Abdominoperineal resection (APR) for low rectal cancer results in permanent stoma, psychosocial distress, and systemic inflammation, impairing quality of life and survival. This study evaluated whether app-based cognitive behavioral therapy (CBT) plus biomarker-guided nutrition could improve recovery and survival. In this prospective, single-center, non-randomized controlled cohort, 186 patients with stage I-III low rectal adenocarcinoma undergoing curative abdominoperineal resection (APR) all received standard Enhanced Recovery After Surgery (ERAS) care. Patients were managed with ERAS alone or ERAS plus an integrative program combining digital cognitive behavioral therapy (CBT) and inflammation-guided precision nutrition, tailored according to prognostic nutritional index (PNI), C-reactive protein (CRP), and interleukin-6 (IL-6). Interventions began two weeks preoperatively and continued for six months. Primary outcomes were longitudinal changes in depression, sleep quality, sexual function, and health-related quality of life. Secondary outcomes included inflammatory markers, skeletal muscle index (SMI), and two-year disease-free and overall survival. By month 3, the intervention group showed greater improvements in all primary outcomes, sustained through 24 months (all p < 0.001). CRP and IL-6 were reduced by day 7 (both p < 0.001), with faster recovery and shorter hospitalization. SMI was better preserved at 24 months (p = 0.046). Two-year DFS (hazard ratio [HR] = 0.48, 95% confidence interval [CI] 0.26-0.89, p = 0.021) and OS (HR = 0.44, 95% CI 0.20-0.95, p = 0.036) were significantly improved. Findings remained robust in multivariable and sensitivity analyses. Among patients undergoing APR managed within an ERAS pathway, the addition of digital CBT and inflammation-guided nutrition was associated with improved multidimensional recovery and favorable survival signals. Given the non-randomized design, these results should be regarded as hypothesis-generating and support further evaluation of ERAS-based integrative strategies in randomized multicenter trials.

Patients who have previously received radiation therapy for primary prostate cancer (PPC) face an elevated risk of developing secondary rectal cancer (SRC). However, the clinical presentation, surgical outcomes, and oncological results of SRC in this context remain poorly characterized. This study aims to compare the clinical and pathological features, as well as treatment outcomes, of patients with primary rectal cancer (PRC) and those with SRC following radiation for prostate cancer. Retrospective cohort study using univariate and propensity-matched analyses. Data extracted from electronic medical records at a single tertiary institution [2001-2021]. Male patients with rectal cancer (RC) who underwent oncological resection with or without a prior history of prostate cancer radiation. Patients with a <3-year interval between radiotherapy and RC diagnosis were excluded. The main outcome measures were pathological analysis, postoperative complications and overall survival. Out of 1,755 patients with RC, 50 cases (2.9%) had SRC. Forty-three out of the 50 patients were included in the analysis. The median time from radiotherapy to SRC diagnosis was 8 ± 4 years (IQR). Patients with SRC were older, with a mean age of 73.7 ± 8.5 versus 61.1 ± 13 years in the control group (p < 0.001), and a higher American Society of Anaesthesiologists (ASA) score (p = 0.006). Most SRCs were distal with a median distance from the anal verge of 4.25 cm (IQR 9.5 cm). Only seven patients (16.3%) in the SRC group received neoadjuvant radiation therapy versus 764 (44.8%) of PRC (p = 0.001). SRC patients required more extensive surgical interventions, including abdominoperineal resection (46.5% vs. 29.9%), pelvic exenteration (4.7% vs. 0.4%), and fewer sphincter-preserving procedures, including low anterior resection (48.8% vs. 68.2%) and transanal resection (0% vs. 1.5%) (p = 0.02). Propensity score matching with a 1:2 ratio matching for age, body mass index (BMI), ASA score, type of surgery, and pathological staging revealed no differences between the groups regarding tumour differentiation, staging, or postoperative complications. Survival analysis at 6 years showed no significant difference in overall survival between the SRC (53.2%, 95% CI: 35%-71%) and PRC (50.3%, 95% CI: 36%-64%) groups (p = 0.61). Retrospective design and reliance on electronic medical records from a single institution. Patients with PPC developed SRC up to 10 years after radiation therapy. Patients with SRC were typically older with more comorbidities. Fewer patients with SRC underwent neoadjuvant therapy, and as a group, required more extensive surgeries with a lower rate of sphincter preservation compared to patients with PRC. Despite these differences, patients with SRC had similar pathological outcomes and overall survival compared to patients with PRC.

