Perioperative and Long-Term Oncological Outcomes of Robotic versus Laparoscopic Total Mesorectal Excision: A Retrospective study of 672 Patients

Perioperative and Long-Term Oncological Outcomes of Robotic versus Laparoscopic Total Mesorectal Excision: A Retrospective study of 672 Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perioperative and Long-Term Oncological Outcomes of Robotic versus Laparoscopic Total Mesorectal Excision: A Retrospective study of 672 Patients Niyaz Shadmanov, Vusal Aliyev, Guglielmo Niccolò Piozzi, Barıs Bakır, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4020628/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Mar, 2024 Read the published version in Journal of Robotic Surgery → Version 1 posted 7 You are reading this latest preprint version Abstract Backround Although there's growing information about the long-term oncological effects of robotic surgery for rectal cancer, the procedure is still relatively new. This study aimed to assess the long-term oncological results of total mesorectal excision (TME) performed laparoscopically versus robotically in the setting of rectal cancer. Methods Restrospective analysis of a prospectively maintained database. A total of 489 laparoscopic (L-TME) and 183 robotic total mesorectal excisions (R-TME) were carried out by a single surgeon between 2013 and 2023. The groups were compared in terms of perioperative and long-term oncological outcomes. Results In the R-TME and L-TME groups, male sex predominated (75.4% and 57.3%, respectively), although the robotic group was significantly greater (p = 0.008). There was no conversion in R-TME group, whereas three (0.6%) converted to open surgery in L-TME group. The R-TME group had a statistically significant higher number of distal rectal tumors (85%) compared to the L-TME group (54.6%). Only three (1.7%) patients in the R-TME group received abdomineperineal resection (APR); in contrast, 25 (5%) patients in the L-TME group received APR (p < 0.001). For R-TME, the mean follow-up was 70.7 months (range 18–138) and for L-TME, it was 60 months (range 14–140). Frequency of completed mesorectum was significantly greater in R-TME group (98.9% vs 94.2%, p < 0.001). The 5-year overall survival rates for R-TME and L-TME groups were 89.6% and 88.7%, respectively. The 5-year disease-free survival for R-TME and L-TME groups were 84.1% and 81.1%, respectively. The local recurrences rates were 7.6% and 6.3%, respectively in R-TME and L-TME groups (p = 0.274). Conclusion R-TME is characterized by no conversion and improved mesorectal integrity. R-TME had longer operation time. The long-term oncological outcomes were comparable between groups. Total mesorectal excision Robotic approach Laparoscopic approach Rectal cancer Oncological outcomes Figures Figure 1 Introduction Since its introduction in the 1980s, Total Mesorectal Excision (TME) has become a widely adopted technique, significantly enhancing local control post-surgery and remaining a pivotal aspect of rectal cancer surgery [ 1 ]. The standard of surgical therapy now includes laparoscopic TME (L-TME), which is universally approved and carried out. L-TME has been shown in many randomized trials to have superior short-term oncological safety, less postoperative pain, improved cosmetic outcomes, faster recovery, and shorter hospital stay than open surgery. Nevertheless, laparoscopic surgery has numerous potential drawbacks, despite its clinical efficacy as a surgical approach for rectal cancer [ 2 – 3 ]. These include the high conversion rate to open surgery and the limited visibility due to unstable cameras [ 4 – 5 ]. Notably, due to the limitations of the limited pelvic anatomy, the laparoscopic approch poses technical obstacles in the successful treatment of low rectal cancer, particularly in cases with bulky tumors and in male or overweight patients undergoing neoadjuvant chemoradiotherapy (NCRT). Theoretically, in an attempt to overcome the drawbacks of laparoscopy, robotic surgery was developed and could provide benefits in limited spaces as for pelvic surgery. Robotic approach has been proving to be safe and to provide good short- and mid-term oncological outcomes for rectal cancer surgery [ 6 ]. Besides improved dexterity, the robotic platform provides robust, readily adjustable three-dimensional imaging and a stable platform for surgeons, minimizing fatigue and improving comfort during rectal dissection [ 7 ]. This study aims to compare the perioperative and long-term oncological outcomes of L-TME and robotic TME (R-TME). Methods Study population This retrospective study evaluated a consecutive series of patients with rectal cancer undergoing either L-TME or R-TME surgery between January 2013 and June 2023. Data were extracted from a prospectively maintained surgical database. This study was conducted in compliance with the Principles of the Declaration of Helsinki. Informed consent was obtained from each patient. Primary aim was to report perioperative and long-term oncological outcomes. Inclusion criteria were: 1) rectal adenocarcinoma; 2) tumor location (15 cm from the anal verge, AV); 3) clinical TNM stage I–III; 4) absence of distant metastases and synchronous tumors; 5) sphincter-saving TME or abdominoperineal resection (APR); 6) elective surgery; 7) curative intent surgery. Exclusion criteria were: 1) sigmoid resections; 2) Hartmann’s resection; 3) local excision; 4) sistemic metastases; 5) palliative surgery. The boundary between the anal mucosa and the perineal skin was defined as AV. The distance between the tumor's caudal border and the anal margin was measured through rectal magnetic resonance imaging (MRI), flexible sigmoidoscopy, and digital rectal examination. Preoperative protocol Preoperative staging included chest X-ray, carcinoembryonic antigen (CEA) levels, flexible or virtual colonoscopy, torax/abdominopelvic CT and MRI of the pelvic phased array. NCRT included: 1) Long-term neoadjuvant chemoradiotherapy with concurrent chemotherapy using capecitabine (1600 mg/m 2 daily during radiotherapy), with a total dose of 50 Gy given in 25 fractions over five weeks. Surgery was undertaken within the timeframe of 4 to 8 weeks following the conclusion of chemoradiotherapy; 2) total neoadjuvant treatment consists of NCRT followed by consolidation chemotherapy. Consolidation chemotherapy involved concurrent administration of oxaliplatin (85 mg/m²) and leucovorin (400 mg/m²) biweekly, followed by a bolus injection of 5-fluorouracil (5-FU) (400 mg/m²), and then infusion with 5-FU (2400 mg/m²). Following June 2018, the consolidation regimen was changed to include capecitabine (1000 mg/m²) twice daily on days 1–14 in addition to oxaliplatin (130 mg/m²) on day one; this was repeated every three weeks for eight cycles; 3) A total of 25 Gy was given in five fractions over 5–7 days to the short-course neoadjuvant radiotherapy group. Within one to four weeks following the end of neoadjuvant radiation therapy, surgery was performed. When there was no chance of positive lateral margins, patients were given short-course radiotherapy. Without the addition of oral antibiotics, all patients underwent oral mechanical bowel preparation. One hour prior to the start of the surgical incision, a single 400 mg intravenous dosage of ciprofloxacin was given. Surgical technique A single surgeon (O.A.), with over twenty years of experience in oncological colorectal surgery, performed all surgical procedures. The surgeries were performed at Maslak Acibadem Hospital in Istanbul, Turkey and Liv Hospital, Department of General Surgery, Istanbul, Turkey. Every patient had a detailed discussion regarding the surgical strategy, which was decided by the surgeon after considering the patient's preferences and the surgeon's assessment. Before the procedure, every patient was given thorough instructions detailing the benefits and drawbacks of both laparoscopic and robotic approach. Both laparoscopic and robotic surgical procedures were previously described in detail [ 8 – 10 ]. The Da Vinci Si® or Xi® platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA) was used in the R-TME group. Any unintended laparotomy that occurred during surgery, regardless of the extent of the incision, was referred to as a conversion. Pathological report During the data evaluation process, pathological staging was modified to conform to the 8th edition staging criteria of the American Joint Committee on Cancer (AJCC) [ 11 ]. Tumor size, number of harvested lymph nodes, distal resection margin (DRM), circumferential resection margin (CRM), and integrity of the mesorectum were all determined by a thorough analysis of all pathology specimens. The criteria established by Quirke et al. were used to assess the mesorectum's quality after dissection [ 12 ]. Positive CRM was described as direct tumor expansion that occurred within 1 mm of the resected specimen's radial, non-peritonealized surface [ 13 ]. Postoperative outcomes and follow-up The Clavien-Dindo classification was used to assess postoperative complications, which are defined as unfavorable events that occur within 30 days following surgery [ 14 ]. Anastomotic leaks were diagnosed and treated in accordance with the protocols