Sexual and urinary functions after robot-assisted versus pure laparoscopic total mesorectal excision for rectal cancer.

Abstract

Dear Editor: Laparoscopic total mesorectal excision (LapTME) is a validated surgical technique for the treatment of rectal cancer, but the surgery is still challenging and therefore functional outcomes are uncertain. Thanks to a 3-D view, better view of the pelvic structures, and articulated instruments, robotic rectal surgery allows for finer dissection and nerve-sparing during total mesorectal excision; thus it is supposed to better preserve urinary and sexual functions versus open and laparoscopic surgery as described in some literature. The aim of this study is to compare pre-operative and post-operative autonomic function after LapTME versus robotic TME (RobTME) for mid to low rectal cancer, in a single surgeon experience. For this purpose we compared the outcomes of the first 30 RobTME, with those of the first 30 Lap TME performed by a single surgeon between January 2009 and July 2013 at our institution. The impact of surgery on autonomic function was assessed with validated questionnaires. For sexual dysfunction, the International Index of Erectile Function (IIEF) questionnaire for males and the Female Sexual Function Index (FSFI) for females were used. For evaluation of urinary dysfunction, the International Consultation on IncontinenceMale/Female Lower Urinary Tract Symptoms (ICIQ-MLUTS, ICIQ-FLUTS) questionnaires were used. The questionnaires submitted to patients pre-operatively and at months 1, 6, and 12 postoperatively. Data were analyzed with Statistical Production and Service Solution (SPSS for Windows, SPSS Inc., Chicago, IL, USA). Of the 30 LapTME, 26 were anterior rectal resections (ARR), 2 intersphincteric resection (ISR), and 2 abdominoperineal resection (APR), while of the 30 RobTME, 20 were ARR, 6 ISR, and 4 APR. A temporary diverting ileostomy was fashioned in 26 cases of LapTME group and in 25 of the RobTME group. With regard to the urinary function, males presented with a significant worsening of voiding symptoms 1 month after surgery in both groups (p<0.05). Urinary retention after catheter removal was observed in two patients in each group. Incontinence worsened 1 month after surgery in both groups (p<0.05). Nevertheless, a gradual improvement in incontinence was observed at 6 months, and at 1 year after surgery, the grade of incontinence was not statistically different when compared with the pre-operative status (p=ns). The analyses of urinary function in female patients showed no difference between the pre-operative and post-operative scores concerning voiding and filling symptoms, in both groups (p=ns). Conversely, there was a significant increase of incontinence in females in the LapTME group 1 and 6 months after surgery (p<0.05 for each pair-wise comparison). Incontinence worsened also in the RobTME group after surgery, but there was a difference not statistically significant with the pre-operative score at 6 months (p=ns). A gradual improvement in incontinence was observed in both groups with no difference at 1 year when compared with the pre-operative status (p=ns). With regard to the impact of urinary symptoms on quality of life (QoL), patients experienced a worsening of QoL in the first month after surgery in both groups (p<0.05). However, with improvement of urinary symptoms 1 year after * Gregorio Di Franco gregoriodifranco@yahoo.it