In the over-century-long history of colorectal tumor surgery, achieving organ function preservation has consistently been a central topic. Currently, advancements in surgical techniques, updates in surgical platforms, and the development of multidisciplinary comprehensive treatment models have collectively driven the inheritance and evolution of theories and technologies for organ function preservation. Regarding innovations in surgical procedures, the progression from abdominoperineal resection to total mesorectal excision represents a developmental inheritance, shifting from mere radical tumor resection to preserving anal and neurological functions. In terms of surgical platform innovations, the evolution from 2D laparoscopy to robotic platforms has provided clearer surgical fields and more precise manipulation, offering a crucial platform guarantee for functional preservation. As for innovations in treatment strategies, the development from neoadjuvant chemoradiotherapy to immunotherapy and the "watch-and-wait" strategy reflects an evolution in treatment concepts, elevating organ preservation to the new height of "surgical exemption". In the future, with continuous progress in fields such as artificial intelligence, medical-engineering integration, and equipment research and development, organ function preservation in colorectal tumor surgery will enter a new stage of multidisciplinary integrated development, leading to more innovative achievements and clinical translations.

Objective: To characterize the endoscopic severity distribution and clinical features of diversion colitis (DC) following curative resection for rectal cancer with concurrent ileostomy. Methods: This descriptive observational study enrolled patients who met the following criteria: (1) preoperative histopathological confirmation of primary rectal adenocarcinoma via colonoscopic biopsy; (2) curative rectal cancer surgery (open or laparoscopic) with simultaneous prophylactic loop ileostomy; (3) subsequent ileostomy closure; and (4) complete medical records of 1-month follow-up data after closure. Patients who underwent abdominoperineal resection or had inadequate bowel preparation precluding clear endoscopic mucosal visualization were excluded. Clinical data were retrospectively collected for 173 patients who underwent the aforementioned procedures at Peking University People's Hospital between January, 2023 and December, 2024. Primary endpoints were the overall incidence of endoscopic DC, its severity distribution (mild, moderate, severe), and specific manifestations (edema, mucosal hemorrhage, and contact bleeding). Secondary endpoints included the low anterior resection syndrome (LARS) score [range 0-42; no LARS (0-20), minor LARS (21-29), major LARS (30-42)] and bowel function-related symptoms (abdominal pain, mucous stool, rectal bleeding before and after closure, and diarrhea after closure). Results: Among the cohort, 108 patients (62.4%) were male, with a median age of 67 years (IQR 59-73). Endoscopic assessment revealed a 100% overall incidence of DC. Moderate to severe edema was present in 113 patients (65.3%), mucosal hemorrhage in 105 (60.7%), and contact bleeding in 66 (38.2%). Based on DC severity scores, cases were classified as mild in 52 (30.1%), moderate in 72 (41.6%), and severe in 49 (28.3%). Compared to the mild/moderate DC group, the severe DC group had a significantly longer median time to stoma closure [5.7 months (IQR 3.8, 7.7) vs. 4.7 months (IQR 3.7, 5.9); Z=2.335, P=0.020] and higher C-reactive protein levels (P=0.002). The severe DC group also exhibited higher incidences of pre-closure abdominal pain [20.4% (10/49) vs. 8.1% (10/124); χ²=5.234, P=0.022] and post-closure rectal bleeding [18.4% (9/49) vs. 8.1% (10/124); χ²=3.813, P = 0.049]. Furthermore, the severe DC group had a higher median LARS total score [31 (IQR 27, 38) vs. 27 (IQR 15, 34); Z=2.370, P=0.018] and a significantly greater proportion of patients with clustered defecation [59.2% (29/49) vs. 37.1% (46/124); χ²=6.977, P=0.031]. There were no statistically significant in other defecation function related symptoms between the two groups (all P>0.05). Conclusion: DC is an extremely common finding after curative rectal cancer surgery with concurrent ileostomy. Severe DC is associated with a longer interval to stoma closure, elevated inflammatory markers, and inferior postoperative bowel function.

