Preservation of urine voiding and sexual function after rectal cancer surgery.
In order to decrease the urinary and sexual morbidity which follows radical pelvic lymphadenectomy for rectal cancer, we began selective preservation of the pelvic autonomic nerves. Between 1985 and 1987, 134 patients with rectal cancer underwent a curative resection (52 abdominoperineal resections, 82 sphincter-saving resections) with extended pelvic lymphadenectomy and selective pelvic autonomic nerve preservation (PANP). PANP was classified into five degrees depending on the extent of pelvic dissection. First-degree PANP indicates complete preservation of the nerves; second-degree PANP indicates destruction of the hypogastric plexus: third-degree PANP indicates partial preservation of the pelvic autonomic plexus; fourth-degree PANP indicates bilateral or unilateral preservation of only the fourth pelvic parasympathetic nerve; and fifth-degree PANP indicates complete destruction of the pelvic autonomic nerves. Most patients with first-degree PANP were able to spontaneously void 7-10 days following the operation. However, 78 percent (28/36) of patients with fifth-degree PANP had not regained bladder sensation by the third postoperative week and were discharged with an indwelling catheter; 58 percent (21/36) had not regained bladder sensation by the 60th postoperative day. The cystometric data indicate a progressive decline in bladder sensation and function with increasingly extensive pelvic dissection. However, preservation of only the fourth parasympathetic nerve (fourth-degree PANP) resulted in partial sparing of bladder sensation and voiding function. Evaluation of sexual function in males under 60 years of age revealed that only 31 percent (12/39) recovered erectile function and only 19 percent (6/39) recovered normal ejaculatory function in the first postoperative year. Most of these patients had complete preservation of their pelvic autonomic plexus (i.e., first-degree PANP). Four patients with partial PANP have recovered erectile function. Complete PANP is the best way to prevent urinary and sexual morbidity after rectal resection. The opposing goals of maximizing the chance for cure and minimizing morbidity must be individualized and balanced in each patient. Our data demonstrate that it is now possible to perform radical pelvic lymphadenectomy in the majority of patients with advanced rectal cancer with a minimum of voiding dysfunction. Preservation of sexual function in males is more difficult and depends on complete PANP and, as such, should be restricted to the group of patients with Dukes' A and B carcinomas.