Robotic-assisted vs laparoscopic-assisted radical resection for rectal cancer: A comparison of surgical indices, postoperative recovery, and complications

Abstract

BACKGROUND

Although radical resection for rectal cancer (RC) is effective in tumor removal and recurrence prevention, further improvement is needed.

AIM

To comparatively analyze the effects of robotic-assisted radical resection (RARR) and laparoscopic-assisted radical resection (LARR) on surgical indicators, postoperative recovery, and complications in RC.

METHODS

A total of 200 patients with RC admitted between November 2023 and November 2025 were included. Patients were assigned to a laparoscopic group (n = 100, received LARR) or a robotic group (n = 100, RARR). Between-group comparative analyses were conducted across surgical indices (operation time, incision length, intraoperative blood loss, intraoperative transfusion, and prophylactic stoma), postoperative day 1 pain (Numeric Rating Scale), postoperative recovery indices (initial ambulation, time to urinary catheter removal, and hospitalization), gastrointestinal function (time to bowel sound recovery, first flatus, first liquid intake, and duration of abdominal distension), postoperative pathological indicators (mesorectal excision completeness, tumor length, differentiation, lymph node yield, T stage, N stage, and TNM stage), tumor markers (carcinoembryonic antigen and carbohydrate antigen 19-9/242), postoperative complications (bleeding, incision infection, rectovaginal fistula, voiding dysfunction, and anastomotic leakage), hospitalization expenses (surgical, total, and non-surgical expenses), and quality of life.

RESULTS

Compared with the laparoscopic group, the robotic group showed significantly shorter incision length (5.28 ± 1.50 cm vs 6.11 ± 1.70 cm), lower intraoperative blood loss [67.00 (44.25, 92.75) mL vs 119.50 (85.25, 149.00) mL], and faster gastrointestinal recovery, including shorter time to bowel sound recovery [3.00 (3.00, 4.00) days vs 3.50 (3.00, 4.00) days], first flatus [3.00 (3.00, 4.00) days vs 3.50 (3.00, 4.00) days], and first liquid intake (62.83 ± 23.29 hours vs 103.33 ± 36.10 hours), as well as shorter abdominal distension duration [4.00 (3.00, 4.75) days vs 4.00 (4.00, 5.00) days]. However, RARR was associated with higher surgical costs (2.91 ± 1.03 ten thousand CNY vs 1.79 ± 0.77 ten thousand CNY) and total hospitalization expenses (5.33 ± 1.45 ten thousand CNY vs 4.35 ± 1.45 ten thousand CNY). Quality-of-life scores were higher in the RARR group than in the LARR group. No significant differences were found between the two techniques in other indicators.

CONCLUSION

RARR offers clinical advantages over LARR for RC management, including shorter incision length, reduced intraoperative bleeding, faster gastrointestinal function recovery, and a superior quality of life, although it is associated with higher costs.

Key Words: Robotic-assisted radical resection of rectal cancer; Laparoscopic-assisted radical resection of rectal cancer; Surgical indicators; Postoperative recovery; Complications

Core Tip: This study compared robotic-assisted radical resection and laparoscopic-assisted radical resection for rectal cancer and found that robotic-assisted radical resection provides improved gastrointestinal function recovery and quality of life, with favorable surgical outcomes but higher costs.

INTRODUCTION

Rectal cancer (RC) is among the most aggressive malignancies worldwide[1]. Risk factors include advanced age, male sex, and inflammatory bowel disease[2,3]. Its etiology involves the accumulation of genetic and epigenetic changes in the rectal epithelium[4]. Radical resection remains the primary treatment for stage I-III RC, enabling the removal of the tumor-bearing intestinal segment and regional lymphatic tissues through the precise dissection of the sigmoid mesocolon and rectal ligaments[5]. Despite its effectiveness, the procedure carries an approximately 2% mortality risk and may lead to postoperative bleeding, incision infection, and rectovaginal fistula, which can hinder smooth recovery of post-surgical patients[6]. Therefore, optimizing surgical approaches based on radical RC resection remains necessary.

