Improved Outcomes in Colon and Rectal Surgery part 42 pot

 improved outcomes in colon and rectal surgery can be used to aid in diagnosis of ureteral injury by retrograde injection of methylene blue through the ureteral catheter. They can also be used to place a retrograde wire under fluoroscopic guidance for placement of an indwelling ureteral double-J stent after a ligation/crush injury. Types of Injury Laceration A laceration or transection of the ureter can usually be repaired with primary anastamosis (ureteroureterostomy with spatulated ends), ureteral stent, and placement of a closed suction drain in the area of the repair (Figure 36.3). Ligation If a ligation injury is apparent intraoperativly, the clamp or tie can be removed followed by ureteral stent placement for up to one month. The patient should undergo repeat imaging either with a renal ultrasound or intravenous pyelogram (IVP) at 3 months to ensure a ureteral stricture has not developed. If the injury is not identified until post operatively, a retrograde ureterogram and stent placement or percutaneous nephrostomy tube placement may be needed before surgical correction. Devascularization A devascularization injury will not be evident intraoperatively and results from the sacrifice of the segmental ureteral blood supply. Intraoperativley a devascularized ureter may appear discolored, lack peristalsis, and may not bleed at a transected site. The irradi- ated ureter is especially susceptible to this type of injury, as the normal healthy ureter has numerous collaterals and is very resist- ant to devascularization, even with extensive dissection. The anat- omy of the blood supply to the ureter (as previously described) should be known as the surgeon is carrying his dissection over the pelvic brim. Thermal Thermal injuries will usually present in the early postoperative period with either fistula or stricture formation. These injuries are repaired in the same fashion as above depending on the location of the injury. Many laparoscopic surgeons use alternatives to monopolar dissec- tors because of the risk of thermal injury and delayed presentation of injuries. Even with these newer technologies, collateral tissue dam- age can be produced depending on the energy level and duration of exposure. In animal models, use of the ultrasonic dissector (Ethicon or USSC) at a level of 3 for <10 seconds per burst resulted in little to no collateral tissue damage.(27) When using an ultrasonic dissector at levels of 4 or 5, energy time should be reduced to <5 seconds to prevent collateral damage due to spread of thermal.(27) lOCatiOn dePendent rePair OF the iatrOgeniC Ureteral injUrY Repair of the injured ureter does not necessitate open conversion if a urologist is available with advanced laparoscopic skills. The basic principles of a ureteral anastamosis: a tension free anasta- mosis; well-vascularized spatulated ends anastamosed over an indwelling ureteral stent ; use of an absorbable suture material 4–0 or 5–0; and placement of a closed drain near the area of the repair. Do not use nonabsorbable suture, as stone formation is inherent with these nonabsorbable materials. Proximal One Third The boundaries of the proximal one-third ureter is from the ure- teropelvic junction (level of the kidney) to the pelvic brim (sac- roiliac joint on KUB). Repairs of injuries to the proximal ureter depend on the length of the damaged segment. Simple spatulated ureteroureterostomy with ureteral stent placement is the pre- ferred method of repair if there is significant length of the unin- jured ureter. A nephropexy can be performed to bring the kidney caudad to allow a tension free anastamosis. In cases with long segments of damaged ureters, a bowel interposition with tapered ileum or an apendiceal interposition can be used (Figure 36.4). At specialized centers, autotransplantation with reanastamosis to the iliac vessels, and native more distal ureter can be performed. Middle One Third The preferred technique for mid-ureteral repair is ureteroureter- ostomy, either laparoscopically or through the open technique. Distal One Third The procedure of choice for the lower one-third ureteral injury is the ureteroneocystotomy. This may be accomplished primarily for very distal ureteral injuries or may require a Psoas hitch or Boari flap for patients with small capacity bladders and injuries near the iliac vessels.