Comparison of oncologic, anorectal, urinary and sexual dysfunction results of minimal invasive surgery and open surgery in rectal cancer

Objective: The aim of the study is to question the adequacy of TME / PME principles applied in open surgery with minimally invasive surgery. For this purpose, we compared the surgical and oncological results, as well as the postoperative quality of life, anal incontinence, rectal, urinary and sexual dysfunctions of patients who underwent open surgery and minimally invasive surgery (robotic and laparoscopic) in rectal cancer patients who underwent curative surgical resection. Materials and methods: The study included 223 patients who were operated for rectal cancer in Sakarya University Training and Research Hospital General Surgery Clinic between January 2015 and 2020. The files of the patients were analyzed retrospectively. The patients were divided into 3 groups as open surgery, laparoscopic surgery and robotic surgery. The groups were demographically (age, gender, comorbidity and multiple comorbidities, ASA risk score), presence of preoperative metastases and distribution of metastases by organs, administration of neoadjuvant therapy, type of neoadjuvant therapy and response to neoadjuvant therapy, location of tumor (upper, middle, lower rectum) and types of surgery performed according to location (LAR and APR, Hartmann procedure and diverting stoma), conversion rate and reasons in minimally invasive surgery, surgery time by groups, liver resection, RF ablation and intraoperative blood transfusion, postoperative hospital stay time complications and hospital mortality, completeness of mesorectal excision by groups, distal surgical margin positivity and radial surgical margin positivity, length of specimen according to groups, TNM stage, number of lymph nodes removed and number of metastatic lymph nodes removed, postoperative local recurrence by groups, distant metastasis ,disease-free survival and overall survival compared. Due to the Covid 19 pandemic, a total of 56 patients could be called. Due to the low number of patients in the robotic group among the patient groups that could be recalled, the quality of life of the patients, anorectal, urinary and sexual dysfunctions were examined and compared in two groups as open and closed SF-36 quality of life scale, IPSS score; Quality of Life QoL Index, ICIQ-UI SF score, IIEF score, FSFI score; Using the Wexner score and low anterior resection syndrome (LARS) scoring systems, patients' quality of life, anorectal, urinary and sexual dysfunctions were prospectively evaluated and compared with these survey studies. Results: The 223 patients analyzed were evaluated in three main groups as open, laparoscopic and robotic according to different surgical approaches to rectal surgery. According to this distinction, 112 (50.2%) of the patients were in the open, 77 (34.5%) laparoscopic and 34 (15.3%) and robotic rectum surgery groups. 145 (65%) of the cases were male and 78 (35%) were female patients. The presence of any additional disease in the patients in the open rectal surgery group was significantly higher than the laparoscopic and robotic surgery groups (p = 0.020). 101 (45.3%) of the patients received preoperative neoadjuvant treatment. There was no significant difference between the groups in terms of receiving neoadjuvant therapy (p = 0.312). Low anterior resection surgery was applied to 190 (85.2%) of the patients, while Miles surgery (Abdominoperineal resection) was performed in 33 (14.8%) patients. The operation time of the patients in the robotic group among the patients in the study group was significantly longer than the open and laparoscopic group (p <0.001). Hospital stay was significantly longer in the open group compared to the laparoscopic and robotic groups (p <0.001). There was no significant difference between the groups in terms of development of complications. Specimen length extracted with open rectal surgery was significantly longer than laparoscopic and robotic surgeries (p = 0.001). During the postoperative follow-up period (25 months), the rate of distant metastasis development in the open group was higher than the other two groups (p = 0.076). There was no significant difference between the groups in terms of mortality (p = 0.095). There was no significant difference in overall survival between the groups (p = 0.095). Disease-free survival was statistically lower in the open group (p = 0.024). There was a significant decrease in the physical quality of life scores in the postoperative period according to the scores of the patients in the open group in the preoperative period (p <0.001). However, SF-36 physical quality of life scores in the preoperative and postoperative periods of the patients in the closed group were similar (p = 0.138). There was no significant difference between the groups in terms of postoperative SF-36 mental quality of life scores (p = 0.156). There was no significant difference between the groups in the comparison of urination satisfaction (p = 0.834), IIEF erectile function score (p = 0.834) and IPSS lower urinary system symptom score (p = 0.999). There was no statistically significant difference between the postoperative FSFI scores of the patients in the open group and the postoperative FSFI scores of the patients in the closed group in female patients (p = 0.193). The score of 40 patients who could be evaluated postoperatively for Wexner fecal incontinence score was significantly higher in the open group compared to the laparoscopic group (p = 0.017). There was no significant difference between the two groups according to the severity of Low anterior resection syndrome symptoms in the postoperative period (p = 0.113). Conclusion: In conclusion, the higher TNM stage, ASA score and comorbidities in the group that underwent open rectal surgery may have negatively affected the disease-free survival time compared to the patients who underwent minimally invasive surgery. No difference was found between the open, laparoscopic and robotic surgery groups in terms of the number of lymph nodes removed, the completeness of mesorectal excision, distal and radial surgical margin positivity, and urinary and sexual dysfunctions. This shows that TME / PME techniques can be applied similarly in all groups.