直肠癌根治术中是否切除Denonvilliers筋膜的争议与展望
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摘要
全直肠系膜切除(TME)是中低位直肠癌手术的金标准。传统的TME手术要求在Denonvilliers筋膜前方解剖并切除Denonvilliers筋膜,然而术后居高不下的排尿及性功能障碍发生率引起国内外学者对该理念的争议及质疑。对中低位直肠癌病人,应施行个体化治疗方案。对于肿瘤不位于直肠前壁及侧壁,或肿瘤局部分期较早的病人,应在保证肿瘤根治性的前提下,选择Denonvilliers筋膜后方施行TME手术,尽可能保留Denonvilliers筋膜的完整性,从而保护盆腔自主神经,避免术后排尿及性功能障碍,提高病人术后生活质量。
Total mesorectal excision(TME) is the golden standard of surgery for mid-low rectal cancer. Traditional TME surgery requires dissection in front of the Denonvilliers' fascia,as well as excision of Denonvilliers' fascia. However,the high incidence of postoperative urogenital dysfunction has led to worldwide controversy and query on TME surgery.Individualized treatment should be applied to patients with middle and low rectal cancer. For patients whose tumors are not located in the anterior and lateral walls of rectum or local stages are early,TME should be performed at the back of Denonvilliers fascia to preserve the integrity of Denonvilliers fascia as far as possible,so as to protect the pelvic autonomic nerve,avoid postoperative urination and sexual dysfunction,improve postoperative life quality of patients.
Total mesorectal excision(TME) is the golden standard of surgery for mid-low rectal cancer. Traditional TME surgery requires dissection in front of the Denonvilliers' fascia,as well as excision of Denonvilliers' fascia. However,the high incidence of postoperative urogenital dysfunction has led to worldwide controversy and query on TME surgery.Individualized treatment should be applied to patients with middle and low rectal cancer. For patients whose tumors are not located in the anterior and lateral walls of rectum or local stages are early,TME should be performed at the back of Denonvilliers fascia to preserve the integrity of Denonvilliers fascia as far as possible,so as to protect the pelvic autonomic nerve,avoid postoperative urination and sexual dysfunction,improve postoperative life quality of patients.
引文
[1]Heald R J,Moran B J,Brown G,et al.Optimal total mesorectal excision for rectal cancer is by dissection in front of Denonvilliers'fascia[J].Br J Surg,2004,91(1):121-123.
[2]Moriya Y,Sugihara K,Akasu T,et al.Patterns of recurrence after nerve-sparing surgery for rectal adenocarcinoma with special reference to loco-regional recurrence[J].Dis Colon Rectum,1995,38(11):1162-1168.
[3]林谋斌,尹路,陈伟国,等.从直肠系膜的解剖学形态来认识直肠系膜全切除术[J].中国实用外科杂志,2008,28(8):629-632.
[4]魏波,卫洪波.再谈直肠癌根治术中Denonvilliers筋膜切除与否[J].中华胃肠外科杂志,2017,20(6):640-641.
[5]Smith GE.Studies in the anatomy of the pelvis,with special reference to the fasciae and visceral supports:Part I[J].J Anat Physiol,1908,42(Pt 2):198-218.
[6]Tobin C,Benjamin J.Anatomical and surgical restudy of Denonvilliers'fascia[J].Surg Gynec Obst,1945,80:373.
[7]Bertrand MM,Alsaid B,Droupy S,et al.Biomechanical origin of the Denonvilliers'fascia[J].Surg Radiol Anat,2014,36(1):71-78.
[8]Kinugasa Y,Murakami G,Uchimoto K,et al.Operating behind Denonvilliers'fascia for reliable preservation of urogenital autonomic nerves in total mesorectal excision:a histologic study using cadaveric specimens,including a surgical experiment using fresh cadaveric models[J].Dis Colon Rectum,2006,49(7):1024-1032.
[9]Mb W.The development and surgical importance of the rectourethralis muscle and Denonvilliers'fascia[J].J Urol,1922,8:339.
[10]Milley PS,Nichols DH.A correlative investigation of the human rectovaginal septum[J].Anat Rec,1969,163(3):443-451.
[11]Kim JH,Kinugasa Y,Hwang SE,et al.Denonvilliers'fascia revisited[J].Surg Radiol Anat,2015,37(2):187-197.
