Robotic surgery following total neoadjuvant therapy in locally advanced rectal cancer: a narrative review

Introduction

Background

The number of patients with rectal cancer is increasing, with 729,702 new cases and 343,761 related deaths reported in 2022 (1). The annual number of new cases worldwide is projected to reach 1.0 million, with related deaths expected to rise to 0.5 million by 2040 (2). A marked increase in incidence has been observed, particularly among adults younger than 50 years, suggesting exposure to risk factors beginning early in life (1,3). The reported risk factors include alcohol consumption, smoking, intake of red and processed meat, excess body fat, physical inactivity, antibiotic exposure affecting the gut microbiome, and a sedentary lifestyle (4). For patients with rectal cancer, achieving both cure and preservation of function and quality of life (QOL) remain the central goals.

Rationale and knowledge gap

Recent advances include organ preservation strategies with total neoadjuvant therapy (TNT) and the increasing adoption of minimally invasive approaches, such as robotic surgery (5-12). However, despite growing clinical interest in robotic surgery for rectal cancer, no randomized controlled trials and no review to date have specifically focused on the role and clinical implications of robotic surgery following TNT, highlighting an important knowledge gap.

Objective

This narrative review aims to provide an overview of TNT and robotic surgery, with a focus on the clinical implications of robotic surgery following TNT for locally advanced rectal cancer (LARC). We present this article in accordance with the Narrative Review reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-65/rc).

Methods

Manual literature searches were conducted using PubMed from database inception to November 2025, limited to English-language publications. The search strategy combined terms related to TNT (“total neoadjuvant therapy” OR “TNT”), robotic surgery (“robotic” OR “robot-assisted”), and rectal cancer (“rectal cancer” OR “LARC”); the detailed strategy is provided in Table 1. Eligible sources comprised randomized controlled trials, prospective and retrospective cohort studies, and relevant review articles on TNT and robotic surgery for LARC. Literature screening was conducted by two reviewers together, and any uncertainties were resolved through discussion until consensus was reached. Additional relevant references were identified via bibliographic screening of retrieved articles and relevant review papers.

Discussion

TNT for LARC: establishment of treatment and concerns

In recent decades, the treatment paradigm for LARC has evolved significantly. Surgical resection with a total mesorectal excision (TME) is the cornerstone of curative treatment (13). Postoperative adjuvant chemotherapy (ACT) was subsequently introduced (14). However, the risk of locoregional recurrence remains a concern.

The addition of preoperative radiotherapy (RT) represents a major step forward, demonstrating reduced local recurrence compared to that via surgery alone (15). Further progress has been achieved with concurrent preoperative chemoradiotherapy (CRT), which became the standard treatment after demonstrating superior local control and higher rates of pathological downstaging (16,17). However, distant metastases still occur in approximately 30–40% of patients, and adherence to ACT is limited owing to toxicity, resulting in only modest survival benefits (16,18).

To address these limitations, TNT that integrates systemic chemotherapy and RT, entirely in the preoperative (neoadjuvant) setting, has emerged as a strategy to improve oncologic outcomes and treatment compliance. In 2018, TNT was incorporated into the National Comprehensive Cancer Network guidelines as a treatment option for LARC. Subsequently, phase III trials including RAPIDO (19), PRODIGE23 (20), STELLAR (21), and the TNT-CRT trial (22) demonstrated that TNT increases pathologic complete response (pCR) rates and improves survival outcomes (overall survival and recurrence-free survival) compared with conventional CRT‑based strategies (Table 2). As shown in Table 2, the pCR rates ranged from 21.8% to 28% in the TNT group and from 9.84% to 14% in the CRT group. However, the results regarding local recurrence were controversial, and no significant difference was observed between the two groups.

