A novel sphincter-preserving technique for radical resection of low rectal cancer with sacral invasion

A novel sphincter-preserving technique for radical resection of low rectal cancer with sacral invasion | 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 Short Report A novel sphincter-preserving technique for radical resection of low rectal cancer with sacral invasion Jianlin Xiao, Mingtian Wei, Yaning Song, Haining Chen, Ziqiang Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8059716/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background For patients with tumors involving the presacral fascia and abutting or invading the sacrum, Pelvic exenteration with en bloc sacrectomy is necessary. However, the resection of multiple pelvic organs significantly impairs the patient's quality of life. Method We introduce a new technology here: for rectal cancer involving the sacrum (at or below S3) or the presacral fascia, we proposed that en bloc tumor resection with colorectal anastomosis is a feasible strategy in patients with tumor-free anal sphincters and at least unilateral single S3 nerve root. Results No one experienced complications above Clavien-Dindo IIIa during the median follow-up period of 8.5 months (range: 4–17 months). Follow-up anorectal manometry at 3 months post-surgery revealed preserved anal sphincter contractile function of all patients, which led to ileostomy reversal procedure. Conclusion The sphincter-preserving technique for the radical resection of low rectal cancer with sacral or presacral fascia invasion is feasible. Figures Figure 1 Figure 2 Introduction Pelvic exenteration (PE) is a curative surgical approach for patients with advanced or recurrent rectal cancer, aiming to achieve a radical (R0) resection. [ 1 ] For patients with tumors involving the presacral fascia and abutting or invading the sacrum, PE with en bloc sacrectomy is necessary to obtain clear margins. Historically, prone sacrectomy was the standard technique for most cases, as it was in our unit. [ 2 ] However, with technical advancements, sacrectomy below S3 can now be performed in the abdominolithotomy position to reduce operating time, blood loss, and complications. [ 3 ] Additionally, Shaikh et al have introduced the less common technique of high anterior cortical sacrectomy for high sacral tumors (S2 and above). [ 4 , 5 ] The benefits of these modern approaches include better preservation of pelvic stability, reduced neurological morbidity, avoidance of an extensive perineosacral wound, and shorter operating time. Resection or injury to the sacral nerves leads to adverse sequelae, including colorectal and urinary dysfunction, sexual impairment, sensory deficits, and mobility issues, which correlate directly with the specific nerve roots sacrificed. [ 6 ] Consequently, current research advocates for maximal preservation of the sacral nerves during tumor resection to maintain pelvic function. [ 7 ] Anorectal and urodynamic studies by Schurch et al. have identified the S2-3 nerve roots as the primary regulators of bowel and bladder control. [ 8 ] Supporting this, Todd et al. reported that preservation of bilateral S1-S3 roots maintained intact bowel function in all patients, while unilateral S3 preservation alone sufficed for normal defecation in 67% of cases. [ 9 ] Therefore, for rectal cancer involving the sacrum (at or below S3) or the presacral fascia, we proposed that en bloc tumor resection with colorectal anastomosis is a feasible strategy. This approach ensures preservation of the main part levator ani muscle, bilateral preservation of the S1-2 nerve roots, and sparing of at least the unilateral S3 root. Building on previous techniques, we have developed a novel sphincter-preserving technique for the radical resection of low rectal cancer with sacral invasion. Method Eligible patients primarily included those with rectal cancer who, after neoadjuvant therapy or upon recurrence, had tumor involvement of the presacral fascia or sacrum at or below S3 level. Preoperative assessment confirmed that the tumor was amenable to en bloc resection, the levator ani muscle was uninvaded and could be preserved, and at least one unilateral S3 nerve root could be spared. Exclusion criteria comprised metastatic colorectal cancer and intraoperative assessment indicating an inability to preserve the puborectalis muscle or bilateral S3 nerve roots. Multidisciplinary consultation was to be comprised of experienced colorectal surgeon, neurosurgeon, radiologist, oncology physician and orthopedic surgeon. All doctors consulted together and unanimously agreed that the patient could attempt the surgery, and obtained informed consent from all patients. Between May 2024 and June 2025, 5 patients have completed this surgery, and their outcomes are reported. Demographic and perioperative data including age, sex, body mass index (BMI), neoadjuvant therapies, Tumor to anal, duration of operation, blood