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Urinary and sexual dysfunction after rectal cancer treatment

Nature Reviews Urology volume 8, pages 51–57 (2011)Cite this article

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Abstract

In light of the improving prognosis for patients with rectal cancer, the quality of functional outcome has become increasingly important. Despite the good functional results achieved by expert surgeons, large multicenter studies show that urogenital dysfunction remains a common problem after rectal cancer treatment. More than half of patients experience a deterioration in sexual function, consisting of ejaculatory problems and impotence in men and vaginal dryness and dyspareunia in women. Urinary dysfunction occurs in one-third of patients treated for rectal cancer. Surgical nerve damage is the main cause of urinary dysfunction. Radiotherapy seems to have a role in the development of sexual dysfunction, without affecting urinary function. Pelvic autonomic nerves are especially at risk in cases of low rectal cancer and during abdominoperineal resection. Data concerning nerve damage during laparoscopic surgery for resection of rectal cancer are awaited. Structured education of surgeons with regard to pelvic neuroanatomy, and systematic registration of identified nerves, could well be the key to improving functional outcome for these patients. Meanwhile, patients should be informed of all associated risks before their operation, and their functional status should be evaluated before and after surgery.

Key Points

  • Sexual and urinary function should be explicitly discussed in preoperative consultations with patients with a rectal carcinoma as they are likely to be compromised after rectal cancer treatment

  • Technical aspects of the surgical procedure play a major role in the etiology of urogenital dysfunction after rectal cancer treatment, with an additional effect of radiotherapy on sexual function

  • Structured education in pelvic neuroanatomy and improved training of junior surgeons is the key to improving functional outcome

  • Several therapies, including further surgery, are available for urogenital dysfunction; conservative treatments should be the first line of treatment

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Figure 1: Incidence of urinary incontinence at several time points after rectal cancer treatment until 5 years postoperatively in the Dutch TME trial.
Figure 2: Incidence of sexual dysfunction 2 years after rectal cancer treatment in the Dutch TME trial.
Figure 3: The pelvic autonomic nerves and their connections with the central nervous system.

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References

  1. Jemal, A., Siegel, R., Xu, J. & Ward, E. Cancer statistics, 2010. CA Cancer J. Clin. 60, 277–300 (2010).

    Article  Google Scholar 

  2. Heald, R. J. & Ryall, R. D. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1, 1479–1482 (1986).

    Article  CAS  Google Scholar 

  3. Kapiteijn, E. et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N. Engl. J. Med. 345, 638–646 (2001).

    Article  CAS  Google Scholar 

  4. Heald, R. J. & Karanjia, N. D. Results of radical surgery for rectal cancer. World J. Surg. 16, 848–857 (1992).

    Article  CAS  Google Scholar 

  5. Murty, M., Enker, W. E. & Martz, J. Current status of total mesorectal excision and autonomic nerve preservation in rectal cancer. Semin. Surg. Oncol. 19, 321–328 (2000).

    Article  CAS  Google Scholar 

  6. Desnoo, L. & Faithfull, S. A qualitative study of anterior resection syndrome: the experiences of cancer survivors who have undergone resection surgery. Eur. J. Cancer Care (Engl.) 15, 244–251 (2006).

    Article  CAS  Google Scholar 

  7. Vironen, J. H., Kairaluoma, M., Aalto, A. M. & Kellokumpu, I. H. Impact of functional results on quality of life after rectal cancer surgery. Dis. Colon Rectum 49, 568–578 (2006).

    Article  Google Scholar 

  8. Moreira, E. D. Jr, Hartmann, U., Glasser, D. B. & Gingell, C. A population survey of sexual activity, sexual dysfunction and associated help-seeking behavior in middle-aged and older adults in Germany. Eur. J. Med. Res. 10, 434–443 (2005).

    PubMed  Google Scholar 

  9. Smith, L. J., Mulhall, J. P., Deveci, S., Monaghan, N. & Reid, M. C. Sex after seventy: a pilot study of sexual function in older persons. J. Sex. Med. 4, 1247–1253 (2007).

    Article  Google Scholar 

  10. Miles, W. E. A method of performing abdominoperineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 2, 1812–1813 (1908).