(24) Care must be taken to maintain a tension free Figure 36.3 Ureteroureterostomy. (A) Spatulation of ureteral margins and placement of running locked sutures. Preferred technique. (B) Oblique anastomosis. (A) (B)  urologic complications of colorectal surgery anastamosis. This can usually be accomplished with a Psoas Hitch (Figure 36.5). The bladder is mobilized by ligating the superior vesical pedicle on the contralateral side of the injury. It is prudent to locate the contralateral ureter and ensure its integrity before this maneuver. The bladder can then be opened through an ante- rior cystotomy and then secured to the Psoas muscle and tendon using several 0–0 SAS sutures through the seromuscular layer of the bladder. Care must be taken not to include the genitofemoral nerve which is located within the belly of the Psaos muscle. Suture should be placed in a linear fashion inline with the fascicles of the muscle to prevent underlying nerve entrapment. The ureter can then be tunneled by passing a clamp from the lumen through all layers of the bladder and then withdrawn with the distal aspect of the proxi- mal salvaged ureter. The ureter should then be widely spatulated and interrupted mucosal stitches (4–0 SAS) should be used circumferen- tially to create the neo-orifice. A ureteral stent can also be placed. The anterior cystotomy is then closed as previously described. A closed suction drain and foley catheter is then left in place. The Boari flap is another effective yet more complex method for replacing an extensive loss of the distal and mid-ureter. A flap of the anterior bladder wall is raised in a rectangular fashion and affixed to the Psoas muscle in same fashion as a Psoas hitch. The ureter is tunneled through the most proximal portion of the flap and a neo-orifice is created as previously described. The bladder flap is then tabularized and closed in a two-layer fashion using running 3–0 SAS to close the mucosa followed by closure of the seromuscular layer using 2–0 SAS (Figure 36.6). The final option is the transureteroureterostomy. The surgeon tunnels the injured ureter under the posterior peritoneum over- lying the great vessels. The allows a spatulated end to side anasta- mosis of the injured ureter to the patient’s native uninjured ureter (Figure 36.7). renal injUries Direct renal injury is a rare occurrence in colorectal surgery. McAnich et al. have reported that 90% of renal injuries can be managed without nephrectomy.(28) Though this work does not Figure 36.4 Ureteral replacement by ileum. Left colon retracted medially. Ileum brought through a hiatus in the colonic mesentary. Ileal ureter is in retroperitoneal position. Figure 36.5 Psoas bladder hitch. Mobilized bladder being anchored to psoas muscle and the ureter is reimplanted.  improved outcomes in colon and rectal surgery address iatrogenic injuries, the principle of renal salvage should be applied. Every attempt to evaluate the extent of the injury as well as an assessment of the entire genitourinary tract should be done before undertaking repair. A one shot IVP can confirm con- tralateral renal function. This can be done by giving the patient 2 ml of contrast per kg up to a maximal of 150 ml IV. An on the table KUB is then done 10 minutes later. Simple palpation of the contralateral kidney does not ensure function. The literature is full of anomalous solitary kidneys which were removed neces- sitating dialysis or transplantation.(29, 30) Pelvic kidneys have an anomalous blood supply generally arising from multiple arteries along the aorta and iliac vessels. A total of 10% are solitary and may easily be taken for a pelvic mass as they are not reniform and have a discoid shape.(23) If caliceal or renal pelvis injury is suspected, intravenous methylene blue or indigo carmine can be administered. Once the injury is well defined, repair can be decided. Minor renal lacerations or penetrating injuries may be repaired primarily with absorbable sutures and retroperitonealized with perinephric fat, omentum, or hemostatic materials. Hilar control is paramount if an attempt at repair is to be performed. If the injury is to the collecting system or renal parenchyma and the ensuing blood loss is able to be managed by pressure and hemostatic agents alone, a ureteral stent and foley catheter can be placed from below and the area drained with a closed suction to prevent urinoma formation. Conservative management is optimal as renorraphy and explora- tion can lead to unnecessary nephrectomy. If a major vascular injury occurs and the patient’s intraoperative condition permits, every attempt should be made to reestablish vascular integrity. Bladder dYsFUnCtiOn The reported incidence of difficulty in reestablishing micturation ranges from 15 to 25% after low anterior resection and up to 50% after abdominoperineal resection.(31) A thorough understand- ing of the neuroanatomy of the pelvis and the technique of total mesorectal excision (TME) and autonomic nerve preservation (ANP) can enable both local tumor control and preservation of autonomic nerve structures thus reducing the risk of urogenital dysfunction.