Short-term and oncological outcomes of natural orifice specimen extraction surgery (NOSES) for colorectal cancer in China: a national database study of 5055 patients

Progress, challenges, and future perspectives of robot-assisted natural orifice specimen extraction surgery for colorectal cancer: a review

With the continuous advancements in precision medicine and the relentless pursuit of minimally invasive techniques, Natural Orifice Specimen Extraction Surgery (NOSES) has emerged. Compared to traditional surgical methods, NOSES better embodies the principles of minimally invasive surgery, making scar-free operations possible. In recent years, with the progress of science and technology, Robot-Assisted Laparoscopic Surgery has been widely applied in the treatment of colorectal cancer. Robotic surgical systems, with their clear surgical view and high operational precision, have shown significant advantages in the treatment process. To further improve the therapeutic outcomes for colorectal cancer patients, some scholars have attempted to combine robotic technology with NOSES. However, like traditional open surgery or laparoscopic surgery, the use of the robotic platform presents both advantages and limitations. Therefore, this study reviews the current research status, progress, and controversies regarding Robot-Assisted Laparoscopic Natural Orifice Specimen Extraction Surgery for colorectal cancer, aiming to provide clinicians with more options in the diagnosis and treatment of colorectal cancer.

Robotic natural orifice specimen extraction surgery versus robotic transabdominal specimen extraction surgery for early-stage rectal cancer: a multicenter propensity score-matched analysis (in China)

BACKGROUND

Despite the global increase in the adoption of robotic natural orifice specimen extraction surgery (R-NOSES), its advantages over robotic transabdominal specimen extraction surgery (R-TSES) for treating early-stage rectal cancer remain debated. There is scant nationwide, multicenter studies comparing the surgical quality and short-term outcomes between R-NOSES and R-TSES for this condition.

OBJECTIVE

This retrospective cohort study was conducted nationally across multiple centers to compare the surgical quality and short-term outcomes between R-NOSES and R-TSES in early-stage rectal cancer.

DESIGN

Multicenter retrospective cohort trial.

SETTING

Eight experienced surgeons from 8 high-volume Chinese colorectal cancer treatment centers.

PATIENTS

The study included 1086 patients who underwent R-NOSES or R-TSES from October 2015 to November 2023 at the 8 centers. Inclusion criteria were: (1) histologically confirmed rectal adenocarcinoma; (2) robotic total mesorectal excision; (3) postoperative pathological staging of TisN0M0 or T1-2N0M0; (4) availability of complete surgical and postoperative follow-up data. Patients were matched 1:1 in the R-NOSES and R-TSES groups using the propensity score matching (PSM) technique.

RESULTS

After PSM, 318 matched pairs with well-balanced patient characteristics were identified. The operation time for the R-NOSES group was significantly longer than that for the R-TSES group [140 min (125-170 min) vs. 140 min (120-160 min), P = 0.032]. Conversely, the times to first flatus and initial oral intake in the R-NOSES group were significantly shorter than those in the R-TSES group [48 h (41-56 h) vs. 48 h (44-62 h), P = 0.049 and 77 h (72-94 h) vs. 82 h (72-96 h), P = 0.008], respectively. Additionally, the length of postoperative hospital stay was shorter in the R-NOSES group compared with the R-TSES group [7 day (7-9 day) vs. 8 day (7-9 day), P = 0.005]. The overall postoperative complication rates were similar between the groups (10.7% in the R-NOSES group vs. 11.9% in the R-TSES group, P = 0.617). However, the R-NOSES group had a lower incidence of wound complications compared to the R-TSES group (0.0% vs. 2.2%, P = 0.015). Regarding surgical stress response, the R-NOSES group showed superior outcomes. Additionally, patients in the R-NOSES group required fewer additional analgesics on postoperative days 1, 3, and 5 and reported lower pain scores compared to the R-TSES group. The body image scale (BIS) and cosmetic scale (CS) scores were also significantly higher in the R-NOSES group. Furthermore, the R-NOSES group demonstrated significantly better outcomes in functional dimensions such as physical, role, emotional, social, and cognitive functioning, and in symptoms like fatigue and pain, when compared to the R-TSES group.

