Clinical Report: Transperineal Minimally Invasive Abdominoperineal Excision in Rectal Cancer
Overview
This multicenter study evaluates the feasibility and early outcomes of transperineal minimally invasive abdominoperineal excision (TpAPE) for low rectal cancer. The technique demonstrated acceptable intraoperative safety, promising histopathological outcomes, and manageable postoperative morbidity including perineal wound complications.
Background
Total mesorectal excision (TME) is critical for local control in rectal cancer surgery, but achieving complete TME in low rectal tumors is challenging due to anatomical constraints. Abdominoperineal excision (APE) is often performed for tumors with threatened margins in the low rectum, but traditional APE has higher rates of involved circumferential resection margins (CRM) and local recurrence. The extralevator APE (ELAPE) technique improves oncological outcomes by wider excision but increases perineal wound complications. Minimally invasive transperineal approaches may reduce morbidity while maintaining oncological safety, but data are limited.
Data Highlights
Parameter
Value/Outcome
Centers involved
5 (Netherlands, Taiwan, Canada, UK)
Patient cohort
Consecutive patients undergoing TpAPE for primary rectal cancer
Procedure types
Unilateral ELAPE, Bilateral ELAPE, APE with external sphincter resection
Primary endpoint
Feasibility assessed by intraoperative complications
Secondary endpoints
30-day major morbidity, perineal wound healing, histopathological outcomes
CRM positivity definition
Tumor cells ≤1 mm from surgical plane
Specimen quality grading
Quirke classification
Statistical significance
p < 0.05
Key Findings
TpAPE is feasible with acceptable intraoperative complication rates across multiple expert centers.
Histopathological outcomes, including CRM positivity and specimen quality, were carefully assessed to ensure oncological safety.
Postoperative morbidity included major complications (Clavien-Dindo ≥3) and perineal wound healing issues, consistent with expectations for extensive pelvic surgery.
Perineal wound complications were managed with primary closure, gluteal turnover flaps, or biological mesh depending on individual cases.
The transperineal minimally invasive approach allows tailored dissection of the pelvic floor muscles, potentially reducing coning and improving margin clearance.
Comparative analysis suggested that the extent of pelvic floor resection (APE vs unilateral vs bilateral ELAPE) may impact outcomes, warranting further investigation.
Clinical Implications
TpAPE offers a minimally invasive alternative for low rectal cancer requiring abdominoperineal excision, potentially improving surgical precision and oncological margins while maintaining manageable morbidity. Surgeons should consider patient-specific factors and extent of pelvic floor involvement when selecting this approach. Close monitoring and tailored management of perineal wounds remain essential, especially in irradiated patients.
Conclusion
Transperineal minimally invasive abdominoperineal excision is a feasible technique with promising early oncological and safety outcomes in expert centers. Further studies are needed to confirm long-term benefits and optimize patient selection.
References
Dutch TME Trial Group 2007 -- Total Mesorectal Excision for Rectal Cancer
Quirke et al. 1986 -- Grading of Mesorectal Excision Specimens
West et al. 2008 -- Extralevator Abdominoperineal Excision
Han et al. 2019 -- Perineal Wound Healing after ELAPE
de Nes et al. 2023 -- Transperineal Minimally Invasive APE Multicenter Study
