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Abdalla et al. Mini-invasive Surg 2019;3:39 I http://dx.doi.org/10.20517/2574-1225.2019.38 Page 7 of 11

Table 3. Postoperative outcomes
Overall (n = 20)
Mortality (%) 1 (5)
Morbidity (%) 8 (40)
Medical complications (%)* 7 (35)
Urinary tract infection (%) 5 (25)
Acute urinary retention (%) 2 (10)
Malnutrition (%) 2 (10)
Pulmonary infection (%) 1 (5)
Septic shock (%) 1 (5)
Clostridium colitis (%) 1 (5)
Ileus (%) 1 (5)
Surgical complications (%)* 9 (45)
Pelvic abscess (%) 4 (20)
Perineal wound disunion (%) 3 (15)
Ureteral fistula (%) 1 (5)
Incisional abscess (%) 2 (10)
Clavien-Dindo > 2 (%) 6 (30)
Complications requiring reoperation (%) 5 (25)
Hospital length of stay in days (mean ± SD) 20.4 ± 17.1
Hospital length of stay > 7 days (%) 17 (85)
*Several patients presented more than one complication

Pathologic outcomes
Pathological results are presented in Table 4. A complete pathologic response was observed in one patient
(5%). Three patients (15%) presented a pT4 tumor on final pathological report. On average, 16.5 lymph
nodes were retrieved. The mean tumor size was 4.6 cm. Mesorectum was complete in 18 patients (90%).

DISCUSSION
Our study showed that RAAPR is feasible, with satisfying pathological results and acceptable postoperative
outcomes.

[12]
During the last decade, the use of the robotic system has progressed . Proctectomy can be technically
hazardous with the straight instruments and limited retraction provided by laparoscopy. Robotic-assisted
pelvic dissection can be potentially associated with better autonomic nerve preservation, lower conversion
[13]
rate, and less blood loss . Despite its theoretical advantages, the benefits of the mini-invasive approach
compared to open surgery in rectal surgery are still under debate, and it is even more questionable for the
robotic approach . Indeed, the only existing randomized clinical trial (ROLARR) comparing the robotic-
[14]
assisted vs. conventional laparoscopic surgery for rectal cancer showed that the robotic approach did not
[15]
significantly reduce the conversion rate . There were also no differences between the two groups in terms
of intraoperative complications, postoperative mortality and morbidity, and positive CRM. The interest of
robotic assistance in APR is even more challenging to demonstrate since very few studies in the literature
focus on RAAPR [Table 5]. We found only four studies that included more than 20 patients: three studies
[18]
compared RAAPR to open APR [16,17] or to open APR and laparoscopic APR , and one non-comparative
[19]
study focused on RAAPR. The ROLARR trial, for its part, did not analyze the outcomes in its specific
sub-population of 52 RAAPR.

Compared to the conventional laparoscopic approach, the benefits of the robotic upgraded handling on
the patient outcomes are difficult to bring to light. Indeed, up to now, robotic assistance seems to remain
equivalent to laparoscopy. In the current study, the operative duration was 218.1 ± 52.5, which is in line
[18]
with the data in the literature [Table 5] and longer than laparoscopic APR . No conversion was required