Curr Bladder Dysfunct Rep (2015) 10:118–124 DOI 10.1007/s11884-015-0298-3

CANCER-ASSOCIATED VOIDING DYSFUNCTION (OL WESTNEY, SECTION EDITOR)

Rectal Cancer-Associated Urinary Dysfunction: a Review Nadav Haim 1 & Steven D. Wexner 1

Published online: 9 April 2015 # Springer Science+Business Media New York 2015

Abstract Urinary dysfunction may result from damage to the nerve supply during pelvic dissection or by the anatomical changes created by altering the physical structure of the pelvis. This problem may occur after appropriate oncologic resection of rectal cancer adhering to the globally accepted tenets of total mesorectal excision with either anterior resection or abdominoperineal resection. The most frequent type of urinary dysfunction is urinary retention, a transient problem which occurs in up to 25 % of men and 15 % of women. Fortunately, more severe chronic dysfunctions including voiding difficulty and incontinence are less common. Laparoscopy may confer a protective benefit although definitive evidence of a lower rate of dysfunction as compared to laparotomy remains elusive. Keywords Urinary dysfunction . Radiation . Laparoscopy . Abdominoperineal resection

Introduction Colorectal cancer is the third most frequent cancer in men (following lung and prostate cancers) and the second most frequent in women (following breast cancer). The rectum is This article is part of the Topical Collection on Cancer-Associated Voiding Dysfunction * Steven D. Wexner [email protected] Nadav Haim [email protected] 1

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA

a common site for these cancers comprising about 30 % of all cases. Surgeries for rectal cancer have evolved during the last 200 years. The first surgeries done for rectal cancer were aimed at relieving debilitating symptoms in patients with locally advanced disease, with a mortality rate close to 100 %. With advances in medicine and a better understanding of the pelvic anatomy and its organs, this high perioperative mortality has been significantly reduced. Initially, almost all patients who were able to survive the surgery experienced severe morbidity including fecal incontinence, sexual dysfunction, urinary dysfunction, and pelvic sepsis. In addition, the majority of these patients experienced short-term local recurrence and reappearance of disease and symptoms [1]. In 1908, Sir W. Miles first published a surgical technique that was based on a better understanding of the rectal and vascular anatomy and lymphatic drainage of the rectum. Sir Ernest Miles reported drastically reduced mortality rates of up to 42 % and 1-year disease-free survival of up to 60 %. The 1980s brought about a major and critical change in the approach to surgery for rectal cancer with the introduction of total mesorectal excision (TME) by Professor Richard J "Bill" Heald [2, 3]. Using TME, Professor Heald showed a 3.6 % local recurrence rate and an 80 % disease-free 5-year survival rate. The combination of TME and preoperative chemoradiotherapy (CRT) further reduced local recurrence to 2.4 % as was shown by the Dutch TME study [4]. These important improvements pushed the technique to the next level in the pursuit of improving the quality of life for these patients. Special care is now given to the pelvic anatomy during surgery in an effort to avoid postoperative pelvic organ dysfunction. Prior to the introduction of TME, the incidence of urinary dysfunction was as high as 60 % [5–7]. From the point where technical skill mandated the preservation of nerves, urinary complications were reduced to less than 5 % [8–10]. The advent of centers of excellence, wherein rectal cancer surgery is performed by highly

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experienced colorectal surgeons, further decreased urinary complications without radiation treatment [11].

Anatomical Aspects Related to Urinary Dysfunction Urinary dysfunction may result from damage to the nerve supply during pelvic dissection or from the anatomical changes created by altering the physical structure of the pelvis. Anal sphincter function, as well as urinary and sexual functions, is known to depend on the integrity of the pelvic autonomic nervous plexuses [12, 13]; preservation of this integrity and function is a major goal in modern rectal cancer surgery. Urinary control is a result of the normal function of three nerve components: sympathetic, parasympathetic (together known as autonomic), and somatic (Fig. 1). The superior hypogastric plexus arises from the T12, L1, and L2 roots and belongs to the sympathetic system. The nerves are in front of the aortic bifurcation, in close proximity to the inferior mesenteric artery. To avoid nerve injury, the IMA should be transected approximately 1 cm above its origin, while letting the nerves drop. This plexus further divides into the hypogastric nerves, at the pelvic brim and bilaterally, 1–2 cm parallel and medial to the ureters along the posterior and superior aspects of the mesorectum. The parasympathetic splanchnic nerves (nervi erigenti) are three to six nerves arising from the S2, S3, and S4 sacral roots and course along the anterior aspect of the sacrum. Damage to these nerves is less common but may result from injury close to their origin at the level of the sacral roots and/or during extended lateral lymph node dissection. Injury of the parasympathetic splanchnic nerves may result in sexual and urinary dysfunctions. The

