Gender‐Specific Cancer‐Related Survival Analysis of Robotic Versus Laparoscopic Low Anterior Resection for Rectal Adenocarcinoma: A Multicenter Study

ABSTRACT

Aim

This study compared short‐ and long‐term outcomes of robotic and laparoscopic low anterior resection (LAR) for rectal adenocarcinoma using sex‐stratified analyses.

Methods

Patients who underwent elective robotic or laparoscopic LAR for rectal cancer were included. Prospectively maintained database of outcomes was analysed retrospectively. To minimise selection bias, groups were matched.

Results

Of 409 identified patients, 380 met the eligibility criteria (mean age: 61 years, BMI: 26.2 kg/m²). In a matched cohort of males (n = 172) and females (n = 114), robotic surgery was associated with significantly shorter hospital stay (p < 0.01). Harvested lymph nodes, margins, morbidity and local recurrence were comparable in males (p > 0.05). Robotic surgery in females was associated with fewer harvested lymph nodes (p = 0.01). Five‐year disease‐specific survival rates did not significantly differ between approaches in either gender.

Conclusions

Robotics and laparoscopic LAR achieved similar oncologic outcomes. The findings should be interpreted as sex‐stratified comparisons rather than evidence of differential effect of surgical approach according to sex.

1. Introduction

Minimally invasive surgery has become the standard of care for rectal cancer due to its association with reduced postoperative pain, shorter hospital stays, and faster recovery [1]. Among these techniques, both laparoscopic and robotic‐assisted approaches are widely employed for low anterior resection (LAR) in patients with rectal adenocarcinoma. While laparoscopic surgery is well‐established, robotic surgery offers potential advantages including enhanced dexterity, superior visualisation, and improved ergonomics, especially in the confined pelvic cavity. These features may be particularly relevant for low pelvic dissections, which are technically demanding and influenced by patient‐specific anatomical factors such as gender [2, 3].

Gender‐related anatomical differences in the pelvis may influence the ease of surgical dissection, operative duration, and oncological outcomes in rectal cancer surgery. Several studies have suggested that male patients may present more challenging pelvic anatomy, while others propose that female patients experience longer operative times or different complication patterns depending on surgical modality [4, 5]. Despite these considerations, few studies have systematically compared laparoscopic and robotic LAR with a focus on gender‐based differences in perioperative and oncological outcomes, particularly in large matched cohorts [6, 7, 8].

This multicenter retrospective cohort study aimed to compare robotic and laparoscopic low anterior resection in male and female patients with rectal adenocarcinoma. By conducting separate matched analyses for each gender, we evaluated perioperative, oncologic, and survival outcomes following robotic and laparoscopic low anterior resection within male and female cohorts.

2. Materials and Methods

This was a multicenter retrospective cohort study including patients diagnosed with rectal adenocarcinoma who underwent either robotic or laparoscopic LAR between October 2010 and December 2023 at Ankara University Hospital and Acıbadem Maslak, Altunizade, and Atakent Hospitals. The study protocol was approved by the Ethics Committee of Acıbadem Mehmet Ali Aydınlar University (ID: 2025‐xxx), and written informed consent was obtained from all participants. Eligible patients were those aged 18 years or older who underwent elective LAR for rectal adenocarcinoma. Exclusion criteria included abdominoperineal resection, stage IV disease, and emergency procedures. These exclusions aimed to ensure a consistent comparison between robotic and laparoscopic approaches.

Collected data included demographic, clinical, and perioperative variables such as age, gender, body mass index (BMI), American Society of Anaesthesiologists (ASA) score, TNM stage, type of resection [total mesorectal excision (TME), partial mesorectal excision (PME), or intersphincteric resection (ISR)], operative time, tumour location (lower, mid, or upper rectum), neoadjuvant therapy, stoma use, mesorectal specimen grade, number of harvested and positive lymph nodes, circumferential resection margin (CRM), distal resection margin, length of hospital stay, 30‐day morbidity, and local recurrence. The analyses were designed as sex‐stratified comparisons; all analyses were performed separately for each group and were not intended to evaluate whether sex modified the effect of surgical approach. Matching was conducted in a 1:1 ratio according to age, BMI, type of resection, year of surgery and receipt of neoadjuvant therapy, as described in the statistical analysis section. The primary outcome was the comparison of the 5‐year disease‐specific survival (DSS) rate between robotic and laparoscopic LAR, stratified by gender.

