Page 186 - Read Online

Chen et al. Mini-invasive Surg 2018;2:42 I http://dx.doi.org/10.20517/2574-1225.2018.59 Page 13 of 17

Table 5. Transanal total mesorectal excision
Group Sample Follow Level of
Ref. Study type Randomization Questionnaires Main findings
studied size up evidence
Koedam et al. [53] , 2017 Prospective No TaTME 30 6 months EORTC QLQ- -TaTME had decreased 4
single C30, QLQ-CR29, urinary function, sexual
center EQ5D, LARS function, fecal inconti-
nence and overall QOL
at 1 month compared to
baseline and returned
to normal by 6 months
-TaTME had decreased
social function and
anal pain at 6 months
compared to baseline
-TaTME had major
LARS in 33% after
ileostomy closure
Veltcamp Helbach et al. [54] , Prospec- No TaTME vs. 54 6 months EORTC QLQ- -TaTME had similar 2b
2018 tive single Lap TME C30, QLQ-CR29, QOL compared to lap
center EQ5D, LARS, -TaTME had worse fecal
IPSS incontinence compared
to lap (EORTC QLQ-
CR29 only)
Deijen et al. [55] , Prospective Yes (2:1) TaTME vs. 1098 60 EORTC QLQ- -Pending 1
2016 (COLOR III) Lap TME months C30, QLQ-CR29,
multicenter EQ5D, LARS
Serra-Aracil et al. [56] , Prospective Yes (1:1) TaTME vs. 116 6 months EORTC QLQ- -Pending 1
2018 multicenter Lap TME C30, QLQ-CR29,
LARS
TaTME: transanal total mesorectal excision; Lap: laparoscopic; TME: total mesorectal excision; LARS: low anterior resection syndrome;
QOL: quality of life; EORTC QLQ-C30: European organization for research and treatment of cancer quality of life questionnaire, 30 cancer
non-specific questions; EORTC QLQ-CR29: European organization for research and treatment of cancer quality of life questionnaire, 29
colorectal cancer specific questions; EQ5D: European quality of life 5 dimensions questionnaire; IPSS: International Prostatic Symptom
Score; Level of evidence: 1: randomized controlled trial; 2a: randomized prospective cohort study; 2b: nonrandomized prospective cohort
study; 3: retrospective cohort study; 4: case series

However, in contrast, the recent multicenter randomized controlled trials have shown the results to be
either equivalent or worse in the laparoscopic group [23-26] . It will be important to follow the final long term
quality of life findings of the large randomized control trials of ACCOSOG Z6051 and ALaCaRT [27,28] . This
may underscore the inherent problem of working in the fixed space of the bony pelvis with conventional
laparoscopy. Restricted movements of working instruments, two-dimensional view, difficult ergonomics
and an unstable platform can make laparoscopy for rectal cancer challenging and may lead to a high con-
version rate or unsatisfactory dissection.

Key advances in robotic technology over the last two decades overcame challenges of laparoscopic and
open surgery and allowed for enhanced three-dimensional view, and “wristed” instruments allowing for
multiple degrees of freedom, a stable platform, and improved ergonomics. This was particularly important
in complex colon and rectal surgery including procedures in the bony pelvis. For these reasons, robotic
usage for all colorectal procedures grew from 2.6% to 6.6% between 2011-2015. In 2015, robotic utiliza-
tion for rectopexy was 27%, for low anterior resection was 13%, and for abdominoperineal resection was
[57]
15% . Although the technology has been limited by decreased haptics, steep learning curve, and concern
of increased cost, widespread utilization of robotics is spreading quickly. In terms of quality of life, ro-
botic surgery may be more promising than laparoscopic surgery in its improvement in chronic pain and
insomnia based on single center studies, showing an earlier return to baseline quality of life compared to
laparoscopic surgery. Furthermore, several small single center short term studies demonstrated a signifi-
cant improvement in sexual function. One study even showed a modest improvement in bladder function
in robotic surgery patients compared to laparoscopic surgery patients [29-36] . Benefits have been attributed to
the superior dissection allowed by robotic surgery. However, the multicenter ROLARR study showed that