• ejaculatory dysfunction
• rectal cancer
• sexual function
• ultra‐low rectal cancer

• Humans
• Male
• Rectal Neoplasms/surgery
• Rectal Neoplasms/pathology
• Middle Aged
• Aged
• Postoperative Complications/etiology
• Follow-Up Studies
• Laparoscopy/adverse effects
• Adult
• Risk Factors
• Erectile Dysfunction/etiology
• Longitudinal Studies
• Anal Canal/surgery
• Anal Canal/pathology
• Sexual Dysfunction, Physiological/etiology
• Proctectomy/adverse effects
• Proctectomy/methods
• Ejaculation/physiology
• Surveys and Questionnaires
• Age Factors
• Postoperative Period

• Early rectal cancer
• Local excision
• Radical resection
• Recurrence
• Staging
• Surveillance
• Survival

• Humans
• Neoplasm Recurrence, Local/pathology
• Neoplasm Recurrence, Local/epidemiology
• Neoplasm Staging
• Rectal Neoplasms/surgery
• Rectal Neoplasms/pathology
• Rectal Neoplasms/mortality
• Treatment Outcome

• chemoprevention
• colorectal cancer
• colorectal polyps
• drug-repurposing
• phosphodiesterase inhibitors

• Humans
• Colonic Polyps/prevention & control
• Prospective Studies
• Phosphodiesterase 5 Inhibitors/therapeutic use
• Phosphodiesterase 5 Inhibitors/pharmacology
• Colorectal Neoplasms/epidemiology
• Case-Control Studies
• Tumor Microenvironment

• Fascia propria of the rectum
• Fascial anatomy
• Total mesorectal excision
• Urinary and sexual functions
• Urogenital fascia

External rectal prolapse is a relatively rare disease, in which male patients account for a minority. The selection of abdominal repair or perineal repair for male patients has rarely been investigated.

Fifty-one male patients receiving abdominal repair (laparoscopic ventral rectopexy) or perineal repair (Delorme or Altemeier procedures) at the Sixth Affiliated Hospital of Sun Yat-sen University (Guangzhou, China) between March 2013 and September 2019 were retrospectively analysed. We compared the recurrence, complication rate, post-operative defecation disorder, length of stay, and quality of life between the abdominal and perineal groups.

Of the 51 patients, 45 had a complete follow-up, with a median of 48.5 months (range, 22.8–101.8 months). A total of 35 patients were under age 40 years. The complication rate associated with abdominal repair was less than that associated with perineal repair (0% vs 20.7%, P = 0.031) and the recurrence rate was also lower (9.5% vs 41.7%, P = 0.018). Multivariate analysis showed that perineal repair (odds ratio, 9.827; 95% confidence interval, 1.296–74.50; P = 0.027) might be a risk factor for recurrence. Moreover, only perineal repair significantly improved post-operative constipation status (preoperative vs post-operative, 72.4% vs 25.0%, P = 0.001). There was no reported mortality in either of the groups. No patient's sexual function was affected by the surgery.

Both surgical approaches were safe in men. Compared with perineal repair, the complication rate and recurrence rate for abdominal repair were lower. However, perineal repair was better able to correct constipation.

• Guangdong Medical Research

• Anejaculation
• cancer surgery
• cryopreservation
• obstructive azoospermia
• retrograde ejaculation

• fertility
• ileal pouch-anal anastomosis
• proctocolectomy
• sexuality

• clinical efficacy
• da Vinci robot
• intersphincteric resection
• laparoscope
• low rectal cancer

The number of patients undergoing robotic surgery for rectal cancer has rapidly increased in Japan, since the government approved the procedure for national insurance coverage in April 2018. Robotic surgery has the potential to overcome some limitations of laparoscopic surgery, especially in the narrow pelvis, providing a three-dimensional view, articulated instruments, and a stable camera platform. Although meta-analyses and randomized controlled trials have failed to demonstrate the superiority of robotic surgery over laparoscopic surgery with respect to the short-term clinical outcomes, the published findings suggest that robotic surgery may be potentially beneficial for patients who are obese, male, or patients undergoing sphincter-preserving surgery for rectal cancer. The safety and feasibility of robotic surgery for lateral lymph node dissection, the standard procedure for locally advanced lower rectal cancer in Japan, have been demonstrated in some retrospective studies. However, additional prospective, randomized trials are required to determine the actual benefits of robotic surgery to ameliorate the urogenital and oncological outcomes. The cost of this approach is a long-standing principal concern. A literature search showed that the cost of robotic surgery for rectal cancer was 1.3-2.5 times higher per patient than that for the laparoscopic approach. We herein describe our surgical technique using a da Vinci Surgical System (S/Si/Xi) with 10 years of experience in performing robotic surgery. We also review current evidence regarding short-term clinical and long-term oncological outcomes, lateral lymph node dissection, and the cost of the procedure.

