Laparoscopic Salvage Surgery for Locally Recurrent Rectal Cancer

Background

Surgical treatment for locally recurrent rectal cancer is challenging, and the value of laparoscopic surgery in such cases is unknown. The purpose of this study was to compare the feasibility of laparoscopic surgery with that of open surgery for locally recurrent rectal cancer.

Methods

Thirty patients with local rectal cancer recurrence at the anastomotic site or lateral pelvic lymph nodes were evaluated. Perioperative outcomes were compared between the laparoscopic (n?=?13) and open (n?=?17) groups.

Results

The median operation time was significantly longer (381 vs. 241 min) but the median estimated blood loss tended to be smaller (110 vs. 450 mL) in the laparoscopic than in the open group. There was only one converted case (7.7 %). The R0 resection rate (100 vs. 94 %) and postoperative complications (31 vs. 24 %) were not significantly different between the two groups. The median times to flatus (1 vs. 2 days), first stool (2 vs. 5 days), and oral intake (2 vs. 5 days) were significantly shorter in the laparoscopic than in the open group.

Conclusion

Laparoscopic surgery for locally recurrent rectal cancer has short-term benefits over open surgery and has potential as a treatment option for locally recurrent rectal cancer.     

Integration of open and laparoscopic approaches for rectal cancer resection: oncologic and short-term outcomes

Background

Laparoscopy is increasingly used for rectal cancer surgery. Laparoscopic surgery is not attempted for some suitable patients because of concerns for conversion or technical difficulty. This study aimed to evaluate oncologic and short-term outcomes for patients undergoing curative resection for rectal cancer via laparoscopic and open approaches.

Methods

A prospective database was reviewed to identify rectal cancer resections from 2005 to 2011. Patients who had primary rectal cancer within 15 cm of the anal verge were included in the study. Those with recurrent or metastatic disease were excluded. Patients were assigned to laparoscopic or open approaches preoperatively based on clinical criteria and imaging. All patients underwent a standard total mesorectal excision and followed a standardized enhanced recovery pathway. The oncologic and clinical outcomes were evaluated by approach.

Results

The analysis included 81 patients. The preoperative assignments consisted of 62 laparoscopic (77 %) and 19 open (23 %) procedures. Nine laparoscopic procedures (14.5 %) were converted to open procedures. After a median follow-up period of 25 months, all oncologic outcomes were comparable. Three patients (two laparoscopic, one open) had a positive circumferential margin (≤1 mm). The laparoscopic and open groups were similar in terms of their 3-year disease-free periods (93.6 vs. 88.2 %; P = 0.450) and overall survival periods (93.5 vs. 90.9 %; P = 0.766). The local recurrence rate was 2.5 %.

Conclusions

Laparoscopic resection for rectal cancer can be attempted for most patients. Conversion to open procedure does not compromise clinical or oncologic outcomes. In practice, combining laparoscopic and open surgery optimizes resource use and results in at least equivalent outcomes.     

Effect of Including Cancer-Specific Variables on Risk-Adjusted Hospital Surgical Quality Comparisons

Background

Quality initiatives are increasingly focusing on the quality of oncologic surgery. However, there is concern that a lack of cancer-specific variables may make risk-adjusted hospital quality comparisons inadequate. Our objective was to assess whether hospital quality rankings for cancer surgery are influenced by the addition of cancer-specific variables to the risk-adjusted models.

Methods

Patients from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and National Cancer Data Base (NCDB) who underwent colon or rectal resection for cancer were linked (2006–2008). Hierarchical models were developed predicting ACS NSQIP outcomes based on ACS NSQIP only vs a model using NSQIP and NCDB-derived cancer variables (e.g., stage and neoadjuvant therapy). Changes in hospital quality rankings were compared.

Results

A total of 11,405 patients underwent colon (n = 9,678, 146 hospitals) or rectal (n = 1,727, 135 hospitals) resection for cancer (2006–2008). Hospital-level complication rates (and standard deviation) after colon surgery were 2.2 % (±2.7 %) for mortality and 17.2 % (±8.7 %) for serious morbidity. After rectal cancer resection, complication rates were 0.9 % (±3.8 %) for mortality and 22.3 % (±20.4 %) for serious morbidity. When cancer-specific variables were included in risk-adjustment, outlier agreement was very good (kappa >0.85), and hospital odds ratio correlations were nearly identical (R > 0.98) for all outcomes assessed. Median changes in hospital rankings with the addition of the cancer-specific variables ranged from 1 to 2 after colon resection to 2–4 after rectal resection.

