Robot-assisted Surgery For Rectal Cancer Research Articles

Robotic-assisted surgery versus open surgery in the treatment of rectal cancer: the current evidence.

The aim of this meta-analysis was to comprehensively compare the safety and efficacy of robotic-assisted rectal cancer surgery (RRCS) and open rectal cancer surgery (ORCS). Electronic database (PubMed, EMBASE, Web of Knowledge, and the Cochrane Library) searches were conducted for all relevant studies that compared the short-term and long-term outcomes between RRCS and ORCS. Odds ratios (ORs), mean differences, and hazard ratios were calculated. Seven studies involving 1074 patients with rectal cancer were identified for this meta-analysis. Compared with ORCS, RRCS is associated with a lower estimated blood loss (mean difference [MD]: −139.98, 95% confidence interval [CI]: −159.11 to −120.86; P < 0.00001), shorter hospital stay length (MD: −2.10, 95% CI: −3.47 to −0.73; P = 0.003), lower intraoperative transfusion requirements (OR: 0.52, 95% CI: 0.28 to 0.99, P = 0.05), shorter time to flatus passage (MD: −0.97, 95% CI = −1.06 to −0.88, P < 0.00001), and shorter time to resume a normal diet (MD: −1.71.95% CI = −3.31 to −0.12, P = 0.04). There were no significant differences in surgery-related complications, oncologic clearance, disease-free survival, and overall survival between the two groups. However, RRCS was associated with a longer operative time. RRCS is safe and effective.

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 Outcomes of Extended Robotic Resection for Rectal Cancer.

Surgery for locally advanced rectal cancers beyond the plane of total mesorectal excision (TME) or extramesorectal nodal involvement should include complete resection. This study evaluated the oncologic feasibility and safety of robot-assisted surgery for rectal cancer beyond the TME plane. The study analyzed the operative, perioperative, and oncologic outcomes for all patients who underwent robot-assisted extended rectal cancer surgery from April 2009 to February 2015. Of 36 patients, 22 underwent multivisceral en bloc resection, and 18 underwent extramesorectal lymph node (EMRLN) dissection. The median tumor location was 5cm [interquartile range (IQR), 2.2-9.0cm] from the anal verge. A total of 32 patients underwent neoadjuvant chemoradiation therapy. The median body mass index of the patients was 26.8kg/m(2) (IQR, 24.0-31.9kg/m(2)). Conversion was required for one patient because of inability to tolerate the Trendelenburg position. All the resections were R0, and there were no incomplete TMEs. The vagina and prostate or periprostatic structures were the most commonly resected (n=13/22), and the lateral pelvic nodes were the most common EMRLNs (n=16/18). The median numbers of examined mesorectal lymph nodes and EMRLNs were respectively 20 (IQR, 18.0-28.0) and 2.5 (IQR, 1.0-6.0). The median hospital stay was 4days (IQR, 3.0-5.5days). Six patients experienced Clavien-Dindo grade 3 complications, the most common of which was deep abscess (n=5, 13.8%). The 5-year actuarial local recurrence rate was 3.6%. Minimally invasive resection for rectal cancer can be performed with extended lymph node dissection or en bloc multivisceral resection using the surgical robot in selected patients. This technique is feasible and has acceptable morbidity.

Dealing with robot-assisted surgery for rectal cancer: Current status and perspectives.

The laparoscopic approach for treatment of rectal cancer has been proven feasible and oncologically safe, and is able to offer better short-term outcomes than traditional open procedures, mainly in terms of reduced length of hospital stay and time to return to working activity. In spite of this, the laparoscopic technique is usually practised only in high-volume experienced centres, mainly because it requires a prolonged and demanding learning curve. It has been estimated that over 50 operations are required for an experienced colorectal surgeon to achieve proficiency with this technique. Robotic surgery enables the surgeon to perform minimally invasive operations with better vision and more intuitive and precise control of the operating instruments, thus promising to overcome some of the technical difficulties associated with standard laparoscopy. It has high-definition three-dimensional vision, it translates the surgeon's hand movements into precise movements of the instruments inside the patient, the camera is held and moved by the first surgeon, and a fourth robotic arm is available as a fixed retractor. The aim of this review is to summarise the current data on clinical and oncologic outcomes of robot-assisted surgery in rectal cancer, focusing on short- and long-term results, and providing original data from the authors' centre.

