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Page 4 of 17 Chen et al. Mini-invasive Surg 2018;2:42 I http://dx.doi.org/10.20517/2574-1225.2018.59

[21]
Braga et al. in 2007 conducted a single center randomized control trial in Italy comparing 168 patients
(83 laparoscopic vs. 85 open) for rectal cancer < 15 cm from anal verge and demonstrated improved gen-
eral health, physical functioning and social functioning in the laparoscopic group at 3, 6, and 12 months
after surgery. In a single center prospective cohort study in India examining sexual and urinary dys-
function in male patients after laparoscopic TME, 34 patients with low (0-6 cm from anal verge) to mid
(7-12 cm from anal verge) rectal cancers who underwent laparoscopic low anterior resections were given
[22]
IPSS and IIEF questionnaires prior to surgery, and at 1, 3, 6, and 12 months after surgery . The study
found patients to have moderate to severe bladder dysfunction in 29.4% of patients at one month which de-
creased to 2.9% at one year. Of the 17 men who were sexually active prior to surgery, 75% of them reported
sexual dysfunction at one month after surgery, which improved with time to 42% of patients at one year af-
ter surgery. The sexual dysfunction reported at one year included impotence for 11% of patients, and issues
[22]
of retrograde ejaculation and decreased climax for 31% patients .
There have been multiple randomized trials examining laparoscopic vs. open surgery for rectal cancer. The
MRC CLASICC trial was a multicenter randomized trial conducted in the UK between 1996 and 2002 in
which 794 patients were randomized to either open (n = 268) or laparoscopic (n = 526) surgery for colon or
rectal cancer [4,23] . Of these patients, 347 completed questionnaires up to three years post-operatively including
the QLQ-C30, QLQ-CR38, IPSS, IIEF, and FSFI. The author found that global quality of life, role functioning,
cognitive functioning, pain, and nausea/vomiting remained the same as baseline at 6 months and 3 years after
surgery. Social function was worse in the laparoscopic group up to three years after surgery, but remained the
same at baseline for the open group. Furthermore, there was no overall difference in bladder function after
open vs. laparoscopic colorectal cancer surgery. Overall sexual function in men was worse at 3 months after
laparoscopic surgery, but by 6 months there was no statistical difference. Additionally, the two independent
risk factors for postoperative male dysfunction were TME and conversion to open surgery. Adjusting for
neoadjuvant radiation therapy did not change the result as the proportion was similar in both groups. No
differences in sexual function were found between laparoscopic vs. open surgery for women [4,23] . However, a
low response rate from women precluded any meaningful conclusions.

The comparison of open vs. laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant
chemoradiotherapy (COREAN) trial in 2014 and colorectal cancer laparoscopic or open resection (COLOR
II) trial in 2015 were both multicenter, non-inferiority, randomized controlled trials that concluded that
laparoscopic surgery was non-inferior to open surgery for the treatment of rectal cancer in terms of three-
year disease free survival, overall survival, and local recurrence [24,25] . In the COREAN trial, the validated
Korean version of the EORTC QLQ-CR38 questionnaire was given pre-operatively and at months 3, 12,
24, and 36 months after proctectomy. Clinical meaningful differences in quality of life were considered if
a ten point difference in a mean score was identified. No clinically significant differences in quality of life
were noted. Therefore, although the study concluded that laparoscopic resection for locally advanced rectal
cancer after neoadjuvant chemoradiation was non-inferior to open resection in the context of oncologic
outcomes, there was no significant benefit in functional outcomes with laparoscopic surgery compared to
[24]
open surgery . Quality of life data from the COLOR II trial also demonstrated no difference in sexual
dysfunction and micturition symptoms after laparoscopic vs. open surgery for rectal cancer [25,26] .

While the COREAN and COLOR II trials both concluded in favor of laparoscopic surgery as a safe non-
inferior alternative to open surgery, the effect of laparoscopic-assisted resection vs. open resection of stage
II or III rectal cancer on pathologic outcomes, the ACOSOG Z6051 trial in the U.S. and Australasian lapa-
roscopic cancer of the rectum (ALaCaRT) trial in Australia both found that laparoscopic surgery failed to
prove to be non-inferior to open surgery in regards to successful oncologic resections [27,28] . They concluded
that the use of laparoscopic surgery for rectal cancer should be conducted with caution. Secondary out-
comes including survival and local recurrence are still being collected. Quality of life outcomes will be
reported in the future.