Conclusions

Addition of the available cancer-specific variables to risk-adjustment models did not affect hospital quality rankings for cancer surgery. Existing ACS NSQIP risk-adjustment variables appears to be sufficient for accurate comparisons of hospital quality.     

Laparoscopic Versus Open Surgery for Stage I Rectal Cancer: Long-term Oncologic Outcomes

Background

Laparoscopic resection is increasingly being performed for rectal cancer. However, few data are available to compare long-term outcomes after open versus laparoscopic surgery for early-stage rectal cancer.

Methods

Included in this retrospective study were 160 patients who underwent surgery for stage I rectal cancer between 2001 and 2008. Perioperative outcomes, overall survival (OS), and disease-free survival (DFS) were compared for open versus laparoscopic surgery.

Results

Altogether, 85 patients were treated using open surgery and 80 with laparoscopic surgery. Postoperative mortality (0 vs. 1.3 %; p = 1.00), morbidity (31.3 vs. 25.0 %; p = 0.38), and harvested lymph nodes (22.5 vs. 20.0; p = 0.84) were similar for the two groups. However, operating time was longer (183.8 vs. 221.0 min; p = 0.008), volume of intraoperative bleeding was less (200.0 vs. 150.0 ml; p = 0.03), time to first bowel movement was shorter (3.54 vs. 2.44 days; p < 0.001), rate of superficial surgical-site infection was lower (7.5 vs. 0 %; p = 0.03), and postoperative hospital stay was shorter (11.0 vs. 8.0 days; p < 0.001) in the laparoscopy group than in the open surgery group. At 5 years, there was no difference in OS (98.6 vs. 97.1 %; p = 0.41) or DFS (98.2 vs. 96.4 %; p = 0.30) between the open and laparoscopy groups.

Conclusions

Long-term outcomes of laparoscopic surgery for stage I rectal cancer were comparable to those of open surgery. Laparoscopic surgery, however, produced more favourable short-term outcomes than open surgery.     

Short-term clinical outcome of robot-assisted intersphincteric resection for low rectal cancer: a retrospective comparison with conventional laparoscopy

Background

A robotic system (da Vinci^® Surgical System, Intuitive Surgical Inc., Sunnyvale, CA, USA) has technical advantages over conventional laparoscopic surgery because it increases the precision and accuracy of anatomical dissection. The present study aimed to compare the short-term outcomes between robot-assisted intersphincteric resection (ISR) and laparoscopic ISR for distal rectal cancer.

Methods

Patients who underwent robot- or laparoscopy-assisted ISR for rectal cancer between March 2008 and July 2011 were included in this retrospective comparative study. Perioperative and postoperative data, including complications and early functional outcomes, were analyzed between the two groups. Functional outcomes were evaluated using the Wexner scoring system, the International Prostate Symptom Score, and the 5-item version of the International Index of Erectile Function.

Results

A total of 40 patients underwent robot-assisted and 40 underwent laparoscopic ISR. The mean operative time was significantly longer in the robotic group than in the laparoscopic group (235.5 vs. 185.4 min; p < 0.001). Transabdominal ISR, in which intersphincteric dissection is completed in the pelvic cavity, was performed more with robotic assistance than with laparoscopic surgery (8 vs. 2 cases; p = 0.043). No difference was observed between groups regarding postoperative morbidity and pathological outcomes. The robot-assisted group showed a trend toward less postoperative blood loss and early recovery of functional outcomes.

Conclusion

Robot-assisted surgery was safe and effective for ISR of distal rectal cancer and showed surgical outcomes similar to those of the latest laparoscopic ISR. The favorable results of the robot-assisted ISR included reduced adaptation time, alleviated difficulty of perineal phase, and early recovery of functional outcomes in this analysis of short-term clinical outcomes.     

Laparoscopic-assisted anterior resection with double-stapling technique anastomosis: safe and feasible for lower rectal cancer?

Background

Laparoscopic surgery for rectal cancer has been considered more demanding than laparoscopic colectomy due to its technical difficulties.