Possible benefits of robot-assisted rectal cancer surgery regarding urological and sexual dysfunction: a systematic review and meta-analysis.

Robot-assisted surgery for rectal cancer may result in lower rates of urogenital dysfunction compared with laparoscopic surgery. A systematic review was conducted of studies reporting urogenital dysfunction after robot-assisted rectal cancer surgery. PubMed, Embase and the Cochrane Library were systematically searched in February 2014. All studies investigating urogenital function after robot-assisted rectal cancer surgery were identified. The inclusion criteria for meta-analysis studies required comparison of robot-assisted with laparoscopic surgery and the evaluation of urological and sexual function by validated questionnaire. The outcome was evaluated using the International Prostate Symptom Score (IPSS), the International Index of Erectile Function (IIEF) and the Female Sexual Function Index. Ten studies including 689 patients were included. For the meta-analysis this fell to four including 152 patients in the robotic group and 161 in the laparoscopic group, without heterogeneity. The IPSS score at 3 and 12months favoured robot-assisted surgery [mean difference (MD) -1.58; 95% CI (-3.1, -0.0), [P=0.04; and MD -0.90 (-1.81, -0.02), P=0.05]. IIEF scores at 3months' follow-up [MD -2.59 (-4.25, -0.94),] P=0.002] and 6months' follow-up [MD -3.06 (-4.53, -1.59), P=0.0001] were better after robot-assisted than laparoscopic surgery. Although there were few data and no randomized controlled trials the results of the review suggested that robot-assisted surgery resulted in improved urogenital function than after laparoscopy.

Learning curve for robotic-assisted surgery for rectal cancer: use of the cumulative sum method.

Few data are available to assess the learning curve for robotic-assisted surgery for rectal cancer. The aim of the present study was to evaluate the learning curve for robotic-assisted surgery for rectal cancer by a surgeon at a single institute. From December 2011 to August 2013, a total of 80 consecutive patients who underwent robotic-assisted surgery for rectal cancer performed by the same surgeon were included in this study. The learning curve was analyzed using the cumulative sum method. This method was used for all 80 cases, taking into account operative time. Operative procedures included anterior resections in 6 patients, low anterior resections in 46 patients, intersphincteric resections in 22 patients, and abdominoperineal resections in 6 patients. Lateral lymph node dissection was performed in 28 patients. Median operative time was 280min (range 135-683min), and median blood loss was 17mL (range 0-690mL). No postoperative complications of Clavien-Dindo classification Grade III or IV were encountered. We arranged operative times and calculated cumulative sum values, allowing differentiation of three phases: phase I, Cases 1-25; phase II, Cases 26-50; and phase III, Cases 51-80. Our data suggested three phases of the learning curve in robotic-assisted surgery for rectal cancer. The first 25 cases formed the learning phase.

Robot-assisted rectal cancer surgery: short-term outcomes for 113 consecutive patients.

The purpose of this study was to assess the short-term outcome of robot-assisted laparoscopic surgery (RALS) for rectal cancer, including robotic, autonomic nerve-preserving, lateral lymph node dissection (RALLD), a new, technically challenging procedure. Between December 2011 and August 2013, 113 consecutive patients underwent RALS for rectal cancer. Surgical outcomes, pathological results, and postoperative complications were prospectively collected. There were 78 males and 35 females; 30 patients (26.5%) had cT1 tumor, 14 (12.4%) had cT2, 56 (49.6%) had cT3, and 12 (10.6%) had cT4 tumor. The types of procedures performed were 82 anterior resections, 23 intersphincteric resections, and 8 abdominoperineal resections. RALLD was performed in 38 patients (33.6%). The overall median operative time was 302 (135-683) min. In cases without RALLD, the median operative time was 242 (135-529) min, while median operative time was 486 (320-683) min with RALLD. None of the cases was converted to an open or laparoscopic procedure. There was no surgical mortality. The overall complication rate for Clavien-Dindo classification grade III-IV was 2.7%. Ten patients who developed urinary retention recovered completely within 30 days after the operation. RALS for rectal cancer is a technically feasible, less invasive procedure. This procedure can be performed with low morbidity and a low conversion rate, even for cases with advanced rectal cancer requiring complicated, robot-assisted, lateral lymph node dissection.