loss, length of stay, and comorbidities were prospectively collected from the electronic clinical records. (Table 1) Postoperative follow-up, including CT reviews and Low Anterior Resection Syndrome (LARS) score, were scheduled at 1, 6, and 12 months after ileostomy at our center. . Surgical Technique The operative technique was performed in two phases: Laparoscopic abdominal phase with Lloyd-Davies position, pelvic dissection proceeded according to the principles of total mesorectal excision (TME). The bilateral dissection was carried down to the levator ani muscles. The anterior dissection was extended as distally as possible. The presacral space was developed down to the inferior border of S3. Then diverting ileostomy was performed. Next followed by a transsacral phase with prone jackknife position, the intraoperative CT-based navigation system was first utilized to determine the cutaneous projection level of the planned sacral resection margin. An oblique 10-cm incision was made over the midsacrum. After exposing the coccyx, the anococcygeal ligament was divided to communicate with the pelvic cavity. Despite the resection of a segment of the pubococcygeus muscle, the majority of the levator ani fibers were preserved. The distal rectum was transected with an arc-shaped cutting stapler. En bloc resection of the tumor was achieved by complete excision of the rectum and the invaded sacrum (Fig. 1 ), with preservation of the bilateral third S3 nerve roots. An osteotome was used to divide the sacrum at the predetermined level. Hemostasis was achieved with electrocautery and application of bone cement. A circular stapler was inserted transanally to perform end-to-end colorectal anastomosis, approximately 2 cm from the anal verge. The anastomosis was reinforced with interrupted silk sutures. (Video) Result In the present study, 5 patients underwent the novel surgical technique successfully. Patient characteristics and surgical outcomes are shown. (Table 1) The 5th patient developed pelvic infection postoperatively, which resolved after intravenous antibiotic therapy and irrigation via the drainage tube. 2 patients experienced incisional infections. Following ileostomy reversal, all patients received active pelvic floor muscle training and transanal irrigation. The LARS score decreased gradually over time and eventually reaching a satisfactory level. no one experienced complications above Clavien-Dindo IIIa during the median follow-up period of 8.5 months (range: 4–17 months). Follow-up anorectal manometry at 3 months post-surgery revealed preserved anal sphincter contractile function of all patients, which led to ileostomy reversal procedure. (Figure.2) Discussion Over time, various modifications of PE with sacrectomy, like abdominolithotomy and high anterior cortical sacrectomy. However, these procedures did not preserve anal function, which significantly compromised the patients' quality of life and predisposed them to complications such as empty pelvis syndrome. [ 3 ] This report is the first to describe a combined rectal and sacral resection with sphincter preservation. In practice, our technique not only conserves the sphincter, thereby enhancing the quality of life, but also avoids the extensive pelvic exenteration that leads to empty pelvis syndrome. Although our technique inevitably required resection of a portion of the levator ani muscle, including the pubococcygeal muscle, it successfully preserved the most critical component—the puborectalis muscle—and at least the unilateral S3 nerve root. The preserved function, when enabled by standardized postoperative pelvic muscle training and rehabilitation, allowed patients to achieve a highly satisfactory quality of life. While resecting the sacrum has historically raised concerns about pelvic organ prolapse, particularly for the rectum, [ 9 , 10 ] our procedure directly mitigates this risk by resecting a sufficient segment of the colon and rectum. This approach substantially reduces the likelihood of postoperative rectal prolapse. In conclusion, the sphincter-preserving technique for the radical resection of low rectal cancer with sacral or presacral fascia invasion is feasible after rigorous multidisciplinary consultation. By sharing this novel technique, we hope more surgeons can collaborate with us to further confirm its effectiveness and feasibility. Declarations Conflict of interest: The authors declare no conflict of interest. Ethics approval: The Institutional Review Committee of West China Hospital of Sichuan University approved this study. The requirement for informed consent was waived due to the retrospective nature of the study. Consent for patients :The authors will provide evidence of consent, if requested by the journal. Availability of data and material : The datasets during and/or analyzed during the current study are not publicly available due to the confidentiality of patient information but are available