2.1. Surgical Technique

All surgical procedures were carried out by experienced colorectal surgeons in line with standardized oncologic principles. Laparoscopic low anterior resections were performed with a medial‐to‐lateral approach with multiport access, involving ligation of the inferior mesenteric artery at its origin, mobilisation of the left colon and rectum, and splenic flexure takedown when required. In robotic resections, patients were placed in a modified lithotomy position, and four robotic ports plus an assistant port were positioned. Robotic dissection proceeded in the embryological plane with careful preservation of autonomic nerves, and vascular ligation was performed at standard oncologic levels. The robotic technique utilised four robotic arms and one assistant port, allowing for precise dissection within the confined pelvic space.

Dissection was initiated at the sacral promontory, continuing in the embryological plane while preserving critical structures such as the ureters and hypogastric nerves. High ligation of the inferior mesenteric artery and vein was performed, followed by mobilisation of the left mesocolon and mesorectum. The rectum was transected with an endoscopic linear stapler under robotic guidance, and intracorporeal anastomosis was completed using a circular stapling device. The robotic system allowed stable retraction, tremor elimination, and enhanced 3D visualisation, particularly advantageous for deep pelvic dissection and precise nerve preservation. The techniques are explained in our previous studies [9, 10].

2.2. Statistical Analysis

Continuous variables were presented as medians with interquartile ranges (IQRs) and compared using the Mann‐Whitney U test. Categorical variables were summarised as frequencies and percentages and analysed using the Chi‐square or Fisher's exact test, as appropriate. To reduce potential confounding factors, 1:1 nearest‐neighbour propensity score matching was performed separately for the male and female subgroups. To assess the adequacy of propensity score matching, covariate balance was evaluated using standardized mean differences (SMDs) before and after matching. Variables included in the propensity score model were age, BMI, type of resection, year of surgery, and receipt of neoadjuvant therapy. In addition, balance was assessed for other clinically relevant variables, including ASA score, TNM stage, tumour location, and treatment centre. Love plots were generated to visually evaluate covariate balance. Balance was achieved after matching for the primary matching covariates (age, BMI, type of resection, year of surgery, and neoadjuvant therapy), whereas treatment centre and ASA score remained imbalanced despite matching. Detailed SMD values before and after matching are provided in Table S1, and Love plots are presented in Figure S1.

Kaplan‐Meier analysis was used to estimate 5‐year DSS, both before and after propensity score matching. All DSS analyses were stratified by sex. Pre‐matching survival comparisons are presented in Figure S2, while results from the matched cohorts are shown in Figure 1. Disease‐specific survival was additionally evaluated using Cox proportional hazards regression, and hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated. The proportional hazard assumption was assessed using Schoenfeld residual‐based diagnostics. All statistical analyses were performed using R software (version 4.2.3; R Foundation for Statistical Computing, Vienna, Austria).

FIGURE 1.

(A) Kaplan‐Meier survival curve comparing surgical approach in the unmatched, overall eligible cohort (n = 380; 204 laparoscopic, 176 robotic) (5‐year disease‐specific survival). (B) Kaplan‐Meier survival curve comparing surgical approach in a matched cohort—Female: 57 patients in each group (5‐year disease‐specific survival). 57 patients in each group (5‐year disease‐specific survival: Laparoscopic 90.3%, Robotic 94.8%; p = 0.56). (C) Kaplan‐Meier survival curve comparing surgical approach in a matched cohort—Male: 86 patients in each group (5‐year disease‐specific survival). 86 patients in each group (5‐year disease‐specific survival: Laparoscopic 93.9%, Robotic 97.1%; p = 0.93). Number‐at‐risk tables are displayed below each Kaplan–Meier curve. Hazard ratios and 95% confidence intervals were estimated using Cox proportional hazards regression.

