An abdominoperineal operation is described that extends rectal resection for low tumours into the intersphincteric plane with removal of the internal sphincter. Bowel continuity is restored by coloanal anastomosis. Of 38 patients who underwent surgery since 1984, 34 had low rectal cancer and four carcinoid or large villous adenoma. There was no mortality. Four patients developed local recurrence during a median observation period of 3 years. Continence was satisfactory in all patients. The median daily number of bowel movements during the first months after colostomy closure was 9 but decreased to 3 after 1 year and 1 after 2 years. Anal manometry demonstrated a significant reduction of mean resting pressure from 91·8 to 35·1 cmH2O with no recovery after 2 years (P<0·0001). Squeeze pressure showed only a transient decrease.

In the treatment of very low rectal cancer, a distal resection margin of more than 1 cm can be obtained by partial internal sphincteric resection, allowing a sphincter preserving surgery. Thus, intersphincteric resection (ISR) has been proposed as an alternative to abdominoperineal resection for selected low rectal cancer.The aim of our study was to assess the morbidity, mortality, and the long-term oncologic and functional results of ISR.Charts of patients who had ISR between 1992 and 2004 were reviewed. Cancer-related survival and locoregional recurrence rates were calculated using the Kaplan-Meier method. Functional outcome was assessed by using a standardized gastrointestinal functional questionnaire. Incontinence was assessed by the continence score of Wexner.Ninety patients (59 males, 31 females) with a tumor at a median distance of 35 mm (range, 22-52) from the anal verge had an ISR. Thirty-seven patients (41%) had preoperative radiotherapy. Histologically complete remission after neoadjuvant radiotherapy (ypT0) was observed in 7 patients (8%), 12 patients (13%) were pT1, 35 patients (39%) pT2, 32 patients (36%) pT3, and 4 patients (4%) pT4. Five patients (5.5%) had synchronous liver metastases. R0 resection was obtained in 85 patients (94.4%). The median distal resection margin on the fixed specimen was 12 mm (range, 5-35) and was positive in 1 case. The circumferential margin was positive (< or =1 mm) in 4 patients (4.4%). There was no mortality. Complication rate was 18.8%: anastomotic leakage occurred in 8 patients (8.8%) and 1 patient had an anovaginal fistula. Five patients (5.6%) underwent secondary abdominoperineal resection: 1 for positive distal margin, 1 for colonic J-pouch necrosis, and 3 for local recurrence. ONCOLOGIC RESULTS: After a median follow-up of 56.2 months (range, 13.3-168.4), local, distant, and combined recurrence occurred in 6 (6.6%), 8 (8.8%), and 2 patients, respectively. Thirteen patients (14.4%) died of cancer recurrence. Five-year overall and disease-free survival was 82% (80-97) and 75% (64-86), respectively. In univariate analysis, overall survival was significantly influenced by pTNM stage and T stage (pT 1-2 vs. 3-4: P = 0.008 and stage I-II vs. III-IV: P = 0.03). In multivariate analysis, we did not find any impact on local recurrence-free survival for the investigated prognostic variables.For a total of 83 patients the mean stool frequency was 2.3 +/- 1.3 per 24 hours. Forty-one percent of patients had stool fragmentation, one-third nocturnal defecation, 19% fecal urgency, and 36% followed low fiber diet. Thirty-four patients (41%) were fully continent, 29 patients (35%) had minor continence problems, and 20 patients (24%) were incontinent. After adjustment for age, gender, tumor level, and pTNM stage, preoperative radiotherapy was the only factor associated with a risk of fecal incontinence [OR (IC 95%) = 3.1 (1.0-9.0), P = 0.04].In selected patients, ISR is a safe operation with good oncologic results. It achieves good functional results in 76% of patients. Functional results are significantly altered by preoperative radiotherapy.

Intersphincteric resection has been performed as an alternative to abdominoperineal resection for low rectal cancer. The purpose of this study was to assess the long-term results after intersphincteric resection in terms of the morbidity, oncologic safety, and defecatory function.Between 1994 and 2006, 107 consecutive patients with low rectal cancer had curative intersphincteric resection, categorized as total, subtotal, or partial resection of the internal anal sphincter.There were no mortalities. Neorectal mucosal prolapse in patients with total intersphincteric resection and coloanal anastomotic stenosis in patients with subtotal or partial intersphincteric resection were observed as characteristic late complications. The five-year disease-free survival rates classified according to the TNM stage were 100 percent for stage I, 83.5 percent for stage II, and 72.0 percent for stage III cases. The five-year cumulative local recurrence rate after intersphincteric resection was 2.5 percent. Defecatory function, which was evaluated by bowel movement in a 24-hour period, and continence after intersphincteric resection were objectively good. The results of the multivariate analysis revealed that age was the only factor associated with a risk of fecal incontinence.Provided strict selection criteria are used, intersphincteric resection may be the optimal sphincter-preserving surgery for low rectal cancer.