from the corresponding author on reasonable request. Sources of funding This study was supported by the Department of Science and Technology of Sichuan Province (Award Number 2021YFS0025); Acknowledgement Not applicable. Consent for publication Not applicable. References KELLY M E, GLYNN R, AALBERS A G J, et al. Surgical and Survival Outcomes Following Pelvic Exenteration for Locally Advanced Primary Rectal Cancer Results From an International Collaboration [J]. Annals of Surgery, 2019, 269(2): 315-21. BROWN K G M, SOLOMON M J, AUSTIN K K S, et al. Posterior high sacral segmental disconnection prior to anterior en bloc exenteration for recurrent rectal cancer [J]. Techniques in Coloproctology, 2016, 20(6): 401-4. SOLOMON M J, TAN K K, BROMILOW R G, et al. Sacrectomy via the abdominal approach during pelvic exenteration [J]. Diseases of the Colon & Rectum, 2014, 57(2): 272. SHAIKH I, HOLLOWAY I, ASTON W, et al. High subcortical sacrectomy: a novel approach to facilitate complete resection of locally advanced and recurrent rectal cancer with high (S1–S2) sacral extension [J]. Colorectal Disease the Official Journal of the Association of Coloproctology of Great Britain & Ireland, 2016, 18(4): 386-92. TEKKIS P P. Towards Standardisation of Technique for En Bloc Sacrectomy for Locally Advanced and Recurrent Rectal Cancer [J]. Journal of Clinical Medicine, 2021, 10. ARSHI A, SHARIM J, PARK D Y, et al. Chondrosarcoma of the Osseous Spine: An Analysis of Epidemiology, Patient Outcomes, and Prognostic Factors Using the SEER Registry From 1973 to 2012 [J]. Spine, 2017, 42(9): 644. MOHAMAD, BYDON, RAFAEL, et al. En Bloc Resection of a Giant Cell Tumor in the Sacrum via a Posterior-Only Approach Without Nerve Root Sacrifice: Technical Case Report [J]. Neurosurgery, 2015. SCHURCH B, RODIC B, JEANMONOD D. Posterior sacral rhizotomy and intradural anterior sacral root stimulation for treatment of the spastic bladder in spinal cord injured patients [J]. Journal of Urology, 1997, 157(2): 610-4. TODD L T, YASZEMSKI M J, CURRIER B L, et al. Bowel and bladder function after major sacral resection [J]. Clinical Orthopaedics and Related Research, 2002, 397: 36-9. ZOUCAS E, FREDERIKSEN S, LYDRUP M L, et al. Pelvic Exenteration for Advanced and Recurrent Malignancy [J]. World Journal of Surgery, 2010, 34(9): 2177-84. Table 1 Table.1 Patient characteristics and Perioperative outcomes Patients (No.) Sex (M,F) Age (y) BMI Tumor to anal (cm) Clinical stage Neoadjuvant therapy(Y,N) Level of invasion* Duration of operation*(min) Blood loss* (mL) Hospital stay(d) Follow-up(M) LARS score 1 F 53 22.59 5 T4N2M0 Y S4 240 100 7 17 16 2 M 57 28.28 6 T4N1M0 Y S3 232 50 6 10 19 3 F 58 27.34 5.5 rT4N0M0 Y S3 289 100 6 7 28 4 M 67 20.94 6.5 rT4N0M0 Y S3 300 250 7 5 32 5 M 68 24.97 5.5 rT4N0M0 Y S4 325 200 8 4 34 *: The level of tumor invasion of the sacrum; Length of hospital stay after operation; BMI= body mass index; L ARS score : What is displayed here is the LARS score at the most recent follow-up. Additional Declarations No competing interests reported. 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2","display":"","copyAsset":false,"role":"figure","size":18296,"visible":true,"origin":"","legend":"\u003cp\u003eSagittal CT 12 months after surgery which highlights the removal of the anterior part of the sacrum.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8059716/v1/8f47214e2d10607894b83fb3.jpg"},{"id":107480054,"identity":"595b37d2-bd4a-4d01-9d0f-cb1cb1418f73","added_by":"auto","created_at":"2026-04-22 02:04:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":253691,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8059716/v1/7b3e134c-6332-40be-8a8d-7d8b3cf964a9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eA novel sphincter-preserving technique for radical resection of low rectal cancer with sacral invasion\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePelvic exenteration (PE) is a curative surgical approach for patients with advanced or recurrent rectal cancer, aiming to achieve a radical (R0) resection.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e For patients with tumors involving the presacral fascia and abutting or invading the sacrum, PE with en bloc sacrectomy is necessary to obtain clear margins. Historically, prone sacrectomy was the standard technique for most cases, as it was in our unit.\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e However, with technical advancements, sacrectomy below S3 can now be performed in the abdominolithotomy position to reduce operating time, blood loss, and complications.\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e Additionally, Shaikh et al have introduced the less common technique of high anterior cortical sacrectomy for high sacral tumors (S2 and above).\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e The benefits of these modern approaches include better preservation of pelvic stability, reduced neurological morbidity, avoidance of an extensive perineosacral wound, and shorter operating time.