Robotic beyond total mesorectal excision surgery for primary and recurrent pelvic malignancy: Feasibility and short-term outcomes

Robotic-assisted surgery for locally advanced rectal cancer beyond total mesorectal excision planes: the Mayo Clinic experience

BACKGROUND

The purpose of this study was to evaluate the surgical and oncological outcomes of robotic-assisted beyond-TME surgery for locally advanced rectal cancer.

METHODS

Consecutive adult (≥ 18 years old) patients who underwent a robotic-assisted proctectomy beyond-TME planes for primary or recurrent rectal cancer at three Mayo Clinic (USA) hospitals from 2017-2023 were included. Patient demographics and tumor and disease characteristics were obtained by review of the electronic health record. Outcomes of interest included postoperative complications, hospital length of stay, and pathologic and oncologic outcomes.

RESULTS

In total, 72 patients were included in the final cohort. Thirty-five (48.6%) patients underwent an extended resection without exenteration, while 22 (30.6%) underwent a multi-visceral en bloc exenteration; 20 (36.1%) patients underwent a lateral pelvic lymph node dissection, with or without a concomitant extended resection. Most cases had an advanced T-stage and an involved mesorectal fascia on pre-treatment MRI. The median operative time was 425.0 min (340.5-504.0) and the median estimated blood loss was 150.0 mL (75.0-277.5). Conversion to open surgery was needed in two (2.8%) cases. Nearly half the cohort (48.3%) experienced a postoperative complication and the median postoperative length of stay was 3.5 (3.0-7.0) days. Five cases had a positive margin, resulting in an R0 rate of 93.1%. None of the exenteration cases had a positive margin. After a median follow-up of 22.0 (13.0-45.7) months, 10 patients experienced a local recurrence (13.8%).

CONCLUSION

Robotic-assisted beyond-TME surgery can be performed safely with favorable postoperative clinical and oncologic outcomes.

Initial experience and results of robotic lateral pelvic lymph node dissection in locally advanced rectal cancer-a single center experience of 17 consecutive procedures

PURPOSE

We have evaluated lateral pelvic lymph node dissection (LPLND) in combination with rectal resection in the treatment of locally advanced rectal cancer in a specialized colorectal surgical department with a focus on safety and feasibility.

METHODS

The study analyzed surgical-pathologic outcomes in 17 consecutive patients who underwent robotic LPLND and rectal resection between May 2018 and June 2024 at a high-volume colorectal cancer center in Denmark. Patients were selected for the procedure based on lateral lymph node (LLN) diameter ≥ 8 mm before and ≥ 5 mm after neoadjuvant treatment.

RESULTS

Out of 17 patients (15 men and 2 females) included in this study, 13 patients (76%) had undergone neoadjuvant therapy. The median age was 63 years (range 35-79) with a median BMI of 25.6 kg/m2 (range 19.4-34.5). The total median operation time was 335 min (range 182-526 min) with no conversions necessary. Additional resection of structures beyond the total mesorectal excision plane was performed in eight patients (47%). The median hospital stay was 4 days (range 2-14) and one patient was readmitted within 30 days. Seven patients experienced postoperative complications within 30 days, with only one CD complication ≥ grade 3. The median number of resected LLNs was 4 (range 0-11) per patient and malignant LLNs were verified in three patients (17.6%).

CONCLUSION

This study shows that simultaneous robot-assisted LPLND and rectal resection can be performed safely and effectively in selected patients with locally advanced rectal cancer, with a short hospital stay and few readmissions and postoperative complications.

Advances in beyond total mesorectal excision surgery: Behind the scenes

The management of locally advanced rectal cancer involving adjacent organs and extending beyond the surgical planes of total mesorectal excision has evolved over the past few decades both in terms of the effectiveness of preoperative treatments and surgical innovation. The use of a robotic platform is increasing, even in complex surgery such as pelvic exenteration together with the advantages of minimally invasive procedures. However, satisfactory surgical, oncological, and functional outcomes are achieved not only minimizing the impact of a demolitive surgery but also when a multidisciplinary specialized team focuses on experienced surgeons, mandatory rules of surgical oncology, appropriate medical treatments, accurate preoperative planning, and an acceptable quality of life.

Open versus robotic-assisted techniques for multivisceral pelvic resections of locally advanced or recurrent colorectal and anal cancers: short-term outcomes from a single centre

BACKGROUND

Pelvic exenterations are now established as a standard of care for locally advanced and recurrent rectal cancer. Traditionally, these radical and complex operations have been performed via an open approach, but with the increasing expertise in robotic-assisted surgery (RAS), there is scope to perform such cases robotically. This study compares outcomes from open and RAS pelvic exenterations.

METHODS

This retrospective observational study includes all pelvic exenterations for locally advanced or recurrent colorectal cancers performed in a single centre between September 2018 and September 2023. Cases were grouped into open or RAS surgery and classified in terms of operative extent and complexity. The primary outcome was resection margin status. Secondary outcomes were postoperative morbidity, length of stay and blood loss.

