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De Nardi. Mini-invasive Surg 2018;2:20 I http://dx.doi.org/10.20517/2574-1225.2018.30 Page 3 of 7

gical morbidity, to the effects of surgery on genitourinary and bowel function, and to adjuvant or neo-
adjuvant therapies. The relationship between postoperative functional disorders and QoL is not fully clari-
fied and is not frequently reported in the literature; the impact of dysfunctions on well-being may vary
according to patients’ expectations and length of follow-up. The first studies investigating QoL after rectal
cancer surgery were mainly focused on the effect of permanent stoma. Although there is a general consen-
sus that QoL is worse after an abdominoperineal resection than after an anterior rectal resection, a recent
Cochrane review failed to demonstrated a clear advantage of sphincter-saving operations over permanent
[27]
[28]
colostomies . In a study by Vironen et al. assessing surgery-related adverse effects on quality of life,
major bowel dysfunction impaired social functioning, while incontinence and fecal urgency also affected
mental health, and general health perception. Urinary dysfunctions worsened social functioning while,
among sexual dysfunctions, only a complete loss of erection but no partial dysfunction, was associated
with significantly worse physical and social functioning.

INSTRUMENTS MEASURING FUNCTION AND QOL
A number of scoring systems for the assessment of symptoms after rectal cancer surgery have been created
in order to objectively describe the characteristics and severity of symptoms and to compare the outcomes
of different conservative and surgical treatments or to compare results of published data.

[29]
For the evaluation of continence, information on frequency and quantity of loss is fundamental , but the
ability to defer defecation, the use of pads, the impact of symptoms on work activity or on lifestyle [30,31] or
[32]
the use of specific medication should be also taken into account.

For other bowel dysfunctions arising after rectal resection, a low anterior resection syndrome score (LARS
[22]
score) has been created and has been recently internationally validated ; based on the results, three
groups with no, minor and major LARS have been described. This scale is a reliable tool in clinical prac-
tice, also considering the high correlation between the LARS score and quality of life: significant differ-
ences were found between patients with no LARS and major LARS particularly in several subscales such as
[33]
global health, social functioning and role functioning .

Concerning the assessment of quality of life, several questionnaires have been expressly created for evalu-
[35]
[34]
ating the health status of cancer patients or, more specifically, of colorectal cancer patients . Postop-
erative QoL in cancer patients depends on many factors related to the tumor itself, to the treatments or to
dysfunctions. These cancer specific questionnaires more accurately reflect the impact of all these factors on
different aspects of health, since more generic questionnaires, or questionnaires for other benign anorectal
conditions, might not be of sufficient sensitivity to detect differences.

A more detailed description of questionnaires employed in the assessment of functional impairment and
QoL in rectal cancer patients is reported in the Supplementary Material.

ANORECTAL, SEXUAL, URINARY, AND QUALITY OF LIFE OUTCOMES AFTER TATME
At present, data on anorectal, sexual and urinary functions after taTME are scanty. There are few studies,
usually involving a limited number of patients, and short follow-up. Moreover, as far as function is con-
cerned, few comparative studies with standard TME and no randomized trial are available.

Four studies published between 2013 and 2015, reflecting the initial experience with this technique, were
mainly focused on feasibility and short term surgical results, however they also tried to assess anorectal
symptoms. All of them only evaluated fecal incontinence symptoms. Three employed the Wexner Inconti-
[39]
nence score [36-38] , while Atallah et al. examined 20 patients with a telephone survey 8 weeks after ileosto-