Meta-analysis and trial sequential analysis of robotic versus laparoscopic total mesorectal excision in management of rectal cancer

Background We aimed to evaluate comparative outcomes of robotic and laparoscopic total mesorectal excision (TME) in patients with rectal cancer. Methods We systematically searched electronic data sources with application of combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits. Perioperative clinical and short-term oncological outcomes were evaluated. Trial Sequential Analysis of the outcomes was conducted. Results Nine randomised-controlled trials reporting 1463 patients evaluating outcomes of robotic TME (n= 728) and laparoscopic TME (n= 735) were included. Although the robotic approach was associated with significantly longer operative time (MD 31.64,P= 0.002), it was associated with significantly longer DRM (MD 0.8,P= 0.004) and shorter time to soft diet (MD - 0.50,P= 0.03) compared to the laparoscopic approach. Moreover, there was no significant difference in intraoperative (RR 1.07,P= 0.76)) and postoperative (RR 0.97,P= 0.81) complications, anastomotic leak (RR 0.93,P= 0.69), conversion to open rate (RR 0.46,P= 0.05), blood loss (MD 19.65,P= 0.74), time to first flatus (MD - 0.30,P= 0.37), LARS (RR 0.83,P= 0.41), ileus (RR 0.72,P= 0.39), positive CRM (RR 0.82,P= 0.49), PRM (MD - 0.5,P= 0.55), number of harvested lymph nodes (MD 0.33,P= 0.58), or length of stay (MD - 0.60,P= 0.12) between two groups. The Trial Sequential Analysis demonstrated that the risk of type 1 and type 2 errors was minimal in most outcomes. Conclusions Moderate-quality evidence suggested that robotic and laparoscopic TME may be comparable in terms of clinical and short-term oncological profile but the robotic approach may be associated with longer procedure time. Future high-quality randomised studies are encouraged to compare the functional, long-term oncological, and cost-effectiveness outcomes of both approaches.