Laparoscopic-assisted radical resection (LARR) of RC is performed via laparoscopy with an auxiliary abdominal incision for specimen removal and anastomosis[7]. Compared with traditional open surgery, it has clinical advantages, including faster recovery, reduced intraoperative blood loss (IBL), and fewer postoperative complications (POCs)[8]. A multicenter study reported comparable long-term oncological outcomes between LARR and open surgery low RC, with no significant difference in three-year overall survival (OS), three-year local recurrence, and five-year OS rates[9]. However, LARR has some limitations, particularly in patients with low RC and pelvic stenosis, in which restricted instrument flexibility may increase circumferential resection margin positivity[10]. Robotic-assisted radical resection (RARR) of RC provides enhanced minimally invasive capabilities, including three-dimensional visualization, improved instrument dexterity, and a stable camera platform. These features help overcome the limitations of LARR in confined pelvic spaces and may improve surgical precision while maintaining comparable oncological safety[11,12]. A systematic review and meta-analysis indicated that RARR offers precise anatomical dissection and favorable operative conditions, improving postoperative outcomes[13]. Existing evidence supports the safety, technical feasibility, and non-inferiority of RARR compared with traditional laparoscopic surgery in terms of long-term outcomes measured via three-year OS and recurrence-free survival[14]. However, its clinical adoption remains limited, possibly due to higher costs[15]. Currently, there are few related studies. This study aimed to compare the effects of RARR and LARR on surgical indicators, postoperative recovery, and POCs, to provide better surgical choices for patients with RC.

MATERIALS AND METHODS

General data

The study cohort included 200 patients with RC treated between November 2023 and November 2025. Among them, 100 patients in the laparoscopic group received LARR, and the remaining 100 patients in the robotic group received RARR. Baseline characteristics were comparable between groups, supporting valid comparative analyses (P > 0.05).

Patient selection criteria

Inclusion criteria: All patients had rectal adenocarcinoma diagnosed via colonoscopy biopsy[16]; age 18-80 years; tumor distance from the anal verge ≤ 12 cm; no extensive abdominal/pelvic or distant metastasis based on preoperative computed tomography or magnetic resonance imaging; first-time treatment; TNM stage I-III; preoperative American Society of Anesthesiologists grade I-II; and complete medical records.

Exclusion criteria: Intestinal obstruction, acute peritonitis, or intestinal perforation; extensive abdominal or pelvic adhesions; pregnancy or lactation; familial adenomatous polyposis, Lynch syndrome, inflammatory bowel disease; conversion to open surgery; presence of other malignancies; or ineligibility for robotic or laparoscopic procedures.

Treatment methods

Patients in the laparoscopic group underwent conventional LARR. Under general anesthesia, patients were placed in a supine position, and a carbon dioxide pneumoperitoneum was established. Abdominal exploration was performed via a laparoscope inserted below the umbilicus to assess tumor location and intra-abdominal conditions. Operation ports were then established on the abdominal wall as follows: A 12-mm incision at the McBurney point in the right lower abdomen (main port), a 5-mm incision at the corresponding left-side position (auxiliary port), a 5-mm incision along the right midclavicular line above the umbilicus (auxiliary port), and a 5-mm incision along the left midclavicular line at the umbilicus (auxiliary port). Under the laparoscopic view, the sigmoid mesentery was sequentially incised using an ultrasonic knife, and surrounding fat and lymphoid connective tissues were dissected and cleared. The tumor-bearing intestinal segment was completely separated, followed by a 4-6-cm auxiliary incision on the lower abdomen. Through this incision, the separated diseased intestinal segment was pulled out of the body. Under direct vision in vitro, the intestinal segment containing the tumor was removed, and the digestive tract was anastomosed. The intestinal tract was returned to the abdominal cavity, the auxiliary incision was sutured, and the pneumoperitoneum was re-established. The anastomosis is examined under the laparoscope for perfusion and active bleeding. After confirming no abnormalities, a drainage tube was placed adjacent to the anastomosis site, and the procedure was completed.

