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Page 8 of 12 De Rosa et al. Mini-invasive Surg 2020;4:34 I http://dx.doi.org/10.20517/2574-1225.2019.53

[60]
Rubinkiewicz et al. , in a comparative study concerning the occurrence and severity of low anterior
resection syndrome, reported similar results between TaTME and LaTME, with a prevalence still high in
both groups (87% and 91%, respectively).

Assessment of patients after TaTME by transanal endoscopic ultrasound and physiological functional
assessments concluded that TaTME has no impact on sphincter structure and evacuatory function, with
[61]
about 10% of patients with major low anterior resection syndrome after 1 year .
In conclusion, TaTME does not appear to increase the negative impact on functional and quality of life
outcomes if compared to conventional laparoscopic transabdominal TME. Existing data concerning ano-
rectal, urinary, and sexual function and quality of life following TaTME are still of low quality and further
studies are needed in this area.

ROBOTIC TaTME
Robotic approaches can overcome several of the technical difficulties associated with traditional
laparoscopic surgery and allow high-quality maneuvers to be performed in narrow spaces such as the pelvic
cavity. Recent studies demonstrate similar clinical and oncological results between robotic and laparoscopic
[62]
transabdominal surgical procedures , but, at present, no significant benefit of robotic over laparoscopic
surgery seems to be detectable, except perhaps conversion rates.

The application of robotic technology to TaTME (rTaTME) appears to be the next logical step in the evolution
of minimal access surgery, allowing the benefits of improved dexterity, stability of the platform, and
3D-vision, while adhering to the principles of NOTES.

[63]
Small rTaTME case series have been reported demonstrating feasibility. Kuo et al. described a combined
rTaTME and transabdominal single-site plus one port approach in 16 patients with low rectal lesions,
showing good oncological results.

[64]
More recently, Hu et al. published a case series of 20 patients treated with r-TaTME with simultaneous
laparoscopic-assisted abdominal phase performed with single-port placed at ileostomy site, demonstrating
the applicability of this approach, but also highlighting some of the limitations of the Da Vinci Xi platform
for transanal surgery.

The introduction of the robotic platform based on the single-port access may represent the start of a new
era for robot-assisted transanal surgery, but ultimately smaller, more flexible robotic systems are required
for true natural orifice procedures where scars are eliminated. If this can be combined with cost control,
then a new era in surgery will be possible.

CONCLUSION
TaTME has demonstrated some tantalizing benefits for the surgeon and the patient, but remains
controversial because of the lack of long-term oncological data and the technical operative challenges that
make widespread dissemination difficult.

[65]
Some consider TaTME as the culmination of 30 years of progress in colorectal cancer surgery . Others,
while applauding the results achieved to date, introduce a note of caution in their interpretation of the
available data, as the majority of the published experience originates from highly trained surgeons in high-
[66]
volume centers with great heterogeneity among studies . It is important that we avoid the indiscriminate
[67]
adoption by inadequately trained surgeons that could undermine the progress achieved thus far .