Additionally, the German CAO/ARO/AIO-12 randomized phase II trial compared induction and consolidation chemotherapy in long-course CRT and showed a higher pCR rate with consolidation (25% vs. 17%) without differences in disease-free survival (DFS) rates or distant metastases, helping to establish consolidation-first sequencing within TNT (23). Furthermore, the OPRA trial showed that TNT enables organ preservation through non-operative management (NOM) without compromising oncologic outcomes; notably, 47% of the patients achieved organ preservation (5,6). In the secondary analysis of the OPRA trial, the 3year probability of preserving the rectum (i.e., avoiding surgical resection) was 77% for patients who achieved a clinical complete response (cCR) and 40% for those with a near complete response (nCR) (7).

Ongoing international phase III studies [ENSEMBLE (Japan; NCT05646511), ACO/ARO/AIO‑18.1 (Germany; NCT05484024), and the Janus Rectal Cancer trial (United States; NCT05610163)] seek to define the optimal TNT approach (doublet vs. triplet chemotherapy; short‑course vs. longcourse CRT) (2).

Concerns related to TNT

However, TNT has potential disadvantages such as overtreatment, worse outcomes in non-responders, long-term functional impairment, and heightened technical difficulty, which often stems from therapy-induced fibrosis, inflammation, and adhesions (24,25). During surgery following TNT, these changes are of concern because they can blur the anatomical planes and hinder layer-correct dissection, potentially leading to longer operations, increased blood loss, functional compromise, and a higher risk of circumferential resection margin (CRM) involvement. Although based on a survey rather than objective intraoperative data, a nationwide Austrian study explored surgeons’ experiences with TNT and its impact on TME quality (24). Among 31 expert colorectal surgeons, 65% reported that TNT changed the quality of the dissection plane, 57% experienced greater difficulty in identifying the correct surgical plane, 47% noticed increased tissue fragility, and 32% observed increased intraoperative bleeding (24). Furthermore, it is generally believed that surgery becomes more difficult as the time after radiation increases. Recent findings support this finding, showing that while a longer time interval (specifically >12 weeks) was associated with a lower rate of distant recurrence, it also led to increased surgical difficulty, including a higher likelihood of conversion to open surgery, greater intraoperative challenges, and a significantly higher risk of postoperative complications (26). In cases operated on after NOM, 64% of respondents found altered tissue planes, and 47% reported tissue fragility (24). In addition to technical difficulties, oncological concerns after TNT have also been reported. A secondary analysis of the RAPIDO trial demonstrated that, in sphincter-preserving surgery, a distal resection margin of ≤10 mm was associated with a significantly higher rate of locoregional recurrence in the TNT group compared with the CRT group. These findings suggest that residual tumor may persist within the original tumor bed despite apparent clinical or radiological tumor regression, underscoring the importance of careful assessment and securement of an adequate distal margin in surgery following TNT (27).

Surgical outcomes in large-scale TNT trials

The trials shown in Table 2 involved over 200 patients in both the TNT and CRT groups, with RAPIDO being a large-scale study with more than 400 patients (19-22). Although they did not specifically focus on surgical outcomes, some findings have been reported. In terms of conversion to open surgery from minimally invasive surgery (MIS), which includes both laparoscopic and robotic procedures, the RAPIDO trial reported slightly higher conversion rates for TNT compared to that for CRT, and similar trends were observed in the TNT-CRT trial. Regarding the TME completion rate (both open and MIS procedures), the RAPIDO trial showed a lower completion rate after TNT (78%) compared to that after CRT (85%). Similarly, in the PRODIGE 23 trial, the completion rate of TNT was 81.4%, whereas CRT had a higher completion rate of 88.6%. However, the results regarding complications of Clavien-Dindo classification Grade 3 or higher and mortality rates are controversial, with no significant differences between the groups.

Of note, the RAPIDO trial reported that MIS accounted for 40% of surgeries, whereas the TNT-CRT trial showed a range of 80–90%. MIS was not mentioned in the other two trials, and the proportion of robotic surgeries was not specified.

