Robot-assisted Total Mesorectal Excision Research Articles

Comparing short-term outcomes of robot-assisted and conventional laparoscopic total mesorectal excision surgery for rectal cancer in elderly patients.

Da Vinci Robotics-assisted total mesorectal excision (TME) surgery for rectal cancer is becoming more widely used. There is no strong evidence that robotic-assisted surgery and laparoscopic surgery have similar outcomes in elderly patients with TME for rectal cancer. To determine the improved oncological outcomes and short-term efficacy of robot-assisted surgery in elderly patients undergoing TME surgery. A retrospective study of the clinical pathology and follow-up of elderly patients who underwent TME surgery at the Department of Gastrointestinal Oncology at the Affiliated Hospital of Nanjing University of Chinese Medicine was conducted from March 2020 through September 2023. The patients were divided into a robot-assisted group (the R-TME group) and a laparoscopic group (the L-TME group), and the short-term efficacy of the two groups was compared. There were 45 elderly patients (≥ 60 years) in the R-TME group and 50 elderly patients (≥ 60 years) in the L-TME group. There were no differences in demographics, conversion rates, or postoperative complication rates. The L-TME group had a longer surgical time than the R-TME group [145 (125, 187.5) vs 180 (148.75, 206.25) min, P = 0.005), and the first postoperative meal time in the L-TME group was longer than that in the R-TME (4 vs 3 d, P = 0.048). Among the sex and body mass index (BMI) subgroups, the R-TME group had better outcomes than did the L-TME group in terms of operation time (P = 0.042) and intraoperative assessment of bleeding (P = 0.042). In the high BMI group, catheter removal occurred earlier in the R-TME group than in the L-TME group (3 vs 4 d, P = 0.001), and autonomous voiding function was restored. The curative effect and short-term efficacy of robot-assisted TME surgery for elderly patients with rectal cancer are similar to those of laparoscopic TME surgery; however, robotic-assisted surgery has better short-term outcomes for individuals with risk factors such as obesity and pelvic stenosis. Optimizing the learning curve can shorten the operation time, reduce the recovery time of gastrointestinal function, and improve the prognosis.

Risk factors for and longitudinal course of male sexual dysfunction after robotic rectal cancer surgery.

The aim of this work was to investigate the risk factors associated with the incidence of sexual dysfunction in patients who underwent robot-assisted surgery with several treatment options, such as neoadjuvant chemoradiotherapy and lateral lymph node dissection, and clarify the longitudinal course of erectile function in risk groups. A total of 203 male patients who underwent robot-assisted total mesorectal excision for rectal cancer between 2013 and 2019 were included. The risk factors for erectile and ejaculatory dysfunction as well as the longitudinal course of erectile function were retrospectively investigated in all cohorts and several risk groups, including those who underwent neoadjuvant chemoradiotherapy, lateral lymph node dissection and adjuvant chemotherapy. Erectile dysfunction was assessed using the International Index of Erectile Function and ejaculatory dysfunction was assessed using original questions. The survey was performed preoperatively and at 3, 6 and 12 months postoperatively. Erectile and ejaculatory dysfunction occurred in 46.8% and 15.7% of the patients, respectively. Multivariate analysis showed that neoadjuvant chemoradiotherapy was an independent risk factor for erectile dysfunction. Erectile function recovered longitudinally to the preoperative level overall, as well as in lateral lymph node dissection and postoperative adjuvant chemotherapy subgroups; however, recovery was poor in the neoadjuvant chemoradiotherapy group, even at 12 months postoperatively. Neoadjuvant chemoradiotherapy was found to be a risk factor for erectile dysfunction after robot-assisted surgery for rectal cancer. Erectile function recovered postoperatively in patients undergoing lateral lymph node dissection; however, those receiving neoadjuvant chemoradiotherapy showed poor recovery, even at 12 months postoperatively.

