Robotic surgery for rectal cancer in 2026: a hierarchical appraisal of the evidence

Robotic total mesorectal excision (TME) now rests on an evidence base that has accumulated layer by layer: randomized trials, meta-analyses, registry cohorts, and dedicated functional-outcomes studies. The publication of the long-term results of the REAL trial (2025) marked a turning point. We propose a hierarchical evidence framework in which the REAL trial functions as confirmatory apex rather than foundational basis. It provided the first randomized evidence of better locoregional control and disease-free survival with robotic surgery compared to laparoscopy (3-year locoregional recurrence 1.6% vs. 4.0%; absolute risk reduction 2.4%; HR 0.45). This narrative review synthesizes the current evidence comparing robotic TME with laparoscopic TME, framing the most recent randomized data within the broader context of the accumulated literature. Across multiple study designs, robotic TME is consistently associated with lower conversion rates, better circumferential resection margin negativity in selected subgroups, and better preservation of urinary and sexual function. These advantages are amplified in male patients, those with obesity, post-neoadjuvant fibrosis, and lower rectal tumors. Important caveats remain: REAL was conducted exclusively at high-volume Chinese centers, an overall survival benefit has not yet been demonstrated, and cost and access barriers continue to shape global adoption. Evidence in 2026 supports robotic TME as the preferred minimally invasive approach for mid-to-low rectal cancer in centers with established expertise, adequate infrastructure, and case volume. When these conditions are not met, expert laparoscopic TME retains its place. Five-year data and validation across diverse healthcare systems are needed before a universal recommendation can be made.