Utility and evidence of robotic surgery in rectal cancer

The ability to perform precise dissection even in the deep, narrow pelvis, afforded by a three-dimensional (3D) magnified view and wristed instruments, has led to certain expectations since its introduction, including a shorter learning curve, a lower conversion rate to open surgery, better preservation of sexual and urinary function, and higher rates of complete TME.

Robotic surgery has been shown to shorten the learning curve, with aspiring colorectal surgeons achieving operative efficiency in as few as 12 cases and reduced complications in approximately 15 cases (28). Furthermore, combining prior laparoscopic experience with a structured and proctored training program can accelerate this process and ensure patient safety during the learning phase (28). In contrast, other anticipated advantages have been less consistent, as the ROLARR randomized trial did not show a clear superiority of robotic surgery over laparoscopy (8). One plausible reason is that ROLARR accrued surgeons during the early adoption of the robotic platform when experience and training were heterogeneous, potentially diluting the incremental benefits. To mitigate variability in surgeon experience, the prospective multicenter phase II VITRUVIANO trial mandated strict credentialing (≥40 prior robotic rectal procedures) and reported a CRM-positivity rate of 4.6% (14/303), 0% conversion to open surgery, a complete TME rate of 98.4%, and a low incidence of severe complications (Clavien-Dindo Grade III–IV: 4.3%), supporting technical reliability and oncologic adequacy in advanced rectal cancer (9). In addition, for technically demanding lateral lymph node (LLN) dissection, recent systematic reviews and meta-analyses suggest more favorable perioperative outcomes with robotic assistance than with laparoscopy, including lower overall morbidity (particularly fewer urinary complications), shorter hospital stay, and a higher LLN yield, albeit with longer operative time (29,30).

Robust randomized evidence regarding the long-term oncological outcomes has only recently become available. The REAL trial, a large multicenter randomized study enrolling 1,240 patients with mid‑to‑low rectal cancer (cT1–T3, N0–N1, or ycT1–T3 Nx), compared robot‑assisted with conventional laparoscopic surgery. The key findings included a 3‑year local recurrence rate of 1.6% in the robotic group vs. 4.0% in the laparoscopic group [hazard ratio (HR) 0.45, P=0.03] and a significantly improved DFS rate [87.2% vs. 83.4%; HR 0.74, P=0.04 (12)]. There was no significant difference in overall survival rates. Functional outcomes (urinary, sexual, and bowel functions) also recovered more rapidly in the robotic group, with significantly improved patient-reported scores. The trial reported that 254 (43.3%) patients in the robotic group and 257 (43.9%) in the laparoscopic group received preoperative RT or CRT; however, the proportion of TNT cases was not specified (12).

However, ROLARR, VITRUVIANO, and REAL were conducted before TNT became widespread. In ROLARR, the proportion of patients receiving neoadjuvant CRT was not specified in the primary report, whereas VITRUVIANO included approximately 18–19% of patients who underwent neoadjuvant therapy, mostly CRT. The REAL trial also included a substantial proportion of patients receiving preoperative RT or CRT, but did not specify the number of TNT cases. Consequently, although these trials provide valuable evidence supporting the technical feasibility and oncologic adequacy of robotic TME, their applicability in post-TNT settings remains limited and should be interpreted with caution.

Evidence suggesting the usefulness of robotic surgery following TNT in rectal cancer