• Laparoscopic surgery
• Lateral lymph node dissection
• Mesorectal excision
• Minimally invasive surgery
• Rectal cancer
• Robotic surgery

In the era of neoadjuvant chemoradiotherapy/radiotherapy and total mesorectal excision, overall oncological outcomes after curative resection of rectal cancer are excellent, with local recurrence rates as low as 5–10%. However, lateral nodal disease is a major cause of local recurrence after neoadjuvant chemoradiotherapy/radiotherapy and total mesorectal excision. Patients with lateral nodal disease have a local recurrence rate of up to 30%. The oncological benefits of lateral pelvic lymph node dissection (LPLND) in reducing local recurrence, particularly in the lateral compartment, have been demonstrated. Although LPLND is not standard in Western countries, technical improvements in minimally invasive surgery have resulted in rapid technical standardization of this complicated procedure. The feasibility and short- and long-term outcomes of laparoscopic and robotic LPLND have been reported widely. A minimally invasive approach has the advantages of less bleeding and providing a better surgical view of the deep pelvic anatomy than an open approach. With precise autonomic nerve preservation, postoperative genitourinary dysfunction has been reported to be minimal. We review recent evidence on the management of lateral nodal disease in rectal cancer and technical improvements of LPLND, focusing on laparoscopic and robotic LPLND.

• Laparoscopic
• Lateral lymph node dissection
• Rectal cancer
• Robotic

Urogenital dysfunction after rectal cancer surgery can largely affect patients’ postoperative quality of life. Whether robotic surgery can be a better option when comparing with laparoscopic surgery is still not well-known.

Comprehensive search in PubMed, Embase, Cochrane Library, and Clinical Trials was conducted to identify relevant studies in March 2018. Studies comparing robotic surgery with laparoscopic surgery were included. Measurement of urogenital function was through the International Prostate Symptom Score and International Index of Erectile Function.

Six studies with 386 patients in robotic group and 421 patients in laparoscopic group were finally included. Pooled analysis indicated that bladder function was better at 12 months in the robotic group after the procedures (mean difference, − 0.30, 95% CI, − 0.52 to − 0.08). No significant difference was found at 3 and 6 months postoperatively (mean difference, − 0.37, 95% CI, − 1.48 to 0.73; mean difference, − 1.21, 95% CI, − 2.69 to 0.28). Sexual function was better at 3 months in the robotic group after surgery (mean difference, − 3.28, 95% CI, − 6.08 to − 0.49) and not significantly different at 6 and 12 months. (mean difference, 3.78, 95% CI, − 7.37 to 14.93; mean difference, − 2.82, 95% CI, − 8.43 to 2.80).

Robotic surgery may offer faster recovery in urogenital function compared to laparoscopic surgery for rectal cancer.

• High ligation
• Inferior mesenteric artery
• Low ligation
• Meta-analysis
• Rectal cancer

• Anastomosis, Surgical
• Anastomotic Leak/epidemiology
• Anastomotic Leak/etiology
• Colorectal Neoplasms/mortality
• Colorectal Neoplasms/surgery
• Digestive System Surgical Procedures/adverse effects
• Digestive System Surgical Procedures/methods
• Female
• Humans
• Ligation/adverse effects
• Ligation/methods
• Lymph Nodes/pathology
• Lymph Nodes/surgery
• Male
• Mesenteric Artery, Inferior/surgery
• Survival Rate
• Treatment Outcome

Even with the use of nerve-sparing techniques, there is a risk of bladder and sexual dysfunction after total mesorectal excision (TME). Laparoscopic TME is believed to improve this autonomic nerve dysfunction, but this is not demonstrated conclusively in the literature. In Indian patients generally, the stage at which the patients present is late and presumably the risk of autonomic nerve injury is more; however, there is no published data in this respect.

