Oncologic Outcomes of One-Team Transanal Versus Laparoscopic Total Mesorectal Excision for Mid and Low Rectal Cancer: A Propensity Score–Matched Study

Oncologic Outcomes of One-Team Transanal Versus Laparoscopic Total Mesorectal Excision for Mid and Low Rectal Cancer: A Propensity Score–Matched Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Oncologic Outcomes of One-Team Transanal Versus Laparoscopic Total Mesorectal Excision for Mid and Low Rectal Cancer: A Propensity Score–Matched Study Chen Su, Junfeng Du, Xiang Xu, Lanxin Hu, Xuefei Zhang, Yinggang Ge, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9359317/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background For mid-to-low rectal cancer, although laparoscopic tumor resection (LapTME) has become a standard minimally invasive surgical approach, technical challenges remain in cases with complex anatomical structures. Transanal TME (TaTME) was developed to address these limitations, yet its widespread adoption has raised oncologic safety concerns in routine clinical practice. Most existing evidence comes from controlled trials using dual-team simultaneous approaches, while data on the common, resource-efficient single-team sequential approach remains insufficient. Methods This retrospective cohort study enrolled 256 consecutive patients with mid/low rectal adenocarcinoma undergoing curative TME at a tertiary center between 2018 and 2022. 2:1 propensity score matching balanced baseline covariates, generating 170 well-matched patients (108 in the one-team TaTME group, 62 in the LapTME group). We compared mid-term oncologic outcomes, perioperative safety, and pathologic margin status. Results After matching, median follow-up was 48 months. The TaTME group had longer operative time and a higher protective stoma rate, with comparable blood loss and postoperative complications. All patients achieved negative resection margins, while TaTME yielded a significantly more consistent distribution of distal margin length. At 3 years, no significant between-group differences were observed in local recurrence (3.7% vs 4.8%), distant metastasis (13.0% vs 14.5%), disease-free survival (83.3% vs 82.3%), or overall survival (88.9% vs 90.3%, all p > 0.05). Conclusions One-team TaTME achieved comparable mid-term oncologic outcomes to LapTME in routine practice, supporting its safety for experienced surgical teams. This real-world evidence facilitates the adoption of single-team TaTME in resource-limited settings. Mid-low rectal cancer Propensity score matching TaTME LapTME Oncological outcomes Technical advantage Figures Figure 1 Figure 2 Figure 3 Introduction Total mesorectal excision (TME) remains the cornerstone of curative surgery for mid and low rectal cancer, with the quality of mesorectal dissection and margin status strongly influencing local recurrence and long-term oncologic outcomes[ 1 , 2 ]. Laparoscopic TME (LapTME) has become widely adopted as a minimally invasive standard approach[ 3 , 4 ]. However, achieving consistent distal pelvic dissection and secure distal margin control through a transabdominal approach remains technically challenging, particularly in patients with a narrow pelvis, obesity, or very low tumors[ 5 , 6 ]. Transanal total mesorectal excision (TaTME) was developed to address these limitations by enabling a bottom-up dissection under direct visualization of the distal rectum and mesorectum[ 1 , 6 – 8 ]. Early studies suggested potential technical advantages, including improved access to the distal pelvis and lower conversion rates in technically demanding cases[ 9 , 10 ]. However, as TaTME has been adopted more broadly, concerns have emerged regarding oncologic safety, including reports of atypical local recurrence patterns and variability in outcomes across centers[ 11 – 13 ]. These findings have highlighted the importance of structured training, procedural standardization, and institutional experience in achieving safe implementation[ 14 – 17 ]. Recent randomized controlled trials, including the TaLaR study[ 18 ], have provided high-level evidence demonstrating that TaTME is not inferior to LapTME in terms of pathologic quality and short-term oncologic outcomes when performed by well-trained surgical teams. Notably, these trials predominantly employed a dual-team simultaneous approach and were conducted under controlled trial conditions. However, this setting does not fully reflect routine clinical practice, where variations in surgical workflow, resource availability, and team structure are common. In many real-world settings, TaTME is performed using a single-team, sequential approach, in which the same surgical team completes both the abdominal and transanal phases. While this approach is more practical and resource-efficient, its oncologic safety remains insufficiently evaluated. In particular, whether comparable tumor control can be maintained without the dual-team setup remains an important and unresolved clinical question. Therefore, we conducted a retrospective cohort study to compare mid-term oncologic outcomes between one-team TaTME and LapTME in patients with mid and low rectal cancer treated under routine clinical practice conditions. Using propensity score matching to minimize selection bias, we evaluated local recurrence, distant metastasis, disease-free survival, and overall survival at 3 years. In addition, we assessed distal resection margin characteristics as a measure of technical consistency and surgical precision. Methods Study Design and Patients This single-center retrospective cohort study was conducted at the Department of Gastrointestinal Surgery, First Affiliated Hospital of Chongqing Medical University. Patients who underwent radical TME surgery for rectal adenocarcinoma from January 2018 to May 2022 were identified from institutional surgical and pathology databases. Inclusion criteria were: (1) histologically confirmed mid- or low-rectal adenocarcinoma (tumor located ≤ 10 cm from the anal verge on preoperative imaging); (2) clinical stage cT1-T3, N0-N2 (M0) before treatment; and (3) age ≥ 18 years undergoing curative-intent TME. Exclusion criteria were: (1) tumor invasion of the anal sphincter or levator musculature requiring abdominoperineal resection; (2) severe organ dysfunction precluding major surgery; (3) emergent surgery for obstruction or perforation; (4) intraoperative discovery of metastatic disease; or (5) a history of other malignancies. The study was approved by the hospital ethics committee (Approval No. 2025-777-01), and because of the retrospective design, informed consent was waived. Surgical Techniques In the one-team TaTME group, a sequential approach was used in which the abdominal phase was followed by the transanal phase. The depth of pelvic mesenteric dissection is determined by the difficulty of the surgery. Generally speaking, the anterior dissection of the rectum is performed 1–2 cm below the peritoneal reflection, the posterior dissection of the rectum reaches the rectosacral fascia, and the bilateral dissection is carried out to a position level with the anterior and posterior planes. Then, place a landmark (such as a radiopaque gauze strip). Place the anal platform through the transanal approach, perform a purse-string suture to close the rectal lumen approximately 1.5 cm below the lower edge of the tumor, and continue the dissection from bottom to top along the correct planes at the posterior, bilateral, and anterior aspects of the rectum until meeting with the marked area, thereby completing the total mesorectal excision. If necessary, the 4-port anal platform can be used to assist in exposing the surgical field. In the LapTME group, conventional multi-port laparoscopic TME was performed transabdominally, with transanal access only for anastomosis. Data Collection Clinical and pathological data were extracted from electronic medical records. Baseline variables included age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, and tumor-related characteristics, American Society of Anesthesiologists (ASA) physical status classification, and tumor-related characteristics including clinical T and N stage by imaging, tumor distance from anal verge measured on MRI, MRI-assessed threatened CRM, and presence of extramural vascular invasion (EMVI). Use of neoadjuvant therapy was also recorded. Intraoperative data included operative time, estimated blood loss, and whether a protective stoma was created. Pathological outcomes recorded were tumor size, pathologic TNM stage, number of lymph nodes harvested, differentiation grade, status of CRM, and distal resection margin (DRM) on final pathology. Postoperative adjuvant chemotherapy administration was also noted. Follow-up information was obtained from clinic records and telephone follow-up, including dates and sites of any tumor recurrence, development of distant metastases, and survival status. Outcome Definitions The primary outcomes were 3-year local recurrence and distant metastasis. Local recurrence was defined as tumor recurrence in the pelvic cavity or rectal mesentery confirmed by radiologic imaging or histopathology. Distant metastasis was defined as any cancer spread to distant organs or non-regional lymph nodes. Secondary outcomes included 3-year disease-free survival (DFS), defined as survival without evidence of local recurrence or distant metastasis, and 3-year overall survival, defined as survival regardless of disease status. Time-to-event outcomes were calculated from the date of surgery to the first event or last follow-up. Patients were scheduled for routine surveillance every 3 months during the first postoperative year and every 6 months during years 2 and 3, with imaging performed according to standard guidelines. The last follow-up date was October 2025, ensuring at least 36 months of potential follow-up for all surviving patients. Statistical Analysis Propensity score matching (PSM) was performed to adjust for baseline differences between the two groups due to non-random treatment assignment. A propensity score for the probability of undergoing TaTME was calculated using the following covariates: age, sex, BMI, tumor distance from anal verge, clinical T stage, clinical N stage, MRI-CRM status, EMVI, and neoadjuvant therapy. Patients were matched in a 2:1 ratio (TaTME:LapTME) using nearest-neighbor matching without replacement (caliper width = 0.05). This yielded a matched cohort for outcome comparisons. The balance between groups after matching was assessed by comparing baseline characteristics. Continuous variables were expressed as mean ± standard deviation if normally distributed or median (interquartile range [IQR]) if skewed. Categorical variables were summarized as counts and percentages. Between-group comparisons in unmatched data used independent t-tests for normally distributed variables, and Mann-Whitney U tests for non-normal variables. Categorical variables were compared by χ 2 test or Fisher's exact test, as appropriate. Kaplan–Meier method was used to estimate DFS and OS curves, with comparisons between groups by the log-rank test. For matched data, paired statistical tests were considered, though in practice most outcomes were compared as rates with χ 2 /Fisher's tests given the 2:1 matching. A two-sided p < 0.05 was considered statistically significant for all analyses. Statistical analyses were performed using R version 4.0.3. Results Patient Characteristics A total of 256 patients met the inclusion criteria (TaTME, n = 129; LapTME, n = 127) before matching. Key baseline characteristics before and after