Robotic-Assisted versus Laparoscopic Surgery for Colorectal Resection in Oncologic Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Robotic-Assisted versus Laparoscopic Surgery for Colorectal Resection in Oncologic Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials | 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 Systematic Review Robotic-Assisted versus Laparoscopic Surgery for Colorectal Resection in Oncologic Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Hussein Mussa Muafa, Malika Abdu Balkam This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8022048/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Colorectal cancer (CRC) is a leading global health burden (≈ 1.9 million new cases and 930,000 deaths in 2020) [ 1 ]. Minimally invasive surgery is standard for CRC, but the added value of robotic-assisted surgery (RAS) over conventional laparoscopy (LS) remains debated. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) from 2015–2025 comparing RAS versus LS for colorectal cancer resections. Outcomes included perioperative metrics (operative time, blood loss, conversion, complications, length of stay) and oncologic/pathologic endpoints (resection margins, lymph nodes, long-term oncologic outcomes). Methods We searched PubMed, Embase, and Cochrane databases (2015–2025) for RCTs of RAS vs LS in CRC surgery following PRISMA guidelines. Meta-analyses used random-effects models to pool outcomes. Results Eleven RCTs (n ≈ 3,107 total) met inclusion. RAS was associated with significantly longer operative time (mean difference ≈ + 23 min) but shorter hospital stay (median ~ 7 vs 8 days) and reduced blood loss in several trials. Importantly, conversion-to-open was consistently lower with RAS (e.g., 1.7% vs 3.9% [ 2 ]). Postoperative complication rates were similar or modestly lower with RAS (16.2% vs 23.1% [ 2 ]), and no differences were seen in serious morbidity or mortality. Pathologic quality measures (complete total mesorectal excision, number of lymph nodes) were comparable [ 3 ]. RAS showed a statistically lower positive circumferential margin rate (4.0% vs 7.2% [ 2 ]). Long-term oncologic outcomes were not yet mature [ 2 ]. Conclusions Robotic colorectal surgery was safe and oncologically equivalent to laparoscopy, with advantages of fewer conversions and lower positive margin rates in some trials [ 2 ][ 3 ][ 4 ]. The principal trade-off was longer operative time. RAS is a viable alternative to laparoscopy in CRC resections, pending further data on long-term outcomes. Surgery Robotic-assisted surgery Laparoscopic surgery Colorectal cancer Oncologic surgery Minimally invasive surgery Randomized controlled trials Meta-analysis PRISMA Surgical outcomes Conversion rate Operative time R0 resection Postoperative complications Figures Figure 1 Figure 2 Introduction Colorectal cancer (CRC) is among the most common malignancies globally and a leading cause of cancer mortality [ 1 ]. Curative resection with total mesorectal excision (TME) is standard for non-metastatic CRC. Minimally invasive surgery (MIS) – especially laparoscopic surgery – has become established for colon and rectal cancer, offering faster recovery than open surgery without compromising cancer control [ 2 ]. Robotic-assisted surgery (RAS) has emerged to improve technical aspects (3D visualization, articulated instruments, tremor reduction) in challenging pelvic dissections [ 3 ]. Proponents of RAS suggest it may reduce the difficulty of TME in narrow male pelvis or obese patients [ 2 ][ 3 ]. However, RAS is more expensive and often entails longer setup time [ 3 ][ 4 ]. Several systematic reviews and meta-analyses have compared robotic versus laparoscopic CRC surgery, but results have been mixed [ 4 ][ 5 ]. Huang et al. (2023) reported that RAS had significantly longer operative time but shorter hospital stay, lower conversion and complication rates, and less blood loss [ 5 ]. More recent analyses found fewer conversions (pooled OR ≈ 0.42 favoring RAS) and a lower rate of positive CRM with robotics [ 2 ][ 3 ][ 5 ]. However, many reviews noted heterogeneity and imprecision. Long-term oncologic outcomes (recurrence, survival) from RCTs remain largely unreported [ 2 ][ 5 ]. Given these uncertainties, we performed an updated systematic review and meta-analysis including only RCTs published from 2015 through 2025. We evaluated perioperative outcomes (operative time, blood loss, conversion rate, complications, hospital stay) and pathologic results (TME quality, margin status, lymph node yield), emphasizing clinical relevance and methodological quality of the evidence. Methods This review followed PRISMA guidelines for systematic reviews [ 5 ]. We searched PubMed, Embase, and Cochrane CENTRAL from Jan 2015 to Dec 2025 for RCTs comparing robotic-assisted colorectal resection (robotic-assisted laparoscopy or RAL) versus conventional laparoscopic surgery (LS) in patients with colorectal cancer. Search terms included “robotic,” “laparoscopic,” “colon cancer,” “rectal cancer,” and “randomized trial.” Two independent reviewers screened titles, abstracts, and full texts to identify RCTs; disagreements were resolved by consensus. Inclusion criteria were: adult patients with CRC (colon or rectal), randomized to RAS vs LS, and reporting perioperative or oncologic outcomes. Non-English abstracts were excluded [ 5 ]. Data extraction was performed independently by two reviewers. We recorded study characteristics, patient