*6.2.4 Urinary complications*

Urinary complications are the second most frequent short-term complication after bleeding and have been reported in 5–10.8% of patients after transanal surgery [12, 54, 57, 66]. Urinary retention is a common complication after transanal procedures, especially in anterior resection, mainly occurring in male patients. Often it is classified as a Clavien-Dindo [89] grade II sequel, and it is easily managed by placement of a transurethral catheter [12, 54, 57, 66]. Reasons may be related to different factors: the anterior location of the excised lesion, preexisting prostatic hypertrophy, spinal anesthesia, and premature removal of the bladder catheter.

### *6.2.5 Rectal stenosis*

Rectal stenosis is relatively infrequent complication after transanal excision of rectal lesions, poorly reported in the literature with an incidence rate of 1.5–5.8% [44, 90–93]. Rectal stenosis is associated with fecal urgency and incontinence, and it has a negative impact on the patients' quality of life [64]. In a recently published series of 761 patients undergoing TEM, the overall stenosis rate was 3.2%; analyzing the correlation between tumor size and subsequent stenosis development, the authors did not find postoperative stenosis in tumors measuring less than 5 cm in diameter, but it appeared in 6.8% of very large tumors (5–9 cm) and in 13.9% of ultralarge tumors (>10 cm) [93]. Altaf et al. report an incidence of stenosis of 5.8% following transanal surgery, but it did not become obstructive in any patient [91], therefore not requiring endoscopic treatment. Bignell et al. reported a 1.5% rate of rectal stenosis underlining that none of the patients

received neoadjuvant therapy before surgery, but 50% of them underwent four quadrants lesion's excision [44].

The etiology of stenosis following anterior resection and total mesorectal excision is multifactorial, and it includes postoperative leaks and pelvic sepsis. It is also widely believed that ischemia plays an important role in stenosis formation. On the contrary, transanal excision is not associated with major alteration of blood supply; therefore, it appears that the only factor that may play a role is mucosal ischemia in association with the extension of the dissection. Several authors agree on the fact that circumferential excision or resection of lesions measuring more than 5 cm in diameter is the main risk factor for rectal stenosis, independently from the distance of the tumor from the anal verge or from neoadjuvant radiotherapy [44, 90, 91]. Once stenosis has occurred, there are several treatment options that have been already described in the setting of rectal stenosis following anterior resection. These options include surgical resection, transanal strictureplasty, balloon or surgical dilatation, and stenting [90, 92, 94]. In the literature, the majority of cases of rectal stenosis following transanal surgery can be easily treated by endoscopic balloon dilatation or with a day-case procedure under general anesthesia using Hegar's dilators by single or multiple sessions [56, 90, 92, 94]. Surgical resection of the stenotic tract or fecal diversion should be reserved only to those patients who are refractory to endoscopic conservative treatment.

#### **6.3 Functional outcomes**

Despite the large diffusion of TEM and TAMIS for organ-sparing tumor resection in rectal cancer, several issues have been investigated to assess the safety of both techniques concerning the postoperative functional outcomes. This is due to the risk that rectal and anal stretching produced by the introduction of a wide proctoscope or platform during surgery, as well as partial organ resection reducing rectal compliance, might be the cause of postoperative functional disorders such as fecal incontinence, urgency, and soiling, with subsequent impairment of the patient's quality of life (QoL). A recently published systematic review including 29 studies reporting the functional results following TEM or TAMIS surgery and including almost 1300 patients reveals that several studies reported some deterioration in manometric scores after both TEM and TAMIS and suggested worsening function, at least in some items of the used scores, including de novo incontinence development in some patients. However, globally the QoL does not seem to be significantly impaired after either procedure [95]. After tumor resection, continence was recovered or improved in several series following both TEM [33, 96–100] and TAMIS [101, 102]. On the contrary, worsening of fecal continence scores was reported by some studies assessing TEM functional outcomes [102–106]. Sphincter damage caused by anal dilation during surgery with the rigid TEM rectoscopes or platforms that are 4 cm in diameter [107, 108] has been advocated as a risk factor for postoperative incontinence, as well the surgical duration [108]. Moreover, partial rectal wall resection reduces rectal compliance, which might also result in later development of fecal symptoms as incontinence and urgency [33]. However, it should be underlined that some studies, including the authors' previous series [33, 100], reported that postoperative incontinence after TEM was transient in many patients and improved at long term postoperative follow-up [97, 107, 109, 110, 111]. All these changes in anorectal

## *Local Excision for the Management of Early Rectal Cancer DOI: http://dx.doi.org/10.5772/intechopen.105573*

physiology are mainly detected within the first 30 postoperative days and seem to significantly improve at 1 year after surgery; hence, they might not be clinically relevant to the patients in the long run [33, 104]. Mora Lopez et al. [104] found that only closer distance to the anal verge seemed to affect continence. Other reported risk factors for fecal incontinence included male gender, age at surgery, surgical time, extended resection, and full-thickness resection [103, 105, 110]. Khoury et al. [112] found that continence can be also affected by repeated TEM procedures, as the result of multiple anal sphincter complex traumas. There are very few available studies that included patients who underwent chemoradiotherapy before TEM [35, 64, 110, 113] and TAMIS [108], hence no conclusive data are available, although worsening functional outcomes have been reported in this group of patients as compared with those who underwent transanal surgery alone [35, 110, 113]. A possible explanation for worse results in irradiated patients can be postulated due to radiotherapy impairment of muscles and nerve fiber integrity and reduced rectal wall elasticity [114, 115]. This was reported by the authors [35] and Ghiselli et al. [110] after TEM surgery and by Clermonts et al. after TAMIS procedures [108]. In conclusion, TEM and TAMIS can be considered safe in terms of long-term functional outcomes, with only transient impairment of fecal continence and worsening QoL, showing almost complete anorectal physiology recovery within 1 year from surgery. Nevertheless, the duration of surgery together with tumor features (location, stage, and size) can be considered as a risk factor for deterioration of functional results together with combination of radiation treatment.
