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and early T1 rectal cancers with less morbidity, faster direction of the nerves, thus remaining unharmed. Blood
recovery, and lower treatment costs. These techniques loss with this method is minimal. This approach provides
are safe, effective, and reproducible. excellent visibility of the anterior wall of the rectum in the
middle portion. However, this approach is more suitable for
Keywords: local transanal excision, minimally invasive urologists in addressing rectovesical and rectourethral fi-
transanal surgery, radical local rectal resection stulas. Transanal excision is comfortable for lesions located
approximately 6 cm from the anocutaneous line. Inadequa-
te retraction and poor visibility reduce the feasibility of this
technique for more proximal changes. Parks and Nicolls
Introduction first described this technique in 1968 . One of the biggest
1
Pathological lesions of the rectum are very common drawbacks is the limited visibility of the surgical field. The
in everyday surgical practice, and their treatment poses a anal sphincter musculature is highly individual and limited
challenge for every surgeon. The choice of treatment met- in its stretchability. Excessive stretching can lead to tearing
hod ranges from the most radical, which ends with the of individual muscle fibers, and sometimes even complete
formation of a definitive colostomy (abdominoperineal tears of the internal or external anal sphincter muscle. This
resection of the rectum according to Miles), to local excisi- approach is often referred to as “keyhole surgery“. Special
ons of pathological lesions, where the patient undergoes retractors have been designed to facilitate access to the
2, 3
treatment of a day surgery. In recent years, there has been interior of the rectum . Due to all the aforementioned re-
increasing promotion of a radical local approach to the tre- asons, minimally invasive transanal techniques have been
atment of advanced pathological lesions along with preo- developed to provide a more adequate transanal approach
perative chemotherapy and radiotherapy. The method of to rectal lesions. Minimally invasive transanal surgeries are
treatment depends on the nature, stage, and localization of indicated for tumors that cannot be removed by endoscopic
the pathological changes. The most common pathological mucosal resection, do not infiltrate the lamina propria mus-
changes treated in the rectum are neoplastic polyps (villous, cularis, show no signs of lymph node metastasis accessible
tubular, and tubulovillous adenomas) and rectal adenocar- by rectoscope, are at least 2 cm away from the dentate line,
cinomas. Pre-cancerous lesions such as neoplastic polyps and are typically located 6-16 cm from the anocutaneous
4
have been traditionally treated using a local approach, line .
while patients with advanced carcinomas have undergone
radical surgical procedures, either through conventional or Transanal Endoscopic Microsurgery (TEMS) was first
laparoscopic methods. introduced in Germany in the early 1980s by the German
surgeon Gerhard Buess . Initially, it was used to remove
5
Local excision is often chosen over radical procedures large rectal polyps that were beyond the reach of standard
for benign adenomas and certain types of early rectal tu- transrectal and colonoscopic techniques. With its three-di-
mors to preserve sphincter function. Local excisions can be mensional image, magnifying stereoscope, and adequate
performed through transcoccygeal, transsphincteric, and illumination of the rectal lumen, it provides exceptional visi-
transanal approaches. Local excision for biopsy purposes bility of the surgical field, allowing the surgeon to perform
can be considered as a total biopsy. Tumor size does not extremely precise excision of lesions, including those that
significantly impact the assessment of lymph node involve- have affected all layers of the rectal wall. The application of
ment, but for practical reasons, tumors up to 4 cm in size this technique has been expanded to include colonoscopi-
that involve no more than 2/5 of the circumference and cally unresectable polyps of larger dimensions and early
are located within 5 cm of the anal verge are considered stages of cancer. Further applications are oriented toward
suitable for local excision. The distance from the anal verge the revision of anastomoses and proximal fistulas. TEMS
can be a determining factor in the choice of surgical met- allows access to the entire rectal cavity, as well as the distal
hod. Local excisions can be performed using three diffe- part of the sigmoid colon, enabling the use of standard la-
rent approaches: transcoccygeal excision, transsphincteric paroscopic instruments, but it requires the experience and
approach, and transanal excision. Transcoccygeal excision knowledge of the operator. Favorable prognostic indicators
(Kraske) involves the removal of tumors in the middle porti- for TEMS exist in patients with well-differentiated T1 adeno-
on of the rectum, along with the resection of the coccygeal carcinoma smaller than 3 cm, without vascular and lympha-
and part of the sacral bone, as well as the detachment of the tic invasion, as well as for sessile lesions (Kikuchi level, stage
insertion of the left gluteal muscle, the left sacrotuberous sm1). TEMS enables the avoidance of radical procedures,
and sacrospinous ligaments, and the fifth sacral nerve. This reducing morbidity and postoperative mortality, avoiding
method has been compromised by a high rate of recurren- abdominal scarring, facilitating faster recovery, shorter hos-
ce, a large number of fistulas, and a high morbidity rate. pitalization, and lower recurrence rates.
The transsphincteric approach involves complete division of
the anal sphincters and provides excellent access to the lu- TEMS does not allow resection of lymph nodes except
men of the rectum. Through a para-sacrococcygeal incision, in patients with a low risk of nodal involvement. For this re-
the levator muscles are dissected medially, preserving the ason, it should be noted that T1 cancers have nodal invasi-
on in 10-15% of cases, while for T2 tumors, it ranges from

12 DOI: 10.5937/Galmed2409015S