3. Results

A total of 409 patients were initially identified from the institutional databases. After excluding patients who underwent abdominoperineal resection (n = 11), had stage IV disease (n = 10), or underwent emergency procedures (n = 8), 380 patients remained eligible for analysis. A flowchart detailing the patient selection process is presented in Figure 2. A total of 380 patients who underwent low anterior resection were analysed, 151 of whom were female. The median age was 58 ± 12 years and median BMI was 26.1 ± 3.6 kg/m². Clinical characteristics were similar in between the groups. Patient demographics and clinical characteristics are summarised in Tables 1 and 2 for males and females, respectively.

FIGURE 2.

Consort diagram of patients undergoing minimally invasive low anterior resection.

TABLE 1.

Characteristics of the study population: male patients (229 patients).

Characteristic	Robotic (n = 108)	Laparoscopic (n = 121)	p value
Age, years
≥ 60	62 (58%)	52 (43%)	0.04
< 60	46 (42%)	69 (57%)
ASA
1	6 (6%)	17 (14%)
2	89 (82%)	92 (76%)	0.09
3	13 (12%)	12 (10%)
BMI, kg/m2
Normal	41 (38%)	37 (31%)	0.48
Overweight	57 (53%)	70 (58%)
Obese	10 (9%)	14 (12%)
TNM stage
1	44 (41%)	51 (42%)	0.73
2	26 (24%)	24 (20%)
3	38 (35%)	46 (38%)
Resection type
TME	49 (51%)	67 (56%)	0.26
PME	31 (32%)	27 (22%)
ISR	19 (18%)	27 (22%)
Cancer location
Lower	36 (33%)	43 (36%)	0.15
Mid	37 (34%)	52 (43%)
Upper	35 (33%)	26 (21%)
Neoadjuvant therapy usage	82 (76%)	88 (73%)	0.69
Stoma usage	91 (84%)	110 (91%)	0.18
Total harvested lymph nodes (median, IQR)	22 (14)	26 (13)	0.45
Positive harvested lymph nodes
0	71 (66%)	77 (64%)	0.45
1–2	25 (23%)	35 (29%)
3+	12 (11%)	9 (7%)

Note: Data are expressed as number (percentage) or median (IQR; Q3–Q1).

Abbreviations: IQR, interquartile ratio; ISR, intersphincteric resection; PME, partial mesorectal excision; TME, total mesorectal excision.

TABLE 2.

Characteristics of the study population: female patients (151 patients).

Characteristic	Robotic (n = 68)	Laparoscopic (n = 83)	p value
Age, years
≥ 60	26 (38%)	33 (40%)	0.98
< 60	42 (62%)	50 (60%)
ASA
1	5 (7%)	15 (18%)	0.1
2	57 (84%)	62 (75%)
3	6 (9%)	6 (7%)
BMI, kg/m2
Normal	26 (38%)	31 (37%)	0.86
Overweight	32 (47%)	42 (51%)
Obese	10 (15%)	10 (12%)
TNM stage
1	31 (46%)	38 (46%)	0.97
2	13 (19%)	17 (20%)
3	24 (35%)	28 (34%)
Resection type
TME	28 (41%)	39 (47%)	0.37
PME	27 (40%)	24 (28%)
ISR	13 (19%)	20 (24%)
Cancer location
Lower	20 (29%)	32 (39%)	0.27
Mid	20 (29%)	27 (32%)
Upper	28 (42%)	24 (29%)
Neoadjuvant therapy usage	44 (65%)	60 (72%)	0.41
Stoma usage	52 (76%)	72 (87%)	0.16
Total harvested lymph nodes (median, IQR)	24 (13)	27 (12)	0.06
Positive harvested lymph nodes
0	45 (66%)	58 (70%)	0.63
1–2	10 (15%)	8 (10%)
3+	13 (19%)	17 (20%)

Note: Data are expressed as number (percentage) or median (IQR; Q3–Q1).

