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Esen et al. Mini-invasive Surg 2018;2:29 I http://dx.doi.org/10.20517/2574-1225.2018.32 Page 5 of 8
[33]
A prospective study by Ströhlein et al. reported 5-year local recurrence rates of 6.9% and 9.5% with lapa-
roscopic and open surgery, respectively. Additionally, there were no significant differences in 5-year surviv-
al rates based on the disease between the two groups (open vs. laparoscopic; stage I, 75.2% vs. 85.4%; stage
[40]
II, 73.4% vs. 66.7%; stage III, 51.3% vs. 60.1%). Similarly, Laurent et al. found no significant differences in
5-year local recurrence, disease-free survival, or overall survival rates between the laparoscopy and open
surgery groups.

In summary, further randomized clinical trials are necessary for complete elucidation of the feasibility of
laparoscopic surgery in rectal cancer. Additionally, the anticipated publication of the long-term results of
the ACOSOG Z6051 and ALaCaRT trials should provide further insight regarding the implementation of
laparoscopic surgery for rectal cancer.

Sexual and urinary dysfunction associated with laparoscopic surgery
Normal bladder and sexual function is controlled by sympathetic input from the superior hypogastric
plexus and parasympathetic input from the pelvic splanchnic nerves, which are susceptible to injury dur-
ing mesorectal resection. Injury to the sympathetic supply results in bladder instability and ejaculatory
difficulties, whereas injury to the parasympathetic supply results in poor detrusor contraction and erectile
dysfunction [41,42] .

The incidence of urinary and sexual dysfunction after open TME is significantly high [43-46] . In laparoscopic
TME, preservation of the nerves can be achieved by magnifying the images. In a series of 274 patients re-
[47]
ported by Runkel and Reiser , only 1.8% of the patients required prolonged urinary catheterization post-
operatively. In other studies, the rate of urinary dysfunction after laparoscopic TME ranged from 6% to
15% [48-52] , and the incidence of dysfunction ranged between 5% and 28% in males who were sexually active
before laparoscopic TME [34,47,51,52] .

[52]
Asoglu et al. reported that the rate of reduction in sexual function among female patients was 7%. In
that comparative study, laparoscopic TME was associated with significantly less sexual dysfunction in both
male and female patients, and the rate of urinary dysfunction was similar between the laparoscopic and
open TME groups.

[41]
In a study on data from 247 patients enrolled in the CLASSIC trial, Jayne et al. reported that the rate of
bladder dysfunction was similar between the open and laparoscopic surgery groups; however, the rate of
erectile dysfunction was higher in the laparoscopic surgery group, which was attributed to the higher fre-
quency of TME in the laparoscopic surgery group.

[34]
In their prospective randomized trial, Ng et al. found that there was no significant difference in urinary
or erectile dysfunction between the laparoscopic and open TME groups. In the COREAN trial, however,
[39]
there were significantly fewer urinary complications in the laparoscopic surgery group . Relatedly, Mc-
[53]
Glone et al. compared patients undergoing proctectomy by laparoscopic and open surgeries. Urinary and
sexual dysfunction was observed in both surgery groups; however, penetration success in males and sexual
activity results in women were found to be better in the laparoscopy group.

Overall, the results of these studies indicate that there was no major difference in urinary or sexual dys-
function between patients undergoing laparoscopic and open rectal surgery and that the main causes of
these complications were rectal resection and TME, not the surgical approaches.

DISCUSSION
The development of minimally invasive colorectal surgery has been the greatest technological advance