March's Paper of the Month compares the three-year locoregional recurrence rates of middle and low rectal cancer in patients who underwent robotic surgery vs conventional laparoscopic surgery.
Robotic vs Laparoscopic Surgery for Middle and Low Rectal Cancer: The REAL Randomized Clinical Trial
Qingyang Feng, Weitang Yuan, Taiyuan Li, et al for the REAL Study Group. Published in JAMA 2025. doi:10.1001/jama.2025.8123
What is known about the subject?
Total mesorectal excision (TME) is the standard surgical treatment for mid and low rectal cancer and remains essential to achieve optimal oncological outcomes. Minimally invasive approaches, particularly laparoscopic surgery, have largely replaced open surgery due to their benefits in postoperative recovery and reduced surgical trauma.
However, laparoscopic rectal surgery remains technically demanding because of the limited working space within the pelvis, particularly in male or obese patients and for low rectal tumours. These technical challenges may increase the risk of incomplete mesorectal excision, positive circumferential resection margins, or conversion to open surgery.
Robotic surgery has been introduced to overcome some of these limitations. The robotic platform provides improved visualisation, enhanced instrument articulation, and greater precision during pelvic dissection. Despite these theoretical advantages, evidence from randomised controlled trials demonstrating improved oncological outcomes compared with laparoscopic surgery has remained limited.
What this study adds
The REAL trial is a multicentre randomised clinical trial - and the first superiority trial-comparing 3-year locoregional recurrence rates of middle and low rectal cancer in patients who underwent robotic surgery vs conventional laparoscopic surgery.
The 3-year locoregional recurrence rate was significantly lower with 1.6% (95% CI, 0.6%-2.6%) in the robotic surgery group compared with 4.0% (95% CI, 2.4%-5.6%) in the laparoscopic surgery group.
The 3-year disease-free survival rate was higher in the robotic group (87.2%) vs the laparoscopic group (83.4%) (HR, 0.74 [95% CI, 0.56-0.98], log-rank P = .04; adjusted HR, 0.67 [95% CI, 0.50-0.89]). No significant between-group difference was observed in 3-year overall survival (94.7% in the robotic group vs 93.0% in the laparoscopic group).
Patients in the robotic group had better urinary function, male and female sexual function, and defecation function at 3 and 6 months after surgery and better urinary function and male sexual function at 12 months after surgery.
Implications for colorectal practice
This trial found that, compared with conventional laparoscopic surgery, robotic surgery significantly improved long-term oncological outcomes in patients with middle or low rectal cancer.
Robotic-assisted TME may improve the technical quality of rectal cancer surgery and reduce the risk of conversion to open procedures, particularly in challenging pelvic anatomy. However, the implementation of robotic surgery must take into account factors such as cost, availability of robotic systems, and surgeon experience.
Further studies evaluating long-term oncological outcomes, functional results, and cost-effectiveness will be essential to define the precise role of robotic surgery in the management of rectal cancer.