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ORIGINAL ARTICLE
Year : 2020  |  Volume : 16  |  Issue : 5  |  Page : 979-989

Robot-assisted versus laparoscopic surgery for rectal cancer: A systematic review and meta-analysis


Department of Colorectal Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China

Date of Submission12-Aug-2018
Date of Decision06-Nov-2018
Date of Acceptance05-Feb-2020
Date of Web Publication29-Sep-2020

Correspondence Address:
Chao He
Department of Colorectal Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_533_18

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 > Abstract 


Aim: This study aimed to compare clinical and oncological outcomes of robot-assisted and laparoscopic surgery for rectal cancer.
Materials and Methods: We searched PubMed/Medline, Embase, the Cochrane Library, Yahoo, and Google Scholar databases for relevant articles published up to 2017. Studies based on comparability between robot-assisted and laparoscopic surgery for rectal cancer were designated. Clinical outcomes included operative time, conversion to open surgery, estimated blood loss (EBL), bowel function recovery time, length of hospital stay (LOS), anastomosis leak, and postoperative complications. Oncological outcomes comprised the number of lymph nodes extracted, the positive circumferential margin (PCRM), and the distal resection margin (DRM)
Results: Twenty studies were designated totaling 5496 patients, comprising a robot-assisted surgery patient group (n = 2168, 39.4%) and a laparoscopic surgery patient group (n = 3328, 60.6%). The robot-assisted surgery group was associated with longer operative time (odds ratio [OR] 0.48, 95% confidence interval [CI]; 0.14, 0.82), lower conversion to open surgery rate (OR 0.55, 95% CI; 0.44, 0.69), shorter LOS (OR − 0.15, 95% CI; −0.30, 0.00), faster bowel function recovery (OR − 0.38, 95% CI; −0.74, −0.02), and lower postoperative complications (OR 0.79, 95% CI; 0.65, 0.97). EBL, anastomosis leak rate, and oncological outcomes including the number of lymph nodes extracted, the DRM, and the PCRM showed no significant differences between groups.
Conclusion: Robot-assisted surgery for rectal cancer showed longer operative time, lower conversion, faster bowel function recovery rates, and shorter hospital stay, and similar oncological outcomes compared to laparoscopic surgery.

Keywords: Laparoscopic surgery, meta-analysis, rectal cancer, robot-assisted


How to cite this article:
Wang X, Cao G, Mao W, Lao W, He C. Robot-assisted versus laparoscopic surgery for rectal cancer: A systematic review and meta-analysis. J Can Res Ther 2020;16:979-89

How to cite this URL:
Wang X, Cao G, Mao W, Lao W, He C. Robot-assisted versus laparoscopic surgery for rectal cancer: A systematic review and meta-analysis. J Can Res Ther [serial online] 2020 [cited 2020 Oct 26];16:979-89. Available from: https://www.cancerjournal.net/text.asp?2020/16/5/979/296437




 > Introduction Top


Total mesorectal excision (TME), the gold standard surgical treatment for rectal cancer, is defined as sharp dissection and complete resection of the mesorectal envelope en bloc within the rectum,[1],[2] and is associated with good control of local recurrence and a better overall survival rate. To date, three surgical techniques have been used for TME, namely open surgery, laparoscopic surgery, and robotic-assisted surgery. Laparoscopic surgery for colon cancer has been widely acknowledged as a curative therapy;[3] however, laparoscopic surgery for rectal cancer has not been recommended except for use in clinical trials.[4] Two clinical trials concluded that laparoscopic surgery for rectal cancer should not be undertaken because of poorer oncological outcomes.[5],[6] However, the COLOR II trial showed that laparoscopic surgery for rectal cancer led to improved recuperation and safety, as well as the same oncological outcomes compared to conventional open surgical procedures for rectal cancer.[7]

However, laparoscopic surgery for rectal cancer involves technical restrictions, such as a two-dimensional view and the restricted mobility of straight laparoscopic instruments.[8],[9] To overcome these technical limitations, the Da Vinci Surgical System was first used by colorectal surgeons in 2002. Pigazzi et al.[10] first described robot-assisted laparoscopic TME surgery for rectal cancer in 2006, and robot-assisted laparoscopic surgery for rectal cancer has since been used widely. To date, there have been numerous scientific studies and meta-analyses comparing robot-assisted surgery versus laparoscopic surgery for colorectal cancers.[11],[12],[13],[14] However, these studies had low patient numbers and low evidence levels. In our analysis, we aimed to evaluate the clinical and oncological outcomes of robot-assisted versus laparoscopic surgery for rectal cancer.