Objective

The aim of this study was to show safety and feasibility of laparoscopic low anterior resection for lower rectal cancer reconstructed by double-stapling technique (DST).

Methods

The present study reviewed 159 patients with rectal cancer undergoing laparoscopic anterior resection reconstructed by DST. They were subdivided into two groups: 98 patients with upper rectal cancer located between 75 and 150 mm from the anal verge (group A) and 61 with lower rectal cancer located within 75 mm from the anal verge (group B). Short-term results and pathological findings were compared between the two groups.

Results

There was no conversion in both groups. Operating time and intraoperative blood loss were similar in the two groups. No mortality occurred in either group. Overall morbidity rate was 10.2% in group A and 11.5% in group B (p = 0.798). Anastomotic leak rate was similar in the two groups (2.0% in group A versus 3.3% in group B; p = 0.638). Pathological examination of resected specimen showed no involvement of distal resection margin or circumferential resection margin in both groups.

Conclusions

The present study shows that laparoscopic surgery is safe and feasible for lower rectal cancer in a very select group of patients.     

Influence of conversion on the perioperative and oncologic outcomes of laparoscopic resection for rectal cancer compared with primarily open resection

Background

This study aimed to evaluate the influence of conversion on perioperative and short- and long-term oncologic outcomes in laparoscopic resection for rectal cancer and to compare these with those for an open control group.

Methods

The data of 276 consecutive patients who underwent surgery for rectal cancer between 2006 and 2010 at a single institution were prospectively collected. Of the 276 patients, 114 underwent primarily open surgery, and 162 underwent laparoscopic surgery (on an intention-to-treat basis). Of the 162 laparoscopic patients, 38 (23.5 %) underwent conversion to open surgery. The three groups of patients were compared: the conversion surgery group, the open surgery group, and the completed laparoscopy surgery group.

Results

The converted patients had more wound infections (18.4 vs 4.8 %, p = 0.009), but the wound infection rate in the primarily open group also was significantly higher than in the laparoscopic resection group (p = 0.007). No further differences in perioperative morbidity, including anastomotic leakage, were found. The perioperative 30-day mortality rate was comparable between all the groups (0.6 vs 2.6 vs 2.6 %, nonsignificant difference). The oncologic parameters such as number of harvested lymph nodes and rate of R0 resection were equal in all the groups. The completed laparoscopy group had a shorter hospital stay [12 vs 16 days in the primarily open group (p = 0.02) vs 15 days in the converted group (p = 0.03)]. The rates for survival, local recurrence (4.5 vs 3 vs 3 %), and metachronous metastasis (10.1 vs 9.3 vs 9 %) did not differ significantly between the three groups after a period of 3 years.

Conclusion

Conversion to open surgery in laparoscopic rectal resection has no negative effect on perioperative or long-term oncologic outcome.     

Long-term oncologic outcome after laparoscopic surgery for rectal cancer

Background

Recent studies demonstrated favorable short- and mid-term results after laparoscopic surgery for rectal cancer. However, long-term results from large series are lacking. The present study analyses long-term results of laparoscopic rectal cancer surgery from a large-volume center.

Methods

From January 1998 until March 2005, 225 patients underwent laparoscopic rectal resection due to carcinoma at the Medical Centre of the University of Regensburg. From 224 patients, a follow-up over 10 years was performed using the data of the Tumour Centre of the University of Regensburg. The data were analysed using oncological data (tumour recurrence) as well as overall survival. In addition, the effect of conversion to open resection on overall survival was analysed.

Results

With a median of 10 years at follow-up, the overall and disease-free survival was 50.5 and 50.1 %, respectively. Local recurrence of all patients was 5.8 % and none of the converted patients was within this group. The median time interval for the development of local recurrence was 30 months. Six of the 13 patients with local recurrence (46.1 %) had received neoadjuvant radiochemotherapy before surgery. Patients with a conversion to open surgery had primarily a significantly worse outcome than patients resected completely laparoscopically (p = 0.003). However, this difference was no longer apparent using a multivariant analysis (hazard ratio 1.221; p = 0.478).

Conclusions

Overall survival and local recurrence rate of patients undergoing laparoscopic resection of rectal cancer are comparable to open surgery. However, in our analysis, patients undergoing laparoscopic anterior resection had a higher survival rate compared with patients with abdominoperineal resection.     