Abbreviations: IQR, interquartile ratio; ISR, intersphincteric resection; PME, partial mesorectal excision; TME, total mesorectal excision.

Among 229 male patients, 108 underwent robotic and 121 laparoscopic surgeries. Patients in the robotic group were significantly older, with 58% aged ≥ 60 years compared to 43% in the laparoscopic group (p = 0.04). ASA classification was well balanced in both cohorts. There were no significant differences in BMI, TNM stage, a type of resection, tumour location, neoadjuvant therapy, or stoma usage. The duration of surgery was significantly longer in the robotic group (median 360 min [IQR 180] vs. 300 min [IQR 105]; p = 0.003) (Table 1).

Among male patients, the median follow‐up was 58 months (IQR 31–84.5) in the robotic surgery group and 69 months (IQR 48–94) in the laparoscopic surgery group. Among female patients, median follow‐up was 72 months (IQR 36.8–97.2) for those undergoing robotic surgery and 60 months (IQR 42–83.5) for those undergoing laparoscopic surgery.

A total of 151 female patients were included, with 68 undergoing robotic surgery and 83 undergoing laparoscopic surgery. Baseline characteristics such as age (≥ 60 years: 38% vs. 40%) and BMI did not significantly differ. ASA classification again differed significantly (p < 0.01), with ASA I being more prevalent in the laparoscopic group (39.5% vs. 7.4%), and ASA III more frequent in the robotic group (8.8% vs. 2.5%). TNM stage, a type of resection, tumour location, neoadjuvant therapy, and stoma formation were all comparable. Although the duration of surgery was slightly longer in the robotic group (median 300 vs. 280 min), the difference was not statistically significant (p = 0.09). Notably, mesorectal grade differed significantly (p = 0.01), with grade 3 more frequent in the laparoscopic group (75.9%) and grade 2 more frequent in the robotic group (44.3%) (Table 2).

The following propensity score matching performed separately in male and female cohorts, 286 patients were included in the matched analyses. In the female group, 114 patients and 172 patients were matched in the male group. In the male cohort, after propensity score matching (86 patients per group), the robotic and laparoscopic groups had similar oncological outcomes. Median total harvested lymph nodes (22 vs. 26; p = 0.14), lymph node positivity, circumferential resection margin (CRM) positivity (2.4% in both), and distal margin involvement (0% in both) were comparable. However, the length of hospital stay was significantly shorter in the robotic group (median 5 vs. 7 days; p < 0.01). No significant differences were observed in 30‐day morbidity (16% vs. 12%; p = 0.51) or local recurrence rates (6% vs. 14%; p = 0.12) (Table 3).

TABLE 3.

Matched postoperative outcomes—male patients.

Characteristic	Robotic (n = 86)	Laparoscopic (n = 86)	p value
Ileostomy creation	11 (12.8)	7 (8.1)	0.45
Total harvested LNs (median, IQR)	22 (14)	26 (16)	0.14
Positive harvested LNs
0	55	55	0.36
1–2	20	25
3+	11	6
CRM positivity	2 (2.4)	2 (2.4)
Distal resection margin positivity	0	0
Length of hospital stay, days	5 (2.75)	7 (2)	< 0.01
Anastomosis leakage	5 (5.8)	4 (4.7)	0.99
30 day morbidity	14 (16)	10 (12)	0.51
Local recurrence	5 (6)	12 (14)	0.12

Note: Data are expressed as number (percentage) or median, IQR.

Abbreviations: CRM, circumferential resection margin; IQR, interquartile range; LN, lymph node.

In the male group, the distribution of surgical procedures was comparable between the laparoscopic and robotic approaches. In the laparoscopic group, ISR was performed in 16 patients, PME in 22 patients, and TME in 48 patients. Similarly, in the robotic group, 15 patients underwent ISR, 25 patients underwent PME and 46 patients underwent TME. In the laparoscopic cohort of female patients, ISR was performed in 11 patients, PME in 17 patients, and TME in 29 patients. In the robotic cohort, ISR was performed in 10 patients, PME in 22 patients, and TME in 25 patients. There were no conversions in any of the cases.