\u003c/p\u003e\u003cp\u003eResection or injury to the sacral nerves leads to adverse sequelae, including colorectal and urinary dysfunction, sexual impairment, sensory deficits, and mobility issues, which correlate directly with the specific nerve roots sacrificed.\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e Consequently, current research advocates for maximal preservation of the sacral nerves during tumor resection to maintain pelvic function. \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e Anorectal and urodynamic studies by Schurch et al. have identified the S2-3 nerve roots as the primary regulators of bowel and bladder control.\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e Supporting this, Todd et al. reported that preservation of bilateral S1-S3 roots maintained intact bowel function in all patients, while unilateral S3 preservation alone sufficed for normal defecation in 67% of cases.\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eTherefore, for rectal cancer involving the sacrum (at or below S3) or the presacral fascia, we proposed that en bloc tumor resection with colorectal anastomosis is a feasible strategy. This approach ensures preservation of the main part levator ani muscle, bilateral preservation of the S1-2 nerve roots, and sparing of at least the unilateral S3 root. Building on previous techniques, we have developed a novel sphincter-preserving technique for the radical resection of low rectal cancer with sacral invasion.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eEligible patients primarily included those with rectal cancer who, after neoadjuvant therapy or upon recurrence, had tumor involvement of the presacral fascia or sacrum at or below S3 level. Preoperative assessment confirmed that the tumor was amenable to en bloc resection, the levator ani muscle was uninvaded and could be preserved, and at least one unilateral S3 nerve root could be spared. Exclusion criteria comprised metastatic colorectal cancer and intraoperative assessment indicating an inability to preserve the puborectalis muscle or bilateral S3 nerve roots. Multidisciplinary consultation was to be comprised of experienced colorectal surgeon, neurosurgeon, radiologist, oncology physician and orthopedic surgeon. All doctors consulted together and unanimously agreed that the patient could attempt the surgery, and obtained informed consent from all patients. Between May 2024 and June 2025, 5 patients have completed this surgery, and their outcomes are reported.\u003c/p\u003e\u003cp\u003eDemographic and perioperative data including age, sex, body mass index (BMI), neoadjuvant therapies, Tumor to anal, duration of operation, blood loss, length of stay, and comorbidities were prospectively collected from the electronic clinical records. (Table\u0026nbsp;1) Postoperative follow-up, including CT reviews and Low Anterior Resection Syndrome (LARS) score, were scheduled at 1, 6, and 12 months after ileostomy at our center.\u003c/p\u003e\u003cp\u003e.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSurgical Technique\u003c/h2\u003e\u003cp\u003eThe operative technique was performed in two phases: Laparoscopic abdominal phase with Lloyd-Davies position, pelvic dissection proceeded according to the principles of total mesorectal excision (TME). The bilateral dissection was carried down to the levator ani muscles. The anterior dissection was extended as distally as possible. The presacral space was developed down to the inferior border of S3. Then diverting ileostomy was performed.\u003c/p\u003e\u003cp\u003eNext followed by a transsacral phase with prone jackknife position, the intraoperative CT-based navigation system was first utilized to determine the cutaneous projection level of the planned sacral resection margin. An oblique 10-cm incision was made over the midsacrum. After exposing the coccyx, the anococcygeal ligament was divided to communicate with the pelvic cavity. Despite the resection of a segment of the pubococcygeus muscle, the majority of the levator ani fibers were preserved. The distal rectum was transected with an arc-shaped cutting stapler. En bloc resection of the tumor was achieved by complete excision of the rectum and the invaded sacrum (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), with preservation of the bilateral third S3 nerve roots. An osteotome was used to divide the sacrum at the predetermined level. Hemostasis was achieved with electrocautery and application of bone cement. A circular stapler was inserted transanally to perform end-to-end colorectal anastomosis, approximately 2 cm from the anal verge. The anastomosis was reinforced with interrupted silk sutures. (Video)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Result","content":"\u003cp\u003eIn the present study, 5 patients underwent the novel surgical technique