Patients in the robotic group underwent RARR under combined intravenous inhalation anesthesia in the Trendelenburg lithotomy position. Following routine skin disinfection and draping, trocars were placed using the “five-port method”, specifically: The camera port (C port) was placed 2 cm above and to the right of the umbilicus; the R1 port (right lower abdomen) served as the main operating arm; the R2 port (left mid-abdomen at the umbilical level) served as the observation port; the R3 port (junction of the left midclavicular and anterior axillary front lines) served as the auxiliary operating arm; and the A port (umbilical level in the right mid-abdomen) served as the assistant operating port. Following abdominal cavity exploration, the greater omentum and other tissues were retracted to expose the jejunum. The robotic arm R1 used a bipolar electrotome or an ultrasonic scalpel, whereas the robotic arms R2 and R3 used non-invasive grasping forceps. The surgery began by dissecting the peritoneum laterally into the Toldt space, followed by opening the mesorectal root peritoneum at the sacral promontory through the intermediate approach. Then, the inferior mesenteric vessels were dissected, lymphadenectomy was performed, and the superior rectal artery was severed while preserving the left colic artery. The space was expanded along the Toldt fascia and care was taken to protect the nerves. Then, the rectum and surrounding mesorectum were dissected, the peritoneal reflection was incised at 0.5 cm anteriorly, and dissection proceeded between the two layers of the Denonvillier fascia, extending distally to at least 2 cm below the lower edge of the rectal tumor. The lateral rectal ligaments on the left and right sides were dissected, and the rectal intestinal tubes were exposed and disconnected. Finally, the specimen was collected via a 5-cm lower abdominal incision. Rectosigmoid end-to-end anastomosis or prophylactic ostomy was performed based on intraoperative assessment; a rectosigmoid anastomosis was performed on patients with anus preservation, with a negative pressure drainage tube and a thick latex tube placed next to the anastomosis. For low RC cases unsuitable for anus preservation, abdominoperineal resection (Miles operation) was performed, with permanent sigmoidostomy and perineal drainage placement.

Detection indicators

Surgical indicators: Operation time (OT), incision length, IBL, intraoperative blood transfusion, and prophylactic ostomy. Pain status[17]: Postoperative day pain assessed using the Numeric Rating Scale (0-10 points); the scores are directly proportional to the pain severity. Postoperative recovery indices: Time to initial ambulation, urinary catheter removal, and length of hospitalization. Gastrointestinal function: Time to bowel sound recovery, first flatus, first liquid intake, and duration of abdominal distension. Postoperative pathological indicators: Mesorectal excision completeness grading, tumor length, tumor differentiation, lymph node yield, and T/N/TNM stages. Tumor markers: 5 mL fasting venous blood was collected pre- and postoperatively. Serum levels of carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9/242 (CA19-9/CA242) were measured using electrochemiluminescence immunoassay. POCs: Bleeding, incision infection, rectovaginal fistula, voiding dysfunction, and anastomotic leakage. Hospitalization expenses: Surgical, total, and non-surgical expenses. Quality of life: Assessed pre- and postoperatively using the World Health Organization Quality-of-Life Instrument, Short Form (WHOQOL-BREF), covering physical function, mental state, physical health, and social function (maximum of 100 points per domain); scores correlate positively with quality of life.

Statistical analysis

Measurement data are presented as mean ± SD, and categorical data as n (%). Between-group comparisons were performed using independent sample t-tests, and within-group comparisons (pre- vs post-treatment) using paired t-tests. Categorical variables were analyzed using the χ² test. Data were processed and analyzed using SPSS 21.0, with P < 0.05 considered statistically significant.

RESULTS

Baseline data

The analysis (Table 1) showed no significant difference between the laparoscopic and robotic groups in sex, age, body mass index, American Society of Anesthesiologists classification, tumor distance from the anal verge, or surgical technique (P > 0.05).

