Robotic surgery contributes to the preservation of bowel and urinary function after total mesorectal excision: comparisons with transanal and conventional laparoscopic surgery

Advantages of robotic surgery for rectal cancer compared to laparoscopic surgery: pelvic anatomy and its impact on urinary dysfunction

The anatomical dimensions and the shape of the pelvis influence surgical difficulty for rectal cancer. Compared to conventional laparoscopic surgery, robot-assisted surgery is expected to improve surgical outcomes due to the multi-joint movement of its surgical instruments. The aim of this study was to investigate the impact of pelvic anatomical indicators on short-term outcomes of patients with rectal cancer. A retrospective analysis was conducted using data from 129 patients with rectal cancer who underwent conventional laparoscopic low anterior resection (L-LAR) or robot-assisted low anterior resection (R-LAR) with total mesorectal excision or tumor-specific mesorectal excision between January 2014 and December 2022. The transverse diameter of the lesser pelvis and the sacral promontory angle were used as indicators of pelvic anatomy. The sacral promontory angle was not associated with age and sex while the pelvic width was smaller in male than in female. The pelvic width did not affect postoperative complications in both L-LAR and R-LAR. In contrast, postoperative urinary dysfunction occurred more frequently in patients with a small sacral promontory angle (p = 0.005) in L-LAR although there was no impact on short-term outcomes in R-LAR. Multivariate analysis demonstrated that a small sacral promontory angle was an independent predictive factor for urinary dysfunction (p = 0.032). Sharp angulation of the sacral promontory was a risk factor for UD after L-LAR. Robot-assisted surgery could overcome anatomical difficulties and reduce the incidence of UD.

Incidence of low anterior resection syndrome and its association with the quality of life in patients with lower rectal tumors

PURPOSE

Low anterior resection syndrome (LARS) causes devastating symptoms and impairs the quality of life (QOL). This study investigated the incidence and risk factors of LARS and their association with the QOL in patients with lower rectal tumors.

METHODS

Patients who underwent anus-preserving surgery for lower rectal tumors between 2014 and 2019 and who had anal defecation between 2020 and 2021 were surveyed. The LARS score measured severity, and the QOL was evaluated using the Japanese version of the Fecal Incontinence Quality-of-Life Scale (JFIQL). The primary endpoint was the incidence of Major LARS, and the secondary endpoints were risk factors and association with the JFIQL.

RESULTS

Of 107 eligible patients, 82 (76.6%) completed the LARS survey. The incidence of Major LARS was 48%. Independent risk factors included neoadjuvant chemoradiotherapy (CRT) and a short interval (< 24 months after surgery; odds ratio, 4.6; 95% confidence interval: 1.1-19, both). The LARS score was moderately correlated with the JFIQL generic score (correlation coefficient: - 0.54). The JFIQL scores were significantly worse in the Minor and Major LARS groups than in the No LARS group.

CONCLUSIONS

Major LARS was found in 48% of lower rectal tumors, and independent risk factors include neoadjuvant CRT and a short interval. The QOL was significantly impaired in patients with both Minor and Major LARS.

Functional outcomes and quality of life following open versus laparoscopic versus robot-assisted versus transanal total mesorectal excision in rectal cancer patients: a systematic review and meta-analysis

BACKGROUND

The standard surgical treatment for rectal cancer is total mesorectal excision (TME), which may negatively affect patients' functional outcomes and quality of life (QoL). However, it is unclear how different TME techniques may impact patients' functional outcomes and QoL. This systematic review and meta-analysis evaluated functional outcomes of urinary, sexual, and fecal functioning as well as QoL after open, laparoscopic (L-TME), robot-assisted (R-TME), and transanal total mesorectal excision (TaTME).

METHODS

A systematic review and meta-analysis, based on the preferred reporting items for systematic reviews and meta-analysis statement, were conducted (PROSPERO: CRD42021240851). A literature review was performed (sources: PubMed, Medline, Embase, Scopus, Web of Science, and Cochrane Library databases; end-of-search date: September 1, 2023), and a quality assessment was performed using the Methodological index for non-randomized studies. A random-effects model was used to pool the data for the meta-analyses.

