Robotic Rectal Cancer Surgery: Perioperative and Long-Term Oncological Outcomes of a Single-Center Analysis Compared with Laparoscopic and Open Approach

<b>Background/Objectives:</b> Robotic-assisted surgery is an attractive and promising option with unique advantages in rectal cancer surgery, but the optimal surgical approach is still debatable. Therefore, we aimed to compare the short- and long-term outcomes of the robotic-assisted approach with the laparoscopic-assisted and open approaches. <b>Methods:</b> A single referral center in Israel retrospectively reviewed all patients that underwent an elective rectal resection for primary non-metastatic rectal cancer between 2010 and 2020. The cohort was separated into three groups according to the surgical approach: robotic, laparoscopic, or open. <b>Results:</b> The cohort included 526 patients with a median age of 64 years (range 31-89), of whom 103 patients were in the robotic group, 144 in the open group, and 279 patients in the laparoscopic group. The robotic group had significantly more lower rectal tumors (24.3% versus 12.7% and 6%, respectively, <i>p</i> < 0.001), more locally advanced tumors (65.6% versus 51.2% and 50.2%, respectively, <i>p</i> = 0.004), and higher rates of neoadjuvant radiotherapy (70.9% versus 54.2% and 39.5%, respectively, <i>p</i> < 0.001). Conversion to an open laparotomy was more common in the laparoscopy group (23.1% versus 6.8%, respectively, <i>p</i> = 0.001). The open approach had higher rates of intraoperative complications (23.2% compared with 10.7% and 13.5% in the robotic and laparoscopic groups, respectively, <i>p</i> = 0.011), longer hospital stays (10 days compared with 7 and 8 days, respectively, <i>p</i> < 0.001), and higher rates of postoperative complications (76% compared with 68.9% and 59.1%, respectively, <i>p</i> = 0.002). The groups were similar in the number of harvested lymph nodes (14) and the incidence of positive resection margins (2.1%). The 5-year overall survival in the robotic group was 92.3% compared with 90.5% and 88.3% in the laparoscopic and open groups, respectively (<i>p</i> = 0.12). The 5-year disease-free survival in the robotic group was 68% compared with 71% and 63%, respectively (<i>p</i> = 0.2). <b>Conclusions:</b> The robotic, laparoscopic, and open approaches had similar histopathological outcomes and long-term oncological outcomes. The open approach was associated with higher rates of perioperative morbidity. These findings suggest that the robotic approach is safe and effective in rectal cancer surgery.