Dear Sir

We would like to thank V. Celentano for the interesting letter on nerve-sparing surgery and urinary dysfunction after multimodality treatment for rectal cancer. Celentano writes that both sexual and urinary functions are dependent on dual autonomic (sympathetic and parasympathetic) innervation, and damage to the preaortic nerve fibers and superior hypogastric plexus, during flush ligation of inferior mesenteric artery, is only one of the four danger zones that are “at risk” of nerve damage during colorectal surgery [1]. In our paper, we describe a new technique for left colectomy for cancer with high ligation, which is associated with a risk of nerve damage during the dissection of the Bacon axilla, described by Bacon [2]. Celentano points out that techniques and results of nerve-sparing surgery have been extensively reported [3]. However, total mesorectal excision (TME) is a completely different dissection, performed in the pelvic cavity where the major problems are the two Walsh bandles [4]. We agree with Celentano that damage to the autonomic nerves is most likely to occur during the pelvic dissection, particularly during the anterior and lateral mobilization of the rectum, and this is when new techniques and devices are more likely to impact on functional results. We would like to emphasize that the technique we used in laparoscopic sigmoidectomy for cancer can be used in rectal cancer surgery, both open and laparoscopic. We use the cavitron ultrasonic surgical aspirator (CUSA, Tyco Healthcare, Mansfield, MA, USA) during laparoscopic TME and especially in transanal TME. This technique is very helpful for dissecting the Denonvilliers’ fascia in males during transanal TME; damage to the nerves by hooks and ultrasonic scissors can be avoided. The CUSA may be useful even in the posterior dissection when for oncologic reasons the dissection is carried out deep to the presacral fascia and there is a risk of damaging the sacral nerves.