直肠癌ELAPE手术会阴操作的神经保护
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摘要
肛提肌外腹会阴联合切除术(ELAPE)已经成为治疗低位进展期直肠癌的重要术式。在降低局部复发率的同时,ELAPE手术由于切除更多肿瘤周围组织,有可能增加泌尿生殖神经损伤的发生率。笔者认为,在ELAPE手术的会阴操作过程中,对盆丛、阴部神经和神经血管束的保护是可行的,有助于保留术后的泌尿功能和性功能。在术前MRI分期的指导下,结合肿瘤的垂直浸润深度和环周生长情况,提出的个体化ELAPE技术,有助于在保证肿瘤根治性前提下,进一步减少手术创伤和保护会阴部神经。
Extralevator abdominoperineal excision(ELAPE) has been an important surgical procedure for low advanced rectal cancer. In addition to reducing the local recurrence rate, ELAPE might increase the incidence of urogenital nerve injury due to the removal of more surrounding tissues compared with conventional operation. We supposed that the protection of pelvic plexus, pudendal nerve and neurovascular bundle is feasible during the perineal phase of ELAPE operation, which might help to retain the urinary and sexual function postoperatively. Under the guidance of preoperative MRI staging, combine the vertical infiltration depth and circumferential extension of the tumor, individualized ELAPE technology might reduce the surgical trauma and protect the perineal nerves with acceptable oncological outcomes.
Extralevator abdominoperineal excision(ELAPE) has been an important surgical procedure for low advanced rectal cancer. In addition to reducing the local recurrence rate, ELAPE might increase the incidence of urogenital nerve injury due to the removal of more surrounding tissues compared with conventional operation. We supposed that the protection of pelvic plexus, pudendal nerve and neurovascular bundle is feasible during the perineal phase of ELAPE operation, which might help to retain the urinary and sexual function postoperatively. Under the guidance of preoperative MRI staging, combine the vertical infiltration depth and circumferential extension of the tumor, individualized ELAPE technology might reduce the surgical trauma and protect the perineal nerves with acceptable oncological outcomes.
引文
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[10]Connell K,Guess MK,La Combe J,et al.Evaluation of the role of pudendal nerve integrity in female sexual function using noninvasive techniques[J].Am J Obstet Gynecol,2005,192(5):1712-1717.
[11]韩加刚,王振军,魏广辉,等.个体化柱状腹会阴联合切除术治疗低位直肠癌的初步研究[J].中华外科杂志,2013,51(3):335-338.
[12]Han JG,Wang ZJ,Wei GH,et al.Randomized clinical trial of conventional versus cylindrical abdominoperineal resection for locally advanced lower rectal cancer[J].Am J Surg,2012,204(3):274-282.
[13]Pai A,Eftaiha SM,Melich G,et al.Robotic site adjusted levatortransection for carcinomaof the rectum:amodification of the existing cylindrical abdominoperineal resectionforeccentrically located tumors[J].World J Surg,2017,41(2):590-595.
[14]Park EJ,Baik SH,Kang J,et al.Short-term outcomes of the modified extralevator abdominoperineal resection for low rectal cancer(with videos)[J].Surg Endosc,2016,30(4):1672-1682.
[2]王振军,高志刚,韩加刚,等.柱状经腹会阴直肠癌切除术及其改进(附10例报告)[J].中国实用外科杂志,2009,29(4):348-351.
[3]姜金波,曲辉,李雪梅,等.柱状经腹会阴切除术治疗直肠癌15例[J].中华普通外科杂志,2010,25(12):955-958.
[4]王振军,钱群,戴勇,等.肛提肌外腹会阴联合切除术治疗低位进展期直肠癌的前瞻性多中心研究[J].中华外科杂志,2014,52(1):11-15.
[5]Eveno C,Lamblin A,Mariette C,et al.Sexual and urinary dysfunction after proctectomy for rectal cancer[J].J Visc Surg,2010,147(1):e21-e30.
[6]Stelzner S,Holm T,Moran BJ,et al.Deep pelvic anatomy revisited for a description of crucial steps in extralevator abdominoperineal excision for rectal cancer[J].Dis Colon Rectum,2011,54(8):947-957.
[7]A?ar H?,Kuzu MA.Perineal and pelvic anatomy of extralevator abdominoperineal excision for rectal cancer:cadaveric dissection[J].Dis Colon Rectum,2011,54(8):1179-1183.
[8]Huang JC,Deletis V,Vodusek DB,et al.Preservation of pudendal afferents in sacral rhizotomies[J].Neurosurgery,1997,41(2):411-415.
[9]Jannini EA,Simonelli C,Lenzi A.Disorders of ejaculation[J].J Endocrinol Invest,2002,25(11):1006-1019.
[10]Connell K,Guess MK,La Combe J,et al.Evaluation of the role of pudendal nerve integrity in female sexual function using noninvasive techniques[J].Am J Obstet Gynecol,2005,192(5):1712-1717.
[11]韩加刚,王振军,魏广辉,等.个体化柱状腹会阴联合切除术治疗低位直肠癌的初步研究[J].中华外科杂志,2013,51(3):335-338.
[12]Han JG,Wang ZJ,Wei GH,et al.Randomized clinical trial of conventional versus cylindrical abdominoperineal resection for locally advanced lower rectal cancer[J].Am J Surg,2012,204(3):274-282.
[13]Pai A,Eftaiha SM,Melich G,et al.Robotic site adjusted levatortransection for carcinomaof the rectum:amodification of the existing cylindrical abdominoperineal resectionforeccentrically located tumors[J].World J Surg,2017,41(2):590-595.
[14]Park EJ,Baik SH,Kang J,et al.Short-term outcomes of the modified extralevator abdominoperineal resection for low rectal cancer(with videos)[J].Surg Endosc,2016,30(4):1672-1682.