2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

MINIMALLY INVASIVE SURGERY OF RECTAL CANCER
nary and sexual function. The investigators hypothesize
that HALS results in shorter operative time while retaining
the benefits associated with laparoscopic surgery.
As we await the results of this trial, several publications
have reported on the role of robotic-assisted laparoscopic
TME. A prospective randomized, controlled trial comparing
robotic-assisted and laparoscopic TME is also ongoing. Comparative
analysis, based on the ultimate data comparing
hand-assisted and robotic-assisted laparoscopic surgery for
rectal cancer, will be challenging. Only one three-arm retrospective
study comparing HALS, robotic-assisted, and laparoscopic
TME has been reported (with 30 patients with
rectal cancer per arm). 34 No significant differences in pathologic
outcome or complications were identified. To ascertain
the equivalence of HALS and robotic surgery, however, a
prospective randomized, controlled trial is needed.
Robotic-Assisted Laparoscopic Surgery for Rectal
Cancer: the Ideal Solution?
Robotic-assisted laparoscopic prostatectomy has become
extremely popular. An excellent three-dimensional visual
system using EndoWrist instruments eliminates many of
the limitations of operating with straight laparoscopic instruments
in a restricted anatomic area. The extraperitoneal
part of the rectum is situated in the pelvic cavity.
Thus, the idea of robotic-assisted laparoscopic surgery for
rectal cancer appeals to surgeons. Loss of free movement to
several quadrants of the abdomen, as well as increases in
cost without benefits when compared to laparoscopic surgery,
limits the use of robotic-assisted laparoscopic colectomy
for colon cancer. A retrospective study comparing 40
robotic-assisted to 135 laparoscopic right hemicolectomies
reported no significant difference in short-term benefits,
including estimated blood loss, rate of conversion, complications,
and hospital stay. Moreover, operative time and costs
were significantly higher in the robotic versus the laparoscopic
group (p � 0.001 vs. p � 0.003, respectively). 35 In
concurrence with the findings of a meta-analysis of seven
nonrandomized studies, the average operative time was 39
minutes longer and $792 more expensive than in conventional
laparoscopy, with no improvement in short-term benefits.
36
As noted, however, the rectum seems suited to robotic
surgery and the learning curve is less steep. Data on 50
robotic-assisted laparoscopic rectal surgery cases suggest
that the learning curve is passed after 15 to 25 operations. 37
Unfortunately, the utilization of this technology has been
limited by cost. Most of the current evidence regarding the
benefits of robotic-assisted laparoscopic rectal cancer surgery
consists of case series. Case-match and nonrandomized
studies conclude that robotic-assisted surgery is feasible and
comparable to laparoscopic TME. 38-40 A large prospective,
randomized, controlled trial is needed, however, to assess
the equivalence of robotic surgery to conventional laparoscopic
surgery.
The United Kingdom MRC ROLARR trial
The United Kingdom Medical Research Council Trial of
Robotic compared with Laparoscopic Resection for Rectal
cancer (ROLARR) trial is a multicenter prospective, randomized,
controlled trial of robotic-assisted compared with
laparoscopic surgery in the curative treatment of rectal
cancer. 41 Four hundred patients will be recruited and randomly
assigned with a 1:1 ratio. This trial is currently in the
randomization phase, which will end by mid-2012. The
primary endpoint is conversion rates to open surgery. Secondary
endpoints are intraoperative and postoperative complications;
oncologic outcomes, including circumferential
margin, 3-year overall and disease-free survival; and quality
of life.
Techniques: Total Robotic or Hybrid Approach?
There is debate over port placements, docking techniques,
and techniques for take-down of the splenic flexure in
robotic-assisted laparoscopic TME. The two major techniques
are 1) totally robotic surgery and 2) a hybrid approach,
depending on which instrument is used in takedown.
Some surgeons are practicing a hybrid approach
consisting of a robotic surgical system for vessel control and
pelvic dissection, and straight laparoscopy for splenic flexure
mobilization. The idea is to decrease the prolonged
operative time caused by multiple dockings of the robot.
The technique of totally robotic surgery is challenging
because of limitations in port placement and positioning of
the robot. Most of the time, more than one docking of the
robot is needed to complete the operation. Some centers have
proposed the feasibility of a single-stage technique. 42,43
However, there are currently no published studies comparing
docking techniques. Surgeon preference and experience
are still the main factors in selecting an operation. From our
perspective, there is no single ideal technique that will fit all
patients. Knowledge of the benefits and limitations of each
technique is crucial, and the surgeon must be prepared to
tailor surgery to each individual patient.
Conclusion
Minimally invasive surgery for rectal cancer is challenging
because of the anatomic restrictions of the bony pelvis
and the necessity of autonomic nerve preservation. Various
techniques have been proposed, including straight laparoscopic,
hand-assisted, and robotic-assisted laparoscopic surgery.
In laparoscopic rectal cancer surgery, the short-term
benefits are similar to those associated with other minimally
invasive techniques. Current data indicate that long-term
oncologic outcomes are similar in terms of recurrence and
survival. Several additional prospective, randomized, controlled
trials are in progress. We believe that the results will
demonstrate the noninferiority of laparoscopic surgery compared
to open surgery.
The data from small case series and one nonrandomized,
controlled trial indicate that the emerging techniques of
hand-assisted and robotic-assisted laparoscopy are feasible
and comparable to the results achieved with conventional
laparoscopic surgery. Prospective randomized, controlled
trials of both techniques are ongoing. At this time, it is not
possible to determine which procedure is “best.” Surgeon
preference and availability of instruments are crucial in
choosing the right procedure for each individual patient.
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