Selective lateral pelvic lymph node dissection: a comparative study of the robotic versus laparoscopic approach

Short-term Outcomes of Robotic Lateral Pelvic Lymph Node Dissection for Lower Rectal Cancer

INTRODUCTION

Rectal cancer is among the main causes of cancer-related mortalities worldwide, necessitating more effective treatment strategies.　It is considered that lateral pelvic lymph node dissection (LPND) for rectal cancer patients can contribute to local tumor control and that robotic LPND (Rob-LPND) may be more suitable for LPND, due to technical advantages of precise manipulation in a narrow pelvic space.

METHODS

In this retrospective study, we evaluated the short-term outcomes of laparoscopic-LPND (Lap-LPND) versus Rob-LPND in patients undergoing radical surgery for rectal cancer.　Operative time, blood loss, urethral catheter reinsertion, duration of pelvic drainage tube placement, drainage volume, and postoperative hospital stay were compared between Lap-LPND and Rob-LPND.

RESULTS

Our findings revealed that Rob-LPND was associated with longer total operation time, but there was no significant difference in operation time between the two LPND techniques.　Urinary catheter re-insertion rates were lower in Rob-LPND; also, significant reductions in drainage tube duration, total drainage volume, and postoperative hospital stay were observed.

CONCLUSION

Rob-LPND may reduce postoperative total drainage volume and shorten postoperative hospital stays.　These improvement in short-term outcomes suggest potential clinical advantages of Rob-LPND.

Learning curve analysis for prophylactic bilateral robot-assisted lateral lymph node dissection for lower rectal cancer: a retrospective study

BACKGROUND

Lateral lymph node dissection (LLND) is an important surgical procedure in the treatment of lower rectal cancer (RC). However, limited data are available regarding the learning curve for robot-assisted LLND (RA-LLND). This study aimed to evaluate the learning curve for prophylactic bilateral RA-LLND for lower RC.

METHODS

We retrospectively analyzed 58 consecutive patients with clinical stage II/III lower RC who had undergone prophylactic bilateral RA-LLND between July 2020 and June 2024. Cumulative sum (CUSUM) analysis was used to evaluate the learning curve for bilateral RA-LLND operative time.

RESULTS

The mean age of patients was 61.5 years, and mean body mass index was 23.4 kg/m2. The proportion of neoadjuvant therapy was 8.6%. Mean prophylactic bilateral RA-LLND operative time was 173.7 min. CUSUM analysis divided the learning curve for prophylactic bilateral RA-LLND operative time into three phases: initial learning phase (20 cases); competence phase (16 cases); and master/proficiency phase (subsequent cases). Mastery of surgical technique was achieved after performing the 36th case. Comparisons of surgical outcomes in terms of operative parameters and complications were made between phases 1 and 2 combined and phase 3. A significant reduction in mean prophylactic bilateral RA-LLND operative time was observed between phases 1 and 2 compared with phase 3 (P < 0.01). Mean blood loss was decreased in phase 3 (40.5 ml) compared to phases 1 and 2 combined (148.2 ml, P < 0.01). The frequencies of overall postoperative complications directly related to LLND and urinary dysfunction were significantly reduced in phase 3 compared to phases 1 and 2 combined (P = 0.04, and P = 0.02, respectively).

CONCLUSIONS

The three phases identified by CUSUM analysis represented characteristics of the learning curve for prophylactic bilateral RA-LLND. These data suggest that 20 cases are required for the early stage of the learning curve, whereas mastery level could be achieved after 36 cases.

Clinical characteristics and predictive factors of pathological lateral pelvic lymph node metastasis in patients with rectal cancer

In recent years, selective lateral lymph node dissection (LLND) has been performed more frequently. The present study aimed to explore the clinical characteristics and predictive factors of pathological lateral pelvic lymph node metastasis (LPLNM), which may be helpful for pre-treatment decisions. The present study included 64 patients with rectal cancer and clinically suspected LPLNM who underwent total mesorectal excision (TME) and LLND between February 2019 and April 2024. According to pathological outcomes, the patients were divided into the negative LPLN (n=40) and positive LPLN (n=24) groups. The primary endpoints were the overall pathological LPLNM positivity rate and different clinical characteristics between the two groups. The secondary endpoint was the identification of predictive factors of pathological LPLNM before surgery. Among the 64 patients, 24 (37.5%) had pathologically confirmed LPLNM, and pathological LPLNM was related to initial lymph node size. When initial LPLN size was <7 mm, the pathological LPLNM rate was 10.5%, whereas when LPLN size was between 7 and 10 mm, the rate was 34.6%, and when LPLN size was >10 mm, the rate was 68.4%. Initial LPLN size (≥7.1 mm, P=0.003) and cN stage (N1-2, P=0.005) were significantly associated with pathological LPLNM. In multivariate analysis of risk factors, initial LPN size (≥7.1 mm; hazard ratio=4.856, 95% confidence interval 1.158-20.359, P=0.031) was the only independent risk factor for pathological LPLNM. When the cut-off initial LPLN size was 7.1 mm, the sensitivity and specificity were 87.5 and 52.5%, respectively, and the area under the curve was 0.748 (P=0.0009). When both LPLN size ≥7.1 mm and cN1-2 were satisfied, the sensitivity was 66.7%, the specificity increased to 77.5%, and the positive and negative predictive values were 64.0 and 79.5%, respectively. In conclusion, initial LPLN size and cN stage were identified as significant clinical characteristics associated with pathological LPLNM. Patients with an initial LPLN size of ≥7.1 mm and with cN1-2 stage cancer could benefit from TME + LLND surgery.

Postoperative Morbidity and Factors Predicting the Development of Lymphoceles Following Lateral Pelvic Node Dissection for Rectal Cancer: A Cohort Study

PURPOSE

Lateral pelvic node dissection (LPLND) is indicated in the surgical management of clinically significant pelvic lymphadenopathy associated with rectal malignancies. However, procedure-related morbidity, including the incidence and predisposing factors for lymphoceles arising in this setting have not been adequately evaluated.

METHODS

This retrospective single-institution study included 183 patients with nonmetastatic, lateral node-positive rectal cancer undergoing total mesorectal excision with LPLND between June 2014 and May 2023 to determine the incidence and severity of postoperative complications using the Clavien-Dindo system, with logistic regression performed to model a relationship between lymphocele-development and potentially-predictive variables.

RESULTS

In this cohort, mean age was 45.3 ± 12.81 years, 62.8% were male, and 27.9% had body mass index ≥ 25 kg/m2. Median tumor-distance from the verge was 3.0 (interquartile range [IQR] 1.0-5.0) cm. Following radiotherapy in 86.9%, all patients underwent surgery: 30.1% had open resection and 26.2% had bilateral LPLND. Median nodal-yield was 6 (IQR 4-8) per side. Postoperatively, 45.3% developed complications, with 18% considered clinically significant. Lymphoceles, detected in 21.3%, comprised the single-most common sequelae following LPLND, 46.2% arising within 30 days of surgery and 33.3% requiring intervention. On multivariate analyses, obesity (hazard ratio [HR] 2.496; 95% confidence interval [CI] 1.094-5.695), receipt of preoperative radiation (HR 10.026; 95% CI 1.225-82.027), open surgical approach (HR 2.779; 95% CI 1.202-6.425), and number of harvested nodes (HR 1.105; 95% CI 1.026-1.190) were significantly associated with lymphocele-development.

CONCLUSIONS

Pelvic lymphoceles and its attendant complications represent the most commonly encountered morbidity following LPLND for rectal cancer, with obesity, neoadjuvant radiotherapy, open surgery, and higher nodal-yield predisposing to their development.

Comparison of robotic and laparoscopic approaches in short- and long-term outcomes of lateral pelvic lymph node dissection for advanced rectal cancer: a Japanese multicenter study

BACKGROUND

Lateral pelvic lymph node dissection (LPND) is a challenging surgical technique with complex anatomy and narrow pelvic manipulation. The outcomes of robotic and laparoscopic surgery for LPND are still unclear.

METHODS

We retrospectively reviewed 169 consecutive patients who underwent rectal cancer surgery with LPND between 2016 and 2023. Patients were divided into two groups according to whether LPND was performed by robotic surgery (R group, n = 40) or laparoscopic surgery (L group, n = 129). Clinicopathological feature and outcomes were compared between groups.

RESULTS

Frequency of surgery with combined resection of adjacent structures (5.0% vs. 19.4%, p = 0.023), frequency of patients with distant metastasis (5.0% vs. 19.4%, p = 0.028), and estimated blood loss from bilateral LPND (74 mL vs. 132 mL, p = 0.013) were all lower in the R group than in the L group. Type of surgical approach did not correlate with postoperative complications. Median follow-up was 31.0 months (range, 1.0-69.0 months). No patients in the R group experienced local recurrence, compared to 4.6% in the L group. Multivariate analysis revealed laparoscopic surgery (odds ratio 3.687, 95% confidence interval 1.505-6.033; p = 0.004) as an independent predictor of poor relapse-free survival.

CONCLUSIONS

Robotic surgery for LPND appears to have good prognostic value in some, but not all, oncologic cases. However, large prospective studies are desirable to validate these findings.

Postoperative urinary dysfunction following lateral lymph node dissection for rectal cancer via minimally invasive surgery

BACKGROUND

Lateral lymph node dissection (LLND) for locally advanced rectal cancer (LARC) is performed widely since it reduces local recurrence. However, there are some disadvantages to LLND, including technical difficulties and association with postoperative urinary dysfunction. Procedures for LARC have also become more minimally invasive: laparoscopic surgery (LS) has become more common, and use of robot-assisted LS (RALS) is increasing. The purpose of this study is to assess differences in postoperative urinary dysfunction after LLND for LARC between LS and RALS, and to identify risk factors for postoperative urinary dysfunction.

