Abdominoperineal Resection (APR)

Removal of the rectum and anus for cancers sitting too low to safely reconnect — with a permanent colostomy created as part of the operation, not as a complication of it.

Request a consultationSurgery is arranged with a coordinator by phone.

Setting: Operative
Anesthesia: General anesthesia, in the operating room
Back to work: 6-8 weeks
Success rate: Greater than 95% (curative intent)
Recurrence: 5-15% (local recurrence)

What it is

What is an Abdominoperineal Resection?

An Abdominoperineal Resection (APR) is a major surgical procedure performed for very low rectal cancers or anal cancers that involves the removal of the anus, rectum, and a portion of the sigmoid colon. Unlike a sphincter-preserving low anterior resection, this operation requires the complete removal of the anal sphincter complex. Consequently, a permanent end colostomy is created on the abdominal wall for the passage of stool. The operation is performed through both an abdominal incision (laparoscopic, robotic, or open) and a perineal incision.

Am I a candidate?

Who is a Good Candidate for an APR?

An APR is indicated for patients with cancers that are too low in the rectum or anal canal to allow for a sphincter-preserving resection with adequate margins. Ideal candidates include:

Patients with distal rectal cancer that invades the anal sphincter muscles or is so close that a negative distal margin cannot be achieved.
Patients with anal squamous cell carcinoma that has failed to respond to chemoradiation or has recurred after treatment.
Select patients with very poor baseline sphincter function who would be severely incontinent after a low anastomosis.
Patients with locally advanced tumors requiring a wide pelvic dissection where the blood supply to a potential anastomosis would be compromised.

How it's done

1Under general anesthesia, working from two directions: through the abdomen (usually keyhole — laparoscopic or robotic) and through a separate incision at the perineum, the skin around the anus.
2The rectum, the anal canal with its sphincter muscles, and the surrounding lymph-node-bearing tissue are removed together — for the lowest cancers, this is what achieves clear margins and the best chance of cure.
3A permanent colostomy is created: the end of the colon is brought out through the abdominal wall. This is part of the operation itself — with the sphincters removed, it is how stool leaves the body from now on.
4The perineal wound is closed in layers, sometimes with a tissue flap when radiation has been part of treatment.
5Before you go home, a specialized stoma nurse teaches you — hands on — how to care for the colostomy.

What to expect

In hospital (about 5–10 days)
Walking early, a urinary catheter for several days, and daily colostomy teaching with the stoma nurse until you're confident.
First weeks
The perineal wound is the slow part — avoid long stretches of sitting directly on it, and expect visits to check its healing.
6–8 weeks
Most people are back to many normal activities; full recovery takes several months.
Ongoing
Adjusting to life with a colostomy is a real process, physically and emotionally. Most people return to fully active lives — work, travel, exercise — and stoma nurses and peer support make the adjustment much easier.

Risks & considerations

What are the Risks?

APR is a major operation with significant risks, including:

Perineal Wound Complications: This is the most common problem, with rates of infection, breakdown (dehiscence), and delayed healing being particularly high, especially in patients who have received pelvic radiation.
Colostomy Complications: Risks include hernia, prolapse, stenosis, or retraction of the stoma.
Bleeding and Infection: Standard surgical risks of bleeding and intra-abdominal or pelvic infection.
Urinary and Sexual Dysfunction: The extensive pelvic dissection carries a high risk of injury to the autonomic nerves, which can lead to permanent bladder dysfunction (urinary retention) and sexual dysfunction (erectile dysfunction, ejaculatory problems).
Phantom Rectum Sensation: Some patients experience a sensation of needing to have a bowel movement, even though the rectum has been removed.
Small Bowel Obstruction: Adhesions from the surgery can lead to bowel blockages in the future.

The risks that matter

Every operation carries a long list of possible complications. These are the ones that are serious enough — and common enough — to understand in real numbers before you decide.

Perineal wound problems (infection, breakdown, slow healing)

observational

The wound where the anus was removed can become infected, open up, or simply heal much more slowly than a normal incision.

about 17–35%, and higher after pelvic radiation— roughly 1 in every 3 to 6 operations

Why it happens: Removing the rectum leaves a large empty space at the very bottom of the pelvis, and the skin there closes under tension in a spot that is hard to rest. Radiation — often a necessary part of good cancer treatment — makes those tissues heal more slowly still. This is the best-documented complication of the operation itself, not a reflection of how it was performed.
If it happens: Most wound problems are handled with dressing care and antibiotics; some need drainage or a return to the operating room. A minority heal slowly over months — in reported series about 10% of patients still have a wound issue a year after surgery — with wound-care support throughout.
How we lower the odds: Careful multi-layer closure, using a tissue flap to bring healthy, unirradiated tissue into the area when radiation has been given, optimizing nutrition, blood sugar and smoking beforehand, and close wound checks after surgery so problems are caught small.

Lowering the odds is not the same as removing them. Even when everything is done right, this can still happen — that is the nature of the operation, not a failure of your care.

Source: BIOPEX and BIOPEX-2 randomized-trial study protocols (Musters GD, et al. BMC Surgery 2014; BIOPEX-2 protocol, BMC Surgery 2020): perineal wound complications 17–35% after primary closure in reported series; up to 35% early; ~10% still present at 1 year.

Sources