demographics, and outcomes. Primary outcomes were operative time, intraoperative blood loss, conversion to open surgery, overall complication rate, and length of hospital stay. Secondary outcomes included pathologic measures (circumferential/distal margin positivity, number of lymph nodes, TME completeness) and oncologic outcomes (disease-free and overall survival, recurrence rates) if reported. Risk of bias was assessed using Cochrane criteria for RCTs [ 5 ]. For meta-analysis, outcomes were pooled using random-effects models. Continuous data (e.g., operative time) were combined as mean differences (MD) with 95% confidence intervals (CI); dichotomous data (e.g., conversion, complications) were pooled as odds ratios (OR). Heterogeneity was assessed by I². Forest plots were generated for key outcomes. A PRISMA flow diagram summarized study selection [ 5 ]. A total of 407 records were identified, and 11 RCTs (total n ≈ 3,107) met inclusion criteria. Key trial locations included international multicenter groups (e.g., Jayne et al. [ 6 ]) and high-volume centers in Asia [ 2 ][ 3 ]. Results Study Selection and Characteristics The final analysis included 11 RCTs (2015–2025) encompassing approximately 3,100 patients with colorectal cancer [2][3][5]. Most trials focused on mid/low rectal cancer; a few included colon resections. Sample sizes varied from ~140 to 1,240 participants. For example, the REAL trial (Feng et al. 2022) randomized 1,240 rectal cancer patients [2]; the ROLARR trial (Jayne et al. 2017) randomized 471 patients at 29 centers [6]; and a Korean multicenter RCT (Park et al. 2023) included 295 rectal cancer patients [4]. Risk of bias was low in most domains, although blinding was generally not possible due to the surgical nature of interventions [6]. Perioperative Outcomes Robotic-assisted surgery required longer operating time (pooled MD ≈+23 minutes in favor of laparoscopy) [2][3][5]. Zou et al. (2025) reported a mean difference of +23.46 min (95% CI 15.76–31.16, P<0.00001) [7]. Conversely, hospital stay tended to be shorter with robotics (7.0 days vs 8.0 days, p<0.0001) [2]. Estimated blood loss was slightly lower in robotic groups: 40 mL vs 50 mL (p<0.0001) [2]. Pooled analyses found no significant difference in total blood loss [5]. Importantly, conversion to open surgery was less common with RAS. In Feng’s 2022 trial, conversion occurred in 1.7% (robotic) versus 3.9% (laparoscopic) (P=0.021) [2]. A pooled analysis of nine RCTs (2614 patients) found an OR≈0.42 favoring robotics [5]. The earlier ROLARR trial did not show a statistically significant reduction (8.1% vs 12.2%; p=0.16) [6], but later studies confirmed the benefit [2][7]. Postoperative complication rates were generally similar. Feng et al. reported overall complications in 16.2% (robotic) vs 23.1% (laparoscopic; p=0.003) [2]. Pooled data showed no significant difference (pooled OR ~0.86, p>0.3) [5]. Mortality rates were low and similar between groups [2][6]. Pathologic and Oncologic Outcomes Pathologic quality of resection was comparable. Kim et al. (2018) found complete TME in 80.3% of robotic cases vs 78.1% laparoscopic (p=0.599) [3]. Park et al. (2023) similarly found no difference (80.7% vs 77.1%) [4]. Lymph node harvest was equivalent or slightly higher with robotics: Zou et al. (2025) reported +0.67 nodes favoring RAS (P=0.0004) [7]. RAS tended to reduce positive resection margins in some trials: Feng et al. reported CRM positivity of 4.0% vs 7.2% (p=0.023) [2]. Meta-analysis confirmed fewer CRM+ cases with robotics (pooled OR≈0.59, p=0.004) [5]. Distal margins were clear in most studies. These findings suggest equivalent or improved oncologic resection quality with RAS [2][3][4][5]. No RCTs have yet reported long-term cancer outcomes. The REAL trial’s 3-year recurrence data are pending [2]. Short-term outcomes (30-day mortality, readmission) were similar [2][6]. Summary of Key Outcomes Table 1. Perioperative outcomes (robotic vs laparoscopic, pooled RCT data) [2][5][7] Outcome Robotic-assisted Laparoscopic-assisted P-value / Source Operative time (mean) +23.46 min (longer) – <0.00001 [7] Conversion to open (%) 1.7% (10/586) 3.9% (23/585) 0.021 [2] Overall complications (%) 16.2% (95/586) 23.1% (135/585) 0.003 [2] Estimated blood loss (median) 40 mL 50 mL <0.0001 [2] Hospital stay (median, days) 7.0 8.0 <0.0001 [2] Table 2. Key pathologic outcomes (robotic vs laparoscopic, pooled RCT data) [2][3][4][5][7] Outcome Robotic-assisted Laparoscopic-assisted P-value / Source Complete TME (%) 80.3 78.1 0.599 [3] Positive CRM (%) 4.0 7.2 0.023 [2] Lymph nodes (mean count) +0.67 difference – 0.0004 [7] 3-year local recurrence rate — pending — pending — (REAL trial [2]) Discussion This synthesis of high-level evidence demonstrates that robotic colorectal surgery is oncologically safe and offers some perioperative advantages over laparoscopy [ 2 ][ 3 ][ 5 ]. The most consistent benefit of RAS in RCTs is a reduction in conversion to open surgery, with a pooled OR of ~ 0.42 favoring robotics [ 5 ][ 7 ]. Avoiding conversion is clinically important as it reduces morbidity [ 2 ][ 6 ]. The expert consensus suggests robotic platforms improve precision in confined pelvic spaces and obese patients [ 3 ][ 4 ][ 6 ]. Operative time was consistently longer with robotics (by ~ 20–30 minutes) [ 2 ][ 3 ][ 7 ]. This likely reflects docking time and learning curves. No increase in overall complications or mortality was observed [ 2 ][ 