Discussion
obesity, tumor, urinary dysfunction
OBESITY, TUMOR, TUMOR RECURRENCE, RECURRENCE, COMPLICATION, DYSFUNCTION, CAVITY, RECTAL CANCER
Urogenital dysfunction has become the major complication of total mesorectum excision (TME) for low-mid rectal cancer. In this study, we revealed that compared with traditional TME surgery, TME surgery with Denonvilliers’ fascia (DVF) preservation had better postoperative urogenital function, with a comparable oncological outcome, thus may be a better choice for male rectal cancer patients with specific staging.It was reported that more than 50% of patients treated for rectal cancer experienced a deterioration in sexual function, while urinary dysfunction occurred in one-third of patientsPrevious studies have proved that DVF acted as a protective sheet for PAN and thus partial resection of DVF may lead to PAN injury and postoperative urogenital dysfunctionFiguring out an appropriate surgical procedure is the key to solve this problem. There used to be two surgical procedures for anterior dissection. First, dissection 1–1.5 cm above peritoneal reflection, which helps better exposure of the anterior pelvic cavity, is especially beneficial for patients with obesity or narrow pelvic cavity. Second, dissection at the lowest level of peritoneal reflection. In clinical practice, it was difficult to dissect posterior to DVF with the first surgical procedure. However, dissection at the lowest level of peritoneal reflection sometimes helps enter the surgical plane posterior to DVF. Based on this, we performed both cadaveric study and surgical video review, finding that DVF began with a white thickened line at the lowest level of peritoneal reflection, and ended at the perineal bodySome may still doubt the general applicability of DVF preservation, especially for high BMI patients. Although the mean BMI was normal in this study, there were also some cases of overweight and obesity, while the procedure was performed smoothly regardless of the high BMI. Usually, for patients with high BMI or narrow pelvic cavity, hanging the peritoneal reflection with a suture or performing traction of the rectum with tieback will help better exposure of both the pelvic cavity and the anterior wall of rectum, and thus make surgery easier to generalize.Although previous studies have strongly indicated that DVF resection may be the reason for PAN injury, there is still a lack of clinical trial studies to prove the effect of DVF preservation on urogenital function protection and confirm the oncological safety. Based on this, we conducted the PUF-01 study with two aims. First, to evaluate the advantage of preserving DVF during laparoscopic TME on protecting postoperative urogenital function in male patients with rectal cancer. Both the initial resultsIn this study, cases of APR or Non-RConsidering that tumor location and T stage may have an impact on DVF preservation and tumor recurrence, we performed a univariate analysis of 3-year DFS and OS based on variables containing tumor location and T stage. The results revealed no differences in either OS or DFS of TNeoadjuvant radiotherapy or chemoradiotherapy was believed to help control local recurrence of locally advanced rectal cancerThis study had several limitations. First, patients with neoadjuvant radiotherapy were not included in this trial. Further studies should be performed to investigate whether laparoscopic TME with DVF preservation is also feasible, as well as of better postoperative urogenital function and comparable oncological outcome for them. Second, some cases in this study did not reach the follow-up of 60 months. Thus, the 5-year OS, DFS, and recurrence rate should be furthered follow-up to get a more convincing result of oncological safety. Third, for rectal cancer located in the anterior wall, only TIn conclusion, the PUF-01 trial revealed that laparoscopic TME with DVF preservation was feasible and safe, had the advantage on postoperative urogenital function, as well as comparable 3-year OS and DFS oncological results, thus may be a better choice for male rectal cancer patients with specific staging.