[12]Moszkowicz D,Alsaid B,Bessede T,et al.Where does pelvic nerve injury occur during rectal surgery for cancer?[J].Colorectal Dis,2011,13(12):1326-1334.
[13]黄江龙,郑宗珩,卫洪波,等.盆腔自主神经活体尸体对比研究[J].中华外科杂志,2014,52(7):500-503.
[14]黄江龙,郑宗珩,卫洪波,等.直肠系膜结构解剖和腔镜下观察的对比研究[J].中山大学学报(医学科学版),2014,35(3):407-411.
[15]王毅,马国龙,梁小波.Denonvilliers筋膜解剖学研究及其在直肠癌手术中的应用[J].中华解剖与临床杂志,2015,20(6):534-539.
[16]池畔,王枭杰.机器人和腹腔镜全直肠系膜切除术中Denonvilliers筋膜解剖的意义及技巧[J].中国实用外科杂志,2017,37(6):609-615.
[17]Moszkowicz D,Alsaid B,Bessede T,et al.Female pelvic autonomic neuroanatomy based on conventional macroscopic and computer-assisted anatomic dissections[J].Surg Radiol Anat,2011,33(5):397-404.
[18]Fang JF,Wei B,Zheng ZH,et al.Effect of intra-operative autonomic nerve stimulation on pelvic nerve preservation during radical laparoscopic proctectomy[J].Colorectal Dis,2015,17(12):O268-O276.
[19]Wei H,Fang J,Zheng Z,et al.Effect of preservation of Denonvilliers'fascia during laparoscopic resection for mid-low rectal cancer on protection of male urinary and sexual functions[J].Medicine,2016,95(24):e3925.
[20]Taguchi K,Tsukamoto T,Murakami G.Anatomical studies of the autonomic nervous system in the human pelvis by the whole-mount staining method:left-right communicating nerves between bilateral pelvic plexuses[J].J Urol,1999,161(1):320-325.
[21]Clausen N,Wolloscheck T,Konerding MA.How to optimize autonomic nerve preservation in total mesorectal excision:clinical topography and morphology of pelvic nerves and fasciae[J].World J Surg,2008,32(8):1768-1775.
[22]Huland H,Noldus J.An easy and safe approach to separating Denonvilliers'fascia from rectum during radical retropubic prostatectomy[J].J Urol,1999,161(5):1533-1534.
[23]Lindsey I,Warren BF,Mortensen NJ.Denonvilliers'fascia lies anterior to the fascia propria and rectal dissection plane in total mesorectal excision[J].Dis Colon Rectum,2005,48(1):37-42.
[24]Kim N K.Anatomic basis of sharp pelvic dissection for curative resection of rectal cancer[J].Yonsei Med J,2005,46(6):737-749.
[25]Lindsey I,Guy RJ,Warren BF,et al.Anatomy of Denonvilliers'fascia and pelvic nerves,impotence,and implications for the colorectal surgeon[J].Br J Surg,2000,87(10):1288-1299.
[26]卫洪波,郑宗珩.腹腔镜保留盆腔自主神经的直肠癌根治术技术要领[J].中华胃肠外科杂志,2015,18(6):529-532.
[27]Heald RJ,Moran BJ.Embryology and anatomy of the rectum[J].Semin Surg Oncol,1998,15(2):66-71.
[2]Moriya Y,Sugihara K,Akasu T,et al.Patterns of recurrence after nerve-sparing surgery for rectal adenocarcinoma with special reference to loco-regional recurrence[J].Dis Colon Rectum,1995,38(11):1162-1168.
[3]林谋斌,尹路,陈伟国,等.从直肠系膜的解剖学形态来认识直肠系膜全切除术[J].中国实用外科杂志,2008,28(8):629-632.
[4]魏波,卫洪波.再谈直肠癌根治术中Denonvilliers筋膜切除与否[J].中华胃肠外科杂志,2017,20(6):640-641.
[5]Smith GE.Studies in the anatomy of the pelvis,with special reference to the fasciae and visceral supports:Part I[J].J Anat Physiol,1908,42(Pt 2):198-218.
[6]Tobin C,Benjamin J.Anatomical and surgical restudy of Denonvilliers'fascia[J].Surg Gynec Obst,1945,80:373.