set by the International Study Group of Rectal Cancer [ 15 ]. The follow-up measures included thoraco-abdominopelvic CT assessment every year, colonic examinations at the first, third, fifth, and tenth years after surgery, and monitoring of oncological markers (CEA, carbohydrate antigen 19 − 9) every three months. Disease-free survival (DFS) was estimated from the date of surgery to the tumor's recurrence, whereas overall survival (OS) was calculated from the date of surgery to the date of death or the last follow-up. Histological confirmation or radiographic identification of expanding lesions established the diagnosis of recurrence. The STROBE declaration principles for cohort studies were followed by this study [ 16 ]. Statistical analysis Data were analyzed using IBM SPSS Statistics for Windows, version 27 (IBM Corp., Armonk, NY, USA) and 95% confidence level was used. For categorical (qualitative) variables, frequency and percentage (n (%)), for numerical (quantitative) variables mean, standard deviation (mean ± ss), minimum, maximum statistics are given. In the pairwise comparison of the measurements determined in the study according to the groups, LSD/Mann Whitney One-way ANOVA/Kruskal Wallis test was used for intergroup comparisons and Chi-square test was used for the relationships between grouped variables. Chi-square test is a test technique used to determine the relationships between grouped variables. LSD/Mann Whitney is a test technique used to compare two independent groups in terms of a quantitative variable. One-way ANOVA/Kruskal Wallis is a test technique used to compare more than two independent groups (k = group > 2) in terms of a quantitative variable. Result Clinical outcomes A total of 672 patients with rectal cancer were enrolled into two groups: L-TME group (n = 489, 72.7%) and R-TME (n = 183, 37.3%). Table 1 shows patients’ clinical and demographic details. Patients in the R-TME group were younger (54.2 ± 12.8 and 57.2 ± 12.8 years for R-TME and L-TME, respectively) (p = 0.007). Male patients made up to 54% of the L-TME group and 75.4% of the R-TME group, respectively. This was statistically significant (p < 0.001). Table 1 Patients characteristics R-TME (n = 183) L-TME (n = 489) p Age 54.2 ± 12.8 57.2 ± 12.8 0.007 t Sex Male 138 (75.4%) 280 (57.3%) 0.008 K Female 45 (24.6%) 209 (42.7%) ASA Score 0.010 t 1 20 (11%) 48 (10%) 0.010 t 2 138 (75.4%) 323 (66%) 3 25 (13.6%) 118 (24%) BMI 26.994 ± 2.622 26.740 ± 2.537 0.252 t Localisation Mid-low 156 (85%) 267 (54.6%) < 0.001 K Proximal 27 (15%) 222 (45.4%) Mean: Average SS: Standard Deviation t: Independent sample t-test K: Pearson chi-square test The American Society of Anesthesiologists Score: ASA Body Mass Index (BMI) Mid-low rectal cancers were significantly more common in the R-TME group (85% and 54.6% for R-TME and L- TME, respectively) (p < 0.001). Perioperative outcomes Table 2 lists the perioperative outcomes. No cases of 30-day death was reported. With R-TME, the operation time was substantially longer (158.9 ± 39.1 vs. 116.1 ± 31.7 min, p < 0.001). In terms of estimated blood loss and postoperative hospital stay, there was no significant difference seen. While the majority of patients in both groups were cT3 and node-positive, there was a greater percentage of cT4 patients in the L-TME group (14.8% in R-TME and 24% in L-TME, respectively). Neoadjuvant therapy was administered to most patients however, the R-TME group received more (84.1% and 52.3% for R-TME and L-TME, respectively; p < 0.001). Table 2 Perioperative outcomes R-TME (n = 183) L-TME (n = 489) p Overall operation time, min 158.9 ± 39.1 116.1 ± 31.7 < 0.001 t Hospital stay, days 4 ± 2.100 3.946 ± 1.135 0.675 t Clinical Stage, n (%) cT1 8 (4.4) 17 (3.5) 0.291 z 0.369 0.032 < 0.001 cT2 16 (8.7) 39 (7.9) cT3 132 (72.1%) 316 (64.6%) cT4 27 (14.8) 117 (24) cN negative 39 (21.4%) 113 (23.1%) 0.308 cN positive 144 (78.6%) 376 (76.8%) Neoadjuvant treatment, n (%) Yes 154 (84.1%) 256(52.3%) < 0.001 z No 29 (15.9%) 233 (47.7%) TME procedure, n (%) APR Anterior resection Low-anterior resection Intersphincteric resection Sphincter preserving 3 (1.7%) 16 (8.7) 100 (54.6) 64 (35) 180 (98.3%) 25 (5%) 152 (31.1) 223(45.6) 89(18.2) 464 (95%) < 0.001 K < 0.001 0.187 < 0.001 0.274 Diverting ileostomy Yes No 157 (85.8) 23(12.5) 231 (47.3) 233 (47.7) < 0.001 z Conversion rates, n (%) 0 (0) 3 (0.6) 0.146 z Mean: Average SS: Standard Deviation t: Independent sample t-test z: Two ratio z-test K: Pearson chi-square test Total mesorectal excision : TME Abdominoperineal resection :APR The R-TME group's patients received more low anterior resections (54.6% vs. 45.6% p = 0.187) and intersphincteric resections (35% vs. 18.2% p < 0.001) because they mostly had distal tumors. Conversely, the L-TME group had a higher frequency of proximal tumors, and there was a marked predilection for anterior resections (8.7% vs. 31.1%, p < 0.001) in this group. Three patients (1.7%) had APR in the R-TME group, while twenty-five patients (5%) received APR in the L-TME group (p < 0.001). Three patients (0.6%) in the L-TME group had open conversions, whereas there were none in the R-TME group. Histopathological outcomes Even though R-TME had a larger mean number of excised lymph nodes, the difference between the two groups was not statistically significant (24.6 ± 9.3 vs 23.5 ± 10.8, p = 0.125). The mean distance of the resection margin (DRM) was longer in L-TME (15.2 ± 14.7 mm and 20.8 ± 15.6 mm for R-TME and L-TME, respectively). Eight (4.3%) patients in R-TME and sixteen (3.2%) patients in L-TME had positive CRM involvement (p = 0.236). A statistical difference was reported between R-TME and L-TME regarding specimen quality (98.9% vs. 94.2%, p < 0.001). There were no notable variations in other histopathology results (Table 3 ). Table 3 Histopathological outcomes R-TME (n = 183) L-TME (n = 489) p DRM, mm 15.2 ± 14.7 20.8 ± 15.6 < 0.001 t Involved CRM, n (%) 8 (4.3%) 16 (3.2%) 0.236 Tumor size, mm 34.4 ± 15.3 41.2 ± 18.8 < 0.001 t Macroscopic quality of TME specimen Complete 181 (98.9%) 461 (94.2%) < 0.001 z Incomplete 2 (1.1%) 28 (5.8%) Pathological Stage, n (%) ypT0 22 (12) 27 (5.5) < 0.001 0.222 < 0.001 0.013 < 0.001 ypT1 24 (13.2) 40 (8.1) ypT2 55 (30) 81 (16.6) ypT3 74 (40.4) 250 (51.1) ypT4 8 (4.4) 91 (18.6) ypN negative 178(60%) 165(54%) 0.052 K ypN positive 119(40%) 143(46%) Harvested LN, n (%) 24.6 ± 9.3 23.5 ± 10.8 0.125 Mean: Average SS: Standard Deviation t: Independent sample z: Two ratio z-test CRM: circumferential resection margin, DRM: Distal resection margin, LN: lymph node Postoperative complications Table 4 shows that the overall complication rate was 17.5% for L-TME and 16.8% for R-TME (p = 0.132). Symptomatic anastomotic leakage occurred in 16 (8.7%) R-TME patients and 47 (9.6%) L-TME patients. All instances of anastomotic leakage were managed conservatively, involving the maintenance of pelvic drainage until clinical resolution of the infection, with selective use of endo-sponge drainage. Table 4 Postoperative complications R-TME (n = 183) L-TME (n = 489) p Overall complications, n (%) 32 (16.7) 86 (17.5) 0.4 Anastomotic leak 16 (8.7) 47 (9.6) 0.034 z Anastomotic stricture 2 (1) 4 (0.8) 0.401 0.176 0.5 0.257 0.351 0.280 0.460 0.397 0.238 Rectourethral fistula 2 (1) 2 (0.4) Rectovaginal fistula 2 (1) 5 (1) Colonic ischemia 1 (0.5) 1 (0.2) Ileus 4 (2) 12 (2.5) Pelvic hematoma 2(1) 8 (1.6) Pelvic abscess 3 (1.5) 7 (1.4) Clavien–Dindo morbidity, n (%) I–II 22 (11.5) 53 (10.8) III–IV 10 (5.2) 32 (6.7) z: Two ratio z-test Rectovaginal fistula occurred in five patients in the L-TME group and two patients in the R-TME group. Two patients, one with R-TME and the other with L-TME, experienced an immediate onset of colonic ischemia. On the third postoperative day, these patients underwent an urgent laparoscopic colon resection and re-anastomosis. According to Clavien-Dindo's classification, there was no significant difference in postoperative morbidity Oncological outcomes The mean follow-up were 70.7 months (interval 18–138) for R–TME and 60 months (interval 14–140) for L–TME. R-TME and L-TME had 5-year OS rates of 89.6% and 88.7%, respectively. The 5-year DFS rates for R-TME and L-TME were 81.1% and 84.1%. The Kaplan–Meier curves for OS and DFS are reported in Fig. 1 . Local recurrence occurred in fourteen (7.6%) of the R-TME group and in thirty-one (6.3%) of the L-TME group of patients (p = 0.276). During the follow-up period, 20 patients (10.9%) in the R-TME group and 62 patients (12.6%) in the L-TME group were found to have distant metastases. However, there was no significant statistical difference between the groups. Discussions The purpose of this study was to compare the perioperative and long-term oncological results of L-TME and R-TME patients with rectal cancer. R-TME was associated with a statistically significant prolonged operation time compared to L-TME (p < 0.001). There were three (0.6%) conversions to open surgery in L-TME, and none in the R-TME group. The conversion rates in previously published randomized controlled trials showed different rates: COLOR II (16%), CLASICC (16%), ACOSOG Z6051 (11%), ALaCaRT (9%), and COREAN (1.2%) [ 2 – 3 , 17 – 19 ]. The present study showed