LIMITATIONS

It is imperative to ensure the safe and standardized implementation of R-NOSES through the establishment of a uniform training protocol.

CONCLUSIONS

These results affirm that R-NOSES is a safe and effective treatment for early-stage rectal cancer when meticulously executed by skilled surgeons.

Comparative long-term outcomes of natural orifice specimen extraction surgery and conventional laparoscopic colectomy for left-sided colorectal cancer: a propensity score-matched analysis

BACKGROUND

Natural orifice specimen extraction surgery (NOSES) is currently widely used in left-sided colorectal cancer. Some clinical comparative studies have been conducted, providing evidence of its safety and oncological benefits. However, these studies are typically characterized by small sample sizes and short postoperative follow-up periods. Consequently, in this research, the authors adopt the propensity score matching method to undertake a large-scale retrospective comparative study on NOSES colectomy for left-sided colorectal cancer, with the goal of further augmenting the body of evidence-based medical support for NOSES.

METHODS

This retrospective study involved patients who underwent NOSES colectomy and conventional laparoscopic (CL) colectomy for left-sided colorectal cancer between January 2014 and April 2021. In the NOSES group, specimens were extracted through the anus with the help of a Cai tube (homemade invention: ZL201410168748.2). The patients were matched at a ratio of 1:1 according to age, sex, BMI, tumor diameter, tumor location (descending and splenic flexure colon/ sigmoid colon/ middle and upper rectum), tumor height from anal verge, ASA grade, previous abdominal surgery, clinical pathologic stage, preoperative CEA. After matching, 132 patients in the NOSES group and 132 patients in the CL group were eligible for analysis.

RESULTS

Compared with CL group, NOSES group was associated with decreased postoperative maximum pain score (2.6±0.7 vs. 4.7±1.7, P=0.000), less additional analgesia required (6.8 vs. 34.8%, P=0.000), faster time to passage of flatus (2.3±0.6 days vs. 3.3±0.7 days, P=0.000), less wound infection (0.0 vs. 6.1%, P=0.007), and longer operative time (212.5±45.8 min vs. 178.0±43.4 min, P=0.000). No significant differences were observed in estimated blood loss, time to resume regular diet, postoperative hospital stay, conversion to open surgery or conventional minilaparotomy, total morbidity, readmission, mortality, pathologic outcomes, and Wexner incontinence score between groups. After a median follow-up of 63.0 months, the 5-year overall survival rates were 88.3 versus 85.0% (P=0.487), disease-free survival rates were 82.9 versus 83.6% (P=0.824), and the local recurrence rates were 4.4 versus 4.0% (P=0.667) in the NOSES and CL groups, respectively.

CONCLUSIONS

This study suggests that NOSES colectomy using a Cai tube for left-sided colorectal cancer is a safe and feasible option with better cosmetic results, less pain, faster recovery of gastrointestinal function, and comparable long-term clinical and oncologic outcomes to CL colectomy.

Short-term and long-term survival outcomes for transrectal specimen extraction after laparoscopic right hemicolectomy: a propensity-score matching study

Background

Natural orifice specimen extraction surgery (NOSES) has been widely applied to the treatment of colorectal cancer. This study aim to investigate the short-term and survival outcomes of transrectal specimen extraction after laparoscopic right hemicolectomy.

Methods

From January 2016 to December 2021, a total of 166 consecutive patients with right colon cancer who underwent laparoscopic right hemicolectomy in Cancer Hospital of Chinese Academy of Medical Sciences and Beijing Hospital were identified. Baseline data, perioperative parameters, anal function, inflammatory indicators and survival outcomes were collected and compared.

