Robotic Surgery Outperforms Laparoscopic Surgery for rectal cancers: LANCET

CHINA: According to a randomized trial reported in The Lancet Gastroenterology & Hepatology, robotic surgery improved the quality of resection for individuals with middle and low rectal cancer compared to traditional laparoscopic surgery.

Jianmin Xu, Ph.D., of the Zhongshan Hospital Fudan University in Shanghai, and colleagues noted that colon cancer patients frequently undergo laparoscopic surgery however, its application to those with rectal cancer is still debatable. Prior studies revealed that laparoscopic surgery did not outperform open surgery in terms of tumor radicality. Additional studies have demonstrated that robotic surgery, as opposed to laparoscopic surgery, is linked with higher surgical quality because it uses three-dimensional vision, a steady camera platform, and flexible arms.

The investigators intended to assess surgical efficacy and long-term oncological results of robotic versus traditional laparoscopic surgery in patients with middle and low rectal cancer.

For this trial, from July 2016 to December 2020, 11 hospitals in China enrolled 1,240 patients and randomly assigned them in a 1:1 ratio to receive robotic or laparoscopic surgery. Subjects between the ages of 18 and 80 who had a middle-stage (>5 to 10 cm from the anal verge) or low-stage (5 cm from the anal verge) rectal adenocarcinoma and no distant metastases were eligible. The 3-year locoregional recurrence rate was the primary outcome, although the results are not yet complete. This study reports two crucial secondary short-term outcomes: circumferential resection margin positivity and 30-day postoperative sequelae (Clavien–Dindo classification grade II or higher). The recruitment for the study is complete, and the follow-up is still going on. The results were analyzed using a modified intention-to-treat population of 1171 individuals, 43-44% of which received radiotherapy or chemoradiotherapy prior to surgery. Laparoscopic surgery was performed on six robotic surgery patients, while robotic surgery was performed on seven laparoscopic patients.

Conclusive points of the study:

• Positive circumferential resection margin (CRM; 1 mm) was present in 4% of the 1,171 individuals who had robotic surgery as opposed to 7.2% of those who underwent laparoscopic surgery (P=0.023).
• Within 30 days of surgery, 16.2% of patients in the robotic group compared to 23.1% of laparoscopic patients reported a minimum of one complication (P=0.003).
• The robotic group had improved gastrointestinal recovery with a faster time to first flatus (38 vs. 44 hours) and defecation (72 vs. 84 hours), reduced hospital stays, and more macroscopic complete resections (95% vs. 92%) along with improved pathological results (median 7 vs. 8 days).
• One robotic patient passed away from bowel necrosis 30 days after surgery, and the other patients who received laparoscopic surgery passed away from a severe stomach infection.

Xu and his colleagues noted the lack of uniform perioperative protocols throughout centers as a study drawback.

"Furthermore, since this study was carried out in China, it's possible that the results can't be extrapolated to other nations," added the researchers.

The authors concluded that secondary short-term results indicate that robotic surgery, compared to traditional laparoscopic surgery, offered superior oncological quality of resection for middle and low rectal cancer, with less surgical trauma and better postoperative recovery.

REFERENCE

Feng Q, et al "Robotic versus laparoscopic surgery for middle and low rectal cancer (REAL): short-term outcomes of a multicentre randomised controlled trial" Lancet Gastroenterol Hepatol 2022; DOI: 10.1016/S2468-1253(22)00248-5.