RESULTS

Thirty-three patients were included. Nineteen (57.6%) cases utilised an open technique, and 14 (42.4%) used RAS. Patient characteristics and operative complexity were equivalent between groups. R0 rate (63.1% vs 71.4%, p = 0.719), median haemoglobin drop (19 (11-30) g/L vs 13 (5-26) g/L, p = 0.208) and postoperative morbidity (18/19 (94.7%) vs 9/14 (64.3%), p = 0.062) were equivalent. Length of stay (16.0 days (8-25) vs 9.5 days (6-16), p = 0.047) was shorter in the RAS group.

CONCLUSIONS

Short-term surgical and histopathological outcomes are equivalent in this small cohort of patients. This study suggests that RAS may be a safe and effective method for performing pelvic exenterations for colorectal malignancies. Larger-scale and robustly designed prospective studies are required to confirm these preliminary findings and report on long-term oncological outcomes.

Perioperative and oncological outcomes following robotic en bloc multivisceral resection for colorectal cancer

AIM

As multidisciplinary treatment strategies for colorectal cancer have improved, aggressive surgical resection has become commonplace. Multivisceral and extended resections offer curative-intent resection with significant survival benefit. However, limited data exist regarding the feasibility and oncological efficacy of performing extended resection via a minimally invasive approach. The aim of this study was to determine the perioperative and long-term outcomes following robotic extended resection for colorectal cancer.

METHOD

We describe the population of patients undergoing robotic multivisceral resection for colorectal cancer at our single institution. We evaluated perioperative details and investigated short- and long-term outcomes, using the Kaplan-Meier method to analyse overall and recurrence-free survival.

RESULTS

Among the 86 patients most tumours were T3 (47%) or T4 (47%) lesions in the rectum (78%). Most resections involved the anterior compartment (72%): bladder (n = 13), seminal vesicle/vas deferens (n = 27), ureter (n = 6), prostate (n = 15) and uterus/vagina/adnexa (n = 27). Three cases required conversion to open surgery; 10 patients had grade 3 complications. The median hospital stay was 4 days. Resections were R0 (>1 mm) in 78 and R1 (0 to ≤1 mm) in 8, with none being R2. The average nodal yield was 26 and 48 (55.8%) were pN0. Three-year overall survival was 88% and median progression-free survival was 19.4 months. Local recurrence was 6.1% and distant recurrence was 26.1% at 3 years.

CONCLUSION

Performance of multivisceral and extended resection on the robotic platform allows patients the benefit of minimally invasive surgery while achieving oncologically sound resection of colorectal cancer.

Short-term results after robot-assisted surgery for primary rectal cancers requiring beyond total mesorectal excision in multiple compartments

AIM

Rectal cancers requiring beyond total mesorectal excision (bTME) are traditionally operated using an open approach, but the use of minimally invasive robot-assisted procedures is increasing. Introduction of minimal invasive surgery for complex cancer cases could be associated with compromised surgical margins or increased complication rates. Therefore, reporting results both clinical and oncological in large series is important. Since bTME procedure reports are heterogeneous, comparing results is often difficult. In this study, a magnetic resonance imaging (MRI) classification system was used to describe the bTME surgery according to pelvic compartments.

METHODS

Consecutive patients with primary rectal cancer operated with laparoscopic robot-assisted bTME were prospectively included for 2 years. All patients had tumors that threatened the mesorectal fascia, invaded adjacent organs, and/or involved metastatic pelvic lateral lymph nodes. Short-term clinical outcomes and oncological specimen quality were registered. Surgery was classified according to pelvic compartments resected.

RESULTS

Clear resection margins (R0 resection) were achieved in 95 out of 105 patients (90.5%). About 26% had Accordion Severity Grading System of Surgical Complications grade 3-4 complications and 15% required re-operations. About 7% were converted to open surgery. The number of compartments resected ranged from one to the maximum seven, with 83% having two or three compartments resected. All 10 R1 resections occurred in the lateral and posterior compartments.

CONCLUSIONS

The short-term clinical outcomes and oncological specimen quality after robot-assisted bTME surgery were comparable to previously published open bTME surgery. The description of surgical procedures using the Royal Marsden MRI compartment classification was feasible.

Feasibility of robotic platform to perform R0 resection for locally advanced multi-visceral pelvic malignancy: an institutional experience on outcomes of robotic pelvic exenteration

BACKGROUND

Exenteration surgery for multi-visceral pelvic malignancy is a complex life-changing operation with high perioperative morbidity and mortality. Traditional open surgery has long been the standard approach for pelvic exenteration for achieving Ro resection which is the main aim of surgery. In the current era of minimally invasive surgery, robotic-assisted pelvic exenteration has provided a promising alternative, offering potential advantages in terms of improved oncological outcomes and enhanced postoperative recovery. This study aims to explore the feasibility of a robotic platform for locally advanced multi-visceral pelvic malignancy.