propensity score matching are summarized in Table 1 . Before matching, there were several significant differences between the groups, indicating baseline imbalances between groups. Table 1 . Comparison of baseline characteristics of the two groups before and after PSM Characteristic Unmatched cohort Matched cohort TaTME (n = 129) LapTME (n = 127) p TaTME (n = 108) LapTME (n = 62) p Sex, n (%) 0.02 0.48 Male, n (%) 91 (70.54) 72 (56.69) 72 (66.67) 38 (61.29) Female, n (%) 38 (29.46) 55 (43.31) 36 (33.33) 24 (38.71) Age, M (Q 1 , Q 3 ) 61.00 (51.00, 68.00) 64.00 (56.00, 71.00) 0.01 62.00 (52.00, 68.00) 64.00 (55.25, 68.75) 0.29 BMI, M (Q 1 , Q 3 ) 23.00 (21.48, 24.80) 22.50 (20.80, 24.60) 0.35 23.00 (21.25, 24.41) 22.15 (20.72, 23.95) 0.11 ASA, n (%) 0.30 0.90 I 1 (0.78) 0 (0.00) 0 (0.00) 0 (0.00) II 83 (64.34) 74 (58.27) 69 (63.89) 39 (62.90) III 45 (34.88) 53 (41.73) 39 (36.11) 23 (37.10) Tumor distance from anal verge (mm), M (Q 1 , Q 3 ) 50.00 (38.00, 60.00) 75.00 (56.50, 90.00) <.001 50.00 (39.00, 63.25) 58.00 (43.00, 69.50) 0.08 CRM, n (%) 0.02 0.08 Positive 27 (20.93) 13 (10.24) 24 (22.22) 7 (11.29) Negative 102 (79.07) 114 (89.76) 84 (77.78) 55 (88.71) EMVI, n (%) 0.81 0.17 Positive 29 (22.48) 27 (21.26) 21 (19.44) 7 (11.29) Negative 100 (77.52) 100 (78.74) 87 (80.56) 55 (88.71) Clinical T stage, n (%) 0.01 0.07 T1 0 (0.00) 1 (0.79) 0 (0.00) 1 (1.61) T2 48 (37.21) 56 (44.09) 41 (37.96) 28 (45.16) T3 75 (58.14) 53 (41.73) 62 (57.41) 26 (41.94) T4 6 (4.65) 17 (13.39) 5 (4.63) 7 (11.29) Clinical N stage, n (%) 0.07 0.07 N0 70 (54.26) 84 (66.14) 58 (53.70) 44 (70.97) N1 34 (26.36) 30 (23.62) 29 (26.85) 12 (19.35) N2 25 (19.38) 13 (10.24) 21 (19.44) 6 (9.68) CEA, M (Q 1 , Q 3 ) 2.90 (1.90, 4.60) 3.00 (1.80, 4.70) 0.79 2.95 (1.98, 4.65) 2.95 (1.90, 4.97) 0.80 Neoadjuvant chemotherapy, n (%) 61 (47.29) 22 (17.32) <.001 45 (40.74) 17 (27.42) 0.08 Preoperative clinical stage, n (%) 0.81 0.71 I 54 (41.86) 51 (40.16) 45 (41.67) 28 (45.16) II 30 (23.26) 34 (26.77) 25 (23.15) 16 (25.81) III 45 (34.88) 42 (33.07) 38 (35.19) 18 (29.03) ASA, American Society of Anesthesiologists; BMI, body mass index (calculated as weight (kg) divided by height (meters) squared); CRM: Circumferential resection margin; EMVI: Extramural Venous Invasion, CEA: Carcinoembryonic Antigen. Preoperative clinical stage: According to the 7th edition of the American Joint Committee on Cancer staging system, clinical stage I includes stages T1 or T2 and N0M0; Stage II includes T3 or T4 and N0M0; Stage III includes any T stage and N1M0 or N2M0; Stage IV includes any T or N stage and M1 stage. Clinical stage was determined using preoperative imaging. Patients undergoing TaTME were younger (median 61 vs 64 years, p = 0.01), more often male (70.5% vs 56.7%, p = 0.021), and had tumors located closer to the anal verge (median 50 vs 75 mm, p < 0.001). They also had a higher rate of MRI-predicted threatened circumferential resection margin (20.9% vs 10.2%, p = 0.02). Clinical T stage distribution differed, with a higher proportion of T3 tumors (58% vs 42%) and a lower proportion of T4 tumors (4.7% vs 13.4%) in the TaTME group ( p = 0.008). In addition, neoadjuvant therapy was more frequently administered in the TaTME group (47.3% vs 17.3%, p < 0.001), consistent with preferential selection of more locally advanced or technically challenging cases. Other baseline characteristics, including BMI, ASA class, clinical N stage, CEA levels, and EMVI status, were comparable between groups (all p > 0.05). After 2:1 PSM, 170 patients were successfully matched (108 TaTME and 62 LapTME). The matched cohorts showed no significant differences in baseline variables (Table 1 ). Median age was 62 years in both groups, and the sex distribution became similar (66.7% vs 61.3% male, p = 0.48). Tumor distance from anal verge was balanced (median ~ 50 mm in TaTME vs 58 mm in LapTME, p = 0.08). Rates of preoperative MRI-CRM risk (22% vs 11%, p = 0.08) and neoadjuvant therapy use (40.7% vs 27.4%, p = 0.08) were no longer significantly different. Clinical T and N stage distributions and other characteristics were well matched ( p > 0.05 for all), indicating that the PSM achieved good balance between the two groups (Fig. 1 ). Thus, subsequent comparisons of outcomes were performed on this matched cohort. Perioperative and Pathologic Outcomes Table 2 summarizes intraoperative metrics and postoperative pathology results for the matched cohorts. The TaTME procedures required significantly longer operative time than LapTME (median 295 vs 220 minutes, p < 0.001). Despite the increased operative duration, intraoperative blood loss was low in both groups (median 50 ml in each, p = 0.76). No cases in either group required conversion from laparoscopic to open surgery, indicating both approaches were completed as intended in all patients. A protective stoma (usually a diverting ileostomy) was created more often in TaTME patients (52.78% vs 32.26%, p = 0.01). The pathological report of the postoperative specimens showed that the distribution of the distance from the distal resection margin of the tumor after fixation with formalin solution in the TaTME group was more concentrated than that in the LapTME group ( p < 0.001) (Fig. 2 ). Table 2 Comparison of intraoperative and postoperative pathological conditions of patients in TaTME and LapTME after PSM [± s, M (P25, P75), or n (%)] Operative time (Min), M (Q 1 , Q 3 ) TaTME (n = 108) LapTME (n = 62) p 295.00 (242.25, 351.25) 220.00 (181.25, 252.50) < .001 Blood loss (Ml), M (Q 1 , Q 3 ) 50.00 (50.00, 100.00) 50.00 (50.00, 100.00) 0.76 Prophylactic stoma creation, n (%) 57 (52.78) 20 (32.26) 0.01 Conversion to open surgery, n (%) 0(0) 0(0) 1.00 Pathological stage, n (%) 0.05 Pathologic complete response 3 (2.78) 1 (1.61) I 50 (46.30) 17 (27.42) II 24 (22.22) 23 (37.10) III 31 (28.70) 21 (33.87) No. of harvested lymph nodes, M (Q 1 , Q 3 ) 12.00 (9.00, 15.00) 13.00 (11.00, 16.00) 0.06 Lymphovascular invasion, n (%) 2 (1.85) 6 (9.68) 0.05 Nerve invasion, n (%) 4 (3.70) 2 (3.23) 1.00 Circumferential resection margin positive, n (%) 0(0) 0(0) 1.00 Distal resection margin positive, n (%) 0(0) 0(0) 1.00 Tumor differentiation, n (%) 0.46 Poor 11 (10.19) 10 (16.13) Moderate 86 (79.63) 47 (75.81) Well 8 (7.41) 5 (8.06) Other (no residual cancer detected) 3 (2.78) 0 (0.00) Pathological stage: Stage I includes T1 or T2 stage and N0M0; Stage II includes T3 or T4 and N0M0; Stage III refers to any T stage with N1M0 or N2M0; Stage IV refers to any T or N stage and M1. Pathological complete remission occurs when no malignant cells are found in the proctectomy specimens of patients treated preoperatively. The pathological stage was determined based on the proctectomy specimen. Pathologic staging of the resected tumors was similar between groups. Rates of pathologic complete response (pCR) after neoadjuvant therapy were not different (TaTME 2.8% vs LapTME 1.6%, part of stage 0 in Table 2 ). The distributions of pathologic stage I, II, and III were statistically comparable ( p = 0.05 for overall stage distribution). The total number of lymph nodes harvested did not differ significantly (median 12 in TaTME vs 13 in LapTME, p = 0.06), and both met oncologic quality benchmarks (all cases had ≥ 12 nodes examined). There was no significant difference in the incidence of lymphovascular invasion (1.85% vs 9.68%, p = 0.05) or perineural invasion (3.7% vs 3.2%, p = 1.00) between TaTME and LapTME. Tumor differentiation grades were similarly distributed (majority moderate differentiation in both, p = 0.46). These findings indicate that, aside from the distal margin length difference, the pathological outcomes (tumor stage, margins, nodal yield, etc.) were equivalent between TaTME and LapTME resections in the matched cohort. Oncologic Outcomes at 3 Years All patients were followed for at least 3 years or until an event; the overall median follow-up time was 48 months (TaTME 47.0 vs LapTME 51.0 months, p = 0.23). During this period, a total of 7 local recurrences (4.1% of 170) were observed in the matched cohort. The 3-year local recurrence rate was 3.7% (4 of 108) in the TaTME group versus 4.8% (3 of 62) in the LapTME group ( p > 0.99) (Table 3 ). There was no significant difference in local tumor control between the two techniques. Distant metastases developed in 23 patients (13.5% of 170) by 3 years. The 3-year distant metastasis rate was 12.96% (14/108) for TaTME and 14.52% (9/62) for LapTME ( p = 0.78). Thus, the risk of developing metastases was statistically equivalent between groups. Table 3 Comparison of postoperative treatment and 3-year postoperative oncological outcomes of patients in TaTME and LapTME groups after PSM Follow-up time(month), M (Q 1 , Q 3 ) TaTME (n = 108) LapTME (n = 62) p 47.00 (35.75, 58.25) 51.00 (39.00, 63.75) 0.23 Ostomy reversal, n (%) 0.56 Yes 54 (94.74) 20 (100.00) No 3 (5.26) 0 (0.00) Anastomotic leak, n (%) 8 (7.41) 8 (12.90) 0.24 Grade of anastomotic leak, n (%) 1.00 I 5 (62.50) 6 (75.00) II 1 (12.50) 0 (0.00) III 2 (25.00) 2 (25.00) Adjuvant chemotherapy, n (%) 51 (47.22) 30 (48.39) 0.88 LR, n (%) 4 (3.70) 3 (4.84) 1.00 Distant metastasis, n (%) 14 (12.96) 9 (14.52) 0.78 DFS, n (%) 90 (83.33) 51 (82.26) 0.86 OS, n (%) 96 (88.89) 56 (90.32) 0.77 Composite event of recurrence, metastasis or death, n (%) 18 (16.67) 11 (17.74) 0.86 Composite events of recurrence, metastasis, or death, including the incidences of local recurrence, distant metastasis, and death. The disease-free survival at 3 years was virtually identical between the two approaches. The 3-year DFS rate was 83.33% for TaTME vs 82.26% for LapTME ( p = 0.86). Overall survival at 3 years was 88.89% vs 90.32% for TaTME and LapTME, respectively ( p = 0.77). Figure 3 depicts the Kaplan–Meier survival curves for DFS and OS, which show no separation between the TaTME and LapTME groups over the 3-year follow-up. A combined endpoint of "any oncologic event" (defined as recurrence, metastasis, or death by 3 years) also showed no difference: 16.67% in TaTME vs 17.74% in LapTME ( p = 0.86). In summary, oncologic outcomes, including locoregional control and survival, at 3 years postoperatively, were equivalent between one-team TaTME and LapTME in this matched cohort. Subgroup Analyses Subgroup analyses were performed to evaluate outcomes in selected patient populations. Among patients who received neoadjuvant therapy (n = 63), 3-year oncologic outcomes were similar between the TaTME (n = 45) and LapTME (n = 18) groups (Table 4 ). Local recurrence rates were 2.2% vs 11.1% ( p = 0.19), and distant metastasis rates were 17.8% vs 16.7% ( p = 1.00). Three-year disease-free survival (80.0% vs 83.3%) and overall survival (88.9% vs 88.9%) were also comparable between groups. Table 4 Comparison of 3-year oncological outcomes between TaTME and LapTME after preoperative neoadjuvant therapy LR, n (%) Total (n = 63) TaTME (n = 45) LapTME (n = 18) p 3 (4.76) 1 (2.22) 2 (11.11) 0.19 Distant metastasis, n (%) 11 (17.46) 8 (17.78) 3 (16.67) 1.00 DFS, n (%) 51 (80.95) 36 (80.00) 15 (83.33) 1.00 OS, n (%) 56 (88.89) 40 (88.89) 16 (88.89) 1.00 Composite event of recurrence, metastasis or death, n (%) 12 (19.05) 9 (20.00) 3 (16.67) 1.00 Composite events of recurrence, metastasis, or death, including the incidences of local recurrence, distant metastasis, and death. In patients with obesity (BMI > 25 kg/m 2 , n = 34), no significant differences were observed between TaTME and LapTME (Table 5 ). No local recurrences occurred in the TaTME group compared with 1 case (9.1%) in the LapTME group, and distant metastasis rates were 13.0% vs 