Same-Day Discharge and Single-Incision Surgery Are Changing Rectal Cancer Care

Minimally invasive options are expanding for people with rectal cancer, large benign polyps and pelvic floor disorders — but timing matters. Lesions that grow or advance can close the door on less invasive approaches, and symptoms like fecal incontinence often go unmentioned for years.

In an interview with CURE, Dr. Mark Zhao, a colorectal surgeon at UCSF Health specializing in colorectal cancer and pelvic floor disorders, discussed transanal minimally invasive surgery, the single port surgical robot and the conversations he wishes patients were having sooner.

CURE: For patients, minimally invasive techniques like transanal minimally invasive surgery are gaining attention. How do these approaches compare with traditional surgery in terms of recovery and effectiveness?

Zhao: Transanal minimally invasive surgery, or TAMIS, is an excellent option for carefully selected patients, most often those with large benign rectal polyps or early rectal cancers that don't require a more radical resection. Early referral is important, because patients may lose the opportunity for these local excision options as lesions become larger or more advanced.

Whenever it's oncologically appropriate, the TAMIS procedure allows us to preserve rectal and anorectal function while avoiding abdominal incisions or the consequences of abdominal surgery. Often this results in less pain and faster recovery, and in a lot of TAMIS cases we can discharge the patient the same day, so it's more convenient as well.

You use the da Vinci single port surgical robot for transabdominal procedures. What does that mean, and how does it help minimize incisions and improve recovery?

Zhao: The single port platform is another example of how we're constantly expanding our minimally invasive options. For carefully selected patients, the single port platform allows us to do surgery through just a single incision, a single access site, while maintaining the same oncologic principles as conventional minimally invasive surgery, where we often have multiple small incisions around the abdomen.

Our group was involved in the early development and early clinical evaluation of the single port robot, which gave us an early preview of what it can do. That's given us substantial experience not only with the technology itself, but also with how we should carefully select patients for it. We always have to go back to our principle that in cancer surgery the priority is getting the cancer out — the oncologic outcomes. But if we're able to do that with as minimal trauma as possible, that allows for fast recovery, and that's good use of the new technology.

How do these techniques change outcomes for patients with pelvic floor disorders?

Zhao: The single port robot allows for less soft tissue trauma compared with the previous multiport robotic system. The single port robot uses a single incision about two to four centimeters in size, whereas the multiport system uses multiple ports at about eight millimeters up to 1.2 centimeters.

At UCSF, we commonly use this approach for appropriately selected patients with rectal prolapse. The treatment of choice, at least in my practice, for rectal prolapse is a robotic ventral mesh rectopexy, and we've done several cases now using the single port robot through a small Pfannenstiel incision to perform the entire operation. Anecdotally, patients have described less discomfort after the single incision ventral mesh rectopexy, and we've seen similar outcomes. Currently we're not doing any transanal procedures for patients with pelvic floor disorders using the robotic platform, but that might change in the future.

What symptoms do patients tend not to bring up unless they're asked directly?

Zhao: This is a very challenging field, because many patients are reluctant to discuss their symptoms, especially fecal incontinence, because of embarrassment or because they don't feel anything could be done to treat them. Patients will often be vague about how to describe their symptoms. They'll say things like accidents or leakage.

For physicians, and especially primary care physicians, a simple screening question such as "How is your bowel function?" — or a more specific question such as "Have you had any problems controlling your bowel?" — often uncovers symptoms that patients would otherwise not volunteer freely. Early recognition is really important, because there are effective treatments for fecal incontinence and pelvic floor disorders, and referral can significantly improve quality of life.

Where do the biggest gaps happen between primary care and colorectal surgery?

Zhao: The biggest referral gap probably remains fecal incontinence. Many patients live with symptoms for years because of embarrassment, or because they feel nothing can be done. The other big gap is figuring out what is fecal incontinence and what is actually overflow related to chronic constipation.

Patients don't need to exhaust every single treatment option before being referred to colorectal surgery, but they'll go through years and years of trying different things on their own without even talking to physicians about what they've been living with. Evaluation with colorectal can clarify the diagnosis and identify effective treatment, because the treatment for chronic constipation is quite different from the treatment for fecal incontinence. Early referral for patients whose quality of life is greatly affected can be really helpful.

What should happen at that initial evaluation, before a referral?

Zhao: Medication review, bowel diary, stool consistency review, and obstetric and surgical history are all very important as part of the initial evaluation. I also encourage initiating some conservative management with fiber supplementation. Fiber should be in the water, to be honest, because I think everybody benefits from a little supplemental fiber. But again, we shouldn't delay referral, because symptoms can greatly affect quality of life.

What trends are you seeing in how often pelvic floor disorders show up?

Zhao: As the patient population ages, pelvic floor disorders are becoming more common. We're also recognizing these disorders at a higher rate than we were previously. They were initially very much underdiagnosed and undertreated, and as time has passed we've gotten better at recognizing pelvic floor issues.

Fecal incontinence, rectal prolapse and obstructive defecation all disproportionately affect women, especially women who have been pregnant or given birth, as those are recognized as really important risk factors.

For patients dealing with overlapping symptoms — say, pelvic organ prolapse alongside rectal prolapse — what does good care look like?

Zhao: Patients with combined pelvic organ prolapse and rectal prolapse are a really challenging population, because they are probably best managed with multiple disciplines. Fecal incontinence remains underrecognized, because many patients hesitate to bring up symptoms or assume it's a natural consequence of aging or childbirth.

Both of these conditions require coordinated care with colorectal surgery and most often urogynecology, because a combined surgery can allow us to address the components of pelvic organ prolapse all in one operation. If a patient has pelvic organ prolapse with rectal prolapse, the outcomes are much better if we address both at the same time, versus addressing one, which may actually make the other problem worse.

Often patients will have urinary incontinence or urinary issues in addition to fecal incontinence, and treatment for both may stem from a similar procedure — the sacral nerve stimulator — so coordination with urogynecology is also really helpful. We often engage pelvic floor physical therapy as well, and they're a very important part of multidisciplinary care. We also have access to the Center for Pelvic Physiology here, where we do physiology testing such as manometry and endoanal ultrasound, and we're able to offer guided biofeedback. When patients have really complicated pelvic floor symptoms, referring to specialists in colorectal and urogynecology gives them the best care.

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