This Article Full Text Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wallner, C. Articles by van de Velde, C. J.H. Search for Related Content PubMed PubMed Citation Articles by Wallner, C. Articles by van de Velde, C. J.H. Related Articles Related Correspondence Social Bookmarking                            What's this?

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

Christian Wallner, Marilyne M. Lange, Bert A. Bonsing, Cornelis P. Maas, Charles N. Wallace, Noshir F. Dabhoiwala, Harm J. Rutten, Wouter H. Lamers, Marco C. DeRuiter, Cornelis J.H. van de Velde

From the Departments of Anatomy and Embryology and Urology and the Liver Center, Academic Medical Center, Amsterdam; Departments of Surgery, Gynaecology, and Anatomy and Embryology, Leiden University Medical Center, Leiden; and Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
Deceased

Corresponding author: Cornelis J.H. van de Velde, MD, PhD, FRCS (London), FRCPS (Glasgow), Department of Surgery, Leiden University Medical Center, K6-R, PO Box 9600, 2300 RC Leiden, the Netherlands; e-mail: c.j.h.van_de_velde{at}lumc.nl

Purpose Total mesorectal excision (TME) for rectal cancer may result in anorectal and urogenital dysfunction. We aimed to study possible nerve disruption during TME and its consequences for functional outcome. Because the levator ani muscle plays an important role in both urinary and fecal continence, an explanation could be peroperative damage of the nerve supply to the levator ani muscle.

Methods TME was performed on cadaver pelves. Subsequently, the anatomy of the pelvic floor innervation and its relation to the pelvic autonomic innervation and the mesorectum were studied. Additionally, data from the Dutch TME trial were analyzed to relate anorectal and urinary dysfunction to possible nerve damage during TME procedure.

Results Cadaver TME surgery demonstrated that, especially in low tumors, the pelvic floor innervation can be damaged. Furthermore, the origin of the levator ani nerve was located in close proximity of the origin of the pelvic splanchnic nerves. Analysis of the TME trial data showed that newly developed urinary and fecal incontinence was present in 33.7% and 38.8% of patients, respectively. Both types of incontinence were significantly associated with each other (P = .027). Low anastomosis was significantly associated with urinary incontinence (P = .049). One third of the patients with newly developed urinary and fecal incontinence also reported difficulty in bladder emptying, for which excessive perioperative blood loss was a significant risk factor.

Conclusion Perioperative damage to the pelvic floor innervation could contribute to fecal and urinary incontinence after TME, especially in case of a low anastomosis or damage to the pelvic splanchnic nerves.

Supported by a grant of the John L. Emmett Foundation for Urology, The Netherlands (to C.W.).

Both C.W. and M.M.L. contributed equally to this work.

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

Related Correspondence

• Why Does Levator Ani Nerve Damage Occur During Rectal Surgery?
  Yusuke Kinugasa and Kenichi Sugihara
  JCO 2009 27: 999-1000 [Full Text]

This article has been cited by other articles:

				M. M. Lange, C. Wallner, M. C. DeRuiter, and C. J.H. van de Velde In Reply J. Clin. Oncol., February 20, 2009; 27(6): 1000 - 1001. [Full Text] [PDF]

				Y. Kinugasa and K. Sugihara Why Does Levator Ani Nerve Damage Occur During Rectal Surgery? J. Clin. Oncol., February 20, 2009; 27(6): 999 - 1000. [Full Text] [PDF]