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Impotence and Sexual Function After Rectal Resection: Is Function After Laparoscopy Better ?

Impotence and Sexual Function After Rectal Resection: Is Function After Laparoscopy Better ?. Richard L. Whelan, MD Section of Colon & Rectal Surgery St. Luke’s Roosevelt Hospital Columbia University New York, N.Y. Disclosures. Olympus Corporation Applied Medical Gore Corporation

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Impotence and Sexual Function After Rectal Resection: Is Function After Laparoscopy Better ?

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  1. Impotence and Sexual Function After Rectal Resection: Is Function After Laparoscopy Better ? Richard L. Whelan, MD Section of Colon & Rectal Surgery St. Luke’s Roosevelt Hospital Columbia University New York, N.Y.

  2. Disclosures • Olympus Corporation • Applied Medical • Gore Corporation • Atrium Corporation • Ethicon Endosurgery • Pepsi & Frito Lay • Anheuser Busch Corporation • National Basketball Association • National Rifle Association

  3. Nerves That Contribute to Sexual Function that are at Risk During Radical Rectal Resection • Superior hypogastric plexus (on anterior surface of aorta) • Hypogastric nerves • Pelvic plexi (nervierigente) • Pelvic splanchnic nerves (S-2, S-3, S-4)

  4. Superior Hypogastric Nerve Plexus • Runs down the anterior surface of the aorta • Send out branches to the left and right at the S-1 level • Unless doing a para-aortic LN dissection / skeletonization it is not likely that this plexus will be injured during TME

  5. Hypogastric Nerves • On the left and right side of pelvic floor • Run a bit dorsal and lateral to the main sigmoidal vessel/IMA • Veer off laterally and a bit ventrally in mid pelvis • A dissection plane ventral to the nerves needs be established once they are located • Must purposefully look for these nerves at start of pelvic dissection

  6. Sparing the Right Hypogastric Nerve in Mid-pelvis

  7. Hypogatric Nerves • These nerves are best seen after incising the lateral peritoneum: • On R side at the base of the rectosigmoid mesentery at sacral promontory & heading into pelvis • On L side after mobilization of sigmoid in iliac fossa and scoring left pelvic gutter • On L side after scoring peritoneum near reflection and then cephalad in left pelvic gutter

  8. Pelvic Plexi (Nervi erigente) • In deeper pelvis • Multiple branches bilaterally • Very hardto see and preserve these nerves • Bill Heald can see them every time. • Many nerve like tendrils in deep pelvis (especially post RT)

  9. It is Not Always Possible to Preserve Nerve Function • Tumors invading into the mesorectum and beyond the CRM (limits of the mesorectum) require a more radical pelvic resection in order to achieve a R-0 resection • Nerve injury or sacrifice may be necessary in some patients • This must be made clear to patients before surgery

  10. Pelvic Radiotherapy Can Injure Pelvic Nerves & Cause Sexual Dysfunction • Direct effects of RT (independent of surgery) • RT related tissue changes (fibrosis, increased vascularity, etc) may obscure the location of the nerves

  11. Total Mesorectal Excision • Described and championed by William Heald • Goal is to remove the entire mesorectum & to mobilize to the pelvic floor • Full circumferential mesorectal resection • Lateral margins very important • Preservation of the hypogastric nerves and nervierigente are important elements of this method • Sharp dissection • Must search for nerves, find them, protect them

  12. Obtaining Information Regarding Sexual Function • Many surgeons don’t ask. • Don’t be afraid to ask the patient: • Do they have intercourse ? • Can they get an erection ? • Can they ejaculate ? • Do they have orgasms ? • Must ask before and after surgery • Discussion of sexual function risk associated with LAR and APR

  13. Methods of Assessing Sexual Function • Very little prospective data gathered • International Prostatic Symptom Score (IPSS) • International Index of Erectile Function (IIEF). • Nocturnal penile tumescence and rigidity monitoring (NPTR) • Many investigators make their own questionnaire

  14. Robotics !!!

  15. Questionnaire Study:Hendron et al: Male Sexual Function* • 99 male patients undergoing open surgery • APR (33 % of total, RT in 52%) • AR (52% of total, RT in 39%) • Transanal Excision of Cancer (15% of total, RT in 20%) • Asked questions regarding pre and postoperative sexual function • Median follow up between 52 and 73 months *Hendren SK et al. Ann Surg 2005;242: 212–223.

