December 2006, 56 male patients with rectal cancer underwent pelvic autonomic nerve preservation of rectal cancer, the results were satisfactory. Are as follows.
1 Materials and Methods
1.1 Clinical data
From January 2003 to December 2006, 198 male patients with rectal cancer patients admitted to our department. Inclusion criteria: age less than 65 years old; spouse alive; non-obese; preoperative voiding dysfunction; preoperative sexual dysfunction (sexual intercourse when the penis can be normal erection and ejaculation); surgery found no distant metastasis. Compliant 112 cases. 112 patients according to the Number of odd and even divided into two groups, the study group and the control group, 56 cases in each. The study group aged 27 to 64 years, with an average age of 52.2 years. Surgical methods: Mile’s performed in 15 cases, Dixon performed in 41 cases. Dukes A, 9 cases, 35 cases of stage B, C of 12 cases. Histological type: 23 cases of well-differentiated adenocarcinoma, moderately differentiated adenocarcinoma in 20 cases, 9 cases of poorly differentiated carcinoma, mucinous adenocarcinoma, three cases of anal squamous cell carcinoma. The control group aged 29 to 63 years old, with an average age of 53.1 years. Surgical methods: Mile’s 17 patients, Dixon performed in 39 cases. Eight cases of Dukes A, B of 30 cases, C of 18 cases. Histological types: well-differentiated adenocarcinoma in 20 cases, 19 cases of moderately differentiated adenocarcinoma, poorly differentiated carcinoma in 14 cases, 3 cases of mucinous adenocarcinoma. Two surgical methods, Dukes stage, age at the time of surgery, the pathological classification differences were not statistically significant.
1.2.1 surgical methods
Rectal cancer, with a focus study groups and retention of all or part of the pelvic autonomic nervous anatomy in the operative process following nerve and protected. Hypogastric plexus (1): The level of the sacrum shoulder blade to cut on both sides of the junction of peritoneal rectosigmoid extend upward to reveal the inferior mesenteric artery, 2cm at its roots downward sweeping fat and lymphoid tissue in the rectal artery root ligation of identifying retroperitoneal abdominal aortic bifurcation form a network in the vicinity of the upper protective hypogastric plexus; (2) hypogastric nerve: inferior hypogastric plexus (pelvic plexus) identification and retention needs first identify the piriformis resection coverage basin on its fascia, in most cases can see the rear of the muscle that erectile nerve, the nerve can enter the inferior hypogastric plexus, thereby identifying the plexus, hypogastric nerves to continue side anatomy, can be seen; (3) pelvis plexus: both sides of the hypogastric nerve of peritoneal beneath, enter the pelvic plexus after upper corner. Along the pelvic plexus and rectum inherent fascia carefully separated, revealing the thin mesh pelvic plexus from piercing the rectal Ministry artery carefully cut, ligation, complete separate the pelvic plexus and rectum; (4 the lower corners along the pelvic plexus) pelvic splanchnic nerves: backward and downward peel, reserved from 2 to 4 presacral hole sent to the bottom corner of the pelvic splanchnic nerve; (5) the pelvic plexus efferent branch: along the pelvic plexus before on angle of the leading edge, you can clearly see the bundle the efferents forward into the sacrum bladder ligament. Rectal cancer step. The control group (n = 56) of routine rectal conventional radical surgery.
Of 1.2.2 followed up the content and method of
Since February 2003 through a questionnaire, out-patient interviews and telephone follow-up of all patients were followed up for six months to three years and a half. Once a month, six months, after six months, once every three months. Establishment of a complete personal follow-up files. Follow-up includes: (1) the urinary function before surgery; (2) pre-operative sexual function (including penile erection and ejaculation); (3) postoperative recovery urinate time: the occlusion of the catheter, filling the bladder urine For urination appears perineal swelling sense of the time required; (4) after removal of the catheter time and recovery of spontaneous voiding time; (5) after 10 days with or without voiding dysfunction? (1) to (5) completed during hospitalization; (6) evaluation of their postoperative urinary function; (7) evaluation of postoperative sexual function (including libido, erectile function and ejaculatory function); (8) recurrence (6) – (8) in the follow-up.
1.2.3 Evaluation Criteria
(1) voiding dysfunction by severity into four : Ⅰ level: normal function, without voiding dysfunction; Ⅱ: mild voiding dysfunction, urinary frequency, residual urine <50 ml; Ⅲ level: moderate voiding dysfunction 50 ml；Ⅳ级：重度排尿障碍，因尿失禁或尿潴留需行导尿治疗。">rare cases need the catheterization treatment, residual urine volume> 50 ml; Ⅳ: severe voiding dysfunction, incontinence or urinary retention need line catheterization treatment. (2) the evaluation of male sexual function erectile function and ejaculation. Erectile function is divided into three : grade Ⅰ is able to fully erect, with no difference preoperative normal erectile function; the Ⅱ level is varying degrees of erectile function decline, but can erectile erection hardness decreased preoperative ; Ⅲ level is completely without an erection, loss of erectile function. Ejaculation feature is also divided into three: Ⅰ grade ejaculation, normal or decreased ejaculate volume, normal ejaculatory function; the Ⅱ level is retrograde ejaculation, ejaculatory dysfunction; and grade Ⅲ is completely without ejaculation.
1.2.4 Statistical Methods
All data SPSS13.0 statistical package for analysis. Count data were compared with the χ2 test.
