Colorectal Surgery and Its Impact on Male Sexual Function
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- Nagpal, K. & Bennett, N. Curr Urol Rep (2013) 14: 279. doi:10.1007/s11934-013-0341-x
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The quality of functional outcome has become increasingly important in view of improvement in prognosis with colorectal cancer patients. Sexual dysfunction remains a common problem after colorectal cancer treatment, despite the good oncologic outcomes achieved by expert surgeons. Although radiotherapy and chemotherapy contribute, surgical nerve damage is the main cause of sexual dysfunction. The autonomic nerves are in close contact with the visceral pelvic fascia that surrounds the mesorectum. The concept of total mesorectal excision (TME) in rectal cancer treatment has led to a substantial improvement of autonomic nerve preservation. In addition, use of laparoscopy has allowed favorable results with regards to sexual function. The present paper describes the anatomy and pathophysiology of autonomic pelvic nerves, prevalence of sexual dysfunction, and the surgical technique of nerve preservation in order to maintain sexual function.
KeywordsSexual dysfunctionRectal surgeryRectal cancerErectile dysfunctionImpotenceEjaculatory dysfunction
Colorectal cancer is the fourth most common malignancy in the USA. One out of 12 current cancer survivors have had treatment for a colorectal tumor . However, in this instance, research regarding male sexual function remains limited. Newer imaging technologies, advances in surgical techniques such as Total Mesorectal excision (TME), adjunct/adjuvant treatment (chemotherapy and radiotherapy) have substantially improved the survival rates of these patients. Neoadjuvant radiotherapy along with TME have resulted in the lowest local recurrence rate (< 5 %) and the highest 5-year survival rate (80 %) in patients with rectal cancer [2, 3]. Sexual dysfunction is a common complication after rectal surgery. The use of pelvic surgery, radiotherapy, and systemic chemotherapy put survivors at risk. Of these, 30–40 % may discontinue sexual activity, and 23–69 % of men may experience new-onset sexual dysfunction [4–6].
Miles described abdominoperineal excision (APE) in 1908, and since then, it has been the standard treatment of choice for rectal cancer . However, with the advent of mechanical stapling devices and advances in technique of rectal anastomosis, anterior resection has become the gold standard for upper and midrectal cancers. The main reason for this change has been the conviction that quality of life, including continence and urogenital function, will improve significantly. Moreover, encouraged by the improved cure rates of oncological treatment, research is becoming less focused on simply eradicating tumor, and more on combining a cure with improved quality of life for patients after treatment. Sexual dysfunction is therefore considered an important outcome, in addition to traditional end points such as survival, tumor recurrence and complication rates.
This review will focus on the overview of sexual dysfunction after colorectal surgery, discussing the epidemiology, surgical anatomy, and types of dysfunction, as well as the various techniques to prevent them.
Although sexual function declines with age, sexuality remains important to men into advanced age . Erectile dysfunction ranges from 17–100 % after abdominoperineal resection and 0–49 % after anterior resction [9–11]. These wide-ranging rates reflect various factors including case-mix, evaluation of dysfunction, definition of dysfunction, indication for resection, technique and expertise.
Radical abdominoperineal resection was invariably associated with urogenital dysfunction due to its mutilating nature. It was even believed that the operation had been incorrectly performed if a male patient did not have erectile dysfunction after their surgery. In late 1970’s, it was demonstrated that distal margin of 2 cm is safe. Also, the development of circular staples transformed rectal cancer surgery from a destructive surgery to sphincter-preserving procedure. However, the incidence of postoperative sexual dysfunction remained high, with reported rates up to 60 % [12, 13].
R.J. Heald introduced the landmark Total Mesorectal Excision (TME) technique in 1979 . Instead of blind blunt dissection, this technique used sharp dissection under direct vision along preexisting embryologically defined planes; dividing the visceral fascia surrounding the mesorectum from the pelvic parietal fascia overlying the pelvic floor . The TME resulted in improved survival, reduced local recurrence, higher degree of sphincter preservation, and reduced blood loss [15, 16]. The concept of TME championed nerve preservation because the pelvic autonomic nerves are located just outside the mesorectal fascia, and therefore not necessarily damaged by TME. However, with the popularization of TME, the damage to pelvic nerves still occurred and sexual dysfunction remained a serious complication. As time progressed, several modifications in surgical technique prompted surgeons to carry dissection medial to the autonomic pelvic nerves, instead of peripheral to the mesorectum resulting in even greater nerve preservation . Enker demonstrated excellent results by retaining sexual function in 90 % of patients using these principles. Additionally, the prospective study by Maas et al. demonstrated the feasibility and safety of nerve-sparing technique . These outcomes have not been reproduced in large series [17, 19]. This unique Dutch TME multicenter trial included 1,861 patients with resectable rectal cancer. They distributed questionnaires to evaluate the preoperative as well as postoperative sexual function with 5-year follow-up. They found that 76 %, 80 %, and 72 % of male patients reported sexual dysfunction, erectile dysfunction, and ejaculatory problems, respectively .
