jcoloproctol(rioj).2014;34(3):129–130
Journal
of
Coloproctology
w w w . j c o l . o r g . b r
Editorial
Current
status
of
robotic
rectal
cancer
surgery
Estado
atual
da
cirurgia
robótica
no
câncer
do
reto
Enthusiasmfortheroboticplatform,asaminimallyinvasive approach, has gained most interest in many surgical spe-cialitiesandtodayalmosttwomillionoperationshavebeen performedintheworldwiththedaVinciSurgicalSystem.The safetyandefficacyofroboticsurgeryhavebeenestablished forcertainoperations,mostnotablyradicalprostatectomy.All colorectaloperationshavebeenperformedsafelyinarobotic fashion;however,thedataonclinicalandeconomicbenefits derivedfromcontrolledtrialshavenotyettotallysupportedits effectiveness,eveninroboticrectalcancersurgery.Itis essen-tialthataproperassessmentofthisnewandsophisticated technologybeperformedbeforeitswidespread recommenda-tion.
Recentstudieshavereportedbettershort-termoutcomes andsimilaroncologicalresultwhencomparinglaparoscopic rectalcancersurgerytoopensurgery.Nevertheless, laparo-scopicrectalsurgerycouldnotachieveahighimpact,mainly, becauseofthesteeplearningcurve,highrateofconversion, andthetechnicalchallengeofworkinanarrowpelviswith limitedinstrumentsmaneuverability,especiallyinobeseand inpatientswhoweretreatedbypreoperativechemo-radiation. Robotic rectal resection represents the main indication of the use of the robotic technique in colorectal surgery. The feasibility of robotics for TME rectal cancer resection was established by Pigazzi et al.1 in 2006. Robotic rectal
surgeryoffersvariousadvantagesovertraditionallaparoscopy becauseitcanprovidesurgeonswithathree-dimension mag-nification(3DHD)viewandtheabilitytocontroltheoperative fieldbymanipulatingthecamera,aswellasenhanced dex-terityand precisiondue to endo-wrist instruments with 7 degreesoffreedom.Theroboticsystemimproves visualiza-tion,exposure,anddissectioninconfinedspacessuchasthe pelviccavity. Additionally, inthe robotic platform the sur-geonisambidextrousandcanoperatetheconsolecomfortably seatedwithexcellentergonomics.Appropriatetrainingand practiceon roboticsystems and the use ofsimulator with trainingsoftwarearehelpfulingainingfamiliaritywiththe
skillsrequiredforsuccessfulroboticsurgery,aswellasto facil-itatetherequirementsforthefinalcredentialingapprovedby theproctor.
Notonlylowerratesofconversionofroboticsurgerywhen compared withlaparoscopiconesin rectalresectionswere reported2 butalsoamarkedlyshorterlearningcurve anda
smallernumberofpatientsforthesurgeontobecome profi-cientatroboticcolorectalsurgery,evenforsurgeonwithless expertinlaparoscopy.3,4Thiscanbeanimportantbenefitas
the conversion isdirectly related to a higherrate of post-operative complicationsand mortalityas haveshowed the CLASICC trial.5 Theroboticsurgeryimproves thequalityof
mesorectalexcisionandprovidesgreaternumberofsurgical specimenswithadegreeofcompleteexcisionandnegative circumferentialresectionmargin,6 whichisrelatedtolower
localrecurrence.Thepreservationofthepelvicplexusnerves isalsosuperiorand,consequently,urinaryandsexual func-tionarebetter.7,8Additionally,inultralowanteriorresection,
the incidenceofanastomoticfistulaislower intherobotic group.9Littlemedicalliteratureexistsdirectlyaddressingthe
costsofroboticrectalcancersurgery;certainly,roboticsurgery ismoreexpensive,butfutureadvancesinrobotictechnology andcompetitioninthemarketplacewillhelptoreducethe costinthenextyears.
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jcoloproctol(rioj).2014;34(3):129–130theobjectivesoftherandomizedcontrolledtrial(Robotic ver-susLaparoscopicresectionforrectalcancer–ROLARR)10that
havetheanticipatedenddatein9/30/2014after400patients’ evaluation.Thereisagreatinterestofthecolorectaland onco-logiccommunitytoknowthoseresultsandespecially,thelevel ofevidenceandthe gradeofrecommendation ofthis tech-nique.Thisstudy,certainly,willprovideimportantdecision orientationtojustifythefutureimplementationofthisoption totreatpatientswithrectalcanceraroundtheworld.
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1. PigazziA,EllenhornJD,BallantyneGH,PazIB.
Robotic-assistedlaparoscopiclowanteriorresectionwith totalmesorectalexcisionforrectalcancer.SurgEndosc. 2006;20:1521–5.
2. BaekSJ,Al-AsariS,JeongDH,HurH,MinBS,BaikSH,etal. Roboticversuslaparoscopiccoloanalanastomosiswithor withoutintersphinctericresectionforrectalcancer.Surg Endosc.2013.
3. BokhariMB,PatelCB,Ramos-ValadezDI,RagupathiM,Haas EM.Learningcurveforrobotic-assistedlaparoscopic colorectalsurgery.SurgEndosc.2011;25:855–60.
4. Jiménez-RodríguezRM,Díaz-PavónJM,delaPortilladeJuanF, Prendes-SilleroE,DussortHC,PadilloJ.Learningcurvefor robotic-assistedlaparoscopicrectalcancersurgery.IntJ ColorectalDis.2013;28:815–21[4157–4163].
5. GuillouPJ,QuirkeP,ThorpeH,WalkerJ,JayneDG,SmithAM, etal.MRCCLASICCtrialgroupshort-termendpointsof conventionalversuslaparoscopic-assistedsurgeryinpatients
withcolorectalcancer(MRCCLASICCtrial):multicentre, randomisedcontrolledtrial.Lancet.2005;365:1718–26.
6.BaikSH,KwonHY,KimJS,HurH,SohnSK,ChoCH,etal. Roboticversuslaparoscopiclowanteriorresectionofrectal cancer:short-termoutcomeofaprospectivecomparative study.AnnSurgOncol.2009;16:1480–7.
7.LucaF,ValvoM,GhezziTL,ZuccaroM,CenciarelliS,Trovato C,etal.Impactofroboticsurgeryonsexualandurinary functionsafterfullyroboticnerve-sparingtotalmesorectal excisionforrectalcancer.AnnSurg.2013;257:672–8.
8.D’AnnibaleA,PernazzaG,MonsellatoI,PendeV,LucandriG, MazzocchiP,etal.Totalmesorectalexcision:acomparisonof oncologicalandfunctionaloutcomesbetweenroboticand laparoscopicsurgeryforrectalcancer.SurgEndosc. 2013;27:1887–95.
9.ZengDZ,ShiY,LeiX,TangB,HaoYX,LuoHX,etal. Short-termefficacyofdaVinciroboticsurgicalsystemon rectalcancerin101patients.ZhonghuaWeiChangWaiKeZa Zhi.2013;16:451–4.
10.CollinsonFJ,JayneDG,PigazziA,TsangC,BarrieJM,EdlinR, etal.Aninternational,multicentre,prospective,randomised, controlled,unblinded,parallel-grouptrialofrobotic-assisted versusstandardlaparoscopicsurgeryforthecurative treatmentofrectalcancer.IntJColorectalDis.2012;27:233–41.
JoseReinanRamos
ServiceofRoboticSurgery,HospitalSamaritano,
RiodeJaneiro,RJ,Brazil
E-mail:[email protected] http://dx.doi.org/10.1016/j.jcol.2014.06.001
