Robotic-assisted lateral lymph node dissection for lower rectal cancer: short-term outcomes in 50 consecutive patients. Surg Endosc. 2015;29:995-1000. [PMID: 25135444 DOI: 10.1007/s00464-014-3760-y]

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.

Advantages of Robotic Total Mesorectal Excision With Partial Prostatectomy Compared With Open Surgery for Rectal Cancer: A Single-Center Retrospective Cohort Study

AIM

Robotic total mesorectal excision (TME) with resection of adjacent organs has been increasingly used for locally advanced rectal cancer; however, few studies have focused on robotic TME with partial prostatectomy. Therefore, this study aimed to demonstrate the advantages of robotic TME with partial prostatectomy compared with open surgery for rectal cancer.

METHOD

This retrospective cohort study examined consecutive patients with rectal cancer who underwent robotic or open TME with partial prostatectomy at a high-volume center in Japan from April 2003 to March 2022. The patients were divided into robotic (n = 14) and open (n = 11) surgery groups. The short- and long-term outcomes of these patients were compared.

RESULTS

More transabdominal partial prostatectomies were performed in the robotic surgery group than in the open surgery group (71.4% vs. 9.1%, p = 0.001). Moreover, sphincter-preserving surgery was performed in 35.7% of patients in the robotic surgery group. The robotic surgery group had shorter operative times (401 min vs. 435 min, p = 0.047), less blood loss (56 mL vs. 484 mL, p < 0.001), lower complication rates (28.6% vs. 72.7%, p = 0.047), and shorter postoperative hospital stays (8 days vs. 18 days, p < 0.001) than the open surgery group. No significant differences were observed in the positive radial margin rate (7.1% vs. 9.1%, p = 1.000) or long-term outcomes between the two groups.

CONCLUSION

Compared with open surgery, robotic TME with partial prostatectomy facilitates transabdominal partial prostatectomy, resulting in more sphincter-preserving surgeries and better short-term outcomes.

The role of lateral pelvic lymph node dissection in advanced rectal cancer: a review of current evidence and outcomes

Metastatic lateral pelvic lymph nodes (LPNs) in rectal cancer significantly impact the prognosis and treatment strategies. Western practices emphasize neoadjuvant chemoradiotherapy (CRT), whereas Eastern approaches often rely on LPN dissection (LPND). This review examines the evolving role of LPND in the context of modern treatments, including total neoadjuvant therapy (TNT), and the impact of CRT on the management of clinically suspicious LPNs. We comprehensively reviewed the key literature comparing the outcomes of LPND versus preoperative CRT for rectal cancer, focusing on recent advancements and ongoing debates. Key studies, including the JCOG0212 trial and recent multicenter trials, were analyzed to assess the efficacy of LPND, particularly in conjunction with preoperative CRT or TNT. Current evidence indicates that LPND can reduce local recurrence rates compared to total mesorectal excision alone in patients not receiving radiation therapy. However, the benefit of LPND in the context of neoadjuvant CRT is influenced by the size and pretreatment characteristics of LPNs. While CRT can effectively control smaller metastatic LPNs, larger or clinically suspicious LPNs may require LPND for optimal outcomes. Advances in surgical techniques, such as robotic-assisted LPND, offer potential benefits but also present challenges and complications. The role of TNT in controlling metastatic LPNs and improving patient outcomes is emerging but remains underexplored. The decision to perform LPND should be individualized based on patient-specific factors, including LPN size, response to neoadjuvant treatment, and surgeon expertise. Future research should focus on optimizing treatment protocols and further evaluating the role of TNT in managing metastatic LPNs.

Incidence and risk factors for perineal hernia after robotic abdominoperineal resection: a single-center, retrospective cohort study

BACKGROUND

Perineal hernia (PH) is a late complication of abdominoperineal resection (APR) that may compromise a patient's quality of life. The frequency and risk factors for PH after robotic APR adopting recent rectal cancer treatment strategies remain unclear.

METHODS

Patients who underwent robotic APR for rectal cancer between December 2011 and June 2022 were retrospectively examined. From July 2020, pelvic reinforcement procedures, such as robotic closure of the pelvic peritoneum and levator ani muscles, were performed as prophylactic procedures for PH whenever feasible. PH was diagnosed in patients with or without symptoms using computed tomography 1 year after surgery. We examined the frequency of PH, compared characteristics between patients with PH (PH+) and without PH (PH-), and identified risk factors for PH.

RESULTS

We evaluated 142 patients, including 53 PH+ (37.3%) and 89 PH- (62.6%). PH+ had a significantly higher rate of preoperative chemoradiotherapy (26.4% versus 10.1%, p = 0.017) and a significantly lower rate of undergoing pelvic reinforcement procedures (1.9% versus 14.0%, p = 0.017). PH+ had a lower rate of lateral lymph node dissection (47.2% versus 61.8%, p = 0.115) and a shorter operative time (340 min versus 394 min, p = 0.110). According to multivariate analysis, the independent risk factors for PH were preoperative chemoradiotherapy, not undergoing lateral lymph node dissection, and not undergoing a pelvic reinforcement procedure.

CONCLUSIONS

PH after robotic APR for rectal cancer is not a rare complication under the recent treatment strategies for rectal cancer, and performing prophylactic procedures for PH should be considered.

Robotic versus laparoscopic pelvic lateral lymph node dissection in locally advanced rectal cancer: a systemic review and meta-analysis

BACKGROUND

There are few available studies that compare the feasibility, efficacy, and safety of robotic pelvic lateral lymph node dissection compared to laparoscopic pelvic lateral lymph node dissection (LPLND) in advanced rectal cancer. This meta-analysis aims to compare perioperative outcomes between robotic and LPLND.

METHODS

We performed a systemic literature review of PubMed, Embase, and Web of Science databases. Perioperative parameters were extracted and pooled for analysis. This meta-analysis provided an analysis of heterogeneity and prediction intervals.