Comparison of Peristomal Adhesion Formation Between Laparoscopic and Open Low Anterior Resection of Rectal Cancer

Background

Postoperative adhesions appear to be less common following laparoscopic surgery than after conventional open surgery. The purpose of this study was to compare the impact of laparoscopic and conventional open rectal surgery on peristomal adhesion formation.

Methods

We enrolled 97 subjects who were participants in a trial comparing open versus laparoscopic surgery for mid and low rectal cancer after neoadjuvant chemoradiotherapy. These patients had undergone rectal cancer surgery with ileostomy formation. Peristomal adhesions were assessed during ileostomy takedown using an adhesion grading system: (1) no adhesions or fine, filmy adhesions separable by blunt dissection; (2) dense adhesions, separable by sharp dissection; (3) very dense adhesions, resulting in enterotomy and/or requiring extension of the abdominal wall incision.

Results

A total of 57 patients underwent laparoscopic resection (group A) and 40 underwent open resection (group B). Operating time for ileostomy dissection was shorter in group A than in group B (14.6 vs. 19.8 min, respectively; p = 0.047). Dense adhesions (grades 2 and 3) were more common in group B (22/40, 55 %) than in group A (12/57, 21 %; p < 0.001). In particular, grade 3 adhesions were present only in group B (6/40).

Conclusions

The present findings suggest that laparoscopic rectal surgery results in less peristomal adhesion formation than does conventional open surgery.     

Laparoscopic versus open surgery for rectal cancer: results of a prospective multicentre analysis of 4,970 patients

Objective

To compare laparoscopic versus open surgery for rectal cancer and analyse the results of the multidisciplinary audited project on total mesorectal excision conducted in Spain.

Background

The safety and therapeutic efficiency of laparoscopic surgery for rectal cancer are controversial due to the technical difficulties it involves. A deviation from the oncological principles of mesorectal excision would mean a potential increase in local recurrence and shorter survival.

Methods

This prospective non-randomised multicentre study includes 4,970 patients with rectal cancer. The study compares perioperative, postoperative, anatomicopathological and survival variables.

Results

Five hundred and sixty five patients were excluded. Of the remaining 4,405, 3,018 (68.51 %) had open surgery (OS) and 1,387 (31.49 %) laparoscopic surgery (LS). The rate of anterior resections was higher in the LS group. The rate of intraoperative tumour perforation, number of red blood cell concentrates transfused and length of hospital stay were greater in the OS group, whereas surgical time was longer in the LS group. The incidence of complications was 45.6 % in the OS group and 38.3 % in the LS group. Involvement of the circumferential and distal margin, as well as unsatisfactory and partially satisfactory quality of the mesorectum, were greater in the OS group. There were no differences for local recurrence and survival rates.

Conclusions

According to these results, laparoscopic surgery is the best option for the surgical treatment of rectal cancer, with similar rates of local recurrence and survival, although there are oncological indicators in this study to suggest that these results can be improved with laparoscopic surgery.     

A case-matched comparison of the short-term outcomes between laparoscopic and open abdominoperineal resection for rectal cancer

Purpose

The aim of this study was to evaluate the short-term surgical outcomes of laparoscopic abdominoperineal resection (APR) for rectal cancer, by comparing it with a case–control series of open APR.

Methods

Fourteen patients with rectal cancer who underwent laparoscopic APR between August 2004 and November 2011 were compared with the open APR group of 14 patients matched for age, gender, and surgical procedure.

Results

There were no cases of conversion to laparotomy in the laparoscopic APR group and no mortality in either of the groups. The median operation was longer (P = 0.002), but the median amount of blood loss was smaller (P = 0.019), in the laparoscopic APR group. The median length of hospital stay of the laparoscopic APR group was 8 days, shorter than that of the open APR group (16 days, P < 0.001). The changes of the WBC count and serum CRP level after operations were significantly smaller in the laparoscopic APR group (P < 0.05). There were no significant differences between the groups in terms of the perioperative morbidity and readmission rates within 30 days.

Conclusion

Patients undergoing laparoscopic APR had superior perioperative outcomes to those undergoing open APR, except for the longer operation.     

