Examining long-term outcomes after robotic versus video-assisted lung resection

Anatomical lung resection continues to be recognised as the gold standard treatment for early-stage non-small cell lung cancer (NSCLC) (1). It also remains a key component of multimodality therapy for a subset of patients with locally advanced NSCLC (2). However, technological advancements in the field of thoracic surgery and beyond means that uncertainty remains as to the most effective surgical approach for patients undergoing lung resection.

Whilst surgery via open thoracotomy was the traditional operative approach, multiple studies, including both meta-analyses and randomised controlled trials (RCTs), have demonstrated superior outcomes for patients undergoing video-assisted thoracoscopic surgery (VATS) (3,4). Consequently, some guidelines now advocate minimally invasive surgery as the gold standard for patients with early-stage lung cancer (5). Further advances in VATS surgery have led to the increased popularity of an approach where only a single incision is required to complete the operation (uniportal surgery) (6). Whilst most studies have shown equipoise between the two approaches (uniportal vs. multiportal VATS) with regards to outcomes (7,8), a meta-analysis by Harris et al. comprising 1,850 patients from eight studies reported a significantly lower post-operative length of stay and rate of complications in the uniportal group (9). Furthermore, a subgroup post-hoc analysis using randomised data from the VIOLET trial also showed a trend towards better pain scores and physical function for the uniportal group (4).

Despite the benefits of VATS, it does have some drawbacks. Operating on large central tumours or tumours with extensive hilar lymphadenopathy can be particularly difficult via VATS, whilst manipulation of the straight, rigid instruments in small or otherwise anatomically challenging chest cavities can also be technically demanding (10). Hence, the development of robotic-assisted thoracoscopic surgery (RATS) as an alternative minimally invasive approach has been fêted for its potential to overcome these issues (11). Moreover, the ability of RATS to facilitate more complex surgery is particularly relevant in the contemporary era, as evidence supporting segmentectomy (generally recognised as a more technically demanding operation) as an oncologically non-inferior resection compared to lobectomy continues to grow (12).

There is already a plethora of retrospective and non-randomised studies in the literature comparing short-term outcomes between patients undergoing surgery via RATS and VATS. Results generally demonstrate that despite higher costs, RATS is associated with significantly lower short-term morbidity (13). However, only a small number of RCTs have been conducted. These studies are small in size and generally show a trend towards improved outcomes for RATS, although this benefit is less marked compared to retrospective and non-randomised studies. Whilst the move towards RCTs in this area of practice is welcome, critical analysis does demonstrate some inherent key flaws. Their primary limitation is the limited sample numbers, combined with higher-than-expected dropout rates in some studies. Moreover, stage II and IIIa NSCLC cases are not well represented in these studies, with stage I NSCLC representing more than 95% of cases in some cohorts. Finally, only one existing RCT reported long-term outcomes, with no difference in overall survival (OS) or disease-free survival (DFS) seen after a median follow-up duration of 38 months. These studies are summarised in Table 1.

Thus, the RVlob trial from Niu et al. is a welcome addition to the small body of literature reporting short and long-term outcomes for patients prospectively randomised to either RATS or VATS for early-stage NSCLC (18). To the best of our knowledge, this study is the largest RCT on this topic (n=320) and has the longest follow-up duration (median follow-up time of 58 months). The study authors have previously published short-term outcomes in the same cohort of patients (19). Their results were broadly comparable to the existing literature, with similar rates of mortality and complications between the RATS and VATS groups, but with a significantly higher lymph node harvest yield in the RATS group.

In this updated publication, the group report encouraging 3-year OS rates of 94.6% (RATS) and 91.5% (VATS), with no significant difference in OS between the two groups. The DFS rates of 83.7% (RATS) and 82.5% (VATS) were also not significantly different. The study was generally well designed and conducted. The presence of a senior surgeon who had already performed over 100 RATS and VATS cases prior to the commencement of the study assuages concerns about the impact of the learning curve on study outcomes (20). Furthermore, the standard VATS approach in this study was uniportal, making this study a true contemporary analysis reflective of current surgical practices. The retention of 93% of patients for analysis at the end of the follow-up period is another strength of the study.

However, one important point to note is that less than 10% of all patients in the study had stage III disease, whilst 75% had stage IA lung cancer. The excellent survival figures for stage IA lung cancer means that 3 years is almost certainly an insufficient time period to detect differences in survival between the RATS and VATS groups, especially in a cohort of this size. Whilst the cohort size and follow-up duration in this study far exceed existing RCTs, 5- and 10-year outcomes will be required to strengthen the conclusions reached in this study.

Similarly, it is increasingly recognised that the primary technical benefit of RATS over VATS is the ability to resect large, bulky, central, node-positive disease successfully with an RATS approach, whereas the limitations of VATS in this scenario would more frequently necessitate an open approach via thoracotomy (21). The dearth of patients included with this type of disease (as highlighted by the presence of only 8.4% of patients with stage III disease) and the absence of patients who have undergone neoadjuvant therapy, means that this study is limited in its ability to examine the potential superiority of RATS in this context. This is a key limitation of the RVlob trial. Thus, whilst the RVlob trial has addressed many of the issues seen in the other RCTs in this area of practice, expansion of inclusion criteria to include a higher proportion of patients with stage II and IIIa NSCLC would strengthen future research in this area.

Finally, the cost implications of each approach cannot be overlooked. RATS is often associated with higher costs (22) and therefore if it fails to deliver overall superior outcomes, healthcare providers may look towards the use of RATS solely for subgroups in whom RATS can deliver a benefit over VATS, such as those with bulky or central tumours and mediastinal node-positive cases. Such an analysis is beyond the scope of the RVlob study but should be borne in mind by researchers conducting future studies in this important area of practice. Translating this concept into clinical practice would require close interaction between clinicians and policymakers and careful analysis of each individual case.

The longer-term outcomes of the RVlob trial are a welcome addition to the literature, and represent the longest follow-up and largest cohort size of any RCT examining outcomes between RATS and VATS to date. The 3-year survival rates are encouraging and the lack of significant survival differences between groups demonstrate that VATS and RATS both remain appropriate surgical treatment modalities for resectable NSCLC. Longer term results are required to determine if differences in outcomes become apparent as mortality rates increase over time.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Video-Assisted Thoracic Surgery. The article has undergone external peer review.

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-24-35/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-24-35/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.

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