When the analysis was restricted to low rectal tumours only, procedural distributions demonstrated a consistent pattern across sexes. Among male patients with low rectal tumours, 31 patients underwent ISR, while 26 patients underwent TME. No PME procedures were performed in this subgroup. Similarly, in female patients with low rectal tumours, 25 patients underwent ISR and 17 patients underwent TME, with no PME procedures observed.

In the matched female cohort (57 patients per group), the robotic group had a significantly shorter hospital stay (median 4 vs. 7 days; p < 0.01) and fewer harvested lymph nodes (median 24 vs. 28; p = 0.01). Rates of positive lymph nodes, CRM and distal margin involvement, 30‐day morbidity (5% both), and local recurrence (7% vs. 11%) did not differ significantly between the groups (Table 4). In the sex‐stratified matched analysis, rates of anastomotic leakage were comparable between robotic and laparoscopic approaches in both male and female patients. Among male patients, anastomotic leakage occurred in 5 patients (5.8%) in the robotic group and 4 patients (4.7%) in the laparoscopic group, with no statistically significant difference between the approaches (p = 0.99). Similarly, in the matched female cohort, anastomotic leakage was observed in 2 patients (3.5%) in each group, again demonstrating no significant difference between robotic and laparoscopic surgery (p = 0.99).

TABLE 4.

Matched postoperative outcomes—female patients.

Characteristic	Robotic (n = 57)	Laparoscopic (n = 57)	p value
Ileostomy creation	9 (16)	5 (8.8)	0.39
Total harvested LNs (median, IQR)	24 (13)	28 (15)	0.01
Positive harvested LNs
0	40	39
1–2	8	7	0.86
3+	9	11
CRM positivity	1 (1.8)	0 (0)
Distal resection margin positivity	0	1 (1.8)
Length of hospital stay, days	4 (3)	7 (2)	< 0.01
Anastomosis leakage	2 (3.5)	2 (3.5)	0.99
30 day morbidity	3 (5)	3 (5)	1
Local recurrence	4 (7)	6 (11)	0.74

Note: Data are expressed as number (percentage) or median, IQR.

Abbreviations: CRM, circumferential resection margin; IQR, interquartile range; LN, lymph node.

In the unmatched, overall eligible cohort (n = 380), no significant difference in 5‐year disease‐specific survival between the groups was observed (p = 0.48) (Figure 1A). This unmatched comparison is presented for the descriptive context; the matched sex‐stratified analyses below form the basis of our primary conclusions. In the female group, laparoscopic cases (n = 57) were compared with robotic cases (n = 57), and 5‐year disease‐specific survival rates were similar (90.3% and 94.8% respectively, p = 0.56) (Figure 1B). In the male group, laparoscopic cases (n = 86) were compared with robotic cases (n = 86), and 5‐year disease‐specific survival rates were not statistically different (93.9% and 97.1% respectively, p = 0.93) (Figure 1C). Disease‐specific event counts, hazard ratios, proportional hazards assessments, and number‐at‐risk data are presented in Tables S2 and S3. Cox proportional hazards analyses demonstrated no statistically significant difference in disease‐specific survival between robotic and laparoscopic surgery in either sex. In females, the hazard ratio for robotic versus laparoscopic surgery was 1.09 (95% CI 0.27–4.38; p = 0.901), whereas in males, the corresponding hazard ratio was 2.04 (95% CI 0.60–6.96; p = 0.257). Hazard ratios and corresponding 95% confidence intervals are summarised in Figure 3. The proportional hazard assumption was satisfied in both cohorts.

FIGURE 3.

Hazard ratio summary.