METHODS

The subjects were 100 patients with LARC (≥ cT3) with the inferior border of the tumor reaching the peritoneal reflection who underwent LS or RALS with LLND between 2009 and 2023 at Juntendo University Hospital. After LLND, the urinary catheter was usually removed on or before postoperative day 5. The duration of urinary catheterization (DUC) was used to evaluate postoperative urinary dysfunction. The standard (S) and long-term (L) groups were defined as cases with urinary catheter removal at ≤ 5 and > 5 days, respectively. DUC was examined for LS vs. RALS and clinicopathological factors were identified that adversely affect DUC.

RESULTS

Of the 100 subjects, 72 underwent LS and 28 received RALS. LLND was bilateral in 65 cases and unilateral in 35 cases. The median DUC was 5 days, with 74 cases in group S and 26 in group L. The most frequent postoperative complication (Clavien-Dindo Grade 2 or higher) was urinary dysfunction, followed by ileus and surgical site infection (SSI), and none differed by procedure (LS vs. RALS). Univariate analysis showed significant differences in LLND laterality (p = 0.02) and SSI (p = 0.04) between groups S and L. In multivariate analysis, bilateral LLND (p < 0.01, HR 7.37) and SSI (p = 0.01, HR 15.36) were independent factors that worsened DUC.

CONCLUSIONS

There was no difference in urinary dysfunction after LLND between LS and RALS. Bilateral LLND and SSI were risk factors for lengthening DUC. Compared to bilateral LLND, unilateral LLND can reduce urinary dysfunction; therefore, selective LLND, which is overwhelmingly unilateral LLND, and prevention of perioperative SSI may be important for maintenance of urinary function.

Meta-analysis of the efficacy and safety of robot-assisted comparative laparoscopic surgery in lateral lymph node dissection for rectal cancer

INTRODUCTION

A meta-analysis was conducted on the perioperative and oncological outcomes of robot-assisted and laparoscopic lateral lymph node dissection in rectal cancer. There are few articles and reports on this topic, and a lack of high-quality research results in unreliable research conclusions. This study includes prospective and retrospective studies to obtain more reliable findings.

MATERIALS AND METHODS

Databases were searched, including PubMed, EMBASE, Cochrane, and Web of Science. The search was conducted from the time of database construction to March 2024. The quality of the literature was evaluated using the NOS scoring system. Meta-analysis was performed using R language software. Statistical heterogeneity was assessed using the I2 statistic, and sensitivity analysis was performed.

RESULTS

Six relevant literatures that met the criteria were finally included, and 652 patients were included, including 316 (48.5%) in the robot-assisted lateral lymph node dissection for rectal cancer group (RLLND) and 336 (51.5%) in the laparoscopic lateral lymph node dissection for rectal cancer group (LLLND). Analysis of the results showed that compared with the laparoscopic group, the robotic group had less mean intraoperative blood loss (MD = - 22, 95% CI - 40.03 to - 3.97, P < 0.05), longer operative time (MD = 51.57, 95%CI 7.69 to 95.45, P < 0.05), and a shorter mean hospital stay (MD = - 1.25, 95%CI - 2.46 to - 0.05, P < 0.05), a low rate of urinary complications (OR 0.39, 95%CI 0.23 to 0.64, P < 0.01), a low overall rate of postoperative complications (OR 0.6, 95%CI 0.42 to 0.87, P < 0.01), and a high number of lateral lymph node dissection (MD = 1.18, 95% CI 0.14 to 2.23, P < 0.05), and there was no statistically significant difference between the two groups in terms of postoperative anastomotic leakage, postoperative intestinal obstruction, and total number of lymph nodes obtained (P > 0.05).

CONCLUSION

Compared with laparoscopy, robotic lateral lymph node dissection for rectal cancer reduces intraoperative blood loss, shortens the average length of hospital stay, reduces urologic complications, decreases overall postoperative complications, and collects more lateral lymph nodes. However, the surgical time is prolonged.

Comparison of short-term outcomes of laparoscopic surgery, robot-assisted laparoscopic surgery, and open surgery for lateral lymph-node dissection for rectal cancer: a network meta-analysis

This study attempted to compare short-term outcomes of laparoscopic surgery (LS), robot-assisted laparoscopic surgery (RS), and open surgery (OS) for lateral lymph-node dissection (LLND) in treatment of rectal cancer through network meta-analysis. Embase, Web of Science, PubMed, and The Cochrane Library databases were searched to collect cohort studies on outcomes of LS, RS, and OS for LLND for rectal cancer. Newcastle-Ottawa Scale (NOS) was utilized to evaluate the quality of cohort studies. Primary outcomes should at least include one of the following clinical outcome measures: operative time, blood loss, total lymph-node harvest, positive resection margin rate, postoperative complications, and postoperative hospital stay. A network meta-analysis was conducted using STATA software. Fourteen cohort studies including 8612 patients were eligible for inclusion. The network meta-analysis results showed that, in terms of intraoperative outcomes, the RS group had the longest operative time, while the OS group had the shortest; the LS and RS groups had significantly less blood loss than the OS group. In terms of histological outcomes, there were no significant differences in the total number of lymph nodes harvested and the positive margin rate among the LS, RS, and OS groups (P > 0.05). Regarding postoperative outcomes, the OS group had the highest probability of postoperative complications and the longest hospital stay, followed by the LS group, with the RS group being the lowest. RS was the best method in blood loss, postoperative complication rate, and postoperative hospital stay, followed by LS. OS had the shortest operative time and the highest blood loss.

Management of internal iliac and obturator lymph nodes in mid-low rectal cancer

In rectal cancer treatment, the diagnosis and management of lateral pelvic lymph nodes (LLN) are critical for preventing local recurrence. Over time, scholars have reached a consensus: when imaging suggests LLN metastasis, combining neoadjuvant chemoradiotherapy (nCRT) with selective LLN dissection (LLND) can mitigate the risk of recurrence. Selective LLND typically encompasses lymph nodes in the internal iliac and obturator regions. Recent studies emphasize distinctions between internal iliac and obturator lymph nodes regarding prognosis and treatment outcomes, prompting the need for differentiated diagnostic and treatment approaches.

Robotic versus laparoscopic total mesorectal excision with lateral lymph node dissection for advanced rectal cancer: A systematic review and meta-analysis

INTRODUCTION

Lateral pelvic node dissection (LPND) poses significant technical challenges. Despite the advent of robotic surgery, determining the optimal minimally invasive approach remains a topic of debate. This study aimed to compare postoperative outcomes between robotic total mesorectal excision with LPND (R-LPND) and laparoscopic total mesorectal excision with LPND (L-LPND).

METHODS

This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) 2020 and AMSTAR 2 (Assessing the Methodological Quality of Systematic Reviews) guidelines. Utilizing the RevMan 5.3.5 statistical package from the Cochrane Collaboration, a random-effects model was employed.

RESULTS

Six eligible studies involving 652 patients (316 and 336 in the R-LPND and L-LPND groups, respectively) were retrieved. The robotic approach demonstrated favourable outcomes compared with the laparoscopic approach, manifesting in lower morbidity rates, reduced urinary complications, shorter hospital stays, and a higher number of harvested lateral pelvic lymph nodes. However, longer operative time was associated with the robotic approach. No significant differences were observed between the two groups regarding major complications, anastomotic leak, intra-abdominal infection, neurological complications, LPND time, overall recurrence, and local recurrence.

CONCLUSIONS

In summary, the robotic approach is a safe and feasible alternative for Total Mesorectal Excision (TME) with LPND in advanced rectal cancer. Notably, it is associated with lower morbidity, particularly a reduction in urinary complications, a shorter hospital stay and increased number of harvested lateral pelvic nodes. The trade-off for these benefits is a longer operative time.

Management of lateral pelvic lymph nodes in rectal cancer: Is it time to reach an Agreement?

In this editorial, we proceed to comment on the article by Chua et al, addressing the management of metastatic lateral pelvic lymph nodes (mLLN) in stage II/III rectal cancer patients below the peritoneal reflection. The treatment of this nodal area sparks significant controversy due to the strategic differences followed by Eastern and Western physicians, albeit with a higher degree of convergence in recent years. The dissection of lateral pelvic lymph nodes without neoadjuvant therapy is a standard practice in Eastern countries. In contrast, in the West, preference leans towards opting for neoadjuvant therapy with chemoradiotherapy or radiotherapy, that would cover the treatment of this area without the need to add the dissection of these nodes to the total mesorectal excision. In the presence of high-risk nodal characteristics for mLLN related to radiological imaging and lack of response to neoadjuvant therapy, the risk of lateral local recurrence increases, suggesting the appropriate selection of strategies to reduce the risk of recurrence in each patient profile. Despite the heterogeneous and retrospective nature of studies addressing this area, an international consensus is necessary to approach this clinical scenario uniformly.

Long-term outcomes of robot-assisted laparoscopic surgery versus conventional laparoscopic surgery for rectal cancer: single-center, retrospective, propensity score analyses

Although the short-term outcomes of robot-assisted laparoscopic surgery (RALS) for rectal cancer are well known, the long-term oncologic outcomes of RALS compared with those of conventional laparoscopic surgery (CLS) are not clear. This study aimed to compare the long-term outcomes of RALS and CLS for rectal cancer using propensity score matching. This retrospective study included 185 patients with stage I-III rectal cancer who underwent radical surgery at our institute between 2010 and 2019. Propensity score analyses were performed with 3-year overall survival (OS) and relapse-free survival (RFS) as the primary endpoints. After case matching, the 3-year OS and 3-year RFS rates were 86.5% and 77.9% in the CLS group and 98.4% and 88.5% in the RALS group, respectively. Although there were no significant differences in OS (p = 0.195) or RFS (p = 0.518) between the groups, the RALS group had slightly better OS and RFS rates. 3-year cumulative (Cum) local recurrence (LR) and 3-year Cum distant metastasis (DM) were 9.7% and 8.7% in the CLS group and 4.5% and 10.8% in the RALS group, respectively. There were no significant differences in Cum-LR (p = 0.225) or Cum-DM (p = 0.318) between the groups. RALS is a reasonable surgical treatment option for patients with rectal cancer, with long-term outcomes similar to those of CLS in such patients.