Fig. 1 Autonomic nervous system: pelvic nerves and plexus. 1 rectum, 2 bladder, 3 prostate, 4 preaortic plexus, 5 hypogastric nerves, 6 lateral pelvic plexus, 7 branches of parasympathetic anterior roots S2, S4, and S4. With permission from Evano, Lamblin, Mariette, and Pocard [19]

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inferior hypogastric plexus is a combination of both sympathetic and parasympathetic nerves that form a plexus, which combines both the efferent and afferent nerves to and from all pelvic organs. These nerves may be injured during rectal dissection at the anterior aspect below the seminal vesicles and during rectal dissection to achieve mobilization at the lateral aspect. Incomplete dissection of the mesorectum while applying forceful retraction towards the sides can cause this damage. Damage may result in both sexual impotence and bladder dysfunction. Urge incontinence can be the result of detrusor instability due to sympathetic nerve injury. Overflow incontinence may result from insufficient bladder contractility and lack of relaxation and contraction as well as diminished sensation being regulated by the parasympathetic nerves. This is the mechanism by which acute retention occurs. If nerves are not completely divided, the dysfunction will be transient (as a neuropraxia for a period of time) as some nerves may regenerate [14]. Stimulating the anal canal may also induce release of the α-adrenergic system, which may induce bladder outlet obstruction [15]. Anatomical changes in the pelvis post-proctectomy may also influence urinary dysfunction. Specifically stress incontinence may result from a lack of support to the urethra and bladder neck when disrupting pubo-urethral-vesicle ligaments, the suburethral vaginal wall, or the levator plate and surrounding connective tissue that provides support [16•].

Type and Duration of Urinary Dysfunction The most frequent urinary dysfunction is urinary retention. This disorder may occur following any abdominal surgery in up to 25 % in men and up to 15 % in women. In most cases, this disorder is transient, resolving over time. Risk factors associated with general urinary retention are preexisting urinary disorders, high usage of analgesia and opiates, longer operations, male gender, and old age [17]. In a series of 210 patients, Kneist et al. [18] reported on 8 patients (3.8 %) discharged with a catheter due to retention and, by 6 months follow-up, 6 patients (2.8 %) remained with a urinary catheter. Urinary dysfunction may be related to bladder emptying, incontinence, or a combination of both [19, 20•]. The rate of urinary dysfunction following surgery for rectal cancer ranges from 30 to 70 % [16•]. The Dutch TME multicenter clinical trial included 1861 rectal cancer patients [4] who were randomized to receive chemoradiation treatment before TME. Follow-up was undertaken at different points over 5 years; 38 % of patients had postoperative urinary incontinence, 72 % of whom had normal preoperative function. It was found that difficulties in bladder emptying were likely to improve by 3 months following surgery but symptoms persisting for up to 6 months were found to be more permanent. Long-term bladder emptying dysfunction occurred in 31 % of the patients.

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Lange et al. [20•] reviewed urinary dysfunction in 780 patients who underwent TME for rectal cancer with and without neoadjuvant chemoradiotherapy over several time points. Baseline preoperative urinary incontinence was seen in 16.7 % of these patients; 22.6 % of these patients suffered worsening of symptoms following surgery. At 3 months follow-up, 25.8 % of all treated patients reported urinary incontinence. A further increase was noted at 6 months follow-up (to ∼30 %), with a steady slow increase to 38.1 % at 5-year follow-up. Of note, only 447 patients completed a 5-year follow-up, 86.1 % (n=385) of whom had no preoperative urinary incontinence and 32.7 % had incontinence noted at the 5-year follow-up. Only female gender and age >65 years were found to be risk factors in this group. In terms of bladder emptying, baseline preoperative bladder emptying difficulties were noted in 22.5 %, 6 % of whom had worsening of symptoms following treatment. At 3month follow-up, 36 % of all treated patients had voiding dysfunction. Improvement was seen at the 18month follow-up and then a stable level thereafter, for a total of 30.6 % of patients experiencing bladder emptying dysfunction. A total of 445 patients completed a 5year follow-up, 351 (78.9 %) of whom had normal baseline preoperative function; 90 (25.6 %) of these patients developed long-term voiding dysfunction after treatment. Preoperative voiding dysfunction, intraoperative blood loss (>1500 ml), and surgical damage to one or more sides of the inferior hypogastric plexus or splanchnic nerves were all found to be independent risk factors.

