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Page 14 of 17 Chen et al. Mini-invasive Surg 2018;2:42 I http://dx.doi.org/10.20517/2574-1225.2018.59

[37]
at 6 months there was no benefit in robotic surgery in terms of quality of life outcomes . The three year
results have yet to be reported. Like laparoscopic surgery though, robotic surgery may prove to have bet-
ter outcomes in future trials once participating surgeons gain more expertise on their learning curve. The
surgeons in the ROLARR trial had varying levels of experience: surgeons performing laparoscopy had an
average of 91 previous laparoscopic cases while surgeons performing a robotic approach had an average of
50 previous robotic cases, possibly still in their learning curve. In addition, robotic systems are still in their
infancy with newer robotic platforms and technology becoming more widely available.

TEM and TAMIS both allow for local resections that do improve quality of life compared to transabdomi-
nal surgeries that require rectal resections and increase need for diverting or permanent ostomies. These
procedures require stretching of the anorectal ring, and patients should be counseled that may have some
transient changes to their bowel function that can last several months. These modalities are mostly limited
to treatment of early stage cancers. TEM and TAMIS may have a role for local excision after neoadjvuant
therapy as well. This will need to be studied more closely with overall effect on quality of life in future ran-
domized studies.

Transanal TME is the newest of MIS rectal cancer treatments and only small retrospective studies have
described its effects on quality of life [53,54] . There has been some early concern for effect on incontinence
and LARS scores possibility due to the low anastomosis. Morbidity including urethral injury warrants the
need of continued studies as surgeons gain more experience. TaTME should be limited to surgeons who
have taken the proper courses and have adequate mentoring. Studies comparing transanal TME to other
approaches of rectal cancer treatment need to be conducted to better assess the potential benefit in cancer-
specific outcomes and patients’ overall wellbeing. Two future randomized studies may help clarify these
questions [55,56] .

In addition to the aforementioned MIS approaches, a new treatment strategy for rectal cancer has the
potential to change quality of life after therapy for rectal cancer. This “watch-and-wait” strategy is for
select patients who demonstrate a complete clinical response to total neoadjuvant therapy. These patients
are observed closely and do not undergo any proctectomy or local excision if they show no evidence of
recurrence in follow-up. This option is being extensively studied and can be used in multiple scenarios
including after treatment for locally advanced (any T3, or N+) and for lower risk tumors including T2
[58]
and high risk T1 lesions . A small study of 29 near-complete responders who underwent TEM vs. 53
complete responders to neoadjuvant chemotherapy who underwent no further surgery demonstrated a
statistically significant improvement in quality of life and incontinence scores in those patients that had
[59]
a complete response (and no TEM) at the end of a three year follow-up period (2.3 vs. 6.5, P < 0.001) .
In another study comparing 41 watch-and-wait patients to 41 patients who had neoadjuvant and surgery
matched by gender, age, tumor stage, and tumor height, two year follow-up revealed better physical and
cognitive function, body image, and overall global health status in the watch-and-wait group compared to
the surgical group. Furthermore, the “watch-and-wait” patients had fewer problems with defecation, sexual
[60]
and urinary tract function . The quality of life problems that are noted in the “watch-and-wait” group
can be partly attributed to the effects of radiation therapy alone and its known effects on fecal incontinence
and genitourinary function. Still, “watch-and-wait” treatment may be a valid option for complete clinical
responders in the future. More studies will need to be done evaluating the concordance of complete clinical
response with a true pathologic complete response to limit future recurrence. “Watch-and-wait” has the
potential to profoundly impact quality of life after therapy for rectal cancer.

Surgery for rectal cancer is difficult and continues to evolve. Completing a TME safely relies on multiple
patient and surgeon factors. Any approach, including organ-preserving options and local excision, can be
associated with significant changes in quality of life. Care must be taken to study innovative new treatment