Robotic surgery shows benefits vs. laparoscopic surgery for middle, low rectal cancer
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Robotic-assisted surgery significantly improved outcomes compared with laparoscopic surgery among patients with middle and low rectal cancer, according to study results presented at ASCO Gastrointestinal Cancers Symposium.
Rationale
Robotic surgery for rectal cancer is gaining popularity, but persuasive evidence on long-term oncologic outcomes is lacking, Jianmin Xu, MD, PhD, researcher in the department of general surgery at Zhongshan Hospital Fudan University in Shanghai, China, and colleagues wrote.
Methods
The multicenter, randomized controlled trial compared robotic surgery vs. laparoscopic surgery among 1,240 patients receiving treatment for middle and low rectal cancer across 11 hospitals in eight Chinese provinces.
Results for the primary endpoint of 3-year locoregional recurrence rate are anticipated by the end of 2023. Xu presented findings from a modified intention-to-treat analysis including 1,180 patients that assessed short-term secondary endpoints, including surgical quality, pathologic radicality and postoperative recovery among those assigned robotic surgery (n = 591) vs. laparoscopic surgery (n = 589).
Key findings
Significantly more low anterior resections occurred in the robotic surgery group (83.1% vs. 76.9%; P = .008).
Moreover, the robotic surgery had more macroscopic complete resections (95.4% vs. 91.9%; P = .012), better integrity of the mesorectal fascia, a lower circumferential resection margin positivity rate (4% vs. 7.1%; 95% CI, 6 to 0.5) and more lymph nodes harvested (median, 15 vs. 14; P = .004).
Researchers additionally observed lower open conversion rates (1.7% vs. 3.9%; P = .021), less estimated blood loss (median, 40 mL vs. 50 mL; P < .001), and lower intraoperative complication rates (5.4% vs. 8.7%; P = .029) and 30-day complication rates after surgery (16.1% vs. 22.9%; P = .003) among those who underwent robotic surgery, which led to better recovery time and shorter hospital stay compared with laparoscopic surgery (7 days vs. 8 days; P < .001).
The two groups had similar 30-day mortality rates (0.2% for both).
Perspective
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Mark Hanna, MD
Much debate and discussion continues regarding the difference and potential superiority of robotic vs. laparoscopic surgery for rectal cancer. Ample literature has shown that the robotic platform for rectal cancer provides comparable outcomes for intraoperative technique, postoperative complications and short-term clinical recovery. This is counterbalanced by the higher intraoperative costs of robotic surgery compared with laparoscopic surgery.
Xu and colleagues should be commended for completing a large randomized controlled trial comparing robotic resection with laparoscopic resection in middle and low rectal cancer. Although these results have not yet been replicated consistently in other trials, it is encouraging to see that as the robotic technique continues to mature in experienced hands and as more surgeons ascend the learning curve, the subtle benefits of the robotic technique may start to become better elucidated.
It is, however, imperative to remember that both the laparoscopic and robotic platforms do not compensate for sound surgical judgement and good technique. A proficient total mesorectal excision remains the most critical factor determining the success of rectal cancer surgical care, and that is achievable both laparoscopically or robotically. Therefore, the ultimate decision on the surgical technique to treat rectal cancer should be based on a sincere weighing of surgeon preference and experience in order to provide the patient with the best care possible regardless of the tools or platforms used.
Collapse
Xu J, et al. Abstract 14. Presented at: ASCO Gastrointestinal Cancers Symposium; Jan. 20-22, 2022; San Francisco.
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