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KMID : 0670719990040020019
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Journal of the Korean Society Hyperthermia Oncology
1999 Volume.4 No. 2 p.19 ~ p.23
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Pelvic Lymph Node Dissection and Pelvic Autonomic Nerve Preservation for Rectal Cancer
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Kenichi Sugihara
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Abstract
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Difficulty in treatment of rectal cancer is represented by the high local recurrence
rate, genitourinary dysfunction and loss of anal sphincter function. In conventional
surgery with limited lymph node dissection, the pelvic recurrence rate was 11% to 30%.
In order to achieve local control, adjuvant radiotherapy, total mesorectal excision and
extended pelvic node dissection have been introduced. Extended pelvic node dissection
aims to eradicate both of superior and lateral lymphatic pathways. So, it is a
combination of removal of the mesorectum and lymph node dissection on the pelvic side
wall. The problems of extended pelvic node dissection are a high incidence of urinary
and sexual dysfunction, longer operation time and more blood loss. In order to decrease
postoperative autonomic nerve dysfunctions, pelvic autonomic nerve preservation(PANP)
has been introduced In the early 1980's. According to preoperative evaluation of tumor
spread, which autonomic nerves will be preserved and which will not be preserved are
decided. Between 1987 and 1991, 199 patients with middle or low rectal cancer
underwent either of PANP. They did not receive any adjuvant chemotherapy or
radiotherapy. During the median follow-up period of 54 months, recurrent diseases were
confirmed in 24%. The local recurrence rate was 5%. The 5 year survival rates of
Dukes'A, Dukes'B and Dukes'C were 96%, 86% and 66%, respectively. In cases with
removal of the truncal sympathetic nerves, ejaculation was lost but erectile ability and
urinary function were maintained. When all truncal autonomic nerves were removed,
male sexual function was destroyed but 70% had the ability to void without
catheterization. From the functional results of this study, urinary function may be
maintained when the unilateral pelvic plexus is preserved. Maintenance of complete male
sexual function need preservation of all truncal pelvic autonomic nerves. In conclusion,
PANP combined with extended pelvic lymph node dissection benefits patients with
middle or lower rectal cancers. The autonomic nerves which will be preserved should be
decided according to preoperative staging which is evaluated by multimodalities including
colonoscopy, barium enema examination, endoscopic ultrasonography and CT.
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