"Near-TME": proposed standardisation of the technique for proctectomy in male patients with ulcerative colitis.

BACKGROUND: The aim of the present study was to describe in detail an approach to proctectomy in ulcerative colitis (UC), which can be standardized; near-total mesorectal excision (near-TME), to prevent injuries to autonomic pelvic nerves and subsequent sexual dysfunction. METHODS: We demonstrate the technique ex vivo on a cadaver from a male patient in lithotomy position and on a sagittal section of a male pelvis. We also demonstrate the technique in vivo in two male patients diagnosed with UC, with no history of sexual dysfunction or bowel neoplasia. The study was performed at the Human Embryology and Anatomy Department. University of Valencia, Spain. RESULTS: The posterolateral dissection during a near-TME is similar to that of an oncologic TME, whereas the anterolateral is similar to that of a close rectal dissection. The near-TME technique preserves the superior hypogastric plexus, the hypogastric nerves, the nervi erigentes, the inferior hypogastric plexus, the pelvic plexus and the cavernous nerves. CONCLUSION: The near-TME technique is the standardisation of the technique for proctectomy in male patients with ulcerative colitis. Near-TME requires experience in pelvic surgery and an exhaustive knowledge of the embryological development and of the surgical anatomy of the pelvis.

Reconsideration of the Anterior Surgical Plane of Total Mesorectal Excision for Rectal Cancer.

INTRODUCTION: Previous studies on total mesorectal excision suggested dissection anterior to Denonvilliers' fascia, which might lead to intraoperative pelvic autonomic nerves injury and a high incidence of urogenital dysfunction. TECHNIQUE: We dissected 4 cases of cadavers, mainly focusing on anatomy of Denonvilliers' fascia, to study the relationship between Denonvilliers' fascia and rectum. In practice, instead of dissection 1 cm above peritoneal reflection, dissection of the peritoneum was performed at the lowest level of peritoneal reflection during laparoscopic resection for mid-low rectal cancer. RESULTS: The cadaveric study revealed that there were loose tissues between Denonvilliers' fascia and rectal specimen, thus a surgical plane posterior to Denonvilliers' fascia did exist. During laparoscopic resection for mid-low rectal cancer, some loose reticulate structures between Denonvilliers' fascia and proper fascia of rectum would present after dissection of peritoneum at the lowest level of peritoneal reflection. Then dissection within the surgical plane posterior to Denonvilliers' fascia became easy and feasible. In this plane, both the pelvic nerves and postoperative urogenital function could be well protected by Denonvilliers' fascia. CONCLUSIONS: The anterior surgical plane for total mesorectal excision should be reconsidered, and dissection posterior to Denonvilliers' fascia is feasible and practicable for patients without risk of positive anterior circumferential resection margin.

Current concepts and practical techniques of nerve-sparing laparoscopic radical hysterectomy.

Laparoscopic radical hysterectomy has been widely performed for patients with early-stage cervical cancer. The operative techniques for nerve-sparing to avoid bladder dysfunction have been established during the past three decades in abdominal radical hysterectomy, but how these techniques can be applied to laparoscopic surgery has not been fully discussed. Prolonged operation time or decreased radicality due to less accessibility via a limited number of trocars may be a disadvantage of the laparoscopic approach, but the magnified visual field in laparoscopy may enable fine manipulation, especially for preserving autonomic nerve tracts. The present review article introduces the practical techniques for sparing bladder branches of pelvic nerves in laparoscopic radical hysterectomy based on understanding of the pelvic anatomy, clearly focusing on the differences from the techniques in abdominal hysterectomy.

Transanal total mesorectal excision: dissection tips using 'O's and 'triangles'.

PURPOSE: Transanal total mesorectal excision (taTME) requires specific technical expertise, as it is often difficult to ascertain the correct dissection plane. Consequently, one can easily enter an incorrect plane, potentially resulting in bleeding (sidewall or presacral vessels), autonomic nerve injury and urethral injury. We aim to demonstrate specific visual features, which may be encountered during surgery and can guide the surgeon to perform the dissection in the correct plane. METHOD: Specific features of dissection in the correct and incorrect planes are demonstrated in the accompanying video. RESULTS: The 'triangles' created using appropriate traction can aid in performing a precise dissection in the correct plane. Recognition of features described as 'O's can alert surgeons that they are entering a new fascial plane and can avoid incursion into an incorrect plane. CONCLUSION: Understanding and recognizing the described features which can be encountered in taTME surgery, a safe and accurate TME dissection can be facilitated.