This prospective study in male patients who underwent laparoscopic TME evaluated the bladder and sexual dysfunction using objective standardised scores, measuring residual urine and post-voided volume. The International Prostatic Symptom Score (IPSS) and International Index of Erectile Function score were used respectively to assess the bladder and sexual dysfunction preoperatively at 1, 3, 6 months and at 1 year.

Mean age of the study group was 58 years. After laparoscopic TME in male patients, the moderate to severe bladder dysfunction (IPSS <8) is observed in 20.4% of patients at 3 months, and at mean follow-up of 9.2 months, it was seen only in 2.9%. There is more bladder and sexual dysfunction in low rectal tumours compared to mid-rectal tumours. At 3 months, 75% had sexual dysfunction, 55% at median follow-up of the group at 9.2 months.

After laparoscopic TME, bladder dysfunction is seen in one-fifth of the patients, which recovers in the next 6 months to 1 year. Sexual dysfunction is observed in 75% of patients immediately after TME which improves to 55% over 9.2 months.

• Functional outcome
• laparoscopy
• rectal cancer
• sexual dysfunction
• total mesorectal excision
• urinary dysfunction

Delayed ejaculation (DE) is a poorly defined and uncommon form of male sexual dysfunction, characterized by a marked delay in ejaculation or an inability to achieve ejaculation. It is often quite concerning to patients and their partners, and sometimes frustrates couples' attempts to conceive. This article aims to review the pathophysiology of DE and anejaculation (AE), to explore our current understanding of the diagnosis, and to present the treatment options for this condition. Electronic databases were searched from 1966 to October 2017, including PubMed (MEDLINE) and Embase. We combined “delayed ejaculation,” “retarded ejaculation,” “inhibited ejaculation,” or “anejaculation” as Medical Subject Headings (MeSH) terms or keywords with “epidemiology,” “etiology,” “pathophysiology,” “clinical assessment,” “diagnosis,” or “treatment.” Relevant sexual medicine textbooks were searched as well. The literature suggests that the pathophysiology of DE/AE is multifactorial, including both organic and psychosocial factors. Despite the many publications on this condition, the exact pathogenesis is not yet known. There is currently no single gold standard for diagnosing DE/AE, as operationalized criteria do not exist. The history is the key to the diagnosis. Treatment should be cause-specific. There are many approaches to treatment planning, including various psychological interventions, pharmacotherapy, and specific treatments for infertile men. An approved form of drug therapy does not exist. A number of approaches can be employed for infertile men, including the collection of nocturnal emissions, prostatic massage, prostatic urethra catheterization, penile vibratory stimulation, probe electroejaculation, sperm retrieval by aspiration from either the vas deferens or the epididymis, and testicular sperm extraction.

• Anejaculation
• Delayed ejaculation
• Diagnosis
• Physiopathology
• Therapy

• Rectal cancer
• laparoscopic surgery
• pelvic surgery
• robotic surgery

• intersphincteric resection
• radiochemotherapy
• rectal cancer

• Proctectomy
• Rectal cancer
• Sexual dysfunction

• Carcinological proctectomy
• Radiation therapy
• Sexual sequelae
• Urinary sequelae

• Digestive System Surgical Procedures/adverse effects
• Digestive System Surgical Procedures/methods
• Female
• Female Urogenital Diseases/diagnosis
• Female Urogenital Diseases/etiology
• Female Urogenital Diseases/therapy
• Humans
• Male
• Male Urogenital Diseases/diagnosis
• Male Urogenital Diseases/etiology
• Male Urogenital Diseases/therapy
• Perioperative Care/methods
• Postoperative Complications/diagnosis
• Postoperative Complications/therapy
• Rectal Neoplasms/surgery
• Rectum/innervation
• Rectum/surgery

• Rectal cancer
• Robotic surgery
• Sexual function
• Urogenital function
• Urological function

To analyses the current literature regarding the urogenital functional outcomes of patients receiving robotic rectal cancer surgery.

A comprehensive literature search of electronic databases was performed in October 2015. The following search terms were applied: “rectal cancer” or “colorectal cancer” and robot* or “da Vinci” and sexual or urolog* or urinary or erect* or ejaculat* or impot* or incontinence. All original studies examining the urological and/or sexual outcomes of male and/or female patients receiving robotic rectal cancer surgery were included. Reference lists of all retrieved articles were manually searched for further relevant articles. Abstracts were independently searched by two authors.