(34, 35) Favorable oncologic outcomes have been Figure 36.6 Boari or bladder flap procedure. (A) Creation of tapered bladder flap, based posteriorly. (B) Submucosal ureteral reimplantation. (C) Closure of bladder flap. (A) (B) (C) Figure 36.7 Transureteroureterostomy. Right-to-left, showing retroperitoneal tunnel anterior to the great vessels. reported for these nerve sparing techniques.(35–39) APR, when performed in accordance with the principles of TME and ANP, ensures the greatest likelihood of resecting all regional disease  urologic complications of colorectal surgery while preserving both urinary and sexual function.(39) Locally advanced tumors and preoperative chemotherapy and radia- tion can make identification of the autonomic nerves and plexus more difficult and sometime impossible.(34) The most common sequela from autonomic nerve damage during surgery of the colon and rectum is detrusor denervation and areflexia. This nor- mally requires clean intermittent catheterization, foley catheter placement, or suprapubic tube placement depending on the over- all dexterity and functional status of the patient. Damage to the pudendal nerve or its branches from Alcocks canal can result in weakening of the striated urinary sphincter with resultant stress urinary incontinence and intrinsic sphincter deficiency. Detrusor function (bladder contractility) is predominantly mediated by the parasympathetic nervous system, namely the pelvic nerve.(33) These parasympathetic fibers originate from the spinal cord at the S2–S4 level. Pelvic nerve branches are redundant within the pelvis. The main trunks to the bladder and proximal urethra course in the visceral pelvic fascia, also called the posterior endopelvic fascia.(33) These preganglionic auto- nomic fibers course alongside the superior vesical vasculature to synapse with postganglionic autonomic fibers within the bladder wall. Multiple pelvic preganglionic nerves pass laterally from the pelvic floor over the rectal fascia investments en route medially to the bladder (Figure. 36.8).(33) Sympathetic innervation to the bladder arises at the level of L2–L4 with a presynaptic fiber to the sympathetic ganglion adja- cent to the spinal cord. Synapse occurs in the ganglion and a long post ganglionic fibers travels through the pelvis to innervate the bladder. Through different end receptors located within the blad- der, the sympathetic component of the autonomic nervous sys- tem helps to cause relaxation of the bladder body (compliance for storage) and contraction of the trigone and bladder neck at resting/storage states. Somatic motor innervation to the striated pelvic floor muscu- lature and sphincter arises from the S2–S4 level and travels via the pudendal nerve through Alcocks canal. The perineal branches of the pudendal nerve follow the perineal artery into the super- ficial pouch to supply the ischiocavernosus, bulbospongiosus, and transverse perinei muscles. Some branches continue anteri- orly to supply sensation to the posterior scrotum and perineum. Additional perineal branches pass deep to the perineal membrane to supply the levator ani and striated urethral spincter.(40) In the study by Junginger on total mesorectal excision (TME), identification of the pelvic autonomic nerves was complete in 72%, partial identification in 10.7%, and not at all in 17.3% of patients.(34) Univariate analysis showed that the case number (experience), gender (males > females), and T stage (T1-2 vs. T3-4) exerted an independent influence on the achievement of complete pelvic nerve identification. In this series of 150 patients with adenocarcinoma of the rectum, identification and preser- vation of the autonomic nerves was achieved in a majority of patients and led to the prevention of urinary dysfunction (4.5% vs. 38.5%; p < 0.001).(34) Management of the postoperative patient with bladder dys- function after colorectal surgery includes teaching clean inter- mittent catheterization (CIC) and having the patient return for full urodynamic evaluation around 2–3 months postoperatively. Urodynamics can be a combination of fluoroscopic pressure/flow studies with EMG tracings and sometimes urethral pressure profil- ing. It may take up to 6 months for bladder function to return to its new baseline and CIC may be a lifelong therapy. CIC is performed with a 12–14 french low friction catheter every 4–6 hours and the duration can be adjusted based on the storage pressures and bladder capacity at the time of urodynamic evaluation. There are no drugs with acceptable pharmacokinetics and side-effect profiles that have been shown to clinically increase contractility in the bladder. In a meta-analysis, Branagan et al., reviewed the colorectal surgery literature on suprapubic catheter placement followed by voiding trial versus urethral catheter placement and standard trial of voiding postoperatively.