Robotic approach has improved outcomes for minimally invasive resection of mediastinal tumors

Robotic-assisted extended thymectomy for large resectable thymoma: 21 years' experience

OBJECTIVE

This study aims to evaluate the perioperative and midterm oncological outcomes of robotic-assisted thoracic surgery extended thymectomy for patients with large resectable thymomas compared with small thymomas.

METHODS

This retrospective single-center study included 204 patients with thymomas who underwent robotic-assisted thoracic surgery extended thymectomy between January 2003 and February 2024. Patients were divided into 2 groups based on the thymoma size (5-cm threshold).

RESULTS

The study comprised 114 patients (55.9%) in the small thymoma group and 90 patients (44.1%) in the large thymoma group. No significant differences were found between the groups regarding gender, age, proportion of elderly patients, or pathologic high-risk classifications. Apart from a longer operative time (P = .009) in the large thymoma group, no differences were observed between the 2 groups regarding surgical parameters and postoperative outcomes. No deaths occurred within 30 days in either group. During a median follow-up of 61.0 months (95% CI, 48.96-73.04), 4 patients experienced recurrence (1.96%). No significant differences in the 5-year overall survival (P = .25) or recurrence-free survival (P = .43) were observed between groups.

CONCLUSIONS

Robotic-assisted thoracic surgery extended thymectomy is technically feasible, safe, and effective for treating large resectable thymomas. Moreover, midterm outcomes for patients with completely resected large thymomas were comparable to those with small thymomas during a median follow-up period of up to 5 years.

Efficacy of the da Vinci robot versus thoracoscopic surgery for patients with mediastinal tumors of different body mass index: a multicenter propensity score-matched study

BACKGROUND

The purpose of the present study was to evaluate the efficacy and safety of da Vinci robot-assisted thoracoscopic surgery (RATS) versus video-assisted thoracoscopic surgery (VATS) for the treatment of patients with mediastinal tumors of different body mass indices (BMI).

METHODS

A retrospective cohort study was used to collect 260 patients with mediastinal tumors admitted to three medical centers in China from December 2020 to March 2024. These patients underwent mediastinal tumor resection by RATS (n = 125) or VATS (n = 135). Propensity score matching (PSM) analysis was performed for the both groups, and further, the patients were divided into the N-BMI group (18.5 kg/m2 ≤ BMI < 25 kg/m2) and the H-BMI group (BMI ≥ 25 kg/m2) based on their BMI to compare patients' surgery-related information.

RESULTS

The RATS group had more advantages than the VATS group in terms of intraoperative blood loss, total postoperative drainage, postoperative drainage time, and postoperative hospital stay. As for hospitalization costs, the VATS group was more advantageous. In the H-BMI group, subgroup analysis showed a statistically significant difference in shorter operative time and lower incidence of postoperative complications in the RATS group.

CONCLUSION

RATS has technical and short-term efficacy advantages in comparison with VATS, although it has the drawback of high costs associated with the treatment of mediastinal tumors. In the patients with mediastinal tumors of H-BMI, RATS can achieve better short-term outcomes and safety, especially in the reduction of the incidence of postoperative complications.

Advantages of robot-assisted resection of large mediastinal tumors: a single-center preliminary study

Current study aims to assess the safety and efficacy of robot-assisted thoracoscopic surgery (RATS) for sizable mediastinal masses with a minimum diameter ≥6 cm, compared with video-assisted thoracoscopic surgery (VATS) and open surgery. This study enrolled 130 patients with mediastinal tumors with no less than 6 cm diameter in Zhongnan Hospital, Wuhan University, including 33 patients who underwent RATS, 52 patients who underwent VATS and 45 patients who underwent open surgery. After classifying based on mass size and whether it has invaded or not, we compared their clinical characteristics and perioperative outcomes. There was no significant difference in age, gender, mass size, myasthenia gravis, mass location, pathological types (p > 0.05) in three groups. Patients undergoing open surgery typically presenting at a more advanced stage (p < 0.05). No obvious difference was discovered in the average postoperative length of stay, operation duration, chest tube duration and average postoperative day 1 drainage output between RATS group and VATS group (p > 0.05), while intraoperative blood loss in RATS group was significantly lower than VATS group (p = 0.046). Moreover, the postoperative length of stay, operation duration, chest tube duration and intraoperative blood loss in RATS group were significantly lower than open surgery group (p < 0.001). RATS is a secure and efficient approach for removing large mediastinal masses at early postoperative period. In comparison with VATS, RATS is associated with lower intraoperative blood loss. Compared with open surgery, RATS is also associated with shorter postoperative length of stay, operation duration, chest tube duration and intraoperative blood loss.

