Robotic surgery for clinical T4 rectal cancer: short- and long-term outcomes

Robotic versus open and laparoscopic pelvic exenterations for pelvic cancer: a multicenter propensity-matched analysis in Japan

BACKGROUND

Pelvic exenteration (PE) is the last resort for achieving a complete cure for pelvic cancer; however, it is burdensome for patients. Minimally invasive surgeries, including robot-assisted surgery, have been widely used to treat malignant tumors and have also recently been used in PE. This study aimed to evaluate the safety and efficacy of robot-assisted PE (RPE) by comparing the outcomes of open PE (OPE) with those of conventional laparoscopic PE (LPE) for treating pelvic tumors.

METHODS

Following the ethics committee approval, a multicenter retrospective analysis of patients who underwent pelvic exenteration between January 2012 and October 2022 was conducted. Data on patient demographics, tumor characteristics, and perioperative outcomes were collected. A 1:1 propensity score-matched analysis was performed to minimize group selection bias.

RESULTS

In total, 261 patients met the study criteria, of whom 61 underwent RPE, 90 underwent OPE, and 110 underwent LPE. After propensity score matching, 50 pairs were created for RPE and OPE and 59 for RPE and LPE. RPE was associated with significantly less blood loss (RPE vs. OPE: 408 mL vs. 2385 ml, p < 0.001), lower transfusion rate (RPE vs. OPE: 32% vs. 82%, p < 0.001), and lower rate of complications over Clavien-Dindo grade II (RPE vs. OPE: 48% vs. 74%, p = 0.013; RPE vs. LPE: 48% vs. 76%, p = 0.002).

CONCLUSION

This multicenter study suggests that RPE reduces blood loss and transfusion compared with OPE and has a lower rate of complications compared with OPE and LPE in patients with locally advanced and recurrent pelvic tumors.

Minimally invasive versus open multivisceral resection for rectal cancer clinically invading adjacent organs: a propensity score-matched analysis

BACKGROUND

Minimally invasive surgery (MIS), such as laparoscopic and robotic surgery for rectal cancer, is performed worldwide. However, limited information is available on the advantages of MIS over open surgery for multivisceral resection for cases clinically invading adjacent organs.

PATIENTS AND METHODS

This was a retrospective propensity score-matching study of consecutive clinical T4b rectal cancer patients who underwent curative intent surgery between 2006 and 2021 at the University of Tokyo Hospital.

RESULTS

Sixty-nine patients who underwent multivisceral resection were analyzed. Thirty-three patients underwent MIS (the MIS group), while 36 underwent open surgery (the open group). Twenty-three patients were matched to each group. Conversion was required in 2 patients who underwent MIS (8.7%). R0 resection was achieved in 87.0% and 91.3% of patients in the MIS and open groups, respectively. The MIS group had significantly less blood loss (170 vs. 1130 mL; p < 0.0001), fewer Clavien-Dindo grade ≥ 2 postoperative complications (30.4% vs. 65.2%; p = 0.0170), and a shorter postoperative hospital stay (20 vs. 26 days; p = 0.0269) than the open group. The 3-year cancer-specific survival rate, relapse-free survival rate, and cumulative incidence of local recurrence were 75.7, 35.9, and 13.9%, respectively, in the MIS group and 84.5, 45.4, and 27.1%, respectively, in the open group, which were not significantly different (p = 0.8462, 0.4344, and 0.2976, respectively).

CONCLUSION

MIS had several short-term advantages over open surgery, such as lower complication rates, faster recovery, and a shorter hospital stay, in rectal cancer patients who underwent multivisceral resection.

Risk factors for lateral lymph node metastasis based on the molecular profiling of rectal cancer

AIM

The association between molecular profiles and lateral lymph node metastasis (LLNM) in patients with rectal cancer remains unclear. Therefore, this study aimed to identify the molecular profiles of rectal cancer associated with LLNM.

METHOD

We retrospectively examined patients who underwent rectal cancer surgery with lateral lymph node dissection without preoperative treatment and whose surgically resected specimens were evaluated using multiomics-based analyses from 2014 to 2019. We compared the clinical characteristics and molecular profiles of patients with pathological LLNM (pLLNM+) with those of patients without (pLLNM-) and identified risk factors for LLNM.

RESULTS

We evaluated a total of 123 patients: 18 with and 105 without pLLNM. The accumulation of mutations in genes key for the development of colorectal cancer were similar between the groups, as was the tumour mutation burden. The distribution of consensus molecular subtypes (CMS) was significantly different between the groups (p = 0.0497). The pLLNM+ patients had a higher prevalance of CMS4 than the pLLNM- patients (77.8% vs. 51.4%). According to the multivariate analysis, the independent risk factors for LLNM were a short-axis diameter of the lateral lymph node of ≥6.0 mm and CMS4; furthermore, the presence of either or both had a sensitivity of 100% for the diagnosis of LLNM.

CONCLUSION

Lateral lymph node size and CMS4 are useful predictors of LLNM. The combination of CMS classification and size criteria was remarkably sensitive for the diagnosis of LLNM.

