An update on robot-assisted and video-assisted lobectomies for non-small cell lung cancer: a narrative review

Introduction

The surgical treatment of non-small cell lung cancer (NSCLC) has undergone a remarkable evolution over the last century. In the early 1900s, thoracic surgeons rarely performed surgery for lung cancer; however, today, they routinely use advanced minimally invasive techniques, such as video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracic surgery (RATS) to perform lobectomies (1). This dramatic shift in surgical approach has been driven by the need to improve both short-term outcomes and long-term survival for patients with NSCLC.

VATS emerged as a groundbreaking minimally invasive alternative to traditional open thoracotomy. By utilizing small incisions and video-assisted visualization, VATS offers the potential for reduced tissue trauma, leading to decreased morbidity and enhanced recovery compared to open procedures. This technique has been widely adopted for the treatment of lung cancer and other thoracic pathologies (2). Numerous large-scale studies conducted in Europe and the United States have demonstrated that VATS lobectomy is associated with improved clinical outcomes, including lower complication rates, faster recovery time, reduced postoperative pain, and better quality of life (QoL) compared to open thoracotomy (3). Since the first VATS lobectomy was performed in 1991 (4), this approach has become the standard of care in many centres worldwide (5) and is now considered the preferred treatment option for patients with early-stage NSCLC (6).

Building upon the success of VATS, RATS emerged in the early 2000s as the next frontier in minimally invasive thoracic surgery, offering enhanced precision and control. This cutting-edge approach harnesses the power of robotic technology to provide surgeons with enhanced visualization and the ability to perform highly precise, complex movements (2). Despite these potential advantages, the widespread adoption of RATS has lagged behind that of VATS.

Several factors have contributed to this slower uptake, including the need for specialized equipment and training, as well as the substantial costs associated with implementing a robotic surgery program. Furthermore, the current lack of high-quality randomized data directly comparing and critiquing post-operative and long-term outcomes of RATS, VATS, and open thoracotomy has made it challenging to definitively establish the superiority of one technique over another. Consequently, RATS has yet to achieve widespread acceptance as a standard surgical approach for NSCLC.

In this narrative review, we aim to address this deficit by critically appraising the current evidence comparing the efficacy of VATS and RATS lobectomies for the treatment of NSCLC. We will evaluate perioperative outcomes, surgical results, long-term oncological outcomes, and patient-centered measures. By synthesizing the available data on these outcomes, we seek to provide a comprehensive understanding of the relative merits and limitations of these minimally invasive approaches. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-24-26/rc).

Methods

We conducted a literature search using the PubMed database on April 20, 2024, to identify relevant studies comparing the efficacy of VATS and RATS lobectomies for the treatment of NSCLC. To capture newly published material, auto-alerts were enabled through May 25, 2024. The search included the following terms: video-assisted thoracoscopic surgery, VATS, robot-assisted thoracic surgery, RATS, non-small cell lung cancer, NSCLC, lobectomy, lymph node dissection, outcomes, complications, survival, recurrence. The results were filtered to include only articles published in English after 2000, considering the relatively recent adoption of RATS in clinical practice. No restrictions were applied regarding study design to ensure a comprehensive review of the available evidence.

Titles and abstracts were screened to exclude articles not directly comparing VATS and RATS for NSCLC treatment, such as those focused solely on surgical techniques, cost analyses, or other thoracic malignancies. The full-text versions of the remaining articles were obtained for further evaluation. Two authors independently assessed the pertinent publications using a standardized data extraction form. This form captured key information including study design, sample size, patient characteristics, surgical outcomes, and long-term results. Any disagreements in data extraction or study inclusion were resolved through discussion and consensus. We conducted a qualitative synthesis of the extracted data, focusing on comparing outcomes between VATS and RATS approaches. The search strategy is summarized in Table 1.

VATS outcomes

VATS is widely accepted to be a safe alternative to open thoracotomy for the treatment of NSCLC. Multiple studies have demonstrated the superiority of VATS over traditional open procedures in terms of short-term outcomes, including reduced duration of chest tube placement and shorter hospital stays (7). Moreover, research indicates that VATS may offer comparable or even lower postoperative mortality rates. This section will examine the outcomes of VATS lobectomy, focusing on perioperative results, surgical outcomes, long-term oncological outcomes, and patient-centered measures.

A landmark study by Falcoz et al. (8) utilized the European Society of Thoracic Surgeons (ESTS) database to compare postoperative outcomes of VATS lobectomy (n=2,721) versus open lobectomy (n=26,050) for primary NSCLC. Using propensity score matching to create two well-matched groups of 2,721 patients each, the authors found that the patients who underwent VATS lobectomy experienced a lower incidence of major cardiopulmonary complications (15.9% vs. 19.6%; P=0.009), fewer total complications (29.1% vs. 31.7%; P=0.04), reduced wound infection (0.2% vs. 17 0.6%; P=0.02), less atelectasis necessitating bronchoscopy (2.4% vs. 5.5%, P<0.001), and shorter postoperative hospital stay [mean difference (MD) of 2 days]. Outcome at discharge also differed, as there was a mortality rate of 1% in the VATS lobectomy group versus 1.9% in the open lobectomy group. These findings strongly support the perioperative benefits of VATS lobectomy over open procedures.

Hireche et al. (9) reviewed the outcomes of 72 patients who underwent VATS or open lobectomy for NSCLC following induction therapy. Considering the available data, platinum-based double chemotherapy was the most common regimen, with surgery typically scheduled 4–6 weeks post-induction therapy. Radiotherapy was also employed as induction therapy. To provide a broader context, the authors performed a meta-analysis spanning 9 studies and comprising a total of 3,770 patients (VATS lobectomy: n=943; open lobectomy: n=2,827). VATS lobectomy was associated with a shorter chest tube drainage duration compared to open lobectomy [random effects MD, −1.42 days; 95% confidence interval (CI): −1.87 to −0.97; P<0.001]. Additionally, VATS lobectomy showed significantly fewer perioperative complications (fixed-effect relative risk, 0.73; 95% CI: 0.59 to 0.91, P=0.006). These findings further support the perioperative advantages of VATS lobectomy over open procedures, even in patients who have undergone induction therapy.