Bowel function and quality of life after superior mesenteric nerve plexus transection in right colectomy with D3 extended mesenterectomy.

BACKGROUND: The aim of this study was to ascertain the impact of injury to the superior mesenteric nerve plexus caused by right colectomy with D3 extended mesenterectomy as performed in the prospective multicenter trial: "Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multi-detector Computed Tomography" in which all soft tissue surrounding the superior mesenteric vessels from the level of the middle colic artery to that of the ileocolic artery was removed. METHODS: Bowel function and gastrointestinal quality of life in two consecutive cohorts that underwent right colectomy with and without D3 extended mesenterectomy were compared. Main outcome measures were the Diarrhea Assessment Scale (DAS) and Gastrointestinal Quality of Life Index (GIQLI). The data were collected prospectively through telephone interviews. RESULTS: Forty-nine patients per group, comparable for age, sex, length of bowel resected but with significantly shorter follow-up time in the experimental group, were included. There was no difference in total DAS scores, subscores or additional questions except for higher bowel frequency scores in the D3 group (p = 0.02). Comparison of total GIQLI scores and subscales showed no difference between groups. Regression analysis with correction for confounding factors showed 0.48 lower bowel frequency scores in the D2 group (p = 0.022). Within the D3 group presence of jejunal arteries cranial to the D3 dissection area showed 1.78 lower DAS scores and 0.7 lower bowel frequency scores. CONCLUSIONS: Small bowel denervation after right colectomy with D3 extended mesenterectomy leads to increased bowel frequency but does not impact gastrointestinal quality of life. Individual anatomical variants can affect postoperative bowel function differently despite standardized surgery.

Recovery of Urinary Functions After Laparoscopic Total Mesorectal Excision for T4 Rectal Cancer.

BACKGROUND: Postoperative urinary dysfunction after total mesorectal excision (TME) is lessened by preservation of the autonomic nerves, but in T4 rectal tumors such injury often cannot be prevented. This retrospective study evaluated the recovery of urinary function of patients with injury to a single pelvic autonomic nerve subsequent to laparoscopic TME, relative to patients without nerve damage. METHODS: Patients with T4 rectal cancer who underwent laparoscopic TME were divided according to the presence of a single pelvic autonomic nerve injury (37 cases) or no injury to autonomic nerves (54 cases; control). Urinary function was evaluated before surgery and at 1 and 6 months after surgery based on catheter indwelling time, urodynamics, International Prostate Symptom Score (IPSS; men only), and Urogenital Distress Inventory (UDI-6) score (women). RESULTS: One month after surgery in the injured and control groups, the postoperative catheter indwelling time was 6.2 ± 2.0 and 1.9 ± 1.2 days, respectively; the maximal urinary flow rates were 16.6 ± 5.8 and 19.7 ± 5.5 mL/s; the voided volumes were 181.6 ± 65.9 and 211.7 ± 63.2 mL; and the residual volumes were 15.0 ± 8.5 and 10.8 ± 8.0 mL. However, at the 6-month follow-up, all urodynamic parameters of the two groups were statistically similar and indicated recovery, and the IPSS and UDI-6 scores were also not statistically different. CONCLUSION: Damage to a single pelvic autonomic nerve during laparoscopic TME does not lead to long-term urinary dysfunction.

Electrophysiology-based quality assurance of nerve-sparing in laparoscopic rectal cancer surgery: Is it worth the effort?