successfully. Patient characteristics and surgical outcomes are shown. (Table\u0026nbsp;1) The 5th patient developed pelvic infection postoperatively, which resolved after intravenous antibiotic therapy and irrigation via the drainage tube. 2 patients experienced incisional infections. Following ileostomy reversal, all patients received active pelvic floor muscle training and transanal irrigation. The LARS score decreased gradually over time and eventually reaching a satisfactory level. no one experienced complications above Clavien-Dindo IIIa during the median follow-up period of 8.5 months (range: 4\u0026ndash;17 months). Follow-up anorectal manometry at 3 months post-surgery revealed preserved anal sphincter contractile function of all patients, which led to ileostomy reversal procedure. (Figure.2)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOver time, various modifications of PE with sacrectomy, like abdominolithotomy and high anterior cortical sacrectomy. However, these procedures did not preserve anal function, which significantly compromised the patients' quality of life and predisposed them to complications such as empty pelvis syndrome.\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e This report is the first to describe a combined rectal and sacral resection with sphincter preservation. In practice, our technique not only conserves the sphincter, thereby enhancing the quality of life, but also avoids the extensive pelvic exenteration that leads to empty pelvis syndrome.\u003c/p\u003e\u003cp\u003eAlthough our technique inevitably required resection of a portion of the levator ani muscle, including the pubococcygeal muscle, it successfully preserved the most critical component\u0026mdash;the puborectalis muscle\u0026mdash;and at least the unilateral S3 nerve root. The preserved function, when enabled by standardized postoperative pelvic muscle training and rehabilitation, allowed patients to achieve a highly satisfactory quality of life. While resecting the sacrum has historically raised concerns about pelvic organ prolapse, particularly for the rectum,\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e our procedure directly mitigates this risk by resecting a sufficient segment of the colon and rectum. This approach substantially reduces the likelihood of postoperative rectal prolapse.\u003c/p\u003e\u003cp\u003eIn conclusion, the sphincter-preserving technique for the radical resection of low rectal cancer with sacral or presacral fascia invasion is feasible after rigorous multidisciplinary consultation. By sharing this novel technique, we hope more surgeons can collaborate with us to further confirm its effectiveness and feasibility.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eThe Institutional Review Committee of West China Hospital of Sichuan University approved this study. The requirement for informed consent was waived due to the retrospective nature of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for patients\u003c/strong\u003e:The authors will provide evidence of consent, if requested by the journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e: The datasets during and/or analyzed during the current study are not publicly available due to the confidentiality of patient information but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSources of funding\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Department of Science and Technology of Sichuan Province (Award Number 2021YFS0025);\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKELLY M E, GLYNN R, AALBERS A G J, et al. Surgical and Survival Outcomes Following Pelvic Exenteration for Locally Advanced Primary Rectal Cancer Results From an International Collaboration [J]. Annals of Surgery, 2019, 269(2): 315-21.\u003c/li\u003e\n\u003cli\u003eBROWN K G M, SOLOMON M J, AUSTIN K K S, et al. Posterior high sacral segmental disconnection prior to anterior en bloc exenteration for recurrent rectal cancer [J]. Techniques in Coloproctology, 2016, 20(6): 401-4.\u003c/li\u003e\n\u003cli\u003eSOLOMON M J, TAN K K, BROMILOW R G, et al. Sacrectomy via the abdominal approach during pelvic exenteration [J]. Diseases of the Colon \u0026amp; Rectum, 2014, 57(2): 272.\u003c/li\u003e\n\u003cli\u003eSHAIKH I, HOLLOWAY I, ASTON W, et al. High subcortical sacrectomy: a novel approach to facilitate complete resection of locally advanced and recurrent rectal cancer with high (S1\u0026ndash;S2) sacral extension [J]. Colorectal Disease the Official Journal of the Association of Coloproctology of Great Britain \u0026amp; Ireland, 2016, 18(4): 386-92.\u003c/li\u003e\n\u003cli\u003eTEKKIS P P. Towards Standardisation of Technique for En Bloc Sacrectomy for Locally Advanced and Recurrent Rectal Cancer [J]. Journal of Clinical Medicine, 2021, 10.\u003c/li\u003e\n\u003cli\u003eARSHI A, SHARIM J, PARK D Y, et al. Chondrosarcoma of the Osseous Spine: An Analysis of Epidemiology, Patient Outcomes, and Prognostic Factors Using the SEER Registry From 1973 to 2012 [J]. Spine, 2017, 42(9): 644.