Table 1 Patients’ baseline data, n (%)/mean ± SD/median (interquartile range).

Indicators	Laparoscopic group (n = 100)	Robotic group (n = 100)	χ2/t/Z	P value
Gender			0.183	0.669
Male	55 (55.00)	58 (58.00)
Female	45 (45.00)	42 (42.00)
Age (years)	55.34 ± 9.47	54.06 ± 11.08	0.878	0.381
Body mass index (kg/m2)	22.00 (20.25, 24.00)	22.00 (20.00, 24.00)	-0.436	0.663
American Society of Anesthesiologists grading			1.624	0.203
I	43 (43.00)	52 (52.00)
II	57 (57.00)	48 (48.00)
Tumor distance from the anal verge (cm)	6.00 (4.00, 7.75)	6.00 (4.25, 8.00)	-0.947	0.344
Surgical technique			1.663	0.197
Low anterior resection	70 (70.00)	78 (78.00)
Abdominoperineal resection	30 (30.00)	22 (22.00)

Surgical indices

As shown in Table 2, although no significant differences in OT, intraoperative blood transfusion, or prophylactic ostomy (P > 0.05), the robotic group had a shorter incision length (5.28 ± 1.50 cm vs 6.11 ± 1.70 cm) and lesser IBL [67.00 (44.25, 92.75) mL vs 119.50 (85.25, 149.00) mL] than the laparoscopic group (P < 0.001).

Table 2 Surgical indexes, n (%)/mean ± SD/median (interquartile range).

Indicators	Laparoscopic group (n = 100)	Robotic group (n = 100)	χ2/t/Z	P value
Operation time (minute)	138.66 ± 21.93	139.26 ± 24.50	0.182	0.855
Incision length (cm)	6.11 ± 1.70	5.28 ± 1.50	3.661	< 0.001
Intraoperative blood loss (mL)	119.50 (85.25, 149.00)	67.00 (44.25, 92.75)	-8.212	< 0.001
Intraoperative blood transfusion	3 (3.00)	0 (0.00)	3.046	0.081
Prophylactic ostomy	20 (20.00)	23 (23.00)	0.267	0.606

Pain on postoperative day 1

Table 3 summarizes the Numeric Rating Scale-based pain scores on postoperative day 1. In the laparoscopic group, 10, 26, 30, 29, and 5 patients scored 1-5 points, respectively, whereas the corresponding scores in the robotic group were 12, 28, 38, 20, and 2. No significant intergroup difference was observed (P > 0.05).

Table 3 Pain status on post-operative day 1, n (%).

NRS (points)	Laparoscopic group (n = 100)	Robotic group (n = 100)	χ2	P value
1	10 (10.00)	12 (12.00)	4.364	0.359
2	26 (26.00)	28 (28.00)
3	30 (30.00)	38 (38.00)
4	29 (29.00)	20 (20.00)
5	5 (5.00)	2 (2.00)

NRS: Numeric Rating Scale.

Postoperative recovery indices

Time to initial ambulation (25.90 ± 4.70 hours vs 25.73 ± 6.20 hours), urinary catheter removal (61.53 ± 20.13 hours vs 58.34 ± 21.06 hours), and hospitalization [8.00 (7.00, 9.00) hours vs 8.50 (7.00, 10.00) hours] were comparable between groups (P > 0.05; Figure 1), indicating similar postoperative recovery.

Figure 1 Postoperative recovery indices. A: Time to initial ambulation; B: Time to urinary catheter removal; C: Length of hospital stay.

Gastrointestinal function

As shown by Figure 2, the robotic group exhibited shorter times to bowel sound recovery [3.00 (3.00, 4.00) days vs 3.50 (3.00, 4.00) days], first flatus [3.00 (3.00, 4.00) days vs 4.00 (3.00, 5.00) days], and first liquid intake (62.83 ± 23.29 hours vs 103.33 ± 36.10 hours), as well as shorter abdominal distension duration [4.00 (3.00, 4.75) days vs 4.00 (4.00, 5.00) days], than the laparoscopic group (P < 0.001).