Fifteen original studies fulfilled the inclusion criteria. A total of 1338 patients were included; 818 received robotic, 498 laparoscopic and 22 open rectal cancer surgery. Only 726 (54%) patients had their urogenital function assessed via means of validated functional questionnaires. From the included studies, three found that robotic rectal cancer surgery leads to quicker recovery of male urological function and five of male sexual function as compared to laparoscopic surgery. It is unclear whether robotic surgery offers favourable urogenital outcomes in the long run for males. In female patients only two studies assessed urological and three sexual function independently to that of males. In these studies there was no difference identified between patients receiving robotic and laparoscopic rectal cancer surgery. However, in females the presented evidence was very limited making it impossible to draw any substantial conclusions.

There seems to be a trend towards earlier recovery of male urogenital function following robotic surgery. To evaluate this further, larger well designed studies are required.

• Rectal neoplasms
• Robotic surgical procedures
• Colorectal surgery
• Sexual dysfunction
• Physiological
• Urinary bladder
• Neurogenic
• Humans

• Erectile dysfunction
• Lymph node dissection
• Randomized controlled trial
• Rectal cancer
• Sexual dysfunction

• Anatomy
• Neurovascular bundle
• Postoperative dysfunction
• Rectal surgery
• Sexual dysfunction

The laparoscopic approach for treatment of rectal cancer has been proven feasible and oncologically safe, and is able to offer better short-term outcomes than traditional open procedures, mainly in terms of reduced length of hospital stay and time to return to working activity. In spite of this, the laparoscopic technique is usually practised only in high-volume experienced centres, mainly because it requires a prolonged and demanding learning curve. It has been estimated that over 50 operations are required for an experienced colorectal surgeon to achieve proficiency with this technique. Robotic surgery enables the surgeon to perform minimally invasive operations with better vision and more intuitive and precise control of the operating instruments, thus promising to overcome some of the technical difficulties associated with standard laparoscopy. It has high-definition three-dimensional vision, it translates the surgeon’s hand movements into precise movements of the instruments inside the patient, the camera is held and moved by the first surgeon, and a fourth robotic arm is available as a fixed retractor. The aim of this review is to summarise the current data on clinical and oncologic outcomes of robot-assisted surgery in rectal cancer, focusing on short- and long-term results, and providing original data from the authors’ centre.

• Rectal cancer
• Robotic total mesorectal excision
• Robotic surgery
• Robotic resection
• Circumferential resection margin
• Lymph node yield
• Distal resection margin positivity

• Clinical Competence
• Cost-Benefit Analysis
• Digestive System Surgical Procedures/adverse effects
• Digestive System Surgical Procedures/economics
• Digestive System Surgical Procedures/methods
• Health Care Costs
• Humans
• Learning Curve
• Postoperative Complications/etiology
• Psychomotor Performance
• Rectal Neoplasms/economics
• Rectal Neoplasms/pathology
• Rectal Neoplasms/surgery
• Robotic Surgical Procedures/adverse effects
• Robotic Surgical Procedures/economics
• Time Factors
• Treatment Outcome

• laparoscopic surgery
• rectal cancer
• robotic surgery
• sexual dysfunction
• total mesorectal excision
• urinary dysfunction

• Rectal neoplasms
• Robotic surgical procedures

• Rectal cancer
• Robotic surgery
• Sexual function
• Urinary function

• Robotic surgery
• sexual dysfunction
• urinary dysfunction

Biologic behavior and management of rectal cancer differ significantly from that of colon cancer. The surgical treatment is challenging since the rectum has dual arterial blood supply and venous drainage, extensive lymphatic drainage and is located in a bony pelvic in close proximity to urogenital and neurovascular structures that are invested with intricate fascial covering. The rectum is encased by fatty lymphovascular tissue (mesorectum) that is surrounded by perirectal fascia that act as barrier to the spread of the cancer and constitute the surgical circumferential margin. Locoregional recurrence after rectal cancer surgery is influenced by tumor-related factors and adequacy of the resection. Local recurrence is associated with incomplete excision of circumferential margin, violation of perirectal fascia, transmesorectal dissection, presence of isolated deposits in the mesorectum and tumor in regional lymph nodes and incomplete lymph node clearance. Hence to eradicate the primary rectal tumor and control regional disease, the rectum, first area of lymph node drainage and surrounding tissue must be completely excised while maintaining an intact fascial envelope around the rectum and preserving surrounding structures. This is achieved with extrafascial dissection and removal of the entire mesorectum including the portion distal to the tumor (total mesorectal excision) within its enveloping fascia as an intact unit. Total mesorectal excision is the standard of care surgical treatment of mid and low rectal cancer and can be performed in conjunction with low anterior resection, abdominoperineal resection, extralevator abdominoperineal resection, and extraregional dissection. To accomplish such a resection, thorough knowledge of the surgical anatomy of the rectum and pelvic structures and fascial planes is paramount.

