Robotic Proctectomy for Rectal Cancer: Analysis of 71 Patients from a Single Institution

Philip M Spanheimer, MD1, John G Armstrong, MD1, Sunyang Fu, BBA1, Junlin Liao, PhD1, Scott E Regenbogen, MD2, John C Byrn, MD1. 1University of Iowa, 2University of Michigan

Background: Despite increasing use of robotic surgery for rectal cancer, reported outcomes have come from highly specialized units and few series have been published from the practice of generalizable US surgeons. Thus, the effect of formal robotic training and learning curves among early cases have not been well studied. We sought to critically evaluate the short- and long-term outcomes of robotic rectal cancer resections by a single colorectal surgeon, self-taught after completion of formal training, in an academic institution without a specialized robotics focus.

Methods: We performed a retrospective chart review for the initial 71 consecutive patients who underwent robotic low anterior resection (LAR) or abdominoperineal resection (APR) for rectal adenocarcinoma between 2010-2014. Demographic, clinicopathologic, and intraoperative and postoperative outcomes data were abstracted from the medical record using a standardized data collection tool. Total mesorectal excision integrity was graded by pathologists in 39 cases (55%).

Results: We identified 46 LARs (65%) and 25 APRs (35%). Fifty patients (70%) received preoperative chemoradiation.  Median procedure time was 219 minutes (IQR 184-275), mean blood loss 165 cc (SD 156 cc), and median length of stay 6 days (IQR 4-8). Radial margin was negative in all 46 LAR patients and 24/25 APR (96%) patients.  Total mesorectal excision integrity was complete/near complete in 23/23 (100%) graded LAR specimens and 15/16 (94%) APR specimen. A mean of 16+/-8 lymph nodes were retrieved.  There was one conversion to open, and no perioperative blood transfusion or ureteral injuries. Within 30 days of surgery, we observed 4 (6%) superficial and 5 (7%) deep organ space infections and no urinary tract infections or deaths.   At median follow up of 21.9 months, there were no local recurrences.  Five year disease free survival was 83.1% and five year overall survival was 94.4%.

Conclusions: Robotic proctectomy for rectal cancer was introduced in to a typical colorectal surgery practice by a single surgeon. Over the first four years of experience, there was a low conversion rate, low complication rate, and satisfactory oncologic outcomes. The role of patient selection, time trends, equipment changes, and training could not be evaluated, yet these data highlight the need for broad improvements in the audit and feedback of surgical outcomes for this rapidly-growing technology.

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