Long-term Complications of Laparoscopic or Robotic Lateral Pelvic Node Dissection After Preoperative Chemoradiotherapy for Locally Advanced Rectal Cancer

BACKGROUND

Patients with rectal cancer who underwent lateral pelvic node dissection might be at a higher risk of postoperative complications derived from technical complexity. However, little is known regarding the long-term complications after lateral pelvic node dissection.

OBJECTIVES

The study aimed to investigate the long-term complications of preoperative chemoradiotherapy, followed by total mesorectal excision with lateral pelvic node dissection for locally advanced rectal cancers.

DESIGN

A retrospective analysis of a prospectively collected database.

SETTINGS

This study was conducted in a tertiary cancer center.

PATIENTS

Patients with rectal cancer who underwent total mesorectal excision with lateral pelvic node dissection after preoperative chemoradiotherapy between 2011 and 2019 were analyzed. All operations were performed via a laparoscopic or robotic approach.

MAIN OUTCOME MEASURES

Long-term complications were defined as adverse events that persisted or newly appeared ≥90 days after surgery and could be related to the surgery.

RESULTS

A total of 164 patients underwent total mesorectal excision with lateral pelvic node dissection after preoperative chemoradiotherapy. Short-term and long-term complication rates were 36.0% and 36.6%, respectively. Lymphocele was the most common long-term complication (17.7% of patients), and 11.6% had anastomotic leakage with chronic sinus. Of the patients with long-term complications, 20.7% of patients needed readmission for treatment. Of the 29 patients with lymphocele, 13 (41.0%) experienced spontaneous absorption and 11 (37.9%) required surgical or percutaneous catheter drainage or antibiotics use. Multivariate analysis showed pathologic pelvic node metastases ( p = 0.008), and a higher number of unilateral harvested pelvic nodes ( p = 0.001) were significantly associated with long-term complications. At the last follow-up (median duration of 43 months), 15.9% of patients had unresolved complications.

LIMITATIONS

The retrospective design.

CONCLUSIONS

Patients undergoing lateral pelvic node dissection experienced a higher frequency of long-term complications, but half of them had asymptomatic lymphoceles, most of which resolved spontaneously. However, further efforts should be paid to reduce anticipated complications related to lateral pelvic node dissection. See Video Abstract .

COMPLICACIONES A LARGO PLAZO DE LA DISECCIN DE LOS GANGLIOS LIFTICOS PLVICOS LATERALES LAPAROSCPICA O ROBTICA DESPUS DE LA QUIMIORRADIOTERAPIA PREOPERATORIA CONTRA EL CNCER DEL RECTO LOCALMENTE AVANZADO

ANTECEDENTES:Los pacientes con cáncer del recto sometidos a disección ganglionar linfática pélvica lateral podrían tener mayor riesgo de complicaciones postoperatorias derivadas de la complejidad técnica. Sin embargo, se sabe poco sobre las complicaciones a largo plazo después de la disección de los ganglios linfáticos pélvicos laterales.OBJETIVOS:Investigar las complicaciones a largo plazo de la quimiorradioterapia preoperatoria, seguida de escisión mesorrectal total con disección de los ganglios linfáticos pélvicos laterales contra el cáncer de recto localmente avanzado.DISEÑO:Un análisis retrospectivo de una base de datos recopilada prospectivamente.AJUSTES:Este estudio se llevó a cabo en un centro oncológico terciario.PACIENTES:Se analizaron pacientes con cáncer de recto que se sometieron a escisión mesorrectal total con disección de ganglios linfáticos pélvicos laterales después de quimiorradioterapia preoperatoria entre 2011 y 2019. Todas las operaciones se realizaron mediante abordaje laparoscópico o robótico.PRINCIPALES MEDIDAS DE RESULTADO:Las complicaciones a largo plazo se definieron como eventos adversos que persistieron o aparecieron recientemente ≥ 90 días después de la cirugía y podrían estar relacionados con la cirugía.RESULTADOS:Un total de 164 pacientes se sometieron a escisión mesorrectal total con disección de los ganglios linfáticos pélvicos laterales después de quimiorradioterapia preoperatoria. Las tasas de complicaciones a corto y largo plazo fueron del 36,0% y 36,6%, respectivamente. El linfocele fue la complicación a largo plazo más común (17,7% de los pacientes) y el 11,6% tuvo fuga anastomótica con seno crónico. De los pacientes con complicaciones a largo plazo, el 20,7% de los pacientes necesitaron reingreso para recibir tratamiento. De 29 pacientes con linfocele, 13 (41,0%) experimentaron absorción espontánea y 11 (37,9%) requirieron drenaje quirúrgico o percutáneo con catéter o uso de antibióticos. El análisis multivariado mostró metástasis patológicas en los ganglios linfáticos pélvicos ( p = 0,008) y un mayor número de ganglios pélvicos extraídos unilateralmente ( p = 0,001) se asociaron significativamente con complicaciones a largo plazo. En el último seguimiento (mediana de 43 meses), el 15,9% de los pacientes tuvieron complicaciones no resueltas.LIMITACIÓN:El diseño retrospectivo.CONCLUSIONES:Los pacientes sometidos a disección de ganglios pélvicos linfáticos laterales experimentaron una mayor frecuencia de complicaciones a largo plazo, pero la mitad de ellos tuvieron linfoceles asintomáticos, la mayoría de los cuales se resolvieron espontáneamente. Sin embargo, se deben realizar mayores esfuerzos para reducir las complicaciones previstas relacionadas con la disección de los ganglios linfáticos pélvicos laterales. (Traducción-Dr. Aurian Garcia Gonzalez ).

Sequential Lateral Lymphatic Metastasis Shows Similar Oncologic Outcomes to Upward Spread in Advanced Rectal Cancer After Preoperative Chemoradiotherapy

BACKGROUND

Whether lateral pelvic node metastasis should be considered as a regional or systemic disease is a long-standing debate. Although previous Japanese studies have considered it to be locoregional disease, Western countries consider it a systemic disease and do not perform lateral pelvic node dissection after preoperative chemoradiotherapy.

OBJECTIVE

To evaluate whether lateral pelvic node metastasis is a systemic or regional disease that is amenable to curative resection.

DESIGN

Retrospective analysis of a prospectively collected database.

SETTING

This study was conducted at a tertiary cancer center.

PATIENTS

There were 616 consecutive patients who underwent curative total mesorectal excision alone or with lateral pelvic node dissection after preoperative chemoradiotherapy for locally advanced rectal cancer between 2011 and 2019.

MAIN OUTCOME MEASURES

Three-year disease-free and overall survival.

RESULTS

A total of 360 patients underwent total mesorectal excision, and 160 patients underwent total mesorectal excision with lateral pelvic node dissection. There was no difference in the 3-year disease-free survival (DFS; p = 0.844) or overall survival rates ( p = 0.921) between the groups. Patients with lateral pelvic node metastasis showed DFS similar to those with perirectal lymph node metastasis in the total mesorectal excision group. In a subgroup analysis, patients with internal iliac pelvic node metastasis showed a disease-free survival comparable to those with perirectal node involvement, and patients with other lateral pelvic node metastasis showed a DFS similar to those with intermediate node involvement. In the lateral pelvic node dissection group, the lateral pelvic node metastatic rate was 32.5%. On multivariate analysis, fewer than 8 of the unilateral harvested lateral pelvic nodes and advanced ypT stage were significantly associated with poor disease-free survival.

LIMITATION

The retrospective design.

CONCLUSIONS

Lateral lymphatic metastasis showed oncologic outcomes similar to those of upward spread, especially perirectal lymph nodes metastasis. Large cohort studies with long-term follow-up are required to confirm these results. See Video Abstract .

LAS METSTASIS LINFTICAS SECUENCIALES LATERALES MUESTRAN RESULTADOS ONCOLGICOS SIMILARES EN LA PROPAGACIN ASCENDENTE DEL CNCER RECTAL AVANZADO DESPUS DE LA RADIOQUIMIOTERAPIA PREOPERATORIA

ANTECEDENTES:Es un debate muy antiguo si las metástasis en los ganglios pélvicos laterales deben considerarse una enfermedad regional o sistémica. Si bien estudios japoneses anteriores las consideran como una enfermedad locorregional, en los países de occidente se las considera como una enfermedad sistémica por la cual no se realiza disección de ganglios pélvicos laterales después de una radioquimioterapia preoperatoria.OBJETIVOS:Evaluar si la metástasis en los ganglios pélvicos laterales se consideran como enfermedad sistémica o enfermedad regional susceptible de resección curativa.DISEÑO:Análisis retrospectivo de una base de datos recopilada prospectivamente.AJUSTE:Este estudio se realizó en un centro oncológico terciario.PACIENTES:616 pacientes consecutivos se sometieron a excisión total del mesorrecto curativa sola o con disección de los ganglios pélvicos laterales después de radioquimioterapia preoperatoria en casos de cáncer de recto localmente avanzado entre 2011 y 2019.PRINCIPALES MEDIDAS DE RESULTADO:Sobrevida global y libre de enfermedad a 3 años.RESULTADOS:Un total de 360 pacientes se sometieron a excisión total del mesorrecto y 160 pacientes se sometieron a excisión total del mesorrecto con disección de ganglios pélvicos laterales.No hubo diferencias en la sobrevida libre de enfermedad a 3 años (p = 0,844) ni en las tasas de sobrevida general (p = 0,921) entre los grupos. Los pacientes con metástasis en los ganglios pélvicos laterales mostraron una sobrevida libre de enfermedad similar a aquellos con metástasis en los ganglios linfáticos perirrectales que se encontraban en el grupo de excisión total del mesorrecto.En el análisis de subgrupos, los pacientes con metástasis en los ganglios pélvicos ilíacos internos mostraron una sobrevida libre de enfermedad comparable a aquellos con afección de los ganglios perirrectales y los pacientes con otras metástasis en los ganglios pélvicos laterales mostraron una sobrevida libre de enfermedad similar a aquellos con afección de los ganglios intermedios.En el grupo de disección de los ganglios pélvicos laterales, la tasa de metástasis en dichos ganglios fué del 32,5%. En el análisis multivariado, < de 8 ganglios pélvicos laterales resecados unilateralmente y el estadio ypT avanzado se asociaron significativamente con una menor sobrevida libre de enfermedad.LIMITACIÓN:El diseño retrospectivo del estudio.CONCLUSIONES:Las metástasis linfáticas laterales mostraron resultados oncológicos similares a la diseminación ascendente, especialmente las metástasis en los ganglios linfáticos perirrectales. Se requieren grandes estudios de cohortes con seguimiento a largo plazo para confirmar estos resultados. (Traducción-Dr. Xavier Delgadillo ).