  16. Male Sexual Function Pre and Postoperatively* Group + Preop Fn + Postop Fn In last Mos. APR 91 % 55 % 33 % AR 94 % 74 % 53 % TransanalRsctn80 % 87 % 73 % * Hendren SK et al. Ann Surg 2005;242: 212–223

  17. Hendon et al: Specifics of Male Sexual Function* • Erectile dysfunction (ED): • Preoperatively ………. 19.2% • Post-surgery ………….. 54.3% • Complete impotence: • Preoperatively ……….. 11.2% • Post-surgery …………… 31.9% (Percentages higher in APR group) • Abnormal ejaculation: • Preoperatively ………… 10.4% • Post-surgery ……………. 42.5% * Hendren SK et al. Ann Surg 2005;242: 212–223.

  18. Male Sexual Function After Surgery* • 42 % reported worse function (n=99) • 50 % were APR patients • 43 % were AR patients • 7 % had a transanal excision (TAE) of tumor • Median age …….. 59 • 60 % had undergone Radiotherapy (including all 3 TAE patients) • 100% were sexually active preoperatively • 40.5% were currently sexually active. * Hendren SK et al. Ann Surg 2005;242: 212–223.

  19. Masui et al: Male Sexual Function After Curative Rectal Cancer Surgery • Japanese study (very radical resection were common in the past) • Looked at sexual function in 3 different groups of patients: • Full nerve preservation • Unilateral preservation of hypogastric & pelvic plexus • Partial preservation of some of pelvic plexus bilaterally (but sacrifice of hypogastric nerves) * Masui et al. Dis Colon Rectum 1996;39:1140-1145.

  20. Male Sexual Function: Masui et al* Group Erection Intercourse Ejaculate Orgasm Full 93 % 90 % 83 % 94 % Unilateral 82 % 53 % 47 % 65 % Partial 61 % 26 % 0 % 22 % * Masui et al. Dis Colon Rectum 1996;39:1140-1145

  21. Questionnaire Study:Hendron et al: Female Sexual Function* • 81 female patients • APR (31 % of total, RT in 48%) • AR (55.6 % of total, RT in 36.4%) • Transanal Excision of Cancer (13% of total, RT in 3%) • Median follow 51 - 79 months • Asked questions regarding pre and postoperative sexual function * HendrenSK et al. Ann Surg 2005;242: 212–223.

  22. Female Sexual Function Pre and Postoperatively* Group + Preop Fn + Postop Fn In last Mos. APR 71 % 64 % 24 % AR 51 % 48 % 34 % TransanalRsctn80 % 80 % 40 % * Hendren SK et al. Ann Surg 2005;242: 212–223.

  23. Surgery May Worsen But Not Eliminate Sexual Function* • 19 women (28.8%) reported worse sexual function after surgery • Median age 50 years. • 10 APR, 8 AR, and 1 transanalexcision. • 14 had pelvic RT (73.7%). • 26 % were sexually active within4 weeks of survey • Quality of sexual function is an important parameter * Hendren SK et al. Ann Surg 2005;242: 212–223.

  24. The Impact of a Stoma on Sexual Function • Negative change in sexual function reported* • 80% female APR patients • 50% male APR patients • Fear of leak during sex • Fear of noise from stoma functioning • Felt less attractive (body image issues) * Hendren SK et al. Ann Surg 2005;242: 212–223

  25. Other Reasons for Decreased or Worse Sexual Function in Women • Dyspareunia • Vaginal & pelvic pain • Sensation that vagina is smaller (1/3 of pts) • Bowel function changes related to surgery • Loss of spontaneity • Decreased libido

  26. Other Reasons for Decreased or Worsened Sexual Function • Fear that partner is: • Less attracted to them • Afraid they may hurt the patient • Arousal issues • Lubrication issues • Difficulty achieving orgasm

  27. We Must Discuss the Possibility of Sexual Dysfunction in Preop Discussions • Hendren et al: For only 9 % of woman going for rectal cancer resection was sexual function discussed* • Literature has few studies where preo sexual function was assessed preoperatively • Surgeons must make questions regarding sexual function a part of the preoperative assessment • Must also track sexual function (rarely done) * Hendren SK et al. Ann Surg 2005;242: 212–223

  28. Hand-Assisted Surgery !!

  29. What About Sexual Function After Laparoscopic TME ???

  30. Quah et al. Br J Surg 2002;89:1551–1556. • 170 rectal cancer patients from Classic trial • Data gathered via retrospective questionnaire and telephone interviews • 80/111 living patients responded (40 open & 40 closed) • 7 of the 15 sexually active men who underwent laparoscopic surgery reported sexual dysfunction vs 1/22 open group men (p=0.004) • All laparoscopic patients with sexual dysfunction had bulky or low rectal cancers

