Robotic versus laparoscopic total mesorectal excision for mid-low rectal cancer after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis of oncological, perioperative, and survival-related outcomes.

A major cause of cancer death, colorectal cancer is becoming more common in younger people. The comparative effectiveness of robotic versus laparoscopic total mesorectal excision (TME) as surgical interventions for mid-low rectal cancer following neoadjuvant chemoradiotherapy (nCRT) remains uncertain. To systematically evaluate oncological, perioperative, and survival outcomes of robotic versus laparoscopic surgery for mid-low rectal cancer following nCRT. A PRISMA-compliant systematic review and meta-analysis included 20 non-randomized studies (13,212 patients) from Web of Science, PubMed, and Embase up to July 2025. Outcomes encompassed pathological completeness (circumferential resection margin, TME quality), perioperative metrics (operative duration, conversion rates), complications, and survival (5-year OS/DFS). Risk of bias was assessed via ROBINS-I; statistical synthesis utilized RevMan5.4 and hazard ratios derived from Kaplan-Meier curves. This meta-analysis of 20 non-randomized studies (13,212 patients) found no significant differences in 5-year overall survival (HR: 1.07, 95% CI 0.20-5.66, p = 0.94, I = 98%) or disease-free survival (HR: 1.16, 95% CI 0.72-1.89, p = 0.54, I = 0%) between robotic and laparoscopic TME after nCRT. Robotic surgery demonstrated superior technical outcomes, including higher rates of complete TME (OR: 1.97, p = 0.02) and reduced conversion to open surgery (OR: 0.46, p < 0.001), but required significantly longer operative time (WMD: + 42.09 min, p < 0.001). Perioperative metrics showed equivalence in intraoperative blood loss (p = 0.20), hospitalization duration (p = 0.78), and postoperative complications, including anastomotic leakage (5.4% vs. 6.5%, p = 0.28) and Clavien-Dindo III-IV events (OR: 1.11, p = 0.54). Pathological outcomes were comparable, with no differences in circumferential resection margin positivity (OR: 1.0, p = 1), distal margin length (p = 0.92), or lymph-node yield (p = 0.55). Local (OR: 0.85, p = 0.34) and distant recurrence rates (p = 0.99) were statistically indistinguishable. Risk-of-bias assessment revealed confounding risks in non-randomized designs, underscoring the need for RCT validation. Robotic and laparoscopic TME achieve equivalent long-term survival and oncological control after nCRT, with robotic advantages in technical precision counterbalanced by prolonged operative duration. The equivalence underscores nCRT's dominant role in tumor control, while procedural differences highlight context-dependent surgical feasibility. High heterogeneity in survival data and reliance on non-randomized evidence necessitate validation through rigorously designed RCTs incorporating standardized protocols and patient-reported functional outcomes.