Assessing the learning curve of robot-assisted total mesorectal excision: a multicenter study considering procedural safety, pathological safety, and efficiency

PurposeEvidence regarding the learning curve of robot-assisted total mesorectal excision is scarce and of low quality. Case-mix is mostly not taken into account, and learning curves are based on operative time, while preferably clinical outcomes and literature-based limits should be used. Therefore, this study aims to assess the learning curve of robot-assisted total mesorectal excision.MethodsA retrospective study was performed in four Dutch centers. The primary aim was to assess the safety of the individual and institutional learning curves using a RA-CUSUM analysis based on intraoperative complications, major postoperative complications, and compound pathological outcome (positive circumferential margin or incomplete TME specimen). The learning curve for efficiency was assessed using a LC-CUSUM analysis for operative time. Outcomes of patients before and after the learning curve were compared.ResultsIn this study, seven participating surgeons performed robot-assisted total mesorectal excisions in 531 patients. Learning curves for intraoperative complications, postoperative complications, and compound pathological outcome did not exceed predefined literature-based limits. The LC-CUSUM for operative time showed lengths of the learning curve ranging from 12 to 35 cases. Intraoperative, postoperative, and pathological outcomes did not differ between patients operated during and after the learning curve.ConclusionThe learning curve of robot-assisted total mesorectal excision based on intraoperative complications, postoperative complications, and compound pathological outcome did not exceed predefined limits and is therefore suggested to be safe. Using operative time as a surrogate for efficiency, the learning curve is estimated to be between 12 and 35 procedures.

Comparison of Laparoscopic Versus Robot-Assisted Surgery for Rectal Cancers: The COLRAR Randomized Controlled Trial.

To evaluate whether robotic for middle or low rectal cancer produces an improvement in surgical outcomes compared with laparoscopic surgery in a randomized controlled trial (RCT). There is a lack of proven clinical benefit of robotic total mesorectal excision (TME) compared with a laparoscopic approach in the setting of multicenter RCTs. Between July 2011 and February 2016, patients diagnosed with an adenocarcinoma located <10cm from the anal verge and clinically rated T1-4aNxM0 were enrolled. The primary outcome was the completeness of TME assessed by a surgeon and a pathologist. The RCT was terminated prematurely because of poor accrual of data. In all, 295 patients were assigned randomly to a robot-assisted TME group (151 in R-TME) or a laparoscopy-assisted TME group (144 in L-TME). The rates of complete TME were not different between groups (80.7% in R-TME, 77.1% in L-TME). Pathologic outcomes including the circumferential resection margin and the numbers of retrieved lymph nodes were not different between groups. In a subanalysis, the positive circumferential resection margin rate was lower in the R-TME group (0% vs 6.1% for L-TME; P =0.031). Among the recovery parameters, the length of opioid use was shorter in the R-TME group ( P =0.028). There was no difference in the postoperative complication rate between the groups (12.0% for R-TME vs 8.3% for L-TME). In patients with middle or low rectal cancer, robotic-assisted surgery did not significantly improve the TME quality compared with conventional laparoscopic surgery (ClinicalTrial.gov ID: NCT01042743).

Evaluation of effect of robotic versus laparoscopic surgical technology on genitourinary function after total mesorectal excision for rectal cancer

ObjectiveBecause the recovery of genitourinary function after total mesorectal excision (TME) is affected by multiple factors, the role of robot-assisted TME technology in postoperative function in previous studies is still controversial. Our study aimed to evaluate the impact of robotic technology on the recovery of genitourinary function after TME for rectal cancer by analysing the correlations between influencing factors of genitourinary function and robotic surgery. MethodsBetween January 2017 and January 2020, patients with rectal cancer (cT1-3NxM0) were registered. Genitourinary function was assessed by the International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF) test, Female Sexual Function Index (FSFI) and urodynamic examination before surgery and 1, 3, 6, and 12 months postoperatively. Genitourinary function was compared between the laparoscopic total mesorectal excision (L-TME) and robotic total mesorectal excision (R-TME) groups, and the correlative factors associated with postoperative genitourinary function were analysed using the generalized estimated equation (GEE). ResultsCompared with L-TME, R-TME showed a superior IPSS, voiding volume, residual urine volume and IIEF score during the early postoperative period. According to the GEE analysis, postoperative genitourinary function was positively correlated with laparoscopic anterior resection/abdomen perineal resection (LAR/APR) but negatively correlated with tumour size, tumour distance to anus, TNM, adjuvant chemotherapy, adjuvant radiotherapy, complete TME, circumferential resection margin (CRM), blood loss, diverting stoma, conversion, and anastomotic leakage. ConclusionDue to the important role of robotic surgical technology on the influential factors of postoperative genitourinary function and the superiority of identifying and preserving autonomic nerves, robotic technology is conducive to the early recovery of postoperative urogenital function while adhering to oncological dissection principles. No significant difference was found between the da Vinci R-TME and MicroHand R-TME groups.