18.2% ( p = 1.00). Disease-free survival (86.96% vs 81.82%, p = 1.00) and overall survival (86.96% vs 100%, p = 0.54) were similar between groups. Table 5 Comparison of 3-year oncological outcomes between TaTME and LapTME in patients with BMI > 25 LR, n (%) Total (n = 34) TaTME (n = 23) LapTME (n = 11) p 1 (2.94) 0 (0.00) 1 (9.09) 0.32 Distant metastasis, n (%) 5 (14.71) 3 (13.04) 2 (18.18) 1.00 DFS, n (%) 29 (85.29) 20 (86.96) 9 (81.82) 1.00 OS, n (%) 31 (91.18) 20 (86.96) 11 (100.00) 0.54 Composite event of recurrence, metastasis or death, n (%) 5 (14.71) 3 (13.04) 2 (18.18) 1.00 Composite events of recurrence, metastasis, or death, including the incidences of local recurrence, distant metastasis, and death. Among male patients (n = 110), outcomes at 3 years were likewise comparable between TaTME and LapTME (Table 6 ), with no significant differences in local recurrence (4.17% vs 7.89%, p = 0.70), distant metastasis (15.3% vs 18.4%, p = 0.67), or survival outcomes. Table 6 Comparison of 3-year oncological outcomes between the TaTME and LapTME in male patients LR, n (%) Total (n = 110) TaTME (n = 72) LapTME (n = 38) p 6 (5.45) 3 (4.17) 3 (7.89) 0.71 Distant metastasis, n (%) 18 (16.36) 11 (15.28) 7 (18.42) 0.67 DFS, n (%) 86 (78.18) 57 (79.17) 29 (76.32) 0.73 OS, n (%) 95 (86.36) 61 (84.72) 34 (89.47) 0.49 Composite event of recurrence, metastasis or death, n (%) 22 (20.00) 14 (19.44) 8 (21.05) 0.84 Composite events of recurrence, metastasis, or death, including the incidences of local recurrence, distant metastasis, and death. Overall, no significant differences were observed across subgroups. However, these analyses were limited by small sample sizes and should be interpreted with caution. Discussion In this propensity score–matched cohort study, we found that one-team transanal total mesorectal excision achieved mid-term oncologic outcomes comparable to those of conventional laparoscopic TME in patients with mid and low rectal cancer. At 3 years, there were no significant differences between approaches in local recurrence, distant metastasis, disease-free survival, or overall survival. These findings provide real-world evidence supporting the oncologic safety of TaTME when performed using a sequential single-team approach. A key feature of this study is its focus on a one-team TaTME strategy. Most existing randomized trials, including the TaLaR study[ 18 ], were conducted under controlled conditions using a dual-team simultaneous approach, which may not reflect routine surgical practice. In contrast, the single-team sequential approach evaluated in this study is more commonly adopted in this center due to practical considerations, including resource availability and operating room logistics. Our findings suggest that, when performed by experienced surgeons, this approach does not compromise oncologic outcomes. This observation is clinically relevant, as it supports the feasibility of implementing TaTME in settings where dual-team coordination is not readily achievable. The oncologic outcomes observed in this study are consistent with those reported in recent randomized and observational studies. The TaLaR trial demonstrated noninferiority of TaTME compared with laparoscopic TME in terms of pathologic quality and 3-year disease-free survival[ 18 ]. Similarly, large propensity score–matched analyses and population-based studies have reported comparable long-term outcomes between the two techniques[ 19 , 20 ]. The present results align closely with these data, supporting the external validity of our findings in a real-world clinical setting. From a technical perspective, TaTME offers improved visualization of the distal rectum and facilitates precise dissection in anatomically challenging conditions[ 6 , 21 – 23 ]. In this study, although all patients achieved negative circumferential and distal margins, the distribution of distal margin length was more consistent in the TaTME group ( p < 0.001) (Fig. 2 ). This finding may reflect the technical advantage of the transanal approach in achieving controlled distal transection. While this did not translate into measurable differences in oncologic outcomes within the follow-up period, it may represent an aspect of procedural reliability that warrants further investigation. Perioperative findings were consistent with the technical characteristics of the procedures. TaTME was associated with longer operative time and a higher rate of protective stoma formation. However, in follow-up, no significant differences were observed between the TaTME and LapTME groups in anastomotic leakage incidence, leakage severity, or stoma reversal rate. Of the 57 TaTME patients with prophylactic stoma, 54 (94.74%) underwent reversal, with no impact on subsequent quality of life. Despite these differences, intraoperative blood loss and major postoperative outcomes were similar between groups, suggesting that the increased technical demands of TaTME do not adversely affect perioperative safety when performed by experienced teams. Subgroup analyses demonstrated consistent results across patients receiving neoadjuvant therapy, as well as in male and overweight patients, who are traditionally considered technically challenging for rectal surgery. These findings are in line with prior studies showing comparable outcomes between TaTME and laparoscopic TME in such subgroups[ 24 , 25 ]. Although these analyses were limited by sample size, the absence of significant differences supports the generalizability of the primary findings. Several limitations should be acknowledged. First, the retrospective design may cause residual confounding despite propensity score matching. Second, the single-center, high-volume setting limits generalizability to less experienced centers. Third, while follow-up was adequate for 3-year outcomes, longer observation is required to evaluate long-term survival and late recurrence. Finally, functional outcomes and quality of life were not assessed and should be included in future studies. One-team transanal total mesorectal excision provides mid-term oncologic outcomes comparable to laparoscopic TME for patients with mid and low rectal cancer, with similar rates of local recurrence, distant metastasis, and survival. This real-world evidence supports its use as a feasible and oncologically safe minimally invasive option in experienced centers, particularly where dual-team approaches are not practical. In addition, the transanal approach may offer technical advantages in distal pelvic dissection and margin control. Prospective multicenter studies with longer follow-up are warranted to further validate these findings and define their optimal role in clinical practice. Declarations Conflicts of interest: there are no conflicts of interest. Funding: This study received no specific funding from any public, commercial, or non-profit funding agencies. Author Contribution C.S. completed the data curation and research methodology design for this study, and drafted the original manuscript; J.F.D., L.X.H., and X.F.Z. jointly assisted in the data curation of the study; X.X. was responsible for the statistical analysis and result visualization of the research, and provided supervision and guidance throughout the study; Y.G.G., Z.W.W., and H.Y.Z. jointly completed the conceptualization, design and resource support of the research, and reviewed and revised the manuscript.All authors reviewed the manuscript. Acknowledgments: The authors thank the patients who participated in this study. We acknowledge the support from the clinical and research teams of the First Affiliated Hospital of Chongqing Medical University, including the Department of Gastrointestinal Surgery, Department of Pathology, and medical records staff for data collection and follow-up. Data Availability All data supporting the findings of this study are available within the paper and its Supplementary Information. References Yi Chi Z, Gang O, Xiao Li F, et al. Laparoscopic total mesorectal excision versus transanal total mesorectal excision for mid and low rectal cancer: A systematic review and meta-analysis. Medicine (Baltimore). 2024;103(4):e36859. doi: 10.1097/MD.0000000000036859 Seow W, Dudi-Venkata NN, Bedrikovetski S, Kroon HM, Sammour T. Outcomes of open vs laparoscopic vs robotic vs transanal total mesorectal excision (TME) for rectal cancer: a network meta-analysis. Tech Coloproctol. 2023;27(5):345–360. doi: 10.1007/s10151-022-02739-1 Liu H, Zeng Z, Zhang H, et al. Morbidity, Mortality, and Pathologic Outcomes of Transanal Versus Laparoscopic Total Mesorectal Excision for Rectal Cancer Short-term Outcomes From a Multicenter Randomized Controlled Trial. Ann Surg. 2023;277(1):1–6. doi: 10.1097/SLA.0000000000005523 Kumar NAN, Usman N, Rajan K, S Shetty P, Crithic VHV, Rao V Narasimha V. Laparoscopic total mesorectal excision for low rectal cancer - A step by step approach - A video vignette. Colorectal Dis. 2022;24(1):141. doi: 10.1111/codi.15927 van der Pas MH, Haglind E, Cuesta MA, et al. Laparoscopic versus open surgery for rectal cancer (COLOR II): Short-term outcomes of a randomised, phase 3 trial. Lancet Oncol. 2013;14(3):210–218. doi: 10.1016/s1470-2045(13)70016-0 . Zuhdy M, Elmore U, Shams N, et al. Transanal versus laparoscopic total mesorectal excision: A comparative prospective clinical trial from two centers. J Laparoendosc Adv Surg Tech A. 2020;30(7):769–776. doi: 10.1089/lap.2019.0828 . Dittrich L, Biebl M, Schmuck R, et al. Initial Experience with the Safe Implementation of Transanal Total Mesorectal Excision (TaTME) as a Standardized Procedure for Low Rectal Cancer. J Clin Med. 2020;10(1):72. Published 2020 Dec 28. doi: 10.3390/jcm10010072 Labalde Martínez, M., García Borda, F.J., Alcalde Escribano, J. et al. Transanal total mesorectal excision and adverse conditions for laparoscopic total mesorectal excision. Eur Surg 52, 88–95 (2020). https://doi.org/10.1007/s10353-019-00626-y Liao CK, Yu YL, Kuo YT, Hsu YJ, Chern YJ, Lin YC, et al. Transanal versus transabdominal total mesorectal excision for rectal cancer in minimally invasive surgery: meta-analysis. BJS Open [Internet]. 2025;9(6). Available from: http://dx.doi.org/10.1093/bjsopen/zraf111 Roodbeen SX, Spinelli A, Bemelman WA, et al. Local Recurrence After Transanal Total Mesorectal Excision for Rectal Cancer: A Multicenter Cohort Study. Ann Surg. 2021;274(2):359–366. doi: 10.1097/SLA.0000000000003757 Wasmuth HH, Faerden AE, Myklebust TÅ, et al. Transanal total mesorectal excision for rectal cancer has been suspended in Norway. Br J Surg. 2020;107(1):121–130. doi: 10.1002/bjs.11459 van Oostendorp SE, Belgers HJ, Bootsma BT, et al. Locoregional recurrences after transanal total mesorectal excision of rectal cancer during implementation. Br J Surg. 2020;107(9):1211–1220. doi: 10.1002/bjs.11525 Atallah S, Sylla P, Wexner SD. Norway versus The Netherlands: will taTME stand the test of time?. Tech Coloproctol. 2019;23(9):803–806. doi: 10.1007/s10151-019-02097-5 Sylla P, Rattner DW, Delgado S, Lacy AM. NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc. 2010;24(5):1205–1210. doi: 10.1007/s00464-010-0965-6 Simillis C, Hompes R, Penna M, Rasheed S, Tekkis PP. A systematic review of transanal total mesorectal excision: is this the future of rectal cancer surgery?. Colorectal Dis. 2016;18(1):19–36. doi: 10.1111/codi.13151 Ren J, Luo H, Liu S, Wang B, Wu F. Short- and mid-term outcomes of transanal versus laparoscopic total mesorectal excision for low rectal cancer: a meta-analysis. Ann Surg Treat Res. 2021;100(2):86–99. doi: 10.4174/astr.2021.100.2.86 Ryan OK, Ryan ÉJ, Creavin B, et al. Surgical approach for rectal cancer: A network meta-analysis comparing open, laparoscopic, robotic and transanal TME approaches. Eur J Surg Oncol. 