Oncologic Outcomes of Robot-Assisted Upfront Surgery Using a Fascia-Guided Total Mesorectal Excision Strategy for T3 Rectal Cancer

BACKGROUND: Local recurrence remains a major challenge in rectal cancer. Total mesorectal excision is the surgical cornerstone; however, early outcomes after its adoption have not consistently achieved satisfactory local control, partly reflecting the difficulty of maintaining appropriate mesorectal dissection. Advances in the understanding of the perirectal fascia and dissection planes, together with robotic technology, have enabled high-quality, fascia-guided total mesorectal excision. Despite this progress, regional strategies differ, emphasizing either the optimization of upfront surgery or intensified preoperative systemic therapy. Long-term oncologic evidence for an upfront robotic strategy remains limited, and concerns, including signals of increased local recurrence after intensified preoperative approaches, have renewed the debate regarding optimal indications. Benchmark data are needed to clarify whether high-quality upfront robotic total mesorectal excision can achieve favorable local control. OBJECTIVE: To evaluate oncologic outcomes after robot-assisted upfront surgery using a study-defined fascia-guided total mesorectal excision framework in a homogeneous cohort limited to pathological T3 rectal cancer. DESIGN: Retrospective cohort study. SETTINGS: Two high-volume medical centers. PATIENTS: Consecutive patients with pathological T3 rectal adenocarcinoma who underwent robot-assisted primary resection between June 2017 and August 2023 were included. MAIN OUTCOME MEASURES: The primary endpoint was the 3-year cumulative incidence of local recurrence. The secondary endpoints included overall survival and relapse-free survival. RESULTS: The final cohort included 125 patients with a median follow-up of 43.4 months. The 3-year cumulative incidence of local recurrence was 2.04% (pathological stage II, 1.80%; pathological stage III, 2.36%). The 3-year overall survival rate was 93.9% and the 3-year relapse-free survival rate was 72.8%. LIMITATIONS: Retrospective design with few local recurrence events; preoperative MRI was not uniformly available. CONCLUSIONS: In a homogeneous pathological T3 cohort, robot-assisted upfront surgery under a fascia-guided total mesorectal excision strategy achieved low 3-year local recurrence and favorable survival, providing stage-specific benchmark outcomes for evaluating upfront surgical approaches. See Video Abstract.