Techniques in Coloproctology (2022) 26:217–226 https://doi.org/10.1007/s10151-022-02579-z MULTIMEDIA ARTICLE “Near‑TME”: proposed standardisation of the technique for proctectomy in male patients with ulcerative colitis A. Garcia‑Granero1,2,3 · G. Pellino4,5 · D. Fletcher‑Sanfeliu6 · M. Millan7 · V. Primo‑Romaguera7 · M. Garcia‑Gausí2 · M. Fernandez1 · X. Gonzalez‑Argente1 · A. Spinelli8,9 · A. Valverde‑Navarro2 · E. Garcia‑Granero7 Received: 30 August 2021 / Accepted: 17 January 2022 / Published online: 1 February 2022 © The Author(s) 2022 Abstract Background The aim of the present study was to describe in detail an approach to proctectomy in ulcerative colitis (UC), which can be standardized; near-total mesorectal excision (near-TME), to prevent injuries to autonomic pelvic nerves and subsequent sexual dysfunction. Methods We demonstrate the technique ex vivo on a cadaver from a male patient in lithotomy position and on a sagittal section of a male pelvis. We also demonstrate the technique in vivo in two male patients diagnosed with UC, with no history of sexual dysfunction or bowel neoplasia. The study was performed at the Human Embryology and Anatomy Department. University of Valencia, Spain. Results The posterolateral dissection during a near-TME is similar to that of an oncologic TME, whereas the anterolateral is similar to that of a close rectal dissection. The near-TME technique preserves the superior hypogastric plexus, the hypogastric nerves, the nervi erigentes, the inferior hypogastric plexus, the pelvic plexus and the cavernous nerves. Conclusion The near-TME technique is the standardisation of the technique for proctectomy in male patients with ulcerative colitis. Near-TME requires experience in pelvic surgery and an exhaustive knowledge of the embryological development and of the surgical anatomy of the pelvis. Keywords Ulcerative colitis · Proctectomy · Close rectal dissection · Intra-mesorectal · Inflammatory bowel diseases · Surgical anatomy Introduction oncologic rectal resection and close rectal dissection (CRD) [2]. Among the proposed techniques for proctectomy in patients Authors of a recent position statement of the Italian with ulcerative colitis (UC), the most frequently described is Society of Colorectal Surgery (SICCR) advised that a total mesorectal excision (TME) [1], commonly used during plane of dissection close to the rectum or an incomplete mesorectal excision is preferred to preserve fertility and 5 * G. Pellino Colorectal Surgery, Vall d’Hebron University Hospital, gianluca.pellino@unicampania.it; gipe1984@gmail.com Barcelona, Spain 6 1 Cardiac Surgery Department, Hospital Universitario Son Colorectal Unit, Hospital Universitario Son Espases, Espases, Palma de Mallorca, Spain Palma de Mallorca, Spain 7 2 Colorectal Surgery, Hospital Universitario Y Politecnico “La Applied Surgical Anatomy Unit, Human Embryology Fe”, Valencia, Spain and Anatomy Department, University of Valencia, Valencia, 8 Spain Department of Biomedical Sciences, Humanitas University, 3 Pieve Emanuele, Milan, Italy Human Embryology and Anatomy Department, University 9 of Islas Baleares, Palma, Spain IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy 4 Department of Advanced Medical and Surgical Sciences, Università Degli Studi Della Campania “Luigi Vanvitelli”, Naples, Italy 13 Vol.:(0123456789) 218 Techniques in Coloproctology (2022) 26:217–226 avoid nerve injuries, if no rectal cancer or dysplasia of Surgical technique any degree is present in the rectum [3]. Some authors confute such an approach, for different reasons, includ- In video 1, we demonstrate the technique on a cadaver from ing the risk of rectal injury, and intraoperative bleeding a male patient in lithotomy position and on a sagittal sec- that makes dissection difficult [4]. The European Crohn’s tion of a male pelvis. In video 2, we demonstrate near-TME and Colitis Organisation (ECCO) consensus on surgery in two male patients diagnosed with UC, with no history of for UC, recommended anterolateral close rectal dissec- bowel neoplasia. tion, in combination with a posterior dissection in the The injury of the autonomic nerves during TME can TME plane [5]. The definition of this technique has not occur at five sites: the superior hypogastric plexus and the been standardised, meaning that a variety of definitions hypogastric nerves can be damaged during the posterior dis- are