[7]Bertrand MM,Alsaid B,Droupy S,et al.Biomechanical origin of the Denonvilliers'fascia[J].Surg Radiol Anat,2014,36(1):71-78.
[8]Kinugasa Y,Murakami G,Uchimoto K,et al.Operating behind Denonvilliers'fascia for reliable preservation of urogenital autonomic nerves in total mesorectal excision:a histologic study using cadaveric specimens,including a surgical experiment using fresh cadaveric models[J].Dis Colon Rectum,2006,49(7):1024-1032.
[9]Mb W.The development and surgical importance of the rectourethralis muscle and Denonvilliers'fascia[J].J Urol,1922,8:339.
[10]Milley PS,Nichols DH.A correlative investigation of the human rectovaginal septum[J].Anat Rec,1969,163(3):443-451.
[11]Kim JH,Kinugasa Y,Hwang SE,et al.Denonvilliers'fascia revisited[J].Surg Radiol Anat,2015,37(2):187-197.
[12]Moszkowicz D,Alsaid B,Bessede T,et al.Where does pelvic nerve injury occur during rectal surgery for cancer?[J].Colorectal Dis,2011,13(12):1326-1334.
[13]黄江龙,郑宗珩,卫洪波,等.盆腔自主神经活体尸体对比研究[J].中华外科杂志,2014,52(7):500-503.
[14]黄江龙,郑宗珩,卫洪波,等.直肠系膜结构解剖和腔镜下观察的对比研究[J].中山大学学报(医学科学版),2014,35(3):407-411.
[15]王毅,马国龙,梁小波.Denonvilliers筋膜解剖学研究及其在直肠癌手术中的应用[J].中华解剖与临床杂志,2015,20(6):534-539.
[16]池畔,王枭杰.机器人和腹腔镜全直肠系膜切除术中Denonvilliers筋膜解剖的意义及技巧[J].中国实用外科杂志,2017,37(6):609-615.
[17]Moszkowicz D,Alsaid B,Bessede T,et al.Female pelvic autonomic neuroanatomy based on conventional macroscopic and computer-assisted anatomic dissections[J].Surg Radiol Anat,2011,33(5):397-404.
[18]Fang JF,Wei B,Zheng ZH,et al.Effect of intra-operative autonomic nerve stimulation on pelvic nerve preservation during radical laparoscopic proctectomy[J].Colorectal Dis,2015,17(12):O268-O276.
[19]Wei H,Fang J,Zheng Z,et al.Effect of preservation of Denonvilliers'fascia during laparoscopic resection for mid-low rectal cancer on protection of male urinary and sexual functions[J].Medicine,2016,95(24):e3925.
[20]Taguchi K,Tsukamoto T,Murakami G.Anatomical studies of the autonomic nervous system in the human pelvis by the whole-mount staining method:left-right communicating nerves between bilateral pelvic plexuses[J].J Urol,1999,161(1):320-325.
[21]Clausen N,Wolloscheck T,Konerding MA.How to optimize autonomic nerve preservation in total mesorectal excision:clinical topography and morphology of pelvic nerves and fasciae[J].World J Surg,2008,32(8):1768-1775.
[22]Huland H,Noldus J.An easy and safe approach to separating Denonvilliers'fascia from rectum during radical retropubic prostatectomy[J].J Urol,1999,161(5):1533-1534.
[23]Lindsey I,Warren BF,Mortensen NJ.Denonvilliers'fascia lies anterior to the fascia propria and rectal dissection plane in total mesorectal excision[J].Dis Colon Rectum,2005,48(1):37-42.
[24]Kim N K.Anatomic basis of sharp pelvic dissection for curative resection of rectal cancer[J].Yonsei Med J,2005,46(6):737-749.
[25]Lindsey I,Guy RJ,Warren BF,et al.Anatomy of Denonvilliers'fascia and pelvic nerves,impotence,and implications for the colorectal surgeon[J].Br J Surg,2000,87(10):1288-1299.
[26]卫洪波,郑宗珩.腹腔镜保留盆腔自主神经的直肠癌根治术技术要领[J].中华胃肠外科杂志,2015,18(6):529-532.
[27]Heald RJ,Moran BJ.Embryology and anatomy of the rectum[J].Semin Surg Oncol,1998,15(2):66-71.