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De Rosa et al. Mini-invasive Surg 2020;4:34 I http://dx.doi.org/10.20517/2574-1225.2019.53 Page 7 of 12

[52]
Hu et al. showed that a complete mesorectal excision rate was 1.93 higher in the TaTME compared
to laparoscopic TME, with a lower positive CRM rate, while positive DRM rate did not reach statistical
difference.

Recently, in 513 TaTME procedures performed in the UK, optimal pathology was observed in 295 patients
[53]
(92.8%), with an involved resection margin (R1) in 13 patients (4.1%) .
Can these preliminary short-term pathological advantages translate into the final target of a lower recurrence
rate?

[54]
Lelong et al. in a comparative series including 72 patients, with a median follow-up period of 31.9 months,
demonstrated similar results following laparoscopic or TaTME (5.3% and 5.7% local recurrence rate,
respectively), but, considering only patients with curative resections (no metastases at diagnosis), local
recurrence rates were 5.7% and 0%, respectively.

A two-center experience of 159 TaTMEs procedures showed the 3- and 5-year local recurrence rates were 2%
[55]
and 4.0%, respectively, with a median time to local recurrence of 19.2 months (range 5.9-30.0 months) .
On the other hand, the Norwegian Colorectal Cancer Group expressed a warning against this technique,
reporting a 9.5% rate of early local recurrence with rapid, multifocal growth in the pelvic cavity and
sidewalls, and a median time to recurrence of 11 months. The observed local recurrence rate following
[56]
laparoscopic TME was 3.4% .
The small sample size of the experiences published thus far underline the need for a larger multicenter RCT
for TaTME to better assess the long-term oncological results compared to conventional techniques.

FUNCTIONAL RESULTS
Bowel, sexual, and urinary dysfunction is common after rectal cancer surgery and is associated with social
and psychological impairment. Anorectal disturbance can be caused by sphincter damage, reduced capacity
of the neo-rectum, level of anastomosis, pelvic nerve damage, and the effects of radiotherapy. Up to one
third of patients experience “anterior resection syndrome”, which is characterized by functional disorders
such as urgency, increased bowel frequency, fragmentation, and incontinence. A similar proportion
experiences genitourinary problems, including impotence and retrograde ejaculation in men and sexual
dysfunction in both sexes.

The relationship between these functional complaints and the quality of life perception is difficult to
establish and poorly reported in the literature. In general, major bowel and urinary alterations affect social
functioning, while incontinence and fecal urgency also impact on mental health.

With acceptable perioperative and oncological results, functional outcome and quality of life measures after
TaTME represent important outcomes for patients.

The transanal approach for low rectal cancer has not been shown to significantly increase bowel and
urologic dysfunction, compared to conventional laparoscopy, but may be associated with better erectile
function with a significantly higher rate of sexual activity [57,58] . Quality of life and functional outcomes,
assessed by validated questionnaires, showed acceptable outcomes after TaTME at 6 months after
[59]
surgery .