Operating Behind Denonvilliers' Fascia for Reliable Preservation of Urogenital Autonomic Nerves in Total Mesorectal Excision: A Histologic Study Using Cadaveric Specimens, Including a Surgical Experiment Using Fresh Cadaveric Models

Abstract

To preserve all autonomic nerves for urogenital function, optimal total mesorectal excision for rectal cancer requires dissection behind Denonvilliers' fascia.

Impact of laparoscopic surgery on bladder and sexual function after total mesorectal excision for rectal cancer

“…Interestingly, the rates of impotence and ejaculatory problems were similar, suggesting that both parasymphathetic and symphathetic nerves are equally at risk of injury and indicating that the most likely site of damage is at the lateral pelvic plexus where both autonomic systems converge. Another explanation attributes this to the proximity of the autonomic nerves to the anterolateral mesorectal fascia of Denonvillier [26,27]. Accurate dissection in this plane can be easier, particularly during laparoscopic surgery, because of magnification features, and this may account for erectile function being the component of male sexual function most commonly affected by open surgery.…”

Push-Back Technique Facilitates Ultra-Low Anterior Resection without Nerve Injury in Total Mesorectal Excision for Rectal Cancer

“…There is also some argument in Japan about anterior dissection for rectal cancer. Based on a histological study of cadaveric specimens, Kinugasa et al [14] suggest that optimal TME requires dissection behind Denonvilliers’ fascia. Kusunoki et al [3] also recommend operating behind Denonvilliers’ fascia to preserve the neurovascular bundles, except in cases of lower rectal cancer with anterior wall involvement.…”

Laparoscopic dissection of Denonvilliers’ fascia and implications for total mesorectal excision for treatment of rectal cancer

“…However, Lindsey et al, based on histologic and embryologic evidence, pointed out that the fascia propria of the rectum and Denonvilliers' fascia would be separable, and thus the correct natural dissection plane of TME should be ''anterior'' to the fascia propria of the rectum and ''posterior'' to Denonvilliers' fascia [4,5]. Moreover, Kinugasa et al found that, at the level of seminal vesicles, incision in front of Denonvilliers' fascia was likely to injure superior parts of the pelvic nerve plexus and the left-right communication; therefore, to preserve all autonomic nerves for normal genitourinary function, optimal TME for rectal cancer, in their opinion, required dissection behind Denonvilliers' fascia [6,7]. On the other hand, the concept of Denonvilliers' fascia in female patients remains unclear for most colorectal surgeons.…”

“…Remarkably, however, ample imaging and surgical practices have suggested that the key to successful anterior dissection in TME is based on full appreciation of Denonvilliers' fascia and its relationship to the anterior mesorectum [3][4][5][6]. Denonvilliers' fascia is generally considered macroscopically to be a one-layer fascia arising from the fusion of the two walls of the embryonic peritoneal cul-de-sac, and thus histologically it actually consists of two-layer fibromuscular tissues and extends from the peritoneal reflection cranially to the perineal body caudally [3].…”