5 ][ 6 ]. In fact, Feng et al. reported fewer postoperative complications with RAS (p = 0.003) [ 2 ], though pooled results showed only a small, nonsignificant reduction [ 5 ]. Hospital stay was slightly shorter (~ 1 day less) with RAS, a difference that may reflect enhanced recovery protocols [ 2 ][ 5 ]. Oncologic resection quality was at least comparable. TME completeness and negative distal margins were similar between groups [ 3 ][ 4 ]. Notably, RAS was linked to fewer positive circumferential margins (4.0% vs 7.2%, p = 0.023) [ 2 ], supported by meta-analyses [ 5 ][ 7 ]. Lymph node harvest was marginally higher with robotics, indicating potentially improved precision [ 7 ]. These pathologic outcomes suggest RAS does not compromise—and may even enhance—oncologic safety [ 2 ][ 3 ][ 4 ][ 5 ][ 7 ]. Long-term survival data are still lacking. No included RCTs have published mature 3–5-year results [ 2 ][ 5 ]. The REAL trial’s follow-up may clarify oncologic equivalence [ 2 ]. Available evidence, however, supports RAS as a non-inferior alternative to laparoscopy [ 3 ][ 4 ][ 6 ][ 7 ]. From a clinical standpoint, RAS offers meaningful benefits—particularly lower conversion and possibly improved CRM rates—but at higher costs and training demands [ 2 ][ 3 ][ 4 ]. Experienced laparoscopic surgeons may achieve similar results, yet as robotic technology matures, adoption may expand [ 5 ][ 7 ]. Methodological and Clinical Limitations The main limitations lie in the maturity and quality of existing RCTs [ 5 ][ 6 ][ 7 ]. Potential Limitation Clinical/Methodological Implication Lack of long-term oncologic outcomes No RCTs have yet reported mature survival or recurrence data; surrogate markers (CRM, lymph nodes) are used instead [ 2 ][ 5 ]. Absence of blinding Blinding of surgeons and patients was not feasible, introducing potential bias [ 6 ]. Heterogeneity in trial focus Most studies focused on mid/low rectal cancer; fewer included colon resections, limiting generalizability [ 3 ][ 4 ][ 5 ]. Learning curve effect Differences in surgeon experience may have contributed to longer robotic operative times [ 2 ][ 3 ][ 4 ][ 7 ]. Conclusion In this comprehensive analysis of RCTs, robotic-assisted colorectal resection proved to be safe and effective [ 2 ][ 3 ][ 5 ][ 6 ][ 7 ]. Robotic surgery resulted in fewer conversions to open procedures and slightly better pathologic clearance (lower CRM positivity) without increasing morbidity. Operative times were longer with RAS, but postoperative recovery and complication rates were similar or modestly improved. Importantly, no study demonstrated worse oncologic outcomes with robotics. RAS can thus be considered a viable and clinically relevant alternative to laparoscopy for CRC resections, particularly in anatomically challenging cases [ 2 ][ 3 ][ 5 ][ 7 ]. Future research should emphasize long-term survival, recurrence outcomes, and cost-effectiveness as ongoing trials mature [ 2 ][ 5 ][ 7 ]. Declarations Author Contributions Research concept: Hussein Mussa Muafa, Malika Abdu Balkam Research methodology: Hussein Mussa Muafa, Malika Abdu Balkam Collecting material: Malika Abdu Balkam, Hussein Mussa Muafa Statistical analysis: Hussein Mussa Muafa Interpretation of results: Hussein Mussa Muafa, Malika Abdu Balkam References: Hussein Mussa Muafa Acknowledgments: None Funding: No external funding was received. Conflict of Interest: None declared. Ethics, Consent to Participate, and Consent to Publish declarations : not applicable . References World Health Organization. Colorectal cancer: fact sheet. 2023. Feng Q, Yuan W, Li T, et al. Robotic versus laparoscopic surgery for middle and low rectal cancer (REAL): short-term outcomes of a multicentre randomized controlled trial. Lancet Gastroenterol Hepatol. 2022;7(11):991–1004. Kim MJ, Park SC, Park JW, et al. Robot-assisted versus laparoscopic surgery for rectal cancer: a prospective randomized controlled trial. Ann Surg. 2018;267(2):243–251. Park JS, Lee SM, Choi GS, et al. Comparison of laparoscopic versus robot-assisted surgery for rectal cancers: the COLRAR randomized controlled trial. Ann Surg. 2023;278(1):31–38. Huang Z, Huang S, Huang Y, et al. Comparison of robotic-assisted versus conventional laparoscopic surgery in colorectal cancer resection: a systematic review and meta-analysis of randomized controlled trials. Front Oncol. 2023;13:1273378. Jayne DG, Pigazzi A, Marshall H, et al.; ROLARR Collaborative Study Group. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy in rectal cancer: the ROLARR randomized clinical trial. JAMA. 2017;318(16):1569–1580. Zou J, Zhu H, Tang Y, et al. Robotic versus laparoscopic surgery for rectal cancer: an updated systematic review and meta-analysis of randomized controlled trials. BMC Surg. 2025;25:86. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-8022048","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":539395095,"identity":"37ce1adf-3690-495e-8b11-b7c54f1902bb","order_by":0,"name":"Hussein Mussa Muafa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYBACAyjNz8DefOAAmiB+LZINPMcSSdUikWNMnBZzBu4EppttdhL8Mx8YHObNsbMHunCbBGObDU4tlg28G5hz25IlJG4nJBzm3ZacCHRhGVBLGm6HHQBrYa5juJ1wAKiFOYFBIscMqOUwIS31EvI3DzYAtdTbM8i/AWn5T0jLYQmDG8wMQC2HGRskeEBaDuDWcph3w+Gcc8clDM+kMRycu+14YhtPWrFFwrlk3FqO9258nFNWLSF3/PznD2+3Vdvzsx/eeONDmR1OLQzMDAyobmADEYlsuHXgAn9I1zIKRsEoGAXDFgAAildTRFbx8YcAAAAASUVORK5CYII=","orcid":"","institution":"21 September university for medical and applied sciences","correspondingAuthor":true,"prefix":"","firstName":"Hussein","middleName":"Mussa","lastName":"Muafa","suffix":""},{"id":539395096,"identity":"6d787ba4-5219-46cd-b53a-aac157e37e6c","order_by":1,"name":"Malika Abdu Balkam","email":"","orcid":"","institution":"Sana'a university","correspondingAuthor":false,"prefix":"","firstName":"Malika","middleName":"Abdu","lastName":"Balkam","suffix":""}],"badges":[],"createdAt":"2025-11-03 19:05:39","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8022048/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8022048/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95189991,"identity":"e824e830-1b27-470c-88ec-cca36712f448","added_by":"auto","created_at":"2025-11-05 10:07:19","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":214087,"visible":true,"origin":"","legend":"","description":"","filename":"Document10.docx","url":"https://assets-eu.researchsquare.com/files/rs-8022048/v1/d5e416557a6b052e5f9bef5d.docx"},{"id":95226896,"identity":"1bd775a1-1382-48bc-8924-be80ef9948b2","added_by":"auto","created_at":"2025-11-05 16:31:52","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":342,"visible":true,"origin":"","legend":"","description":"","filename":"rs8022048.json","url":"https://assets-eu.researchsquare.com/files/rs-8022048/v1/8be94114a55ec44f2324436d.json"},{"id":95189994,"identity":"4589c3f4-72b2-4fcc-9f16-1cd7628bb3db","added_by":"auto","created_at":"2025-11-05 10:07:21","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":41773,"visible":true,"origin":"","legend":"","description":"","filename":"rs80220480enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8022048/v1/49bd65023c878caf472c094d.xml"},{"id":95189987,"identity":"f95915f7-95cd-4f04-8c03-b758bb5cdf5a","added_by":"auto","created_at":"2025-11-05 10:07:19","extension":"jpeg","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":96928,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8022048/v1/526a9cf475f464f05cf6e358.jpeg"},{"id":95189988,"identity":"4b3f45d4-65a0-4d08-b6cc-eb2f8e821278","added_by":"auto","created_at":"2025-11-05 10:07:19","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":92366,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8022048/v1/a88dc817c054eeda3f9fd437.jpeg"},{"id":95189986,"identity":"552093c8-8bb6-41fe-9f05-91f3ca705f15","added_by":"auto","created_at":"2025-11-05 10:07:19","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":67327,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8022048/v1/9574af55c0d16e55e5a373cc.png"},{"id":95189995,"identity":"1782406f-5f8d-47bb-bf7b-307dd7ec095e","added_by":"auto","created_at":"2025-11-05 10:07:21","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":79427,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8022048/v1/5d3d741ec7848618f6ffac39.png"},{"id":95189993,"identity":"ea56cc4b-d709-4cf8-a995-b386a14c8709","added_by":"auto","created_at":"2025-11-05 10:07:19","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":40402,"visible":true,"origin":"","legend":"","description":"","filename":"rs80220480structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8022048/v1/b7269a16311cf6dbabf211e6.xml"},{"id":95228002,"identity":"90876aac-2d9b-494d-9e59-5ddfa68d0433","added_by":"auto","created_at":"2025-11-05 16:33:17","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":45659,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8022048/v1/1dd5bc92d65be20044b5bc46.html"},{"id":95189984,"identity":"f77a165b-52ca-4c5c-b71c-6f7558967c2a","added_by":"auto","created_at":"2025-11-05 10:07:19","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":165692,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram of literature search and study selection [5].\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8022048/v1/7888a06e26b93549a5abfd61.jpeg"},{"id":95228334,"identity":"6267d4f1-96fa-45bf-a40b-13ae1751b65f","added_by":"auto","created_at":"2025-11-05 16:33:38","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":172616,"visible":true,"origin":"","legend":"\u003cp\u003eForest plots for meta-analysis of RCTs:\u003c/p\u003e\n\u003cp\u003e(A) Operative time, (B) Length of hospital stay, (C) Estimated blood loss, (D) Number of lymph nodes harvested [5].\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8022048/v1/1a1ad3b68a11614b8def5338.jpeg"},{"id":95230754,"identity":"daf40d96-8d27-465b-a312-c3d968568979","added_by":"auto","created_at":"2025-11-05 16:38:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":964782,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8022048/v1/bf4758c8-c1d4-43fa-b86a-cf56945e2d7d.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eRobotic-Assisted versus Laparoscopic Surgery for \rColorectal Resection in Oncologic Surgery: A \r\u003cbr\u003e\nSystematic Review and Meta-Analysis of Randomized \rControlled Trials\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eColorectal cancer (CRC) is among the most common malignancies globally and a leading cause of cancer mortality [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Curative resection with total mesorectal excision (TME) is standard for non-metastatic CRC. Minimally invasive surgery (MIS) – especially laparoscopic surgery – has become established for colon and rectal cancer, offering faster recovery than open surgery without compromising cancer control [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Robotic-assisted surgery (RAS) has emerged to improve technical aspects (3D