Controversies in abdominoperineal excision.

Abdominoperineal excision (APE) is a necessary operation in many patients with low rectal cancer. Outcomes after this procedure, however, have been variable and often suboptimal. With a new concept of APE, three different types of procedures can be described, based on pelvic and pelvic floor anatomy: intersphincteric APE, extralevator APE (ELAPE), and ischioanal APE. Improved outcomes have been reported after ELAPE but the concept is still controversial and there are disagreements related to the extent of pelvic floor removal, positioning of the patient, and methods of pelvic floor reconstruction.