Robotic and laparoscopic TME gave similar five-year survival in COLRAR

Design

Multicentre randomised controlled trial, five-year follow-up

Population

295 adults with rectal adenocarcinoma within 10 cm of the anal verge, three Korean centres

Primary outcome

Five-year overall and relapse-free survival (secondary endpoints)

Effect

OS 92.4% vs 92.6% (p=0.838); RFS 83.0% vs 81.9% (p=0.801), robotic vs laparoscopic

COLRAR randomised adults with rectal adenocarcinoma within 10 cm of the anal verge to robotic or laparoscopic total mesorectal excision at three Korean centres between 2011 and 2016. These are the five-year results, published in October, for 295 analysed patients with a median follow-up of 72.6 months. Survival outcomes were prespecified secondary endpoints.

Five-year overall survival was 92.4% robotic versus 92.6% laparoscopic, and relapse-free survival 83.0% versus 81.9%. Local recurrence was 1.3% after robotic and 4.9% after laparoscopic surgery, but local recurrence-free survival did not differ significantly (p=0.076). In a post hoc analysis of 146 patients who had neoadjuvant chemoradiotherapy, five-year local recurrence-free survival was 98.6% robotic versus 90.7% laparoscopic (p=0.039).

For surgeons choosing between platforms, the oncological case for robotic TME over laparoscopy is not made by this trial. The post hoc chemoradiotherapy signal is interesting but is exactly the kind of result that needs a prospective test. Where robotic access is limited or costly, as in most Indian centres, a well-performed laparoscopic TME remains oncologically sound.

• Counsel patients that robotic and laparoscopic TME showed similar five-year survival in this trial.
• Choose the platform on surgeon experience, access and cost rather than expected oncological gain.
• Treat the better local control after chemoradiotherapy as a hypothesis, not a reason to refer for robotic surgery.
• Audit local recurrence rates for your own TME practice whichever approach you use.

Why it matters

It removes the main oncological argument for paying more for robotic rectal surgery, while leaving the technical arguments open.

Don't overread it

The local-control benefit after chemoradiotherapy comes from a post hoc subgroup and does not show robotic surgery is superior.

The statistics, in plain English

Survival was a secondary endpoint, so the trial was not sized to prove equivalence on it. The local recurrence difference did not reach significance (p=0.076). The chemoradiotherapy subgroup result was decided after the fact and could be chance.

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