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A summary of studies examining quality of life after laparoscopic surgery for rectal cancer is found in
Table 1.

ROBOTIC SURGERY FOR RECTAL CANCER
Robotic surgery was developed to overcome many of the challenges of laparoscopic surgery while main-
taining a minimally invasive approach. The multi-arm robotic platform can provide constant retraction
avoiding fatigue, while the steady, high-definition three-dimensional view and enhanced articulation of in-
struments may allow for a precise dissection. Proponents argue that the approach may decrease the rate of
conversion to open surgery, while allowing a more complete TME to achieve a superior oncologic outcome
without injury to the sphincters, or nerves involved in urinary and sexual function.

Early studies on robotic surgery for rectal cancer focused on safety and feasibility while more recent stud-
ies transitioned to studying oncologic outcomes followed by quality of life measurements. Multiple single
center comparison studies have been done reporting both cancer specific outcomes and quality of life as-
[29]
sessment. D’Annibale et al. in 2013 performed a retrospective study of 60 patients, 30 who underwent
robotic TME and 30 who underwent laparoscopic TME, and found that both groups demonstrated signifi-
cantly worse erectile function one month after surgery. However, erectile function was completely restored
one year after surgery in the robotic group but only partially restored in the laparoscopic group. Bladder
[29]
function was significantly worse at one month after surgery but normalized at one year in both groups .
[30]
Similarly, a prospective study by Kim et al. in 2012 found that out of 30 robotic TME and 39 laparoscopic
TME patients, there was an earlier restoration of both bladder function and sexual function in the robotic
group compared to the laparoscopic group. This was again demonstrated in another retrospective study of
29 men, 14 who underwent robotic intersphincteric resections, and 15 who underwent laparoscopic inter-
[31]
sphincteric resections . The authors found improvement in sexual function at 6 months post-operatively
[31]
in the robotic group but no difference in bladder function or fecal incontinence . An additional study of
robotic vs. laparoscopic TME patients demonstrated significant improvement in sexual function in only the
[32]
robotic group at 6 months . A meta-analysis of these four studies found significant improvement in male
[33]
sexual function, specifically erectile function at 3 and 6 months after robotic surgery . Although there
was a trend toward improved urinary function with robotic surgery compared to laparoscopic surgery, it
[33]
was not statistically significant .
[34]
Kamali et al. followed 36 consecutive patients, 18 who underwent a laparoscopic anterior resection and
18 who underwent a robotic anterior resection for a median of 12 months after surgery. The EORTC QLQ-
CR30 and QLQ-CR29 questionnaires were used. The laparoscopic group reported better social function
than the robotic group. The robotic group, however, reported lower pain scales and lower levels of insomnia
than the laparoscopic group. Furthermore, there was higher male impotence scores in the laparoscopic
[34]
group compared to the robotic group (33 ± 35 vs. 7 ± 21, P = 0.03) . The authors attributed this positive
finding to the enhanced vision, sharp targeted dissection, and limited thermal injury of robotic surgery.

Two larger single center studies have been done more recently. One was a quality of life study using a
[35]
propensity score matched analysis, studying a total of 260 patients (130 robotic and 130 laparoscopic) .
Patients were given questionnaires (EORTC QLQ-C30, IPSS, and IIEF-5) preoperatively and at 3, 6, and
12 months after surgery. A subgroup of 48 matched male pairs who were sexually active prior to surgery
was analyzed. The matched groups showed no significant differences in quality of life scores prior to sur-
gery. The laparoscopic group had significantly impaired role and social function 3 months after surgery,
which the robotic surgery group did not exhibit. At 6 months after surgery, the robotic group had higher
emotional function scores than the laparoscopic group. In examining symptom scores, the laparoscopic
group showed worsening fatigue, insomnia, and financial difficulties at three months after surgery, which
the robotic group did not. The robotic group also had significantly better urinary function (lower IPSS