The Mesentery in Robot-Assisted Total Mesorectal Excision.

In recent decades, surgery for rectal cancer has evolved from an operation normally performed under poor vision with a lot of blood loss, relatively high morbidity, and mortality to a safer operation. Currently, minimally invasive rectal procedures are performed with limited blood loss, reduced morbidity, and minimal mortality. The main cause is better knowledge of anatomy and adhering to the principle of operating along embryological planes. Surgery has become surgery of compartments, more so than that of organs. So, rectal cancer surgery has evolved to mesorectal cancer surgery as propagated by Heald and others. The focus on the mesentery of the rectum has led to renewed attention to the anatomy of the fascia surrounding the rectum. Better magnification during laparoscopy and improved optimal three-dimensional (3D) vision during robot-assisted surgery have contributed to the refinement of total mesorectal excision (TME). In this chapter, we describe how to perform a robot-assisted TME with particular attention to the mesentery. Specific points of focus and problem solving are discussed.

Local recurrence of robot-assisted total mesorectal excision: a multicentre cohort study evaluating the initial cases

PurposeEvidence regarding local recurrence rates in the initial cases after implementation of robot-assisted total mesorectal excision is limited. This study aims to describe local recurrence rates in four large Dutch centres during their initial cases.MethodsFour large Dutch centres started with the implementation of robot-assisted total mesorectal excision in respectively 2011, 2012, 2015, and 2016. Patients who underwent robot-assisted total mesorectal excision with curative intent in an elective setting for rectal carcinoma defined according to the sigmoid take-off were included. Overall survival, disease-free survival, systemic recurrence, and local recurrence were assessed at 3 years postoperatively. Subsequently, outcomes between the initial 10 cases, cases 11–40, and the subsequent cases per surgeon were compared using Cox regression analysis.ResultsIn total, 531 patients were included. Median follow-up time was 32 months (IQR: 19–50]. During the initial 10 cases, overall survival was 89.5%, disease-free survival was 73.1%, and local recurrence was 4.9%. During cases 11–40, this was 87.7%, 74.1%, and 6.6% respectively. Multivariable Cox regression did not reveal differences in local recurrence between the different case groups.ConclusionLocal recurrence rate during the initial phases of implantation of robot-assisted total mesorectal procedures is low. Implementation of the robot-assisted technique can safely be performed, without additional cases of local recurrence during the initial cases, if performed by surgeons experienced in laparoscopic rectal cancer surgery.

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer.

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex procedures. The high-quality 3-D visual, multijoint arm and natural tremor filtration allow the surgeon to expose and dissect more accurately with minimal invasion. Total mesorectal excision is the standard surgical technique for the treatment of resectable rectal cancer. To reduce the lateral recurrence rate, lateral pelvic lymph node dissection can be performed, as it is a safe and feasible procedure for locally advanced middle-low rectal cancer with a high possibility of metastasis to the lateral lymph nodes. However, the complexity of the anatomic structures and the high postoperative complication rate limit its application. Recently, several surgeons have increasingly used robotic techniques for total mesorectal excision and lateral pelvic lymph node dissection. Compared with open and laparoscopic surgery, the robotic technique has several advantages, such as less blood loss, fewer blood transfusions, minimal trauma, shorter postoperative hospitalization, and quicker recovery. A robotic approach is generally regarded as a reasonable alternative for complicated procedures such as lateral pelvic lymph node dissection, although there are a limited number of high-quality prospective randomized controlled studies reporting direct evidence. Here, we provide the detailed steps of robot-assisted total mesorectal excision and lateral pelvic lymph node dissection performed at the First Affiliated Hospital of Xi'an Jiaotong University.

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer

Robot-Assisted Total Mesorectal Excision Versus Laparoscopic Total Mesorectal Excision: A Retrospective Propensity Score-Matched Cohort Analysis in Experienced Centers.

