In this study, 46% of patients who underwent surgery for SCT experienced long-term uro-anorectal dysfunction with minor impact on the QoL. Our findings suggest that the ITH may be a predictive factor for uro-anorectal impairment in this context.
Anorectal impairments were the most common type of dysfunction and manifested as constipation (67%) and/or fecal incontinence (23%). On the other hand, detrusor sphincter dyssynergia (60%) followed by neurogenic bladder (40%) were the most common urologic issues in patients with urinary dysfunction. Previous studies have shown a substantial heterogeneity in the frequency of urinary and anorectal problems following surgical excision of SCT. Urological and anorectal functional outcomes following SCT resection were reportedly observed in 7–37% and 8–47% of patients respectively, without description of combined or isolated dysfunction. (Table 6). Whether functional disorders are caused by a mass effect of the tumor size or surgical damage to intrapelvic nerves and muscles remains controversial in the literature [5,6].
A high incidence of functional impairment in patients operated for SCT resection found to be related to the age at the time of surgery, tumor size, or high-grade Altman classification [5,6,12,13].
In a study similar to ours, Partridge et al. reviewed the outcomes of SCT resection in 45 patients and demonstrated that 58% of the patients did not have impairment of bladder or bowel function, while 42% had dysfunctional sequelae [12]. Likewise, Malone et al. found that 41% of the patients in his study had functional sequelae following resection of SCT [5]. Both Partridge et al. and Malone et al. showed that tumors with Altman type III or higher grades had a higher incidence of fecal and/or urinary incontinence [5, 12]. However, some studies showed no correlation between the Altman type and functional impairment disorders in patients who underwent surgery for SCT [14-16]. Masahata et al. and Hambraeus et al. reported that the maximum tumor size was significantly associated with the high incidence of dysfunctional outcomes [6, 15], while Güler et al. found no significant difference [7]. We were unable to find significant correlations between a high Altman classification or histopathological characteristics of tumors and dysfunctional outcomes (p>0.05) (Table 1). Similar observations were reported by Shalaby et al. [9] However, we observed a significant clinical correlation between ITH and functional impairment (p <0.05) (Table 4), which may be explained by anorectal and urinary bladder innervation. The parasympathetic fibers in the inferior hypogastric plexus originate in between the second and fourth sacral segments of the spinal cord. The sympathetic fibers that innervate the bladder originate between spinal cord segments T11 and L2, and fibers from L5 supply the rectum and anal internal sphincter [17,18]. This supports our observation that functional impairments in patients who underwent surgery for SCT were significantly correlated to ITH and explains why all patients with urinary dysfunction also experienced anorectal dysfunction. Therefore, this suggests that ITH may be a better predictive factor than Altman classification for uro-anorectal dysfunction in patients who underwent surgery for SCT.
The QoL of our patients was assessed using the PinQ, which showed that most of the patients (92%) reported that uro-anorectal functional outcomes only mildly impacted their daily life activities. It has been suggested that the QoL of patients treated for SCT may be impaired due to urinary and anorectal dysfunctions [8,14], however, no correlation was found in our study. Hambraeus et al. were also not able to establish a statistical correlation between physical function and QoL [19].
This study had some limitations, which include its retrospective and single center design and small sample size. The number of patients was insufficient to establish significant correlations for various outcomes. Moreover, only a few patients reported both urological and anorectal dysfunction, but some experienced isolated anorectal dysfunction. Thus, a larger sample size is required to explore this finding. Nonetheless, this has been one of the few studies to use both medical records and questionnaire analysis to evaluate the long-term functional outcomes and predictive factors of uro-anorectal dysfunction in patients treated for SCT. This study emphasizes the need for multi-institutional collaborative research to highlight the main predictive factors of functional impairment.
In conclusion, urinary and anorectal dysfunctions are non-negligible long-term outcomes in patients treated for SCT. These functional impairments were found to be significantly related to the ITH. Thus, preoperative radiological exploration by MRI or CT should be considered for all patients with SCT as a predictive assessment. Moreover, postoperative follow-up allows for the early detection of bladder and anorectal impairments and treatment by conservative measures, which can improve a patient’s QoL. Further multi-center studies are needed to confirm these findings.