Robotic-assisted surgery may be a useful approach to protect urinary function in the modern era of diverse surgical approaches for rectal cancer



Urinary dysfunction (UD) remains a significant complication of rectal cancer surgery. In modern surgical treatment for rectal cancer, multiple operative approaches are used. Such approaches include open, laparoscopic, and robotic-assisted surgery; and multiple procedures, including anterior, intersphincteric, and abdominoperineal resection. Thus, modern surgical treatments for rectal cancer have diversified. This study aimed to identify risk factors for early UD (EUD) after total mesorectal excision (TME) and to explore the methods for decreasing postoperative EUD in diverse surgical treatments for rectal cancer.


In our retrospective cohort study, we enrolled patients with lower rectal cancer who underwent TME alone at a single high-volume cancer center between 2010 and 2017. EUD was defined as the presence of ≥ 50 mL residual urine volume. Multivariate analysis was performed to determine clinicopathological factors significantly associated with postoperative EUD.


Of a total of 337 eligible patients, 32 patients (10%) had postoperative EUD. Multivariate analysis revealed that only the operative approach (laparoscopic surgery: odds ratio [OR], 8.93; 95% confidence interval [CI], 2.94–27.14, open surgery: OR, 11.55; 95% CI 2.10–63.83) was significantly associated with an increase in postoperative EUD. Robotic-assisted surgery was associated with significant reduction in postoperative EUD.


Only robotic-assisted surgery was inversely correlated with postoperative EUD. Robotic-assisted surgery may be a useful approach to protect urinary function in lower rectal cancer surgery.

This is a preview of subscription content, access via your institution.

Fig. 1


  1. 1.

    Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK (1998) Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg 133:894–899

    CAS  Article  Google Scholar 

  2. 2.

    Watanabe T, Muro K, Ajioka Y, Hashiguchi Y, Ito Y, Saito Y, Hamaguchi T, Ishida H, Ishiguro M, Ishihara S, Kanemitsu Y, Kawano H, Kinugasa Y, Kokudo N, Murofushi K, Nakajima T, Oka S, Sakai Y, Tsuji A, Uehara K, Ueno H, Yamazaki K, Yoshida M, Yoshino T, Boku N, Fujimori T, Itabashi M, Koinuma N, Morita T, Nishimura G, Sakata Y, Shimada Y, Takahashi K, Tanaka S, Tsuruta O, Yamaguchi T, Yamaguchi N, Tanaka T, Kotake K, Sugihara K, Japanese Society for Cancer of the Colon, and Rectum (2018) Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2016 for the treatment of colorectal cancer. Int J Clin Oncol 23:1–34

    Article  Google Scholar 

  3. 3.

    Enker WE (1992) Potency, cure, and local control in the operative treatment of rectal cancer. Arch Surg 127:1396–1401

    CAS  Article  Google Scholar 

  4. 4.

    Pocard M, Zinzindohoue F, Haab F, Caplin S, Parc R, Tiret E (2002) A prospective study of sexual and urinary function before and after total mesorectal excision with autonomic nerve preservation for rectal cancer. Surgery 131:368–372

    Article  Google Scholar 

  5. 5.

    Lange MM, Maas CP, Marijnen CA, Wiggers T, Rutten HJ, Kranenbarg EK, van de Velde CJ, Cooperative Clinical Investigators of the Dutch Total Mesorectal Excision Trial (2008) Urinary dysfunction after rectal cancer treatment is mainly caused by surgery. Br J Surg 95:1020–1028

    CAS  Article  Google Scholar 

  6. 6.

    Lee SY, Kang SB, Kim DW, Oh HK, Ihn MH (2015) Risk factors and preventive measures for acute urinary retention after rectal cancer surgery. World J Surg 39:275–282

    Article  Google Scholar 

  7. 7.