that the conversion rate (0.6%) is significantly lower than the aforementioned studies. This may be explained by the standardization of techniques, surgeons' experiences, and the learning curve [ 20 , 21 ]. A study conducted between 2005 and 2012 by the same group showed a 6.5% conversion rate in L-TME [ 20 ]. We believe that conversion to open surgery had a negative effect on the survival of rectal cancer patients. In fact, the 10-year results of the aforementioned study showed inferior outcomes in the converted group (DFS 50.0% vs. 78.3% and OS 46.7% vs. 68.5%) [ 22 ]. There was no statistically significant difference in the CRM involvement rate between L-TME and R-TME (p = 0.236). Completeness of mesorectum was higher in R-TME with statistical difference (98.9% vs. 94.2%; p < 0.001). The mesorectal completeness and margin-free CRM are key histopathologic factors for achieving improved local recurrences rates [ 12 , 13 ]. The overall CRM positivity rates were 19% in a Dutch study, 13% in the CLASSİC trial, 10.0% COLOR II, 5.7% ROLARR, and 4.1% COREAN trial [ 2 – 3 , 17 , 23 – 24 ]. In the current investigation the R-TME and L-TME showed 3.2% and 4.3% CRM involvement, respectively. There was no statistically significant difference in the CRM involvement between the laparoscopic and robotic low-anterior resection groups in the prospective study conducted by Baik et al. [ 25 ]. The quality of specimen is considered as a parameter for the evaluation of prognosis. The majority of studies consistently showed that preventing incomplete mesorectum might greatly enhance OS and dramatically lower the chance of recurrence following TME surgery. Classification of a mesorectal specimen was described by Quirke et al. in the CR07 trial, which included 1,156 patients [ 12 ]. Surgery was considered complete in 604 (52%), near complete in 398 (34%), and incomplete in 154 (13%). Additionally, they observed that the three-year local recurrence for each of the three groups was 4% for complete, 7% for nearly complete, and 13% for incomplete (p = 0.0039), indicating the greatest possible association between the local recurrence and mesorectal integrity. According to our research, the robotic group had more mesorectal completeness (98.9% vs. 94.2% p < 0.001). This outcome is in line with our earlier results [ 9 – 10 , 26 – 28 ]. Comparable 5-year OS and DFS rates were seen in the L-TME and R-TME groups (p = 0.741 and p = 0.368., respectively). This study revealed similar results in terms of local recurrence rate (p = 0.274). The distant metastasis rates were also comparable in L-TME and R-TME (p = 0.27). In contrast to the present study, our previous research, which compared L-TME and R-TME procedures in male patients with mid-low rectal tumors, revealed substantial differences [ 27 ]. Specifically, the R-TME group of male patients exhibited significantly superior rates of improved local recurrence, as well as mesorectal completeness. These studies once again demonstrated that robotic approach can potentially overcome some technical challenges related to pelvic anatomical differences between sexes compared to laparoscopy. However, our two previously published studies indicated that robotic approach did not provide any benefit in female patients with rectal cancer when compared with laparoscopy [ 29 – 30 ]. There is a possible bias in the present study between the two groups: 1) since robotic surgery was introduced in our study in 2013, laparoscopic cases performed during the same period were included for comparison; 2) the robotic approach was preferred in male patients; 3) due to the high cost of robotics in Turkey, we opted for the robotic approach in technically difficult cases (narrow pelvis, obese patients). This study has several limitations. Firstly, it constitutes a retrospective analysis of data collected prospectively from a single surgeon's experience. Secondly, the number of R-TME procedures is lower than L-TME. To validate our results, a large prospective randomized study is necessary. Thirdly, we did not evaluate comparative functional outcomes. Lastly, cost-effectiveness was not investigated in this study. However, the strength of this study lies in its long median follow-up and standardized single surgeon setting, coupled with extensive colorectal expertise. Conclusion This study reports a higher rate of mesorectal integrity, no conversions to open and/or abdominoperineal resection, and a lower postoperative complication rate in patients undergoing R-TME. R-TME was associated with a longer operative time. Both R-TME and L-TME showed good OS, DFS, and local recurrence rates. Declarations Author contributions Conceptualization: Oktar Asoglu, Niyaz Shadmanov, Vusal Aliyev; Methodology: Oktar Asoglu; Niyaz Shadmanov; Formal analysis and investigation: Niyaz Shadmanov, Oktar Asoglu; Writing- original draft preparation: Niyaz Shadmanov, Vusal Aliyev, Oktar Asoglu; Writing- review and editing: Niyaz Shadmanov, Vusal Aliyev, Guglielmo Niccolò Piozzi, Barıs Bakır, Suha Goksel, Oktar Asoglu; Supervision: Oktar Asoglu Disclosure of potential conflicts of interest The authors have no relevant financial or non-financial interests to disclose. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Ethics approval This study was conducted in compliance with the Principles of the Declaration of Helsinki. Institutional Review Board (IRB) approval was waived following the retrospective nature of the study. 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Surgery 2010; 147: 339–51. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008; 61: 344–9 an der Pas MH, Haglind E, Cuesta MA, et al. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 2013;14:210–8. Fleshman J, Branda ME, Sargent DJ, Boller AM, George VV, Abbas MA et al. Disease-free Survival and Local Recurrence for Laparoscopic Resection Compared With Open Resection of Stage II to III Rectal Cancer: Follow-up Results of the ACOSOG Z6051 Randomized Controlled Trial. Ann Surg. 2019;269(4):589–595. doi: 10.1097/SLA.0000000000003002 . PMID: 30080730; PMCID: PMC6360134. Stevenson ARL, Solomon MJ, Lumley JW et al (2015) Efect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the AlaCart randomized clinical trial. JAMA 314(13):1356–1363 Asoglu O, Kunduz E, Rahmi Serin K et al (2014) Standardized laparoscopic sphincter preserving total mesorectal excision for rectal cancer: long-term oncologic outcome in 217 unselected consecutive patients. Surg Laparosc Endosc Percutan Tech 24:145–152 Aliyev V, Arslan NC, Goksoy B, Guven K, Goksel S, Asoglu O. Is robotic da Vinci Xi® superior to the da Vinci Si® for sphincter-preserving total mesorectal excision? Outcomes in 150 mid-low rectal cancer patients. J Robot Surg. 2022;16(6):1339–1346. Bademler S, Koza KB, Ucuncu MZ, Tokmak H, Bakir B, Oral EN, et al. Standardized Laparoscopic Sphincter-preserving Total Mesorectal Excision For Rectal Cancer: Median of 10 Years' Long-term Oncologic Outcome in 217 Unselected Consecutive Patients. Surg Laparosc Endosc Percutan Tech 2019; 29: 354–61. Kapiteijn E, Putter H, van de Velde CJ, Cooperative investigators of the Dutch ColoRectal Cancer Group (2002) Impact of the introduction and training of total mesorectal excision on recurrence and survival in rectal cancer in The Netherlands. Br J Surg 89:1142–1149 Corrigan Neil, Marshall Helen, Croft Julie, et al. Exploring and adjusting for potential learning effects in ROLARR: a randomised controlled trial comparing robotic-assisted vs. standard laparoscopic surgery for rectal cancer resection. Trials 2018;19:33. Baik SH, Kwon HY, Kim JS et al (2009) Robotic versus laparoscopic low anterior resection of rectal cancer: short-term outcome of a prospective comparative study. Ann Surg Oncol 16:1480–1487 Asoglu O, Tokmak H, Bakir B, Aliyev V, Saglam S, Iscan Y, Bademler S, Meric S. Robotic versus laparoscopic sphincter-saving total mesorectal excision for mid or low rectal cancer in male patients after neoadjuvant chemoradiation therapy: comparison of long-term outcomes. J Robot Surg. 2020;14(3):393–399 Aliyev V, Goksel S, Bakir B, Guven K, Asoglu O. Sphincter-Saving Robotic Total Mesorectal Excision Provides Better Mesorectal Specimen and Good Oncological Local Control Compared with Laparoscopic Total Mesorectal Excision in Male Patients with Mid-Low Rectal Cancer. Surg Technol Int. 2021;38:160–166. doi: 10.52198/21.STI.38.CR1391 . PMID: 33537982. Aliyev V, Piozzi GN, Bulut A, Guven K, Bakir B, Saglam S, Goksel S, Asoglu O. Robotic vs. laparoscopic intersphincteric resection for low rectal cancer: a case matched study reporting a median of 7-year long-term oncological and functional outcomes. Updates Surg. 2022;74(6):1851–1860. doi: 10.1007/s13304-022-01396-1 . Epub 2022 Oct 5. PMID: 36198884. Aliyev V, Piozzi GN, Huseynov E, Mustafayev TZ, Kayku V, Goksel S, Asoglu O. Robotic male and laparoscopic female sphincter-preserving total mesorectal excision of mid-low rectal cancer share similar specimen quality, complication rates and long-term oncological outcomes. J Robot Surg. 2023;17(4):1637–1644. doi: 10.1007/s11701-023-01558-2. Epub 2023 Mar 21. PMID: 36943657. Aliyev V, Piozzi GN, Shadmanov N, Guven K, Bakır B, Goksel S, Asoglu O. Robotic and laparoscopic sphincter-saving resections have similar peri-operative, oncological and functional outcomes in female patients with rectal cancer. Updates Surg. 2023;75(8):2201–2209. doi: 10.1007/s13304-023-01686-2. Epub 2023 Nov 13. PMID: 37955804. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Mar, 2024 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Accepted 24 Mar, 2024 Reviews received at journal 21 Mar, 2024 Reviewers agreed at journal 12 Mar, 2024 Reviewers invited by journal 10 Mar, 2024 Editor assigned by journal 08 Mar, 2024 Submission checks completed at journal 08 Mar, 2024 First submitted to journal 06 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4020628","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":277854831,"identity":"80167d65-ae51-45ff-981e-011b1db43922","order_by":0,"name":"Niyaz Shadmanov","email":"","orcid":"","institution":"Bogazici Academy for Clinical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Niyaz","middleName":"","lastName":"Shadmanov","suffix":""},{"id":277854832,"identity":"8d19ca6e-dee7-4346-8c79-8b68c5a0115b","order_by":1,"name":"Vusal Aliyev","email":"","orcid":"","institution":"Bogazici Academy for Clinical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Vusal","middleName":"","lastName":"Aliyev","suffix":""},{"id":277854833,"identity":"c0ca9ff1-c392-4200-ace9-3097cb5be28a","order_by":2,"name":"Guglielmo Niccolò Piozzi","email":"","orcid":"","institution":"Portsmouth Hospitals University NHS Trust","correspondingAuthor":false,"prefix":"","firstName":"Guglielmo","middleName":"Niccolò","lastName":"Piozzi","suffix":""},{"id":277854834,"identity":"43edad9a-46b9-43a6-a3fc-f977ffecd4df","order_by":3,"name":"Barıs Bakır","email":"","orcid":"","institution":"Istanbul University","correspondingAuthor":false,"prefix":"","firstName":"Barıs","middleName":"","lastName":"Bakır","suffix":""},{"id":277854835,"identity":"856bd1fd-94c1-4056-a1ae-30584abee77c","order_by":4,"name":"Suha Goksel","email":"","orcid":"","institution":"Maslak Acibadem Hospital","correspondingAuthor":false,"prefix":"","firstName":"Suha","middleName":"","lastName":"Goksel","suffix":""},{"id":277854836,"identity":"639afaa0-cee8-4d9f-a40d-a8e73540ed01","order_by":5,"name":"Oktar Asoglu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYDACHhiDnYHxAQPDAWK0MEMZzAzMBiRrYZMgSgs/z/mDnytq6uTknXnMqnlq7sjxMzA/fHQDjxbJ3mZmyTPHDhsbHuYxu81z7JmxZAObsXEOHi0G55kZgIoOJG5sBmlhO5y44QAPmzQBLcw/G/7VgbUU8/wjRsvZZjbJxjbmxPnMPGbMvG1EaJHsOWxm2dh32NiAma1Yci6QIdlMwC/8PImPbzZ8A4ZYe/PGD2++HZbjZ29++BifFoQLDzAwMIGTAjMBlXAg38DAwPiDWNWjYBSMglEwogAA3bhITaM+JEEAAAAASUVORK5CYII=","orcid":"","institution":"Bogazici Academy for Clinical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Oktar","middleName":"","lastName":"Asoglu","suffix":""}],"badges":[],"createdAt":"2024-03-06 11:19:46","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4020628/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4020628/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11701-024-01922-w","type":"published","date":"2024-03-30T15:01:24+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":52538030,"identity":"78508b94-2860-4611-8a58-0c27cb605133","added_by":"auto","created_at":"2024-03-12 16:53:49","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":92140,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eKaplan-Meier curves of disease-free survival (a) and overall survival (b).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage126.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4020628/v1/4e1ba8e050051bf90a2fc891.jpeg"},{"id":53869866,"identity":"c35ed089-aef6-4ce2-a798-85fbe1cc1f8a","added_by":"auto","created_at":"2024-04-01 15:12:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":366344,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4020628/v1/72ebb2d2-992a-49a2-911d-f0e17beec707.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perioperative and Long-Term Oncological Outcomes of Robotic versus Laparoscopic Total Mesorectal Excision: A Retrospective study of 672 Patients","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSince its introduction in the 1980s, Total Mesorectal Excision (TME) has become a widely adopted technique, significantly enhancing local control post-surgery and remaining a pivotal aspect of rectal cancer surgery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The standard of surgical therapy now includes laparoscopic TME (L-TME), which is universally approved and carried out. L-TME has been shown in many randomized trials to have superior short-term oncological safety, less postoperative pain, improved cosmetic outcomes, faster recovery, and shorter hospital stay than open surgery. Nevertheless, laparoscopic surgery has numerous potential drawbacks, despite its clinical efficacy as a surgical approach for rectal cancer [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These include the high conversion rate to open surgery and the limited visibility due to unstable cameras [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Notably, due to the limitations of the limited pelvic anatomy, the laparoscopic approch poses technical obstacles in the successful treatment of low rectal cancer, particularly in cases with bulky tumors and in male or overweight patients undergoing neoadjuvant chemoradiotherapy (NCRT).\u003c/p\u003e \u003cp\u003eTheoretically, in an attempt to overcome the drawbacks of laparoscopy, robotic surgery was developed and could provide benefits in limited spaces as for pelvic surgery. Robotic approach has been proving to be safe and to provide good short- and mid-term oncological outcomes for rectal cancer surgery [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Besides improved dexterity, the robotic platform provides robust, readily adjustable three-dimensional imaging and a stable platform for surgeons, minimizing fatigue and improving comfort during rectal dissection [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study aims to compare the perioperative and long-term oncological outcomes of L-TME and robotic TME (R-TME).\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eThis retrospective study evaluated a consecutive series of patients with rectal cancer undergoing either L-TME or R-TME surgery between January 2013 and June 2023. Data were extracted from a prospectively maintained surgical database. This study was conducted in compliance with the Principles of the Declaration of Helsinki. Informed consent was obtained from each patient.\u003c/p\u003e \u003cp\u003ePrimary aim was to report perioperative and long-term oncological outcomes.\u003c/p\u003e \u003cp\u003eInclusion criteria were: 1) rectal adenocarcinoma; 2) tumor location (15 cm from the anal verge, AV); 3) clinical TNM stage I\u0026ndash;III; 4) absence of distant metastases and synchronous tumors; 5) sphincter-saving TME or abdominoperineal resection (APR); 6) elective surgery; 7) curative intent surgery.\u003c/p\u003e \u003cp\u003eExclusion criteria were: 1) sigmoid resections; 2) Hartmann\u0026rsquo;s resection; 3) local excision; 4) sistemic metastases; 5) palliative surgery.\u003c/p\u003e \u003cp\u003eThe boundary between the anal mucosa and the perineal skin was defined as AV. The distance between the tumor's caudal border and the anal margin was measured through rectal magnetic resonance imaging (MRI), flexible sigmoidoscopy, and digital rectal examination.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePreoperative protocol\u003c/h2\u003e \u003cp\u003ePreoperative staging included chest X-ray, carcinoembryonic antigen (CEA) levels, flexible or virtual colonoscopy, torax/abdominopelvic CT and MRI of the pelvic phased array.\u003c/p\u003e \u003cp\u003eNCRT included: 1) Long-term neoadjuvant chemoradiotherapy with concurrent chemotherapy using capecitabine (1600 mg/m\u003csup\u003e2\u003c/sup\u003e daily during radiotherapy), with a total dose of 50 Gy given in 25 fractions over five weeks. Surgery was undertaken within the timeframe of 4 to 8 weeks following the conclusion of chemoradiotherapy; 2) total neoadjuvant treatment consists of NCRT followed by consolidation chemotherapy. Consolidation chemotherapy involved concurrent administration of oxaliplatin (85 mg/m\u0026sup2;) and leucovorin (400 mg/m\u0026sup2;) biweekly, followed by a bolus injection of 5-fluorouracil (5-FU) (400 mg/m\u0026sup2;), and then infusion with 5-FU (2400 mg/m\u0026sup2;). Following June 2018, the consolidation regimen was changed to include capecitabine (1000 mg/m\u0026sup2;) twice daily on days 1\u0026ndash;14 in addition to oxaliplatin (130 mg/m\u0026sup2;) on day one; this was repeated every three weeks for eight cycles; 3) A total of 25 Gy was given in five fractions over 5\u0026ndash;7 days to the short-course neoadjuvant radiotherapy group. Within one to four weeks following the end of neoadjuvant radiation therapy, surgery was performed. When there was no chance of positive lateral margins, patients were given short-course radiotherapy.\u003c/p\u003e \u003cp\u003e Without the addition of oral antibiotics, all patients underwent oral mechanical bowel preparation. One hour prior to the start of the surgical incision, a single 400 mg intravenous dosage of ciprofloxacin was given.