Background: Perineal wound healing complications frequently occur following abdominoperineal resection (APR) for low-lying rectal cancers, posing significant reconstructive challenges. Among various reconstructive options, gracilis muscle flaps have gained prominence due to their reliability in addressing sacral dead-space defects. Despite their popularity, decision-making criteria regarding unilateral versus bilateral gracilis flap use, supplementary adipose tissue flaps, and optimal timing for reconstruction remain inadequately defined. Materials and Methods: We conducted a retrospective single-center cohort study including 25 patients who underwent perineal reconstruction using unilateral or bilateral gracilis muscle flaps after APR complications. Variables collected encompassed demographic characteristics, preoperative treatments, operative details, and postoperative outcomes classified according to the Clavien–Dindo criteria. Additionally, we assessed the efficacy of supplementary adipose tissue flaps harvested from the ischiorectal region. Results: Among the 25 patients studied, unilateral gracilis flap reconstruction was performed in 64%, and bilateral flaps in 36%. Eleven cases (44%) received supplementary adipose tissue flaps. The overall complication rate was 44%, with 28% requiring surgical revision. Negative pressure wound therapy (NPWT) cycles pre-reconstruction significantly correlated with higher complication rates ( P = 0.013), likely reflecting underlying wound severity. Although not statistically significant, a trend indicated that a shorter interval between oncological resection and reconstructive surgery resulted in fewer complications (mean: 8.2 vs. 34.8 months; P = 0.14). Ultimately, complete healing was achieved in all patients. Conclusion: Gracilis muscle flaps, complemented by ischiorectal adipose flaps, represent an effective strategy for perineal reconstruction post-APR, though the optimal timing warrants further investigation. Although these findings are limited by the small cohort size and retrospective design, minimizing preoperative NPWT cycles and avoiding excessive delays in reconstruction may improve clinical outcomes.

Risk factors for perineal wound infection after abdominoperineal resection of rectal cancer

Radical pelvic extirpative surgery is associated with high perioperative morbidity. The inferior gluteal artery myocutaneous (IGAM) flap was introduced and subsequently refined to optimize patient results in this setting. This study evaluated perioperative factors, flap-specific complications, donor-site morbidity and long-term outcomes in patients undergoing IGAM reconstructions following pelvic exenteration or abdominoperineal resection. Data were prospectively collected and reviewed for adult patients treated at the Peter MacCallum Cancer Centre, Melbourne, Australia between January 2013 and 2025. Statistical analyses assessed the relationships between patient demographics, clinical features, reconstructive characteristics, and outcomes. The primary outcome was partial or total flap failure. Secondary outcomes included unplanned return to theatre, wound dehiscence, surgical site infection, and perioperative transfusion. Among 107 patients, the median age was 63 years and there was a male predominance (57.9%). Within this cohort 53.3% had recurrent disease and 98.1% were irradiated prior to reconstruction. The median overall survival was 68.6 months and the 5-year overall survival was 54.9%. Univariate analysis demonstrated significantly increased rates of perioperative complications in males, smokers, sarcopenic patients and those with recurrent disease. Multivariate logistic regression confirmed these associations. Sarcopenic patients were 4.9 times more likely to experience perioperative complications (p = 0.010). IGAM flaps provided acceptable flap-specific complication rates, low donor-site morbidity and consistently favourable treatment outcomes for complex perineal reconstruction. Male sex, smoking, sarcopenia and recurrent disease were significantly associated with worse perioperative outcomes. These findings support the continued use of the IGAM for patients undergoing radical pelvic and perineal surgery.

Combined prophylactic negative-pressure wound therapy and preoperative oral antibiotics reduce perineal wound complications after abdominoperineal resection.

ABSTRACTRobotic surgery has become increasingly widespread; however, device‐related complications specific to robotic platforms are rarely reported. We describe a case of rectal cancer treated with robotic‐assisted abdominoperineal resection using the da Vinci Surgical System. At the end of the procedure, the tip cover of the robotic scissors detached and was inadvertently retained within the abdominal wall. It was invisible on plain radiography but was detected on postoperative computed tomography as a cylindrical structure beneath the rectus abdominis muscle. The patient underwent reoperation to retrieve the tip cover and recovered uneventfully, being discharged without further complications. This case highlights a rare but important complication of robotic surgery—detachment and retention of the tip cover of robotic scissors in the abdominal wall. Because tip covers may not be reliably detected on plain radiography, computed tomography is crucial for their identification. Strict counting protocols and heightened awareness are essential to prevent such events.

