Page 42 - Read Online

Page 4 of 11 Montagne et al. Mini-invasive Surg 2020;4:17 I http://dx.doi.org/10.20517/2574-1225.2019.74

Paul et al. [33] Comparison of short-term RATS vs. VATS
outcomes after a lobectomy Length of hospital stay 5 days vs. 5 days, P = 0.23 in median
RATS and VATS in a sample Complication rate 50.1% vs. 45.2%, P = 0.32
of a nationwide database In-Hospital mortality 0.7% vs. 1.3%, P = 0.15
n = 2498 RATS Total Costs 22.582$ vs. 17.874$ P < 0.001 (Median)
n = 37,595 VATS
Emmert et al. [35] Comparison of short-term RATS vs. VATS
outcomes after a lobectomy Length of hospital stay -1.08 days (95%CI -2.33 to -0.17) P = 0.078 mean
RATS and VATS difference
n = 3758 RATS Operative time 8.97 min (95%CI -28.12 to -46.07) P = 0.56 mean
n = 58,677 VATS difference
Chest tube duration -0.71 days (95%CI -1.5 to -0.1) P = 0.064 mean
difference
Mortality OR 0.52 (95%CI 0.29-0.93)
Louie et al. [34] Comparison of short term RATS vs. VATS
outcomes after a lobectomy Operative time 186 min vs. 173 min P < 0.001
RATS and VATS Air Leak > 5 days 10% vs. 9.8% P = 0.8135
n = 1220 RATS Length of hospital stay < 4 days 48% vs. 39% P < 0.001
n = 12,378 VATS 30-day mortality 0.6% vs. 0.8% P = 0.4
National Database
Wei et al. [36] Comparison of short-term RATS vs. VATS for matched
outcomes after a lobectomy cohort
RATS and VATS 30-day mortality RR 0.12 (95%CI 0.01-1.07) P = 0.06
n = 4727 RATS Postoperative morbidity RR 0.95 (95%CI 0.83-1.08) P = 0.41
n = 56,232 VATS before
matched analysis
DFS: disease free survival; HR: hazard ratio; OS: overall survival; OR: odds ratio; RATS: robotic-assisted thoracic surgery; RR: risk ratio;
VATS: video-assisted thoracic surgery; WMD: weighted mean difference; NSCLC: non-small cell lung cancer

principles as anatomical dissection and allows better lymph node dissection [20,21] . The main limitations for
[22]
the wide deployment of RATS are the higher cost of the procedure compared to VATS and logistical
issues.

Lymph node dissection and nodal upstaging by RATS, VATS, and open thoracotomy
Intraoperative lymph node assessment is a critical component in the surgical treatment of NSCLC. Since
the development of VATS, there has been controversy concerning lymph node dissection performed by
VATS compared to open surgery. Studies have described the feasibility of using VATS to perform complete
lymph node dissection and even nodal upstaging, although less commonly than by open surgery. With
its intrinsic features, lymph node dissection has been described as easier to perform by RATS than by
VATS [21,23] .

Kneuertz et al. recently published a propensity-score adjusted comparison of lymph node upstaging by
[24]
RATS, VATS, and open surgery during lobectomy for a cN0/N1 NSCLC in two centers. Between 2011 and
2018, 911 patients were included (254 RATS, 296 VATS, and 261 open surgery). The overall rate of lymph
node upstaging was highest with open lobectomy (21.8%), followed by RATS (16.2%) and VATS (12.3%) (P =
0.03), with no difference concerning mediastinal N2 upstaging (P = 0.6). More nodes were sampled by open
surgery (4) than by RATS (3.8) and VATS (3.6) (P = 0.001). Finally, on multivariate analysis, the rate of lymph
node upstaging was lower for VATS compared to open surgery (OR 0.5, 95%CI 0.29-0.85, P = 0.01) and not
different between RATS and open surgery (OR 0.72, 95%CI 0.44-1.18, P = 0.19). Multiple contemporary studies
have reported the same overall long-term survival between VATS lobectomy and open lobectomy, which
[27]
suggests that there is no decreased long-term survival for patients treated by VATS [25,26] . Medbery et al.
reported a lower rate of nodal upstaging with VATS than with open surgery (P < 0.001), but, in the
subgroup of patients operated on in a university hospital, there was no difference between groups (P =
0.08). Recently, Yang et al. reported an absence of difference in the rate of nodal upstaging of patients
[28]
with clinical T1-T2 N1 MO NSCLC and performed by VATS or open surgery (12% and 10.5%, respectively,
P = 0.41). The five-year overall survival was not different between the two groups (48.6% and 48.7%,
respectively, P = 0.76). With RATS, the rate of nodal upstaging was not different compared to open surgery,
and higher than with VATS [20,21] .