Comparison of the efficacy and safety of single-port versus multi-port robotic total mesorectal excision for rectal cancer: A propensity score-matched analysis

BACKGROUND

It is unknown whether the da Vinci single-port system performs similarly to the previous multi-port system during complicated procedures, such as rectal cancer surgery. Therefore, we compared the short-term clinical outcomes of single-port and multi-port robotic total mesorectal excision for the treatment of rectal cancer.

METHODS

This retrospective study reviewed 128 patients who underwent robotic total mesorectal excision between July 2020 and June 2022, of whom 84 (42 each: single-port versus multi-port) were included in the propensity score-matched cohort. Perioperative and pathologic outcomes were compared between groups.

RESULTS

Median tumor height was similar between groups (single-port versus multi-port, 5.9 ± 2.1 vs 5.6 ± 1.8 cm, P = .719). Preoperative chemoradiotherapy was performed equally. The total operative time was less (160.0 ± 42.2 minutes vs 199.6 ± 78.6 minutes, P = .005), the total length of incision was shorter (4.0 ±0.3 vs 5.4 ± 0.7 cm, P = .003), postoperative hospital stay was shorter (6.2 ±1.7 vs 7.2 ±2.8 days, P = .050), and C-reactive protein levels on postoperative day 3 trended to be lower (7.3 ± 4.7 vs 8.9 ± 5.6 mg/L, P = .096) in the single-port group, compared with the multi-port group. Postoperative complications did not differ between groups (single-port versus multi-port, 11.9% vs 16.6%, P = .864). Anastomotic leakage occurred in 1 and 2 patients in the single-port and multi-port groups, respectively. The circumferential resection margins were positive in 1 patient in the multi-port group.

CONCLUSION

The perioperative outcomes of single-port robotic total mesorectal excision were comparable to those of multi-port robotic TME. The single-port robot can be considered a surgical option for treating rectal cancer.

Comparison of laparoscopic lateral lymph node dissection for rectal cancer with and without routine resection of the visceral branches of internal iliac artery

PURPOSE

This study aimed to explore the safety and feasibility of the modified lateral lymph node dissection (LLND) with routine resection of the visceral branches of internal iliac vessels (IIVs) for mid-low-lying rectal cancer.

MATERIALS AND METHOD

Consecutive patients undergoing LLND for rectal cancer were divided into the routine visceral branches of the IIVs resection group (RVR group) and the NRVR group (without routine resection). The main outcomes were postoperative complications and the number of lateral lymph nodes harvested.

RESULTS

From 2012 to 2021, a total of 75 and 57 patients were included in the RVR and NRVR group, respectively. The operative time was reduced in the RVR group (p = 0.020). No significant difference was observed between the two groups for the incidence of total, major, or minor postoperative complications. Pathologically confirmed LLNM were 24 (32%) patients in the RVR group and 12 (21.1%) in the NRVR group (p = 0.162). The number of lateral lymph nodes harvested had no significant difference between two groups (11 vs. 12, p = 0.329).

CONCLUSION

LLND with routine resection of visceral branches of IIVs is safe and feasible, which brings no major complication or long-term urinary disorder.

Robotic Lateral Pelvic Lymph Node Dissection in Rectal Cancer: A Feasibility Study from a European Centre

INTRODUCTION

The role of robotic lateral pelvic lymph node dissection (LPLND) for lateral pelvic nodal disease (LPND) in rectal cancer has yet to be investigated in the Western hemisphere. This study aims to investigate the safety and feasibility of robotic LPLND by utilising a well-established totally robotic TME protocol.

METHODS

We conducted a retrospective study on 17 consecutive patients who underwent robotic LPLND for LPND ± TME for rectal cancer between 2015 and 2021. A single docking totally robotic approach from the left hip with full splenic mobilisation was performed using the X/Xi da Vinci platform. All patients underwent a tri-compartmental robotic en bloc excision of LPND with preservation of the obturator nerve and pelvic nerve plexus, leaving a well-skeletonised internal iliac vessel and its branches.

RESULTS

The median operative time was 280 min, which was 40 min longer than our standard robotic TME. The median BMI was 26, and there were no conversions. The median inpatient stay was 7 days with no Clavien-Dindo > 3 complications. One patient (6%) developed local recurrence and metastatic disease within 5 months. The proportion of histologically confirmed LPND was 41%, of which 94% were well to moderately differentiated adenocarcinoma. Median pre-operative lateral pelvic node size was significantly higher in positive nodes (14 mm vs. 8 mm (p = 0.01)). All patients had clear resection margins on histology.

DISCUSSION

Robotic LPLND is safe and feasible with good peri-operative and short-term outcomes, with the ergonomic advantages of a robotic TME docking protocol readily transferrable in LPLND.

Comparison of robotic-assisted versus conventional laparoscopic surgery in colorectal cancer resection: a systemic review and meta-analysis of randomized controlled trials

Introduction

There is still controversy on whether or not robot-assisted colorectal surgery (RACS) have advantages over laparoscopic-assisted colorectal surgery(LACS).

Materials and methods

The four databases (PubMed, Embase, Web of Science and Cochrane Library)were comprehensively searched for randomized controlled trials (RCTs) comparing the outcomes of RACS and LACS in the treatment of colorectal cancer from inception to 22 July 2023.

Results

Eleven RCTs were considered eligible for the meta-analysis. Compared with LACS,RACS has significantly longer operation time(MD=5.19,95%CI: 18.00,39.82, P<0.00001), but shorter hospital stay(MD=2.97,95%CI:-1.60,-0.33,P = 0.003),lower conversion rate(RR=3.62,95%CI:0.40,0.76,P = 0.0003), lower complication rate(RR=3.31,95%CI:0.64,0.89,P=0.0009),fewer blood loss(MD=2.71,95%CI:-33.24,-5.35,P = 0.007),lower reoperation rate(RR=2.12, 95%CI:0.33,0.96,P=0.03)and longer distal resection margin(MD=2.16, 95%CI:0.04,0.94, P = 0.03). There was no significantly difference in harvested lymph nodes, the time of first flatus, the time of first defecation,the time of first resume diet, proximal resection margin, readmission rates, mortalities and CRM+ rates between two group.

Conclusions

Our study indicated that RACS is a feasible and safe technique that can achieve better surgical efficacy compared with LACS in terms of short-term outcomes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023447088.

Robotic pelvic side-wall lymph node dissection for rectal cancer: a systematic review of videos and application of the IDEAL 2A framework

Lateral pelvic lymph node dissection (LPLND) in rectal cancer has gained increasing traction worldwide. Robotic LPLND is an emerging technique. Utilising the IDEAL (idea, development, exploration, assessment and long-term follow-up) framework for surgical innovation, robotic LPLND is currently at the IDEAL 2A stage (development) mainly limited to case reports, case series and videos. A systematic literature review was performed for videographic robotic LPLND. Pubmed, Ovid and Web of Science were searched with a predefined search strategy. The LapVEGAS score for peer review of video surgery was adapted for the robotic approach (RoVEGAS) and applied to measure video quality. Two reviewers independently reviewed videos and consensus reached on technical steps and learning points. Data are presented as a narrative synthesis of results. The IDEAL 2A framework was applied to videos to assess their content at the present stage of innovation. A total of 83 abstracts were identified. In accordance with the PRISMA statement, nine videos were analysed. Adherence to the complete IDEAL 2a framework was low. All videos demonstrated LPLND; however, reporting of clinical outcomes was heterogeneous and completed in six of nine videos. Histopathology was reported in six videos, with other outcomes variably reported. No videos presented patient-reported outcome measures. Two videos reported presence or absence of recurrence on follow-up. Video articles provide a valuable educational resource in dissemination and adoption of robotic techniques. Standardisation of reporting objectives are needed. Complete reporting of pathology and oncologic outcomes is required in videographic procedural-based publications to meet the IDEAL 2A framework criteria.

Robot-assisted lateral pelvic lymph node dissection in patients with advanced rectal cancer: a single-center experience of 65 cases

The treatment of lateral pelvic lymph node (LPLN) metastasis of rectal cancer has evolved because of technical difficulties from open surgery to laparoscopy and, recently, robot-assisted surgery. This study aimed to evaluate the technical feasibility and short- and long-term outcomes of robot-assisted LPLN dissection (LPND) following total mesorectal excision (TME) in advanced rectal cancer. Clinical data of 65 patients who underwent robotic-assisted TME with LPND from April 2014 to July 2022 were reviewed. Data regarding operative details, postoperative morbidity (within 90 postoperative days) for short-term outcomes and lateral recurrence as long-term outcomes were analyzed. Among the 65 patients with LPND, preoperative chemoradiotherapy was performed in 49 (75.4%). The mean operative time was 306.8 (range 191-477) min, and the mean time of unilateral LPND was 38.6 (range 16-66) min. LPND was bilaterally performed in 19 (29.2%) patients. The mean number of each side of harvested LPLNs was 6.8. Lymph node metastasis was observed in 15 (23.0%) patients, and 10 (15.4%) patients had postoperative complications. Lymphocele (n = 3) and pelvic abscess (n = 3) were the most common, followed by voiding difficulty, erectile dysfunction, obturator neuropathy, and sciatic neuropathy (all n = 1). During the 25 months of median follow-up, no lateral recurrence of the LPND site was noted. Robot-assisted LPND following TME is safe and feasible and showed acceptable short- and long-term outcomes. Despite some study limitations, we may be able to apply this strategy more widely through subsequent prospective controlled studies.