Abstract Low rectal cancer is surgically managed with one of two primary procedures: low anterior resection (LAR) or abdominoperineal resection (APR). Each procedure has a unique profile of potential complications, oncologic outcomes, and quality-of-life impacts. The acceptability of these outcomes is highly driven by patient values. Consequently, shared decision-making is essential to selecting the optimal procedure for each patient. Evidence has shown that patient decision aids (PtDAs) improve patient knowledge, reduce decisional conflict, and support value-congruent decisions. This review describes the development of a rectal cancer PtDA for the choice between LAR and APR. This PtDA was designed according to the International Patient Decision Aid Standards and Ottawa Decision Support Framework. Evaluation of this rectal cancer PtDA demonstrated increased patient knowledge, reduced decisional conflict, and enhanced patient preparedness for decision-making. Despite strong evidence for their utility, PtDAs remain underutilized. This review highlights key barriers in implementing PtDAs and proposes strategies to facilitate the effective integration of PtDAs into surgical practice.

Objective. To demonstrate laparoscopic perineal hernia repair using VRAM flap after previous extralevator abdominoperineal excision. Material and methods. A 60-year-old patient developed large perineal hernia in 6 months after extralevator laparoscopic abdominoperineal resection for lower rectum cancer T2N0M0. In 10 months after primary surgery, the patient underwent laparoscopic perineal hernia repair using VRAM flap. Results. Surgery time was 210 min, intraoperative blood loss — 50 ml. The patient was activated on the day of surgery. Postoperative period proceeded without complications. The patient was discharged in 7 days after surgery. There was no recurrence of hernia throughout 12 months. Conclusion. Postoperative perineal hernias can be effectively repaired laparoscopically using VRAM flap.

Colonic surgery for Crohn's disease (CD) frequently involves sparing uninvolved segments of the colon. Few studies have assessed recurrence rates after segmental colectomy (SC). The aim of this study was to determine the rate of and identify the risk factors for postoperative CD recurrence. This was a multicenter retrospective study from 3 tertiary inflammatory bowel disease (IBD) referral centers of CD patients who underwent SC between 2000 and 2019. We defined endoscopic recurrence as the presence of ulcers in the remaining colon upon postoperative colonoscopy. A total of 108 patients were included. Sixty-nine (63.9%) patients had evidence of postoperative CD endoscopic recurrence. Age at surgery <40 years and disease duration ≤156 months predicted an increased likelihood for postoperative recurrence (odds ratio [OR], 2.43; P = .031 and OR, 3.29; P = .005, respectively), whereas abdominal perineal resection (OR, 0.21; P = .005), indication for SC of malignancy (OR, 0.14; P = .016), and postoperative use of tumor necrosis factor α (TNFα) inhibitor for prophylactic purposes (OR, 0.38; P = .040) negatively predicted disease recurrence. Disease duration ≤156 months (OR, 2.86; P = .039) and postoperative TNFα inhibitor prophylaxis remained significant (OR, 0.26; P = .013) upon multivariable modeling. Although high rates of recurrence persist within the postoperative phase of SC for CD, the postoperative use of TNFα inhibitor for prophylactic purposes for a subset of patients may promote a more durable endoscopic remission.

Extralevator abdominoperineal excision (ELAPE) improves surgical margins in distal rectal cancer compared to conventional amputation; however, it is associated with higher rates of perineal morbidity. This study aimed to evaluate the incidence of perineal infections and identify associated risk factors in patients with rectal adenocarcinoma undergoing ELAPE with perineal reconstruction using an absorbable synthetic prosthesis. This prospective observational study including consecutive patients treated between 2009 and 2024. All patients underwent standardized perineal reconstruction with an absorbable synthetic prosthesis. Clinical, tumor, surgical, and postoperative complication variables were recorded. Univariate and multivariate analyses were performed to identify factors associated with perineal infection. A total of 61 patients were analyzed. Perineal infection occurred in 23%, with most infections developing within the first 30 postoperative days. Multivariate analysis identified obesity (Odds Ratio [OR] 74.3), active smoking (OR 33.7), and circumferential margin involvement observed on basal magnetic resonance imaging (OR 28) as independent risk factors. Patients with perineal infection had longer hospital stays, more readmissions, more postoperative visits, and higher complications severity. Infection was not associated with an increased rate of perineal hernia, which was low in our cohort (3%). In conclusion,perineal reconstruction with an absorbable synthetic prosthesis following ELAPE is safe and effective. Identification of patients at high risk for perineal infection enables targeted preventive strategies and informs future comparative studies of perineal reconstruction techniques.

