Rectal Mucosal Melanoma (RMM) is a rare but highly aggressive malignancy with poor prognosis. Due to its rarity, the optimal surgical approach (local excision [LE] vs. radical resection [RR]) remains controversial. While RR aims to achieve wider margins and lymph node dissection, LE offers advantages in reduced morbidity and better functional preservation. This SEER-based study comparatively evaluated long-term survival outcomes between LE and RR in RMM patients. Clinicopathological data of patients with RMM were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. A 1:1 propensity score matching (PSM) approach was employed to balance baseline covariates between the surgical groups (P < 0.05). Cox proportional hazards models were used to identify risk factors for cancer-specific survival (CSS) and overall survival (OS). Among 196 eligible patients, those in the RR group were older and more likely to present with advanced N-stage disease. Both pre- and post-PSM analyses showed no survival advantage of RR over LE. Multivariate analysis identified diagnosis during 2000–2008, N2 stage, and M1 stage as independent predictors of poorer CSS. For OS, N2 stage and omission of postoperative radiotherapy were independently associated with worse outcomes. Radical resection does not confer a survival benefit over local excision in the treatment of RMM. LE may be the preferred surgical approach, offering an optimal balance between oncological efficacy and functional preservation.

PURPOSE:This study aimed to perform a threshold analysis of residual tumour size (RTS) to identify the critical threshold influencing distant metastasis (DM), thereby enabling more precise risk stratification. METHODS:This multicentre retrospective cohort study included patients with locally advanced rectal cancer who underwent radical surgery following neoadjuvant chemoradiotherapy (nCRT). Kaplan-Meier survival curves were plotted and compared using the log-rank test. Multivariable Cox proportional hazards models were used to identify independent prognostic factors. The threshold-effect analysis was performed to determine the potential critical point of RTS. RESULTS:In this multi-institutional study, threshold-effect analysis identified a significant inflection point at 3 cm for the association between RTS and DM risk. Below this threshold, each 1-cm increase was associated with a markedly higher risk (HR = 1.70, p = 0.015), whereas no significant association was observed above 3 cm (p = 0.692). Patients with an RTS ≥3 cm exhibited significantly poorer early (≤ 24 months) recurrence-free survival (RFS) and disease-free survival (DFS). After 24 months, the pattern was reversed. RTS ≥3 cm was an independent risk factor for both worse RFS (HR = 1.45, p = 0.033) and DM. Subgroup analyses confirmed the consistent negative prognostic impact of RTS ≥3 cm across most strata. CONCLUSIONS:This study established an objective prognostic threshold for RTS following nCRT. This marks a shift in the understanding of this indicator-from a static association between 'risk and size' to a dynamic association between 'risk and time'.

Objective To derive and externally validate a four-parameter blood-based TDCP (total bilirubin, direct bilirubin, creatinine, platelets) index that quantifies long-term oncological risk after neoadjuvant chemoradiotherapy (CRT) and total mesorectal excision (TME) for locally advanced rectal cancer, with explicit emphasis on patients whose pre-CRT CEA and CA19-9 levels remain within the normal range. Method Among 577 patients with clinical stage II/III rectal cancer who completed long-course neoadjuvant CRT and curative TME, this retrospective analysis nested within the LASRE multicentre trial (22 Chinese centres, 2013–2018) derived and froze the TDCP cut-off in the derivation cohort (Fujian Union Hospital, n = 237) before prognostic evaluation in the geographically independent validation cohort (21 centres, n = 340). Results High TDCP (n = 114) predicted poorer 3-year DFS (derivation HR 3.093, 95% CI 1.691–5.659; validation HR 1.670, 95% CI 1.038–2.687) and doubled early-recurrence rates (42.9% vs 19.6% and 30.2% vs 18.5%). Within the biomarker-silent subgroup (343 [59.5%] with normal pre-CRT CEA and CA19-9), high TDCP remained associated with shorter DFS (derivation HR 3.310, 95% CI 1.542–7.105; validation HR 2.386, 95% CI 1.159–4.914). Multivariate Cox regression in the derivation cohort confirmed that TDCP-high was an independent predictor of shorter DFS, with prognostic weight equivalent to pathological stage II disease. Bootstrap optimism correction (HR 1.81) and head-to-head comparison against established inflammation-based indices (NLR, PLR, SII, PNI) confirmed the robustness and superior transportability of the prognostic signal, with consistent effect direction in both men and women. Conclusion The TDCP index is an externally validated prognostic biomarker that stratifies long-term recurrence risk after neoadjuvant CRT/TME specifically in patients with normal pre-CRT CEA and CA19-9, independent of sex and pathological stage. While its prognostic association is robust across geographically distinct cohorts, prospective interventional trials are required to establish clinical utility. Trial Registration Parent trial: ClinicalTrials.gov NCT01899547.