Robotic and laparoscopic salvage lateral pelvic node dissection for the treatment of recurrent rectal cancer

BACKGROUND

The lateral pelvic sidewall is a major site of local recurrence after radical resection of rectal cancer. Salvage lateral pelvic node dissection (LPND) may be the only way to eliminate recurrent lateral pelvic nodes (LPNs). This study aimed to describe the technical details of robotic and laparoscopic salvage LPND and assess the short-term clinical and oncological outcomes in patients with recurrent LPNs who underwent salvage LPND by a minimally invasive approach for curative intent.

METHODS

Between September 2010 and 2019, 36 patients who underwent salvage surgery for LPN recurrence were retrospectively analyzed from a prospectively maintained database. Patients' characteristics, index operation, MRI findings, and perioperative and pathological outcomes were analyzed.

RESULTS

Eleven and 14 patients underwent robotic and laparoscopic salvage LPND, respectively. Eight patients (32.0%) underwent a combined salvage operation for resectable extra-pelvic sidewall metastases. There were four cases of open-conversion during the laparoscopic approach due to uncontrolled bleeding of iliac vessels. In these patients, metastatic LPNs were suspected of iliac vessel invasion and were found to be larger in size (median 15 mm; range 12-20) than that in patients who underwent successful LPND using the minimally invasive approach (median 10 mm; range 5-20). The median number of metastatic LPNs and harvested LPNs was 1 (range 0-3) and 6 (range 1-16), respectively. Six patients (24.0%) experienced postoperative complications including lymphoceles and voiding difficulties. During the follow-up (median 44.6 months; range 24.0-87.7), eight patients developed recurrences, mainly the lung and para-aortic lymph nodes, and one patient developed pelvic sidewall recurrence after laparoscopic salvage LPND. The 3-year disease-free survival and overall survival after salvage LPND were 66.4% and 79.2%, respectively.

CONCLUSIONS

Robotic and laparoscopic salvage LPND for recurrent LPNs are safe and feasible with favorable short-term surgical outcomes. However, the surgical approach should be carefully chosen in patients with large-sized and invasive recurrent LPNs.

Robotic Lateral Pelvic Lymph Node Dissection Could Harvest More Lateral Pelvic Lymph Nodes over Laparoscopic Approach for Mid-to-Low Rectal Cancer: A Multi-Institutional Retrospective Cohort Study

Lateral pelvic lymph node dissection (LPND) is a technically demanding procedure. This study aimed to compare the short-term outcomes of laparoscopic and robotic LPNDs. This multi-institutional retrospective study included 108 consecutive patients who underwent laparoscopic or robotic total mesorectal excision with LPND for locally advanced rectal cancer. There were 74 patients in the laparoscopic and 34 in the robotic groups. The median operation time was longer in the robotic group than in the laparoscopic group (353 vs. 275 min, p < 0.001). No patients underwent conversion to open surgery in either group. Pathological LPN metastases were observed in 24 and 8 patients in the laparoscopic and robotic groups, respectively (p = 0.347). Although the number of harvested mesorectal lymph nodes was similar (15.5 vs. 15.0, p = 0.968), the number of harvested LPNs was higher in the robotic than in the laparoscopic group (7.0 vs. 5.0, p = 0.004). Postoperative complications and length of hospital stay were similar (robotic vs. laparoscopic, 35.3% and 7 days vs. 37.8% and 7 days, respectively). Both laparoscopic and robotic LPND are safe and feasible for locally advanced rectal cancers, but robotic LPND showed more harvested lateral lymph node than laparoscopic LPND.

Essential updates 2020/2021: Advancing precision medicine for comprehensive rectal cancer treatment

In the paradigm shift related to rectal cancer treatment, we have to understand a variety of new emerging topics to provide appropriate treatment for individual patients as precision medicine. However, information on surgery, genomic medicine, and pharmacotherapy is highly specialized and subdivided, creating a barrier to achieving thorough knowledge. In this review, we summarize the perspective for rectal cancer treatment and management from the current standard-of-care to the latest findings to help optimize treatment strategy.

Short- and long-term outcomes of robotic-assisted laparoscopic surgery for rectal cancer: A single-center retrospective cohort study

INTRODUCTION

Whether rectal cancer surgery by robotic-assisted laparoscopic surgery provides beneficial advantages remains controversial. Although favorable outcomes in terms of the safety and technical feasibility of robotic-assisted laparoscopic surgery have been demonstrated for rectal cancer, long-term oncological outcomes for robotic-assisted laparoscopic surgery have only been examined in a few studies. This retrospective study of subjects who underwent robotic-assisted laparoscopic surgery evaluated short- and long-term outcomes of consecutive rectal cancer patients.

METHODS

Between November 2016 and January 2020, we analyzed the records of 62 consecutive patients who underwent robotic-assisted laparoscopic surgery for rectal adenocarcinoma without distant metastasis to evaluate short- and long-term outcomes.

RESULTS

Tumors were located in the lower or mid-rectum (88.7%) in most patients. The median operative time was 357 min. No patient received transfusions, and the median blood loss was 10.5 ml. Open laparotomy was not required in any patient. A Clavien-Dindo classification of all grades was observed in 12 patients (19.4%). Positive radial margin was not observed in any patient. Duration of median follow-up was 40.5 mo, while 3-y overall survival and 3-y relapse-free survival rates were 96.8% and 85.0%, respectively. The local recurrence rate was 3.4%.

CONCLUSION

Favorable short- and long-term outcomes demonstrated robotic-assisted laparoscopic surgery was safe and technically feasible for rectal cancer.

Robotic pelvic side-wall dissection and en-bloc excision for locally advanced and recurrent rectal cancer: outcomes on feasibility and safety

BACKGROUND

Global differences exist in managing lateral pelvic nodes in rectal cancer. Recent studies demonstrate improved local recurrence rates in patients undergoing lateral pelvic lymph node dissections (LPND) in addition to total mesorectal excision (TME) for advanced lower rectal cancer. This study aims to report on the safety and feasibility of the robotic approach in patients undergoing pelvic sidewall lymph node dissection or en-bloc sidewall resection for advanced lower rectal cancer.

METHODS

Patients who underwent an elective robotic pelvic sidewall lymph node dissection or en-bloc sidewall resection for locally advanced rectal cancer with suspicious lateral lymph nodes or pelvic side wall involvement between January 2018 and March 2021 were included. Demographic, clinical, perioperative and histopathological variables were recorded and analysed.

RESULTS

Eight patients (3 males) with a mean age of 55 (33-73) years and mean body mass index of 26.3 (20.7-30.0) kg/m² were included. The median operative time and blood loss were 458.75 (360-540) min and 143.75 (100-300) mL, respectively. There were no conversions or intra-operative complications. There were three post-operative complications recorded (two ileus and one anastomotic leak which required an endoscopic washout in theatre and intravenous antibiotics thereafter). Median length of stay was 12.75 (7-23) days. All patients had an R0 resection, and the median lateral pelvic lymph node yield was 9.1 (6-14).

CONCLUSION

This series demonstrates the practicality and the safety of the robotic approach in the introduction of this technique for en-bloc resection or LPND in patients with locally advanced rectal cancer.

Stepwise Improvement of Surgical Quality in Robotic Lateral Pelvic Node Dissection: Lessons From 100 Consecutive Patients With Locally Advanced Rectal Cancer

BACKGROUND

Lateral pelvic node dissection has significant technical difficulty and a high incidence of surgical morbidity. A steep learning curve is anticipated in performing lateral pelvic node dissection. However, no study has previously analyzed the learning curve and surgical skill acquisition for this complex procedure.

OBJECTIVES

We aimed to evaluate the learning process for performing robotic total mesorectal excision with lateral pelvic node dissection in patients with rectal cancer.

DESIGN

This is a retrospective analysis of a prospectively collected database.

SETTING

This study was conducted at a tertiary cancer center.

PATIENTS

A total of 100 patients who underwent robotic total mesorectal excision with lateral pelvic node dissection between 2011 and 2017 were included.

MAIN OUTCOME MEASURES

A cumulative sum analysis was calculated based on the number of unilateral retrieved lateral pelvic nodes. Operative time, estimated bloodloss, lateral pelvic node metastatic rate, postoperative morbidities, and local recurrence were also analyzed.

RESULTS

Cumulative sum modeling suggested 4 learning phases: learning I (33 patients), learning II (19 patients), consolidation (30 patients), and competence (18 patients). In the consolidation and competence phases, we adopted fluorescence imaging and standardized the surgical procedure on the basis of anatomical planes. The competence phase had the greatest number of unilateral retrieved lateral pelvic nodes (12.8 vs 4.9, 8.2, and 10.4; p < 0.001). Urinary complications, including urinary retention and postoperative α-blocker usage, were more frequently observed in learning phase I than in the competence phase (39.4% vs 16.7%, p = 0.034). During the median follow-up of 44.2 months, local recurrence in the pelvic sidewall was observed in 4 patients from learning phase I and in 1 patient from learning phase II.

LIMITATIONS

This study was limited by its retrospective design.

CONCLUSION

Completeness of the lateral pelvic node dissection procedure increased with the surgeon's experience and as new imaging systems and surgical technique standardization were implemented. Further studies are warranted to determine the oncologic outcomes associated with each phase. See Video Abstract at http://links.lww.com/DCR/B774.