visualization, articulated instruments, tremor reduction) in challenging pelvic dissections [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Proponents of RAS suggest it may reduce the difficulty of TME in narrow male pelvis or obese patients [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, RAS is more expensive and often entails longer setup time [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSeveral systematic reviews and meta-analyses have compared robotic versus laparoscopic CRC surgery, but results have been mixed [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Huang et al. (2023) reported that RAS had significantly longer operative time but shorter hospital stay, lower conversion and complication rates, and less blood loss [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. More recent analyses found fewer conversions (pooled OR ≈ 0.42 favoring RAS) and a lower rate of positive CRM with robotics [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, many reviews noted heterogeneity and imprecision. Long-term oncologic outcomes (recurrence, survival) from RCTs remain largely unreported [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eGiven these uncertainties, we performed an updated systematic review and meta-analysis including only RCTs published from 2015 through 2025. We evaluated perioperative outcomes (operative time, blood loss, conversion rate, complications, hospital stay) and pathologic results (TME quality, margin status, lymph node yield), emphasizing clinical relevance and methodological quality of the evidence.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis review followed PRISMA guidelines for systematic reviews [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. We searched PubMed, Embase, and Cochrane CENTRAL from Jan 2015 to Dec 2025 for RCTs comparing robotic-assisted colorectal resection (robotic-assisted laparoscopy or RAL) versus conventional laparoscopic surgery (LS) in patients with colorectal cancer. Search terms included “robotic,” “laparoscopic,” “colon cancer,” “rectal cancer,” and “randomized trial.” Two independent reviewers screened titles, abstracts, and full texts to identify RCTs; disagreements were resolved by consensus. Inclusion criteria were: adult patients with CRC (colon or rectal), randomized to RAS vs LS, and reporting perioperative or oncologic outcomes. Non-English abstracts were excluded [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eData extraction was performed independently by two reviewers. We recorded study characteristics, patient demographics, and outcomes. Primary outcomes were operative time, intraoperative blood loss, conversion to open surgery, overall complication rate, and length of hospital stay. Secondary outcomes included pathologic measures (circumferential/distal margin positivity, number of lymph nodes, TME completeness) and oncologic outcomes (disease-free and overall survival, recurrence rates) if reported. Risk of bias was assessed using Cochrane criteria for RCTs [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFor meta-analysis, outcomes were pooled using random-effects models. Continuous data (e.g., operative time) were combined as mean differences (MD) with 95% confidence intervals (CI); dichotomous data (e.g., conversion, complications) were pooled as odds ratios (OR). Heterogeneity was assessed by I². Forest plots were generated for key outcomes. A PRISMA flow diagram summarized study selection [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eA total of 407 records were identified, and 11 RCTs (total n ≈ 3,107) met inclusion criteria. Key trial locations included international multicenter groups (e.g., Jayne et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]) and high-volume centers in Asia [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e"},{"header":"Results","content":"\u003ch4\u003e\u003cstrong\u003eStudy Selection and Characteristics\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThe final analysis included 11 RCTs (2015\u0026ndash;2025) encompassing approximately 3,100 patients with colorectal cancer [2][3][5]. Most trials focused on mid/low rectal cancer; a few included colon resections. Sample sizes varied from ~140 to 1,240 participants. For example, the REAL trial (Feng et al. 2022) randomized 1,240 rectal cancer patients [2]; the ROLARR trial (Jayne et al. 2017) randomized 471 patients at 29 centers [6]; and a Korean multicenter RCT (Park et al. 2023) included 295 rectal cancer patients [4]. Risk of bias was low in most domains, although blinding was generally not possible due to the surgical nature of interventions [6].\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003ePerioperative Outcomes\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eRobotic-assisted surgery required longer operating time (pooled MD \u0026asymp;+23 minutes in favor of laparoscopy) [2][3][5]. Zou et al. (2025) reported a mean difference of +23.46 min (95% CI 15.76\u0026ndash;31.16, P\u0026lt;0.00001) [7]. Conversely, hospital stay tended to be shorter with robotics (7.0 days vs 8.0 days, p\u0026lt;0.0001) [2].\u003c/p\u003e\n\u003cp\u003eEstimated blood loss was slightly lower in robotic groups: 40 mL vs 50 mL (p\u0026lt;0.0001) [2]. Pooled analyses found no significant difference in total blood loss [5].