Effect of preservation of Denonvilliers’ fascia during laparoscopic resection for mid-low rectal cancer on protection of male urinary and sexual functions

Abstract

The aim of this study was to investigate the effect of preservation of Denonvilliers’ fascia (DF) during laparoscopic resection for mid-low rectal cancer on protection of male urogenital function. Whether preservation of DF during TME is effective for protection of urogenital function is largely elusive.Seventy-four cases of male mid-low rectal cancer were included. Radical laparoscopic proctectomy was performed, containing 38 cases of preservation of DF (P-group) and 36 cases of resection of DF (R-group) intraoperatively. Intraoperative electrical nerve stimulation (INS) on pelvic autonomic nerve was performed and intravesical pressure was measured manometrically. Urinary function was evaluated by residual urine volume (RUV), International Prostatic Symptom Score (IPSS), and quality of life (QoL). Sexual function was evaluated using the International Index of Erectile Function (IIEF) scale and ejaculation function classification.Compared with performing INS on the surfaces of prostate and seminal vesicles in the R-group, INS on DF in the P-group exhibited higher increasing intravesical pressure (7.3 ± 1.5 vs 5.9 ± 2.4 cmH2O, P = 0.008). In addtion, the P-group exhibited lower RUV (34.3 ± 27.2 vs 57.1 ± 50.7 mL, P = 0.020), lower IPSS and QoL scores (7 days: 6.1 ± 2.4 vs 9.5 ± 5.9, P = 0.002 and 2.2 ± 1.1 vs 2.9 ± 1.1, P = 0.005; 1 month: 5.1 ± 2.4 vs 6.6 ± 2.2, P = 0.006 and 1.6 ± 0.7 vs 2.1 ± 0.6, P = 0.003, respectively), higher IIEF score (3 months: 10.7 ± 2.1 vs 8.9 ± 2.0, P = 0.000; 6 months: 14.8 ± 2.2 vs 12.9 ± 2.2, P = 0.001) and lower incidence of ejaculation dysfunction (3 months: 28.9% vs 52.8%, P = 0.037; 6 months: 18.4% vs 44.4%, P = 0.016) postoperatively.Preservation of DF during laparoscopic resection for selective male mid-low rectal cancer is effective for protection of urogenital function.

Preservation of Denonvilliers' fascia for nerve‐sparing laparoscopic total mesorectal excision: A neuro‐histological study

“…Follow‐up data in the present study further showed patients who underwent DVF resection and had more nNOS‐positive nerves removed had worse sexual function. This clinical result was consistent with our previous study, and the report by Miyake et al (Miyake et al, ; Wei et al, ). This emphasized the importance of the nerve fibers closely located to the DVF (Hoyle et al, ).…”

“…Recent discussions on anterior dissection during TME have focused on the attachment of the DVF to the resected side (Lindsey et al, ; Heald et al, ; Kinugasa et al, ) . Our previous retrospective studies on DVF‐sparing laparoscopic TME for male patients with mid‐low rectal cancer found that preservation of the DVF effectively protected against urogenital dysfunction (Wei et al, ). Nevertheless, the capability of DVF‐preserving laparoscopic TME to minimize damage to the pelvic autonomic nerves has not been verified through microscopy.…”

“…The operation was performed under general anesthesia and patients were placed in lithotomy position. As we previously described, sharp dissection was performed in front of the DVF for the R group (Wei et al, ). However, in the P group, transverse dissection of the peritoneum was performed at the peritoneal reflection.…”

“…Removal of the DVF has however been suggested to be responsible for damaging the pelvic autonomic nerves and post‐operative urogenital sequelae (Zhang et al, ; Moszkowicz et al, , ; Kim et al, ). To clarify this argument, we previously performed DVF‐sparing laparoscopic TME in male patients with mid‐low rectal cancer, and found that preservation of the DVF afforded protection to urogenital function (Wei et al, ). However, whether this effect is owing to the protection of autonomic nerve accompanied with DVF preservation has not been substantiated by microscopic evaluation in adult male patients.…”

The ‘multilayer’ theory of Denonvilliers’ fascia: anatomical dissection of cadavers with the aim to improve neurovascular bundle preservation during rectal mobilization

“…These findings may explain the recommendation of Lindsey et al [24] that the anterior rectal dissection surgical plane should lie posterior to DVF as a nervesparing technique to lower the incidence of deterioration of uro-sexual function postoperatively. In addition, our findings are compatible with other studies which used intra-operative nerve stimulation during pelvic operations such as TME and prostatectomy in order to identify the NVB, and all showed obvious stimulation on application of the intra-operative nerve stimulator anterolaterally [25][26][27][28][29].…”