Initial experience of a surgical fellow in laparoscopic colorectal cancer surgery under training protocol and supervision: comparison of short-term results for 70 early cases (under supervision) and 73 late cases (without supervision)

Purpose

Laparoscopic colorectal surgery is a technically challenging procedure for beginners, such as surgical fellows. The purpose of this study was to assess the safety, feasibility, and short-term surgical outcomes of laparoscopic colorectal cancer surgery by a single surgical fellow.

Methods

The study analyzed the data from 143 consecutive patients who underwent laparoscopic colorectal resection by a single surgical fellow between August 2009 and October 2010. The patients were divided into two groups: the early group—the first 70 patients (under supervision of experienced surgeon), and the late group—the last 73 patients (without supervision). The short-term surgical results were compared between two groups.

Results

The operations were 24 right colon resections, two transverse colectomies, six left colectomies, 36 anterior resections, 57 low anterior resections, 12 intersphincteric resections, two abdominoperineal resections, three Hartmann’s operations, and 1 total colectomy. The mean operating time, mean amounts of blood loss, and conversion rate were similar between the two groups. The morbidity rate, anastomosis leak rate, and mortality rate within 30 days of surgery did not differ significantly. The mean number of lymph nodes was larger in the late group (23.8 vs. 31.7, P = 0.017). In terms of low anterior resection, the mean number of endo-linear staplers used was smaller in the late group (2.46 ± 0.81 vs. 1.97 ± 0.83, P = 0.028). The anastomosis leakage rate in rectal cancer surgery was not significantly different between the two groups.

Conclusions

This study demonstrates that laparoscopic colorectal resections can be independently performed safely after a period of supervision and training by an experienced surgeon.     

Transvaginal specimen extraction versus conventional minilaparotomy after laparoscopic anterior resection for colorectal cancer: mid-term results of a case-matched study

Background

Although the vagina is considered a viable route during laparoscopic surgery, a number of concerns have led to a need to demonstrate the safety of a transvaginal approach in colorectal surgery. However, the data for transvaginal access in left-sided colorectal cancer are extremely limited, and no study has compared the clinical outcomes with a conventional laparoscopic procedure.

Objective

We compared the clinical outcomes of totally laparoscopic anterior resection with transvaginal specimen extraction (TVSE) with those of the conventional laparoscopic approach with minilaparotomy (LAP) for anastomosis construction and specimen retrieval in left-sided colorectal cancer.

Methods

Fifty-eight patients underwent TVSE between October 2006 and July 2011 and were matched by age, surgery date, tumor location, and tumor stage with patients who underwent conventional LAP for left-sided colorectal cancer.

Results

Operative time was significantly longer in the TVSE group (149.3 ± 39.8 vs. 131.9 ± 41.4 min; p = 0.023). Patients in the TVSE group experienced less pain (pain score 4.9 ± 1.6 vs. 5.8 ± 1.9; p = 0.008), shorter time to passage of flatus (2.2 ± 1.1 vs. 2.7 ± 1.2 days; p = 0.026), and higher satisfaction with the cosmetic results (cosmetic score 8.0 ± 1.4 vs. 6.3 ± 1.5; p = 0.001). More endolinear staplers for rectal transection were used in the LAP group (1.2 ± 0.5 vs. 1.1 ± 0.2; p = 0.021). Overall morbidities were similar in both groups; however, three wound infections only occurred in the LAP group. After a median follow-up of 34.4 (range 11–60) months, no transvaginal access-site recurrence occurred. The 3-year disease-free survival was similar between groups (91.5 vs. 90.8 %; p = 0.746).

Conclusions

Transvaginal access after totally laparoscopic anterior resection is safe and feasible for left-sided colorectal cancer in selected patients with better short-term outcomes.     

Laparoscopic Total Mesorectal Excision for Extraperitoneal Rectal Cancer: Long-Term Results of a 18-Year Single-Centre Experience

Background and Objectives

The oncologic efficacy of laparoscopic total mesorectal excision (TME) for middle–low rectal cancer is still under discussion because of the few long-term data. This study reports the results arising from a single-institution experience during a 18-year period.

Methods

Data about 132 consecutive laparoscopic TME performed between January 1994 and January 2012 were analysed with Kaplan–Meier method and a uni- and multi-variate analysis was conducted to define independent survival predictors.