Surgical Anatomy of the Autonomic Nerves of the Pelvis
In 1836, Denonvilliers reported his discovery of a prostato-peritoneal membranous layer between the rectum and seminal vesicles, which he later described in more detail. Although the term Denonvilliers’ fascia is often used in descriptions of operations, its precise nature varies from patient to patient. It is currently the key landmark for colorectal surgeons and urologists in terms of not only the oncological, but also the functional outcome of surgery. The appearance of the fascia at operation varies considerably from a fragile translucent layer to a tough leathery membrane . It is more prominent in younger patients, patient with preoperative radiotherapy and in patients with transmural rectal inflammation. Histologically, Denonvilliers’s fascia is composed of dense collagen, smooth muscle fibers and coarse elastic fibers. It is related to the prostate and seminal vesicles anteriorly and to the rectal wall, thin anterior mesorectum and the fascia propria posteriorly.
Superior Hypogastric Plexus
This plexus is a network of sympathetic fibers from the upper lumbar region of spinal cord and it is located just below the aortic bifurcation. Above, it is continuous with the sympathetic trunks and caudally fibers exit as hypogastric nerves, which unite the inferior and superior hypogastric plexuses.
The superior hypogastric plexus bifurcates into 2–3 mm diameter hypogastric nerves, and these lie 1–2 cm medial to the ureters along the posterolateral wall of the pelvis. The nerves lie superficially in the plane between the peritoneum and the endopelvic fascia. The trunks are situated at the posterolateral aspect of the mesorectum, and so are at risk at the beginning of rectal mobilization.
The pelvic parasympathetic (splanchnic) nerves also called as nervi erigentes arise from the sacral roots of S2, S3 and S4. They pierce the endopelvic fascia from behind to enter the plane of pelvic plexuses. The pelvic parasympathetics join the sympathetic hypogastric nerve in a Y-shaped connection to form the pelvic plexuses.
Pelvic (Inferior Hypogastric) Plexus and Cavernous Nerves
The pelvic plexus is a network of nerves forming a neural sheet that lies lateral in the pelvis at the level of lower third of rectum . Branches from the pelvic plexuses run laterally to medial immediately under the peritoneum. Nerves from the plexus to the bladder and sexual organs run deeper and incline anteriorly .The cavernous nerves run in neurovascular bundles at the lateral border of Denonvilliers’ fascia . These nerves eventually run anterior to Denonvilliers’ fascia at the posterolateral border of apex and prostate, but are closely related to the anterior wall of rectum. It is these nerves that mediate the signal for penile tumescence.
The periprostatic plexus is made up of fibers from the pelvic plexus, which supplies branches to the prostate, seminal vesicles, corpi cavernosi, and terminal parts of the vas deferens.
Four danger zones exist that are sites ‘at risk’ of nerve damage during colorectal surgery. One of these sites is in the abdomen and three are in pelvis.
Origin of the Inferior Mesenteric Artery:
The purely sympathetic nerves in superior hypogastric plexus are vulnerable to injury at this zone. The risk occurs when inferior mesentery artery pedicle is ligated flush with the aorta.
This is the first pelvic danger zone. The damage is purely sympathetic at this level, as nerve ergentes have not yet joined the bundle. Anatomic dissection of the rectum is carried out in the loose areolar connective tissue immediately outside the fascia propria, and the nerves lie just outside this plane. Injury can occur if correct plane is not entered, dissection is not done under vision, blunt dissection is used or bleeding is not controlled.
The second pelvic zone of risk is the lateral plane of rectal dissection. Straying laterally out of the mesorectal plane may injure the pelvic plexuses, especially if excess traction is placed on the rectum, tenting the plexus superiorly and medially . Given recent anatomical findings of a relatively insignificant contribution from a small middle rectal artery and the waning concept of the lateral ligaments as distinct anatomical structures, significant reduction of damage in this zone may be possible. Avoidance of both hooking of the lateral tissue with the finger and clamping of the middle rectal pedicle may help to achieve this .
The third pelvic danger zone is encountered during anterior dissection. This is a very narrow space between the rectum and the prostate and seminal vesicles. During deep dissection of the anterior extra-peritoneal rectum away from the prostate and seminal vesicles, or during haemostasis in this difficult-to-access area, the cavernous nerves are at risk. This is probably where most parasympathetic nerve damage occurs, and may explain why impotence is more common the deeper the pelvic dissection goes.
Types of Sexual Dysfunction
Erectile Dysfunction (ED)
Erectile dysfunction can be partial or complete. Damage to parasympathetic nerve fibers supplying vasodilator fibers to the erectile tissue of the penis results in ED. Radiotherapy can cause obliterative endarteritis of the small blood vessels to the penile bulb, which will reduce blood flow and impair erectile function thereby contributing to erectile dysfunction. Duplex ultrasonography of the cavernous arteries in the penis has shown that radiotherapy-related ED  is predominantly arteriogenic in nature . The most likely site of damage is at the level of periprostatic plexus. This may partially explain increased incidence of impotence following abdomino-perineal resection (APR) versus anterior resection ( AR). Apart from psychological aspect due to permanent colostomy [29••], increased risk of surgical damage to pelvic autonomic nerves contribute to the morbidity associated with the procedure. Perineal phase of APR involves tearing of the presacral parietal fascia, which subsequently leads to inadvertent avulsion of the pelvic splanchnic nerves from their sacral roots [5, 30].
