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of this system performed by thoracotomy continued to decline. One study showed that, in 2008, 76.2% of
lobectomies were performed using the open approach, compared with 23.4% and < 1.0% for VATS and
[1]
robotic approaches, respectively . In 2014, the majority of lobectomies was no longer performed via the
[1]
open approach, and VATS and robotic approaches comprised 31.6% and 25.0% of lobectomies, respectively .
Another study demonstrated that, from 2011 to 2015, lobectomies performed by thoracotomy had an
absolute decline of 11.5% . Lobectomies performed using the robotic approach had an absolute increase of
[2]
[2]
10%, yet VATS only had an absolute increase of 1.5% .
While the use of the robotic platform for lobectomy is growing and its safety has been evaluated and found
[2-5]
to be acceptable , additional considerations for utilizing the robotic approach over other techniques
and starting a robotic lobectomy program are still under evaluation, including costs and patient reported
outcomes (PRO). A systematic review of the literature on the cost of robotic-assisted lobectomy that was
[6]
performed by Singer et al. from our institution, which included six observational studies published before
1 December 2017, found that, in general, the costs of robotic lobectomy exceed those of VATS. The studies
that they reviewed were primarily based on early experiences, with the study period ranging from 2007 to
2013, and were only from the USA.

In this article, an updated review of the literature of the cost of robotic lobectomy is presented and the
quality of life in these patients is reviewed.

METHODS
Literature search
An electronic literature search on PubMed was performed to identify studies that included either robotic
lobectomy costs or quality of life on 9 September 2019. Search terms used included: (“cost” or “charges” or
“quality of life” or “patient reported outcomes”) AND (“robotic” or “robot”) AND (“lobectomy” or “anatomic
resection”). Abstracts from the search result were screened for relevance to include studies that evaluated
costs and/or quality of life in patients undergoing robotic lobectomy. Original articles written in English
were selected. Case reports and abstract-only publications were excluded. The full-text of the remaining
studies were reviewed for eligibility. Additional studies were identified from reviewing the references of the
studies found in the electronic literature search.

RESULTS
The literature search for costs associated with robotic lobectomy and review of its references resulted in
16 relevant articles [Table 1] from five different countries (Canada, 1; China, 2; France, 1; Italy, 1; and
USA, 11) [1,7-21] . These articles were published from 2008 to 2019 with the study period ranging from 2008
to 2017. The number of patients undergoing robotic lobectomy ranged from 12 to 2498. All studies were
observational. The majority of studies were retrospective analyses of prospectively collected data from a
[7]
single institution. Other studies included one prospective observational study and four population-based
cohort studies [1,8-10] . In addition to analyzing costs of patients undergoing robotic lobectomy, seven of these
studies also included patients who underwent robotic segmentectomy or wedge resection [7,9,11,13-15,18] . The
majority of studies reported using the da Vinci Si system. Only two studies noted the use of the Xi [16,17] .
Both four-arm [11,13,14,17,18,20] and three-arm [7,12,15,19,21] techniques were reported. There were three relevant
articles identified that studied quality of life in patients undergoing robotic lobectomy [21-23] .

ROBOTIC LOBECTOMY COST
Cost definition and analysis
Costs reported in these studies were based on the index hospitalization. There was significant heterogeneity
in the definition of cost, how it was analyzed, and the detail provided of these costs. Studies reported total