Total Mesorectal Excision with Intraoperative Assessment of Internal Anal Sphincter Innervation Provides New Insights into Neurogenic Incontinence

Kneist, W.; Kauff, Daniel W.; Gockel, Ines; Huppert, Sabine; Koch, Klaus Peter; Hoffmann, K.; Lang, Hauke

doi:10.1016/j.jamcollsurg.2011.11.013

Cited by 28 publications

(14 citation statements)

References 26 publications

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“…After that, INS has been increasingly applied in pelvic surgeries containing TME surgery for rectal cancer, and it has been proved to be effective and sensitive in identification and preservation of the PAN. [20,21,22] In this study, INS on DF revealed more obvious increasing intravesical pressure compared to performance of INS on the surfaces of prostate and seminal vesicles. The real-time monitoring result suggested that resection of DF might cause damage of PAN and thus lead to urogenital dysfunction.…”

Section: Discussionmentioning

confidence: 58%

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

H¹,

Fang²,

Zheng³

et al. 2016

Medicine

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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.

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Section: Discussionmentioning

confidence: 58%

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

H¹,

Fang²,

Zheng³

et al. 2016

Medicine

View full text Add to dashboard Cite

show abstract

“…Nevertheless, signal loss during continuous neuromonitoring did not occur throughout the whole dissection in each animal, which indicated nervesparing and confirmed intact autonomic innervation. Initial clinical results in patients undergoing total mesorectal excision demonstrated that intermittent neuromonitoring of internal anal sphincter innervation is feasible [3]. Patients with positive stimulation results were fecal continent, whereas those with negative results demonstrated severed, impaired sphincter function at follow-up.…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, it was shown that total mesorectal excision could also result in newly developed fecal incontinence [2], which is one characteristic factor of the so-called anterior resection syndrome. Neurogenic incontinence could be attributed to the intraoperative denervation of the internal anal sphincter [3], which accounts for approximately 52-85% of the anal resting pressure [4].…”

Section: Introductionmentioning

confidence: 99%

“…Further developments of this new method were carried out to improve the reliability of the stimulation-induced internal anal sphincter electromyographic signals [12]. Initial results of a clinical study demonstrated that intermittent neuromonitoring under electromyography of the internal anal sphincter is feasible in rectal cancer patients [3].…”

Section: Introductionmentioning

confidence: 99%

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Continuous intraoperative monitoring of autonomic nerves during low anterior rectal resection: an innovative approach for observation of functional nerve integrity in pelvic surgery

Kauff

Kempski

Koch

et al. 2012

Langenbecks Arch Surg

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Purpose: The aim of this study was to develop a methodological setup for continuous intraoperative neuromonitoring with intent to improve nerve-sparing pelvic surgery. Methods: Fourteen pigs underwent low anterior rectal resection. Continuous stimulation of pelvic autonomic nerves was carried out with a newly developed tripolar surface electrode during lateral, anterolateral, and anterior mesorectal dissection. Neuromonitoring was performed under electromyography of the autonomic innervated internal anal sphincter. Results: Continuous neuromonitoring resulted in significantly increased electromyographic amplitudes of the internal anal sphincter, confirming intact innervation throughout the whole dissection in each animal (median 0.9 V, interquartile range 0.5; 1.5 vs. median 3.4 V, interquartile range 2.1; 4.7) (p < 0.001). The median dissection time in each animal was 10 min within a median number of ten (range 8-13) tripolar electric stimulations. Conclusion: The pres ent study is the first to demonstrate that continuous intraoperative monitoring of pelvic autonomic nerves during low anterior rectal resection is feasible

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“…Thus, the exact moment of a clinical relevant nerve damage and its causes during the operation can only be speculated. Insights into the complex functional pelvic neuroanatomy were provided by a novel IONM method based on electric stimulation of pelvic autonomic nerves under electromyography of the internal anal sphincter (IAS), which was recently introduced to rectal cancer surgery [1].…”

Section: Introductionmentioning

confidence: 99%

Impact of selective surgical pelvic autonomic nerve damage on the evoked neuromonitoring signal of the internal anal sphincter

Kauff

Koch

Kempski

et al. 2012

Biomedical Engineering / Biomedizinische Technik

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Introduction:A novel intraoperative neuromonitoring (IONM) method based on electric stimulation of pelvic autonomic nerves under electromyography of the internal anal sphincter (IAS) has been recently introduced to rectal cancer surgery. The aim of this experimental study was to investigate the impact of selective surgical pelvic autonomic nerve damaging on the evoked IONM signal of the IAS. Methods: For this purpose 12 pigs underwent low anterior rectal resection. The pelvic splanchnic nerves were identified by means of electric stimulation under continuous electromyography of the IAS. For standardized neurostimulation, currents of 3 mA, frequency of 30 Hz and monophasic rectangular pulses with pulse duration of 200 μs were chosen. Surgical autonomic nerve damaging was performed on both pelvic sides while recording the evoked IONM signal of the IAS. Nerve damaging was carried out proximal to the stimulation point at the level of the pelvic splanchnic nerves and then distally at the level of the inferior hypogastric plexus. Scissors, monopolar diathermy, ultracision and waterjet were used for nerve damaging, each in 3 animals. Results: Selective instrumental nerve damaging during neurostimulation resulted in a dissection specific superimposed artefact followed by a change in the evoked electromyographic amplitude, which could be observed online on the monitor of the IONM device. Comparison of the recorded IONM signals before and after proximal nerve damaging demonstrated a significant decrease in the evoked amplitude level (median 2.8 μV (interquartile range (IQR) 1.6; 5.7) vs. median 1.4 μV (IQR 0.6; 2.9), (p=0.026)). Nerve damaging performed distally to the stimulation point resulted in absence of evoked IONM signals. Conclusion: The present study provided first differentiated insights into the dynamic IONM signal behaviour in response to selective pelvic autonomic nerve damaging. Further studies with neurophysiological and surgical IONM signal analysis are mandatory to reach a more accurate IONM resulting in effective nerve sparing pelvic surgery.

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Total Mesorectal Excision with Intraoperative Assessment of Internal Anal Sphincter Innervation Provides New Insights into Neurogenic Incontinence

Cited by 28 publications

References 26 publications

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

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

Continuous intraoperative monitoring of autonomic nerves during low anterior rectal resection: an innovative approach for observation of functional nerve integrity in pelvic surgery

Impact of selective surgical pelvic autonomic nerve damage on the evoked neuromonitoring signal of the internal anal sphincter

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