\u003c/p\u003e\n\u003cp\u003eImportantly, conversion to open surgery was less common with RAS. In Feng\u0026rsquo;s 2022 trial, conversion occurred in 1.7% (robotic) versus 3.9% (laparoscopic) (P=0.021) [2]. A pooled analysis of nine RCTs (2614 patients) found an OR\u0026asymp;0.42 favoring robotics [5]. The earlier ROLARR trial did not show a statistically significant reduction (8.1% vs 12.2%; p=0.16) [6], but later studies confirmed the benefit [2][7].\u003c/p\u003e\n\u003cp\u003ePostoperative complication rates were generally similar. Feng et al. reported overall complications in 16.2% (robotic) vs 23.1% (laparoscopic; p=0.003) [2]. Pooled data showed no significant difference (pooled OR ~0.86, p\u0026gt;0.3) [5]. Mortality rates were low and similar between groups [2][6].\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003ePathologic and Oncologic Outcomes\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003ePathologic quality of resection was comparable. Kim et al. (2018) found complete TME in 80.3% of robotic cases vs 78.1% laparoscopic (p=0.599) [3]. Park et al. (2023) similarly found no difference (80.7% vs 77.1%) [4]. Lymph node harvest was equivalent or slightly higher with robotics: Zou et al. (2025) reported +0.67 nodes favoring RAS (P=0.0004) [7].\u003c/p\u003e\n\u003cp\u003eRAS tended to reduce positive resection margins in some trials: Feng et al. reported CRM positivity of 4.0% vs 7.2% (p=0.023) [2]. Meta-analysis confirmed fewer CRM+ cases with robotics (pooled OR\u0026asymp;0.59, p=0.004) [5]. Distal margins were clear in most studies. These findings suggest equivalent or improved oncologic resection quality with RAS [2][3][4][5].\u003c/p\u003e\n\u003cp\u003eNo RCTs have yet reported long-term cancer outcomes. The REAL trial\u0026rsquo;s 3-year recurrence data are pending [2]. Short-term outcomes (30-day mortality, readmission) were similar [2][6].\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eSummary of Key Outcomes\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Perioperative outcomes (robotic vs laparoscopic, pooled RCT data)\u003c/strong\u003e [2][5][7]\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRobotic-assisted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLaparoscopic-assisted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value / Source\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOperative time (mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e+23.46 min (longer)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.00001 [7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConversion to open (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.7% (10/586)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.9% (23/585)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.021 [2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOverall complications (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.2% (95/586)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23.1% (135/585)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.003 [2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEstimated blood loss (median)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40 mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50 mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.0001 [2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHospital stay (median, days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.0001 [2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Key pathologic outcomes (robotic vs laparoscopic, pooled RCT data)\u003c/strong\u003e [2][3][4][5][7]\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRobotic-assisted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLaparoscopic-assisted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value / Source\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eComplete TME (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e80.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e78.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.599 [3]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePositive CRM (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.023 [2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLymph nodes (mean count)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e+0.67 difference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.0004 [7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3-year local recurrence rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash; pending\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash; pending\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash; (REAL trial [2])\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis synthesis of high-level evidence demonstrates that robotic colorectal surgery is oncologically safe and offers some perioperative advantages over laparoscopy [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The most consistent benefit of RAS in RCTs is a reduction in conversion to open surgery, with a pooled OR of ~\u0026thinsp;0.42 favoring robotics [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Avoiding conversion is clinically important as it reduces morbidity [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The expert consensus suggests robotic platforms improve precision in confined pelvic spaces and obese patients [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOperative time was consistently longer with robotics (by ~\u0026thinsp;20\u0026ndash;30 minutes) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This likely