A commentary on “Robotic versus laparoscopic surgery for middle and low rectal cancer: a retrospective cohort study emulating the target trial”

Dear Editor, The target trial emulation by Wang et al reports a statistically significant, yet modest, 3.4% absolute improvement in 3-year disease-free survival (DFS) with robotic versus laparoscopic surgery for middle and low rectal cancer (86.7% vs 83.3%; HR = 0.800)[1]. However, declaring broad clinical superiority based on this finding is premature, absent a robust health economic evaluation and a critical appraisal of the study’s generalizability, given the substantial cost differences involved. First, the referenced REAL trial – a high-quality RCT published in The Lancet Gastroenterology & Hepatology – confirmed short-term advantages of robotics but also highlighted a nearly 50% higher direct surgical cost, a pivotal factor omitted from the current discussion[2]. Second, real-world evidence suggests that the benefits observed in high-volume, expert-center studies may not consistently extend to broader practice settings – a limitation not fully mitigated by propensity score matching[1,3]. Third, contemporary ESMO guidelines stress that surgical approach selection should balance oncologic outcomes, functional results, and cost-effectiveness, not rely solely on statistical superiority in a single endpoint[4]. The reported number needed to treat (NNT) of 29.4 to avert one DFS event further implies considerable resource use for a limited population-level benefit[1]. Proponents may cite the lower positive circumferential resection margin (2.2% vs. 4.2%) and abdominoperineal resection rates (7.5% vs. 12.4%) as justification for robotic adoption. While these are valuable surgical and pathological quality indicators, their translation into improved long-term survival or quality-adjusted life-years (QALYs) remains unquantified. Moreover, as evidenced in the ROLARR trial, confounding by surgeon proficiency and center-specific factors persists in platform comparisons[5]. The current emulation design cannot fully resolve this, particularly as two participating centers performed only laparoscopic surgery, potentially clustering outcomes according to unmeasured expertise rather than technology[1]. Before concluding robotics is the unequivocally “better choice,” we urge the integration of these clinical data into a formal cost-effectiveness analysis. A decision-analytic model should estimate long-term outcomes – such as 5- to 10-year overall survival and QALYs – against comprehensive costs encompassing initial surgery, recurrence management, and stoma-related care. Established methodologies from prior oncology health-economic studies, including those evaluating adjuvant therapies, offer a validated template for this essential step[6]. The conclusion should thus be refined to state: robotic surgery demonstrates promising oncologic outcomes in selected settings, but its recommendation for widespread implementation should be contingent upon demonstrating cost-effectiveness, defined as a meaningful clinical benefit that justifies its significant incremental cost. Therefore, conclusions should be drawn cautiously: while robotic surgery demonstrates promising oncological outcomes in selected settings, its recommendation for widespread adoption should be contingent on proven cost-effectiveness, i.e., on demonstrating clinically meaningful benefits that justify its substantially higher costs.