To the Editor:
We have read with great interest the article by Hendren et al.1 Hendren et al revealed high prevalence of sexual dysfunction among both male and female patients undergoing total mesorectal excision (TME) for rectal cancer. Furthermore, they demonstrated that pelvic radiation, operative procedures, and males were independent risk factors for worsening sexual life after surgery by multivariate analysis. Although their work is excellent, there are two major points that need further discussion.
First, Hendren et al speculated that perioperative radiation could deteriorate sexual function after TME based on the result of multivariate analysis. However, their multivariate analysis included only 2 surgery-related variables, namely, radiation and operative procedures, and no other surgical factors were evaluated. Considering the indication of radiation in rectal cancer, radiation in this study might be an indicator of advanced lesions, or in other words, an indicator of more radical surgery, which is more likely to damage autonomic nerves and cause sexual dysfunction. Indeed, the incidence of sexual dysfunction after TME rises in more complex operations with advanced disease, narrow pelvis, or bleeding.2–4 Therefore, these indicators of surgical complexity should be also included in the multivariate analysis before concluding that radiation truly has an additive effect on the postoperative sexual dysfunction.
Another aspect that deserves further comment is the statement that “combining less radical surgery with radiation might not spare sexual function.” It has been advocated that extended pelvic lymphadenectomy reduces local recurrence as well as prolongs survival of lower rectal cancer.5 However, we have previously demonstrated, by a randomized controlled study, that preoperative radiation is as curative as extended pelvic lymphadenectomy but effectively decreases sexual dysfunction after surgery.6,7 This study is a good example that combining less radical surgery with radiation effectively spares sexual function.
We agree with Hendren et al that high frequency of sexual dysfunction after TME should be more explained to patients before operation. However, premature “cause and effect” explanation for perioperative radiation and sexual dysfunction might mislead patients to abandon the appropriate treatments. With acceptance on this point, further study is needed to determine whether radiation truly has an additive effect on the risk of sexual dysfunction after TME.
Tsuyoshi Konishi, MD
Toshiaki Watanabe, MD, PhD
Tomomichi Kiyomatsu, MD
Hirokazu Nagawa, MD, PhD
Department of Surgical Oncology
University of Tokyo
Tokyo, Japan
KONISHIT-SUR@h.u-tokyo.ac.jp
REFERENCES
- 1.Hendren SK, O’Connor BI, Liu M, et al. Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer. Ann Surg. 2005;242:212–223. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Mannaerts GH, Schijven MP, Hendrikx A, et al. Urologic and sexual morbidity following multimodality treatment for locally advanced primary and locally recurrent rectal cancer. Eur J Surg Oncol. 2001;27:265–272. [DOI] [PubMed] [Google Scholar]
- 3.Lindsey I, Guy RJ, Warren BF, et al. Anatomy of Denonvilliers’ fascia and pelvic nerves, impotence, and implications for the colorectal surgeon. Br J Surg. 2000;87:1288–1299. [DOI] [PubMed] [Google Scholar]
- 4.da Silva GM, Zmora O, Borjesson L, et al. The efficacy of a nerve stimulator (CaverMap) to enhance autonomic nerve identification and confirm nerve preservation during total mesorectal excision. Dis Colon Rectum. 2004;47:2032–2038. [DOI] [PubMed] [Google Scholar]
- 5.Fujita S, Yamamoto S, Akasu T, et al. Lateral pelvic lymph node dissection for advanced lower rectal cancer. Br J Surg. 2003;90:1580–1585. [DOI] [PubMed] [Google Scholar]
- 6.Nagawa H, Muto T, Sunouchi K, et al. Randomized, controlled trial of lateral node dissection vs. nerve-preserving resection in patients with rectal cancer after preoperative radiotherapy. Dis Colon Rectum. 2001;44:1274–1280. [DOI] [PubMed] [Google Scholar]
- 7.Watanabe T, Tsurita G, Muto T, et al. Extended lymphadenectomy and preoperative radiotherapy for lower rectal cancers. Surgery. 2002;132:27–33. [DOI] [PubMed] [Google Scholar]