Research progress on urogenital function preservation in extralevator abdominoperineal resection / 中华胃肠外科杂志

Extralevator abdominoperineal excision (ELAPE) has been suggested to potentially improve oncological outcomes in advanced low rectal cancer patients. However, the urogenital function impairment as one of the main complications deteriorates the quality of life in these patients. The key point to prevent urogenital function impairment is to avoid autonomic nerve injury, including the superior and inferior hypogastric nerve plexus and neurovascular bundle. Three areas should be especially focused during surgery, including the posterolateral aspect of the prostate during the separation of the rectum from prostate, the lateral wall of ischioanal fossa and the area in front of anal canal. Previous presumption supposed that extended resection, though promoting oncologic outcomes, might lead to enlarged injury to surrounding vessels and nerves that deteriorated patients′ urogenital function. But recent studies show that postoperative urogenital function outcomes of rectal cancer patients who underwent ELAPE are not inferior to conventional APE after the induction of minimal invasive approaches including laparoscopic and robotic surgery. Their quality of life can be comparable with patients who underwent conventional APE, and are even better in some particular area. Moreover, as further improvement of ELAPE procedure has been made, the concept of individualized ELAPE addressed the importance of personalized surgical procedure based on tumor stage and location, dedicating to avoid injury to vessels and nerves through preserving more surrounding tissues. Urogenital function outcomes, as part of postoperative outcomes, get more and more attention in recent years. We review current studies on urogenital function after ELAPE from anatomy to clinical research, in order to raise surgeons′ attention of nerve preservation technique and to improve their understanding of ELAPE procedure.

Short-term Outcomes of an Extralevator Abdominoperineal Resection in the Prone Position Compared With a Conventional Abdominoperineal Resection for Advanced Low Rectal Cancer: The Early Experience at a Single Institution

PURPOSE: This study compared the perioperative and pathologic outcomes between an extralevator abdominoperineal resection (APR) in the prone position and a conventional APR. METHODS: Between September 2011 and March 2014, an extralevator APR in the prone position was performed on 13 patients with rectal cancer and a conventional APR on 26 such patients. Patients' demographics and perioperative and pathologic outcomes were obtained from the colorectal cancer database and electronic medical charts. RESULTS: Age and preoperative carcinoembryonic antigen (CEA) level were significantly different between the conventional and the extralevator APR in the prone position (median age, 65 years vs. 55 years [P = 0.001]; median preoperative CEA level, 4.94 ng/mL vs. 1.81 ng/mL [P = 0.011]). For perioperative outcomes, 1 (3.8%) intraoperative bowel perforation occurred in the conventional APR group and 2 (15.3%) in the extralevator APR group. In the conventional and extralevator APR groups, 12 (46.2%) and 6 patients (46.2%) had postoperative complications, and 8 (66.7%) and 2 patients (33.4%) had major complications (Clavien-Dindo III/IV), respectively. The circumferential resection margin involvement rate was higher in the extralevator APR group compared with the conventional APR group (3 of 13 [23.1%] vs. 3 of 26 [11.5%]). CONCLUSION: The extralevator APR in the prone position for patients with advanced low rectal cancer has no advantages in perioperative and pathologic outcomes over a conventional APR for such patients. However, through early experience with a new surgical technique, we identified various reasons for the lack of favorable outcomes and expect sufficient experience to produce better peri- or postoperative outcomes.

Amputación abdominoperineal extraelevador como tratamiento de neoplasias anorrectales localmente avanzadas. Experiencia inicial / Extralevator abdominoperineal resection as treatment of locally advanced anorectal neoplasias. Initial experience

Introducción: la amputación abdominoperineal (AAP) fue durante muchas años el tratamiento de elección para los tumores de recto bajo y especialmente aquellos con compromiso del aparato esfinteriano. Algunas modificaciones a la técnica original, sugieren el aumento de la radicalidad a través de una resección cilíndrica (amputación abdominoperineal extraelevador). Esta estrategia permite ampliar los márgenes de resección circunferencial, con menor posibilidad de perforación o apertura tumoral, permitiendo así una menor recidiva local y mejores resultados oncológicos. El siguiente trabajo tiene por objetivo exponer los aspectos técnicos más relevantes y los resultados de la experiencia inicial con esta variante técnica. Diseño: Serie de casos. Pacientes y métodos: se analizaron todos los pacientes sometidos a una amputación abdominoperineal extraelevador (AAPE) intervenidos en el Sanatorio Güemes, en el período comprendido desde mayo 2011 hasta septiembre del 2013. Fueron analizadas variables: demográficas, índice ASA (American Society of Anesthesiologist), índice de masa corporal (IMC), distancia del tumoral margen anal, tipo de cirugía, estadía hospitalaria y la morbilidad perioperatoria. Resultados: se incluyeron 5 pacientes, 4 de ellos pertenecían al sexo masculino. La media de edad fue de 61 años mientras que para el IMC fue de 29,8. Solamente en 1 paciente se realizó el abordaje laparoscópico. El tiempo operatorio medio fue de 266 minutos. La estadía hospitalaria en promedio fue de 8,6 días. Se registraron las siguientes complicaciones: dehiscencia parcial de colgajo cutáneo en 2 pacientes, fistula uretral (1 paciente) y eventración de la incisión mediana (1 paciente). El seguimiento medio de la serie fue de1 5 (8-24) meses. No hubo mortalidad en la serie. Un paciente presento una recidiva local...

