Resection quality and oncologic outcomes after robotic versus laparoscopic total mesorectal excision for mid and low rectal cancer: a systematic review and meta-analysis of randomised trials

Total mesorectal excision (TME) for mid and low rectal cancer is technically demanding, and resection quality strongly influences local control and survival. Robotic platforms may offer technical advantages over conventional laparoscopy, but oncologic benefits remain uncertain. This meta-analysis evaluates resection quality and early oncologic outcomes using evidence exclusively from randomised trials. A PRISMA aligned systematic review of MEDLINE, Embase, CENTRAL and Google Scholar was performed to 22 September 2025. Eligible studies were parallel-group randomised controlled trials comparing robotic with laparoscopic TME for mid or low rectal adenocarcinoma, defined as tumour height of 10 cm or less from the anal verge. Co-primary outcomes were circumferential resection margin (CRM) positivity and completeness of the mesorectum. Secondary outcomes included conversion to open surgery, intraoperative complications, and three-year locoregional recurrence, disease-free survival, and overall survival. Odds ratios and hazard ratios were pooled using random effects models. Four randomised trials met inclusion, enrolling 1,952 patients. Robotic TME reduced CRM positivity (OR 0.58, 95% CI 0.38 to 0.87) and increased complete TME rates (OR 1.55, 95% CI 1.14 to 2.12). Conversion to open surgery was less frequent with robotics (OR 0.41, 95% CI 0.21 to 0.79). Intraoperative and early postoperative complications did not differ. Two trials reported three-year oncologic outcomes. Robotic TME was associated with lower three-year locoregional recurrence (OR 0.43, 95% CI 0.23-0.81) and a modest improvement in disease-free survival (HR 0.78, 95% CI 0.61-0.99), although event rates were low and estimates should be interpreted cautiously. Overall survival did not differ (HR 0.79, 95% CI 0.57-1.11). In mid and low rectal cancer, robotic TME was associated with improved pathological resection quality and lower conversion rates compared with laparoscopic TME, without clear differences in early perioperative morbidity There is emerging evidence of improved three-year locoregional recurrence and disease-free survival.