(31) They found favorable results for the suprapubic catheter in terms of incidence of urinary tract infection, and a shorter magnitude and duration of pain and dis- comfort. The ability to simply clamp and unclamp the suprapubic catheter makes management and voiding trials relatively simple especially in patients unable to perform CIC or those at especially high risk for postoperative bladder dysfunction. Suprapubic catheters are particularly useful if autonomic nerves have to be removed during radical pelvic surgery, because normal voiding may be difficult to reestablish and may take several months to recover. In the select patient with voiding dysfunction and delayed recovery, suprapubic catheter placement results in less morbidity and patient discomfort than urethral catheterization.(32) seXUal dYsFUnCtiOn In the urologic community, an emphasis on postoperative sexual function has arisen from studies by Walsh on the anatomic ret- ropubic prostatectomy with preservation of the neurovascular bundles that contribute to erectile function.(41) Most recently, post operative penile rehabilitation is being performed in mul- tiple settings with a theoretical benefit of reducing the time of neuropraxia to the penis and prevention of apoptosis induced atrophy. Although no standardization exists with these rehabili- tation programs, patients are very interested and at the authors’ institution this is discussed preoperatively. Sexual dysfunction has long been associated with rectal surgery in both male and female patients. In male patients, erectile dysfunction is reported in 5 to 65% of patients and ejaculatory dysfunction is reported in Figure 36.8 Innervation of lower urinary tract  improved outcomes in colon and rectal surgery 14 to 69%.(43) Damage to the sacral splanchnic nerve (parasym- pathetic) or the hypogastric nerve (sympathetic) during surgery is the propsed mechanism of injury.(43) Sexual dysfunction is a broad term that encompasses failure of arousal, erection, orgasm, ejaculation, and emission. Complaints from patients after radical pelvic surgery are usually mixed. Erection is parasympathetically mediated and is governed by impulses traveling along the nervi ergentes (S2–S4).(41) The pel- vic plexus is located retroperitoneally on the lateral surface of the rectum 5–11 cm from the anal verge with its midpoint located at the tip of the seminal vesicles. The preganglionic fibers from the nervi ergentes coalesce on the pelvic wall with contributions from the sympathetic fibers and from the hypogastric plexus (T10–L4). Damage to the sympathetic plexus will result in problems with ejaculation including retrograde ejaculation or anejaculation. In a study by Henderson et al., eighty one women and 99 men that had undergone curative rectal cancer surgery were given a validated sexual function questionnaire.(42) Thirty-two percent of women and 50% of men were sexually active compared with 61% and 91% preoperatively. Twenty-nine percent of women and 49% of men reported that “surgery made their sexual lives worse”. Specific sexual problems in women were libido 41%, arousal 29%, lubrication 56%, orgasm 35%, and dyspareunia 46%. In men complaints were impotence/erectile dysfunction 84%, libido 47%, orgasm difficulty 41%, and ejaculation diffi- culties 43%. Patients seldom remembered discussing sexual risks preoperatively and were seldom referred or treated for symptoms postoperatively. Sexual dysfunction should be discussed with rec- tal cancer patients, and when appropriate, efforts to prevent and treat sexual dysfunction should be instituted.(42) In a study of patients by Nam et al., on patients undergoing TME and ANP for rectal carcinoma, factors that most affected postop- erative sexual dysfunction were age older than 60 (sexual desire, p = 0.019), time period within 6 months of surgery (erectile function, p = 0.04), and lower rectal cancer (erectile function p = 0.02).(43) In the urologic literature, penile rehabilitation is started at approxi- mately 1 month postoperatively with evidence suggesting that lack of natural erections during this period of time produces cavern- osal hypoxia.