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my closure: most patients stated they had less than one accident per day, and one patient reported lifestyle-
limiting incontinence that did not improve 12 months post-resection. In three of the studies incontinence
symptoms were only evaluated after surgery [36,37,39] . In one study 6 patients completed the Wexner incon-
[38]
tinence score one week and 6 months after surgery : mean score only slightly deteriorated from 0 to 3 at
6 months after surgery and 4 months after stoma closure. A similar mean Wexner score value of 3.3 was re-
[36]
ported by Borreca et al. with no patient complaining of urgency symptoms. A worse anorectal function
[37]
was reported by Rouanet et al. who studied 30 patients with advanced or recurrent low rectal tumor with
complex anatomical (male gender, high BMI, fatty mesorectum), or tumor characteristics (bulky anterior
tumor, narrow radial margin). The patients completed the Wexner Incontinence score 12 months after
stoma closure and the median score was 11. Only 40 % of patients were fully continent, while 15% and 35%
reported incontinence to liquids and gas respectively; additionally 25% of the patients complained stool
fragmentation.

The first study focusing more on functional results was published in 2015 and involved 52 patients with low
rectal cancer, who underwent colo-anal or intersphincteric resection; the patients were evaluated at least
12 months after surgery or after stoma closure with the Wexner incontinence score questionnaire; bladder
and sexual function were also evaluated. Three patients (5.7%) required a colostomy because of severe fecal
incontinence after intersphincteric resection. For the remaining 49 patients without a stoma, the median
Wexner score was 4 (range: 3-12), 13 patients (28%) reported stool fragmentation and difficult evacuation.
Five patients (8.9%) developed postoperative urinary retention that resolved within 3 months. Deteriora-
tion of sexual function, in male patients, was reported by 22.2%, decreased potency by 2 and impotence by
2 patients (11.2%). The authors concluded that taTME does not negatively impacts on functional outcomes,
[40]
however there was not a comparative group .
[41]
Kneist et al. published in 2016 the first study with a comprehensive prospective assessment of urinary,
sexual and intestinal function after taTME using validated instruments. The study involved 10 patients
who underwent taTME with colo-anal or intersphincteric resection. Preoperative function was compared
to functional outcomes at 3, 6 and 9 months, after surgery or stoma closure. A unique and added value of
this study was that pelvic autonomic nerve preservation was intraoperatively assessed electrophysiologi-
cally: an electromyography of the anal sphincter and a cystomanometry were performed during electric
stimulations along the pelvic walls during mesorectal dissection. All patients completed validated ques-
[43]
[42]
tionnaires assessing: urinary function (IPSS score) , Quality of Life (QoL Index) , male sexual function
[44]
[30]
[45]
(IIEF score) ; female sexual function (FSFI) ; anorectal function, determined by the Wexner score ,
[22]
and by the low anterior resection syndrome (LARS) score . In addition residual urine volume was evalu-
ated. None of the patients developed pathological residual urine volumes after at least unilateral functional
pelvic nerve-sparing. No significant difference in bladder function was noted nevertheless IIEF score was
lower than preoperative values. Of note sexual function was already impaired in 60% of patients preopera-
tively. The median Wexner score deteriorated from 1 to 7 at 6 months (P = 0.029). Four patients had major
LARS at 1 month but only one at 6 months, with 40% of patients categorized as having no LARS and 50%
minor LARS. A worse QoL due to fecal incontinence was found in 3 out of the 10 patients, 2 of whom had
a partial intersphincteric resection, and 1 suffered tumor progression. The authors’ conclusion was that
taTME has the potential to preserve continence, sufficient bowel function, and urogenital function. Al-
though the study examined in a rigorous and comprehensive way all the functional outcomes, the sample
[41]
size is small and there are too many confounding factors to draw any definitive conclusion .
[15]
The most recently published study involved 30 patients with low and medium rectal cancer . The follow-
ing questionnaires were completed by the patients 1 week before and 1 and 6 months after surgery: Euro-
[46]
[47]
QoL, (EORTC) QLQ-CR29 , and QLQ-C30 , LARS score. Preoperative LARS score ranged between 7.3
and 23.5, with the mean score being 15.4; a significative increase to 35.7 was recorded at 1 month, but after
6 months, it fell to 21.7, with no significative difference with respect to preoperative value; 33% of patients