2021;47(2):285–295. doi: 10.1016/j.ejso.2020.06.037 Zeng Z, Luo S, Zhang H, et al. Transanal vs Laparoscopic Total Mesorectal Excision and 3-Year Disease-Free Survival in Rectal Cancer: The TaLaR Randomized Clinical Trial. JAMA. 2025;333(9):774–783. doi: 10.1001/jama.2024.24276 Manchon-Walsh P, de Lacy FB, Pera M, et al. Transanal Total Mesorectal Excision Versus Anterior Total Mesorectal Excision for Rectal Cancer: A Propensity Score Matched, Population-Based Study in Catalonia, Spain. Dis Colon Rectum. 2022;65(2):207–217. doi: 10.1097/DCR.0000000000002147 Li Z, Liu H, Luo S, et al. Long-term oncological outcomes of transanal versus laparoscopic total mesorectal excision for mid-low rectal cancer: a retrospective analysis of 2502 patients. Int J Surg. 2024;110(3):1611–1619. Published 2024 Mar 1. doi: 10.1097/JS9.0000000000000992 Lorenzon L, Bini F, Landolfi F, et al. 3D pelvimetry and biometric measurements: a surgical perspective for colorectal resections. Int J Colorectal Dis. 2021;36(5):977–986. doi: 10.1007/s00384-020-03802-9 Grass JK, Perez DR, Izbicki JR, Reeh M. Systematic review analysis of robotic and transanal approaches in TME surgery- A systematic review of the current literature in regard to challenges in rectal cancer surgery. Eur J Surg Oncol. 2019;45(4):498–509. doi: 10.1016/j.ejso.2018.11.010 Ziati J, Souadka A, Benkabbou A, et al. Transanal total mesorectal excision for patients with rectal cancer: a Systematic review and meta-analysis. Gulf J Oncolog. 2021;1(35):66–76. Li Z, Xiao J, Hou Y, et al. Transanal versus Laparoscopic Total Mesorectal Excision in Male Patients with Low Tumor Location after Neoadjuvant Therapy: A Propensity Score-Matched Cohort Study. Gastroenterol Res Pract. 2022;2022:2387464. Published 2022 Feb 27. doi: 10.1155/2022/2387464 Tejedor P, Arredondo J, Simó V, et al. The role of transanal compared to laparoscopic total mesorectal excision (taTME vs. lapTME) for the treatment of mid-low rectal cancer in obese patients: outcomes of a multicenter propensity-matched analysis. Updates Surg. 2023;75(8):2191–2200. doi: 10.1007/s13304-023-01676-4 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 03 May, 2026 Reviewers agreed at journal 20 Apr, 2026 Reviewers agreed at journal 17 Apr, 2026 Reviewers invited by journal 16 Apr, 2026 Editor assigned by journal 16 Apr, 2026 Submission checks completed at journal 10 Apr, 2026 First submitted to journal 08 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9359317","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":626220023,"identity":"c7368362-438a-40b8-97c8-59746cf1af4e","order_by":0,"name":"Chen Su","email":"","orcid":"","institution":"The First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chen","middleName":"","lastName":"Su","suffix":""},{"id":626220025,"identity":"d20ca0c3-1ec0-49a8-bb98-d0a10c1815b2","order_by":1,"name":"Junfeng Du","email":"","orcid":"","institution":"The First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Junfeng","middleName":"","lastName":"Du","suffix":""},{"id":626220028,"identity":"24716a8c-8878-470e-9180-6d1c5487fe3e","order_by":2,"name":"Xiang Xu","email":"","orcid":"","institution":"The First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xiang","middleName":"","lastName":"Xu","suffix":""},{"id":626220029,"identity":"24152575-8f15-4b72-8add-0cc98338d0da","order_by":3,"name":"Lanxin Hu","email":"","orcid":"","institution":"The First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Lanxin","middleName":"","lastName":"Hu","suffix":""},{"id":626220030,"identity":"a6711c58-7686-48c9-a851-708bed52caea","order_by":4,"name":"Xuefei Zhang","email":"","orcid":"","institution":"The First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xuefei","middleName":"","lastName":"Zhang","suffix":""},{"id":626220031,"identity":"c02885e4-a04b-415a-a0ad-e7b62f5331be","order_by":5,"name":"Yinggang Ge","email":"","orcid":"","institution":"The First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yinggang","middleName":"","lastName":"Ge","suffix":""},{"id":626220032,"identity":"8263fb0f-07c5-4e67-96df-5a3220c90c4c","order_by":6,"name":"Ziwei Wang","email":"","orcid":"","institution":"The First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ziwei","middleName":"","lastName":"Wang","suffix":""},{"id":626220033,"identity":"16983d12-073a-4c30-8c0e-5d750e1faf2b","order_by":7,"name":"Hongyu Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIiWNgGAWjYBACeWb24z8+GPzjYeNvPkCcFsN2ngTJGRUHZPgkjiUQac15BgNpnjMHbOQYcgyI08HYzJBgwNt2h4eN4czHG28Y7OR0GwhoYWdmPJAg2faMh425d7PlHIZkY7MDRNhywLCNGWjL2W3SPAwHErcR0sJwmMGwIRGsJecZ0VqMGQ6cOQzSwkacFsNmnjTGhoo0HjaJY8aWcwyI8Is8//FjzH8MbOzl+5sf3nhTYSdHUAsKkOAhMmqQtZCqYxSMglEwCkYEAACDRz57q1eElQAAAABJRU5ErkJggg==","orcid":"","institution":"The First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":true,"prefix":"","firstName":"Hongyu","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2026-04-08 16:10:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9359317/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9359317/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107834469,"identity":"50e6be27-1798-4dea-bf18-daa0a4a3cc3f","added_by":"auto","created_at":"2026-04-26 15:45:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":218030,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of clinical patient selection in this study.\u003c/p\u003e\n\u003cp\u003eAbbreviations: TaTME, Transanal Total Mesorectal Excision; LapTME, Laparoscopic Total Mesorectal Excision; PSM, Propensity Score Matching; CRM, Circumferential Resection Margin.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9359317/v1/2b47322e744c6859ce323093.png"},{"id":107869559,"identity":"b7b5cf96-2aa5-46a2-bdb8-3b93de84fdba","added_by":"auto","created_at":"2026-04-27 07:37:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":152328,"visible":true,"origin":"","legend":"\u003cp\u003eConcentration diagram of the distance from the distal margin after specimen fixation in TaTME and LapTME after PSM.\u003c/p\u003e\n\u003cp\u003eAbbreviations: TaTME, Transanal Total Mesorectal Excision; LapTME, Laparoscopic Total Mesorectal Excision; PSM, Propensity Score Matching.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9359317/v1/850bd487a6f7c9932937a7d9.png"},{"id":107870554,"identity":"4876266b-b389-449e-89d2-b5d364ee1b0d","added_by":"auto","created_at":"2026-04-27 07:39:54","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":244699,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier curves showing the (A) 3-year LR, (B) distant metastasis rates, (C) DFS, (D) OS, and (E) the incidence of composite events in the TaTME and the LapTME after PSM. Abbreviations: LR, Local Recurrence; DFS, Disease-Free Survival; OS, Overall Survival; TaTME, Transanal Total Mesorectal Excision; LapTME, Laparoscopic Total Mesorectal Excision; PSM, Propensity Score Matching.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9359317/v1/c066e22b382d2ff436d7d29a.png"},{"id":108181052,"identity":"4a900e64-6490-460a-85b8-4971f90c6222","added_by":"auto","created_at":"2026-04-30 08:56:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1042380,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9359317/v1/203bfd1a-8ea6-47eb-9ad4-8a471362cfa6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Oncologic Outcomes of One-Team Transanal Versus Laparoscopic Total Mesorectal Excision for Mid and Low Rectal Cancer: A Propensity Score–Matched Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTotal mesorectal excision (TME) remains the cornerstone of curative surgery for mid and low rectal cancer, with the quality of mesorectal dissection and margin status strongly influencing local recurrence and long-term oncologic outcomes[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Laparoscopic TME (LapTME) has become widely adopted as a minimally invasive standard approach[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, achieving consistent distal pelvic dissection and secure distal margin control through a transabdominal approach remains technically challenging, particularly in patients with a narrow pelvis, obesity, or very low tumors[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTransanal total mesorectal excision (TaTME) was developed to address these limitations by enabling a bottom-up dissection under direct visualization of the distal rectum and mesorectum[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Early studies suggested potential technical advantages, including improved access to the distal pelvis and lower conversion rates in technically demanding cases[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, as TaTME has been adopted more broadly, concerns have emerged regarding oncologic safety, including reports of atypical local recurrence patterns and variability in outcomes across centers[\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These findings have highlighted the importance of structured training, procedural standardization, and institutional experience in achieving safe implementation[\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecent randomized controlled trials, including the TaLaR study[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], have provided high-level evidence demonstrating that TaTME is not inferior to LapTME in terms of pathologic quality and short-term oncologic outcomes when performed by well-trained surgical teams. Notably, these trials predominantly employed a dual-team simultaneous approach and were conducted under controlled trial conditions. However, this setting does not fully reflect routine clinical practice, where variations in surgical workflow, resource availability, and team structure are common.\u003c/p\u003e \u003cp\u003eIn many real-world settings, TaTME is performed using a single-team, sequential approach, in which the same surgical team completes both the abdominal and transanal phases. While this approach is more practical and resource-efficient, its oncologic safety remains insufficiently evaluated. In particular, whether comparable tumor control can be maintained without the dual-team setup remains an important and unresolved clinical question.\u003c/p\u003e \u003cp\u003eTherefore, we conducted a retrospective cohort study to compare mid-term oncologic outcomes between one-team TaTME and LapTME in patients with mid and low rectal cancer treated under routine clinical practice conditions. Using propensity score matching to minimize selection bias, we evaluated local recurrence, distant metastasis, disease-free survival, and overall survival at 3 years. In addition, we assessed distal resection margin characteristics as a measure of technical consistency and surgical precision.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Patients\u003c/h2\u003e \u003cp\u003eThis single-center retrospective cohort study was conducted at the Department of Gastrointestinal Surgery, First Affiliated Hospital of Chongqing Medical University. Patients who underwent radical TME surgery for rectal adenocarcinoma from January 2018 to May 2022 were identified from institutional surgical and pathology databases.