Hireche et al. (9) further analyzed the surgical outcomes of VATS lobectomy compared to open lobectomy in their meta-analysis. They found that VATS lobectomy was associated with significantly reduced intraoperative blood loss (random-effects MD, −97.76 mL; 95% CI: −189.55 to −5.97; P=0.04). Additionally, VATS procedures demonstrated significantly shorter surgery times (fixed-effects MD, −16.4 minutes; 95% CI: −19.37 to −13.45; P<0.001). These findings suggest that VATS lobectomy may offer advantages in terms of surgical efficiency and reduced blood loss compared to open procedures.

A 2022 parallel-group, multicenter, randomized trial by Lim et al. (10) provided further insights into the surgical outcomes of VATS versus open resection. This study, which included 503 patients with known or suspected early-stage lung cancer, primarily aimed to assess physical function at 5 weeks post-operatively as a measure of recovery. Patients were randomized into two groups: VATS resection (n=247) or open resection (n=256). In terms of surgical outcomes, the study found no significant differences between the two groups in several key parameters. The median number of lymph node stations harvested was identical for both groups (n=5), as was the median number of mediastinal lymph nodes harvested (n=3). Furthermore, there were no statistically significant differences between the VATS and open resection groups in rates of complete pathologic (R0) resection, upstaging from cN0 to pN1, or upstaging from cN0/1 to pN2. These findings suggest that VATS resection can achieve comparable surgical outcomes to open resection in terms of lymph node harvesting and oncological staging, which are critical factors in the surgical management of lung cancer.

The long-term oncological outcomes of VATS lobectomy compared to open thoracotomy have been a subject of significant interest in recent studies. Hireche et al. (9) provided valuable insights into this area. Their findings revealed no statistically significant differences between VATS lobectomy and open thoracotomy in several crucial long-term outcomes. Specifically, they observed comparable rates of 30-day mortality, 3-year overall survival (OS), and 3-year disease-free survival (DFS) between the two surgical approaches. While these results suggest that VATS lobectomy can achieve similar long-term oncological outcomes to open thoracotomy, the authors emphasized the need for further studies focusing specifically on oncologic outcomes to solidify these findings.

Complementing these results, the randomized controlled trial (RCT) conducted by Lim et al. (10) provided additional data on long-term oncological outcomes, albeit with a shorter follow-up period. In their study, which had a median follow-up of 12 months, they found no significant difference in the rates of disease progression or recurrence between the VATS and open surgery groups. Specifically, 7.7% of patients in the VATS group and 8.2% in the open surgery group experienced progression or recurrence of lung cancer during the follow-up period. This similarity in outcomes extends to mortality rates as well. At the 12-month follow-up point, 5.8% of patients in the VATS group and 7.9% in the open surgery group had died. While these differences were not statistically significant, the slightly lower mortality rate in the VATS group may warrant further investigation in larger, long-term studies.

These findings collectively suggest that VATS lobectomy can achieve comparable long-term oncological outcomes to open thoracotomy in the treatment of NSCLC. However, the two studies by Hireche et al. and Lim et al. underscore the need for more extensive, long-term research to definitively establish the oncological efficacy of VATS lobectomy. Future randomized studies with larger sample sizes and extended follow-up periods will be crucial in further elucidating the long-term oncological impacts of VATS compared to open procedures in lung cancer treatment.

Building upon the previously discussed VIOLET trial (10), which compared VATS lobectomy (n=247) to open lobectomy (n=256) in 503 patients with suspected or known early-stage lung cancer, this section focuses on the patient-centered outcomes of the study. While the trial’s primary outcome was to assess recovery using physical function at 5 weeks post-operation, it also provided valuable insights into patients’ QoL and functional status over a 52-week follow-up period. These patient-reported outcomes offer an important perspective on the comparative effectiveness of VATS and open lobectomy beyond traditional clinical endpoints.

The results of the VIOLET trial demonstrated a significant advantage for VATS lobectomy in terms of early postoperative recovery. The authors employed the European Organization for Research and Treatment of Cancer (EORTC) core health-related QoL questionnaire (QLQ-C30). At 5 weeks post-operation, patients in the VATS group demonstrated significantly greater physical function compared to those in the open group (73 vs. 67; MD, 4.65 points; 95% CI: 1.69 to 7.61; P=0.009). This finding led the authors to conclude that VATS is superior to open lobectomy when considering improved recovery of physical function at five weeks post-operation.

Interestingly, the study revealed that the magnitude of this difference in physical function between the two groups changed over the full 52-week follow-up period. While the improvement in physical function was more substantial in the VATS group during the early postoperative period, this difference became less pronounced from the 6-month point onwards. Nevertheless, an overall MD in favor of VATS was maintained throughout the study period (MD, 4.22 points; 95% CI: 1.48 to 6.97; P=0.009).

These findings from the VIOLET trial provide strong evidence for the patient-centered benefits of VATS lobectomy, particularly in terms of early postoperative recovery and physical function. The persistent, albeit diminishing, advantage in physical function over the long-term follow-up suggests that VATS may offer lasting benefits to patients. This study underscores the importance of considering patient-centered outcomes alongside traditional clinical endpoints in evaluating surgical approaches for lung cancer.

