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Sebastián-Tomás et al. Mini-invasive Surg 2019;3:30 I http://dx.doi.org/10.20517/2574-1225.2019.29 Page 5 of 10
[26]
The ROLARR study, however, only found benefits in the men subgroup . Although the study found no
significant differences in the rest of the short-term outcomes being evaluated, trial’s sample estimation, and
[26]
the varying expertise on robotics of the participating surgeons assured the debate after its publication .
Existing research demonstrated longer operative time for robotics compared with open and laparoscopic
[64]
rectal resections [28,65,66] . Ohtani et al. reported an operative time 44 minutes greater than laparoscopy
[64]
[weighted mean difference (MD), 44.80; 95%CI: 28.44-61.15; P < 0.00001] . Lee et al. showed no
[67]
[67]
differences in operative time between robotic and transanal-TME . Other studies reported less blood loss
for robotic TME, compared with the open and laparoscopic approaches [68,69] . Intraoperative complications
were found similar for robotic surgery when compared with the open and laparoscopic approaches [26,66] .

Postoperative outcomes
Anastomotic leak rate was not significantly different for robotics compared with open and laparoscopic
operations [28,69] . Laparoscopic, transanal, and robotic TME also showed similar leak and reoperation
rates [67,70] . Postoperative ileus, wound infection, and urinary retention were similar between open,
laparoscopic, transanal procedures in comparison with robotic approach [30,65,69] . Length of hospital stay
was shorter after robotic surgery compared with open (7.5 days vs. 13.24 days) [66,69] , but no difference was
found when comparing it with conventional laparoscopy [28,70] . Perioperative complications and mortality
rates appear to be similar for all four approaches [28,30,69] . Mortality is low in elective rectal surgery, with only 2
[26]
cases in each arm among 466 patients (0.9%) in the ROLARR study .
Pathologic outcomes
As robotic assistance seems to facilitate mesorectal dissection, particularly in mid and low rectal tumours,
a reduced rate of positive CRM+ was presupposed to be one of the major benefits conferred by the novel
technology. However, different studies showed that CRM+ is similar when compared with the other
[26]
techniques. Jayne et al. reported no statistically significant differences in the odds of CRM+ between
[26]
robotic and laparoscopic groups (OR, 0.78; 95%CI: 0.35-1.76; P = 0.56) . Accordingly, a propensity adjusted
analysis of 7616 patients support both for the resection of locally advanced rectal cancer, with equivalent
[71]
CRM- rates (93% vs. 94%; 95%CI: 0.69-1.06) .

The completeness of the mesorectal resection became a valuable item to assess the oncologic safety of
[72]
[30]
a rectal resection and predicts tumor recurrence in the pelvis . Rausa et al. showed no significant
differences in complete, near-complete or incomplete mesorectal excision between laparoscopic and robotic
approaches (complete RR, 0.8; 95%CI: 0.7-1.0; nearly-complete RR, 1.6; 95%CI: 0.9-2.7; incomplete RR, 1.5;
[30]
95%CI: 0.8-2.5) .

[27]
Liao et al. associated the robotic approach with a longer distance to the distal margin in comparison with
[27]
laparoscopy (MD, 0.83 cm, 95%CI: 0.29-1.37; P = 0.003) . When comparing robotic and open surgeries, no
[69]
differences were found (MD, 0.17; 95%CI: -0.14 to 0.48; P = 0.27) .
[73]
Truong et al. analysed a retrospective cohort of patients looking at successful resections, defined as
a circumferential and distal resection margins < 1 mm and complete mesorectal resection, which were
similar between the robotic (75%) and open (76%) approaches . There were no differences in the studies
[73]
comparing all four approaches for rectal cancer regarding the number of lymph nodes retrieved [26,27,30,69] .

Long-term oncologic outcomes
Local recurrence rates were similar between laparoscopic vs. robotic (RR, 1.4; 95%CI: 0.7-2.4) and transanal-
[30]
TME vs. robotic (RR, 1.4; 95%CI: 0.5-3.4) in the meta-analysis performed by Rausa et al. . Moreover,
[64]
Ohtani et al. also reported no differences in terms of local, metastatic, and overall recurrences, 3-year OS
[27]
[64]
and 3-year DFS between robotic and laparoscopic approaches . In their recent meta-analysis, Liao et al.