Abstract
Objective
Preliminary results of the transanal approach for low rectal cancer suggest better oncological outcomes than the conventional laparoscopic approach. We currently report the functional results.
Methods
From 2008 to 2012, 100 patients with low rectal cancer and suitable for sphincter-saving resection were randomized between transanal and laparoscopic low rectal dissection. Patients derived from this randomized trial were enrolled for functional assessment. End points were bowel function (LARS bowel and Wexner continence scores) and urogenital function (IPSS, IIEF-5 and FSFI-6 scores) obtained by questionnaires sent to patients with a follow-up more than 12 months.
Results
Overall, 76 patients were eligible and 72 responded to the questionnaire: 38 in the transanal group and 34 in the laparoscopic group. The bowel function did not differ between the transanal and the laparoscopic groups: LARS 36 versus 37 (p = 0.941) and Wexner 9 versus 10 (p = 0.786). The urologic function was also similar between the two groups: IPSS 5.5 versus 3.5 (p = 0.821). Among sexually active patients before surgery, 20 of 28 (71 %) patients in the transanal group and 9 of 23 (39 %) in the laparoscopic group maintained an activity after surgery (p = 0.02). Erectile function was also better in men after transanal compared to laparoscopic low rectal dissection: IIEF 17 versus 7 (p = 0.119).
Conclusion
Transanal approach for low rectal cancer did not change bowel and urologic functions compared to the conventional laparoscopic approach. However, there was a trend to a better erectile function with a significantly higher rate of sexual activity in the transanal group.
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References
Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK (1998) Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg 133:894–899
Schiessel R, Karner-Hanusch J, Herbst F, Teleky B, Wunderlich M (1994) Intersphincteric resection for low rectal tumors. Br J Surg 81:1376–1378
Jayne DG, Guillou PJ, Thorpe H, Quirke P, Copeland J, Smith AM et al (2007) Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASSIC Trial Group. J Clin Oncol 25:3061–3068
Kang SB, Park JW, Jeong SY, Nam BH, Choi HS, Kim DW et al (2010) Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol 11:637–645
Laurent C, Leblanc F, Wutrich P, Scheffler M, Rullier E (2009) Laparoscopic versus open surgery for rectal cancer: long-term oncologic results. Ann Surg 250:54–61
Park JS, Choi GS, Jun SH, Hasegawa S, Sakai Y (2011) Laparoscopic versus open intersphincteric resection and coloanal anastomosis for low rectal cancer: intermediate-term oncologic outcomes. Ann Surg 254:941–946
Akiyoshi T, Kuroyanagi H, Oya M, Konishi T, Fukuda M, Fujimoto Y et al (2009) Factors affecting the difficulty of laparoscopic total mesorectal excision with double stapling technique anastomosis for low rectal cancer. Surgery 146:483–489
Nagtegaal ID, Quirke P (2008) What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol 26:303–312
Denost Q, Adam JP, Rullier A, Buscail E, Laurent C, Rullier E (2014) Perineal transanal approach: a new standard laparoscopic sphincter-saving resection in low rectal cancer, a randomized trial. Ann Surg 260:993–999
Teramoto T, Watanabe M, Kitajima M (1997) Per anum intersphincteric rectal dissection with direct coloanal anastomosis for lower rectal cancer: the ultimate sphincter-preserving operation. Dis Colon Rectum 40(10 Suppl):S43–S47
Watanabe M, Teramoto T, Hasegawa H et al (2000) Laparoscopic ultralow anterior resection combined with per anum intersphincteric rectal dissection for lower rectal cancer. Dis Colon Rectum 43(10 Suppl):S94–S97
Uchikoshi F, Nishida T, Ueshima S, Nakahara M, Matsuda H (2006) Laparoscope-assisted anal sphincter-preserving operation preceded by transanal procedure. Tech Coloproctol 10:5–9
Funahashi K, Koike J, Teramoto T, Saito N, Shiokawa H, Kurihara A (2009) Transanal rectal dissection: a procedure to assist achievement of laparoscopic total mesorectal excision for bulky tumor in the narrow pelvis. Am J Surg 197:46–50
Funahashi K, Shiokawa K, Teramoto T, Koike J, Kaneko H (2011) Clinical outcome of laparoscopic intersphincteric resection combined with transanal rectal dissection for T3 low rectal cancer in patients with a narrow pelvis. Int J Surg Oncol 2011:901574. doi:10.1155/2011/901574
Portier G (2007) Recommendations for clinical practice. Therapeutic choices for rectal cancer. How should neoadjuvant therapies be chosen? Gastroenterol Clin Biol 31:55–67
Bretagnol F (2007) Recommendations for clinical practice. Therapeutic choices for rectal cancer. What role should local treatment play in rectal cancer? Gastroenterol Clin Biol 31(1):1S63-74–1S97-100
Gérard JP, Conroy T, Bonnetain F, Bouché O, Chapet O, Ducreux M et al (2006) Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3–4 rectal cancers: results of FFCD 9203. J Clin Oncol 1(24):4620–4625
Emmertsen KJ, Laurberg S (2012) Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer. Ann Surg 255:922–928
Juul T, Ahlberg M, Biondo S, Espin E, Jimenez LM, Matzel KE et al (2014) International validation of the low anterior resection syndrome score. Ann Surg 259:728–734
Jorge JM, Wexner SD (1993) Etiology and management of fecal incontinence. Dis Colon Rectum 36:77–97
