Table 2.
Basic characteristics of the included studies (meta-analyses excluded).
| Reference | Country/area | Patients (NOSES/CL) | Agea, years NOSES/CL) | Gender (NOSES/CL) (M/F) | BMIa, kg/m2 (NOSES/CL) | Tumor sizea, cm (NOSES/CL) | Approach | cTNM | nCRT (NOSES/CL) | Location (NOSES/CL) (RC/LC/SC/REC) | Tumor height from anal vergea, cm (NOSES/CL) | Important short-term prognosis (NOSES group) | Important long-term prognosis (NOSES group) | ||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Kim et al [12] | Korea | 58/58 | 62.8 ± 9.0/63.2 ± 10.7 | 0/58 | 0/58 | 23.5 ± 2.9/23.2 ± 3.3 | 3.4 ± 1.8/3.7 ± 1.8 | TV | I–III | 0/0 | 0/0/21/37 | 0/0/22/36 | NA/NA | Longer operative time; less pain; shorter flatus passage time; better cosmetic results | No difference in DFS at 3 years |
| Zhang et al[15] | China | 196/243 | 61.36 ± 13.27/60.35 ± 11.08 | 90/106 | 145/98 | 22.53/23.26 | 3.68 ± 1.59/NA | TS | 0–IV | 0/2 | NA | NA | NA/NA | Less blood loss; shorter flatus passage time; less protective ileostomy | No difference in OS and DFS at 5 years |
| Zheng et al[16] | China | 92/90 | 61.05 ± 10.14/59.58 ± 10.98 | 47/45 | 44/46 | 24.09 ± 3.19/25.12 ± 3.92 | NA | TS | NA | NA | 0/0/0/92 | 0/0/0/90 | 11.94 ± 6.19/ | Longer operative time; shorter drainage tube retention time; shorter postoperative hospital stays | NA |
| 11.50 ± 3.49 | |||||||||||||||
| Ding et al[19] | China | 43/43 | 56.48 ± 10.23/58.02 ± 9.66 | 25/18 | 22/21 | 23.6 ± 3.1/23.2 ± 3.4 | 3.1 ± 1.7/3.6 ± 1.9 | TS | I–III | 0/0 | 0/0/13/30 | 0/0/16/27 | 13.8 ± 5.5/ | Less blood loss; less pain; shorter postoperative exhaust time and regular diet time; better cosmetic results | No difference in the rate of tumor recurrence and 45-month DFS after surgery |
| 14.3 ± 6.1 | |||||||||||||||
| Wolthuis et al[20] | Belgium | 20/20 | 54 (31–72)/58 (40–73) | 5/15 | 10/10 | 23.5 (18–29)/24 (20–29) | NA | TS | NA | 0/0 | 0/0/20/0 | 0/0/20/0 | NA | Longer operative time; more treatment costs; less pain; higher levels ofinflammatory response; better cosmetic results | No difference in Cleveland Clinic Incontinence Scores and anal manometry recordings at 3 months |
| Zhu et al[21] | China | 104/119 | 61.4 ± 12.3/62.5 ± 12.1 | 50/64 | 65/56 | 23.2 ± 1.6/24.4 ± 3.7 | 3.2 ± 1.2/3.6 ± 1.4 | TS | I–III | 0/0 | 0/0/0/104 | 0/0/0/119 | 11.1 ± 8.3/ | Longer operative time; less blood loss; faster bowel function recovery; shorter postoperative hospital stays; less pain; lower complication rate | No difference in DFS at 40 months; better quality of life at 6 months after operation |
| 13.0 ± 11.1 | |||||||||||||||
| Leung et al[22] | Hong Kong | 35/35 | 62 (51–86)/72 (49–84) | 13/22 | 12/23 | NA | 2 (2–4)/3 (2–4) | TS | I–IV | NA | NA | NA | NA | Lower maximum pain score; less wound infection | NA |
| Zhou et al[23] | China | 100/119 | 60.14 ± 11.2/61.2 ± 10.4 | 49/51 | 63/56 | 23.3 ± 2.6/23.4 ± 2.7 | 3.2 ± 1.2/3.5 ± 1.5 | TS | I–III | 0/0 | 0/0/0/100 | 0/0/0/119 | 2.5 ± 1.2/2.4 ± 1.3 | Longer operative time; less blood loss; faster bowel function recovery; less pain; shorter postoperative hospital stays; lower complication rate | No difference in DFS at 3 years |
| Hisada et al[24] | Japan | 20/50 | 63.7 ± 9.0/66.3 ± 11.0 | 12/8 | NA | NA | 2.7 ± 0.9/3.85 ± 1.8 | TS | I–III | NA | 0/0/0/20 | 0/0/0/50 | NA | Less frequent use of analgesics; shorter duration of pain | No local recurrence or distant metastasis in 30 months |
| Zhou et al[26] | China | 52/52 | 55.6 ± 10.4/57.0 ± 10.7 | 27/25 | 27/25 | 22.7 ± 2.7/23.1 ± 2.9 | 3.4 ± 1.3/3.7 ± 1.0 | TS | I–III | 8/10 | 0/0/21/41 | 0/0/20/32 | NA | Shorter time to passage of flatus; less pain; less frequent use of analgesics; higher levels of inflammatory response; | No difference in OS and DFS at 5 years |
