Dear Sir,

I would like to thank Husher and Rossetti for demonstrating a purely anatomical approach to dissection of the inferior mesenteric artery during sigmoid colectomy with the use of the Cavitron Ultrasonic Surgical Aspirator (CUSA) (SonoSurg, Olympus, Tokyo, Japan) [1], where the sympathetic nerves of the superior hypogastric plexus are vulnerable to injury.

It is important to note that both sexual and urinary function are dependent on dual autonomic (sympathetic and parasympathetic) innervation, and damage to the preaortic nerve fibers and superior hypogastric plexus, during flush ligation of the inferior mesenteric artery, is only one of four danger zones that are ‘at risk’ of nerve damage during colorectal surgery [2].

Techniques and results of nerve-sparing surgery have been extensively reported [3], focusing on functional outcomes following rectal resection for several reasons. Firstly, the pelvic dissection, particularly during the anterior and lateral mobilization of the rectum, is where the damage to the autonomic nerves is most likely to occur, and it is where new techniques and devices are more likely to impact on functional results.

Secondly, sexual and urinary problems after surgery for rectal cancer are multifactorial [4], and other concomitant causes exist, such as preexisting comorbidities, radiotherapy and psychological factors. In fact, this is confirmed by the impossibility of eradicating the risk even when a full nerve-preserving operation is intended and documented [5], or when the procedure is performed for non-oncological indications, or with the use of a sophisticated intraoperative neuromonitoring device [6].