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Page 2 of 7 De Nardi. Mini-invasive Surg 2018;2:20 I http://dx.doi.org/10.20517/2574-1225.2018.30

open surgery, more sphincter-saving procedures and no impairment of oncological outcomes [8-10] . Another
benefit is that the visualization of the surgical plane is improved in the more difficult part of the operation,
namely the mid- and low rectum, thus allowing more accurate dissection. Potentially, this could enhance
the identification of the pelvic autonomic nerves and their sparing, thus better preserving sexual and void-
[11]
ing functions. Chouillard et al. compared intraoperative visualization of the neurovascular bundles of
Walsh in patients undergoing standard laparoscopic TME or taTME. Bilateral visualization of the nerves
was achieved in 77.8% of patients in the taTME group and in only 33.3% of patients in the standard lapa-
roscopic TME group. Besides better visualization, in the standard TME during anterior dissection of the
mesorectum an excessive traction at the level of the seminal vesicles might injure the neurovascular bundle
[12]
while during the taTME procedure this traction is avoided . Nevertheless taTME has also several draw-
backs. Prolonged dilatation of the anal canal with the trans-anal platform, might damage the sphincter
[13]
muscles and a significantly longer distal resection margin has been described with taTME in several
studies [13,14] . As a result the anastomosis is potentially created more distally with a higher number of hand-
sewn colo-anal anastomosis. This may impair anorectal function. Furthermore, a dissection in a more
peripheral plane could produce inadvertent neural damage, particularly within the learning phase of the
[15]
procedure . Finally an increased rate of urethral injury has been reported in the taTME international reg-
[16]
istry, which could lead to urinary incontinence and dysfunction .

FUNCTIONAL OUTCOME AFTER TME
After rectal cancer surgery a substantial number of patients may report different complaints related to
bowel, sexual, and urinary functions, social relationships and psychological aspects.

[17]
Functional bowel disturbance after rectal resection affects significant numbers of rectal cancer patients .
Many factors have been related to bowel dysfunction such as reduced capacity of the neorectum, dam-
age to the bowel innervation and to the anal sphincter muscles and pudendal nerves, or loss of the recto-
anal inhibitory reflex [18,19] . The level of anastomosis also plays a significant role while lower anastomosis,
particularly colo-anal anastomosis and intersphincteric resections, can lead to a higher risk. In an attempt
to improve postoperative bowel function, the construction of a side-to-end anastomosis, a J-pouch or a
coloplasty has been performed with short term functional improvement but with minimal differences after
[20]
a 2-year follow-up . After rectal resection approximately 60% of patients experience some degree of fecal
incontinence (FI). When evaluated by anorectal manometry, significant impairment of both internal and
[21]
external sphincters, as well as reduced capacity of the neorectum have been demonstrated .
In addition to fecal incontinence, one-third of patients complain other symptoms such as urgency, in-
creased bowel frequency, fragmentation and soiling. These defecation disorders called “anterior resection
[22]
syndrome” can seriously impact on quality of life . Although the symptoms tend to improve over the first
two years after surgery, a permanent impairment of anorectal function is often observed.

Genitourinary function impairment is mainly related to nerve injury during pelvic dissection. After lapa-
roscopic or open TME the reported incidence of urinary dysfunction, including incontinence, retention
and dysuria, ranges between 0% and 26%. Sexual dysfunctions have been more intensively studied in men
than in women; they involve erectile and ejaculatory problems, loss of desire, diminished sexual activity
and anospermia, and ranges between 11% and 38% [23-25] . In the Dutch trial, involving 1861 patients, urinary
incontinence, 5 years postoperatively, was reported by 38% of patients, 72% of whom had normal urinary
function before surgery. Additionally, general sexual dysfunctions 2 years after rectal cancer treatment
[26]
were reported by 62% of women, and by 76% of men .

QUALITY OF LIFE AFTER TME
Quality of life (QoL) in rectal cancer patients is related to the presence and severity of the tumor, to sur-