Background Radiation therapy is a common treatment for patients with esophageal cancer (EC). Local recurrence after radiotherapy is one of the main reasons for treatment failure. Exosomal microRNA (miRNA) is associated with the initiation and progression of EC. However, the efficacy of exosomal miRNA in sensitivity to radiotherapy in EC remains unknown. Materials and Methods This study exploited engineered exosomes to deliver miR-423-5p mimic oligonucleotide simultaneously to EC cells. We cocultured EC cell lines by constructing engineered exosomes overexpressing miR-423-5p. Radiotherapy was given concomitantly. The CCK8 and flow cytometric assays were used to detect proliferation and apoptosis, respectively. The dual-luciferase reporter was used to verify MAP7D1 as a putative target of miR-423-5p. The expression levels of MAP7D1 in patients with EC were analyzed to study the clinical value of this parameter. Results The results demonstrated that the upregulation of miR-423-5p reduced tumor proliferation (P < 0.01) and increased apoptosis (P < 0.01) during radiotherapy. Notably, cotreatment with Exo-miR-423-5p enhanced both early apoptotic and necrotic cell populations, suggesting potential immunogenic cell death. The luciferase reporter demonstrated that miR-423-5p targeted MAP7D1 3'UTR. Moreover, MAP7D1 expression was lower in EC cancer tissues than adjacent tissues (P < 0.001). In vivo, xenograft studies in nude mice revealed that systemic administration of Exo-miR-423-5p combined with radiation significantly inhibited tumor growth, improved survival, and exhibited favorable biodistribution with minimal toxicity. Conclusions The strategy of delivering miR-423-5p via exosomes foreshadows a potential approach for improving EC radiotherapy sensitivity and, consequently, the efficacy of cancer treatment.

Background: Early recurrence (ER) after curative resection of colorectal cancer (CRC) remains a major clinical challenge, and accurate postoperative risk stratification is still limited by conventional clinicopathological tools. Pathomics, which enables quantitative analysis of routine hematoxylin and eosin (H&E)-stained tumor sections, offers a promising means of capturing tumor heterogeneity and may improve early prediction of postoperative recurrence. Methods: In this retrospective multicenter study, 1,167 patients with CRC who underwent radical surgery between 2010 and 2018 at two tertiary hospitals in China were included. Follow-up was continued through August 2024, and patients were classified into ER and non-ER groups according to postoperative outcomes. Ninety pathomics features were extracted from postoperative H&E-stained whole-slide images, and five machine-learning (ML) algorithms were developed to predict ER. Clinicopathological factors associated with ER were then incorporated to build clinical and fusion models. Model performance was evaluated using the AUROC, sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and F1 score. Prognostic value was assessed by Kaplan–Meier analysis, SHapley Additive exPlanations (SHAP) were used to interpret feature contributions, and pathogenomic analysis was performed to explore the biological correlates of key pathomics features. Results: The cohort was divided into internal training, internal validation, and external validation sets. Pathomics-based ML models showed robust predictive performance in both the internal validation cohort (AUC 0.764–0.832) and the external validation cohort (AUC 0.760–0.815). Fusion models integrating pathomics and clinical factors outperformed single-modality models (internal AUC 0.867–0.909; external AUC 0.787–0.865). Among the tested algorithms, XGBoost showed the most stable overall performance. The XGBoost-based pathomics model effectively stratified patients into distinct risk groups for disease-free survival and overall survival. Pathogenomic analysis further suggested that key predictive pathomics features were associated with CRC progression-related pathways, including the MAPK, PI3K–AKT, and RAS signaling pathways. Conclusions: The pathomics-based ML model developed in this study showed promising performance for predicting early recurrence after CRC surgery and may support postoperative risk stratification.