MEJORA GRADUAL DE LA CALIDAD QUIRRGICA EN LA DISECCIN LINFTICA PLVICA LATERAL ROBTICA LECCIONES DE PACIENTES CONSECUTIVOS CON CNCER DE RECTO LOCALMENTE AVANZADO

ANTECEDENTES:La disección linfática pélvica lateral tiene una dificultad técnica significativa y una alta incidencia de morbilidad quirúrgica. Se prevé una curva de aprendizaje muy pronunciada al realizar la disección linfática pélvica lateral. Sin embargo, ningún estudio ha analizado previamente la curva de aprendizaje y la adquisición de habilidades quirúrgicas para este procedimiento.OBJETIVOS:Nuestro objetivo fue evaluar el proceso de aprendizaje para realizar la escisión total de mesorrecto robótica con disección linfática pélvica lateral en pacientes con cáncer de recto.DISEÑO:Este es un análisis retrospectivo de una base de datos recopilada prospectivamente.AJUSTE:Este estudio se realizó en un centro oncológico terciario.PACIENTES:Un total de 100 pacientes fueron sometidos a escisión total de mesorrecto robótica con disección linfática pélvica lateral entre 2011 y 2017.PRINCIPALES MEDIDAS DE DESENLACE:Se calculó un análisis de suma acumulativa basado en el número unilateral de ganglios pélvicos laterales recuperados. También se analizaron el tiempo operatorio, la pérdida de sangre estimada, la tasa de metástasis ganglionares pélvicas laterales, las morbilidades postoperatorias y la recidiva local.RESULTADOS:El modelado total acumulativo sugirió cuatro fases de aprendizaje: aprendizaje I (33 pacientes), aprendizaje II (19 pacientes), consolidación (30 pacientes) y competencia (18 pacientes). En las fases de consolidación y competencia, adoptamos imágenes de fluorescencia y estandarizamos el procedimiento quirúrgico basado en planos anatómicos, respectivamente. La fase de competencia tuvo el mayor número de ganglios pélvicos laterales recuperados unilateralmente (12,8 frente a 4,9, 8,2 y 10,4; p < 0,001). Las complicaciones urinarias, incluida la retención urinaria y el uso posoperatorio de bloqueadores beta, se observaron con más frecuencia en la fase de aprendizaje I que en la fase de competencia (39,4% frente a 16,7%, p = 0,034). Durante la mediana de seguimiento de 44,2 meses, se observó una recidiva local en la pared lateral pélvica en cuatro pacientes de la fase de aprendizaje I y en un paciente de la fase de aprendizaje II.LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo.CONCLUSIÓNES:La completitud del procedimiento de disección linfática pélvica lateral aumentó con la experiencia del cirujano y a medida que se implementaron nuevos sistemas de imágenes y estandarización de técnicas quirúrgicas. Se necesitan más estudios para determinar los resultados oncológicos asociados con cada fase. Consulte Video Resumen en http://links.lww.com/DCR/B774.

Oncologic Status of Obturator Lymph Node Metastases in Locally Advanced Low Rectal Cancer: A Japanese Multi-Institutional Study of 3487 Patients

BACKGROUND

The American Joint Committee on Cancer tumor-node-metastasis staging system for rectal cancer defines lateral pelvic lymph nodes (LPLNs) only in the internal iliac region as regional. However, the Japanese Society for Cancer of the Colon and Rectum (JSCCR) staging system, also considers obturator lymph nodes (LNs) as regional. This retrospective cohort study evaluated the oncologic status of obturator LNs in low rectal cancer.

METHODS

The study identified 3487 patients with pT3-T4 low rectal cancer who had undergone curative resections without preoperative radiotherapy or chemotherapy between 2003 and 2011 in the JSCCR database and divided them into six groups. Overall survival (OS) and recurrence-free survival (RFS) were analyzed by groups.

RESULTS

Histologic LPLN metastases were identified in 8% (279/3487) of all the patients and in 18.2% (279/1530) of the patients who underwent lateral pelvic node dissection. The 5-year OS and RFS rates of the obturator-LPLN group (P = 0.095) were worse than those of the internal-LPLN group (P = 0.075), but the difference was not significant. The OS of the obturator-LPLN group was similar to that of the resectable liver metastasis group (P = 0.731), and the RFS of the obturator-LPLN group was significantly better than that of the other-LPLN group (P = 0.016).

CONCLUSION

The prognosis for obturator LN metastases in low rectal cancer was not significantly worse than for internal iliac LN metastases, defined as regional by the current American Joint Committee on Cancer staging system, and the oncologic status of obturator LNs warrants more studies.

How to do a robotic lateral pelvic side wall dissection for rectal cancer

Our article describes the anatomy, technical steps, common pitfalls, and our recommendations for performing a successful robotic lateral pelvic side wall dissection for rectal cancer. This is supplemented with videos and an image to clearly demonstrate our technique.

Evaluation of the learning curve for robot-assisted rectal surgery using the cumulative sum method

BACKGROUND

There is no clear evidence on the number of cases required to master the techniques required in robot-assisted surgery for different surgical fields and techniques. The purpose of this study was to clarify the learning curve of robot-assisted rectal surgery for malignant disease by surgical process.

METHOD

The study retrospectively analyzed robot-assisted rectal surgeries performed between April 2014 and July 2020 for which the operating time per process was measurable. The following learning curves were created using the cumulative sum (CUSUM) method: (1) console time required for total mesorectal excision (CUSUM tTME), (2) time from peritoneal incision to inferior mesenteric artery dissection (CUSUM tIMA), (3) time required to mobilize the descending and sigmoid colon (CUSUM tCM), and (4) time required to mobilize the rectum (CUSUM tRM). Each learning curve was classified into phases 1-3 and evaluated. A fifth learning curve was evaluated for robot-assisted lateral lymph node dissection (CUSUM tLLND).

RESULTS

This study included 149 cases. Phase 1 consisted of 32 cases for CUSUM tTME, 30 for CUSUM tIMA, 21 for CUSUM tCM, and 30 for CUSUM tRM; the respective numbers were 54, 48, 45, and 61 in phase 2 and 63, 71, 83, and 58 in phase 3. There was no significant difference in the number of cases in each phase. Lateral lymph node dissection was initiated in the 76th case where robot-assisted rectal surgery was performed. For CUSUM tLLND, there were 12 cases in phase 1, 6 in phase 2, and 7 cases in phase 3.

CONCLUSIONS

These findings suggest that the learning curve for robot-assisted rectal surgery is the same for all surgical processes. Surgeons who already have adequate experience in robot-assisted surgery may be able to acquire stable technique in a smaller number of cases when they start to learn other techniques.

Current status and role of robotic approach in patients with low-lying rectal cancer

Utilization of robotic surgical systems has increased over the years. Robotic surgery is presumed to have advantages of enhanced visualization, improved dexterity, and reduced tremor, which is purported to be more suitable for rectal cancer surgery in a confined space than laparoscopic or open surgery. However, evidence supporting improved clinical and oncologic outcomes after robotic surgery remains controversial and limited despite the widespread adoption of robotic surgical systems. To date, numerous observational studies and a few randomized controlled trials have failed to demonstrate that short-term, oncological, and functional outcomes after a robotic surgery are superior to those of laparoscopic surgery for low rectal cancer patients. The objective of this review is to summarize the current state of robotic surgery and its impact on low-lying rectal cancer.

Extended Lymphadenectomy in Locally Advanced Rectal Cancers: A Systematic Review

Purpose

The surgical treatment of advanced low rectal cancer remains controversial. Extended lymphadenectomy (EL) is the preferred option in the East, especially in Japan, while neoadjuvant radiotherapy is the treatment of choice in the West. This review was undertaken to review available evidence supporting each of the therapies.

Methods

All studies looking at EL were included in this review. A comprehensive search was conducted as per PRISMA guidelines. Primary outcome was defined as 5-year overall survival, with secondary outcomes including 3-year overall survival, 3- and 5-year disease-free survival, length of operation, and number of complications.

Results

Thirty-one studies met the inclusion criteria. There was no significant publication bias. There was statistically significant difference in 5-year survival for patient who underwent EL (odds ratio, 1.34; 95 confidence interval, 0.09–0.5; P=0.006). There were no differences noted in secondary outcomes except for length of the operations.

Conclusion

There is evidence supporting EL in rectal cancer; however, it is difficult to interpret and not easily transferable to a Western population. Further research is necessary on this important topic.

Lateral lymph node dissection in rectal cancer: State of the art review

Half of the local regional recurrences from rectal cancer are nowadays located in the lateral compartments, most likely due to lateral lymph node (LLN) metastases. There is evidence that a lateral lymph node dissection (LLND) can lower the lateral local recurrence rate. An LLND without neoadjuvant (chemo)radiotherapy in patients with or without suspected LLN metastases has been the standard of care in the East, while Western surgeons believed LLN metastases to be cured by neoadjuvant treatment and total mesorectal excision (TME) only. An LLND in patients without enlarged LLNs might result in overtreatment with low rates of pathological LLNs, but in patients with enlarged LLNs who are treated with (C)RT and TME only, the risk of a lateral local recurrence significantly increases to 20%. Certain Eastern and Western centers are increasingly performing a selective LLND after neoadjuvant treatment in the presence of suspicious LLNs due to new scientific insights, but (inter)national consensus on the indication and surgical approach of LLND is lacking. An LLND is an anatomically challenging procedure with intraoperative risks such as bleeding and postoperative morbidity. It is therefore essential to carefully select the patients who will benefit from this procedure and where possible to perform the LLND in a minimally invasive manner to limit these risks. This review gives an overview of the current evidence of the assessment of LLNs, the indications for LLND, the surgical technique, pitfalls in performing this procedure and the future studies are discussed, aiming to contribute to more (inter)national consensus.

Initial experience of preoperative short-course radiotherapy followed by oxaliplatin-based consolidation chemotherapy for locally advanced rectal cancer

PURPOSE

We analyzed the safety and feasibility of preoperative short-course radiotherapy (SCRT) followed by consolidation chemotherapy for patients with locally advanced rectal cancer (LARC).

