Robotic and laparoscopic abdominoperineal resections for anal cancer may improve outcomes compared with open surgery:...

Abdominoperineal resection (APR) is an important treatment option for anal cancer patients with incomplete response or recurrence after chemoradiation, yet the frequency and effectiveness of minimally invasive surgery (MIS) remain poorly described. This study examines trends and outcomes of robotic, laparoscopic, and open APR using the National Cancer Database (NCDB).

Patients undergoing APR for anal cancer in the NCDB (2010-2022) were categorized by surgical approach based on the initial operative technique, approximating an intention-to-treat framework. The study period was divided into early (2010-2016) and late (2017-2022) eras to assess temporal trends. Demographics, tumor characteristics, and perioperative outcomes were compared. Primary endpoints included 30- and 90-day mortality, length of stay, margin positivity, and overall survival.

Among 3756 patients (831 robotic, 723 laparoscopic, 2202 open), baseline characteristics were similar across approaches. Robotic APR increased significantly in the late era (33.3% vs 13.2%, p < 0.001), whereas open APR declined (48.2% vs 66.9%) and laparoscopic APR remained stable (18.5% vs 19.9%). MIS approaches demonstrated lower 30-day mortality (1.2% robotic vs 1.7% laparoscopic vs 2.2% open, p < 0.001), lower 90-day mortality (3.2% vs 3.6% vs 4.9%, p < 0.001), and fewer margin positivity rates (14.4% vs 14.1% vs 17.8%; p < 0.001). Median length of stay was 5, 6, and 8 days for robotic, laparoscopic, and open, respectively (p < 0.001). Five-year overall survival was 56%, 54%, and 49%. On Cox regression adjusted for age, year, comorbidity, and stage, open APR was associated with a 25% higher hazard of all-cause mortality compared with robotic APR (HR 1.247, CI 1.061-1.466, p = 0.007), while laparoscopic and robotic demonstrated comparable survival.

Minimally invasive APR for anal cancer has increased over time and is associated with shorter hospital stays, lower perioperative mortality, fewer positive margins, and improved survival. These findings support laparoscopic and robotic APR as preferred approaches for appropriately selected anal cancer patients.