RATS outcomes

RATS represents the latest evolution in minimally invasive techniques for the treatment of NSCLC. Despite its potential advantages, RATS has experienced a slower rate of adoption in thoracic surgery compared to its predecessor, VATS. This hesitancy in widespread implementation is multifactorial, with the significant costs associated with robotic technology often cited as a primary barrier. However, mounting evidence suggests that RATS, like VATS before it, is proving to be a safe and efficacious approach to the surgical management of NSCLC. As the body of research on RATS continues to grow, it becomes increasingly important to critically evaluate its outcomes across various domains. This section will examine the current evidence regarding RATS lobectomy for NSCLC, focusing on four key areas: perioperative outcomes, surgical outcomes, long-term oncological results, and patient-centered measures.

Several recent studies have investigated the perioperative outcomes of RATS compared to open thoracotomy in various patient populations with NSCLC. Huang et al. (11) conducted a multicentre RCT comparing RATS to open thoracotomy in patients with clinical N2 NSCLC. Their findings demonstrated that RATS was associated with a significantly lower median postoperative chest tube duration compared to open thoracotomy (4 vs. 5 days; P<0.01). While the RATS group showed reduced incidences of postoperative complications, such as pulmonary embolism, acute respiratory distress syndrome (ARDS), and oesophageal fistula, these reductions did not reach statistical significance. Interestingly, the authors reported that the cost of RATS was 22.40% higher on average per patient than open thoracotomy, highlighting an important consideration in the adoption of this technology.

Focusing on a specific high-risk population, Casiraghi et al. (12) investigated postoperative outcomes of RATS in obese NSCLC patients. Their study revealed that patients in the RATS group experienced a significantly shorter hospital stay compared to the open thoracotomy group (5 vs. 6 days; P=0.047). Moreover, the open thoracotomy group was associated with a significantly higher rate of postoperative complications, including ARDS, pneumonia, and atrial fibrillation (AF), than the RATS group (42.9% vs. 16.7%; P=0.03).

A 2023 retrospective study by Zirafa et al. (13) evaluated the impact of RATS on postoperative outcomes in patients with marginal lung function, defined as forced expiratory volume in one second (FEV₁) <1.5 L. The study included 98 patients with marginal lung function, divided into two groups: RATS lobectomy (n=40) and open lobectomy (n=58). The authors found that RATS lobectomy was associated with a decreased mean length of hospital stay (7.43 vs. 8.69 days) and a reduced incidence of postoperative complications (15% vs. 26%). However, RATS procedures were associated with longer mean operating times (231 vs. 128 minutes). These findings led the authors to conclude that RATS is a practical and safe approach for patients with marginal pulmonary function.

Collectively, these studies suggest that RATS may offer several perioperative advantages over open thoracotomy, including shorter chest tube duration, reduced hospital stay, and lower complication rates, even in high-risk patient populations. However, the increased costs and longer operating times associated with RATS remain important considerations. Further research is needed to determine whether these perioperative benefits translate into cost-effectiveness.

Several studies have examined the surgical outcomes of RATS in comparison to open thoracotomy and VATS for NSCLC treatment. Casiraghi et al. (12) reported a statistically significant difference in median operative time between RATS and open thoracotomy groups. The RATS procedures took longer, with a median time of 200 minutes compared to 158 minutes for open thoracotomy (P=0.003). This finding suggests that RATS may require more time in the operating room, which could have implications for resource allocation and scheduling.

Conversely, Huang et al. (11) found that RATS was associated with significantly less intraoperative blood loss compared to open thoracotomy. Patients in the RATS arm experienced mean blood loss of 86.3±41.1 mL, while those in the open thoracotomy arm lost 165.7±46.4 mL on average (P<0.001). This reduction in blood loss could potentially lead to better postoperative outcomes and reduced need for blood transfusions.

A comprehensive non-systematic review by Mattioni et al. (2) in 2023 examined 72 articles on RATS lobectomy for lung cancer treatment. This review included a large meta-analysis by Aiolfi et al. (14) comparing RATS, VATS, and open thoracotomy across 34 retrospective studies. Their findings revealed that RATS procedures had significantly longer operative times compared to open surgery, with a MD of 61 minutes [95% credible intervals (CrI): 51.1 to 70.64]. However, RATS was associated with a statistically significantly shorter length of hospital stay compared to open procedures, with a MD of −2.17 days (95% CrI, −2.81 to −1.53). Interestingly, no significant differences were found between RATS and open lobectomy in terms of lymph node harvesting (MD, 0.73; 95% CrI, −1.06 to 2.55) or R0 resection rates (14).

The PORTAL study, a large retrospective analysis of 5,721 lobectomy cases published in 2023, provided further insights into the surgical outcomes of RATS, VATS, and open lobectomy (15). Contrary to some previous findings, this study reported shorter operative times for RATS compared to both open lobectomy (P<0.001) and VATS (P<0.001). This discrepancy with earlier studies and common perceptions highlights the potential for improvement in RATS efficiency as surgeons gain more experience with the technology. Importantly, the PORTAL study found no significant difference in 30-day mortality rates between the three surgical approaches.

These studies collectively paint a complex picture of the surgical outcomes associated with RATS. While some research indicates longer operative times for RATS, more recent large-scale studies suggest this may be changing. RATS appears to offer benefits in terms of reduced blood loss and shorter hospital stays compared to open procedures. However, it does not seem to provide significant advantages in lymph node harvesting or R0 resection rates. The conflicting findings regarding operative time underscore the need for further research, particularly as surgical teams become more experienced with robotic technology. Future studies should aim to clarify these discrepancies and investigate whether the potential benefits of RATS translate into improved long-term patient outcomes.

The long-term oncological outcomes of RATS in comparison to VATS and open lobectomy have been a subject of considerable interest in recent research. Several studies have aimed to elucidate whether the choice of surgical approach impacts long-term survival and cancer-related mortality.

In their comprehensive meta-analysis, Aiolfi et al. (14) provided substantial insights into the long-term outcomes of these surgical approaches. Analyzing data from 16 studies including a total of 70,965 patients, the authors found no statistically significant difference in 5-year OS rates when comparing RATS, VATS, and open lobectomy. This finding suggests that the choice of surgical technique may not significantly influence long-term survival outcomes in lung cancer patients.