The patients preoperative urinary function and sexual function were normal. 10 days after voiding dysfunction total incidence study group 25.00% (14/56), the control group was 60.71% (34/56). Study Group erectile dysfunction in January after total incidence rate of 26.79% (15/56), ejaculatory dysfunction total incidence rate of 28.57% (16/56), the control group, erectile function and ejaculation dysfunction incidence was 75.00% ( 42/56), 69.64% (39/56). The two groups of patients with voiding dysfunction and sexual dysfunction incidence compared in Table 1 and 2. Table 1 patients postoperative urinary function compare treatment group Ⅱ + Ⅲ + Ⅳ grade voiding function with the control group compared by χ2 test was statistically significant (χ2 = 14.58 P <0.01) of local recurrence, the study group 0.05)。">The local recurrence rate of the control group were 7.14% (4/56) and 8.93% (5/56), the difference was not statistically significant (P> 0.05). Table 2 postoperative erectile and ejaculatory function comparison (for example,%)
Group Cases erectile function ejaculation grade Ⅰ Ⅱ grade Ⅲ grade Ⅰ Ⅱ grade level III treatment group control group of 5641 (73.21) 10 (17.86) (8.93) 40 (71.43) 9 (16.07) 7 (12.50) 5614 ( 25.00) 17 (30.36) 25 (44.64) 17 (30.36) 21 (37.50) 18 (32.14)
Treatment group Ⅱ + Ⅲ level erectile function compared to the control group. Χ2 test, statistically significant (χ2 = 26.04, P <0.01); treatment group Ⅱ + Ⅲ level ejaculatory function compared to the control group, a statistically significant by χ2 test (χ 2 = 18.90, P <0.01) 3 discussions
Traditional rectal cancer in a high incidence of postoperative sexual function and voiding dysfunction. Reported 25% to 100% of the male patients with complete or partial erectile dysfunction, loss of 19% to 59% of patients with ejaculatory function, voiding dysfunction rate of incidence of 7% to 70% . The reason is mainly associated with damage to the pelvic autonomic surgery.
1981 anatomist Sato detailed report anatomy of autonomic pelvis. The research results show that the : pelvic autonomic hypogastric nerve and pelvic splanchnic nerves. Former Secretary ejaculation easier to identify. The latter Secretary erectile function, both merged into the pelvic autonomic plexus. Pelvic organs by sympathetic, parasympathetic and somatic nerve: the hypogastric nerve damage caused the urine reservoir ejaculation disorders, pelvic splanchnic nerve injury cause urination and erectile impaired. On the basis of this study, Japanese scholars Tsuchiya Tuesday in 1983 spearheaded the pelvic autonomic nerve preservation rectal cancer (PANP surgery). Postoperative quality of life has been effectively improved. Some people will retain the pelvic autonomic nerves rectal cancer the (PANP surgery) is divided into four types . Ⅰ: fully retained pelvic autonomic nerves; Ⅱ: resection of sacral plexus retain bilateral pelvic nerve plexus; Ⅲ type: removal of the presacral plexus retain the side of the pelvic nerve plexus; Ⅳ: complete resection of pelvic autonomic nerve. Of PANP surgical indications, most scholars put forward radical premise suitable for 60-year-old former male patients with Dukes C . This technique has in recent years been gradually our surgeons understand and accept.
Anus  reported that the traditional rectal cancer postoperative erectile function and ejaculation dysfunction incidence was 63.5% and 71.2%, respectively; PANP postoperative erectile function and ejaculation dysfunction was 32.7% and 44.2%, respectively. Such as Deng weeks recorded  reported that the traditional rectal cancer postoperative male patients with sexual dysfunction was 63.9% (46/72), PANP postoperative dysfunction occurred only 34.6%. Gu Jin et al  reported total obstacles PANP postoperative voiding rate of 1.8% to 28.0%, postoperative 63% to 96% of men retained sexual function, erectile dysfunction was 12.3% to 13.3%, ejaculation the obstacle rate of 12.1 % to 33.1%. The data showed that, 10 days after voiding dysfunction total incidence study group 25.00% (14/56), the control group was 60.71% (34/56). Study Group erectile dysfunction in January after the total incidence rate of 26.79% (15/56), the total incidence of ejaculatory dysfunction 28.57% (16/56); reported results consistent with the literature. The total incidence of the control group after January erectile function and ejaculation disorder were 75.00% (42/56), 69.64% (39/56). The corresponding item two groups statistically significant by χ2 test. Description reserved pelvic autonomic can significantly reduce the incidence of voiding dysfunction and sexual dysfunction.
Data , PANP postoperative local recurrence rate was 5.6% to 6.7%, no significant change compared to the traditional surgery. The group results also show that the the PANP group and the control group in the local recurrence rate after radical were 7.14% (4/56) and 8.93% (5/56), slightly higher relapse rate compared with the literature, may be we select cases related. 0.05）。">The two groups was not statistically significant (P> 0.05). Description in radical surgery uplink PANP surgery, does not increase the rate of local recurrence.
PANP surgery should pay attention to the following points: (1) the presacral space and seminal vesicle rear is the most easy to damage the pelvic plexus surgery operating here should be just as careful; (2) dealing with the lateral ligament of the rectum, as far as possible away from the pelvic sidewall to avoid pelvic plexus damage; care to preserve the integrity of the prostate capsule, (3) separation of the bladder and bowel clearance, because some of the nerves of the pelvic plexus extends to the penis through the prostate capsule; (4) removal of abdominal taken to avoid vascular “bone" to protect nerve fibers showed a network-like, around the aorta and iliac vessels lymphatic adipose tissue; (5) cancer postoperative voiding dysfunction and sexual dysfunction with time more than a certain degree of recovery, the line PANP surgery should not affect radical as a precondition.