For a select group of patients proctectomy with intersphincteric resection (ISR) for low rectal cancer may be a viable alternative to abdominoperineal resection, with good oncological outcomes while preserving sphincter function. The purpose of this systematic review was to evaluate the current evidence regarding oncological outcomes, morbidity and mortality, and functional outcomes after ISR for low rectal cancer.A systematic review of the literature was undertaken to evaluate evidence regarding oncological outcomes, morbidity and mortality after ISR for low rectal cancer. Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The review included all original articles reporting outcomes after ISR, published in English, from January 1950 to March 2011.Eighty-four studies were identified. After applying inclusion and exclusion criteria, 14 studies involving 1289 patients were included (mean age 59.5 years, 67.0 per cent men). R0 resection was achieved by ISR in 97.0 per cent. The operative mortality rate was 0.8 per cent and the cumulative morbidity rate 25.8 per cent. Median follow-up was 56 (range 1-227) months. The mean local recurrence rate was 6.7 (range 0-23) per cent. Mean 5-year overall and disease-free survival rates were 86.3 and 78.6 per cent respectively. Functional outcome was reported in eight studies; among these, the mean number of bowel motions in a 24-h period was 2.7.Oncological outcomes after ISR for low rectal cancer are acceptable, with diverse, often imperfect functional results. These data will aid the clinician when counselling patients considering an ISR for management of low rectal cancer.Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

With the optimization of neoadjuvant treatment regimens, the indications for intersphincteric resection (ISR) have expanded. However, limitations such as unclear surgical field, impaired anal function, and failure of anal preservation still exist. Transanal total mesorectal excision can complement the drawbacks of ISR. Therefore, this study combined these two techniques and proposed transanal endoscopic intersphincteric resection (taE-ISR), aiming to explore the value of this novel technique in anal preservation for ultra-low rectal cancer.Four high-volume centres were involved. After 1:1 propensity score-matching, patients with ultra-low rectal cancer underwent taE-ISR ( n =90) or ISR ( n =90) were included. Baseline characteristics, perioperative outcomes, pathological results, and follow-up were compared between the two groups. A nomogram model was established to assess the potential risks of anal preservation.The incidence of adjacent organ injury (0.0% vs. 5.6%, P =0.059), positive distal resection margin (1.1% vs. 8.9%, P =0.034), and incomplete specimen (2.2% vs. 13.3%, P =0.012) were lower in taE-ISR group. Moreover, the anal preservation rate was significantly higher in taE-ISR group (97.8% vs. 82.2%, P =0.001). Patients in the taE-ISR group showed a better disease-free survival ( P =0.044) and lower cumulative recurrence ( P =0.022) compared to the ISR group. Surgery procedure, tumour distance, and adjacent organ injury were factors influencing anal preservation in patients with ultra-low rectal cancer.taE-ISR technique was safe, feasible, and improved surgical quality, anal preservation rate and survival outcomes in ultra-low rectal cancer patients. It held significant clinical value and showed promising application prospects for anal preservation.Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.

The anatomy of the levator hiatus and tunnel has been studied, aiming at the elucidation of their functional role in mechanisms of defecation, urination, and continence. The material comprised 25 cadavers studied by dissection and serial histologic sections. The levator hiatus occupies the anterior portion of the levator plate which consists of two "crura," that bound the hiatus, and two "lateral masses." Three crural patterns could be identified: classic, crural overlap and crural scissor. The levator tunnel is a muscular tube which surrounds the intrahiatal organs along their way down from the levator hiatius to the perineum. It is double sheathed, with an inner coat of the suspensory sling and an outer of the puborectalis. Both coats are of striped muscle bundles. The inner coat is a tunnel "dilator," whereas the outer is a tunnel "constrictor." The puborectalis not only acts as a "common tunnel" sphincter but provides an "individual" sphincter for each intrahiatal organ. A detailed study of the hiatal ligament which firmly binds the levator plate to the intrahiatal organs is presented. A "tunnel septum" could be identified to line the levator tunnel, and separate it from the intrahiatal organs. Its surgical significance as a landmark for mobilizing the intrahiatal organs from within the tunnel is stressed. The levator plate consists of two functionally separate zones: a lateral "visceral support" zone and medial "dilator" one. The double sphincteric control provided to each intrahiatal organ by the "individual" and "common" sphincters would suggest that unless both sphincters are destroyed, continence could be maintained by either. The role of the "levator complex" which comprises levator crura, tunnel and hiatal ligament in fixation of intrahiatal structures, as well as in mechanisms of defecation, urination, and continence, is discussed. The understanding of the anatomic details of the levator hiatus and tunnel could be of value in mobilizing the intrahiatal structures from within the levator tunnel with preservation of their voluntary sphincteric mechanism.