| Hu et al[27] | China | 26/26 | 63.1 ± 8.3/61.5 ± 7.6 | 17/9 | 15/11 | 26.5 ± 4.7/26.4 ± 4.6 | NA | TS | I–III | 0/0 | 0/0/0/26 | 0/0/0/26 | 4.9 ± 0.7/4.9 ± 0.6 | Faster bowel function recovery; shorter postoperative hospital stays; less pain; less frequent use of analgesics; better cosmetic results | NA |
| Zhang et al[28] | China | 65/132 | 56.1 ± 9.3/55.5 ± 9.5 | 32/33 | 57/75 | 23.7 ± 2.9/23.1 ± 3.1 | 2.9 ± 1.5/3.7 ± 1.7 | TS | I–III | 0/0 | 0/0/27/38 | 0/0/46/86 | 14.1 ± 6.1/14.1 ± 6.6 | Less blood loss; shorter time to passage of flatus; shorter time to first defecation; shorter time to ambulation; shorter postoperative hospital stays; less pain | No difference in bowel function |
| Liu et al[32] | China | 356/412 | 64 (29–79)/62 (32–81) | 192/164 | 235/177 | 22 (17–31)/23 (18–32) | 3 (1–7)/4 (1–9) | TS | I–III | 17/31 | 0/0/0/356 | 0/0/0/412 | NA | None | None |
| Gao et al[35] | China | 45/45 | 58.1 ± 11.8/59.1 ± 10.8 | 0/45 | 0/45 | 22.1 ± 2.7/21.6 ± 2.2 | 3.5 ± 1.3/3.6 ± 1.2 | TV | I–III | NA | 0/0/16/29 | 0/0/18/27 | NA | Longer operative time; less pain; less frequent use of analgesics; shorter time to first flatus | No difference in OS and DFS at 3 years |
| Awad et al[36] | USA | 20/20 | 66.9 ± 8.90/63.6 ± 9.08 | 0/20 | 0/20 | 25.1 ± 6.65/31.6 ± 8.33 | 4.735 ± 3.61/3.42 ± 1.16 | TV | I–III | NA | 20/0/0/0 | 20/0/0/0 | NA | Longer operative time; better cosmetic results | None |
| Tang et al[38] | China | 186/186 | 59.0 ± 10.4/59.9 ± 11.3 | 94/92 | 92/94 | 22.9 ± 2.8/22.8 ± 3.2 | NA | TS | I–III | 0/0 | 15/7/31/133 | 17/9/25/135 | NA | Less blood loss; less pain; less frequent use of analgesics; faster bowel function recovery; shorter postoperative hospital stays; less Postoperative complication | No difference in OS and DFS at 5 years; better quality of life at 3 months after operation; no difference in anal function at 6 months after operation |
| Zhang et al[41] | China | 39/39 | 72.7 ± 5.8/71.4 ± 5.1 | 19/20 | 20/19 | 21.5 ± 3.2/22.9 ± 3.0 | NA | TS | I–III | 0/0 | 0/0/7/32 | 0/0/13/26 | NA | Less pain; shorter time to first flatus; better cosmetic results; less postoperative complication | No difference in OS, DFS, LR rates and DM rates at 5 years; better quality of life at 3 months after operation; no difference in anal function at 6 months after operation |
| Park et al[42] | Korea | 138/138 | 60.3 ± 10.6/60.4 ± 11.3 | 32/106 | 41/97 | 23.4 ± 2.9/23.3 ± 3.2 | 3.36 ± 1.73/3.54 ± 1.90 | TS/TV | 0–III | 8/10 | 0/0/0/138 | 0/0/0/138 | NA | Longer operative time; less blood loss; shorter time to resume regular diet; shorter postoperative hospital stays | No difference in DFS and LR rates at 3 and 5 years |
| Denost et al[43] | France | 122/98 | 63 (20–90)/65 (25–85) | 70/52 | 69/29 | 24.3 (17.3–33.6)/25.8 (18.8–38.3) | 3.9 (1–10)/4 (1–15) | TS | 0–III | 104/88 | 0/0/0/122 | 0/0/0/98 | 4 (1–6)/4 (1.5–6) | NA | No difference in OS, DFS and LR rates at 5 years; no difference in anal function at 2 years |
| Ng et al[44] | China | 35/38 | 65.14 ± 9.14/63.95 ± 9.19 | 20/15 | 11/16 | 22.64 ± 1.95/23.41 ± 1.60 | 3.05 ± 0.92/3.25 ± 0.99 | TS | I–III | 14/12 | 0/0/24/11 | 0/0/20/18 | 17.31 ± 5.56/15.61 ± 5.39 | Less blood loss; longer operative time; similar operative time | NA |
| Bu et al[45] | China | 46/46 | 66.26 ± 13.34/65.33 ± 10.68 | 25/21 | 26/20 | 21.80 ± 2.78/21.76 ± 2.39 | NA | TS | I–III | 0/0 | 14/2/12/18 | 16/3/10/17 | NA | Similar operative time; less pain; better cosmetic results; similar total medical costs | No difference in OS and DFS at 5 years; similar quality of life |