\u003c/p\u003e \u003cp\u003eInclusion criteria were: (1) histologically confirmed mid- or low-rectal adenocarcinoma (tumor located\u0026thinsp;\u0026le;\u0026thinsp;10 cm from the anal verge on preoperative imaging); (2) clinical stage cT1-T3, N0-N2 (M0) before treatment; and (3) age\u0026thinsp;\u0026ge;\u0026thinsp;18 years undergoing curative-intent TME. Exclusion criteria were: (1) tumor invasion of the anal sphincter or levator musculature requiring abdominoperineal resection; (2) severe organ dysfunction precluding major surgery; (3) emergent surgery for obstruction or perforation; (4) intraoperative discovery of metastatic disease; or (5) a history of other malignancies.\u003c/p\u003e \u003cp\u003eThe study was approved by the hospital ethics committee (Approval No. 2025-777-01), and because of the retrospective design, informed consent was waived.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical Techniques\u003c/h3\u003e\n\u003cp\u003eIn the one-team TaTME group, a sequential approach was used in which the abdominal phase was followed by the transanal phase. The depth of pelvic mesenteric dissection is determined by the difficulty of the surgery. Generally speaking, the anterior dissection of the rectum is performed 1\u0026ndash;2 cm below the peritoneal reflection, the posterior dissection of the rectum reaches the rectosacral fascia, and the bilateral dissection is carried out to a position level with the anterior and posterior planes. Then, place a landmark (such as a radiopaque gauze strip). Place the anal platform through the transanal approach, perform a purse-string suture to close the rectal lumen approximately 1.5 cm below the lower edge of the tumor, and continue the dissection from bottom to top along the correct planes at the posterior, bilateral, and anterior aspects of the rectum until meeting with the marked area, thereby completing the total mesorectal excision. If necessary, the 4-port anal platform can be used to assist in exposing the surgical field.\u003c/p\u003e \u003cp\u003eIn the LapTME group, conventional multi-port laparoscopic TME was performed transabdominally, with transanal access only for anastomosis.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eClinical and pathological data were extracted from electronic medical records. Baseline variables included age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, and tumor-related characteristics, American Society of Anesthesiologists (ASA) physical status classification, and tumor-related characteristics including clinical T and N stage by imaging, tumor distance from anal verge measured on MRI, MRI-assessed threatened CRM, and presence of extramural vascular invasion (EMVI). Use of neoadjuvant therapy was also recorded. Intraoperative data included operative time, estimated blood loss, and whether a protective stoma was created. Pathological outcomes recorded were tumor size, pathologic TNM stage, number of lymph nodes harvested, differentiation grade, status of CRM, and distal resection margin (DRM) on final pathology. Postoperative adjuvant chemotherapy administration was also noted. Follow-up information was obtained from clinic records and telephone follow-up, including dates and sites of any tumor recurrence, development of distant metastases, and survival status.\u003c/p\u003e\n\u003ch3\u003eOutcome Definitions\u003c/h3\u003e\n\u003cp\u003eThe primary outcomes were 3-year local recurrence and distant metastasis. Local recurrence was defined as tumor recurrence in the pelvic cavity or rectal mesentery confirmed by radiologic imaging or histopathology. Distant metastasis was defined as any cancer spread to distant organs or non-regional lymph nodes.\u003c/p\u003e \u003cp\u003eSecondary outcomes included 3-year disease-free survival (DFS), defined as survival without evidence of local recurrence or distant metastasis, and 3-year overall survival, defined as survival regardless of disease status. Time-to-event outcomes were calculated from the date of surgery to the first event or last follow-up.\u003c/p\u003e \u003cp\u003e Patients were scheduled for routine surveillance every 3 months during the first postoperative year and every 6 months during years 2 and 3, with imaging performed according to standard guidelines. The last follow-up date was October 2025, ensuring at least 36 months of potential follow-up for all surviving patients.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003ePropensity score matching (PSM) was performed to adjust for baseline differences between the two groups due to non-random treatment assignment. A propensity score for the probability of undergoing TaTME was calculated using the following covariates: age, sex, BMI, tumor distance from anal verge, clinical T stage, clinical N stage, MRI-CRM status, EMVI, and neoadjuvant therapy. Patients were matched in a 2:1 ratio (TaTME:LapTME) using nearest-neighbor matching without replacement (caliper width\u0026thinsp;=\u0026thinsp;0.05). This yielded a matched cohort for outcome comparisons. The balance between groups after matching was assessed by comparing baseline characteristics.\u003c/p\u003e \u003cp\u003eContinuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation if normally distributed or median (interquartile range [IQR]) if skewed. Categorical variables were summarized as counts and percentages. Between-group comparisons in unmatched data used independent t-tests for normally distributed variables, and Mann-Whitney U tests for non-normal variables. Categorical variables were compared by χ\u003csup\u003e2\u003c/sup\u003e test or Fisher's exact test, as appropriate. Kaplan\u0026ndash;Meier method was used to estimate DFS and OS curves, with comparisons between groups by the log-rank test. For matched data, paired statistical tests were considered, though in practice most outcomes were compared as rates with χ\u003csup\u003e2\u003c/sup\u003e/Fisher's tests given the 2:1 matching. A two-sided \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant for all analyses. Statistical analyses were performed using R version 4.0.3.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePatient Characteristics\u003c/h2\u003e \u003cp\u003eA total of 256 patients met the inclusion criteria (TaTME, n\u0026thinsp;=\u0026thinsp;129; LapTME, n\u0026thinsp;=\u0026thinsp;127) before matching. Key baseline characteristics before and after propensity score matching are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Before matching, there were several significant differences between the groups, indicating baseline imbalances between groups.\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e. Comparison of baseline characteristics of the two groups before and after PSM\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnmatched cohort\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eMatched cohort\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTaTME\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 129)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLapTME\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 127)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTaTME\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 108)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLapTME\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSex, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMale, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e91 (70.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e72 (56.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e72 (66.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38 (61.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38 (29.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55 (43.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24 (38.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge, M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e61.00 (51.00, 68.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e64.00 (56.00, 71.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62.00 (52.00, 68.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e64.00 (55.25, 68.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBMI, M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.00 (21.48, 24.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.50 (20.80, 24.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.00 (21.25, 24.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.15 (20.72, 23.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eASA, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (0.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e83 (64.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e74 (58.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e69 (63.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39 (62.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45 (34.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e53 (41.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39 (36.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23 (37.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTumor distance from anal verge (mm), M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50.00 (38.00, 60.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75.00 (56.50, 90.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50.00 (39.00, 63.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e58.00 (43.00, 69.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCRM, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27 (20.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (10.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24 (22.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (11.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e102 (79.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e114 (89.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e84 (77.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55 (88.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEMVI, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29 (22.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27 (21.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 (19.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (11.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100 (77.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100 (78.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e87 (80.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55 (88.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eClinical T stage, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (0.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e48 (37.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56 (44.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41 (37.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28 (45.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eT3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75 (58.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e53 (41.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62 (57.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26 (41.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eT4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (4.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17 (13.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (4.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (11.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eClinical N stage, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eN0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e70 (54.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e84 (66.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e58 (53.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e44 (70.