Analysis of conversion factors in robotic-assisted rectal cancer surgery

Robotic surgical management of rectal cancer has a series of advantages which might facilitate the surgical approach to the pelvic cavity and reduce conversion rates. The aim of the present study is to identify independent factors for conversion during robotic rectal cancer surgery. A total of 67 patients underwent preoperative CT scan in order to obtain a three-dimensional image of the pelvis, the tumour and prostate. We measured maximum and minimum ilio-iliac, sacral promontory-pubis, coccyx-pubis diameters and maximum lateral axis. Further variables under consideration were age, BMI and use of neoadjuvant therapy. We recorded short-term follow-up outcomes of the resected tumour. The present study included 67 patients (39 males) with an average age of 65.11 ± 10.30 years and a BMI of 27.70 ± 3.97 kg/m(2). Operative procedures included nine abdominoperineal resections and 58 low anterior resections. There were 15 (22.38 %) conversions. Mean operating time was 192.2 ± 42.73 min. Minimum ilio-iliac, maximum ilio-iliac, promontory-pubic and coccyx-pubis diameter as well as maximum lateral axis were 100.38 ± 7.65, 107.10 ± 10.01, 109.97 ± 9.20, 105.61 ± 9.27 and 129.01 ± 9.94 mm, respectively. Mean tumour volume was 37.06 ± 44.08 cc; mean prostate volume was 42.07 ± 17.49 cc. The univariate analysis of the variables showed a correlation between conversion and BMI and minimum ilio-iliac and coccyx-pubis diameters (p = 0.004, 0.047, 0.046). In the multivariate analysis, the only independent predictive factor for conversion was the BMI (p = 0.004).No correlation was found between conversion and sex, age, tumour volume or the rest of pelvic diameters. BMI is an independent factor for conversion in robotic-assisted rectal cancer surgery.

Current status of laparoscopy for the treatment of rectal cancer.

Surgery for rectal cancer in complex and entails many challenges. While the laparoscopic approach in general and specific to colon cancer has been long proven to have short term benefits and to be oncologically safe, it is still a debatable topic for rectal cancer. The attempt to benefit rectal cancer patients with the known advantages of the laparoscopic approach while not compromising their oncologic outcome has led to the conduction of many studies during the past decade. Herein we describe our technique for laparoscopic proctectomy and assess the current literature dealing with short term outcomes, immediate oncologic measures (such as lymph node yield and specimen quality) and long term oncologic outcomes of laparoscopic rectal cancer surgery. We also briefly evaluate the evolving issues of robotic assisted rectal cancer surgery and the current innovations and trends in the minimally invasive approach to rectal cancer surgery.

Prospective Randomized Study Comparing Robotic-Assisted Surgery with Traditional Laparotomy for Rectal Cancer-Indian Study.

Rectal cancer is one of the common cancers in India. Surgical management is the mainstay of initial treatment for majority of patients. Minimally invasive surgery has gained acceptance for the surgical treatment of rectal cancer because, compared with laparotomy, it is associated with fewer complications, shorter hospitalization, and faster recovery. The aim of this study is to evaluate the safety, feasibility, technique, and outcomes (postoperative, oncological, and functional) of robotic-assisted rectal surgery in comparison with open surgery in the Indian population. A prospective randomized study was undertaken from August 2011 to December 2012. Fifty patients who presented with rectal carcinoma were randomized to either robotic arm (RA) or open arm (OA) group. Both groups were matched for clinical stage and operation type. Technique and feasibility of robotic-assisted surgery in terms of operating time, estimated blood loss, margins status, total number of lymph nodes retrieved, hospital stay, conversion to open procedure, complications, and functional outcomes were analyzed. The mean operative time was significantly longer in the RA than in the OA group (310 vs 246min, P < 0.001) but was significantly reduced in the latter part of the robotic-assisted patients compared with the initial patients. The mean estimated blood loss was significantly less in the RA compared with the OA group (165.14 vs 406.04ml, P < 0.001). None of the patients had margin positivity. The mean distal resection margin was significantly longer in the RA than in the OA group (3.6 vs 2.4cm, P < 0.001). A total of 100% of patients in the RA group had complete mesorectal excision while two patients in the OA group had incomplete mesorectal excision. The average number of retrieved lymph nodes was adequate for accurate staging. The number of lymph nodes removed by robotic method is slightly higher than the open method (16.88 vs 15.20) but with no statistical significance. Conversion rate was nil. The mean hospital stay was significantly shorter in the RA group (7.52 vs 13.24days, P < 0.001). Postoperative and functional outcomes were comparable between the two groups. Robotic-assisted surgery is an emerging technique in our country. Robotic-assisted rectal cancer surgery is safe with low conversion rates and acceptable morbidity and is oncologically feasible.