  31. Jayne et al. 2005;Br J Surg 92:1124–1132 • Classic randomized trial (British Study) • Single postoperative time point assessed in regards to sexual function • Erectile function (p=0.068) and overall sexual function (p=0.063) trended worse in male laparoscopic rectal cancer patients vs open patients • No differences in the other categories assessed (sexual desire and intercourse satisfaction)

  32. Jayne et al. 2005;Br J Surg 92:1124. • TME was performed more frequently in laparoscopic patients than open patients • Use of the TME method and conversion were independent predictors of postoperative male sexual dysfunction. • No differences in female sexual function noted between open and laparoscopic groups

  33. Asoglu et al. SurgEndosc 2009 Feb;23(2):296-303. • IIEF study (retrospective questionnaire) • Total 63 TME patients completed the survey • 29 Open • 34 Laparoscopic • Impotence was noted in 6/17 Open sexually active males VS 1/18 Laparoscopic patients (p=0.04) • Decreased sexual function was noted in 5/10 Open VS 1/14 Closed women who underwent TME (p=0.03) • Bladder dysfunction in 1/29 Open but 3/34 Closed patients (p=ns)

  34. Breukink et a. IntJ Colorectal Dis. 2008 Dec;23(12):1199-205. • 9 patients studied who had lap. TME • IIEF, IPSS + USG (blood flow), and NPTR used to assess function • Erectile function was maintained in 71% • Ejaculation function maintained in 89%.

  35. Breukink et a. Int J Colorectal Dis. 2008 Dec;23(12):1199-205. • Asignificant deterioration in intercourse satisfaction was seen after radiotherapy and LTME (p= 0.042) • Overall satisfaction remained unchanged (8.0 vs 7.0, p = 0.246). • NPTR parameters (duration of erectile episodes, duration of tip rigidity > or =60%) decreased following radiotherapy and LTME.

  36. Yang et al. Eur J SurgOncol 2007;33:575–579. • 125 Lap TME vs 103 Open TME pts studied • Assessed function at 3-6 mos, 12-18 mos, and 2-5 years • Less male sexual problems and better sexual function 12-18 months after surgery in Lap TME pts. (not seen with open pts) • Better sexual enjoyment noted after 24 months in Lap TME pts. (vs Open pts)

  37. Yang et al. Eur J SurgOncol 2007;33:575–579. • Lap TME pts showed improvement in male sexual function from the 1st to the 2nd time period • Open TME pts showed showed improvement in male sexual function from the 2nd to the 3rd time period

  38. Sexual Function After Lap TME: Summary • Sexual function is notably decreased in both males and females after both open and laparoscopic TME • The only multi-center trial data suggests that sexual dysfunction is worse in Laparoscopic patients • Early experience • Not all had TME’s • Function worse when TME done

  39. Summary • Several smaller, single center studies suggest that Lap TME is associated with improved function vs Open TME • Single center studies are underpowered • Cannot make firm conclusions • Logical that laparoscopic approach would better preserve nerve function

  40. Summary • Surgeon and his skill set is a critical variable in both open and closed setting • We need to improve our surgical skills • Must ask questions about sexual function preoperatively • To establish baseline function for later comparison • Decent % have dysfunction preop • Should include this data in our data bases

  41. Laparoscopic Vs Open Articles

  42. Sexual Function After Laparoscopic LAR/APR ? * • Total of 56 patients with mid or distal cancers • 38 Open patients • 18 Laparoscopic patients • Operation performed:** • 38 LAR • 18 APR • TME method used for all patients • Utilized the International Index of Erectile Function (IIEF) to assess sexual function *Stamopoulos et al. SurgEndosc (2009)23:2665–2674 **Percentage of APR and LAR very similar between open & closed groups

  43. Stamopoulos et al Results* • Sexual function significantly & similarly decreased function scores after both Open and Closed LAR/APR at 3 and 6 months • Was a trend in favor of laparoscopic surgery at 6 months (p = 0.076) • Baseline IIEF score and the baseline, 3-, and 6-month sexual desire scores were better in the LAR than the APR groups (independent of surgical method) • Patients with T-3, T-4 tumors had significantly worse baseline & 3 & 6 month post op function than T-1, T-2 patients *Percentage of patients who got pelvic radiotherapy similar for open & lap groups

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