The technique for radical retropubic prostatectomy has been modified to avoid injury to the branches of the pelvic plexus that innervate the corpora cavernosa. The surgical procedure is based on an understanding of the anatomical relationships between the branches of the pelvic plexus that innervate the corpora cavernosa, the capsular branches of the prostatic vessels that provide the scaffolding for these nerves, and the lateral pelvic fascia. The modifications involve two steps in the procedure: 1) the incision in the lateral pelvic fascia is placed anterior to the neurovascular bundle, which is located dorsolateral to the prostate along the pelvic sidewall; 2) the lateral pedicle is divided close to the prostate to avoid injury to the branches of the pelvic plexus that accompany the capsular vessels of the prostate. Pathologic evaluation of 16 prostatic specimens removed by this modified procedure demonstrated no compromise in the adequacy of the surgical margins. Postoperative sexual function was evaluated in 12 men who underwent the procedure 2-10 months previously. All have experienced erections and six have achieved successful vaginal penetration and orgasm. Of the six patients with sexual partners who have been followed 6 months or longer, five (83%) are fully potent. These data indicate that it is possible to cure localized prostatic cancer with surgery and maintain postoperative sexual function.

Urogenital complications due to pelvic autonomic nerve damage frequently occur following rectal surgery. We investigated whether total mesorectal excision (TME) with preservation of the Denonvilliers' fascia (DVF) can effectively prevent the removal of pelvic autonomic nerves through microscopy. Twenty consecutive male patients with mid-low rectal cancer who received TME with preservation or resection of the Denonvilliers' fascia (P and R groups, respectively) were included. Serial transverse sections from surgical specimens were studied histologically. Nerve fibers at the surfaces of the mesorectum were counted. Clinical correlation between the amount of nerve fibers removed and post-operative sexual function was analyzed. Nerve fibers closely localized to the DVF in the R group displaying rich erectile activity (positive anti-nNOS immunostaining). At the anterior surface of the mesorectum, the mean numbers of nNOS-positive nerve fibers per specimen in the P group were significantly lower than the R group (3.0 ± 1.8 vs. 5.0 ± 2.3, P < 0.05). Compared to the R group, patients in the P group had higher IIEF scores and better erectile function at 3 and 6 months post-operatively. The DVF is a key risk zone for pelvic denervation during laparoscopic TME. Preservation of the DVF can prevent the removal of autonomic nerves and protect post-operative erectile function. Clin. Anat. 32:439-445, 2019. © 2019 Wiley Periodicals, Inc.© 2019 Wiley Periodicals, Inc.

In abdominoperineal resection (APR) in male patients with rectal cancer, high margin involvement and urethral injury have been reported to result from difficulty in dissecting the anterior anorectum. Recently, the efficacy of an endoscopic down-to-up rectal dissection was reported. Here, we present a safe and simple technique for anterior dissection using a simultaneous laparoscopic and transperineal endoscopic approach.We perform transperineal APR (TpAPR) using both the laparoscopic and transperineal approach (a 2-team approach). Anterior dissection commences just behind the superficial transverse perineal muscle. Next, the striated muscle complex surrounding the rectum (levator ani and puborectalis muscle) is divided. At this point, it is difficult to identify the dissection plane between the membranous urethra and anterior rectum; thus, dissection along the lateral aspect of neurovascular bundle from the lateral to anterior side with the assistance of the laparoscopic team is helpful in identifying the posterior surface of the prostate. Once the prostate is identified, it is relatively easy to divide the rectourethralis muscles. The key steps of our procedure are shown in the video.Between April 2016 and July 2019, we performed 14 TpAPR procedures in male patients with rectal cancer without distant metastasis. Extended surgery was performed in 8 patients, including pelvic sidewall dissection and combined resection of adjacent organs. Median operative time was 453 min and median blood loss was 46 g. There was 1 (7.1%) circumferential-positive case, but no cases of urethral injury or rectal perforation.The 2-team TpAPR procedure is beneficial for appropriate dissection of the anterior side during APR surgery.