Optimal total mesorectal excision for rectal cancer is by dissection in front of Denorvilliers' fascia

Comment on total mesorectal excision for rectal cancer is by dissection in front of Denorvilliers' fascia Optimal total mesorectal excision for rectal cancer is by dissection in front of Denonvilliers’ fascia (Br J Surg 2004; 91: 121–123) Sir Heald et al. claim that total mesorectal excision (TME) should be carried out by dissection in front of Denonvilliers’ fascia rather than behind it, as suggested by others1,2. In their opinion a plane of dissection posterior to the fascia would be more difficult and oncologically suboptimal. Data in support of Heald’s statements are based on a comparison of two retrospective series2,3 which showed a different outcome only in patients with Dukes’ stage C rectal cancer. Local recurrence rates were 6·5 per cent following TME with an anterior dissection plane, compared to 21 per cent with dissection posterior to Denonvilliers’ fascia. No mention of postoperative sexual dysfunction is made in either of these series. Routine resection of Denonvilliers’ fascia would expose patients to increased risk of parasympathetic nerve damage1. The technique adopted by Killingbach et al.2 is clearly a Denonvilliers’ sparing technique, but within a non- TME procedure. In contrast, the technique proposed by Lindsey et al.1 is a standard TME with an anterior plane of dissection in the mesorectal plane, immediately outside the fascia propria recti and behind the Denonvilliers’ fascia. The higher incidence of recurrence observed in a non-TME series2 might be expected also following the technique proposed by Lindsey. In a recent study4, it was shown that short-term pre-operative radiotherapy reduces the risk of local recurrence in patients with rectal cancer who undergo TME.Why shouldDenonvilliers’ fascia routinely be resected in posterior rectal tumours scheduled for pre-operative radiotherapy? Perhaps it would be more appropriate to perform a TME with resection of Denonvilliers’ fascia only for anterior tumours, or in technically difficult cases. G. Flati, B. Porowska, F. Procacciante Department of Surgery, University of Rome ‘La Sapienza’, Via R. D’Aronco 18, Rome 00163, Italy DOI: 10.1002/bjs.4817 1 Lindsey I, Guy RJ, Warren BF, Mortensen McC. Anatomy of Denonvilliers’ fascia and pelvic nerves, impotence, and implications for colorectal surgeons. Br J Surg 2000; 87: 1288–1299. 2 Killingbach M, Barron P, Dent OF. Local recurrence after curative resection of cancer of the rectum without total mesorectal excision. Dis Colon Rectum 2001; 44: 473–483. 3 Mac Farlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet 1993; 341: 457–460. 4 Kapiteijn E, Marijnen CAM, Nagtegaal ID et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. New Engl J Med 2001; 345: 638–646.