    Ito M, Kobayashi A, Fujita S, Mizusawa J, Kanemitsu Y, Kinugasa Y, Komori K, Ohue M, Ota M, Akazai Y, Shiozawa M, Yamaguchi T, Akasu T, Moriya Y, Colorectal Cancer Study Group of Japan Clinical Oncology Group (2018) Urinary dysfunction after rectal cancer surgery: results from a randomized trial comparing mesorectal excision with and without lateral lymph node dissection for clinical stage II or III lower rectal cancer (Japan Clinical Oncology Group Study, JCOG0212). Eur J Surg Oncol 44:463–468

    Article  Google Scholar 

  8. 8.

    Tekkis PP, Cornish JA, Remzi FH, Tilney HS, Strong SA, Church JM, Lavery IC, Fazio VW (2009) Measuring sexual and urinary outcomes in women after rectal cancer excision. Dis Colon Rectum 52:46–54

    CAS  Article  Google Scholar 

  9. 9.

    Duran E, Tanriseven M, Ersoz N, Oztas M, Ozerhan IH, Kilbas Z, Demirbas S (2015) Urinary and sexual dysfunction rates and risk factors following rectal cancer surgery. Int J Colorectal Dis 30:1547–1555

    Article  Google Scholar 

  10. 10.

    Duchalais E, Larson DW, Machairas N, Mathis KL, Dozois EJ, Kelley SR (2019) Outcomes of early removal of urinary catheter following rectal resection for cancer. Ann Surg Oncol 26:79–85

    CAS  Article  Google Scholar 

  11. 11.

    Dayal S, Battersby N, Cecil T (2017) Evolution of surgical treatment for rectal cancer: a review. J Gastrointest Surg 21:1166–1173

    Article  Google Scholar 

  12. 12.

    Brierley JD, Gospodarowicz MK, Wittekind C (2017) TNM classification of malignant tumours, 8th edn. Wiley-Blackwell, Oxford

    Google Scholar 

  13. 13.

    Yamaoka Y, Kinugasa Y, Shiomi A, Yamaguchi T, Kagawa H, Yamakawa Y, Numata M, Furutani A (2017) Preoperative chemoradiotherapy changes the size criterion for predicting lateral lymph node metastasis in lower rectal cancer. Int J Colorectal Dis 32:1631–1637

    Article  Google Scholar 

  14. 14.

    Yamaguchi T, Kinugasa Y, Shiomi A, Tomioka H, Kagawa H (2016) Robotic-assisted laparoscopic versus open lateral lymph node dissection for advanced lower rectal cancer. Surg Endosc 30:721–728

    Article  Google Scholar 

  15. 15.

    Shiomi A, Kinugasa Y, Yamaguchi T, Kagawa H, Yamakawa Y (2016) Robot-assisted versus laparoscopic surgery for lower rectal cancer: the impact of visceral obesity on surgical outcomes. Int J Colorectal Dis 31:1701–1710

    Article  Google Scholar 

  16. 16.

    Yamaoka Y, Yamaguchi T, Kinugasa Y, Shiomi A, Kagawa H, Yamakawa Y, Furutani A, Manabe S, Torii K, Koido K, Mori K (2019) Mesorectal fat area as a useful predictor of the difficulty of robotic-assisted laparoscopic total mesorectal excision for rectal cancer. Surg Endosc 33:557–566

    Article  Google Scholar 

  17. 17.

    Kinugasa Y, Murakami G, Suzuki D, Sugihara K (2007) Histological identification of fascial structures posterolateral to the rectum. Br J Surg 94:620–626

    CAS  Article  Google Scholar 

  18. 18.

    Kinugasa Y, Murakami G, Uchimoto K, Takenaka A, Yajima T, Sugihara K (2006) Operating behind Denonvilliers' fascia for reliable preservation of urogenital autonomic nerves in total mesorectal excision: a histologic study using cadaveric specimens, including a surgical experiment using fresh cadaveric models. Dis Colon Rectum 49:1024–1032

    Article  Google Scholar 

  19. 19.

