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Innovation in surgical technique
Female near-TME: standardization of proctectomy in women with ulcerative colitis
Estandarización de la proctectomia en mujeres con colitis ulcerosa
E. Ferrer-Inaebnita, S. Jeri McFarlenea,b,c, A. García-Granero García-Fustera,b,c,
Corresponding author
alvarogggf@hotmail.com

Corresponding author.
, X. González Argentéa,c
a Unidad de Coloproctología, Servicio Cirugía General y Aparato Digestivo, Hospital Universitario Son Espases, Palma de Mallorca, Spain
b Instituto de Investigación Sanitaria Illes Balears (IdISBa), Spain
c Profesor del Departamento de Anatomía y Embriología Humana, Universidad de Islas Baleares (UIB), Palma de Mallorca, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Within 10 years of their initial diagnosis&#44; 16&#37; of patients with ulcerative colitis &#40;UC&#41; require surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Two surgical techniques are used for proctectomy in UC&#58; total mesorectal excision &#40;TME&#41; and close rectal dissection &#40;CRD&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> However&#44; the main guidelines for inflammatory bowel disease recommend a dissection that combines both techniques&#44; without providing a description of the technique or assigning it a proper name&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In a recent publication&#44; our working group has proposed the standardization of this technique&#44; calling it Near-TME&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Said article demonstrates the main anatomical landmarks to conduct the technique and reduce the chances of injury to the pelvic autonomic nerves and nerve plexi &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4</span></a> However&#44; the description focuses on proctectomy in males&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The objective of this paper is to standardize the Near-TME technique for females &#40;Female Near-TME&#41; based on illustrations&#44; as well as the case of a patient who was treated laparoscopically&#46; In addition&#44; we will address the advantages and disadvantages of this technique compared to TME or CRD in terms of female genitourinary and sexual function&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Surgical technique</span><p id="par0020" class="elsevierStylePara elsevierViewall">The patient is a 46-year-old female with UC who had undergone total colectomy with end ileostomy 10 years earlier due to poor response to medical treatment&#46; At that time&#44; proctectomy was not performed due to severe malnutrition and longstanding corticosteroid treatment&#46; The patient presented mucus and rectal bleeding&#46; Rectoscopy showed proctitis&#44; and biopsies confirmed ulcerative colitis with moderate activity&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Due to the worsening of the symptoms despite several changes in medical treatment&#44; we decided to operate&#46; The patient agreed to intersphincteric proctectomy&#44; which was performed using the Near-TME technique &#40;Video 1&#41;&#46; Given the patient&#8217;s history of several perianal fistulae&#44; we reached the decision with the patient to rule out the creation of an ileoanal reservoir&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Posterior and lateral dissection of the mesorectum should be similar to the TME technique in order not to leave too much of the mesorectal remnant in the pelvis&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> An appropriate anatomical approach is essential to avoid injury to the superior hypogastric plexus and bilateral hypogastric nerves&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It should begin with the identification of the superior rectal artery&#44; continuing with the dissection between it and the promontory to slide through the presacral space to the rectosacral fascia &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5</span></a> After dissection&#44; Waldeyer&#8217;s fascia and the levator ani plane are reached &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The landmark used for posterolateral dissection is the ureterohypogastric fascia&#44; which contains the ureters and hypogastric nerves on each side&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Once identified&#44; the dissection is performed between it and the mesorectal fascia&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> If this fascia is identified bilaterally&#44; we will observe a single fascia that continues presacrally&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This element allows us to preserve the superior hypogastric plexus and both hypogastric nerves &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;8</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The lateral dissection begins where the posterior dissection encounters the lateral ligaments of the rectum&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Lympho-fatty tissue encompasses the middle rectal artery &#40;present in 30&#8211;40&#37;&#41; and nerve branches from the inferior hypogastric plexus to the rectum or rectal nerves&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The presence of the lateral ligaments indicates where to initiate the intramesorectal dissection up to the rectal wall&#44; thereby reducing the risk of injury to the inferior hypogastric plexus&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The anterior dissection of the rectum begins with the opening of the pouch of Douglas and the beginning of the rectovaginal septum&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Although the rectovaginal septum needs to be divided&#44; the uterosacral ligament can be preserved if it does not hinder dissection or access to the rectovaginal space&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The anterolateral dissection is trans-mesorectal up to the rectal muscle wall &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In this manner&#44; both pelvic plexi are preserved with their anterior connections to the mesorectum&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Lastly&#44; the