Results

A total of 116 sphincter-preserving operations and 16 abdominoperineal resections were performed. Postoperative mortality and morbidity were 0.8 and 18.2 %, with a rate of anastomotic leakage of 13.8 %. Average follow-up was 85.9 months (range 13–210). Actuarial local recurrence rate was 4.13 % at 5 years (any pelvic recurrence developed after 3 years from surgery). Overall and disease-free survival was respectively 83 and 79.8 % at 5 years, 71 and 73 % at 10 years and then remained constant until 18 years. Survival was correlated only to tumour stage and the type of surgery.

Conclusions

Laparoscopic TME for extraperitoneal rectal cancer shows long-term oncologic outcomes similar to open rectal resections.     

Feasibility of Single-Port Laparoscopic Surgery for Sigmoid Colon and Rectal Cancers and Preoperative Assessment of Operative Difficulty

Purpose

Single-port laparoscopic surgery is more difficult for sigmoid colon and rectal cancers than for right-sided colon cancer. We sought to analyze the feasibility of this procedure for sigmoid colon and rectal cancers and to estimate its difficulty.

Methods

We analyzed prospectively collected data from 63 consecutive patients with sigmoid colon or rectal cancers who underwent single-port laparoscopic surgery at our institution from June 2009 to December 2011. Patient and tumor characteristics, including patients’ pelvic anatomy which was assessed on CT scan imaging, were evaluated to elucidate what factors would affect the difficulty of the procedure and the necessity of using an additional trocar.

Results

Overall, the median operative duration was 190 min and blood loss was 20 ml, with no postoperative complications. The median number of lymph nodes harvested was 17 and the distal margin was 58 mm. The tumor was located significantly closer to the anus in cases in which an additional trocar was required in the right lower quadrant (9.5 vs 18 cm, p?<?0.0001). Procedural difficulty was significantly increased in cases in which the sacral promontory protruded ventrally (odds ratio 0.779 [95 % confidence interval 0.613 to 0.945], p?=?0.0236).

Conclusions

Depending on tumor location and sacral promontory shape, the introduction of an additional trocar might render single-port laparoscopic surgery feasible for sigmoid colon and rectal cancer resection.     

Comparison of post-operative intravesical recurrence and oncological outcomes after open versus laparoscopic nephroureterectomy for upper urinary tract urothelial carcinoma

Object

To retrospectively evaluate intravesical recurrence and oncological outcomes after open or laparoscopic radical nephroureterectomy (RNU) for the upper urinary tract urothelial carcinoma (UUT-UC).

Patients and methods

This study comprised 122 patients diagnosed UUT-UC and subsequently nephroureterectomy was performed on. Several clinical and pathological parameters were emphasized for comparison of clinical outcomes.

Results

Among 122 patients with UUT-UC, 101 (82.8 %) and 21 (17.2 %) underwent open or laparoscopic radical nephroureterectomy (ONU or LNU), respectively. In univariable and multivariable Cox regression models, the surgical procedure exerted an impact neither on post-operative intravesical recurrence rate (p = 0.179 and 0.213, respectively) nor on cancer-specific mortality rate (p = 0.561 and 0.159, respectively). The 1-, 2- and 5-year cancer-specific survival (CSS) rates of patients undergoing ONU or LNU were 92.1 versus 95.2 %, 87.1 versus 90.5 %, 79.2 versus 85.7 %, respectively, and the Kaplan–Meier plot illustrated that patients from two groups enjoyed an equivalent survival rate (p = 0.559). Moreover, we added that previous history of bladder tumor and pre-operative hydronephrosis was associated with intravesical recurrence, whereas three prognostic factors, including pathological tumor stage, grade, and lymphovascular invasion, showed possibility to be predictors of cancer-specific mortality.

Conclusion

There existed no significant difference of intravesical recurrence and CSS between patients after ONU and LNU. Conclusively, laparoscopic radical nephroureterectomy did not present superiority to open management for patients with UUT-UC.     

Total mesorectal excision: a comparison of oncological and functional outcomes between robotic and laparoscopic surgery for rectal cancer

Background

Long-term data from the CLASICC study demonstrated the oncologic equivalence of laparoscopic and open rectal cancer surgery despite an increased circumferential resection margin involvement in the laparoscopic group in the initial report. Moreover, laparoscopic total mesorectal excision (TME) may be associated with increased rates of male sexual dysfunction compared to conventional open TME. Robotic surgery could potentially obtain better results than laparoscopy. The aim of this study was to compare the clinical and functional outcomes of robotic and laparoscopic surgery in a single-center experience.