 > Materials and Methods Top


Search strategy

An electronic search was carried out by two unbiased researchers of PubMed/Medline, Embase, the Cochrane Library, Yahoo, and Google Scholar to identify relevant articles published up to April 2017. All acceptable articles were reviewed and evaluated. Letters to the editor and responses were omitted as they did not meet the inclusion criteria, outlined below. Abstracts were extracted for consistency and completeness of data assortment. The literature review search was based on the following key phrases: rectal cancer, robot-assisted surgery and laparoscopic surgery.

Selection criteria

Two evaluators scrutinized the titles and abstracts of reports, in which the results of robot-assisted surgery and laparoscopic surgery for rectal cancer were compared. The selected articles were assessed to determine their suitability for comprehensive evaluation. Based on the following inclusion criteria, studies had to involve: (1) Randomized and nonrandomized studies comparing the outcomes of robot-assisted surgery and laparoscopic surgery for rectal cancer; (2) a report on at least one of ten clinical or oncological outcomes, namely, operative time, conversion to open surgery, estimated blood loss (EBL), time of bowel function recovery, length of hospital stay (LOS), anastomosis leak rate, postoperative complications concerning clinical outcomes, the number of lymph nodes extracted, the positive circumferential margin (PCRM), and the distal resection margin (DRM) concerning oncological outcomes, and; (3) where studies originated within the same institution or were written by the same authors, the study that included greater patient numbers was selected.

Exclusion criteria involved studies that: (1) Did not report on clinical and oncological outcomes, (2) included colorectal surgery but did not focus on the rectal surgery to treat rectal cancer, and (3) those with overlaps within the same institution or with the same authors.

Outcomes

The ten clinical and oncological outcomes listed in the inclusion criteria were used to compare the robot-assisted and laparoscopic surgical procedures.

Statistical analysis

A meta-analysis was performed comparing the clinical and oncological outcomes between robot-assisted surgery and laparoscopic surgery for rectal cancer. Continuous variables were pooled using the mean difference (MD) with a 95% confidence interval (CI), and dichotomous variables were pooled using the odds ratio (OR) with a 95% CI. Publication bias was assessed using funnel plots. Heterogeneity among studies was assessed through calculating the I2 measure of inconsistency, which was considered statistically significant if the I2 was 50%. Stata Statistical Software, version 12.0 (Stata Corp, College Station, TX, USA), was used for the statistical analysis.


 > Results Top


A Prisma flowchart of the study is depicted in [Figure 1].[15] In total, 256 studies were identified through electronic searches. Excluding duplicates, 240 abstracts were reviewed, of which 42 appeared relevant, and 42 full studies were assessed. Ultimately, 20 studies were selected for inclusion and data extraction. The characteristics of the 20 eligible studies are summarized in [Table 1].
Figure 1: PRISMA flowchart of the study

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Table 1: The characteristics of 20 selected studies included in the meta-analysis

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Operation times

Nineteen studies reported operation times.[10],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33] A Forest plot showed that the robot-assisted surgery group had a significantly longer operation time than the laparoscopic surgery group (MD = 0.48; 95% CI; 0.14, 0.82), showing high heterogeneity among the studies ( P = 0.000, P < 0.0001, I 2 = 93.9%) [Figure 2].
Figure 2: A meta-analysis of the operation time for robot-assisted versus laparoscopic surgery for rectal cancer

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Estimated blood loss

Fifteen studies reported EBL.[10],[17],[19],[20],[22],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33] A Forest plot showed no significant difference in EBL between the two groups (MD = −0.08, 95% CI; −0.31, 0.15), showing high heterogeneity among the studies (P = 0.000, P < 0.0001, I 2 = 84.6%) [Figure 3].
Figure 3: A meta-analysis of estimated blood loss for robot-assisted versus laparoscopic surgery for rectal cancer

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Conversion to open surgery rate

Seventeen studies reported the rate of conversion to open surgery.[16],[17],[18],[19],[21],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34] A Forest plot showed that the robot-assisted surgery group had a significantly lower chance of conversion to open surgery than the laparoscopic surgery group (MD = 0.55, 95% CI; 0.44, 0.69), showing moderate heterogeneity among the studies (P = 0.016, I 2 = 50.3%) [Figure 4].
Figure 4: A meta-analysis of the conversion to open surgery rate for robot-assisted versus laparoscopic surgery for rectal cancer