The superiority of robot-assisted over laparoscopic total mesorectal excision has not been proven. Most studies do not consider the learning curve while comparing the surgical technique. This study aims to compare laparoscopic with robot-assisted total mesorectal excision performed by surgeons who completed the learning curve of the technique. This is a multicenter retrospective propensity score-matched analysis. The study was performed in 2 large, dedicated robot-assisted hospitals and 5 large, dedicated laparoscopic hospitals. Patients were included if they underwent a robot-assisted or laparoscopic total mesorectal excision for rectal cancer with curative intent at a dedicated center for the minimally invasive technique between January 1, 2015, and December 31, 2017. We compared robot-assisted with laparoscopic total mesorectal excision. The main outcome was conversion to laparotomy during surgery. Secondary outcomes were postoperative morbidity and positive circumferential resection margin. A total of 884 patients were included and, after matching, 315 patients per treatment group remained. Conversion was similar between laparoscopic and robot-assisted total mesorectal excision (4.4% vs 2.5% (p = 0.20)). Positive circumferential resection margin was equal (3.2% vs 4.4% (p = 0.41)). Overall morbidity was comparable as well, although a lower rate of wound infections was observed in the robot-assisted group (5.7% vs 1.9% (p = 0.01)). More primary anastomoses were constructed in the robot-assisted group (50.8% vs 68.3% (p < 0.001)). Finally, more open procedures were performed in dedicated laparoscopic centers, with an overrepresentation of cT4N+ tumors in this group. This is a retrospective multicenter cohort; however, propensity score matching was applied to control for confounding by indication. Robot-assisted and laparoscopic total mesorectal excision are equally safe in terms of short-term outcomes. However, with the robot-assisted approach, more primary anastomoses were constructed, and a lower wound infection rate was observed. See Video Abstract at http://links.lww.com/DCR/B677.ESCISIÓN MESORRECTAL TOTAL ASISTIDA POR ROBOT VERSUS ESCISIÓN MESORRECTAL TOTAL LAPAROSCÓPICA: UNA PUNTUACIÓN DE PROPENSIÓN RETROSPECTIVA ANÁLISIS DE COHORTES EMPAREJADAS EN CENTROS EXPERIMENTADOS. No se ha demostrado la superioridad de la escisión mesorrectal total asistida por robot sobre la laparoscópica. La mayoría de los estudios no tienen en cuenta la curva de aprendizaje al comparar la técnica quirúrgica. Este estudio tiene como objetivo comparar la escisión mesorrectal total laparoscópica con la asistida por robot realizada por cirujanos que completaron la curva de aprendizaje de la técnica. Este es un análisis multicéntrico retrospectivo emparejado por puntuación de propensión. El estudio se realizó en dos grandes hospitales dedicados asistidos por robots y cinco grandes hospitales laparoscópicos dedicados. Se incluyeron pacientes que se sometieron a escisión mesorrectal total asistida por robot o laparoscópica para cáncer de recto con intención curativa, en un centro dedicado a la técnica mínimamente invasiva entre el 1 de enero de 2015 y el 31 de diciembre de 2017. Comparamos la escisión mesorrectal total asistida por robot con la laparoscópica. El principal resultado fue la conversión a laparotomía durante la cirugía. Los resultados secundarios fueron la morbilidad posoperatoria y el margen circunferencial positivo. Se incluyó a un total de 884 pacientes y, después de emparejar, quedaron 315 pacientes por grupo de tratamiento. La conversión fue similar entre la escisión mesorrectal total laparoscópica y asistida por robot (4,4% frente a 2,5% [p = 0,20]). El margen de resección circunferencial positivo fue igual (3,2% vs 4,4% [p = 0,41]). La morbilidad general también fue comparable, aunque se observó una menor tasa de infecciones de heridas en el grupo asistido por robot (5,7% frente a 1,9% [p = 0,01]). Se construyeron más anastomosis primarias en el grupo asistido por robot (50,8% frente a 68,3% [p < 0,001]). Finalmente, se realizaron procedimientos más abiertos en centros laparoscópicos dedicados, con una sobrerrepresentación de tumores cT4N + en este grupo. Ésta es una cohorte multicéntrica retrospectiva; sin embargo, se aplicó el emparejamiento por puntuación de propensión para controlar los factores de confusión por indicación. La escisión mesorrectal total asistida por robot y laparoscópica son igualmente seguras en términos de resultados a corto plazo. Sin embargo, con el abordaje asistido por robot, se construyeron más anastomosis primarias y se observó una menor tasa de infección de la herida. Consulte Video Resumen en http://links.lww.com/DCR/B677. (Traducción-Dr. Gonzalo Hagerman).

Comparison of the short-term efficacy of two types of robotictotal mesorectal excision for rectal cancer.

