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A plea for preservation of the pelvic autonomic nerves

1999; Elsevier BV; Volume: 354; Issue: 9180 Linguagem: Inglês

10.1016/s0140-6736(05)76009-8

1474-547X

Kees Maas, Yoshihiro Moriya, Gemma G. Kenter, Baptist Trimbos, Cornelis J.�H. van de Velde,

Anorectal Disease Treatments and Outcomes

Anjan Banerjee's June 5 commentary1Banerjee AK Sexual dysfunction after surgery for rectal cancer.Lancet. 1999; 353: 1900-1901Summary Full Text Full Text PDF PubMed Scopus (55) Google Scholar addresses the importance of preservation of the pelvic autonomic nerves in the prevention of sexual dysfunction after surgery for rectal cancer. He implies that more radical excision techniques such as mesorectal excision carry a higher risk of nerve damage. We did a prospective study to assess the results of a nerve-preserving technique that is used in Japan in 47 Dutch patients.2Maas CP Moriya Y Steup WH Kiebert GM Kranenbarg WM van deVelde CJH Radical and nerve-preserving surgery for rectal cancer in the Netherlands: a prospective study on morbidity and functional outcome.Br J Surg. 1998; 85: 92-97Crossref PubMed Scopus (176) Google Scholar The dissection was always outside the mesorectum.3MacFarlane JK Ryall RDH Heald RJ Mesorectal excision for rectal cancer.Lancet. 1993; 341: 457-460Summary PubMed Scopus (1555) Google Scholar After median follow-up of 42 months, the local recurrence-free interval was 92% in the 42 patients who had a curative operation (RO and R1). Local recurrence after low anterior resection was 4·2% (one in 17), which is among the lowest reported.3MacFarlane JK Ryall RDH Heald RJ Mesorectal excision for rectal cancer.Lancet. 1993; 341: 457-460Summary PubMed Scopus (1555) Google Scholar Given the experimental stage of our study, we deliberately sacrificed nerves in some cases to avoid any adverse effect on cure. Incidental sacrifice of the superior hypogastric plexus and the hypogastric nerves proved these structures to be crucial for ejaculation: 1 year follow-up revealed that only one out of 11 men after preservation had ejaculatory disorders, whereas all of five in whom these structures were sacrificed had a retrograde ejaculation (χ2 test p<0·005). Bilateral preservation of the inferior hypogastric plexus seems important for erection: only one in 17 was impotent, whereas after one-sided sacrifice of the inferior hypogastric plexus one of two patients was impotent, the other had a diminished erection (p<0·05). Unfortunately, too few female patients were sexually active to draw conclusions. The figure shows an intraoperative view of the superior hypogastric plexus and the hypogastric nerves: they are of considerable size, highly recognisable, and can easily be preserved. Continuing surgical experience since our study has led us to the conclusion that in total mesorectal excision all essential nerves can be preserved unless there is evidence of tumour ingrowth in nerve structures.3MacFarlane JK Ryall RDH Heald RJ Mesorectal excision for rectal cancer.Lancet. 1993; 341: 457-460Summary PubMed Scopus (1555) Google Scholar We believe nerve preservation in principle does not compromise radicality. The pelvic autonomic nerves have a crucial role in sexual dysfunction after surgery. Bergmark and colleagues' study4Bergmark K Avall-Lundqvist E Dickman PW Henningsohn L Steineck G Vaginal changes and sexuality in women with a history of cervical cancer.N Engl J Med. 1999; 340: 1383-1389Crossref PubMed Scopus (589) Google Scholar of sexual dysfunction in women treated for cervical cancer showed decreased lubrication and genital swelling during arousal, which compromised sexual activity and resulted in substantial distress. The pelvic autonomic nerves supply the blood vessels of the female internal genitals and are involved in the neural control of the lubrication-swelling response. Surgical damage to the pelvic autonomic nerves may influence these functions.4Bergmark K Avall-Lundqvist E Dickman PW Henningsohn L Steineck G Vaginal changes and sexuality in women with a history of cervical cancer.N Engl J Med. 1999; 340: 1383-1389Crossref PubMed Scopus (589) Google Scholar The Japanese introduced techniques to preserve pelvic autonomic nerves in surgery for cervical cancer, to prevent bladder dysfunction.5Sakamoto S Takazawa K An improved radical hysterectomy with fewer urological complications and with no loss of therapeutic results for cervical cancer.Baillieres Clin Obstet Gynaecol. 1988; 2: 953-962Summary Full Text PDF PubMed Scopus (80) Google Scholar Essential elements of these techniques have been adopted in our institution and are currently being studied for effects on sexual function. As in rectal cancer surgery, careful preservation of the pelvic autonomic nerves in surgery for cervical cancer might be a key to the prevention of sexual dysfunction. At a time when therapeutic interventions are increasingly judged by the resulting quality of life, the pelvic autonomic nerves deserve more attention in operating theatres.