Comparative study of anatomic lung resection by robotic vs. video-assisted thoracoscopic surgery

Performing High-Quality Sublobar Resections: Key Differences Between Wedge Resection and Segmentectomy

Lung cancer remains the leading cause of cancer-related deaths worldwide. The introduction of targeted treatments and immunotherapy in lung cancer has transformed patient care by offering "precision medicine" focused on the characteristics of the disease. The same concept has emerged in lung cancer surgery. This "precision surgery" aims to determine the best surgical approach based on the characteristics of the cancer, the patient's cardiorespiratory status, and technological advances in thoracic surgery. While lobectomy continues to be the gold standard for managing early-stage lung cancer, the implementation of screening programs has enabled the earlier detection of smaller tumors. In this context, sublobar resections, particularly segmentectomy, have emerged as valuable options in the treatment of early-stage lung cancer. Recent studies suggest that sublobar resections, including segmentectomy and wedge resection, provide a viable alternative to lobectomy. This review explores the various resection strategies available, tailored to patient and tumor characteristics, and highlights modern preoperative techniques aimed at advancing precision surgery.

Factors Associated With Margin Positivity After Lung Resection Surgery

INTRODUCTION

The purpose of this study is to utilize a representative national sample to investigate the factors associated with margin positivity after attempted surgical resection. Given the changes in surgical approaches to lung cancer for the last 10 years, margin positivity and outcomes between robotic, video assisted thoracoscopic surgery (VATS) and open surgical resections may vary.

METHODS

This retrospective cohort study utilized the National Cancer Database. Patients with non-small-cell lung cancer, 18 or older and who had a surgical lung resection between 2010 and 2019 were included. Demographic data, along with patient-level clinical variables were extracted. Patient-level outcome variables including 30-day, 90-day mortality and readmission rates were analyzed. Univariable and multivariable logistic regression was utilized to assess factors associated with margin positivity.

RESULTS

A total of 226,884 patients were identified. Of the total cohort, 9229 had positive margins (4.2%). Patients with positive margins had statistically significant increased 30-day, 90-day mortality, as well as increased readmission rate. Older age, male sex, patients undergoing an open resection, patients who underwent a wedge resection, higher clinical stage, larger tumor size, squamous and adenosquamous histologies, and higher Charlson-Deyo Comorbidity Index were all associated with having a positive margin after resection.

CONCLUSION

In conclusion, there was no difference in margin positivity when comparing robotic and VATS resection, however, open resection had increased rates of margin positivity. Increasing tumor size, clinical stage, squamous and adenosquamous histologies, male sex, and patients undergoing a wedge resection were all associated with increased rates of margin positivity.

Incidence of air leaks in patients undergoing robotic thoracic surgery and video-assisted thoracic surgery

Postoperative air leakage is the most common complication in surgery for malignant lung tumors, leading to extended hospital stays and substantial medical expenses. This study aimed to identify the incidence and characteristics of intraoperative and postoperative air leaks in both robotic-assisted thoracic surgery (RATS) and video-assisted thoracic surgery (VATS), as well as the causes of persistent air leakage following RATS. We conducted a retrospective analysis of patients who underwent lung resection for malignant lung tumors at our institution from October 2018 to August 2022. We compared the incidence rates of intraoperative air leak, postoperative air leak, and persistent air leak between patients who underwent RATS and those who underwent VATS. Background factors were adjusted using propensity score matching. A subanalysis was performed to compare unexpected air leaks, defined as air leaks not observed intraoperatively but confirmed postoperatively. The study included 295 cases of RATS and 227 cases of VATS. In both the overall population and the matched group (187 cases each for RATS and VATS), RATS demonstrated a significantly higher incidence of persistent air leaks compared to VATS (11% vs 3%, p < 0.01; 9% vs 3%, p = 0.02, respectively). RATS also had a significantly higher incidence of unexpected air leaks compared with VATS (29% vs 18%, p = 0.05). Although there was no statistically significant difference in hospital stays, RATS showed a higher incidence of postoperative persistent air leaks and unexpected postoperative air leaks than VATS.

Results of an exploratory survey within ESTS membership in 2022 on current trend of robotic-assisted thoracic surgery and its training perspectives

OBJECTIVES

Robotic-assisted thoracic surgery (RATS) is increasingly used in our specialty. We surveyed European Society of Thoracic Surgeons membership with the objective to determine current status of robotic thoracic surgery practice including training perspectives.