RESULTS

Five studies were included: 567 patients divided between 266 robotic and 301 LPLND. Overall operation time was longer in the robotic group than laparoscopic group (difference in means = 67.11, 95% CI [30.80, 103.42], p < 0.001) but the difference in the pelvic lateral lymph dissection time was not statistically significant (difference in means =  - 1.212, 95% CI [ - 11.594, 9.171], p = 0.819). There were fewer overall complications in the robotic than in the laparoscopic group (OR = 1.589, 95% CI [1.009, 2.503], p = 0.046), especially with respect to urinary retention (OR = 2.23, 95% CI [1.277, 3.894], p = 0.005). More pelvic lateral lymph nodes were harvested by robotic surgery than by laparoscopy (differences in means =  - 1.992, 95% CI [ - 2.421, 1.563], p < 0.001).

CONCLUSIONS

In this meta-analysis, robotic pelvic lateral lymph node dissection was associated with more pelvic lateral lymph nodes harvested and lower overall complications, especially urinary retention when compared to LPLND. Further studies are needed to reinforce these findings.

Oncologic outcomes of intersphincteric resection versus abdominoperineal resection for lower rectal cancer: a systematic review and meta-analysis

BACKGROUND

The efficacy of intersphincteric resection (ISR) surgery for patients with lower rectal cancer remains unclear compared to abdominoperineal resection (APR). The aim of this study is to compare the oncologic outcomes for lower rectal cancer patients after ISR and APR through a systematic review and meta-analysis.

MATERIALS AND METHODS

A systematic electronic search of the Cochrane Library, PubMed, EMBASE, and MEDLINE was performed through January 12, 2022. The primary outcomes included 5-year disease-free survival (5y-DFS) and 5-year overall survival. Secondary outcomes included circumferential resection margin involvement, local recurrence, perioperative outcomes, and other long-term outcomes. The pooled odds ratios, mean difference, or hazard ratios (HRs) of each outcome measurement and their 95% CIs were calculated.

RESULTS

A total of 20 nonrandomized controlled studies were included in the qualitative analysis, with 1217 patients who underwent ISR and 1135 patients who underwent APR. There was no significant difference in 5y-DFS (HR: 0.84, 95% CI: 0.55-1.29; P =0.43) and 5-year overall survival (HR: 0.93, 95% CI: 0.60-1.46; P =0.76) between the two groups. Using the results of five studies that reported matched T stage and tumor distance, we performed another pooled analysis. Compared to APR, the ISR group had equal 5y-DFS (HR: 0.76, 95% CI: 0.45-1.30; P =0.31) and 5y-LRFS (local recurrence-free survival) (HR: 0.72, 95% CI: 0.29-1.78; P =0.48). Meanwhile, ISR had equivalent local control as well as perioperative outcomes while significantly reducing the operative time (mean difference: -24.89, 95% CI: -45.21 to -4.57; P =0.02) compared to APR.

CONCLUSIONS

Our results show that the long-term survival and safety of patients is not affected by ISR surgery, although this result needs to be carefully considered and requires further study due to the risk of bias and limited data.

Contemporary management of rectal cancer

The management of rectal cancer has undergone significant changes over the past 50 years, and this has been associated with major improvements in overall outcomes and quality of life. From standardization of total mesorectal excision to refinements in radiation delivery and shifting of chemoradiotherapy treatment to favor a neoadjuvant approach, as well as the development of targeted chemotherapeutics, these management strategies have continually aimed to achieve locoregional and systemic control while limiting adverse effects and enhance overall survival. This article highlights evolving aspects of rectal cancer therapy including improved staging modalities, total neoadjuvant therapy, the role of short-course and more selective radiotherapy strategies, as well as organ preservation. We also discuss the evolving role of minimally invasive surgery and comment on lateral pelvic lymph node dissection.

Key message

Rectal cancer management is constantly evolving through refinements in radiation timing and delivery, modification of chemoradiotherapy treatment schedules, and increasing utilization of minimally invasive surgical techniques and organ preservation strategies. This manuscript aims to provide a synopsis of recent changes in the management of rectal cancer, highlighting contemporary modifications in neoadjuvant approaches and surgical management to enhance the knowledge of surgeons who care for this challenging population.

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.

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.

Management of lateral pelvic lymph nodes in rectal cancer

Lateral pelvic lymph node (LPLN) involvement occurs in 10%-25% of rectal cancer cases. Total mesorectal excision (TME) with routine LPLN dissection (LPLND) is predominantly applied in Japan whereas TME with neoadjuvant treatment are used in the West. LPLND is a morbid procedure and minimally invasive techniques may help reduce its morbidity. Selective lateral pelvic node dissection with TME following neoadjuvant treatment achieves acceptable disease-free and overall survival.

Robotic versus laparoscopic approach for minimally invasive lateral pelvic lymph node dissection of advanced lower rectal cancer: a retrospective study comparing short-term outcomes

PURPOSE

The importance of lateral pelvic lymph node dissection (LLND) for advanced low rectal cancer is gradually being recognized in Europe and the USA, where some patients were affected by uncontrolled lateral pelvic lymph node (LLNs) metastasis, even after total mesorectal excision (TME) with neoadjuvant chemoradiotherapy (CRT). The purpose of this study was thus to compare robotic LLND (R-LLND) with laparoscopic (L-LLND) to clarify the safety and advantages of R-LLND.

METHODS

Sixty patients were included in this single-institution retrospective study between January 2013 and July 2022. We compared the short-term outcomes of 27 patients who underwent R-LLND and 33 patients who underwent L-LLND.

RESULTS

En bloc LLND was performed in significantly more patients in the R-LLND than in the L-LLND group (48.1% vs. 15.2%; p = 0.006). The numbers of LLNs on the distal side of the internal iliac region (LN 263D) harvested were significantly higher in the R-LLND than in the L-LLND group (2 [0-9] vs. 1 [0-6]; p = 0.023). The total operative time was significantly longer in the R-LLND than in the L-LLND group (587 [460-876] vs. 544 [398-859]; p = 0.003); however, the LLND time was not significantly different between groups (p = 0.718). Postoperative complications were not significantly different between the two groups.

CONCLUSION

The present study clarified the safety and technical feasibility of R-LLND with respect to L-LLND. Our findings suggest that the robotic approach offers a key advantage, allowing significantly more LLNs to be harvested from the distal side of the internal iliac region (LN 263D). Prospective clinical trials examining the oncological superiority of R-LLND are thus necessary in the near future.

