Robotic-assisted thoracic surgery (RATS) versus video-assisted thoracic surgery (VATS) in oncological lung resections—comparative study during initial experience of 3 surgeons
Alejandro García-Pérez
, María Delgado Roel, Anna Minasyan, Hector Manuel Tovar Durán, Ricardo Fernández-Prado, Eva María Fieira Costa, Luis Fernández Vago, Ignacio Alfonso Sánchez Valenzuela, María Castiñeira Gamborino, Mercedes de la Torre Bravos
Contributions: (I) Conception and design: A García-Pérez, M Delgado Roel; (II) Administrative support: All authors; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: A García-Pérez, M Delgado Roel; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Background: Robotic-assisted thoracic surgery (RATS) has been introduced in recent years as an alternative minimally invasive approach for surgical treatment of non-small cell lung cancer (NSCLC). As with any new technique, an inevitable learning curve may affect outcomes after introducing a robotic program. This study compares the short-term outcomes of a recently implemented RATS program to those of a uniportal video-assisted thoracic surgery (uVATS) program for anatomical lung resections in NSCLC in A Coruña University Hospital.
Methods: This is a retrospective study of 154 patients diagnosed with NSCLC and treated at the Department of Thoracic Surgery and Lung Transplant of A Coruña during the first two years after implementing the robotic program. We compared demographic variables such as sex, age, type of resection, histology size of tumor or neoadjuvant and patient perioperative characteristics such operating time, days of drainage, days of hospitalization, reintervention, readmisson, number of lymphnode stations, N1 stations, N2 stations, occult N1 and occult N2 between two groups of 77 patients divided into RATS and VATS arms and treated by the same three surgeons between January 2022 and January 2024. We performed univariate analysis using the Student’s t-test for quantitative variables and Chi-squared for categorical variables.
Results: The surgical time was lower in the VATS group (176.7 min uVATS vs. 243.1 min RATS), but the number of resected nodal stations (N1 and N2) was superior in the RATS {4.88 [95% confidence interval (CI): 4.61–5.15]} group compared to uVATS [4.35 (95% CI: 4.10–4.59)]. In the multivariable model, after adjusting for size, type of resection, and neoadjuvant therapy, the number of stations resected comparing both techniques remains significant (P=0.002). We did not see any statistically significant difference between the two groups regarding demographics, type of resection, pathological anatomy, tumor size, or previous chemotherapy. In addition, no differences were found in reintervention rate, admission, or chest drain duration, and the readmission rates during the first 30 days were similar.
Conclusions: A RATS program can be established safely with similar postoperative outcomes to a running uVATS program. Compared to the standard technique by uVATS, a longer surgical time and a better lymphadenectomy have been observed.
Keywords: Robotic-assisted thoracic surgery (RATS); video-assisted thoracic surgery (VATS); minimally invasive surgery; lung cancer
Received: 16 March 2024; Accepted: 25 November 2024; Published online: 03 March 2025.
doi: 10.21037/vats-24-13
Highlight box
Key findings
• Compared to the standard technique by uniportal video-assisted thoracic surgery (uVATS), a longer surgical time and a better lymphadenectomy have been observed in robotic-assisted thoracic surgery (RATS) approach.
What is known and what is new?
• Introducing a new technique is challenging for any surgical team since it inevitably entails a learning curve.
• RATS is a feasible and safe technique compared to the standard uVATS technique.
What is the implication, and what should change now?
• This study may be helpful for Thoracic Surgery teams that begin a new robotic surgery program in oncological lung resections.
Introduction
Anatomical lung resection and systematic mediastinal lymph node dissection by minimally invasive video-assisted surgery is currently the Gold Standard in the surgical management of early-stage non-small cell lung cancer (NSCLC) (1,2). In addition to video-assisted thoracic surgery (VATS), robotic-assisted thoracic surgery (RATS) is gaining rapid popularity in the Thoracic Surgical Community. VATS and its different variants, such as uniportal VATS (uVATS), gained rapid popularity among thoracic surgeons due to reduced postoperative pain, faster recovery, fewer complications, and better quality of life than conventional thoracotomy (3). However, it is essential to recognize that VATS also comes with inherent limitations like two-dimensional vision, complex hand-eye coordination, amplification of manual tremors, a difficult learning curve, and limited instrument maneuverability (4). On the other hand, RATS has demonstrated technical advantages like a three-dimensional view, camera stability, improved maneuverability due to instruments with seven degrees of freedom, and articulations that mimic human finger joints without physiological tremors (5,6). Introducing a new technique is challenging for any surgical team since it inevitably entails a learning curve. Our department’s RATS program is relatively young, especially compared to our well-established uVATS program. As with any new technique introduced in a surgical department, robotic surgeons suffer a learning curve following the adoption of this approach. This learning curve can affect the results of the surgery that is gradually minimized with practice. This study aims to compare the short-term outcomes of coexisting RATS and uVATS surgical programs for NSCLC anatomical lung resections performed by the same three thoracic surgeons in our department. This article is written in accordance with the STROBE reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-24-13/rc).