Removal of Foley Catheter A recent study by Zmora et al. [21] included 118 patients with no preoperative urinary problems who were randomly assigned to one of 3 groups for removal of the urinary catheter on postoperative day 1, 3, or 5. Urinary retention was found in 5.3–14.6 % of patients with no significant difference among the groups. The authors concluded that the urinary catheter can be removed as early as postoperative day 1. Lee et al. [22] reviewed 352 patients who underwent a surgical procedure for rectal cancer. Urinary retention occurred in 13.6 % of patients. Removal of the urinary catheter on postoperative day 1 or 2 was found to carry a 21.6 % urinary retention rate compared to 14.4 % for removal on days 3 or 4 and 7.8 % for day 5 or longer. The difference between the first and last groups was significant (p=0.018). Currently, no consensus exists as to when the urinary catheter should be removed. Risk factors for urinary retention are additive and should be taken into consideration prior to removing the catheter. Patients with no special risk factors may benefit from early removal of the urinary catheter.

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Radiation-Associated Urinary Dysfunction Chemoradiation plays a major role in the treatment of rectal cancer: down staging, sphincter preservation, local control, and recurrence. Lange et al. [20•] published a large series of 448 patients and reported no associated urinary incontinence or bladder emptying dysfunction following radiation therapy at a 5-year follow-up. In their review, Evano et al. [19] concluded that despite the late effects on sexual dysfunction seen as early as 8–11 months after chemoradiation, no such significant effects were seen relative to urinary dysfunction. In another review published by Lange et al. [16•], radiationassociated urinary dysfunction was reported after pelvic radiation for pelvic organ cancer; the authors reported that this effect is dependent on the dose and size of the irradiated field. In addition, radiation-induced fibrosis of the urinary bladder and urethral sphincter was seen, but this same effect was not reported after radiotherapy for rectal cancer. Pietro et al. [23] compared the genitourinary function of patients treated by preoperative short-term radiation (5 consecutive days of 5Gy radiation for a total of 25 Gy) and chemoradiotherapy (5-FU-based chemotherapy and 28 doses of 1.8 Gy daily over 6 weeks, for a total 50.4 Gy) followed by surgery (2–3 days after a short course and 4–6 weeks after a long course) to that of patients who underwent surgery alone. A total of 166 males and 71 females completed a median 51-month follow-up (range 12–99). Of these, 125 (51.2 %) patients experienced urinary incontinence and 73 (29.9 %) had stress incontinence (16.1 vs. 60.5 % male to female); only female gender was found to be a risk factor in both disorders. Bregendahl et al. [24] looked for urinary dysfunction in 516 women following resection of rectal cancer with and without preoperative radiotherapy (a short course or long course of 5-FU-based chemoradiotherapy) at a median of 55 (range 26–98)months follow-up. The use of preoperative radiation was significantly associated with voiding problems, particularly problems related to interrupted stream (odds ratio (OR) 1.63, 95 % confidence interval (CI) 1.09–2.44); no effect was seen related to bladder filling, dysfunction, or incontinence. There was no statistical difference between the short- or long-term regimens of radiotherapy. In the recent European Registry of Cancer Care (EURECCA) consensus meeting [25•], a general consensus noted that long-term functional problems are significantly increased among patients receiving neoadjuvant treatment compared with those who undergo surgery alone. Furthermore, recent Scandinavian studies [26] found that urinary incontinence increased from 2 to 9 % following radiotherapy. In conclusion, it is unclear whether radiotherapy plays any role in urinary dysfunction. There seems to be no disadvantage with longer chemoradiation regimens compared to shorter protocols.