The EAES released guidelines on the role of taTME in the management of rectal cancer in 2022. To develop updated, evidence-informed recommendations to support clinicians involved in the management of taTME; to provide guidance for hospital managers, policymakers, and patients with low- and mid-rectal cancers. We performed a systematic review to identify randomized trials and matched nonrandomized studies comparing transanal total mesorectal excision (taTME) to laparoscopic TME (laTME) or robotic TME (roTME) in patients with low- and mid-rectal cancer. A panel of general and colorectal surgeons, a radiologist, a pathologist, and patient partners appraised the certainty of the evidence using GRADE. The panel developed recommendations using an evidence-to-decision framework during an in-person consensus meeting. We applied a Delphi survey to establish consensus. The panel recommends taTME over laTME in patients with low- and selected mid-rectal cancers when access to surgeons with expertise in performing taTME in high-volume rectal cancer centers is available (strong recommendation). This recommendation applies to patients eligible for sphincter preservation who are at high risk for conversion to abdominoperineal resection, including male gender with BMI > 30kg/m2. The recommendation is supported by a reduction in 30-day major complications and disease recurrence at 2years with taTME compared to laTME. When access to a surgeon with expertise in performing taTME is not available, the panel recommends against taTME over laTME (strong recommendation). Further, the panel suggests roTME as an alternative to taTME in patients with low- and selected mid-rectal cancers when access to surgeons with expertise in performing taTME is not available (conditional recommendation). We provide evidence-informed guidance on the role of taTME in the surgical management of patients with low- and mid-rectal cancers. Patients and surgeons should exercise shared-decision making to apply patient-tailored decisions when considering treatment options.

Various strategies have been explored to reduce perineal wound-related morbidity after abdominoperineal resection for rectal cancer. The two BIOPEX trials evaluated the role of biological mesh closure and gluteal turnover flap, but both were negative at their primary endpoint (30-day wound healing). However, several secondary endpoints at different time points might be of clinical relevance. This was a post-hoc analysis of the BIOPEX and BIOPEX-2 trials. A composite endpoint was defined based on Southampton wound score 2-3 or 4-5 at five different time points during the 12-month postoperative period, presacral abscess, perineal-wound related radiological or surgical reintervention, and readmission. Win-ratio analysis was used, which prioritizes outcomes based on their importance. Sensitivity analyses were conducted and additionally a points-based scoring system was applied to evaluate the degree of wound healing complications. A total of 269 patients were included. The win-ratio analysis revealed a net benefit for biological mesh closure in the BIOPEX study (15.4%, 95%CI -5.4%-36.7%), and for gluteal turnover flap in the BIOPEX-2 study (16.9%, 95%CI 0.1%-33.2%) compared to primary perineal closure, but only the latter reached statistical significance. Various sensitivity analyses showed robustness of the win-ratio results with comparable estimates. Points-based regression analysis did not reveal significant differences: IRR 0.76 (95%CI 0.38-1.52, p=0.441) and IRR 0.67 (95%CI 0.40-1.14, p=0.139), respectively. This post-hoc analysis sheds new light on perineal wound healing in randomized studies by integrating various outcome measures. Although a similar numerical advantage of the intervention was shown in both BIOPEX trials using win-ratio analysis, it only reached statistical significance for the gluteal turnover flap.