The advantages and disadvantages of robotic technology compared with conventional surgery for low rectal cancer have been discussed extensively. However, a few studies on the efficacy of total mesorectal excision (TME) with different robotic technologies have been reported. The aim of this study was to evaluate the efficacy of two types of robot-assisted TME (R-TME) compared with laparoscopic TME (L-TME). A prospective comparative study was conducted comparing da Vinci R-TME, Micro Hand S R-TME, and L-TME for rectal cancer. This study was registered with "Clinicaltrials.gov" (ID: NCT02752698) and approved by the Association for the Accreditation of Human Research Protection Program (AAHRPP) (Project number: T16007). Between January 2017 and May 2019, patients with rectal cancer (cT1-3NxM0) were prospectively registered in the Third Xiangya Hospital. The integrity of the TME sample served as the primary outcome. Secondary outcomes included the involvement of the circumferential and distal resection margins (CRM and DRM), number of lymph nodes retrieved, blood loss, operative time, conversion rate, comprehensive complication index score, the International Prostate Symptom score, the International Index of Erectile Function, and the Female Sexual Function Index. Of 134 patients with rectal cancer (74 males, mean age [SD] 59.1 ± 8.27years), 46 patients underwent laparoscopic TME, 45 patients underwent da Vinci R-TME, and 43 patients underwent Micro Hand S R-TME. There were no differences in results between the two types of R-TME. Compared with laparoscopic TME, significant reductions in blood loss (median 65.50ml da Vinci; median 66.54ml Micro Hand S vs median 95.04ml L-TME p = 0.037 and p = 0.041, respectively) and conversion rate (2.2% da Vinci; 2.3% Micro Hand S vs 6.8% L-TME p = 0,040 for the comparison daVinci L-TME and p = 0.038 for the comparison Micro Hand S vs. L-TME) with da Vinci Si and Micro Hand S R-TME were noted, and significant increases in operation time (230.05min da Vinci; 235.03min Micro Hand S vs. 205.53min L-TME p = 0.045 and p = 0.043, respectively) was observed. Additionally, more patients underwent TME with sphincter-preserving methods in the two R-TME groups based on the type of operation (da Vinci97.7%; Micro Hand S97.9% vs. L-TME82% resulting in p = 0.033 for the comparison daVinci L-TME and p = 0.035 for the comparison Micro Hand S vs. L-TME). In comparison with L-TME, there was a larger number of lymph nodes retrieved (da Vinci mean 17.54; Micro Hand S mean 17.32 vs. L-TME mean 14.96 p = 0.031 for the comparison daVinci L-TME and p = 0.033 for the comparison Micro Hand S vs L-TME) and less blood loss (da Vinci mean 65.50ml; Micro Hand S mean 66.54ml vs. L-TME mean 95.04ml, p = 0.037 for the comparison daVinci L-TME and p = 0.041 for the comparison Micro Hand S vs. L-TME), and incidence of severe postoperative complications was similar among three TME groups except forthe earlier recovery of urogenital function (mean IPSS scoreda Vinci 7.73±1.35; Micro Hand S7.75±1.47 vs L-TME 14.26±1.41 p<0.001 for the comparison da Vinci L-TME and p<0.001 for the comparison Microhand S vs L-TME) in the two R-TME groups. In our study, compared with laparoscopic surgery, da Vinci or Micro Hand R-TME exhibited similar superiority in the quality of oncologic resection, postoperative morbidity, and recovery of postoperative function.

A nationwide comparison of short-term outcomes after transanal, open, laparoscopic, and robot-assisted total mesorectal excision.

Laparoscopic rectal cancer surgery has several limitations. Transanal total mesorectal excision (TaTME) can potentially overcome these limitations. The aim of this study was to compare the rates of non-radical surgery and anastomotic leakage after TaTME, open TME (OpTME), laparoscopic TME (LaTME) and robotic TME (RoTME) procedures in a nationwide cohort. We extracted the demographic, perioperative and pathological data of patients who underwent a curative OpTME, LaTME, RoTME or TaTME procedure between January 2014 and December 2018 from the national database of the Danish Colorectal Cancer Group (DCCG). We conducted multiple group-comparisons, uni- and multivariate analyses to determine the factors associated with positive resection margin (+RM) and anastomotic leakage. We included 2393 patients (OpTME = 205, LaTME = 1163, RoTME = 713 and TaTME = 312). The rate of +RM was 5.7% after TaTME. The lowest rate of +RM was achieved after RoTME (8.2%, 4.7%, 2.52%, and 5.7%, after OpTME, LaTME, RoTME and TaTME respectively, p<0.001). In multivariate analysis, having a T4 tumour and intraoperative bowel perforation were associated with the risk of +RM (p<0.001, p<0.001, respectively). The factors associated with anastomotic leakage in multivariate analysis were male gender, high BMI and intraoperative bowel perforation (p<0.001, p=0.049, p=0.002, respectively). TaTME was associated with the highest rate of sphincter-saving procedures (79.8%, p<0.001), the lowest rate of bowel perforation (2.9%, p=0.028) and the lowest rate of conversion to open surgery (1.3%, p<0.001). In a nationwide audit of TME approaches, the rate of +RM was lowest after RoTME. No differences were found between the four approaches regarding the risk of anastomotic leakage. TaTME offered advantages related to sphincter-saving, perforation and conversion.