\u003c/li\u003e\n\u003cli\u003eMOHAMAD, BYDON, RAFAEL, et al. En Bloc Resection of a Giant Cell Tumor in the Sacrum via a Posterior-Only Approach Without Nerve Root Sacrifice: Technical Case Report [J]. Neurosurgery, 2015.\u003c/li\u003e\n\u003cli\u003eSCHURCH B, RODIC B, JEANMONOD D. Posterior sacral rhizotomy and intradural anterior sacral root stimulation for treatment of the spastic bladder in spinal cord injured patients [J]. Journal of Urology, 1997, 157(2): 610-4.\u003c/li\u003e\n\u003cli\u003eTODD L T, YASZEMSKI M J, CURRIER B L, et al. Bowel and bladder function after major sacral resection [J]. Clinical Orthopaedics and Related Research, 2002, 397: 36-9.\u003c/li\u003e\n\u003cli\u003eZOUCAS E, FREDERIKSEN S, LYDRUP M L, et al. Pelvic Exenteration for Advanced and Recurrent Malignancy [J]. World Journal of Surgery, 2010, 34(9): 2177-84.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 1","content":"\u003cp\u003eTable.1 Patient characteristics and Perioperative outcomes\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"1085\" class=\"fr-table-selection-hover\" style=\"margin-left: calc(0%); width: 100%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 6.4757%;\"\u003e\n \u003cp\u003ePatients (No.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3549%;\"\u003e\n \u003cp\u003eSex\u003cbr\u003e\u0026nbsp;(M,F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.42804%;\"\u003e\n \u003cp\u003eAge\u003cbr\u003e\u0026nbsp;(y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.5203%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.91882%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eTumor to anal (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.02583%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eClinical stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.13284%;\"\u003e\n \u003cp\u003eNeoadjuvant therapy(Y,N)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.82657%;\"\u003e\n \u003cp\u003eLevel of invasion*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0701%;\"\u003e\n \u003cp\u003eDuration of operation*(min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.0554%;\"\u003e\n \u003cp\u003e\u0026nbsp;Blood loss* (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.76384%;\"\u003e\n \u003cp\u003e\u0026nbsp;Hospital stay(d)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.38007%;\"\u003e\n \u003cp\u003eFollow-up(M)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.90406%;\"\u003e\n \u003cp\u003eLARS score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.64207%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 6.4757%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3549%;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.42804%;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5203%;\"\u003e\n \u003cp\u003e22.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.91882%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.02583%;\"\u003e\n \u003cp\u003e\u0026nbsp;T4N2M0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.13284%;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.82657%;\"\u003e\n \u003cp\u003eS4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0701%;\"\u003e\n \u003cp\u003e240\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.0554%;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.76384%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.38007%;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.90406%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.64207%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 6.4757%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3549%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.42804%;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5203%;\"\u003e\n \u003cp\u003e28.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.91882%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.02583%;\"\u003e\n \u003cp\u003eT4N1M0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.13284%;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.82657%;\"\u003e\n \u003cp\u003eS3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0701%;\"\u003e\n \u003cp\u003e232\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.0554%;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.76384%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.38007%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.90406%;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.64207%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 6.4757%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3549%;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.42804%;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5203%;\"\u003e\n \u003cp\u003e27.