(44) Prolonged periods of cavernosal hypoxia induce fibrosis, which later increases the incidence of venous leak and thus potentiates long-term or permanent erectile dysfunction In consultation with a urologist, sexual dysfunction in the man can be treated with many different modalities. For erectile dys- function, oral phosphodiesterase inhibitors, intraurethral vasoac- tive suppositories, intracavernosal injections, vacuum errection devices, and implantable devices are all options. For ejaculatory dysfunction in a patient desiring pregnancy, semen may be col- lected from the bladder in the case of retrograde ejaculation. Sympathomimetic agents may also be used. For refractory cases, electro-vibratory ejaculation can be performed at specialized cent- ers. It is important to discuss sexual function with the patient both pre and postoperatively as there are many therapeutic options that have been shown to be very satisfactory for both partners. artiFiCial deViCes Thousands of artificial urinary sphincters (AUS) and inflatable penile prosthesis (IPP) have been implanted worldwide for the treatment of stress urinary incontinence and erectile dysfunction, respectively (Figure 36.9). The IPP has one to three components, while the AUS has three components. The three component sys- tems have a reservoir, pump, and cuff or prosthesis that is inter- connected with reinforced tubing. These devices are silicone but develop a capsule around them after implantation. The reservoir is typically placed suprapubically in the space of Retzius. One should make every attempt to refrain from entering this capsule and to prevent contamination of these silicone devices. If con- tamination occurs, either device removal or salvage therapy with copious antibiotic irrigation is recommended, preferably the lat- ter. The risk of device contamination, post operative infection, and damage to the tubing necessitating device removal or reop- eration should be discussed with the patient preoperatively. It is the authors practice to be very conservative in patients with AUS, and we recommend all patients have their device de-activated by a urologist familiar with the AUS before placement of a urethral catheter. There are numerous reports of patients “turning off” their own AUS when in reality they only cycle them, followed by urethral catheterization at the time of surgery and the result is a device ero- sion through the urethra. This is a medico-legal issue that usually can be averted with a preoperative consultation with a urologist. The FDA approved sacral neuromodualtor is the Interstim device manufactured by Medtronic Corp.(45) It is approved for use in patients with refractory urgency and frequency or nonob- structive nonneurogenic urinary retention. A tined lead is placed through the S3 foramen and an implanted generator is placed in a pocket created in the gluteal area/upper hip. The manufacturer recommends against using electrocautery near the generator and to not perform a MRI on any patients with the Interstim device. Figure 36.9 Artificial urinary sphincter (AVS-800); American Medical Systems Inc, Minnetonka, MN. (A) reservoir. (B) cuff. (C) pump. (A) (B) (C)  urologic complications of colorectal surgery It is the authors practice to turn off the device with a Medtronic supplied magnet before any radical pelvic operation. In small patients, appropriate padding must be applied to the area of the implanted generator. MRI is contraindicated although there has been at least one study to show deactivation of the device before MRI to be safe.(46, 47) reFerenCes 1. Rivera R, Barboglio PG, Hellinger M, Gousse AE. Staging rectourinary fistulas to guide surgical treatment. J Urol 2007; 177: 586–8. 2. Fengler SA, Abcarian H. The York Mason approach to repair of iatrogenic rectourinary fistulae. Am J Surg 1997; 173: 213–7. 3. Dreznik Z, Alper D, Vishne TH, Ramadan E. Rectal flap advancement-a simple and effective approach for the treat- ment of rectourethral fistula. Colorectal Dis 2003; 5: 53–5. 4. Culkin DJ, Ramsey CE. Urethrorectal fistula: transanal, trans- sphincteric approach with locally based pedicle interposition flaps. J Urol 2003; 169: 2181–3. 5. Mason AY. Surgical access to the rectum-a transsphincteric exposure. Proc R Soc Med 1970; 63 suppl: 91–4. 6. Crippa A, Dall’oglio MF, Nesrallah HJ et al. The York- Mason technique for recto-urethral fistulas. Clinics 2007; 62: 699–704. 7. Yousseff AH, Fath-Alla M, El-Kassaby AW. Perineal subcuta- neous dartos pedicled flap as a new technique for repairing urethrorectal fistula. J Urol 1999; 161: 1498–500. 8. Visser BC, McAninch JW, Welton ML. Rectourethral fistulae: the perineal approach. JACS 2006; 195: 138–43. 9. Zmora O, tulchinsky H, Gur E et al. Gracilis muscle transpo- sition for fistulas between the rectum and urethra or vagina. Dis Colon Rectum 2006; 49(9): 1316–21. 10. Bruce RG, El-Galley RE, Galloway NT et al. Use of rec- tus abdominis muscle flap for the treatment of complex and refractory urethrovaginal fistulas. J Urol 2000; 163: 1212–5. 11. Elliott SP, McAninch JW, Chi T et al. Management of severe urethral complications of prostate cancer therapy. J Urol 2006; 176; 2508–13. 12. Moore EE, Cogbill TH, Jurkovich GJ et al. Organ injury scal- ing III: Chest wall, abdominal vascular, ureter, bladder, and urethra. J Trauma 1992; 33: 337–9. 13. Armenakas NA, Pareek G, Fracchia JA. Iatrogenic bladder perforations: longterm followup of 65 patients. JACS 2004; 198: 78–82. 