Robotic surgery for rectal cancer is popular, but persuasive evidence of long-term oncological outcomes in real-world populations is still lacking. This retrospective cohort study emulated the target trial to compare surgical quality and long-term oncological outcomes between robotic and conventional laparoscopic surgery for middle and low rectal cancer in real-world populations. Patients were consecutively enrolled from a multicenter cohort database in Shanghai, China, with middle or low rectal adenocarcinoma, cT1-T3 N0-N1 or ycT1-T3 Nx, no distant metastasis. Eligible patients were classified into robotic or laparoscopic groups and propensity score matched at a 1:1 ratio. The primary endpoint was 3-year disease-free survival rate. From 3742 eligible patients, 2702 were included in primary analyses after matching: 1351 in robotic group and 1351 in laparoscopic group. The median follow-up time was 42.4months (interquartile range=39.5-45.3). The robotic group had higher 3-year disease-free survival rate (86.7% vs. 83.3%, p=0.017, unadjusted hazard ratio [HR]=0.800, 95% confidence interval [CI]=0.666-0.961, adjusted HR=0.786, 95% CI=0.654-0.945). The robotic group also had lower 3-year locoregional recurrence rate (2.2% vs. 4.7%, p=0.001), lower 30-day postoperative complication rate (14.3% vs. 19.5%, p < 0.001), lower abdominoperineal resection rate (7.5% vs. 12.4%, p < 0.001), and lower circumferential resection margin positivity rate (2.2% vs. 4.2%, p=0.005). No significant difference in 3-year overall survival rate was observed (96.4% vs. 95.5%, p=0.063). Compared with conventional laparoscopic surgery, robotic surgery significantly improved long-term oncological outcomes and short-term recovery of middle and low rectal cancer in real-world populations.

This report presents a woman in her 70s with locally advanced rectal adenocarcinoma invading the posterior vaginal wall. She received total neoadjuvant therapy (TNT) consisting of six cycles of capecitabine-oxaliplatin followed by long-course chemoradiotherapy, resulting in significant tumour downstaging. Definitive surgery involved extralevator abdominoperineal excision with near-total vaginectomy and reconstruction using a sigmoid colon flap vaginoplasty. Histopathology confirmed an R0 resection, with two of 17 lymph nodes positive for metastasis. The patient recovered uneventfully, with a viable neovagina, preserved lubrication and no stricture formation. Transient urinary retention resolved with conservative management. This case demonstrates that TNT can facilitate curative resection of complex T4b rectal cancers and enable successful functional reconstruction. The use of a sigmoid colon flap provides a versatile and well-vascularised option for vaginal reconstruction, supporting both oncologic safety and quality of life in extensive pelvic resections.

Treatment patterns of anal melanoma in the era of immunotherapy.

A 78-year-old man was referred to our institution with bloody stools. Colonoscopy revealed advanced rectal cancer with stenosis at the lower rectum(anal verge 4-12 cm). Biopsy findings revealed highly differentiated adenocarcinoma. Magnetic resonance imaging(MRI)/computed tomography(CT)/positron emission tomography(PET)showed the tumor on the rectal wall, mesenteric lymph nodes, and an enlarged left lateral lymph nod(e No. 283), but no metastasis was detected. The patient was diagnosed with rectal cancer(cT4aN3M0, cStgae Ⅲc)and received neoadjuvant chemoradiotherapy(CRT) (50.4 Gy irradiation of the primary tumor and small pelvis, including the lateral lymph nodes, and oral capecitabine). After CRT, the diagnosis was revised to ycT2N3M0, ycStage Ⅲb. He subsequently underwent robot-assisted abdominoperineal resection and D3+ltLD2 dissection. Lymph node metastasis was detected in No. 283-lt and No. 241, and the pathological diagnosis was ypT2N3M0, ypStage Ⅲb. Histological evaluation of response to treatment was Grade 2. He showed a favorable postoperative course and was discharged on postoperative day 18. He received 8 courses of adjuvant chemotherapy with CAPOX from postoperative day 32 and is alive with recurrence-free 9 months after surgery. This case suggests that CRT is a viable option for treating locally advanced rectal cancer.

A 60's man was admitted with melena. A colonoscopy was detected lower rectal cancer, and a enhanced CT scan revealed invasion of the prostate and enlarged left lateral lymph node. Total neoadjuvant therapy(TNT)considered of preoperative 7 courses of CAPOX followed by 5 Gy×5 short course RT, after treatment PET-MRI showed shrinkage of the tumor and left lateral lymph node, but invasion of the prostate was remained, preoperative diagnosis was ycT4b(AI:prostate) N3M0, ycStage Ⅲc. In collaboration with urologists, robot-assisted abdominoperineal resection with en bloc prostatec t omy and left lateral lymph dissection was performed. He exhibited a good post operative course and was discharged on the 17th postoperative day. Pathological examination revealed no tumor invasion into prostate and any lymph node metastasis, ypT3N0M0, ypStage Ⅱa.