Is Minimally Invasive Resection of Large Thymoma Appropriate?

BACKGROUND

Current practice patterns suggest open rather than minimally invasive (MIS) approaches for thymomas >4 cm. We hypothesized there would be similar perioperative outcomes and overall survival between open and MIS approaches for large (>4 cm) thymoma resection.

METHODS

The National Cancer Database was queried for patients who underwent thymectomy from 2010 to 2020. Surgical approach was characterized as either open or MIS. The primary outcome was overall survival and secondary outcomes were margin status, and length of stay (LOS). Differences between approach cohorts were compared after a 1:1 propensity match.

RESULTS

Among 4121 thymectomies, 2474 (60%) were open and 1647 (40%) were MIS. Patients undergoing MIS were older, had fewer comorbidities, and had smaller tumors (median; 4.6 vs 6 cm, P < .001). In the unmatched cohort, MIS and open had similar 90-day mortality (1.1% vs 1.8%, P = .158) and rate of positive margin (25.1% vs 27.9%, P = .109). MIS thymectomy was associated with shorter LOS (2 (1-4) vs 4 (3-6) days, P < .001). Propensity matching reduced the bias between the groups. In this cohort, overall survival was similar between the groups by log-rank test (P = .462) and multivariate cox hazard analysis (HR .882, P = .472). Multivariable regression showed shorter LOS with MIS approach (Coef -1.139, P < .001), and similar odds of positive margin (OR 1.130, P = .150).

DISCUSSION

MIS has equivalent oncologic benefit to open resection for large thymomas, but is associated with shorter LOS. When clinically appropriate, MIS thymectomy may be considered a safe alternative to open resection for large thymomas.

Robotic portal resection for mediastinal tumours: a prospective observational study

BACKGROUND

To demonstrate the effectiveness and feasibility of robotic portal resection (RPR) for mediastinal tumour using a prospectively collected database.

METHODS

Data from 73 consecutive patients with mediastinal tumours who underwent RPRs were prospectively collected from August 2018 to April 2023. All patients underwent chest and abdominal enhanced computed tomography (CT) and preoperative multidisciplinary team (MDT) discussion. The patients were stratified into two groups based on tumour size: Group A (tumour size < 4 cm) and Group B (tumour size ≥ 4 cm). General clinical characteristics, surgical procedures, and short outcomes were promptly recorded.

RESULTS

All of the cases were scheduled for RPRs. One patient (1/73, 1.4%) was switched to a small utility incision approach because of extensive pleural adhesion. Two patients (2.8%) converted to sternotomy, however, no perioperative deaths occurred. Most of the tumours were located in the anterior mediastinum (51/73, 69.9%). Thymoma (27/73, 37.0%) and thymic cyst (16/73, 21.9%) were the most common diagnoses. The median diameter of tumours was 3.2 cm (IQR, 2.4-4.5 cm). The median total operative time was 61.0 min (IQR, 50.0-90.0 min). The median intraoperative blood loss was 20 mL (IQR, 5.0-30.0 ml), and only one patient (1.4%) experienced an intraoperative complication. The median length of hospital stay was 3 days (IQR, 2-4 days). Compared with Group A, the median total operative time and console time of Group B were significantly longer (P = 0.006 and P = 0.003, respectively). The volume of drainage on the first postoperative day was greater in group B than in group A (P = 0.013).

CONCLUSION

RPR is a safe and effective technique for mediastinal tumour treatment, which can expand the application of minimally invasive surgery for the removal of complicated mediastinal tumours.