Results

Totally, 24 patients who underwent transrectal NOSE were matched with 24 patients who received conventional laparoscopic surgery (LAP). Patients in NOSES group had a significantly lower incidence of incision infection (0 vs 20.8%, P=0.048), faster recovery of gastrointestinal function (2.1 vs 3,1 days, P=0.032) compared with those in LAP group. In addition, patients in the NOSE group experienced significantly less postoperative pain on POD1 (2.3 vs 4.4, P<0.001), POD3 (2.1 vs 3.9, P<0.001), and POD5 (1.7 vs 2.8, P=0.011). Regarding to anal function 6 months after surgery, no significant difference was observed in Wexner incontinence scale (9.8 vs 9.5, P=0.559) between the two groups. In terms of indicators of the inflammatory response, there were no significant differences in body temperature, neutrophils, and PCT levels between the two groups. However, CRP levels in the NOSES group on POD 3 (6.9 vs 5.1 mg/L, P=0.016) and POD 5 (3.8 vs 2.6 mg/L, P=0.027) were significantly higher than in the LAP group. With regarded to survival outcomes, patients in the NOSES group were similar to those in the LAP group for 3-year OS (100% vs 91.2%, P=0.949), 3-year DFS (86.2% vs 84.8%, P=0.949), and 3-year LRFS (94.2% vs 88.7%, P=0.549).

Conclusion

For total laparoscopic right hemicolectomy, transrectal NOSE is effective and safe, and associated with lower incidence of wound infection, less pain, faster recovery, and similar survival outcomes compared to conventional laparoscopic surgery.

Natural orifice specimen extraction surgery versus small-incision assisted laparoscopic radical right hemicolectomy

Conventional laparoscopic-assisted right hemicolectomy requires a small abdominal incision to extract the specimen, which becomes an important source of postoperative complications and impairs perioperative experience. Transvaginal natural orifice specimen extraction surgery (NOSES VIIIA) avoids this small incision by extracting the specimen through the vagina. Here we describe the design of a multicenter, open-label, parallel, noninferior, phase III randomized controlled trial (NCT05495048). The aim of this study is to confirm that the NOSES VIIIA procedure is not inferior to small-incision assisted right hemicolectomy in long-term oncological efficacy. A total of 352 female patients with right colon adenocarcinoma/high-grade intraepithelial neoplasia will be randomly assigned to the NOSES VIIIA arm and the small-incision arm in a 1:1 ratio. The primary end point of this trial is 3 year disease-free survival. Clinical Trial Registration: NCT05495048 (ClinicalTrials.gov).

Development of a machine learning algorithm to predict complications of total laparoscopic anterior resection and natural orifice specimen extraction surgery in rectal cancer

BACKGROUND

Total laparoscopic anterior resection (tLAR) and natural orifice specimen extraction surgery (NOSES) has been widely adopted in the treatment of rectal cancer (RC). However, no study has been performed to predict the short-term outcomes of tLAR using machine learning algorithms to analyze a national cohort.

METHODS

Data from consecutive RC patients who underwent tLAR were collected from the China NOSES Database (CNDB). The random forest (RF), extreme gradient boosting (XGBoost), support vector machine (SVM), deep neural network (DNN), logistic regression (LR) and K-nearest neighbor (KNN) algorithms were used to develop risk models to predict short-term complications of tLAR. The area under the receiver operating characteristic curve (AUROC), Gini coefficient, specificity and sensitivity were calculated to assess the performance of each risk model. The selected factors from the models were evaluated by relative importance.

RESULTS

A total of 4313 RC patients were identified, and 667 patients (15.5%) developed postoperative complications. The machine learning model of XGBoost showed more promising results in the prediction of complication than other models (AUROC 0.90, P < 0.001). The performance was similar when internal and external validation was used. In the XGBoost model, the top four influential factors were the distance from the lower edge of the tumor to the anus, age at diagnosis, surgical time and comorbidities. In risk stratification analysis, the rate of postoperative complications in the high-risk group was significantly higher than in the medium- and low-risk groups (P < 0.001).

CONCLUSION

The machine learning model shows potential benefits in predicting the risk of complications in RC patients after tLAR. This novel approach can provide reliable individual information for surgical treatment recommendations.

Preliminary surgical outcomes of laparoscopic right hemicolectomy with transrectal specimen extraction: a propensity score matching study of 120 cases (with video)

Background

Compared with conventional laparoscopic surgery, natural orifice specimen extraction surgery (NOSES) has many advantages. Laparoscopic right colectomy with transvaginal specimen extraction has been reported, but the safety and feasibility of transrectal specimen extraction in male patients with ascending colon cancer remain to be verified. This study aimed to preliminarily evaluate the feasibility and safety of laparoscopic right hemicolectomy with transrectal specimen extraction.