BACKGROUND:Although neoadjuvant Chemoradiotherapy (NCRT) has been used to shorten the distal resection margin (DRM) and enable sphincter preservation, the hypothesis that-once the margin is microscopically clear-DRM length itself no longer affects prognosis has never been tested in an equivalence trial. We examined whether any negative DRM length yields equivalent oncological outcomes. METHODS:A total of 453 patients treated at 22 Chinese centres between 2013 and 2018 were included in this post-hoc study of the multicentre LASRE trial. All patients had clinical stage II-III low rectal adenocarcinoma (≤5 cm from dentate line), completed NCRT and underwent curative-intent sphincter-preserving resection. Fresh-specimen DRM was prospectively measured to the nearest millimetre. PRIMARY ENDPOINT:3-year disease-free survival (DFS). Equivalence margins: HR 0.90-1.11. Two one-sided tests (TOST) used α = 0.05. RESULTS:After exclusion of 5 patients with positive DRM, 73 (16.3 %) had DRM ≤1 cm, 160 (35.7 %) 1-2 cm and 215 (48.0 %) >2 cm. Three-year DFS (log-rank P = 0.155), locoregional recurrence (P = 0.386) and overall survival (P = 0.127) were comparable across groups. Adjusted HRs for DRM were 1.00 (95 % CI 0.98-1.01) for DFS, 0.98 (0.95-1.01) for OS and 1.00 (0.95 to 1.05) for local recurrence; all estimates lay within equivalence margins (TOST P < 0.05). CONCLUSION:Once the DRM is microscopically negative after NCRT, its length does not influence prognosis; sphincter-preserving surgery need not be deferred solely to obtain a longer margin. TRIAL REGISTRATION:Parent trial: ClinicalTrials.gov NCT01899547; distal margin length analysis protocol preregistered at Open Science Framework (Doi: osf.io/z8uab).

There are no consistent recommendations for postoperative surveillance intervals for rectal cancer in the major guidelines. Knowledge about recurrence hazards can help develop appropriate surveillance schedules. This study aimed to investigate transitions in recurrence hazard and peak recurrence time in patients with locally advanced rectal cancer (LARC) treated with neoadjuvant chemoradiotherapy (nCRT). Between 2011 and 2016, 785 consecutive patients with LARC who underwent nCRT and curative resection were analyzed. The hazard rates of recurrence were calculated using the hazard function. Potential risk factors for recurrence were assessed. The recurrence rates of patients with stage I or pathological complete response (pCR), stage II and stage III were 10.7

Rectal mucinous adenocarcinoma (MAC) is a distinct rectal cancer subtype with heterogeneous outcomes after neoadjuvant chemoradiotherapy (nCRT), and robust tools for prognostic stratification remains limited. We retrospectively analyzed 159 patients with rectal MAC treated with nCRT and pathologically assessed the lymph node regression sum score (LRG-sum) and the highest nodal metastatic station. Kaplan-Meier and Cox regression analyses were performed to identify prognostic factors for disease-free survival (DFS), and a nomogram was subsequently constructed and validated against conventional ypN staging. DFS decreased progressively with increasing LRG-sum, with the high-score group showing the poorest survival and the low-score group the most favorable outcome (P = 0.0018). Multivariable analysis identified LRG-sum (HR = 1.016, P = 0.008), apical nodal metastasis (HR = 3.968, P = 0.013), and perineural invasion (HR = 2.123, P = 0.010) as independent predictors of DFS. The LRG-based nomogram outperformed ypN staging, with 1-, 3-, and 5-year AUCs of 0.779, 0.733, and 0.718, respectively, and demonstrated good calibration. Among ypN0 patients, complete nodal regression was associated with a prognosis comparable to that of patients with uninvolved lymph nodes (P = 0.641). These findings indicate that LRG-sum and highest nodal metastatic station provide prognostic information beyond conventional staging for rectal MAC, and we recommend their integration in routine pathologic reporting to facilitate individualized management.

Protecting the obturator nerve (ON) is crucial during selective lateral pelvic lymph node dissection (SLPLND). This study evaluated the feasibility of an artificial intelligence (AI)-assisted system for real-time intraoperative identification of the ON in laparoscopic surgery. This study retrospectively analyzed surgical video from 30 patients who underwent laparoscopic SLPLND between June 2023 and December 2024. The obturator nerves in selective lateral pelvic lymph node dissection videos were analyzed using FDIM HoloSurg software. The panel of experts consisted of three senior surgeons with extensive experience in SLPLND, who analyzed the videos and scored them using a Likert scale (0, very poor; 1, poor; 2, acceptable; 3, good; and 4, excellent). This research successfully established a real-time obturator nerve recognition model based on YOLOv11. The model was trained and validated using a dataset consisting of 1,530 high-quality surgical images, which were divided into training and validation sets at a ratio of 7:3. It achieved an overall accuracy of 0.962, a precision of 0.781, a recall of 0.775, and an F1 score of 0.778. Thirty challenging scenarios were selected from the validation cohort. In the vast majority of cases (73.3

