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.

Figure 1

Surgical plane behind Denonvilliers’ fascia (DF). In the P-group, dissection of peritoneum is performed 1 cm anterior superior to peritoneal reflection (PR), then the surgical plane (white dotted line) is dissected between DF and proper fascia of rectum (PFR).

Figure 2

Cadaver study on Denonvilliers’ fascia (DF). DF is located between the prostate (P) and rectum (R). DF is more closely adherent to the prostate than to the rectum. There are some loose reticulate structures (LRS) between DF and rectum. B = bladder.

Figure 3

Anatomy of Denonvilliers’ fascia (DF) during surgery. There are some loose reticulate structures (LRSs) between DF and proper fascia of rectum (PFR). The black dotted line presents the dissection plane.

Figure 4

Comparison of the 2 surgical planes during TME surgery. (A) Sharp dissection is performed in front of Denonvilliers’ fascia (DF). Subtotal DF is resected, and the prostate (P) and bilateral seminal vesicles (SV) are visible. (B) Sharp dissection is performed behind DF. DF is well-preserved; the prostate and bilateral seminal vesicles are covered by DF and cannot be observed.

Figure 5

Application of intraoperative electrical nerve stimulation (INS). The stimulating electrode (SE) is placed into the abdominal cavity through the 12 mm trocar. Monopolar stimulation is performed using constant voltage (Stimuplex HNS 12, Braun, Germany). Application of the currents ranges from 3 to 5 mA, frequencies 2 Hz, and lasted 5 to 20 seconds. (A) In the R-group, INS is performed on the surfaces of prostate (P) and bilateral seminal vesicles (SV). (B) In the P-group, INS is performed on Denonvilliers’ fascia.