METHODS

A survey of 17 questions was rolled out with 1 surgeon per unit responses considered as acceptable.

RESULTS

A total of 174 responses were obtained; 56% (97) were board-certified thoracic surgeons; 28% (49) were unit heads. Most responses came from Italy (20); 22% (38) had no robot in their institutions, 31% (54) had limited access and only 17% (30) had full access including proctoring. Da Vinci Xi was the commonest system in 56% (96) centres, 25% (41) of them had dual console in all systems, whereas RATS simulator was available only in half (51.18% or 87). Video-assisted thoracic surgery (VATS) was the most commonly adopted surgical approach in 81% of centres (139), followed by thoracotomy in 67% (115) and RATS in 36% (62); 39% spent their training time on robotic simulator for training, 51% on robotic wet/dry lab, which being no significantly different to 46-59% who had training on VATS platform. There was indeed huge overlap between simulator models or varieties usage; 52% (90) reported of robotic surgery not a part of training curriculum with no plans to introduce it in future. Overall, 51.5% (89) responded of VATS experience being helpful in robotic training in view of familiarity with minimally invasive surgery anatomical views and dissection; 71% (124) reported that future thoracic surgeons should be proficient in both VATS and RATS. Half of the respondents found no difference in earlier chest drain removal with either approach (90), 35% (60) reported no difference in postoperative pain and 49% (84) found no difference in hospital stay; 52% (90) observed better lymph node harvest by RATS.

CONCLUSIONS

Survey concluded on a positive response with at least 71% (123) surgeons recommending to adopt robotics in future.

Impact of Endoscopic Surgery Versus Robot CAS-R-2 Assisted with Stereotactic Drainage on Prognosis of Basal Ganglia Hypertensive Intracerebral Hemorrhage

OBJECTIVE

To evaluate the impact of endoscopic surgery (ES) versus robot CAS-R-2 assisted with stereotactic drainage on prognosis of basal ganglia hypertensive intracerebral hemorrhage (HICH).

METHODS

This retrospective observational study included patients who underwent ES or robot CAS-R-2 assisted with stereotactic drainage for basal ganglia HICH in Shanghai Sixth People's Hospital between June 2017 and May 2022. The outcomes were 6-month mortality and modified Rankin Scale (mRS) score.

RESULTS

A total of 94 patients were included; 68 (age 51.26 ± 9.18 years, 17 women) of them underwent ES, while the other 26 (age 56.50 ± 12.91, 11 women) underwent robot CAS-R-2. The 6-month mortality rates were similar (P > 0.05) between the patients who underwent ES (6 of 68, 8.82%) and robot CAS-R-2 (2 of 26,7.69%), while the rate of good prognosis in the ES group was significantly higher compared with that in the robot CAS-R-2 group (P = 0.024). Univariate logistic analysis found that endoscopic surgery, age, and hematoma volume were associated with poor prognosis at 6 months. Multivariate logistic regression analysis showed that, after adjusted for the preoperative hematoma volume and age, endoscopy surgery (relative risk 0.21, 95% CI 0.06-0.68, P = 0.009) was associated with good prognosis at 6 months follow-up.

CONCLUSIONS

Compared with robot CAS-R-2 assisted with stereotactic drainage, ES might have higher rate of good prognosis at 6-month follow-up for basal ganglia HICH.

Long-term outcomes of robotic versus video-assisted pulmonary lobectomy for non-small cell lung cancer: systematic review and meta-analysis of reconstructed patient data

Background

Video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS) are two viable options in patients undergoing lobectomy for non-small cell lung cancer (NSCLC); however, the debate on which one is superior is unceasing.

Methods

PubMed and Scopus databases were queried for studies including patients who underwent either VATS or RATS lobectomy. This meta-analysis is in accordance with the recommendations of the PRISMA statement. Individual patient data on overall survival (OS) and disease-free survival (DFS) were extracted from Kaplan-Meier curves. One- and two-stage survival analyses, and random-effects meta-analyses were conducted.

