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Zirafa et al. Mini-invasive Surg 2020;4:13 I http://dx.doi.org/10.20517/2574-1225.2019.35 Page 3 of 6

is observed in about one-third of the patients after surgery. Rocha described a N2 upstaging in 8.3% of
[7]
patients with preoperative negative nodes, investigated by mediastinoscopy .

[8]
The last element that may obviously affect the quality of lymphadenectomy is the surgical technique .
Specifically, the dissection of nodes in the hilum seems to be directly related to the surgeon’s experience
[9]
and, consequently, nodal upstaging represents a surrogate for expertise in a specific surgical approach .
This is confirmed by the variability of results about the lymphadenectomy in the different studies, which
show higher upstaging rate in more experienced facilities.

The role of the various surgical tools is to facilitate the operation, allowing to perform high-quality surgical
procedures, in a safe and comfortable manner. VATS has represented a lucky break in lung cancer therapy,
allowing to treat patients with a less traumatic approach. VATS is yet strongly dependent on surgeon’s
technical skills, resulting in some level of discrepancy in the quality of the surgery. Robotic surgery with
its technological features embodies the minimally invasive approach and the possibility to carry out the
operation versatilely, overcoming potential difficulties.

Over the latest years, papers have focused the attention on lymphadenectomy and nodal upstaging in order
to evaluate the quality of minimally invasive surgery (MIS), compared to open surgery in the treatment
of lung cancer. Video-assisted thoracic surgery and the most innovative robotic surgery are associated
with better postoperative results, in terms of length of stay, rate of complications and quality of life [10,11] .
Nevertheless, due to their most recent introduction in daily practice, data on long-term outcomes in lung
cancer patients who underwent MIS are bounded. For this reason, the analysis of nodal upstaging rate has
become a fundamental element to evaluate the completeness of surgical resection provided by minimally
invasive technique, in comparison with the more established open approach.

Initial studies have discussed the quality of lymphadenectomy in patients with clinical early NSCLC who
underwent VATS and thoracotomy. The results of the comparison between these two techniques are
discordant. Despite the number of nodal stations resected being similar, in the group of patients treated by
[6]
VATS, a lower upstaging rate was observed when compared to the other group. Decaluwé et al. reported
an overall nodal upstaging in 15.9% of clinical stage I patients, with a substantially lower rate in VATS
group, although there was no difference in the global number of dissected nodal stations (in the open
group: 5 ± 1.9; in the VATS group: 5 ± 1.7; P = 0.99). Licht, in his analysis of 1513 lobectomy of Danish
registry, observed nodal upstaging in 18.6% of cases, with a higher percentage in open than VATS group.
In particular, N1 upstaging was 13.1% in open lobectomy and 8.1% in VATS lobectomy, whereas N2
upstaging was 11.5% in open group and 3.8% with VATS approach. In contrast with the lower percentage
of nodal upstaging reported in VATS resections, the overall survival results superior in patients treated by
[1]
the minimally invasive approach . In fact, VATS seems to be associated with an improvement of survival
in pathologic stage I, probably due to the reduction of complications and consequent higher early-survival
[12]
in elderly and compromised patients . The divergence in nodal upstaging is probably caused by various
factors. One of them is surely represented by the selection of the patients, as bigger and central lesions
are not usually selected for MIS. In addition, the surgical technique can influence the quality of resection
obtained by VATS procedures and the surgeon’s experience in minimally invasive surgery and the use of
fissureless technique have a particular impact over the result obtained, evading the N1 dissection located in
the interlobar site.

NODAL UPSTAGING EVALUATION IN ROBOTIC SURGERY FOR LUNG CANCER
More recently, the surgeon’s assessment has focused on robotic surgery and its oncologic long-term
[8]
outcomes. In 2015, Lee et al. described similar upstaging in VATS and robotic groups, with a trend of a