Maintaining anal sphincter function when performing intersphincteric resection for patients with ultralow rectal cancer (defined as a tumor lying <5 cm from the anal verge) is challenging for colorectal surgeons. In male patients who had previously been treated with radical prostatectomies (RPs), the loss of anatomical landmarks around the anterior rectal wall and rectourethral muscle increases the risk of intraoperative complications. Transanal total mesorectal excision (taTME) is a minimally invasive technique that approaches these structures linearly and at short distances in a magnified view.1,2 This procedure can provide fine dissection and reliably secure circumferential and distal resection margins. In this video vignette, we demonstrate an intersphincteric resection technique using a hybrid approach that combines taTME with robot-assisted total mesorectal excision (TME) for ultralow rectal cancer after RP.
A 56-year-old male patient underwent robot-assisted RP and vesicourethral anastomosis reconstruction for prostate cancer management 8 months before the current presentation. A cT2N0M0 rectal cancer was found 3.5 cm from the anal verge and 1.5 cm from the dentate line, respectively. We planned a hybrid minimally invasive procedure to preserve urinary function and avoid a permanent stoma.3
A mucosal incision was made 5 mm distal to the dentate line. A transanal access platform system was then attached, and taTME was initiated. Because the “holy plane” of the posterior aspect of the prostate gland disappeared, it was separated cautiously to avoid damaging the rectal wall and vesicourethral anastomosis. After taTME, robotic TME was performed using da Vinci Xi (Intuitive Surgical, Inc., CA). The coloanal anastomosis was hand-sutured, and diverting ileostomy was performed. The postoperative course was uneventful. No anastomotic or urinary complications were observed. After a manometric anorectal function test, the temporary ileostomy was closed.4,5 The patient has not complained of major fecal incontinence.
We successfully resected ultralow rectal cancer after RP while avoiding visceral injury using a hybrid approach of transanal and robotic TME. See Video Vignette.
Footnotes
Funding/Support: None reported.
Financial Disclosure: None reported.
Contributor Information
Fumikazu Koyama, Email: fkoyama@naramed-u.ac.jp.
Yosuke Iwasa, Email: y-iwasa@naramed-u.ac.jp.
Takeshi Takei, Email: takeshi.takei.13@naramed-u.ac.jp.
Tadataka Takagi, Email: T.takagi@naramed-u.ac.jp.
Kosuke Fujimoto, Email: kou-fuji-0214@naramed-u.ac.jp.
Suzuka Harada, Email: sharada1016@naramed-u.ac.jp.
Masayuki Sho, Email: m-sho@naramed-u.ac.jp.
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