Results

Ten studies met our eligibility criteria, incorporating 1,231 and 814 patients in the VATS and RATS groups, respectively. Patients who underwent VATS had similar OS compared with those who underwent RATS [hazard ratio (HR): 1.05, 95% confidence interval (CI): 0.88-1.27, P=0.538] during a weighted median follow-up of 51.7 months, and this was validated by the two-stage meta-analysis (HR: 1.27, 95% CI: 0.85-1.90, P=0.24, I2=68.50%). Regarding DFS, the two groups also displayed equivalent outcomes (HR: 1.07, 95% CI: 0.92-1.25, P=0.371) and this was once again validated by the two-stage meta-analysis (HR: 1.05, 95% CI: 0.85-1.30, P=0.67, I2=28.27%). Both RATS and VATS had similar postoperative complication rates, prolonged air leak, conversion to thoracotomy and operative times. RATS was found to be superior to VATS in terms of length of hospital stay and number of lymph nodes dissected.

Conclusions

In patients undergoing lobectomy for NSCLC, VATS and RATS have equivalent overall and DFS at a median follow-up of 51.7 months.

Beyond the Frontline: A Triple-Line Approach of Thoracic Surgeons in Lung Cancer Management-State of the Art

Non-small cell lung cancer (NSCLC) is now described as an extremely heterogeneous disease in its clinical presentation, histology, molecular characteristics, and patient conditions. Over the past 20 years, the management of lung cancer has evolved with positive results. Immune checkpoint inhibitors have revolutionized the treatment landscape for NSCLC in both metastatic and locally advanced stages. The identification of molecular alterations in NSCLC has also allowed the development of targeted therapies, which provide better outcomes than chemotherapy in selected patients. However, patients usually develop acquired resistance to these treatments. On the other hand, thoracic surgery has progressed thanks to minimally invasive procedures, pre-habilitation and enhanced recovery after surgery. Moreover, within thoracic surgery, precision surgery considers the patient and his/her disease in their entirety to offer the best oncologic strategy. Surgeons support patients from pre-operative rehabilitation to surgery and beyond. They are involved in post-treatment follow-up and lung cancer recurrence. When conventional therapies are no longer effective, salvage surgery can be performed on selected patients.

Pulmonary Open, Robotic, and Thoracoscopic Lobectomy (PORTaL) Study: Survival Analysis of 6646 Cases

OBJECTIVE

The aim of this study was to analyze overall survival (OS) of robotic-assisted lobectomy (RL), video-assisted thoracoscopic lobectomy (VATS), and open lobectomy (OL) performed by experienced thoracic surgeons across multiple institutions.

SUMMARY BACKGROUND DATA

Surgeons have increasingly adopted RL for resection of early-stage lung cancer. Comparative survival data following these approaches is largely from single-institution case series or administrative data sets.

METHODS

Retrospective data was collected from 21 institutions from 2013 to 2019. Consecutive cases performed for clinical stage IA-IIIA lung cancer were included. Induction therapy patients were excluded. The propensity-score method of inverse-probability of treatment weighting was used to balance baseline characteristics. OS was estimated using the Kaplan-Meier method. Multivariable Cox proportional hazard models were used to evaluate association among OS and relevant risk factors.

RESULTS

A total of 2789 RL, 2661 VATS, and 1196 OL cases were included. The unadjusted 5-year OS rate was highest for OL (84%) followed by RL (81%) and VATS (74%); P =0.008. Similar trends were also observed after inverse-probability of treatment weighting adjustment (RL 81%; VATS 73%, OL 85%, P =0.001). Multivariable Cox regression analyses revealed that OL and RL were associated with significantly higher OS compared with VATS (OL vs. VATS: hazard ratio=0.64, P <0.001 and RL vs. VATS: hazard ratio=0.79; P =0.007).

CONCLUSIONS

Our finding from this large multicenter study suggests that patients undergoing RL and OL have statistically similar OS, while the VATS group was associated with shorter OS. Further studies with longer follow-up are necessary to help evaluate these observations.

Long-Term Survival Following Minimally Invasive Lung Cancer Surgery: Comparing Robotic-Assisted and Video-Assisted Surgery

Simple Summary

Video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS) are known to be safe and efficient surgical procedures to treat lung cancer. Both VATS and RATS allow anatomical resection associated with radical lymph node dissection. However, RATS, unlike VATS, allows the thoracic surgeon to mimic an open approach and to perform lung resection. We hypothesized that the technical advantages of RATS, compared with VATS, would allow more precise resection, with “better lymph node dissection” which could increase survival compared to VATS. Nevertheless, VATS, and RATS nodal up-staging are still debated, with conflicting results and in our study, as well as in the medical literature, RATS failed to show its superiority over VATS in resectable non-small cell lung cancer.

