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Page 2 of 17 Chen et al. Mini-invasive Surg 2018;2:42 I http://dx.doi.org/10.20517/2574-1225.2018.59

INTRODUCTION
[1]
The introduction of laparoscopy in the 1990s revolutionized the practice of surgery . Minimally invasive
surgery (MIS) forever changed a breadth of specialties including not only gynecology, urology, and general
[2]
surgery, but also colorectal surgery . The benefits of MIS are innumerable, including a reduction in pain
and narcotic use, shorter length of stay, and earlier return to work compared to conventional open sur-
[2,3]
gery . These tremendous improvements in functional outcomes have translated into an improved quality
of life. Given the significant reduction in overall complications and costs, MIS has become the standard of
[2]
care for multiple benign disease processes .
In the setting of malignant disease, MIS must achieve equivalent oncologic outcomes in survival and lo-
cal control compared to open surgery. The colon cancer laparoscopic or open resection (COLOR) trial and
the United Kingdom Medical Research Council (MRC) conventional vs. laparoscopic-assisted surgery in
colorectal cancer (CLASICC trial) demonstrated laparoscopic surgery for colon cancer to be as effective as
[1,4]
open surgery in terms of oncologic outcomes and preservation of quality of life . Since then, other mul-
ticenter prospective controlled studies have further supported the use of laparoscopic surgery as a safe and
effective alternative to open surgery in the treatment of colon cancer, with five to ten year follow-up analy-
[4,5]
ses showing equal if not better oncologic and functional outcomes .

Despite the strong evidence for the treatment of colon cancer, the evidence in support of MIS as a standard
for rectal cancer is not clear. Furthermore, the definition of MIS for rectal cancer is broad and continues
to evolve with the incorporation of multiple platforms for treatment including robotic-assisted approaches,
transanal endoscopic microsurgery (TEM), transanal minimally invasive surgery (TAMIS), and transanal
total mesorectal excision (TaTME). Given the unique anatomic location of rectal cancers deep in the pel-
vis, the pelvic blood vessels, autonomic nerves, and anal sphincters are all at high risk for injury during
surgery. Open surgery is associated with significant rates of postoperative sexual and urinary dysfunction
[6,7]
ranging from 20% to 100% leading to a profound effect on overall well-being .

There has been more emphasis on measuring “quality of life” after oncologic resection in recent years.
This perhaps is rooted in the The World Health Organization’s definition of health as “a state of complete
physical, mental, and social well-being and not merely the absence of disease.” Quality of life may depend
on many variables including patient factors (e.g., age, culture), tumor factors (e.g., size, distance from anal
verge) and treatment factors (e.g., need for ostomy, radiation, type of surgery).

Early studies on minimally invasive approaches for rectal cancer have not all shown equivalent oncologic
outcomes, and it is still unclear what the effect of these approaches is on functional outcomes. Clinicians
need to counsel patients on the potentially profound effects on quality of life with any approach. In this
review, we examine the evidence on the quality of life outcomes of MIS in treating rectal cancer.

SEARCH STRATEGY
The PubMed database was queried for keywords “rectal cancer”, “quality of life”, “functional outcomes”,
“minimally invasive surgery”, “laparoscopic”, “robotic”, “transanal endoscopic microsurgery”, “transanal
minimally invasive surgery”, and “transanal total mesorectal excision”. Clinical trials, review articles, and
meta-analyses in English that measured patients’ quality of life after rectal cancer were included for review.
Studies were excluded if patients were not distinguished between colon and rectal cancer in the study.

QUALITY OF LIFE ASSESSMENT
The assessment of quality of life depends on patient-reported outcomes conducted through questionnaires.
The most common questionnaires include the non cancer-specific instrument, the medical outcomes study