Skip to main content

Advertisement

SpringerLink
Log in

Transanally assisted lateral pelvic lymph node dissection for rectal cancer

  • Dynamic Manuscript
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Although lateral pelvic lymph node dissection (LLND) might be an effective approach for patients with rectal cancer with lateral lymph node metastasis, it is technically challenging because of the anatomical complexity and location of the deep pelvis. An assistance by transanal approach might be useful for a successful LLND.

Methods

From September 2016 to May 2021, 39 patients with low rectal cancer underwent transanal total mesorectal excision with LLND. Among them, 18 patients underwent LLND using a conventional laparoscopic approach alone, while the remaining 21 underwent LLND using both conventional and transanal approaches. Their clinical outcomes were retrospectively compared.

Results

The operation time for LLND on each side was significantly shorter in the transanal group (105 min vs. 54 min, P < 0.001). The intraoperative blood loss was also significantly less in the transanal group (40 g vs. 0 g, P = 0.031). The rate of overall postoperative complications ≥ grade II according to the Clavien–Dindo classification was significantly less in the transanal group (66.7% vs. 28.6%, odds ratio: 5.000, 95% confidence intervals: 1.313–19.047, P = 0.040). The number of harvested lateral lymph nodes in both groups was similar (8.5 vs. 8, P = 0.544).

Conclusion

The transanal approach for LLND reduced operative time, blood loss, and morbidity compared with the conventional approach alone in a cohort of patients with rectal cancer.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Fujita S, Mizusawa J, Kanemitsu Y, Ito M, Kinugasa Y, Komori K, Ohue M, Ota M, Akazai Y, Shiozawa M, Yamaguchi T, Bandou H, Katsumata K, Murata K, Akagi Y, Takiguchi N, Saida Y, Nakamura K, Fukuda H, Akasu T, Moriya Y (2017) Mesorectal excision with or without lateral lymph node dissection for clinical stage II/III lower rectal cancer (JCOG0212): a multicenter, randomized controlled, noninferiority trial. Ann Surg 266:201–207

    Article  PubMed  Google Scholar 

  2. Tsukamoto S, Fujita S, Ota M, Mizusawa J, Shida D, Kanemitsu Y, Ito M, Shiomi A, Komori K, Ohue M, Akazai Y, Shiozawa M, Yamaguchi T, Bando H, Tsuchida A, Okamura S, Akagi Y, Takiguchi N, Saida Y, Akasu T, Moriya Y (2020) Long-term follow-up of the randomized trial of mesorectal excision with or without lateral lymph node dissection in rectal cancer (JCOG0212). Br J Surg 107:586–594

    Article  CAS  PubMed  Google Scholar 

  3. Hida K, Nishizaki D, Sumii A, Okamura R, Sakai Y, Konishi T, Akagi T, Yamaguchi T, Akiyoshi T, Fukuda M, Yamamoto S, Arizono S, Uemura M, Hasegawa H, Kawada K, Morita S, Watanabe M (2021) Prognostic impact of lateral pelvic node dissection on the survival of patients in low rectal cancer subgroups based on lymph node size. Ann Surg Oncol. https://doi.org/10.1245/s10434-021-10312-7

    Article  PubMed  Google Scholar 

  4. Schaap DP, Boogerd LSF, Konishi T, Cunningham C, Ogura A, Garcia-Aguilar J, Beets GL, Suzuki C, Toda S, Lee IK, Sammour T, Uehara K, Lee P, Tuynman JB, van de Velde CJH, Rutten HJT, Kusters M (2021) Rectal cancer lateral lymph nodes: multicentre study of the impact of obturator and internal iliac nodes on oncological outcomes. Br J Surg 108:205–213

    Article  CAS  PubMed  Google Scholar 

  5. Liu Y, Shang L, Zhou C, Fang Z, Du F, Wu H, Li L (2021) Prognostic value of lateral pelvic lymph node dissection for rectal cancer: a meta-analysis. J Surg Res 267:414–423

    Article  PubMed  Google Scholar 

  6. Ogura A, Konishi T, Cunningham C, Garcia-Aguilar J, Iversen H, Toda S, Lee IK, Lee HX, Uehara K, Lee P, Putter H, van de Velde CJH, Beets GL, Rutten HJT, Kusters M (2019) Neoadjuvant (Chemo)radiotherapy with total mesorectal excision only is not sufficient to prevent lateral local recurrence in enlarged nodes: results of the multicenter lateral node study of patients with low cT3/4 rectal cancer. J Clin Oncol 37:33–43