Robotic Surgery

Although robotic technology aims to obviate some of the limitations of conventional laparoscopic surgery, the role of robotics in colorectal surgery is still largely undefined and different with respect to its application in abdominal versus pelvic surgery. This review aims to elucidate current developments in colorectal robotic surgery.In colon surgery, robotic techniques are associated with longer operative times and higher costs compared with laparoscopic surgery. However, robotics provides a stable camera platform and articulated instruments that are not subject to human tremors. Because of these advantages, robotic systems can play a role in complex procedures such as the dissection of lymph nodes around major vessels. In addition robot-assisted hand-sewn intracorporeal anastomoses can be easily performed by the surgeon, without a substantial need for a competent assistant. At present, although the short-term outcomes and oncological adequacy of robotic colon resection have been observed to be acceptable, the long-term outcomes of robotic colon resection remain unknown.In rectal surgery, robotic-assisted surgery for rectal cancer can be carried out safely and in accordance with current oncological principles. However, to date, the impact of robotic rectal surgery on the long-term oncological outcomes of minimally invasive total mesorectal excision remains undetermined. Robotic total mesorectal excision may allow for better preservation of urinary and sexual functions, and robotic surgery may attenuate the learning curve for laparoscopic rectal resection. However, a major drawback to robotic rectal surgery is the high cost involved.Large-scale prospective randomized clinical trials such as the international randomized trial ROLARR are required to establish the benefits of robotic rectal surgery.

Learning curve for robotic-assisted laparoscopic rectal cancer surgery

One of the main uses of robotic assisted abdominal surgery is the mesorectal excision in patients with rectal cancer. The aim of the present study is to analyse the learning curve for robotic assisted laparoscopic resection of rectal cancer. We included in our study 43 consecutive rectal cancer resections (16 females and 27 males) performed from January 2008 through December 2010. Mean age of patients was 66 ± 9.0years. Surgical procedures included both abdomino-perineal and anterior resections. We analysed the following parameters: demographic data of the patients included in the study, intra- and postoperative data, time taking to set up the robot for operations (set-up or docking time), operative time, intra- and postoperative complications, conversion rates and pathological specimen features. The learning curve was analysed using cumulative sum (CUSUM) methodology. The procedures understudied included seven abdomino-perineal resections and 36 anterior resections. In our series of patients, mean robotic set-up time was 62.9 ± 24.6min, and the mean operative time was 197.4 ± 44.3min. Once we applied CUSUM methodology, we obtained two graphs for CUSUM values (operating time and success), both of them showing three well-differentiated phases: phase 1 (the initial 9-11 cases), phase 2 (the middle 12 cases) and phase 3 (the remaining 20-22 cases). Phase 1 represents initial learning; phase 2 plateau represents increased competence in the use of the robotic system, and finally, phase 3 represents the period of highest skill or mastery with a reduction in docking time (p = 0.000), but a slight increase in operative time (p = 0.007). The CUSUM curve shows three phases in the learning and use of robotic assisted rectal cancer surgery which correspond to the phases of initial learning of the technique, consolidation and higher expertise or mastery. The data obtained suggest that the estimated learning curve for robotic assisted rectal cancer surgery is achieved after 21-23 cases.

134. Robotic assisted surgery – Rectal

Background: Robotic-assistance is gaining popularity in rectal cancer surgery due to the technical difficulties associated with the laparoscopic approach. This presentation will discuss the current evidence base for robotic-assisted rectal cancer surgery, its potential advantages and disadvantages, and recent data from the MRC/EME/NIHR ROLARR randomised controlled trial comparing robotic with laparoscopic rectal cancer resection.

