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appear to be high BMI and a previously irradiated pelvic field. In females, there is also a risk of vaginal

injury during the anterior dissection with the subsequent development of a rectovaginal fistula. The same
registry study reported a 0.3% rate of vaginal perforation.

Long-term functional data is not yet readily available, although some short-term studies have been
[27]
published. Koedam et al. published a prospective quality of life study on thirty patients that showed that
at 6 months, TaTME and laparoscopic TME had similar postoperative functional outcomes. It must be noted
that TaTME patients in this study had initial (1 month) significant decrease in quality of life, physical and
social functioning, fatigue, general experienced pain, anal pain, low anterior resection syndrome and male
[28]
sexual interest which appeared to recover.A second study by Pontallier et al. also showed no functional

difference in bowel habits or urologic function when TaTME was compared to laparoscopic TME.

FUTURE DIRECTIONS
The most pertinent piece of missing literature is a randomized control trial. The COLOR III trial is designed
to fill this gap as a multicenter randomised clinical trial comparing TaTME vs. laparoscopic TME for mid
[29]
and low rectal cancer. Initially, the CRM rate was chosen as primary endpoint within a superiority design ;
however, the trial was subsequently changed to a non-inferiority design with a clinically relevant primary
endpoint of local recurrence rate. This trial is currently in the recruitment phase. However, publication of the
recent ALaCaRT (Australasian Laparoscopic Cancer of the Rectum Trial) and ACOSOG (American College
of Surgeons Oncology Group) Z6051 trials which examined successful achievement of TME both failed to
show non-inferiority of laparoscopy compared to open surgery place some doubt to the use of laparoscopic
TME as a gold standard [30,31] . The authors anticipate that due to this, the publication of COLOR III will not
settle the oncological questions surrounding low rectal cancer surgical technique. Continuing information
will come from the registry data and other case series, including 5-year oncological data.

Developments in surgical equipment and in technology may fill the gap. Surgeons have started to attempt
[32]
a hybrid between TaTME with a robotics platform either for the transanal or intraperitoneal dissection .
Of most interest is the use of a flexible TEMs platform which may alleviate the many ergonomic and access
issues that a single port system such as TAMIS introduces. There have been unpublished reports that
surgeons have started experimenting with this system in TaTME.

Further research is needed to define whether TaTME will provide the perioperative, oncological and
functional outcomes in low rectal cancer surgery. In addition, further development in the education of both
surgeons and trainees is needed to spread this technique if it does prove valuable. It is likely that rather than
prove to be a “silver bullet” solution, TaTME will prove another weapon in the armament of the modern
colorectal surgeon in dealing with low rectal cancer.

DECLARATIONS
Authors’ contributions
Concept and design, drafting the manuscript: Yap R, Monson J

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.