The ROLARR study provides the first rigorous evaluation of robotic-assisted surgery compared with laparoscopic surgery for rectal cancer. It has failed to show an advantage for the robotic technique, although interesting trends have been noted. In particular, the trend to reduced conversions in males, and perhaps those patients undergoing LAR, deserves further investigation. A registry is currently being designed under the auspices of the European Society of Coloproctology that should enable data on several hundred robotic rectal cancer operations to be collected in a relatively short time frame and might provide further insight into the trends observed in the ROLARR study.

The health economic evaluation performed in the ROLARR study concludes that robotic rectal cancer surgery is not cost-effective compared with laparoscopic surgery. Although it is tempting to generalise this to wider surgical practice and the health-care provision of future robotic services, it should be borne in mind that the ROLARR study investigated only a single robotic system, the da Vinci surgical robot, which was the only system that was commercially available at the time. There have subsequently been rapid developments in other surgical robotic platforms, with several expected to come to market within the next couple of years. Future systems promise to be more competitive in terms of costs, with per-procedure costs challenging those of laparoscopic surgery. The health economic data from the ROLARR study will be beneficial to commercial companies developing robotic systems, in particular highlighting the need to bring the cost of robotic instruments down in order to be competitive with laparoscopic surgery.

Any judgement about the future of robotic surgery based on the ROLARR study should be tempered with future developments borne in mind. The situation is further complicated by the recent debate about the benefits of laparoscopic surgery that has been stirred by the recent publication of two large randomised trials comparing laparoscopic with open surgery for rectal cancer: the ALaCarte and ACOSOG trials. Both these studies failed to show the non-inferiority of laparoscopic surgery compared with open surgery for rectal cancer in terms of a short-term composite pathological outcome. It is therefore not clear whether or not any future analysis of robotic rectal cancer surgery should include an assessment of open surgery as well as laparoscopic techniques. In the UK’s NHS, the adoption of laparoscopic rectal cancer surgery is probably too advanced to countenance reverting back to open surgery, unless there is hard long-term evidence to suggest otherwise.