Transanal lateral lymph node dissection with intraoperative hologram support in low rectal cancer

BACKGROUND

In Japan, the standard treatment for stage II/III advanced low rectal cancer is total mesorectal excision plus lateral lymph node dissection (LLND). There are also recent reports on the use of transanal LLND. However, the transanal anatomy is difficult to understand, and additional support tools are required to improve the surgical safety. The present study examined the utility of holograms with mixed reality as an intraoperative support tool for assessing the complex pelvic anatomy.

METHODS

Polygon (stereolithography) files of patients' pelvic organs were created and exported from the SYNAPSE VINCENT imaging system and uploaded into the Holoeyes MD virtual reality software. Three-dimensional images were automatically converted into patient-specific holograms. Each hologram was then installed into a head mount display (HoloLens2), and the surgeons and assistants wore the HoloLens2 when they performed transanal LLND. Twelve digestive surgeons with prior practice in hologram manipulation evaluated the utility of the intraoperative hologram support by means of a questionnaire.

RESULTS

Intraoperative hologram support improved the surgical understanding of the lateral lymph node region anatomy. In the questionnaire, 75% of the surgeons answered that the hologram accurately reflected the anatomy, and 92% of the surgeons answered that the anatomy was better understood by simulating the hologram intraoperatively than preoperatively. Moreover, 92% of the surgeons agreed that intraoperative holograms were a useful support tool for improving the surgical safety.

CONCLUSIONS

Intraoperative hologram support improved the surgical understanding of the pelvic anatomy for transanal LLND. Intraoperative holograms may represent a next-generation surgical tool for transanal LLND.

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.

Comparison of robotic versus laparoscopic lateral lymph node dissection for advanced lower rectal cancer: a retrospective study at two institutions

BACKGROUND

Lateral lymph node dissection (LLND) represents a technically challenging procedure. This study aimed to evaluate the perioperative, genitourinary functional and mid-term oncological outcomes of laparoscopic lateral lymph node dissection (LLLND) and robotic lateral lymph node dissection (RLLND) for advanced lower rectal cancer (ALRC).

METHODS

Between January 2015 and April 2021, consecutive patients who underwent RLLND and LLLND at two high-volume centres were enrolled. The perioperative outcomes, genitourinary function recovery and mid-term oncological outcomes of the patients were compared. A subgroup analysis of patients who underwent neoadjuvant chemoradiotherapy (nCRT) was performed.

RESULTS

A total of 205 patients were included in the analysis, with 95 in the RLLND group and 110 in the LLLND group. The patients in the RLLND group had a longer operative time, less blood loss, and more harvested internal iliac lymph nodes than did those in the LLLND group. In postoperative complication, urinary retention was less frequent in the RLLND group than in the LLLND group. Additionally, the RLLND group had better genitourinary function recovery. Similar results were also observed from the nCRT subgroup analysis. Moreover, there was no significant difference in mid-term oncological outcomes between the two groups. Further subgroup analysis indicated that the patients who underwent nCRT + LLLND/RLLND had better local control than those who underwent only LLLND/RLLND.

CONCLUSIONS

RLLND is safe and feasible for ALRC and is associated with more harvested internal iliac lymph nodes and better genitourinary function recovery. NCRT combined with minimally invasive LLND could constitute an improved strategy for ALRC.

Comparison between robotic-assisted and laparoscopic sphincter-preserving operations for ultra-low rectal cancer

Aim

Sphincter-preserving operations for ultra-low rectal cancer include low anterior and intersphincteric resection. In low anterior resection, the distal rectum is divided by a transabdominal approach, which is technically demanding. In intersphincteric resection, a perineal approach is used. We aimed to evaluate whether robotic-assisted surgery is technically superior to laparoscopic surgery for ultra-low rectal cancer. We compared the frequency of low anterior resection in cases of sphincter-preserving operations.

Method

We investigated 183 patients who underwent sphincter-preserving robotic-assisted or laparoscopic surgery for ultra-low rectal cancer (lower border within 5 cm of the anal verge) between April 2010 and March 2020. The frequency of low anterior resection was compared between laparoscopic and robotic-assisted surgeries. The clinicopathological factors associated with an increase in performing low anterior resection were analyzed by multivariate analyses.

Results

Overall, 41 (22.4%) and 142 (77.6%) patients underwent laparoscopic and robotic-assisted surgery, respectively. Patient characteristics were similar between the groups. Low anterior resection was done significantly more frequently in robotic-assisted surgery (67.6%) than in laparoscopic surgery (48.8%) (P = 0.04). Multivariate analyses showed that tumor distance from the anal verge (P < 0.01) and robotic-assisted surgery (P = 0.02) were significantly associated with an increase in the performance of low anterior resection. The rate of postoperative complications or pathological results was similar between the groups.

Conclusion

Compared with laparoscopic surgery, robotic-assisted surgery significantly increased the frequency of low anterior resection in sphincter-preserving operations for ultra-low rectal cancer. Robotic-assisted surgery has technical superiority over laparoscopic surgery for ultra-low rectal cancer treatment.

Strangulated small bowel obstruction caused by isolated obturator nerve and pelvic vessels after pelvic lymphadenectomy in gynecologic surgery: two case reports

Background

Although small bowel obstruction (SBO) is a major complication occurring after abdominal surgery, few reports have described strangulated SBO after pelvic lymphadenectomy (PL). This report describes two cases of strangulated SBO caused by a skeletonized obturator nerve and pelvic vessels after laparoscopic PL during gynecologic surgery.

Case presentation

Case 1: A 57-year-old woman with endometrial cancer underwent a laparoscopic semi-radical total hysterectomy with PL. Nine months after the operation, she visited our emergency room complaining about subacute pain spreading in the right groin, right buttock, and dorsal part of the right thigh. She had no abdominal pain. Although her symptoms were not typical, computed tomography (CT) revealed strangulated SBO in the right pelvis. Laparoscopic surgery revealed that the small bowel was ischemic. Then we converted to open surgery. We transected the right obturator nerve and umbilical artery, which constructed an internal hernia orifice in the right pelvis, followed by resection of the ischemic small bowel. Fortunately, during 6-month follow-up, she showed only slight difficulty in walking as a postoperative complication. Case 2: A 62-year-old woman with cervical cancer underwent laparoscopic radical hysterectomy with PL. Six months after the operation, she visited our hospital emergently because of sudden onset of abdominal pain and vomiting. CT showed strangulated SBO. Urgent laparoscopic surgery exhibited the incarcerated small bowel at the right pelvis. Consequently, we converted to open surgery. The terminal ileum was detained into the space constructed by the right umbilical artery. We cut the umbilical artery and performed ileocecal resection. After the surgery, she was discharged with no complication or sequela.

