European Journal of Surgical Oncology 47 (2021) 2087e2092

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European Journal of Surgical Oncology

journal homepage: www.ejso.com

Risk factors for sexual dysfunction after rectal cancer surgery in 948
consecutive patients: A prospective cohort study
Kai Li, Xiaobo He, Shilun Tong, Yongbin Zheng*
Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China

a r t i c l e i n f o a b s t r a c t

Article history: Background: Sexual dysfunctions seriously affect the quality of life of patients. The aim of this study was
Received 17 March 2021 to identify the risk factors for sexual dysfunction after rectal cancer surgery.
Accepted 23 March 2021 Methods: A total of 948 consecutive patients undergoing rectal cancer radical resection were included
Available online 29 March 2021
between January 2012 and August 2019. The sexual functions were evaluated by the 5-item version of the
International Index of Erectile Function (IIEF-5) in men and Index of Female Sexual Function (IFSF) in
Keywords:
women at 12 months postoperatively.
Sexual dysfunction
Results: Postoperative sexual dysfunction was observed in 228 patients with rectal cancer (24.05%),
Rectal cancer
Risk factor
which included 150 cases in male patients (25.0%) and 78 cases in female patients (22.5%). A multivariate
Multivariate analysis logistic regression analysis results showed that age
45 years old (OR ¼ 1.72, p ¼ 0.001), tumor below
the peritoneal reflection (OR ¼ 1.64, p ¼ 0.005), receiving preoperative radiotherapy (OR ¼ 4.12,
p < 0.001) and undergoing abdominoperineal resection (APR), intersphincteric resection (ISR) and
Hartmann surgery (OR ¼ 2.43, p < 0.001) were the independent risk factors of sexual dysfunction for
patients with rectal cancer.
Conclusion: Age
45 years old, tumors below the peritoneal reflection, receiving preoperative radio-
therapy, and undergoing APR, ISR and Hartmann surgery were the independent risk factors of sexual
dysfunction. Patients should be informed about the sexual dysfunctions in the pre-operative consulta-
tions. More attention should be paid to intraoperative pelvic autonomic nerve preservation on rectal
cancer patients with these risk factors for clinic surgeons.
© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction postoperative sexual dysfunction still occurs in 11e55% of patients

Surgery is the foundation of curative treatment of rectal cancer,
sexual dysfunction is a major postoperative complication of rectal
cancer surgery, which seriously affects the quality of life of patients.
It is well known that postoperative sexual dysfunction is mainly
attributed to damage to the pelvic autonomic nerves during oper-
ation, which included the inferior mesenteric plexus, superior hy-
pogastric plexus, hypogastric nerves, and/or pelvic plexus [1].
However, even if more and more techniques about total mesorectal
excision with pelvic autonomic nerve preservation have been
recognized by most surgeons in rectal cancer surgery [2e4],
Abbreviations: IIEF, International Index of Erectile Function; IFSF, Index of Fe-
male Sexual Function; APR, abdominoperineal resection; ISR, intersphincteric
resection; ASA, American Society of Anesthesiologist; AR, anterior resection.
* Corresponding author.430060, PR China.
E-mail address: yongbinzheng@whu.edu.cn (Y. Zheng).
[2e4].
In recent years, postoperative functional dysfunction of rectal
cancer patients has received growing attention, such as urinary and
sexual dysfunction [7,8], bowel dysfunction [9,10], these problems
become an important part of the factors that negatively affect the
life quality of the patients following rectal cancer surgery. However,
there has been limited focus on sexual dysfunction, especially for
female patients, which may be associated with the reason that fe-
male sexual dysfunction is multifactorial and more easily influ-
enced by other factors, such as psychological and social factors, in
addition, most female patients are not willing and feel embarrassed
to do questionnaire survey on sexual function, especially in China.
Several studies have also investigated the possible risk factors of
sexual dysfunction, such as age, gender, neoadjuvant chemo/
radiotherapy, advanced tumor stage, and the presence of a stoma
[11e13], however, there is a general lack of large sample and pro-
spective studies concerning the risk factor of sexual dysfunction