Methods
Population data and study design
We analyzed the data obtained from A Coruña University Hospital patients diagnosed with NSCLC and undergoing anatomical lung resection (segmentectomy, lobectomy, bilobectomy, or pneumonectomy) by RATS between January 2022 and January 2024. The results were compared to postoperative outcomes of patients treated surgically during the same period by uVATS. We only included RATS and uVATS cases performed by the same three surgeons. We analyzed the results of 154 patients, 77 patients in each group. The indications for RATS and VATS lobectomy were clinical T1–T3, N0–N1, and M0. All patients underwent preoperative assessments, including chest computed tomography (CT), positron emission tomography (PET)/CT, pulmonary function and cardiological assessment, and standard blood tests. We analyzed the following variables: gender, age, type of resection, tumor size, anatomy, presence or absence of neoadjuvant therapy, operative time, reintervention, hospitalization days, chest drain days, number of resected lymph node stations, N1 stations, N2 stations, readmission in first 30 days and occult N1 or N2. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) and the study was approved by regional ethics committee of A Coruña Board (No. 2024/322) without the need to present informed consent because it is a retrospective study without disclosure of personal data.
The surgical team and operative technique
Our robotic surgery team consists of three surgeons with more than 12 years of experience in VATS. The robotic approach was uniportal or multiportal, depending on the preferences of each surgeon and the patient characteristics. In our hospital, we perform the uniportal RATS (uRATS) according to the technique described by Gonzalez-Rivas et al. (7) and the multiportal RATS (mRATS) following the approach described by Cerfolio et al. (8). In case of VATS, our standard approach is the uVATS technique using a single incision of 2.5–3 cm and advanced instrumentation (9).
Statistical analysis
We used the Stata 14.0 program for the statistical analysis. Univariate analysis was used to establish initial differences between groups, using Student’s t for quantitative variables and Chi-squared for categorical variables. Values of P<0.05 were considered significant.
Results
During the study period, 154 patients received elective anatomical lung resection through a minimally invasive approach. 77 were treated by RATS (uRATS or mRATS), and the remaining 77 cases by uVATS. The demographic variables of both groups are shown in Table 1. Both groups were comparable in sex, age, type of resection, pathological anatomy, tumor size, or previous chemotherapy. We did not find any differences regarding reintervention rates, the length of hospital stay, chest drain duration, or readmission rates during the first 30 postoperative days. The difference in duration of surgery was statistically significant, being uVATS faster than the RATS approach (176.7 min VATS vs. 243.1 min RATS). On the other hand, the number of resected nodal stations was superior in the RATS group {[4.35 (95% CI: 4.10–4.59)] vs. [4.88 (95% CI: 4.61–5.15)]; Table 2}. We found no significant difference regarding occult lymph node metastasis.
Table 1
| Variables | VATS | RATS | P value |
|---|---|---|---|
| Sex | 0.62 | ||
| Male | 40 (52%) | 43 (56%) | |
| Female | 37 (48%) | 34 (44%) | |
| Age, years | 67.9 (65.77–70.01) | 66.3 (64.07–68.51) | 0.30 |
| Resection | 0.55 | ||
| Segmentectomy | 8 (10%) | 6 (8%) | |
| Lobectomy | 61 (79%) | 67 (87%) | |
| Bilobectomy | 5 (6%) | 3 (4%) | |
| Pneumonectomy | 3 (5%) | 1 (1%) | |
| Histology | 0.54 | ||
| Squamous | 24 (31%) | 19 (25%) | |
| Adenocarcinoma | 47 (61%) | 51 (66%) | |
| Atypical carcinoid | 0 (0%) | 1 (1%) | |
| Typical carcinoid | 4 (5%) | 2 (3%) | |
| Large cells | 2 (3%) | 4 (5%) | |
| Size of tumor (cm) | 3.24 (3.11–3.97) | 3.28 (2.86–3.69) | 0.32 |
| Neoadjuvant | 0.40 | ||
| Yes | 16 (21%) | 12 (16%) | |
| No | 61 (79%) | 65 (84%) |
Data are presented as median (interquartile range ) or n (%). VATS, video-assisted thoracic surgery; RATS, robotic-assisted thoracic surgery.