BACKGROUND: After low anterior resection for rectal cancer, visual assessment of pelvic autonomic nerve preservation can be difficult due to the complexity of neuroanatomy, as well as surgery- and patient-related factors. The present study aimed to evaluate nerve-sparing quality assurance using the laparoscopic neuromapping (LNM) technique. METHODS: We prospectively investigated a series of 30 patients undergoing laparoscopic low anterior resection. Nerve-sparing was evaluated both visually and electrophysiologically. LNM was performed using stimulation of pelvic autonomic nerves under simultaneous cystomanometry and processed electromyography of the internal anal sphincter. Urogenital and anorectal functions were evaluated using validated and standardized questionnaires preoperatively, at short-term follow-up, and at mid-term follow-up at a median of 9 months (range 6-12 months) after surgery. RESULTS: One patient reported new onset of urinary dysfunction, and another patient reported new onset of anorectal dysfunction. Of the 20 sexually active patients, five reported sexual dysfunction. Visual assessment by laparoscopy confirmed complete nerve preservation in 28 of 30 cases. For prediction of urinary and anorectal function, LNM sensitivity, specificity, positive and negative predictive value, and overall accuracy were each 100 %. LNM with combined assessment for prediction of sexual function yielded a sensitivity of 80 %, specificity of 93 %, positive predictive value of 80 %, negative predictive value of 93 %, and overall accuracy of 90 %. CONCLUSIONS: LNM is an appropriate method for reliable quality assurance of laparoscopic nerve-sparing.

Nerve-guided laparoscopic total mesorectal excision for distal rectal cancer.

BACKGROUND: Urogenital dysfunctions are well-recognized problems after rectal cancer surgery and are often due to autonomic nerve damage. Although following holy planes during total mesorectal excision (TME) reduces the possibility of damage to the autonomic nerve fibers, these could still be affected in some critical areas.1 (,) 2 To improve the quality of surgery and prevent nerve damage, accurate intraoperative anatomical orientation of autonomic nerve is essential.3 Thanks to advancement of the high-definition laparoscopic technology, even the finest nerve fibers deep in the pelvic cavity can be identified through illumination and magnification.4 We aim to present a surgical technique of using the autonomic nerves as landmarks to guide laparoscopic TME for distal rectal cancer, with the purpose of preventing autonomic nerve damage to the largest extent. METHODS: The video describes the technique of performing nerve-guided laparoscopic TME in a 50-year-old man with a rectal cancer (7 cm from anal verge). Preoperative staging by endorectal ultrasound and pelvic magnetic resonance imaging is stage I rectal cancer (cT2N0M0). Five trocars (two 12 mm and three 5 mm) are used. All procedures are performed with conventional laparoscopic instruments. The sigmoid colon is mobilized using a medial approach. The superior hypogastric plexus lies just posterior to the inferior mesenteric artery (IMA) are clearly identified and protected. Then the root of the IMA is ligated and cut. The left Toldt space is dissected, followed by complete mobilization of the sigmoid colon. The superior hypogastric plexus nerve fibers combine to a strong pair of hypogastric nerves as they enter the pelvic cavity, and can be clearly identified when the mesorectum is lifted. Then the mesorectum is separated from the hypogastric nerves by sliding down along the nerves. Dissection of the mesorectum is continued in the loose areolar plane along the midline down to the sacrococcygeal junction. Then the mesorectum is dissected laterally from posterior midline up to 9 o'clock on the left and to 3 o'clock on the right side. The splanchnic nerves can be identified as they swing from the sacrum and straight into the pelvic plexus. The peritoneum is dissected in an arc line about 0.5 cm above the line of rectovesical pouch. After the anterior side of the rectum is mobilized, the mesorectum is dissected along the seminal vesicles downward and sideward to the lateral margin. The neurovascular bundle of Walsh at the anterolateral side of the rectum is clearly identified and protected. The mobilization of the mesorectum ceases at the tendinous arch of levator ani. Then the rectum is only fixed to the pelvic side wall by its lateral ligaments, which are consisted by rectal branch of the inferior pelvic plexus and vessels. Thus care should be taken to cut only those rectal nerve fibers, leaving the inferior pelvic plexus intact. The mesorectum is divided 5 cm distal to the lesion with one firing of an endoscopic stapler. The specimen is extracted through a 3 cm transumbilical laparotomy. End-to-end anastomosis using a circular stapler is performed intra-abdominally. RESULTS: There were no intraoperative complications. The operating time was 160 min. Blood loss was 20 mL. The patient underwent an uneventful recovery and was discharged home on postoperative day 6. Final pathology was pT2N0M0. At 6-month follow-up, the patient had no urogenital dysfunctions. CONCLUSIONS: Nerve-guided laparoscopic total mesorectal excision for distal rectal cancer is safe and feasible. This technique should be considered whenever possible as a means to prevent autonomic nerve damage and subsequent loss of urogenital function.

