Journal of Clinical Sexology - Vol. 3; No.3: July- September 2020 107

RECTO-SIGMOID TUMOR PATHOLOGY AND DISORDERS OF NORMAL SEXUAL INTERCOURSE- POINTS OF VIEW

1*Alexandru RUNCANU MD, PhD. , 2**Valentin NIȚESCU MD 1.* Surgery Clinic-Emergency Clinical Hospital Bucharest “Floreasca”, Romania 2.** Surgery Clinic - Louis Pasteur Hospital, Colmar, France

Abstract: Malignant tumors have a great histopathological diversity (adenocarcinomas, carcinoid tu- mors, lymphomas and sarcomas - the four major histopathological types), which generate localiza- tion, clinical presentation, prognosis, and treatment particularities.

In terms of oncological pathology, colorectal cancer is one of the most common types of malig- nancy in both sexes, accounting for 10% of all new cases diagnosed worldwide.

In men, the incidence is in third place, with an estimated 746,000 new cases per year, respec- tively 614,000 in women, in which it ranks second. In the global mortality hierarchy, colorectal cancer ranks fourth, with an estimated 649,000 deaths per year (1).

The incidence and mortality of this digestive neoplasm increase with age, more than 90% of newly diagnosed cases and, respectively, over 94% of deaths occur in people aged over 50 years.

The occurrence of colorectal malignancies in patients under the age of 40 is extremely rare, ex- cept for individuals with a genetic predisposition and those with acquired predisposing pathologies, such as chronic inflammatory bowel disease (2).

Colorectal cancer is a heterogeneous genetic pathology, in which the major feature is represen- ted by genomic instability. Despite advances in understanding the tumor genome, colorectal cancer continues to rank second worldwide in mortality, due to the potential for metastasis and resistance to therapy. The involvement of molecular mechanisms in the formation of adenomas, with their possible transformation into carcinomas, and later into metastatic cancer, tends to be used for new therapeutic concepts (2).

Finally, the surgery of recto-sigmoid tumor pathology, through extensive pelvic interventions, resulting in significant organ and vascular-nervous lesions produced intraoperatively, is responsi- ble for the appearance of sexual dysfunctions in men, especially of the erection one.

Keywords: tumor, colon, surgical dissection, neurovascular lesions, sexual dysfunction

* Correspondence: 1* .A.Runcanu MD, Phd,46 Doamna Oltea Street, District 2, Bucharest, 2**Nițescu Valentin MD,E-mail: [email protected] 108 Journal of Clinical Sexology - Vol. 3; No.3: July- September 2020

Anatomical data: Between the two peritoneal sheets of the The is an intraperitoneal sigmoid mesocolon, pass the sigmoid vessels organ and extends from the level of the iliac and the superior rectal artery. The sigmoid crest to the level of the S3 vertebra, where arteries, branches of the inferior mesenteric it continues with the , which is in the artery, are in variable number, between 1 and minor pelvis. 9 (Fig.1 a, b), (5,6). In the abdomen, the sigmoid colon pro- Classically, 3 sigmoid arteries are descri- jects to the left iliac fossa and hypogastrium. bed (upper, middle, and lower) which, right It has the following anatomical relations: from the beginning, enter the mesosigmoid, anterior-with the anterior abdominal wall where they are divided into ascending and and the ileal loops, posterior-with the iliac descending branches, which anastomose muscle, with the common and external iliac between them. Vascular abnormalities (ana- vessels, with the femoral and genito-femoral tomical variants) must be well known by the nerves, with the left genital vessels and the surgeon, primarily to prevent heavy arterio- left ureter; laterally-with the iliac muscle, venous bleeding that may occur in a very with the lateral half of the inguinal ligament, narrow space, such as the pelvis, or in the with the external iliac vessels, with the obtu- curvature of the sacrum in men. rator nerve and with the ovary or with the vas Venous drainage is performed through ho- deferens; medially-with the intestinal loops; monymous veins that flow into the inferior inferior-with the urinary bladder. mesenteric vein.

Fig. 1a Supernumerary arteries in the abdominal aortic system. They may cause clinical signs or are discovered during surgery or autopsy or during anatomical dissection of corpses. Journal of Clinical Sexology - Vol. 3; No.3: July- September 2020 109

Fig. 1b Diagram of multiple abnormalities of the abdominal aortic system. They can be encountered while exploring a surgical or medical condition, accidentally or during abdominal surgery.