4. Discussion

This multicenter matched cohort study investigated the outcomes of robotics versus laparoscopic low anterior resection in patients with rectal adenocarcinoma using sex‐stratified analyses. Our analysis provides important insights into the comparative performance of these two minimally invasive techniques when stratified by gender, which is a relatively underexplored area in colorectal surgical research. The findings indicate that robotic surgery, while associated with longer operative times across both male and female patients, results in comparable oncologic outcomes and potentially more favourable perioperative recovery, particularly in terms of reduced hospital stay. Most notably, five‐year disease‐specific survival (DSS) rates were not significantly different between the robotic and laparoscopic groups, regardless of gender.

These observations are consistent with emerging literature that investigates the intersection of pelvic anatomy, gender‐specific technical challenges, and the evolution of minimally invasive surgical platforms. In particular, prior work by Aliyev et al. [4] demonstrated that male patients undergoing robotic total mesorectal excision (TME) and female patients undergoing laparoscopic TME achieved similar outcomes with respect to CRM involvement, mesorectal specimen quality, complication rates, and long‐term oncologic control. Our findings align with this study, suggesting that robotic and laparoscopic approaches achieve comparable oncologic outcomes, while robotic surgery may offer potential technical and ergonomic advantages in selected patients.

In addition, recent evidence has explored the outcomes of robotic rectal surgery separately in male and female patients, highlighting the potential influence of anatomical and physiological differences on perioperative recovery. A retrospective study by Ali et al. [11], including 155 patients undergoing robotic rectal cancer surgery, demonstrated that although overall complication rates were comparable between genders, female patients experienced a higher proportion of severe (Clavien–Dindo grade III–IV) complications and longer hospital stays, whereas male patients tended to have shorter recovery periods. These findings suggest that even within the robotic approach, gender‐specific physiological and anatomical factors may influence postoperative recovery patterns. In contrast, our study did not demonstrate a significant difference in morbidity or complication severity between genders after matching, which may be explained by differences in cohort size, matching methodology, and inclusion of both laparoscopic and robotic approaches.

One of the most consistent findings in the literature, and reaffirmed by our results, is the prolonged operative duration associated with robotic surgery [12, 13]. Multiple studies, including those by Bilgin et al. [2] and others, have documented that robotic TME requires longer operative times than laparoscopic approaches. This can be attributed to factors such as robotic docking, more meticulous dissection techniques, and the time‐intensive nature of using articulated instruments in a confined pelvic workspace. However, it is critical to emphasise that extended operative duration did not translate into increased morbidity or longer recovery. On the contrary, in our cohort, robotic procedures were associated with significantly shorter hospital stays, indicating that enhanced intraoperative control and precision may contribute to smoother postoperative recovery. This mirrors the findings of Bilgin et al., who reported similar postoperative complication rates and reduced lengths of hospital stay in patients undergoing robotic colorectal surgery.

Robotic platforms were initially developed to overcome the inherent limitations of conventional laparoscopy, particularly in technically demanding procedures such as pelvic surgery. Rigid laparoscopic instruments and limited range of motion make it challenging to achieve optimal visualisation and precision within the narrow confines of the pelvis, particularly in male patients with a deep and angulated pelvic cavity. Robotic systems offer wristed instrumentation with seven degrees of freedom, high‐definition 3D visualisation, and improved ergonomics, all of which enhance the surgeon's ability to perform fine dissection and maintain oncologic principles during TME [3]. These advantages are especially beneficial during dissection along the pelvic sidewalls, nerve preservation, and accurate resection in low rectal tumours.

Despite these technological advances, the superiority of minimally invasive techniques, whether robotic or laparoscopic, over open surgery remains a topic of debate. While many studies support their positive impact on short‐term outcomes, including reduced blood loss, less postoperative pain, and faster return to bowel function, their influence on long‐term oncologic results is less definitive [1, 14]. Notably, the ACOSOG Z6051 and ALaCaRT trials, two of the most robust randomized controlled trials in this field, failed to demonstrate non‐inferiority of laparoscopic surgery when compared to open surgery in terms of pathological endpoints such as CRM positivity and TME completeness [15, 16]. In the discussion of the ACOSOG trial, Fleshman et al. highlighted that the inherent technical difficulty of proctectomy, particularly in the male pelvis, might be further complicated by the limitations of rigid laparoscopic instruments. They suggested that alternative platforms, such as robotics, may offer improved ergonomics and precision, thereby enhancing the quality of resection in these anatomically challenging scenarios [16].

