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Extralevator APR: what the wider operation does and who it is for | CION Cancer Clinics
An extralevator APR is an abdominoperineal resection in which the surgeon removes the rectum, the anus and the pelvic floor muscles around them as one wide piece. It is used for cancers that sit very low, at or into the pelvic floor, where a standard APR would cut too close. The trade is a larger perineal wound that heals more slowly. The colostomy is permanent in both versions. CION Cancer Clinics’ surgical oncologists in Hyderabad can talk this through with you.
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Medically reviewed by Dr. Mohammed ImaduddinConsultant Surgical Oncologist · MBBS, MS (General Surgery), MCh (Surgical Oncology) · last reviewed September 2026, next review due September 2027
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The short answer
What is an extralevator APR?
An extralevator APR is a version of the operation for a low rectal cancer in which the surgeon removes the rectum, the anus and the pelvic floor muscles around them as one wide piece. The point is to keep a clear rim of healthy tissue around a tumour that sits very low down, where a standard APR can cut in too close.
What "extralevator" means
The levator muscles form the floor of the pelvis. In a standard APR the removed piece narrows at the level of these muscles, a shape surgeons call a waist. In the extralevator version the cut is taken outside the levator muscles, so the removed piece stays wide all the way down, like a cylinder.
What it is trying to achieve
Two things. A clear margin, which means no cancer cells at the edge of what was removed. And no tear in the bowel wall near the tumour, which can spill cells into the pelvis. Your team weighs these against the cost of a larger perineal wound, which is the main drawback.
Whether this version suits you is a decision for your treating team, made from your MRI and your examination. This page explains what they are weighing, not what they should choose.Side by side
How does it differ from a standard APR?
Standard APR
Extralevator APR
Removed piece narrows at the pelvic floor, with a waist
Removed piece stays wide, taking the pelvic floor muscles with it
Smaller perineal wound, usually closed with stitches alone
Larger gap in the perineum, often closed with a flap of muscle or a mesh
Used where the tumour sits a little above the sphincter
Used where the tumour reaches or grows into the pelvic floor
Perineal part is usually done with you lying on your back
Perineal part is often done with you turned face down
Not sure whether this applies to you?
Ask an oncologistWho it is considered for
When is the extralevator approach usually discussed?
It is a choice made from your MRI pictures, not from the stage number alone.
Very low tumours
A cancer that sits at or within the ring of muscle that controls the bowel, where a standard APR would have to cut close to the tumour on its way down.
Tumours growing into the pelvic floor
When the MRI shows the cancer reaching the levator muscles themselves, taking those muscles as part of the removed piece is the only way to keep a clear rim around it.
Often described on the MRI as
- Threatened or involved margin
- Tumour reaching the levators
- Growth into the sphincter complex
After chemoradiation that did not shrink it enough
Many low rectal cancers are treated with radiotherapy and chemotherapy first. If the tumour still sits close to the edge on the repeat scan, the wider removal is often the safer plan.
Where it adds little
It does not suit a tumour that sits higher in the rectum, where a standard APR or a sphincter-saving operation gives a clear margin already. Taking the pelvic floor when it is not needed only leaves a bigger wound to heal.
In the theatre
What happens during the operation?
The abdominal part
Through the belly, by open surgery or keyhole, the surgeon frees the rectum from the tissue around it and divides the bowel higher up. The colostomy is brought out at the spot marked before surgery.
Turning you over
For the extralevator version you are often turned to lie face down, with the hips raised. This gives the surgeon a clear view of the pelvic floor from below. You are fully asleep throughout and remember none of it.
The perineal part
The surgeon cuts around the anus and works upward, staying outside the levator muscles until the removed piece meets the part already freed from above. The whole cylinder comes out through the perineum.
Closing the gap
Because the pelvic floor has gone, there is a larger space to fill. It may be closed with stitches alone, with a mesh, or with a flap of muscle and skin moved in from the buttock or the belly. Your surgeon will tell you beforehand which is planned.
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After you go home: the one thing that cannot wait
A fever with a foul-smelling or increasing discharge from the perineal wound, or the wound edges coming apart with bleeding, needs to be seen the same day. Ring the number on your discharge sheet or go to the nearest emergency department and say you have had rectal cancer surgery. Do not wait for the next clinic date, and do not start antibiotics from a pharmacy on your own.
Being straight with you
What does the wider operation cost you afterwards?
The price of the extralevator approach is paid in the perineum. The wound is larger, it heals more slowly, and it is more likely to need a flap or a mesh to close. Everything else about recovery, including the permanent colostomy, is the same as for a standard APR.