The lymph nodes that drain the lymph and mesenteric plexuses, through the lumbar from the colon are divided into four groups: splanchnic nerves. From these plexuses, the epicolic-subserosal, paracolic-on the path of fibers reach the colon via the periarterial ple- the marginal arch, intermediate-on the me- xuses. senteric arteries and their branches and, re- The parasympathetic innervation comes spectively, central-at the origin of the mesen- from the sacral level S2-S4. teric arteries. The pelvic splanchnic nerves (erectors) Regarding innervation, the sigmoid co- originate here, providing nerve fibers that as- lon receives sympathetic and parasympathe- cend through the inferior hypogastric plexus, tic vegetative innervation. The sympathetic superior and then inferior mesenteric, these innervation comes from the lumbar and sa- fibers then reaching the colon through the pe- cral level, the fibers reaching the lower aortic riarterial plexuses (3). 110 Journal of Clinical Sexology - Vol. 3; No.3: July- September 2020

The rectum is the last segment of the bowel, presenting two portions: the rectal am- pulla-the more dilated upper portion, which, after crossing the perineum, continues with the second portion, namely the , which, anatomically, is delimited superior by the line dentate (pectinate) and lower than the ano-cutaneous line. The surgical anal canal has as its upper limit the place through which the rectum crosses the anal lifting muscles. The rectum is delimited superiorly by the sigmoid colon, at the level of the S3 vertebra, and inferiorly by the anal orifice, having a length of about 15 cm and a width of 6-7 cm, in the most dilated portion. In the sagittal plane, the rectum has two Fig. 2 Remaining rectal segment after rectal resection. curves; initially, the rectum descends into the The secretion of remaining anal canal mucous glands is sacro-coccygeal curvature and has an ante- deposited in the rectal ampulla, in the sinuses and rectal rior concave curvature (sacral flexure), then columns and near the anal orifice. In the biological the rectum crosses the anal lifting muscle and product harvested from the anal area, Proteus mirabilis continues with the anal canal. At this level, colonies were found on the culture media in 78% of it has a posterior concave curvature (perineal cases. This secretion, as well as the presence of the curvature). In the frontal plane, the rectum has colostomy, are factors of sexual inhibition, especially three curves, which determine the appearan- in the first 2-3 years postoperatively, respectively ce of folds inside (the Houston valves). The during the accommodation period of the sexual partner. lower and upper curves are concave on the left, and the middle is concave on the right. As the rectum continues with the anal canal, The intraperitoneal segment is covered by the lumen narrows, so that the smooth rectal the peritoneum on the anterior and lateral si- mucosa folds into 6-10 longitudinal columns, des, the peritoneum on the anterior side of the which are called Morgagni columns (Fig.2). rectum is folded on the bladder- in male- and The base of the is joined by the on the posterior vaginal and uterine wall-in , and all the anal valves form the female. This forms the bottom of the Douglas . Above each anal valve are for- fold. The anterior anatomical relations of the med the crypts or anal sinuses in which the intraperitoneal segment are represented by anal glands open (3). the ileal loops and the sigmoid colon, the bot- The rectal ampulla is a pelvic organ, being tom of the bladder (in man), respectively the partially covered by the visceral peritoneum and posterior face of the uterus, the uterine tubes, having an initial intraperitoneal segment and one the ovaries and the posterior vaginal wall (in in the small (minor)- the subperitoneal pelvis. woman). The lateral relations are represented Journal of Clinical Sexology - Vol. 3; No.3: July- September 2020 111