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSurgical technique\u003c/h2\u003e \u003cp\u003eA single surgeon (O.A.), with over twenty years of experience in oncological colorectal surgery, performed all surgical procedures. The surgeries were performed at Maslak Acibadem Hospital in Istanbul, Turkey and Liv Hospital, Department of General Surgery, Istanbul, Turkey. Every patient had a detailed discussion regarding the surgical strategy, which was decided by the surgeon after considering the patient's preferences and the surgeon's assessment. Before the procedure, every patient was given thorough instructions detailing the benefits and drawbacks of both laparoscopic and robotic approach. Both laparoscopic and robotic surgical procedures were previously described in detail [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Da Vinci Si\u0026reg; or Xi\u0026reg; platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA) was used in the R-TME group.\u003c/p\u003e \u003cp\u003eAny unintended laparotomy that occurred during surgery, regardless of the extent of the incision, was referred to as a conversion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePathological report\u003c/h2\u003e \u003cp\u003eDuring the data evaluation process, pathological staging was modified to conform to the 8th edition staging criteria of the American Joint Committee on Cancer (AJCC) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Tumor size, number of harvested lymph nodes, distal resection margin (DRM), circumferential resection margin (CRM), and integrity of the mesorectum were all determined by a thorough analysis of all pathology specimens. The criteria established by Quirke et al. were used to assess the mesorectum's quality after dissection [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Positive CRM was described as direct tumor expansion that occurred within 1 mm of the resected specimen's radial, non-peritonealized surface [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative outcomes and follow-up\u003c/h2\u003e \u003cp\u003eThe Clavien-Dindo classification was used to assess postoperative complications, which are defined as unfavorable events that occur within 30 days following surgery [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Anastomotic leaks were diagnosed and treated in accordance with the protocols set by the International Study Group of Rectal Cancer [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe follow-up measures included thoraco-abdominopelvic CT assessment every year, colonic examinations at the first, third, fifth, and tenth years after surgery, and monitoring of oncological markers (CEA, carbohydrate antigen 19\u0026thinsp;\u0026minus;\u0026thinsp;9) every three months.\u003c/p\u003e \u003cp\u003eDisease-free survival (DFS) was estimated from the date of surgery to the tumor's recurrence, whereas overall survival (OS) was calculated from the date of surgery to the date of death or the last follow-up. Histological confirmation or radiographic identification of expanding lesions established the diagnosis of recurrence. The STROBE declaration principles for cohort studies were followed by this study [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using IBM SPSS Statistics for Windows, version 27 (IBM Corp., Armonk, NY, USA) and 95% confidence level was used. For categorical (qualitative) variables, frequency and percentage (n (%)), for numerical (quantitative) variables mean, standard deviation (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;ss), minimum, maximum statistics are given. In the pairwise comparison of the measurements determined in the study according to the groups, LSD/Mann Whitney One-way ANOVA/Kruskal Wallis test was used for intergroup comparisons and Chi-square test was used for the relationships between grouped variables. Chi-square test is a test technique used to determine the relationships between grouped variables. LSD/Mann Whitney is a test technique used to compare two independent groups in terms of a quantitative variable. One-way ANOVA/Kruskal Wallis is a test technique used to compare more than two independent groups (k\u0026thinsp;=\u0026thinsp;group\u0026thinsp;\u0026gt;\u0026thinsp;2) in terms of a quantitative variable.\u003c/p\u003e \u003c/div\u003e"},{"header":"Result","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eClinical outcomes\u003c/h2\u003e \u003cp\u003eA total of 672 patients with rectal cancer were enrolled into two groups: L-TME group (n\u0026thinsp;=\u0026thinsp;489, 72.7%) and R-TME (n\u0026thinsp;=\u0026thinsp;183, 37.3%). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows patients\u0026rsquo; clinical and demographic details. Patients in the R-TME group were younger (54.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8 and 57.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8 years for R-TME and L-TME, respectively) (p\u0026thinsp;=\u0026thinsp;0.007). Male patients made up to 54% of the L-TME group and 75.4% of the R-TME group, respectively. This was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatients characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR-TME (n\u0026thinsp;=\u0026thinsp;183)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL-TME (n\u0026thinsp;=\u0026thinsp;489)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.007 \u003csup\u003e\u003cem\u003et\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e138 (75.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e280 (57.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.008\u003csup\u003e\u003cem\u003eK\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (24.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e209 (42.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.010 \u003csup\u003e\u003cem\u003et\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.010 \u003csup\u003et\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e138 (75.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e323 (66%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e3\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (13.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e118 (24%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.994\u0026thinsp;\u0026plusmn;\u0026thinsp;2.622\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.740\u0026thinsp;\u0026plusmn;\u0026thinsp;2.537\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.252 \u003csup\u003e\u003cem\u003et\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocalisation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMid-low\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e156 (85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e267 (54.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001 \u003csup\u003e\u003cem\u003eK\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eProximal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e222 (45.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eMean: Average SS: Standard Deviation t: Independent sample t-test K: Pearson chi-square test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eThe American Society of Anesthesiologists Score: ASA Body Mass Index (BMI)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMid-low rectal cancers were significantly more common in the R-TME group (85% and 54.6% for R-TME and L- TME, respectively) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePerioperative outcomes\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e lists the perioperative outcomes. No cases of 30-day death was reported. With R-TME, the operation time was substantially longer (158.9\u0026thinsp;\u0026plusmn;\u0026thinsp;39.1 vs. 116.1\u0026thinsp;\u0026plusmn;\u0026thinsp;31.7 min, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In terms of estimated blood loss and postoperative hospital stay, there was no significant difference seen. While the majority of patients in both groups were cT3 and node-positive, there was a greater percentage of cT4 patients in the L-TME group (14.8% in R-TME and 24% in L-TME, respectively). Neoadjuvant therapy was administered to most patients however, the R-TME group received more (84.1% and 52.3% for R-TME and L-TME, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerioperative outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR-TME (n\u0026thinsp;=\u0026thinsp;183)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL-TME (n\u0026thinsp;=\u0026thinsp;489)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall operation time, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e158.9\u0026thinsp;\u0026plusmn;\u0026thinsp;39.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e116.1\u0026thinsp;\u0026plusmn;\u0026thinsp;31.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001 \u003csup\u003e\u003cem\u003et\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital stay, days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.946\u0026thinsp;\u0026plusmn;\u0026thinsp;1.135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.675 \u003csup\u003e\u003cem\u003et\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Stage, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ecT1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.291 \u003csup\u003ez\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e0.369\u003c/p\u003e \u003cp\u003e0.032\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ecT2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (7.