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procedures were performed in centers worldwide (682 from Europe, 95 from Asia, 56 from North America,
and 23 from South America). Most RAMIEs were performed as a 2-stage Ivor Lewis (n = 622, 73%) and a
smaller percentage via a 3-stage McKeown approach (n = 234, 27%). The increased utilization of the 2-stage
Ivor Lewis esophagectomy is likely reflective of the large number of European and American centers
represented in the UGIRA consortium. Overall, robotic surgery was used in variable phases of the
esophagectomies: in both the thoracic and abdominal phase (n = 386, 45%), only the thoracic phase (n =
415, 49%), or only the abdominal phase (n = 55, 6%) . Moving forward, the URGIRA registry promises to
[24]
provide real-time data on RAMIE to ensure appropriate implementation in diverse settings.

Completed randomized control trials comparing conventional MIE to RAMIE
RAMIE trial
The RAMIE trial represents the first randomized control trial comparing conventional MIE and RAMIE for
esophageal squamous cell cancer. The trial was conducted across six centers in China over a 2-year period
(2017-2019). Given the increased incidence of esophageal squamous cell cancer in Asia with primary
tumors located in the proximal or mid esophagus, all cases were completed using a completely minimally
invasive modified McKeown esophagectomy technique. A total of 358 patients were randomized to either
RAMIE (n = 181) or conventional MIE (n = 177). There was no significant difference in demographics or
illness severity between the two groups. RAMIE resulted in a shorter total operation time, with RAMIE
taking 203.8 vs. 244.9 min for conventional MIE (P < 0.001). When broken down to the thoracic and
abdominal portions, both portions of conventional MIE were longer [Thoracic: 84.2 vs. 111.6 min for
conventional MIE (P < 0.001); Abdomen: 38.0 vs. 53.3 min for conventional MIE (P < 0.001)]. There was no
significant difference in other perioperative outcomes including blood loss, conversion rate, postoperative
complications, readmission, or mortality within 90 days. In terms of oncologic resection, there was no
significant difference in R0 resection, pathologic disease severity, or lymph nodes resected. However, on
post-hoc analysis when the groups were stratified by neoadjuvant therapy, the median number of retrieved
thoracic lymph nodes and bilateral (right and left) RLN lymph nodes was significantly higher in patients
who underwent RAMIE after neoadjuvant therapy (15 vs. 12, P = 0.016; 3 vs. 2, P = 0.033; 2 vs. 1, P = 0.041,
respectively). RAMIE also demonstrated higher rates of achievement in resection of left RLN lymph nodes
[25]
in neoadjuvant patients (79.5% vs. 67.6%, P = 0.001) . The significant difference in lymph node resection
after stratification by neoadjuvant therapy could once again highlight the benefit of the robotic platform
with improved dexterity and three-dimensional visualization that could circumvent the scarring and
friability associated with neoadjuvant therapy, leading to improved oncologic resection.

Robotic-assisted esophagectomy vs. video-assisted thoracoscopic esophagectomy trial
The robotic-assisted esophagectomy vs. video-assisted thoracoscopic esophagectomy (REVATE) trial is a
multicenter randomized control trial comparing robotic esophagectomy to conventional thoracoscopic MIE
for left RLN lymphadenectomy in ESCC . The primary endpoint of this study focused on the left RLN
[26]
lymph nodes given they are often the most difficult lymph node basin resulting in low resection rates and
high morbidity associated with RLN palsy. The secondary endpoints of the trial included right RLN
lymphadenectomy, total lymph nodes collected, and perioperative outcomes. The trial was completed and
the results were presented at the UGIRA clinical congress in 2023. The REVATE trial demonstrated
increased resection of left RLN lymph nodes in the RAMIE group (88%) compared to conventional
thoracoscopic MIE (66%) (P < 0.001). Despite the great lymph node yield, the RAMIE cohort had a
decreased incidence in left RLN palsy immediately post op (21% to 34%, P = 0.03) and at 6 months (5% to
17%, P = 0.007). In terms of their secondary perioperative outcomes, the RAMIE group also had a higher
mediastinal lymph node harvest (16 [12-22] vs. 14 [10-20], P = 0.04). There was a significant increase in the
thoracic operative time with conventional MIE (124 [103.5-154] vs. 110 [89-137] P = 0.004) and there was
earlier chest tube removal (4 [3-7] vs. 6 [4-9] days, P = 0.007). All other outcomes were similar, including R0