Figure 2 Gastrointestinal function recovery. A: Time to bowel sounds recovery in robotic and laparoscopic groups; B: Time to first flatus; C: Abdominal distension duration; D: Time to first liquid intake.

Postoperative pathological indicators

As shown in Table 4, the groups differed insignificantly in mesorectal excision completeness grading, tumor length, tumor differentiation, lymph node yield, and T/N/TNM stages (P > 0.05).

Table 4 Postoperative pathological indicators, n (%)/median (interquartile range).

Indicators	Laparoscopic group (n = 100)	Robotic group (n = 100)	χ2/Z	P value
Mesorectal excision completeness grading			1.087	0.297
Intact	90 (90.00)	94 (94.00)
Nearly complete	10 (10.00)	6 (6.00)
Incomplete	0 (0.00)	0 (0.00)
Tumor length (cm)	4.08 (3.54, 4.78)	4.22 (3.56, 4.76)	-0.601	0.548
Tumor differentiation			1.070	0.301
High	16 (16.00)	11 (11.00)
Moderate or low	84 (84.00)	89 (89.00)
Lymph node count	13.00 (11.00, 17.00)	15.00 (11.00, 19.00)	-1.840	0.066
T-staging			4.167	0.244
T1	6 (6.00)	10 (10.00)
T2	5 (5.00)	11 (11.00)
T3	14 (14.00)	10 (10.00)
T4	75 (75.00)	69 (69.00)
N-staging			1.146	0.564
N0	63 (63.00)	60 (60.00)
N1	20 (20.00)	26 (26.00)
N2	17 (17.00)	14 (14.00)
TNM staging			0.673	0.714
I	11 (11.00)	14 (14.00)
II	50 (50.00)	45 (45.00)
III	39 (39.00)	41 (41.00)

TNM: Tumor, node, and metastasis.

Tumor markers

As summarized in Table 5, no significant intergroup differences were found in CEA, CA19-9, or CA242 levels pre- and postoperatively (P > 0.05). Within-group comparisons indicated significant postoperative reductions in tumor marker levels compared with baseline (laparoscopic group: CEA: 14.80 ± 5.28 μg/mL vs 23.27 ± 4.62 μg/mL; CA19-9: 25.28 ± 6.26 U/mL vs 47.70 ± 9.31 U/mL; CA242: 20.72 ± 5.28 U/mL vs 40.14 ± 7.08 U/mL; robotic group: CEA: 15.91 ± 5.21 μg/mL vs 22.40 ± 3.91 μg/mL; CA19-9: 24.86 ± 7.32 U/mL vs 47.16 ± 8.47 U/mL; CA242: 19.40 ± 4.95 U/mL vs 39.94 ± 5.53 U/mL; P < 0.001).

Table 5 Pre- and post-operative tumor markers, mean ± SD.

Indicators	Laparoscopic group (n = 100)	Robotic group (n = 100)	t	P value
CEA (μg/mL)
Preoperative	23.27 ± 4.62	22.40 ± 3.91	1.437	0.152
After surgery	14.80 ± 5.28c	15.91 ± 5.21c	1.496	0.136
CA19-9 (U/mL)
Preoperative	47.70 ± 9.31	47.16 ± 8.47	0.429	0.668
After surgery	25.28 ± 6.26c	24.86 ± 7.32c	0.436	0.663
CA242 (U/mL)
Preoperative	40.14 ± 7.08	39.94 ± 5.53	0.223	0.824
After surgery	20.72 ± 5.28c	19.40 ± 4.95c	1.824	0.070

^cP < 0.001 vs preoperative in the same group.

CEA: Carcinoembryonic antigen; CA19-9/CA242: Carbohydrate antigen 19-9/242.