used (e.g. “badTME”, CRD, intramesorectal dissec- section of the mesorectum, at the level of the promontory; tion, incomplete mesorectal excision), even if only a few the nervi erigentes can be injured during posterior dissec- of them have been clearly described, suggesting that its tion, at the level of S3-S4; the inferior hypogastric plexus surgical steps might need to be clarified. is threatened during the lateral mesorectal dissection, the The aim of the present study was to describe in detail cavernous nerves during anterolateral dissection, and the an approach to proctectomy in UC, which can be stand- connections of cavernous nerves of both sides during the ardised, the near-total mesorectal excision (near-TME), anterior dissection [6] (Fig. 1). to prevent injuries to autonomic pelvic nerves and subse- To preserve the superior hypogastric plexus, during CRD, quent sexual dysfunction. the dissection starts close to the wall of the sigmoid colon, and ligation of the terminal branches of the sigmoid vessels Fig. 1  Drawing and cadaveric dissection showing male pelvic auto- hypogastric plexus, 6: Pelvic plexus, 7: Cavernous nerves, 8: Connec- nomic nerves. 1: Superior hypogastric plexus, 2: Hypogastric tions between the cavernous nerves nerves, 3: Rectal nerves from inferior hypogastric plexus, 5: Inferior 13 Techniques in Coloproctology (2022) 26:217–226 219 is carried out [1]. The dissection during near-TME is started wall of the rectum, most often, accompanied by the middle below the superior rectal artery, and the plexus must be iden- rectal artery. tified at the level of the mesorectum (Fig. 2). The uretero- At this level, the lateral mesenteric fascia is opened, to hypogastric fascia/endopelvic fascia is a useful landmark achieve access to the intra-mesorectal plane, avoiding inju- to preserve both hypogastric nerves [7]. Since this fascia ries to the inferior hypogastric plexus (Fig. 5). contains the hypogastric nerves, performing the dissection Denonvilliers’ fascia can be used as a landmark to avoid between the mesorectal fascia and the ureterohypogastric/ injuries to the cavernosal nerves and their connections. This endopelvic fascia ensures that injuries to hypogastric nerves fascia runs from the pouch of Douglas down to the leva- are avoided. Posterior dissection is performed along this tor ani. The rectum lies posterior to Denonvilliers’ fascia, plane, continued downward to reach the levator ani, as no and the seminal vesicles and the prostate are anterior to the other nerve structures are encountered following this route fascia. The cavernosal nerves originate from the inferior (Fig. 3). hypogastric plexus and run anterolaterally to Denonvilliers’ The nervi erigentes runs laterally to the ureterohypogas- fascia. The connections between the cavernous nerves of tric fascia, and then joins the hypogastric nerves to form the both sides are also anterior to the fascia [8]. During anterior hypogastric pelvic plexus. Such nerve connections are lateral pelvic dissection, the structure should be identified and dis- to the ureterohypogastric fascia, so that they can be pre- sected for no more than 1 cm, to open the pouch of Douglas. served if the posterolateral dissection is continued between The cavernous nerves and their connections are preserved the mesorectal and the ureterohypogastric fascia. if the anterolateral dissection is performed by entering the The posterolateral dissection between the mesorectum mesorectum, following the limited opening in Denonvilliers’ and the ureterohypogastric fascia, continues until inferior fascia (Fig. 6). rectal nerves area (Fig. 4). The inferior rectal nerves come Lastly, the remaining anterior dissection is performed fol- from inferior hypogastric plexus and run to the posterolateral lowing the perirectal plane (Fig. 7), whereas Heald et al. in Fig. 2  Drawing and cadaveric dissection comparing close rectal dis- ervation. 1: Inferior mesenteric artery (IMA), 2: Inferior mesenteric section (CRD), total mesorectal excision (TME) and near-TME dur- vein (IMV), 3: Left colic artery (LCA), 4: Inferior mesenteric plexus, ing inferior mesenteric plexus and superior hypogastric plexus pres- 5: Superior hypogastric plexus 13 220 Techniques in Coloproctology (2022) 26:217–226 Fig. 3  Drawing, cadaveric, and laparoscopic dissection compar- inferior hypogastric plexus, 5: Inferior hypogastric plexus, 6: Pelvic ing close rectal dissection (CRD), total mesorectal excision (TME) plexus, 7: Cavernous nerves, 8: Connections between the cavernous and near-TME during posterior pelvic rectal dissection. 