In the ENSEMBLE-1 and ENSEMBLE-2 phase II trials, which were conducted as Japanese multicenter studies that investigated short-course RT followed by capecitabine plus oxaliplatin (CAPOX) ×6 (ENSEMBLE-1) and long-course CRT followed by CAPOX ×4 (ENSEMBLE-2), 20 and 21 patients underwent surgery in ENSEMBLE-1 and ENSEMBLE-2, respectively. Of these patients, 22% underwent laparoscopy and 78% underwent robotic procedures, with no conversion to open surgery. Specifically, in the ENSEMBLE-1 trial, 95% of patients underwent robotic surgery and 5% underwent laparoscopic procedures. In the ENSEMBLE-2 trial, 61.9% of patients underwent robotic surgery and 38.1% underwent laparoscopic surgery. The curative (R0) resection rate was 92.7%, with 100% in ENSEMBLE-1 and 85.7% in ENSEMBLE-2. The overall postoperative complication rate was 24.4%, with Grade ≥3 events in 4.9% of cases (5% in ENSEMBLE-1 and 4.8% in ENSEMBLE-2). These results demonstrated the feasibility and safety of MIS, particularly robotic surgery, after TNT (10,11).

In the EUREKA collaborative study (n=1,390 robotic TMEs from European centers), 59.7% and 33.8% of the patients received neoadjuvant therapy and TNT, respectively. Outcomes were favorable, with a CRM-positive rate of 5.5% and a 3year local recurrence rate of 2.9% (31). Furthermore, a recent single-institution study from the Mayo Clinic evaluating TNT followed by TME for LARC reported favorable surgical and oncologic outcomes, and 71.1% of 311 patients underwent robotic surgery. The study reported an R0 resection rate of 99.4%, CRM positivity of 0.6%, and complete or near-complete TME quality in 96.4% of patients (32). The 5‑year local recurrence rate was 5.7%, and the 5year DFS was 80.5% (32). A meta-analysis of 12 studies involving 11,686 patients compared robotic and laparoscopic surgeries for rectal cancer following preoperative neoadjuvant therapy (CRT and TNT where specified) (33). The operative time was longer (P<0.001), whereas postoperative complications (P=0.43), positive margin rate (P=0.54), distal margin involvement (P=0.16), blood loss (P=0.40), length of hospital stay (P=0.89), mortality (P=0.15), and lymph node yield (P=0.23) did not differ significantly (33).

Collectively, the emerging TNT-specific series and post-neoadjuvant comparative data indicate that robotic surgery improves technical precision and TME quality, which may translate into better oncologic outcomes in anatomically demanding pelves, although most available data consistently show longer operative times with the robotic approach. To date, no randomized trial has specifically evaluated robotic TME following TNT. Therefore, well-designed TNT-specific prospective studies are essential to establish the true magnitude, efficiency, and clinical relevance of these potential benefits.

Limitations of current evidence

Despite the growing interest, current evidence remains limited and heterogeneous. Most available studies are retrospective, single-institution, and single-arm analyses with relatively small sample sizes, which restrict the strength of the inferences. Even in studies that included preoperative treatment cohorts, TNT and conventional CRT cases were often analyzed together, making it difficult to distinguish the specific impact of each approach. Randomized controlled trials designed specifically to evaluate robotic surgery in post-TNT settings are lacking. In addition, follow-up in most available studies is relatively short, limiting the assessment of long-term oncological and functional outcomes.

Considerable heterogeneity exists across published studies on TNT regimens (short vs. long course, induction vs. consolidation chemotherapy), timing of surgery following TNT, and surgical expertise. These variations impeded meaningful cross-study comparisons.

Another important limitation was selection bias. Patients undergoing robotic surgery after TNT are often treated in high-volume tertiary centers and may represent a more favorable subgroup with better access to specialized care. Differences in surgeons’ experience and institutional resources further limit the generalizability of the results.

Future perspectives

An overview of the treatment strategies for LARC is shown in Figure 1. It is expected that the treatment strategy of transitioning to NOM after TNT will be increasingly adopted in the future. However, the 3-year probability of requiring surgery because of recurrence was 23% in patients who achieved cCR and 60% in those who achieved nCR (7). This underscores that surgery remains an important treatment option even after achieving a clinical response. As mentioned earlier, prolonged times after radiation exposure are expected to increase surgical difficulty, particularly in patients undergoing NOM. In such cases, the benefits of robotic surgery can be leveraged.