Conclusion

When examining a patient after PL who complains of severe pain or symptoms, one should consider the possibility of PL-related SBO, even if the pain is apparently atypical for SBO.

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.

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.

Lateral lymph node dissection in advanced low rectal cancer treatment

Lateral lymph node (LLN) metastasis is a determinant of local recurrence in advanced low rectal cancer. Lateral lymph node dissection (LLND) is effective in removing metastatic lymph nodes, and has been shown to have a decreased local recurrence rate. However, because of its complexity and complications it induces, there is still tremendous controversy about its usage. Neoadjuvant chemoradiotherapy (nCRT) and total mesorectal excision (TME) are recommended as a conventional treatment for advanced rectal cancer. However, LLN metastasis and local recurrence still occur despite nCRT with TME. In Japan, TME with LLND is the standard surgical treatment for Stage II/III of advanced low rectal cancer. Before surgery, a proper evaluation of LLN status should be performed. Laparoscopic LLND and robotic-assisted LLND are useful for this. More research is necessary to improve the oncological outcomes of LLND. In this review, we retrospectively examine previous reports about LLND, aiming to emphasize its application prospects to improve patient survival and life quality.

Transanal total mesorectal excision and transabdominal robotic surgery for rectal cancer: A retrospective study

BACKGROUND

Transabdominal robotic surgery and transanal total mesorectal excision (TaTME) are newly introduced strategies for rectal cancer. These procedures might have many advantages in rectal cancer treatment in terms of improving oncological and functional outcomes, especially in cases involving advanced cancer or technical difficulty. In the present study, we aimed to clarify the advantages and disadvantages of transabdominal robotic surgery and laparoscopic TaTME as a hybrid surgery for rectal cancer.

MATERIALS AND METHODS

We retrospectively evaluated six patients who underwent hybrid surgery for rectal cancer from August 2018 to April 2020. Both clinical and pathological outcomes were assessed.

RESULTS

Two patients showed circumferential margin involvement both before and after neoadjuvant therapy. Three patients were planned to undergo hybrid surgery with intersphincteric resection because of a narrow pelvis. One patient was planned to undergo hybrid surgery for a giant tumor of >10 cm. The median length of hospitalization was 17 days. No patients required conversion to an open procedure. All patients underwent formation of defunctioning ileostomies. Two patients had a stapled anastomosis and four had a hand-sewn coloanal anastomosis. Complications included one case of anastomotic leakage, which was managed conservatively with ultrasound- and computed tomography-guided drainage and antibiotics. Histological analysis revealed that all specimens had a negative radial margin and distal margin. The median number of lymph nodes harvested was 17.5. Two patients showed extensive lymph node metastases, including lateral node metastasis.

CONCLUSION

Hybrid surgery was performed safely and may improve oncological outcomes for rectal cancer. This technique has many potential benefits and would be alternative option in multimodal strategies for rectal cancer.

Advantages of robotic abdominoperineal resection compared with laparoscopic surgery: a single-center retrospective study

PURPOSE

Although robotic surgery for rectal cancer can overcome the shortcomings of laparoscopic surgery, studies focusing on abdominoperineal resection are limited. The aim of this study was to compare the operative outcomes between robotic and laparoscopic abdominoperineal resection.

METHODS

This retrospective cohort study was conducted from April 2010 to March 2020. Patients with rectal cancer who underwent robotic or laparoscopic abdominoperineal resection without lateral lymph node dissection were enrolled. The perioperative and oncological outcomes were compared.

RESULTS

We evaluated 33 and 20 patients in the robotic and laparoscopic groups, respectively. The median operative time and blood loss were comparable between the two groups. No significant differences in the overall complication rates were noted, whereas the rates of urinary dysfunction (3% vs. 26%, p = 0.02) and perineal wound infection (9% vs. 35%, p = 0.03) in the robotic group were significantly lower in comparison to the laparoscopic group. The median postoperative hospital stay was significantly shorter in the robotic group (8 days vs. 11 days, p < 0.01). The positive resection margin rates were comparable between the two groups.

CONCLUSION

Robotic abdominoperineal resection demonstrated better short-term outcomes than laparoscopic surgery, suggesting that it could be a useful approach.

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.

Potential urinary function benefits of initial robotic surgery for rectal cancer in the introductory phase

We aimed to evaluate the advantages and disadvantages of initial robotic surgery for rectal cancer in the introduction phase. This study retrospectively evaluated patients who underwent initial robotic surgery (n = 36) vs. patients who underwent conventional laparoscopic surgery (n = 95) for rectal cancer. We compared the clinical and pathological characteristics of patients using a propensity score analysis and clarified short-term outcomes, urinary function, and sexual function at the time of robotic surgery introduction. The mean surgical duration was longer in the robot-assisted laparoscopy group compared with the conventional laparoscopy group (288.4 vs. 245.2 min, respectively; p = 0.051). With lateral pelvic lymph node dissection, no significant difference was observed in surgical duration (508.0 min for robot-assisted laparoscopy vs. 480.4 min for conventional laparoscopy; p = 0.595). The length of postoperative hospital stay was significantly shorter in the robot-assisted laparoscopy group compared with the conventional laparoscopy group (15 days vs. 13.0 days, respectively; p = 0.026). Conversion to open surgery was not necessary in either group. The International Prostate Symptom Score was significantly lower in the robot-assisted laparoscopy group compared with the conventional laparoscopy group. Moderate-to-severe symptoms were more frequently observed in the conventional laparoscopy group compared with the robot-assisted laparoscopy group (p = 0.051). Robotic surgery is safe and could improve functional disorder after rectal cancer surgery in the introduction phase. This may depend on the surgeon’s experience in performing robotic surgery and strictly confined criteria in Japan.

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.

Prevalence of Metastatic Lateral Lymph Nodes in Asian Patients with Lateral Lymph Node Dissection for Rectal Cancer: A Meta-analysis

Importance

Rectal cancers occupy the eighth position worldwide for new cases and deaths for both men and women. These cancers have a high tendency to form metastases in the mesorectum but also in the lateral lymph nodes. The therapeutic approach for the involved lateral lymph nodes remains controversial.

