Comparative analysis of anal sphincter-preserving surgical techniques in ultra-low rectal cancer

Ultra-low rectal cancer refers to a tumor situated very close to the anal verge, typically within 3 cm from the proximal end of the anal dentate line. Its location creates significant challenges for achieving clear surgical margins necessary to achieve local tumor control while preserving sphincter function to minimize the risk of developing fecal incontinence and other complications.This review summarizes six sphincter-preserving techniques for ultra-low rectal cancer: local excision, low anterior resection(LAR, with or without prophylactic ileostomy or ileal stent), intersphincteric resection (ISR), modified Bacon and Parks procedures, transanal total mesorectal excision (TaTME), and Natural Orifice Specimen Extraction Surgery with Precision Functional Sphincter-Preserving Surgery(NOSES-PPS). While most approaches achieve satisfactory oncological outcomes, postoperative anal function remains a major concern. Preliminary evidence suggests NOSES-PPS may offer benefits in preserving anal function, though current studies are limited by small sample sizes and lack of large-scale trials. Optimal outcomes depend on patient selection, surgical expertise, and perioperative management.