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.

The role of the robotic technique in minimally invasive surgery in rectal cancer.

Laparoscopic rectal surgery is feasible, oncologically safe, and offers better short-term outcomes than traditional open procedures in terms of pain control, recovery of bowel function, length of hospital stay, and time until return to working activity. Nevertheless, laparoscopic techniques are not widely used in rectal surgery, mainly because they require a prolonged and demanding learning curve that is available only in high-volume and rectal cancer surgery centres experienced in minimally invasive surgery. Robotic surgery is a new technology that enables the surgeon to perform minimally invasive operations with better vision and more intuitive and precise control of the operating instruments, promising to overcome some of the technical difficulties associated with standard laparoscopy. The aim of this review is to summarise the current data on clinical and oncological outcomes of minimally invasive surgery in rectal cancer, focusing on robotic surgery, and providing original data from the authors' centre.

Impact of robotic surgery on sexual and urinary functions after fully robotic nerve-sparing total mesorectal excision for rectal cancer.

BACKGROUND: Urinary and sexual dysfunctions are recognized complications of rectal cancer surgery. Their incidence after robotic surgery is as yet unknown. The aim of this study was to prospectively evaluate the impact of robotic surgery for rectal cancer on sexual and urinary functions in male and female patients. METHODS AND PROCEDURES: From April 2008 to December 2010, 74 patients undergoing fully robotic resection for rectal cancer were prospectively included in the study. Urinary and sexual dysfunctions affecting quality of life were assessed with specific self-administered questionnaires in all patients undergoing robotic total mesorectal excision (RTME). Results were calculated with validated scoring systems and statistically analyzed. RESULTS: The analyses of the questionnaires completed by the 74 patients who underwent RTME showed that sexual function and general sexual satisfaction decreased significantly 1 month after intervention: 19.1 ± 8.7 versus 11.9 ± 10.2 (P < 0.05) for erectile function and 6.9 ± 2.4 versus 5.3 ± 2.5 (P < 0.05) for general satisfaction in men; 2.6 ± 3.3 versus 0.8 ± 1.4 (P < 0.05) and 2.4 ± 2.5 versus 0.7 ± 1.6 (P < 0.05) for arousal and general satisfaction, respectively, in women. Subsequently, both parameters increased progressively, and 1 year after surgery, the values were comparable to those measured before surgery. Concerning urinary function, the grade of incontinence measured 1 year after the intervention was unchanged for both sexes. CONCLUSIONS: RTME allows for preservation of urinary and sexual functions. This is probably due to the superior movements of the wristed instruments that facilitate fine dissection, coupled with a stable and magnified view that helps in recognizing the inferior hypogastric plexus.

Operative blood loss and use of blood products after full robotic and conventional low anterior resection with total mesorectal excision for treatment of rectal cancer.

To date, no studies have investigated the estimated blood loss (EBL) after full robotic low anterior resection (R-LAR) in a case-matched model, comparing it with the conventional open approach (O-LAR). Forty-nine patients in the R-LAR and 105 in the O-LAR group were matched for age, gender, BMI (body mass index), ASA (American Society of Anesthesiology) class, tumor-node-metastasis (TNM) classification and UICC (Union for International Cancer Control) stage, distance of the lower edge of the tumor from the anal verge, presence of comorbidities, and preoperative hemoglobin (Hb). EBL was significantly higher in the O-LAR group (P < 0.001); twelve units of packed red blood cells were globally transfused in the O-LAR group, compared to one unit only in the R-LAR (P = 0.051). A significantly higher postoperative Hb drop (3.0 vs. 2.4 g/dL, P = 0.015) was registered in the O-LAR patients. The length of hospital stay was much lower for the R-LAR group (8.4 vs. 12.4 days, P < 0.001). The number of harvested lymph nodes (17.4 vs. 13.5, P = 0.006) and extent of distal margin (2.9 vs. 1.9 cm, P < 0.001) were significantly higher in the R-LAR group. Open surgery was confirmed as the sole variable significantly associated (P < 0.001) with blood loss (odds ratio = 4.41, 95% CI 2.06-9.43). It was a confirmed prognosticator of blood loss (P = 0.006) when a preoperative clinical predictive model was built, using multivariate analysis (odds ratio = 3.95, 95% CI 1.47-10.6). In conclusion, R-LAR produced less operative blood loss and less drop in postoperative hemoglobin when compared to O-LAR. Other clinically relevant outcomes were similar or superior to O-LAR.

Surgical and pathological outcomes after right hemicolectomy: case-matched study comparing robotic and open surgery.

OBJECTIVE: To compare the surgical and pathological outcomes of patients with right-sided colon cancers operated on by means of open and robotic surgery with extracorporeal anastomosis. METHODS: Thirty-three consecutive patients who underwent robotic right hemicolectomy due to right-sided colon cancer were retrospectively well matched with 102 patients operated on by the open approach. Data were included in a prospectively maintained database. RESULTS: Mean operative time was longer in the robotic group (P < 0.001), 191.7 min (134-250) versus 136.2 (45-240) min in the open group. Estimated intraoperative blood loss was less in the robotic group, which presented a mean of 6.1 ml versus 94.8 ml in the open group (P < 0.001). Despite the similar length of the surgical specimen and number of lymph nodes retrieved between both groups, 15 or more lymph nodes were found in the specimen in 90 out of 102 patients (88.2%) operated on by the open technique versus 33 out of 33 patients (100%) who underwent robotic hemicolectomy (P = 0.038). The median length of postoperative hospital stay was shorter in the robotic group, 5 versus 8 days (P < 0.001). No other statistically significant difference was observed in terms of pathological and postoperative results. CONCLUSIONS: Robotic right hemicolectomy is an oncologically safe and effective procedure. The number of lymph nodes retrieved in the robotic group compared with the open group of our series was more homogeneous, and none of the patients operated on with this technique had a suboptimal lymphadenectomy. Further clinical trials are needed to confirm current evidence and determine whether this can influence the prognosis.

