Meta-Analysis
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. Nov 15, 2018; 10(11): 449-464
Published online Nov 15, 2018. doi: 10.4251/wjgo.v10.i11.449
Robotic total meso-rectal excision for rectal cancer: A systematic review following the publication of the ROLARR trial
Katie Jones, Mohamed G Qassem, Parv Sains, Mirza K Baig, Muhammad S Sajid
Katie Jones, Mohamed G Qassem, Parv Sains, Muhammad S Sajid, Department of General and Laparoscopic Colorectal Surgery, Brighton and Sussex University Hospitals NHS Trust, the Royal Sussex County Hospital, Brighton, West Sussex BN2 5BE, United Kingdom
Mohamed G Qassem, Lecturer of General Surgery, Faculty of Medicine, Ain Shams University, Cairo 11566, Egypt
Mirza K Baig, Department of General and Laparoscopic Colorectal Surgery, Western Sussex Hospitals NHS Foundation Trust, Worthing Hospital, West Sussex BN11 2DH, United Kingdom
Author contributions: Jones K contributed to literature search, data extraction, manuscript writing and approval; Qassem MG contributed to data extraction, data confirmation, manuscript writing and approval; Sains P contributed to data confirmation, data interpretation, manuscript writing and approval; Baig MK contributed to data interpretation, data confirmation, manuscript writing and approval; Sajid MS contributed to idea conception, literature search, study selection, data analysis, data interpretation, manuscript writing and approval.
Conflict-of-interest statement: None to declare.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Muhammad S Sajid, BM BCh, FCPS, FRCS (Ed), FRCS (Gen Surg), MBBS, MSc, Attending Doctor, Research Fellow, Surgeon, Department of General and Laparoscopic Colorectal Surgery, Western Sussex Hospitals NHS Foundation Trust, Worthing Hospital, Lyndhurst Road, Worthing, West Sussex BN11 2DH, United Kingdom. surgeon1wrh@hotmail.com
Telephone: +44-1273-696955 Fax: +44-7891-667608
Received: April 16, 2018
Peer-review started: April 17, 2018
First decision: May 17, 2018
Revised: June 25, 2018
Accepted: June 28, 2018
Article in press: June 29, 2018
Published online: November 15, 2018
Processing time: 213 Days and 3.7 Hours
ARTICLE HIGHLIGHTS
Research background

Robotic total meso-rectal excision (TME) is used at least for a decade to treat rectal cancer and the only evidence in favour of robotic TME was based on case control studies. Recently first ever RCT evaluating feasibility of robotic TME was published as ROLARR trial. This aims of this study was to strengthen the existing evidence on this technique which is mainly based upon the meta-analysis of case control studies and compare it with the results of ROLARR trial.

Research motivation

Although robotic TME is being presented a way forward for rectal resection but its superiority over laparoscopic TME is not proven yet. Most of the evidence was based upon the systematic review of case-controlled studies, the publication of ROLARR trial is an attempt to answer this question. Comparison between the findings of ROLARR trial and systematic review of case-controlled trials can guide the surgeons in future about role of robotic TME.

Research objectives

The objective of this systematic review is to strengthen the existing evidence on the role of robotics for TME technique which is mainly based upon the meta-analysis of case control studies and compare it with the results of recently published ROLARR trial reporting robotic TME vs laparoscopic TME.

Research methods

Standard medical databases were searched. RCTs and all types of comparative studies reporting the effectiveness of robotic TME vs laparoscopic TME in the management of rectal cancer were retrieved and their data was extracted. The extracted data was analyzed using the principles of meta-analysis to generate higher level of evidence. RevMan 5.3 was used for statistical analysis and GradePro was used to generate summary of evidence.

Research results

One RCT (ROLARR trial) and 27 other comparative studies reporting the non-oncological and oncological outcomes following robotic TME vs laparoscopic TME were included in this review. In the random effects model analysis using the statistical software Review Manager 5.3, the RTME was associated with longer operation time (SMD, 0.46; 95%CI: 0.25, 0.67; z = 4.33; P = 0.0001), early passage of first flatus (P = 0.002), lower risk of conversion (P = 0.00001) and shorter hospitalization (P = 0.01). The statistical equivalence was seen between robotic TME and laparoscopic TME for non-oncological variables like blood loss, morbidity, mortality and re-operation risk. The oncological variables such as recurrence (P = 0.96), number of harvested nodes (P = 0.49) and positive circumferential resection margin risk (P = 0.53) were also comparable in both groups. The length of distal resection margins was similar in both groups.

Research conclusions

Robotic TME is feasible and oncologically safe but failed to demonstrate any superiority over laparoscopic TME for many surgical outcomes except early passage of flatus, lower risk of conversion, lower conversion to laparotomy rate and shorter hospitalization.

Research perspectives

Robotic TME failed to demonstrate superiority over laparoscopic TME. Laparoscopic TME may continuously be used to treat rectal cancer. More RCTs are needed to consolidate the findings of ROLARR trial [42] and current study. Better outcomes and reduced cost may be anticipated in future trials due to the use of cost effective advanced technology and operating surgeons with extensive experience in robotic surgery. Until then the ROLARR trial and current study may provide the best possible evidence in this relatively innovative intervention for rectal cancer management.