by the reflection of the peritoneum from the transverse muscle of the perineum, the bulb rectum on the pelvic wall, forming the para- of the penis, the tendon center of the perine- rectal fossae, in which we find ileal loops and um. Posteriorly, the anal canal is related to sigmoid colon (3). the ano-coccygeal ligament, and laterally-to the ischio-anal fossa. The ischio-anal fossa is In the pelvis, subperitoneally and anteri- a space that surrounds the anal canal and its orly, in man there are the seminal vesicles, sphincterian complex, on the outside. the vas deferens, the ureters and the base of the bladder, and between the rectum and The arterial vascularization of the rectum these structures there is the Denonvilliers is configured by several arterial sources, re- recto-vesico-prostatic fascia. In woman, the spectively by the upper, middle, and lower anatomical relation is with the posterior va- rectal arteries. The superior rectal artery re- ginal wall, separated from the rectum by the presents the continuation of the inferior me- recto-vaginal septum (3). senteric artery. It descends through the sig- moid mesocolon and then crosses from the The lateral anatomical relations are with lateral to the medial, the left common iliac the inferior hypogastric plexuses and with the vessels, descends posteriorly from the rectum middle rectal arteries, and the posterior ana- and at the level of S3 divides into two bran- tomical relations are made with the presacral ches - right and left. The terminal branches fascia, with the middle rectal vessels, with cross the rectal muscles to reach the submu- the lateral sacral vessels, with the sympathe- cosa. In the it anastomoses with tic nerve fibers chains and with the sacred the ascending branches of the lower rectal ar- spinal nerves. At the subperitoneal space, the tery. The middle rectal artery separates from rectum is surrounded by adipose tissue called the internal iliac artery or its branches, usu- the mesorectum, which is covered on the out- ally from the inferior bladder artery (in man) side by the mesorectal fascia or the rectum's and from the uterine artery (in woman). own fascia. The inferior rectal artery detaches from Inside the mesorectum, there are the ter- the internal pudenda artery at the level of the minal branches of the superior rectal vessels Alcock canal, from here the trajectory beco- and lymph nodes (3). When the rectum is mes transversal, from the lateral to the medi- dissected, due to sectioning of the vascular al, at the level of the ischio-anal fossa, perfo- elements, ischemia of the perineal muscle rates the sphincter and reaches the submucosa planes occurs, affecting the anal orifice and of the anal canal. Here it anastomoses with the perianal area, respectively the base of the branches from the upper rectal artery. penis (morpho-pathophysiological changes), with the necessary repercussions. The blood of the rectum and anal canal is drained by three veins: the superior rectal The anal canal has the following anatomi- vein, the middle rectal vein and the inferior cal anterior relations: in woman - the lower rectal vein. The superior rectal vein drains the part of the vagina and the tendon center of blood from the rectum and the upper portion the perineum, and in man - the tip of the of the anal canal into the superior mesenteric prostate, the membranous urethra, the deep vein. The middle rectal vein drains the blood 112 Journal of Clinical Sexology - Vol. 3; No.3: July- September 2020

of the lower rectum and the upper portion of as correctly, in the cleavage plan, the seminal the anal canal into the internal iliac vein, and vesicles could be damaged. the inferior rectal vein drains the blood from the lower portion of the anal canal into the internal venous vein and then into the internal iliac vein. The surgical treatment: The innervation of the rectum is ensured mainly by the nerve fibers coming from the inferior mesenteric plexus; it contains both Colorectal cancers are mostly adenocarci- sympathetic and parasympathetic fibers. nomas, and surgical resection is the only cu- rative approach. These nerve fibers accompany the upper rectal artery. The rectum also receives nerve The purpose of the surgery is to excise the fibers from the lower hypogastric plexus, lo- primary tumor together with the lymph no- cated in its lateral parts, subperitoneally. des that drain the respective colonic segment, which means that, automatically, by dissec- The anal canal receives somatic informa- ting the tumor, the vascular-nervous forma- tion through the lower rectal nerve, which tions are sectioned, sometimes producing detaches from the internal pudendum nerve. lesions of the genitals, which will directly The rectum and anal canal have a com- influence sexuality. plex innervation with a role in continence and The surgical resection margins: the limit defecation (3), and, from a surgical point of of oncologically safe surgical incision, in the view, the sectioning of the vascular-nervous case of the colon, is of 5 cm. Thus, the resec- structures modifies the morpho-physiology ted colon segment must include at least 5 cm of the genital organs. more than each pole of the tumor. Colorectal carcinoma is a malignant epi- In general, the resection margins are much thelial tumor, originating in the bowel, whi- wider, a situation imposed for the complete ch, by definition, infiltrates, through the mus- excision of the mesocolon, because a central cularis mucosae, the submucosa of the colon vascular ligature can determine the devascu- or rectum. larization of a much wider colonic segment. In relation to the depth of tumor infiltrati- The lymphadenectomy has a curative on, with own muscularis and the presence or role through the excision of the tumor-inva- absence of metastases in the regional lymph ded lymph nodes, but also a prognostic role nodes (2), the number of vascular-nervous through the information it provides in order to sections, as well as the interest of adjoining guide the multimodal oncological treatment; genitals, may be lower or higher. for a correct TNM staging, adequate analysis With the disappearance of sensitive tissue- of at least 12 lymph nodes is necessary, thus receptors, including the testosterone ones, the avoiding substadialization (2). penile erection no longer occurs. An example For neoplasms located in the sigmoid co- is given that if the operator does not enter, lon, patients benefit from left hemicolectomy Journal of Clinical Sexology - Vol. 3; No.3: July- September 2020 113