METHODS

From April 2018 to May 2019, 19 patients with LARC were treated with SCRT followed by three cycles of consolidation chemotherapy with leucovorin, fluorouracil, and oxaliplatin (FOLFOX6) before surgery. Adjuvant chemotherapy relied on oxaliplatin. Tumor response, patient compliance, and toxicities were analyzed.

RESULTS

The median age was 60 years (range 44-71), and 16 of the patients were male. The median tumor height was 5 cm (range 0-9) from anal verge. All patients received a total dose of 25 Gy in five fractions. The number of cycles of FOLFOX6 before surgery was three in 17, four in one, five in one. Five patients required dose reductions in consolidation chemotherapy. The median interval between initiation of SCRT and surgery was 10.6 weeks (range 8.6-16.4). A pathologic complete response was seen in two patients (11%). Grade III toxicities to the preoperative treatment were seen in five patients (26%): diarrhea in two, a decreased white blood cell count in one, and anemia in two. Postoperative complications arising within 30 days developed in five patients (26%). During the median follow-up period of 20.4 months, there was no tumor recurrence.

CONCLUSION

Preoperative SCRT followed by oxaliplatin-based consolidation chemotherapy showed acceptable toxicity and feasibility in patients with LARC. Prospective randomized trials are warranted to verify the efficacy and safety of this treatment strategy compared with conventional long-course concurrent chemoradiotherapy.

Optimizing outcomes of colorectal cancer surgery with robotic platforms

Advanced robotic technology makes it easier to perform total mesorectal excision procedures in the narrow pelvis for rectal cancer while maintaining the advantages of minimally invasive surgery. Robotic surgery for rectal cancer leads to lower conversion rates and faster recovery of urogenital function than conventional laparoscopic surgery. However, longer operative time and high cost are major weaknesses of robotic surgery. To date, most other short-term surgical outcomes, pathologic outcomes, and long-term oncologic outcomes of robotic surgery have not shown significant advantages over laparoscopic surgery. However, robotic surgery is still a valid and highly anticipated surgical approach for rectal cancer because it greatly reduces the surgeon's workload and learning curve. There are also advantages when robotic techniques are applied to technically demanding procedures such as lateral pelvic lymph node dissection or intersphincteric resection. The introduction of new surgical robot systems, including the da Vinci® SP system, is expected to expand the applications of robotic surgery and provide new advantages.

Difference in surgical outcomes of rectal cancer by study design: meta-analyses of randomized clinical trials, case-matched studies, and cohort studies

Background

RCTs are considered the standard in surgical research, whereas case-matched studies and propensity score matching studies are conducted as an alternative option. Both study designs have been used to investigate the potential superiority of robotic surgery over laparoscopic surgery for rectal cancer. However, no conclusion has been reached regarding whether there are differences in findings according to study design. This study aimed to examine similarities and differences in findings relating to robotic surgery for rectal cancer by study design.

Methods

A comprehensive literature search was conducted using PubMed, Scopus, and Cochrane CENTRAL to identify RCTs, case-matched studies, and cohort studies that compared robotic versus laparoscopic surgery for rectal cancer. Primary outcomes were incidence of postoperative overall complications, incidence of anastomotic leakage, and postoperative mortality. Meta-analyses were performed for each study design using a random-effects model.

Results

Fifty-nine articles were identified and reviewed. No differences were observed in incidence of anastomotic leakage, mortality, rate of positive circumferential resection margins, conversion rate, and duration of operation by study design. With respect to the incidence of postoperative overall complications and duration of hospital stay, the superiority of robotic surgery was most evident in cohort studies (risk ratio (RR) 0.83, 95 per cent c.i. 0.74 to 0.92, P < 0.001; mean difference (MD) –1.11 (95 per cent c.i. –1.86 to –0.36) days, P = 0.004; respectively), and least evident in RCTs (RR 1.12, 0.91 to 1.38, P = 0.27; MD –0.28 (–1.44 to 0.88) days, P = 0.64; respectively).

Conclusion

Results of case-matched studies were often similar to those of RCTs in terms of outcomes of robotic surgery for rectal cancer. However, case-matched studies occasionally overestimated the effects of interventions compared with RCTs.

Long-term effects of laparoscopic lateral pelvic lymph node dissection on urinary retention in rectal cancer

BACKGROUND

The addition of lateral pelvic lymph node dissection (LPLND) in rectal cancer surgery has been reported to increase the incidence of post-operative urinary retention. Here, we assessed the predictive factors and long-term outcomes of urinary retention following laparoscopic LPLND (L-LPLND) with total mesorectal excision (TME) for advanced lower rectal cancer.

METHODS

This retrospective single-institutional study reviewed post-operative urinary retention in 71 patients with lower rectal cancer who underwent L-LPLND with TME. Patients with preoperative urinary dysfunction or who underwent unilateral LPLND were excluded. Detailed information regarding patient clinicopathologic characteristics, post-void residual urine volume, and the presence or absence of urinary retention over time was collected from clinical and histopathologic reports and telephone surveys. Urinary retention was defined as residual urine > 100 mL and the need for further treatment.

RESULTS

Post-operative urinary retention was observed in 25/71 patients (35.2%). Multivariate analysis revealed that blood loss ≥ 400 mL [odds ratio (OR) 4.52; 95% confidence interval (CI) 1.24-16.43; p = 0.018] and inferior vesical artery (IVA) resection (OR 8.28; 95% CI 2.46-27.81; p < 0.001) were independently correlated with the incidence of urinary retention. Furthermore, bilateral IVA resection caused urinary retention in more patients than unilateral IVA resection (88.9% vs 47.1%, respectively; p = 0.049). Although urinary retention associated with unilateral IVA resection improved relatively quickly, urinary retention associated with bilateral IVA resection tended to persist over 1 year.

CONCLUSION

We identified the predictive factors of urinary retention following L-LPLND with TME, including increased blood loss (≥ 400 mL) and IVA resection. Urinary retention associated with unilateral IVA resection improved relatively quickly. L-LPLND with unilateral IVA resection is a feasible and safe procedure to improve oncological curability. However, if oncological curability is guaranteed, bilateral IVA resection should be avoided to prevent irreversible urinary retention.

Long-term clinical outcomes of total mesorectal excision and selective lateral pelvic lymph node dissection for advanced low rectal cancer: a comparative study of a robotic versus laparoscopic approach

BACKGROUND

The long-term outcomes of minimally invasive lateral pelvic lymph node dissection (LPND) are not completely known. The aim of this study was to compare long-term outcomes between robotic and laparoscopic LPND in low rectal cancer patients with suspected lymph node metastasis in the pelvic sidewall.

METHODS

We retrospectively reviewed the records of all rectal cancer patients who had laparoscopic or robotic total mesorectal excision (TME) with LPND between March 2006 and June 2016. Stage IV patients were excluded. The outcomes of patients who had laparoscopic and robotic TME with LPND were compared.

RESULTS

Twenty-nine patients had laparoscopic LPND and 70 had robotic LPND. No significant differences in patient characteristics were observed between the two groups. The urinary retention rate was lower in the robotic group than in the laparoscopic group (7.1% vs. 24.1%; p = 0.043). During a median follow-up of 44.3 months, the overall recurrence rates were 48.3% and 31.4% in the laparoscopic and robotic groups, respectively (p = 0.175). The 5-year disease-free survival rates were 50.4% and 67.0% in the laparoscopic and robotic groups, respectively (p = 0.227). The 5-year overall survival rates were 65.0% and 92.2% in the laparoscopic and robotic groups, respectively (p = 0.017).

CONCLUSIONS

Robotic TME with LPND is safe and feasible. In particular, it is associated with lower urinary retention. Robotic TME with LPND might yield a similar local recurrence rate and 5-year disease-free survival, but favorable long-term overall survival as compared to the laparoscopic approach. However, considering the retrospective nature and both major variables of TME and LPND involved together, this should be cautiously interpreted.

Robotics Total Mesorectal Excision Up To the Minute

Surgical techniques have evolved over the past few decades, and minimally invasive surgery has been rapidly adapted to become a preferred operative approach for treating colorectal diseases. However, many of the procedures remain a technical challenge for surgeons to perform laparoscopically, which has prompted the development of robotic platforms. Robotic surgery has been introduced as the latest advance in minimally invasive surgery. The present article provides an overview of robotic rectal surgery and describes many advances that have been made in the field over the past two decades. More specifically, the introduction of the robotic platform and its benefits, and the limitations of current robotic technology, are discussed. Although the main advantages of robotic surgery over conventional laparoscopy appear to be lower conversion rates and better surgical specimen quality, oncological and functional outcomes appear to be similar to those of other alternatives. Other potential benefits include earlier recovery of voiding and sexual function after robotic total mesorectal excision. Nevertheless, the costs and lack of haptic feedback remain the primary limitations to the widespread use of robotic technology in the field.

Robotic lateral pelvic lymph node dissection after chemoradiation for rectal cancer: a Western perspective

AIM

There are limited outcome data for lateral pelvic lymph node dissection (LPLND) following neoadjuvant chemoradiotherapy (nCRT), particularly in the West. Our aim was to evaluate the short-term perioperative and oncological outcomes of robotic LPLND at a single cancer centre.

METHOD

A retrospective analysis of a prospective database of consecutive patients undergoing robotic LPLND for rectal cancer between November 2012 and February 2020 was performed. The main outcomes were short-term perioperative and oncological outcomes. Major morbidity was defined as Clavien-Dindo grade 3 or above.

