Three-dimensional versus two-dimensional laparoscopic surgery for rectal cancer: better promote postoperative sexual and urinary function of a propensity-matched study

Abstract

Laparoscopic total mesorectal excision (TME) with autonomic nerve preservation (ANP) is a common procedure for rectal cancer (RC), associated with a high prevalence of postoperative urogenital and anorectal dysfunctions. Compared to 2D laparoscopy, 3D laparoscopy provides better depth perception of the surgical field and hand-eye coordination to achieve better outcomes. We compared the performance of 2D and 3D laparoscopy on preserving urogenital and anorectal function in TME+ANP surgery for rectal cancer using propensity-score matching. Data were collected from consecutive male patients who underwent 3D or 2D laparoscopic TME+ANP for primary RC at our institution between March 2012 and December 2020. The primary outcome was sexual and urinary function 1 year after surgery. A total of 450 male patients were eligible. After 1:1 matching, 146 cases were included in each group for analysis. One year after surgery, the prevalence of sexual dysfunction (International Index of Erectile Function score <26) was 8.22% in the 3D laparoscopic group and 44.52% in the 2D laparoscopic group, respectively (P=0.000) and a significant difference in the incidence of urinary retention was observed (n=3 and 24, respectively (P=0.000)). Moreover, blood loss, operative time, duration of hospital stay, and the time to first flatus in the 3D laparoscopic group were significantly less than in the 2D laparoscopic group. In conclusion, 3D laparoscopic TME is associated with lower incidences of postoperative sexual and urinary dysfunction than 2D laparoscopic TME for rectal cancer in male patients.

Keywords: Rectal cancer; autonomic nerve preservation; laparoscopic; sexual and urinary function; total mesorectal excision.

Figure 1

Preservation of the abdominal autonomic nervous system. A. The fascia of the prehypogastric nerve and the SHP and intermembranous nerve branches are preserved. B. Nerve branch surrounding the sympathetic trunk at the root of the IMA in a network-like manner, especially the left lumbar splanchnic nerve attached to the left side of the IMA. C. The root of the IMA is cut off, and the lumbar splanchnic nerve around the root of the IMA is preserved. The sympathetic nerve trunk accompanying the IMA is seen, and the vascular nerve sheath is resected along the IMA. D. Small blood vessels are visible along with the autonomic trunk and branches.

Figure 2

The left and right HGN give rise to small network-like nerve branches and anastomose with each other. A. Left HGN and pelvic plexus, small nerve branches to the pelvic sidewall, showing network-like anastomosis. B. Right HGN is divided into 4 trunks; each trunk emits small nerve branches to the pelvic sidewall that anastomose with each other. C. There are many small nerve branches between the left and right HGN, which exhibit a network-like anastomosis and travel in the fascia of the prehypogastric nerve. D. Small nerves in the fascia of the prehypogastric nerve of the left pelvic wall exhibit a network distribution and anastomose with each other. HGN: hypogastric nerve.

Figure 3

Small branching vessel and nerve branches from the pelvic plexus to the rectum. The NVB in the left pelvis and the left and right pelvic plexus emit nerves and branches to the levator ani muscle and the S2, S3, and S4 nerve branches. A. Small blood vessels and nerves in the left ligament are seen. The small nerve branches exhibit a network distribution in the pelvic sidewall behind the lateral ligament. B. Cutting the upper part of the lateral ligament showed the pelvic plexus nerve distribution to the small branches of the lower rectum. C. The NVB and pelvic plexus on the left side emit nerve branches distributed to the levator ani muscle. D. Pelvic splanchnic nerve S2, S3, S4. NVB: neurovascular bundle; LAN: levator ani nerve.

Figure 4

Changes in IIEF erectile function score in 3D laparoscopic group and 2D laparoscopic group (Charts with error bars corresponding to the 95% CI).