1: Superior nerves hypogastric plexus, 2: Hypogastric nerves, 3: Rectal nerves from the their original description of the technique considered that reasons, including the risk of rectal injury, intraoperative Denonvilliers fascia should be resected in TME surgery [1]. bleeding that makes dissection difficult, and the conse- At this stage, the entire rectal circumference has been quences of leaving an inflamed or affected mesorectum in dissected, and the rectum can be divided (Fig. 8). the pelvis of patients with inflammatory bowel disease since, in the opinion of some authors, this might impact negatively pouch function [4]. Even if the latter might be more relevant Discussion in patients with Crohn’s disease than in those with UC, it should be considered that a proportion of patients might be In male patients, retrograde ejaculation and erectile dysfunc- diagnosed with Crohn’s disease after pouch construction tion are the main sexuality- and fertility-related complica- [10]. tions that may occur after an ileal pouch–anal anastomosis The near-TME dissection relies on a perfect knowledge of [5]. the surgical anatomy of the rectum, mesorectum, autonomic TME is associated with higher risk of injury to autonomic pelvic nerves, and their relationship with pelvic structures. pelvic nerves [6]. CRD consists of a perirectal dissection, In order to safely implement such standardised procedure, with the aim of reducing the risk of injury to these nerves this knowledge can be obtained by surgeons during surgical [2]. Furthermore, some authors argue that the retained mes- simulation on cadavers. Then, surgeons learning near-TME orectal fat would allow for better pelvic filling and could should be supervised by surgeons with experience in mini- reduce the risk of a pre-sacral sinus if the anastomosis leaks mally invasive and inflammatory bowel disease surgery. [9]. Other authors confute such an approach, for different 13 Techniques in Coloproctology (2022) 26:217–226 221 Fig. 4  Cadaveric and laparoscopic dissection showing the area of the tric plexus, 2: Hypogastric nerves, 3: Rectal nerves from inferior inferior rectal nerves. Nerves coming from the inferior hypogastric hypogastric plexus, *endopelvic/ureterohypogastric fascia plexus to the posterolateral wall of the rectum. 1: Superior hypogas- The posterolateral dissection between the mesorectum fascia. However, the anterior mesorectum is much thinner and the ureterohypogastric fascia, makes it possible to pro- and less represented. Hence, during near-TME, the rectal tect the superior hypogastric plexus, the hypogastric nerves serosa should be identified, to avoid damaging the above and the inferior hypogastric plexus, and the nervi erigen- reported nerve structures. tes. To avoid injuries to the pelvic plexus, the cavernous nerves and their connection with the contralateral bundle, the dissection must be performed posterior to Denonvilliers’ 13 222 Techniques in Coloproctology (2022) 26:217–226 Fig. 5  Drawing and laparoscopic dissection comparing close rectal 2: Hypogastric nerves, 3: Rectal nerves from inferior hypogastric dissection (CRD), total mesorectal excision (TME) and near-TME plexus, 5: Inferior hypogastric plexus, 6: Pelvic plexus, 7: Cavernous during lateral pelvic rectal dissection. 1: Superior hypogastric plexus, nerves, 8: Connections between the cavernous nerves 13 Techniques in Coloproctology (2022) 26:217–226 223 Fig. 6  Drawing and laparoscopic dissection comparing close rec- tric plexus, 2: Hypogastric nerves, 3: Rectal nerves from inferior tal dissection (CRD), total mesorectal excision (TME) and near- hypogastric plexus, 5: Inferior hypogastric plexus, 6: Pelvic plexus, 7: TME during anterior pelvic rectal dissection. 