With the understanding and mastery of TME and TSD techniques by the majority of colorectal specialists, their application in radical rectal cancer surgery has become more and more widespread. Strictly following the TME technique, the pelvic vegetative nerve should not be damaged in general; although the TSD technique has a larger clearance range, as long as one is familiar with the anatomy and carefully recognizes it, preserving the pelvic vegetative nerve is not too much of a problem. So, can the preservation of the vegetative nerves ensure the radicality of the tumor, is there any impact on postoperative survival, and what is the quality of patient’s survival? This study and the literature show that preservation of the presacral nerves, inferior hypogastric nerves and pelvic plexus on the basis of radical treatment does not increase the rate of local recurrence. In patients with intermediate and advanced rectal cancer, the application of the TME technique and the TSD technique with preservation of the vegetative nerves ( PANP) significantly reduces the incidence of anal and genitourinary dysfunction. Under normal conditions, urinary and sexual functions are innervated by the pelvic vegetative nerves (sympathetic and parasympathetic) and the trunk nerves. The abdominal aortic plexus is located away from the origin of the inferior mesenteric artery; the inferior epigastric plexus is close to the surface of the sacral promontory; the infra-abdominal nerves are partially adjacent to the ureter; the pelvic visceral nerves are accompanied by the lateral portion of the middle rectal artery; the inferior epigastric plexus is located in the posterior and lateral part of the mesorectal tract; the lateral rectal branches are located in the lateral rectal ligament, and the anterior rectal branch crosses anteriorly over the posterior lobe of the Denonvilliers’ fascia; the anterior lobe of the Denonvilliers’ fascia has an erectile nerve in the lateral portion of the tract. The erectile nerve is distributed in the lateral part. Sensory fibers for the bladder run along the parasympathetic nerves to the sacral segments, where they form the spinal reflex centers for the bladder. The pelvic plexus is located in the retroperitoneum and forms secondary plexuses on either side of the rectum and posterior part of the bladder (within the collateral ligaments) in the prostate, seminal vesicles, ejaculatory ducts, corpus cavernosum of the penis in males, and in the uterus, vagina, and clitoris in females. Sympathetic nerves cause the male seminal vesicles and ejaculatory ducts to contract, and at the same time inhibit the bladder detrusor muscle and cause the urethral sphincter to contract, preventing the flow of semen into the bladder; make the penis or clitoris weak; and parasympathetic nerves make the penis or clitoris congested and erect. Short-term dysuria after rectal cancer surgery is mostly caused by traumatic and bacterial periampullary cystitis, edema and fibrosis around the bladder leading to hardening of bladder wall and decrease of contraction force, and displacement of bladder after rectal resection due to loss of support in the void behind the bladder, which can also cause obstruction of bladder neck and cause dysuria, and most of the patients return to normal urination within 3 months; while long-term dysuria is related to more serious pelvic plexus injury. It manifests as bladder urine retention and difficulty in voiding. Maintenance of normal sexual function (especially in men) requires preservation of the pelvic plexus. The anal sphincter is mostly innervated by the pubic nerve, which is not easy to be damaged during the operation, and this is further confirmed by the fact that there are few anal incontinence patients after anal preservation in our group.There are various classifications of PANP surgery according to the parts and number of preserved pelvic phytonaemes, and the more commonly used one is the Sugihara classification. Type I: preservation of all vegetative nerves; type II: removal of presacral plexus, but preservation of bilateral pelvic plexus; type III: removal of presacral plexus, preservation of healthy pelvic plexus; type IV: removal of bilateral pelvic plexus and removal of lymph nodes on both sides, without preservation of vegetative nerves. Domestic and foreign scholars’ opinions on the surgical indications of PANP are not uniform, and most of them think that rectal cancer before Dukes stage C is an excellent indication for PANP, and they advocate bilateral lateral lymph node dissection and preservation of the healthy side of the vegetative nerves. Japanese scholars, based on the experience that normal function can still be maintained by resecting one side or part of the vegetative nerve, advocate expanding the indications for PANP and preserving as much as can be preserved under the premise of radical treatment. In our group, those whose intraoperative cancer was not visible to the naked eye and directly invaded the pelvic plexus underwent TME technique with Sugihara type I or II PANP; those whose tumors had invaded outside the intestinal wall and were in close proximity to the pelvic plexus underwent TSD and bilateral pelvic physeal nerves were preserved as much as possible, which resulted in a good outcome both oncologically and functionally. In this study, we found that a good preoperative evaluation using ultrasound and CT is very critical. A preoperative understanding of the extent of tumor infiltration and its relationship to the pelvic plexus, and a careful determination of the tumor stage during surgery