Initial experience of Chinese surgical robot “Micro Hand S″-assisted versus open and laparoscopic total mesorectal excision for rectal cancer: Short-term outcomes in a single center

BackgroundA Chinese surgical robot, Micro Hand S, was introduced for clinical use as a novel robotic platform. This study aimed to comprehensively compare the early experience of the Micro Hand S robot-assisted total mesorectal excision (TME) with conventional approaches. MethodsBetween May 2017 and April 2018, 99 consecutive patients who underwent open, laparoscopic and Micro Hand S robot-assisted TME (O-/L-/RTME) for rectal cancer were included. Clinical and pathological outcomes were retrospectively analyzed. Surgical success as the primary endpoint was defined as the absence of (i) conversion, (ii) incomplete TME, (iii) involved circumferential and distal resection margins (CRM/DRM), (iv) severe complications. ResultsThe rate of surgical success was similar (89.7 vs. 86.4 vs. 84.6%, p = 0.851) in the three groups and the respective incidences were as follows: conversion (not applicable, 4.5 vs. 2.3%, p = 1.000), incomplete TME (6.9 vs. 6.8 vs. 3.8%, p = 0.980), involved CRM/DRM (0 vs. 2.3 vs. 3.8%, p = 0.592), severe complications (3.4 vs. 4.5 vs. 7.7%, p = 0.844). Compared with open and laparoscopic surgery, the robotic surgery was associated with longer operative time, less blood loss, earlier first flatus time and liquid intake time, and shorter length of hospital stay (p < 0.05). ConclusionsThe Micro Hand S assisted TME is safe and feasible, showing comparable outcomes than conventional approaches, with superiority in blood loss, recovery of bowel function, length of hospital stay, but with increased operative time.

Comparison of the operative outcomes and learning curves between laparoscopic and \u201cMicro Hand S\u201d robot-assisted total mesorectal excision for rectal cancer: a retrospective study

BackgroundThe Micro Hand S robot is a new surgical tool that has been applied to total mesorectal excision (TME) surgery for rectal cancer in our center. In this study, we compared the operative outcomes, functional outcomes and learning curves of the Micro Hand S robot-assisted TME (RTME) with laparoscopic TME (LTME).MethodsA total of 40 patients who underwent RTME and 65 who underwent LTME performed by a single surgeon between July 2015 and November 2018 were included in this retrospective study. Clinicopathologic characteristics, operative and functional outcomes, and learning curves were compared between the two groups. The learning curve was analyzed using the cumulative sum method and two stages (Phase 1, Phase 2) were identified and analyzed. All patients were followed up for at least 12 months.ResultsThe clinicopathologic characteristics of the two groups were similar. The learning curve was 17 cases for RTME and 34 cases for LTME. Compared with LTME, RTME was associated with less blood loss (148.2 vs. 195.0 ml, p = 0.022), and shorter length of hospital stay (9.5 vs. 12.2 days, p = 0.017), even during the learning period. With the accumulation of experience, the operative time decreased significantly from Phase 1 to Phase 2 (RTME, 360.6 vs. 323.5 min, p = 0.009; LTME, 338.1 vs. 301.9 min, p = 0.005), whereas other outcomes did not differ significantly.ConclusionsMicro Hand S robot-assisted TME is safe and feasible even during the learning period, with outcomes comparable to laparoscopic surgery but superior in terms of blood loss, length of hospital stay, and learning curve.Trial registration Clinicaltrial.gov, NCT04836741, retrospectively registered on 5 April 2021.

Implementation of robot-assisted total mesorectal excision by multiple surgeons in a large teaching hospital: Morbidity, long-term oncological and functional outcome.

