Robotic versus laparoscopic rectal cancer surgery after neoadjuvant chemoradiotherapy

Neoadjuvant chemoradiotherapy improves local control in locally advanced rectal cancer but can make total mesorectal excision technically demanding because treatment-related fibrosis and tissue changes constrain dissection in the pelvis. Robotic platforms may improve dexterity and visualization, yet their comparative value over laparoscopy in the specifically pretreated population remains uncertain. PubMed, Scopus and the Cochrane Library were searched from inception to 30 August 2026. Two reviewers independently screened records, extracted data and assessed risk of bias. Eligible studies compared robotic with laparoscopic rectal cancer surgery after neoadjuvant chemoradiotherapy. Risk ratios (RRs) and mean differences (MDs) were pooled with random-effects models and small-sample-adjusted confidence intervals. Median-based summaries were converted using established methods. ROBINS-I was used for nonrandomized studies and RoB 2 for the pilot randomized trial; certainty was judged with GRADE. Nineteen reports representing 18 independent cohorts and 6,538 participants were included; 15 cohorts contributed to at least one meta-analysis. Major complications (RR 1.42 (95% CI 0.75 to 2.70; p = 0.217; I²=0.0%; k = 6)), minor complications (RR 0.94 (95% CI 0.51 to 1.74; p = 0.812; I²=33.0%; k = 6)), anastomotic leakage (RR 0.82 (95% CI 0.54 to 1.24; p = 0.311; I²=0.0%; k = 11)) and length of stay (MD -1.29 (95% CI -3.18 to 0.60; p = 0.163; I²=88.2%; k = 13)) did not differ clearly. Robotic surgery reduced conversion to open surgery (RR 0.38 (95% CI 0.15 to 0.94; p = 0.039; I²=0.0%; k = 11)) but prolonged operative time (MD 37.29 (95% CI 1.24 to 73.34; p = 0.044; I²=89.4%; k = 11)). Overall complications (p = 0.596), circumferential-margin positivity (p = 0.995), complete total mesorectal excision (p = 0.306) and blood loss (p = 0.459) did not differ clearly. After neoadjuvant chemoradiotherapy, robotic and laparoscopic rectal cancer surgery have broadly comparable morbidity and pathological outcomes. Robotics may reduce conversion at the cost of longer operating time, but residual confounding, learning-curve effects and substantial heterogeneity prevent a claim of overall superiority. Large multicenter trials restricted to standardized neoadjuvant pathways are required.