Corroborating these results, Casiraghi et al. (12) reported on long-term outcomes in their study focusing on high-risk, obese NSCLC patients. They found no statistically significant difference in either the 5-year OS rate or the 5-year cumulative incidence of cancer-related deaths between RATS and open lobectomy groups. This consistency in outcomes across different patient populations adds weight to the notion that RATS can achieve comparable long-term oncological results to traditional open procedures, even in challenging patient cohorts.

In recent years, there has been an increasing focus on patient-reported outcomes and QoL measures in evaluating surgical interventions for lung cancer. A contribution to this field is a retrospective review conducted by Asemota et al. (16), which compared patient QoL following RATS, VATS, and open lobectomy. This study employed two well-established QoL questionnaires developed by the EORTC: the QLQ-C30, which assesses general QoL following cancer treatment, and the QLQ-LC13, which specifically evaluates lung cancer-related symptoms. The authors analyzed the results using the EORTC Scoring Guide and applied relevant statistical methods to evaluate changes in QoL before and after surgery.

The findings of this study revealed several interesting patterns in patient-reported outcomes following RATS. When comparing pre- and post-RATS states, the authors observed an improvement in global QoL following RATS. However, this improvement did not reach statistical significance (P=0.11). Improvements were reported across all functional QoL domains post-RATS. Notably, emotional functioning showed a statistically significant improvement, with a final score increase of 9 points (P<0.001). The QLQ-C30 questionnaire revealed that 66% of the assessed symptoms showed improvement post-RATS, although these improvements were not statistically significant. However, some symptoms appeared to worsen. Nausea and vomiting (Final Score increase: +1.42) and diarrhea (Final Score increase: +0.71) showed slight increases. More concerning was the significant worsening of dyspnea according to QLQ-C30 (Final Score increase: +11.34; P=0.02). It is important to note, however, that this worsening of dyspnea symptoms reported in the QLQ-C30 was not corroborated by the lung cancer-specific QLQ-LC13 questionnaire, suggesting a potential discrepancy in how this symptom is captured by different assessment tools. Regarding pain, both questionnaires indicated a trend towards decreased overall pain following RATS, although this reduction did not reach statistical significance.

These findings provide valuable insights into the patient experience following RATS for lung cancer. The improvements in emotional functioning and overall QoL, despite being a major surgical intervention, are particularly encouraging. However, the worsening of certain symptoms, especially dyspnea, warrants further investigation and may inform postoperative care strategies. It is also important to interpret these results in the context of the study’s retrospective design, which may introduce certain biases. Furthermore, the lack of direct statistical comparisons with VATS and open lobectomy in this section limits our ability to draw conclusions about the relative benefits of RATS in terms of patient-centered outcomes. Future research in this area should aim to conduct prospective, comparative studies of patient-reported outcomes across different surgical approaches for lung cancer. Such studies would provide more robust evidence to guide clinical decision-making and improve patient counseling regarding expected postoperative QoL.

RATS versus VATS

Recent studies have compared the perioperative outcomes of RATS and VATS for lung cancer treatment. A summary of key outcomes from various studies comparing RATS and VATS lobectomy, including perioperative and oncological results, is presented in Table 2.

Catelli et al. (21) conducted a monocentric prospective randomized comparing RATS (n=25) and VATS (n=50) lobectomies. With a mean follow-up of 37.9±10.9 months, they reported significant reductions in postoperative pleural effusion in the RATS group compared to the VATS group on both day 1 (140 vs. 214 mL; P=0.003) and day 2 (186 vs. 321 mL; P=0.001). Interestingly, the incidence of cardiac arrhythmias, particularly AF, was significantly lower in the RATS group (0% vs. 18%, P=0.04).

Miyajima et al. (22) further corroborated these findings, demonstrating that RATS was associated with shorter mean chest tube duration (1.9 vs. 2.6 days; P=0.045) and lower incidence of persistent air leakage (2.9% vs. 9.7%; P=0.03) compared to VATS. Additionally, patients in the RATS group experienced shorter average postoperative hospital stays (10.0 vs. 11.5 days).

A meta-analysis conducted by Ma et al. (17) in 2021 sought to compare the short and long-term outcomes of VATS and RATS for the management of patients with NSCLC. Analysing 18 studies including 11,247 patients (VATS: n=5,114; RATS: n=6,133), they found that RATS was associated with several advantages. The analysis revealed reduced blood loss in the RATS group, with a weighted MD (WMD) of −50.40 mL (95% CI: −90.32 to −10.48; P=0.01). Hospital stays were also shorter for RATS patients, with a WMD of −1.12 days (95% CI: −1.58 to −0.66; P<0.001). Furthermore, RATS was associated with decreased postoperative chest tube drainage duration (WMD, −0.61 days; 95% CI: −0.78 to −0.44; P<0.001) and lower overall complication rates [odds ratio (OR), 0.90; 95% CI: 0.83 to 0.99; P=0.02]. However, it is important to note that RATS was associated with significantly higher financial costs, with a WMD of 3,909.87 USD (95% CI: 3,706.90 to 4,112.84; P<0.001).

These studies suggest that RATS may offer several perioperative advantages over VATS, including reduced postoperative complications and shorter hospital stays. However, the higher associated costs of RATS remain a significant consideration in its widespread adoption.

The comparison of surgical outcomes between RATS and VATS has yielded mixed results across various studies. Catelli et al. (21) reported that surgery time in the VATS group was significantly shorter than in the RATS group (160 vs. 180 minutes; P=0.04), suggesting a potential efficiency advantage for VATS. However, Miyajima et al. (22) observed more nuanced differences in their comparison of VATS and RATS for lung cancer surgery. They found a significant reduction in intraoperative blood loss with RATS compared to VATS (53.3 vs. 120.3 mL), indicating improved hemostasis with robotic assistance. Interestingly, they reported comparable rates of surgical complications (RATS: 10.0% vs. VATS: 13.0%; P=0.66) and similar operating times (RATS: 215.0 minutes vs. VATS: 210.1 minutes; P=0.57), suggesting that RATS may not significantly prolong procedure duration in experienced hands.