Topography of the extrinsic internal anal sphincter nerve supply during laparoscopic-assisted TAMIS TME: five key zones of risk from the surgeons' view.

PURPOSE: Sparing the extrinsic autonomic innervation of the internal anal sphincter during total mesorectal excision is important for the preservation of anal sphincter function. This study electrophysiologically confirmed the topography of the internal anal sphincter nerve supply during laparoscopic-assisted transanal minimally invasive surgery for total mesorectal excision. METHODS: This prospective study was conducted at two large multispecialty referral centers. Six patients (five males and one female) aged between 45 and 65 years with low rectal cancer (≤5 cm from the anal verge) were enrolled. Surgery was performed under electric stimulation of the pelvic autonomic nerves with observation of the electromyographic signals of the internal anal sphincter. RESULTS: The minimally invasive transanal surgical approach enabled advantageous visualization of the pelvic autonomic nerves in all patients. In particular, extrinsic innervation to the internal anal sphincter near the levator muscle was consciously spared under electrophysiological confirmation. The evoked absolute electromyographic amplitudes of the internal anal sphincter during transanal minimally invasive surgery were significantly lower than the initial results of the laparoscopic approach [3.7 µV (interquartile range 2.4; 5.7) vs. 4.3 µV (interquartile range 3.1; 8.6); p = 0.002]. Five key zones of risk for pelvic autonomic nerve damage were identified. No complications occurred. CONCLUSIONS: The electromyographic results of this preliminary study indicate advantages for sparing the internal anal sphincter innervation during transanal minimally invasive mesorectal dissection considering the specific in situ neuroanatomical topography.

Functional long-term results after rectal cancer surgery--technique of the athermal mesorectal excision.

PURPOSE: The total mesorectal excision (TME), embedded in a multimodal therapeutic concept, is accepted as the standard therapy of the advanced adenocarcinoma of the middle and lower thirds. The thermal damages of the autonomous nerves in the little pelvis caused by dissection devices remains a large problem. For our patients, we use water-jet dissection (WJD)-aided TME with the intention to minimise the rate of bladder and sexual function disorders. METHODS: From October 2001 until June 2010, we recorded 125 patients with an adenocarcinoma of the middle and lower third of the rectum. Ninety deep anterior rectum resections and 35 abdominoperineal rectum extirpations by WJD were performed. Of the patients, 27.2 % received neoadjuvant radiochemotherapy. Bladder and sexual function disorders were assessed by International Prostate Symptom Score and International Index of Erectile Function. RESULTS: The median follow-up period was 46 (2-117) months. Considering a local recurrence rate of 9.6 %, the tumour-specific 5-year survival of the entire collective was 75.4 %. Long-term bladder function disorders showed in 6.0 % (4/64) and sexual function disorders in 25.0 % (9/36) of the male patients in the course of time. CONCLUSION: The specific advantage of the WJD technique is not only the facilitated dissection between the mesorectal fascia and the surrounding nervous structures in the little pelvis but also a completely athermal TME. The rate of bladder and sexual function disorders is an excellent result compared to that of international centres. Due to the size of the patient collective and the retrospective character of the study, further studies are necessary to validate the presented results.

Classical and nerve-sparing radical hysterectomy: an evaluation of the nerve trauma in cardinal ligament.

OBJECTIVES: This study evaluated histopathology and clinical outcome of autonomic nerve trauma and vessels removal within the cardinal ligament (CL) during nerve-sparing radical hysterectomy (NSRH) compared with radical hysterectomy (RH). METHODS: 25 women with FIGO stage Ib1-IIa cervical cancer underwent RH (n=13) or NSRH (n=12). Removed CLs lengths were measured. Biopsies were collected from the proximal, middle and distal segment of CLs and fixed. Different markers were used for immunohistochemisty analysis: tyrosine hydroxylase for sympathetic nerves; vasoactive intestinal polypeptide for parasympathetic nerves; CD34 for blood vessels; and D2-40 for lymphatic vessels. The volume density (Vv), a parameter of biological stereology, was used to quantitatively measure CL components, while post-operative functions, such as defecation, micturition and two-year disease free survival in RH and NSRH groups were compared. RESULTS: The nerves mainly existed in the middle and distal segments of CLs. The Vv was greater in RH compared with NSRH for both sympathetic and parasympathetic nerve markers (P<0.05), while the Vv of blood and lymphatic vessels were same in the two groups. Average time to achieve residual urine≤50ml and first defecation were shorter in NSRH than in RH (P<0.05). CONCLUSIONS: Less autonomic nerves within CL are transected in NSRH than in RH, while blood/lymphatic vessels are efficiently removed in both treatments. Compared to RH, NSRH decreases iatrogenic injury, which leads to reduced post-operative co-morbidities, with ensure the same radicality.