are crucial to the decision of whether to perform TME or TSD, PANP or non-PANP, and to what extent to perform PANP. For TME, it should be noted that the left trunk of the abdominal aortic plexus should be preserved when dealing with the inferior mesenteric vessels, and the peritoneal wall should be carefully separated at the level of the sacral promontory when entering the presacral space and removing lymph nodes at the bifurcation of the abdominal aorta so as not to injure the epigastric plexus, which is in the form of a network in the deeper part of the peritoneum; the submental nerves should be preserved from the bifurcation of the submental nerves, i.e., from the 2 cm below the sacral promontory, when entering the presacral space and separating the rectum. Lateral rectum, when cutting the lateral rectal ligament and clearing lymph nodes, care should be taken to preserve the inferior celiac plexus and pelvic visceral nerves; before separating the rectal mesentery, the general location of the pelvic plexus should be determined according to the projection of the pelvic plexus, as long as it does not exceed the lateral rectum by 1.0 cm and avoids the area between the upper lateral recto-cystic recess of about 4.5 cm and 3.0 cm downward, the pelvic plexus is generally not damaged even if it is not separated or exposed during the operation. Avoid excessive detachment of the posterior lateral aspect of the bladder base and the lateral aspect of the prostate and seminal vesicle glands, as these are the areas where the nerves enter the organ; when detaching the Denonvilliers’ fascia, care should be taken to preserve the integrity of the prostatic peritoneum, as some of the nerve fibers from the pelvic plexus extend across the peritoneum of the prostate to the penis, and damage to this will result in impaired erectile function of the penis. The common requirement for these maneuvers is that the rectal mesentery is operated sharply in the posterior rectal space under direct visualization to avoid excessive retraction of the rectal mesentery. The anatomical scope of TSD is large, and the demands on the surgeon are higher than those of TME, which is prone to comorbidities such as hemorrhage, ureteral injury, presacral venous hemorrhage, and pelvic physeal nerve injury. The findings of Dong Xinshu et al[2] showed that:the lateral metastasis rate of rectal cancer was around 10%, mainly concentrated in the occlusal foramen and internal iliac lymph nodes; lateral metastasis mainly occurred in cancers below the peritoneal reentry fold. Wan Yuanlian et al. reported that the metastasis rate of 462 cases was 41.8%, and the lateral lymph node metastasis rate was 5.7%, and pointed out that age, depth of infiltration, gross staging, and tumor size were important factors affecting metastasis, and that awareness of lymphatic metastasis of rectal cancer should be raised, and it was recommended to perform TSD.In the data of this group, it was not found that the urinary sexual function or the anal sphincter function after TSD was significantly worse than that after TME, and it should be related to the very well preservation of the pelvic vegetative nerves. The present study further confirmed that there was no significant difference in the local recurrence rate between TSD and TME, and more samples are needed to support whether this is related to the pre- and postoperative chemotherapeutic measures in this group of patients. However, the operation of TME is relatively simple, and the resection of rectal mesentery is adjusted from the traditional principle of 5 cm to 2-3 cm, which increases the rate of anus preservation without changing the survival rate and reducing the recurrence rate. TME emphasizes the sharp separation of rectal mesentery under direct vision, which is conducive to the protection of pelvic nerve plexus, and thus performs the nerve-preserving radical rectal cancer surgery. In contrast to conventional surgery, where about 50% of patients lose sexual function and have severely impaired urinary function, Enker et al. reported that in a group of patients under 60 years of age with nerve preservation using the TME technique, only about 15% of patients had impaired sexual function after surgery, and very few had impaired urinary function. Of course, case composition may vary among case groups, as may the surgeon’s understanding of TSD or TME and anatomical maneuvers for urogenital function preservation. However, whether PANP can be widely used in patients with rectal cancer depends on the impact of the procedure on patient survival, recurrence and metastasis.Shirouzu K et al. reported that the 5-year survival rates after PANP surgery for rectal cancer were: 88% to 96.4% for Ducks stage A, 74% to 91.7% for Ducks stage B, and 56.7% to 67.3% for Ducks stage C. The local recurrence rate was 4.8% to 4.3%, and the local recurrence rate was 4.8% to 4.3%, and the local recurrence rate was 4.8% to 4.3%. The local recurrence rate was 4.8%~7.9%; postoperative survival mainly depended on the early detection and intervention of the cancer. Analysis of the literature and the data of our group shows that the comprehensive treatment effect of standardized and standardized PANP is good, and whether the indications for PANP surgery should be appropriately relaxed in the future is an issue worth exploring. Under the “sandwich” therapy (neoadjuvant radiotherapy + surgery + postoperative radiotherapy), the authors believe that the application of TME technique to preserve the vegetative nerve should be an excellent procedure for the majority of rectal cancers.