Robotic-Assisted Compared to Laparoscopic Resection of Rectal Cancer in Patients Aged ≥65 Years: A Propensity Score–Matched Analysis of the NCDB

Background: Older adults constitute a large proportion of patients with rectal cancer, yet rectal-specific comparative data on minimally invasive approaches remain limited. This study compared outcomes of laparoscopic versus robotic rectal resection in patients aged ≥65 years. Methods: We performed a retrospective analysis of patients with stage I–III rectal adenocarcinoma from the U.S. National Cancer Database (NCDB) from 2010 to 2021. Patients undergoing laparoscopic or robotic-assisted surgery were identified and propensity-score matched for clinically relevant covariates. The primary outcome was conversion to open surgery. Secondary outcomes included short-term mortality, readmission, hospital stay, pathological outcomes, and 5-year overall survival (OS). Results: Among 18,877 eligible patients, 4099 patients were matched in each group. Robotic surgery was more frequently performed for patients with stage III tumors (45.0% versus 36.9%), elevated carcinoembryonic antigen levels (60.2% versus 48.1%), and those who underwent abdominoperineal resection (25.2% versus 18.9%). After matching, robotic surgery was associated with a significantly lower conversion rate compared with laparoscopy (6.2% versus 14.9%; OR 0.38, 95% CI 0.33–0.44; P < .001). No significant differences were observed in 30-day mortality (1.2% versus 1.5%), 90-day mortality (2.5% versus 2.7%), unplanned 30-day readmission (7.3% versus 7.6%), or 5-year OS (70.5% versus 69.0%; P = .062). Median hospital stay was 5 days for both groups. Suboptimal lymph node yield (<12 nodes) was more frequent after laparoscopy (27.7% versus 24.1%; P < .001). Conclusion: In older adults with rectal cancer, robotic surgery was associated with significant reduction in conversion rates and potentially modestly improved lymph node harvest, while both approaches provided comparable safety and long-term oncologic outcomes.These findings must be considered in the context of the heterogenous definitions of conversion and the availability of the robotic platform and training in both robotic and laparoscopic technqiues. .