Abstract

Background: Nowadays, video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS) are known to be safe and efficient surgical procedures to treat early-stage non-small cell lung cancer (NSCLC). We assessed whether RATS increased disease-free survival (DFS) compared with VATS for lobectomy and segmentectomy. Methods: This retrospective cohort study included patients treated for resectable NSCLC performed by RATS or VATS, in our tertiary care center from 2012 to 2019. Patients’ data were prospectively recorded and reviewed in the French EPITHOR database. Primary outcomes were 5-year DFS for lobectomy and 3-year DFS for segmentectomy, compared by propensity-score adjusted difference of Kaplan–Meier estimates. Results: Among 844 lung resections, 436 VATS and 234 RATS lobectomies and 46 VATS and 128 RATS segmentectomies were performed. For lobectomy, the adjusted 5-year DFS was 60.9% (95% confidence interval (CI) 52.9–68.8%) for VATS and 52.7% (95%CI 41.7–63.7%) for RATS, with a difference estimated at −8.3% (−22.2–+4.9%, p = 0.24). For segmentectomy, the adjusted 3-year DFS was 84.6% (95%CI 69.8–99.0%) for VATS and 72.9% (95%CI 50.6–92.4%) for RATS, with a difference estimated at −11.7% (−38.7–+7.8%, p = 0.21). Conclusions: RATS failed to show its superiority over VATS for resectable NSCLC.

Updated Evaluation of Robotic- and Video-Assisted Thoracoscopic Lobectomy or Segmentectomy for Lung Cancer: A Systematic Review and Meta-Analysis

Objectives

Robot-assisted thoracic surgery (RATS) and video-assisted thoracic surgery (VATS) are the two principal minimally invasive surgical approaches for patients with lung cancer. This study aimed at comparing the long-term and short-term outcomes of RATS and VATS for lung cancer.

Methods

A comprehensive search for studies that compared RATS versus VATS for lung cancer published until November 31, 2021, was conducted. Data on perioperative outcomes and oncologic outcomes were subjected to meta-analysis. PubMed, Web of Science, and EMBASE were searched based on a defined search strategy to identify eligible studies before November 2021.

Results

Twenty-six studies comparing 45,733 patients (14,271 and 31,462 patients who underwent RATS and VATS, respectively) were included. The present meta-analysis showed that there were no significant differences in operative time, any complications, tumor size, chest drain duration, R0 resection rate, lymph station, 5-year overall survival, and recurrence rate. However, compared with the VATS group, the RATS group had less blood loss, a lower conversion rate to open, a shorter length of hospital stay, more lymph node dissection, and better 5-year disease-free survival.

Conclusions

RATS is a safe and feasible alternative to VATS for patients with lung cancer.

The Role of Surgery in the Treatment of Melanoma Pulmonary Metastases in the Modern Era

INTRODUCTION

The lung represents a frequent site of spread for metastatic melanoma, which has historically been managed with surgical resection achieving promising outcomes. We hypothesized that the role of surgery in the management of melanoma pulmonary metastases (MPM) is evolving among the development of less invasive diagnostic and novel systemic therapeutic strategies.

MATERIALS AND METHODS

A single-center thoracic surgery database was reviewed and patients who underwent surgical resection of MPM between 1998 and 2019 were identified. Demographic, clinicopathologic, and surgical data were collected and analyzed, as were the annual volumes and indications for surgical resection. A Cochran-Armitage test was used to assess the trend in surgical indication.

RESULTS

Three hundred and seventy seven surgical procedures for MPM were performed during the years of study in the care of 347 patients. Patients were predominantly male, with a mean age of 59.3 y. The mean number of annual resections was 17 and while this number initially increased from six in 1998 to a peak of 39 cases in 2008, a decline was subsequently observed. Diagnostic resection decreased from 22% in 1998-1999 to 5% at the peak of procedures in 2008-2009 and to 0 in 2018-2019 (P = 0.02). Curative resection increased from 44% in 1998-1999 to 73% in 2008-2009 (P < 0.001) and remained the dominant reason for surgery in later years.

