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Chen et al. Mini-invasive Surg 2018;2:42 I http://dx.doi.org/10.20517/2574-1225.2018.59 Page 7 of 17

There is only one randomized study looking at quality of life between the robotic and laparoscopic
[37]
approach. Jayne et al. conducted the effect of robotic vs. laparoscopic resection for rectal cancer
(ROLARR) trial. In this international multicenter study, 471 patients were randomized between 2011 and
2014 to either robotic-assisted or laparoscopic rectal cancer surgery for either high (upper rectum) or
low (total rectum) anterior resection or abdominoperineal resection (rectum and perineum). The study
included 40 surgeons at 29 sites across 10 countries between 2011 to 2014. To be part of the study, surgeons
were required to have performed 30 minimally-invasive rectal resections with at least 10 robotically and
10 laparoscopically. On average, patients received an operation performed by a surgeon with experience
of a median 91 previous laparoscopic operations or a median 50 previous robotic-assisted operations. The
primary outcome revealed a conversion to open rate of 8.1% for robotic-assisted and 12.2 % for laparoscopic
surgery with no statistical significant difference (P = 0.16). The two factors that did show a statistically
significant odds ratio for conversion to open surgery were a high body mass index and male gender. Of
the two quality of life measures compared, bladder dysfunction and sexual dysfunction, neither were
statistically different. The IPSS scores for bladder function were similar at baseline between the two groups
pre-operatively and at 6 months post-operatively. In examining male sexual dysfunction with IIEF scores
and female sexual dysfunction with FSFI scores, no statistically significant differences were identified
[37]
between groups comparing baseline scores to 6 months after surgery .
A summary of studies examining quality of life after robotic surgery for rectal cancer is found in Table 2.

TEM
TEM is a method by which select mid and proximal T1N0 rectal cancer and adenomas are excised endo-
scopically. A 40 mm diameter and up to 20 cm long rectoscope is inserted through the anus using a blunt
obturator. Once the obturator is removed, a faceplate with ports is inserted. An insufflation system gener-
ates and maintains constant pneumorectum. The entire rigid platform is attached to the operating table.
Proponents describe the technique as one allowing a local excision to be performed with a lower rate of
[38]
positive margins, tumor fragmentation, and local recurrence compared to transanal excision . Further-
more, the technique allows for the local resection of more proximal tumors than accessible through con-
ventional transanal excision to be performed without a transabdominal complete mesorectal excision and
rectal resection. This technique additionally negates the need for a diverting stoma. However, critics argue
that the 40 mm diameter rectoscope may stretch the sphincter complex, impair anorectal function, and
can cause fecal incontinence impairing quality of life. Furthermore, the cost of the instruments and plat-
forms is greater than that of a TAMIS set up, but less than open surgery.

[39]
Allaix et al. was one of the first to assess TEM for effects on quality of life. They studied 93 patients who
had undergone TEM for benign rectal lesions or T1N0 rectal cancer and found that the Wexner inconti-
nence scale (range 0-10) was increased from baseline at 3 months, began to decline at 12 months and re-
[39]
turned to baseline preoperative value at 60 months . Another single center study was conducted in which
a EuroQol (EQ-5D-5L) quality of life questionnaire and a Wexner fecal incontinence scale was given to
132 patients who underwent TEM for a variety of rectal lesions including adenocarcinoma with a median
[40]
follow-up period of 96 months . Those considered to have minor to no fecal incontinence were rated as
having a Wexner score of 2 or less. Those considered to have non-minor incontinence were rated as hav-
ing a Wexner score of 3 or more. Thirty eight patients (28.8%) had higher Wexner scores of 3 or more and
worse quality of life. The study concluded that TEM has significant rate of fecal incontinence that impairs
quality of life. In comparison to laparoscopic low anterior resections which have reported Wexner scores of
5.2 ± 4.2 at 6 months postoperatively, and scores of 3.7 ± 3.4 at 12 months, the Wexner scores were similar
[40]
for TEM . TEM, however, still results in much lower fecal incontinence than open surgery which has re-
[36]
ported Wexner scores as high as 14.2 at 6 months and 10.3 at 12 months after surgery .
Another single center study followed 102 patients after TEM, including benign and malignant lesions, from
[41]
2009 to 2012 . Questionnaires including the European quality of life 5 dimensions questionnaire (EQ-