What are the differences between Laparoscopic Proctocolectomy with Restorative Proctocolectomy (LPR) and Abdominoperineal Resection (APR) surgeries?

Differences Between Laparoscopic Proctocolectomy with Restorative Proctocolectomy (LPR) and Abdominoperineal Resection (APR) Surgeries

Abdominoperineal Resection (APR) necessitates a permanent colostomy, while Laparoscopic Proctocolectomy with Restorative Proctocolectomy (LPR) preserves intestinal continuity, offering better quality of life outcomes despite potentially more complex bowel function management. 1, 2

Anatomical and Surgical Differences

• APR involves en bloc resection of the rectosigmoid, rectum, and anus, along with surrounding mesentery, mesorectum, and perianal soft tissue, requiring creation of a permanent colostomy 1, 2
• LPR preserves the anal sphincter and involves resection of the affected rectum with total mesorectal excision (TME), followed by creation of a colorectal or coloanal anastomosis, maintaining intestinal continuity 2
• Both procedures incorporate total mesorectal excision (TME), which involves en bloc removal of the mesorectum with associated vascular and lymphatic structures 2
• Laparoscopic approaches for both procedures offer benefits including less blood loss, shorter hospital stays, and quicker return of bowel function, though with longer operation times 1

Indications

• APR is indicated when the tumor directly involves the anal sphincter or levator muscles, or when a margin-negative resection would result in loss of anal sphincter function and incontinence 1, 2
• LPR is indicated when the tumor is located in the mid to upper rectum, anal function is intact, and adequate distal clearance (4-5 cm below tumor edge) can be achieved 2
• For patients with very low rectal tumors who would traditionally receive APR, intersphincteric resection may offer an alternative that preserves anal continence in carefully selected cases 3

Oncological Outcomes

• Recent retrospective comparisons show that patients treated with APR have worse local control and overall survival compared to those treated with sphincter-preserving procedures 1, 2
• A retrospective study of 3,633 patients with T3-T4 rectal cancer suggests an association between the APR procedure itself and increased risks of recurrence and death 1, 2
• The 5-year survival rate for patients undergoing sphincter-preserving procedures is approximately 80%, compared to 68% for APR, with lower pelvic recurrence rates (9% vs 14%) 4
• Laparoscopic approaches show equivalent oncological outcomes to open procedures, with no significant differences in local recurrence, disease-free survival, or overall survival 1

Quality of Life Considerations

• Patients who underwent APR reported worse body image, worse micturition symptoms, and less sexual enjoyment at 1-year post-surgery compared to those who had sphincter-preserving surgery 1, 2
• Despite having a permanent stoma, some studies suggest that overall quality of life between patients with or without a permanent colostomy may be comparable in certain aspects 1, 2
• Patients with sphincter-preserving procedures experience more issues with bowel function, including constipation, diarrhea, and potentially incontinence, especially with low anastomoses 5, 6
• Sexual function is more significantly impaired in patients undergoing APR compared to those with sphincter-preserving procedures 5, 6

Technical Considerations

• An extralevator APR approach may offer benefits over conventional APR, including lower rates of intraoperative perforation, circumferential resection margin involvement, and local recurrence 1, 2
• The height of the anastomosis in sphincter-preserving procedures impacts functional outcomes, with lower anastomoses (<3 cm from anal verge) associated with more incontinence issues 5
• Laparoscopic approaches for both procedures are associated with shorter hospital stays, less blood loss, and quicker return of bowel function 1
• Previous pelvic, abdominal, or anal surgery is not necessarily a contraindication to restorative procedures, though it may increase technical difficulty 7

Recovery and Postoperative Management

• Bowel management with stool softeners is particularly important for patients with sphincter-preserving procedures to prevent straining during recovery 8
• Patients with sphincter-preserving procedures more frequently require anti-diarrheal medication compared to those with APR 5
• Radiation therapy can significantly worsen rectal function in patients with sphincter-preserving procedures, increasing frequency, urgency, and incontinence 5