Denost Q, Laurent C, Capdepont M, Zerbib F, Rullier E (2011) Risk factors for fecal incontinence after intersphincteric resection for rectal cancer. Dis Colon Rectum 54:963–968
Dumont F, Goéré D, Honoré C, Elias D (2012) Transanal endoscopic total mesorectal excision combined with single-port laparoscopy. Dis Colon Rectum 55:996–1001
Sylla P, Bordeianou LG, Berger D, Han KS, Lauwers GY, Sahani DV et al (2013) A pilot study of natural orifice transanal mesorectal excision with laparoscopic assistance for rectal cancer. Surg Endosc 27:3396–3405
De Lacy AM, Rattner DW, Adelsdorfer C, Tasende MM, Fernandez M, Delgado S et al (2013) Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: “down-to-up” total mesorectal excision (TME)—short-term outcomes in the first 20 cases. Surg Endosc 27:3165–3172
Deijen CL, Velthuis S, Tsai A, Mavroveli S, De Lange-de Klerk ES, Sietses C, et al (2015) COLOR III: a multicentre randomised clinical trial comparing transanal TME versus laparoscopic TME for mid and low rectal cancer. Surg Endosc
Del Río C, Sánchez-Santos R, Oreja V, De Oca J, Biondo S, Parés D et al (2004) Long-term urinary dysfunction after rectal cancer surgery. Colorectal Dis 6:198–202
Jayne DG, Brown JM, Thorpe H, Walker J, Quirke P, Guillou PJ (2005) Bladder and sexual function following resection for rectal cancer in a randomized clinical trial of laparoscopic versus open technique. Br J Surg 92:1124–1132
Stephens RJ, Thompson LC, Quirke P (2010) Impact of short-course preoperative radiotherapy for rectal cancer on patients’ quality of life: data from the Medical Research Council CR07/National Cancer Institute of Canada Clinical Trials Group C016 randomized clinical trial. J Clin Oncol 20(28):4233–4239
Hendren SK, O’Connor BI, Liu M, Asano T, Cohen Z, Swallow CJ et al (2005) Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer. Ann Surg 242:212–223
Tekkis PP, Cornish JA, Remzi FH, Tilney HS, Strong SA, Church JM et al (2009) Measuring sexual and urinary outcomes in women after rectal cancer excision. Dis Colon Rectum 52:46–54
Traa MJ, De Vries J, Roukema JA, Den Oudsten BL (2012) The preoperative sexual functioning and quality of sexual life in colorectal cancer: a study among patients and their partners. J Sex Med 9:3247–3254
Segelman J, Martling A, Machado M, Holm T, Bergmark K, Radestad AF (2013) Preoperative sexual function in women with rectal cancer. Eur J Surg Oncol 39:1079–1086
Lange MM, Marijnen CA, Maas CP, Putter H, Rutten HJ, Stiggelbout AM et al (2009) Risk factors for sexual dysfunction after rectal cancer treatment. Eur J Cancer 45:1578–1588
Denost Q, Adam JP, Pontallier A, Celerier B, Laurent C, Rullier E (2015) Laparoscopic total mesorectal excision with coloanal anastomosis for rectal cancer. Ann Surg 261:138–143
Rouanet P, Mourregot A, Azar CC et al (2013) Transanal endoscopic proctectomy: an innovative procedure for difficult resection of rectal tumors in men with narrow pelvis. Dis Colon Rectum 56:408–415
Fernández-Hevia M, Delgado S, Castells A et al (2015) Transanal total mesorectal excision in rectal cancer: short-term outcomes in comparison with laparoscopic surgery. Ann Surg 261:221–227
Tuech JJ, Karoui M, Lelong B et al (2015) A step toward NOTES total mesorectal excision for rectal cancer: endoscopic transanal proctectomy. Ann Surg 261:228–233
Kneist W, Wachter N, Paschold M, Kauff DW, Rink AD, Lang H et al (2016) Midterm functional results of taTME with neuromapping for low rectal cancer. Tech Coloproctol 20:41–49
Pocard M, Zinzindohue F, Haab F, Caplin S, Parc R, Tiret E (2002) A prospective study of sexual and urinary function before and after total mesorectal excision with autonomic nerve preservation for rectal cancer. Surgery 131:368–372
Nishizawa Y, Ito M, Saito N, Suzuki T, Sugito M, Tanaka T (2011) Male sexual dysfunction after rectal cancer surgery. Int J Colorectal Dis 26:1541–1548
Moriya Y (2006) Function preservation in rectal cancer surgery. Int J Clin Oncol 11:339–343
Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Pena BM (1999) Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res 11:319–326
Baser RE, Li Y, Carter J (2012) Psychometric validation of the Female Sexual Function Index (FSFI) in cancer survivors. Cancer 15(118):4606–4618
Targarona EM, Balague C, Pernas JC, Martinez C, Berindoague R, Gich I et al (2008) Can we predict immediate outcome after laparoscopic rectal surgery? Multivariate analysis of clinical, anatomic, and pathologic features after 3-dimensional reconstruction of the pelvic anatomy. Ann Surg 247:642–649
Costello AJ, Brooks M, Cole OJ (2004) Anatomical studies of the neurovascular bundle and cavernosal nerves. BJU Int 94:1071–1076
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Dr. Arnaud Pontallier, Dr. Quentin Denost, Dr. Bart van Geluwe, Dr. Jean-Philippe Adam, Dr. Bertrand Celerier, and Pr. Eric Rullier have no conflicts of interest or financial ties to disclose.
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Pontallier, A., Denost, Q., Van Geluwe, B. et al. Potential sexual function improvement by using transanal mesorectal approach for laparoscopic low rectal cancer excision. Surg Endosc 30, 4924–4933 (2016). https://doi.org/10.1007/s00464-016-4833-x
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DOI: https://doi.org/10.1007/s00464-016-4833-x