Textbook outcome of robotic rectal resection with primary anastomosis for cancer: a composite quality measure to evaluate functional and midterm outcomes.

Textbook outcome (TO) is an "all-or-none" composite quality metric increasingly used to benchmark oncologic surgery, but its relationship with functional recovery after rectal cancer resection remains unclear. We evaluated TO after robotic rectal resection with primary anastomosis, identified predictors of TO achievement, and assessed associations with oncologic and urogenital outcomes. We retrospectively analyzed consecutive patients undergoing robotic rectal cancer resection with primary anastomosis between January 2015 and December 2025 in a high-volume robotic general surgery unit. Pelvic magnetic resonance imaging pelvimetry was reviewed preoperatively. Validated urinary and sexual function questionnaires were administered preoperatively and at 1, 6, and 12 months postoperatively. Disease-free survival (DFS) was assessed in stage II-III patients. Among 115 patients, 67 (58.2%) achieved TO. On multivariable logistic regression, greater interspinous distance was independently associated with higher likelihood of TO achievement (odds ratio 1.57 per 1-cm increase; 95% confidence interval 1.03-2.52; p = 0.046). In stage II-III patients, TO achievement was associated with improved DFS (86.9% vs. 61.5%; log-rank p = 0.028). Urinary function worsened at 1 month in both groups but returned to baseline by 12 months only in patients achieving TO. TO was achieved in nearly 60% of patients undergoing robotic rectal resection with primary anastomosis. TO was associated with favorable pelvic anatomy, improved disease control, and better urinary recovery. These findings support TO as a meaningful composite quality benchmark integrating perioperative, oncologic, and patient-reported outcomes.