Skip to main content

Advertisement

SpringerLink
Log in

Robotic surgery for locally advanced T4 rectal cancer: feasibility and oncological quality

  • Original Article
  • Published:
Updates in Surgery Aims and scope Submit manuscript

Abstract

For T4 rectal tumours and local recurrences (LR) of rectal cancer, a radical resection beyond TME, sometimes by multi-visceral resection, is important to obtain safe margins and improve survival. The use of the laparoscopic approach (LA) for these cases is still controversial and associated with a high rate of conversion. However, robotic surgery might offer some advantages that can overcome some of the limitations of LA. Therefore, we aimed to analyse the postoperative outcomes and medium-term oncological results of robotic surgery for locally advanced rectal cancer (pathological T4) and LR. A retrospective analysis was performed including patients who had undergone robotic rectal resection in a single institution over an 11-year period, and had a T4 tumour confirmed in the pathological report. Primary endpoint was to analyse postoperative complications (30-day) and the rate of conversion. Secondary endpoints include pathological assessment of the quality of the specimen, local recurrence and survival [2-year disease-free survival (DFS) and overall survival (OS)]. A total of 41 patients were analysed, including a total of 24 patients (60%) that required a multivisceral resection. The median distance from the tumour to the anorectal junction was 7 (4–12) cm. Conversion to open surgery was necessary in 2 cases (5%). The overall morbidity rate was 78% (n = 32), with 37% of major complications, most of them urinary (n = 7). Median length of hospital stay (LOS) was 13 (7–27) days. The 30-day mortality rate was 7% (n = 3). An R0 resection was achieved in 85.4% of the cases (n = 35) due to 6 cases of the positive circumferential resection margin. 2-year disease-free survival (DFS) and overall survival (OS) for the T4 tumours were 72% and 85%, respectively. There were 8 cases of local recurrence (22.2%); 6 of them met the selection criteria for salvage surgery. Robotic surgery for locally advanced T4 rectal cancer and multi-visceral resections is safe and feasible, with a low rate of conversion and an acceptable rate of postoperative morbidity in this subgroup of patients. Oncological results have shown to be comparable with the laparoscopic series published, preserving a good quality of the resected specimen. However, comparative studies and a longer follow-up period is needed to confirm the oncologic findings and to support the general adoption of the robotic system for these complex interventions.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Data availability

Data available on request from the authors.

References

  1. Heald RJ (1988) The “Holy Plane” of rectal surgery. J R Soc Med 81:503–508. https://doi.org/10.1177/014107688808100904

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Ike H, Shimada H, Ohki S et al (2003) Outcome of total pelvic exenteration for locally recurrent rectal cancer. Hepatogastroenterology 50:700–703

    PubMed  Google Scholar 

  3. Jeong S-Y, Park JW, Nam BH et al (2014) Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol 15:767–774. https://doi.org/10.1016/S1470-2045(14)70205-0

    Article  PubMed  Google Scholar 

  4. Fleshman J, Branda M, Sargent DJ et al (2015) Effect of laparoscopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA 314:1346–1355. https://doi.org/10.1001/jama.2015.10529

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Bonjer HJ, Deijen CL, Haglind E, COLOR II Study Group (2015) A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 373:194. https://doi.org/10.1056/NEJMc1505367

    Article  PubMed  Google Scholar 

  6. Stevenson ARL, Solomon MJ, Brown CSB et al (2019) Disease-free survival and local recurrence after laparoscopic-assisted resection or open resection for rectal cancer: the Australasian laparoscopic cancer of the rectum randomized clinical trial. Ann Surg 269:596–602. https://doi.org/10.1097/SLA.0000000000003021

    Article  PubMed  Google Scholar 

  7. Stevenson ARL, Solomon MJ, Lumley JW et al (2015) Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial. JAMA 314:1356–1363. https://doi.org/10.1001/jama.2015.12009

    Article  CAS  PubMed  Google Scholar 

  8. Hida K, Okamura R, Sakai Y et al (2018) Open versus laparoscopic surgery for advanced low rectal cancer: a large, multicenter, propensity score matched cohort study in Japan. Ann Surg 268:318–324. https://doi.org/10.1097/SLA.0000000000002329

    Article  PubMed  Google Scholar 

  9. Kulkarni N, Arulampalam T (2020) Laparoscopic surgery reduces the incidence of surgical site infections compared to the open approach for colorectal procedures: a meta-analysis. Tech Coloproctol 24:1017–1024. https://doi.org/10.1007/s10151-020-02293-8

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. de Angelis N, Landi F, Vitali GC et al (2017) Multicentre propensity score-matched analysis of laparoscopic versus open surgery for T4 rectal cancer. Surg Endosc 31:3106–3121. https://doi.org/10.1007/s00464-016-5332-9

    Article  Google Scholar 

  11. Nasir IUI, Shah MF, Panteleimonitis S et al (2022) Spotlight on laparoscopy in the surgical resection of locally advanced rectal cancer: multicenter propensity score match study. Ann Coloproctol 38:307–313. https://doi.org/10.3393/ac.2020.01060.0151