Robotic surgery and limitations

A decade after the approval of the Da Vinci Surgical System (DVSS) by the US Food and Drug Administration (FDA), evidence of its superiority with respect to safety and efficacy for selected types of surgery compared with conventional laparoscopic surgery (CLS) has been accumulated. The potential advantages of the DVSS over CLS include its greater precision, lower error rates, reduced bleeding, shorter hospital stays, more rapid patient recovery, and reduced pain. As a result many surgeons have begun to use the DVSS in daily practice for a wide variety of surgeries, including general, oncological, urological, gynecological, and cardiothoracic [1]. However, because robotic surgery is still in its early stages, comparativeeffectiveness research (CER) evidence is scarce, and costs must be considered in an economical crisis [2], a more critical approach is required [2]. Robotic surgery may not be suitable for specific types of surgical procedures. A paradigm of potential limitations of robotic surgery was published by Scozzari et al. [3] in the February issue of Surgical Endoscopy. Given the difficulties with traditional laparoscopic surgery for morbidly obese patients, the authors thought to use the DVSS to improve the outcomes of these patients. Data from 110 morbidly obese patients who underwent laparoscopic Roux-en-Y gastric bypass with robot-assisted hand-sewn gastrojejunal anastomosis using the DVSS (DVSS group) were compared with data of 423 patients who underwent standardized CLS group. The patients had a mean weight of 127.5 kg and a mean body mass index (BMI) of 46.7 kg/ m. There were statistically significant differences in favor of the CLS over the DVSS group with respect to the operative time (P \ 0.001) and the cost per patient (P \ 0.001), whereas no differences were found in terms of the intraor postoperative complication rates, revision surgery, or hospital length of stay. The authors concluded that although robot-assisted surgery was safe and intuitive, it did not seem to provide a real advantage over standard laparoscopy in terms of hospital length of stay and complications rates. This study suggests that the use of the DVSS may be indicated for some specific organs and anatomical areas, while it may not be superior to CLS for other disorders and locations. Minimally invasive surgery such as laparoscopyor robot-assisted surgery also has important implications in surgical oncology for a variety of solid tumors. For example, laparoscopic surgery has been the standard approach for colon cancer and promising data have been available for its use in other gastrointestinal cancers, whereas evidence is increasing for the superiority of robotassisted surgery for rectal cancer [4–10]. The age of robotic surgery has dawned and there is still a lot of improvement to be made in the near future. For example, robotic surgery for prostate cancer or rectal cancer is new and has its own learning curve to be overcome. If we remind ourselves of all the debates brought by each new innovative technology, such as laparoscopic surgery, on its first appearance, we believe that further intensive and largescaled studies will answer the upcoming questions about the safety and efficacy of robotic surgery. Translating innovative ideas and concepts into medical practice suggests a key driver to improve health care. However, costs should be considered. A prime paradigm of how costs can drastically be reduced is the competition between biotechnology and pharmaceutical companies and academia regarding next-generation sequencing technology. C. Hottenrott (&) Chirurgische Klinik, St. Elisabethenkrankenhaus, Ginnheimer Strase 3, 60487 Frankfurt am Main, Germany e-mail: info@gastricbreastcancer.com

Short-Term Outcomes After Robotic-Assisted Total Mesorectal Excision for Rectal Cancer

Laparoscopic total mesorectal excision for rectal cancer remains a difficult procedure with high conversion rates. We have sought to improve on some of the pitfalls of laparoscopy by using the DaVinci robotic system. Here we report our two-year experience with robotic-assisted laparoscopic surgery for primary rectal cancer. A prospectively maintained database of all rectal cancer cases starting in November 2004 was created. A series of 39 consecutive unselected patients with primary rectal cancer was analyzed. Clinical and pathologic outcomes were reviewed retrospectively. 22 patients had low anterior, 11 intersphincteric and six abdominoperineal resections. Postoperative mortality and morbidity were % and 12.8%, respectively. The median operative time was 285 minutes (range 180-540 mins). The conversion rate was 2.6%. A total mesorectal excision with negative circumferential and distal margins was accomplished in all patients, and a median of 13 (range 7-28) lymph nodes was removed. The anastomotic leak rate was 12.1%. The median hospital stay was 4 days. There have been no local recurrences at a median follow-up of 13 months. Robotic-assisted surgery for rectal cancer can be carried out safely and according to oncological principles. This approach shows promising short-term outcomes and may facilitate the adoption of minimally invasive rectal surgery.