Wallner Christian, Lange Marilyne M, Bonsing Bert A, Maas Cornelis P, Wallace Charles N, Dabhoiwala Noshir F, Rutten Harm J, Lamers Wouter H, Deruiter Marco C, van de Velde Cornelis J H
Department of Anatomy and Embryology, Liver Center, Academic Medical Center, Amsterdam, the Netherlands.
J Clin Oncol. 2008 Sep 20;26(27):4466-72. doi: 10.1200/JCO.2008.17.3062.
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.
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.
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.
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.
直肠癌全直肠系膜切除术（TME）可能导致肛门直肠和泌尿生殖功能障碍。我们旨在研究TME过程中可能的神经损伤及其对功能结局的影响。由于肛提肌在控尿和控便中均起重要作用，一种解释可能是手术中对肛提肌神经供应的损伤。
在尸体骨盆上进行TME手术。随后，研究盆底神经支配的解剖结构及其与盆腔自主神经支配和直肠系膜的关系。此外，对荷兰TME试验的数据进行分析，以将肛门直肠和泌尿功能障碍与TME手术过程中可能的神经损伤相关联。
尸体TME手术表明，尤其是低位肿瘤，盆底神经支配可能受损。此外，肛提肌神经的起源位置与盆内脏神经的起源位置紧邻。TME试验数据分析显示，分别有33.7%和38.8%的患者出现新发生的尿失禁和粪失禁。两种类型的失禁之间存在显著相关性（P = 0.027）。低位吻合与尿失禁显著相关（P = 0.049）。三分之一新发生尿失禁和粪失禁的患者还报告存在膀胱排空困难，围手术期失血过多是其显著危险因素。
围手术期盆底神经支配损伤可能导致TME术后出现粪失禁和尿失禁，尤其是在低位吻合或盆内脏神经受损的情况下。
