APR surgery, short for abdominoperineal resection, is a major operation used to treat rectal cancer. It involves removing the anus, rectum, and part of the lower colon, then creating a permanent opening in the abdomen called a colostomy so stool can leave the body. It’s typically recommended when a tumor sits low in the rectum, close to or involving the anus, making it impossible to remove the cancer while preserving normal bowel function.
Why APR Is Performed
APR is reserved for rectal cancers that are too close to the anus to be removed with sphincter-sparing alternatives. In those alternatives, a surgeon can reconnect the remaining bowel after removing the tumor, allowing a person to eventually pass stool normally. But when the cancer has grown into or very near the anal sphincter (the ring of muscle that controls bowel movements), there’s no way to save that structure and still get clean margins around the tumor.
According to National Comprehensive Cancer Network guidelines, APR is used for tumors in the lower rectum that have grown into the anus or the nearby pelvic floor muscles. It applies to cancers that have invaded at least into the muscle layer of the rectal wall, and sometimes to smaller or larger tumors depending on their exact position and whether lymph nodes are involved. Any cancerous lymph nodes in the surrounding area are removed during the same operation.
What the Surgery Involves
The operation gets its name from the two areas where the surgeon works: the abdomen and the perineum (the area between the genitals and the anus). Regardless of the technique used, both areas require incisions.
Through the abdominal approach, the surgeon frees the lower colon and rectum from surrounding tissue. Through the perineal incision, the surgeon removes the anus and the remaining rectal tissue from below. Once the anus and rectum are out, the surgeon brings the cut end of the colon through the abdominal wall to create a stoma, which is the small opening where a pouch attaches to collect waste. This stoma is usually placed on the lower left side of the abdomen, roughly two inches from the belly button.
Open, Laparoscopic, and Robotic Approaches
The abdominal portion of APR can be done three ways. In traditional open surgery, the surgeon makes one long incision down the abdomen. In laparoscopic surgery, several small incisions are used instead, and a tiny camera and specialized instruments are inserted to complete the work. Robotic-assisted surgery uses a similar set of small incisions but adds a robotic system that gives the surgeon a three-dimensional, high-definition view and instruments capable of bending and rotating beyond the range of a human hand.
The perineal incision is the same in all three approaches. Minimally invasive techniques (laparoscopic or robotic) generally mean less blood loss, smaller scars, and a somewhat faster initial recovery compared to open surgery, though the overall scope of what’s removed is identical.
Living With a Permanent Colostomy
Because the rectum and anus are completely removed, there is no path left for stool to exit naturally. A permanent colostomy is always part of APR. The stoma itself is a small, pinkish-red circle of intestinal tissue that protrudes slightly from the skin. It has no nerve endings, so it doesn’t hurt.
A flat, adhesive pouch fits over the stoma and collects waste throughout the day. Most people empty or change the pouch a few times daily. Before surgery, a specialized nurse typically marks the ideal stoma location on your abdomen, choosing a spot that sits on a flat area of skin away from belt lines, skin folds, and scars so the pouch seals well. After surgery, that same nurse or a wound care specialist teaches you how to care for the stoma, change the pouch, and manage your skin. Most people become comfortable with the routine within a few weeks.
Recovery After APR
Hospital stays after APR typically range from about five to seven days, though this varies depending on whether the surgery was open or minimally invasive and how quickly bowel function returns. You won’t eat solid food right away. The surgical team gradually advances your diet from clear liquids to soft foods as your intestines wake up after anesthesia.
The perineal wound, where the anus was removed and the opening sutured closed, is often the slowest part to heal. This area bears pressure when you sit and is naturally exposed to moisture and bacteria, so it can take several weeks to fully close. Keeping the wound clean, using a cushion when sitting, and following wound care instructions closely all help. Some people experience drainage from the perineal site for weeks after surgery, which is normal as long as there are no signs of infection like increasing redness, warmth, or fever.
Most people need six to eight weeks before returning to work or resuming regular physical activity, though lighter tasks can often resume sooner. Full recovery, including regaining stamina and adjusting to the colostomy, can take several months.
Potential Complications
APR is a significant operation, and complications are possible. Perineal wound problems are among the most common: the incision can break down or become infected because of its location. Nerve damage during surgery can affect bladder function, sometimes causing difficulty urinating in the early postoperative period. Sexual function can also be affected, since the nerves that control arousal and erection in men, and sensation in women, run close to the rectum and may be stretched or damaged during removal. The degree of impact varies widely from person to person.
Other general surgical risks include bleeding, infection at the abdominal incision site, blood clots, and bowel obstruction from internal scar tissue. Stoma-related issues, such as the surrounding skin becoming irritated or the stoma narrowing over time, can occur but are usually manageable with proper care.
Survival and Outcomes
For very low rectal cancers, APR produces survival rates comparable to sphincter-sparing surgery. A study published in the Journal of Gastrointestinal Surgery found five-year disease-free survival of about 72% for APR patients versus 79% for those who had the alternative sphincter-preserving procedure, a difference that was not statistically significant. Overall five-year survival was roughly 78% for APR and 81% for the alternative, again without a meaningful statistical gap. Complication rates, hospital stays, and recurrence rates were also similar between the two approaches.
The overall recurrence rate in that study was about 20%, which includes both local recurrence near the original tumor site and distant spread. Whether someone also receives chemotherapy or radiation before or after surgery significantly influences these numbers. Many people with locally advanced rectal cancer undergo radiation and chemotherapy before APR to shrink the tumor, which can improve outcomes and make the surgery itself more straightforward.