Figure 1 Treatment strategy for locally advanced rectal cancer. cCR, clinical complete response; CT, computed tomography; iCR, indeterminate complete response; MRI, magnetic resonance imaging; nCR, near complete response; NOM, non-operative management; TNT, total neoadjuvant therapy; W&W, watch and wait.

Future research should prioritize the generation of high-quality evidence to clarify the role of robotic surgery after TNT, especially after NOM. Large-scale, multicenter, randomized trials are required to compare robotic, laparoscopic, and open approaches following TNT, with an emphasis on oncologic outcomes such as R0 resection, CRM involvement, pCR, and long-term survival. Trials should also evaluate functional outcomes (urinary, sexual, and bowel functions) and patient-reported QOL to comprehensively assess the full clinical value of robotic surgery following TNT and guide individualized strategies that balance oncologic safety with functional preservation.

Identifying the patient subgroups that are most likely to benefit is critical. Patients with technically demanding pelvic anatomies, such as male sex, obesity, or a narrow pelvis, are theoretically more likely to benefit from the dexterity and visualization provided by robotic surgery. Stratified analyses and tailored trial designs are key to establishing evidence-based selection criteria.

Technological innovations will shape the future of rectal cancer surgery. Artificial intelligence and machine learning support intraoperative decision-making by facilitating real-time recognition of anatomical planes and autonomic nerves (34). Augmented reality and fluorescence-guided imaging may further enhance orientation and precision (35). As these technologies mature, their integration with robotic platforms can improve the surgical safety and functional outcomes in patients with TNT-treated rectal cancer.

Finally, the broader adoption of robotics will depend on a careful evaluation of its cost-effectiveness and accessibility. Although robotic systems are increasingly available in high-volume centers, their diffusion is limited by financial and infrastructural barriers. Comparative health-economic analyses together with policy-level considerations are essential to ensure that technological advances translate into equitable and sustainable improvements in patient outcomes.

Conclusions

Surgery for rectal cancer following TNT is technically demanding because of the treatment-induced tissue changes (fibrosis and inflammation). Robotic surgery offers potential advantages in this complex setting by enhancing visualization, precision, and dexterity. Current evidence suggests that robotics can improve short-term technical outcomes and that early randomized data support better locoregional control and DFS in anatomically challenging populations, including patients with mid-to-low rectal cancer, although TNT-specific high-level data remain limited. With an increasing number of patients opting for NOM, the potential benefits of robotic surgery may become even more pronounced, particularly in cases where salvage surgery is required following local recurrence. Well-designed prospective trials are essential to establish the definitive role of robotic surgery after TNT, evaluate long-term oncologic and functional outcomes, and define optimal patient selection.

Acknowledgments

We would like to thank Editage (www.editage.jp) for the English language editing.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-65/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-65/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-65/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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References

1. Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2024;74:229-63. [Crossref] [PubMed]
2. Kagawa Y, Smith JJ, Fokas E, et al. Future direction of total neoadjuvant therapy for locally advanced rectal cancer. Nat Rev Gastroenterol Hepatol 2024;21:444-55. [Crossref] [PubMed]
3. Siegel RL, Torre LA, Soerjomataram I, et al. Global patterns and trends in colorectal cancer incidence in young adults. Gut 2019;68:2179-85. [Crossref] [PubMed]
4. Spaander MCW, Zauber AG, Syngal S, et al. Young-onset colorectal cancer. Nat Rev Dis Primers 2023;9:21. [Crossref] [PubMed]
5. Garcia-Aguilar J, Patil S, Gollub MJ, et al. Organ Preservation in Patients With Rectal Adenocarcinoma Treated With Total Neoadjuvant Therapy. J Clin Oncol 2022;40:2546-56. [Crossref] [PubMed]
6. Verheij FS, Omer DM, Williams H, et al. Long-Term Results of Organ Preservation in Patients With Rectal Adenocarcinoma Treated With Total Neoadjuvant Therapy: The Randomized Phase II OPRA Trial. J Clin Oncol 2024;42:500-6. [Crossref] [PubMed]
7. Thompson HM, Omer DM, Lin S, et al. Organ Preservation and Survival by Clinical Response Grade in Patients With Rectal Cancer Treated With Total Neoadjuvant Therapy: A Secondary Analysis of the OPRA Randomized Clinical Trial. JAMA Netw Open 2024;7:e2350903. [Crossref] [PubMed]
8. Jayne D, Pigazzi A, Marshall H, et al. Effect of Robotic-Assisted vs Conventional Laparoscopic Surgery on Risk of Conversion to Open Laparotomy Among Patients Undergoing Resection for Rectal Cancer: The ROLARR Randomized Clinical Trial. JAMA 2017;318:1569-80. [Crossref] [PubMed]
9. Hamabe A, Takemasa I, Kotake M, et al. Feasibility of robotic-assisted surgery in advanced rectal cancer: a multicentre prospective phase II study (VITRUVIANO trial). BJS Open 2024;8:zrae048. [Crossref] [PubMed]
10. Kagawa Y, Watanabe J, Uemura M, et al. Short-term outcomes of a prospective multicenter phase II trial of total neoadjuvant therapy for locally advanced rectal cancer in Japan (ENSEMBLE-1). Ann Gastroenterol Surg 2023;7:968-76. [Crossref] [PubMed]
11. Kagawa Y, Ando K, Uemura M, et al. Phase II study of long-course chemoradiotherapy followed by consolidation chemotherapy as total neoadjuvant therapy in locally advanced rectal cancer in Japan: ENSEMBLE-2. Ann Gastroenterol Surg 2024;8:1067-75. [Crossref] [PubMed]
12. Feng Q, Yuan W, Li T, et al. Robotic vs Laparoscopic Surgery for Middle and Low Rectal Cancer: The REAL Randomized Clinical Trial. JAMA 2025;334:136-48. [Crossref] [PubMed]
13. MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet 1993;341:457-60. [Crossref] [PubMed]
14. Krook JE, Moertel CG, Gunderson LL, et al. Effective surgical adjuvant therapy for high-risk rectal carcinoma. N Engl J Med 1991;324:709-15. [Crossref] [PubMed]
15. van Gijn W, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer: 12-year follow-up of the multicentre, randomised controlled TME trial. Lancet Oncol 2011;12:575-82. [Crossref] [PubMed]
16. Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004;351:1731-40. [Crossref] [PubMed]
17. Gérard JP, Conroy T, Bonnetain F, et al. Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3-4 rectal cancers: results of FFCD 9203. J Clin Oncol 2006;24:4620-5. [Crossref] [PubMed]
18. Bosset JF, Collette L, Calais G, et al. Chemotherapy with preoperative radiotherapy in rectal cancer. N Engl J Med 2006;355:1114-23. [Crossref] [PubMed]
19. Bahadoer RR, Dijkstra EA, van Etten B, et al. Short-course radiotherapy followed by chemotherapy before total mesorectal excision (TME) versus preoperative chemoradiotherapy, TME, and optional adjuvant chemotherapy in locally advanced rectal cancer (RAPIDO): a randomised, open-label, phase 3 trial. Lancet Oncol 2021;22:29-42. [Crossref] [PubMed]