with central vascular ligation of the lower Surgery for rectal tumors requires careful mesenteric artery, and in cases with multiple dissection in anatomical planes, any devia- comorbidities, segmental sigmoid colectomy tion to the medial from the dissection plane is also considered, which, although inferior in results in increased local recurrence rate, and terms of oncological principles, provides an lateral deviations in the dissection plane de- overall survival rate similar to left hemicolec- termine comorbidities related to damage to tomy with central vascular ligation. adjacent nerve structures; in men, erectile dysfunction (sexual impotence) occurs, and The incidence of tumors with local inva- bladder dysfunction may appear in both se- sion is about 70% of cases of colorectal can- xes (Fig. 3). cer, a situation in which the tumor adheres to an anatomical structure in the vicinity, in the remaining 30% of cases these adhesions are At the sacrum promontory level, the hypo- inflammatory. gastric nerves are identified, which descend The impossibility of intraoperative diffe- into the pre-sacral space in the shape of the rentiation of adhesion types leads to the in- letter "Y". Keeping these nerve fibers intact dication of block resection, studies showing is necessary in order to preserve sexual and that the separation of these structures during urinary functions. The dissection is continu- surgery leads to a local recurrence rate of ed posteriorly; Waldeyer's presacral fascia about 100% and a marked decrease in survi- is divided and dissected continuously under val at 5 years (2). direct visual control, down to the coccyx. Postero-lateral mobilization of the rectum is Left hemicolectomy with complete exci- performed by dissection from posterior to la- sion of the mesocolon and central vascular li- teral, a maneuver necessary to be gently per- gation by open approach is the recommended formed to maintain the integrity of the endo- intervention in cancers of the left colon. pelvic fascia as well as to preserve the pelvic This intervention involves resection of splanchnic nerves. the distal segment of the , To complete the antero-lateral dissecti- and sigmoid to the level of on, it is necessary to open the bottom of the the upper rectum, 2-3 cm from the sacral pro- Douglas fold and to place the patient in the montory (2). anti-Trendelenburg position. In the antero-in- Rectal tumors affect the last 15 cm of the ferior dissection, the Denonvilliers fascia is bowel, having similar characteristics to co- previously incised on the midline, being con- lonic tumors from a genetic, biological, and sidered the anterior limit of the mesorectum morphological point of view. and a constituent part of the resection piece. In the case of tumors located in the rectum, The anatomical area of the rectum may have the Denonvilliers fascia can be kept lower in variants or peculiarities, related to the retroperi- order to reduce the risk of injury to the pe- neal position in the small pelvis, with possible riprostatic pelvic nerves. The middle rectal close relationships with the urogenital tract, the artery, depending on its size, can be ligated or vegetative nervous system, and the anal sphinc- electrocoagulated. ter, making surgical access difficult. 114 Journal of Clinical Sexology - Vol. 3; No.3: July- September 2020

Fig.3 Nerve branches innervating the rectum and the bladder that could be sectioned intraoperatively (Adapted after Latarjet and Bonnet 1931, JCS,Vol.2, No.3-4/2019)

The pelvic nerves include: the sacral ple- (right and left) detach from the lower angles. xus (originating at the lumbar level L4, L5, Each hypogastric nerve terminates in a lower S1, S2 and S3), which ensures the innervati- hypogastric plexus (right and left). on of the pelvic muscles and lower limbs), the These plexuses contain, in addition to pudendum plexus (originating at the sacral the sympathetic fibers, parasympathetic fi- level S2, S3 and S4), (Fig.4a, b), fibers are bers from the S2, S3 and S4 segments; these intended for the pelvic viscera and genitals parasympathetic fibers ensure an erection in and the autonomic pelvic plexuses (the upper men. Each inferior hypogastric plexus is lo- hypogastric plexus and the lower hypogastric cated laterally to the rectum, prostate, semi- plexus) - intertwined with the previous ones. nal vesicles, and the back of the bladder-in The superior hypogastric plexus consists of men and, respectively, laterally to the rectum, sympathetic thoraco-lumbar nerve fibers (res- cervix, vaginal fornix and the back of the bla- ponsible for ejaculation, in men) and is loca- dder-in women. ted in the extraperitoneal connective tissue, anterior to the bifurcation of the aorta and the The branches of the lower hypogastric left common iliac vein, near the L5 vertebra plexuses ensure the innervation of the rectum, and promontory; it has the shape of a triangle bladder, prostate, seminal vesicles, urethra, with a cranial tip, and the hypogastric nerves and corpora cavernosa. The cavernous nerves Journal of Clinical Sexology - Vol. 3; No.3: July- September 2020 115