Objective

We performed a systematic review and meta-analysis to assess the prevalence of metastatic lateral lymph nodes in patients with lateral lymph node dissection (LLND) for rectal cancer, which seems to be a fundamental and necessary criterion to discuss any possible indications for LLND.

Methods

Data sources–study selection–data extraction and synthesis–main outcome and measures. We searched MEDLINE, EMBASE and COCHRANE from November 1, 2018, to November 19, 2018, for studies reporting the presence of metastatic lateral lymph nodes (iliac, obturator and middle sacral nodes) among patients undergoing rectal surgery with LLND. Pooled prevalence values were obtained by random effects models, and the robustness was tested by leave-one-out sensitivity analyses. Heterogeneity was assessed using the Q-test, quantified based on the I2 value and explored by subgroup analyses.

Results

Our final analysis included 31 studies from Asian countries, comprising 7599 patients. The pooled prevalence of metastatic lateral lymph nodes was 17.3% (95% CI: 14.6–20.5). The inter-study variability (heterogeneity) was high (I² = 89%). The pooled prevalence was, however, robust and varied between 16.6% and 17.9% according to leave-one-out sensitivity analysis. The pooled prevalence of metastatic lymph nodes was not significantly different when pooling only studies including patients who received neoadjuvant treatment or those without neoadjuvant treatment (p = 0.44). Meta-regression showed that the pooled prevalence was associated with the sample size of studies (p < 0.05), as the prevalence decreased when the sample size increased.

Conclusion

The pooled prevalence of metastatic lateral lymph nodes was 17.3% among patients who underwent rectal surgery with LLND in Asian countries. Further studies are necessary to determine whether this finding could impact the therapeutic strategy (total mesorectal excision with LLND versus total mesorectal excision with neoadjuvant radiochemotherapy).

Supplementary Information

The online version contains supplementary material available at(10.1007/s00268-021-05956-1)

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.

Lateral pelvic lymph node dissection in the management of locally advanced low rectal cancer: Summary of the current evidence

Lateral pelvic lymph nodes (LPLN) are a major site for local recurrence following curative resection for low locally advanced rectal cancer. Ongoing advances in imaging techniques have improved predicting LPLN metastasis (LPLNM) during pre-operative staging. However, there is ongoing debate on optimal management of this subgroup of patients with variation between guidance of different societies. In Japan, LPLNM is considered as local disease and addressed by lateral pelvic node dissection (LPLND) in addition to total mesorectal excision (TME). However, in the west, LPLNM is considered as metastatic disease and those patients are offered neoadjuvant chemoradiotherapy (nCRT) followed by TME surgery. The potential surgical risks and morbidity associated with LPLND as well as the uncertainty of the oncological outcome have raised the concern that patients with locally advanced low rectal cancer with LPLNM could be over or under-treated. A comprehensive review of literature was performed, summarizing the current evidence on available modalities for predicting LPLNM, the role of LPLND in the management of advanced low rectal cancer and the available surgical approaches with their impact on surgical and oncological outcomes. LPLND is associated with increased operative time, blood loss and post-operative morbidity. The potential benefits for local disease control and survival still awaits high quality studies. There has been increasing number of reports of the use minimally invasive approaches in LPLND in an attempt to reduce post-operative complications. There is need for high quality evidence to define the role of LPLND in management of patients with advanced low rectal cancer.

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.

Robotic Surgery for Rectal Cancer and Cost-Effectiveness

Robotic surgery is considered as one of the advanced treatment modality of minimally invasive surgery for rectal cancer. Robotic rectal surgery has been performed for three decades and its application is gradually expanding along with technology development. It has several technical advantages which include magnified three-dimensional vision, better ergonomics, multiple articulated robotic instruments, and the opportunity to perform remote surgery. The technical benefits of robotic system can help to manipulate more meticulously during technical challenging procedures including total mesorectal excision in narrow pelvis, lateral pelvic node dissection, and intersphincteric resection. It is also reported that robotic rectal surgery have been shown more favorable postoperative functional outcomes. Despite its technical benefits, a majority of studies have been reported that there is rarely clinical or oncologic superiority of robotic surgery for rectal cancer compared to conventional laparoscopic surgery. In addition, robotic rectal surgery showed significantly higher costs than the standard method. Hence, the cost-effectiveness of robotic rectal surgery is still questionable. In order for robotic rectal surgery to further develop in the field of minimally invasive surgery, there should be an obvious cost-effective advantages over laparoscopic surgery, and it is crucial that large-scale prospective randomized trials are required. Positive competition of industries in correlation with technological development may gradually reduce the price of the robotic system, and it will be helpful to increase the cost-effectiveness of robotic rectal surgery.

Diagnostic and management strategies for lateral pelvic lymph nodes in low rectal cancer-a review of the evidence

Patients with low rectal cancer who have enlarged lateral pelvic lymph nodes are known to have a worse prognosis. There is however uncertainty over what constitutes a lateral pelvic lymph node of clinical significance. As the main modality for the detection of such lymph nodes is magnetic resonance imaging (MRI), characteristics of these lateral lymph nodes identified may have prognostic value and assist with guiding treatment. Options to manage such lateral lymph nodes includes neoadjuvant chemoradiotherapy as well as lateral lymph node dissection. Surgery is extensive and may lead to significant morbidity to the patient. This review article evaluates diagnostic and management strategies in patients with lateral pelvic lymph nodes in low rectal cancer.

Short-Term Outcomes of Robotic versus Laparoscopic Total Mesorectal Excision for Rectal Cancer: A Cohort Study

The aim of this study was to evaluate and compare the intestinal function recovery time and other short-term outcomes between robotic-assisted total mesorectal excision (R-TME) and laparoscopic total mesorectal excision (L-TME) for rectal cancer. This is a retrospective study using a prospectively collected database. Patients’ records were obtained from Gansu Provincial Hospital between July 2015 and October 2017. Eighty patients underwent R-TME, and 116 with the same histopathological stage of the tumor underwent an L-TME. Both operations were performed by the same surgeon, comparing intra- and postoperative outcomes intergroups. The time to the first passage of flatus ( P < 0.001), the time to the first postoperative oral fluid intake ( P < 0.001), and the length of hospital stay ( P < 0.01) of the R-TME group were about three days faster than those in the L-TME group. The rate of conversion to open laparotomy ( P = 0.038) and postoperative urinary retention ( P = 0.016) were significantly lower in the R-TME group than in the L-TME group. Intraoperative blood loss of the R-TME group was more than that of the L-TME group ( P < 0.01).The operation time, number of lymph nodes harvested, and rate of positive circumferential resection margin were similar intergroup. The total cost of the R-TME group was higher than that of the L-TME group, but with a lack of statistical significance (85,623.91 ± 13,310.50 vs 67,356.79 ± 17,107.68 CNY, P = 0.084). The R-TME is safe and effective and has better postoperative short-term outcomes and faster intestinal function recovery time, contrasting with the L-TME. The large, multicenter, prospective studies were needed to validate the advantages of robotic surgery system used in rectal cancer.