POCs

Postoperative bleeding, incision infection, rectovaginal fistula, voiding dysfunction, and anastomotic leakage occurred in 2, 1, 2, 3, and 2 cases, respectively, in the laparoscopic group, compared with the corresponding 0, 0, 0, 2, and 5 cases in the robotic group (Table 6). No significant difference was observed in overall POC rates (P > 0.05).

Table 6 Postoperative complications, n (%).

Indicators	Laparoscopic group (n = 100)	Robotic group (n = 100)	χ2	P value
Postoperative haemorrhage	2 (2.00)	0 (0.00)
Incision infection	1 (1.00)	0 (0.00)
Rectovaginal fistula	2 (2.00)	0 (0.00)
Voiding dysfunction	3 (3.00)	2 (2.00)
Anastomotic leakage	2 (2.00)	5 (5.00)
Total	10 (10.00)	7 (7.00)	0.579	0.447

Hospitalization expenses

As shown in Table 7, the robotic group incurred significantly higher surgical costs (2.91 ± 1.03 ten thousand CNY vs 1.79 ± 0.77 ten thousand CNY) and total hospitalization expenses (5.33 ± 1.45 ten thousand CNY vs 4.35 ± 1.45 ten thousand CNY) than the laparoscopic group (P < 0.001), while non-surgical expenses were comparable (P > 0.05).

Table 7 Hospitalization expenses, mean ± SD/median (interquartile range).

Indicators	Laparoscopic group (n = 100)	Robotic group (n = 100)	t/Z	P value
Surgical expenses (in 10000 CNY)	1.79 ± 0.77	2.91 ± 1.03	8.709	< 0.001
Non-surgical expenses (in 10000 CNY)	2.48 (1.53, 3.64)	2.49 (1.76, 3.01)	-0.457	0.648
Total hospitalization expenses (in 10000 CNY)	4.35 ± 1.45	5.33 ± 1.45	4.779	< 0.001

Quality of life

As shown in Table 8, preoperative WHOQOL-BREF scores were comparable between groups across all dimensions (P > 0.05). Postoperatively, scores improved in both groups, with greater increases observed in the robotic group (P < 0.001). Specifically, physical function improved from 65.66 ± 6.62 to 76.70 ± 6.11 in the laparoscopic group and from 65.98 ± 6.36 to 82.98 ± 7.69 in the robotic group. Regarding mental state, scores improved from 65.08 ± 5.64 to 75.07 ± 7.12 in the laparoscopic group, and from 63.56 ± 7.39 to 82.71 ± 8.52 in the robotic group. Regarding physical health, scores improved from 66.99 ± 6.81 to 75.58 ± 7.46 in the laparoscopic group, and from 68.33 ± 7.36 to 83.32 ± 8.95 in the robotic group. Regarding social function, scores improved from 69.96 ± 8.10 to 69.71 ± 6.99 in the laparoscopic group and from 72.10 ± 6.82 to 82.29 ± 8.24 in the robotic group.

Table 8 Pre- and post-operative quality of life.

Indicators	Laparoscopic group (n = 100)	Robotic group (n = 100)	χ2/t	P value
Physiological function (points)
Preoperative	65.66 ± 6.62	65.98 ± 6.36	0.349	0.728
Postoperative	76.70 ± 6.11c	82.98 ± 7.69c	6.394	< 0.001
Mental state (points)
Preoperative	65.08 ± 5.64	63.56 ± 7.39	1.635	0.104
Postoperative	75.07 ± 7.12c	82.71 ± 8.52c	6.881	< 0.001
Physical health (points)
Preoperative	66.99 ± 6.81	68.33 ± 7.36	1.336	0.183
Post-operative	75.58 ± 7.46c	83.32 ± 8.95c	6.643	< 0.001
Social function (points)
Preoperative	69.96 ± 8.10	69.71 ± 6.99	0.234	0.816
Postoperative	72.10 ± 6.82c	82.29 ± 8.24c	6.527	< 0.001

^cP < 0.001 vs preoperative in the same group.