METHODS

A retrospective review from the prospectively maintained robotic colorectal surgery database at University Hospital Coventry and Warwickshire (UHCW) Trust was performed. Demographic details and clinical and surgical details were documented from the case records. Data was analysed using SPSS version 22.

RESULTS

Thirteen female patients diagnosed with primary or recurrent pelvic malignancy who underwent robotic pelvic exenteration at UHCW between February 2019 and April 2023 at UHCW were included. The mean age of our patients was 60.4 (± 10.1) years. Complete Ro resection was achieved in all 13 (100%) cases on final histopathology. The median length of hospital stay was 15 days after this extensive surgery. Grade 3 morbidity on Clavien-Dindo classification was observed in four (30.7%) patients, while zero percent 30-day mortality was experienced in this study. At a median follow-up of 21 (3-53) months, we observed tumor recurrence in three (23.7%) patients, while death in four (30.7%) patients. Only few studies have highlighted outcomes of robotic pelvic exenteration, and our results were quite comparable to them.

CONCLUSION

Robotic-assisted pelvic exenteration for primary or recurrent pelvic malignancy is feasible with improved oncological and acceptable postoperative outcomes.

Analysis of clinical efficacy and safety of hand-sewn anastomosis for the digestive tract with Da Vinci robot in rectal cancer surgery

PURPOSE

The study aimed to analyze the clinical efficacy and safety of hand-sewn anastomosis for the digestive tract with Da Vinci robot in rectal cancer surgery.

METHODS

A retrospective study was conducted to collect the clinical data from 27 patients who underwent Da Vinci robotic rectal cancer radical surgery in the department of gastrointestinal surgery at the Second Affiliated Hospital of Dalian Medical University from August 2019 to February 2022. All patients received a manual suture for digestive tract reconstruction. After the posterior wall was sutured, the anterior wall was sutured continuously. Finally, a prilling thread was used to sew the junction of the front and rear walls. Perioperative indexes and complications were recorded.

RESULTS

All 27 patients successfully underwent the operation. Neither conversion to laparotomy nor perioperative death occurred. The operation time and intraoperative blood loss were 183.6 ± 44.8 min and 54.8 ± 34.4 ml, respectively. A total of 15.3 ± 7.8 lymph nodes were harvested. The pain score 24 h after operation was 1.3 ± 1.3. The time out of bed, the time to exhaust, and the time to eat were 15.6 ± 2.9 h, 2.2 ± 0.8 days, and 2.1 ± 0.6 days, respectively. A total of 4 patients (14.8%) developed complications after the operation. Grade B anastomotic leakage gradually resolved after drainage and antibiotic therapy in 1 case. A patient with grade C anastomotic leakage received a second operation for ileostomy. One patient with postoperative pneumonia recovered after anti-infective treatment. Another patient with intraperitoneal hemorrhage improved after symptomatic treatment with blood transfusion and hemostasis. The postoperative hospitalization time and total hospitalization costs were 8.9 ± 4.4 days and 89,236.1 ± 13,527.9 yuan, respectively.

CONCLUSIONS

Manual suture with Da Vinci robotic surgery system is safe and feasible for reconstructing the digestive tract in rectal cancer surgery.

Outcomes of extended total mesorectal excision in patients with locally advanced rectal cancer

AIM

Extended total mesorectal excision (eTME) is a complex procedure involving en bloc resection of the structures surrounding the various quadrants of the rectum. This study, presenting the largest series so far of patients undergoing eTME, aimed to assess the surgical and survival outcomes of patients following treatment with eTME and to compare these outcomes with historical data on pelvic exenteration.

METHOD

The study is a retrospective review of all patients with locally advanced rectal cancer requiring an eTME (2014-2020). The database includes the demographic profile, operative details, histopathological features and follow-up.

RESULTS

One hundred and sixty three patients who underwent eTME were analysed. The overall Clavien-Dindo complication rate of > IIIa was 21.1%. The anterior quadrant was the most common anatomical site resected (68.5%). The R1 resection rate was 10.4%. After a median follow-up of 28 months, there were 51 recurrences in the study and twenty two deaths were recorded. The local recurrence rate was 7.3% among the study population. The disease-free survival (DFS) and overall survival were 66.7% and 80.4%, respectively, at 3 years. The majority of the recurrences were distant metastasis (84.3%). In univariate analysis, the quadrant involved did not affect survival. In multivariate analysis, signet ring histology, metastatic presentation, inadequate tumour response and R1 resection affected DFS.

CONCLUSION

The recurrence pattern, R1 resection rate and survival outcomes of patients in the present study were comparable with those for patients undergoing an exenteration. Therefore, eTME is probably a safe alternative to pelvic exenterations when R0 resection is achievable and when the procedure is performed in high-volume specialist tertiary care centres.

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.