CONCLUSIONS

Surgical indications in the management of MPM have transformed in conjunction with systemic modalities, and the volume of resections has decreased in the modern era. Despite innovations in systemic management and shifting goals of operative interventions, surgeons continue to play a vital role in caring for these patients with an advanced disease.

The impact of marginal lung function on outcomes in the era of minimally invasive thoracic surgery

Background

The effect of marginal lung function on outcomes after lung resection has traditionally been studied in the context of open thoracic surgery. Its impact on postoperative outcomes in the era of minimally invasive lung resection is unclear.

Methods

In this retrospective cohort study, we included adult patients who underwent minimally invasive lung resection at our institution between January 2017 and May 2020 for known malignancy or lung nodule. Marginal lung function was defined as pre-operative forced expiratory volume in 1 second (FEV1) and/or diffusion lung capacity of carbon monoxide <60% of predicted. Our outcomes included a composite outcome of pulmonary morbidity and/or 30- and 90-day mortality, and hospital length of stay. We used multivariable logistic and Poisson regression models to identify associations with outcomes, and Kaplan-Meier and Cox models to estimate survival.

Results

Of 300 patients, 88 (29%) had marginal lung function. Patients in the marginal group were more likely to be female (69% vs. 56%; P=0.028), and more likely to have: hypertension (HTN) (83% vs. 71%; P=0.028), chronic obstructive pulmonary disease (COPD) (38% vs. 12%; P<0.001), interstitial lung disease (ILD) (9% vs. 3%; P<0.019), and ischemic heart disease (28% vs. 18%; P=0.033). Patients were similar in terms of age (68±8 vs. 68±10 years; P=0.932), and other comorbidities. Anatomic lung resection comprised 56.8% of the marginal group vs. 74% in the non-marginal group (P=0.003). The most common complication was prolonged air leak (18.2% vs. 11.8%; P=0.479). Marginal lung function had a trend toward increased composite respiratory complications (22.7% vs. 15.1%; P=0.112) and 90-day mortality (5.7% vs. 4.2%; P=0.591), although they did not reach statistical significance. There was a statistically significant 1-day average increase in length of stay in the marginal lung function cohort (4.6 vs. 3.4 days; P<0.015) with a stronger association with diffusion lung capacity of carbon monoxide than FEV1. Survival was similar (marginal function HR =1.0; P=0.994).

Conclusions

In the era of minimally invasive thoracic surgery, lung resection in patients with marginal lung function may be considered in select patients. These findings aid in the selection consideration and counseling of this patient population.

Segmentectomy for clinical stage I non-small cell lung cancer: National benchmarks for nodal staging and outcomes by operative approach

BACKGROUND

Segmentectomy is increasingly used for parenchyma sparing anatomical resection for small stage I non-small cell lung cancer (NSCLC). This study characterizes the national outcomes for lymph node assessment and perioperative outcomes of segmentectomy for clinical stage I NSCLC by robotic-assisted surgery (RATS), video-assisted thoracoscopic surgery (VATS), and open thoracotomy approach.

METHODS

A retrospective cohort study was conducted of patients who underwent segmentectomy for clinical stage I NSCLC captured in the national Society of Thoracic Surgeons General Thoracic Surgery Database between years 2012 and 2018. Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. Lymph node (LN) staging and 30-day outcomes were compared by approach.

RESULTS

A total of 3680 patients (VATS 61.9%, RATS 20%, open 18%) underwent segmentectomy. The IPTW adjusted rate of pathologic LN upstaging (pN1/pN2) was 6.2% (RATS 6.3%, VATS 5.6%, open 8.6%; P = .05). On multivariate analysis, there was no differences in pN1/N2 upstaging between RATS (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.44-1.49) or VATS (OR, 0.96; 95% CI, 0.57-1.63) with open segmentectomy. The RATS and VATS approach was associated with fewer postoperative events (RATS 31.3%, VATS 28.8%, open 38.3%; P < .001) and shorter length of stay (RATS 4.3 days, VATS 4.4 days, open 5.2 days; P < .001) as compared with thoracotomy. RATS segmentectomy-specific complications included a higher rate of pneumothorax after chest tube removal and discharge with chest tube. Major complications were lower after RATS and VATS as compared with open segmentectomy (RATS 5.9%, VATS 4.5%, open 7.2%; P = .028).

