Outcomes of robotic versus laparoscopic surgery for mid and low rectal cancer after neoadjuvant chemoradiation therapy and the effect of learning curve

Abstract

Randomized controlled trials have demonstrated that laparoscopic surgery for rectal cancer is safe and can accelerate recovery without compromising oncological outcomes. However, such a surgery is technically demanding, limiting its application in nonspecialized centers. The operational features of a robotic system may facilitate overcoming this limitation. Studies have reported the potential advantages of robotic surgery. However, only a few of them have featured the application of this surgery in patients with advanced rectal cancer undergoing neoadjuvant chemoradiation therapy (nCRT).From January 2012 to April 2015, after undergoing nCRT, 40 patients with mid or low rectal cancer were operated using the robotic approach at our institution. Another 38 patients who were operated using the conventional laparoscopic approach were matched to patients in the robotic group by sex, age, the body mass index, and procedure. All operations were performed by a single surgical team. The clinicopathological characteristics and short-term outcomes of these patients were compared. To assess the effect of the learning curve on the outcomes, patients in the robotic group were further subdivided into 2 groups according to the sequential order of their procedures, with an equal number of patients in each group. Their outcome measures were compared.The robotic and laparoscopic groups were comparable with regard to pretreatment characteristics, rectal resection type, and pathological examination result. After undergoing nCRT, more patients in the robotic group exhibited clinically advanced diseases. The complication rate was similar between the 2 groups. The operation time and the time to the resumption of a soft diet were significantly prolonged in the robotic group. Further analysis revealed that the difference was mainly observed in the first robotic group. No significant difference was observed between the second robotic and laparoscopic groups.Although the robotic approach may offer potential advantages for rectal surgery, comparable short-term outcomes may be achieved when laparoscopic surgery is performed by experienced surgeons. However, our results suggested a shorter learning curve for robotic surgery for rectal cancer, even in patients who exhibited more advanced disease after undergoing nCRT.

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

“…A longer operative duration was the most consistent shortterm outcome in the series of meta-analysis and RCTs published on RRS for rectal cancer [8,9,[18][19][20][21][22][23][24], (Table 1). Jayne et al reported [8] that the mean operative duration was 37.5 min longer with RRS than with LRS performed by a surgeon experienced with a median of 91 LRS and 50 RRS cases.…”

“…In contrast, the learning curve for RRS ranged from 15 to 30 cases. Moreover, Huang et al [18] indicated that the learning curve for robotic surgery was shorter for patients with rectal cancer, and even for patients who principally exhibited more advanced disease after undergoing neoadjuvant chemoradiation therapy. Another significant aspect of the learning curve is related to whether it has an impact on the pathological outcomes for RRS.…”

Rectal Cancer, Version 2.2018, NCCN Clinical Practice Guidelines in Oncology

“…101 Several studies have also compared outcomes of robotic-assisted resection to conventional laparoscopic resection. [102][103][104][105][106] Comparable results are generally seen between the approaches in conversion to open resection, TME quality, postoperative complications, and quality of life.…”

Robotic‐assisted surgery for rectal cancer: Current state and future perspective

“…Use of the cumulative sum methodology to evaluate the learning process of RALS for rectal cancer has been reported. To date, nine studies have reported the learning curve of RALS for rectal cancer using the cumulative sum method, providing a range of 15–44 cases for the learning period . Conversely, previous studies that focused on the learning curve of laparoscopic rectal surgery estimated that approximately 40–90 cases are required to attain proficiency .…”