Robotic low anterior resection versus transanal total mesorectal excision in rectal cancer: A comparison of 115 cases

doi:10.1016/j.ejso.2017.11.011

European Journal of Surgical Oncology

Volume 44, Issue 2, February 2018, Pages 237-242

https://doi.org/10.1016/j.ejso.2017.11.011 Get rights and content

Abstract

Background

Robotic low anterior resection (RLAR) and transanal total mesorectal excision (TaTME) are novel surgical techniques for resection of rectal cancer. To our knowledge, no data exist on direct comparison of these procedures in terms of oncological or functional parameters.

Methods

60 RLAR and 55 TaTME for rectal cancer were compared in respect to patient characteristics, clinicopathological parameters, intraoperative and perioperative results and anatomopathological outcome.

Results

62 surgeries addressed tumors of the lower third (53.9%). No intergroup differences in terms of patient characteristics and clinicopathological parameters were observed. Operating time did not differ between groups (p = 0.312), nor did the perioperative complication rate (p = 0.176). Circumferential resection margin was wider in the RLAR than in the TaTME group (p < 0.001), while no differences were found in the remaining oncological parameters.

Conclusion

Our study shows comparable results for RLAR and TaTME in rectal cancer treatment. Both procedures should be considered equally feasible for low rectal cancer cases and as an alternative to conventional anterior resections (open or laparoscopic). Furthermore, both techniques allow excellent oncological outcome especially in patients with anatomical limitations.

Introduction

Colorectal cancer (CRC) is the fourth most common malignant disease with over 1 million new cases each year worldwide [1]. Despite recent advances in the management of the disease, CRC remains the second leading cancer-related cause of death in western countries [1]. Recently, novel surgical techniques for resection of low rectal cancer have been introduced. These approaches have the potential to overcome especially anatomical limitations like obesity, narrow male pelvis and bulky and low tumors [2].

Two of these procedures are robotic low anterior resection (RLAR) and transanal total mesorectal excision (TaTME). Both have been compared retrospectively to open and conventional laparoscopic surgery in various trials, which show that these methods are safe and feasible [3], [4], [5], [6], [7]. Furthermore, studies suggest that RLAR and TaTME have certain advantages in the resection of low cancers compared to laparoscopic or open surgery such as lower conversions rates, especially in obese patients, and better preservation of the autonomic function, while oncological results are similar [8], [9], [4], [10], [11], [12]. However, data on comparison of these two techniques regarding above-mentioned parameters are still lacking.

This prompted us to analyse two similar patient cohorts undergoing either RLAR or TaTME for rectal cancer in respect to differences in clinicopathological parameters, intraoperative and perioperative results and anatomopathological outcome.

Section snippets

Patients

In this study, a total of 115 selected patients underwent either RLAR (n = 60) or TaTME (n = 55) for rectal cancer in the low (<6 cm from anal verge) or middle (6–12 cm from anal verge) third of the rectum in two different institutions within the same period. The analysis was performed retrospectively on a prospective maintained database, therefore no power calculation was conducted. Study protocols were approved by the appropriate review committee of University Medical Center Hamburg-Eppendorf

Results

A total of 185 and 122 patients with primary rectal cancer were treated at the two institutions during the observational period. The first TaTME was performed in the one center in November 2014.

One hundred-fifteen (n = 115) selected patients underwent either RLAR (n = 60) or TaTME (n = 55) for rectal cancer in the low (<6 cm from anal verge) or middle third (6–12 cm from anal verge) of the rectum in the two institutions within the above mentioned period.

Discussion

Our study shows comparable results between RLAR and TaTME for rectal cancer regarding oncological surrogate parameters and suggests that both procedures are equally applicable for resection of low rectal cancer especially in patients with anatomical limitations such as male gender and bulky tumors. As only 11.6% of patients are considered as obese, this study is underpowered to detect the role of obesity on the outcome of both techniques.

We studied two groups of patients with similar

Conflict of interest statement

All authors have no disclosures.

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Surgery began with the abdominal part in lithotomy position using the da Vinci Xi system (Intuitive Surgical, Sunnyvale, California, USA). The technique has previously been described by our group.10 In short, the dorsal mesorectal plane was dissected down to the pelvic floor so as to separate the mesorectum from the presacral fascia.
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Does transanal total mesorectal excision of rectal cancer improve histopathology metrics and/or complication rates? A meta-analysis
2019, Surgical Oncology
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This difference was neither statistically nor clinically significant [OR (95%CI) = 0.92 (0.64, 1.32); p = 0.65; NNT (95%CI) = 33 (>13 to harm, >64 to benefit)] with moderate among-study heterogeneity (I2 = 40%) (Fig. 1B). Four out of the six studies included only patients with mid- and low rectal cancer [13–16]. A subgroup meta-analysis of the data extracted from those studies was conducted.
The aim of this meta-analysis was to determine whether transanal total mesorectal excision (taTME) improves histopathology metrics and/or complication rates when compared to robotic total mesorectal excision (R-TME) of resectable rectal cancer.
MEDLINE, Pubmed, Cochrane Library, and Scopus were systematically searched by two independent researchers. Six observational studies totaling 1,572 patients (811 taTME; 761 R-TME) were included after screening 14 potentially eligible records. Mantel-Haenszel method using odds ratios with 95% confidence intervals (OR (95%CI)) and inverse variance with mean difference with 95% confidence intervals (MD (95%CI)) as an effect measure for dichotomous and continuous variables, respectively, was employed for meta-analysis. Statistical heterogeneity among effect estimates was evaluated using I² and Tau².
Circumferential resection margin (CRM) involvement rates (3.8% taTME; 5.3% R-TME) did not differ [OR (95%CI) = 0.86 (0.35, 2.15); p = 0.75] with low among-study heterogeneity (I² = 21%). Complication rates (35.4% taTME; 32.3% R-TME) did not differ [OR (95%CI) = 0.92 (0.64, 1.32); p = 0.65], although with moderate among-study heterogeneity (I² = 40%). CRM involvement [OR (95%CI) = 0.76 (0.40, 1.43); p = 0.40] and complication rates [OR (95%CI) = 0.84 (0.59, 1.21); p = 0.35] did not significantly differ in subgroup meta-analysis including mid- and low rectal cancer. Distal resection margin (mm) did not significantly differ between the interventions [MD (95%CI) = −0.41 (−1.29, 0.47); p = 0.37].
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¹: DP and NM contributed equally to this study.

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Robotic low anterior resection versus transanal total mesorectal excision in rectal cancer: A comparison of 115 cases

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Patients

Results

Discussion

Conflict of interest statement

J Am Coll Surg

Eur J Surg Oncol

Eur J Surg Oncol J Eur Soc Surg Oncol Br Assoc Surg Oncol

Lancet Oncol

Cancer statistics, 2017

CA Cancer J Clin

Totale mesorektale Exzision durch den minimal-invasiven transanalen Zugang

Coloproctology

Robotic-assisted versus laparoscopic surgery for low rectal cancer: case-matched analysis of short-term outcomes

Ann Surg Oncol

Robotic colorectal surgery: our initial experience

Am Surg

Comparison of short-term and oncologic outcomes of robotic and laparoscopic resection for mid- and distal rectal cancer

Surg Endosc

Clinical outcomes and case volume effect of transanal total mesorectal excision for rectal cancer: a systematic review

Tech Coloproctol