Hypothesis / aims of study
Colorectal cancer is the second most common cancer in women and the third most common cancer in men. Nearly 40% of these tumours are located in the rectum. Standard of surgical care is a nerve and sphincter sparing total mesorectal excision (TME). This technique consists of excising the rectum, together with the total mesorectal envelope. By performing a TME, the rectal reservoir as such is lost. This can result not only in a wide range of bowel symptoms, but also urinary and/or sexual symptoms. [1, 2] The aim of the present study was to assess the impact of TME on urinary and sexual dysfunction in rectal cancer survivors, from preoperatively to 1, 4, 6 and 12 months after surgery (or after stoma closure) as well as to assess the impact of age and neoadjuvant radiotherapy.
Study design, materials and methods
Patients who had a TME for rectal cancer between January 2017 and January 2021 (in three different hospitals) were eligible, but were excluded if they: (1) had another type of surgery for colorectal cancer: a Hartmann procedure, abdominoperineal excision, transanal endoscopic microsurgical resection, or sigmoid resection, (2) were incontinent for faeces before surgery, (3) had neurological diseases, (4) already had previous pelvic surgery, previous pelvic radiation or LAR for non-cancer reasons.
After consent, patients were asked to fill out a numeric rating scale (NRS) regarding bother from urinary complaints and the International Consultation on Incontinence Questionnaire Male/Female Lower Urinary Tract Symptoms Module (ICIQ-M/FLUTS) regarding urinary symptoms. The numeric rating scale was scored between 0 and 10. The ICIQ-MLUTS consists of 13 questions (scored from 0 to 4) leading to a voiding- and incontinence- subscale score and scores for individual items regarding frequency and nocturia. The ICIQ-FLUTS consists of 12 questions (scored from 0 to 4), leading to a filling, voiding- and incontinence subscale score. The ICIQ bother scales are not incorporated into the overall score, but all of the bother scores were added to provide a general overview. Concerning sexual symptoms, male patients were asked to fill out the International Index of Erectile Function (IIEF) and female patients the Female Sexual Functioning Index (FSFI). The IIEF (15 questions) amounts to subscale scores for erectile function, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction and the FSFI (19 questions) represent subscale scores for desire, arousal, lubrication, orgasm, satisfaction and pain as well as a total score.
All measurement methods were completed concerning the preoperative period and at 1, 4, 6 and 12 months after surgery. Linear mixed effects models were used to assess changes over time (from 0-12 months). To explore overall trajectories, we included random effects (intercept and slope) and fixed effects (time, age and radiotherapy) into the model. The alpha level was set at 0.05. Analyses were performed by the Biostatistics and Statistical Bioinformatics Centre.
Results
In total, 104 patients participated in this study. The median age for male patients was 61 years (range 32-85) and 55 years (range: 29-84) for female patients. Urinary and sexual dysfunction according to the NRS, ICIQ-MLUTS/FLUTS and the IIEF/FSFI is presented in Table 1.
Linear mixed effects models showed that for male as well as female patients, no significant evolution was found over time for urinary symptoms. I.e., symptoms assessed with neither the NRS nor the ICIQ-MLUTS/FLUTS showed significant differences over time from the preoperative period until one year post-TME/after stoma closure. Regarding sexual symptoms in males, all subscales (erectile function, orgasm, desire, sexual satisfaction, overall satisfaction) of the IIEF showed significant decreases over time (p < 0,001 for all subscales). In female rectal cancer patients, FSFI-subscales for desire (p = 0,017), arousal (p = 0,039) and pain (p = 0,029) decreased significantly over time. None of the sexual symptoms with a significant evolution over time reached preoperative values after treatment for rectal cancer.
Furthermore, linear mixed effects models showed that neoadjuvant radiotherapy had a negative influence on NRS-scores as well as voiding and incontinence symptoms in male patients and older age was shown to have a negative influence on nocturia and all IIEF-scores, except for overall satisfaction. In female patients after rectal cancer treatment, radiotherapy did not influence urinary nor sexual symptoms. Older age did significantly influence NRS-scores and filling symptoms as well as all FSFI-scores, except for satisfaction. An overview of these results is presented in Table 2.
Interpretation of results
Rectal cancer treatment does not seem to significantly influence urinary symptoms over time in male or female patients. Sexual functioning however is affected after TME: male sexual functioning decreases in every aspect, while female patients report problems with desire, arousal and pain. These values for sexual symptoms do not reach preoperative values one year after surgery/stoma closure. Radiotherapy influences the amount of bother from urinary symptoms, voiding and incontinence in male patients. Age influences the trajectory of all sexual symptoms and nocturia in male patients. In female patients, age influences the amount of bother from urinary symptoms and filling symptoms, as well as all sexual symptoms. Overall satisfaction however, is not influenced by age.
Concluding message
Functional outcomes such as urinary and sexual symptoms should be questioned during patient follow-up after rectal cancer treatment, certainly in older patients. Furthermore, following the results of this study, sexual symptoms are most definitely present in men as well as women after RC. Therefore, sexual symptoms should not be underestimated, should be questioned adequately in every patient and treated as needed.