PURPOSE:This study aimed to evaluate the association between preoperative endoscopic obstruction (eOB) and site-specific patterns of metastasis in patients with non-metastatic colorectal cancer (CRC) undergoing curative resection. METHODS:This two-center retrospective cohort study included 2208 patients with non-metastatic colorectal cancer who underwent radical resection. eOB was present in 520 patients (23.6%). The primary endpoints were liver metastasis-free survival (LiMFS), lung metastasis-free survival (LuMFS), peritoneal metastasis-free survival (PMFS), and local recurrence-free survival (LRFS). Kaplan-Meier curves with log-rank tests were used to compare survival outcomes, with analyses stratified by primary tumor site. Multivariable Cox proportional hazards regression was employed to identify independent risk factors for organ-specific metastases. RESULTS:Multivariable analysis identified endoscopic obstruction (eOB) as an independent risk factor for liver metastasis (HR = 3.00, 95% CI: 1.54-5.86, P = 0.001). Additionally, liver metastasis-free survival (LiMFS) was significantly reduced in patients with eOB, both in the overall cohort and in both the colon cancer and rectal cancer subgroups (all P < 0.001). In contrast, eOB showed no significant association with lung metastasis or local recurrence. Although eOB was associated with shorter peritoneal metastasis-free survival (PMFS) in patients with colorectal cancer (P < 0.05), it was not an independent risk factor after adjustment for T3-4 stage and pN2 stage. Furthermore, no association between eOB and PMFS was observed in rectal cancer. CONCLUSIONS:Endoscopic obstruction is a promising clinical marker associated with advanced pathological features and appears to be an independent predictor of liver metastasis in this cohort. However, its incremental predictive value beyond standard pathologic factors and molecular features warrants further prospective validation.

BACKGROUND:Low rectal cancer poses unique surgical challenges due to its anatomy, complicating the balance between radical resection and functional preservation. Early-onset low rectal cancer (EO-LRC, < 50 years) adds complexity: it has distinct, more aggressive biological/clinical features but no age-stratified surgical guidelines. Moreover, laparoscopic surgery's efficacy in EO-LRC is controversial-though non-inferior in general low rectal cancer, EO-LRC's aggressiveness may offset its benefits. This study aims to compare oncologic outcomes of laparoscopic versus open surgery in EO-LRC patients. PATIENTS AND METHODS:In this post-hoc analysis of the LASRE trial, the cohort included 240 EO-LRC and 799 late-onset low rectal cancer (LO-LRC, ≥ 50 years) patients, and were randomly assigned to open or laparoscopic resection. Primary endpoints were 3-year overall survival (OS) and disease-free survival (DFS). RESULTS:EO-LRC exhibited better ECOG performance status and lower ASA scores; however, they presented with more advanced disease and received more preoperative therapy. The operative time and blood loss were comparable. EO-LRC patients had a higher proportion of pN2 stage and poorly differentiated tumors. The total mesorectal excision quality and negative margins were similar. The 3-year OS (laparoscopic 91.3% vs. open 95.5%, p = 0.270) and DFS (laparoscopic 78.6% vs. open 76.1%, p = 0.657) were comparable between groups. Multivariate analysis identified preoperative therapy and pN classification as significant prognostic factors for DFS. No significant differences in oncologic outcomes were observed between groups. CONCLUSIONS:Laparoscopic TME provides non-inferior oncologic control in EO-LRC patients. The small EO-LRC sample size necessitates cautious interpretation of findings, requiring validation in larger cohorts.

The Tianhe Procedure is a functional sphincter-preserving surgical approach developed for patients with rectal cancer following radiotherapy. This technique involves proximal extended resection of the colon beyond the pelvic cavity, followed by anastomosis of the non-irradiated proximal colon to the distal rectum or anal canal. This strategy aims to reduce the incidence of anastomotic complications and postoperative bowel dysfunction. However, there is currently a lack of standardized practice guidelines for implementing the Tianhe Procedure in China. Therefore, the Chinese Radiation Intestinal Injury Research Group, the Colorectal Surgery Group of Surgery Branch of the Chinese Medical Association, the Anorectal Branch of Chinese Medical Doctor Association, the Colorectal Cancer Committee of the Chinese Medical Doctor Association, the Colorectal Cancer Committee of China Anti-cancer Association, and the Gastrointestinal Surgical Branch of Guangdong Medical Doctor Association have jointly convened a panel of national experts to discuss and establish this standardized surgical procedure. This standard, based on the latest evidence from literature, research advancements, and expert experience, focuses on key aspects of the Tianhe Procedure, including its precise definition, indications, critical procedural steps, postoperative complications, and functional rehabilitation strategies. It aims to promote standardized implementation and broader clinical adoption of this innovative surgical technique.