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ecT3\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e132 (72.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e316 (64.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ecT4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e117 (24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ecN negative\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (21.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e113 (23.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.308\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ecN positive\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e144 (78.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e376 (76.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoadjuvant treatment, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e154 (84.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e256(52.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001 \u003csup\u003e\u003cem\u003ez\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (15.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e233 (47.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTME procedure, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAPR\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eAnterior resection\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eLow-anterior resection\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eIntersphincteric resection\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eSphincter preserving\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.7%)\u003c/p\u003e \u003cp\u003e16 (8.7)\u003c/p\u003e \u003cp\u003e100 (54.6)\u003c/p\u003e \u003cp\u003e64 (35)\u003c/p\u003e \u003cp\u003e180 (98.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (5%)\u003c/p\u003e \u003cp\u003e152 (31.1)\u003c/p\u003e \u003cp\u003e223(45.6)\u003c/p\u003e \u003cp\u003e89(18.2)\u003c/p\u003e \u003cp\u003e464 (95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001 \u003csup\u003e\u003cem\u003eK\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003cp\u003e0.187\u003c/p\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003cp\u003e0.274\u003c/p\u003e\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDiverting ileostomy\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e157 (85.8)\u003c/p\u003e \u003cp\u003e23(12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e231 (47.3)\u003c/p\u003e \u003cp\u003e233 (47.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ez\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eConversion rates, n (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.146 \u003csup\u003ez\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eMean: Average SS: Standard Deviation t: Independent sample t-test z: Two ratio z-test\u003c/em\u003e K: Pearson chi-square test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eTotal mesorectal excision : TME Abdominoperineal resection :APR\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe R-TME group's patients received more low anterior resections (54.6% vs. 45.6% p\u0026thinsp;=\u0026thinsp;0.187) and intersphincteric resections (35% vs. 18.2% p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) because they mostly had distal tumors. Conversely, the L-TME group had a higher frequency of proximal tumors, and there was a marked predilection for anterior resections (8.7% vs. 31.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in this group.\u003c/p\u003e \u003cp\u003eThree patients (1.7%) had APR in the R-TME group, while twenty-five patients (5%) received APR in the L-TME group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Three patients (0.6%) in the L-TME group had open conversions, whereas there were none in the R-TME group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eHistopathological outcomes\u003c/h2\u003e \u003cp\u003eEven though R-TME had a larger mean number of excised lymph nodes, the difference between the two groups was not statistically significant (24.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3 vs 23.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8, p\u0026thinsp;=\u0026thinsp;0.125). The mean distance of the resection margin (DRM) was longer in L-TME (15.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.7 mm and 20.8\u0026thinsp;\u0026plusmn;\u0026thinsp;15.6 mm for R-TME and L-TME, respectively). Eight (4.3%) patients in R-TME and sixteen (3.2%) patients in L-TME had positive CRM involvement (p\u0026thinsp;=\u0026thinsp;0.236).\u003c/p\u003e \u003cp\u003eA statistical difference was reported between R-TME and L-TME regarding specimen quality (98.9% vs. 94.2%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There were no notable variations in other histopathology results (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHistopathological outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR-TME (n\u0026thinsp;=\u0026thinsp;183)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL-TME (n\u0026thinsp;=\u0026thinsp;489)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDRM, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.8\u0026thinsp;\u0026plusmn;\u0026thinsp;15.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001 \u003csup\u003e\u003cem\u003et\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvolved CRM, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (3.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.236\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor size, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.4\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.2\u0026thinsp;\u0026plusmn;\u0026thinsp;18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001 \u003csup\u003e\u003cem\u003et\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMacroscopic quality of TME\u003c/p\u003e \u003cp\u003especimen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eComplete\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e181 (98.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e461 (94.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001 \u003csup\u003e\u003cem\u003ez\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIncomplete\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (5.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological Stage, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eypT0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.222\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.013\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eypT1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (13.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (8.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eypT2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81 (16.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eypT3\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (40.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e250 (51.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eypT4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 (18.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eypN negative\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e178(60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e165(54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.052 \u003csup\u003e\u003cem\u003eK\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eypN positive\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119(40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e143(46%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHarvested LN, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.125\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eMean: Average SS: Standard Deviation t: Independent sample z: Two ratio z-test\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eCRM: circumferential resection margin, DRM: Distal resection margin, LN: lymph node\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative complications\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows that the overall complication rate was 17.5% for L-TME and 16.8% for R-TME (p\u0026thinsp;=\u0026thinsp;0.132). Symptomatic anastomotic leakage occurred in 16 (8.7%) R-TME patients and 47 (9.6%) L-TME patients. All instances of anastomotic leakage were managed conservatively, involving the maintenance of pelvic drainage until clinical resolution of the infection, with selective use of endo-sponge drainage.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative complications\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR-TME (n\u0026thinsp;=\u0026thinsp;183)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL-TME (n\u0026thinsp;=\u0026thinsp;489)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall complications, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (17.