DISCUSSION

This study found that RARR and LARR for patients with RC yield comparable outcomes in OT, intraoperative blood transfusion, and prophylactic ostomy, while RARR offers significant advantages in shorter incision length and reduced intraoperative bleeding. Consistent with our findings, Ye et al[18] also reported less IBL but similar OT with robotic approaches in middle and low RC. Yang et al[19] further noted that although similar to laparoscopic-assisted mesorectal excision in cure rates and short-term effects, robotic-assisted mesorectal excision may lead to better short-term outcomes for at-risk patients such as those with obesity or pelvic stenosis, complementing our findings. Postoperative pain on day 1 was similar between groups, aligning with evidence that RARR does not significantly reduce pain despite potential reductions in analgesic use[20]. No significant differences were observed in postoperative recovery indicators, including initial ambulation, time to urinary catheter removal, or length of hospitalization.

Additionally, RARR showed superiority in accelerating postoperative gastrointestinal function recovery, with shorter times to bowel sound recovery, first flatus, and first liquid intake, as well as abdominal distension duration. In low anterior resection surgery for RC, the robotic-assisted approach has been shown to be advantageous over the laparoscopic-assisted method in shortening the time for patients to initiate liquid diets post-operation, though with higher total hospitalization costs, consistent with our findings[21]. Both techniques demonstrated comparable pathological outcomes, including mesorectal excision completeness grading, tumor length, tumor differentiation, lymph node yield, and T/N/TNM staging. Similarly, Wang et al[22] reported similar oncological results with robot-assisted and laparoscopic RC surgical procedures in lymph node count, positive circumferential margin, and distal resection margin. In a prospective randomized controlled trial, Tang et al[23] also reported comparable efficacy of RARR and LARR in the length of tumor specimen, proximal and distal margin distances, mesorectal excision completeness grading, number of positive lymph nodes, postoperative pathological staging, tumor differentiation degree, time to catheter removal, and hospitalization duration. Reductions in tumor marker levels (CEA, CA19-9, and CA242) were also similar, indicating comparable effectiveness tumor removal and considerable curative effects at the molecular level.

Despite technical advantages, RARR did not significantly reduce the overall incidence of POCs (bleeding, incision infection, rectovaginal fistula, voiding dysfunction, and anastomotic leakage). This aligns with previous findings showing that robot-assisted proctectomy exhibits an insignificant lower trend of overall Clavien-Dindo ≥ grade III POCs compared with laparoscopic proctectomy[24]. Feng et al[25] compared the application of robot-assisted resection surgery with traditional laparoscopic surgery in patients with middle and low rectal adenocarcinoma. The robot-assisted approach significantly improved long-term oncological outcomes and contributed to an increase in the three-year disease-free survival rate, complementing our results. Also, this study found that RARR was associated with significantly higher costs, primarily driven by surgical expenses, rather than postoperative management, consistent with the research results of Khajeh et al[26]. In the cost-benefit study by Quijano et al[27], robot-assisted surgery for RC had a higher average operating cost than laparoscopic surgery, but is more cost-effective, complementing our study’s results. Finally, a more significant quality-of-life improvement was determined in patients receiving RARR.

This study has several limitations. First, the lack of long-term follow-up limits the assessment of survival outcomes; future studies should include 3-5-year follow-up data. Second, perioperative biological markers, such as oxidative stress and inflammatory indices, were not evaluated in this study and should be included in future analyses. Third, factors influencing surgical efficacy were not analyzed in depth, and stratified analyses are needed to elucidate the patient subgroups that may benefit most from robotic surgery than from laparoscopic procedure.

CONCLUSION

In summary, RARR offers significant clinical advantages over LARR in terms of reduced invasiveness, lower IBL, faster gastrointestinal function recovery, and a superior quality of life, although at higher costs. These findings may help guide surgical decision-making for optimizing perioperative outcomes in patients with RC.