RESULTS

Nineteen studies were included, reporting on 2495 patients (88 open, 1171 L-TME, 995 R-TME, and 241 TaTME). Quantitative analyses comparing L-TME vs. R-TME showed no significant differences regarding urinary and sexual functioning, except for urinary function at three months post-surgery, which favoured R-TME (SMD [CI] -0 .15 [- 0.24 to - 0.06], p = 0.02; n = 401). Qualitative analyses identified most studies did not find significant differences in urinary, sexual, and fecal functioning and QoL between different techniques.

CONCLUSIONS

This systematic review and meta-analysis highlight a significant gap in the literature concerning the evaluation of functional outcomes and QoL after TME for rectal cancer treatment. This study emphasizes the need for high-quality, randomized-controlled, and prospective cohort studies evaluating these outcomes. Based on the limited available evidence, this systematic review and meta-analysis suggests no significant differences in patients' urinary, sexual, and fecal functioning and their QoL across various TME techniques.

Urinary and sexual function after robotic and laparoscopic rectal cancer surgery: a systematic review and meta-analysis

The purpose of the study was to compare the protective effects of robotic rectal cancer surgery (RRCS) and laparoscopic rectal cancer surgery (LRCS) on urinary and sexual function of patients. We conducted a systematic search in the PubMed, Web of Science, Cochrane Library, and Embase for studies comparing the impact of RRCS and LRCS on urinary function and sexual function. The International Prostate Symptom Score (IPSS), the five-item version of the International Index of Erectile Function (IIEF-5) and the Female Sexual Function Index(FSFI) were used to evaluate the urinary function and sexual function of patients. A total of 13 studies comprising 1964 patients were included in this meta-analysis, including 3 randomized controlled trials, 5 retrospective cohort studies, 3 prospective cohort studies, and 2 propensity score-matched studies. Nine hundred and fifty-nine patients underwent RRCS and 1005 patients underwent LRCS. Statistical analysis of the IPSS scores indicated urinary function was significantly better in the RRCS group than in the LRCS group at 3, 6 and 12 months postoperatively [mean difference (MD), - 1.06, 95% CI - 1.85 to - 0.28; and MD, - 0.96, 95% CI - 1.60 to - 0.32; and MD, - 1.09, 95% CI - 1.72 to - 0.46]. Statistical analysis of the IIEF-5 scores indicated male sexual function was significantly better in the RRCS group than in the LRCS group at 3, 6 and 12 months postoperatively (MD, 1.76, 95% CI 0.80 to 2.72; and MD, 1.83, 95% CI 0.34 to 3.33; and MD, 1.05, 95% CI 0.09 to 2.01). Statistical analysis of the FSFI scores indicated female sexual function was significantly better in the RRCS group than in the LRCS group at 6 and 12 months postoperatively (MD, 2.86; 95% CI 1.38 to 4.35; and MD, 4.19; 95% CI 1.85 to 6.54). RRCS is more favorable than LRCS in preserving the urinary and sexual function of patients with rectal cancer.

Hybrid robot-assisted abdominoperineal resection supported by simultaneous trans-perineal approach for anal gland adenocarcinoma with vaginal invasion: a case report

Hybrid surgery (abdominal robotic approach with a trans-anal approach) has been reported to improve oncological outcomes in cases involving advanced cancer or technical difficulties. A 74-year-old woman presented with anal pain and stenosis. Examination revealed palpable sclerosis on the anterior wall at the anal verge with possible vaginal invasion. A biopsy revealed an adenocarcinoma. We performed a two-team robot-assisted abdominoperineal resection combined with resection of the vagina supported by a simultaneous trans-perineal approach. After rendezvous at the posterior side, the abdominal team cut the posterior wall of the vaginal vault while the perineal team confirmed the surgical margin. Histopathological findings identified the tumour as an anal gland adenocarcinoma (pT4b [vagina] N0M0 pathological stage IIC) with a negative circumferential resection margin. Hybrid surgery combined with resection of the posterior wall of the vagina may be performed safely and is a valuable surgical option for multimodal treatment of anal adenocarcinomas.

