Comparative Outcomes of Natural Orifice Specimen Extraction Surgery, Laparoscopic Surgery, and Open Surgery for Rectal Cancer: A Multicenter Propensity-Weighted Study.

BACKGROUND

Natural orifice specimen extraction surgery has been increasingly adopted in rectal cancer surgery, but comparative evidence across natural orifice specimen extraction surgery, laparoscopic surgery, and open surgery remains limited, especially regarding functional and long-term oncological outcomes.

OBJECTIVE

To compare short-term recovery, 6-month functional outcomes, and long-term survival among natural orifice specimen extraction surgery, laparoscopic surgery, and open surgery for rectal cancer within a uniform treatment period.

DESIGN

Multicenter retrospective analysis of prospectively collected real-world data using inverse probability of treatment weighting.

SETTINGS: Four tertiary colorectal cancer centers in China.

PATIENTS: A total of 3,385 patients underwent curative-intent resection for rectal adenocarcinoma between 2017 and 2019, including 1379 treated with open surgery, 1520 with laparoscopic surgery, and 486 with natural orifice specimen extraction surgery.

MAIN OUTCOME MEASURES: Short-term postoperative recovery, complications, 6-month bowel and urinary function assessed using the low anterior resection syndrome score and the International Prostate Symptom Score, and long-term disease-free survival and overall survival.

RESULTS

After weighting, baseline characteristics were well balanced (standardized mean differences < 0.1). Natural orifice specimen extraction surgery showed the fastest short-term recovery among the 3 groups, with significantly shorter time to gastrointestinal recovery, lower pain scores, and fewer wound-related complications compared with both laparoscopic surgery and open surgery. Functional outcomes favored minimally invasive approaches: both natural orifice specimen extraction surgery and laparoscopy surgery showed significantly lower low anterior resection syndrome score and International Prostate Symptom Score than open surgery, with no differences between the 2 minimally invasive approaches. Long-term oncological outcomes were comparable across groups; 5-year disease-free survival was 62.2% for laparoscopic surgery, 63.4% for natural orifice specimen extraction surgery, and 60.5% for open surgery, and 5-year overall survival was 72.2, 74.5, and 73.5%, respectively (all p > 0.05).

LIMITATIONS: Retrospective design and potential residual confounding despite weighting.

CONCLUSIONS

The short-term recovery advantage of natural orifice specimen extraction surgery was most evident compared with open surgery and more modest relative to laparoscopy surgery, while functional and long-term oncological outcomes remained comparable. When performed under standardized oncological principles, natural orifice specimen extraction surgery is a safe and effective minimally invasive option for selected rectal cancer patients. See Video Abstract.