To compare the overall survival (OS) and cancer-specific survival (CSS) of right-sided colon cancer patients undergoing CME versus D2 surgery after 5 years of follow-up, and to assess the heterogeneity of treatment effectiveness of CME between different subgroups. The 3-year result of the Radical Extent of lymphadenectomy of Laparoscopic Right Colectomy for colon cancer (RELARC) trial showed that standard D2 dissection should be performed in right-sided colon cancer patients. In patients with lymph node metastasis, complete mesocolic excision (CME) showed potentially favorable results. The parallel, open label, randomized controlled trial was conducted between January, 2016 to December, 2019 in 17 hospitals in China. Of a total of 1072 eligible patients enrolled, 995 patients were included in the modified intention-to-treat analysis. In the present study, the primary outcome was 5-year OS and the secondary outcome was 5-year CSS. The trial is registered with ClinicalTrials.gov (Identifier: NCT02619942). 995 patients were included in the final analysis. There was no significant difference between the 5-year OS (HR: 0.74, 95%CI: 0.51–1.07, P=0.105) or CSS (HR: 0.72, 95%CI: 0.49–1.06, P=0.091) in the CME and D2 groups. CME appears to improve 5-year outcomes in patients with stage III disease (OS: HR: 0.58, 95% CI: 0.37–0.93, P=0.023; CSS: HR: 0.59, 95% CI: 0.37–0.94, P=0.028), particularly in those with pN2 (OS: HR: 0.25, 95% CI: 0.11–0.57, P=0.001; CSS: HR: 0.25, 95% CI: 0.11–0.57, P=0.001), where a statistically significant interaction was identified. Patients with lymphovascular invasion also demonstrated favorable outcomes with CME with significant interaction effect (OS: HR: 0.34, 95% CI: 0.17–0.70; interaction P=0.009; CSS: HR: 0.32, 95% CI: 0.15–0.67, interaction P=0.008). The standard D2 dissection provides oncologic outcomes comparable to CME on the 5-year follow-up. However, CME seems to improve 5-year outcomes in patients with stage III, particularly those with pN2 status, and may confer benefit in patients with LVI.

BACKGROUND:Radiation-induced colorectal fibrosis (RICF) is a chronic condition that can develop after pelvic radiation therapy for colorectal cancer. Adipose-derived mesenchymal stem cells (ADSCs) have emerged as promising candidate for fibrosis treatment, yet the mode of action of ADSC upon RICF remains obscure. This study aimed to investigate the optimal delivery route, treatment timing, anti-fibrotic effects, and underlying mechanisms of ADSCs upon RICF. METHODS:The RICF rat model was constructed by single dose of 20 Gy irradiation, and ADSCs were delivered via diverse ways (e.g., tail vein injection, abdominal aorta injection, peritoneal injection, or perianal tissue injection) at different frequencies (once, twice, or thrice a week) for 10 weeks. TMT-labelled proteomic and phosphoproteomic analysis was conducted for dissecting the underlying mechanisms of ADSCs upon RICF. ADSCs were co-cultured with primary human intestinal fibroblasts to verify the anti-fibrotic effects upon radiation-induced fibroblasts. Additionally, 4D label-free proteomic analysis and 4D-parallel reaction monitoring were carried out to explore their molecular mechanisms. RESULTS:RICF rats revealed better outcomes after intraperitoneal injection of ADSCs rather than the relative ways, and in particular, those with thrice-weekly injections showed effective prevention and improvement in RICF. Proteomic and phosphoproteomic analyses, together with multifaceted analyses (e.g., co-culture, 4D-PRM analysis), indicated Cytochrome b-245 alpha chain (Cyba) as a candidate target in mediating the efficacy of ADSCs upon RICF. CONCLUSIONS:This comprehensive multilevel proteomic study provides valuable insights into the molecular mechanisms underlying RICF and enhances understanding of the potential of ADSCs-based cytotherapy.