Methods

This study was based on 100 patients who underwent minimally invasive anterior rectal resection with TME. Fifty consecutive robotic rectal anterior resections with TME (R-TME) were compared to the first 50 consecutive laparoscopic rectal resections with TME (L-TME).

Results

Median operative time was 270 min in R-TME and 275 min in L-TME. No conversions occurred in the R-TME group whereas six conversions occurred in the L-TME group. The mean number of harvested lymph nodes was 16.5 ± 7.1 for R-TME and 13.8 ± 6.7 for L-TME. The circumferential margin (CRM) was <2 mm in six L-TME patients, whereas no one in R-TME group had a CRM <2 mm. The International Prostate Symptom Score (IPSS) scores were significantly increased 1 month after surgery in both the L-TME and R-TME groups, but they normalized 1 year after surgery. Erectile function worsened significantly 1 month after surgery in both the groups but it was restored completely 1 year after surgery in the R-TME group and partially in the L-TME group.

Conclusions

Robotic TME is oncologically safe and adequate for rectal cancer treatment, showing better results than laparoscopic TME in terms of CRM, conversions, and hospital length of stay. Better recovery in voiding and sexual function is achieved with the robotic technique.     

Comparative effectiveness of laparoscopic versus robot-assisted colorectal resection

Background

During the past 20 years, laparoscopy has revolutionized colorectal surgery. With proven benefits in patient outcomes and healthcare utilization, laparoscopic colorectal surgery has steadily increased in use. Robotic surgery, a new addition to colorectal surgery, has been suggested to facilitate and overcome limitations of laparoscopic surgery. Our objective was to compare the outcomes of robot-assisted laparoscopic resection (RALR) to laparoscopic resections (LAP) in colorectal surgery.

Methods

A national inpatient database was evaluated for colorectal resections performed over a 30-month period. Cases were divided into traditional LAP and RALR resection groups. Cost of robot acquisition and servicing were not measured. Main outcome measures were hospital length of stay (LOS), operative time, complications, and costs between groups.

Results

A total of 17,265 LAP and 744 RARL procedures were identified. The RALR cases had significantly higher total cost ($5,272 increase, p < 0.001) and direct cost ($4,432 increase, p < 0.001), significantly longer operating time (39 min, p < 0.001), and were more likely to develop postoperative bleeding (odds ratio 1.6; p = 0.014) than traditional laparoscopic patients. LOS, complications, and discharge disposition were comparable. Similar findings were noted for both laparoscopic colonic and rectal surgery.

Conclusions

RALR had significantly higher costs and operative time than traditional LAP without a measurable benefit.     

Robotic versus Laparoscopic Proctectomy for Rectal Cancer: A Meta-analysis

Background

Robot-assisted laparoscopic surgery is being performed more frequently for the minimally invasive management of rectal cancer. The objective of this meta-analysis was to compare the clinical and oncologic safety and efficacy of robot-assisted versus conventional laparoscopic surgery.

Methods

A search of the Medline and Embase databases was performed for studies that compared clinical or oncologic outcomes of conventional laparoscopic proctectomy with robot-assisted laparoscopic proctectomy for rectal cancer. The methodological quality of the selected studies was critically assessed to identify studies suitable for inclusion. Meta-analysis was performed by a random effects model and analyzed by Review Manager. Clinical outcomes evaluated were conversion rates, operation times, length of hospital stay, and complications. Oncologic outcomes evaluated were circumferential margin status, number of lymph nodes collected, and distal resection margin lengths.

Results

Eight comparative studies were assessed for quality, and seven studies were included in the meta-analysis. Two studies were matched case-control studies, and five were unmatched. A total of 353 robot-assisted laparoscopic surgery proctectomy cases and 401 conventional laparoscopic surgery proctectomy cases were analyzed. Robotic surgery was associated with a significantly lower conversion rate (P?=?0.03; 95% confidence interval 1?C12). There was no difference in complications, circumferential margin involvement, distal resection margin, lymph node yield, or hospital stay (P?=?NS).

Conclusions

Robot-assisted surgery decreased the conversion rate compared to conventional laparoscopic surgery. Other clinical outcomes and oncologic outcomes were equivalent. The benefits of robotic rectal cancer surgery may differ between population groups.