Annals of Surgical Oncology

, Volume 25, Issue 12, pp 3572–3579 | Cite as

Robotic Versus Laparoscopic Total Mesorectal Excision for Sphincter-Saving Surgery: Results of a Single-Center Series of 400 Consecutive Patients and Perspectives

  • Philippe RouanetEmail author
  • Martin Marie Bertrand
  • Marta Jarlier
  • Anne Mourregot
  • Drissa Traore
  • Christophe Taoum
  • Hélène de Forges
  • Pierre-Emmanuel Colombo
Colorectal Cancer



The aim of this study is to compare robotic total mesorectal excision (R-TME) with laparoscopic TME (L-TME) in a series of consecutive rectal cancer patients.


R-TME and L-TME have drawn contradictory reports. A recent phase III trial (ROLARR) concluded that R-TME performed by surgeons with varying experience did not confer an advantage in rectal cancer resection.

Patients and Methods

In this retrospective single-center cohort study (8/2008 to 4/2015), data were prospectively registered. A total of 200 L-TME and 200 R-TME were operated consecutively without selection. The primary outcome was the conversion rate to open laparotomy or transanal TME. The secondary endpoints were type of anastomosis, operative time, postoperative morbidity, circumferential radial (CRM) and distal margins, quality of life, bladder and sexual dysfunction, and oncological outcomes.


Baseline characteristics were well balanced. Type of anastomosis [colo-anal anastomosis (CAA) 40% vs 49%; p < 0.001], transanal TME (5% vs 13%; p = 0.005), and conversion rate (2% vs 9.5%; odd ratio (OR): 0.19 [95% confidence interval (CI): 0.05–0.60]) were significantly different. Intersphincteric resection (39% vs 47%), diverting stoma (66.5% vs 68%), CRM involvement, median operative time (243 vs 232 min), and R0 resection rate were similar. Conversion risk was lower for R-TME in male patients and those with small tumors (< 5 cm). The 3-year overall survival rate was 84.1% [77.3–88.9%] and 88.4% [82.9–92.2%] in the R-TME and L-TME group. No significant differences were reported in quality of life, and urinary or sexual function.


R-TME is less likely to be converted to open surgery than L-TME; operative time and curative pathologic criteria are equivalent. Future prospective trial should compare standardized procedures performed by experienced surgeons for subgroups of high-risk patients.



The authors thank Drs. Mathias Alline, Julien Coget, and Fabien Wilk for participating in the study and surgical assistance. The authors also thank Nabila Bouazza for valuable help regarding data collection and management of the database and the project, and Sylvain Boudon for data management.


PR is proctor for Intuitive Surgical Inc. All other authors have nothing to disclose regarding the present study.

Supplementary material

10434_2018_6738_MOESM1_ESM.docx (77 kb)
Supplementary material 1 (DOCX 77 kb)
10434_2018_6738_MOESM2_ESM.docx (128 kb)
Supplementary material 2 (DOCX 127 kb)


