Causes of fecal and urinary incontinence after total mesorectal excision for rectal cancer based on cadaveric surgery: a study from the Cooperative Clinical Investigators of the Dutch total mesorectal excision trial.
OBJECTIVE
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.


METHODS
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.


RESULTS
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.


CONCLUSIONS
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.
Wallner
Christian
C
Department of Anatomy and Embryology, Liver Center, Academic Medical Center, Amsterdam, the Netherlands.
Lange
Marilyne M
MM
Bonsing
Bert A
BA
Maas
Cornelis P
CP
Wallace
Charles N
CN
Dabhoiwala
Noshir F
NF
Rutten
Harm J
HJ
Lamers
Wouter H
WH
Deruiter
Marco C
MC
van de Velde
Cornelis J H
CJ
D000368:Aged; D000369:Aged, 80 and over; D001003:Anal Canal / Q000294:innervation; D002102:Cadaver; D003082:Colectomy / Q000009:adverse effects*; D005242:Fecal Incontinence / Q000209:etiology* / Q000473:pathology*; D006801:Humans; D016015:Logistic Models; D008160:Lumbosacral Plexus / Q000033:anatomy & histology; D008297:Male; D015999:Multivariate Analysis; D017773:Pelvic Floor / Q000294:innervation*; D012004:Rectal Neoplasms / Q000601:surgery*; D012007:Rectum / Q000033:anatomy & histology; D012307:Risk Factors; D013153:Splanchnic Nerves / Q000033:anatomy & histology / Q000293:injuries; D014549:Urinary Incontinence / Q000209:etiology* / Q000473:pathology*