Robotic versus laparoscopic rectal resection surgery: Short-term outcomes and complications: A retrospective comparative study

BACKGROUND

The safety of robotic-assisted surgery (RAS) remains a concern. This study aimed to compare the complications after RAS versus laparoscopic-assisted surgery (LAS) for rectal cancer using the Clavien-Dindo classification and to identify risk factors related to the complications.

METHOD

Between March 2010 and June 2016, 556 rectal cancer patients who underwent successful RAS and 1029 patients who received LAS were enrolled in this study. The complications were graded according to the Clavien-Dindo classification, and the possible risk factors related to the complications were analyzed.

RESULTS

The overall postoperative complication rate was 14.9%, with a 5% rate of severe complications that were classified as grade III or above in RAS group compared with 17.1% and 4.4% in LAS group. However, no significant difference was found (P = 0.608). A high ASA score was identified as an independent risk factor for overall and severe complications in both groups. The use of more than 3 staples in each operation and the anastomotic site of the anal verge at less than 5 cm were independent risk factors for complications.

CONCLUSIONS

RAS for rectal cancer is technically safe and it does not significantly improve the complication rate. The incidence of overall complications is still related to tumor location, the general condition of the patients, and the surgical approach.

Short- and long-term outcomes of robotic-assisted laparoscopic surgery for rectal cancer: results of a single high-volume center in Japan

PURPOSE

Scientific evidence supporting robotic-assisted laparoscopic surgery (RALS) for rectal cancer remains inconclusive because most previous reports were retrospective case series or case-control studies, with few reports focusing on long-term oncological outcomes with a large volume of patients. The aim of this study was to clarify the short- and long-term outcomes of a large number of consecutive patients with rectal cancer who underwent RALS in a single high-volume center.

METHODS

The records of 551 consecutive patients who underwent RALS for rectal adenocarcinoma between December 2011 and March 2017 were examined to reveal the short-term outcomes. The oncological outcomes of the 204 patients who underwent surgery between December 2011 and March 2014 were evaluated.

RESULTS

Most patients had tumors located in the lower or mid-rectum (86.0%). Only 7.6% of patients underwent neoadjuvant chemoradiotherapy. Lateral lymph node dissection was performed for 191 patients (34.7%). The median operative time was 257 min, median blood loss was 10 mL, and no transfusions were needed. No conversion to open surgery was necessary. Eighteen patients (3.3%) had Clavien-Dindo grade III postoperative complications. Six patients (1.1%) had positive resection margins. The mean follow-up duration of the 204 patients was 43.6 ± 9.8 (months). The 5-year cancer-specific survival rate for stage I/II/III/IV was 100%/100%/100%/not reached, respectively. The 5-year relapse-free survival rate for stage I/II/III/IV was 93.6%/75.0%/77.6%/ not reached, respectively. The rate of local recurrence was 0.5%.

CONCLUSIONS

Our results suggest that RALS is technically feasible for rectal cancer and has good short- and long-term outcomes.

Lateral Lymph Node Dissection With the Focus on Indications, Functional Outcomes, and Minimally Invasive Surgery

The lateral lymph node dissection (LLND) is still a subject of great debate as to the appropriate treatment for patients with mid to low advanced rectal cancer. The guidelines of the Japanese Society for Cancer of the Colon and Rectum recommend a LLND for patients with T3/4 rectal cancer below the peritoneal reflection. However, in most Western countries, a routine LLND is not recommended unless a node or nodes are clinically suspicious for metastasis. Even after preoperative chemoradiotherapy (CRT), an 8% to 12% lateral pelvic recurrence was noted. The size of the lateral lymph node and responsiveness to preoperative CRT should be the main factors for selecting appropriate patients to undergo a LLND. In addition, from the recent literature, a laparoscopic LLND is safe and oncologically feasible and might have some advantages in short-term outcomes.

The short-term outcomes of robotic sphincter-preserving surgery for rectal cancer: comparison with open and laparoscopic surgery using a propensity score analysis

PURPOSE

The aim of this study is to clarify the short-term outcomes of robotic sphincter-preserving surgery for rectal cancer in a retrospective study.

METHODS

The short-term outcomes of robotic sphincter-preserving surgery (n = 130) were retrospectively compared to open (n = 234) and laparoscopic surgery (n = 318) by a propensity score analysis.

RESULTS

Robotic surgery was performed more frequently for patients with lower rectal cancer (55%) than open (30%, p < 0.0001) or laparoscopic surgery (36%, p < 0.0001). None of the robotic surgery cases were converted to open surgery. After propensity score matching, robotic surgery was found to be associated with a longer operation time (342 vs. 230 min, p < 0.0001) and less blood loss (7 vs. 420 mL, p < 0.0001) than open surgery. The overall complication rate of robotic surgery was lower than that of open surgery (13 vs. 28%, p = 0.032). Robotic surgery was associated with a lower incidence of surgical site infections (SSIs) than laparoscopic surgery (0 vs. 7%, p = 0.028). There were no cases of anastomotic leakage after robotic surgery. The circumferential resection margin was involved in 0.8% of the patients who underwent robotic surgery; the incidence did not differ among the treatment groups.

CONCLUSIONS

Although robotic surgery for rectal cancer was associated with a longer operation time, it was associated with a very low incidence of SSIs. The degree of safety was comparable to both open and laparoscopic surgery.