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eN1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34 (26.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30 (23.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29 (26.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (19.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eN2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25 (19.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (10.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 (19.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (9.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCEA, M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.90 (1.90, 4.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.00 (1.80, 4.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.95 (1.98, 4.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.95 (1.90, 4.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNeoadjuvant chemotherapy, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e61 (47.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22 (17.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45 (40.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17 (27.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePreoperative clinical stage, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e54 (41.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e51 (40.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45 (41.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28 (45.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30 (23.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34 (26.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25 (23.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (25.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45 (34.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42 (33.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38 (35.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18 (29.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eASA, American Society of Anesthesiologists; BMI, body mass index (calculated as weight (kg) divided by height (meters) squared); CRM: Circumferential resection margin; EMVI: Extramural Venous Invasion, CEA: Carcinoembryonic Antigen. Preoperative clinical stage: According to the 7th edition of the American Joint Committee on Cancer staging system, clinical stage I includes stages T1 or T2 and N0M0; Stage II includes T3 or T4 and N0M0; Stage III includes any T stage and N1M0 or N2M0; Stage IV includes any T or N stage and M1 stage. Clinical stage was determined using preoperative imaging.\u003c/p\u003e\u003cp\u003ePatients undergoing TaTME were younger (median 61 vs 64 years, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01), more often male (70.5% vs 56.7%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021), and had tumors located closer to the anal verge (median 50 vs 75 mm, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). They also had a higher rate of MRI-predicted threatened circumferential resection margin (20.9% vs 10.2%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02). Clinical T stage distribution differed, with a higher proportion of T3 tumors (58% vs 42%) and a lower proportion of T4 tumors (4.7% vs 13.4%) in the TaTME group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.008). In addition, neoadjuvant therapy was more frequently administered in the TaTME group (47.3% vs 17.3%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), consistent with preferential selection of more locally advanced or technically challenging cases. Other baseline characteristics, including BMI, ASA class, clinical N stage, CEA levels, and EMVI status, were comparable between groups (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eAfter 2:1 PSM, 170 patients were successfully matched (108 TaTME and 62 LapTME). The matched cohorts showed no significant differences in baseline variables (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Median age was 62 years in both groups, and the sex distribution became similar (66.7% vs 61.3% male, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.48). Tumor distance from anal verge was balanced (median\u0026thinsp;~\u0026thinsp;50 mm in TaTME vs 58 mm in LapTME, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.08). Rates of preoperative MRI-CRM risk (22% vs 11%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.08) and neoadjuvant therapy use (40.7% vs 27.4%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.08) were no longer significantly different. Clinical T and N stage distributions and other characteristics were well matched (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05 for all), indicating that the PSM achieved good balance between the two groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Thus, subsequent comparisons of outcomes were performed on this matched cohort.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePerioperative and Pathologic Outcomes\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes intraoperative metrics and postoperative pathology results for the matched cohorts. The TaTME procedures required significantly longer operative time than LapTME (median 295 vs 220 minutes, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Despite the increased operative duration, intraoperative blood loss was low in both groups (median 50 ml in each, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.76). No cases in either group required conversion from laparoscopic to open surgery, indicating both approaches were completed as intended in all patients. A protective stoma (usually a diverting ileostomy) was created more often in TaTME patients (52.78% vs 32.26%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01). The pathological report of the postoperative specimens showed that the distribution of the distance from the distal resection margin of the tumor after fixation with formalin solution in the TaTME group was more concentrated than that in the LapTME group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of intraoperative and postoperative pathological conditions of patients in TaTME and LapTME after PSM [\u0026plusmn;\u0026thinsp;s, M (P25, P75), or n (%)]\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOperative time (Min), M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTaTME\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;108)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLapTME\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e295.00 (242.25, 351.25)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e220.00 (181.25, 252.50)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (Ml), M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.00 (50.00, 100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.00 (50.00, 100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProphylactic stoma creation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (52.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (32.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConversion to open surgery, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological stage, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathologic complete response\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (46.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (27.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (22.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (37.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (28.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (33.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of harvested lymph nodes, M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.00 (9.00, 15.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.00 (11.00, 16.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymphovascular invasion, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (9.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNerve invasion, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCircumferential resection margin positive, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistal resection margin positive, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor differentiation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (10.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (16.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86 (79.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (75.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWell\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (7.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (8.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther (no residual cancer detected)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ePathological stage: Stage I includes T1 or T2 stage and N0M0; Stage II includes T3 or T4 and N0M0; Stage III refers to any T stage with N1M0 or N2M0; Stage IV refers to any T or N stage and M1. Pathological complete remission occurs when no malignant cells are found in the proctectomy specimens of patients treated preoperatively. The pathological stage was determined based on the proctectomy specimen.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePathologic staging of the resected tumors was similar between groups. Rates of pathologic complete response (pCR) after neoadjuvant therapy were not different (TaTME 2.8% vs LapTME 1.6%, part of stage 0 in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The distributions of pathologic stage I, II, and III were statistically comparable (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05 for overall stage distribution). The total number of lymph nodes harvested did not differ significantly (median 12 in TaTME vs 13 in LapTME, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.06), and both met oncologic quality benchmarks (all cases had\u0026thinsp;\u0026ge;\u0026thinsp;12 nodes examined). There was no significant difference in the incidence of lymphovascular invasion (1.85% vs 9.68%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05) or perineural invasion (3.7% vs 3.2%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.00) between TaTME and LapTME. Tumor differentiation grades were similarly distributed (majority moderate differentiation in both, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.46). These findings indicate that, aside from the distal margin length difference, the pathological outcomes (tumor stage, margins, nodal yield, etc.) were equivalent between TaTME and LapTME resections in the matched cohort.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eOncologic Outcomes at 3 Years\u003c/h2\u003e \u003cp\u003eAll patients were followed for at least 3 years or until an event; the overall median follow-up time was 48 months (TaTME 47.0 vs LapTME 51.0 months, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.23). During this period, a total of 7 local recurrences (4.1% of 170) were observed in the matched cohort. The 3-year local recurrence rate was 3.7% (4 of 108) in the TaTME group versus 4.8% (3 of 62) in the LapTME group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.99) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). There was no significant difference in local tumor control between the two techniques. Distant metastases developed in 23 patients (13.5% of 170) by 3 years. The 3-year distant metastasis rate was 12.96% (14/108) for TaTME and 14.52% (9/62) for LapTME (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.78). Thus, the risk of developing metastases was statistically equivalent between groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of postoperative treatment and 3-year postoperative oncological outcomes of patients in TaTME and LapTME groups after PSM\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFollow-up time(month), M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTaTME\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;108)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLapTME\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47.00 (35.75, 58.25)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.00 (39.00, 63.75)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOstomy reversal, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54 (94.