https://doi.org/10.1016/j.ejso.2021.03.251
0748-7983/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
K. Li, X. He, S. Tong et al.
after rectal cancer surgery, especially in female patients. At our
hospital, we have performed a prospective questionnaire-based
survey of postoperative functions after rectal cancer surgery since
2012, which included bowel, urinary and sexual function. The aim
of this study was to identify the rate and the risk factor of sexual
dysfunction for patients following rectal cancer surgery.
Materials and methods
Patients
This prospective study was conducted between January 2012
and August 2019. The inclusion criteria were as follows: (1) rectal
cancer confirmed pathologically by endoscopic biopsy, (2) Amer-
ican Society of Anesthesiologist (ASA) score I-III, (3) no sexual
dysfunction evaluated by the preoperative questionnaire-based
survey, (4) planned radical resection (including simultaneous
radical resection for patients with stage IV). The exclusion criteria
were as follows: (1) emergency surgery due to the complication
(bleeding, obstruction, or perforation), (2) palliative surgery and
local excision, (3) pelvic operation again due to complications or
other factors. Based on the inclusion and exclusion criteria, even-
tually, 1236 patients who underwent rectal cancer radical resection
in the department of gastrointestinal surgery, Renmin hospital of
Wuhan University were included in this study. This study was
approved by Renmin hospital of Wuhan University review board,
and written consent was provided by all participating patients.
Surgery and adjuvant therapy
All participants underwent radical resection of rectal cancer,
which included simultaneous radical resection for patients with
stage IV. Surgical approach including open and laparoscopic and
surgical procedure including anterior resection (AR), abdomi-
noperineal resection (APR), intersphincteric resection (ISR) and
Hartmann of patients were determined by their surgeons. Patients
with rectal cancer staged as cT3-4N0 or cTanyN1-2 by CT, MRI, or
endoscopic ultrasonography were treated with preoperative neo-
adjuvant radiochemotherapy. The preoperative chemotherapy
regimen was capecitabine plus oxaliplatin (CAPOX), while preop-
erative radiotherapy was external beam radiation with a cumula-
tive dose of 50.4 Gy in 25 fractions. The interval time between
neoadjuvant radiochemotherapy and surgery was 6e8 weeks. The
postoperative chemotherapy regimen was 6 months of CAPOX or
fluorouracil, leucovorin, and oxaliplatin (FOLFOX).
Assessment of sexual function
The 5-item version of the International Index of Erectile Func-
tion (IIEF-5) has been developed to assess male erectile function
[14], which was recognized by most surgeons. The IIEF-5 total score
ranged from 1 to 25, with a lower score indicating more severe
erectile dysfunction, male sexual dysfunction was defined as the
IIEF-5 score 11points in this study [1]. The Female Sexual Func-
tional Index (FSFI) has also been developed to assess female sexual
function [15], which is a validated questionnaire comprised of 19-
item. The index is comprised of 6 domains: desire, arousal, lubri-
cation, orgasm, satisfaction, and pain. The FSFI total score ranged
from 2 to 36, with a lower score indicating more severe sexual
dysfunction, female sexual dysfunction was defined as the FSFI
score 26.55 points in this study [16].
Follow up
All participants were informed to complete the corresponding
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European Journal of Surgical Oncology 47 (2021) 2087e2092
questionnaires before and one year after surgery. Patients who
were unwilling to fill out the questionnaire or showed sexual
dysfunction preoperatively were excluded from this study. The
original questionnaire will be filed with the medical record, and the
copies will be saved by researchers, including paper copies and
electronic files. All participants were asked to complete the corre-
sponding questionnaires and send them to the researchers one year
after surgery by email and WeChat. All participants were reim-
bursed with a ￥50 gift card for survey completion in this study.
Statistical analysis
The data are presented as the mean (±SD) for continuous vari-
ables and as the frequency (%) for categorical variables. Categorical
variables as numbers (%). Clinical data are set as a dichotomous
variable, the differences between the groups were assessed using
the Chi-square test. Univariate and multivariate logistic regression
was used to identify the risk factors of sexual dysfunction. All p-
values were two-sided, and statistical significance was defined as
p < 0.05. All statistical analyses were performed using SPSS version
20.0 software (IBM, Armonk, New York, USA).
Results
Patient characteristics
A total of 1236 patients met the inclusion criteria in this study,
and 288 patients (23.3%) have not completed or returned the
questionnaire packet one year after surgery, including 112 cases
died within 1 year after surgery, 56 cases could not be contacted,
102 cases were unwilling or unable to complete the questionnaire
and 18 cases left one or more question blank even if we tried to
contact again (Fig. 1). Eventually, A total of 948 patients (76.7%)
were enrolled in this study, which included 601 males (63.4%) and
347 female patients (36.36%). For all participants, the mean age was
53.7 ± 7.6 years old, below and above the peritoneal reflection
rectal cancers comprised 42.5% and 57.5% of tumors, 29.1% of the
patients received preoperative radiotherapy, and 40% of patients
received postoperative chemotherapy. For 347 female participants,
the mean age was 51.2 ± 5.8 years old, below and above the peri-
toneal reflection rectal cancers comprised 45.0% and 55.0% of tu-