The incidence of erectile dysfunction after APR is higher than after AR. Santangelo et al. , in a study of men aged less than 60 years, described an incidence of permanent impotence of 44 % after APR compared to 25 % after AR. However, when these cases were divided into high and low AR, the incidence was 0 % and 33 %, respectively. The concept of total mesorectal excision (TME) has led to a substantial improvement of autonomic pelvic nerve preservation. Consequentially, this highly precise and sharp dissection technique under vision reduces postoperative ED from 70–100 % to less than 30 % .
Disruption of the sympathetic fibers can lead to absent, retrograde or painful ejaculation. The most frequent site is at the sacral promontory, before its entrance into the seminal vesicles . Injury to superior hypogastric plexus and hypogastric nerves leads to retrograde ejaculation, while injuries to hypogastric plexus and neurovascular bundles lead to incomplete/lack of ejaculation . As with impotence, ejaculatory dysfunction is worse after APR in comparison with sphincter-preserving surgery, given the more extensive pelvic dysfunction .The addition of extended pelvic lymph node dissection adversely influences ejaculatory function. Mechanical injury to nerve fibers and ischemic injury caused by devascularization during dissection are thought to play a role. Ejaculatory function is especially affected probably because of the short distance between the internal iliac vessels and the hypogastric nerves [34••].
Body Image Dysmorphia
Apart from nerve injury, other factors may affect quality of life. There may also be a psychological component, with concerns about the underlying disease, surgery and the presence of a stoma . The presence of stoma may lead to body image problems. The anxieties and fears include noise, odor, leakage, visibility of an appliance and perceived attractiveness to others. These issues bring emotional pressure and psychological disturbance leading to loss of libido and sexual dysfunction [3, 19]. Distress associated with having a colostomy or having bowel incontinence may also play a role in addition to body image. Lack of social support has also been shown to be associated with sexual dysfunction . Milbury et al. [37•] studied the association between psychosocial and medical factors with long-term sexual dysfunction after treatment of colorectal cancer. They concluded that impairment in sexual function is related to psychosocial factors in addition to demographic and medical factors. Even though the role of psychosocial factors is minor, the association of medical, demographic and psychosocial factors can help to identify patients at high risk for sexual problems in order to assist restoring sexual function if desired.
Sexual Dysfunction with Colorectal Surgery
Conventional Surgery and TME
Male sexual function after conventional rectal surgery
Male sexual function after total mesorectal excision (TME)
No. of patients
Loss /Dimnished Erection
Lack of Ejaculation
Leveckis et al. 
Havenga et al. 
Maas et al. 
Saito et al. 
Nagawa et al. 
Quah et al. 
Pocard et al. 
Kim et al. 
Laparoscopic Versus Open Resection
Laparoscopic colorectal cancer resection is known to provide shorter recovery times than open resection, in addition to comparable morbidity and oncological outcomes. It has been argued that laparoscopic approach may enable better visualization of autonomic nerves, contributing to their preservation and thereby reducing the incidence of sexual dysfunction [39•]. However, it has also been proposed that laparoscopic surgery provides reduced tension on tissue planes, and thereby nerve preservation may be less achievable .
The studies performed in early era of laparoscopic surgery have demonstrated poorer postoperative sexual function in males than open surgery [40, 41]. This has been recently disproven in the high volume centers performing laparoscopic rectal surgery. They have shown preservation of sexual function following laparoscopic surgery as compared to open surgery. This was significantly different with regard to erectile dysfunction . Although this is not consistent with other studies, the authors stated that their superior outcomes were probably due to increased experience with laparoscopic techniques, as surgeons who performed laparoscopic resections were national trainers and most of their elective practice consisted of laparoscopic resections.
Rectal cancer treatment, despite improving outcomes, is still plagued by the complications and long-term consequences. Sexual dysfunction can have a great impact on functional outcomes of these surgical procedures. Understanding of the anatomy between rectum and prostate to improve functional outcomes after rectal excision is vital. The growing concept of total mesorectal excision has led to substantial improvement in autonomic pelvic nerve preservation. The recent laparoscopic outcomes portend the use of this technique to obtain favorable postoperative sexual function. However, the learning curve in this highly precise and technically demanding procedure plays a major role with regard to satisfactory nerve preservation. Standardized subjective parameters, minimizing confounding factors and multicentre randomized trials are needed to confirm the efficacy of these techniques.
Compliance with Ethics Guidelines
Conflict of Interest
Dr. Kamal Nagpal reported no potential conflicts of interest relevant to this article.
Dr. Nelson Bennett reported receiving consultancies and travel/accommodations expenses covered or reimbursed from American Medical Systems and Coloplast. Dr. Bennett reported receiving payment for the development of educational presentations, including service on speakers’ bureaus from Pfizer.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.