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Urinary Dysfunction Following Laparoscopy vs. Open Surgery Laparoscopy may offer a better anatomical field of vision (resolution and magnification of the operative field) and better control over dissection in comparison to open surgery, but it is generally accepted that a learning curve needs to be met to achieve the same outcomes as with open surgery [25•]. Data from the CLASSIC study suggests that urinary function is similar using both the open and minimally invasive techniques [16•]. McGlone et al. [27] conducted a retrospective comparison between 78 patients with rectal cancer who underwent laparoscopic rectal resection and 65 patients with rectal cancer who underwent open rectal resection. Patients were matched for gender, age, BMI, type of procedure (AR, APER, Hartman, and diverting ileostomies), distance of tumor, T stage, CRT, and circumferential radial margin (CRM). Of note, laparoscopy had a significantly higher number of anterior resections, fewer Hartman procedures, a higher median distance of tumor from the anal verge (10 cm for laparoscopy vs. 7 cm for open groups), and lower CRM involvement compared to the open group. At 6 months after surgery, both groups showed deterioration in urinary function but no significant difference was noted between men and women and between laparoscopy and the open approach. In another review of published articles comparing the functional outcome after laparoscopic vs. open surgery, McGlone et al. [28] showed no difference when comparing International Prostate Symptom Scores (IPSS) and/or post void residual urine measurements and uroflowmetry for both men and women. Lee et al. [22] suggested that the laparoscopic procedure could carry a higher incidence of acute urinary retention in comparison to open surgery (16.9 vs. 9.3 % but not statistically significant). An independent factor for this difference was over-administration of IV fluids during the laparoscopic procedure (>2000 ml). It was speculated that due to the increase in intra-abdominal pressure during laparoscopy, administrating fluid without correspondence to the actual excretion of urine by the kidneys may serve as a predisposing risk factor for bladder distention and voiding difficulties with early removal of the urinary catheter. In addition, the authors speculated that the small graspers used during laparoscopy may cause pinching of the nerves, resulting in temporary neuropraxia and a higher incidence of acute urinary retention. In a systemic review and meta-analysis between the laparoscopic and open approaches, Lim et al. [29•] reviewed five publications, four of which concluded that there was no difference in urinary dysfunction and one that reported significantly less micturition problems at 3–6 and 12–18 months in the laparoscopic vs. the open group, respectively. To conclude, despite the many advantages offered by laparoscopy and it's widespread acceptance a significant decrease

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in the incidence and/or severity of urinary dysfunction, remains unproven.

Abdominoperineal Resection and Associated Urinary Dysfunction Abdominoperineal resection (APR) is believed to carry a higher rate of sexual and urinary dysfunction compared to low anterior resection and construction of an anastomosis [30, 31]. In part, colostomy may play a major role in sexual dysfunction due to altered body image and psychological effects; in terms of urinary dysfunction, removing the levator muscle is expected to carry some effect on the nearby splanchnic nerves, especially during the perineal dissection portion of the procedure. Removal of the levator muscle also affects pelvic floor stability, thus precipitating urinary incontinence or voiding difficulties. Following the Dutch TME trial, Lange et al. [20•] found that APR had no worsening effect on both urinary incontinence and bladder emptying at 5-year follow-up. In a systemic review and meta-analysis, Yu et al. [32] compared the effect of intra- and extralevator resection on urogenital function, as part of the general surgical complications. No significant difference was noted in terms of urinary dysfunction (RR 1.53; 95 % CI 0.88–2.67). However, urogenital dysfunction was found to be the most common complication in both intra- and extralevator APR techniques. Han et al. [33] conducted a prospective multicenter study for locally advanced low rectal cancer. A total of 102 patients with a tumor located 0.5–5.0 cm from the anal verge underwent extralevator APR; 96 % of the patients had T3 or T4 tumor staging and 89 % of the patients had sacrococcygeal resection. Urinary retention was found in 19 patients (18.6 %); of these, 15 had resolution of symptoms during the hospitalization period, while 4 had resolution by 3 months post surgery. In summary, APR may be associated with a higher incidence of urinary dysfunction. Extended levator excision may affect sexual function but has not been found to be associated with increased urinary dysfunction.

Robotic vs. Laparoscopic Surgery Proponents of robotic surgery have claimed that the addition of degrees of freedom and 3-D visualization offer advantages as compared to laparoscopic techniques. However, all studies have uniformly failed to prove any clinical or oncological advantages of robotic surgery over laparoscopy. Xiong et al. [34] conducted a meta-analysis, which included 8 studies related to robotic vs. laparoscopic TME for rectal cancer. Of the 8 studies, only 2 addressed voiding assessment, showing no significant difference in urinary retention when comparing 81 patients who underwent robotic TME to 160 patients undergoing laparoscopic TME (OR 1.94; 95 % CI