mors, 30.3% of the patients received preoperative radiotherapy, and
41.2% of patients received postoperative chemotherapy. The clinical
and pathological characteristics both the all and female partici-
pants are presented in Table 1.
Sexual function
Sexual dysfunction occurred in 228 cases (24.05%) in this study,
there was no statistical difference for sexual dysfunction between
male and female patients ((25.0% vs. 22.5%, p ¼ 0.389). The mean
score of IIEF-5 for male patients at baseline was significantly higher
than one year postoperatively (19.32 ± 3.27 vs. 16.89 ± 2.37,
p < 0.001), and the mean score of FSFI at baseline for female pa-
tients were also significantly higher than one year postoperatively
(30.89 ± 3.27 vs. 28.72 ± 1.56, p < 0.001).
Univariate and multivariate analyses
We analyzed the variables of age, sex, BMI, ASA, diabetes, tumor
location (below the peritoneal reflection and above the peritoneal
reflection), tumor differentiation, tumor size, preoperative radio-
therapy, postoperative chemoradiotherapy, T stage, N stage, M
stage, preoperative CEA level, surgical approach (open and lapa-
roscopic), and surgical procedure (AR, APR, ISR and Hartmann). For
K. Li, X. He, S. Tong et al.
Fig. 1. Flowchart for inclusion in the study.
all participants, we identified age (p ¼ 0.003), tumor location
(p < 0.001), preoperative radiotherapy (p < 0.001), and surgical
procedure ((p < 0.001) were associated with postoperative sexual
dysfunction for rectal cancer patients (Table 2). To further investi-
gate the independent risk factors of postoperative sexual
dysfunction, variables with a p < 0.05 in the univariate analysis
were included in the multivariate analysis. The multivariate logistic
regression analysis indicated that age
45 years old (OR ¼ 1.72, 95%
CI, 1.24e2.40, p ¼ 0.001), tumors below the peritoneal reflection
(OR ¼ 1.64, 95%CI, 1.17e2.32, p ¼ 0.005), receiving preoperative
radiotherapy (OR ¼ 4.12, 95%CI, 2.96e5.73, p < 0.001) and under-
going APR, ISR and Hartmann surgery (OR ¼ 2.43, 95%CI, 1.71e3.45,
p < 0.001) were independent risk factors of sexual dysfunction for
all participating patients after rectal cancer surgery (Table 2). We
also performed the multivariate analysis to evaluate the relation-
ship between the variables and postoperative sexual dysfunction
for female patients. As shown in Table 3, age
45 years old
(OR ¼ 2.27, 95%CI, 1.27e4.04, p ¼ 0.005), tumors below the peri-
toneal reflection (OR ¼ 2.12, 95%CI, 1.16e3.88, p ¼ 0.015), receiving
preoperative radiotherapy (OR ¼ 4.42, 95%CI, 2.50e7.81, p < 0.001)
and undergoing APR, ISR and Hartmann surgery (OR ¼ 2.78, 95%CI,
1.51e5.13, p ¼ 0.001) were also independent risk factors of sexual
dysfunction for female patients after rectal cancer surgery.
Discussion
Compared with numerous outcome assessments about mor-
tality, morbidity, disease recurrence, and long-term survival in
rectal cancer, few studies focused on postoperative function as-
sessments including urinary, sexual, and bowel function after rectal
cancer surgery, especially for sexual function and in China. Because
they felt embarrassed and do not relate their symptoms to their
rectal cancer surgery, they even never mentioned these problems
to the doctors. Therefore, we filled this gap and asked patients to be
aware of the effect on sexual function by self-administered
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European Journal of Surgical Oncology 47 (2021) 2087e2092
questionnaires after rectal cancer surgery since 2012. In this study,
948 consecutive rectal cancer patients were prospectively enrolled
to evaluate the sexual function one year after surgery by the
questionnaire-based survey.
The rate of sexual dysfunction was 24.1% (228/948) in this
prospective study, male and female patients with sexual dysfunc-
tion accounted for 25.0% and 22.5%, respectively, which lies within
11e55% of the previous studies [5,6], however, widely varying rates
of postoperative sexual dysfunction have been reported in other
studies, which may be due to the different exclusion criteria and
outcome measures used in those studies [17e19].
In this study, age
45 years old (OR ¼ 1.69, p ¼ 0.001) is an
important risk factor that affects the sexual dysfunction of all
participating patients after rectal cancer surgery. Although the
different cutoff value of age was used in several studies, such as 45,
60, 65, and 70, they reported that the rate of sexual dysfunction is
increased as age increases [20e23], which may be due to some
situation, such as cardiovascular disease, diabetes, and antihyper-
tensive drug usage, was more likely to occur in the older patients.
However, Schimdt et al. [24] found that younger patients may suffer
from more psychological pressure on sexual function than older
patients, thus, quality of life of young patients may be more seri-
ously affected by sexual dysfunction. In this study, we used age 45
as a cutoff, because most patients over 60 years old were excluded
in this study because they are confirmed to have preoperative
sexual dysfunction.
Tumor below the peritoneal reflection (OR ¼ 1.54, p ¼ 0.011)
was also the risk factor of the sexual dysfunction in this study.
Consistent with the present study, Tekkiss et al. [25] also reported
that tumor localization 5 cm was the risk factor of postoperative
sexual dysfunction, which might show that tumor below the
peritoneal reflection might increase the risk of the pelvic auto-
nomic nerve injury. The S4 pelvic nerve and neuro-vascular bundles
are thought to be associated with sexual function [1,26], which are
more vulnerable to be injured when dissection planes should be
K. Li, X. He, S. Tong et al. European Journal of Surgical Oncology 47 (2021) 2087e2092