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Time of bowel function recovery

Twelve studies reported the time of bowel function recovery.[16],[18],[19],[20],[21],[22],[23],[26],[27],[29],[30],[33] A Forest plot showed that the robot-assisted surgery group had a significantly shorter bowel function recovery time than the laparoscopic surgery group (MD = −0.38; 95% CI; −0.74, −0.02), showing high heterogeneity among the studies (P = 0.000, P < 0.0001, I2 = 91.8%) [Figure 5].
Figure 5: A meta-analysis of bowel function recovery time for robot-assisted versus laparoscopic surgery for rectal cancer

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Length of hospital stay

All the studies reported the LOS.[10],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34] A Forest plot showed that the robot-assisted surgery group had a significantly shorter LOS than the laparoscopic surgery group (MD = −0.15, 95% CI; −0.30, 0.00), showing high heterogeneity among the studies (P = 0.000, P < 0.0001, I 2 = 79.9%) [Figure 6].
Figure 6: A meta-analysis of length of hospital stay for robot-assisted versus laparoscopic surgery for rectal cancer

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Anastomosis leak rate

Seventeen studies reported the anastomosis leak rate.[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32] A Forest plot showed no significant difference in anastomosis leak rates between the two groups (MD = 0.97, 95% CI; 0.69, 1.37), showing low heterogeneity among the studies (P = 0.746, I 2 = 0.00%) [Figure 7].
Figure 7: A meta-analysis of the anastomosis leak rate for robot-assisted versus laparoscopic surgery for rectal cancer

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Postoperative complications

Nineteen of the studies reported postoperative complications.[10],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33] A Forest plot showed that the robot-assisted surgery group experienced a significantly lower rate of postoperative complications than the laparoscopic surgery group (MD, 0.79; 95% CI; 0.65, 0.97), showing low heterogeneity among the studies (P = 0.041, I 2 = 39.3%) [Figure 8].
Figure 8: A meta-analysis of postoperative complications for robot-assisted versus laparoscopic surgery for rectal cancer

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Number of lymph nodes extracted

Nineteen studies reported the number of lymph nodes extracted.[10],[16],[17],[18],[19],[20],[21],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33] A Forest plot showed no significant difference in the number of lymph nodes extracted between the two groups (MD, 0.06; 95% CI; −0.05, 0.17), showing moderate heterogeneity among the studies (P = 0.003, I 2 = 54.0%) [Figure 9].
Figure 9: A meta-analysis of number of lymph node extraction for robot-assisted versus laparoscopic surgery for rectal cancer

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Positive circumferential margin

Fourteen studies reported the PCRM.[16],[18],[20],[21],[23],[24],[25],[26],[27],[29],[30],[31],[32],[33] A forest plot showed no significant difference in the PCRM between the two groups (MD, 1.02; 95% CI; 0.76, 1.37), showing low heterogeneity among the studies (P = 0.589, I 2 = 0.00%) [Figure 10].
Figure 10: A meta-analysis of positive circumferential margin for robot-assisted versus laparoscopic surgery for rectal cancer

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Distal resection margin

Fourteen of the studies reported the DRM.[6],[16],[17],[21],[23],[24],[26],[27],[28],[29],[30],[31],[32],[33] A Forest plot showed no significant difference in the DRM between the two groups (MD, 0.13; 95% CI; −0.08, 0.35), showing high heterogeneity among the studies (P = 0.000, P < 0.001, I 2 = 80.0%) [Figure 11].
Figure 11: A meta-analysis of distal resection margin for robot-assisted versus laparoscopic surgery for rectal cancer

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 > Discussion Top


Laparoscopic colorectal surgery was first performed in early 1991,[35] as well as a minimally invasive procedure that has gained popularity for treating colorectal cancers. However, there are numerous constraints in relation to laparoscopic rectal cancer surgery, specifically for patients with a narrow and deep pelvis. Robot-assisted laparoscopic surgery provides a firm three-dimensional camera view, with enhanced degrees of freedom for instruments, and makes pelvic dissection easier than laparoscopic surgery for rectal cancer.[36] Hao et al.[37] reported that robotic radical hysterectomy, which is also a pelvic procedure, was better than laparoscopy hysterectomy for postoperative recovery in patients with early-stage cervical cancer. Several meta-analyses [11],[12],[13],[14] have compared robot-assisted surgery with laparoscopic surgery for rectal cancer, and have compared the clinical and oncological outcomes between the two surgical techniques; however, the number of studies involved in the meta-analyses was small. Our meta-analysis is the first with a large number of studies that have compared both techniques for rectal cancer.