Table 2
| Variables | VATS | RATS | P value |
|---|---|---|---|
| Operating time (min) | 176.67 (161–192) | 243.1 (221.4–264.92) | <0.01 |
| Days of drainage | 4.90 (1–35) | 4.14 (1–20) | 0.39 |
| Days of hospitalization | 4.72 (1–30) | 4.70 (1–15) | 0.94 |
| Reintervention | 1 (1.3) | 4 (5.2) | 0.17 |
| Readmission during first 30 days | 9 (11.7) | 8 (10.4) | 0.79 |
| Number of lymphnode stations | 4.35 (4.10–4.59) | 4.88 (4.61–5.15) | <0.01 |
| N1 stations | 1.62 (1.46–1.78) | 1.88 (1.72–2.03) | 0.02 |
| N2 stations | 2.71 (2.52–2.90) | 3 (2.8–3.20) | 0.04 |
| Occult N1 | 0.34 | ||
| Yes | 4 (5.2) | 7 (9.1) | |
| No | 73 (94.8) | 70 (90.9) | |
| Occult N2 | 0.42 | ||
| Yes | 4 (5.2) | 6 (7.8) | |
| No | 73 (94.8) | 71 (92.2) |
Data are presented as median (interquartile range) or n (%). VATS, video-assisted thoracic surgery; RATS, robotic-assisted thoracic surgery.
In the multivariable model, after adjusting for tumor size, type of resection, and neoadjuvant therapy, the difference between the number of stations analyzed in both techniques remains significant (P=0.002) (Table 3).
Table 3
| RATS/VATS | Coef. | Std.Err | P | 95% CI |
|---|---|---|---|---|
| Nstations | −0.1064177 | 0.0345291 | 0.002 | −0.1746477, −0.0381877 |
| Intervention time | 0.0512884 | 0.0522616 | 0.33 | −0.0519811, 0.1545579 |
| Size | 0.0243654 | 0.0215515 | 0.26 | −0.0182206, 0.0669514 |
| Post-chemotherapy | −0.1200395 | 0.1041624 | 0.25 | −0.3258658, 0.0857868 |
VATS, video-assisted thoracic surgery; RATS, robotic-assisted thoracic surgery; Coef., coefficient; Std.Err, standard error; CI, confidence interval.
Discussion
Any innovation in the field of surgery must demonstrate its effectiveness and safety. Specifically, when discussing lung resections in NSCLC, these innovations must ensure a correct oncological result. The use of VATS has demonstrated similar oncological results compared to the traditional thoracotomy approach, improving the postoperative recovery period for the patients. The RATS approach is characterized by providing excellent maneuverability and improvement in high-quality 3D vision (6). The advantages of the RATS platform enable surgeons to perform complex procedures more comfortably. Several authors have analyzed the use of the RATS approach in thoracic surgery compared to VATS using comparative groups (10-18). Meta-analyses of the RATS approach’s results in oncological surgery also demonstrate that this technique is feasible and safe (4,19,20) compared to the standard VATS technique. Our study compared two groups of patients who underwent surgery for NSCLC during the same period by the same surgeons. The two groups are comparable in demographic and tumor characteristics, which minimizes possible inclusion biases.
Our results are consistent with the currently available data, showing no statistically significant differences in the length of hospital stay, chest drain days, need for reintervention, and readmission rates during the first 30 postoperative days (10-18). One fact that deserves mention is the issue of reinterventions. We can see that, although it is not significant, there is a difference of one case of reintervention in VATS compared to four in RATS. In our study we have taken as a “reintervention” any surgery that had to be performed on the patient after the initial surgery during the hospital stay, including minor and major surgery. Analyzing each case, we see that there has only been one case of major reoperation due to bleeding in the RATS group, the same as VATS. The remaining cases were two due to chylothorax and one due to wound infection and drain replacement.