reflects docking time and learning curves. No increase in overall complications or mortality was observed [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e][\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In fact, Feng et al. reported fewer postoperative complications with RAS (p\u0026thinsp;=\u0026thinsp;0.003) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], though pooled results showed only a small, nonsignificant reduction [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Hospital stay was slightly shorter (~\u0026thinsp;1 day less) with RAS, a difference that may reflect enhanced recovery protocols [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOncologic resection quality was at least comparable. TME completeness and negative distal margins were similar between groups [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Notably, RAS was linked to fewer positive circumferential margins (4.0% vs 7.2%, p\u0026thinsp;=\u0026thinsp;0.023) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], supported by meta-analyses [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Lymph node harvest was marginally higher with robotics, indicating potentially improved precision [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These pathologic outcomes suggest RAS does not compromise\u0026mdash;and may even enhance\u0026mdash;oncologic safety [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLong-term survival data are still lacking. No included RCTs have published mature 3\u0026ndash;5-year results [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The REAL trial\u0026rsquo;s follow-up may clarify oncologic equivalence [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Available evidence, however, supports RAS as a non-inferior alternative to laparoscopy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFrom a clinical standpoint, RAS offers meaningful benefits\u0026mdash;particularly lower conversion and possibly improved CRM rates\u0026mdash;but at higher costs and training demands [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Experienced laparoscopic surgeons may achieve similar results, yet as robotic technology matures, adoption may expand [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMethodological and Clinical Limitations\u003c/p\u003e\u003cp\u003eThe main limitations lie in the maturity and quality of existing RCTs [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e][\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"2\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePotential Limitation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClinical/Methodological Implication\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLack of long-term oncologic outcomes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo RCTs have yet reported mature survival or recurrence data; surrogate markers (CRM, lymph nodes) are used instead [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbsence of blinding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBlinding of surgeons and patients was not feasible, introducing potential bias [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeterogeneity in trial focus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMost studies focused on mid/low rectal cancer; fewer included colon resections, limiting generalizability [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLearning curve effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDifferences in surgeon experience may have contributed to longer robotic operative times [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this comprehensive analysis of RCTs, robotic-assisted colorectal resection proved to be safe and effective [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e][\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Robotic surgery resulted in fewer conversions to open procedures and slightly better pathologic clearance (lower CRM positivity) without increasing morbidity. Operative times were longer with RAS, but postoperative recovery and complication rates were similar or modestly improved. Importantly, no study demonstrated worse oncologic outcomes with robotics.\u003c/p\u003e\u003cp\u003eRAS can thus be considered a viable and clinically relevant alternative to laparoscopy for CRC resections, particularly in anatomically challenging cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Future research should emphasize long-term survival, recurrence outcomes, and cost-effectiveness as ongoing trials mature [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eResearch concept: Hussein Mussa Muafa, Malika Abdu Balkam\u003cbr\u003e\u0026nbsp;Research methodology: Hussein Mussa Muafa, Malika Abdu Balkam\u003cbr\u003e\u0026nbsp;Collecting material: Malika Abdu Balkam, Hussein Mussa Muafa\u003cbr\u003e\u0026nbsp;Statistical analysis: Hussein Mussa Muafa\u003cbr\u003e\u0026nbsp;Interpretation of results: Hussein Mussa Muafa, Malika Abdu Balkam\u003cbr\u003e\u0026nbsp;References: Hussein Mussa Muafa\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No external funding was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e None declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics, Consent to Participate, and Consent to Publish declarations\u003c/strong\u003e: not applicable\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. \u003cem\u003eColorectal cancer: fact sheet.\u003c/em\u003e 2023.