Methods

The study was conducted at a single tertiary medical center in China. A total of 494 consecutive patients who underwent laparoscopic right colectomy between September 2018 and September 2020 were included. Transrectal specimen extraction was performed in 40 male patients (the NOSES group). Patients in the NOSES group were matched to the conventional laparoscopic group using propensity score matching at a 1:2 ratio. Short-term and long-term outcomes between the two groups were compared and evaluated.

Results

Forty patients in the NOSES group and 80 patients in the conventional laparoscopic group were matched for analysis. Baseline characteristics were balanced after propensity matching. The operative features, including operating time, intraoperative bleeding, and the number of harvested lymph nodes, were statistically comparable in both groups. In terms of post-operative recovery, patients in the NOSES group showed preferable outcomes, as evidenced by less post-operative pain and faster return to flatus, defecation, and discharge. The post-operative complications rate, according to the Clavien-Dindo classification system, was similar in both groups. No differences in overall survival or disease-free survival were observed between the two groups.

Conclusions

Laparoscopic right colectomy with transrectal specimen extraction is oncologically safe. Compared with conventional laparoscopic right colectomy, it can reduce post-operative pain, accelerate post-operative recovery, shorten the hospital stay, and achieve better cosmetic effect.

Transvaginal versus transabdominal specimen extraction surgery for right colon cancer: A propensity matching study

Background

The transvaginal route for specimen extraction is considered ideal for colorectal surgery, but its safety is still questioned. There has been little research on transvaginal natural orifice specimen extraction surgery (NOSES) in the right hemicolectomy. As a result, we conducted a study comparing transvaginal NOSES to traditional transabdominal specimen extraction surgery.

Patients and methods

Data on female patients who underwent radical right hemicolectomy at the First Affiliated Hospital of Nanchang University between January 2015 and December 2020 were collected retrospectively. A total of 847 patients were compliant, with 51 undergoing the transvaginal specimen extraction surgery (NOSES) group and 796 undergoing the transabdominal specimen extraction surgery (TISES) group. A propensity score matching method (1:2) was used to balance the clinicopathological characteristics of the two groups.

Results

Finally, 138 patients were enrolled in our study, with 46 in the NOSES group and 92 in the TISES group. Compared to the TISES group, the NOSES group had less intraoperative blood loss (p = 0.036), shorter time to first flatus (p &lt; 0.001), shorter time to first liquid diet (p &lt; 0.001), lower postoperative white blood cell counts (p = 0.026), lower C-reactive protein levels (p = 0.027), and lower visual analog scale (VAS) scores (p &lt; 0.001). Regarding the quality of life after surgery, the NOSES group had better role function (p &lt; 0.01), emotional function (p &lt; 0.001), and improved symptoms of postoperative pain (p &lt; 0.001) and diarrhea (p = 0.024). The scar satisfaction was significantly higher in the NOSES group than in the TISES group. Overall survival and disease-free survival in two groups were similar.

Conclusion

The short-term results of transvaginal NOSES were superior to conventional transabdominal specimen extraction surgery. At the same time, transvaginal NOSES could improve the abdominal wall appearance and quality of life. The long-term survival was similar in the two surgical approaches. Therefore, transvaginal NOSES is worthy of our implementation and promotion.

Comparison of transabdominal wall specimen retrieval and natural orifice specimen extraction robotic surgery in the outcome of colorectal cancer treatment

Background

Natural orifice specimen extraction surgery (NOSES), as a new star of minimally invasive techniques, has been increasingly favored and promoted in the field of surgery around the world. Most previous studies were comparative studies of laparoscopic NOSES and conventional laparoscopic surgery. However, there is little research on comparing robotic colorectal cancer NOSES with conventional robotic-assisted colorectal cancer resection surgery.

Participant and methods

This study is a retrospective study of propensity score matching (PSM). This study included Ninety-one propensity score-matched pairs of the participant who had undergone robotic colorectal cancer resection surgery at our center between January 2017 and December 2020. The covariates used in the propensity score included gender, age, BMI, ASA score, maximum tumor diameter, the tumor's height from the anal verge, histological differentiation, AJCC stage, T stage, N stage, and history of previous abdominal surgery. The outcome measurement criteria included postoperative complications, inflammatory response, pelvic floor function, anal function, cosmetic outcome, quality of life, disease-free survival (DFS), and overall survival (OS).

