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Funahashi et al. Mini-invasive Surg 2018;2:27 I http://dx.doi.org/10.20517/2574-1225.2018.28 Page 5 of 12

and anorectal function. Blood tests at each visit included carcinoembryonic antigen and carbohydrate
antigen 19-9 (CA19-9) levels. Patients were evaluated every 3 months using computed tomography or ab-
dominal ultrasonography for the first 3 years and every 6 months thereafter. Local recurrence was defined
as any recurrence that was diagnosed or suspected in the pelvis, either alone or with other metastases.

Function was assessed using a questionnaire that included questions on stool frequency and fecal ur-
gency. We used the WI score and assessed patient satisfaction using the VAS score previously described.
This questionnaire was administered by the medical staff to all patients who underwent SPR at all clinical
follow-up appointments. We evaluated the effects of the degree of IAS resection on the patients’ long-term
anorectal function.

Statistical analysis
Data were analyzed using either the chi-squared test or Fisher’s exact test. Continuous variables were com-
pared using the Kruskal Wallis H-test. Survival rates were assessed using Kaplan-Meier curves and the log-
rank test. A P-value of < 0.05 was considered statistically significant. Statistical analyses were performed
using Predictive Analytics SoftWare (PASW), version 18 (SPSS, Inc., Chicago, IL).

RESULTS
Patient characteristics
Ninety patients (63 male, 27 female) with a median age of 62 years (range 33-80 years) were enrolled. The
2
2
median BMI was 22.5 kg/m (range 16.7-32.9 kg/m ). Fifteen patients (16.7%) had received preoperative
chemoradiation therapy (pre-CRT). In this series, all tumors were designated as type II-III, according to
[19]
Rullier’s classification . Seventeen patients (18.9%) required intraoperative conversion to APR: in 14 pa-
tients, this was because of the surgeon’s suspicion for direct tumor invasion into the levator ani muscle,
prostate, or vagina; in 2 patients, there was ischemia of the descending colon; and in 1 patient, anatomic
disorientation occurred. In the 73 patients who underwent successful SPR, efforts were made to preserve
the IAS as much as possible to avoid postoperative anorectal dysfunction. In 21 of these 73 patients (28.8%),
the IAS was completely preserved, and the coloanal anastomosis was hand sewn; 33 patients underwent
partial ISR, and 19 underwent massive ISR. According to Quirke’s classification, the weighted mean of the
quality of the mesorectum dissection was complete TME in 94.5% and nearly complete TME in 1.4%. Also,
the rate of involvement of the circumferential resection margin was 2.7%.

The pathologic tumor-node-metastasis (pTNM) staging in the patients who underwent SPR was stage I in
27 patients (37.0%), stage II in 23 patients (31.5%), and stage III in 22 patients (30.1%). The pTNM staging of
the patients who underwent APR was stage I in 3 patients (17.6%), stage II in 9 patients (52.9%), and stage
III in 4 patients (23.5%). Because of a complete response to pre-CRT, pTNM staging could not be performed
in 2 patients (1 in each group). Although in stage II and III advanced disease was observed more frequently
in the patients who underwent APR, there was no statistically significant difference between the APR and
SPR groups [Table 1].

Oncologic results
During a median follow-up period of 3958 days (range 2778-6583 days), recurrence developed in 13 of the
SPR patients (17.8%) and in 5 of the APR patients (29.1%). Distant recurrence developed more frequently
in the APR patients, while local recurrence occurred exclusively in those patients who underwent SPR
[Table 2]. Local recurrences developed around the internal iliac artery in 4 patients and around the pros-
tate in 1 patient. One patient with a local recurrence underwent pre-CRT because of locally advanced can-
cer (cT4N2M0), and the remaining 4 patients were diagnosed with clinical stage III disease [Table 3].

The 5-year overall survival rates were 88.1% and 87.5% in the SPR and APR groups, respectively. The 5-year
disease-free survival rates were 85.0% and 80.8% in the SPR and APR groups, respectively. No significant