are grouped in a nerves bundle, having a di- immediately outside this plane and can be da- rect path to the postero-lateral portion of the maged if the anatomical plan is not followed prostate; from this level, the nerves accom- or if a blunt dissection is performed or if the pany the capsular arteries and veins, climb to bleeding is not rigorously controlled and, as the top of the prostate, and pass through the a result, there is no good visualization of the urogenital diaphragm. dissection plan. The pelvic plexuses are located laterally During lateral dissection, excessive tracti- and posteriorly to the seminal vesicles, so on of the rectum brings the lower hypogastric the seminal vesicles are, intraoperatively, the plexus up and to the medial, exposing it to benchmark for plexus identification. Also, the damage during ligation/electrocoagulation of cavernous nerves can be identified postero- the middle rectal artery and sectioning of the laterally of the prostate and antero-laterally lateral ligament. of the rectum, due to their constant associati- Damage to the parasympathetic fibers on with the prostatic arteries and capsular ve- at this level leads to erectile dysfunction ins, with which they form a vascular-nervous in male, and vaginal dryness (followed by bundle (4). dyspareunia) in female. The superior hypogastric plexus (contai- Extensive lymphadenectomy, which in- ning sympathetic fibers responsible for eja- cludes the lymph nodes in the lateral com- culation) may be damaged during ligation partment (surgical procedure recommended of the inferior mesenteric artery. When there by Japanese authors) has a major risk of is no palpable lymphadenopathy along the damaging these nerves, which, at this level, lower mesenteric artery, ligation of the artery contain both sympathetic and parasympathe- is done above or below the origin of the left tic fibers. colic artery. The anterior dissection occurs in the When ligation of the inferior mesenteric narrow space between the rectum (located artery is made from the origin of the aorta, posteriorly) and the seminal vesicles and it is preferable that the nerve threads located prostate (located anteriorly). immediately behind the artery be separated by sharp dissection. During dissection at this level or during hemostasis in this difficult area, the caverno- During posterior dissection of the meso- us nerves are exposed to damage; these ner- rectum, there is a risk of damage to the hypo- ves contain mainly parasympathetic fibers, gastric nerves, which contain purely sym- and their damage leads to erectile dysfunc- pathetic nerve fibers. tion. The correct dissection is made in the loo- The anterior dissection can take place in se connective tissue located immediately out- three planes: perirectal, mesorectal and extra- side the mesorectal fascia. In the avascular mesorectal. space between the rectal sheath and the pre- sacral fascia, detachment is easy and there is The perirectal (perimuscular) plane is lo- no bleeding; hypogastric nerves are located cated in the immediate vicinity of the rectal 116 Journal of Clinical Sexology - Vol. 3; No.3: July- September 2020

muscles, but inside it’s own rectal fascia; it is viously, but the risk of injury to the cavernous not a proper anatomical plan, and dissection nerves is high. As the anterior mesorectum is with this location causes a high rate of local thin, for oncological reasons, the systematic recurrence. dissection of the anterior Denonvilliers fascia is justified. The mesorectal plane is an anatomical plan, in which the rectal fascia separates from Therefore, to minimize the risk of uro- the Denonvillers fascia, but it is not as obvi- genital sequelae, the previous dissection of ous as in the lateral and posterior portion of the Denonvilliers fascia is indicated only in the rectum. cancers of the anterior wall of the rectum, for posterior or lateral location tumors being pre- The extra-mesorectal plane involves the ferable to use the mesorectal plane (4). resection of the Denonvillers fascia; the pros- tate and seminal vesicles are visualized pre- During the operation, several moments

Fig. 4a Nerve threads and vascular branches which, by surgical sectioning, modify the morpho-functionality of the penis, causing sexual dysfunctions (Adapted after Sobotta- Figge Vol.III, Part I, 1.963, JCS, Vol.2,No.2/2019) Journal of Clinical Sexology - Vol. 3; No.3: July- September 2020 117

Fig. 4b Perineal vascular-nervous elements, which by surgical sectioning, modify the vulvo-vaginal morphophysiology (after Sobotta- Figge Vol.III, Part I, 1.963)

with increased risk of pelvic nerve damage In this context, pelvic and rectal surgery can be identified, especially the sectioning are often associated with sexual and urinary and ligation of the inferior mesenteric artery, postoperative complications (7). Rigorous performed simultaneously with the anterior, observance of the anatomical principles of posterior, and lateral dissection of the rectum, dissection minimizes the risk of injury to the- with possible repercussions such as sexual se nerve structures and the occurrence of con- dysfunction (especially erectile dysfunction). secutive urogenital complications