Comparison of clinical outcomes and quality of life for robotic versus laparoscopic surgery in elderly patients with mid-low rectal cancer: a multicenter cohort study with inverse probability of treatment weighting analysis

Background – The rising incidence of rectal cancer (RC) in elderly patients contrasts with the scarcity of robust evidence comparing robotic-assisted and laparoscopic resection in this population. This study evaluated clinical outcomes and quality-of-life (QoL) metrics between these approaches in elderly patients with mid-low RC. Methods – Consecutive patients aged 70 years or older with mid-low RC who underwent minimally invasive resection at two tertiary centers from January 2017 to December 2024 were categorized into robotic (n=211) and laparoscopic (n=812) cohorts. Outcomes were analyzed using inverse probability of treatment weighting (IPTW) based on propensity scores. Results – After IPTW, the effective sample comprised 2036 patients (1012 robotic group, 1024 laparoscopic group) with balanced clinicopathological characteristics. After matching, the pure operation time was comparable between groups (P>0.05), but the robotic approach achieved superior intraoperative outcomes, with significantly reduced estimated blood loss and lower incidence of intraoperative complications (all P < 0.05). Postoperatively, the cohort undergoing robotic-assisted procedures exhibited significantly lower rates of both overall complications and specific incidents of urinary retention. Longitudinal QoL assessment revealed sustained advantages in functional recovery, with the robotic cohort showing significantly better preserved urinary function, defecatory function, and male sexual function throughout the 12-month follow-up period (all P < 0.05). For patients with T4 stage tumors, the robotic approach demonstrated superior cancer-specific survival compared to laparoscopy, a benefit that was maintained after IPTW. Conclusions – Robotic-assisted surgery is a safe and feasible alternative for elderly patients with mid-low RC, offering reduced perioperative complications, superior functional preservation, and potential CSS benefits in T4 disease.