    Article  Google Scholar 

  11. Chang, P. L. & Fan, H. A. Urodynamic studies before and/or after abdominoperineal resection of the rectum for carcinoma. J. Urol. 130, 948–951 (1983).

    Article  CAS  Google Scholar 

  12. Fazio, V. W., Fletcher, J. & Montague, D. Prospective study of the effect of resection of the rectum on male sexual function. World J. Surg. 4, 149–152 (1980).

    Article  CAS  Google Scholar 

  13. Santangelo, M. L., Romano, G. & Sassaroli, C. Sexual function after resection for rectal cancer. Am. J. Surg. 154, 502–504 (1987).

    Article  CAS  Google Scholar 

  14. Heald, R. J. A new approach to rectal cancer. Br. J. Hosp. Med. 22, 277–281 (1979).

    CAS  PubMed  Google Scholar 

  15. [No authors listed] Improved survival with preoperative radiotherapy in resectable rectal cancer. Swedish Rectal Cancer Trial. N. Engl. J. Med. 336, 980–987 (1997).

  16. Heald, R. J. & Ryall, R. D. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1, 1479–1482 (1986).

    Article  CAS  Google Scholar 

  17. Mynster, T., Nielsen, H. J., Harling, H. & Bulow, S. Blood loss and transfusion after total mesorectal excision and conventional rectal cancer surgery. Colorectal Dis. 6, 452–457 (2004).

    Article  CAS  Google Scholar 

  18. Peeters, K. C. et al. The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma. Ann. Surg. 246, 693–701 (2007).

    Article  Google Scholar 

  19. Havenga, K. et al. Male and female sexual and urinary function after total mesorectal excision with autonomic nerve preservation for carcinoma of the rectum. J. Am. Coll. Surg. 182, 495–502 (1996).

    CAS  PubMed  Google Scholar 

  20. Masui, H., Ike, H., Yamaguchi, S., Oki, S. & Shimada, H. Male sexual function after autonomic nerve-preserving operation for rectal cancer. Dis. Colon Rectum 39, 1140–1145 (1996).

    Article  CAS  Google Scholar 

  21. Hojo, K., Vernava, A. M. III, Sugihara, K. & Katumata, K. Preservation of urine voiding and sexual function after rectal cancer surgery. Dis. Colon Rectum 34, 532–539 (1991).

    Article  CAS  Google Scholar 

  22. Enker, W. E. Potency, cure, and local control in the operative treatment of rectal cancer. Arch. Surg. 127, 1396–1401 (1992).

    Article  CAS  Google Scholar 

  23. Maas, C. P., Moriya, Y., Steup, W. H., Klein, K. E. & van de Velde, C. J. A prospective study on radical and nerve-preserving surgery for rectal cancer in the Netherlands. Eur. J. Surg. Oncol. 26, 751–757 (2000).

    Article  CAS  Google Scholar 

  24. Junginger, T., Kneist, W. & Heintz, A. Influence of identification and preservation of pelvic autonomic nerves in rectal cancer surgery on bladder dysfunction after total mesorectal excision. Dis. Colon Rectum 46, 621–628 (2003).

    Article  CAS  Google Scholar 

  25. Marijnen, C. A. et al. Impact of short-term preoperative radiotherapy on health-related quality of life and sexual functioning in primary rectal cancer: report of a multicenter randomized trial. J. Clin. Oncol. 23, 1847–1858 (2005).

    Article  Google Scholar 

  26. Moriya, Y. Function preservation in rectal cancer surgery. Int. J. Clin. Oncol. 11, 339–343 (2006).

    Article  Google Scholar 

  27. Pollack, J. et al. Late adverse effects of short-course preoperative radiotherapy in rectal cancer. Br. J. Surg. 93, 1519–1525 (2006).

    Article  CAS  Google Scholar 

  28. Pietrangeli, A. et al. Sexual dysfunction following surgery for rectal cancer—a clinical and neurophysiological study. J. Exp. Clin. Cancer Res. 28, 128 (2009).

    Article  Google Scholar 

  29. Sterk, P. et al. Voiding and sexual dysfunction after deep rectal resection and total mesorectal excision: prospective study on 52 patients. Int. J. Colorectal Dis. 20, 423–427 (2005).