Comparison of robotic‑assisted versus conventional laparoscopic surgery for mid-low rectal cancer: a systematic review and meta-analysis

PURPOSE

Scarce research has reported the comparison between robotic and laparoscopic surgery in mid-low rectal cancer. Therefore, this meta-analysis is aimed to compare the safety and efficacy of the two surgical approaches.

METHODS

A comprehensive search of the databases (PubMed, EMBASE, Cochrane, and Web of Science) was performed for studies comparing robotic and laparoscopic surgery. The outcomes of interest acquired from eight articles included three aspects: intraoperative conditions, postoperative status of patients, and complications. All data (robotic = 1350 patients, laparoscopic = 1330 patients) enrolled were analyzed using Rev Man 5.4.

RESULTS

Compared to the laparoscopic group, the robotic group indicated a noticeable superiority in estimated blood loss (P < 0.0001), number of lymph nodes dissected (P = 0.004), time to first flatus (P = 0.001), time to first fluid diet (P = 0.001), hospital stay (P < 0.0001), conversion (P = 0.009), and urinary retention (P = 0.0006), but devoted much more operation time (P = 0.0004).

CONCLUSION

Robotic surgery was associated with superiority over laparoscopic surgery in increasing surgical safety, accelerating postoperative recovery, and reducing complications, which suggested that robotic surgery could be a safe and effective method for treating mid-low rectal cancer.

Propensity matched analysis of robotic and laparoscopic operations for mid-low rectal cancer: short-term comparison of anal function and oncological outcomes

Laparoscopic surgery for rectal cancer, while in some respects equivalent or even preferable to open surgery, is challenged in specific conditions where the tumor is located in the middle and lower third of the rectum. Robotic surgery equipped with a superior arm of machinery and gained better visualization can compensate for the deficiency of the laparoscopic approach. This study adopted a propensity matched analysis to compare the functional and oncological short-term outcomes of laparoscopic and robotic surgery. All patients who underwent proctectomy have been collected prospectively between December 2019 and November 2022. After censoring for inclusion criteria, we performed a propensity matching analysis. A detailed collection of post-operative examination indicators was performed, while the K-M survival curves were plotted to analyze post-operative oncology outcomes. The LARS scale was designed to evaluate the anal function of patients in the form of questionnaires. Totally, 215 patients underwent robotic operations while 1011 patients selected laparoscopic operations. Patients matched 1∶1 by propensity score were divided into the robotic and laparoscopic groups, 210 cases were included in each group. All patients underwent a follow-up for a median period of 18.3 months. Robotic surgery was connected with an enhanced recovery including the earlier time to first flatus passage without ileostomy (P = 0.050), the earlier time to liquid diet without ileostomy (P = 0.040), lower incidence of urinary retention (P = 0.043), better anal function 1 month after LAR without ileostomy (P < 0.001), longer operative time (\P = 0.042), compared with laparoscopic operations. The oncological outcomes and occurrence of other complications were comparable between the two approaches. For mid-low rectal cancer, robotic surgery could be recognized as an effective technique with identical short-term outcomes of oncology and better anal function in comparison to laparoscopic surgery. However, multi-center studies with larger samples are expected to validate the long-term outcomes of robotic surgery.

Robotic Total Mesorectal Excision for Low Rectal Cancer: A Narrative Review and Description of the Technique

Robotic surgery may offer significant advantages for treating extraperitoneal rectal cancer. Although laparoscopy has been shown to be safe and effective, laparoscopic total mesorectal excision (TME) remains technically challenging and is still performed in selected centers. Robotic anterior resection (RAR) may overcome the drawback of conventional laparoscopy, providing high-quality surgery with favorable oncological outcomes. Moreover, recent data show how RAR offers clinical and oncological benefits when affording difficult TMEs, such as low and advanced rectal tumors, in terms of complication rate, specimen quality, recurrence rate, and survival. This series aims to review the most recent and relevant literature, reporting mid- and long-term oncological outcomes and focusing on minimally invasive RAR for low rectal cancer.

Possible Advantages of Minimal-Invasive Approaches in Rectal Cancer Surgery: A Nationwide Analysis

(1) Background: Laparoscopic resection for colon and rectal cancer was introduced in the early 1990s; the aim of this analysis was to show possible advantages of minimal-invasive approaches in rectal cancer surgery. (2) Methods: From 2016 to 2020, all patients undergoing open, laparoscopic or robotic-assisted rectal cancer surgery in Germany were retrospectively analyzed regarding sex distribution, conversion rates and in-hospital mortality rates according to nationwide hospital billing data based on diagnosis-related groups (DRGs). (3) Results: In total, 68,112 patients were analyzed, and most commonly, low anterior rectal resections with primary anastomosis (n = 25,824) were performed with an increase of minimal-invasive procedures over the years (open: 51% to 27%; laparoscopic: 47% to 63% and robotic: 2% to 10%). In-hospital mortality rate was 2.95% (n = 2012). In total, 4.61%, 1.77%, 1.14% and 3.95% of patients with open, laparoscopic, robotic and converted-to-open surgery died during hospital stay, respectively (open vs. laparoscopic p < 0.0001; open vs. robotic p < 0.00001; laparoscopic vs. robotic p = 0.001). Conversion rates were significantly more favorable in the robotic compared to the laparoscopic group. (11.94% vs. 2.53%; p < 0.0001). (4) Conclusion: Minimal-invasive rectal cancer surgery might have some advantages in terms of a reduced in-hospital mortality, and an improved conversion rate for the robotic approach.