Robot-assisted laparoscopic resection of clinical T4b tumours of distal sigmoid and rectum: initial results

BACKGROUND

Radical resection by multivisceral resection of colorectal T4 tumours is important to reduce local recurrence and improve survival. Oncological safety of laparoscopic resection of T4 tumours is controversial. However, robot-assisted resections might have advantages, such as 3D view and greater range of motion of instruments. The aim of this study is to evaluate the initial results of robot-assisted resection of T4 rectal and distal sigmoid tumours.

METHODS

This is a cohort study of a prospectively kept database of all robot-assisted rectal and sigmoid resections between 2012 and 2017. Patients who underwent a multivisceral resection for tumours appearing as T4 cancer during surgery were included. Rectal and sigmoid resections are routinely performed with the DaVinci robot, unless an indication for intra-operative radiotherapy exists.

RESULTS

28 patients with suspected T4 rectal or sigmoid cancer were included. Most patients (78%) were treated with neoadjuvant chemoradiotherapy (n = 19), short course radiotherapy with long waiting interval (n = 2) or chemotherapy (n = 1). En bloc resection was performed with the complete or part of the invaded organ (prostate, vesicles, bladder, abdominal wall, presacral fascia, vagina, uterus, adnex). In 3 patients (11%), the procedure was converted to laparotomy. Twenty-four R0-resections were performed (86%) and four R1-resections (14%). Median length of surgery was 274 min (IQR 222-354). Median length of stay was 6 days (IQR 5-11). Twelve patients (43%) had postoperative complications: eight (29%) minor complications and four (14%) major complications. There was no postoperative mortality.

CONCLUSIONS

Robot-assisted laparoscopy seems to be a feasible option for the resection of clinical T4 cancer of the distal sigmoid and rectum in selected cases. Radical resections can be achieved in the majority of cases. Therefore, T4 tumours should not be regarded as a strict contraindication for robot-assisted surgery.

Oncological outcomes of robotic-assisted laparoscopic versus open lateral lymph node dissection for locally advanced low rectal cancer

BACKGROUND

The long-term outcomes of robotic-assisted laparoscopic lateral lymph node dissection (RALLD) have not been fully investigated. This study aimed to assess the oncological and long-term outcomes of RALLD for rectal cancer through comparison with those of open lateral lymph node dissection (OLLD) in a retrospective study.

METHODS

Between September 2002 and October 2014, the medical data of 426 patients who underwent total mesorectal excision with lateral lymph node dissection for primary rectal cancer were collected. Of these, 115 patients were excluded after data collection (stage IV, n = 61; total pelvic exenteration, n = 31; multiple cancer, n = 20; conventional laparoscopic surgery, n = 3). Before matching, 311 patients with clinical stage II/III were analyzed. Using exact matching, patients were stratified into RALLD (n = 78) and OLLD (n = 78) groups. Pathological findings and long-term outcomes were compared between the groups.

RESULTS

The pathological stage and number of harvested lymph nodes showed no significant differences between the groups. The rate of positive resection margin in the RALLD group tended to be lower compared with that of the OLLD group (p = 0.059). The median follow-up duration was 54.0 months in 156 patients. The 5-year overall survival rate was 95.4 and 87.8% in the RALLD and OLLD groups, respectively (p = 0.106). The 5-year relapse-free survival rate was 79.1 and 69.9% in the RALLD and OLLD groups, respectively (p = 0.157). The 5-year local relapse-free survival rate was 98.6 and 90.9% in the RALLD and OLLD groups, respectively (p = 0.029).

CONCLUSIONS

The short- and long-term outcomes indicated that RALLD may be a useful modality for locally advanced low rectal cancer.

Surgical outcomes of robot-assisted rectal cancer surgery using the da Vinci Surgical System: a multi-center pilot Phase II study

Introduction

We conducted a multi-center pilot Phase II study to examine the safety of robotic rectal cancer surgery performed using the da Vinci Surgical System during the introduction period of robotic rectal surgery at two institutes based on surgical outcomes.

Methods

This study was conducted with a prospective, multi-center, single-arm, open-label design to assess the safety and feasibility of robotic surgery for rectal cancer (da Vinci Surgical System). The primary endpoint was the rate of adverse events during and after robotic surgery. The secondary endpoint was the completion rate of robotic surgery.

Results

Between April 2014 and July 2016, 50 patients were enrolled in this study. Of these, 10 (20%) had rectosigmoid cancer, 17 (34%) had upper rectal cancer, and 23 (46%) had lower rectal cancer; six underwent high anterior resection, 32 underwent low anterior resection, 11 underwent intersphincteric resection, and one underwent abdominoperineal resection. Pathological stages were Stage 0 in 1 patient, Stage I in 28 patients, Stage II in 7 patients and Stage III in 14 patients. Pathologically complete resection was achieved in all patients. There was no intraoperative organ damage or postoperative mortality. Eight (16%) patients developed complications of all grades, of which 2 (4%) were Grade 3 or higher, including anastomotic leakage (2%) and conversion to open surgery (2%).

Conclusion

The present study demonstrates the feasibility and safety of robotic rectal cancer surgery, as reflected by low morbidity and low conversion rates, during the introduction period.

Robotic-assisted multivisceral resection for rectal cancer: short-term outcomes at a single center

BACKGROUND

The safety and feasibility of robotic-assisted multivisceral resection for locally advanced rectal cancer remain unclear. The aim of this study was to assess the short-term outcomes of this procedure at our institution.

METHODS

From December 2011 to December 2016, patients who underwent robotic-assisted multivisceral resection for rectal cancer were investigated. Patient demographics, treatment characteristics, perioperative outcomes, and pathological results were evaluated retrospectively.

RESULTS

There were 31 patients; 17 men (54.8%) and 14 women (45.2%), with a median age of 65 years (range 40-82 years). Twenty-one patients (67.7%) had a cT4 tumor, 9 patients (29.0%) had a pT4b tumor, and all patients except one (96.8%) underwent complete resection of the primary tumor with negative resection margins. Eleven patients (35.5%) received neoadjuvant chemoradiation. The most commonly resected organ was the vaginal wall (n = 12, 38.7%), followed by the prostate (n = 10, 32.3%). Lateral lymph node dissection was performed in 20 patients (64.5%). The median operative time was 394 min (range 189-549 min), and the median blood loss was 41 mL (range 0-502 mL). None of the patients received intraoperative blood transfusions or required conversion to open. Overall, postoperative complications occurred in 11 patients (35.5%). The most frequent complication was urinary retention (n = 5, 16.1%), and none of the patients developed serious complications classified as Clavien-Dindo grades III-V.