    Article  PubMed  Google Scholar 

  12. Park SY, Lee SM, Park JS et al (2021) Robot surgery shows similar long-term oncologic outcomes as laparoscopic surgery for mid/lower rectal cancer but is beneficial to ypT3/4 after preoperative chemoradiation. Dis Colon Rectum 64:812–821. https://doi.org/10.1097/DCR.0000000000001978

    Article  PubMed  Google Scholar 

  13. Crolla RMPH, Tersteeg JJC, van der Schelling GP et al (2018) Robot-assisted laparoscopic resection of clinical T4b tumours of distal sigmoid and rectum: initial results. Surg Endosc 32:4571–4578. https://doi.org/10.1007/s00464-018-6210-4

    Article  PubMed  Google Scholar 

  14. Shin JW, Kim J, Kwak JM et al (2014) First report: robotic pelvic exenteration for locally advanced rectal cancer. Colorectal Dis 16:O9-14. https://doi.org/10.1111/codi.12446

    Article  CAS  PubMed  Google Scholar 

  15. Smith N, Murphy DG, Lawrentschuk N et al (2020) Robotic multivisceral pelvic resection: experience from an exenteration unit. Tech Coloproctol 24:1145–1153. https://doi.org/10.1007/s10151-020-02290-x

    Article  CAS  PubMed  Google Scholar 

  16. Chen T-C, Liang J-T (2019) Robotic radical surgery in the multidisciplinary approach for the treatment of locally advanced T4 rectosigmoid colon cancer. Dis Colon Rectum 62:121–122. https://doi.org/10.1097/DCR.0000000000001253

    Article  PubMed  Google Scholar 

  17. Hino H, Yamaguchi T, Kinugasa Y et al (2017) Robotic-assisted multivisceral resection for rectal cancer: short-term outcomes at a single center. Tech Coloproctol 21:879–886. https://doi.org/10.1007/s10151-017-1710-0

    Article  CAS  PubMed  Google Scholar 

  18. von Elm E, Altman DG, Egger M et al (2014) The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg 12:1495–1499. https://doi.org/10.1016/j.ijsu.2014.07.013

    Article  Google Scholar 

  19. Collaborative PelvEx (2018) Minimally invasive surgery techniques in pelvic exenteration: a systematic and meta-analysis review. Surg Endosc 32:4707–4715. https://doi.org/10.1007/s00464-018-6299-5

    Article  Google Scholar 

  20. Jayne D, Pigazzi A, Marshall H et al (2017) Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: the ROLARR randomized clinical trial. JAMA 318:1569–1580. https://doi.org/10.1001/jama.2017.7219

    Article  PubMed  PubMed Central  Google Scholar 

  21. Ahmed J, Cao H, Panteleimonitis S et al (2017) Robotic vs laparoscopic rectal surgery in high-risk patients. Colorectal Dis 19:1092–1099. https://doi.org/10.1111/codi.13783

    Article  CAS  PubMed  Google Scholar 

  22. Yamaoka Y, Shiomi A, Kagawa H et al (2022) Robotic surgery for clinical T4 rectal cancer: short- and long-term outcomes. Surg Endosc 36:91–99. https://doi.org/10.1007/s00464-020-08241-9

    Article  PubMed  Google Scholar 

  23. Larach JT, Flynn J, Fernando D et al (2022) Robotic beyond total mesorectal excision surgery for primary and recurrent pelvic malignancy: feasibility and short-term outcomes. Colorectal Dis 24:821–827. https://doi.org/10.1111/codi.16136

    Article  PubMed  Google Scholar 

  24. Bladou F, Houvenaeghel G, Delpéro JR, Guérinel G (1995) Incidence and management of major urinary complications after pelvic exenteration for gynecological malignancies. J Surg Oncol 58:91–96. https://doi.org/10.1002/jso.2930580204

    Article  CAS  PubMed  Google Scholar 

  25. Harris DA, Davies M, Lucas MG et al (2011) Multivisceral resection for primary locally advanced rectal carcinoma. Br J Surg 98:582–588. https://doi.org/10.1002/bjs.7373

    Article  CAS  PubMed  Google Scholar 

  26. Howell AM, Jarral OA, Faiz O et al (2013) How should perineal wounds be closed following abdominoperineal resection in patients post radiotherapy–primary closure or flap repair? Best evidence topic (BET). Int J Surg 11:514–517. https://doi.org/10.1016/j.ijsu.2013.05.004

    Article  CAS  PubMed  Google Scholar 

  27. Copeland-Halperin LR, Stewart T, Chen Y et al (2020) Perineal reconstruction following abdominoperineal resection: comprehensive review of the literature. J Plast Reconstr Aesthet Surg 73:1924–1932. https://doi.org/10.1016/j.bjps.2020.08.090

    Article  PubMed  Google Scholar 

  28. Han JG, Wang ZJ, Gao ZG et al (2019) Perineal wound complications after extralevator abdominoperineal excision for low rectal cancer. Dis Colon Rectum 62:1477–1484. https://doi.org/10.1097/DCR.0000000000001495