Robot-assisted total mesorectal excision (TME) might offer benefits in less morbidity, better functional and long-term outcome over laparoscopic TME. All consecutive patients undergoing robot-assisted TME for rectal cancer during implementation between May 2015 and December 2019 performed by five surgeons in a single centre were included. Outcomes included local recurrence rate at 3years, conversion rate, circumferential resection margin (CRM) positivity rate, 30-day postoperative morbidity and outcomes of low anterior resection syndrome (LARS) questionnaires. In 105 robot-assisted TME, local recurrence rate at 3years was 7.4%, conversion to open surgery rate was 8.6%, CRM positivity rate was 5.7%, 73.3% had good quality specimen, postoperative morbidity rate was 47.6% and anastomotic leakage rate was 9.0%. Incidence of major LARS was 55.3%. results of this study described acceptable morbidity, functional and long-term outcome during implementation of robotic TME for rectal cancer by multiple surgeons in a single centre.

Re-evaluation of possible vulnerable sites in the lateral pelvic cavity to local recurrence during robot-assisted total mesorectal excision.

Despite mechanical and technical improvements in laparoscopic and robot-assisted (LAR) rectal cancer procedures, the absence of prognostic disparities among various approaches cannot improve the quality of TME. The present study re-evaluated robot-assisted total mesorectal excision (TME) procedures to determine whether these procedures may reveal technical faults that may increase the rate of local recurrence (LR). This study enrolled 886 consecutive patients with rectal cancer, who underwent curative robot-assisted LAR at Asan Medical Center (Seoul, Korea) between July 2010 and August 2017 (the first vs second period; n = 399 vs 487). The quality of TME and lateral pelvic mesorectal excision (LPME) were analyzed, as were LR rates and survival outcomes. Complete TME and LPME were achieved in 89.2% and 80.1% of these patients, respectively, with ≤ 1% having incomplete TME excluding intramesorectal excision. LR rates were 13.5 and 14.5 times higher in patients with incomplete TME and LPME, respectively, than in patients with complete TME and LPME (14.8% vs 1.1% and 8.7% vs 0.6%; p < 0.001 each by univariate analyses). Multivariate analyses showed that defective LPME was independently associated with incomplete TME and vice versa (p < 0.001). Cox regression analysis showed that defective LPME was independently correlated with reduced 5-year disease-free survival rate (hazard ratio, 1.563; 95% confidence interval, 1.052-2.323; p = 0.027). LR in rectal cancer patients was largely due to incomplete LPME, which was significantly associated with incomplete TME. Complete LPME may enhance the likelihood of complete TME, reducing LR rates.

Evaluation of Impact of Surgical Robotic Technology on Quality of Total Mesorectal Excision for Rectal Cancer:Chinese Experience of R-TME &lt;i&gt;via&lt;/i&gt; Diverse Robotic Technology

Objective: The advantages and disadvantages of robotic technology compared with conventional surgery for low rectal cancer has been discussed extensively, but few studies of the impact on total mesorectal excision (TME) efficacy based on different robotic technologies have been reported. This study aims to evaluate the differences in TME quality between two different robot-assisted TME (R-TME) methods. Methods: Between January 2017 and May 2019, patients who suffered from rectal cancer (cT1-3NxM0) were prospectively registered. Patients independently chose to undergo da Vinci R-TME, MicroHand S R-TME, or laparoscopic TME (L-TME). The integrity of the TME sample served as the primary outcome. Secondary outcomes included the involvement of circumferential and distal resection margins (CRM and DRM), lymph node retrieval number, blood loss, operative time (OT), conversion rate, comprehensive complication index (CCI) scores, IPSS,IIEF and FSFI scores. Results: In total, 46 patients underwent laparoscopic TME, 45 patients underwent da Vinci R-TME and 43 patients underwent MicroHand S R-TME. TME quality improved in both two R-TME groups, which was reflected by a reduced DRM involvement rate, more retrieved lymph nodes, reduced blood loss, reduced incidence of severe complications, and earlier urogenital function recovery. However, the operative times for both R-TME methods were significantly longer than that of the L-TME approach. Conclusion: In this study, compared with laparoscopic surgery, Da Vinci or MicroHand R-TME exhibit similar superiority in oncologic resection quality, postoperative morbidity, and recovery of postoperative function. Trial Registration: This study was registered with Clinicaltrials.gov (ID: NCT02752698). Funding Statement: This study was supported by the National Natural Science Foundation of China (No: 51875580) and National Key Research and Development Plan Fund (Grant No: 2017YFC0110402). Declaration of Interests: All authors declare that there are no conflicts of interest. Ethics Approval Statement: Approved by the Association for the Accreditation of Human Research Protection Program (AAHRPP) (Project number: T16007).