Table 1 sample.
Clinicopathological characteristics of patients. It is known that preoperative radiotherapy was an important
Variables All (N ¼ 948) Female (N ¼ 347) risk factor of sexual dysfunction [11,12,28,29]. The cause of
Gender
radiotherapy-related sexual dysfunction is complicated and
Male 601 (63.4%) 0 (0%) multifactorial, involving vascular and genital tissue fibrosis, vaginal
Female 347 (36.6%) 347 (100%) narrowing and loss of elasticity, pelvic pain, neurological damage,
Age and psychological factors [29e31], besides, radiotherapy-induced
<45 430 (45.4%) 169 (48.7%)
impairment of ovarian androgen production also contributed to

45 518 (54.6%) 178 (51.3%)
Mean ± SD 53.7 ± 7.6 51.2 ± 5.8 sexual function [32]. Preoperative radiotherapy (OR ¼ 2.24,
BMI (kg/m2) p < 0.001) was an important risk factor of sexual dysfunction in our
<25 665 (70.1%) 238 (68.6%) study.

25 283 (29.9%) 109 (31.4%)
In addition to preoperative radiotherapy, a well-known risk
ASA
I 486 (51.3%) 183 (52.7%)
factor for postoperative sexual dysfunction is surgical procedures
II 309 (32.6%) 109 (31.4%) including APR, ISR, and Hartmann surgery (OR ¼ 2.50, p < 0.001).
III 153 (16.1%) 53 (15.9%) Most studies have reported and confirmed that APR surgery is
Diabetes associated with worse sexual function [33e35], There may be
Yes 111 (11.7%) 43 (12.4%)
several reasons for worse sexual dysfunction. First, sacral
No 837 (88.3% 304 (87.6%)
Tumor location splanchnic nerves s may be damaged during the perineal resec-
Below the peritoneal reflection 403 (42.5%) 156 (45.0%) tion and the branches of the pelvic autonomous nerves were also
Above the peritoneal reflection 545 (57.5%) 191 (55.0%) easy to damage during APR as well [35], Second, psychological
Tumor differentiation# factor may be also associated with sexual dysfunction for patients
Well 757 (79.9%) 245 (70.6%)
Poor 191 (21.1%) 102 (29.4%)
without an anus, finally, for patients undergoing APR or Hartmann
Tumor size (cm) surgery, opening stoma is also an important cause of sexual
<4 491 (51.8%) 185 (53.3%) dysfunction, which were also reported by some previous studies