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (5.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic leak, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (7.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (12.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade of anastomotic leak, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (62.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (75.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (12.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (25.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (25.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjuvant chemotherapy, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51 (47.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30 (48.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLR, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (3.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (4.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistant metastasis, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (12.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (14.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDFS, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e90 (83.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51 (82.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOS, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e96 (88.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56 (90.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComposite event of recurrence, metastasis or death, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (16.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (17.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eComposite events of recurrence, metastasis, or death, including the incidences of local recurrence, distant metastasis, and death.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe disease-free survival at 3 years was virtually identical between the two approaches. The 3-year DFS rate was 83.33% for TaTME vs 82.26% for LapTME (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.86). Overall survival at 3 years was 88.89% vs 90.32% for TaTME and LapTME, respectively (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.77). Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e depicts the Kaplan\u0026ndash;Meier survival curves for DFS and OS, which show no separation between the TaTME and LapTME groups over the 3-year follow-up. A combined endpoint of \"any oncologic event\" (defined as recurrence, metastasis, or death by 3 years) also showed no difference: 16.67% in TaTME vs 17.74% in LapTME (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.86). In summary, oncologic outcomes, including locoregional control and survival, at 3 years postoperatively, were equivalent between one-team TaTME and LapTME in this matched cohort.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSubgroup Analyses\u003c/h2\u003e \u003cp\u003eSubgroup analyses were performed to evaluate outcomes in selected patient populations. Among patients who received neoadjuvant therapy (n\u0026thinsp;=\u0026thinsp;63), 3-year oncologic outcomes were similar between the TaTME (n\u0026thinsp;=\u0026thinsp;45) and LapTME (n\u0026thinsp;=\u0026thinsp;18) groups (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Local recurrence rates were 2.2% vs 11.1% (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.19), and distant metastasis rates were 17.8% vs 16.7% (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.00). Three-year disease-free survival (80.0% vs 83.3%) and overall survival (88.9% vs 88.9%) were also comparable between groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of 3-year oncological outcomes between TaTME and LapTME after preoperative neoadjuvant therapy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLR, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTaTME\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;45)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLapTME\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4.76)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.22)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (11.11)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistant metastasis, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (17.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (17.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (16.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDFS, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51 (80.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36 (80.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15 (83.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOS, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56 (88.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40 (88.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16 (88.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComposite event of recurrence, metastasis or death, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (19.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (20.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (16.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eComposite events of recurrence, metastasis, or death, including the incidences of local recurrence, distant metastasis, and death.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn patients with obesity (BMI\u0026thinsp;\u0026gt;\u0026thinsp;25 kg/m\u003csup\u003e2\u003c/sup\u003e, n\u0026thinsp;=\u0026thinsp;34), no significant differences were observed between TaTME and LapTME (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). No local recurrences occurred in the TaTME group compared with 1 case (9.1%) in the LapTME group, and distant metastasis rates were 13.0% vs 18.2% (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.00). Disease-free survival (86.96% vs 81.82%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.00) and overall survival (86.96% vs 100%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.54) were similar between groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of 3-year oncological outcomes between TaTME and LapTME in patients with BMI\u0026thinsp;\u0026gt;\u0026thinsp;25\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLR, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTaTME\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLapTME\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.94)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.00)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (9.09)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistant metastasis, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (14.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (13.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (18.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDFS, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29 (85.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (86.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9 (81.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOS, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31 (91.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (86.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComposite event of recurrence, metastasis or death, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (14.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (13.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (18.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eComposite events of recurrence, metastasis, or death, including the incidences of local recurrence, distant metastasis, and death.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong male patients (n\u0026thinsp;=\u0026thinsp;110), outcomes at 3 years were likewise comparable between TaTME and LapTME (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e), with no significant differences in local recurrence (4.17% vs 7.89%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.70), distant metastasis (15.3% vs 18.4%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.67), or survival outcomes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of 3-year oncological outcomes between the TaTME and LapTME in male patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLR, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;110)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTaTME\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLapTME\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (5.45)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.17)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (7.89)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistant metastasis, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (16.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (15.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7 (18.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDFS, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e86 (78.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57 (79.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29 (76.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOS, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e95 (86.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61 (84.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34 (89.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComposite event of recurrence, metastasis or death, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (20.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (19.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8 (21.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eComposite events of recurrence, metastasis, or death, including the incidences of local recurrence, distant metastasis, and death.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOverall, no significant differences were observed across subgroups. However, these analyses were limited by small sample sizes and should be interpreted with caution.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this propensity score\u0026ndash;matched cohort study, we found that one-team transanal total mesorectal excision achieved mid-term oncologic outcomes comparable to those of conventional laparoscopic TME in patients with mid and low rectal cancer. At 3 years, there were no significant differences between approaches in local recurrence, distant metastasis, disease-free survival, or overall survival. These findings provide real-world evidence supporting the oncologic safety of TaTME when performed using a sequential single-team approach.