lateral and anterior perirectal dissection is continued up to the plane of the levator ani muscle&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The perineal stage concludes with proctectomy after accessing the supralevator plane through perianal intersphincteric dissection &#40;<a class="elsevierStyleCrossRefs" href="#fig0030">Figs&#46; 6 and 7</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">On its posterior side&#44; the surgical piece demonstrates a dissection plane similar to that of TME&#44; while on the anterolateral plane it is similar to that of CRD &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46; Perineal reconstruction was performed on 3 planes with approximation of the puborectalis muscle&#44; external sphincter muscle and skin&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The patient was discharged on the fifth postoperative day with no complications&#46; Over the course of a one-year follow-up&#44; she presented no alterations in sexual or genitourinary function&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Three surgical techniques have been described for proctectomy in UC&#58; TME&#44; CRD and Near-TME&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;10</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The advantage of TME in ulcerative colitis is that it is a continuation of the surgical planes that colorectal surgeons are already familiar with in rectal cancer surgery&#46; Furthermore&#44; it avoids the pelvic mesorectal remnant&#44; which is associated with malfunction of the ileoanal reservoir due to its proinflammatory activity&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;10</span></a> On the downside&#44; TME increases the risk of pelvic autonomic nerve injury&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">CRD reduces the risk of nerve injury&#44; but the mesorectal remnant is associated with the aforementioned disadvantages&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Nevertheless&#44; some authors have linked the persistence of this remnant with a decrease in postoperative complications&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In addition&#44; CRD increases the risk of intraoperative rectal bleeding and perforation&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;10</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Our working group has recently standardized the Near-TME technique&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> both for proctectomy in UC with or without creating an ileoanal reservoir&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">This description and protocol have come about for 2 reasons&#46; The first is due to the recommendation by clinical guidelines to perform a posterior dissection similar to TME&#44; but anterolateral similar to CRD&#44; without clearly indicating how to carry this out&#46; The second is the lack of consensus and the different methods described&#58; perimuscular&#44; intramesorectal&#44; trans-mesorectal or mesorectal-sparing proctectomy&#46; This also hinders training in the technique and its implementation&#44; while impairing the evaluation of results&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In Near-TME&#44; it is possible for the specimens to be classified by the pathologist&#44; and prospective studies may thus be carried out with correct methodology&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> If TME has been performed&#44; the surgical piece will show a correct mesorectal plane&#44; both posterior and anterolateral&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> If CRD has been performed&#44; the entire circumference of the rectal muscle plane will be observed&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Lastly&#44; if Near-TME is performed&#44; the posterolateral mesorectal plane and anterolateral perirectal plane will be observed&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Therefore&#44; it would not be indicated in patients with a diagnosis of associated cancer&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Until now&#44; the Near-TME technique had been described in men but not in women&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The landmarks used in men include&#58; the superior rectal artery and the presacral space for posterior dissection&#59; the ureterohypogastric fascia for posterolateral dissection&#59; the lateral ligament of the rectus for lateral dissection&#59; and Denonvilliers&#8217; fascia for anterior dissection&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The technique also needed to be defined in females due to the dissimilar landmarks that must be used and the different consequences arising from possible pelvic nerve injuries&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The anatomical reference points that vary in the Female Near-TME technique are found in the anterolateral dissection&#44; which is completely different from the male procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Likewise&#44; one of the dissimilar structures is the uterosacral ligament&#44; which is the result of embryological tissue reinforcing the endopelvic fascia&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The main difference&#44; however&#44; lies in the presence of Denonvillier&#8217;s fascia in males&#44; resulting from the embryological adhesion of the 2 mesothelial layers of the peritoneal sac&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In females&#44; this adhesion also occurs&#44; but the resulting fascia adheres to the posterior vaginal wall&#44; becoming part of it in adulthood&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The portion of this adhesion that lies between the pouch of Douglas and the posterior vaginal wall is the beginning of the rectovaginal septum&#46; Therefore&#44; the anterior dissection of the Female Near-TME begins with the division of the pouch of Douglas&#44; continues with the beginning of the rectovaginal septum&#44; and ends with the anterior mesorectum up to the rectal muscle wall&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">There are identical