Guidelines for natural orifice specimen extraction surgery (NOSES) in elderly patients with colorectal cancer

doi:10.3877/cma.j.issn.2095-3224.2026.01.002

Abstract

Abstract:

As an innovative minimally invasive surgical technique, natural orifice specimen extraction surgery (NOSES) has been widely applied in the field of colorectal cancer with significant technological breakthroughs. Currently, amid the accelerating global aging process, the incidence of colorectal cancer among the elderly remains persistently high. Population aging poses multiple challenges to the diagnosis and treatment of colorectal cancer: elderly patients exhibit diminished physiological functions, complex comorbidities, and delayed postoperative recovery, which places higher demands on surgical tolerance and perioperative management. Meanwhile, physicians must balance the benefits of minimal invasiveness with surgical risks while ensuring oncological radicality, making traditional diagnosis and treatment models increasingly inadequate to meet the needs of this special population. These challenges serve as the intrinsic motivation for formulating this guideline. For the specific group of elderly patients, standardizing the safe application of NOSES in elderly colorectal cancer patients is of paramount importance. Based on the Guidelines for natural orifice specimen extraction surgery (NOSES) in colorectal cancer (2023 Edition) and integrated with the concept of enhanced recovery after surgery (ERAS), this guideline is formulated. It systematically elaborates on the core principles of NOSES for elderly colorectal cancer, perioperative multidisciplinary collaboration, and other key content, with a focus on critical aspects such as comprehensive preoperative assessment of elderly patients, individualized principles for indications and contraindications, optimized strategies for perioperative multidisciplinary collaboration (including organ function preservation, nutritional status improvement, anesthetic management, surgical technique optimization, ERAS pathways, etc.), and prevention and treatment of postoperative complications. By integrating evidence-based medical evidence with clinical practice experience, this guideline aims to provide standardized technical standards that balance oncological safety and minimally invasive benefits for elderly patients, thereby promoting the scientific application and high-quality development of NOSES in the elderly population.

Key words: Colorectal cancer, Elderly patients, Natural orifice specimen extraction surgery(NOSES), Guideline

Colorectal Cancer Professional Committee of the Chinese Medical Doctor Association;, Chinese Anti-Cancer Association NOSES Professional Committee;, Chinese NOSES Alliance. Guidelines for natural orifice specimen extraction surgery (NOSES) in elderly patients with colorectal cancer[J]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2026, 15(01): 17-30.

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对比维度	老年男性患者	老年女性患者
共同原则	术前全面评估器官功能、优化基础疾病；术中精准操作，减少创伤，注重"无菌、无瘤"原则；术后预防感染、深静脉血栓等并发症	同左
术前评估重点	前列腺功能（增生情况、排尿功能、前列腺特异性抗原检测）、心血管疾病（冠心病、高血压病、房颤抗凝方案）、脑血管疾病（血压管理、血糖血脂调控）、营养与肺功能（吸烟、饮酒史相关）	除心脑血管及肺功能外，阴道条件（黏膜弹性、宽度、炎症）、阴道分泌物检查、盆底功能（子宫脱垂、阴道壁膨出）、骨质疏松与关节疾病
手术路径选择	经直肠取标本为主	同时具有直肠和阴道两个取标本途径，可根据术中具体情况选择
术中操作要点	沿Denonvilliers筋膜分离，避免损伤前列腺；直肠前壁切开及缝合需远离前列腺	沿直肠阴道隔锐性分离，避免阴道壁撕裂；需提拉子宫以暴露视野，防止子宫韧带损伤；阴道后壁切开位置远离宫颈
主要术中风险	前列腺损伤（可能导致血尿、尿瘘）、系膜血管撕裂	阴道壁撕裂、子宫脱垂加重
术后管理重点	尿潴留（常规留置导尿管2~3天，拔管前训练膀胱功能，拔管后首次排尿时间一般不超过8 h，重点关注残余尿量及尿失禁情况）；心血管监测（48 h心电监护，控制血压）	阴道残端护理（碘伏纱布阴道填塞消毒，每日更换一次，连用5~7天）；预防盆腔感染；避免用力排便（使用缓泻剂）
术后常见并发症	尿潴留、心血管事件（心肌缺血、血压波动）	阴道切口愈合不良（渗血、感染）、盆腔感染、盆底功能异常加重
特殊管理措施	术前/术后使用α受体阻滞剂（如坦索罗辛）改善排尿；营养不良者围手术期营养干预	术前3天阴道消毒；部分阴道黏膜变薄、弹性降低的患者可局部使用雌激素软膏改善黏膜状态；术后1周开始盆底肌训练（如凯格尔运动，每日3次，每次10~15 min）

对比维度	老年男性患者	老年女性患者
共同原则	术前全面评估器官功能、优化基础疾病；术中精准操作，减少创伤，注重"无菌、无瘤"原则；术后预防感染、深静脉血栓等并发症	同左
术前评估重点	前列腺功能（增生情况、排尿功能、前列腺特异性抗原检测）、心血管疾病（冠心病、高血压病、房颤抗凝方案）、脑血管疾病（血压管理、血糖血脂调控）、营养与肺功能（吸烟、饮酒史相关）	除心脑血管及肺功能外，阴道条件（黏膜弹性、宽度、炎症）、阴道分泌物检查、盆底功能（子宫脱垂、阴道壁膨出）、骨质疏松与关节疾病
手术路径选择	经直肠取标本为主	同时具有直肠和阴道两个取标本途径，可根据术中具体情况选择
术中操作要点	沿Denonvilliers筋膜分离，避免损伤前列腺；直肠前壁切开及缝合需远离前列腺	沿直肠阴道隔锐性分离，避免阴道壁撕裂；需提拉子宫以暴露视野，防止子宫韧带损伤；阴道后壁切开位置远离宫颈
主要术中风险	前列腺损伤（可能导致血尿、尿瘘）、系膜血管撕裂	阴道壁撕裂、子宫脱垂加重
术后管理重点	尿潴留（常规留置导尿管2~3天，拔管前训练膀胱功能，拔管后首次排尿时间一般不超过8 h，重点关注残余尿量及尿失禁情况）；心血管监测（48 h心电监护，控制血压）	阴道残端护理（碘伏纱布阴道填塞消毒，每日更换一次，连用5~7天）；预防盆腔感染；避免用力排便（使用缓泻剂）
术后常见并发症	尿潴留、心血管事件（心肌缺血、血压波动）	阴道切口愈合不良（渗血、感染）、盆腔感染、盆底功能异常加重
特殊管理措施	术前/术后使用α受体阻滞剂（如坦索罗辛）改善排尿；营养不良者围手术期营养干预	术前3天阴道消毒；部分阴道黏膜变薄、弹性降低的患者可局部使用雌激素软膏改善黏膜状态；术后1周开始盆底肌训练（如凯格尔运动，每日3次，每次10~15 min）

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