Sexual and Urinary Disorders after Treatment of Rectal Cancer by Radiotherapy and Surgery at the Dantec University Hospital of Dakar

We performed a descriptive retrospective study of sexual and urinary disorders after treatment of rectal cancer by radiotherapy and/or surgery at the Dantec University Hospital in Dakar from 2008 to 2015. The objective of the study was to evaluate these sexual and urinary complications and the factors influencing it. We have collected 50 patients. The average age of is 55.7 years with a sex ratio of 0.78. The dominant clinical signs are rectorrhagia (66.0%). Endoscopy (94.0% of patients) showed an ulcerative-budding appearance in 84.0% of cases. The preferred location was the lower rectum 66.0%). The predominant histologic type is adenocarcinoma lieberkunien (82.0%). Computed tomography is performed in 78% of cases and MRI in 30%. Stage III accounts for 70.0% of cases. Thirty-two patients (64.0%) were treated with conventional 2-beam 2D radiation therapy with or without chemotherapy. The total dose of 46 Gy in 23 sessions was the most used, found in 22 patients; 30 Gy in 10 sessions in 9 cases. And 16 Gy in 10 sessions, found in 1 case. Surgery performed was abdominoperineal amputation (58.0%) and conservative surgery (42.0%). We note a complete response in 28.0% of patients; 8.0%, an increase of 16.0% and a stabilization of 4.0%. The sexual disorders are more important after radiotherapy compared to non-irradiated patients: 31.3% vs 5.6% (p = 0.035). We observe respectively that 2%, 6% and 8% of our patients had urinary disorders in the form of acute retention, urinary incontinence, and urinary burning. Patient follow-up time was between 0 and 42.83 months with an estimated average of 34.9 ± 3.37. The evolution is marked at 6 months by a persistence of sexual disorders in 63.8% of cases and urinary dysfunction in 4% of cases.


Introduction
Surgery is the cornerstone of rectal cancer treatment. It consists of total removal of the mesorectum. Neoadjuvant radiotherapy is indicated for locally advanced operable tumors [1].
The locoregional treatment constituted by the association of radiotherapy and surgery can lead to sexual and urinary disorders. We are evaluating this type of complication in the management of rectal cancers at CHU, The Dantec of Dakar.

Study Framework
This study was conducted at the Joliot Curie Institute of Dakar, which includes a radiotherapy unit, a surgery unit and a chemotherapy unit.

Type of Study
It is a descriptive retrospective study of 50 patients treated by surgery and/or radiotherapy for rectal cancer from January 2008 to December 2015.

Objective of the Study
The objective is to assess sexual complications and the influencing factors.

Selection Criteria
We included during this period all consecutive patients with histologically confirmed rectal cancer.

Data Collection and Analysis
We used the following documents: patient medical records, hospitalization, operating room and histopathology laboratory records.
The data collected were entered into Excel and processed using the SPSS 21 software.
At 6 months, the evolution is marked by persistent sexual problems in 63.8% of cases and urinary dysfunction in 4% of cases.
From 3 months the survival, which was 0.978 ± 0.022, decreases to 0.878 ± 0.052 at the 6 th month and stabilizes until the 26th month. It is 0.658 ± 0.194 and was obtained from the 28 th month (Figure 1).

Discussion
The average age of our patients is 55.7 years. It ranges from 65 to 75 years in Western literature [2]. This young age is one more argument for studying sexual disorders after treatment.
We can improve the pre-therapeutic assessment of our patients. Computed tomography is performed for 78% of them. It has a diagnostic accuracy of 55% to 72% for tumor and 25% to 75% for adenopathies.
Magnetic resonance imaging has better resolution for mesorectum. We have done it for 30% of our patients. According to Beets-Tan et al., an IRM distance of 5 mm between the tumor and fascia led to a resection margin of 1 mm on  Abdominal amputation is performed in 58% of cases and sphincter conservation surgery in 42%. The sphincterial conservation rate of different foreign series is given in Table 3.

Sexual Disorders
Very few studies have specifically studied sexual disorders in women. Age is associated with decreased sexual activity in both the male and female population.
Post-operative sexual activity is 86% among those under 60 years and 46% after 60 years [5] [6] [7]. We find a rate of sexual disorders in men lower than that found in foreign series (Table 4).
According to Lange, the risk of nerve damage during dissection in the narrow male pelvis is higher than in women. However, the instruments used to assess sexual disorders are different between men and women, so comparison between the two sexes is difficult [8].
The rate of sexual impotence after rectal surgery varies from 5% to 92% [9] [10]. We found a significant difference depending on the type of surgery. Thus, 66% of our patients had functional sexual disorders after prior resection of the rectum. They were more important after abdominal-perineal amputation. Our results are consistent with the data in the literature [11]. However, the preservation of the autonomic nervous system is not specified in our patients' operating reports.
Like Bonnel et al., Heriot [12]. A Dutch study including 990 patients reported a decline in sexual activity in both sexes after radiotherapy [13].
The efficacy of sildenafil on these disorders has been described. Erectile function is improved in 80% of patients compared to 17% with placebo [14].
Finally, the insertion of a penile prosthesis is effective but irreversible and Table 3. Sphincter conservation rates in our series and in the literature [23].   Short-term estrogen therapy is recommended for genital trophicity disorders [17].

Urinary Problems
Post-operatively, we observed respectively that 2%, 6% and 8% of our patients had urinary problems in the form of acute transient urine retention, urinary incontinence, and urinary burning.
In the literature, the rate of urinary disorders varies between 30% and 70% [18]. According to Fish, the risk of urinary dysfunction increases with age [9].  The persistence of urinary disorders in our series is 4% to 6 months postoperative, higher than the data in the literature 0 to 2.8% [19].
We have an overall survival rate at 5 years of 10%, lower than the data in the literature [20]. This could be explained by the fact that the majority of our patients are received in advanced stages and the preoperative radiochemotherapy indicated to reduce the stage often results in difficult, often incomplete R1-type excision, source of recurrence and mortality in the medium term.

Conclusion
The reduction of sexual and urinary complications in the treatment of rectal cancers and their better evaluation and management will only be achieved through wider transdisciplinary consultation. It will also require the accessibility of modern irradiation methods.