The oncological quality of resection was better with robotic surgery in patients with middle and low rectal cancer with fewer positive resection margins compared to the standard laparoscopic surgery, reports a multicenter, randomized trial from China in the Lancet Gastroenterology & Hepatology.1

Researchers recruited 1240 patients, aged 18-80 years, with low (≤5 cm from the anal verge) and middle (>5 to 10 cm from the anal verge) adenocarcinoma of the rectum, cT1-T3 N0-N1 or ycT1-T3 Nx stage with no sign of distant metastasis. They (620 patients in each group) were randomized 1:1 to undergo robotic or laparoscopic resection from July 2016 to December 2020.

Locoregional (pelvic/perineal) recurrence rate at 3 years was the primary outcome of the study, while a positive circumferential resection margin and complications within one month of the surgery were the secondary endpoints. The objective of this multicentre, randomised, controlled, superiority trial was to compare the two procedures in terms of surgical quality and outcomes in the long-term. This trial is ongoing and only the short-term outcomes have been reported at present. The primary endpoint results are expected by the end of next year.

Among the 1171 patients in the modified intention-to-treat analysis, results showed fewer positive circumferential resection margin in 4% (22/547) patients who underwent robotic surgery versus 7.2% (39/543) among those in the laparoscopic surgery group. The postoperative complication rate within 30 days of surgery was 16.2% with robotic surgery vs 23.1% with laparoscopic surgery. Grossly, the resection was more complete in the robotic surgery group (95.4%; 559/586) compared to the laparoscopic surgery group (91.8%; 537/585). The benefits of robotic surgery were also evident intraoperatively with less estimated blood loss (40 ml vs 50 ml) and fewer complications (5.5% vs 8.7%). Ninety-nine (~17%) robotic surgery patients needed abdominoperineal resections for low rectal cancer, while this number was 133 (~23%) in the laparoscopic group.

Postoperatively, robotic surgery patients exhibited better GI recovery (shorter time to first flatus and bowel movement); they also had shorter hospitalization (7 days vs 8 days, respectively [median]). Just 10 patients in this group required conversion of the procedure to open surgery, whereas 23 patients in the laparoscopic group needed open surgery. Although the total costs incurred were higher with the robotic surgery, the costs in the postoperative period were less ($2,768 vs $3,060).

The short-term results of the secondary endpoints of this study demonstrate better circumferential resection margins indicating “better oncological quality of resection” with robotic surgery compared to laparoscopic surgery with “better postoperative recovery” suggesting that robotic surgery was superior to laparoscopic surgery for patients with mid or low rectal cancer.

Reference

1. 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.