14. Van Goor H. Consequences and complications of peritoneal adhesions. Colorectal Dis 2007; 9(Suppl 2): 25–34. 15. Deck AJ, Shaves S, Talner L, Porter JR. Computerized tomog- raphy cystography for the diagnosis of traumatic bladder rupture. J Urol 2000; 164: 43–6. 16. Jarrett TW, Vaughan ED Jr. Accuracy of computerized tomography in the diagnosis of colovesical fistula secondary to diverticular disease. J Urol 1995; 153: 44–6. 17. Kwon EO, Armenakas NA, Scharf SC et al. The poppy seed test for colovesical fistula: big bang, little bucks! J Urol 2008; 179: 1425–7. 18. Nam YS, Wexner SD. Clinical value of prophylactic ureteral stent indwelling during laparoscopic colorectal surgery. J Korean Med Sci 2002; 17: 633–5. 19. Larach SW, Gallagher JT. Complications of laparoscopic sur- gery for rectal cancer: Avoidance and management. Semin Surg Oncol 2000; 18: 265–8. 20. Chahin F, Dwivedi AJ, Paramesh A et al. The implications of lighted ureteral stenting in laparoscopic colectomy. JSLS 2002; 6: 49–52. 21. Scala A, Huang A, Dowson HM, Rockall TA. Laparoscopic colorectal surgery - results from 200 patients. Colorectal Dis 2007; 9: 701–5. 22. Fry et al. Iatrogenic Ureteral Injury. Arch Surg 1983; 118: 454–7 23. Perlmutter AD, Retik AB, Gauer SB. Anomalies of the upper urinary tract. In Harrison JH, Gittees RF, Perlmutter AD, et al., eds. Campbell’s Urology, 4th ed. Philadelphia: WB Saunders, 1979: 1309–98. 24. Anderson, Kabalin, Cadeddu et al. Surgical anatomy of the Retroperitoneum, Adrenals, Kidneys, and Ureters. 34–37. Campbell-Walsh Urology, Elsevier Inc. 9th Edition; 2007 25. Kyzer S, Gordon PH. The prophylactic use of ureteral catheters during colorectal operations. Am Surg 1994; 60: 212–6. 26. Larach SW, Patankar SK, Ferrara A et al. Complications of lap- aroscopic colorectal surgery. Analysis and comparison of early vs. latter experience. Dis Colon Rectum 1997; 40: 592–6. 27. Emam TA, Cuschieri A. How safe is high-power ultrasonic dissection. Ann Surg 2003; 237: 186–91. 28. McAninch JW, Carroll PR, Klosterman PW et al. Renal reconstruction after injury. J Urol 1991; 145: 932–7. 29. Granat M, Gordon T, Issaq E, Shabtai M. Accidental punc- ture of a pelvic kidney: a rare complication of culdocentesis. Am J Obstet Gynecol 1980; 138: 233–5. 30. Zusmer NR Maturo V, Stern M. Pelvic kidney masquerading as adnexal mass. Rev Interam Radiol 1980; 5: 95–6. 31. Branagan GW, Moran BJ. Published evidence favors the use of suprapubic catheters in pelvic colorectal surgery. Dis Colon Rectum 2002; 45: 1104–8. 32. Chaudhri S, Maruthachalam K, Kaiser A et al. Successful voiding after trial without catheter is not synonymous with recovery of bladder function after colorectal surgery. Dis Colon Rectum 2006; 49: 1066–70. 33. Hollabaugh RS Jr, Steiner MS, Sellers KD et al. Neuroanatomy of the pelvis: implications for colonic and rectal resection. Dis Colon Rectum 2000; 43: 1390–7. 34. Junginger T, Kneist W, Heintz A. Influence of identification and preservation of pelvic autonomic nerves in rectal cancer surgery on bladder dysfunction after total mesorectal exci- sion. Dis Colon Rectum 2003; 46: 621–8. 35. Shirouzu K, Ogata Y, Araki Y. Oncologic and functional results of total mesorectal excision and autonomic nerve- preserving operation for advanced lower rectal cancer. Dis Colon Rectum 2004; 47:1442–7. 36. Saito N, Koda K, Nobuhiro K et al. Nerve-sparing surgery for advanced rectal cancer patients: special reference to Dukes C patients. World J Surg 1999; 23: 1062–8.  improved outcomes in colon and rectal surgery 37. Yamakoshi H, Ike H, Oki S et al. Metastasis of rectal cancer to lymph nodes and tissues around the autonomic nerves spared for urinary and sexual function. Dis Colon Rectum 1997; 40: 1079–84. 38. Moriya Y, Sugihara K , Akasu T, Fujita S. Importance of extended lymphadenectomy with lateral node dissection for advanced lower rectal cancer. World J Surg 1997; 21: 728–32. 39. Enker WE, Havenga K, Polyak T et al. Abdominoperineal resec- tion via total mesorectal excision and autonomic nerve preser- vation for low rectal cancer. World J Surg 1997; 21: 715–20. 40. Brooks. Anatomy for the Lower Urinary Tract and Male Genitalia. 2;p69. Campbell-Walsh Urology, 9th Edition, Elsevier Inc; 2007. 41. Walsh PC, Schlegel PN. Radical pelvic surgery with preserva- tion of sexual function. Ann Surg 1988; 208: 391–400. 42. 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: 212–23. 43. Kim NK, Aahn TW, Park JK et al. Assessment of sexual and voiding function after total mesorectal excision with pelvic autonomic nerve preservation in males with rectal cancer. Dis Colon Rectum 2002; 45: 1178–85. 44. Raina R, Pahlajani G, Ararwal A, Zippe CD. Early penile rehabilitation following radical prostatectomy: Cleveland clinic experience. Int J Impot Res 2008; 20: 121–6. 