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Robotic-Assisted Low Anterior Resection of a Rectal Tumor with Concern for Invasion of the Seminal Vesicles
We present a case of a 60-year-old male with low-lying rectal cancer initially staged as a T4b tumor with concern for seminal vesicle invasion. A multidisciplinary decision was made to proceed with a jejunal-sparing operation, resecting only the seminal vesicles to preserve urinary continence. The anatomy of the Denonvilliers’ fascia remains controversial, with important implications for the surgical management of rectal cancers affecting adjacent urogenital structures. The anterior and posterior layers of the Denonvilliers’ fascia were successfully dissected, preserving the seminal vesicles and prostate. Pathology confirmed a mucinous adenocarcinoma with negative margins, and the patient is scheduled for ileostomy reversal. This case highlights how meticulous robotic-assisted dissection of the Denonvilliers’ fascia can avoid the need for urostomy and colostomy, preserving urinary function and demonstrating the potential benefits of improved anatomical understanding in pelvic surgery.
The anatomy of the Denonvilliers’ fascia remains controversial, with important implications for the surgical management of rectal cancers affecting adjacent urogenital structures. We present a case of a 60-year-old male with low-lying rectal cancer initially staged as a T4b tumor with concern for seminal vesicle invasion. A multidisciplinary decision was made to proceed with a jejunal-sparing operation, resecting only the seminal vesicles to preserve urinary continence. The anterior and posterior layers of the Denonvilliers’ fascia were successfully dissected, preserving the seminal vesicles and prostate. Pathology confirmed a mucinous adenocarcinoma with negative margins, and the patient is scheduled for ileostomy reversal. This case highlights how meticulous robotic-assisted dissection of the Denonvilliers’ fascia can avoid the need for urostomy and colostomy, preserving urinary function and demonstrating the potential benefits of improved anatomical understanding in pelvic surgery.
The anatomy of the Denonvilliers’ fascia remains controversial and poorly understood. This has implications for the surgical management of rectal cancers affecting adjacent urogenital structures. There is a current hypothesis that the Denonvilliers’ Fascia consists of an anterior, posterior, and interfascial plane, which is an important anatomical consideration when performing a total mesorectal excision (TME), and before committing to a urostomy. This demonstrates the potential ability of robotic-assisted surgery to perform meticulous and precise fascial dissections to improve post-operative outcomes.
We present the case of a 60-year-old male, who was found to have a low-lying rectal cancer on initial imaging by MRI was a T4b tumor with concern for invasion into the seminal vesicles. The patient underwent Total Neoadjuvant Therapy with incomplete response. He presented for surgical management of his disease, which included a robotic low anterior resection and planned loop ileostomy.
With the concern for ongoing invasion of the genitourinary structures and for potential invasion into the seminal vesicles and prostate, the patient was seen in clinic and a discussion was had regarding the possibility of total pelvic exenteration vs. coloanal anastomosis with resection of the seminal vesicles and diverting loop ileostomy. Both Colorectal and Urology were involved. Due to the location and complexity of this tumor resection, the decision was made to perform a jejunal sparing operation and to only resect the seminal vesicles to preserve urinary continence.
The anterior dissection was then performed by urology, and the seminal vesicles were found to not be involved. The anterior and posterior layers of Denonvilliers Fascia were dissected from one another. The plane was developed nicely with no concern for tumor invasion. The distal limit of the separation was then reached, leaving the seminal vesicles and prostate intact.
Final pathology showed a mucinous adenocarcinoma with all resection margins negative for tumor. The patient recovered as expected and is currently scheduled for an ileostomy reversal.
The meticulous dissection of Denonvilliers’ Fascia allowed for the avoidance of a urostomy and colostomy in the management of a patient with a low-lying rectal cancer with concern for invasion of the seminal vesicles. Instead, this dissection resulted in a temporary ileostomy and preserved the patient’s urinary function. This demonstrates the ability of robotic-assisted surgery to perform meticulous and precise fascial dissections to improve post-operative outcomes. Furthermore, an improved understanding of the Denonvilliers’ fascia anatomy can help to improve post-operative outcomes in pelvic surgeries.
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