Abdelli A, Tillou X, Alves A, Menahem B
Service de chirurgie générale et digestive, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14032 Caen cedex, France; UFR de médecine de Caen, 14000 Caen, France.
Service d'urologie et de transplantation rénale, CHU de Caen, 14032 Caen cedex, France; UFR de médecine de Caen, 14000 Caen, France.
J Visc Surg. 2017 Apr;154(2):93-104. doi: 10.1016/j.jviscsurg.2016.10.002. Epub 2017 Feb 1.
Although we have seen revolutionary changes with multi-disciplinary management of patients with rectal cancer, the evaluation of genito-urinary sequelae remains of great concern. Precise pre-operative evaluation with validated scores allows detection of urinary disorders in 16 to 23% of patients, and sexual disorders in nearly 35% of men and 50% of women. Regardless of the surgical approach, it is fundamental to respect the autonomic innervation during total mesorectal excision in order to prevent these sequelae. Identification of these nerves can be facilitated by intra-operative neuro-stimulation. In spite of these precautions, de novo urinary sequelae are observed in nearly 33% of patients and bladder evacuation disorders in 25% of patients. Advanced age, pre-operative urinary disorders, female gender, and abdomino-perineal resection are independent risk factors for urinary sequelae. Early post-operative urodynamic abnormalities might be predictive of these sequelae and justify early physiotherapy. Likewise, sexual sequelae such as erectile and/or ejaculatory disorders, dyspareunia and lubrication deficits result in de novo cessation of sexual activity in 28% of men and 18% of women. Advanced age, neo-adjuvant radiation therapy, and abdomino-perineal resection are independent risk factors for sexual dysfunction. Pharmacotherapy with sildenafil has proven useful in the treatment of erectile disorders. Genito-urinary and ano-rectal sequelae occur concomitantly in more than one of ten patients, suggesting a potential common pathophysiology.
尽管我们已经看到直肠癌患者多学科管理带来了革命性变化，但对生殖泌尿系统后遗症的评估仍然备受关注。使用经过验证的评分进行精确的术前评估，可在16%至23%的患者中检测出泌尿系统疾病，在近35%的男性和50%的女性中检测出性功能障碍。无论采用何种手术方式，在全直肠系膜切除术中尊重自主神经支配以预防这些后遗症至关重要。术中神经刺激有助于识别这些神经。尽管采取了这些预防措施，但仍有近33%的患者出现新发泌尿系统后遗症，25%的患者出现膀胱排空障碍。高龄、术前泌尿系统疾病、女性性别和腹会阴切除术是泌尿系统后遗症的独立危险因素。术后早期尿动力学异常可能预示着这些后遗症，因此有理由早期进行物理治疗。同样，勃起和/或射精障碍、性交困难和润滑不足等性功能后遗症导致28%的男性和18%的女性新发性功能停止。高龄、新辅助放疗和腹会阴切除术是性功能障碍的独立危险因素。西地那非药物治疗已被证明对治疗勃起障碍有效。超过十分之一的患者同时出现生殖泌尿系统和肛门直肠后遗症，提示可能存在共同的病理生理学机制。