    Article  Google Scholar 

  30. Bruheim, K. et al. Sexual function in females after radiotherapy for rectal cancer. Acta Oncol. 49, 826–832 (2010).

    Article  Google Scholar 

  31. Frumovitz, M. et al. Quality of life and sexual functioning in cervical cancer survivors. J. Clin. Oncol. 23, 7428–7436 (2005).

    Article  Google Scholar 

  32. Jayne, D. G. et al. Bladder and sexual function following resection for rectal cancer in a randomized clinical trial of laparoscopic versus open technique. Br. J. Surg. 92, 1124–1132 (2005).

    Article  CAS  Google Scholar 

  33. Platell, C. F., Thompson, P. J. & Makin, G. B. Sexual health in women following pelvic surgery for rectal cancer. Br. J. Surg. 91, 465–468 (2004).

    Article  CAS  Google Scholar 

  34. Lange, M. M. et al. Risk factors for sexual dysfunction after rectal cancer treatment. Eur. J. Cancer 45, 1578–1588 (2009).

    Article  CAS  Google Scholar 

  35. Lange, M. M. et al. Urinary dysfunction after rectal cancer treatment is mainly caused by surgery. Br. J. Surg. 95, 1020–1028 (2008).

    Article  CAS  Google Scholar 

  36. Lindsey, I., Guy, R. J., Warren, B. F. & Mortensen, N. J. Anatomy of Denonvilliers' fascia and pelvic nerves, impotence, and implications for the colorectal surgeon. Br. J. Surg. 87, 1288–1299 (2000).

    Article  CAS  Google Scholar 

  37. Wallner, C. et al. Causes of fecal and urinary incontinence after total mesorectal excision for rectal cancer based on cadaveric surgery: a study from the Cooperative Clinical Investigators of the Dutch total mesorectal excision trial. J. Clin. Oncol. 26, 4466–4472 (2008).

    Article  Google Scholar 

  38. Kinugasa, Y. et al. Operating behind Denonvilliers' fascia for reliable preservation of urogenital autonomic nerves in total mesorectal excision: a histologic study using cadaveric specimens, including a surgical experiment using fresh cadaveric models. Dis. Colon Rectum 49, 1024–1032 (2006).

    Article  Google Scholar 

  39. Grigsby, P. W. et al. Late injury of cancer therapy on the female reproductive tract. Int. J. Radiat. Oncol. Biol. Phys. 31, 1281–1299 (1995).

    Article  CAS  Google Scholar 

  40. Ulmsten, U. Some reflections and hypotheses on the pathophysiology of female urinary incontinence. Acta Obstet. Gynecol. Scand. Suppl. 166, 3–8 (1997).

    CAS  PubMed  Google Scholar 

  41. Grise, P. & Thurman, S. Urinary incontinence following treatment of localized prostate cancer. Cancer Control 8, 532–539 (2001).

    Article  CAS  Google Scholar 

  42. Marks, L. B., Carroll, P. R., Dugan, T. C. & Anscher, M. S. The response of the urinary bladder, urethra, and ureter to radiation and chemotherapy. Int. J. Radiat. Oncol. Biol. Phys. 31, 1257–1280 (1995).

    Article  CAS  Google Scholar 

  43. Havenga, K., Maas, C. P., DeRuiter, M. C., Welvaart, K. & Trimbos, J. B. Avoiding long-term disturbance to bladder and sexual function in pelvic surgery, particularly with rectal cancer. Semin. Surg. Oncol. 18, 235–243 (2000).

    Article  CAS  Google Scholar 

  44. Maas, C. P. et al. Radical and nerve-preserving surgery for rectal cancer in The Netherlands: a prospective study on morbidity and functional outcome. Br. J. Surg. 85, 92–97 (1998).

    Article  CAS  Google Scholar 

  45. Maurer, C. A. et al. Total mesorectal excision preserves male genital function compared with conventional rectal cancer surgery. Br. J. Surg. 88, 1501–1505 (2001).

    Article  CAS  Google Scholar 

  46. Nesbakken, A., Nygaard, K., Bull-Njaa, T., Carlsen, E. & Eri, L. M. Bladder and sexual dysfunction after mesorectal excision for rectal cancer. Br. J. Surg. 87, 206–210 (2000).