BACKGROUND:Pathological complete response (pCR) following neoadjuvant chemoradiotherapy (nCRT) for locally advanced rectal cancer (LARC) does not eliminate tumor recurrence risk, with distant metastasis remaining a critical challenge. This study aimed to identify novel prognostic factors for risk stratification in pCR patients after nCRT. METHODS:We enrolled 149 LARC patients who achieved pCR between 2016 and 2020. Acellular mucin pools (AMP) were classified by the deepest tissue layer of AMP (A0: absent; A1: within the muscularis propria; A2: exceeding the muscularis propria). The primary endpoint was disease-free survival (DFS); secondary endpoints included overall survival (OS) and recurrence patterns. RESULTS:After a median follow-up of 75.3 months, the 5-year OS and DFS rates were 95.3% and 89.9%, respectively. Among 15 recurrence events, all were distant metastases (80% pulmonary). AMP were present in 17.4% (26/149) of patients. Multivariate analysis identified AMP exceeding the muscularis propria (HR = 3.996, 95% CI: 1.073-14.660, P = 0.039), preoperative neutrophil-to-lymphocyte ratio (NLR) >4.4 (HR = 3.658, 95% CI: 1.304-10.263, P = 0.014) and tumour distance from the anal verge on pretreatment magnetic resonance imaging (MRI) (HR = 0.667, 95% CI: 0.481-0.925, P = 0.015) as independent predictors of distant metastasis-free survival (DMFS). A nomogram integrating these factors showed robust discriminative performance for 1-, 3-, and 5-year DMFS (AUC = 0.689, 0.815, 0.795). Meanwhile, AMP exceeding the muscularis propria (HR = 6.632, P = 0.010) and pretreatment MRI-assessed tumour distance from the anal margin (HR = 0.614, P = 0.018) were independent predictors for pulmonary metastasis. CONCLUSIONS:AMP exceeding the muscularis propria and high pretreatment NLR are complementary prognostic markers that refine risk stratification in pCR patients, enabling personalized surveillance and treatment strategies to improve outcomes.

PURPOSE:The textbook outcome has emerged as a valuable metric for quality assessment in oncological surgery. However, its application and impact within randomized controlled trials involving patients with low rectal cancer remain underexplored. This study aimed to investigate the incidence and predictors of textbook outcome in patients with low rectal cancer undergoing laparoscopic or open resection. METHODS:This post-hoc analysis included patients from the prospective, multicentric LASRE trial with clinically staged I-III rectal cancer located within 5 cm of the dentate line, tumor diameter < 6 cm, and undergoing radical laparoscopic or open resection. A total of 914 patients were analyzed. RESULTS:A textbook outcome was achieved in 74.9% of patients, with a higher rate in the laparoscopic group (76.7%) than in the open group (71.2%, P = 0.07). Multivariate analysis identified independent predictors of textbook outcome failure, including BMI > 24 kg/m2, surgical type (abdominoperineal resection), and operative time > 200 min. Achievement of a textbook outcome was associated with improved disease-free survival (DFS). CONCLUSION:Achieving a textbook outcome is significantly associated with improved DFS in patients with low rectal cancer. These findings highlight the importance of optimizing perioperative and intraoperative care to enhance surgical outcomes, particularly within the context of randomized controlled trials. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: https://clinicaltrials.gov/study/NCT01899547 .

This study aims to assess the short- and long-term outcomes of rectal cancer patients undergoing robotic versus laparoscopic surgery after receiving neo-adjuvant therapy. There is a lack of clarity on this topic, necessitating a comprehensive comparison. Between January 2017 and December 2021, consecutive patients who underwent laparoscopic and robotic rectal resection at a major public medical center were enrolled. All participants received neo-adjuvant chemoradiotherapy (nCRT) before surgery. The primary objective of this study was to assess the sphincter preservation rate and the rate of conversion to open surgery, using propensity score matching (PSM) analysis. Secondary endpoints included 5-year disease-free survival (DFS), 5-year overall survival (OS), short-term postoperative complications, long-term oncological prognosis, and the occurrence of low anterior resection syndrome (LARS). A total of 575 patients diagnosed with rectal cancer participated in the cohort study, with 183 individuals undergoing robotic surgery and 392 undergoing laparoscopic surgery. Patients in the robotic group tended to be younger and had higher ypT, cT, and cN stages, lower tumor locations, and higher rates of extramural vascular invasion (EMVI) and circumferential resection margin (CRM) positivity. PSM resulted in 183 patients in the robotic group and 187 in the laparoscopic group. We found a higher sphincter preservation rate in robotic group compared with laparoscopic group (92.9