Robotic surgery for locally advanced T4 rectal cancer: feasibility and oncological quality

For T4 rectal tumours and local recurrences (LR) of rectal cancer, a radical resection beyond TME, sometimes by multi-visceral resection, is important to obtain safe margins and improve survival. The use of the laparoscopic approach (LA) for these cases is still controversial and associated with a high rate of conversion. However, robotic surgery might offer some advantages that can overcome some of the limitations of LA. Therefore, we aimed to analyse the postoperative outcomes and medium-term oncological results of robotic surgery for locally advanced rectal cancer (pathological T4) and LR. A retrospective analysis was performed including patients who had undergone robotic rectal resection in a single institution over an 11-year period, and had a T4 tumour confirmed in the pathological report. Primary endpoint was to analyse postoperative complications (30-day) and the rate of conversion. Secondary endpoints include pathological assessment of the quality of the specimen, local recurrence and survival [2-year disease-free survival (DFS) and overall survival (OS)]. A total of 41 patients were analysed, including a total of 24 patients (60%) that required a multivisceral resection. The median distance from the tumour to the anorectal junction was 7 (4-12) cm. Conversion to open surgery was necessary in 2 cases (5%). The overall morbidity rate was 78% (n = 32), with 37% of major complications, most of them urinary (n = 7). Median length of hospital stay (LOS) was 13 (7-27) days. The 30-day mortality rate was 7% (n = 3). An R0 resection was achieved in 85.4% of the cases (n = 35) due to 6 cases of the positive circumferential resection margin. 2-year disease-free survival (DFS) and overall survival (OS) for the T4 tumours were 72% and 85%, respectively. There were 8 cases of local recurrence (22.2%); 6 of them met the selection criteria for salvage surgery. Robotic surgery for locally advanced T4 rectal cancer and multi-visceral resections is safe and feasible, with a low rate of conversion and an acceptable rate of postoperative morbidity in this subgroup of patients. Oncological results have shown to be comparable with the laparoscopic series published, preserving a good quality of the resected specimen. However, comparative studies and a longer follow-up period is needed to confirm the oncologic findings and to support the general adoption of the robotic system for these complex interventions.

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.

Minimally invasive versus open pelvic exenterations for rectal cancer: a comparative analysis of perioperative and 3-year oncological outcomes

BACKGROUND

This study compared the surgical and oncological outcomes of open and minimally invasive pelvic exenteration.

METHODS

Patients who underwent pelvic exenterations for primary locally advanced rectal cancers with invasion of the urogenital organs (central and anterior disease) between August 2013 and September 2020 were reviewed retrospectively. Patients were categorized as undergoing open or minimally invasive surgery (MIS) and these groups were compared for perioperative outcomes and 3-year survival (overall, recurrence-free and local relapse-free survival). Multivariable Cox regression analysis was performed to assess the independent influence of approach of surgery and cancer features on recurrence-free survival (RFS).

RESULTS

Of the 158 patients who underwent pelvic exenteration, 97 (61.4 per cent) had open exenterations and 61 (38.6 per cent) patients had an MIS resection (44 patients (72 per cent) using laparoscopy and 17 (28 per cent) using robotic surgery). There were 96 (60.8 per cent) total pelvic exenterations and 62 (39.2 per cent) posterior pelvic exenterations. MIS exenterations had significantly longer operative times (MIS versus open: 640 mins versus 450 mins; P < 0.001) but reduced blood loss (MIS versus open: 900 ml versus 1600 ml; P < 0.001) and abdominal wound infections (MIS versus open: 8.2 versus 17.5 per cent; P = 0.020) without a difference in hospital stay (MIS versus open: 11 versus 12 days; P = 0.620). R0 resection rates and involvement of circumferential resection margins were similar (MIS versus open: 88.5 versus 91.8 per cent, P = 0.490 and 13.1 versus 8.2 per cent, P = 0.342 respectively). At a median follow-up of 29 months, there were no differences in 3-year overall survival (MIS versus open: 79.4 versus 60.2 per cent; P = 0.251), RFS (MIS versus open: 51.9 versus 47.8 per cent; P = 0.922) or local relapse-free survival (MIS versus open: 89.7 versus 75.2 per cent; P = 0.491. On multivariable analysis, approach to surgery had no bearing on RFS, and only known distant metastasis, aggressive histology and inadequate response to neoadjuvant radiation (pathological tumour regression grade greater than 3) predicted worse RFS.

CONCLUSION

MIS exenterations documented longer procedures but resulted in less blood loss and fewer wound infections compared with open surgeries. In the setting of an experienced centre, the hospital stay, R0 resection rates and oncological outcomes at 3 years were similar to those of open exenterations.