This hypothesis is further supported by the recent REAL (Robotic vs. Laparoscopic Surgery for Middle and Low Rectal Cancer) randomized clinical trial, which enrolled over 1200 patients across 11 centres. The study demonstrated a significantly lower 3‐year locoregional recurrence rate in the robotic group (1.6%) compared to the laparoscopic group (4.0%), along with improved disease‐free survival (87.2% vs. 83.4%) and better postoperative urinary, gender, and defecatory function [17]. These results suggest that robotic surgery may offer not only short‐term technical advantages but also meaningful improvements in oncologic and functional outcomes in anatomically complex cases, such as low rectal cancer. Notably, the benefits observed were consistent across gender subgroups, reinforcing the platform's utility beyond ergonomic feasibility alone.

Our gender‐stratified analysis provides descriptive observations regarding outcomes within male and female cohorts. In the male cohort, robotic surgery achieved comparable oncologic outcomes and shorter hospital stay; however, these findings should not be interpreted as evidence that male patients derive greater benefit from robotic surgery than female patients. In male patients, who typically present with narrower pelvic dimensions and greater operative difficulty, the robotic approach yielded favourable outcomes in terms of surgical margin status and lymph node harvest, without increasing morbidity. A meta‐analysis by Abdelsamad et al. [5] demonstrated studies showing better CRM and distal resection margin (DRM) values in male patients undergoing robotic TME, along with higher lymph node yields. Such improvements may be attributable to the robotic system's ability to facilitate stable, precise dissection in deep pelvic planes and enhance surgeon comfort, thereby reducing fatigue‐related errors. Furthermore, these technical improvements may shorten the learning curve and increase the reproducibility of high‐quality TME, especially among less experienced surgeons managing male rectal cancer patients.

An exploratory finding of our study was the numerically lower local recurrence rate observed in male patients undergoing robotic surgery compared with laparoscopic surgery (6% vs. 14%). However, this difference did not reach statistical significance and should therefore be interpreted with caution. While this pattern is consistent with observations reported by Aliyev et al. [18], our results do not provide sufficient evidence to conclude that robotic surgery improves local disease control in male patients. Rather, these findings may be considered hypothesis‐generating and warrant further investigation in adequately powered prospective studies. Additionally, recent evidence from Masayuki et al. and the large‐scale real‐world cohort by Hanaoka et al. demonstrated worse survival outcomes in males undergoing laparoscopic rectal cancer surgery compared with robotic approaches [19, 20]. Conversely, Aliyev et al. reported no significant oncological differences between robotic and laparoscopic sphincter‐saving resections in female patients, supporting the concept that pelvic geometry may explain the modality‐specific advantage seen in males [21].

Interestingly, despite the technical advantages of the robotic approach in male patients, our long‐term analysis showed no significant difference in five‐year DSS between the two modalities. This underscores a critical concept in colorectal oncology, that oncologic success is strongly linked to surgeon experience, case volume, and adherence to surgical principles, rather than the surgical platform alone.

In female patients, where the pelvic anatomy tends to be wider and more accommodating for laparoscopic instruments, robotic surgery did not demonstrate substantial additional benefit in terms of either oncologic or short‐term surgical outcomes. These observations may be related to anatomical differences between male and female pelvises. Nevertheless, the present study was designed to evaluate robotic and laparoscopic outcomes within each gender separately, and therefore the findings should be interpreted as sex‐stratified comparisons rather than evidence of differential treatment effects according to sex. As Aliyev et al. have proposed, the benefits of robotic assistance are more evident in anatomically challenging situations, whereas in less constrained surgical fields, such as the female pelvis, conventional laparoscopy may be equally effective [4, 22].