4 457 (48.2%) 162 (46.7%) [35,36]. Besides, for patients undergoing ISR surgery, post-
Mean ± SD 3.3 ± 1.1 3.5 ± 1.2
operative worse bowel functions also an important cause of sexual
Preoperative radiotherapy
Yes 276 (29.1%) 105 (30.3%) dysfunction.
No 672 (70.9%) 242 (69.7%) In this study, there was no statistical difference for sexual
Postoperative chemotherapy dysfunction between male and female patients ((25.0% vs. 22.5%,
Yes 379 (40%) 143 (41.2%) p ¼ 0.389), although some studies have their different results [21],
No 569 (60%) 204 (58.8%)
T stage*
some literature reported that more severe sexual dysfunction was
T0 79 (8.3%) 26 (7.5%) observed in male patients than in female patients [37], on the
T1 109 (11.5%) 36 (10.4%) contrary, other studies also reported the relatively higher rates of
T2 203 (21.4%) 72 (20.8%) sexual dysfunction were observed in female than in male patients
T3 340 (35.9%) 115 (33.1%)
[19], these different results might be due to the limitation of their
T4 217 (22.9%) 98 (28.2%)
N stage* studies, such as the few female respondents, limited sample size
N- 741 (78.2%) 271 (78.1%) and the different definition of sexual dysfunction. We also analyzed
Nþ 207 (21.8%) 76 (21.9%) the risk factor for female sexual dysfunction by the multivariate
M stage* logistic regression analysis and found that age
45 years old
M0 916 (96.6%) 336 (96.8%)
M1 32 (3.4%) 11 (3.2%)
(OR ¼ 2.28, p ¼ 0.004), tumors below the peritoneal reflection
Preoperative CEA level (ng/ml) (OR ¼ 1.97, p ¼ 0.024), receiving preoperative radiotherapy
<5 281 (29.6%) 95 (27.4%) (OR ¼ 2.33, p ¼ 0.002) and undergoing APR, ISR and Hartmann

5 667 (70.4%) 252 (72.6%) surgery (OR ¼ 3.00, p < 0.001) were also independent risk factors of
Mean ± SD 6.8 ± 2.7
sexual dysfunction for female patients.
Surgical approach
Open 367 (38.7%) 138 (39.8%) There are several limitations associated with our study. First,
Laparoscopic 581 (61.3%) 209 (60.2%) this was a single-center retrospective study, which may have
Surgical procedure resulted in a potential selection bias. Therefore, a multicenter
AR 667 (70.4%) 247 (71.2%) randomized controlled trial is required to confirm these results.
APR 151 (15.9%) 75 (21.6)
Hartmann 102 (10.8%) 17 (4.9%)
Next, any treatment concerning sexual dysfunction after rectal
ISR 28 (2.9%) 8 (2.3%) cancer surgery was not mentioned during the follow-up for one
Sexual dysfunction year. Finally, sexual dysfunction is multifactorial, many confound-
Yes 228 (24.1%) 78 (22.5%) ing factors such as surgeon's experiences and sexual partner cause
No 720 (75.9%) 269 (77.5%)
bias.
APR, abdominoperineal resection; ISR, intersphincteric resection; ASA, American
Society of Anesthesiologist; AR, anterior resection.
#
Poor including mucinous, signet-ring cell carcinoma and poorly differentiated, well
differentiation including well differentiated and moderately differentiated.
Conclusion
*The 7th edition of the American Joint Committee on Cancer (AJCC) staging system
was used. Age
45 years old, tumors above the peritoneal reflection,
receiving preoperative radiotherapy and undergoing APR, ISR, and
Hartmann surgery were the independent risk factors of post-
operative sexual dysfunction one year after surgery. Patients with
low enough to the anastomosis, especially for male patients with a these risk factors should be informed about the sexual dysfunction
narrow pelvis. However, some studies even reported tumor loca- in the pre-operative consultations. More attention should be paid
tion or level of anastomosis was not associated with sexual to intraoperative pelvic autonomic nerve preservation on rectal
dysfunction [19,27], which may be due to the relatively small cancer patients with these risk factors for clinic surgeons.
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K. Li, X. He, S. Tong et al. European Journal of Surgical Oncology 47 (2021) 2087e2092

Table 2
Univariate and multivariate analysis of sexual dysfunction for all participants.