Prevalence and outcome of urinary retention after laparoscopic surgery for severe endometriosis--does histology provide answers?

INTRODUCTION AND HYPOTHESIS: Urinary retention after radical laparoscopic surgery for severe endometriosis is a clinically relevant complication. We hypothesized a relationship between the amount of resected nerves and the occurrence of urinary retention. METHODS: We evaluated, retrospectively, a cohort of 221 patients. The expression of nerves in the resected specimens was investigated in patients with urinary retention and matched controls using standardized immunohistochemistry techniques. RESULTS: The prevalence of urinary retention was 4.6% (n = 10). Importantly, there was no difference between cases and controls regarding the quantity of nerves in the resected specimens. The cumulative probability of 50% to overcome urinary retention was reached after 5.6 months. Age was the main risk factor for persistent retention (40.3 years with vs. 31.6 years without, p = 0.01). CONCLUSIONS: In older endometriosis patients, surgical radicality should be balanced against preservation of organ function. There is a fairly good chance to recover, even after 6 months, which is important for patient counseling.

Selective pelvic autonomic nerve stimulation with simultaneous intraoperative monitoring of internal anal sphincter and bladder innervation.

BACKGROUND: Pelvic autonomic nerve preservation avoids postoperative functional disturbances. The aim of this feasibility study was to develop a neuromonitoring system with simultaneous intraoperative verification of internal anal sphincter (IAS) activity and intravesical pressure. METHODS: 14 pigs underwent low anterior rectal resection. During intermittent bipolar electric stimulation of the inferior hypogastric plexus (IHP) and the pelvic splanchnic nerves (PSN), electromyographic signals of the IAS and manometry of the urinary bladder were observed simultaneously. RESULTS: Stimulation of IHP and PSN as well as simultaneous intraoperative monitoring could be realized with an adapted neuromonitoring device. Neurostimulation resulted in either bladder or IAS activation or concerted activation of both. Intravesical pressure increase as well as amplitude increase of the IAS neuromonitoring signal did not differ significantly between stimulation of IHP and PSN [6.0 cm H(2)O (interquartile range [IQR] 3.5-9.0) vs. 6.0 cm H(2)O (IQR 3.0-10.0) and 12.1 µV (IQR 3.0-36.7) vs. 40.1 µV (IQR 9.0-64.3)] (p > 0.05). CONCLUSIONS: Pelvic autonomic nerve stimulation with simultaneous intraoperative monitoring of IAS and bladder innervation is feasible. The method may enable neuromonitoring with increasing selectivity for pelvic autonomic nerve preservation.

Prospective study of sexual dysfunction in men with rectal cancer: feasibility and results of nerve sparing surgery.

PURPOSE: Rectal cancer surgery is impaired by a high rate of postoperative sexual dysfunction cause of frequent nerve injuries. The aim of this study was to prospectively evaluate sexual function in a group of male patients after total mesorectal excision (TME) for rectal cancer, using an autonomic nerve sparing technique. METHODS: All patients underwent autonomic nerve preserving TME. Sexual function was assessed using the International Index of Erectile Function standardized questionnaire. All patients were studied preoperatively and at 3, 6, 12, 18, and 24 months after surgery. RESULTS: Fifty-one patients with adenocarcinoma of the rectum were enrolled; after excluding 16 patients not sexually active, nine with T4 stage disease and six with metastatic disease, 20 patients were prospectively evaluated. The preoperative erectile function (EF) domain score of the International Index of Erectile Function was 24.3 (±4.1). The score of the EF domain was 17.6 (±7.5), 19.l9 (±7.2), 20.3 (±7.4), 20.5 (±7.4), and 20.6 (±7.4) at 3, 6, 12, 18, and 24 months after surgery. In the group of patients in which there were no macroscopic damages to the nerves, only two out of 15 (13.3%) developed erectile dysfunction. All five patients in whom incomplete pelvic nerve preservation was necessary developed erectile dysfunction. CONCLUSION: Our data show that nerve sparing technique can reduce the incidence of sexual dysfunction. Unfortunately, the technique is not applicable in every patient. Indications and techniques of autonomic nerve preservation are not standardized. Controlled trials with long-term follow-up seem to be necessary.