Robotic total mesorectal excision for rectal cancer based on the theory of fundamental use of surgical energy

BACKGROUND

Improving oncological curability and preserving urinary function must be established in robotic total mesorectal excision (TME) for rectal cancer. To achieve this, it is important to avoid nerve injury by sharp dissection of the avascular plane by the monopolar device and thermal spread. The aim of this study was to improve the robotic TME quality by focusing on the theory of fundamental use of surgical energy (FUSE) of the monopolar device and investigating the surgical procedure.

METHODS

In this single-center retrospective study, 26 consecutive patients who underwent robotic TME for rectal cancer at Tokyo Medical University Hospital between June 2022 and August 2022 were included. All surgeries were performed by FUSE-certified surgeons in accordance with FUSE theory, which was, thermal effect = current density (current/area) squared × tissue resistance × contact time.

RESULT

The median age of the patients was 64 years (range 40-79 years), and 17 patients were male. The median operative time was 287 min (range 229-430 min); median bleeding volume, 22 ml (range 5-223 ml); and the median number of harvested lymph nodes, 17 (range 4-40). The conversion rate to open surgery was 0%. A breakdown of Clavien-Dindo classification Grade ≥ II post-operative complications was as follows: surgical site infection, one patient (3.8%); ileus, one patient (3.8%); and urinary dysfunction, one patient (3.8%). No surgery-related or in-hospital deaths occurred. The pathological positive resection margin was not observed.

CONCLUSIONS

Robotic TME for rectal cancer based on the theory of FUSE can be safely performed, making it a promising surgical procedure. It is suggested that robotic surgeons acquire surgical operation skills with monopolar devices based on the principles of FUSE, which may lead to an increased quality of robotic TME.

Essential updates 2020/2021: Advancing precision medicine for comprehensive rectal cancer treatment

In the paradigm shift related to rectal cancer treatment, we have to understand a variety of new emerging topics to provide appropriate treatment for individual patients as precision medicine. However, information on surgery, genomic medicine, and pharmacotherapy is highly specialized and subdivided, creating a barrier to achieving thorough knowledge. In this review, we summarize the perspective for rectal cancer treatment and management from the current standard-of-care to the latest findings to help optimize treatment strategy.

Outcomes of Robot-Assisted Surgery in Rectal Cancer Compared with Open and Laparoscopic Surgery

With increasing trends for the adoption of robotic surgery, many centers are considering changing their practices from open or laparoscopic to robot-assisted surgery for rectal cancer. We compared the outcomes of robot-assisted rectal resection with those of open and laparoscopic surgery. We searched Medline, Web of Science, and CENTRAL databases until October 2022. All randomized controlled trials (RCTs) and prospective studies comparing robotic surgery with open or laparoscopic rectal resection were included. Fifteen RCTs and 11 prospective studies involving 6922 patients were included. The meta-analysis revealed that robotic surgery has lower blood loss, less surgical site infection, shorter hospital stays, and higher negative resection margins than open resection. Robotic surgery also has lower conversion rates, lower blood loss, lower rates of reoperation, and higher negative circumferential margins than laparoscopic surgery. Robotic surgery had longer operation times and higher costs than open and laparoscopic surgery. There were no differences in other complications, mortality, and survival between robotic surgery and the open or laparoscopic approach. However, heterogeneity between studies was moderate to high in some analyses. The robotic approach can be the method of choice for centers planning to change from open to minimally invasive rectal surgery. The higher costs of robotic surgery should be considered as a substitute for laparoscopic surgery (PROSPERO: CRD42022381468).