The primary strength of our study lies in its matched cohort design, stratified by gender, and conducted across multiple centres, increasing its external validity. By matching for key confounding variables and focusing on gender‐based anatomical differences, we were able to evaluate the nuanced impact of surgical platform selection on outcomes in rectal cancer. However, the study is not without limitations. Its retrospective design introduces the potential for selection bias and residual confounding despite propensity score matching. Although matching was performed using key clinical variables, some imbalance persisted for treatment centre, likely reflecting the non‐random distribution of robotic and laparoscopic procedures across participating institutions and surgical eras. Standardized mean differences for treatment centre remained large after matching (SMD 2.089 in the male cohort and 2.449 in the female cohort). Because centre, institutional case volume, and surgeon experience are closely intertwined and may independently influence perioperative outcomes and long‐term survival, residual confounding by these factors cannot be excluded, and the present matched comparisons should be interpreted with this limitation in mind. An expanded sensitivity analysis incorporating centre as an additional matching covariate was not performed in this study but represents an important direction for future work. In addition, the ASA score was not available for all patients, and surgeon‐level identifiers and mesorectal specimen grade were not consistently recorded, precluding their incorporation into the matching model. Functional outcomes such as urinary, sexual, and bowel function were not assessed. Additionally, quality‐of‐life measures and long‐term functional recovery remain unaddressed, representing important areas for future research.

In conclusion, robotic and laparoscopic low anterior resection achieved broadly comparable oncologic outcomes in this matched multicenter cohort. Although robotic surgery was associated with a longer operative time, it was also associated with a shorter hospital stay. The gender‐stratified analyses provide descriptive information regarding outcomes in male and female patients; however, the present findings do not support using gender alone to guide surgical platform selection. Future prospective studies with standardized functional outcome reporting and longer follow‐up are warranted to determine whether these perioperative advantages translate into sustained patient‐centred benefits.

Author Contributions

Ismaıl Ahmet Bilgin, Mehmet Ayhan Kuzu, Bilgi Baca, Ismaıl Hamzaoglu and Tayfun Karahasanoglu contributed to the study's conception and design. Data collection was performed by Nur Ramoglu, Ayse Gulsah Kaya and Burak Kutlu. Metincan Erkaya conducted data analysis and interpretation. The first draft of the manuscript was written by Cigdem Benlice and Nur Ramoglu. All authors critically revised the manuscript for important intellectual content, approved the final version, and agreed to be accountable for all aspects of the work.

Funding

The authors have nothing to report.

Ethics Statement

The study was approved by the Ethics Committee of Acıbadem Mehmet Ali Aydınlar University and conducted in accordance with the Declaration of Helsinki.

Consent

Written informed consent was obtained from all participants prior to their inclusion in the study.

Conflicts of Interest

The authors declare no conflicts of interest.

Permission to Reproduce Material From Other Sources

This study does not contain any previously published material, images, or tables requiring permission to reproduce.

Supporting information

Figure S1: Covariate balance before and after propensity score matching. Love plots for (A) male and (B) female subgroups show standardized mean differences of baseline covariates before (blue) and after (grey) matching. Post‐matching, covariate balance substantially improved in both cohorts.

Figure S2: Kaplan‐Meier survival curve comparing surgical approach before matching. (A) Female: 151 patients in total (5‐year disease‐specific overall survival: laparoscopic 93.1%, robotic 94.0%; p = 0.89). (B) Male: 229 patients in total (5‐year disease‐specific overall survival: laparoscopic 94.4%, robotic 92.9%; p = 0.27).

Table S1: Covariate balance before and after matching using original matching covariates.

Table S2: Disease‐specific survival results in the recreated matched cohorts.

Table S3: Number at risk for Kaplan‐Meier disease‐specific survival curves.

Benlice C., Ramoglu N., Bilgin I. A., et al., “Gender‐Specific Cancer‐Related Survival Analysis of Robotic Versus Laparoscopic Low Anterior Resection for Rectal Adenocarcinoma: A Multicenter Study,” The International Journal of Medical Robotics and Computer Assisted Surgery (2026): e70234, 10.1002/rcs.70234.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.