  1. 1.
    Park EJ, Cho MS, Baek SJ, et al. Long-term oncologic outcomes of robotic low anterior resection for rectal cancer: a comparative study with laparoscopic surgery. Ann Surg. 2015;261:129–137.CrossRefGoogle Scholar
  2. 2.
    Gómez Ruiz M, Alonso Martin J, Cagigas Fernández C, et al. Short- and mid-term outcomes of robotic-assisted total mesorectal excision for the treatment of rectal cancer. Our experience after 198 consecutive cases. Eur J Surg Oncol. 2016;42:848–854.CrossRefGoogle Scholar
  3. 3.
    Kang J, Yoon KJ, Min BS, et al. The impact of robotic surgery for mid and low rectal cancer: a case-matched analysis of a 3-arm comparison—open, laparoscopic, and robotic surgery. Ann Surg. 2013;257:95–101.CrossRefGoogle Scholar
  4. 4.
    Hara M, Sng K, Yoo BE, et al. Robotic-assisted surgery for rectal adenocarcinoma: short-term and midterm outcomes from 200 consecutive cases at a single institution. Dis Colon Rectum. 2014;57:570–577.CrossRefGoogle Scholar
  5. 5.
    Tang B, Zhang C, Li C, et al. Robotic total mesorectal excision for rectal cancer: a series of 392 cases and mid-term outcomes from a single center in China. J Gastrointest Surg. 2017;21:569–576.CrossRefGoogle Scholar
  6. 6.
    Jayne D, Pigazzi A, Marshall H, et al. 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. 2017;318:1569–1580.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Wright JD. Robotic-assisted surgery: balancing evidence and implementation. JAMA. 2017;318:1545–1547.CrossRefGoogle Scholar
  8. 8.
    Colombo P-E, Bertrand MM, Alline M, et al. Robotic versus laparoscopic total mesorectal excision (TME) for sphincter-saving surgery: Is there any difference in the transanal TME rectal approach? A single-center series of 120 consecutive patients. Ann Surg Oncol. 2016;23:1594–1600.CrossRefGoogle Scholar
  9. 9.
    Bertrand MM, Colombo P-E, Mourregot A, et al. Standardized single docking, four arms and fully robotic proctectomy for rectal cancer: the key points are the ports and arms placement. J Robot Surg. 2016;10:171–174.CrossRefGoogle Scholar
  10. 10.
    Rouanet P, Mourregot A, Azar CC, et al. Transanal endoscopic proctectomy: an innovative procedure for difficult resection of rectal tumors in men with narrow pelvis. Dis Colon Rectum. 2013;56:408–415.CrossRefGoogle Scholar
  11. 11.
    Fayers P, Aaronson N, Bjordal K, et al. Microsoft Word—SCmanual.doc—SCManualQLQ-C30.pdf. European Organisation for Research and Treatment of Cancer. Accessed 8 Mar 2018.
  12. 12.
    Kwak JM, Kim SH, Kim J, et al. Robotic vs laparoscopic resection of rectal cancer: short-term outcomes of a case-control study. Dis Colon Rectum. 2011;54:151–156.CrossRefGoogle Scholar
  13. 13.
    Pigazzi A, Luca F, Patriti A, et al. Multicentric study on robotic tumor-specific mesorectal excision for the treatment of rectal cancer. Ann Surg Oncol. 2010;17:1614–1620.CrossRefGoogle Scholar
  14. 14.
    Baek SJ, Kim CH, Cho MS, et al. Robotic surgery for rectal cancer can overcome difficulties associated with pelvic anatomy. Surg Endosc. 2015;29:1419–1424.CrossRefGoogle Scholar
  15. 15.
    Cho MS, Baek SJ, Hur H, et al. Short and long-term outcomes of robotic versus laparoscopic total mesorectal excision for rectal cancer: a case-matched retrospective study. Medicine (Baltimore). 2015;94:e522.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Lin S, Jiang H-G, Chen Z-H, et al. Meta-analysis of robotic and laparoscopic surgery for treatment of rectal cancer. World J Gastroenterol. 2011;17:5214–5220.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Trastulli S, Farinella E, Cirocchi R, et al. Robotic resection compared with laparoscopic rectal resection for cancer: systematic review and meta-analysis of short-term outcome. Colorectal Dis. 2012;14:e134–156.CrossRefGoogle Scholar
  18. 18.
    Memon S, Heriot AG, Murphy DG, et al. Robotic versus laparoscopic proctectomy for rectal cancer: a meta-analysis. Ann Surg Oncol. 2012;19:2095–2101.CrossRefGoogle Scholar
  19. 19.