1: Superior hypogas- Cavernous nerves, 8: Connections between the cavernous nerves 13 224 Techniques in Coloproctology (2022) 26:217–226 Fig. 7  Male sagittal pelvis. Drawing and cadaveric dissection com- 4: Anterior mesorectum, 5: Prostate, 6: Seminal vesicle, 7: Denonvil- paring close rectal dissection (CRD), total mesorectal excision (TME) liers´ fascia, 8: Pouch of Douglas, 9: Bladder, 10: Levator ani muscle, and near-TME. 1: Rectum, 2: Anal canal, 3: Posterior mesorectum, 11: Sacrum, 12: Pubis 13 Techniques in Coloproctology (2022) 26:217–226 225 Fig. 8  Surgical specimen of proctectomy comparing close rectal dissection (CRD), total mesorectal excision (TME) and near-TME. (CRD speci- men: courtesy of Dr Antonino Spinelli, Humanitas Research Hospital, Rozzano (MI), Italy; TME specimen from a rectal cancer procedure, courtesy of Dr Eduardo Garcia-Granero, Hospital Unviersitario y Politec- nico La Fe, Valencia, Spain) Conclusion References Near-TME is a proposed standardisation of the technique for 1. Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery–the clue to pelvic recurrence? Br J Surg proctectomy in male patients with ulcerative colitis, which 69:613–616 can potentially reduce the risks of nerve injuries and bleed- 2. Lee EC, Dowling BL (1972) Perimuscular excision of the rectum ing, provided that this is performed by adequately trained for Crohn’s disease and ulcerative colitis. A conservative tech- surgeons. The posterolateral dissection is similar to that of nique. Br J Surg 59:29–32 3. Pellino G, Keller DS, Sampietro GM, Carvello M, Celentano V, an oncologic TME, whereas the anterolateral is similar to Coco C, Colombo F, Geccherle A, Luglio G, Rottoli M, Scarpa that of a CRD. M, Sciaudone G, Sica G, Sofo L, Zinicola R, Leone S, Danese S, Spinelli A, Delaini G, Selvaggi F; Italian Society of Colorec- Supplementary Information The online version contains supplemen- tal Surgery SICCR (2020) Inflammatory bowel disease position tary material available at https://​doi.​org/​10.​1007/​s10151-​022-​02579-z. statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis. Tech Coloproctol. 24:397-419. doi: https://​doi.​ Funding No funding was received for the current manuscript. org/​10.​1007/​s10151-​020-​02175-z 4. Carannante F, Mazzotta E, Mascianà G, Caricato M, Capolupo G (2020) Intramesorectal or total mesorectal excision for ulcerative Declarations colitis: what is better for the patient? Minerva Chir 75:470–471 5. Oresland T, Bemelman WA, Sampietro GM, Spinelli A, Windsor Conflict of interest The authors declare no conflict of interests. A, Ferrante M et al (2015) European evidence based consensus on surgery for ulcerative colitis. J Crohns Colitis 9:4–25 Open Access This article is licensed under a Creative Commons Attri- 6. Kim NK, Kim YW, Cho MS (2015) Total mesorectal excision bution 4.0 International License, which permits use, sharing, adapta- for rectal cancer with emphasis on pelvic autonomic nerve pres- tion, distribution and reproduction in any medium or format, as long ervation: expert technical tips for robotic surgery. Surg Oncol as you give appropriate credit to the original author(s) and the source, 24:172–180 provide a link to the Creative Commons licence, and indicate if changes 7. Takenaka A, Hara R, Soga H, Murakami G, Fujisawa M (2005) A were made. The images or other third party material in this article are novel technique for approaching the endopelvic fascia in retropu- included in the article's Creative Commons licence, unless indicated bic radical prostatectomy, based on an anatomical study of fixed otherwise in a credit line to the material. If material is not included in and fresh cadavers. JU Int 95:766–771 the article's Creative Commons licence and your intended use is not 8. Chew M-H, Yeh Y-T, Lim E, Seow-Choen F (2016) Pelvic auto- permitted by statutory regulation or exceeds the permitted use, you will nomic nerve preservation in radical rectal cancer surgery: changes need to obtain permission directly from the copyright holder. To view a in the past 3 decades. Gastroenterol Rep (Oxf) 4:173–185 copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. 13 226 Techniques in Coloproctology (2022) 26:217–226 9. Bartels SA, Gardenbroek TJ, Aarts M et al (2015) Short-term mor- Publisher's Note Springer Nature remains neutral with regard to bidity and quality of life from a randomized clinical trial of close jurisdictional claims in published maps and institutional affiliations. rectal dissection and total mesorectal excision in ileal pouchanal anastomosis. Br J Surg 102:281–287 10. Pellino G, Vinci D, Signoriello G, Kontovounisios C, Canonico S, Selvaggi F, Sciaudone G (2020) Long-term bowel function and fate of the ileal pouch after restorative proctocolectomy in patients with crohn’s disease: a systematic review with meta-analysis and metaregression. J Crohns Colitis 14:418–427 13