    Hino H, Yamaguchi T, Kinugasa Y, Shiomi A, Kagawa H, Yamakawa Y, Numata M, Furutani A, Yamaoka Y, Manabe S, Suzuki T, Kato S (2017) Robotic-assisted multivisceral resection for rectal cancer: short-term outcomes at a single center. Tech Coloproctol 21:879–886

    CAS  Article  Google Scholar 

  20. 20.

    Akasu T, Sugihara K, Moriya Y (2009) Male urinary and sexual functions after mesorectal excision alone or in combination with extended lateral pelvic lymph node dissection for rectal cancer. Ann Surg Oncol 16:2779–2786

    Article  Google Scholar 

  21. 21.

    Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250:187–196

    Article  Google Scholar 

  22. 22.

    Jayne D, Pigazzi A, Marshall H, Croft J, Corrigan N, Copeland J, Quirke P, West N, Rautio T, Thomassen N, Tilney H, Gudgeon M, Bianchi PP, Edlin R, Hulme C, Brown J (2017) Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: the ROLARR randomized clinical trial. JAMA 318:1569–1580

    Article  Google Scholar 

  23. 23.

    Yamaguchi T, Kinugasa Y, Shiomi A, Kagawa H, Yamakawa Y, Furutani A, Manabe S, Yamaoka Y, Hino H (2018) Oncological outcomes of robotic-assisted laparoscopic versus open lateral lymph node dissection for locally advanced low rectal cancer. Surg Endosc 32:4498–4505

    Article  Google Scholar 

  24. 24.

    Kneist W, Junginger T (2004) Residual urine volume after total mesorectal excision: an indicator of pelvic autonomic nerve preservation? Results of a case-control study. Colorectal Dis 6:432–437

    CAS  Article  Google Scholar 

  25. 25.

    Maeda K, Maruta M, Utsumi T, Sato H, Toyama K, Matsuoka H (2003) Bladder and male sexual functions after autonomic nerve-sparing TME with or without lateral node dissection for rectal cancer. Tech Coloproctol 7:29–33

    CAS  Article  Google Scholar 

  26. 26.

    Asoglu O, Matlim T, Karanlik H, Atar M, Muslumanoglu M, Kapran Y, Igci A, Ozmen V, Kecer M, Parlak M (2009) Impact of laparoscopic surgery on bladder and sexual function after total mesorectal excision for rectal cancer. Surg Endosc 23:296–303

    Article  Google Scholar 

  27. 27.

    Kneist W, Wachter N, Paschold M, Kauff DW, Rink AD, Lang H (2016) Midterm functional results of taTME with neuromapping for low rectal cancer. Tech Coloproctol 20:41–49

    CAS  Article  Google Scholar 

  28. 28.

    Tokunaga K, Matsuzawa Y, Kotani K, Keno Y, Kobatake T, Fujioka S, Tarui S (1991) Ideal body weight estimated from the body mass index with the lowest morbidity. Int J Obes 15:1–5

    CAS  PubMed  Google Scholar 

  29. 29.

    Barry MJ, Fowler FJ Jr, O'Leary MP, Bruskewitz RC, Holtgrewe HL, Mebust WK, Cockett AT (1992) The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol 148:1549–1557

    CAS  Article  Google Scholar 

Download references


No funding was received for this research.

Author information



Corresponding author

Correspondence to Hiroyasu Kagawa.

Ethics declarations


Drs. Yusuke Yamaoka, Hiroyasu Kagawa, Akio Shiomi, Yushi Yamakawa, Hitoshi Hino, Shoichi Manabe, and Yusuke Kinugasa and have no conflicts of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Yamaoka, Y., Kagawa, H., Shiomi, A. et al. Robotic-assisted surgery may be a useful approach to protect urinary function in the modern era of diverse surgical approaches for rectal cancer. Surg Endosc 35, 1317–1323 (2021).

Download citation


  • Rectal cancer
  • Mesorectal excision
  • Urinary dysfunction
  • Robotic-assisted surgery
  • Laparoscopic surgery
  • Open surgery