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but returned to baseline by 26 weeks. Anorectal function was worse at 6 weeks after surgery but returned
to preoperative function at 12 weeks. Urinary function was not affected at any point after surgery. The
study concluded that TEM has a transient and reversible impact on quality of life and anorectal function,
[41]
without affecting urinary function .
TEM has also been studied as a treatment after neoadjuvant chemotherapy and radiation. In a study
comparison between 31 patients with T2 and T3 rectal cancer who underwent either TEM vs. laparoscopic
TME after neoadjuvant therapy, the authors found that the TEM resulted in better body image (P = 0.006),
[42]
defecation function (P = 0.01) and weight loss (P = 0.005) than the laparoscopic group . At one month
after surgery, the TEM group had better symptoms in terms of nausea, vomiting, appetite loss, and
constipation compared to the laparoscopic group. At 6 months, the laparoscopic group had significantly
worse global health status, emotional function, insomnia, and appetite loss, body image, and defecation
problems. At one year, the TEM group showed better body image, defecation problems and weight loss
[42]
compared to the laparoscopic group .

A summary of studies examining quality of life after TEM for rectal cancer is found in Table 3.

TAMIS
TAMIS emerged recently as an alternative to TEM. A flexible transanal multichannel laparoscopic port is
used that is shorter in length than the conventional TEM rectoscope. Advocates state the benefit of TAMIS
as being easier to learn for surgeons who are already proficient in laparoscopy, and more readily available
because no specialized insufflators are needed. Furthermore, the flexible TAMIS platform is lower in cost
and requires less time to setup than TEM. Contrary to TEM which uses a long rectoscope and insufflation,
the TAMIS technique depends entirely on adequate insufflation for maximal exposure due to the short
length of the port. Similar to TEM, TAMIS does not include a TME, and therefore usually yields no nodal
information. Existing data suggests that TAMIS and TEM both only be performed for rectal adenomas and
low risk T1N0 rectal cancers, and patients who refuse proctectomy. If final pathology does reveal high risk
features, positive margins, high tumor grade, then a salvage TME or adjuvant therapy may be needed.

In 2016, a short-term single-center study followed 24 patients with rectal adenomas and low risk T1 cancers
with a median tumor height of 8 cm from the anal verge from 2011 to 2013 before TAMIS and 6 months
[43]
afterwards (2-17 cm) . In total, there were 20 adenomas and 4 low risk T1 cancers. Functional outcomes
were assessed with the fecal incontinence severity index (FISI), and fecal incontinence quality of life (FIQL),
and the generic EuroQol EQ-5D questionnaire. FISI and FIQL scores were unchanged from baseline at 6
[43]
[44]
months, and EQ-5D improved at 6 months . García-Flórez et al. followed 32 patients who underwent
TAMIS over a 40 months period. These patients were not given quality of life questionnaires but ques-
tioned during clinic visit. Four weeks after surgery, 5 patients (15%) complained of minor fecal inconti-
nence to flatus or liquid stool. However, by eight weeks after surgery the incontinence resolved. No urinary
or sexual dysfunction was affected. This study revealed that TAMIS resulted in good short-term and long-
[44]
term functional outcomes comparable to TEM .

Another study published in 2018 compared 37 patients who underwent a TAMIS between 2011 and 2014,
and then compared their quality of life outcomes to 37 matched healthy controls to the same age, gender,
[45]
and socio-economic status . Questionnaires including the SF-36 and FISI questionnaire were given after
a median follow-up duration of 36 months to patients with either adenomas or T1 carcinomas. They found
that TAMIS resulted in impaired social function. This worsening was attributed possibly to the fecal incon-
tinence that occurred in 70% of the patients who underwent TAMIS. The FISI score worsened from 8.3 points
pre-operatively to 10.1 points 3 years after this study. TAMIS patients reported an overall similar quality
of life in comparison to their counterparts. TAMIS patients scored a higher mental health and bodily pain