The meta-analysis by Ma et al. (17) provided a broader perspective on surgical outcomes. Their analysis revealed several advantages for RATS over VATS, including a lower conversion rate to open surgery (OR, 0.50; 95% CI: 0.43 to 0.60; P<0.001), increased number of sampled lymph nodes (WMD, 1.72; 95% CI: 0.63 to 2.81; P=0.002) and lymph node stations (WMD, 0.51; 95% CI: 0.15 to 0.86; P=0.005), and a lower rate of recurrence (OR, 0.51; 95% CI: 0.36 to 0.72; P<0.001). However, they found no statistically significant differences in operative time, mortality, DFS, or OS between RATS and VATS.

Preliminary data from the RAVAL trial (23), an international, multicenter, RCT comparing RATS versus VATS lobectomy for early-stage lung cancer, further supports the potential superiority of RATS in lymph node dissection. The study reported a higher median number of nodal stations sampled in the RATS arm compared to the VATS arm {6 [interquartile range (IQR), 5–7] vs. 5 (IQR, 4–6); P=0.02}, as well as a greater median number of lymph nodes examined [10 (IQR, 8–13) vs. 8 (IQR, 5–10); P=0.003]. Furthermore, the RATS arm displayed a significantly higher median number of N1 and N2 stations sampled [3 (IQR, 2–3) and 3 (IQR, 3–4), respectively] than the VATS arm [2 (IQR, 1–3) and 3 (IQR, 2–4), respectively; P=0.01 for both N1 and N2 stations, respectively]. Despite these differences, there was no significant difference in nodal upstaging between the two approaches (5.88% for RATS vs. 8.11% for VATS; P=0.59).

Zeng et al. (24) evaluated RATS and VATS following neoadjuvant chemoimmunotherapy in NSCLC patients, finding superior results for RATS in terms of lymph node dissection. The RATS arm showed a higher number of lymph nodes dissected (20.4±10.3 vs. 13.5±9.3; P<0.001) and more lymph node stations dissected (8.1±5.7 vs. 5.6±1.8; P<0.001). Additionally, RATS demonstrated improved yield pathologic N assessment (ypN0, 88.5% vs. 67.6%; ypN1, 12.6% vs.7.6%; ypN2, 19.7% vs. 3.8%; P<0.001).

The most important prognostic factor for OS and DFS in patients with NSCLC is the degree of lymph node involvement (25). Indeed, the International Association for the Study of Lung Cancer (IASLC) (26) states, the 5-year survival rates are 56%, 38%, 26%, and 6% in pathologic (p) N0, pN1, pN2, and pN3 disease, respectively (27). Thus it is imperative that the procedures for lymph node sampling, dissection, and intraoperative lymph node staging are evaluated and defined (28).

The findings from these studies suggest that while RATS may offer advantages in terms of lymph node dissection and reduced blood loss, its benefits in other surgical outcomes remain mixed. The lack of significant differences in survival outcomes and the variability in operative times across studies indicate that both RATS and VATS remain viable options, with the choice potentially depending on surgeon experience, patient factors, and institutional resources.

The comparison of long-term oncological outcomes between RATS and VATS lobectomy for NSCLC has been a subject of increasing research interest. Several studies have sought to elucidate potential differences in survival rates, recurrence patterns, and quality of life between these two minimally invasive approaches.

Pan et al. (18) conducted a real-world study focusing on a unique population of NSCLC patients aged 35 years or younger. Using propensity score-matched analysis to compare RATS and VATS lobectomy outcomes, they found no statistically significant differences in recurrence patterns (P=0.61), mortality rates (P=1.00), OS (P=0.96), or 5-year recurrence-free survival (P=0.96) between the two surgical approaches. This suggests that in younger NSCLC patients, both RATS and VATS may offer comparable long-term oncological outcomes.

Yang et al. (19) provided a broader perspective by exploring the relationship between long-term survival and surgical approach in patients with clinical stage I NSCLC. Their study included 470 propensity score-matched patients undergoing RATS (n=172), VATS (n=141), or open lobectomy (n=157). With a median follow-up of 52.7 months, they observed tumor recurrence in 25, 33, and 37 cases for the RATS, VATS, and open groups, respectively. Interestingly, while there was no statistically significant difference in 5-year OS among the three arms (RATS: 77.6%, VATS: 73.5%, open: 77.9%), they did find a statistically significant difference in 5-year DFS between RATS and VATS (72.7% vs. 65.5%, P=0.047). However, it is important to note that multivariate analysis did not show an independent association between OS/DFS and the surgical approach, suggesting that other factors may contribute to this observed difference.

A study conducted by Fabbri et al. (20) provides compelling evidence for potential long-term oncological benefits of RATS over VATS in NSCLC patients. The investigators observed a significant overall improvement in DFS for patients who underwent RATS compared to those who had VATS. At the 3-year mark, DFS rates were 92.4% for RATS versus 81.2% for VATS, with this advantage persisting at 5 years (90.3% vs. 77.6%). These findings suggest a potential long-term oncological benefit associated with the robotic approach. Subgroup analysis stratified by pathological stage revealed interesting patterns. For stage I NSCLC, RATS demonstrated a significant DFS advantage over VATS (3-year DFS: 94.4% vs. 88.9%; 5-year DFS: 91.8% vs. 85.2%; P=0.04). This difference was even more pronounced in stage III disease, where RATS showed markedly superior DFS rates (3-year DFS: 82.4% vs. 51.1%; 5-year DFS: 82.4% vs. 37.7%; P=0.02). Interestingly, while patients with stage II disease who underwent RATS showed a trend towards improved DFS, this difference did not reach statistical significance (3-year DFS: 92.6% vs. 77.7%; 5-year DFS: 92.6% vs. 73.4%; P=0.11). This finding suggests that the benefits of RATS may vary across disease stages, potentially due to differences in tumor characteristics or the extent of required surgical intervention. After adjusting for confounding factors, RATS remained significantly associated with better DFS compared to VATS. This analysis also identified advanced pathological stage and male gender as independent risk factors for worse DFS, providing additional insights into prognostic factors for NSCLC. However, it is important to interpret these findings in the context of other studies and consider factors such as surgeon experience, patient selection, and institutional practices that may influence outcomes.