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.034 \u003csup\u003e\u003cem\u003ez\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic stricture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"9\" rowspan=\"10\"\u003e \u003cp\u003e0.401\u003c/p\u003e \u003cp\u003e0.176\u003c/p\u003e \u003cp\u003e0.5\u003c/p\u003e \u003cp\u003e0.257\u003c/p\u003e \u003cp\u003e0.351\u003c/p\u003e \u003cp\u003e0.280\u003c/p\u003e \u003cp\u003e0.460\u003c/p\u003e \u003cp\u003e0.397\u003c/p\u003e \u003cp\u003e0.238\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRectourethral fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRectovaginal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColonic ischemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIleus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (2.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvic hematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (1.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvic abscess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavien\u0026ndash;Dindo morbidity, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u0026ndash;II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (10.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u0026ndash;IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ez: Two ratio z-test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRectovaginal fistula occurred in five patients in the L-TME group and two patients in the R-TME group.\u003c/p\u003e \u003cp\u003eTwo patients, one with R-TME and the other with L-TME, experienced an immediate onset of colonic ischemia. On the third postoperative day, these patients underwent an urgent laparoscopic colon resection and re-anastomosis.\u003c/p\u003e \u003cp\u003eAccording to Clavien-Dindo's classification, there was no significant difference in postoperative morbidity\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eOncological outcomes\u003c/h2\u003e \u003cp\u003eThe mean follow-up were 70.7 months (interval 18\u0026ndash;138) for R\u0026ndash;TME and 60 months (interval 14\u0026ndash;140) for L\u0026ndash;TME. R-TME and L-TME had 5-year OS rates of 89.6% and 88.7%, respectively. The 5-year DFS rates for R-TME and L-TME were 81.1% and 84.1%. The Kaplan\u0026ndash;Meier curves for OS and DFS are reported in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eLocal recurrence occurred in fourteen (7.6%) of the R-TME group and in thirty-one (6.3%) of the L-TME group of patients (p\u0026thinsp;=\u0026thinsp;0.276). During the follow-up period, 20 patients (10.9%) in the R-TME group and 62 patients (12.6%) in the L-TME group were found to have distant metastases. However, there was no significant statistical difference between the groups.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussions","content":"\u003cp\u003eThe purpose of this study was to compare the perioperative and long-term oncological results of L-TME and R-TME patients with rectal cancer. R-TME was associated with a statistically significant prolonged operation time compared to L-TME (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There were three (0.6%) conversions to open surgery in L-TME, and none in the R-TME group. The conversion rates in previously published randomized controlled trials showed different rates: COLOR II (16%), CLASICC (16%), ACOSOG Z6051 (11%), ALaCaRT (9%), and COREAN (1.2%) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The present study showed that the conversion rate (0.6%) is significantly lower than the aforementioned studies. This may be explained by the standardization of techniques, surgeons' experiences, and the learning curve [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A study conducted between 2005 and 2012 by the same group showed a 6.5% conversion rate in L-TME [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. We believe that conversion to open surgery had a negative effect on the survival of rectal cancer patients. In fact, the 10-year results of the aforementioned study showed inferior outcomes in the converted group (DFS 50.0% vs. 78.3% and OS 46.7% vs. 68.5%) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere was no statistically significant difference in the CRM involvement rate between L-TME and R-TME (p\u0026thinsp;=\u0026thinsp;0.236). Completeness of mesorectum was higher in R-TME with statistical difference (98.9% vs. 94.2%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mesorectal completeness and margin-free CRM are key histopathologic factors for achieving improved local recurrences rates [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The overall CRM positivity rates were 19% in a Dutch study, 13% in the CLASSİC trial, 10.0% COLOR II, 5.7% ROLARR, and 4.1% COREAN trial [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In the current investigation the R-TME and L-TME showed 3.2% and 4.3% CRM involvement, respectively. There was no statistically significant difference in the CRM involvement between the laparoscopic and robotic low-anterior resection groups in the prospective study conducted by Baik et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe quality of specimen is considered as a parameter for the evaluation of prognosis. The majority of studies consistently showed that preventing incomplete mesorectum might greatly enhance OS and dramatically lower the chance of recurrence following TME surgery. Classification of a mesorectal specimen was described by Quirke et al. in the CR07 trial, which included 1,156 patients [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Surgery was considered complete in 604 (52%), near complete in 398 (34%), and incomplete in 154 (13%). Additionally, they observed that the three-year local recurrence for each of the three groups was 4% for complete, 7% for nearly complete, and 13% for incomplete (p\u0026thinsp;=\u0026thinsp;0.0039), indicating the greatest possible association between the local recurrence and mesorectal integrity. According to our research, the robotic group had more mesorectal completeness (98.9% vs. 94.2% p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This outcome is in line with our earlier results [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eComparable 5-year OS and DFS rates were seen in the L-TME and R-TME groups (p\u0026thinsp;=\u0026thinsp;0.741 and p\u0026thinsp;=\u0026thinsp;0.368., respectively). This study revealed similar results in terms of local recurrence rate (p\u0026thinsp;=\u0026thinsp;0.274). The distant metastasis rates were also comparable in L-TME and R-TME (p\u0026thinsp;=\u0026thinsp;0.27). In contrast to the present study, our previous research, which compared L-TME and R-TME procedures in male patients with mid-low rectal tumors, revealed substantial differences [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Specifically, the R-TME group of male patients exhibited significantly superior rates of improved local recurrence, as well as mesorectal completeness. These studies once again demonstrated that robotic approach can potentially overcome some technical challenges related to pelvic anatomical differences between sexes compared to laparoscopy. However, our two previously published studies indicated that robotic approach did not provide any benefit in female patients with rectal cancer when compared with laparoscopy [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is a possible bias in the present study between the two groups: 1) since robotic surgery was introduced in our study in 2013, laparoscopic cases performed during the same period were included for comparison; 2) the robotic approach was preferred in male patients; 3) due to the high cost of robotics in Turkey, we opted for the robotic approach in technically difficult cases (narrow pelvis, obese patients).\u003c/p\u003e \u003cp\u003eThis study has several limitations. Firstly, it constitutes a retrospective analysis of data collected prospectively from a single surgeon's experience. Secondly, the number of R-TME procedures is lower than L-TME. To validate our results, a large prospective randomized study is necessary. Thirdly, we did not evaluate comparative functional outcomes. Lastly, cost-effectiveness was not investigated in this study. However, the strength of this study lies in its long median follow-up and standardized single surgeon setting, coupled with extensive colorectal expertise.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study reports a higher rate of mesorectal integrity, no conversions to open and/or abdominoperineal resection, and a lower postoperative complication rate in patients undergoing R-TME. R-TME was associated with a longer operative time. Both R-TME and L-TME showed good OS, DFS, and local recurrence rates.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: Oktar Asoglu, Niyaz Shadmanov, Vusal Aliyev; Methodology: Oktar Asoglu; Niyaz Shadmanov; Formal analysis and investigation: Niyaz Shadmanov, Oktar Asoglu; Writing- original draft preparation: Niyaz Shadmanov, Vusal Aliyev,\u0026nbsp;Oktar Asoglu; Writing- review and editing: Niyaz Shadmanov, Vusal Aliyev, Guglielmo Niccol\u0026ograve; Piozzi, Barıs Bakır, Suha Goksel, Oktar Asoglu; Supervision: Oktar Asoglu\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure of potential conflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in compliance with the Principles of the Declaration of Helsinki. Institutional Review Board (IRB) approval was waived following the retrospective nature of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInformed consent was obtained from all individual participants included in the study.