CONCLUSIONS

Robotic-assisted multivisceral resection for rectal cancer is safe and technically feasible.

Preoperative chemoradiotherapy changes the size criterion for predicting lateral lymph node metastasis in lower rectal cancer

PURPOSE

The purpose of this study was to identify the size criteria of lateral lymph node metastasis in lower rectal cancer both in patients who underwent preoperative CRT and those who did not.

METHODS

This study enrolled 150 patients who underwent resection for primary lower rectal adenocarcinoma with lateral lymph node dissection between 2013 and 2015. Patients were divided into two groups: the CRT group, treated with preoperative chemoradiotherapy before surgery, and the non-CRT group, treated with surgery alone. The short-axis diameter of each dissected lateral lymph node was measured. Receiver-operating characteristic curves were generated to reveal the optimal cutoff values for determining lateral lymph node metastasis in both groups.

RESULTS

In the non-CRT group (n = 131), the ROC curve demonstrated that the optimal cutoff value for determining metastasis was 6.0 mm, with a sensitivity of 78.5% and specificity of 82.9%, and the AUC was 0.845. In comparison, in the CRT group (n = 19), the optimal cutoff value was 5.0 mm, with a sensitivity of 71.4% and specificity of 85.3% and an AUC of 0.836.

CONCLUSION

The cutoff size for determining lateral lymph node metastasis was smaller in the CRT group than in the non-CRT group.

Robotic surgery for rectal cancer

Laparoscopic surgery has gained acceptance as a less invasive approach in the treatment of colon cancer. However, laparoscopic surgery for rectal cancer, particularly cancer of the lower rectum, is still challenging because of limited accessibility. Robotic surgery overcomes the limitations of laparoscopy associated with anatomy and offers certain advantages, including 3-D imaging, dexterity and ambidextrous capability, lack of tremors, motion scaling, and a short learning curve. Robotic rectal surgery has been reported to reduce conversion rates, particularly in low anterior resection, but it is associated with longer operative times than the conventional laparoscopic approach. Postoperative morbidities are similar between the robotic and conventional laparoscopic approaches, and oncological outcomes such as the quality of the mesorectum and the status of resection margins are also equivalent. The possible superiority of robotic surgery in terms of the preservation of autonomic function has yet to be established in research based on larger numbers of patients. Although robotic rectal surgery is safe, feasible, and appears to overcome some of the technical limitations associated with conventional laparoscopic surgery, the advantages provided by this technical innovation are currently limited. To justify its expensive cost, robotic surgery is more suitable for select patients, such as obese patients, men, those with cancer of the lower rectum, and those receiving preoperative chemoradiotherapy.

Robot-assisted versus laparoscopic surgery for lower rectal cancer: the impact of visceral obesity on surgical outcomes

PURPOSE

The purpose of this study was to evaluate the advantages of robot-assisted laparoscopic surgery (RALS) for lower rectal cancer and for visceral obesity cases, which have been regarded as challenging situations in rectal cancer surgery, comparing their surgical outcomes with those of conventional laparoscopic surgery (CLS).

METHODS

Patients who underwent robotic or laparoscopic total mesorectal excision for rectal cancer were included in this retrospective study. Surgical outcomes including perioperative, postoperative, and pathological data were compared between the RALS and CLS groups. Patients were stratified into obese and non-obese groups according to visceral fat area (VFA). Obesity was defined by VFA ≥130 cm(2).

RESULTS

Two hundred thirty-six patients were enrolled, including 127 cases in the RALS group and 109 cases in the CLA group. A total of 82 (34.7 %) cases were categorized as VFA obese, including 52 cases in the RALS and 30 cases in the CLS groups. RALS for lower rectal cancer was associated with less blood loss (p = 0.007), a lower overall complication rate (9.4 % in RALS vs 23.9 % in CLS, p = 0.003), and shorter postoperative stay (p < 0.01) than CLS, with similar operative time and pathological results. The overall complication rate was significantly lower in the RALS group with VFA obesity; blood loss was significantly less and the postoperative stay was shorter in the RALS group with visceral obesity.

CONCLUSIONS

The present study demonstrated that RALS has some advantages in terms of surgical outcomes over CLS in challenging situations of rectal cancer surgery, such as lower rectal cancer cases and visceral obesity cases.

Oncologic Outcomes of Extended Robotic Resection for Rectal Cancer

BACKGROUND

Surgery for locally advanced rectal cancers beyond the plane of total mesorectal excision (TME) or extramesorectal nodal involvement should include complete resection. This study evaluated the oncologic feasibility and safety of robot-assisted surgery for rectal cancer beyond the TME plane.

METHODS

The study analyzed the operative, perioperative, and oncologic outcomes for all patients who underwent robot-assisted extended rectal cancer surgery from April 2009 to February 2015.

RESULTS

Of 36 patients, 22 underwent multivisceral en bloc resection, and 18 underwent extramesorectal lymph node (EMRLN) dissection. The median tumor location was 5 cm [interquartile range (IQR), 2.2-9.0 cm] from the anal verge. A total of 32 patients underwent neoadjuvant chemoradiation therapy. The median body mass index of the patients was 26.8 kg/m(2) (IQR, 24.0-31.9 kg/m(2)). Conversion was required for one patient because of inability to tolerate the Trendelenburg position. All the resections were R0, and there were no incomplete TMEs. The vagina and prostate or periprostatic structures were the most commonly resected (n = 13/22), and the lateral pelvic nodes were the most common EMRLNs (n = 16/18). The median numbers of examined mesorectal lymph nodes and EMRLNs were respectively 20 (IQR, 18.0-28.0) and 2.5 (IQR, 1.0-6.0). The median hospital stay was 4 days (IQR, 3.0-5.5 days). Six patients experienced Clavien-Dindo grade 3 complications, the most common of which was deep abscess (n = 5, 13.8 %). The 5-year actuarial local recurrence rate was 3.6 %.

CONCLUSIONS

Minimally invasive resection for rectal cancer can be performed with extended lymph node dissection or en bloc multivisceral resection using the surgical robot in selected patients. This technique is feasible and has acceptable morbidity.