\u003c/p\u003e \u003cp\u003eA key feature of this study is its focus on a one-team TaTME strategy. Most existing randomized trials, including the TaLaR study[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], were conducted under controlled conditions using a dual-team simultaneous approach, which may not reflect routine surgical practice. In contrast, the single-team sequential approach evaluated in this study is more commonly adopted in this center due to practical considerations, including resource availability and operating room logistics. Our findings suggest that, when performed by experienced surgeons, this approach does not compromise oncologic outcomes. This observation is clinically relevant, as it supports the feasibility of implementing TaTME in settings where dual-team coordination is not readily achievable.\u003c/p\u003e \u003cp\u003eThe oncologic outcomes observed in this study are consistent with those reported in recent randomized and observational studies. The TaLaR trial demonstrated noninferiority of TaTME compared with laparoscopic TME in terms of pathologic quality and 3-year disease-free survival[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Similarly, large propensity score\u0026ndash;matched analyses and population-based studies have reported comparable long-term outcomes between the two techniques[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The present results align closely with these data, supporting the external validity of our findings in a real-world clinical setting.\u003c/p\u003e \u003cp\u003eFrom a technical perspective, TaTME offers improved visualization of the distal rectum and facilitates precise dissection in anatomically challenging conditions[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In this study, although all patients achieved negative circumferential and distal margins, the distribution of distal margin length was more consistent in the TaTME group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This finding may reflect the technical advantage of the transanal approach in achieving controlled distal transection. While this did not translate into measurable differences in oncologic outcomes within the follow-up period, it may represent an aspect of procedural reliability that warrants further investigation.\u003c/p\u003e \u003cp\u003ePerioperative findings were consistent with the technical characteristics of the procedures. TaTME was associated with longer operative time and a higher rate of protective stoma formation. However, in follow-up, no significant differences were observed between the TaTME and LapTME groups in anastomotic leakage incidence, leakage severity, or stoma reversal rate. Of the 57 TaTME patients with prophylactic stoma, 54 (94.74%) underwent reversal, with no impact on subsequent quality of life. Despite these differences, intraoperative blood loss and major postoperative outcomes were similar between groups, suggesting that the increased technical demands of TaTME do not adversely affect perioperative safety when performed by experienced teams.\u003c/p\u003e \u003cp\u003eSubgroup analyses demonstrated consistent results across patients receiving neoadjuvant therapy, as well as in male and overweight patients, who are traditionally considered technically challenging for rectal surgery. These findings are in line with prior studies showing comparable outcomes between TaTME and laparoscopic TME in such subgroups[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Although these analyses were limited by sample size, the absence of significant differences supports the generalizability of the primary findings.\u003c/p\u003e \u003cp\u003eSeveral limitations should be acknowledged. First, the retrospective design may cause residual confounding despite propensity score matching. Second, the single-center, high-volume setting limits generalizability to less experienced centers. Third, while follow-up was adequate for 3-year outcomes, longer observation is required to evaluate long-term survival and late recurrence. Finally, functional outcomes and quality of life were not assessed and should be included in future studies.\u003c/p\u003e \u003cp\u003eOne-team transanal total mesorectal excision provides mid-term oncologic outcomes comparable to laparoscopic TME for patients with mid and low rectal cancer, with similar rates of local recurrence, distant metastasis, and survival. This real-world evidence supports its use as a feasible and oncologically safe minimally invasive option in experienced centers, particularly where dual-team approaches are not practical. In addition, the transanal approach may offer technical advantages in distal pelvic dissection and margin control. Prospective multicenter studies with longer follow-up are warranted to further validate these findings and define their optimal role in clinical practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflicts of interest:\u003c/h2\u003e \u003cp\u003ethere are no conflicts of interest.\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis study received no specific funding from any public, commercial, or non-profit funding agencies.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eC.S. completed the data curation and research methodology design for this study, and drafted the original manuscript; J.F.D., L.X.H., and X.F.Z. jointly assisted in the data curation of the study; X.X. was responsible for the statistical analysis and result visualization of the research, and provided supervision and guidance throughout the study; Y.G.G., Z.W.W., and H.Y.Z. jointly completed the conceptualization, design and resource support of the research, and reviewed and revised the manuscript.All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgments:\u003c/h2\u003e \u003cp\u003eThe authors thank the patients who participated in this study. We acknowledge the support from the clinical and research teams of the First Affiliated Hospital of Chongqing Medical University, including the Department of Gastrointestinal Surgery, Department of Pathology, and medical records staff for data collection and follow-up.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data supporting the findings of this study are available within the paper and its Supplementary Information.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYi Chi Z, Gang O, Xiao Li F, et al. Laparoscopic total mesorectal excision versus transanal total mesorectal excision for mid and low rectal cancer: A systematic review and meta-analysis. Medicine (Baltimore). 2024;103(4):e36859. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/MD.0000000000036859\u003c/span\u003e\u003cspan address=\"10.1097/MD.0000000000036859\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeow W, Dudi-Venkata NN, Bedrikovetski S, Kroon HM, Sammour T. Outcomes of open vs laparoscopic vs robotic vs transanal total mesorectal excision (TME) for rectal cancer: a network meta-analysis. Tech Coloproctol. 2023;27(5):345\u0026ndash;360. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10151-022-02739-1\u003c/span\u003e\u003cspan address=\"10.1007/s10151-022-02739-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu H, Zeng Z, Zhang H, et al. Morbidity, Mortality, and Pathologic Outcomes of Transanal Versus Laparoscopic Total Mesorectal Excision for Rectal Cancer Short-term Outcomes From a Multicenter Randomized Controlled Trial. Ann Surg. 2023;277(1):1\u0026ndash;6. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/SLA.0000000000005523\u003c/span\u003e\u003cspan address=\"10.1097/SLA.0000000000005523\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar NAN, Usman N, Rajan K, S Shetty P, Crithic VHV, Rao V Narasimha V. Laparoscopic total mesorectal excision for low rectal cancer - A step by step approach - A video vignette. 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Updates Surg. 2023;75(8):2191\u0026ndash;2200. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s13304-023-01676-4\u003c/span\u003e\u003cspan address=\"10.1007/s13304-023-01676-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Mid-low rectal cancer, Propensity score matching, TaTME, LapTME, Oncological outcomes, Technical advantage","lastPublishedDoi":"10.21203/rs.3.rs-9359317/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9359317/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFor mid-to-low rectal cancer, although laparoscopic tumor resection (LapTME) has become a standard minimally invasive surgical approach, technical challenges remain in cases with complex anatomical structures. Transanal TME (TaTME) was developed to address these limitations, yet its widespread adoption has raised oncologic safety concerns in routine clinical practice. Most existing evidence comes from controlled trials using dual-team simultaneous approaches, while data on the common, resource-efficient single-team sequential approach remains insufficient.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study enrolled 256 consecutive patients with mid/low rectal adenocarcinoma undergoing curative TME at a tertiary center between 2018 and 2022. 2:1 propensity score matching balanced baseline covariates, generating 170 well-matched patients (108 in the one-team TaTME group, 62 in the LapTME group). We compared mid-term oncologic outcomes, perioperative safety, and pathologic margin status.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAfter matching, median follow-up was 48 months. The TaTME group had longer operative time and a higher protective stoma rate, with comparable blood loss and postoperative complications. All patients achieved negative resection margins, while TaTME yielded a significantly more consistent distribution of distal margin length. At 3 years, no significant between-group differences were observed in local recurrence (3.7% vs 4.8%), distant metastasis (13.0% vs 14.5%), disease-free survival (83.3% vs 82.3%), or overall survival (88.9% vs 90.3%, all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOne-team TaTME achieved comparable mid-term oncologic outcomes to LapTME in routine practice, supporting its safety for experienced surgical teams. This real-world evidence facilitates the adoption of single-team TaTME in resource-limited settings.\u003c/p\u003e","manuscriptTitle":"Oncologic Outcomes of One-Team Transanal Versus Laparoscopic Total Mesorectal Excision for Mid and Low Rectal Cancer: A Propensity Score–Matched Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-26 15:45:29","doi":"10.21203/rs.3.rs-9359317/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-03T09:50:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"61052030179315004167061511271164705475","date":"2026-04-20T10:35:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"229726538802114822761307074202473244769","date":"2026-04-17T09:25:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-16T22:28:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-16T21:22:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-11T03:50:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"Techniques in Coloproctology","date":"2026-04-08T16:03:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"3e67844a-814b-4231-88b5-d8479913ac01","owner":[],"postedDate":"April 26th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-03T09:50:40+00:00","index":8,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-26T15:45:29+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-26 15:45:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9359317","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9359317","identity":"rs-9359317","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}