In the study by Catelli et al. (21), comparison of DFS and OS between RATS and VATS showed no significant difference (95.5% vs. 93.1%, respectively; P=0.31; and 95.5% vs. 89.7%, respectively; P=0.46). In the same study, interestingly, the authors observed that pain on the first postoperative day, assessed by the Visual Analogue Scale, was significantly lower in the RATS group compared to the VATS group (0.92 vs. 1.17; P=0.005). However, quality of life assessment during follow up also displayed no statistically significant difference between the groups.

Another study that can provide useful insights into patient-centered outcomes following RATS compared to VATS is the RAVAL trial (29). The study’s primary aim is to ascertain any difference in 12-week patient-reported health-related quality of life outcomes between VATS and RATS lobectomy. The authors also aim to highlight and quantify any differences in 5-year mortality and cost-effectiveness between the two groups (29). Preliminary data suggests that RATS lobectomy is cost-effective and offers short-term patient-reported health utility scores comparable to VATS lobectomy [0.85 (0.10) for RATS and 0.80 (0.19) for VATS; P=0.02] (23). It remains to be seen however what, if any, lasting impact the results of this study will have on the use of RATS lobectomy in thoracic surgery.

Discussion

The landscape of surgical interventions for NSCLC has evolved significantly over the past two decades, with minimally invasive techniques becoming increasingly prevalent. VATS has established itself as a standard approach, offering reduced postoperative pain, shorter hospital stays, and faster recovery compared to open thoracotomy (6,7). The more recent introduction of RATS represents the next iteration in this evolution, promising enhanced visualization and improved instrument maneuverability (2).

However, the adoption of RATS for NSCLC lobectomy has been met with both enthusiasm and skepticism within the thoracic surgery community. While proponents argue that RATS offers superior technical capabilities, critics point to increased costs and a lack of clear long-term oncological benefits (17,30). This review’s findings reflect this ongoing debate, revealing a complex picture where RATS and VATS each demonstrate distinct advantages and limitations.

The heterogeneity of results across studies highlights the challenges in definitively establishing the superiority of one approach over the other. Factors such as surgeon experience, patient selection criteria, and institutional protocols likely contribute to the variability in outcomes reported in the literature. Moreover, the rapid technological advancements in both VATS and RATS platforms mean that studies conducted even a few years apart may be comparing substantially different iterations of these techniques. Another important consideration in comparing RATS and VATS lobectomy outcomes is the disparity in training and credentialing frameworks between the two approaches. RATS benefits from a structured training program provided by the Intuitive Company, which includes standardized credentialing and proctoring not only for the primary surgeon but also for the entire surgical team. This comprehensive approach ensures a consistent level of technical proficiency and adherence to best practices across institutions, potentially leading to more standardized surgical outcomes. In contrast, VATS does not have a universally accepted training and credentialing system, which may result in variations in skill levels among surgeons and surgical teams. As a result, comparisons between the two approaches may inadvertently reflect differences in training backgrounds rather than inherent advantages of one technique over the other.

One of the most noteworthy findings in our review is the potential advantage of RATS in lymph node dissection. Multiple studies have consistently reported higher lymph node yield rates with RATS compared to VATS (15,31). This difference is particularly significant given the crucial role of thorough lymphadenectomy in accurate staging and prognosis of NSCLC (19,20,29). The superior 3D visualization, stable camera platform, and enhanced instrument articulation offered by robotic systems may contribute to this improved lymph node harvest (26).

This raises the question of whether further robotic lymph node dissection can explain the DFS results obtained (32). Studies have shown an association between patients with lymph node micro metastasis and worse OS and DFS compared with patients without lymph node micro metastasis (28). The association between RATS and longer DFS and lower recurrence rate (especially local) found in this study may be explained by more successful lymphadenectomy. However, it is worth noting that there may be group differences or selection bias in favor (31) of the RATS group, regardless of lymph node status (33).

However, it is important to critically evaluate the clinical significance of these findings. While RATS may facilitate more extensive lymph node sampling, the impact on staging accuracy and, more importantly, on long-term survival outcomes remains unclear. The study by Zeng et al. (24) demonstrated superior results for RATS in terms of lymph node dissection following neoadjuvant chemoimmunotherapy, suggesting potential benefits in more complex cases. Yet, the RAVAL trial (23) found no significant difference in nodal upstaging between RATS and VATS, despite the higher number of lymph nodes harvested in the RATS group. While RATS may offer enhanced visualization and instrument articulation, challenges remain in addressing complex anatomical situations such as incomplete fissures, dense adhesions within the thoracic cavity, and lymph node dissection in areas tightly adhered to major vascular structures like the pulmonary artery and superior vena cava. These limitations highlight the need for further technical advancements and improved training protocols to enhance the capabilities of RATS in such cases.

