One hundred and two consecutive robotic-assisted minimally invasive colectomies--an outcome and technical update

Robotic surgery for colorectal disease: review of current port placement and future perspectives

Purpose

As robotic surgery is increasingly performed in patients with colorectal diseases, understanding proper port placement for robotic colorectal surgery is necessary. This review summarizes current port placement during robotic surgery for colorectal diseases and provides future perspective on port placements.

Methods

PubMed were searched from January 2009 to December 2018 using a combination of the search terms “robotic” [MeSH], “colon” [MeSH], “rectum” [MeSH], “colorectal” [MeSH], and “colorectal surgery” [MeSH]. Studies related to port placement were identified and included in the current study if they used the da Vinci S, Si, or Xi robotic system and if they described port placement.

Results

This review included 77 studies including a total of 3,145 operations. Fifty studies described port placement for left-sided and mesorectal excision; 17, 3, and 7 studies assessed port placement for right-sided colectomy, rectopexy, transanal surgery, respectively; and one study assessed surgery with reduced port placement. Recent literatures show that the single-docking technique included mobilization of the second and third robotic arms for the different parts without movement of patient cart and similar to previous dual or triple-docking technique. Besides, use of the da Vinci Xi system allowed a more simplified port configuration.

Conclusion

Robot-assisted colorectal surgery can be efficiently achieved with successful port placement without movement of patient cart dependent on the type of surgery and the robotic system.

Feasibility and safety of robotic resection of complicated diverticular disease

This study aimed to assess intra- and postoperative outcomes of robotic resection of left-sided complicated diverticular disease. Retrospective analysis of a prospectively maintained institutional database on consecutive patients undergoing elective robotic resection for diverticular disease (2014-2018). All procedures were performed within an enhanced recovery pathway (ERP). Demographic, surgical and ERP-related items were compared between patients with simple and complicated diverticular disease according to intra-operative presentation. Postoperative complications and length of stay were compared between the two groups. Out of 150 patients, 78 (52%) presented with complicated and the remaining 72 (48%) with uncomplicated disease. Both groups were comparable regarding demographic baseline characteristics and overall ERP compliance. Surgery for complicated disease was longer (288 ± 96 vs. 258 ± 72 min, p = 0.04) and more contaminated (≥ class 3: 57.7 vs. 23.6%, p < 0.001) with a trend to higher conversion rates (10.3 vs. 2.8%, p = 0.1). While postoperative overall complications tended to occur more often after resections for complicated disease (28.2 vs. 15.3%, p = 0.075), major, surgical and medical complications did not differ between the two groups, and median length of stay was 3 days in both settings (p = 0.19). Robotic resection of diverticular disease was feasible and safe regardless of disease presentation by the time of surgery.

Advantages of Robotic Right Colectomy With Intracorporeal Anastomosis

Through retrospective review of consecutive charts, we compare the short-term and long-term clinical outcomes after robotic-assisted right colectomy with intracorporeal anastomosis (RIA) (n=89) and laparoscopic right colectomy with extracorporeal anastomosis (LEA) (n=135). Cohorts were similar in demographic characteristics, comorbidities, pathology, and perioperative outcomes (conversion, days to flatus and bowel movement, and length of hospitalization). The RIA cohort experienced statistically significant: less blood loss, shorter incision lengths, and longer specimen lengths than the LEA cohort. Operative times were significantly longer for the RIA group. No incisional hernias occurred in the RIA group, whereas the LEA group had 5 incisional hernias; mean follow-up was 33 and 30 months, respectively. RIA is effective and safe and provides some clinical advantages. Future studies may show that, in obese and other technically challenging patients, RIA facilitates resection of a longer, consistent specimen with less mesentery trauma that can be extracted through smaller incisions.

Evolution and literature review of robotic general surgery resident training 2002-2018

The University of Illinois purchased their first da Vinci System in September of 2002. Within the first calendar year, their program began orienting trainees to the da Vinci Standard System to make its inclusion in their clinical training run more smoothly. During the ensuring 16 years, their program has evolved into more frequent resident orientations, lectures, and courses. The program has grown over the course of different versions of the da Vinci System. Currently, their program houses three Xi and two Si systems. Led by Dr. Crawford and Mr. Dwyer they have formalized their curriculum using a systematic progression of skill acquisition. The lecture will detail the program's organic development over the last 16 years. It will also explain the scientific measurement tools recently applied to the curriculum.

Comparison of Open, Laparoscopic, and Robotic Colectomies Using a Large National Database: Outcomes and Trends Related to Surgery Center Volume

BACKGROUND

Previous studies have shown that high-volume centers and laparoscopic techniques improve outcomes of colectomy. These evidence-based measures have been slow to be accepted, and current trends are unknown. In addition, the current rates and outcomes of robotic surgery are unknown.

OBJECTIVE

The purpose of this study was to examine current national trends in the use of minimally invasive surgery and to evaluate hospital volume trends over time.

DESIGN

This was a retrospective study.

SETTINGS

This study was conducted in a tertiary referral hospital.

PATIENTS

Using the National Inpatient Sample, we evaluated trends in patients undergoing elective open, laparoscopic, and robotic colectomies from 2009 to 2012. Patient and institutional characteristics were evaluated and outcomes compared between groups using multivariate hierarchical-logistic regression and nonparametric tests. The National Inpatient Sample includes patient and hospital demographics, admission and treating diagnoses, inpatient procedures, in-hospital mortality, length of hospital stay, hospital charges, and discharge status.

MAIN OUTCOME MEASURES

In-hospital mortality and postoperative complications of surgery were measured.

RESULTS

A total of 509,029 patients underwent elective colectomy from 2009 to 2012. Of those 266,263 (52.3%) were open, 235,080 (46.2%) laparoscopic, and 7686 (1.5%) robotic colectomies. The majority of minimal access surgery is still being performed at high-volume compared with low-volume centers (37.5% vs 28.0% and 44.0% vs 23.0%; p < 0.001). A total of 36% of colectomies were for cancer. The number of robotic colectomies has quadrupled from 702 in 2009 to 3390 (1.1%) in 2012. After adjustment, the rate of iatrogenic complications was higher for robotic surgery (OR = 1.73 (95% CI, 1.20-2.47)), and the median cost of robotic surgery was higher, at $15,649 (interquartile range, $11,840-$20,183) vs $12,071 (interquartile range, $9338-$16,203; p < 0.001 for laparoscopic).

LIMITATIONS

This study may be limited by selection bias by surgeons regarding the choice of patient management. In addition, there are limitations in the measures of disease severity and, because the database relies on billing codes, there may be inaccuracies such as underreporting.

CONCLUSIONS

Our results show that the majority of colectomies in the United States are still performed open, although rates of laparoscopy continue to increase. There is a trend toward increased volume of laparoscopic procedures at specialty centers. The role of robotics is still being defined, in light of higher cost, lack of clinical benefit, and increased iatrogenic complications, albeit comparable overall complications, as compared with laparoscopic colectomy.

Robotic-assisted versus laparoscopic colectomy: cost and clinical outcomes

BACKGROUND AND OBJECTIVES

Laparoscopic colectomies, with and without robotic assistance, are performed to treat both benign and malignant colonic disease. This study compared clinical and economic outcomes for laparoscopic colectomy procedures with and without robotic assistance.

METHODS

Patients aged ≥18 years having primary inpatient laparoscopic colectomy procedures (cecectomy, right hemicolectomy, left hemicolectomy, and sigmoidectomy) identified by International Classification of Diseases, Ninth Edition procedure codes performed between 2009 and the second quarter of 2011 from the Premier Hospital Database were studied. Patients were matched to a control cohort using propensity scores for disease, comorbidities, and hospital characteristics and were matched 1:1 for specific colectomy procedure. The outcomes of interest were hospital cost of laparoscopic robotic-assisted colectomy compared with traditional laparoscopic colectomy, surgery time, adverse events, and length of stay.

RESULTS

Of 25,758 laparoscopic colectomies identified, 98% were performed without robotic assistance and 2% were performed with robotic assistance. After matching, 1066 patients remained, 533 in each group. Lengths of stay were not significantly different between the matched cohorts, nor were rates of major, minor, and/or surgical complications. Inpatient procedures with robotic assistance were significantly more costly than those without robotic assistance ($17,445 vs $15,448, P = .001). Operative times were significantly longer for robotic-assisted procedures (4.37 hours vs 3.34 hours, P < .001).

CONCLUSION

Segmental colectomies can be performed safely by either laparoscopic or robotic-assisted methods. Increased per-case hospital costs for robotic-assisted procedures and prolonged operative times suggest that further investigation is warranted when considering robotic technology for routine laparoscopic colectomies.

Laparoscopy Versus Robotic Surgery for Colorectal Cancer: A Single-Center Initial Experience

Background Minimally invasive approach has gained interest in the treatment of patients with colorectal cancer. The purpose of this study is to analyze the differences between laparoscopy and robotics for colorectal cancer in terms of oncologic and clinical outcomes in an initial experience of a single center. Materials and Methods Clinico-pathological data of 100 patients surgically treated for colorectal cancer from March 2008 to April 2014 with laparoscopy and robotics were analyzed. The procedures were right colonic, left colonic, and rectal resections. A comparison between the laparoscopic and robotic resections was made and an analysis of the first and the last procedures in the 2 groups was performed. Results Forty-two patients underwent robotic resection and 58 underwent laparoscopic resection. The postoperative mortality was 1%. The number of harvested lymph nodes was higher in robotics. The conversion rate was 7.1% for robotics and 3.4% for laparoscopy. The operative time was lower in laparoscopy for all the procedures. No differences were found between the first and the last procedures in the 2 groups. Conclusions This initial experience has shown that robotic surgery for the treatment of colorectal adenocarcinoma is a feasible and safe procedure in terms of oncologic and clinical outcomes, although an appropriate learning curve is necessary. Further investigation is needed to demonstrate real advantages of robotics over laparoscopy.

Robotic right colectomy: A worthwhile procedure? Results of a meta-analysis of trials comparing robotic versus laparoscopic right colectomy

BACKGROUND:

Robotic right colectomy (RRC) is a complex procedure, offered to selected patients at institutions highly experienced with the procedure. It is still not clear if this approach is worthwhile in enhancing patient recovery and reducing post-operative complications, compared with laparoscopic right colectomy (LRC). Literature is still fragmented and no meta-analyses have been conducted to compare the two procedures. This work aims at reducing this gap in literature, in order to draw some preliminary conclusions on the differences and similarities between RRC and LRC, focusing on short-term outcomes.

MATERIALS AND METHODS:

A systematic literature review was conducted to identify studies comparing RRC and LRC, and meta-analysis was performed using a random-effects model. Peri-operative outcomes (e.g., morbidity, mortality, anastomotic leakage rates, blood loss, operative time) constituted the study end points.

RESULTS:

Six studies, including 168 patients undergoing RRC and 348 patients undergoing LRC were considered as suitable. The patients in the two groups were similar with respect to sex, body mass index, presence of malignant disease, previous abdominal surgery, and different with respect to age and American Society of Anesthesiologists score. There were no statistically significant differences between RRC and LRC regarding estimated blood loss, rate of conversion to open surgery, number of retrieved lymph nodes, development of anastomotic leakage and other complications, overall morbidity, rates of reoperation, overall mortality, hospital stays. RRC resulted in significantly longer operative time.

CONCLUSIONS:

The RRC procedure is feasible, safe, and effective in selected patients. However, operative times are longer comparing to LRC and no advantages in peri-operative and post-operative outcomes are demonstrated with the use of the robotic surgical system.

Use of robotics in colon and rectal surgery

The pace of innovation in the field of surgery continues to accelerate. As new technologies are developed in combination with industry and clinicians, specialized patient care improves. In the field of colon and rectal surgery, robotic systems offer clinicians many alternative ways to care for patients. From having the ability to round remotely to improved visualization and dissection in the operating room, robotic assistance can greatly benefit clinical outcomes. Although the field of robotics in surgery is still in its infancy, many groups are actively investigating technologies that will assist clinicians in caring for their patients. As these technologies evolve, surgeons will continue to find new and innovative ways to utilize the systems for improved patient care and comfort.

Modifiable factors to decrease the cost of robotic-assisted procedures

In 2000, the US Food and Drug Administration approved the da Vinci Surgical System® for use in the United States. Since that time, the number of surgical robotic systems throughout the United States has continued to grow. The costs for using the system include the initial purchase ($1 million to $2.3 million) plus annual maintenance fees ($100,000 to $150,000) and the cost of limited-use or disposable instruments. Increasing the number of procedures that are performed using the robotic system can decrease the per-procedure costs. Two modifiable factors that contribute to increasing the annual caseload are increasing the number of surgeons capable of using the system and having a properly educated perioperative nursing team. An educated surgical team decreases turnover time, facilitates proper flow of each surgical procedure, and is able to actively and passively solve intraoperative problems.

Is minimally invasive colon resection better than traditional approaches?: First comprehensive national examination with propensity score matching

IMPORTANCE

Minimally invasive colectomies are increasingly popular options for colon resection.

OBJECTIVE

To compare the perioperative outcomes and costs of robot-assisted colectomy (RC), laparoscopic colectomy (LC), and open colectomy (OC).

DESIGN, SETTING, AND PARTICIPANTS

The US Nationwide Inpatient Sample database was used to examine outcomes and costs before and after propensity score matching across the 3 surgical approaches. This study involved a sample of US hospital discharges from 2008 to 2010 and all patients 21 years of age or older who underwent elective colectomy. MAIN OUTCOMES AND MEASURES In-hospital mortality, complications, ostomy rates, conversion to open procedure, length of stay, discharge disposition, and cost.

RESULTS

Of the 244129 colectomies performed during the study period, 126284 (51.7%) were OCs, 116261 (47.6%) were LCs, and 1584 (0.6%) were RCs. In comparison with OC, LC was associated with a lower mortality rate (0.4% vs 2.0%), lower complication rate (19.8% vs 33.2%), lower ostomy rate (3.5 vs 13.0%), shorter median length of stay (4 vs 6 days), a higher routine discharge rate (86.1% vs 68.4%), and lower overall cost than OC ($11742 vs $13666) (all P<.05). Comparison between RC and LC showed no significant differences with respect to in-hospital mortality (0.0% vs 0.7%), complication rates (14.7% vs 18.5%), ostomy rates (3.0% vs 5.1%), conversions to open procedure (5.7% vs 9.9%), and routine discharge rates (88.7% vs 88.5%) (all P>.05). However, RC incurred a higher overall hospitalization cost than LC ($14847 vs $11966, P<.001).

CONCLUSIONS AND RELEVANCE

In this nationwide comparison of minimally invasive approaches for colon resection, LC demonstrated favorable clinical outcomes and lower cost than OC. Robot-assisted colectomy was equivalent in most clinical outcomes to LC but incurred a higher cost.

[Robotics-assisted laparoscopic colorectal resection]

The value of laparoscopic surgery for rectal cancer is still controversially discussed. Robotics offers the opportunity to leave the limitations of conventional laparoscopy behind us. The three-dimensional visualization and the superior dexterity by wristed instruments should be particularly helpful in complex laparoscopic procedures in confined spaces such as the small pelvis. Colorectal resections using the Da Vinci® system are well established and becoming increasingly more standard procedures. Nerve-sparing total mesorectal excision in patients with rectal cancer, total mesocolic excision in patients with right-sided colon cancer and rectopexy in patients with pelvic floor insufficiency are the most promising indications. The prospective randomized ROLARR study has been evaluating the application of the Da Vinci® system in laparoscopic rectal cancer surgery since 2011. Besides the currently available clinical data the perioperative and intraoperative logistics and strategy will be presented in detail.

Outcomes of robotic-assisted colorectal surgery compared with laparoscopic and open surgery: a systematic review

BACKGROUND

Robotic technology has been applied to colorectal surgery over the last decade. The aim of this review is to analyze the outcomes of robotic colorectal surgery systematically and to provide objective information to surgeons.

METHODS

Studies were searched and identified using PubMed and Google Scholar from Jan 2001 to Feb 2013 with the search terms "robot," "robotic," "colon," "rectum," "colorectal," and "colectomy." Appropriate data in the studies about the outcomes of robotic colorectal surgery were analyzed.

RESULTS

Sixty-nine publications were included in this review and composed of 39 case series, 29 comparative studies, and 1 randomized controlled trial. Most of the studies reported that robotic surgery showed a longer operation time, less estimated blood loss, shorter length of hospital stay, lower complication and conversion rates, and comparable oncologic outcomes compared to laparoscopic or open surgery.

CONCLUSION

Robotic colorectal surgery is a safe and feasible option. Robotic surgery showed comparable short-term outcomes compared to laparoscopic surgery or open surgery. However, the long operation time and high cost are the limitations of robotic surgery.

Robotic versus open total mesorectal excision for rectal cancer: comparative study of short and long-term outcomes

BACKGROUND

Despite the several series in which the short-term outcomes of robotic-assisted surgery were investigated, data concerning the long-term outcomes are still scarce.

METHODS

The prospectively collected records of 65 consecutive patients with extraperitoneal rectal cancer who underwent robotic total mesorectal excision (RTME) were compared with those of 109 consecutive patients treated with open surgery (OTME). Patient characteristics, pathological findings, local and systemic recurrence rates and 5-year survival rates were compared.

RESULTS

There were no statistically significant differences in postoperative complications, reoperation and 30-day mortality. There were significant differences comparing groups: number of lymph nodes harvested (RTME: 20.1 vs. OTME: 14.1, P < 0.001), estimated blood loss (RTME: 0 vs. OTME: 150 ml, P = 0.003), operation time (RTME: 299.0 vs. OTME: 207.5 min, P < 0.001) and length of postoperative stay (RTME: 6 vs. OTME: 9 days, P < 0.001). The rate of circumferential resection margin involvement and distal resection margin were not statistically different between groups. There were no statistically significant differences at the 5-year follow-up: overall survival, disease-free survival and cancer-specific survival. The cumulative local recurrence rate was statistically lower in the robotic group (RTME: 3.4% vs. OTME: 16.1%, P = 0.024).

CONCLUSION

RTME showed a significant reduction in local recurrence rate and a higher, although not statistically significant, long-term cancer-specific survival with respect to OTME. Prospective randomized studies are needed to confirm or deny significantly better local control rates with robotic surgery.

Robotic colorectal surgery

INTRODUCTION

Minimally invasive surgery has many potential benefits, and the application of recently developed robotic technology to patients with colorectal diseases is rapidly gaining popularity.

QUALITY AND OUTCOMES

However, the literature evaluating such techniques, including the outcomes, risks, and costs, is limited. In this review, we evaluate and summarize the existing information, calling attention to areas where future investigation should occur.

Improved perioperative and short-term outcomes of robotic versus conventional laparoscopic colorectal operations

BACKGROUND

Robotic assistance may offer unique advantages over conventional laparoscopy in colorectal operations.

METHODS

This prospective observational study compared operative measures and postoperative outcomes between laparoscopic and robotic abdominal and pelvic resections for benign and malignant disease.

RESULTS

From 2005 through 2012, 200 (58%) laparoscopic and 144 (42%) robotic operations were performed by a single surgeon. After adjustment for differences in demographics and disease processes using propensity score matching, all laparoscopic operations had a significantly shorter operative time (P < .01), laparoscopic left colectomies had a longer length of hospital stay (2009 and 2010: 6.5 vs 3.6 days, P = .01); and laparoscopic right colectomies had a higher risk for overall complications (P = .03) and postoperative ileus (P = .04). There were no significant differences in the outcomes of pelvic operations (P = .15).

CONCLUSIONS

Compared with conventional laparoscopy, some types of robotic-assisted colorectal operations may offer advantages regarding postoperative length of stay and perioperative complications.

Robotic colonic surgery: is it advisable to commence a new learning curve?

BACKGROUND

Robotic surgery has potential advantages in rectal and pelvic surgery, in which the dissection is performed within a confined operative field. However, the position of robotic colonic surgery remains largely undefined with limited insight of whether it offers any potential advantages over open or laparoscopic colon surgery.

OBJECTIVES

The aim of this systematic review was to compare the short-term outcomes of the published robotic colonic surgery with those of laparoscopic colonic surgery.

DATA SOURCES

The search was performed in September 2012 with the use of PubMed, MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. The search terms used were "colorectal," "colon," "colectomy," and "robotic/robot."

DATA SELECTION

All studies reporting outcomes on robotic colonic resection were included in the review process. Colonic robotic data were compared with data on the short-term outcomes of laparoscopic colonic surgery from a Cochrane review and 4 main randomized controlled trials.

INTERVENTIONS

A comparison was conducted of robotic colonic surgery vs standard laparoscopic colonic surgery.

MAIN OUTCOME MEASURES

Short-term outcomes and the complication profile of colonic robotic surgery were compared with conventional multiple-port laparoscopic colonic surgery.

RESULTS

Fifteen robotic colonic surgery articles with 351 patients (173 males, 178 females) were considered for analysis. The operative time and financial cost of robotic colonic surgery was greater than standard laparoscopic colonic surgery with comparable short-term outcomes and early postoperative complications profile.

CONCLUSIONS

The present evidence on robotic colonic surgery has shown both feasibility and a safety profile comparable to standard laparoscopic colonic surgery. However, operative time and cost were greater in robotic colonic surgery, with no difference in the length of postoperative stay in comparison with standard laparoscopic colonic surgery. Whether the general surgical community should embark on a new learning curve for robotic colonic surgery can only be answered in the light of future studies.

No differences in short-term morbidity and mortality after robot-assisted laparoscopic versus laparoscopic resection for colonic cancer: a case-control study of 263 patients

BACKGROUND

Robot-assisted laparoscopy has been reported to be a safe and feasible alternative to traditional laparoscopy. The aim of this study was to compare short-term results in patients with colonic cancer who underwent robot-assisted laparoscopic colonic resection (RC) or laparoscopic colonic resection (LC).

METHODS

The study was a retrospective case control study of all patients with colonic cancer who underwent RC from March 2010 to March 2012 or LC from January 2009 to December 2011 at a tertiary-care university hospital. Data were retrieved from the national chart database and patient journals. Biochemical markers [C-reactive protein (CRP), hemoglobin, white blood cell count, and thrombocyte count] were recorded before surgery and for the first 3 days after surgery.

RESULTS

A total of 101 patients underwent RC and 162 patients underwent LC. There were no significant differences in the rate of conversion to open surgery, number of permanent enterostomies, number of intraoperative complications, level of postoperative cellular stress response, number of postoperative complications, length of postoperative hospital stay, or 30-day mortality between the two groups. There was a significantly longer setup time for RC (77.1 vs. 69.7 min, P = 0.000), but surgical time was significantly shorter for RC (165.8 vs. 183.4 min, P = 0.006) and there was no difference in the overall procedure time (254.0 vs. 243.6 min, P = 0.086).

CONCLUSION

We found RC to be a safe and feasible alternative to LC for colonic cancer. We found that for RC surgical time was shorter and overall procedure time was comparable to that for LC; however, these results should be confirmed in future randomized clinical trials.

Single-site colectomy with miniature in vivo robotic platform

There has been a continuing push to reduce the invasiveness of surgery by accessing the abdominal cavity through a single incision, such as with laparoendoscopic single-site (LESS) surgery. Although LESS procedures offer significant benefits, added complexities still inhibit the procedures. Robotic surgery is proving to be an excellent option to overcome these limitations. This paper presents the experimental results of the single-incision in vivo surgical robot (SISR), a multifunctional, dexterous, two-armed robot capable of performing surgical tasks while overcoming the issues associated with manual LESS operations. In vivo surgical procedures have been used to demonstrate the efficacy of using a robotic platform over traditional laparoscopic tools. The most recent experimental test resulted in the first successful in vivo robotic LESS colectomy utilizing a robot completely contained within the abdominal cavity. In this test, SISR showed significant benefits including access to all quadrants in the peritoneal cavity and improved dexterity.

Robotic versus laparoscopic anterior resection of sigmoid colon cancer: comparative study of long-term oncologic outcomes

BACKGROUND

Robotically assisted colon resection is a new type of surgery for colon cancer. However, the evidence is inadequate for the general adaptation of robotic colon surgery. This study aimed to show the oncologic and perioperative clinical results of robotically assisted anterior resection (R-AR) compared with those of laparoscopically assisted anterior resection (L-AR) for sigmoid colon cancer.

METHODS

A total of 180 patients (sigmoid colon cancer stages 1-3) were assigned to receive either R-AR (n = 34) or L-AR (n = 146) between April 2006 and September 2008. Patient characteristics, perioperative clinical results, and long-term oncologic outcomes were compared between the two groups.

RESULTS

The patient characteristics did not differ significantly between the two groups. The mean operation time was 217.6 ± 70.7 min for L-AR versus 252.5 ± 94.9 min for R-AR (p = 0.016). The total postoperative complication rate was 10.3 % for R-AR versus 5.9 % for L-AR (p = 0.281). The 3-year overall survival rate for all the patients was 93.4 % for L-AR versus 92.1 % for R-AR (p = 0.723). The 3-year overall survival rate was 100 % for both L-AR and R-AR in stage 1, 95.5 % for L-AR versus 100 % for R-AR (p = 0.386) in stage 2, and 88.4 % for L-AR versus 72.9 % (p = 0.881) for R-AR in stage 3.

CONCLUSION

In this study, R-AR showed safety and feasibility in terms of perioperative clinical and long-term oncologic outcomes. However, the advanced technologies of R-AR did not translate into better long-term oncologic outcomes compared with L-AR.