    Article  CAS  PubMed  Google Scholar 

  7. Akiyoshi T, Ueno M, Matsueda K, Konishi T, Fujimoto Y, Nagayama S, Fukunaga Y, Unno T, Kano A, Kuroyanagi H, Oya M, Yamaguchi T, Watanabe T, Muto T (2014) Selective lateral pelvic lymph node dissection in patients with advanced low rectal cancer treated with preoperative chemoradiotherapy based on pretreatment imaging. Ann Surg Oncol 21:189–196

    Article  PubMed  Google Scholar 

  8. Matsuda T, Sumi Y, Yamashita K, Hasegawa H, Yamamoto M, Matsuda Y, Kanaji S, Oshikiri T, Nakamura T, Suzuki S, Kakeji Y (2018) Outcomes and prognostic factors of selective lateral pelvic lymph node dissection with preoperative chemoradiotherapy for locally advanced rectal cancer. Int J Colorectal Dis 33:367–374

    Article  PubMed  Google Scholar 

  9. Yang X, Gu C, Hu T, Wei M, Meng W, Wang Z, Deng X, Zhou Z (2021) Indications and oncological outcomes of selective dissection for clinically suspected lateral lymph node metastasis in patients with rectal cancer based on pretreatment imaging. Tech Coloproctol 25:425–437

    Article  PubMed  Google Scholar 

  10. Akasu T, Sugihara K, Moriya Y (2009) Male urinary and sexual functions after mesorectal excision alone or in combination with extended lateral pelvic lymph node dissection for rectal cancer. Ann Surg Oncol 16:2779–2786

    Article  PubMed  Google Scholar 

  11. Matsuoka H, Masaki T, Sugiyama M, Atomi Y (2005) Impact of lateral pelvic lymph node dissection on evacuatory and urinary functions following low anterior resection for advanced rectal carcinoma. Langenbecks Arch Surg 390:517–522

    Article  PubMed  Google Scholar 

  12. Ogura A, Akiyoshi T, Nagasaki T, Konishi T, Fujimoto Y, Nagayama S, Fukunaga Y, Ueno M, Kuroyanagi H (2017) Feasibility of laparoscopic total mesorectal excision with extended lateral pelvic lymph node dissection for advanced lower rectal cancer after preoperative chemoradiotherapy. World J Surg 41:868–875

    Article  PubMed  Google Scholar 

  13. Sylla P, Rattner DW, Delgado S, Lacy AM (2010) NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc 24:1205–1210

    Article  PubMed  Google Scholar 

  14. Penna M, Hompes R, Arnold S, Wynn G, Austin R, Warusavitarne J, Moran B, Hanna GB, Mortensen NJ, Tekkis PP (2017) Transanal total mesorectal excision: international registry results of the first 720 cases. Ann Surg 266:111–117

    Article  PubMed  Google Scholar 

  15. de Lacy AM, Rattner DW, Adelsdorfer C, Tasende MM, Fernández M, Delgado S, Sylla P, Martínez-Palli G (2013) Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: “down-to-up” total mesorectal excision (TME)–short-term outcomes in the first 20 cases. Surg Endosc 27:3165–3172

    Article  PubMed  Google Scholar 

  16. Hasegawa S, Hida K, Kawada K, Sakai Y (2016) Transanal total mesorectal excision for rectal cancer: a video demonstration of rectal dissection. Dis Colon Rectum 59:157

    Article  PubMed  Google Scholar 

  17. de Lacy FB, van Laarhoven J, Pena R, Arroyave MC, Bravo R, Cuatrecasas M, Lacy AM (2018) Transanal total mesorectal excision: pathological results of 186 patients with mid and low rectal cancer. Surg Endosc 32:2442–2447

    Article  PubMed  Google Scholar 

  18. Matsuda T, Yamashita K, Hasegawa H, Urakawa N, Kanaji S, Oshikiri T, Nakamura T, Kakeji Y (2021) Two-team lateral pelvic lymph node dissection assisted by the transanal approach. Dis Colon Rectum. https://doi.org/10.1097/DCR.0000000000002143

    Article  PubMed  Google Scholar 

  19. Weiser MR (2018) AJCC 8th Edition: Colorectal Cancer. Ann Surg Oncol 25:1454–1455

    Article  PubMed  Google Scholar 

  20. Konishi T, Kuroyanagi H, Oya M, Ueno M, Fujimoto Y, Akiyoshi T, Yoshimatsu H, Watanabe T, Yamaguchi T, Muto T (2011) Multimedia article. Lateral lymph node dissection with preoperative chemoradiation for locally advanced lower rectal cancer through a laparoscopic approach. Surg Endosc 25:2358–2359