Outcomes of robot-assisted versus video-assisted mediastinal mass resection during the initial learning curve

To compare the learning curve of mediastinal mass resection between robot-assisted surgery and thoracoscopic surgery. Retrospective perioperative data were collected from 160 mediastinal mass resection cases. Data included 80 initial consecutive video-assisted thoracoscopic surgery (VATS) resection cases performed from February 2018 to February 2020 and 80 initial consecutive robotic-assisted thoracic surgery (RATS) resection cases performed from March 2020 to March 2023. All cases were operated on by a thoracic surgeon. The clinical characteristics and perioperative outcomes of the two groups were compared. The operation time in both the RATS group and VATS group was analyzed using the cumulative sum (CUSUM) method. Based on this method, the learning curves of both groups were divided into a learning period and mastery period. The VATS group and the RATS group crossed the inflection point in the 27th and 21st case, respectively. Subsequently, we found that the learning period was longer than the mastery period with statistically significant differences in terms of the operating time, and postoperative hospital stay in the VATS group and the RATS group. A certain amount of VATS experience can shorten the learning curve for RATS.

[Robot-assisted Mediastinal Surgery]

Because of the many important anatomical structures located closely together at very small distances, mediastinal surgery has been traditionally demanding and challenging within thoracic surgery. With their great variability, mediastinal masses in the anterior, middle or posterior mediastinal compartment result in surgical indications with different principle focuses. The technical opportunities of robotic assistance can thereby most effectively support the requirement of precision for all oncological aspects. Anterior mediastinal operations are most often performed, thymectomy being the most common operation. The radicality of thymectomy is of special importance. The worldwide tremendous development of robot-assisted mediastinal surgery confirms its initial and continuous role as a pacemaker for minimally invasive thoracic surgery.

Robotic resection of ectopic mediastinal parathyroid adenoma in multiple endocrine neoplasia 1

BACKGROUND

Hyperparathyroidism in patients with multiple endocrine neoplasia 1 is attributed to the excessive secretion of parathyroid hormone (PTH) from multiple parathyroid glands. This can be successfully treated through complete resection of the parathyroid glands; however, subsequent surgery is often required because of the presence of supernumerary or ectopic parathyroid glands. Therefore, identifying the locations of all functional glands is crucial for precise resection. Here, we report a case of ectopic mediastinal parathyroid adenoma that was successfully resected using robot-assisted thoracoscopic surgery.

CASE PRESENTATION

A 53-year-old woman underwent a total parathyroidectomy with autotransplantation for multiple endocrine neoplasia 1-associated primary hyperparathyroidism. The patient previously underwent laparoscopic distal pancreatectomy for a pancreatic neuroendocrine tumor. She also presented with a mediastinal tumor and nonfunctional pituitary adenoma that could be followed up. Blood tests before total parathyroidectomy showed high levels of intact PTH (183 pg/mL) and calcium (Ca; 10.3 mg/dL); however, postoperative blood tests still revealed high levels of intact PTH (103 pg/mL) and Ca (11.4 mg/dL). Computed tomography and magnetic resonance imaging revealed a 45-mm-sized mass in the right upper mediastinum as a well-defined solid and cystic lesion, whereas ^99mTc-methoxyisobutylisonitrile scintigraphy indicated a strong accumulation of tracers, suggesting an ectopic lesion in the mediastinum. Persistent hyperparathyroidism after total parathyroidectomy via neck incision was attributed to an ectopic parathyroid tumor in the mediastinum. Thus, we decided to resect the tumor using robot-assisted thoracoscopic surgery to perform the procedure gently and carefully. During surgery, a mediastinal tumor was identified as it was detected radiographically. Because it did not invade the surrounding tissues, it could be completely resected without injuring the capsule. The patient was discharged without complications. Postoperatively, Ca and intact PTH levels decreased back to normal. The final pathological diagnosis confirmed that the mass was an ectopic mediastinal parathyroid adenoma.

CONCLUSIONS

Minimally invasive surgical resection of a remnant ectopic lesion was successfully performed in a patient with multiple endocrine neoplasia 1 using robot-assisted thoracoscopic surgery.

