Comparison of Clinical and Economic Outcomes Between Robotic, Laparoscopic and Open Rectal Cancer Surgery: Early Experience at a Tertiary Academic Center

Karim M Ramji, MD¹, Jonathan M Josse, MD, MSc¹, Michelle C Cleghorn, MSc³, Haiyan Jiang, PhD², Andrea MacNeill, MD, MSc¹, Usmaan Hameed, MD¹, Catherine O’Brien, MD, PhD³, David Urbach, MD, MSc³, Fayez A Quereshy, MD, MBA³. ¹University of Toronto, ³University Health Network, ²Princess Margaret Cancer Center

Introduction: Robotic surgery is gaining popularity in surgical oncology. Rectal cancer surgery, known to be technically challenging, may benefit from robotics in achieving better mesorectal dissection and may contribute to improved perioperative outcomes. Our objective was to compare our early experience in robotic rectal cancer surgery to conventional approaches with regards to clinico-pathologic and economic parameters.

Methods: We retrospectively reviewed a prospectively maintained database of rectal cancer surgeries performed at a tertiary academic center from 2007 to 2013. These resections included those performed via laparotomy, conventional laparoscopy, and robotic-assisted operations. Perioperative demographic and tumor characteristics were collected and short-term clinico-pathologic parameters were compared among these three cohorts. Additionally, economic variables were compared including direct and indirect costs for each patient’s episode of care. ANOVA was used to compare continuous variables, and Fisher’s exact test was used for categorical variables.

Results: 79 rectal cancer cases were compared between 2007 and 2013, including 26 completed via open approach, 27 laparoscopically, and 26 with robotic assistance. Demographic characteristics were similar between all groups including age, gender, BMI, and Charlson score. Tumor characteristics were also similar including size, cancer stage, and distance from anal margin. Intraoperative comparison showed a lower rate of conversion to laparotomy in the robotic group compared to laparoscopy (12% vs 37%, p=0.05), and additionally, estimated intraoperative blood loss was lower between robotic and laparoscopic approaches (mean 296cc vs. 524cc p=0.035). There was no significant difference in tumor pathologic characteristics including quality of TME and number of lymph nodes harvested. Perioperative parameters, namely post-operative complication rate, median length of stay, ICU admission rate, 30-day readmission, and 30-day mortality were comparable between cohorts. Median cost of episode of care was lower in laparoscopic surgery at $11,750, compared to open and robotic surgery at $12,168 and $18,462, respectively (p=0.006).

Conclusions: Our findings demonstrate comparable perioperative and short-term outcomes between robotic surgery and conventional approaches. Robotic assistance is further associated with decreased intraoperative blood loss and fewer conversions, albeit at an overall increased cost. Given these intraoperative benefits, as data and experience matures, future study is needed to determine the cost-effectiveness and value of the robotic approach.