45. Interstim Device Trademarked by Medtronic Corp. 46. Holley et al. MRI Following Interstim Therapy. Presentation at SESAUA Annual Meeting; 2007. 47. Elkelini MS, Hassouna MM. Safety of MRI at 1.5 Tesla in Patients with Implanted Sacral Nerve Neurostimulator. Eur Urol 2006; 50: 311–6.  Index 5-Aminosalicylates (5-ASA) 336–7 5-FU 300 Bevacizumab 301 Cetuximab 301 indications for 301 Irinotecan-Containing Regimens 301 with leucovorin 300 with levamisole 300 Oxaliplatin-Containing Regimens 300–1 see also chemotherapy 6-methyl-mercaptopurine (6-MMP) 337–8 6-methylprednisolone 337 6-Thioguanine Nucleotide (6-TGN) 337–8 AAST grades 378 abdominal colectomy ileorectal anastomosis with 322 abdominal CT 377 abdominal discomfort 367 abdominal radiography 97 bowel obstruction and dilatation 97–8 cecal volvulus 99 pneumoperitoneum 97 sigmoid volvulus 98–9 toxic megacolon 98 abdominal surgery 263 functional outcomes 267 oncologic outcomes 263 preoperative evaluation 263–4 surgical technique 264 patient-centered outcomes 267–8 surgical outcomes anastomotic bleeding 265–6 anastomotic complications 264 anastomotic leak 264–5 anastomotic stricture 265 autonomic nerves injury 267 pelvic hemorrhage 266 splenic injury 266–7 ureteral injuries 267 abdominal trauma colostomy closure outcomes of 384 antibiotic therapy 385–6 blunt colon injury 383 diagnosis 376 epidemiology 375 military perspective 384–5 physical exam computed tomography 377 diagnostic peritoneal lavage (DPL) 376 injury scale 377–8 laparoscopy 377 peritoneal sign 376 seat belt sign 376 ultrasound 376–7 preoperative assessment 375–6 retained fragments 386–7 World War I 375 World War II 375 abdominal wall contouring 356–7 caring 356–7 flap dissection 356, 357 abdominoperineal resection (APR) 278 closure, methods of 280–1 complications 281 abscess 281 intraoperativ hemorrhage 281 non-healing wound and perineal sinus 282 perineal wound complications 282 postoperative hemorrhage 281–2 epidemiology 278 evisceration 283 operative technique 278–80 perineal hernia 283 positioning 278 leg positioning 279 preparation 278 risk factors 282–3 carcinoma 282 fecal contamination 282–3 radiation therapy 282 sexual and urinary function 280 treatment 283 abscess 340 absorbable regenerated cellulose 266 Acticon TM Neosphincter device 231 acute anal fissure 200 calcium channel antagonists versus nitrates acute pilonidal disease 216 Adalimumab 338 adhesions 47–9 grading system for bowel 47, 47 adjuvant chemotherapy for T3 302–3 stage II and IV colon cancer 301–2 stage III colon cancer 302 Advanced Trauma Life Support principles 375 adynamic ileus 110 Agency for Healthcare Research and Quality (AHRQ) 164 aging 8 Altmeier procedure 241–2 alvimopan 367 American College of Surgeons (ACS) 3, 164 American Heart Association (AHA) 134 American Joint Committee on Cancer (AJCC) 301 American Society of Anesthesiologists (ASA) 2, 19 classification 2 American Society of Clinical Oncology (ASCO) 164, 165 American Society of Colon and Rectal Surgeons (ASCRS) 14, 15, 27, 164, 200, 251, 253 aminosalicylates 336 anal dilation 207  index anal encirclement 242, 243–4 anal fissure acute 200–1 chronic 201 classification 199 conservative therapy 200 diagnosis 200 pathophysiology 199 posterior and anterior 199 surgery therapy 206–8 see also acute anal fissure; chronic anal fissure anal fistula 174 Crohn’s disease 192 diagnosis 184–5 etiology 183–4 HIV-positive patient 193 incontinence 190–1 non-surgical management 192–3 recurrence 189–90 surgical therapy advancement flap 186–7 anal fistula plug 188–9 extrasphincteric fistulas 186 fibrin glue 187–8 fistulotomy 186 incision and drainage 185–6 seton placement 186 anal fistula plug 188–9 Anal Fistula Plug™ (AFP) 188 anal skin tags 175 anal sphincter 226–7 anal sphincter injury 389 life-threatening injuries 389 anal sphincteroplasty 229 anal stenosis 174, 208–210 anal ultrasonography 91–2 anastomosis 380 anastomotic complications, postoperative 56 bowel preparation , mechanical 58 case management 56 clinical presentation 59–60 considerations 56–7 dehiscence 56 diagnosis 60 diagnosis 64–5 management 60–2 asymptomatic 60–1 colocutaneous fistula 62 leak with associated abscess 61–2 leak without abscess 61 peritonitis 62 omental pedicle 58 operative intervention 62–3 colostomy creation 62 leaking anastomosis @4:exteriorization of 63 @4:leaving, in place 63 @4:repeat anastomosis after resection 63 @4:resection of 62 @4:short and long-term implications of 63 pelvic drains 59 proximal diversion 57–8 radiation 58–9 stricture 63–4 techniques 58 treatment 64–5 anastomotic leak 264, 324 anemia 1 anesthesia 1 awareness 23 local anesthesia 19 Monitored Anesthetic Care (MAC) 20–1 regional anesthesia 21–3 anoderm 172 anorectal foreign bodies bedside extraction 389 initial assessment 388–9 operative removal 