Excisão total do mesorreto por técnica robótica: resultados cirúrgicos e oncológicos iniciais / Robotic total mesorectal excision: early surgical and oncological outcomes

OBJETIVOS: avaliar os resultados cirúrgicos e oncológicos imediatos em pacientes com câncer de reto extraperitoneal submetidos à excisão total do mesorreto (ETM) robótica. MÉTODOS: de janeiro de 2007 a março de 2010 um total de 60 pacientes foram operados de forma consecutiva por técnica robótica. Os dados cirúrgicos e os desfechos oncológicos iniciais foram prospectivamente registrados em um banco de dados. RESULTADOS: foram operados 35 homens e 25 mulheres. A idade média foi de 60,3 ± 11,7 anos. Cirurgia com preservação esfincteriana foi possível em 52 pacientes. A média da amostra linfonodal foi de 18,7 ± 8,8 linfonodos. A média da margem cirúrgica distal foi de 2,9 ± 1,7 cm, enquanto a margem radial foi negativa em todos os pacientes. O tempo de seguimento pós-operatório foi de 14,3 meses. Apenas uma recidiva pélvica foi observada. As taxas de sobrevida geral e sobrevida câncer-específica foram respectivamente de 97,6 por cento e 98,3 por cento. CONCLUSÕES: ETM robótica é uma cirurgia exequível e segura. Apresenta resultados iguais ou mesmo melhores que as técnicas aberta e laparoscópica em termos de morbimortalidade, taxa de preservação esfincteriana e desfechos oncológicos iniciais.

OBJECTIVES: to evaluate the surgical and oncological outcomes of patients with extraperitoneal rectal cancer who underwent robotic total mesorectal excision (TEM). METHODS: from January 2007 to March 2010 a total of 60 patients were consecutively operated on through robotic technique. Data regarding surgical data and oncological outcomes were prospectively registered in a database. RESULTS: 35 men and 25 women underwent surgery. The mean age was 60.3 ± 11.7 years. Sphincter preserving surgery was possible in 52 patients. The mean number lymph node harvested was 18.7 ± 8.8 lymph nodes. The mean distal surgical margin was 2.9 ± 1.7 cm, while the radial margin was negative in all patients. The duration of postoperative follow-up was 14.3 months. Only one local recurrence was observed. The overall and the cancer-specific survival were respectively 97.6 percent and 98.3 percent. CONCLUSIONS: robotic TEM is feasible and safe. It is equal or superior to open and laparoscopic techniques in terms of morbidity and mortality rates, sphincter preservation rates and early oncological outcomes.

Multicentric study on robotic tumor-specific mesorectal excision for the treatment of rectal cancer.

BACKGROUND: Recently, traditional laparoscopic anterior resection has been used for rectal cancer, offering good functional results compared with open resection and resulting in better early postoperative outcomes. Few studies investigating the role of robot-assisted tumor-specific rectal surgery (RTSRS) have been carried out to show its feasibility. The aim of the study was to verify on a multicentric basis the perioperative and oncologic outcome of RTSRS. METHODS: One hundred forty-three consecutive patients undergoing RTSR in three centers were reviewed. Pathologic data, and postoperative and oncologic outcome measures were prospectively collected and analyzed by an independent researcher. RESULTS: A total of 112 restorative surgeries and 31 abdominoperineal resections were carried out. Conversion rate was 4.9%, mean blood loss was 283 ml, and mean operative time was 297 min. The number of harvested nodes (14.1 +/- 6.5) and margin status compared favorably with those of open series (mean distal margin 2.9 +/- 1.8 cm; negative radial margin in 142 cases). The 3-year overall survival rate was 97%, and no isolated local recurrences were found at mean follow-up of 17.4 months. CONCLUSION: RTSRS is a safe and feasible procedure that may facilitate mesorectal excision. Randomized clinical trials and longer follow-up are needed to evaluate a possible influence of RTSRS on patient survival.

Full robotic left colon and rectal cancer resection: technique and early outcome.

OBJECTIVE: The technique for robotic resection of the left colon and anterior resection of the rectum with total mesorectal excision is not well defined. In this study we describe a method that standardizes robot and trocar position, and allows for a complete mobilization of the left colon and the rectum, without repositioning of the surgical cart. Outcome and pathology findings are also reported. METHODS: From January 2007 to May 2008 a total of 55 consecutive patients affected by rectal and left colon cancer were operated on, with full robotic technique, using the Da Vinci robot. Data regarding outcome and pathology reports were prospectively collected in a dedicated database. RESULTS: The following procedures were performed 27 left colectomies, 17 anterior resections, 4 intersphincteric resections, 7 abdominoperineal resections. There were 21 female and 34 male patients with a mean age of 63 +/- 9.9 years. Mean operative time was 290 +/- 69 minutes, ranging from 164 to 487 min., none were converted to open surgery. The median number of lymph nodes harvested was 18.5 +/- 8.3 (range 5-45), and circumferential margin was negative in all cases. Distal margin was 25.15 +/- 12.9 mm (range 6-55) for patients with rectal cancer, and 31.6 +/- 20 mm for all the patients in this series. Anastomotic leak rate was 12.7% (7/55); in all cases conservative treatment was successful. CONCLUSIONS: Full robotic colorectal surgery is a safe and effective technique that exploits the advantages of the Da Vinci robot during the whole intervention, without the need to make use of hybrid operations. Outcome and pathology findings are comparable with those observed in open and laparoscopy procedures.