RESULTS

Forty patients underwent robotic LPLND during the study period. The mean age was 54 years (SD ± 15 years) and 13 (31.0%) were female. The median body mass index was 28.6 kg/m² (IQR 25.5-32.6 kg/m² ). Neoadjuvant CRT was performed in all patients. Resection of the primary rectal cancer and concurrent LPLND occurred in 36 (90.0%) patients, whilst the remaining 4 (10.0%) patients had subsequent LPLND after prior rectal resection. The median operating time was 420 min (IQR 313-540 min), estimated blood loss was 150 ml (IQR 55-200 ml) and length of hospital stay was 4 days (IQR 3-6 days). The major morbidity rate was 10.0% (n = 4). The median lymph node harvest from the LPLND was 6 (IQR 3-9) and 13 (32.5%) patients had one or more positive LPLNs. The median follow-up was 16 months (IQR 5-33 months), with 1 (2.5%) local central recurrence and 7 (17.5%) patients developing distant disease, resulting in 3 (7.5%) deaths.

CONCLUSION

Robotic LPLND for rectal cancer can be performed in Western patients to completely resect extra-mesorectal LPLNs and is associated with acceptable perioperative morbidity.

Robotic-assisted resection for beyond TME rectal cancer: a novel classification and analysis from a specialized center

Locally advanced rectal cancer often requires an extended resection beyond the total mesorectal excision plane (bTME) to obtain clear resection margins. We classified three types of bTME rectal cancer following local disease diffusion: radial (adjacent pelvic organs), lateral (pelvic lateral lymph nodes) and longitudinal (below 3.5 cm from the anal verge, submitted to intersphincteric resection). The primary aim of this study was to evaluate the application of robotic surgery to the three types of bTME regarding the short and long-term oncological outcomes. Secondary aim was to identify survival prognostic factors for bTME rectal cancers. A total of 137 patients who underwent robotic-assisted bTME procedures between 2008 and 2018 were extracted from a prospectively collected database. Patient-related, operative and pathological factors were assessed. Morbidity was moderately high with 66% of patients reporting postoperative complications. Median follow up was 47 months (IQR, 31.5-66.5). Local recurrence rate was 15.3% with a statistical difference between the three types of bTME (p = 0.041). Disease progression/distant metastasis rate was 33.6%. Overall survival was significantly different (p = 0.023) with 1- and 3-years rates of: 77.8% and 55.0% (radial; n = 19); 96.6% and 84.8% (lateral; n = 30); 97.7% and 86.9% (longitudinal; n = 88). No statistical difference was observed for disease-free survival (p = 0.897). Local recurrence-free survival was significantly different between the groups (p = 0.031). Multivariate analysis showed that (y)pT (p = 0.028; HR (95% CI) 5.133 (1.192-22.097)), (y)pN (p = 0.014; HR (95% CI) 2.835 (1.240-6.482)) and type of bTME were associated to OS whilst (y)pT (p = 0.072) and type of bTME were not associated to LRFS.

Laparoscopic versus open selective lateral pelvic lymph node dissection following total mesorectal excision for locally advanced low rectal cancer

PURPOSES

Lateral pelvic lymph node (LPLN) dissection represents a technically challenging procedure with a high potential risk of surgical morbidity. The purpose of this study was to compare the technical feasibility, safety, and oncological efficacy of laparoscopic LPLN dissection (LPLD) following total mesorectal excision (TME) with open LPLD for locally advanced low rectal cancer (LALRC).

METHODS

Between January 2010 and December 2016, consecutive patients with LALRC and swollen LPLNs who underwent laparoscopic or open TME with LPLD at our institution were enrolled in this retrospective observational study. Data regarding patient demographics, perioperative characteristics, and oncological outcomes were analyzed and compared.

RESULTS

A total of 64 patients met the inclusion criteria. Thirty-four patients underwent open procedure, and 30 underwent laparoscopic procedure. The mean blood loss volume was significantly less in the laparoscopic group than in the open group (165 vs. 422 mL; P = 0.012). The mean operative time was not significantly different between the laparoscopic and the open groups (354 ± 91 vs. 315 ± 78 min; P = 0.522). The overall postoperative complication rates were 30.0% and 35.3% for the laparoscopic and open groups (P = 0.428), respectively. Postoperative urinary retention was significantly less in the laparoscopic group than in the open group (14.7 vs. 0%; P = 0.036).The duration of postoperative hospital stay was significantly shorter in the laparoscopic group (8.5 ± 3.8 vs. 13.6 ± 6.5 days; P = 0.025). The numbers of harvested lymph nodes and positive resection margin rates showed no significant differences. Pathological LPLN metastases were confirmed in 10 patients (29.4%) in the open group and 11 (36.7%) in the laparoscopic group (P = 0.537). The median follow-up duration was 41.5 months (range 3-98). The laparoscopic and open groups also showed a similar 3-year overall survival rate (88.2% vs. 85.3%; P = 0.577), relapse-free survival rate (73.3% vs. 67.6%; P = 0.889), and local recurrence rate (3.3 vs. 5.9%; P = 0.653).

CONCLUSIONS

Laparoscopic TME with LPLD is technically feasible and safe in selected patients with LALRC and is associated with similar oncological outcomes as open approach.

Robotic surgery for rectal cancer as a platform to build on: review of current evidence

Laparoscopy in colorectal surgery reduces the rate of postoperative complications, shortens the length of stay in hospital, and improves the quality of patient care. Despite these established benefits, the technical challenges of rectal resection for cancer have resulted in most operations being performed through open surgery in the USA. Moreover, controversy in the current literature questions the oncologic safety of a laparoscopic approach for rectal cancer. How then can surgeons innovate to overcome the technical challenges while preserving the critical oncological outcomes of high-quality rectal cancer surgery? Robotics may be a platform that allows us to overcome the technical challenges in the pelvis while maintaining both oncological outcomes and the benefits of a minimally invasive technique. Current evidence suggests that the quality of total mesorectal excision, the rates of circumferential margin involvement, and postoperative outcomes are comparable between robotic and laparoscopic surgery. While a robotic approach demonstrates lower conversion rates and reduced surgeon workload, the operative time is longer and initial costs are higher; however, time and future science will determine its true benefits. We review the current state of robotic surgery and its impact on rectal cancer surgery.

Robotic Surgery for Rectal Cancer: Operative Technique and Review of the Literature

The number of patients undergoing robotic surgery for rectal cancer has rapidly increased in Japan, since the government approved the procedure for national insurance coverage in April 2018. Robotic surgery has the potential to overcome some limitations of laparoscopic surgery, especially in the narrow pelvis, providing a three-dimensional view, articulated instruments, and a stable camera platform. Although meta-analyses and randomized controlled trials have failed to demonstrate the superiority of robotic surgery over laparoscopic surgery with respect to the short-term clinical outcomes, the published findings suggest that robotic surgery may be potentially beneficial for patients who are obese, male, or patients undergoing sphincter-preserving surgery for rectal cancer. The safety and feasibility of robotic surgery for lateral lymph node dissection, the standard procedure for locally advanced lower rectal cancer in Japan, have been demonstrated in some retrospective studies. However, additional prospective, randomized trials are required to determine the actual benefits of robotic surgery to ameliorate the urogenital and oncological outcomes. The cost of this approach is a long-standing principal concern. A literature search showed that the cost of robotic surgery for rectal cancer was 1.3-2.5 times higher per patient than that for the laparoscopic approach. We herein describe our surgical technique using a da Vinci Surgical System (S/Si/Xi) with 10 years of experience in performing robotic surgery. We also review current evidence regarding short-term clinical and long-term oncological outcomes, lateral lymph node dissection, and the cost of the procedure.

Laparoscopic and robotic lateral lymph node dissection for rectal cancer

In the era of neoadjuvant chemoradiotherapy/radiotherapy and total mesorectal excision, overall oncological outcomes after curative resection of rectal cancer are excellent, with local recurrence rates as low as 5–10%. However, lateral nodal disease is a major cause of local recurrence after neoadjuvant chemoradiotherapy/radiotherapy and total mesorectal excision. Patients with lateral nodal disease have a local recurrence rate of up to 30%. The oncological benefits of lateral pelvic lymph node dissection (LPLND) in reducing local recurrence, particularly in the lateral compartment, have been demonstrated. Although LPLND is not standard in Western countries, technical improvements in minimally invasive surgery have resulted in rapid technical standardization of this complicated procedure. The feasibility and short- and long-term outcomes of laparoscopic and robotic LPLND have been reported widely. A minimally invasive approach has the advantages of less bleeding and providing a better surgical view of the deep pelvic anatomy than an open approach. With precise autonomic nerve preservation, postoperative genitourinary dysfunction has been reported to be minimal. We review recent evidence on the management of lateral nodal disease in rectal cancer and technical improvements of LPLND, focusing on laparoscopic and robotic LPLND.

Evaluating predictive factors for determining the presence of lateral pelvic node metastasis in rectal cancer patients following neoadjuvant chemoradiotherapy

AIM

The need or otherwise for lateral pelvic node dissection (LPND) in rectal cancer patients with clinical lateral pelvic node metastasis (LPNM) after neoadjuvant chemoradiotherapy (nCRT) is controversial. This study was designed to explore the predictive factors for pathological LPNM in rectal cancer patients with clinical LPNM after nCRT.

METHOD

From January 2010 to February 2018, a consecutive series of patients with rectal cancer and clinical LPNM after nCRT who underwent total mesorectal excision and LPND were reviewed. Patient demographics, operative and pathological outcomes were collected and analysed.

RESULTS

A total of 76 consecutive cases were included in this study: 53 (69.7%) patients underwent unilateral LPND and 23 (30.3%) bilateral LPND. The pathological results showed that LPNM was found in 13 (17.1%) patients. Multivariate logistic regression analysis showed that the post-nCRT lateral pelvic node size ≥ 5 mm (OR = 7.67, 95% CI = 1.45-40.63, P = 0.017) and mucinous/signet-ring adenocarcinoma (OR = 4.60, 95% CI = 1.11-19.08, P = 0.035) were independent risk factors for pathological LPNM.

CONCLUSION

Post-nCRT lateral pelvic node size ≥ 5 mm and mucinous/signet-ring adenocarcinoma were independent predictive factors of pathological LPNM for rectal cancer patients with clinical LPNM after nCRT, and patients with these characteristics may benefit from LPND.