Total mesorectal excision (TME) is the gold standard for rectal cancer surgery. Robotic (RoTME) and transanal (TaTME) approaches have gained popularity, but their comparative effectiveness remains uncertain and previous meta-analysis include many retrospective studies which are prone to biases. This meta-analysis aims to bridge this gap. A systematic review and meta-analysis was conducted following PRISMA guidelines. PubMed, Scopus, Embase, and Web of Science were searched for prospective studies comparing RoTME and TaTME. Meta-analysis was performed using random-effects models. Sensitivity analysis included a "leave-one-out" approach. Subgroup analysis was performed for overweight patients. Five non-randomized prospective studies (n = 1941) were included. RoTME and TaTME had no significant differences regarding operative duration (MD: 27.29, 95% CI -56.18 to 110.76, P = 0.29, I² = 95%) and comparable hospital stay (MD: 3.12, 95% CI -6.14 to 12.39, P = 0.27, I² = 98%). Blood loss was similar (MD: -22.70, 95% CI -145.80 to 100.40, P = 0.42, I² = 89%). Conversion rates favored TaTME (OR: 2.39, 95% CI 0.39 to 14.69, P = 0.04, I² = 26%) but with a wide confidence interval, limiting significance. Sphincter preservation favored TaTME (OR: 0.44, 95% CI 0.17 to 1.16, P < 0.0001, I² = 32%), but with wide confidence interval, limiting significance. No significant differences were noted for minor complications (OR: 0.88, P = 0.51, I² = 37%), major complications (OR: 1.21, P = 0.24, I² = 7%), anastomotic leakage (OR: 1.35, P = 0.09, I² = 0%), mortality (OR: 1.15, P = 0.82, I² = 0%), and morbidity (OR: 1.26, P = 0.75, I² = 95%). R0 resection was significantly higher in RoTME (OR: 1.70, 95% CI 0.92 to 3.16, P = 0.02, I² = 0%), but with wide confidence interval limiting its significance. No difference was found in lymph node yield (MD: 1.83, 95% CI -2.57 to 6.24, P = 0.06, I² = 51%). Sensitivity analysis revealed that excluding specific studies reduced heterogeneity and affected operative duration and anastomotic leakage trends. In the overweight subgroup, only hospital stay was significantly shorter in TaTME (MD: 1.50, 95% CI 1.07 to 1.92, P < 0.00001, I² = 0%). RoTME and TaTME yield comparable perioperative, postoperative, and short-term oncological outcomes. While the pooled results for conversion rate and sphincter preservation numerically favored TaTME, the confidence intervals crossed the line of no effect, indicating that these differences were not statistically significant. Sensitivity analysis highlighted variability among studies. In overweight patients, TaTME reduced hospital stay, though data were limited. Due to the limited number of identified studies and moderate risk of bias, no recommendations can be made to surgeons, patients and healthcare policy makers. Future large-scale RCTs are needed to clarify long-term outcomes, cost-effectiveness, and functional results and determine superiority of either approach. PROSPERO registration: CRD420250654891.

Keywords: Laparoscopic surgery; Meta-analysis; Rectal cancer; Robotic surgery; TME.

© 2025. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.

完全 mesorectal 切除术（TME）是治疗直肠癌手术的金标准。机器人辅助 TME（RoTME）和经肛 TME（TaTME）方法越来越受欢迎，但它们之间的比较效果尚不清楚，并且之前的 meta 分析包括了许多容易产生偏差的回顾性研究。本 meta 分析旨在填补这一空白。按照 PRISMA 指南进行系统评价和元分析。在 PubMed、Scopus、Embase 和 Web of Science 中搜索了对比 RoTME 和 TaTME 的前瞻性研究。采用随机效应模型进行了元分析。敏感性分析包括“剔除一个”的方法。亚组分析针对超重患者。纳入了 5 项非随机化前瞻性研究（n = 1941）。RoTME 和 TaTME 在手术时间方面没有显著差异（MD：27.29，95% CI -56.18 至 110.76，P = 0.29，I² = 95%）和住院时间相当（MD：3.12，95% CI -6.14 至 12.39，P = 0.27，I² = 98%）。出血量相似（MD：-22.70，95% CI -145.80 至 100.40，P = 0.42，I² = 89%）。转为开腹手术的比例更有利于 TaTME（OR：2.39，95% CI 0.39 至 14.69，P = 0.04，I² = 26%），但置信区间较宽，限制了其统计显著性。保留括约肌的比例更有利于 TaTME（OR：0.44，95% CI 0.17 至 1.16，P < 0.0001，I² = 32%），但置信区间较宽，限制了其统计显著性。没有发现轻微并发症（OR：0.88，P = 0.51，I² = 37%）、严重并发症（OR：1.21，P = 0.24，I² = 7%）、吻合口漏（OR：1.35，P = 0.09，I² = 0%）、死亡率（OR：1.15，P = 0.82，I² = 0%）和发病率（OR：1.26，P = 0.75，I² = 95%）之间的显著差异。RoTME 的 R0 切除率显著更高（OR：1.70，95% CI 0.92 至 3.16，P = 0.02，I² = 0%），但置信区间较宽限制了其统计显著性。在淋巴结产量方面没有发现差异（MD：1.83，95% CI -2.57 至 6.24，P = 0.06，I² = 51%）。敏感性分析显示排除特定研究后异质性减少，并且影响了手术时间和吻合口漏的趋势。在超重组中，仅 TaTME 的住院时间显著较短（MD：1.50，95% CI 1.07 至 1.92，P < 0.00001，I² = 0%）。RoTME 和 TaTME 在围手术期、术后和短期肿瘤学结果方面具有可比性。虽然汇总的转为开腹手术比例和保留括约肌比例数据数值上更有利于 TaTME，但置信区间跨越了无效应线，表明这些差异在统计上并不显著。敏感性分析强调了各研究之间的变异性。对于超重患者，TaTME 减少了住院时间，尽管数据有限。由于识别的研究数量较少且存在中等风险偏倚，不能向外科医生、患者和卫生政策制定者提供推荐意见。未来需要大规模的 RCT 研究来比较这两种方法的效果。 关键词：腹腔镜手术；元分析；直肠癌；机器人手术；TME。

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