Robot-assisted radical surgery for colorectal cancer: technical advances, lymphadenectomy, natural orifice specimen extraction, and ongoing controversies

Robot-assisted surgery expands the technical options for colorectal cancer resection, but its clinical value depends on the operative setting and the outcome assessed. This narrative review examines lymphadenectomy and natural orifice specimen extraction surgery (NOSES), distinguishing colon from rectal cancer and technical feasibility from demonstrated clinical benefit. Literature published through 1 July 2026 was considered. Randomized evidence in rectal cancer is heterogeneous: ROLARR and COLRAR did not demonstrate superiority for their respective primary outcomes, whereas REAL reported better selected perioperative outcomes and lower 3-year locoregional recurrence after robotic surgery. These findings do not establish an overall survival advantage or a benefit mediated specifically by more extensive lymphadenectomy. Evidence for robotic colectomy remains less definitive. Lymph node yield, dissection extent, vascular ligation and specimen quality should be evaluated separately, with attention to geographical differences in practice. Robotic NOSES may reduce pain and wound morbidity in selected patients; a recent randomized trial supports short-term benefits, while long-term oncological equivalence remains unproven. Selection bias, limited external validity, cost and variable surgeon experience constrain broader conclusions. Adoption should therefore be guided by procedure-specific evidence, appropriate oncological resection and patient priorities rather than technical capability alone.