Our meta-analysis showed that robot-assisted surgery had a longer operation time than reported for laparoscopic surgery, which is likely attributable to the following factors: (1) The time taken for docking the robot instrument, and setting the systems; (2) in some cases, more time is required to adjust the robotic arms for the mobilization of the splenic flexure colon; (3) learning curves, experience, and skills differ between surgeons, and; (4) whether a fully robotic or a robotic-assisted hybrid technique had been used.[38]

We observed that the robot-assisted surgery group had a lower rate of conversion to open surgery, less postoperative complications, a faster bowel function recuperation time, and a shorter LOS. The subordinate conversions in the open surgery rate were closely related to the ability to perform fine dissection in a narrow surgical field utilizing the robotic system.[16] The technological advantages of the robotic surgeries have lessened the potential risk of injury to tissues and blood vessels and this has decreased the postoperative complication rate, which, in turn, has frequently resulted in a faster bowel function recovery rate and a reduced hospital stay.

Our meta-analysis found limited differences in terms of EBL and anastomosis leak rates. The EBL in the robot-assisted group was less than that of the laparoscopic group; however, the difference was not statistically significant. The laparoscopic surgical technique has been used for many years; therefore, the EBL during the surgery is minimal, and robot-assisted surgery allows a better view that helps to prevent greater blood loss. Colorectal anastomotic leakage is a serious complication after rectal surgery for rectal cancer. Several studies [39],[40],[41],[42],[43] reported that patients who had received preoperative neoadjuvant chemoradiotherapy (NCRT) had an increased anastomosis leak rate. Kang et al.[42] reported that preoperative NCRT did not increase the postoperative anastomosis leak rate. We did not find any increased anastomosis leaks in the robot-assisted surgery group, where a large number of patients had received NCRT. However, our findings may have been influenced by the unclear laparoscopic methods used to perform a linear anastomosis. Our findings also showed that robot-assisted surgery for rectal cancer appears to have the same perioperative outcomes as laparoscopic surgery.

Oncological outcomes, such as the number of lymph nodes extracted, the DRM, and the PCRM, showed no significant differences between the two groups. All the relevant guidelines recommend TME as the gold standard treatment for rectal cancer surgery to reduce local recurrence and improve quality of life. Moreover, the relevant guidelines suggest the extraction of at least 12 lymph nodes during the operation.[43] Only three studies [17],[19],[25] reported fewer than 12 lymph nodes extracted. The oncological outcome is an important factor when assessing any novel approach in cancer surgery. The DRM and the PCRM provide further parameters to identify the oncological outcomes, with a <1 mm DRM or a <2 mm PCRM predictive of an increased risk of local recurrence and shorter disease-free survival.[44],[45],[46] Our meta-analysis found that the PCRM rate was lower in the robot-assisted surgery group than in the laparoscopic surgery group; however, no significant differences were identified. Because of the location of rectal cancer, it was difficult to compare the DRM between the two groups. Robot-assisted surgery for rectal cancer can help to achieve complete resection of a specimen without circumferential margin involvement.

Within our meta-analysis, only a small number of studies focused entirely on comparing semi-permanent oncological outcomes, for example, local recurrence, disease-free survival, and overall survival. In future, more randomized controlled studies are needed to compare long-term oncological outcomes.

Our meta-analysis had some limitations. First, the quality of the original studies determined the quality of the meta-analysis and almost every study was a nonrandomized controlled trial. As such, the overall level of clinical evidence was low, with some studies containing opinion-based reports that may have biased the overall interpretation of their results. Second, it was challenging to match the patient characteristics in all the studies, and some degree of heterogeneity between the two groups remained. Finally, there was also limited long-term oncological and postoperative complication data accessible for comparison.


 > Conclusion Top


In our study, we compared robot-assisted surgery to laparoscopic surgery for rectal cancer and found that robot-assisted surgery involved longer operation time, lower conversion to open surgery rate, faster bowel function recovery, and shorter hospital stay, while both surgical techniques were found to have similar oncological outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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