    Yang Y, Wang F, Zhang P, et al. Robot-assisted versus conventional laparoscopic surgery for colorectal disease, focusing on rectal cancer: a meta-analysis. Ann Surg Oncol. 2012;19:3727–3736.CrossRefGoogle Scholar
  20. 20.
    González Fernández AM, Mascareñas González JF. Total laparoscopic mesorectal excision versus robot-assisted in the treatment of rectal cancer: a meta-analysis. Cirugia Espanola. 2012;90:348–354.CrossRefGoogle Scholar
  21. 21.
    Ortiz-Oshiro E, Sánchez-Egido I, Moreno-Sierra J, et al. Robotic assistance may reduce conversion to open in rectal carcinoma laparoscopic surgery: systematic review and meta-analysis. Int J Med Robot Comput Assist Surg MRCAS. 2012;8:360–370.CrossRefGoogle Scholar
  22. 22.
    Xiong B, Ma L, Zhang C, et al. Robotic versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis. J Surg Res. 2014;188:404–414.CrossRefGoogle Scholar
  23. 23.
    Li X, Wang T, Yao L, et al. The safety and effectiveness of robot-assisted versus laparoscopic TME in patients with rectal cancer: a meta-analysis and systematic review. Medicine (Baltimore). 2017;96:e7585.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Jiménez-Rodríguez RM, Rubio-Dorado-Manzanares M, Díaz-Pavón JM, et al. Learning curve in robotic rectal cancer surgery: current state of affairs. Int J Colorectal Dis. 2016;31:1807–1815.CrossRefGoogle Scholar
  25. 25.
    Kim HJ, Choi G-S, Park JS, et al. Multidimensional analysis of the learning curve for robotic total mesorectal excision for rectal cancer: lessons from a single surgeon’s experience. Dis Colon Rectum. 2014;57:1066–1074.CrossRefGoogle Scholar
  26. 26.
    Jiménez-Rodríguez RM, Díaz-Pavón JM, de la Portilla de Juan F, et al. Learning curve for robotic-assisted laparoscopic rectal cancer surgery. Int J Colorectal Dis. 2013;28:815–821.CrossRefGoogle Scholar
  27. 27.
    Green BL, Marshall HC, Collinson F, et al. Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer. Br J Surg. 2013;100:75–82.CrossRefGoogle Scholar
  28. 28.
    Bonjer HJ, Deijen CL, Haglind E, et al. A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med. 2015;373:194.PubMedGoogle Scholar
  29. 29.
    Jeong S-Y, Park JW, Nam BH, et al. 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. 2014;15:767–774.CrossRefGoogle Scholar
  30. 30.
    Stevenson ARL, Solomon MJ, Lumley JW, et al. Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial. JAMA. 2015;314:1356–1363.CrossRefGoogle Scholar
  31. 31.
    Fleshman J, Branda M, Sargent DJ, et al. 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. 2015;314:1346–1355.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Penna M, Hompes R, Arnold S, et al. Transanal total mesorectal excision: international registry results of the first 720 cases. Ann Surg. 2017;266:111–117.CrossRefGoogle Scholar
  33. 33.
    Escal L, Nougaret S, Guiu B, et al. MRI-based score to predict surgical difficulty in patients with rectal cancer. Br J Surg. 2018;105:140–146.CrossRefGoogle Scholar
  34. 34.
    Rouanet P, Gourgou S, Gogenur I, et al. Rectal Surgery Evaluation Trial (RESET): protocol for a parallel cohort trial of outcomes using surgical techniques for total mesorectal excision with low anterior resection in high-risk rectal cancer patients. Colorectal Dis. (submitted).Google Scholar

Copyright information

© Society of Surgical Oncology 2018

Authors and Affiliations

  • Philippe Rouanet
    • 1
    Email author
  • Martin Marie Bertrand
    • 1
  • Marta Jarlier
    • 2
  • Anne Mourregot
    • 1
  • Drissa Traore
    • 1
  • Christophe Taoum
    • 1
  • Hélène de Forges
    • 3
  • Pierre-Emmanuel Colombo
    • 1
  1. 1.Surgical Oncology DepartmentInstitut du Cancer de Montpellier (ICM), Univ MontpellierMontpellierFrance
  2. 2.Biometrics UnitInstitut du Cancer de Montpellier (ICM), Univ MontpellierMontpellierFrance
  3. 3.Clinical Research UnitInstitut du Cancer de Montpellier (ICM), Univ MontpellierMontpellierFrance

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