A slower perineal wound
The perineal wound heals slowly after any APR, because the area has usually had radiotherapy and because you sit on it. Removing the pelvic floor leaves a deeper space beneath the skin, so this wound may take a few months to close, and it is more likely to open partly and need dressings at home.
A higher chance of a perineal hernia
With the muscular floor gone, the bowel can push down into the gap over time and form a bulge, called a perineal hernia. It is one reason a mesh or a flap is often used to close the space.
What this page cannot tell you
It cannot tell you whether your tumour needs this approach, and it cannot give you a figure for how likely the cancer is to come back. Those answers come from your own MRI, the pathology report after surgery and your team.
Not every centre performs the extralevator version. Ask your surgeon whether it is in their practice.Commonly believed
Four things families ask, and what is actually true
"Extralevator is the newer, more advanced version, so we should ask for it."
It is a wider operation, not a better one. For a tumour that sits above the pelvic floor it adds a bigger wound while adding nothing to the margin. The right version is the one the MRI calls for.
"With this version the stoma might only be temporary."
No. Any APR removes the anus and the muscles that control it, so there is nothing to join the bowel back to. The colostomy is permanent in both versions.
"If the surgeon needs a flap, something must have gone wrong."
A flap is often planned from the start, because the gap left when the pelvic floor is removed is too large to close well with stitches alone. It is a sign the surgeon is planning the closure, not a sign the operation failed.
"Because more was removed, the cancer is definitely all gone."
A wider removal improves the chance of a clear margin, and that is why it is done. But whether cancer remains anywhere depends on the pathology report and the scans, not on the size of the operation. Nobody can promise it from the theatre.
Questions we are asked
Common questions about extralevator APR
Is extralevator APR a different operation or the same one done differently?
The same operation, done more widely at the bottom end. Both remove the rectum and anus and both leave a permanent colostomy. The extralevator version also removes the pelvic floor muscles around the lowest part of the rectum, so the surgeon never cuts close to a very low tumour.
Will I be turned face down during the operation?
Often, yes. Many surgeons do the perineal part with the patient face down and the hips raised, because it gives a clearer view of the pelvic floor. You are under a general anaesthetic for all of it, and the anaesthetist pads and protects your face, chest and joints while you are turned.
Can it be done by keyhole or robot?
The belly part often can, which means smaller cuts on the abdomen. The perineal part is always done through the perineum by hand, whatever is used above. Ask your centre which approach your surgeon uses for the abdominal part and why.
How long will the perineal wound take to heal?
Longer than the belly wound, and often longer than people expect. Many perineal wounds after this version take a few months to close fully, and some open partly and need dressings at home for a while. Radiotherapy before surgery, diabetes and smoking all slow it further. Nobody can give you an exact date.
What is the flap made from?
Usually a piece of muscle with its skin, moved from the inside of the thigh, the buttock or the lower belly while still attached to its own blood supply. It fills the space where the pelvic floor was and brings well-supplied tissue into an area that has often had radiotherapy. You will have a second wound where the flap was taken.
Will I be able to sit normally afterwards?
Eventually, yes, but sitting is uncomfortable for longer than after a standard APR, because the wound sits exactly where your weight rests. Lying on your side, standing and short walks are easier in the early weeks. Ask before buying a ring cushion, as these can pull on the wound.
Why did my MRI report mention the levators or the sphincter?
Because that is what decides the version of the operation. The radiologist is describing how close the tumour sits to the pelvic floor muscles and the ring of muscle around the anus. A tumour that reaches them is usually the reason an extralevator approach is discussed. Ask your surgeon to show you on the pictures.
Is it covered by Aarogyasri or my insurance?
Rectal cancer surgery is covered under Aarogyasri, CGHS, ECHS and EHS, and most cashless insurers cover it as part of a cancer treatment plan. A flap closure may be listed separately, so ask the centre to check your specific cover before the date is fixed. The helpline can check this with you.
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Sources
- Cancer Research UK — Surgery for bowel cancer
- American Cancer Society — Surgery for rectal cancer
- National Cancer Institute — Rectal cancer treatment (PDQ), patient version
- Macmillan Cancer Support — Surgery for cancer
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
Abdominoperineal Resection: What Is RemovedThe standard operation this page builds onAPR vs Low Anterior Resection: How the Choice Is MadeWhy some low tumours can keep the anus and some cannotFlap Closure of the Perineal WoundHow the larger gap is closed and what the second wound is likeWhy the Perineal Wound Heals SlowlyThe main drawback of the wider operation, explainedChoosing a Surgeon and a CentreWhat to ask about experience with this version
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Been told you need an APR?
Send us your MRI report and biopsy, or call the helpline. A surgical oncologist will explain which version of the operation is being proposed and why. One helpline serves every CION centre.