Variable Univariate analysis Multivariate analysis

Odds ratio (95%CI) p Odds ratio (95%CI) p

Gender (female vs male) 1.15 (0.84e1.57) 0.390

Age (<45 vs
45) 1.59 (1.17e2.15) 0.003 1.72 (1.24e2.40) 0.001
BMI (kg/m2) (<25 vs
25) 0.94 (0.68e1.31) 0.732
ASA (I vs IIþIII) 1.29 (0.95e1.73) 0.098
Diabetes (no vs yes) 0.91 (0.57e1.46) 0.689
Tumor location ((above the PR vs below the PR) 2.07 (1.53e2.80) <0.001 1.64 (1.17e2.32) 0.005
Tumor differentiation (well vs. poor) # 1.61 (0.76e3.42) 0.213
Tumor size (cm) (<4 vs.
4) 1.21 (0.90e1.62) 0.219
Preoperative radiotherapy (no vs. yes) 3.82 (2.79e5.22) <0.001 4.12 (2.96e5.73) <0.001
Postoperative chemotherapy (no vs. yes) 0.95 (0.70e1.29) 0.739
T stage (T0þ2 vs. T3þ4) * 1.10 (0.81e1.49) 0.533
N stage (N0 vs. Nþ) * 1.08 (0.75e1.54) 0.684
M stage (M0 vs. M1) * 1.06 (0.47e2.38) 0.898
CEA level (ng/ml) (<5 vs.
5) 1.36 (0.97e1.90) 0.079
Surgical approach (open vs. laparoscopic) 1.14 (0.84e1.55) 0.412
Surgical procedure (APR þ ISRþ Hartmann vs. AR) 2.85 (2.09e3.88) <0.001 2.43 (1.71e3.45) <0.001

APR, abdominoperineal resection; ISR, intersphincteric resection; ASA, American Society of Anesthesiologist; AR, anterior resection; PR, peritoneal reflection.
#Poor including mucinous, signet-ring cell carcinoma and poorly differentiated, well differentiation including well differentiated and moderately differentiated.
*The 7th edition of the American Joint Committee on Cancer (AJCC) staging system was used.

Table 3
Univariate and multivariate analysis of sexual dysfunction for female patients.

Variable Univariate analysis Multivariate analysis

Odds ratio (95%CI) p Odds ratio (95%CI) p

Age (<45 vs
45) 1.97 (1.17e3.31) 0.011 2.27 (1.27e4.04) 0.005

BMI (kg/m2) (<25 vs
25) 1.40 (0.82e2.37) 0.214
ASA (I vs IIþIII) 1.15 (0.70e1.91) 0.582
Diabetes (no vs yes) 1.05 (0.49e2.24) 0.896
Tumor location (above the PR vs below the PR) 2.95 (1.74e5.00) <0.001 2.12 (1.16e3.88) 0.015
Tumor differentiation (well vs. poor) # 1.53 (0.57e3.08) 0.182
Tumor size (cm) (<4 vs
4) 1.36 (0.82e2.25) 0.238
Preoperative radiotherapy (no vs yes) 4.10 (2.42e6.96) <0.001 4.42 (2.50e7.81) <0.001
Postoperative chemotherapy (no vs yes) 0.99 (0.59e1.65) 0.970
T stage (T0þ2 vs T3þ4) * 1.44 (0.85e2.46) 0.177
N stage (N0 vs Nþ) * 1.31 (0.73e2.36) 0.365
M stage (M0 vs M1) * 0.76 (1.16e3.59) 0.729
CEA level (ng/ml) (<5 vs
5) 1.22 (0.68e2.19) 0.498
Surgical approach (open vs laparoscopic) 1.24 (0.73e2.08) 0.428
Surgical procedure (APR þ ISRþ Hartmann vs. AR) 3.41 (2.01e5.78) <0.001 2.78 (1.51e5.13) 0.001

APR, abdominoperineal resection; ISR, intersphincteric resection; ASA, American Society of Anesthesiologist; AR, anterior resection; PR, peritoneal reflection.
#Poor including mucinous, signet-ring cell carcinoma and poorly differentiated, well differentiation including well differentiated and moderately differentiated.
*The 7th edition of the American Joint Committee on Cancer (AJCC) staging system was used.

Funding source References

This work was supported by grants from Clinical Research of Wu
Jieping Medical Foundation (320.2710.1855).
CRediT authorship contribution statement
Kai Li: Data curation, Formal analysis Funding acquisition,
Writing e original draft, Writing - review & editing. Xiaobo He:
Data curation, Methodology, Software, Writing - review & editing.
Shilun Tong: Data curation, Project administration, Investigation,
Validation, Writing -review & editing. Yongbin Zheng: Conceptu-
alization, Funding acquisition, Supervision, Resources, Writing -
review & editing.
Declaration of competing interest
None.
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