    Article  PubMed  Google Scholar 

  21. Ueno M, Oya M, Azekura K, Yamaguchi T, Muto T (2005) Incidence and prognostic significance of lateral lymph node metastasis in patients with advanced low rectal cancer. Br J Surg 92:756–763

    Article  CAS  PubMed  Google Scholar 

  22. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213

    Article  PubMed  PubMed Central  Google Scholar 

  23. Kanemitsu Y, Shida D, Tsukamoto S, Moritani K, Sakamoto R (2020) Japanese evidences on nerve-preserving lateral pelvic lymh node dissection for rectal cancer: major historical milestones and clinical impact: the past, present and future. Clin Colon Rectal Surg 33:349–354

    Article  PubMed  PubMed Central  Google Scholar 

  24. Wasmuth HH, Faerden AE, Myklebust TÅ, Pfeffer F, Norderval S, Riis R, Olsen OC, Lambrecht JR, Kørner H, Larsen SG, Forsmo HM, Baekkelund O, Lavik S, Knapp JC, Sjo O, Rashid G, Norwegian TaTME Collaborative Group, on behalf of the Norwegian Colorectal Cancer Group (2020) Transanal total mesorectal excision for rectal cancer has been suspended in Norway. Br J Surg 107(1):121–130

    Article  CAS  PubMed  Google Scholar 

  25. van Oostendorp SE, Belgers HJ, Bootsma BT, Hol JC, Belt EJTH, Bleeker W, Den Boer FC, Demirkiran A, Dunker MS, Fabry HFJ, Graaf EJR, Knol JJ, Oosterling SJ, Slooter GD, Sonneveld DJA, Talsma AK, Van Westreenen HL, Kusters M, Hompes R, Bonjer HJ, Sietses C, Tuynman JB (2020) Locoregional recurrences after transanal total mesorectal excision of rectal cancer during implementation. Br J Surg 107(9):1211–1220

    Article  PubMed  PubMed Central  Google Scholar 

  26. Sylla P, Knol JJ, D’Andrea AP, Perez RO, Atallah SB, Penna M, Hompes R, Wolthuis A, Rouanet P, Fingerhut A, International taTME Urethral Injury Collaborative (2021) Urethral injury and other urologic injuries during transanal total mesorectal excision: an international collaborative study. Ann Surg 274(2):e115–e125

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan

    Takeru Matsuda, Ryuichiro Sawada, Hiroshi Hasegawa, Kimihiro Yamashita, Masako Utsumi, Hitoshi Harada, Naoki Urakawa, Hironobu Goto, Shingo Kanaji, Taro Oshikiri & Yoshihiro Kakeji

  2. Division of Minimally Invasive Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-chou, Chuo-ku, Kobe, 650-0017, Japan

    Takeru Matsuda

Authors
  1. Takeru Matsuda
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ryuichiro Sawada
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hiroshi Hasegawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kimihiro Yamashita
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Masako Utsumi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Hitoshi Harada
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Naoki Urakawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Hironobu Goto
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Shingo Kanaji
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Taro Oshikiri
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Yoshihiro Kakeji
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Takeru Matsuda.

Ethics declarations

Disclosure

Takeru Matsuda, Ryuichiro Sawada, Hiroshi Hasegawa, Kimihiro Yamashita, Masako Utsumi, Hitoshi Harada, Naoki Urakawa, Hironobu Goto, Shingo Kanaji, Taro Oshikiri, and Yoshihiro Kakeji have no conflicts of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (WMV 46349 kb) The lateral pelvic space was entered from the anal side by separating the S4 splanchnic nerve from the levator ani muscle, encountering fatty tissues around the distal branches of the internal iliac vessels, such as the inferior vesical vessels. These fatty tissues were dissected from the vesicohypogastric fascia.

Supplementary file2 (WMV 34974 kb) The fatty tissues, including the obturator compartment, were separated from the levator ani and internal obturator muscles. The obturator nerve was preserved.

Supplementary file3 (WMV 39302 kb) The fatty tissues were dissected from the bottom plane, including the sciatic nerve, coccygeal muscle, and internal pudendal artery. LLND was completed by dissecting these fatty tissues from the obturator nerve and umbilical artery.

Rights and permissions

Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Matsuda, T., Sawada, R., Hasegawa, H. et al. Transanally assisted lateral pelvic lymph node dissection for rectal cancer. Surg Endosc 37, 1562–1568 (2023). https://doi.org/10.1007/s00464-022-09617-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-022-09617-9

Keywords

Search

Navigation