CONCLUSIONS

Segmentectomy by VATS and robotic approach resulted in similar high rates of lymph node upstaging as a global marker of the quality of lymph node dissection and were associated with lower overall morbidity and shorter length of stay as compared with open thoracotomy. These national outcomes may serve as benchmarks for future comparative studies.

Global status of the robotic thoracic surgery

Robotics has taken its place in thoracic surgery since the end of the 20th century. Since then, it has been developed worldwide with many different applications, such as the treatment of mediastinal tumors and lung cancer. Although, the contradictory results comparing this new technology to other minimally invasive techniques may raise some skepticism, the high quality of the instrument and images provided by the robot brings a whole new perspective for the thoracic surgeon, since the robotic platform can ally the ease of movement obtained with open technique with the advantages of the minimally invasive surgery. When it comes to the implementation of a robotic program the costs of RATS are an important issue. However, it is necessary to take into account not only the cost of the robotic platform itself but also the maintenance expenses, disposable tools, and training programs. Nevertheless, the cost of the robotic surgery is expected to decrease in the coming years and like the instrumentation, virtual reality will see improvements. Many different countries around the world have contributed with original articles for the development of the robotic thoracic surgery and in this paper, we aim at describing the global status of the robotic thoracic surgery.

Surgeon experience is associated with prolonged air leak after robotic-assisted pulmonary lobectomy

BACKGROUND

Prolonged air leak (>5 days) following robotic-assisted pulmonary lobectomy is a significant complication. This study aimed to determine patient and surgeon factors that can predict prolonged air leak (PAL) after robotic lobectomy for lung cancer.

METHODS

We performed a retrospective review from a single-center experience of robotic-assisted lobectomy for lung cancer. Perioperative variables including surgeon case experience, patient demographics, DLCO, FEV1, BMI, and smoking status were evaluated.

RESULTS

A total of 305 robotic-assisted lobectomies performed by four surgeons met inclusion criteria from June 2016 to February 2019. Thirty-day post-operative mortality was 1.2%. 27 out of 305 (8.8%) patients developed PAL. We grouped surgeon robotic experience by 10 case increments. When adjusted for age and gender, the odds for PAL decreased by 15% for every 10 robotic lobectomies our surgeons performed (OR=0.85, 95% CI: 0.74-0.99, p=0.0384). Logistic regression models showed a linear transition curve was at the 50^th case. Female gender (OR=2.62, 95% CI: 1.03-6.69, p=0.0314) and younger age (OR=0.61; 95% CI: 0.41-0.91, p=0.0184) were statistically significant risk factors for PAL. Cumulative sum analysis similarly showed strong association between experience and PAL. Preoperative DLCO, FEV1, BMI, and smoking status were not statistically significant predictive factors.

CONCLUSIONS

These results show that surgeon robotic case experience is associated with the rate of postoperative PAL - as the number of robotic lobectomies increases, the rate of PAL significantly decreases. It is imperative to emphasize a learning curve exists for this approach that directly impacts patient outcomes.

Comparison between robot-assisted thoracoscopic surgery and video-assisted thoracoscopic surgery for mediastinal and hilar lymph node dissection in lung cancer surgery

OBJECTIVES

Lymph node dissection (LND) with robot-assisted thoracoscopic surgery (RATS) in lung cancer surgery has not been fully evaluated. The aim of this study was to compare LND surgical results between video-assisted thoracoscopic surgery (VATS) and RATS.

METHODS

We retrospectively compared perioperative parameters, including the incidence of LND-associated complications (chylothorax, recurrent and/or phrenic nerve paralysis and bronchopleural fistula), lymph node (LN) counts and postoperative locoregional recurrence, among 390 patients with primary lung cancer who underwent lobectomy and mediastinal LND by RATS (n = 104) or VATS (n = 286) at our institution.