The discrepancies in operative times reported across studies (17,21,22) reflect the evolving nature of robotic surgery in thoracic oncology. While some studies report longer operative times for RATS, others, such as the PORTAL study (15), have found shorter times compared to both VATS and open lobectomy. This variability likely reflects differences in surgeon experience and learning curves across institutions. As surgical teams gain more proficiency with robotic systems, it is reasonable to expect that procedure durations will decrease. The steep learning curve of RATS presents a unique opportunity for young surgeons to adopt and master the technique early in their careers. The intuitive robotic interface and advanced visualization capabilities may facilitate skill acquisition and improve surgical confidence, potentially leading to better long-term outcomes with increased experience. However, the impact of potentially longer operating times on patient outcomes, resource utilization, and overall healthcare system efficiency needs careful consideration.

Intraoperative blood loss is another area where RATS has shown potential benefits. Multiple studies, including those by Huang et al. (11) and Miyajima et al. (22), have reported significantly less blood loss with RATS compared to both VATS and open procedures. This reduction in blood loss could potentially lead to better postoperative outcomes and reduced need for blood transfusions.

Despite these potential advantages, it is important to note that both RATS and VATS have demonstrated comparable or superior outcomes to open thoracotomy in terms of postoperative recovery, pain management, and overall complication rates (8,10,12). This suggests that the choice between RATS and VATS may ultimately depend on factors beyond purely surgical outcomes, including cost-effectiveness, availability of technology, and surgeon preference and experience.

The comparison of long-term oncological outcomes between RATS and VATS remains a subject of intense scrutiny and debate. Our review has revealed a complex picture, with some studies suggesting potential advantages for RATS, while others show comparable results between the two approaches.

The study by Fabbri et al. (20) provided compelling evidence for potential long-term oncological benefits of RATS over VATS. They observed significantly better DFS rates for RATS at both 3- and 5-year post-surgery, with this advantage persisting across different pathological stages. Similarly, Yang et al. (19) reported improved 5-year DFS rates for RATS compared to VATS, although the difference was less pronounced. These findings suggest that factors inherent to the robotic approach may contribute to improved outcomes.

However, it is crucial to interpret these results cautiously. The mechanisms underlying these potential DFS advantages are not fully understood. While improved lymph node dissection with RATS is often cited as a possible explanation, other factors such as selection bias, differences in surgeon experience, or variations in postoperative management may also play a role. Moreover, the lack of significant differences in OS between RATS and VATS in most studies (5,18,26) raises questions about the clinical relevance of the observed DFS differences.

The meta-analysis by Ma et al. (17) further complicates the picture. While the authors found a lower rate of recurrence associated with RATS, they reported no statistically significant differences in DFS or OS between RATS and VATS. This discrepancy highlights the need for larger, well-designed RCTs to definitively establish the long-term oncological impacts of these surgical approaches.

It is also important to consider the potential impact of stage migration due to more extensive lymph node dissection in RATS. While this could lead to more accurate staging and potentially improved outcomes through appropriate adjuvant therapy, it may also artificially inflate survival rates for higher-stage diseases when comparing RATS to VATS.

The ongoing RAVAL trial (27) may provide more definitive answers regarding the long-term outcomes of RATS versus VATS. However, until these results are available, the current evidence suggests that while RATS may offer some advantages in terms of DFS, its impact on OS remains uncertain. This underscores the need for continued rigorous evaluation and long-term follow-up studies to fully understand the oncological implications of choosing RATS over VATS for NSCLC lobectomy.

The adoption of any new surgical technique inevitably involves a learning curve, and this is particularly true for complex procedures, such as RATS lobectomy. The impact of this learning curve on surgical outcomes, operative times, and complication rates is a critical factor that has not been adequately addressed in many comparative studies between RATS and VATS.

The proficiency of surgeons with robotic systems likely varies significantly across institutions and studies, potentially confounding comparisons with the more established VATS technique. For instance, the discrepancies in operative times reported by different studies (17,21,22) may be partly attributed to varying levels of experience with robotic systems. The PORTAL study (15), which reported shorter operative times for RATS compared to both VATS and open lobectomy, likely reflects data from highly experienced robotic surgeons, and may not be representative of the broader surgical community.

Veronesi et al. (34) investigated the learning curve for RATS lobectomy and found that 18 cases may be the learning curve using a four-armed robotic approach, based on decreased operating time trends in 54 lung cancer patients. However, the learning curve for RATS may be steeper than for VATS, particularly for surgeons without prior VATS experience (34,35). This suggests that the transition to RATS may initially be associated with longer operative times and potentially higher complication rates, which could impact short-term outcomes and resource utilization.

The question of how to effectively train surgeons in RATS techniques while maintaining optimal patient outcomes is crucial. Simulation-based training programs and proctorship models have been proposed as potential solutions (36,37). However, the development and implementation of standardized training protocols for RATS remain a challenge, particularly given the rapid evolution of robotic technology. Moreover, the learning curve for RATS extends beyond the primary surgeon to the entire surgical team, including anesthesiologists, nursing staff, and other operating room personnel. The efficient use of robotic systems requires a coordinated team approach, which may necessitate additional training and adaptation periods for the entire surgical unit.

As robotic technology continues to evolve, ongoing assessment of learning curves and development of effective training strategies will be paramount. Future comparative studies between RATS and VATS should aim to control for surgeon experience and learning curve effects to provide a more accurate comparison of these techniques. Additionally, the development of standardized, evidence-based training programs for RATS could help to mitigate the impact of the learning curve on patient outcomes and facilitate broader adoption of this technology.

The economic impact of adopting RATS for NSCLC lobectomy remains a significant point of contention in the thoracic surgery community. The high initial capital investment required for robotic systems, coupled with ongoing maintenance costs and expenses for disposable instruments, presents a substantial financial barrier for many healthcare institutions. The costs can be divided into two categories: upfront costs and long-term costs. The upfront cost of purchasing a da Vinci surgical system (Intuitive Surgical, Sunnyvale, California, USA) is approximately $2 million (38).