Effect of a local delivery of triiodothyronine (T3) within neuroregenerative guide on recovery of erectile function in a rat-model of cavernous nerve injury.

INTRODUCTION: A promoting effect of thyroid hormones has been established on the maturation of central and peripheral nervous systems. However, effects on autonomic nerves have never been experimentally investigated. AIM: To assess the effect of a local treatment combining silicone guides and local administration of Triiodothyronine (T3) on the erectile function and the histological neuroregeneration of crushed cavernous nerves (CNs) in rats. METHODS: Forty-five rats were divided into five equal groups: SHAM surgery, guide without crush, crush, crush + guide, crush + guide + T3. All surgical procedures were bilateral. CNs were crushed with microvascular bulldog clamp of 100 g/cm(2). A silicone guide was placed around the nerves. The guides were filled with T3 neuroregenerative solution. MAIN OUTCOME MEASURES: Erectile function was assessed 10 weeks post-operatively. Intra-cavernous pressure (ICP) and mean arterial pressure (MAP) were monitored during electrical stimulation of CNs at various frequencies. The main outcome was hardness of erection defined as DeltaICP/MAP. Fluorescent immunohistochemical analysis of CNs was performed to assess regeneration of nerves morphologically. RESULTS: Electrophysiological data showed increased recovery of erectile function in the group with guide + T3 neuroregenerative solution compared with the empty guide. Immunohistochemical analysis of cavernous nerves demonstrated in morphology that regenerated axons were straighter in nerves with guide and more regular if guides had been filled with T3. CONCLUSION: The use of guides prevented axonal sprouting, facilitated functional neuroregeneration and enabled a local delivery of thyroid hormones. Triiodothyronine improved neuroregeneration and recovery of erectile function after a nerve-sparing-like injury in a rat model.

Autonomic denervation and the origins of chronic Western diseases.

Many chronic Western diseases result from lifestyles that include refined diets, poor bowel habits, limited physical exercise and suboptimal patterns of childbirth. Western diets result in reduced stool weights, increased bowel transit times and persistent physical efforts during defaecation. Prolonged physical efforts during defaecation and childbirth cause latent, or direct, injuries to branches of the cardiac (thorax), coeliac (abdomen) and hypogastric (pelvis) plexi. Injuries to autonomic nerves result in impaired visceral function including visceral dysmotility, tissue hypoplasia and hyperplasia, increased susceptibility to infection, and, aberrant reinnervation with sensitisation of the central nervous system (CNS). These unrecognised injuries are vulnerable to the long list of causes of autonomic Dysfunction, e.g. stress, alcohol, drugs, infection, trauma, cancer, etc. Specific injuries at different anatomical locations in midline autonomic pathways give rise to a wide range of Western diseases from infancy to old age, through diverse and cumulative mechanisms.

Reversible chest tube horner syndrome.

A 54-year-old woman who underwent chest tube placement after a lung biopsy was found on the first postoperative day to have ipsilateral ptosis and miosis, suggesting a Horner syndrome. A chest CT scan showed that the tip of the chest tube was apposed to the stellate ganglion. Repositioning of the chest tube later on the first postoperative day led to complete reversal of the Horner syndrome within 24 hours. We propose that the Horner syndrome arose as a result of pressure on the stellate ganglion, which interrupted neural conduction but did not sever the sympathetic pathway ("neurapraxia"). Whether prompt repositioning of the chest tube was critical in reversing the Horner syndrome is uncertain.

[Nerve sparing radical hysterectomy]. / Radykalna histerektomia oszczedzajaca unerwienie wegetatywne.

The aim of the study was to review the literature concerning nerve sparing radical hysterectomy (NSRH). The data about anatomical and physiological background of this operation, its history, technique and perspectives has been presented. In conclusion it has been estimated that the technique is new and its oncological efficiency is not yet fully established; it requires special anatomical knowledge and new instruments.