Novel multi-image view for neuromapping meets the needs of the robotic surgeon.

Pelvic intraoperative neuromonitoring during nerve-sparing robot-assisted total mesorectal excision (RTME) is feasible. However, visual separation of the neuromonitoring process from the surgeon console interrupts the workflow and limits the usefulness of available information as the procedure progresses. Since the robotic surgical system provides multi-image views in the surgeon console, the aim of this study was to integrate cystomanometry and internal anal sphincter electromyography signals to aid the robotic surgeon in his/her nerve-sparing technique. We prospectively investigated 5 consecutive patients (1 male, 4 females) who underwent RTME for rectal cancer at our institution in 2017. The robotic surgery was performed using the da Vinci Xi combined with pelvic intraoperative neuromapping with real-time electromyography and cystomanometry signal transmission by multi-image view during RTME. The adapted two-dimensional pelvic intraoperative neuromonitoring imaging successfully simulcasted to the surgeon console view in all 5 cases. The technical note is complemented by an intraoperative video. This report demonstrates the technical feasibility of an improved neuromonitoring process during nerve-sparing RTME. Robotic neuromapping can be fully visualized from the surgeon console.

Evaluation of Sexual and Urinary Function After Implementation of Robot-assisted Surgery for Rectal Cancer: A Single-Center Study.

Our objective was to report postoperative urogenital dysfunction after rectal cancer surgery, identifying possible predictors including conventional laparoscopic total mesorectal excision and robot-assisted total mesorectal excision laparoscopic surgery. Questionnaires were mailed to 184 patients who underwent laparoscopic rectal cancer surgery between January 2009 and May 2013. Single questions were used to retrospectively assess preoperative urogenital dysfunction. Surgical data were collected from hospital records. Postoperative urinary and sexual function was measured with validated questionnaires and the results were statistically analyzed. A total of 97 questionnaires were included in the study. Of those sexually active before the operation, 81% reported some degree of erectile dysfunction (ED). In total, 73% reported some degree of orgasmic dysfunction (OD). On multivariate analyses, older age was the only predictor for ED (P=0.0012). Older age (P=0.007) and having a rectal extirpation procedure (P=0.013) were predictors of OD. ED and OD are common after rectal cancer surgery. Robotic surgery was seemingly not associated with ED or OD.

Oncologic and Clinicopathologic Outcomes of Robot-Assisted Total Mesorectal Excision for Rectal Cancer.

Minimally invasive rectal cancer surgery is challenging and technically difficult. Robotic technology offers a stable surgical platform with magnified 3-dimensional vision and endowristed instruments, which may facilitate the minimally invasive procedure. Data on short-term and long-term outcomes indicate results comparable to laparoscopic and open surgery. We assessed the perioperative, clinicopathologic, and oncologic outcomes of robotic surgery for rectal cancer. This study was a review of a prospective database of patients over a 7-year period. Procedures took place in the colorectal division at a tertiary hospital. From August 2005 to October 2012, 101 patients with rectal cancer were operated on using the robotic approach. Rectal cancers were defined as tumors within 15 cm from the anal verge. Patients received either a totally robotic or a hybrid laparoscopic-robotic operation with rectal dissection performed robotically. Operative and perioperative data, pathologic outcomes, and disease-free and overall survival were examined. There were 63 men (62.4%) and 38 women (37.6%) in the study; the mean age was 61.5 years. Mid rectal and low rectal cancers composed 74.2% of cases. Preoperative chemoradiation was given to 74.3% of patients. Four conversions to open surgery occurred. Circumferential margin positivity was 5%, and median lymph node yield was 15. At a mean follow-up of 34.9 months, the disease-free survival was 79.2% and overall survival 90.1%. The mean cost of robotic surgery was $22,640 versus $18,330 for the hand-assisted laparoscopic approach (p = 0.005). This was a single-institution study with no head-to-head comparative group. Robotic surgery for rectal cancer extirpation is safe and feasible. It has a low conversion rate, satisfies all measures of pathologic adequacy, and offers acceptable oncologic outcomes. Robotic surgery is significantly more expensive than hand-assisted laparoscopic surgery. The absence of randomized data limits recommending it as the standard of care at present.