Robotic versus Laparoscopic abdominoperineal resection for rectal cancer: an updated systematic review and meta-analysis.

Background and Aim: As robotic surgery gains momentum in colorectal surgery, its role in abdominoperineal resections remains debatable. This systematic review and meta-analysis aims to update the current literature.

Methods

A comprehensive search was conducted in PubMed, Scopus, and Cochrane Library up to October 22, 2025. Outcomes were pooled using random-effects models with DerSimonian–Laird for dichotomous and Hartung–Knapp–Sidik–Jonkman for continuous data. Heterogeneity was assessed using I², and study quality was evaluated with ROBINS-I and RoB 2 tools. Subgroup analysis was also performed.

Results

Nine studies (n = 10,838; eight observational and one RCT) were included. Robotic APR was associated with longer operative time (MD 21.43 min; p = 0.03), lower blood loss (MD − 26.31 mL; p = 0.0002), reduced conversion to open surgery (OR 0.34; p = 0.01), and shorter hospital stay (MD − 1.18 days; p = 0.01) compared with laparoscopy. No significant differences were observed in intraoperative or postoperative complications, reoperation, readmission, oncologic parameters, or costs. In cohorts > 100 patients/arm, only conversion rate remained significant (OR 0.32; p = 0.02). In cohorts < 100 patients/arm, robotic surgery showed lower blood loss (p = 0.03), fewer positive circumferential margins (p = 0.04), and shorter hospital stay (p = 0.04). In propensity-matched studies, only positive circumferential margins favored robotics (OR 0.32; p = 0.01). No significant differences were found in patients ≥ 65 years. In patients < 65 years, robotics was associated with lower blood loss (p = 0.01), lower conversion rates (p = 0.006), shorter hospital stay (p = 0.03), but higher costs (p = 0.02).

Conclusion

RAPR demonstrates comparable safety and oncologic outcomes to laparoscopy, while offering advantages in reducing blood loss, conversion to open surgery, and hospital stay. These benefits were more pronounced in younger patients and smaller cohorts. However, operative time and costs remain higher, and overall certainty of evidence ranged from very low to moderate, underscoring the need for further large-scale randomized trials. PROSPERO registration: CRD420261298072.