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used or analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHeald RJ, Ryall RD (1986) Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1:1479\u0026ndash;1482\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 2005;365(9472):1718\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKang SB, Park JW, Jeong SY, Nam BH, Choi HS, Kim DW et al. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol. 2010;11(7):637\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang M-J, Liang J-L, Wang H, et al. Laparoscopic assisted versus open surgery for rectal cancer: a meta-analysis of randomized controlled trials on oncologic adequacy of resection and long-term oncologic outcomes. Int J Colorectal Dis. 2011;26: 415\u0026ndash;421.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNg SSM, Lee JFY, Yiu RYC, et al. Long-term oncologic outcomes of laparoscopic versus open surgery for rectal cancer: a pooled analysis of 3 randomized controlled trials. Ann Surg. 2014;259:139\u0026ndash;147.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark 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\u0026ndash;137.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorcione F, Esposito C, Cuccurullo D, et al. Advantages and limits of robot-assisted laparoscopic surgery: preliminary experience. Surg Endosc. 2005;19:117\u0026ndash;119.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBademler S, Koza KB, Ucuncu MZ, Tokmak H, Bakir B, Oral EN, et al. Standardized Laparoscopic Sphincter-preserving Total Mesorectal Excision For Rectal Cancer: Median of 10 Years' Long-term Oncologic Outcome in 217 Unselected Consecutive Patients. Surg Laparosc Endosc Percutan Tech 2019; 29: 354\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAliyev V, Tokmak H, Goksel S, Guven K, Bakir B, Kay H, et al. Robotic Sphincter-Saving Total Mesorectal Excision for Rectal Cancer Treatment: A Single-Surgeon Experience in 103 Consecutive Male Patients. Surg Technol Int 2020; 37: 93\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAliyev V, Tokmak H, Goksel S, Meric S, Acar S, Kaya H, et al. The long-term oncological outcomes of the 140 robotic sphincter-saving total mesorectal excision for rectal cancer: a single surgeon experience. J Robot Surg 2020; 14: 655\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeiser MR (2018) AJCC 8th edition: colorectal cancer. Ann Surg Oncol 25:1454\u0026ndash;1455.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuirke P, Steele R, Monson J, Grieve R, Khanna S, Couture J et al (2009) Efect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet 373:821\u0026ndash;828\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNagtegaal ID, Marijnen CA, Kranenbarg EK, van de Velde CJ, van Krieken JH, Pathology Review C et al (2002) Circumferential margin involvement is still an important predictor of local recurrence in rectal carcinoma: not one millimeter but two millimeters is the limit. Am J Surg Pathol 26:350\u0026ndash;357\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. 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Lancet Oncol 2013;14:210\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFleshman J, Branda ME, Sargent DJ, Boller AM, George VV, Abbas MA et al. Disease-free Survival and Local Recurrence for Laparoscopic Resection Compared With Open Resection of Stage II to III Rectal Cancer: Follow-up Results of the ACOSOG Z6051 Randomized Controlled Trial. Ann Surg. 2019;269(4):589\u0026ndash;595. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/SLA.0000000000003002\u003c/span\u003e\u003cspan address=\"10.1097/SLA.0000000000003002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 30080730; PMCID: PMC6360134.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStevenson ARL, Solomon MJ, Lumley JW et al (2015) Efect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the AlaCart randomized clinical trial. JAMA 314(13):1356\u0026ndash;1363\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsoglu O, Kunduz E, Rahmi Serin K et al (2014) Standardized laparoscopic sphincter preserving total mesorectal excision for rectal cancer: long-term oncologic outcome in 217 unselected consecutive patients. Surg Laparosc Endosc Percutan Tech 24:145\u0026ndash;152\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAliyev V, Arslan NC, Goksoy B, Guven K, Goksel S, Asoglu O. Is robotic da Vinci Xi\u0026reg; superior to the da Vinci Si\u0026reg; for sphincter-preserving total mesorectal excision? Outcomes in 150 mid-low rectal cancer patients. J Robot Surg. 2022;16(6):1339\u0026ndash;1346.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBademler S, Koza KB, Ucuncu MZ, Tokmak H, Bakir B, Oral EN, et al. 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PMID: 37955804.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Total mesorectal excision, Robotic approach, Laparoscopic approach, Rectal cancer, Oncological outcomes","lastPublishedDoi":"10.21203/rs.3.rs-4020628/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4020628/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackround\u003c/h2\u003e \u003cp\u003eAlthough there's growing information about the long-term oncological effects of robotic surgery for rectal cancer, the procedure is still relatively new. This study aimed to assess the long-term oncological results of total mesorectal excision (TME) performed laparoscopically versus robotically in the setting of rectal cancer.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eRestrospective analysis of a prospectively maintained database. A total of 489 laparoscopic (L-TME) and 183 robotic total mesorectal excisions (R-TME) were carried out by a single surgeon between 2013 and 2023. The groups were compared in terms of perioperative and long-term oncological outcomes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn the R-TME and L-TME groups, male sex predominated (75.4% and 57.3%, respectively), although the robotic group was significantly greater (p\u0026thinsp;=\u0026thinsp;0.008). There was no conversion in R-TME group, whereas three (0.6%) converted to open surgery in L-TME group. The R-TME group had a statistically significant higher number of distal rectal tumors (85%) compared to the L-TME group (54.6%). Only three (1.7%) patients in the R-TME group received abdomineperineal resection (APR); in contrast, 25 (5%) patients in the L-TME group received APR (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). For R-TME, the mean follow-up was 70.7 months (range 18\u0026ndash;138) and for L-TME, it was 60 months (range 14\u0026ndash;140). Frequency of completed mesorectum was significantly greater in R-TME group (98.9% vs 94.2%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The 5-year overall survival rates for R-TME and L-TME groups were 89.6% and 88.7%, respectively. The 5-year disease-free survival for R-TME and L-TME groups were 84.1% and 81.1%, respectively. The local recurrences rates were 7.6% and 6.3%, respectively in R-TME and L-TME groups (p\u0026thinsp;=\u0026thinsp;0.274).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eR-TME is characterized by no conversion and improved mesorectal integrity. R-TME had longer operation time. The long-term oncological outcomes were comparable between groups.\u003c/p\u003e","manuscriptTitle":"Perioperative and Long-Term Oncological Outcomes of Robotic versus Laparoscopic Total Mesorectal Excision: A Retrospective study of 672 Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-12 16:53:45","doi":"10.21203/rs.3.rs-4020628/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2024-03-24T12:31:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-21T16:22:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"10f68d79-bfd8-4157-81ab-0565d2fd21d0","date":"2024-03-12T09:19:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-10T08:51:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-09T00:53:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-08T07:54:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2024-03-06T10:10:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f98a932e-4da5-4714-a240-836708599907","owner":[],"postedDate":"March 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-04-01T15:08:43+00:00","versionOfRecord":{"articleIdentity":"rs-4020628","link":"https://doi.org/10.1007/s11701-024-01922-w","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2024-03-30 15:01:24","publishedOnDateReadable":"March 30th, 2024"},"versionCreatedAt":"2024-03-12 16:53:45","video":"","vorDoi":"10.1007/s11701-024-01922-w","vorDoiUrl":"https://doi.org/10.1007/s11701-024-01922-w","workflowStages":[]},"version":"v1","identity":"rs-4020628","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4020628","identity":"rs-4020628","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}