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questionnaires, in which scores dropped significantly one month after surgery, but were no longer significantly
different at 6 months after surgery except for social function (P = 0.013) and anal pain (P = 0.013). Bladder
function, male sexual function, and anorectal function after stoma closure was similarly significantly
[53]
worse at one month postoperatively but not significantly different after 6 months .
Another recent study examined 54 consecutive patients with rectal cancer (27 had TaTME vs. 27 had lapa-
roscopic TME) and found that there were comparable functional and quality of life outcomes at 6 months.
On the EORTC QLQ-CR29 questionnaire, more patients in the TaTME group reported more fecal incon-
tinence vs. the laparoscopic TME group, but the overall low anterior resection syndrome (LARS) score was
[54]
no different .
Two ongoing multicenter trials will examine quality of life outcomes in patients who undergo transanal
TME. The COLOR III trial will be an international multicenter superiority trial that will compare 1098
patients with mid or low rectal cancers scheduled for either transanal TME and conventional laparoscopic
[55]
TME for the treatment of low rectal cancers . Although the primary endpoint will be the circumferential
resection margin, the secondary endpoints will include disease-free survival, overall survival, and quality
[56]
of life. Serra-Aracil et al. published a protocol to study a combined TaTME combined with laparoscopy
to evaluate if there would be a lower conversion rate than laparoscopic low anterior resection, and poten-
tially improve patient recovery and overall morbidity, and quality of life measures. Quality of life measures
will be examined preoperatively and 6 months after the closure of protective ileostomy using the EORTC
QLQ-C30, QLQ-CR29, and LARS score.

A summary of studies examining quality of life after TaTME for rectal cancer is found in Table 5.

DISCUSSION
The ideal treatment objectives for rectal cancer include local and systemic disease control, overall survival
and preservation of quality of life. Oncologic outcomes can be measured objectively, following rates of re-
currence and mortality in follow up. On the other hand, questionnaires remain the mainstay of collecting
data on quality of life in rectal cancer patients. These instruments are cost-efficient and practical, and tre-
mendous amounts of data points can be collected in one setting. However, disadvantages of questionnaires
include possible low completion rate, subjective nature of responses, issues interpreting the questions, lack
of conscientious responses, and inability to probe responses. In addition, there may be a statistically sig-
nificant numeric difference found on a quality of life instrument between two approaches, but may not be
clinically relevant. Moreover, the term “quality of life” encompasses many facets of a patient’s well-being
and includes not only fecal incontinence, urinary incontinence, and sexual function, but also body image,
pain, social connections and participation in activities of daily living. As a result, there are many types of
questionnaires and not all studies utilize the same surveys. These factors make it challenging at times to
compare quality of life data across studies. Large randomized studies should all utilize the most validated
and updated scales available.

The results of our review suggest that minimally invasive surgeries for rectal cancer have tremendous
potential in achieving equivalent outcomes to conventional open surgeries with the possible benefit of an
improved quality of life. Most early studies of each of these MIS techniques were single institution and
observational, focusing on safety and feasibility, and then cancer-specific outcomes. As experience grew,
there was a transition to comparative studies, and then finally randomized control trials. Later studies
examine quality of life as a relevant outcome. The most frequently used quality of life questionnaires were
EORTC QLQ-C30, the colorectal module QLQ-CR38 and the SF-36, all validated instruments. Early single
center studies of laparoscopic TME showed potential benefit in quality of life with an MIS approach [20-22] .