Results

The robotic NOSES group had faster recovery time from gastrointestinal function (P = 0.014), shorter abdominal incision length (P < 0.001), less pain (P < 0.001), less additional analgesia required (P < 0.001), and lower postoperative indicators of white blood cell count (P < 0.001) and C-reactive protein content compared to the robotic-assisted resection surgery (RARS) group (P = 0.035). Additionally, the robotic NOSES group had significantly better body imagery (P < 0.001), cosmetic scores (P < 0.001), somatic function (P = 0.003), role function (P = 0.039), emotional function (P = 0.001), social function (P = 0.004), and overall function (P < 0.001) than the RARS group. The two groups demonstrated no significant difference between DFS and OS.

Conclusion

Robotic colorectal cancer NOSES is a safe and feasible minimally invasive procedure and offers shorter abdominal incisions, less pain, less surgical stress response, and better postoperative quality of life. Therefore, this technique can be further promoted for colorectal cancer patients eligible for NOSES.

Is natural orifice specimen extraction surgery the future direction of minimally invasive colorectal surgery?

As science and technology have advanced, surgical techniques have become increasingly sophisticated. A revolution was triggered by the appearance of new electrical and optical instruments, shifting the field of surgery in the direction of "minimally invasive" and "noninvasive" procedures. Natural orifice specimen extraction surgery has emerged as a rising star in the field of minimally invasive surgery. It has increased rapidly, and it has become a hot topic in recent years. Natural orifice specimen extraction surgery has shown advantages in alleviating postoperative pain, improving bowel movements, providing a cosmetic effect, and improving psychological state without adversely affecting cancer outcomes. Different approaches have been classified and summarized for natural orifice specimen extraction surgery based on the procedure for specimen extraction and the location of the tumor, and natural orifice specimen extraction surgery can be used in resection all parts of the colorectum. The international natural orifice specimen extraction surgery consensus and monograph have also been published to improve the standardization of the application of this technique. Additional steps need to be taken to standardize natural orifice specimen extraction surgery, such as conducting large-scale randomized controlled trials, establishing a training system, and developing specific tools. Still, the natural orifice specimen extraction surgery procedure continues to follow the development of minimally invasive surgery and may be one of the future treatment options.

Long-term oncologic outcomes of natural orifice specimen extraction surgery versus conventional laparoscopic-assisted resection in the treatment of rectal cancer: a propensity-score matching study

BACKGROUND

Natural orifice specimen extraction surgery (NOSES) has been increasingly applied in radical surgery of abdominal and pelvic organs, but it is still in the exploratory stage. There is insufficient evidence to prove its efficacy.

METHODS

From January 2013 to June 2017, a total of 351 patients diagnosed with rectal cancer were eventually included in this study. Patients who underwent NOSES were assigned to the NOSES group, while patients undergoing conventional laparoscopic assisted resection were assigned as to the LAP group. Propensity score matching was used to align clinicopathological features between the two groups.

RESULTS

From the perioperative data and postoperative follow-up results of both groups, patients in the NOSES group had less intraoperative bleeding (47.0 ± 60.4 ml vs 87.1 ± 101.2 ml, P = 0.011), shorter postoperative gastrointestinal recovery (50.7 ± 27.3 h vs 58.6 ± 28.5 h, P = 0.040), less postoperative analgesic use (36.8% vs 52.8%, P = 0.019), lower postoperative pain scores (P < 0.001), lower rate of postoperative complications (5.7% vs 15.5%, P = 0.020), more satisfaction with body image (P = 0.001) and cosmesis (P < 0.001) postoperatively. The NOSES group had a higher quality of life. Moreover, there was no significant difference in overall survival (OS) and disease-free survival (DFS) between the two groups.

CONCLUSION

NOSES could be a safe and reliable technique for radical resection of rectal cancer, with better short-term outcomes than conventional laparoscopy, while long-term survival is not significantly different from that of conventional laparoscopic surgery.