Background: abdominoperineal resection (APR) has been, for many years, the treatment of choice for low rectal tumors, or those with sphincter involvement. In recent years, technical modifications (extralevator abdominoperineal resection) were performed, increasing the radicality of the original surgery. Thus oncologic outcomes were improved, with a decrease in the values of tumor perforation, circumferential resection margins involvement and a consequent lower local recurrence rates. This paper attempts to show the initial experience in this type of procedure. Design: Case series. Patients and methods: all patients who underwent extralevator abdominoperineal resection (EAPR) in the Sanatorio Güemes in the period from May 2011 to September 2013 were included. The variables analyzed were: demographic, ASA index (American Society of Anesthesiologist), body mass index (BMI), tumor distance from the anal verge, type of surgery, hospital stay, and intraoperative and postoperative complications. Results: five extralevator abdominoperineal resection were performed in 4 males. The mean age was 61 years and the mean BMI was 29.8. Only 1 laparoscopic approach was performed. The mean operative time was 266 min. The hospital stay was 8.6 days. The postoperative complications were: partial flap dehiscence (2 patients), urethral fistula (1 patient) and median incision hernia (1 patient). The median follow-up was 15 (8-24) months. Only one patient had a local recurrence...

Four-arm single docking full robotic surgery for low rectal cancer: techniques and post-operative outcomes / Cirurgia totalmente robótica para o tratamento do câncer do reto distal: técnicas e resultados do pós-operatório imediato

BACKGROUND: laparoscopic rectal surgery has not yet achieved a high penetration rate because of its steep learning curve and its relatively high conversion rate. Robotic rectal resection represents the main indication of the use of the robotic platform in colorectal surgery. The aim of this study was to present an early experience with robotic surgery to treat mid and low rectal cancer focusing on the technique and early postoperative outcomes. METHODS: from December 2012 to October 2013, a total of 16 patients with colorectal diseases were operated on using a four-arm single docking full robotic procedure (daVinci Si Surgical System). The treatment of six consecutive patients who underwent robotic rectal cancer surgery for mid or low rectal adenocarcinoma was prospectively analyzed regarding technique standardization, pathological findings and postoperative outcomes. RESULTS: there were no conversions and one intraoperative complication. The mean operative time was 245 min (180-360 min). The mean console time was 170 min (110-240 min). All patients underwent a standardized totally robotic rectal dissection. There were no mortality or urinary dysfunction and one complication (postoperative ileo-16%). The median length of hospital stay was 6 (4-11 days). The median number of lymph nodes harvested was 22 (7-38), and distal and circumferential resection margins were negative in all specimen. R0 resection was achieved in all cases and complete total mesorectal excision in five specimen and nearly complete in one. CONCLUSION: standardized robotic rectal surgery is a promising alternative to treat patients with mid or low rectal cancer and is expected to overcome the low penetration rate of laparoscopic surgery in this field. This technique was successfully performed in six patients with excellent immediate postoperative and pathological results. Additional studies in a large series of patients are necessary to confirm those advantages. (AU)

INTRODUÇÃO: a utilização da cirurgia videolaparoscópica para o tratamento do câncer do reto ainda não apresentou uma alta penetração devido a longa curva de aprendizado e a uma taxa de conversão relativamente alta. A ressecção retal robótica é a principal indicação para o uso da plataforma robótica na cirurgia colorretal. O objetivo desse estudo é apresentar as técnicas e os resultados pós-operatórios imediatos com o uso da cirurgia robótica para o tratamento do câncer do reto distal. PACIENTES E MÉTODOS: no período de dezembro de 2012 a outubro de 2013 foram operados 16 pacientes com patologias colorretais utilizando o robô daVinci SI Surgical System. O tratamento de 6 consecutivos pacientes portadores de câncer do reto do terço médio e do terço inferior foram prospectivamente avaliados quanto a sistematização técnica, achados patológicos e evolução pós-operatória. RESULTADOS: não houve conversão e ocorreu uma complicação intraoperatória. A duração média das operações foi de 245 minutos (180-360 minutos) e o tempo médio do uso do console foi de 170 minutos (110-240 minutos). Ocorreu uma complicação pós-operatória (Íleo) e não houveram nenhuma disfunção urinária ou mortalidade. A duração média da internação hospitalar foi de 6 dias (4-11 dias). O número médio de linfonodos examinados foi de 22 (7-38) e todas as peças tinham margens distal e circunferencial negativas. Ressecção RO foi observada em todos os casos e o grau de excisão total do mesorreto foi completo em 5 peças e quase completo em uma. CONCLUSÃO: cirurgia robótica sistematizada esta tendo uma crescente aceitação e é uma ótima alternativa para o tratamento dos pacientes com câncer do reto distal. Esta tecnologia foi utilizada em 6 pacientes com excelentes resultados não só na recuperação pós-operatória imediata como também nos achados da avaliação patológica. Grandes series randomizadas são importantes para confirmar as possíveis vantagens dessa nova tecnologia. (AU)