Is there still a place for abdominoperineal resection of the rectum?

During the past two decades, low anterior resection (LAR) with colo-rectal or colo-anal anastomosis has replaced abdominoperineal resection (APR) as the primary surgical therapy for rectal cancer. Several studies, although not prospectively randomized, have shown that the outcome after LAR with deep anastomosis and APR is comparable concerning mortality, local recurrence rate and survival. Adequate clearance of the tumour, and not the surgical procedure performed, is the determinant factor influencing the outcome. Whereas most tumours in the upper third and mid-rectum are amenable to a sphincter-saving procedure (SSP), the lower third of the rectum is of debate in this respect. Small tumours (T1) in the lower third can be treated by peranal local excision. Low grade tumours with a T2 or T3 stage located above 3 cm from the dentate line are treated by SSP. There is still a place for APR for advanced tumours (T3 and T4) below 5 cm from the anal verge, in case of deficiency of the anal sphincter, and when the sphincter complex is infiltrated by the tumour. Preoperative staging measures are essential for patient selection in relation to height of the tumour above the anal canal, depth of tumour invasion into the rectal wall, and presence or absence of regional lymph node metastases. Biology of rectal cancer and its implication on surgery, preoperative staging of rectal cancer, technique and results of the main three surgical options, and the advent of laparoscopy are discussed in this article.