title: Electrophysiology-based quality assurance of nerve-sparing in laparoscopic rectal cancer surgery: Is it worth the effort?
abstract: After low anterior resection for rectal cancer, visual assessment of pelvic autonomic nerve preservation can be difficult due to the complexity of neuroanatomy, as well as surgery- and patient-related factors. The present study aimed to evaluate nerve-sparing quality assurance using the laparoscopic neuromapping (LNM) technique.
  
  
  
  We prospectively investigated a series of 30 patients undergoing laparoscopic low anterior resection. Nerve-sparing was evaluated both visually and electrophysiologically. LNM was performed using stimulation of pelvic autonomic nerves under simultaneous cystomanometry and processed electromyography of the internal anal sphincter. Urogenital and anorectal functions were evaluated using validated and standardized questionnaires preoperatively, at short-term follow-up, and at mid-term follow-up at a median of 9 months (range 6-12 months) after surgery.
  
  
  
  One patient reported new onset of urinary dysfunction, and another patient reported new onset of anorectal dysfunction. Of the 20 sexually active patients, five reported sexual dysfunction. Visual assessment by laparoscopy confirmed complete nerve preservation in 28 of 30 cases. For prediction of urinary and anorectal function, LNM sensitivity, specificity, positive and negative predictive value, and overall accuracy were each 100 %. LNM with combined assessment for prediction of sexual function yielded a sensitivity of 80 %, specificity of 93 %, positive predictive value of 80 %, negative predictive value of 93 %, and overall accuracy of 90 %.
  
  
  
  LNM is an appropriate method for reliable quality assurance of laparoscopic nerve-sparing.
authors.affiliation: Department of General, Visceral and Transplant Surgery, University Medicine of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
authors.forename: D W
authors.initials: DW
authors.lastname: Kauff
authors.affiliation: Department of General, Visceral and Transplant Surgery, University Medicine of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
authors.forename: N
authors.initials: N
authors.lastname: Wachter
authors.affiliation: Department of General, Visceral and Transplant Surgery, University Medicine of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
authors.forename: R
authors.initials: R
authors.lastname: Bettzieche
authors.affiliation: Department of General, Visceral and Transplant Surgery, University Medicine of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
authors.forename: H
authors.initials: H
authors.lastname: Lang
authors.affiliation: Department of General, Visceral and Transplant Surgery, University Medicine of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany. werner.kneist@unimedizin-mainz.de.
authors.forename: W
authors.initials: W
authors.lastname: Kneist
mesh_terms: D000368:Aged; D001003:Anal Canal / Q000294:innervation* / Q000503:physiopathology; D017776:Autonomic Pathways / Q000293:injuries / Q000502:physiology / Q000503:physiopathology*; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D004576:Electromyography; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods; D008297:Male; D008365:Manometry; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods; D059351:Organ Sparing Treatments / Q000379:methods*; D010388:Pelvis / Q000294:innervation; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D012004:Rectal Neoplasms / Q000601:surgery*; D012735:Sexual Dysfunction, Physiological / Q000209:etiology / Q000517:prevention & control; D011795:Surveys and Questionnaires; D001743:Urinary Bladder / Q000294:innervation* / Q000503:physiopathology; D014555:Urination Disorders / Q000209:etiology / Q000517:prevention & control
keywords: Autonomic nerves; Electric stimulation; Intraoperative monitoring; Laparoscopy; Quality assurance; Rectal cancer