RESULTS

The median total dissected LN numbers significantly differed between the RATS and the VATS groups (RATS: 18, VATS: 15; P < 0.001). They also significantly differed in right upper zone and hilar (#2R + #4R + #10L) (RATS: 12, VATS: 10; P = 0.002), left lower paratracheal and hilar (#4L + #10L) (RATS: 4, VATS: 3; P = 0.019), aortopulmonary zone (#5 + #6) (RATS: 3, VATS: 2; P = 0.001) and interlobar and lobar (#11 + #12) LNs (RATS: 7, VATS: 6; P = 0.041). The groups did not significantly differ in overall nodal upstaging (P = 0.64), total blood loss (P = 0.69) or incidence of LND-associated complications (P = 0.77).

CONCLUSIONS

In this comparison, it was suggested that more LNs could be dissected using RATS than VATS, especially in bilateral superior mediastinum and hilar regions. Accumulation of more cases and longer observation periods are needed to verify whether RATS can provide the acceptable quality of LND and local control of lung cancer.

The Role of Surgery in Lung Cancer Treatment: Present Indications and Future Perspectives-State of the Art

Non-small cell lung cancers (NSCLC) are different today, due to the increased use of screening programs and of innovative systemic therapies, leading to the diagnosis of earlier and pre-invasive tumors, and of more advanced and controlled metastatic tumors. Surgery for NSCLC remains the cornerstone treatment when it can be performed. The role of surgery and surgeons has also evolved because surgeons not only perform the initial curative lung cancer resection but they also accompany and follow-up patients from pre-operative rehabilitation, to treatment for recurrences. Surgery is personalized, according to cancer characteristics, including cancer extensions, from pre-invasive and local tumors to locally advanced, metastatic disease, or residual disease after medical treatment, anticipating recurrences, and patients' characteristics. Surgical management is constantly evolving to offer the best oncologic resection adapted to each NSCLC stage. Today, NSCLC can be considered as a chronic disease and surgery is a valuable tool for the diagnosis and treatment of recurrences, and in palliative conditions to relieve dyspnea and improve patients' comfort.

Long-term and short-term outcomes of robot- versus video-assisted anatomic lung resection in lung cancer: a systematic review and meta-analysis

OBJECTIVES

Minimally invasive thoracic surgery has evolved with the introduction of robotic platforms. This study aimed to compare the long-term and short-term outcomes of the robot-assisted thoracic surgery (RATS) and video-assisted thoracic surgery (VATS) for anatomic lung resection.

METHODS

We searched published studies that investigated RATS and VATS in anatomic lung resection. Long-term outcomes (disease-free survival and overall survival) and short-term outcomes (30-day mortality, postoperative complications, conversion rate to open surgery and lymph node upstaging) were extracted. The features were compared and tested as hazard ratios (HRs) and odds ratios (ORs) at a 95% confidence interval (CI).

RESULTS

Twenty-five studies with 50 404 patients (7135 for RATS and 43 269 for VATS) were included. The RATS group had a longer disease-free survival than the VATS group (HR: 0.76; 95% CI: 0.59-0.97; P = 0.03), and the overall survival showed a similar trend but was not statistically significant (HR: 0.77; 95% CI: 0.57-1.05; P = 0.10). The RATS group showed a significantly lower 30-day mortality (OR: 0.55; 95% CI: 0.38-0.81; P = 0.002). No significant difference was found in postoperative complications (OR: 1.01; 95% CI: 0.87-1.16; P = 0.94), the conversion rate to open surgery (OR: 0.92; 95% CI: 0.56-1.52; P = 0.75) and lymph node upstaging (OR: 0.89; 95% CI: 0.52-1.54; P = 0.68).

CONCLUSIONS

RATS has comparable short-term outcomes and potential long-term survival benefits for anatomic lung resection compared with VATS.

Pulmonary lobectomy for cancer: Systematic review and network meta-analysis comparing open, video-assisted thoracic surgery, and robotic approach

BACKGROUND

Although minimally invasive lobectomy has gained worldwide interest, there has been debate on perioperative and oncological outcomes. The purpose of this study was to compare outcomes among open lobectomy, video-assisted thoracic surgery lobectomy, and robotic lobectomy.

METHODS

PubMed, EMBASE, and Web of Science databases were consulted. A fully Bayesian network meta-analysis was performed.