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0.38–9.84). Only 1 of the 8 studies reported long-term effect and found that in both groups (laparoscopy and robotic TME), the International Prostate Symptom Scores (IPSS) were significantly increased 1 month following surgery but normalized 1 year after surgery. Park et al. [35] conducted a casematched, non-randomized comparison between 32 patients undergoing robotic TME and 32 patients undergoing laparoscopic TME. Patients were matched for age, BMI, tumor distance from the anal verge, tumor stage, and neoadjuvant chemoradiation. Urinary dysfunction was evaluated using the IPSS standardized questionnaires before and again at 3 and 12 months following surgery. Both groups showed that the highest impairment to urinary function occurred at 3 months following surgery. No significant difference was found between the two groups. In addition, most symptoms resolved by the 12-month follow-up in both groups, with no significant difference. Of note, removing the inferior mesenteric artery— a point where damage to the superior epigastric plexus can occur, was performed laparoscopically in all cases in both groups; hence, only the TME portion was performed using the robotic approach. In this study, no difference was demonstrated between the two techniques in urinary outcomes. To conclude, robotic techniques may Bflatten^ and shorten the learning curve, allowing low-volume rectal cancer surgeons who have not yet acquired the laparoscopic learning curve to offer minimally invasive techniques to their patients. Unfortunately, low-volume robotic rectal cancer surgeons, like low-volume open and laparoscopic rectal cancer surgeons, offer inferior outcomes to their patients as compared to high-volume rectal cancer surgeons. Despite a consistently significantly higher cost, robotic treatment of rectal cancer has failed to be advantageous.

Where Do We Go to from Here? In search for new ways to minimize tissue damage and gain better access in technically challenging cases of rectal cancer surgeries, Natural Orifice Translumenal Endoscopic Surgery (NOTES) may seem promising in the morbidly obese and narrow pelvis cases. With early publication of surgeries on human patients first published on 2010 for TME rectal cancer surgeries, it seems that initial data supports this technique as being safe with comparable complication rates and oncological outcomes. In a review of all published cases up to 2014, Emhoff et al. [36] included a total of 72 (1–30 patients per publication) patients who underwent transanal NOTES TME for rectal cancer. Of the 72, 59 underwent neoadjuvant CRT. All patients had negative resection margins and CRM. Six patients (8.3 %) had urinary complication, 2 of whom had urinary retention and 4 had unspecified urinary dysfunction. One new appealing approach is the Intraoperative Neuromonitoring (IONM). Kneist et al. [37, 38] reported using

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IONM based on EMG of the internal anal sphincter and cystomanometry of the urinary bladder. BNeuro-mapping^ was performed during and after the surgery at the postero-lateral, lateral, anterior, and at the level of the pelvic floor in order to identify neural tissue and avoid injury. Any macroscopically visualized pelvic splanchnic nerves were directly stimulated using a bipolar micro-fork probe. Signals were taken by the device from electrodes connected to the internal anal sphincter and by measuring contraction of the bladder that elevated intravesical pressure >1 cm H2O. Urinary symptoms were quantified using IPSS and Qol (quality of life) questionnaires well as by measuring residual urine volume and the long-term catheterization rate (beyond the discharge date). Two matched groups of 15 patients each were included in IONM vs. nonIONM open TME surgery. A new onset of impaired urinary function was reported by 1/15 patients in the IONM group vs. 6/15 patients in the control group. Of these, 3 of the affected control patients underwent neoadjuvant chemoradiation. The median follow-up was 10 months. Despite promising results, this study had a number of limitations: it was non-randomized and single institution, and selection bias could not be ruled out. Another novel approach that has gained attention in the last decade is the Bwatch and wait^ policy. Despite major advancements in the treatment of rectal cancer, there is still a high incidence of fecal incontinence, sexual dysfunction, and urinary dysfunction following surgery. Ten to 20 % of patients who receive neoadjuvant chemoradiation have complete pathological response after radical surgery. It has been advocated that these patients could benefit from not having surgery and instead remain under tight surveillance as clinical complete responders. Chawla et al. [39] reviewed the current status of the Bwatch and wait^ policy. The main concern is that clinical complete response is not standardized and may have poor correlation with pathological complete response, meaning some patients may be found to have clinical complete response and still have cancer in the rectum or mesorectum. Shwaartz et al. [40] showed that out of 78 patients who received neoadjuvant chemoradiation and underwent TME, 8 patients had pathological complete response in the rectal wall; however, 1 patient had residual malignant cells in the mesorectum (T0N1). Eleven patients were down staged to T1, but 2 (18 %) had residual mesorectal disease. It appears that further advancements in providing better quality of life may be derived from new and promising surgical techniques, better intraoperative monitoring, and possibly a better selection process for identifying patients who can benefit from the Bwatch and wait^ policy.

Conclusions Rectal cancer surgery has come a long way from alleviating patient’s symptoms to preserving and prolonging life, and

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more recently to improving the patient’s quality of life following surgery. All these advances should help decrease the incidence and severity of postoperative urinary and sexual dysfunction.

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15. Compliance with Ethics Guidelines 16.• Conflict of Interest Steven D. Wexner declares payment for being a consultant for Incontinence Devices, Inc.; Mederi Therapeutics; Medtronic, Inc.; Renew Medical; and Salix Therapeutics. Nadav Haim declares no conflict of interest. 17. 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.

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