Understanding Textbook outcome failure after robotic colorectal cancer surgery: a multicenter domain-specific...

Textbook Outcome (TO) is increasingly used as a composite measure of surgical quality in colorectal cancer, but its binary structure may obscure why the endpoint is not achieved. We evaluated component-specific and domain-specific patterns of TO failure after robotic colorectal cancer surgery. This multicenter retrospective cohort study analyzed consecutive adult patients undergoing elective colorectal cancer resection at five Polish tertiary referral centers between January 2022 and August 2025. TO required 30-day survival, R0 resection with ≥ 12 lymph nodes retrieved, no surgical reintervention, no unplanned stoma, no major postoperative complication, and length of stay ≤ 14 days without 30-day readmission. For interpretative analysis, TO failure was decomposed into radicality, pathological staging, surgical safety, functional preservation, and recovery domains. Failure burden was assessed among patients not achieving TO. Among 1,124 eligible patients, 785 had complete TO data: 312 open, 169 laparoscopic, and 304 robotic resections. TO was achieved in 469 patients (59.7%), with crude rates of 62.2% after open, 71.0% after laparoscopic, and 51.0% after robotic surgery. The dominant failed domain after robotic surgery was pathological staging failure, mainly retrieval of fewer than 12 lymph nodes, present in 95 of 149 robotic TO failures (63.8%). Radicality, surgical safety, and recovery failures were not disproportionately increased after robotic surgery. Among patients who did not achieve TO, most failures reflected a single failed component or domain. After adjustment, including adjustment for neoadjuvant treatment, robotic surgery was not independently associated with overall Textbook Outcome achievement or pathological staging failure. Robotic colorectal cancer surgery showed a distinct TO failure fingerprint. Global TO rates should be interpreted alongside component-specific and domain-specific failure patterns, particularly in rectal cancer.