Quality of life and functional outcomes after low anterior rectal resection with total mesorectal excision: a propensity score-matched comparison of robotic-assisted versus open surgery

Abstract Background Robotic-assisted surgery (RAS) for rectal cancer is increasingly adopted. However, a recent systematic review highlighted a significant gap in the literature regarding quality of life (QOL) after different total mesorectal excision (TME) techniques, with open TME being particularly underrepresented. This study aimed to compare QOL and anorectal function between robotic-assisted and open low anterior rectal resection with TME. Methods Patients who underwent low anterior rectal resection with TME and primary anastomosis between 2006 and 2021 at a single tertiary centre were identified. Propensity score matching was performed based on sex, age, BMI, UICC stage and tumour height. After excluding patients without QOL follow-up or with a persistent diverting stoma, 40 patients per group were available. QOL was assessed using the EORTC QLQ-C30, QLQ-CR29, and LARS score. Results In the matched cohort, baseline characteristics were well balanced except for tumour height ( p = .002), with more lower-third tumours in the open group. No significant differences were observed in any EORTC QLQ-C30 domain, including global health status (66.5 vs. 71.7, p = .197). QLQ-CR29 showed comparable outcomes for most domains; however, sexual interest was significantly lower in the RAS group for women (88.1 vs. 55.6, p = .008). LARS scores were similar between groups (24.4 vs. 25.6, p = .765). Perioperative outcomes including morbidity (10.0% vs. 22.5%, p = .130) and anastomotic leakage (2.5% vs. 5.0%, p = .526) did not differ significantly. Conclusions Robotic-assisted and open low anterior rectal resection with TME resulted in comparable QOL and anorectal function across all assessed domains. Notably, approximately one third of patients in both groups reported major LARS, underscoring the persistent functional burden irrespective of surgical approach. By providing direct comparative data on open TME – an approach underrepresented in the literature – these findings contribute to closing an important evidence gap.