    Article  PubMed  Google Scholar 

  29. Althumairi AA, Canner JK, Gearhart SL et al (2016) Risk factors for wound complications after abdominoperineal excision: analysis of the ACS NSQIP database. Colorectal Dis 18:O260–O266. https://doi.org/10.1111/codi.13384

    Article  CAS  PubMed  Google Scholar 

  30. Yamamoto S, Fujita S, Ishiguro S et al (2008) Wound infection after a laparoscopic resection for colorectal cancer. Surg Today 38:618–622. https://doi.org/10.1007/s00595-007-3684-4

    Article  PubMed  Google Scholar 

  31. Adam IJ, Mohamdee MO, Martin IG et al (1994) Role of circumferential margin involvement in the local recurrence of rectal cancer. Lancet 344:707–711. https://doi.org/10.1016/s0140-6736(94)92206-3

    Article  CAS  PubMed  Google Scholar 

  32. Bretagnol F, Dedieu A, Zappa M et al (2011) T4 colorectal cancer: is laparoscopic resection contraindicated? Colorectal Dis 13:138–143. https://doi.org/10.1111/j.1463-1318.2010.02380.x

    Article  CAS  PubMed  Google Scholar 

  33. Heriot AG, Tekkis PP, Darzi A, Mackay J (2006) Surgery for local recurrence of rectal cancer. Colorectal Dis 8:733–747. https://doi.org/10.1111/j.1463-1318.2006.01018.x

    Article  CAS  PubMed  Google Scholar 

  34. Hahnloser D, Nelson H, Gunderson LL et al (2003) Curative potential of multimodality therapy for locally recurrent rectal cancer. Ann Surg 237:502–508. https://doi.org/10.1097/01.SLA.0000059972.90598.5F

    Article  PubMed  PubMed Central  Google Scholar 

  35. Ueno H, Mochizuki H, Akagi Y et al (2012) Optimal colorectal cancer staging criteria in TNM classification. J Clin Oncol 30:1519–1526. https://doi.org/10.1200/JCO.2011.39.4692

    Article  PubMed  Google Scholar 

  36. Goto K, Watanabe J, Suwa Y et al (2021) A multicenter, propensity score-matched cohort study about short-term and long-term outcomes after laparoscopic versus open surgery for locally advanced rectal cancer. Int J Colorectal Dis 36:1287–1295. https://doi.org/10.1007/s00384-021-03871-4

    Article  PubMed  Google Scholar 

  37. Zhang X, Wu Q, Hu T et al (2019) Laparoscopic versus conventional open surgery in T4 rectal cancer: a case-control study. J Minim Access Surg 15:37–41. https://doi.org/10.4103/jmas.JMAS_67_18

    Article  PubMed  PubMed Central  Google Scholar 

  38. Manchon-Walsh P, Aliste L, Biondo S et al (2019) A propensity-score-matched analysis of laparoscopic vs open surgery for rectal cancer in a population-based study. Colorectal Dis 21:441–450. https://doi.org/10.1111/codi.14545

    Article  CAS  PubMed  Google Scholar 

Download references

Funding

No funding.

Author information

Authors and Affiliations

  1. Colorectal Surgery Unit, General Surgery Department, Marqués de Valdecilla University Hospital, 39008, Santander, Spain

    Marcos Gomez Ruiz, Carmen Cagigas Fernandez, Lidia Cristobal Poch, Natalia Suarez Pazos & Julio Castillo Diego

  2. Urology, Marqués de Valdecilla University Hospital, 39008, Santander, Spain

    Roberto Ballestero Diego

  3. Valdecilla Biomedical Research Institute (IDIVAL), 39010, Santander, Spain

    Marcos Gomez Ruiz, Roberto Ballestero Diego, Carmen Cagigas Fernandez, Lidia Cristobal Poch, Natalia Suarez Pazos & Julio Castillo Diego

  4. Colorectal Surgery Unit, General Surgery Department, Gregorio Marañón University Hospital, Madrid, Spain

    Patricia Tejedor

Authors
  1. Marcos Gomez Ruiz
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Roberto Ballestero Diego
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Patricia Tejedor
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Carmen Cagigas Fernandez
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Lidia Cristobal Poch
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Natalia Suarez Pazos
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Julio Castillo Diego
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors critically revised the paper for important intellectual content. All authors have contributed to the work and agreed on the final version. This manuscript is not being considered by any other journal.

Corresponding author

Correspondence to Patricia Tejedor.

Ethics declarations

Conflict of interest

MGR received research grants from Intuitive Surgical, education grants from Intuitive Surgical and Medtronic and is currently a Medical Advisor to Intuitive Surgical, Medtronic, and J&J. CCF is a proctor for Intuitive Surgical. Other authors have no conflict of interest.

Ethical approval

All procedures performed in studies involving humans were in accordance with the ethical standards of the institutional research committee and the 1964 Helsinki declaration and its later amendments.

Informed consent

Informed consent was obtained from all participants.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gomez Ruiz, M., Ballestero Diego, R., Tejedor, P. et al. Robotic surgery for locally advanced T4 rectal cancer: feasibility and oncological quality. Updates Surg 75, 589–597 (2023). https://doi.org/10.1007/s13304-023-01450-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13304-023-01450-6

Keywords

Search

Navigation