We found a striking difference of an hour in surgical procedure duration favoring the uVATS over the RATS approach (VATS: 176.7 min; RATS: 243.1 min). Several authors have studied the surgical time (11-14,16,21), finding values ranging from 122.4 to 269.4 minutes in VATS compared to the duration between 130.3 and 253.8 minutes in RATS (Table 4). Therefore, our data is consistent with the existing literature. However, in our study, several factors justify this significant difference in times. First, as RATS is a relatively new technique in our department, the surgeons were still on their learning curve. Moreover, the rest of the surgical team, including the nurses and the anesthesia staff, also needed to adapt to the RATS approach. Second, as we have two different RATS approaches—uniportal and muliportal, we have experienced two different learning curves in a short period (initially, the multiportal RATS learning curve and later the uniportal RATS curve). In addition, the relatively small volume of patients who have undergone RATS in our center during these two years hampers the surgeons’ ability to practice and gain experience. Finally, we used nursing records to collect the surgical time data. Usually, in our hospital, the nursing staff records the start of surgery as the moment in which the surgeons begin to place the trocars and not from the start of surgery on the console, with the consequent increase in time compared to uVATS, where the surgical time is counted since the skin incision. Another interesting fact that this study reveals is related to lymphadenectomy. As seen in Table 2, the number of lymphatic stations (N1 and N2) has significantly favored the RATS approach.
Table 4
| Study | VATS | RATS | P value |
|---|---|---|---|
| Swanson et al. 2014 (11) | 269.4 | 253.8 | 0.96 |
| Lee et al. 2014 (21) | 128 | 161 | <0.001 |
| Reddy et al. 2018 (12) | 222.6 | 247.2 | <0.0001 |
| Paradela et al. 2023 (16) | 144.6 | 130.3 | 0.13 |
| Lampridis et al. 2023 (14) | 122.4 | 132.4 | 0.001 |
| Catelli et al. 2023 (13) | 160 | 180 | 0.04 |
| Current study | 176.7 | 243.1 | <0.01 |
VATS, video-assisted thoracic surgery; RATS, robotic-assisted thoracic surgery.
However, these data do not influence the number of hidden N1 and N2 in the RATS group and do not affect the upstaging. These results are consistent with previously published data (22,23), where a relationship between the quality of lymphadenectomy and the RATS approach is demonstrated.
One of the limitations of our study is that a proper counting of resected lymph nodes was impossible due to pathological anatomy protocols so we have decided not to analyze them. We were not expecting significant differences in lymph node resection because, routinely, all the surgeons participating in the study perform the lymphadenectomy of the same stations during both surgical approaches. Probably the improvement in the maneuverability and vision of the robotic approach and the comfort of sitting on the work console enabled the surgeon to explore and sample more lymph node stations. Our study demonstrates that RATS is a feasible and safe technique compared to the standard uVATS technique. However, our study has several limitations. On the one hand, it is a single-center and retrospective study. In addition, it should be taken into account that these patients had different stages of disease and had undergone more or less extensive surgical interventions (from segmentectomy to pneumonectomy). Finally, we must also consider the low number of patients and overcoming two learning curves for the RATS technique in a short period of two years. This study may be helpful to for Thoracic Surgery teams that begin a new robotic surgery program in oncological lung resections.
Conclusions
Implementing an RATS program can be safely accomplished with postoperative results similar to VATS. Compared to the standard technique by uVATS, a longer surgical time and a better lymphadenectomy have been observed.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-24-13/rc
Data Sharing Statement: Available at https://vats.amegroups.com/article/view/10.21037/vats-24-13/dss
Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-24-13/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-24-13/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) and the study was approved by regional ethics committee of A Coruña Board (No. 2024/322) without the need to present informed consent because it is a retrospective study without disclosure of personal data.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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Cite this article as: García-Pérez A, Delgado Roel M, Minasyan A, Durán HMT, Fernández-Prado R, Fieira Costa EM, Fernández Vago L, Sánchez Valenzuela IA, Gamborino MC, de la Torre Bravos M. Robotic-assisted thoracic surgery (RATS) versus video-assisted thoracic surgery (VATS) in oncological lung resections—comparative study during initial experience of 3 surgeons. Video-assist Thorac Surg 2025;10:3.