| Chang et al[46] | Taiwan | 94/94 | 63.5 ± 12.8/63.9 ± 13.1 | 51/43 | 55/39 | 23.8 ± 4.4/23.9 ± 3.7 | 3.0 ± 1.4/3.0 ± 1.5 | TS | I–III | NA | 0/0/66/28 | 0/0/68/26 | NA | Longer operative time; shorter time to first flatus; shorter postoperative hospital stays | No difference in OS, DFS and LR rates at 5 years |
| Zhou et al[47] | China | 172/172 | 59.3 ± 11.0/59.2 ± 8.4 | 103/69 | 105/67 | 23.2 ± 3.1/23.0 ± 2.7 | 3.5 ± 1.4/3.6 ± 1.2 | TS | I–III | NA | 0/0/64/108 | 0/0/65/107 | NA | Longer operative time; less pain; less frequent use of analgesics; less wound infection; shorter time to first flatus | NA |
| ReDati et al[48] | China | 24/24 | 59.5 ± 2.1/59.8 ± 2.3 | 21/3 | 19/5 | 22.9 ± 3.0/23.2 ± 3.1 | 3.1 ± 1.2/3.3 ± 1.5 | TS | I–III | 0/0 | 24/0/0/0 | 24/0/0/0 | NA | Less wound infection; shorter time to first flatus; less pain | No difference in OS, DFS and LR rates at 5 years |
| Zhong et al[49] | China | 38/38 | 57.8 ± 10.3/60.3 ± 9.6 | 21/17 | 20/18 | 22.7 ± 2.5/23.3 ± 2.6 | NA | TS | I–III | 0/0 | 0/0/0/38 | 0/0/0/38 | NA | Less blood loss; shorter time to first flatus; shorter regular diet time; less pain | No difference in OS, DFS and LR rates at 3 years; no difference in OS and DFS at 5 years |
| Yu et al[51] | China | 36/128 | 62 ± 7/61 ± 8 | 20/16 | 70/58 | 23.0 ± 1.7/23.4 ± 1.7 | 4.2 ± 0.5/4.6 ± 0.6 | TS | I–III | NA | 0/0/15/21 | 0/0/60/68 | NA | Less pain; shorter postoperative hospital stays; lower incidence of the incisional infection; similar total medical costs | No difference in OS at 3 and 5 years |
| Zheng et al[54] | China | 52/48 | ≤60: 33; >60: 19/ ≤ 60: 30; > 60: 18 | 0/52 | 0/48 | ≤23: 28; > 23: 24/ ≤ 23: 25; > 23: 23 | NA | TV | I–II | NA | 0/0/0/52 | 0/0/0/48 | ≤10: 28; ≥10: 24/≤ 10: 26; > 10: 22 | Less blood loss; shorter postoperative hospital stays; less pain; shorter time to first flatus; shorter time to resume regular diet | More number of lymph nodes retrieved; no difference in sexual function quality at the third postoperative month; higher in OS at 2 years; better quality of life at 6 months after operation |
| Zheng et al[58] | China | 92/92 | 61.67 ± 8.56/60.45 ± 9.07 | 43/49 | 45/47 | 23.97 ± 2.86/23.75 ± 3.45 | 3.65 (3–4)/4 (3–4) | TS | I–III | NA | 0/0/40/52 | 0/0/25/67 | NA | None | Higher positive rate of bacterial culture; no difference in postoperative peritoneal washings’ tumor cytology results; no difference in DFS at 2 years; no significant correlation between positive bacterial culture and intra-abdominal infection |
| Ouyang et al[59] | China | 96/89 | 58 ± 11/61 ± 11 | 44/52 | 49/40 | 22.5 ± 2.9/22.9 ± 2.6 | NA | TS | 0–III | 0/0 | 2/3/10/81 | 5/3/19/62 | NA | Less pain; less frequent use of analgesics; shorter postoperative hospital stays; lower incision-related complications rate | No difference between bacteriological and oncologic positive results; no difference in LR rates at 2 years |
| Liu et al[60] | China | 50/75 | 60.68 ± 9.90/58.00 ± 10.11 | 29/21 | 45/30 | 23.35 ± 4.11/23.86 ± 3.82 | 3.29 ± 1.00/3.53 ± 1.01 | TS | I–III | 0/0 | 0/0/23/27 | 0/0/34/41 | NA | Higher levels of inflammatory response | No difference betweenbacteriological and oncologic positive results |
BMI, body mass index; CL, conventional laparoscopic surgery; cTNM, clinical TNM stage; F, female; LC, left colon; M, male; NA, not available; nCRT, neoadjuvant chemoradiotherapy; NOSES, natural orifice specimen extraction surgery; RC, right colon; REC, rectum; SC, sigmoid colon; SD, standard deviation; TS, transanal; TV, transvaginal.
There was no statistically significant difference between NOSES and CL in this regard.
a
Mean ± SD or median (range).