Robotic Resection is a Good Prognostic Factor in Rectal Cancer Compared with Laparoscopic Resection: Long-term Survival Analysis Using Propensity Score Matching

Abstract

BACKGROUND: Robotic total mesorectal excision for rectal cancer has rapidly increased and has shown short-term outcomes comparable to conventional laparoscopic total mesorectal excision. However, data for long-term oncologic outcomes are limited. OBJECTIVE: The aim of this study is to evaluate long-term oncologic outcomes of robotic total mesorectal excision compared with laparoscopic total mesorectal excision. DESIGN: This was a retrospective study. SETTINGS: This study was conducted in a tertiary referral hospital. PATIENTS: A total of 732 patients who underwent totally robotic (n = 272) and laparoscopic (n = 460) total mesorectal excision for rectal cancer were included in this study. MAIN OUTCOME MEASURES: We compared clinicopathologic outcomes of patients. In addition, short- and long-term outcomes and prognostic factors for survival were evaluated in the matched robotic and laparoscopic total mesorectal excision groups (224 matched pairs by propensity score). RESULTS: Before case matching, patients in the robotic group were younger, more likely to have undergone preoperative chemoradiation, and had a lower tumor location than those in the laparoscopic group. After case matching most clinicopathologic outcomes were similar between the groups, but operative time was longer and postoperative ileus was more frequent in the robotic group. In the matched patients excluding stage IV, the overall survival, cancer-specific survival, and disease-free survival were better in the robotic group, but did not reach statistical significance. The 5-year survival rates for robotic and laparoscopic total mesorectal excision were 90.5% and 78.0% for overall survival, 90.5% and 79.5% for cancer-specific survival, and 72.6% and 68.0% for disease-free survival. In multivariate analysis, robotic surgery was a significant prognostic factor for overall survival and cancer-specific survival (p = 0.0040, HR = 0.333; p = 0.0161, HR = 0.367). LIMITATIONS: This study has the potential for selection bias and limited generalizability. CONCLUSIONS: Robotic total mesorectal excision for rectal cancer showed long-term survival comparable to laparoscopic total mesorectal excision in this study. Robotic surgery was a good prognostic factor for overall survival and cancer-specific survival, suggesting potential oncologic benefits.

Systemic review and network meta‐analysis comparing minimal surgical techniques for rectal cancer: quality of total mesorectum excision, pathological, surgical, and oncological outcomes

“…Historically, open rectal resection and TME had been considered technically difficult, especially in the narrow pelvis . With improved technology including laparoscopy, robotics, and energy devices, there has been a shift towards minimally invasive TME with better patient recovery and reduced length of stay at hospital . However, there have been concerns over the quality of TME in minimally invasive techniques .…”

“…However, despite the improvements in laparoscopy and robotics including improved ergonomics, magnified view, and stable camera platform, minimally invasive TME requires good technical skills and has a steep learning curve, especially in very low rectal resections. Transanal TME (taTME), a “down‐to‐up” procedure, has been suggested as an alternative procedure, but early reports have been viable, and long‐term oncological results are still under review …”

Robotic rectal surgery has advantages over laparoscopic surgery in selected patients and centres

“…The ROLARR subgroup analysis suggests a similar trend of lower conversion in high-risk cases. Moreover, Kim et al [19] recently reported a trend towards improved overall survival and cancer-specific survival with robotic resection for mid-to low-rectal cancer (mean tumour height from the anal verge was 6.8 cm) compared with laparoscopic resection. On univariate and multivariate analysis the robotic approach was a significant positive prognostic factor.…”

Robotic colorectal surgery: more than a fantastic toy?

“…The literature has been predominantly limited to level 3 evidence thus far. Matched comparisons by Kim et al [7] and Cho et al [8] have not shown statistically significant differences in 5-year overall survival or disease-free survival between robotic and laparoscopic colorectal surgery, although Kim et al [7] did demonstrate a trend to improved survival.…”

“…Apart from improvements in short-term outcomes and conversion rates, using our own data and experience, we reported on the long-term outcomes of robotic and laparoscopic total mesorectal excision for mid and low rectal cancers (robotic, n=272; laparoscopic, n=460), showing that the robotic procedure is a positive prognostic factor in rectal cancer surgery [7]. Our study was the first in the literature to do so.…”