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.91882%;\"\u003e\n \u003cp\u003e5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.02583%;\"\u003e\n \u003cp\u003erT4N0M0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.13284%;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.82657%;\"\u003e\n \u003cp\u003eS3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0701%;\"\u003e\n \u003cp\u003e289\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.0554%;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.76384%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.38007%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.90406%;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.64207%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 6.4757%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3549%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.42804%;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5203%;\"\u003e\n \u003cp\u003e20.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.91882%;\"\u003e\n \u003cp\u003e6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.02583%;\"\u003e\n \u003cp\u003erT4N0M0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.13284%;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.82657%;\"\u003e\n \u003cp\u003eS3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0701%;\"\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.0554%;\"\u003e\n \u003cp\u003e250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.76384%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.38007%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.90406%;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.64207%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 6.4757%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3549%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.42804%;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5203%;\"\u003e\n \u003cp\u003e24.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.91882%;\"\u003e\n \u003cp\u003e5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.02583%;\"\u003e\n \u003cp\u003erT4N0M0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.13284%;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.82657%;\"\u003e\n \u003cp\u003eS4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0701%;\"\u003e\n \u003cp\u003e325\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.0554%;\"\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.76384%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.38007%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.90406%;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.64207%;\"\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\u003cp\u003e*: The level of tumor invasion of the sacrum; Length of hospital stay after operation; BMI= body mass index;\u003cstrong\u003e\u0026nbsp;L\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eARS score\u003c/em\u003e\u003c/strong\u003e: What is displayed here is the LARS score at the most recent follow-up.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8059716/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8059716/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eFor patients with tumors involving the presacral fascia and abutting or invading the sacrum, Pelvic exenteration with en bloc sacrectomy is necessary. However, the resection of multiple pelvic organs significantly impairs the patient's quality of life.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e\u003cp\u003eWe introduce a new technology here: for rectal cancer involving the sacrum (at or below S3) or the presacral fascia, we proposed that en bloc tumor resection with colorectal anastomosis is a feasible strategy in patients with tumor-free anal sphincters and at least unilateral single S3 nerve root.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eNo one experienced complications above Clavien-Dindo IIIa during the median follow-up period of 8.5 months (range: 4\u0026ndash;17 months). Follow-up anorectal manometry at 3 months post-surgery revealed preserved anal sphincter contractile function of all patients, which led to ileostomy reversal procedure.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe sphincter-preserving technique for the radical resection of low rectal cancer with sacral or presacral fascia invasion is feasible.\u003c/p\u003e","manuscriptTitle":"A novel sphincter-preserving technique for radical resection of low rectal cancer with sacral invasion","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-02 14:23:49","doi":"10.21203/rs.3.rs-8059716/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f6138123-67a9-4182-9a5a-4a85f9b900c8","owner":[],"postedDate":"December 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-12T19:54:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-02 14:23:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8059716","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8059716","identity":"rs-8059716","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}