RESULTS

Thirty-four studies (183,426 patients) were included; 88,865 (48.4%) underwent open lobectomy, 79,171 (43.2%) video-assisted thoracic surgery lobectomy, and 15,390 (8.4%) robotic lobectomy. Compared with open lobectomy, video-assisted thoracic surgery, lobectomy and robotic lobectomy had significantly reduced 30-day mortality (risk ratio = 0.53; 95% credible intervals, 0.40-0.66 and risk ratio = 0.51; 95% credible intervals, 0.36-0.71), pulmonary complications (risk ratio = 0.70; 95% credible intervals, 0.51-0.92 and risk ratio = 0.69; 95% credible intervals, 0.51-0.88), and overall complications (risk ratio = 0.77; 95% credible intervals, 0.68-0.85 and risk ratio = 0.79; 95% credible intervals, 0.67-0.91). Compared with video-assisted thoracic surgery lobectomy, open lobectomy, and robotic lobectomy had a significantly higher total number of harvested lymph nodes (mean difference = 1.46; 95% credible intervals, 0.30, 2.64 and mean difference = 2.18; 95% credible intervals, 0.52-3.92) and lymph nodes stations (mean difference = 0.37; 95% credible intervals, 0.08-0.65 and mean difference = 0.93; 95% credible intervals, 0.47-1.40). Positive resection margin and 5-year overall survival were similar across treatments. Intraoperative blood loss, postoperative transfusion, hospital length of stay, and 30-day readmission were significantly reduced for minimally invasive approaches.

CONCLUSION

Compared with open lobectomy, video-assisted thoracic surgery lobectomy, and robotic lobectomy seem safer with reduced 30-day mortality, pulmonary, and overall complications with equivalent oncologic outcomes and 5-year overall survival. Minimally invasive techniques may improve outcomes and surgeons should be encouraged, when feasible, to adopt video-assisted thoracic surgery lobectomy, or robotic lobectomy in the treatment of lung cancer.

Perioperative outcomes of robot-assisted vs video-assisted and traditional open thoracic surgery for lung cancer: A systematic review and network meta-analysis

BACKGROUND

The superiority of robot-assisted thoracic surgery (RATS) over video-assisted thoracic surgery (VATS) and thoracotomy remains controversial for lung cancer.

METHODS

A network meta-analysis (NMA) and pairwise meta-analysis (PMA) were performed to evaluate the perioperative outcomes using five databases.

RESULTS

Thirty-two studies involving 6593 patients were included for analysis. The NMA showed that RATS had similar operative time, conversion rate to thoracotomy, number of lymph node, postoperative morbidity, and length of hospital stay with VATS, except for lower 30-day mortality. Compared with thoracotomy, longer operative time and shorter hospital stay were observed in RATS, but no significant difference was observed in number of lymph node, postoperative morbidity, and 30-day mortality in both NMA and PMA. In lobectomy/segmentectomy subgroup, all outcomes, except for operative time of RATS vs VATS and number of lymph node, were similar with overall analyses.

CONCLUSIONS

RATS had comparable perioperative outcomes with VATS and open surgery.

Impact of da Vinci Xi robot in pulmonary resection

Background

This study sought to evaluate the impact of a da Vinci Xi surgical robot on perioperative outcomes after pulmonary resections.

Methods

A retrospective analysis of prospectively collected STS data was performed at a single institution for patients who underwent elective lung resections from 2012 to 2019. Patient outcomes were compared at three different time periods: before the adoption of the robot technology (predominately VATS), during the initial robot experience (the first 18 months), and after the mature robot experience (the second 18 months). Univariate and multivariate logistic regression modeling was performed to determine the factors associated with perioperative complications.

Results

Five hundred and four patients underwent pulmonary resection between the three time periods: 220 patients (43.7%) had surgery prior to the first use of the robot (predominately VATS), 126 patients (25%) had surgery during the initial experience with robot, and 158 patients (31.1%) had surgery during the mature robot experience. There were significantly less post-operative complications (15.2% vs. 34.9% vs. 39.1%, P<0.001), shorter median length of stay (2 vs. 3 vs. 4 days, P<0.001), and lower hospital readmission rates (1.9% vs. 4% vs. 11.8%, P<0.001) in the mature robot period compared to the initial robot period and the predominately VATS period, respectively. Multivariate analysis showed that the robot was associated with a decrease in post-operative complications (OR 0.36; 95% CI, 0.23–0.57, P<0.001).

Conclusions

The adoption of a da Vinci Xi robot in our institution was associated with improved outcomes in patients having pulmonary resections.