Robotic natural orifice specimen extraction surgery versus traditional robotic-assisted surgery (NOTR) for patients with colorectal cancer: a study protocol for a randomized controlled trial

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.

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).

Application of artificial intelligence in diagnosis and treatment of colorectal cancer: A novel Prospect

In the past few decades, according to the rapid development of information technology, artificial intelligence (AI) has also made significant progress in the medical field. Colorectal cancer (CRC) is the third most diagnosed cancer worldwide, and its incidence and mortality rates are increasing yearly, especially in developing countries. This article reviews the latest progress in AI in diagnosing and treating CRC based on a systematic collection of previous literature. Most CRCs transform from polyp mutations. The computer-aided detection systems can significantly improve the polyp and adenoma detection rate by early colonoscopy screening, thereby lowering the possibility of mutating into CRC. Machine learning and bioinformatics analysis can help screen and identify more CRC biomarkers to provide the basis for non-invasive screening. The Convolutional neural networks can assist in reading histopathologic tissue images, reducing the experience difference among doctors. Various studies have shown that AI-based high-level auxiliary diagnostic systems can significantly improve the readability of medical images and help clinicians make more accurate diagnostic and therapeutic decisions. Moreover, Robotic surgery systems such as da Vinci have been more and more commonly used to treat CRC patients, according to their precise operating performance. The application of AI in neoadjuvant chemoradiotherapy has further improved the treatment and efficacy evaluation of CRC. In addition, AI represented by deep learning in gene sequencing research offers a new treatment option. All of these things have seen that AI has a promising prospect in the era of precision medicine.

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.

Influence of transvaginal laparoscopic surgery on sexual function, life quality and short-term efficacy of patients diagnosed with colorectal cancer

OBJECTIVE

To analyze the effect of transvaginal specimen removal on sexual function, life quality and short-term efficacy of patients diagnosed with colorectal cancer.

METHOD

We retrospectively analyzed the clinical data of 100 patients with colorectal cancer treated in the Cancer Hospital Chinese Academy of Medical Sciences from September 2017 to December 2019. Among them, 52 patients who underwent transvaginal laparoscopic mid-to-high rectal cancer radical resection without assisted abdominal incision who were chosen as the observation group, and 48 patients with conventional laparoscopic-assisted mid-to-high rectal cancer radical resection were set as the control group. Intraoperative blood loss, number of lymph nodes retrieved, operation time, time of urinary catheter removal, drainage tube removal time and postoperative hospital stay were recorded and compared between the two groups. During the process, the Visual Analogue Scale (VAS) was used to assess the pain status of both groups of patients 24 hours after the operation, and the Female Sexual Function Index was used to evaluate the sexual function quality of patients before and 3 months after surgery. Postoperative complications, 2-year survival rate and 6-month postoperative quality of life of both groups of patients were evaluated and compared.

RESULTS

In comparison with the control group, the amount of intraoperative blood loss, catheter removal time, drainage tube removal time, and length of postoperative hospital stay were significantly reduced in the observation group, while the number of lymph nodes retrieved was significantly greater. The VAS score 24 hours after operation was lower in the observation group compared with the control group, with statistical significance. There was no significant difference in postoperative sexual function and complication rates between the two groups. However, the 2-year survival rate and the quality of life 6 months after surgery were comparatively higher in the observation group.

CONCLUSION

Natural orifice specimen extraction surgery (NOSES) is effective for transvaginal specimen removal of patients with colorectal cancer, and can significantly improve the prognosis and life quality of patients without affecting their sexual function, with a high safety profile, which is worthy of clinical promotion.