• Mesorectum
• Pelvic fascia
• Mesorectal excision

• circumferential margin
• rectal cancer
• single-incision laparoscopic surgery
• total mesorectal excision
• tumor-specific mesorectal excision

• Adenocarcinoma/pathology
• Adenocarcinoma/surgery
• Aged
• Digestive System Surgical Procedures/methods
• Digestive System Surgical Procedures/statistics & numerical data
• Female
• Humans
• Laparoscopy/statistics & numerical data
• Lymph Nodes/pathology
• Male
• Middle Aged
• Neoplasm Recurrence, Local/epidemiology
• Postoperative Complications/epidemiology
• Postoperative Period
• Rectal Neoplasms/pathology
• Rectal Neoplasms/surgery
• Republic of Korea/epidemiology
• Retrospective Studies
• Robotics/statistics & numerical data

Although rectal cancer is a very common malignancy and has an improved cure rate in response to oncological treatment, research on rectal-cancer survivors' sexual function remains limited. Sexual dysfunction (SD) after rectal cancer treatment was measured, and possible predisposing factors that may have an impact on the development of this disorder were identified.

Patients undergoing curative rectal cancer surgery from January 2012 to September 2013 were surveyed using questionnaires. The female sexual function index or the International Index of Erectile Function was recorded. A multiple logistic regression was used to test associations of clinical factors with outcomes.

Fifty-six men (56%) and 28 women (44%) who completed the questionnaire were included in the study. A total of 76 patients of the 86 patients (90.5%) with the diagnosis of rectal cancer who were included in this study reported different levels of SD after radical surgery. A total of 64 patients (76%) from the whole cohort reported moderate to severe SD after treatment of rectal cancer. Gender (P = 0.011) was independently associated with SD. Female patients reported significantly higher rates of moderate to severe SD than male patients. Patients were rarely treated for dysfunction.

Sexual problems after surgery for rectal cancer are common, but patients are rarely treated for SD. Female patients reported higher rates of SD than males. These results point out the importance of sexual (dys)function in survivors of rectal cancer. More attention should be drawn to this topic for clinical and research purposes.

• Rectal neoplasms
• Sexual dysfunction

Laparoscopic colectomy for colon cancer is a well-established procedure supported by several well-conducted large-scale randomised controlled trials. Patients could now be conferred the benefits of the minimally invasive approach while retaining comparable oncologic outcomes to the open approach. However, the benefits of laparoscopic proctectomy for rectal cancer remained controversial. While the laparoscopic approach is more technically demanding, results from randomised controlled trials regarding long term oncologic outcomes are only beginning to be reported. The impacts of bladder and sexual functions following proctectomy are considerable and are important contributing factors to the patients' quality of life in the long-term. These issues present a delicate dilemma to the surgeon in his choice of operative approach in tackling rectal cancer. This is compounded further by the rapid proliferation of various laparoscopic techniques including the hand assisted, robotic assisted, and single port laparoscopy. This review article aims to draw on the significant studies which have been conducted to highlight the short- and long-term outcomes and evidence for laparoscopic resection for rectal cancer.

• laparoscopic surgery
• rectal cancer
• sexual function
• total mesorectal excision
• voiding function

• Adult
• Aged
• Anastomotic Leak/etiology
• Digestive System Surgical Procedures/adverse effects
• Digestive System Surgical Procedures/methods
• Erectile Dysfunction/etiology
• Humans
• Ileostomy
• Laparoscopy/adverse effects
• Length of Stay
• Lymphatic Metastasis
• Male
• Middle Aged
• Neoplasm Staging
• Operative Time
• Prospective Studies
• Rectal Neoplasms/physiopathology
• Rectal Neoplasms/surgery
• Urination

• China
• Colorectal cancer
• surgical treatment

• Humans
• Laparoscopy/methods
• Ligation
• Minimally Invasive Surgical Procedures
• Patient Positioning
• Patient Safety
• Recovery of Function
• Rectal Neoplasms/surgery
• Robotics/instrumentation
• Robotics/methods