critical areas of potential nerve injury in both males and females&#58;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> the superior hypogastric plexus and hypogastric nerves during dissection of the posterior mesorectum&#59; pelvic splanchnic nerves during posterolateral dissection at S3-S4&#59; and the inferior hypogastric plexus during lateral dissection&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#44;8</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In women&#44; the pelvic plexus and its branches are located lateral to the cervix and the lateral vaginal fornix&#44; in the paracervix&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;12</span></a> At the intersection of the ureter and the uterine artery&#44; we encounter a nerve trunk that rapidly divides into 2 branches&#58; the vaginal nerve&#44; which innervates the uterus and vagina&#59; and the superior rectal nerve&#44; which innervates the upper part of the anterior surface of the rectum&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The posterior vaginal branch passes in the direction of the posterior vaginal wall&#44; whose branches cross the rectovaginal septum and are distributed to the anterior rectal wall&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Possible alterations of the genitourinary and sexual function as the result of injury to the different female nerve regions are described below&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Injury to the sacral splanchnic nerves can result in detrusor denervation and decreased bladder sensation&#44; resulting in urinary retention and overflow incontinence&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Dissection of the retrorectal space can cause damage to the superior hypogastric plexus and&#47;or hypogastric nerves&#44; causing reduced bladder capacity and urge incontinence&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Anterolateral dissection is the area most vulnerable to possible autonomic nerve damage&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> which can damage the inferior hypogastric plexus and efferent pathways&#44; leading to urinary incontinence&#44; voiding dysfunction and bladder irritation&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Female patients present much less pronounced sexual manifestations of autonomic nerve damage&#44; which is more difficult to define&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> These lesions can cause vaginal dryness&#44; dyspareunia&#44; irritative leucorrhea&#44; malodorous discharge and changes in genital sensitivity&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;14</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Possible sexual and urinary dysfunction should be assessed with questionnaires that have been validated for this purpose&#46; In the present study&#44; this was done during an interview at a follow-up appointment&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0155" class="elsevierStylePara elsevierViewall">The Near-TME technique in proctectomy for UC decreases the possibility of pelvic nerve injury and reduces the pelvic mesorectal remnant&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3&#44;8</span></a> The anatomical landmarks vary between men and women&#44; especially in the anterolateral hemicircumference&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The procedure should be conducted by surgeons with experience in inflammatory bowel disease surgery who have extensive knowledge of surgical anatomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;14</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors confirm the absence of conflict of interest and the absence of any funding for this case&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Traditionally&#44; 2 surgical techniques for proctectomy in ulcerative colitis have been used&#58; total mesorectal excision &#40;TME&#41;&#44; and close rectal dissection &#40;CRD&#41;&#46; Recently&#44; our research group has proposed the standardization of the Near-TME technique&#44; which unites the advantages of both methods&#46; It decreases the risk of pelvic autonomic nerve injury and reduces the volume of mesorectal remnant&#46; When performing the Near-TME&#44; the anatomical landmarks differ between men and women&#44; especially in the anterolateral hemicircumference&#46; The objective of this paper is to standardize the Near-TME technique in women &#40;Female Near-TME&#41; using characteristic surgical-anatomic landmarks of the female pelvis based on illustrations and a real case treated laparoscopically&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">This technique should be carried out by surgeons with experience in inflammatory bowel disease surgery and extensive knowledge of surgical anatomy&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Dos t&#233;cnicas quir&#250;rgicas de proctectom&#237;a en colitis ulcerosa han sido empleadas tradicionalmente&#59; la escisi&#243;n total de mesorrecto &#40;TME&#41; y la disecci&#243;n perirrectal &#40;CRD&#41;&#46; Recientemente&#44; el presente grupo de trabajo ha propuesto la estandarizaci&#243;n de la t&#233;cncia Near-TME&#44; la cual re&#250;ne las ventajas de &#233;stas dos&#46; Disminuye el riesgo de lesi&#243;n nerviosa aut&#243;noma p&#233;lvica y disminuye el volumen de remanente mesorrectal&#46; Las referencias anat&#243;micas a la hora de realizar la Near-TME var&#237;an entre el var&#243;n y la mujer&#44; sobre todo en la hemicircunferencia anterolateral&#46; El objetivo del presente trabajo es estandarizar la t&#233;cnica de Near-TME en mujeres &#40;FEMALE NEAR-TME&#41; a partir de <span class="elsevierStyleItalic">landmarks</span> anatomoquir&#250;rgicos caracter&#237;sticos de la pelvis femenina a partir de ilustraciones y de un caso real intervenido de forma laparosc&#243;pica&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Esta t&#233;cnica debe ser llevada a cabo por cirujanos con experiencia en cirug&#237;a de la enfermedad inflamatoria intestinal y con amplios conocimientos anatomoquir&#250;rgicos&#46;</p></span>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos