Evaluation of the robotic approach concerning pitfalls in rectal surgery

Robotic rectal resection preserves anorectal function: Systematic review and meta-analysis

BACKGROUND

Improving survival rates in rectal cancer patients has generated a growing interest in functional outcomes after total mesorectal excision (TME). The well-established low anterior resection syndrome (LARS) score assesses postoperative anorectal impairment after TME. Our meta-analysis is the first to compare bowel function after open, laparoscopic, transanal, and robotic TME.

METHODS

All studies reporting functional outcomes after rectal cancer surgery (LARS score) were included, and were compared with a consecutive series of robotic TME (n = 48).

RESULTS

Thirty-two publications were identified, including 5 565 patients. Anorectal function recovered significantly better within one year after robotic TME (3.8 [95%CI -9.709-17.309]) versus laparoscopic TME (26.4 [95%CI 19.524-33.286]), p = 0.006), open TME (26.0 [95%CI 24.338-29.702], p = 0.002) and transanal TME (27.9 [95%CI 22.127-33.669], p = 0.003).

CONCLUSIONS

Robotic TME enables better recovery of anorectal function compared to other techniques. Further prospective, high-quality studies are needed to confirm the benefits of robotic surgery.

Feasibility of robot-assisted surgery in elderly patients with rectal cancer

Background:

Although surgical resection is the main treatment for rectal cancer, the optimal surgical protocol for elderly patients with rectal cancer remains controversial. This study evaluated the feasibility of robot-assisted surgery in elderly patients with rectal cancer.

Patients and Methods:

This retrospective study enrolled 156 patients aged 28–93 years diagnosed with Stage I–III rectal cancer, who underwent robot-assisted surgery between May 2013 and December 2018 at a single institution.

Results:

In total, 156 patients with rectal cancer, including 126 non-elderly (aged < 70 years) and 30 elderly (aged ≥70 years) patients, who underwent robot-assisted surgery were recruited. Between the patient groups, the post-operative length of hospital stay did not differ statistically significantly (P = 0.084). The incidence of overall post-operative complications was statistically significantly lower in the elderly group (P = 0.002). The disease-free and overall survival did not differ statistically significantly between the two groups (P = 0.719 and 0.390, respectively).

Conclusions:

Robot-assisted surgery for rectal cancer was well tolerated by elderly patients, with similar results to the non-elderly patients. Oncological outcomes and survival did not depend on patient age, suggesting that robot-assisted surgery is a feasible surgical modality for treating operable rectal cancer and leads to age-independent post-operative outcomes in elderly patients.

Obese patients and robotic colorectal surgery: systematic review and meta-analysis

BACKGROUND

Obesity is a major health problem, demonstrated to double the risk of colorectal cancer. The benefits of robotic colorectal surgery in obese patients remain largely unknown. This meta-analysis evaluated the clinical and pathological outcomes of robotic colorectal surgery in obese and non-obese patients.

METHODS

MEDLINE, Embase, Global Health, Healthcare Management Information Consortium (HMIC) and Midwives Information and Resources Service (MIDIRS) databases were searched on 1 August 2018 with no language restriction. Meta-analysis was performed according to PRISMA guidelines. Obese patients (BMI 30 kg/m2 or above) undergoing robotic colorectal cancer resections were compared with non-obese patients. Included outcome measures were: operative outcomes (duration of surgery, conversion to laparotomy, blood loss), postoperative complications, hospital length of stay and pathological outcomes (number of retrieved lymph nodes, positive circumferential resection margins and length of distal margin in rectal surgery).

RESULTS

A total of 131 full-text articles were reviewed, of which 12 met the inclusion criteria and were included in the final analysis. There were 3166 non-obese and 1420 obese patients. A longer duration of surgery was documented in obese compared with non-obese patients (weighted mean difference -21·99 (95 per cent c.i. -31·52 to -12·46) min; P < 0·001). Obese patients had a higher rate of conversion to laparotomy than non-obese patients (odds ratio 1·99, 95 per cent c.i. 1·54 to 2·56; P < 0·001). Blood loss, postoperative complications, length of hospital stay and pathological outcomes were not significantly different in obese and non-obese patients.

CONCLUSION

Robotic surgery in obese patients results in a significantly longer duration of surgery and higher conversion rates than in non-obese patients. Further studies should focus on better stratification of the obese population with colorectal disease as candidates for robotic procedures.

Hybrid minimally invasive/open approach versus total minimally invasive approach for rectal cancer resection: short- and long-term results

OBJECTIVES

To reduce the technical challenges of a totally minimally invasive approach (TMA) and to decrease the morbidity associated with open surgery, a hybrid minimally invasive/open approach (HMOA) has been introduced as a surgical technique for rectal cancer. The aim of this study was to compare postoperative results and long-term oncologic outcomes between hybrid minimally invasive/open approach and totally minimally invasive approach in patients who underwent rectal resection for cancer.

METHODS

All patients with rectal cancer undergoing a totally minimally invasive approach or hybrid minimally invasive/open approach proctectomy between 2012 and 2016 were analyzed. Preoperative and postoperative outcomes were collected from a prospectively maintained institutional database.

RESULTS

Among 283 patients, 138 (48.8%) underwent a hybrid minimally invasive/open approach and 145 (51.2%) a totally minimally invasive approach. Preoperative characteristics were similar between groups except for distance from the anal verge, which was lower in totally minimally invasive approach group (50.7% vs 29%; p = 0.0008). Length of stay (LOS) was significantly longer in the hybrid minimally invasive/open approach group (6.4 vs 4.3; p = < 0.0001). The median follow-up was 29.6 (14-40.6) months. Overall survival and disease-free survival were not significantly different between groups.

CONCLUSIONS

Compared with a hybrid minimally invasive/open approach, a totally minimally invasive approach has a shorter length of stay and may improve short-term outcomes in patients undergoing proctectomy for cancer.

Preservation of Pathologic Outcomes in Robotic versus Open Resection for Rectal Cancer: Can the Robot Fill the Minimally Invasive Gap?

Open resection remains the standard of care in the surgical management of rectal cancer with recent studies unable to prove noninferiority of laparoscopic resection. Few studies directly compare robotic versus open techniques. This is a retrospective chart review of all consecutive patients undergoing robotic or open rectal cancer resection during a three-year period. The primary endpoint was a composite of complete mesorectal excision, circumferential resection margin <1 mm, and distal resection margin <1 mm. The study cohort included 64 patients undergoing robotic (n = 28) or open (n = 36) resection. Successful surgical resection was similar between the robotic (75%) and open (76%) approaches. Robotic resection was associated with significantly lower blood loss ( P = 0.02) and significantly longer operative times ( P = 0.009) compared with open resection. Length of hospital stay and complications were similar between groups. Both male gender ( P = 0.03) and shorter tumor distance from the anal verge ( P = 0.01) were predictors for unsuccessful surgical resection in open, but not robotic, surgery. Pathologic outcomes are similar between robotic and open rectal cancer resection, even early in the learning curve. Tumor distance from the anal verge complicates open total mesorectal excision; however, robotic surgery is less impacted. Robotic resection may be a promising minimally invasive approach for rectal cancer resection.

Systematic review analysis of robotic and transanal approaches in TME surgery- A systematic review of the current literature in regard to challenges in rectal cancer surgery

Several patients' and pathological characteristics in rectal surgery can significantly complicate surgical loco regional tumor clearance. The main factors are obesity, short tumor distance from anal verge, bulky tumors, and narrow pelvis, which have been shown to be associated to poor surgical results in open and laparoscopic approaches. Minimally invasive surgery has the potential to reduce perioperative morbidity with equivalent short- and long-term oncological outcomes compared to conventional open approach. Achilles' heel of laparoscopic approaches is conversion to open surgery. High risk for conversion is evident for patients with bulky and low tumors as well as male gender and narrow pelvis. Hence, patient's characteristics represent challenges in rectal cancer surgery especially in minimally invasive approaches. The available surgical techniques increased remarkably with recently developed and implemented improvements of minimally invasive rectal cancer surgery. The controversial discussions about sense and purpose of these novel approaches are still ongoing in the literature. Herein, we evaluate, if latest technical advances like transanal approach or robotic assisted surgery have the potential to overcome known challenges and pitfalls in rectal cancer surgery in demanding surgical cases and highlight the role of current minimally invasive approaches in rectal cancer surgery.

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

Interest in minimally invasive surgery has increased in recent decades. Robotic-assisted laparoscopic surgery (RALS) was introduced as the latest advance in minimally invasive surgery. RALS has the potential to provide better clinical outcomes in rectal cancer surgery, allowing for precise dissection in the narrow pelvic space. In addition, RALS represents an important advancement in surgical education with respect to use of the dual-console robotic surgery system. Because the public health insurance systems in Japan have covered the cost of RALS for rectal cancer since April 2018, RALS has been attracting increasingly more attention. Although no overall robust evidence has yet shown that RALS is superior to laparoscopic or open surgery, the current evidence supports the notion that technically demanding subgroups (patients with obesity, male patients, and patients treated by extended procedures) may benefit from RALS. Technological innovation is a constantly evolving field. Several companies have been developing new robotic systems that incorporate new technology. This competition among companies in the development of such systems is anticipated to lead to further improvements in patient outcomes as well as drive down the cost of RALS, which is one main concern of this new technique.

Outcomes of Early Removal of Urinary Catheter Following Rectal Resection for Cancer

PURPOSE

Early postoperative urinary catheter removal decreases urinary tract infection (UTI) rate and accelerates patient mobilization. The aim of this study is to determine the results of systematic urinary catheter removal on postoperative day (POD) 1 in patients undergoing rectal resection for cancer.

PATIENTS AND METHODS

Using a prospectively maintained database of 469 patients who underwent rectal resection for cancer, a retrospective review of all patients with urinary catheter removal on POD1 was conducted. Patients unable to void 6 h after catheter removal underwent in and out urinary catheterization (IOC group) and were compared with patients who voided spontaneously (non-IOC group) to determine risk factors for IOC.

RESULTS

A total of 417 patients were identified, including 274 (66%) men. Median age was 59 (50-68) years. Abdominoperineal resection (APR) was performed in 134 (32%), and complex surgery with resection of at least one other organ in 72 (17%) patients. Non-IOC and IOC groups included 245 (59%) and 172 (41%) patients, respectively. Five independent predictive factors for IOC were male gender, obesity, history of obstructive urinary disease, APR, and metastatic disease. The cumulative risk of IOC in patients with zero, one, two, and at least three risk factors was 8%, 31%, 52%, and 68% on POD1, and 2%, 12%, 23%, and 30% on POD5, respectively (p < 0.001). Thirteen patients (3%) developed UTI.

CONCLUSIONS

Early removal of urinary catheter resulted in 59% of patients voiding spontaneously with no need for IOC following rectal resection. Patients without any predictive factors had less than 10% risk of urinary dysfunction.

Does obesity impact postoperative outcomes following robotic-assisted surgery for rectal cancer?

INTRODUCTION

Obesity has been identified as a risk factor for both conversion and severe postoperative morbidity in patients undergoing laparoscopic rectal resection. Robotic-assisted surgery (RAS) is proposed to overcome some of the technical limitations associated with laparoscopic surgery for rectal cancer. The aim of our study was to determine if obesity remains a risk factor for severe morbidity in patients undergoing robotic-assisted rectal resection.

PATIENTS

This study was a retrospective review of a prospective database. A total of 183 patients undergoing restorative RAS for rectal cancer between 2007 and 2016 were divided into 2 groups: control (BMI < 30 kg/m²; n = 125) and obese (BMI ≥ 30 kg/m²; n = 58). Clinicopathologic data, 30-day postoperative morbidity, and perioperative outcomes were compared between groups. The main outcome was severe postoperative morbidity defined as any complication graded Clavien-Dindo ≥ 3.

RESULTS

Control and obese groups had similar clinicopathologic characteristics. Severe complications were observed in 9 (7%) and 4 (7%) patients, respectively (p > 0.99). Obesity did not impact conversion, anastomotic leak rate, length of stay, or readmission but was significantly associated with increased postoperative morbidity (29 vs. 45%; p = 0.04) and especially more postoperative ileus (11 vs. 26%; p = 0.01). Obesity and male gender were the two independent risk factors for postoperative overall morbidity (OR 1.97; 95% CI 1.02-3.94; p = 0.04 and OR 2.23; 95% CI 1.10-4.76; p = 0.03, respectively).

CONCLUSION

‎Obesity did not impact severe morbidity or conversion rate following RAS for rectal cancer but remained a risk factor for overall morbidity and especially postoperative ileus.

Lower Gastrointestinal Surgery: Robotic Surgery versus Laparoscopic Procedures

Introduction

For a long time, the comprehensive application of minimally invasive techniques in lower gastrointestinal (GI) surgery was substantially impaired by inherent anatomical and technical complexities. Recently, several new techniques such as robotic operating platforms and transanal total mesorectal excision (taTME) have revolutionized the minimally invasive approach. This review aims to depict the current state of the art and evaluates the advantages and drawbacks in regard to perioperative outcome and quality of oncological resection.

Methods

A systematic literature search was performed using the search terms 'colorectal cancer', 'rectal cancer', 'minimally invasive surgery', 'laparoscopic surgery', and 'robotic' to identify relevant studies reporting on robotic surgery (RS) either alone or in comparison to laparoscopic surgery (LS). Publications on taTME were analyzed separately.

Results

69 studies reporting on RS with a total of 20,872 patients, and 17 articles on taTME including 881 patients, were identified.

Conclusion

Both RS and taTME can facilitate a minimally invasive approach for lower GI surgery in an increasing number of patients. Furthermore, combining both techniques might become an auspicious approach in selected patients; further prospective and randomized trials are needed to verify its benefits over conventional laTME.

Robotic low anterior resection versus transanal total mesorectal excision in rectal cancer: A comparison of 115 cases

BACKGROUND

Robotic low anterior resection (RLAR) and transanal total mesorectal excision (TaTME) are novel surgical techniques for resection of rectal cancer. To our knowledge, no data exist on direct comparison of these procedures in terms of oncological or functional parameters.

METHODS

60 RLAR and 55 TaTME for rectal cancer were compared in respect to patient characteristics, clinicopathological parameters, intraoperative and perioperative results and anatomopathological outcome.

RESULTS

62 surgeries addressed tumors of the lower third (53.9%). No intergroup differences in terms of patient characteristics and clinicopathological parameters were observed. Operating time did not differ between groups (p = 0.312), nor did the perioperative complication rate (p = 0.176). Circumferential resection margin was wider in the RLAR than in the TaTME group (p < 0.001), while no differences were found in the remaining oncological parameters.

CONCLUSION

Our study shows comparable results for RLAR and TaTME in rectal cancer treatment. Both procedures should be considered equally feasible for low rectal cancer cases and as an alternative to conventional anterior resections (open or laparoscopic). Furthermore, both techniques allow excellent oncological outcome especially in patients with anatomical limitations.