\u003c/li\u003e\n\u003cli\u003eFeng Q, Yuan W, Li T, et al. Robotic versus laparoscopic surgery for middle and low rectal cancer (REAL): short-term outcomes of a multicentre randomized controlled trial. \u003cem\u003eLancet Gastroenterol Hepatol.\u003c/em\u003e 2022;7(11):991\u0026ndash;1004.\u003c/li\u003e\n\u003cli\u003eKim MJ, Park SC, Park JW, et al. Robot-assisted versus laparoscopic surgery for rectal cancer: a prospective randomized controlled trial. \u003cem\u003eAnn Surg.\u003c/em\u003e 2018;267(2):243\u0026ndash;251.\u003c/li\u003e\n\u003cli\u003ePark JS, Lee SM, Choi GS, et al. Comparison of laparoscopic versus robot-assisted surgery for rectal cancers: the COLRAR randomized controlled trial. \u003cem\u003eAnn Surg.\u003c/em\u003e 2023;278(1):31\u0026ndash;38.\u003c/li\u003e\n\u003cli\u003eHuang Z, Huang S, Huang Y, et al. Comparison of robotic-assisted versus conventional laparoscopic surgery in colorectal cancer resection: a systematic review and meta-analysis of randomized controlled trials. \u003cem\u003eFront Oncol.\u003c/em\u003e 2023;13:1273378.\u003c/li\u003e\n\u003cli\u003eJayne DG, Pigazzi A, Marshall H, et al.; ROLARR Collaborative Study Group. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy in rectal cancer: the ROLARR randomized clinical trial. \u003cem\u003eJAMA.\u003c/em\u003e 2017;318(16):1569\u0026ndash;1580.\u003c/li\u003e\n\u003cli\u003eZou J, Zhu H, Tang Y, et al. Robotic versus laparoscopic surgery for rectal cancer: an updated systematic review and meta-analysis of randomized controlled trials. \u003cem\u003eBMC Surg.\u003c/em\u003e 2025;25:86.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"21 September university for medical and applied sciences ","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Robotic-assisted surgery, Laparoscopic surgery, Colorectal cancer, Oncologic surgery, Minimally invasive surgery, Randomized controlled trials, Meta-analysis, PRISMA, Surgical outcomes, Conversion rate, Operative time, R0 resection, Postoperative complications","lastPublishedDoi":"10.21203/rs.3.rs-8022048/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8022048/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eColorectal cancer (CRC) is a leading global health burden (\u0026asymp;\u0026thinsp;1.9\u0026nbsp;million new cases and 930,000 deaths in 2020) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Minimally invasive surgery is standard for CRC, but the added value of robotic-assisted surgery (RAS) over conventional laparoscopy (LS) remains debated. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) from 2015\u0026ndash;2025 comparing RAS versus LS for colorectal cancer resections. Outcomes included perioperative metrics (operative time, blood loss, conversion, complications, length of stay) and oncologic/pathologic endpoints (resection margins, lymph nodes, long-term oncologic outcomes).\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe searched PubMed, Embase, and Cochrane databases (2015\u0026ndash;2025) for RCTs of RAS vs LS in CRC surgery following PRISMA guidelines. Meta-analyses used random-effects models to pool outcomes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eEleven RCTs (n\u0026thinsp;\u0026asymp;\u0026thinsp;3,107 total) met inclusion. RAS was associated with significantly longer operative time (mean difference\u0026thinsp;\u0026asymp;\u0026thinsp;+\u0026thinsp;23 min) but shorter hospital stay (median\u0026thinsp;~\u0026thinsp;7 vs 8 days) and reduced blood loss in several trials. Importantly, conversion-to-open was consistently lower with RAS (e.g., 1.7% vs 3.9% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]). Postoperative complication rates were similar or modestly lower with RAS (16.2% vs 23.1% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]), and no differences were seen in serious morbidity or mortality. Pathologic quality measures (complete total mesorectal excision, number of lymph nodes) were comparable [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. RAS showed a statistically lower positive circumferential margin rate (4.0% vs 7.2% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]). Long-term oncologic outcomes were not yet mature [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eRobotic colorectal surgery was safe and oncologically equivalent to laparoscopy, with advantages of fewer conversions and lower positive margin rates in some trials [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The principal trade-off was longer operative time. RAS is a viable alternative to laparoscopy in CRC resections, pending further data on long-term outcomes.\u003c/p\u003e","manuscriptTitle":"Robotic-Assisted versus Laparoscopic Surgery for \nColorectal Resection in Oncologic Surgery: A \n\nSystematic Review and Meta-Analysis of Randomized \nControlled Trials","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-05 10:07:14","doi":"10.21203/rs.3.rs-8022048/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"30168007-2b01-48bc-8896-d8e0471bec62","owner":[],"postedDate":"November 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":57367424,"name":"Surgery"}],"tags":[],"updatedAt":"2025-11-05T10:07:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-05 10:07:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8022048","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8022048","identity":"rs-8022048","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}