20. Conroy T, Bosset JF, Etienne PL, et al. Neoadjuvant chemotherapy with FOLFIRINOX and preoperative chemoradiotherapy for patients with locally advanced rectal cancer (UNICANCER-PRODIGE 23): a multicentre, randomised, open-label, phase 3 trial. Lancet Oncol 2021;22:702-15. [Crossref] [PubMed]
21. Jin J, Tang Y, Hu C, et al. Multicenter, Randomized, Phase III Trial of Short-Term Radiotherapy Plus Chemotherapy Versus Long-Term Chemoradiotherapy in Locally Advanced Rectal Cancer (STELLAR). J Clin Oncol 2022;40:1681-92. [Crossref] [PubMed]
22. Wang X, Liu P, Xiao Y, et al. Total neoadjuvant treatment with long-course radiotherapy versus concurrent chemoradiotherapy in local advanced rectal cancer with high risk factors (TNTCRT): A multicenter, randomized, open-label, phase 3 trial. J Clin Oncol 2024;42:LBA3511.
23. Fokas E, Allgäuer M, Polat B, et al. Randomized Phase II Trial of Chemoradiotherapy Plus Induction or Consolidation Chemotherapy as Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer: CAO/ARO/AIO-12. J Clin Oncol 2019;37:3212-22. [Crossref] [PubMed]
24. Jäger T, Zitt M, Riss S, et al. Does Total Neoadjuvant Therapy Impact Surgical Precision in Total Mesorectal Excision? A Nationwide Survey of the Experiences of Expert Surgeons. Cancers (Basel) 2025;17:283.
25. Chong CX, Koh FH, Tan HL, et al. The impact of short-course total neoadjuvant therapy, long-course chemoradiotherapy, and upfront surgery on the technical difficulty of total mesorectal excision: an observational study with an intraoperative perspective. Ann Coloproctol 2024;40:451-8. [Crossref] [PubMed]
26. Guzmán Y, Ríos J, Paredes J, et al. Time Interval Between the End of Neoadjuvant Therapy and Elective Resection of Locally Advanced Rectal Cancer in the CRONOS Study. JAMA Surg 2023;158:910-9. [Crossref] [PubMed]
27. Prata I, Tanaka MD, Glimelius B, et al. Factors influencing locoregional recurrence rates in locally advanced rectal cancer after total neoadjuvant treatment versus chemoradiotherapy in the RAPIDO trial. Br J Surg 2025;112:znaf190. [Crossref] [PubMed]
28. Wong NW, Teo NZ, Ngu JC. Learning Curve for Robotic Colorectal Surgery. Cancers (Basel) 2024;16:3420. [Crossref] [PubMed]
29. Chaouch MA, Hussain MI, Carneiro da Costa A, et al. Robotic versus laparoscopic total mesorectal excision with lateral lymph node dissection for advanced rectal cancer: A systematic review and meta-analysis. PLoS One 2024;19:e0304031. [Crossref] [PubMed]
30. Chen YC, Tsai YY, Ke TW, et al. Robotic versus laparoscopic pelvic lateral lymph node dissection in locally advanced rectal cancer: a systemic review and meta-analysis. Surg Endosc 2024;38:3520-30. [Crossref] [PubMed]
31. Geitenbeek RTJ, Genders CMS, Taoum C, et al. An International Multicentre Retrospective Cohort Study Evaluating Robot-Assisted Total Mesorectal Excision in Experienced Dutch, French, and United Kingdom Centres-The EUREKA Collaborative. Cancers (Basel) 2025;17:1268. [Crossref] [PubMed]
32. Ng JC, Sassun R, Sileo A, et al. Real-world clinical outcomes of total neoadjuvant therapy followed by total mesorectal excision for locally advanced rectal cancer at a high-volume institution. Eur J Surg Oncol 2025;51:110181. [Crossref] [PubMed]
33. Zhang Y, Dong B, Li G, et al. Short-term outcomes of robotic vs. laparoscopic surgery for rectal cancer after neoadjuvant therapy: a meta-analysis. Front Surg 2023;10:1292031.
34. Knudsen JE, Ghaffar U, Ma R, et al. Clinical applications of artificial intelligence in robotic surgery. J Robot Surg 2024;18:102. [Crossref] [PubMed]
35. Galema HA, Meijer RPJ, Lauwerends LJ, et al. Fluorescence-guided surgery in colorectal cancer; A review on clinical results and future perspectives. Eur J Surg Oncol 2022;48:810-21. [Crossref] [PubMed]