Kneist Werner, Heintz Achim, Junginger Theodor
Clinic of General and Abdominal Surgery, Johannes Gutenberg-University, Mainz, Germany.
J Am Coll Surg. 2004 Jan;198(1):59-66. doi: 10.1016/j.jamcollsurg.2003.09.004.
Preservation of parasympathetic and sympathetic nerves is required to avoid urogenital function disturbances after total mesorectal excision (TME) for rectal carcinoma. This study sought to determine whether intraoperative stimulation of parasympathetic nerves with monitoring of bladder contraction is useful in meeting this demand.
In a prospective pilot study, 17 patients, 11 men and 6 women, underwent TME with pelvic autonomic nerve preservation performed by an experienced surgeon. The parasympathetic nerves were stimulated by an electrostimulation device (Screener 3625, Medronic), and the resulting bladder contraction was measured manometrically in all patients. Variations in pulse rate and voltage were measured to determine optimal stimulation parameters. A standardized questionnaire was used to record urogenital function disturbances. Residual urine volume was measured by ultrasound pre- and postoperatively. Shortterm outcomes data were evaluated to establish a possible association between intraoperative test results and postoperative bladder function.
In 15 of 17 patients undergoing TME with pelvic autonomic nerve preservation for rectal carcinoma, the parasympathetic nerves were identified based on nerve stimulation-induced bladder contraction. Two patients with negative results on intraoperative nerve stimulation had persisting bladder dysfunction requiring an indwelling catheter after discharge from hospital. In spite of a short median followup of 2 months (range 1 to 4 months), in 7 of 10 men with intact erectile function prior to surgery, postoperative erectile dysfunction could be excluded. The study showed a pulse rate of 35 Hz and an electric potential of 12 V to be optimal stimulation parameters, associated with a mean intravesical pressure rise of 12.7 cm H(2)O (range 2.8 to 18.0 cm H(2)O).
Intraoperative nerve stimulation with monitoring of intravesical pressure represents a technically simple procedure for the identification and verification of function of pelvic parasympathetic nerves during TME for rectal carcinoma.
直肠癌全直肠系膜切除术（TME）后，需要保留副交感神经和交感神经以避免泌尿生殖功能障碍。本研究旨在确定术中刺激副交感神经并监测膀胱收缩是否有助于满足这一需求。
在一项前瞻性试点研究中，17例患者（11例男性和6例女性）接受了由经验丰富的外科医生进行的保留盆腔自主神经的TME手术。使用电刺激装置（Medronic公司的Screener 3625）刺激副交感神经，并对所有患者的膀胱收缩进行压力测量。测量脉搏率和电压的变化以确定最佳刺激参数。使用标准化问卷记录泌尿生殖功能障碍。术前和术后通过超声测量残余尿量。评估短期结果数据以确定术中测试结果与术后膀胱功能之间可能存在的关联。
在17例接受保留盆腔自主神经的直肠癌TME手术的患者中，有15例基于神经刺激引起的膀胱收缩识别出了副交感神经。2例术中神经刺激结果为阴性的患者存在持续的膀胱功能障碍，出院后需要留置导尿管。尽管中位随访时间较短，仅2个月（范围1至4个月），但在术前勃起功能正常的10例男性患者中，有7例可排除术后勃起功能障碍。该研究表明，脉搏率35Hz和电势12V是最佳刺激参数，平均膀胱内压升高12.7cm H₂O（范围2.8至18.0cm H₂O）。
术中神经刺激并监测膀胱内压是一种技术上简单的方法，可用于在直肠癌TME手术中识别和验证盆腔副交感神经的功能。
