Functional outcomes and quality of life following open versus laparoscopic versus robot-assisted versus transanal total mesorectal excision in rectal cancer patients: a systematic review and meta-analysis
Authors: Geitenbeek Ritch T. J. , Burghgraef Thijs A. , Moes Carmen A. , Hompes Roel , Ranchor Adelita V. , Consten Esther C. J. ,   the MIRECA study group, van Acker G. J. D. , Aukema T. S. , Belgers H. J. , Beverdam F. H. , Bloemen J. G. , Bosscha K. , Breukink S. O. , Coene P. P. L. O. , Crolla R. M. P. H. , van Duijvendijk P. , van Duyn E. B. , Faneyte I. F. , Fransen S. A. F. , van Geloven A. A. W. , Gerhards M. F. , van Grevenstein W. M. U. , Havenga K. , de Hingh I. H. J. T. , Hoff C. , Kats G. , Leijtens J. W. A. , Holzik M. F. Lutke , Melenhorst J. , Poelman M. M. , Pronk A. , Schiphorst A. H. W. , Schreinemakers J. M. J. , Sietses C. , Smits A. B. , Somers I. , Spillenaar-Bilgen E. J. , Stockmann H. B. A. C. , Talsma A. K. , Tanis P. J. , Tuynman J. , Verdaasdonk E. G. G. , Warmerdam F. A. R. M. , van Westreenen H. L. , Zimmerman D. D. E. 
Published: June 2024

Abstract
Background
The standard surgical treatment for rectal cancer is total mesorectal excision (TME), which may negatively affect patients’ functional outcomes and quality of life (QoL). However, it is unclear how different TME techniques may impact patients’ functional outcomes and QoL. This systematic review and meta-analysis evaluated functional outcomes of urinary, sexual, and fecal functioning as well as QoL after open, laparoscopic (L-TME), robot-assisted (R-TME), and transanal total mesorectal excision (TaTME).

Methods
A systematic review and meta-analysis, based on the preferred reporting items for systematic reviews and meta-analysis statement, were conducted (PROSPERO: CRD42021240851). A literature review was performed (sources: PubMed, Medline, Embase, Scopus, Web of Science, and Cochrane Library databases; end-of-search date: September 1, 2023), and a quality assessment was performed using the Methodological index for non-randomized studies. A random-effects model was used to pool the data for the meta-analyses.

Results
Nineteen studies were included, reporting on 2495 patients (88 open, 1171 L-TME, 995 R-TME, and 241 TaTME). Quantitative analyses comparing L-TME vs. R-TME showed no significant differences regarding urinary and sexual functioning, except for urinary function at three months post-surgery, which favoured R-TME (SMD [CI] –0 .15 [− 0.24 to − 0.06], p = 0.02; n = 401). Qualitative analyses identified most studies did not find significant differences in urinary, sexual, and fecal functioning and QoL between different techniques.

Conclusions
This systematic review and meta-analysis highlight a significant gap in the literature concerning the evaluation of functional outcomes and QoL after TME for rectal cancer treatment. This study emphasizes the need for high-quality, randomized-controlled, and prospective cohort studies evaluating these outcomes. Based on the limited available evidence, this systematic review and meta-analysis suggests no significant differences in patients' urinary, sexual, and fecal functioning and their QoL across various TME techniques.