Robotic surgery for rectal cancer: may it improve also survival?

Abstract

Treatment and survival of patients with solid cancers havebeen improved over the last years. Two of the major goalsand challenges for various cancers including colorectal,stomach, breast and other tumors are: local control byappropriate surgery alone or plus chemoradiotherapy [1–4]and personalized adjuvant systemic treatment throughmolecular and genetic biomarkers [5–8].Laparoscopic surgery has been increasingly adopted intoclinical practice, mostly to improve the quality of life(QOL) of patients with gastrointestinal cancer. However,there is no evidence that it improves also survival rates.Perhaps, low anterior rectal resection with total mesorectalexcision (TME) represents a field in which the laparoscopicapproach might lead to better local control, disease-freesurvival, and overall survival than the open procedure.In a recent issue of the Journal Baik et al. report on theuse of the da Vinci system in rectal cancer surgery [9].Why should this technique, beyond QOL improvement,also provide survival benefit? Why can this benefit not beobtained for other cancer sites in the gastrointestinal tract?Total mesorectal excision (TME) has become the stan-dard surgical procedure for localized rectal cancer [1]. Theprinciple underlying TME is secure dissection of an avas-cular plane between the presacral fascia and the fasciapropria of the rectum without injuring the proper fascia ofthe rectum [1]. This principle can better be ensured withthe laparoscopic than the open approach. The da Vincisystem, beyond this, provides the surgeon with a three-dimensional surgical view that permits a steadier dissectionwith tremor elimination and motion scaling.Baik et al. report on safety, feasibility, and efficiency innine patients who underwent robotic TME using fourrobotic arms for the treatment of mid or low rectal cancer.The facts that this technique allows a perfect TME thatmight also result in sparing radiation if pathologicalexamination reveals tumor-free proper fascia of the rectum,and perhaps most importantly local recurrence reductionand improved survival, suggests that a prospective vali-dation of this robotic technique is warranted.Personalization in health care maximizes the benefits forsociety and individual patients. At the present time, thisgoal appears more realistic in the prevention and treatmentof the inherited cancer syndromes than of the sporadiccommon cancers. Indeed, prophylactic surgery in carriersof mutations in mismatch-repair genes (hereditary nonpo-lyposis colorectal cancer or Lynch syndrome), in BRCA1/2(hereditary breast ovarian cancer syndrome) and in CDH1(hereditary diffuse gastric cancer syndrome) seems to bemore effective than close surveillance [10–17]. Given that,with the exception of early-stage cancer [18–21], cure ratesof patients with colorectal, gastric, breast, and other com-mon solid tumors are moderate or low [22–31], appropriatepreventive intervention may save the lives of many indi-vidual patients.Although longer follow-up data after laparoscopic sur-gery over open traditional resection demonstrates that thebenefits in QOL for colorectal cancer are limited to theearly postoperative course of months or a few years,robotic surgery for rectal cancer through an excellent TMEmay improve local control without the addition of radiationin some selected patients. A prospective evaluation toassess whether robotic surgery may improve local recur-rence and survival is warranted.