Robot-assisted thoracoscopic resection of a posterior mediastinal tumor with preserving the artery of Adamkiewicz

Background

The artery of Adamkiewicz (AKA) provides the major blood supply to the lower two-thirds of the spinal cord. As the AKA typically arises from a left posterior intercostal artery at the levels between 9 and 12th thoracic vertebrae, injury of the AKA during thoracic surgery such as resection of a lower paravertebral tumor may cause serious neurological complications. Robot-assisted thoracic surgery (RATS) has several advantages over video-assisted thoracic surgery including three-dimensional and high-definition view with high image magnification and reduced restriction in movement of surgical instruments. Here, we present a case of a left paravertebral ganglioneuroma originating from the sympathetic trunk. Whereas both tumor-feeding arteries and the AKA arose from the 9^th intercostal artery, complete tumor resection with preserving the AKA was achieved by RATS.

Case presentation

A 15-year-old girl admitted for surgery for a posterior mediastinal tumor. Chest computed tomography showed a well-circumscribed 8.0 cm tumor adjacent to 8–11th thoracic vertebrae and the descending aorta. Contrast-enhanced CT and angiography revealed that the AKA arose from the left 9^th intercostal artery that ran between the tumor and the vertebrae and that tumor-feeding arteries also arose from the same intercostal artery. RATS was performed with the left intercostal approach using the da Vinci Xi system (Intuitive Surgical, Mountain View, CA). The tumor originating from the sympathetic trunk was completely resected with preserving the sympathetic trunk and the AKA. Postoperative course was uneventful without any adverse event, such as neurological complications. The final pathological diagnosis of the tumor was ganglioneuroma.

Conclusions

RATS is a useful surgical approach for removal of a mediastinal tumor with preserving surrounding organs or tissues, such as the AKA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40792-022-01487-6.

Robotic Mediastinal Tumor Resections: Position and Port Placement

This study aimed to determine the optimal position and port placement during robotic resection for various mediastinal tumors. For anterior mediastinal tumors, total or extended thymectomy is commonly performed in the supine position using the lateral or subxiphoid approach. Although it is unclear which approach is better during robotic thymectomy, technical advantages of subxiphoid approach are beneficial for patients with myasthenia who require extended thymectomy. Partial thymectomy is performed in the supine position using a lateral approach. Superior, middle, and posterior mediastinal tumors are resected in the decubitus position using the lateral approach, whereas dumbbell tumor resection, which requires a posterior approach, can be performed in the prone position. The position and port placement should be chosen depending on the size, location, and aggressiveness of the tumor. In this study, we describe how to choose which of these different robotic approaches can be used based on our experience and previous reports.

Comparison of perioperative outcomes between robotic-assisted and video-assisted thoracoscopic surgery for mediastinal masses in patients with different body mass index ranges: A population-based study

Background

The effectiveness of robotic-assisted thoracoscopic surgery (RATS) for mediastinal masses has not been fully evaluated. This study aimed to compare the perioperative outcomes between RATS and video-assisted thoracoscopic surgery (VATS) for mediastinal masses, and then explore which group of people would benefit more from RATS.

Methods

This retrospective study compared the perioperative outcomes of patients with mediastinal masses who underwent RATS and VATS from September 2018 to December 2021. Subgroup analysis were performed according to body mass index (BMI) ranges.

Results

A total of 212 patients with mediastinal masses (106 RATS cases and 106 VATS cases) were included. Compared with the VATS group, the RATS group had a significantly reduced incidence of overall postoperative complications (5.7% vs. 14.2%, p = 0.039), complications of grade II or less (3.8% vs. 12.3%, p = 0.023), and pneumonia (2.8% vs. 9.4%, p = 0.045). Hospitalization costs were significantly higher in the RATS group (¥ 49350.0 vs. ¥ 32551.9, p < 0.001). There was no significant difference in operation duration, intraoperative estimated blood loss, postoperative chest tube drainage volume, NRS pain score, day of chest tube removal, complications of grade III or more, or in-hospital mortality rate (p > 0.05). Subgroup analysis indicated that the incidence of overall postoperative complications (3.1% vs. 15.2%, p = 0.017), complications of grade II or less (1.5% vs. 12.1%, p = 0.033) and postoperative length of stay (4 days vs. 4.5 days, p = 0.046) were significantly reduced in the RATS group for overweight and obese patients (BMI ≥ 24 kg/m²), while these differences became insignificant in the BMI < 24 kg/m² subgroup.

Conclusion

RATS could reduce the incidence of postoperative complications, shorten the postoperative length of stay and might be a more cost-effective surgical treatment for overweight and obese patients with mediastinal masses.