Several studies in our review have highlighted the increased costs associated with RATS compared to VATS (11,17). However, it is essential to consider these increased costs in the context of potential clinical benefits and long-term outcomes. Some studies have reported shorter hospital stays and lower complication rates with RATS (12,22), which could partially offset the higher upfront costs. The RAVAL trial’s preliminary data (23) suggests that RATS lobectomy may be cost-effective and offer comparable health utility scores to VATS lobectomy, although the full results of this trial are still pending.

A comprehensive cost-effectiveness analysis should consider not only the direct surgical costs but also long-term outcomes, quality of life measures, and potential savings from reduced complications or readmissions. For instance, if the improved lymph node dissection associated with RATS leads to more accurate staging and optimized treatment plans, this could potentially result in long-term cost savings and improved patient outcomes. The economic feasibility of RATS may also vary depending on the healthcare system and reimbursement models in different countries. In systems where hospitals bear the burden of initial investment costs but do not directly benefit from long-term savings in patient care, the adoption of RATS may be slower. Furthermore, as robotic technology continues to evolve and more manufacturers enter the market, competition may lead to reduced costs for robotic systems and instruments. This could potentially improve the cost-effectiveness of RATS in the future.

It is also worth considering the broader economic impact of investing in advanced surgical technologies. While the costs are high, the adoption of cutting-edge techniques like RATS can attract patients and skilled surgeons, potentially benefiting institutions in competitive healthcare markets. Ultimately, the decision to adopt RATS must balance its potential clinical benefits against its economic impact. As more long-term data become available, particularly from large-scale randomized trials, we will be better positioned to make informed decisions about the cost-effectiveness of RATS versus VATS for NSCLC lobectomy.

While our review has shed light on the current state of RATS versus VATS for NSCLC lobectomy, it has also highlighted several areas where further research is needed to definitively establish the relative merits of these approaches.

Firstly, there is a pressing need for large-scale, multicentre, RCTs comparing RATS and VATS. The ongoing RAVAL trial (27) is a step in the right direction, but more such studies are required to provide high-quality evidence on long-term oncological outcomes, quality of life, and cost-effectiveness. These trials should aim to control for factors such as surgeon experience, patient characteristics, and institutional practices to minimize confounding variables.

Secondly, longer follow-up periods are crucial to fully understand the impact of surgical approach on DFS and OS. While some studies have reported improved DFS with RATS (26,28), the mechanisms underlying these findings and their impact on OS remain unclear. Extended follow-up studies could help elucidate whether the potential advantages of RATS in lymph node dissection and short-term outcomes translate to meaningful long-term benefits.

Thirdly, research into the molecular and immunological implications of different surgical approaches could provide valuable insights. For instance, studies investigating whether the reduced tissue trauma associated with minimally invasive techniques affect tumour immunology or the efficacy of adjuvant therapies could have significant clinical implications.

Fourthly, as robotic technology continues to evolve, ongoing evaluation of newer robotic platforms and their impact on surgical outcomes is necessary. This includes assessing the learning curve associated with new technologies and developing effective training protocols to ensure optimal patient outcomes during the adoption phase.

Fifthly, there is a need for more comprehensive health economic analyses that consider not only the direct costs of the surgical procedure but also long-term outcomes, quality of life measures, and broader societal impacts. Such analyses could provide a more nuanced understanding of the cost-effectiveness of RATS versus VATS.

Lastly, patient-reported outcomes and quality of life measures should be a key focus of future research. While some studies have begun to address this (16,21), more comprehensive assessments of how different surgical approaches affect patients’ postoperative experiences, recovery, and long-term quality of life are needed.

This review is not without limitations that should be considered when interpreting its findings. As a narrative review, our approach lacks the systematic rigor of a meta-analysis or systematic review. While this allowed for a more flexible and inclusive discussion of the literature, it may have introduced potential bias in study selection and interpretation (30). The absence of a formal quality assessment of included studies means that the strength of evidence varies across the reviewed literature. Furthermore, the heterogeneity of the included studies poses a significant challenge. Variations in study design, patient populations, surgical techniques, and outcome measures make direct comparisons between studies difficult. This heterogeneity is particularly evident in the reporting of surgical outcomes and complications, where definitions and classification systems often differ between studies. Moreover, the rapid evolution of robotic technology means that studies conducted even a few years apart may be comparing significantly different iterations of RATS. This technological progression makes it challenging to draw definitive conclusions about the current state of RATS compared to VATS. Additionally, the learning curve associated with RATS is a confounding factor that is difficult to control for across studies. The varying levels of surgeon experience with robotic systems may significantly impact outcomes, making it challenging to isolate the true effect of the surgical approach itself. Furthermore, it has been observed that surgeons who prefer RATS may have previously avoided performing VATS procedures, introducing a self-selection bias that could influence reported outcomes. Studies have shown that well-trained VATS surgeons can achieve oncologically sound resections comparable to those of open surgery, with complete hilar and mediastinal lymph node dissection, capable of removing on average 15.8 lymph nodes per case (9,10). Therefore, when interpreting outcome differences between RATS and VATS, it is essential to account for the potential impact of training disparities, surgical experience, and institutional learning curves. Addressing these factors through the establishment of standardized VATS training programs and credentialing processes could help minimize variability and provide a more accurate comparison of surgical techniques. Finally, industry-funded studies may introduce bias, although we have attempted to consider funding sources where relevant.

Conclusions

In conclusion, while RATS shows promise in several areas, its definitive role in the treatment of NSCLC remains to be established. As we await the results of ongoing trials and conduct further research, the choice between RATS and VATS should be based on a careful consideration of individual patient factors, surgeon experience, institutional resources, and the evolving body of evidence. Continued rigorous evaluation and open dialogue within the thoracic surgery community are vital for optimizing the surgical management of NSCLC in the coming years.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-24-26/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-24-26/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-24-26/coif). S.L. serves as the co-Editor-in-Chief of Video-Assisted Thoracic Surgery from September 2023 to August 2025. A.B. serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from April 2024 to December 2025. The other 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.

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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