389 sexual implements 388 anorectal manometry 117, 364 anorectal physiology tests (ARP) 228–9 limitations of 87 case management 87 anal ultrasonography 91–2 constipation 92 balloon expulsion test 94 biofeedback 94 colonic transit studies 93 defecography 93 MRI 94 small bowel transit 94 electromyography concentric needle 89–90 single fiber 90 surface 90 fecal continence 87 fecal incontinence, investigations for biofeedback 92 electomyography 91 manometry 87–8, 88 ultrasound 92 pudendal nerve terminal motor latency 90, 90 rectal capacity and sensation 89 Recto-Anal inhibitory reflex 89 sphincter pressure measurement 88–89 anorectal sexually transmitted disease 156–7 anorectal varices 175 antegrade colonic enema 233–4 anthraquinones 367 antibiotic prophylaxis 14 antibiotic therapy abdominal trauma 385–6 anti-Saccharomyces cerevisiae mannan antibodies (ASCA) 332 anti-Saccharomyces cerevisiae 327 apocrine sweat glands 221 appendicitis 117 areflexia 401 argon plasma coagulation 306 arteriovenous sinusoids 178 artificial bowel sphincter 231 artificial urinary sphincters (AUS) components 402 traumatic foley catheter placement 395 ASA Closed Claims Project 21 ASCRS see American Society of Colon and Rectal Surgery Aspirin 135  index ATLS principles see Advanced Trauma Life Support principles AUS see artificial urinary sphincters Australian Safety and Efficacy Register of New Interventional Procedures-Surgical 232 autonomic nerves injury 267 AVASTIN® 301 azathioprine (AZA) 337 Babcock clamp 140 bacteremia 22 bacterium Clostridium botulinum see botulinum toxin Bacteroides 386 balloon expulsion test 94, 364 balloon proctography 117 balsalazide 337 barium enema 112–15, 367 Crohn’s disease 114–15 diverticulitis 115 diverticulosis 115 double contrast 112–13 limitations of 113–14 lymphoma 115 single contrast 112–13 ulcerative colitis 114 Bascom II procedure 220 Bascom operation 219 bedside extraction 389 benzodiazepines 133 Bevacizumab (AVASTIN®) 301 biofeedback therapy failure of 368 for constipation 94 for fecal incontinence 92 limitations 92 pelvic floor dyssynergia dyssynergic-type constipation 368 treatment of 367–8 on slow-transit constipation 368 Bioplastique® 233 bispectral index (BIS) 23 bladder dysfunction autonomic nerve structures 400 innervations 401 oncologic outcomes 400–1 postoperative patient clean intermittent catheterization (CIC) 401 resection 400 total mesorectal excision 401 bladder flap see Boari flap bladder injury delayed bladder injury 396 iatrogenic injury stages 396 risk factor 396 two layer technique 396 bleeding complications 69 bleeding 178, 265–6 blunt colon injury (BCI) 383 Boari flap 399 body temperature and oxygenation 28 botulinum toxin (BT) 205 vs nitrates 206 vs placebo 205–6 randomized controlled trials 205 sphincterotomy 206 bowel function adhesions, grading system for 47, 47 preparation 33–4 mechanical 58 status 34 bowel obstruction and dilatation 97–8 Bridgewater 135 brooke ileostomy proctocolectomy with 319–20 budesonide 337 bupivicaine 19 calcium channel antagonists 203–5 vs nitrates 204 vs placebo 203–4 vs sphincterotomy 204 calcium polycarbophil 179 Cancer Care Outcomes Research and Surveillance Consortium” (CanCORS) 165 cardiovascular disease 3–4 functional status, assessment of 4 preoperative cardiac evaluation Goldman risk model 3 Lee index 3 care paths benefits of 80 case management 79 challenges and concerns 83–4 in colon and rectal surgery 79 development of 80–3 fast track surgery 84–5 guidelines 79 implementation of 80–3 institutional experience 83 objectives of 79 outcome measures, defining and improving 80 realistic expectations 84 cathartic colon” 367 caudal anesthetic 21 cecal volvulus 99 Centers of Medicare and Medicaid Services (CMS) 161, 162 central nervous system (CNS) 20, 227 central neuraxial blockade 21–2 caudal 21 contraindications 22 epidural 21–2 heparin 22 spinal 21 cerebrospinal fluid (CSF) 21 cerebrovascular accidents (CVA) 8 Cetuximab (ERBITUX®) 301 Chance fractures” 376 chemotherapy 287, 300, 314 with colorectal cancer 300–1 future directions 303–4 indications and timing 301–3 side effects 303 chlamydia trachomatis infections 157 chronic anal fissure 201 botulinum toxin (BT) 205 vs nitrates 206 . result in weakening of the striated urinary sphincter with resultant stress urinary incontinence and intrinsic sphincter deficiency. Detrusor function (bladder contractility) is predominantly. dysfunction is reported in 5 to 65% of patients and ejaculatory dysfunction is reported in Figure 36.8 Innervation of lower urinary tract  improved outcomes in colon and rectal surgery 14 to 69%.(43). Colon and Rectal Surgery Aspirin 135  index ATLS principles see Advanced Trauma Life Support principles AUS see artificial urinary sphincters Australian Safety and Efficacy Register of New Interventional