    Article  CAS  Google Scholar 

  47. Bonnel, C. et al. Effects of preoperative radiotherapy for primary resectable rectal adenocarcinoma on male sexual and urinary function. Dis. Colon Rectum 45, 934–939 (2002).

    Article  Google Scholar 

  48. Bruheim, K. et al. Sexual function in males after radiotherapy for rectal cancer. Int. J. Radiat. Oncol. Biol. Phys. 76, 1012–1017 (2010).

    Article  Google Scholar 

  49. Zelefsky, M. J. & Eid, J. F. Elucidating the etiology of erectile dysfunction after definitive therapy for prostatic cancer. Int. J. Radiat. Oncol. Biol. Phys. 40, 129–133 (1998).

    Article  CAS  Google Scholar 

  50. Ogilvy-Stuart, A. L. & Shalet, S. M. Effect of radiation on the human reproductive system. Environ. Health Perspect. 101 (Suppl. 2), 109–116 (1993).

    PubMed  PubMed Central  Google Scholar 

  51. Bachmann, G. A. & Leiblum, S. R. The impact of hormones on menopausal sexuality: a literature review. Menopause 11, 120–130 (2004).

    Article  Google Scholar 

  52. Daniels, I. R., Woodward, S., Taylor, F. G., Raja, A. & Toomey, P. Female urogenital dysfunction following total mesorectal excision for rectal cancer. World J. Surg. Oncol. 4, 6 (2006).

    Article  Google Scholar 

  53. Kyo, K., Sameshima, S., Takahashi, M., Furugori, T. & Sawada, T. Impact of autonomic nerve preservation and lateral node dissection on male urogenital function after total mesorectal excision for lower rectal cancer. World J. Surg. 30, 1014–1019 (2006).

    Article  Google Scholar 

  54. Hendren, S. K. et al. Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer. Ann. Surg. 242, 212–223 (2005).

    Article  Google Scholar 

  55. Schmidt, C., Daun, A., Malchow, B. & Kuchler, T. Sexual impairment and its effects on quality of life in patients with rectal cancer. Dtsch. Arztebl. Int. 107, 123–130 (2010).

    PubMed  PubMed Central  Google Scholar 

  56. Nelson, H. et al. Guidelines 2000 for colon and rectal cancer surgery. J. Natl Cancer Inst. 93, 583–596 (2001).

    Article  CAS  Google Scholar 

  57. Sugihara, K. et al. Indication and benefit of pelvic sidewall dissection for rectal cancer. Dis. Colon Rectum 49, 1663–1672 (2006).

    Article  Google Scholar 

  58. Akasu, T., Sugihara, K. & Moriya, Y. Male urinary and sexual functions after mesorectal excision alone or in combination with extended lateral pelvic lymph node dissection for rectal cancer. Ann. Surg. Oncol. 16, 2779–2786 (2009).

    Article  Google Scholar 

  59. Jayne, D. G. et al. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3 year results of the UK MRC CLASICC Trial Group. J. Clin. Oncol. 25, 3061–3068 (2007).

    Article  Google Scholar 

  60. Kim, S. H., Park, I. J., Joh, Y. G. & Hahn, K. Y. Laparoscopic resection for rectal cancer: a prospective analysis of thirty-month follow-up outcomes in 312 patients. Surg. Endosc. 20, 1197–1202 (2006).

    Article  Google Scholar 

  61. Leroy, J. et al. Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: long-term outcomes. Surg. Endosc. 18, 281–289 (2004).

    Article  CAS  Google Scholar 

  62. Ng, S. S. et al. Laparoscopic-assisted versus open abdominoperineal resection for low rectal cancer: a prospective randomized trial. Ann. Surg. Oncol. 15, 2418–2425 (2008).

    Article  Google Scholar 

  63. Breukink, S., Pierie, J. & Wiggers, T. Laparoscopic versus open total mesorectal excision for rectal cancer. Cochrane Database of Systemic Reviews Issue 4. Art. No.: CD005200. doi:10.1002/14651858.CD005200.pub2 (2006).

  64. Buunen, M. et al. COLOR II. A randomized clinical trial comparing laparoscopic and open surgery for rectal cancer. Dan. Med. Bull. 56, 89–91 (2009).

    CAS  PubMed  Google Scholar 

  65. Guillou, P. J. et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365, 1718–1726 (2005).

    Article  Google Scholar 

  66. Breukink, S. O. et al. Prospective evaluation of quality of life and sexual functioning after laparoscopic total mesorectal excision. Dis. Colon Rectum 50, 147–155 (2007).

    Article  CAS  Google Scholar 

  67. Breukink, S. O. et al. Male sexual function and lower urinary tract symptoms after laparoscopic total mesorectal excision. Int. J. Colorectal Dis. 23, 1199–1205 (2008).

    Article  CAS  Google Scholar 

  68. Morino, M. et al. Male sexual and urinary function after laparoscopic total mesorectal excision. Surg. Endosc. 23, 1233–1240 (2009).

    Article  Google Scholar 

  69. Lindsey, I. & Mortensen, N. J. Iatrogenic impotence and rectal dissection. Br. J. Surg. 89, 1493–1494 (2002).

    Article  CAS  Google Scholar 

  70. Jones, O. M., Stevenson, A. R., Stitz, R. W. & Lumley, J. W. Preservation of sexual and bladder function after laparoscopic rectal surgery. Colorectal Dis. 11, 489–495 (2009).

    Article  CAS  Google Scholar 

  71. Safar, B. & Fleshman, J. Laparoscopic total mesorectal excision for rectal cancer. Semin. Colon Rectal Surg. 75–80 (2010).

  72. Herbison, G. P. & Arnold, E. P. Sacral neuromodulation with implanted devices for urinary storage and voiding dysfunction in adults. Cochrane Database of Systemic Reviews Issue 2. Art. no.: CD004202. doi:10.1002/14651858.CD004202.pub2 (2009).

  73. Lindsey, I., George, B., Kettlewell, M. & Mortensen, N. Randomized, double-blind, placebo-controlled trial of sildenafil (Viagra) for erectile dysfunction after rectal excision for cancer and inflammatory bowel disease. Dis. Colon Rectum 45, 727–732 (2002).

    Article  Google Scholar 

  74. Syme, D. B., Corcoran, N. M., Bouchier-Hayes, D. M. & Costello, A. J. Hope springs eternal: cavernosal nerve regeneration. BJU Int. 97, 17–21 (2006).

    Article  Google Scholar 

  75. Denton, A. S. & Maher, E. J. Interventions for the physical aspects of sexual dysfunction in women following pelvic radiotherapy. Cochrane Database of Systemic Reviews Issue 1. Art. No.: CD003750. doi:10.1002/14651858.CD003750 (2003).

  76. Safra, T. et al. Improved quality of life with hyperbaric oxygen therapy in patients with persistent pelvic radiation-induced toxicity. Clin. Oncol. (R. Coll. Radiol.) 20, 284–287 (2008).

    Article  CAS  Google Scholar 

  77. Kinugasa, Y., Murakami, G., Suzuki, D. & Sugihara, K. Histological identification of fascial structures posterolateral to the rectum. Br. J. Surg. 94, 620–626 (2007).

    Article  CAS  Google Scholar 

  78. de Heer, P. et al. Caspase-3 activity predicts local recurrence in rectal cancer. Clin. Cancer Res. 13, 5810–5815 (2007).

    Article  CAS  Google Scholar 

  79. Lahaye, M. J. et al. USPIO-enhanced MR imaging for nodal staging in patients with primary rectal cancer: predictive criteria. Radiology 246, 804–811 (2008).

    Article  Google Scholar 

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  1. Department of Surgery, Leiden University Medical Center, Leiden, 2300, RC, The Netherlands

    Marilyne M. Lange & Cornelis J. H. van de Velde

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M. M. Lange and C. J. H. van de Velde were both involved in researching data for this article, contributed to discussions of content, wrote the article and reviewed and edited the manuscript before submission.

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Correspondence to Cornelis J. H. van de Velde.

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Lange, M., van de Velde, C. Urinary and sexual dysfunction after rectal cancer treatment. Nat Rev Urol 8, 51–57 (2011). https://doi.org/10.1038/nrurol.2010.206

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