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Optimal Complete Rectum Mobilization Focused on the Anatomy of the Pelvic Fascia and Autonomic Nerves: 30 Years of Experience at Severance Hospital.

ABSTRACT: The primary goal of surgery for rectal cancer is to achieve an oncologically safe resection, i.e., a radical resection with a sufficient safe margin. Total mesorectal excision has been introduced for radical surgery of rectal cancer and has yielded greatly improved oncologic outcomes in terms of local recurrence and cancer-specific survival. Along with oncologic outcomes, functional outcomes, such as voiding and sexual function, have also been emphasized in patients undergoing rectal cancer surgery to improve quality of life. Intraoperative nerve damage or combined excision is the primary reason for sexual and urinary dysfunction. In the past, these forms of damage could be attributed to the lack of anatomical knowledge and poor visualization of the pelvic autonomic nerve. With the adoption of minimally invasive surgery, visualization of nerve structure and meticulous dissection for the mesorectum are now possible. As the leading hospital employing this technique, we have adopted minimally invasive platforms (laparoscopy, robot-assisted surgery) in the field of rectal cancer surgery and standardized this technique globally. Here, we review a standardized technique for rectal cancer surgery based on our experience at Severance Hospital, suggest some practical technical tips, and discuss a couple of debatable issues in this field.

SUBMITTER: Kim NK

PROVIDER: S-EPMC7934104 | biostudies-literature | 2021 Mar

REPOSITORIES: biostudies-literature

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Optimal Complete Rectum Mobilization Focused on the Anatomy of the Pelvic Fascia and Autonomic Nerves: 30 Years of Experience at Severance Hospital.

Kim Nam Kyu NK Kim Ho Seung HS Alessa Mohmmed M Torky Radwan R

Yonsei medical journal 20210301 3

The primary goal of surgery for rectal cancer is to achieve an oncologically safe resection, i.e., a radical resection with a sufficient safe margin. Total mesorectal excision has been introduced for radical surgery of rectal cancer and has yielded greatly improved oncologic outcomes in terms of local recurrence and cancer-specific survival. Along with oncologic outcomes, functional outcomes, such as voiding and sexual function, have also been emphasized in patients undergoing rectal cancer surg ...[more]

PMID: 33635008

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Project description:The disruption of coordination between smooth muscle contraction in the bladder and the relaxation of the external urethral sphincter (EUS) striated muscle is a common issue in dysfunctional bladders. It is a significant challenge to overcome for neuromodulation approaches to restore bladder control. Bladder-sphincter dyssynergia leads to undesirably high bladder pressures, and poor voiding outcomes, which can pose life-threatening secondary complications. Mixed pelvic nerves are potential peripheral targets for stimulation to treat dysfunctional bladders, but typical electrical stimulation of pelvic nerves activates both the parasympathetic efferent pathway to excite the bladder, as well as the sensory afferent pathway that causes unwanted sphincter contractions. Thus, a novel pelvic nerve stimulation paradigm is required. In anesthetized female rats, we combined a low frequency (10 Hz) stimulation to evoke bladder contraction, and a more proximal 20 kHz stimulation of the pelvic nerve to block afferent activation, in order to produce micturition with reduced bladder-sphincter dyssynergia. Increasing the phase width of low frequency stimulation from 150 to 300 ?s alone was able to improve voiding outcome significantly. However, low frequency stimulation of pelvic nerves alone evoked short latency (19.9-20.5 ms) dyssynergic EUS responses, which were abolished with a non-reversible proximal central pelvic nerve cut. We demonstrated that a proximal 20 kHz stimulation of pelvic nerves generated brief onset effects at lower current amplitudes, and was able to either partially or fully block the short latency EUS responses depending on the ratio of the blocking to stimulation current. Our results indicate that ratios >10 increased the efficacy of blocking EUS contractions. Importantly, we also demonstrated for the first time that this combined low and high frequency stimulation approach produced graded control of the bladder, while reversibly blocking afferent signals that elicited dyssynergic EUS contractions, thus improving voiding by 40.5 ± 12.3%. Our findings support advancing pelvic nerves as a suitable neuromodulation target for treating bladder dysfunction, and demonstrate the feasibility of an alternative method to non-reversible nerve transection and sub-optimal intermittent stimulation methods to reduce dyssynergia.

Dataset Information

Optimal Complete Rectum Mobilization Focused on the Anatomy of the Pelvic Fascia and Autonomic Nerves: 30 Years of Experience at Severance Hospital.

Publications

Optimal Complete Rectum Mobilization Focused on the Anatomy of the Pelvic Fascia and Autonomic Nerves: 30 Years of Experience at Severance Hospital.

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